[The Montana Professor 18.1, Fall 2007 <http://mtprof.msun.edu>]
Allison McIntosh
Nursing
Montana Tech-UM
The first ripples of a demographic tidal wave, "a silver tsunami," are lapping on the shores of America. We have been hearing about this graying of America for some time now, usually in conversations about reforming our health care system or the need to "fix" Social Security. So far no real changes or solutions have occurred in anticipation of the wave. It seems the wave must hit first and then we will somehow react. The numbers are clear: the fastest growing age group in our country are those 85 years and older. By 2030 the number of people over 65 years of age will have doubled. In this time period, Montana is expected to move from 14th to 3rd in the nation for the percentage of older adults. This question is posed for all immersed in higher education: how do I help students learn and lead in a society which undoubtedly will look quite different in the next 25 years?
As a nurse educator at Montana Tech of the University of Montana, I think about the traditional aged nursing students who will enter the prime of their nursing careers just about the time when most of us reading this article might be in need of nursing services and health care. Judy Murphy, a nurse educator, has observed, "Much of what one learns as a student about nursing practice will later be obsolete."/1/ With the changing nature of nursing and medical research, drug therapies, laboratory and diagnostic modalities, new medical and informational technologies, and an increasingly complex web of health care services, all health professions students must embrace life-long learning and stay current for safe and effective practice. When students graduate from school it is only just the beginning. Their success depends upon how well their education prepares them to engage in critical thinking and clinical reasoning in order to apply new, yet to be acquired, knowledge.
There are clinical opportunities in high-risk neonatal care, pediatric, and obstetric nursing specialties, but often the majority of these jobs are located in large, out of state medical facilities. The most likely scenario is that new graduates will spend two-thirds of their careers working with older adults./2/ This is particularly true of the high number of our Montana University System nursing graduates who stay and practice in Montana with our increasingly aging population.
Another focus of future nursing care and practice concerns chronic disease management, as 80% of all older adults experience at least one chronic disease, with increasing age being associated with increasingly chronic and complex care. The "fix it and forget it" approach to health care is no longer an option with growing numbers of aging clients and increased incidences of heart and lung disease, diabetes, and arthritis. Perhaps the most dramatic increase is with Alzheimer's disease, where cases are predicted to triple in the coming decades./3/
The very nature of chronic disease makes a "cure" impossible. Nurses of the next generation will need to be competent in providing comfort to their patients and their families, as increasing age and frailty complicate everything they have learned about chronic diseases in their nursing programs. Indeed, every patient and family is experiencing a unique and diverse set of circumstances and there is no one-size-fits all approach. The nursing care must be individualized and flexible to meet the needs and priorities of patients and their caregivers. This may be difficult for new nursing graduates as this is care at the highest, most expert level.
In 1999, the Institute of Medicine shocked the health care community and the public with a report of extremely high rates of iatrogenesis in hospitalized patients./4/ Iatrogenesis refers to medical errors and negligence by health care providers. Older hospitalized patients, often severely ill and the most functionally impaired, are extremely vulnerable to this condition. Often characterized as the "geriatric cascade," adverse events triggered by a medical or nursing intervention cause cascading physical decline, or even death. Indeed, a follow-up study in 2004 found that 195,000 Medicare patients die every year in hospitals as a result of medical errors at a cost of $2.85 billion annually./5/ The 2006 report continues to expose a nation-wide problem with minimal improvement./6/
Nurses must develop high levels of clinical vigilance to protect older patients in the hospital and upon discharge. The hazards are endless and frightening. One of the first is simply being relocated to a new environment. Older patients may have lived in their homes for over 60 years. They are used to their own doors, lights, and hallways, and find relocation especially stressful. Age-related sensory losses, especially vision, are associated with falls and environmental hazards such as a new pair of slippers, walker, wheelchair, bedrail, or bedside commode which can actually do harm if not used properly. Several relocations to different units or rooms during an illness have also been associated with delirium, which is experienced by 30% of hospitalized older patients. Noise from machines, sleep deprivation, glaring lights, and a complete change in routine add to the insults. Often several different medications are initiated upon admission that can quickly overwhelm the patient's aging kidneys as they attempt to excrete high doses of drugs, but sometimes not at a fast enough rate, leading to a toxic build-up in their system. There is a constant threat of the patient receiving wrong medications or doses. New tests and procedures all have possible adverse effects and can harm the patient.
Nosocomial (hospital-acquired) infections are extremely tough and sometimes drug resistant, and can invade any open skin, surgical wound, the lungs, a urinary catheter or an IV site. Bed rest makes the potential for a pressure ulcer (bedsore) a real concern even in the first several hours. It has been estimated that malnutrition and deteriorated nutritional states occur in close to 78% of all hospitalized patients. Patients often will lose significant weight in the hospital because food is withheld for tests or surgery, patients need more help to eat because they are weak, or their preferences are not honored. Urinary incontinence occurs in 33% of hospitalized patients with many of these cases related to the patient not being able to get to the bathroom on time in a new environment, which is made worse if they are given medications that are strong diuretics. Incontinence is one of the most common causes of nursing home placement and can be the most troubling to the patients and their families.
In the fast paced health care setting, patients often do not maintain their functional abilities, as up to 40% leave the hospital at a lower functional capacity than when they came in. Indeed, one study showed that there is statistically significant deterioration in hospitalized patients over the age of 74 by the second day of hospitalization in terms of mobility, transferring, toileting, feeding, and grooming./7/ Sometimes nurses and other care providers do not allow patients enough time to complete their own self-care, or take extra time to encourage walking and exercise programs, as these activities generally fall to the bottom of the priority list in an acute care hospital setting. Often there is a lack of communication among the staff and an incomplete baseline assessment of the patient's functional status on admission that then could be used to set a benchmark for progress. Indeed, a lack of sensitivity or knowledge by nursing, medical, and hospital staff about the devastating effects of functional impairment on the patient's quality of life has actually been shown to contribute to this iatrogenic problem./8/ Put another way, has the hospital staff done any service if they treat and cure a patient with pneumonia but at the end of the hospital stay the patient has extreme difficulty walking as a result of de-conditioning and weakness and now must go to a nursing home?
The length of hospital stays is dropping to an average of just a few days for most conditions, while at the same time the patients who are admitted are increasingly the frail elderly who can experience a cascade of decline starting within 48 to 72 hours of admission. Often the new iatrogenic problems persist well beyond discharge, greatly impacting the person's ability to return to independent living. Nurses who care for patients round the clock in the hospital have a duty to anticipate, intervene, and ideally eliminate iatrogenic problems from hospital admissions. Students and new nursing graduates are often shocked to see iatrogenesis occur in their patients as this does not fit the care plan from the nursing text. An increasingly older population of hospitalized patients are at daily risk all over our nation.
There is a myth held by some students and others who wrongly assume that most older adults live in nursing homes or institutions on a long term basis. Nationally only about 5% of older adults are institutionalized in a nursing home at any given time and this number is expected to continue to decrease./9/ Looking specifically at Butte-Silver Bow, which has a higher population of elderly residents (about 16%, compared to the national number of 13%) this number is about 7%. In 2002 there were 401 licensed nursing home beds in the county. Additionally, 181 assisted living beds were available. The remaining 4,964 adults aged 65 and older lived in the community. Other pertinent data included the high rate of older county residents who lived in poverty, and the 41% disability rate in the non-institutionalized population that was 21 years or older. The measure of disability in a population includes the percent of people who have blindness, severe vision or hearing impairment, and/or a substantial limitation in performing basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying objects, difficulty learning, remembering, or concentrating, or difficulty dressing, bathing, or getting around inside the house. In addition to the above, people are considered to have a disability if they have difficulty walking outside the home alone to shop or visit the doctor's office./10/
To sum up, in the coming decades most current nursing graduates will end up being gerontological nurses who encounter increasingly older, often disabled adults, mostly over the age of 85, all across a complicated health care system. Their patients will have multiple chronic illnesses for which there is no real cure, but often there can be comfort. The future geronotological nurses will need to be especially vigilant to protect their patients as they move between facilities and health care providers to prevent iatrogenic events and poor outcomes. New and more complex technology may either help or hurt our patients, and nurses must be there in both cases. Their patients will most likely try to remain in the community, avoiding institutions and nursing homes, and may need nursing care, especially if they live in poverty and/or have disabilities. Health care policies and programs will experience sweeping changes in reaction to the great tsunami wave. The changes could come fast and harsh and it will not be practice as usual. There is clearly a mandate to change now and it should start with educational culture.
Historically, "geriatric nursing" was viewed by students, practicing nurses, and the public as less glamorous, less skilled, less technical, and less financially and professionally rewarding when compared to other roles in nursing and health care. Students learned geriatric or "long-term care" nursing meant limited lecture content and sparse clinical experience, with maybe a short rotation in a nursing home. Often the main objective was to learn how to administer physical care to frail, elderly residents. After this limited exposure, if a student did aspire to care for older adults, he often thought his only option was to apply for employment at a nursing home, sacrificing the opportunity to learn more technical skills and a higher paycheck in an acute care hospital. Times have changed and caring for older patients is now the mainstay of nursing practice in many different types of settings, including most areas of acute hospital care, long-term nursing home care, assisted living facilities, outpatient or ambulatory care, and home health and hospice care.
In 1999, however, fewer than one third of baccalaureate nursing programs had a stand-alone course in geriatrics, and of these, only 61% were required courses. If a stand-alone course was not available, many programs indicated that they integrated content throughout the curriculum, but the degree of integration was found to be quite limited. There has been a great deal of research generated in nursing and other health care professions during the last decade, which has generated new "evidenced-based" practice recommendations for ways of caring for older adults across all health care settings. There are new things to teach nursing students now about better ways to practice. This new research has encouraged curricular revisions in nursing programs across the country. National accrediting bodies, especially the American Association of Colleges of Nursing, have come out with recommendations and standards for schools of nursing to use as a guide. Baccalaureate nursing education has made a serious commitment to assuring a nurse workforce is prepared to care for older adults./11/
In 2000, a document was put forth by the American Association of Colleges of Nursing (AACN) and the John A. Hartford Foundation Institute for Geriatric Nursing at New York University titled Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care. After I heard about this publication, I was inspired. I called NYU and they graciously mailed a huge binder to Butte in 2001, my first year of teaching at Montana Tech. This landmark work, along with the Institute's blueprint for Baccalaureate Curriculum Models of Excellence, has elevated the standards for nursing programs across the country. Common elements of curriculum models of excellence identified by the Institute include the availability of a freestanding course in geriatric nursing and also the integration of gerontological experiences into the overall curriculum. Creative use of multiple locations for clinical experiences and the development of community partnerships to establish clinical sites are also highly valued. The Institute recommends the use of experiential teaching techniques in both the classroom and the clinical settings. The knowledge of faculty and their commitment to geriatric nursing education are considered key elements./12/
The curriculum guide outlined thirty competencies. My vision was to enrich the nursing curriculum at Montana Tech to meet these newly published competencies by threading the more basic competencies in the Associate of Science in Nursing (ASN) program, eventually weaving the more advanced competencies into a free-standing aging class and community health nursing class within the Bachelor of Science in Nursing (BSN) program when it was launched in the Fall of 2003. In the meantime, I was very interested in developing more experiential teaching and learning opportunities as they related to aging adults within the curriculum. As a new faculty member, I was thankful for the direction the curriculum guide provided, but was challenged by teaching courses that were new to me while also trying to reach the new curriculum standards, as our entire nursing program was under development. I kept reminding myself that the timing of the dissemination of the guidelines provided our program a real opportunity.
As I considered the number of older adults in Butte-Silver Bow who have a relatively high poverty and disability rate, I drew inspiration and courage from Lillian Wald, the founder of public health nursing and a believer in its underlying premise of social justice. In New York City at the turn of the last century, she established and served as the director for the Henry Street Visiting Nurse Service for over forty years. The community center is still in operation today. Many of her patients were recent immigrants to America, lived in tenement housing, were exposed to deadly communicable diseases, and knew very little about hygiene and food safety. They had a difficult time gaining access to basic health care. Not only did she direct her nursing care to treating sickness, but she also was determined to rout out the underlying, social causes of poor health. She clearly insisted that nurses should be at the call of the people who needed them, that they should bring care to the people. She asserted that nurses should be able to independently help those in need without having to overcome barriers in the health care system, or wait for a referral or order for nursing care. If a patient needed further medical care, he would be referred to a collaborating physician at one of the free dispensaries./13/ Lillian Wald also taught nursing courses at Columbia University, and she integrated clinical experiences for students into the visiting nurse service. In her writings, she stresses that nursing should transcend the current system (or lack of a system), and that new practice innovations should always be developed in order to reach vulnerable patients. Perhaps this is the most important thing she taught her students, and it applies today, in a time of needed health care reform. Nursing students should be taught early on to think about new ways to bring care to their patients and to collaborate with community partners. They should not be afraid of reaching out to those in need. So where in Butte could I apply her ideas?
In the spring of 2002, I had the opportunity to develop a project with the support of a new faculty research seed grant offered through Montana Tech. As I considered options, I had the opportunity to meet the Executive Director of Butte's Belmont Senior Center, Nancy Gibson, and other members of the Area V Agency on Aging Board of Directors. At our first meeting around the Belmont's fireplace on a cold Friday in January, we were able to articulate the terms of a future partnership between the Montana Tech nursing program and the Belmont. We established that the primary goal of the partnership was to bring students and older adults together, thereby creating access to healthcare while providing valuable clinical experiences for supervised nursing students. As we talked that day, I learned a great deal about the Belmont and realized that what might start out as a blood pressure clinic could eventually evolve into a rich experiential learning environment for nursing students. The Belmont Senior Center is the hub for at-risk senior services for both the center's visitors and the entire community. Besides providing Meals on Wheels and congregate dining, the center also sponsors a commodities food subsidy program, a home chore program which helps with light housekeeping, and transportation services. The center also collaborates with many agencies, including Butte's Community Health Center, the Montana Department of Senior and Long Term Care, Butte's Public Housing Authority, St. James Healthcare, and the adult protection team. The Belmont is a major information and referral base for many older adults with emergent needs. The goal of the Center is to keep older adults as active and independent as possible in the community. I was thrilled to have the opportunity to work with the Belmont and other team players on this project.
The weekly Montana Tech nursing clinic began in the Fall of 2002 with seed grant funding and matching funds from the Belmont and the Adult Protective Services Division of the Montana Department of Health and Human Services. The students and faculty gained the trust of the Belmont visitors relatively easily. The Belmont reported that in the first year, attendance increased by 20% on the days we offered the clinic. We were situated in a room where the clinic visitors could access us if and when they chose on any particular day. Students respected their autonomy and privacy and one student remarked, "This is different, we are on their turf." Another student remarked, "In the hospital often the patients are too sick to talk much, but not here!"
The students gained an appreciation for this opportunity to spend more time talking and listening to their "patients." The students, with faculty oversight, provided physical assessment of heart sounds, lung sounds, pulses, blood pressure readings, skin and wound problems, oxygen level checks, blood sugar readings, ear exams, and weight checks. The students quickly gained an appreciation for the large number of medications many older adults take, and also some of the difficulties they were having with side effects, expense, miscommunication with different health care providers, and frustration with taking so many medications.
The students were surprised to see the number of clinic visitors in their eighties or nineties who did not list a primary care physician or provider. If a finding in the nursing assessment required follow-up medical attention, we offered to make a referral to a health care provider of their choice or to call Butte's Community Health Center, and the medical social worker would make arrangements for same or next day appointments. If needed, transportation was immediately arranged on the Belmont bus. Examples of some of the clients for whom we made referrals include the following:
In all we made 23 referrals for medical care in the first year. Additional referrals were made to the Elder Care Specialist at the Belmont, who would follow-up with the clinic visitors if help was needed with medical insurance applications, energy or housing assistance, transportation, Meals on Wheels, respite for caregivers, and housekeeping. The students were able to see comprehensive, interdisciplinary teamwork. They also learned about the many community resources and the referral process. Students attended two to three clinics over a semester and were delighted to see their clinic visitors returning on a weekly basis.
Sometimes clinic visitors sought encouragement from the students for "staying on top" of their conditions. One of the identified competencies is to "facilitate older adults' active participation in all aspects of their own health care." There was a large group of people in their 90s who had no significant past medical history, were taking no medications, and sought the clinic services with the goal of "staying healthy." The students were able to appreciate how some older adults show the usual age-related changes but have very little evidence of disease processes that limit their functional abilities. The students began to appreciate concepts in health promotion as they assessed the lifestyle habits, exercise programs, socialization patterns, diets, and other key methods of primary prevention in even the oldest (and healthiest) clinic visitors. One student remarked of her clinic visitor, "She walks more in a day than I do in a week and she is 90 years old!" Another student remarked of her clinic visitor, "She has the healthiest diet.... She told me she makes home-made tomato sauce everyday and the reason she is so healthy is because she is Italian!" Many students remarked how social their clinic visitors were, with many still driving their cars and volunteering many hours a week in the community. Several clinic visitors have remarked to me how they enjoy "volunteering to help teach (or "break in") the students." Several have stated, "They need to learn how to talk to you and give you a check up," and to "ask the questions about your pills and your health and what is bothering you." Students could see that normal aging does not equal disease and dysfunction. They were able to make the distinction that aging can complicate disease presentations and functional performance when they do appear, but they are not the same.
Regarding the concept of "iatrogenesis," many clinic visitors reported they lost weight, fell, had numerous tests, could not sleep, got confused, and became a lot weaker in the hospital, and they just felt lucky to have "gotten out alive." Many visitors told the students stories of their "adventures" when they had gotten sick. One gentleman offered, "I went more places than you did on your last vacation!" He then went on to describe going to the emergency room in Butte, being transferred to a hospital in Missoula, moving to three different units in the hospital and experiencing "going out of my head," "almost falling," and then "being released, sort of" back to a nursing home in Butte. After a three-week stay, he returned to his own home and the next week he came up to the Belmont "to see the nursing students and to tell you what I have been through!" This gentleman's account provided the students with a real life example of the hazards of multiple relocations in our health care system and its effect on an older patient.
The students were required to keep a clinical journal in which they documented significant learning events, their goals, and self-evaluation of their progress for each clinical day. I studied the journals and began to realize that most students were not just listing tasks, the steps, and procedures; rather, they were describing in greater detail their communications and relationships with the clinic visitors. Examples include the following:
I loved talking to them and finding out about their past lives and history. It is very interesting to me to see the conditions people adapt to in order to live.
This is very beneficial to my geriatric education...; it made me realize they are just like the rest of the population...in need of some care and compassion.
These people range from extremely high functioning to having multi-system problems and each has wonderful things to share.
They are so thankful for all we do but I don't think they realize how much they help us learn.
I didn't think this area of nursing was for me but now I know this is what I want to do!
Within three months of holding the weekly nursing clinic, we discovered only 5% of the clinic visitors lived in public housing. The Belmont staff realized that we might be missing some of the most at-risk older residents of Butte. We met with Butte's Public Housing Authority staff and were informed that there were many older residents who rarely left their apartments and would benefit from the screening clinic. We decided to expand the Belmont Nursing Clinic into several of these apartment complexes on a rotating basis. The same model was applied, and we set up the weekly clinic in the activity rooms of the buildings and offered the clinic on a free and voluntary basis. In the first clinic we made three referrals to Butte's Community Health Center. One older gentleman, who had suffered a previous stroke and was in a wheelchair, was in immediate need of attention for a large, draining, open wound on a leg that showed very poor circulation. He stated he was afraid to seek any care at all because he "might need an amputation." With encouragement he did see a doctor for the first time in five years. He did not need an amputation, but was given a very large dose of antibiotics. He came to the next clinic, to show his nicely healing wound and to every clinic thereafter. He graciously shares his story with new nursing students.
Between the fall of 2002 and the fall of 2006, the total number of unduplicated clinic visitors has totaled nearly 400, with an average attendance at the clinics approaching 30-40 at the Belmont and the outreach public housing sites. Referrals for follow-up medical care and for social services continue to increase. The total number of students who have taken part is over 300 on a rotating basis. The students have been invited to take part in other health-related activities at the Belmont. Butte's Community Health Center has conducted several memory and depression screenings, and flu shot clinics, the past several years. The students have always been faculty supervised but in these instances, they would pair with other nurses working in the community to learn additional clinical skills.
After the clinic model was well integrated into both the Belmont and the public housing units, additional clinical experiences were expanded to meet the experiential learning needs of the BSN students. These students are all registered nurses completing the requirements for the Bachelor of Science in Nursing degree. One of the competencies is to "assess older adults' living environment with special awareness of the functional, physical, cognitive, psychological, and social changes common in old age." Another more advanced competency asks that students "incorporate into daily practice valid and reliable tools to assess the functional, physical, cognitive, psychological, social, and spiritual status of older adults."/14/ It was determined that several of these competencies would best be achieved in the home setting. The proliferation of research-based screening and assessment tools for older adults has refined the process of a comprehensive geriatric assessment. The students were provided with specific assignment guidelines and a procedure for conducting the visits. Part of the assessment included an evaluation of home safety. Because students were sent in pairs to individual residences with a supervising faculty available by phone, they would have the opportunity to develop greater skill in these private settings.
The Belmont and the Public Housing Authority staff were very helpful and effective in launching this new idea. Nancy Gibson, from the Belmont, suggested that in order to reach more frail and homebound seniors, a letter from the Montana Tech nursing program could be placed on each of the 200-plus "Meals on Wheels" trays which were delivered from the Belmont every day. She explained to the meal delivery and administrative support staff that if someone was interested in having a Montana Tech nursing student visit, she should contact the Belmont. Since its inception, this program has maintained a census of approximately 20 older adults who live in a variety of home environments.
Each student visited his assigned client at home several times over the semester. The students physically checked in at the Belmont and then called to either the Belmont or the instructor when they had completed their visit. This component of the program has illuminated the complex needs of homebound older adults that often go undetected in the health care system. As in the clinic model, the home visit program has produced referrals for follow-up medical care and social services. In one example, students found their assigned patient unable to bathe in her apartment and unsteady when negotiating the rim of a large claw-foot tub. A referral was made to the Belmont's Elder Care Specialist, who followed up with the gentleman's physician, a physical therapist from a home care agency, and a local medical equipment company to provide a bath bench. This allowed the return of the patient's functional ability for self-care and hygiene. Other referrals have been made to set up Life-Lines (a home safety device worn around the neck in case of a fall), housekeeping and home chore assistance, and for "Phone a Friend," a program where the older adult can be called daily for welfare checks and medication reminders. The nursing process--defined as assessment, planning, intervention, and evaluation--is emphasized with this assignment. Over the semester the students have an opportunity to follow-up and evaluate the nursing interventions that they have implemented.
Another BSN level competency is to "involve, educate, and when appropriate, supervise family, friends, and assistive personnel in implementing best practices for older adults."/15/ Again, the Belmont staff had a wonderful suggestion on how to provide this experiential activity. They have a very active Caregiver Support Group that meets bi-monthly at the Belmont. Approximately 20 caregivers attend, many in their 70s and 80s, who are heavily involved in caring for a loved one with Alzheimer's disease or other protracted and debilitating diseases. The group's facilitator, Cynthia Evans, from Butte's Community Health Center, invited the students to present ten-minute teaching sessions at the beginning of their meetings with the theme, "Caring for the Caregiver." In my experience in teaching, health promotion concepts seem simple, but in order to deliver an effective message the presentation needs to be well planned and specifically targeted to the audience. This assignment encourages skill development in patient teaching. The students have chosen topics ranging from relaxation techniques to ways to get better sleep, nutrition, and exercise. The students also learn a great deal by engaging with this special group of family caregivers during the support group meeting that follows the presentations. The students commented how they were daunted by the overwhelming demands and responsibilities these caregivers face on a daily basis. One student remarked, "So often they (the caregivers) are forgotten in the system..., so many are exhausted, they have no relief, and I don't know how they do it." One caregiver shared how he cared for his wife with Alzheimer's disease for twelve years. He expressed his frustration at trying to find some respite for several hours a week, but being unable to arrange for caregivers he could trust enough to leave with his wife. Exposing students to caregivers early in their education imprints on them the importance of considering the patient's family as a part of the care they provide. This will increasingly be an important part of care as nurses begin to encounter the explosion of people who are diagnosed with Alzheimer's disease and dementia in the next several decades.
Another BSN level assignment was inspired by a book titled Geriatric Nursing Protocols for Best Practice./16/ For this assignment BSN students return to the local acute care hospital after they have taken part in the community-based experiences. This publication outlines several research-based nursing practice standards in acute care, including fall prevention, medication safety, urinary incontinence, delirium, and skin care. The students are given specific guidelines and have been well received by the hospital's quality improvement nurse coordinators. Each student selects a practice standard for the semester and spends clinical hours at the hospital reviewing charts and evaluating the actual care provided to older patients. Often the results of their research show the care could improve when measured against the national "best practice" standards. At the end of the semester, the students present their findings to their classmates and also to the hospital nurses who have been supportive and collaborative in their work with the students, as they are continually seeking to improve the quality of nursing care at the hospital. This assignment further emphasizes the need for the nurse to develop clinical vigilance to protect his hospitalized patients from poor outcomes starting immediately upon admission to the hospital. The students have had the opportunity to meet clinic visitors and home-visit patients who have experienced various iatrogenic events after they have been to the hospital. Community-based experiences which allow students to build relationships and learn the stories of individual clients has enhanced the students' critical thinking abilities and their clinical expertise so that they can advocate for each of their older clients as they maneuver through our complex health care system.
Let me return to the question: how do I help students learn and lead in a society which undoubtedly will look quite different in the next 25 years? Competencies, curriculum, policies, programs, and best practices all change and evolve. These may be important to faculty, but students need not dwell on them excessively. What matters is to show students the importance of their work, the way student-led projects can and should evolve over time, and the blessings of community partnerships such as the Belmont, Butte's Community Health Center, St. James Healthcare, and Butte's Public Housing Authority, and all of the involved staff members who have been the key to these projects. The students and I are grateful and humbled by the real teachers: the clinic visitors at the Belmont, the home visit patients, and the Caregiver Support Group members. Nursing students should learn early on to be at the call of the people, and to continually think of new ways to transcend the system by using the best research-based information at the time, and to reach out to their patients. They should not be afraid as they lead us through the coming wave.
Notes
[The Montana Professor 18.1, Fall 2007 <http://mtprof.msun.edu>]