 Samantha Heath |
 Sue Hudson |
 Pam Foster |
 Shobha Johnson |
 Molly Page |
 Ruth Crawford |
 Victoria Munro |
 Bernie Solomon |
 Michelle Eleno |
 Peta Taylor |
 Janice Groube |
 Christianah Adesina |
 Michele Rogalin Henderson |
 Adrianna Grogan |
 Fiona Soper |
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About the authors:
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KEYWORDSUndergraduate nursing students, older adults, aged care, education, future workforce |
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Research topic and context
AOTEAROA NEW ZEALAND’s population is ageing rapidly. Between 2021 and 2031, the number of people over 65 will increase by 36 per cent (Stats NZ, 2020). Increasing age is highly correlated with disease, but life expectancy has continued to increase with good health-care standards and improvements in medical technologies. Prospectively, people will live longer with chronic illnesses and disabilities, increasing pressure on health services. Consequently, promoting healthy ageing and improving access to health services for older adults will increase in importance (New Zealand Government, 2019).
At the frontline, nurses are well-positioned to meet the health-care needs of an ageing population who are likely to access most specialist health services. Therefore, it is essential that the future nursing workforce be adequately prepared. The polytechnic sector, which graduates three times more nursing students than the university sector and approximately 70 per cent of all pre-registration nursing students (Brownie & Broman, 2024), is responsible for ensuring readiness to meet contemporary health-care needs.
The Nursing Council of New Zealand (NCNZ, 2002) requires polytechnics to provide curriculum content which addresses nursing care across the lifespan. Since polytechnics operated individual curricula when this research was conducted, there was no common understanding of how undergraduate programmes prepared students to care for older adults, apart from the confidential curriculum reviews by the Nursing Council. When this research was conducted, sector restructuring was underway, and a national, unified pre-registration nursing curriculum was proposed. Predictions about the rapidly ageing population and the necessity for the future nursing workforce to respond to this changing demographic, made it clear there was a need for stocktaking of how well existing curricula in New Zealand polytechnics were preparing nurses to care for older adults.
To carry out this stocktaking, an initial keyword search was undertaken, limiting citations to the last 30 years. Post-registration nursing education was excluded. The literature search identified contemporary issues beyond curriculum content alone (Boscart et al, 2017; Foster et al., 2022; McCloskey et al., 2020). Additional factors, such as the clinical examples provided for students in their undergraduate programmes (Garbrah et al., 2017, 2020; Hebditch et al., 2020); the type, timing, and appropriateness of placements; and the quality of supervision and preparation of students and their supervisors were reviewed (Leonardsen et al., 2021; Splitgerber et al., 2021). Furthermore, Francis-Cracknell et al., (2022) and Hikaka & Kerse (2021) highlighted the opportunity to increase the visibility of any intersectionalities the changing demographic might emphasise within the curriculum review.
Overview of methodology
The study replicated a cross-sectional descriptive survey by Neville et al. (2008), commissioned by the Australian Government Department of Health and Ageing, to determine core components in undergraduate nursing curricula. The research questions were:
- How do polytechnics define aged-care clinical placements?
- At what stage of pre-registration programmes are aged-care clinical placements undertaken?
- Which health services are used for aged-care clinical placements?
- What educational activities and experiences are offered students by the health services?
- What preparations are made for staff and clinical teachers to support and supervise students?
- In what ways are students prepared for undertaking aged-care clinical placements?
Ethical requirements
Ethical approval for the study was granted by the Unitec Institute of Technology ethics committee (UREC 2021-1044). Access to the head of each school of nursing was negotiated with and granted by all 13 polytechnics offering nursing programmes.
Procedures for data collection
Shared characteristics between the Australian and New Zealand nursing education systems, such as degree programme length, comprehensive qualification and clinical practice hours, indicated the suitability of the Australian survey for the New Zealand stocktake (NCNZ, 2021; ANMAC, 2019). After piloting the survey, minor terminology adjustments were made to reflect the New Zealand care context. The revised version was distributed by email from the principal investigator to the schools of nursing heads for completion during May/June 2022. Submission of the digital survey implied consent.
Precis of findings
Eleven fully completed responses were received. Completed surveys reported on the bachelor of nursing (BN), bachelor of nursing (Māori), bachelor of nursing (Pacific), diploma of enrolled nursing (DEN), and return to nursing (RTN)/internationally qualified nursing (IQN) competence programmes. Data for all programmes provided a comprehensive overview of curriculum delivery and clinical placement usage.
The definition of an “aged-care” placement most frequently reflected the facility’s core business, for example, aged residential care (ARC) or clinical areas with an intentional focus on older adult health care. One school of nursing suggested that suitable placements for learning aged-care skills could be in any part of the health service providing health care for people over 65 years. This more open definition illustrated the potential for using a greater variety of clinical areas for clinical placements, reflecting more closely Nursing Council pre-registration education standards. Other schools of nursing (n = 3, 27%) used community facilities for aged care clinical placements, and one used Māori and Pacific health-care providers. Rural placements were never reported. Data showed that ARC facilities accommodated clinical placements from all 11 schools of nursing, but at some risk, as sometimes norovirus outbreaks occurred, and facilities were closed to students.
Curriculum objectives for clinical experiences also varied. Where the clinical objective was the development of “foundational skills”, year-one students were most frequently allocated. In contrast, where the complexity of nursing care was prioritised, bachelor of nursing students in years two, three or transition were allocated. Enrolled nurses experienced an aged-care placement in both programme years.
Three models of overarching curriculum organisation were observed. These were a lifespan approach, where the curriculum model transitioned from infancy to old age; a once-only deep dive into the particular health needs of older adults, with complementary clinical placement; and lastly, an integrated approach, where older people’s health needs were considered in teaching and learning material presented across the programme.
The schools of nursing agreed on what would be desirable clinical experiences within an aged-care placement. These included exposure to palliative care, dementia care, and wound management. However, achievement of these learning goals was not guaranteed because only three schools of nursing had a memorandum of understanding with the health service providing their aged-care placements. The lack of formal arrangements between polytechnics and services providing aged-care clinical placements could suggest discrepancies between intended and actual learning opportunities.
All schools of nursing reported on placement supervision, although it was evident that the credentials required to undertake this role varied. The schools of nursing most frequently reported standard (n = 7, 64%) was a minimum of two years as a registered nurse, not necessarily including experience with older adults. It was concerning to learn that in some cases health-care assistants were directly supervising bachelor of nursing students, contrary to Nursing Council requirements for this programme (NCNZ, 2002).
Some aged-care clinical placement areas received specific preparation from schools of nursing to receive students (n = 7, 64%). Preparation consisted of face-to-face meetings or in-service sessions. One school provided weekly visits to support clinical staff, and another allocated an academic staff member to the facility for the duration of the placement. All schools of nursing specifically prepared students for an aged-care placement. Academic material included theoretical perspectives, such as the biology of ageing and the types of diseases encountered later in life, and simulation lab experiences to prepare students for using clinical skills such as using hoists, communication, and washing patients.
Implications for practice and future research
The paradox of defining older-adult health needs either by age, or by showcasing those most dependent through continued use of ARC facilities, is that it reinforces ageist stereotypes. It obscures a person-centred caring intention and recognition of how power dynamics in nursing encounters affect health and health inequalities. Using a broad range of placements for “aged care” is a welcome expansion. As life expectancy increases, nursing students are more likely to meet older adults in various health specialties, as they maintain their relative health and independence for longer than previously occurred.
The dominant use of ARC facilities as placements for aged-care experience may serve to re-emphasise Pākehā models of care, given the absence of older Māori and Pacific people, as their use of these facilities is low. Given the population of Māori over 65 years will double to around 90,000 by 2029 (Hikaka & Kerse, 2021), educators must ensure that placements adequately expose nursing students to the health needs of a changing population. The updated education programme standards (NCNZ, 2021) identify the requirement for a deeper understanding of a Māori world view of health and call for the adoption of content to address Indigenous peoples’ health-care needs, which will strengthen this area of the curriculum (Doran et al., 2019).
The timing and purpose of clinical placements need reconsideration and agreement between academic and clinical partners if aged care is to be recognised as a specialist endeavour by new nurses. Using ARC placements as a proxy for learning foundational skills is unacceptable, given the complexity of care required by people who live there. Developing the most appropriate teaching and learning methods for an integrated understanding of the health-care needs of our ageing population, whose health-care needs are likely to use all available resources, would be far more pertinent in the face of New Zealand’s changing demographic. Preparing a workforce ready to deliver the most appropriate nursing care for older adults, wherever they seek health care, is a desirable learning outcome.
Conclusion
The speed at which the population is ageing and the time it takes to complete a nursing programme mean that nursing curricula need urgent modification to prepare the future nursing workforce to meet forthcoming health demands. Immediate action is required if older adults are to benefit from the expertise that nurses are ideally placed to deliver.
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