How Do Nursing Students Perceive the Needs of Older Clients? Addressing a Knowledge Gap

Background. Many nurse educators understand that students need to embrace the challenges and rewards of working with older clients. Yet, they might wonder how they can help students to develop and what is the specialized knowledge necessary to care for older clients. Question. How do students perceive the nursing needs of older adults? Method. A qualitative descriptive study was undertaken. Data collection occurred through semistructured interviews (9 students) and one focus group (8 students) using a photoelicitation technique. The researchers used a descriptive approach to analyze the data. Findings. Six themes emerged from the data: ask the older client!; physiology rules; personal, not professional; who can validate?; hierarchy of needs; and help us learn. Conclusion. Participants relied upon previous patterns of learning, primarily experiential, and on the views of health care colleagues in clinical practice to make decisions about the health needs of older clients. Participants clearly recognized the need to and significance of understanding the health care requirements of older clients. Findings have implications for how the care of older clients is introduced into nursing education programs.


Introduction
Over the past several decades, nurse researchers have identified that undergraduate students do not choose to work with older clients. Their lack of interest has been expressed in negative stereotyping of older clients and in not selecting option courses with a focus on older adults [1][2][3][4][5]. Their views do not change after graduation and they do not select gerontological practice as their career of choice [6,7]. Consequently, strategies have been proposed to enrich the experiences of nursing students caring for older adults, such as structuring their early clinical experiences to involve well older clients; the hope is that they will view their clients positively and be more apt to choose this specialty in the future [8].
Many nurse educators understand that nursing students need to embrace the challenges and rewards of working with older clients. Yet, they might wonder how they could help students to develop the specialized knowledge necessary to care for older clients. Within their teaching plans, how do they build on what a student might know about older adults, without knowing what this point looks like? This triggered the research team to ask several fundamental questions. How do students perceive older clients? What lens do they apply in their practice working with older clients? How does this impact their assessments and interventions with these individuals?
Within this article, the context for the importance of the study by outlining demographic and health care trends and situating the study within the nursing literature is presented. The study addressed the question. How do students perceive the nursing needs of older adults?
An impetus to examine student nurses' knowledge of the needs of older clients stems from demographic trends within Canada and from health services utilization rates. Currently, one out of seven Canadians is 65 years of age or older. The number of Canadians aged 65 and older is close to 5 million. The 2011 Census counted 4,945,060 people aged 65 and older in Canada, an increase of more than 609,810, or 14.1%, between 2006 and 2011 [9]. This rate of growth was more than double the 5.9% increase for the Canadian population as a whole. Compared with other age groups, older clients use a disproportionate amount of acute care hospital services. For example, although they make up 14% of the population, in 2009-2010, 40% of acute hospital stays were for clients of age 65 and older [10]. The escalating population of older adults coupled with the rates of health care services utilization heightens the need for registered nursing students, the gerontological nurses of the future, to develop knowledge specific to older clients. This Canadian trend is reflective of international demographic and health care changes.

Review of the Literature
There are several bodies of literature in which the research on the importance of understanding how student nurses perceive older clients and determine their health needs: nurses' knowledge of caring for older clients, student nurses' knowledge of gerontological nursing, and older clients' expectations of nurses are situated.

Nurses' Knowledge of the Health Needs of Older Clients.
Despite the aging of the population, as well as the significant proportion of older clients utilizing the health care system, the literature reveals that health care professionals, including registered nurses and nursing students, lack knowledge of how older clients differ from their younger counterparts in symptom presentation and potential complications. To illustrate this previous point, some registered nurses do not realize that older clients experience particular illnesses differently than their younger counterparts, such as myocardial infarctions, pneumonia, drug interactions, and depression [11]. Wells and associates [12] found that nurses had less accurate knowledge about aging than other health professionals. Cognitive impairment may complicate the assessment of pain, resulting in nurses feeling uncertain about their assessments and reluctant to administer pain medication [13,14] and may also impede end of life care [15]. Further, health related challenges arising from hospitalization are often not recognized and addressed by registered nurses. For instance, hospitalization often results in a functional decline in older clients, and yet many registered nurses lack knowledge in preventing and treating deconditioning [16][17][18]. Another example is that delirium, a frequent and potentially life threatening condition experienced by hospitalized older clients, is under recognized by nurses [19,20].

Student Nurses' Knowledge of Gerontological Nursing.
Most research examining student nurses' knowledge of the needs of older clients has focused on attitudes towards caring for this population group [21][22][23][24] and the lack of gerontological content in baccalaureate programs or proposed changes for gerontological content in nursing education [25][26][27]. There is substantially less research that examines how students perceive the health needs of older clients and how they decide upon their responses.  [28] research revealed the importance of older clients' satisfaction with nursing care. Older clients who were satisfied with nursing care were more likely to seek prompt treatment for future health concerns. Unfortunately, there may be discrepancies between what registered nurses and older clients perceive as the health needs of older clients [29,30] and between nursing staff and the views of family members of older clients [31].

2.4.
Situating the Study. So, how does this study address a gap in the literature? First, rather than addressing attitudes of student nurses towards older clients, this study is a beginning step towards ascertaining how they make sense, or perceive, the health needs of older clients. Second, if nurse educators understand how students perceive the health needs of older clients and make decisions about care, then the discomfort and uncertainty felt by registered nurses in understanding older clients may be resolved. That is, if educators learn how to teach gerontological content with a view to help students to confidently perceive and respond to the needs of older clients, then these students will potentially feel greater confidence in responding to the health complexities faced by some older clients (e.g., deconditioning, delirium, and dementia) when they are registered nurses. Third, if students have greater sensitivity towards how they perceive the needs of the older clients they care for, then they may, as registered nurses, demonstrate increased thoughtfulness towards how older clients perceive them and the expectations that these clients have for them. This study is a step towards understanding how students, registered nurses of the future, perceive and respond to the needs of older clients.

Ethics.
Ethical approval was obtained from the University's ethics committee. Participants were informed of what their participation entailed, the potential risks, the benefits associated with participation, and their rights to withdraw from the study. Since participants were students who might perceive their involvement as required due to their position within the academic institution, the voluntary nature of participation is strongly promoted. Confidentiality was maintained and participants' names were not identified in documentation related to the study. Confidentiality could not be maintained in the focus group and participants were advised of this fact.

Method
A qualitative descriptive study was undertaken using photographs. Descriptive studies provide "straight and largely unadorned answers" to questions of special interest to practitioners (p. 337) [32]. These studies tend to draw from naturalistic inquiry, which purports a commitment to study something in its natural state to the extent that is possible within the context of the research arena [33]. It was the view of the research team that the study question was best answered within the academic setting in which students were educated.
Visual method approaches, such as photographs and dialogue as data generation strategies, can provide insight about the human condition. Harper [34] stated that visual images elicit a kind of information, which is grounded in emotive responses unique to the respondent; in other words, photoelicitation evokes a more intimate involvement from the participant. This method has been used by researchers to examine topics of interest to registered nurses in general and gerontological nurses in particular, such as living with ALS [35], urinary incontinence [36], cultural experiences [37], dementia and driving [38], and pain in older clients [39].
For the study, seven photographs representative of Canada's older client population with respect to gender, age, race, ethnicity, and location of care were used. The photos displayed realistic images of situations which are regularly encountered in the health care setting such as a nurse transferring an older person on a hoist and an older man sitting in a wheelchair and looking forlornly out of a window. Seven were selected as it was anticipated that conversation would be generated by each one and the length of the focus groups was one hour. It was also felt that the seven photographs adequately reflected the Canadian older client population. Prior to their use with participants, the trustworthiness of the data in the photographs was reviewed by a panel of three certified gerontological nurses. They suggested no change to the number or images of the photographs.

Sample and Recruitment.
Students in three academic programs in Alberta were asked to participate in individual interviews and in a focus group. Initial contact was made through the educational program's administrative head and then to the nursing students' association in that facility. Recruitment yielded 9 participants for the interviews and 8 participants for the focus group. See the following list for description of the participants. Two of the nursing programs offer the same integrated curriculum on different sites; students do not take a separate gerontological course. Seniors' health is a curriculum thread that is woven throughout the programs, starting late in their second year. None of the second year participants had received specific seniors' health content. Students in subsequent years of the programs had theoretical knowledge. No participants had clinical or work experience in a gerontological unit, but third and fourth year students did describe their experiences on acute care hospital units and had nursed older adults. Only one of the participants who was interviewed came from the third program. While this program did offer a specific seniors' health course, the student had not taken it as yet. She also had not worked on a gerontological unit.

Demographics of Nursing Student Participants
Interviews Ages: 19-21 years of age: 2 participants 22-25 years of age: 5 participants. 26 years of age and older: 2 participants.
All participants were female (8) except for one male.

Focus Group
The students ranged in age from 19 to 25.
There was one male in the group of 8.

Time in Program
9: third and fourth year. 16: second year.

Data Collection.
Data was collected using in-depth semistructured interviews and a focus group. It was anticipated that individual interviews would generate a richness and depth to the data from an individual perspective; however, a focus group would permit sharing of ideas and perceptions among its members. The researcher utilized a photoelicitation technique to inquire about caring practices of nursing students. This technique involved using a series of photographs as a stimuli to promote depth of discussion of the knowledge base in the assessment of the health care needs of older clients. Interview questions included the following. Describe the care this older client needs. Why do you feel this person needs this care? What nursing care do you see being given or not given? What other nursing care may be needed by this older client? All questions were asked during an interview, but the sequence was sometimes changed based on the comments made by the participant. What psychosocial nursing care can be given in this situation? Interviews lasted from 45 minutes to 1 hour and were audiotaped.
A focus group was conducted with participants on one site. The objective of the focus group was to discuss the data arising from the individual interviews. This also provided the opportunity for students to learn from each other about the nursing care required by older clients in the health care system.

Data Analysis.
Analysis of the data involved two distinct phrases. In the first phrase, the data was transcribed verbatim, using different fonts so that the researcher's voice was distinguished from the participant's. The entire data set was read so that the whole picture of the studied phenomenon could be viewed. Each of the two researchers systematically read and coded the transcripts for major topics: physiology, learning needs, and hierarchy of needs. These topics were anticipated on the basic of the interview questions and emergent on the basis of reading the whole transcript and discussions by the researchers.
During initial readings, insights began to emerge and were written down as memos. Finfgeld-Connett [40] described memos as written notations about the data that are drafted as data analysis progresses. This reflection influenced later steps of the analysis because the first relevancies started to emerge. Next, the data was divided into distinctive meaning units. As the units were delineated, redundancies were removed. A consecutive code (in numbers and letters) was assigned to each meaning unit. The units were then categorized. In this process, the units were constantly compared to each other and to the emerging categories, until all the data was sorted. The code material was then reviewed independently and discrepancies resolved through a consensus process. Consistent with the premise of qualitative research, coding reached a point at which no new categories (or themes) were appearing in the data [41,42].
Phrase two involved exploring the themes generated in phrase 1 with the focus group. Data was then combined across these two stages and reviewed for similarities and differences. As in the first phrase, the code material was reviewed independently and discrepancies resolved through a consensus process.

Rigor
Rigor in qualitative research relates to the ability to determine if the conclusions drawn by the researchers are trustworthy. The trustworthiness of qualitative work is often questioned by positivists, conceivably because their concepts of validity and reliability cannot be addressed in the same way in naturalistic inquiry. Findings should reflect the reality of the experience [40,41]. In this study, this was done by using the four criteria described by Lincoln and Guba [43]. Credibility was achieved by the early start of reflexivity through the field notes and the use of the focus group for participant checking. Checking, auditing, and archiving of all steps of the analysis were a natural part of the research. Archiving was done to maintain the data for the duration of the study and to adhere to ethical guidelines regarding data storage. The analysis was systematic and organized so that provisional results of the analysis could be tracked back to the context of the data [44]. Dependability was achieved through the code-recode process; confirmability was obtained by reflexivity, and transferability was obtained by obtaining dense description of data from participants. In addition, transferability was supported by the use of triangulation of data, where the data obtained through the interviews was explored in the context of the focus group data and the memos of the researchers.

Findings
In this study, nursing students' perceptions of the health care needs of older clients were investigated. The six themes that emerged from data analysis are explicated below (Italics indicates a direct quote from a student).
Theme 1 (ask the older client!). This theme describes the process of initiating conversations with an older adult, as part of the therapeutic nursing relationship. The conversation was placed within the context of this relationship and was seen as contribution to the assessment process required of them. Assessment was emphasized as the means to identify the health problems of the older client. Participants who were younger in age or earlier in their nursing education were more likely to state that they would first ask the older client about what was happening for him or her. They used phrases such as find out what is the need, do an assessment, and use the nursing process. Then, the participants stated that they would check the client's chart or talk to members of the interprofessional team. As one said, talk to the primary nurse, while another expressed the following: we could ask our clinical instructor. Participants who came later in age into their programs and had more experiences in nursing and health care often responded that they would check the chart and look at the lab values, first.
Theme 2 (physiology rules). This theme describes the emphasis that was placed by participants upon the physiological health care needs of the older client. Physiology is about what the function of specific organs and how ineffective function can contribute to disease pathology. Participants made decisions about the health care needs of older clients based on what they did not know or wanted to know, with a notable emphasis on physiological functioning. One participant said physiology is important, and others voiced that cardioconcerns can occur with age and it helps us understand how medications might work. One participant voiced that we need to know how the body works and our instructor assumes that we know this already. One other participant added to this comment: we took anatomy and physiology last year but were not using it. They wanted to understand the health needs of older clients and respond accordingly, and they wanted to learn about physiological needs in a client physiology course, rather than in stand-alone courses specifically tailored to the older population.
Theme 3 (personal, not professional). This theme describes the fact that personal experiences influence nursing decisions. Participants, particularly those with experience working with older clients, relied on previous personal experiences rather than research or written materials to provide care for older clients. As one said the following: if it were my grandmother. Another student said the following: I remember my grandparents, while another said the following: I suppose having grandparents might help me understand. While one commented that we are taught to respect our elders. Their comments indicated that they viewed their clients through the lens of current or previous relationships.
Theme 4 (who can validate?). Validation describes confirming or verifying subjective and objective data collected are reliable and accurate. Participants needed to have their impressions of their older clients validated by health care team members. As one participant stated the following: that is what our nursing practice instructor is for, while another commented as follows: we have to ask as we are still new to practice. Participants confirmed assessment of older clients' health status with team members (e.g., recreational therapists, physicians) rather than with research evidence, as one said the following: I asked my preceptor, and another one said the following: at this stage of our education, we verify everything. We do not have enough trust in ourselves.
Theme 5 (hierarchy of needs). Maslow's [45] hierarchy of needs includes five motivational needs, often depicted as hierarchical levels within a pyramid. This five-stage model can be divided into basic (or deficiency) needs (e.g., physiological, safety, love, and esteem) and growth needs (selfactualization). The deficiency is said to motivate people when a need is unmet.
Participants exhibited sensitivity towards the importance of the culture of older clients and that they needed, as nurses, to honour that culture. While they often focused on physical needs, they demonstrated knowledge that extended across the need range of Maslow's [45] hierarchy of needs. One participant expressed that they are unique, while others commented that they have different cultural needs and they have lived longer than me.
Theme 6 (help us learn). The most important thing a nurse educator can know about students is how they learn and the way their minds work. Students want to learn how to integrate theory appropriately with practice. Successful nursing care requires complex and comprehensive knowledge. It is the responsibility of the nurse educator to facilitate this learning.
It was a serendipitous finding that participants often spoke about how to help them integrate knowledge of older clients into their educational program. They expressed the need to link physiology to the older client. Participants would like to see older client content integrated into their courses, as one expressed the following: help us make the linkages, referring to pharmacology and pathophysiology concepts. Other comments included the following: we want to do a good job and this is all part of our learning, and we look to our nursing instructors to help us learn and link theory and practice together.

Discussion of Findings
We were surprised by the degree to which participants relied upon previous patterns of learning to make decisions. They demonstrated an understanding of the holistic needs of older clients that we found refreshing. While most expressed a desire to work in high technological areas (e.g., ICU) and others wanted pediatric settings, there appeared to be no devaluation of older clients in their comments.
Several conclusions can be drawn from this study that have implications for nurse educators. Older client content needs to be thoughtfully and strategically inserted throughout a curriculum. This means that faculty teaching medical/surgical nursing, pathophysiology, or pharmacology needs to have a good grasp of how older clients differ from their younger counterparts in physiology, responses to medications, and presentation of mental illness. One way to achieve this is to have instructors who work in the clinical environment with students and also present gerontological information within pathophysiology and pharmacology lectures. Kerridge [46] described this as the link lecturer, who teaches in the classroom and the clinical environment. As such, they can support their students by bringing classroom material into the real life clinical examples in which they and their students were involved.
A number of teaching strategies may be effected to facilitate the integration of learning for students. Bergman et al. [47] suggested building opportunities for formal contact and interaction with older clients and reflections on these interactions into age-related coursework wherever possible. In community courses, or medical/surgical nursing, students could have assignments that involve interviewing older clients to develop positive relationships with them. Also, segregated gerontological nursing courses are vital. While they are often optional and attract those who are already committed to working with older clients, they can help students develop the interest and translate this into solid knowledge and skills. These courses can include advanced knowledge and skill development in working with older client families, assisting older clients with transitions, and leadership in long-term care settings. However, when seniors' health content is introduced in an integrated curriculum, this content can still provide positive attitudes [48].
Additionally, findings from this study suggest that the psychosocial/mental health needs of older clients need to be explicated in class teaching and clinical practice. In this study, beginning students demonstrated exquisite sensitivity towards the feelings and mood of older clients. This needs to be nurtured throughout their education, even as they gain greater knowledge and confidence in understanding lab values, physicians' orders, and plans of care. As some older clients experience significant depression, particularly men over the age of 85 who have high rates of suicide [49], students need to acquire knowledge and skills in how to assess and respond to older clients with mental illness [50].
An important component of addressing the mental health needs of older clients involves communication. Although most students enter nursing practice with some ability in communication skills, clinical practice with older clients poses communication challenges, such as hearing deficits, aphasia, and dementia. The ability to communicate effectively is a prerequisite for the practice of nursing, yet the acquisition of these skills can prove to be difficult. By consciously helping students to communicate effectively with older clients, nurse educators can help students to recognize and value the personhood of older clients. When students value their older clients as persons, how they conceptualize aging and respond to aging clients may become embedded within their personal and professional selves. This engaged manner of working with older clients may be maintained by these students as they become registered nurses.
Another strategy to increase students' interest in working with older clients is present career opportunities. Koskinen et al. 's [51] study with Finnish nursing students suggested that gerontological interest can be enhanced if linked to an understanding of career advancement opportunities. Bergman et al. [47] wrote that students need to be informed about the opportunities that exist to work professionally with older clients.
The findings from this study have implications for research. If gerontological content is included in courses that typically do not include it, then research needs to be conducted examining the attitudes of faculty towards this approach, as well as their concerns about competency and strategies to enhance their knowledge. Researchers also needs to examine the effectiveness of curricula that integrates gerontological content versus segregation. Additionally, how do students best learn to perceive the needs of older clients and respond knowledgeably and skillfully?
The merit of this study lies in the knowledge that it generates for nurse educators who are developing and revising curriculum. Findings suggest that integration of gerontology content with pathology and nursing interventions may stimulate students' interest and facilitate their learning. This may suggest ways of teaching in seminar and classroom settings to maximize learning for students. It also offers a strategy for clinical instructors working in acute care hospitals where many of the clients are older clients. For example, it may help them if they use pathology content as an introduction to gerontological nursing care.

6.1.
Limitations. The small sample size for interviews has an effect on the usability of the findings. However, the sample size can be considered a representative of nursing students because it was homogenous. Sampling bias was reduced by choosing different educational facilities. This study did not validate students' reports with their nursing practice instructors with observations of clinical practice. Despite these limitations, the analysis revealed positive findings about students' perceptions of working with older clients.

Conclusion
On the basis of the findings, students are not opposed to learning about older clients. They clearly recognized the significance of understanding the needs of older clients. This information will help nurse educators to structure learning activities, in both the classroom and clinical settings, to promote the integration of knowledge that students seek. It will also help educators understand the role of health care colleagues in influencing students in their decision making processes.