Australian Aged Care Nursing:
A Critical Review of Education, Training, Recruitment and Retention in
Residential and Community Settings
2. Nursing Education and Training in Aged Care
2.1 - Introduction
2.2 - Protocol for the Review
2.3 - Key Findings of the Review
2 Nursing Education and Training in Aged Care
2.1 Introduction
The highly skilled nature of nursing and the possible ramifications of engaging poorly skilled staff to deliver care, has led to the regulation of nursing as a profession in Australia and all countries in the developed world. A major component of this regulation is the monitoring of training and education for entry to the register of nurses. Although pre-service and undergraduate education and training is important in protecting the public from unsafe practice, an evaluation of continuing education is also of importance in ensuring that nurses maintain and update their skills and knowledge.
This review examines the best available evidence regarding optimal models for aged care nursing education and training, including:
- current models of nursing education;
- the skills and knowledge required to meet the changing needs of the nursing workforce;
- refresher and re-entry training for nurses re-entering the aged care nursing workforce; and
- continuing education and professional development.
2.2 Protocol for the Review
2.2.1 Review Question
The purpose of this review was to present the best available information in relation to the issues surrounding training and education for nurses either studying to work in, or currently working in aged care.
2.2.2 Inclusion Criteria
Types of participants
This review considered studies that included nurses or nursing students who were undertaking or who had completed education and training relating to aged care nursing.
Types of intervention
The interventions of interest to this review included models of: pre-service and undergraduate nursing courses; sources of continuing education and professional training; and refresher or re-entry training that has been applied in aged care nursing settings. The instruments used to validate and investigate these models were also of interest.
Types of outcome measures
The outcome measures included those variables that provided an indication of education and training efficacy, including preparedness for the workforce, competency and expertise, student satisfaction, economic, institutional and staffing indicators.
Types of studies
All studies relating to training and education for aged care nursing, including tertiary courses, continuing education and refresher/re-entry training models, where appropriate methods were used were considered as part of the review.
2.2.3 Search Strategy
The search strategy was designed to access both published and unpublished materials and comprised three stages:
A limited search of CINAHL and Medline to identify relevant keywords contained in the title, abstract and subject descriptors.
Terms identified in this way, and the synonyms used by respective databases, were used in an extensive search of the literature.
Reference lists and bibliographies of the articles collected from those identified in stage two above were searched.
Articles published in the last 5 years in English and indexed in the following databases were searched:
- CINAHL
- Medline
- Australasian Medical Index
- Australian Public Affairs Information Service - Health Database
- Health & Society Database
- Psychinfo
- Sociological Abstracts
The initial CINAHL search terms were "Gerontologic Nursing Education", "Refresher or Re-entry Training" and "Continued Training or Education". Equivalent terms as defined by the respective thesauruses of other databases were used.
Full copies of articles identified by the search, and considered to meet the inclusion criteria, based on their title, abstract and subject descriptors, were obtained for data synthesis. Articles identified through reference list and bibliographic searches were also considered for data collection based on their title.
2.2.4 Critical Appraisal
Assessment of the appropriateness and quality of the study methods employed was undertaken. Studies were considered for inclusion in a narrative summary to enable the identification of current approaches and possible strategies.
2.2.5 Data Collection
Relevant data was extracted from each of the studies reviewed.
2.2.6 Data Synthesis
The findings were summarised by narrative. Data generated from observational and descriptive studies were summarised by narrative, listing significant factors or themes.
2.3 Key Findings of the Review
2.3.1 Pre-service and undergraduate education and training
Attracting able and enthusiastic registered and enrolled nurses to the aged care sector is highly dependent upon the initial exposure to the care of older people in pre-service and undergraduate programs. Current approaches to the education and training of registered nurses in all Australian states and territories largely focus on primary health care and the delivery of acute care services in hospitals. The education and training of enrolled nurses is largely focused on aged care. Until recently, articulation between VET programs for enrolled nurses and higher education programs for registered nurses has been limited but a number of nursing degree programs now offer shortened degree programs for enrolled nurses. Given the focus on aged care in enrolled nurse programs, increased articulation may arguably both increase the recruitment of trainee enrolled nurses, and those enrolled nurses who go on to become registered nurses may be recruited into the aged care sector. Nay and Pearson (2001) argue for a radical reform in pre-service nursing education and training, suggesting that a four year degree program, articulating with a two year enrolled nurse program, is required to address nursing workforce problems that have existed for most of the past 50 years. They suggest that a relatively large workforce of "practical nurses" with more education and training than existing enrolled nurses, and led by a much smaller group of registered nurses holding four year degrees, would create a scenario more likely to meet the community's need for a nursing service in general than current models.
The attitudes of nursing students towards aged care nursing has critical implications for the successful implementation of specialised education, the design and implementation of higher education curricula to encourage interest in aged care, and the subsequent recruitment of graduating nurses into aged care. A number of studies have been undertaken to examine students' attitudes towards aged care, and outcomes of exposure to aged care curriculum and clinical placements.
A review of the literature indicates that nursing students do not typically hold a favourable view of aged care nursing. Happell (1999) found from a study of nursing students' preferences for various areas of nursing practice, that at the commencement of their undergraduate nursing course, students display little interest in aged care. Similarly, Neilsen (1999) indicated from an evaluation of one cross campus Melbourne course specialising in aged care, that 44 of the 49 students involved in the evaluation of the course reported being indifferent to disappointed when asked about how 'excited' they were with the aged care placement. However 36 graduates indicated that they were satisfied to very satisfied with the completion of the placement. The large majority of the graduates indicated that they had been able to achieve their goals from the course, and stated that they learned various skills, including clinical skills, knowledge of medications and time management. Overall, though the students reported satisfaction with undertaking a comprehensive aged care placement, the reported findings indicated that graduates were not enthusiastic to undertake aged care placements. Happell (1999) has concluded that nursing educators must actively seek to portray the equal importance of all aspects of nursing care and to deter the situation where certain aspects of practice are considered more important and/or desirable than others.
One study has identified several factors that may encourage or discourage nursing students from choosing to work in a residential aged setting. A longitudinal study by Fagerberg, Winbald and Elkman (2000) followed students through the duration of their nursing course, interviewing the students at the end of each year about their experiences in residential aged care. The study found that overall, elder care was a low status subject. The factors likely to discourage students from selecting residential aged care settings as their workplace include: caring for the same resident with the same care needs over a long period of time; the pace being too slow; working alone with no support; and working in a workplace with poor resources and staffing levels. However the factors identified as likely to encourage students to choose to work in residential aged care after graduating include: a positive clinical experience; a positive experience with a preceptor; and meeting residents with many different conditions, thereby presenting opportunities to learn a lot and provide individualised care.
Furthermore, encouraging findings in one study have indicated that appropriate development and implementation of tertiary curriculum can positively influence students' approach to aged care. A study by Aday and Campbell (1995) investigated the changes in tertiary nursing students' attitudes and work preferences after completion of a gerontology curriculum. The curriculum included 62 hours of upper division nursing across 4 semesters. In addition to theory there was a clinical component in acute and home settings. The findings indicated significant changes in students' perceptions of ageing and aged care. Compared to attitudes prior to undertaking the curriculum, students held fewer negative stereotypical views at the end of their coursework. Further, there was greater sentiment for working with the elderly when students had more favourable attitudes towards them. It was concluded that educational programs can significantly change preconceptions about the elderly, and that education oriented towards the elderly may influence prospective students to choose to work in aged care.
2.3.2 The learning needs of aged care nurses
The educational needs of aged care nurses, as perceived by nurses and nursing experts in the aged care sector was a key focus in the literature reviewed. This in itself is an important step towards the further development of gerontological components in educational programs at an undergraduate/postgraduate level, and for the development of suitable continuing education and professional development programs for nurses currently working in, or wishing to enter aged care.
A review of the literature undertaken by Joy, Carter and Smith (2000) addressed the specialist skills and knowledge that are required to provide adequate care for older adults. The authors identified the need for development of gerontological nurse specialists who are able to demonstrate detailed knowledge of older people's health and social needs, and who are highly competent practitioners skilled in holistic care. A vast body of the literature has indicated the lack of aged care specific educational opportunities. Many nurses had undertaken nursing education at a time when little focus was placed on gerontology, and more recent concerns have also been expressed regarding the aged care knowledge and experience of nursing educators, and inadequate course time spent on aged care in current nursing curricula. Low participation rates in post-registration and postgraduate aged care education was also noted in the literature. One study indicated that less than 25% of the staff in a number if nursing homes had undertaken any form of continuing professional education.
Specialty education in aged care is now considered to be essential in ensuring quality care for older Australians (Illefe & Kennerson, 1995; Stolley, Buckwalter & Harper, 1995). Illefe and Kennerson (1995) have indicated that educational preparation for Gerontological Nursing is well established. However, changes to Australia's ageing population, health care delivery and promotion, and community support are all influencing the skills mix, and as a result, educational needs of those working in aged care. Therefore, it is essential that education providers ensure that course content is relevant to current practice and care delivery standards.
Several researchers have set out to identify specific elements of nursing education required to meet the current needs and demands in aged care nursing. In a study examining the specific continuing education needs of nurses, Glass and Todd-Atkinson (1999) found from a survey of 164 nurses' self-perceived learning needs that nurses had a large number of continuing education needs that differed across night shift and day shift nurses. The key learning needs identified by nurses included the development of management skills, drug therapies and interactions, and dealing with behavioural problems in residents.
In an Australian study involving a survey of 1874 nurses, Orb (1996) examined the gerontological learning needs of nurses working in rural areas. The findings indicated that overall, 64.7% of nurses worked regularly with elderly people, however only 41% had received some form of education specific to aged care. Nurses were asked to rate the relevance of the nursing competencies that are required to work as a gerontological nurse. Nurses identified forty-four competencies, subdivided into 5 main areas: problem solving, ethical/legal, communication, collaboration, and nursing care. Seven specific competencies were identified by nurses as most relevant; legal knowledge, handling of disturbed patients, needs for continuing education, protection of patients' rights, prevention of harmful situations, accountability, and practicing in an ethical manner. Overall, 46% of nurses were interested in undertaking an external educational package in gerontology, with 63% of nurses who regularly worked with elderly people indicating that they would be interested in the course. Nurses who were undertaking part-time or casual employment were more interested in interactive learning (including audio-visual materials) than those who were working full-time, who indicated a preference for text-based learning.
Learning needs relating to end-of-life care were identified in a study by Ersek, Kraybill and Hanberry (2000). Major issues reported by nurses involved difficulties with pain management; stressful interactions with residents, families, and other health care providers; lack of clarity related to role expectations; uncertainty about goals of care; time constraints; and unmet needs for self-care. Central to end of life care was the strong feeling of attachment that staff have for residents. The authors suggest that these findings can be used to guide the design of educational programs aimed at assisting nursing home staff in providing high level end of life care.
Oberski, Carter, Gray and Ross (1999) identified three key community care educational themes in a series of focus groups with registered nurses: specialist vs. generalist issues in role definitions and gerontological specialisation; social vs. medical approaches to care when nurses move into the community setting; and general nursing vs. mental nursing. The authors discussed these themes in relation to the design of an effective educational program, identifying a number of important issues: continuing and unexpected time pressures faced by nurses, adapting to older adults' living spaces and standards, working effectively under a range of circumstances, and working autonomously. The findings identified an essential element of future educational programs; for nurses to gain a sounder insight and understanding of their professional role when working in community aged care or moving across from a hospital setting to community care.
Other studies have indicated a broader range of learning needs in aged care nurses, including a survey of gerontological nurses and nursing experts in the UK and US (Timms & Ford, 1995). They found little consensus amongst nurses on the most necessary topics in aged care education, which included; normal changes in ageing, death and dying, medications, health promotion, nutritional needs, safety/fall prevention, mobility problems, psychosocial issues and physical assessments. Each topic was listed by some nurses within their 'top 5', suggesting the importance of a large range of specialty topics in aged care nursing.
2.3.3 Specialised training in aged care
Gerontological nursing faces the problem of difficulties in recruiting newly registered nurses. This is argued to relate back to difficulties faced by nursing educators in changing the negative attitudes among students towards aged care (Ford and McCormick, 2000). Furthermore, there are currently nurses with higher degrees in nursing or gerontology, but there is no demonstrable outcome or evidence of expert practice in working with older people (Ford and McCormick, 2000).
Several papers have identified the need for specialised aged care training, that leads to a recognised position such as Gerontological Nurse Specialist (Illefe & Kennerson, 1995; King, 1995; Stolley, Buckwatelter & Harper, 1995; Moyle, 1996; Ford & McCormick, 2000). Moyle (1996) argued for the critical need for aged care specialists, to both promote the positive image of aged care and ageing, as well as to meet needs of the increasingly more complex and demanding nature of caring for older individuals. Moyle (1996) indicates that it is essential that nursing academics consider strategies to increase the number of gerontology specialists, and provides a number of recommendations:
- a more positive emphasis on aged care in undergraduate courses, to improve care outcomes and entice more nurses to consider aged care;
- renegotiating challenging clinical placements from first year to second and third year, and providing positive clinical experiences in first year, such as introductions to healthy and active older adults;
- the development of specialty courses for gerontological nurses; both tertiary, and more flexible course structures with various study options, for nurses without a tertiary background;
- joining gerontological specific nursing groups (that provide courses and conferences);
- train the trainer schemes; and
- using innovative means of education, such as learning strategies via computers, video and self-directed learning with support.
King (1995) has also argued that the development of gerontological nursing courses may enhance the image of gerontological nurses. Clinical experts suggest separate, specific courses are needed to provide a comprehensive understanding of gerontology. Understanding the gerontological nurse's expanding role may enhance the students' ability to care for elders. It is suggested that the problems associated with integration include a tendency to integrate gerontologic teaching with more general content, the perceived lack of importance of integrated content, and poor faculty preparation.
Studies have addressed the specific needs within specialised aged care education courses. A survey conducted to review the gerontological content in baccalaureate nursing programs was distributed nationally in the USA and completed by 480 baccalaureate (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). Criteria for excellence in gerontological nursing programs included: the presence of a stand alone course in gerontological nursing; utlilisation of multiple clinical placement sites, at least one full time faculty member with certification; a masters program in gerontological nursing; and a university centre for ageing. The findings indicated that in the US:
- 23% of programs have a stand-alone course in gerontology.
- 40% of programs contain at least one full time American Nurses Association certification in gerontology.
- No school met all of the five, and only 19 met a combination of 4 criteria.
Recommendations included:
- The number and focus of questions on the National Council Licensure Examination- Registered Nurse must reflect the knowledge base expected of nurses whose responsibilities will centre around care of the elderly.
- Professional organisations that accredit baccalaureate programs should revise their standards for program certification to reflect the importance of preparing graduates to care for the elderly.
- Baccalaureate programs must revise their curriculum to reflect the needs of society and of their students.
- Existing resources and new technologies must be directed to assuring that faculty are adequately prepared to teach students state-of-the-art care of the elderly.
2.3.4 Collaborative education and teaching nursing homes
Among the strategies identified in the literature to improve the education and training of nurses in aged care, the further development of collaboration between educational institutions and aged care facilities was highlighted as a key issue. By developing further links between education and aged care homes and encouraging the development of teaching nursing homes, a number of benefits may be achieved. These include further professional input for nursing curricula (Joy, Carter & Smith, 2000), improved opportunities for quality clinical experiences for nursing students and potential for greater recruitment (ACWC, 2000), opportunities for nursing homes to establish best practice based upon advancements in research and knowledge in the universities, and improvements in the status of aged care (Chilvers & Jones, 1997).
Studies have indicated the importance of quality clinical experiences in a range of aged care facilities, in the professional development of nursing students, and development of positive attitudes to aged care nursing. One study evaluating the quality of a Graduate Certificate in Gerontology in the US indicated that students would like more training and experience with practical and applied elements of aged care (Usita, Blieszener & Roberto, 1998). Strengths of the course identified by the students included: multidisciplinary opportunities for learning, quality of instruction, opportunities for professional development and exposure to diverse backgrounds and experiences. Storey and Adams (1999) concluded that, through the development and evaluation of a program designed to improve the clinical placement experience for students in nursing homes, placements can provide excellent experience, and may help to banish any negative stereotypes of nursing home nurses thereby affirming the value of geriatric care.
A number of papers have addressed the development of teaching nursing homes, as a means of raising the profile of, and improving the quality of aged care, and improving the education and recruitment of nurses and nursing students (Chilvers & Jones, 1997; ACWC, 2000; Upex, 2000).
A report to the Aged Care Workforce Committee (ACWC; 2000) identified a number of developments proposed to improve nursing homes and facilitate the recruitment of nurses in aged care, including the development of teaching nursing homes that have affiliations with a university. This recommendation is based on the premise that teaching nursing homes will attract more qualified nurses who have familiarity with the homes via clinical placements, greater professional standards of the homes, and a view to further opportunities for continuing education and professional development via the affiliated university.
The Warabrook Centre for Aged Care is an Australian model of this recommendation, operating in conjunction with the University of Newcastle. As outlined in the report, the design for the home incorporated the needs of the university, providing a training room and lunch area for visiting students, rotations for 4th year medical students, placements for nursing students and provision of a part-time Medical Director to supervise medical students.
The La Trobe University Gerontic Nursing Clinical School located at Bundoora Extended Care Centre and linked to the Australian Centre for Evidence Based Residential Aged Care provides practice-focused education and training for enrolled nurses and undergraduate and postgraduate nursing students. A large research program is a feature of this collaborative unit, including a large PhD program focusing on aged care.
Chilvers and Jones (1997) explored the potential value of teaching nursing homes as a possible alternative placement to facilitate learning, through a review of the literature. The authors concluded that the concept of teaching nursing homes offers vast potential, not only to nursing education, but also in raising the profile of care of the elderly. One example of this was the program undertaken by Robert Wood Johnson Foundation, in association with the American Academy of Nursing, using a care-oriented approach. This program promotes the affiliation of nursing schools with nursing homes. In this approach the focus is on education, practice and clinical research in an attempt to improve the knowledge base in relation to long-term care and increasing the number of qualified carers. Teaching nursing homes originated in the US in 1963 but gained recognition/ funding in the 1980s when the National Institute for Aging Director (Butler) established a teaching nursing home research program. The homes were associated with medical schools and focussed on research into the ageing process and disease prevention. Coming under criticism for this medical emphasis, they broadened to affiliate with nursing schools and include in their scope education, practice and clinical research.
2.3.5 An interdisciplinary approach to education and training
Adopting an interdisciplinary approach to the education and training of aged care nurses, including nursing, medicine and social work, was highlighted in several papers (Richardson, Cooper, Swanson & Ward, 1995; Clark, 1997; Gariola, 1997; Howe, Mellor & Cassel, 1999; McKinna and Conners, 1999). Clark (1997) discussed the importance of developing new interdisciplinary curricular models of aged care education, to enable students to gain additional instructional outcomes from interdisciplinary experiences based upon knowledge and skills gained from collaboration amongst aged care professionals. An interdisciplinary approach to aged health care services and education is also viewed to provide a holistic approach to patient care that emphasises a best practice approach (Gariola, 1997).
The majority of the literature in this area has involved overviews of current programs that have been developed to incorporate various disciplinary approaches to aged care. Three of these programs were selected for review in this report. A paper by Howe, Mellor and Cassel (1999) outlines an interdisciplinary approach to aged care nursing education. The authors outline the Mount Sinai Medical Center Geriatric Interdisciplinary Team Training Program (GITT), designed to prepare future health professionals; nurse practitioner trainees, social work students and medical residents, to work within interdisciplinary geriatrics teams and deliver quality care. The program aims to ensure that trainees have a shared knowledge base, attitudes, and skills about teamwork and care of older people. The program offers two choices for training: an intensive training program and a less intensive program consisting of one-day workshops. The intensive training program consists of practicum-based experience and didactic curriculum that are flexibly integrated in the course. For nursing students, the course length is typically 15 weeks in duration. Students also have the option of a comprehensive one-day workshop, offered 2-3 times each academic year. Topics covered in the course include geriatrics and gerontology, working in interdisciplinary teams, and managed care. The program uses a variety of teaching approaches, including team teaching, journaling, standardised patients, 'real time' experiences, one-day workshops and program enhancements.
The program has been running for two years, and its coordinators are continuing to assess and refine the program through ongoing reviews. The authors reported on the positive and enduring impact of the training program on the faculty and management team, clinical sites, and academic institutions involved in the program. The program has been reported as an impetus for a critical review of clinical teaching, precepting and team functioning in the participating clinical institutions. In the participating academic institutions, geriatrics and gerontology have been given a 'heightened status' in the participating schools, through the existence of the GITT program. Schools (social work) have also been reported to effect change in their curriculum, to identify gaps in learning related to ageing and interdisciplinary teamwork.
McKinna and Conners (1999) provided an overview of a Certificate in Gerontological Nursing (Division 1), a hospital based course run by the Bendigo Health Care Group that emphasises an interdisciplinary approach to aged care. The aim of the program is to provide specialist theoretical and clinical education and practicum in gerontological nursing, for nurses to competently practice as part of a specialist interdisciplinary team providing holistic care for older individuals. This course was developed in response to three major imperatives: the growth in the ageing population and changes in health care needs; the need for quality, specialised gerontological nursing care that meets national standards; and the professional development needs of nursing professionals. The course providers acknowledge that it is not possible for all nurses to participate in tertiary post-graduate courses. However the hospital based course is argued to provide not only knowledge and skills, but also 'educational confidence' for nurses which may result in nurses extending their studies to tertiary institutions. One course is run each year for 26 weeks, consisting of two 13-week semesters. Credit points may be transferred across to other tertiary graduate and postgraduate courses at universities. The course consists of 6 units: normal biological ageing, pathophysiology, psychosocial aspects, complex care, professional and political issues, and ageing in the community. The course provides a number of advantages and opportunities: specialisation in gerontology, a strong clinical base for improving practice, familiarisation with computers and programs, lectures from a variety of experts, and networking.
Siegler, Cotter, Goldberg-Glen, Brice and Ellis (1996) evaluated an interdisciplinary experiential seminar format for educating medical, nursing and social work students. The seminar program consisted of 2 components, a series of eight 90-minute sessions, and 2 visits to demented individuals and their families. All seminars were interactive, including videotapes and age simulation games. The experiential component involved students maintaining a diary of the visits and their impressions of dementia before and after the course. A final questionnaire was completed to rate how well the course filled its objectives. Results revealed that students were receptive to the materials and incorporated the most important concepts into their observations and understanding of dementia. The experiential component was the most valuable part of the course and the authors concluded that an experiential opportunity for health professional students to learn about dementia is both feasible and effective.
2.3.6 Continuing education and professional development
The development and evaluation of continuing education programs is a key issue prioritising best practice in aged care homes, as well as providing aged care nursing staff with continued opportunities for professional development and increased job satisfaction (Girvin, 1999). A large number of papers were identified in the literature that describe recent education and training programs, and evaluations of the outcomes of educational programs.
Several benefits to the use of continuing education programs have been identified in the literature. Support for benefits of the identification of learning needs and provision of continuing education for nursing home staff was found in a study by Davies, Slack, Laker and Philp (1999). They found from a cross sectional survey of 676 senior nurses within a random sample of nursing homes in England, that educational preparation of nursing staff was found to be significantly associated with the quality of care (as measured by resident autonomy) of residents in each aged care home.
Biddington (1996) found that a learner-centred program for nursing staff with the teacher acting as the facilitator resulted in improved motivation, sense of worth, achievement and confidence. McLeod and Buikema (1996) identified similar findings through use of a self-directed approach to nursing staff training. After 20 nurses assessed their own learning needs via a questionnaire, articles were selected by the educator and clinical nurse specialist (CNS) based on staff perceptions of learning needs (based on gerontological nursing practice that contributes to program development in the unit). Nurses were invited to read articles of interest to them regarding various psychogeriatric programs, activities promoting mental health, common psychiatric illnesses, and effective nursing interventions. Over a 10-week period, nurses presented synopses of the articles and led discussions in a series of meetings with their peers. The program generated much enthusiasm amongst the staff. It gave them the opportunity to participate in a group, to agree or disagree on a professional issue, thereby increasing staff involvement in the issue as well as their own learning. The article reviews and presentations were described by nurses as "group therapy for the staff".
A study by Proctor, Stratton-Powell, Burns, Tarrier, Reeves, Emerson and Hatton (1998) found that changes in the quality of interaction between staff and residents can be obtained by providing regular training and support to care workers. Assessments were made with 51 nursing home staff before, during and at the end of the training intervention using an adaptation of the Quality of Interactions Schedule. A significant increase in the proportion of time staff spent in positive interactions with residents was observed over a 6-month period, both in direct care and social contact at the end of training.
Following the implementation of a 3-month staff education program on resident aggression with 134 nursing staff, Hagen and Sayers (1995) found that reports of resident aggression dropped by 50%. The education program consisted of 3 modules using theory, group discussions, and brainstorming. Topics included: relationship between dementia and aggression; risk factors for aggression; goals of care for demented elderly; strategies to prevent aggression in the demented elderly; strategies to de-escalate aggression; and protective interventions.
Smith (1998) outlined a 2-year project on education for Registered Nursing Home Association staff, that aimed to provide courses on the principals and practice of palliative care to nurses and other aged care staff. The palliative care course was developed upon three main areas that were identified at the start of the project by registered nurses working in aged care homes: the assessment and management of pain and other symptoms, communication skills, and support of families and colleagues following a bereavement. The educational team developed a problem-based reflective practice framework for the course that drew upon nurses' experiences. Each course was presented during 12 days over a 6-month period. Nurses were required to identify an area of practice that they hoped to change as a result of the learning. Therefore a 3-month gap in the course was provided, to enable nurses to adopt changes in their practice and report back on their progress and any issues that arose, at the end of the course. Participants indicated several benefits to the course, including improved ability to cope with residents and family, increased confidence in raising issues, and improved understandings of the support needs of relatives. The author stressed the importance of designing a course that is specific to aged care homes and staff.
Peterson, Hakendorf and Gusgott (1999) described the development and assessment of an aged care continuing education program that was developed to improve participants' expertise in clinical management of older individuals and ability to facilitate changes in response to the needs of clients, thus improving quality of care in their nursing home. The course was based upon principles of problem-based learning, which allow nurses to further develop their knowledge, clinical reasoning skills and capacity to become self-directed learners. Using both quantitative and qualitative approaches to evaluate the program, data on the course effectiveness were collected through observations, journals and pre-post questionnaires. The findings of the evaluation indicated that participants were able to develop a more holistic approach to aged care nursing, reflect on their practice, further develop their understanding of current aged care guidelines, and acquire new skills and strategies for improving their workplace. It was concluded that problem-based learning was an effective tool in linking theory with practice and improving nurses' approach to aged care.
Brazil, Jewell, Lyle, Zuraw and Stanton (1998) undertook an evaluation of a 2-day geriatric workshop for nurses in a long-term care hospital. A quasi-experimental pre-post intervention design with a non-matched comparison group was used with 51 Registered Nurses, 31 of whom were in the control group. Participation increased knowledge of gerontological issues and improved ability to assess patients and to plan and document nursing interventions. However, the workshop did not improve collaborative practice, job satisfaction, or role ambiguity. The authors suggest that the workshop is a valid approach to change relevant nursing behaviour in the workplace, however the selection of measurement instruments is critical in designing an evaluation.
Taft (1999) studied the effectiveness of a team educational approach to managing urinary incontinence (UI). The nursing staff were surveyed prior to, and 4 months after completion of the program. The focus of the program was to increase nurses self worth by instilling a sense of belonging and thereby improving job performance. Written materials were provided prior to the program to give an understanding of the causes and specific types of UI and possible interventions. The team met once a week to discuss new and ongoing cases, arrive at impressions, and make recommendations. It was found that incontinence was easier to manage after the program was implemented. The authors concluded that nursing staff have a better opportunity for behavioral change when their practice is valued and they are included as members of the UI management team led by advanced practice nurses.
In a study investigating a train-the-trainer model, 57 nurses completed a questionnaire of their perceptions as a result of the training project (Smith, Mitchell, & Buckwalter, 1995). The train-the-trainer approach was designed to overcome numerous barriers to effective geriatric mental health training observed by CMHC nurse specialists in the years prior to the project. This method was utilised to encourage long term care nurses to become internal specialists on mental health issues. The train-the-trainer model developed self-contained training modules on various geriatric mental health topics, such as depression & dementia. Each module contained detailed program materials, including goals and objectives, notes for instructors, materials checklist, training scripts, slides, handouts, exercises & activities, and a glossary of terms. Using these modules, the nurses completed 3 separate 2-day intensive training sessions. In turn, these nurse trainers trained additional staff in their own facilities. The train-the-trainer model proved to be a viable method of providing geriatric mental health consultation and training that targets both improved quality of life for both residents and staff in charge of residents' care.
A review of a train-the-trainer program was undertaken with twenty-five participants who had an interest in ageing and the ability to successfully teach their peers (Langer, 1999). The program included both gerontological content as well as fundamental teaching methodologies. The primary educational concern was how to effectively improve the professional and personal understanding of ageing on the part of those who work closely with older adults. A 150-page binder of learning materials was provided, including lecture summaries, pamphlets and printouts for topics covered in the workshop, sample lesson plans, descriptions of teaching methodologies and venues for appropriate application, references to journal articles, and guidelines for accessing library, internet, community, and national resources for participants and their future trainees.
At the conclusion of the Train-the-Trainer Partnership workshop, the participant nurses' attitudes towards ageing and the elderly were assessed using an open-ended questionnaire. Results suggested that the program was successful at improving the participants' attitudes towards ageing and the aged. Nurses also commented positively on having learned relevant content and acquired the methodological tools with which to integrate this content into experiences for their future trainees.
In support of these findings, a study by Cheney, Schank and Simpson (1996) concluded that the 'train-the-trainer' programs are needed to help nurse educators acquire the knowledge and skills needed to develop cost effective curricula. This system was found in their study to be effective in delivering inservice programs in multiple settings and across multiple instructors.
An investigation of the use of an educational intervention to improve aged care in a rural area indicated that a needs-based geriatric educational intervention can significantly improve the geriatric assessment skills of health care professionals (Brymer, Cormack, & Spezowka, 1998). The study involved a pre and post-test with 164 subjects, 66 of whom completed all of the 4 sessions of a geriatric educational intervention developed for all non physician health professionals in a rural community. Self reported practices with elderly patients were noted in assessment of medication use, physical assessment, mental status assessment, screening for elder abuse, and the use of community resources. Demonstration of a change in practice was the primary outcome measure. This intervention was concluded to be inexpensive & feasible, and the authors suggest that similar interventions should be more widely implemented.
Rae and Colles (2000) outlined a person-centred holistic approach to training nurses in dementia care. The training sessions usually last three hours, and are led by nurses experienced in dementia care. The sessions are intended to be a catalyst for change by raising awareness and enabling nurses to review their practice. The training also aims to change negative attitudes that a diagnosis of dementia provokes. Very encouraging comments were received via questionnaires answered by 597 nurses who took part in the training sessions. Although over half reported that establishing a definitive diagnosis was one of the most difficult aspects of caring for people with dementia, over 69% reported that the session helped them in this area. A change in attitude was also apparent, with 59% of nurses feeling more optimistic after the training session that something could be done.
An evaluation of the Australian National Residential Dementia Training Initiative (NRDTI; 1998) outlines the program and changes in service delivery as a result of the program. The mid term review of the National Action Plan for Dementia Care identified a need for a more coordinated approach to dementia care training for all staff working in residential aged care facilities. The NRDTI was established to provide systematic training for staff in Commonwealth funded residential aged care facilities in order to improve dementia care practice.
Three main training components were offered. Information sessions for managers aimed to provide knowledge and information about the importance of dementia care training staff and stimulate management to facilitate the implementation of good dementia care practices. The second component, the Direct Care Workers course, provided basic knowledge and skills for direct care staff to promote improved care practices for people with dementia. Train the Trainer, the third component, aimed to provide industry with an infrastructure to sustain dementia care training after the end of the Initiative.
The changes in care practices and attitudes towards residents with dementia reported represent a definite and significant improvement in the quality of service delivery for residents with dementia.
Respondents reported improvements in attitudes and care practices, as a result of the NRDTI dementia care training in the following areas: increased knowledge about dementia; health and personal care; resident lifestyle; management practices; benefits of training. However some workers reported that they had not been able to implement changes due to constraints caused by management attitudes and practices, the physical environment and the attitudes and practices of other staff.
Despite successes with several continuing education programs, the literature has identified difficulties that nurses experience in either undertaking or accessing further education and training. Several strategies have been identified to counter this difficulty. A survey of 41 nurses from aged care homes, found that almost two-thirds of the nurses received no support from their employer to undertake continued education, despite an increase in training needs, workload, and patient dependency (Nazarko, 1996). Similarly, almost two-thirds of the nurses indicated that they found it difficult to access professional education. Nazarko (1996) discusses these findings in relation to current recruitment difficulties in aged care, indicating that nurses are choosing alternative positions with better salaries and educational opportunities. Nazarko (1996) makes several recommendations to counter current educational and recruitment difficulties:
- Further research to identify skill needs, to which educational programs must be tailored
- Establishing links between aged care homes and universities, to the benefit of both. These links would facilitate the development of new roles such as lecturer/practitioner and gerontological specialist within nursing homes, provide students with clinical experience in homes, and assist in bridging the gap between practice and theory.
- Provision of funding for nurses to continue their education, and providing the same educational opportunities for aged care nurses as are available in other nursing sectors.
In a report on the needs for dementia care, The Victorian Government Department of Human Services (2000) provided recommendations for education and training. The first objective described in the report addresses the improvement of quality of care, by promoting measures and initiatives that relate to education and training needs. The training and education of dementia workers is considered essential. Recommended actions relevant to aged care nurses included:
- Statewide dementia training, addressing: identification of workforce groups that require training; development of a sound understanding of the education needs in particular aged care settings; and provision of on-site in-service training for aged care staff.
- Facilitating the continuing availability of dementia related educational resources and establishment of a central dementia resource repository
- Inclusion of dementia-specific educational components in undergraduate courses
2.3.7 Re-entry and refresher training
The development and provision of re-entry and refresher training for nurses wishing to enter into aged care is a key strategy identified in recent recruitment and retention research (e.g., Pearson, Nay and Koch, 2001). However to date there has been minimal research to develop and evaluate such programs in the age care sector. Two papers are presented below, that outline the implementation and outcome of aged care re-entry courses in the US.
One re-entry program designed for the aged care sector was outlined by Damukaitis and Schirm (1989). The program ran for four weeks, including content relevant to aged care such as physical and psychological changes in the ageing process, nutrition, skin and foot care, respiratory function and medication management. Presentations by the nurse educator were augmented by representatives from appliance and supply companies. The course ran for a total of 70 hours, with a minimum allocation of 15 hours for clinical experience.
Damukaitis and Schirm (1989) also outlined additional strategies for recruiting nurses; the collaboration between a group of nursing homes to form their own nursing agency, and a mail out to nurses to market the refresher course and agency. Benefits to the program included a higher proportion of nurses returning, thereby enhancing continuity of care, and employing "known" staff. The homes shared the cost of a co-ordinator and were able to pay the nurses a higher rate from the savings made from agency fees (which were more than double the hourly rate received by the nurses). Benefits for the nurses included greater flexibility of employment and the higher wages.
A brief paper by Nagy (1991) described a program implemented in the United States to recruit nurses into the aged care sector. Their approach was to attract inactive older nurses (50 + years) into the aged care workforce via a re-entry course, Project ONE-AGE - Older Nurses Enthusiastic about Geriatric Employment. The course was developed in response to a survey that indicated that 25% of nurses meeting those criteria in Illinois would be interested in long-term care rather than return to the acute sector. The aim of the project was to assess older nurses' perception of the nursing shortage, their proposed solutions for it, and their perceived need for retraining upon returning to nursing. The findings indicated that adequate staffing levels, increased pay, flexible hours, ability to use life experience for patient care, and adequate orientation would contribute to nurses returning to work. The most dominant reason for nurses not returning to work was a perception of themselves as too old. It was concluded that a program convincing nurses that their experience and expertise is needed may encourage nurses to return to the workforce, and in particular long term care.
Following implementation of the project, nearly 50% of nurses who undertook the program reported an interest in working in long term care, despite not having considered it before the project was presented. Recommendations based on the outcomes of the project included: a revision of re-entry course to include a component on long term care, and inclusion of gerontology in the curricula of nursing education programs.
2.3.8 Flexible learning options
The need for flexible learning options is a key issue in the successful provision of aged care education. A paper by Nazarko (2000) provided a number of suggestions for residential aged care nurses considering or wishing to undertake further education and training, based upon needs and time available. Her recommendations included: nurses examining their skills in light of the needs of the residents they are caring for, to identify and prioritise personal education needs; visiting a centre for excellence; spending a day with a nurse specialist to keep up-to-date; and/or attending a study day or national board course. Nazarko (2000) argues that nurses with well developed skills are able to provide a higher level of quality care, enjoy greater job satisfaction and confidence, and improved promotional opportunities, whilst employers supporting further education for their staff will benefit from higher levels of staff morale, and reduced staff turnover.
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