Uncovering the art of gerontology nursing: a master's thesis aims to change the image of gerontology nursing from that of a poor relation and to offer solutions to ongoing nurse recruitment and retention problems in the area.

WHEN 31 YEAR-OLD student nurse Anne Schumacher of Wellington did her first placement in a continuing care hospital, she hated it. All she could see was the relentless hard work and apparently degrading tasks nurses and caregivers were called to do. "I don't think this area of nursing would be right for me," she told the charge nurse. Ten years on, she has become so passionate about gerontology nursing, she cannot imagine a more satisfying area in which to work.

"Those words, spoken in ignorance and naivete to the charge nurse, couldn't have been further from the truth," said Schumacher. "When I completed my comprehensive nursing diploma, I had intended getting a glamorous, well paid nursing job in New York. But there were no jobs available and I accepted a position as coordinator of home care options with the Wesley Wellington Mission. My first staff nurse position was at Wesley Ewart Hospital. This was followed by experience as a psychogeriatric community support nurse with the then Capital Coast Health and, most recently, as manager of WesleyCare Ewart Centre, a 52-bed continuing care hospital.

"I quickly gained an appreciation of the opportunities in gerontology nursing, particularly the privilege of building long-term relationships with patients. This doesn't happen in other areas of nursing. In gerontology, you use all your nursing skills and work holistically. You care for the whole person, not just one particular condition, because you know you are likely to be nursing that patient until their death."

Schumacher says she is inspired and moved by the old people she has nursed. (She uses the term "old people" advisedly, as a mark of respect for their life achievements.) Knowing they have connected in some way, that she has been able to make a difference in their lives, often through the smallest of actions, is what gives her satisfaction.

Last year, she completed her master's thesis through Victoria University, entitled "More than meets the eye: Explicating the essence of gerontology nursing". Her motivation for this subject was based primarily on a desire to change the image of gerontology nursing, thus contributing to its value and worth as a specialty nursing area. She also wanted to shed some light on its art and practice, and to offer some guidelines on how to recruit and retain nurses in this field. "Gerontology nursing is hard and challenging work, and it can be lonely in terms of professional support, especially when you are the only registered nurse on duty on a particular ward or unit. In these sorts of circumstances, it can be difficult for nurses to see the rewards. But if you are open to what is there and willing to look, the rewards are huge. That is why my thesis is entitled 'More than meets the eye'."

Schumacher is concerned at the numbers of new graduates coming into gerontology but given little preparation for the challenges involved. "Nursing shortages are always at their worst in gerontology, which is seen as the Cinderella of the nursing profession. Most new graduates are ill prepared for the responsibilities that are unique to gerontology nursing. It is hardly surprising staff turnover rates are so high. There are also those who see gerontology nursing as just a stepping stone, an easy and convenient way to re-enter the workforce. It is not taken seriously as a career option.

"As a manager I was amazed at how difficult it was to find committed, experienced gerontology nurses. They are a rare breed. While I agree working with old people is not for everyone, I do believe gerontology nursing is generally misunderstood and maligned."

Schumacher describes her thesis as a hermeneutic phenomenological study exploring the essence of gerontology nursing. The research was based on hour-long interviews with four gerontology nurses, two of whom were in education, one of whom worked in a public hospital, the fourth in a private hospital. Two began their nursing careers as enrolled nurses and one was Maori. All were passionate and committed to their work. She also included her own, ten-year-long experience, exploring her story and history to uncover the essence of gerontology practice.

"I wanted to understand what motivated these nurses in their practice, how they saw gerontology nursing and who they were as people. The four participants all had a huge respect and understanding of old age and an awareness of why they had chosen to work in this area."

Schumacher used van Manen's approach to researching lived [experience..sub.1] Painstakingly working and reworking her information, she eventually identified three central aspects of gerontology nursing. These were the centrality of temporality, the interconnectedness of human relationships and the significance of the lived body. Temporality, says Schumacher, refers to both the nurse's awareness of time and its demands, and the importance of time and history to the clients. "Nurses need to understand a client's time and the impact this has had on the person's life, attitudes and beliefs. For example, someone who has lived through the depression of the 1930s knows what it is like to have to be frugal with food and may still exhibit those kinds of behaviours. How a nurse gives her time is also a key element to practice. Most nursing is structured around time and shift constraints. This structure is not so appropriate in gerontology nursing where routines need to be broken to meet the needs of clients. The best gerontology nursing is not constrained by time."

Interconnectedness refers to the nurse/ client relationship. This is built on shared life events over months and years; a large degree of honesty, without which relationships with clients would become superficial; and emotional commitment. "In gerontology nursing, it is legitimate to have an emotional attachment to your patients, to feel a sense of family. It is not only allowed to happen, but is something committed practitioners strive to achieve because it gives meaning to their practice. Becoming a real part of the patient's world nurtures and sustains nurses in their work.

"As a nurse manager, I observed a clear distinction between those nurses who wanted to be in gerontology and those who did not. Those nurses who did not have a commitment were difficult to motivate, disinterested and often disruptive to the team environment. This was manifested in medication errors, care plans not done, and so on. Some nurses managed to improve their performance, others did not."

Being present with clients, being willing to give of oneself, and having the ability to communicate, both verbally and non-verbally, are vital parts of interconnectedness. "A skilled nurse will know her patients well and be able to interpret even the smallest of responses. This may be the flick of an eye or the way someone squeezes your hand. A nurse who is not prepared to slow down and spend the time can easily miss this non-verbal communication. A nurse also needs to know herself well in order to know someone else. The four nurses I interviewed all had a deep sense of personal knowing."

The third aspect--corporeality--concerns the importance of the body for both nurse and patient. Fundamental to this are the reasons why a nurse chooses to work in gerontology. Schumacher identifies the key attitudinal factors as a genuine liking for old people and a greater acceptance of them as valued members of society. This influences how a nurse views the older body. "Some nurses might view an old person as simply a bag of wrinkly old bones. Others see who the person really is and feel genuine respect, even awe for that person's life journey.

"Nurses caring for old people come face to face with the future. They see the normal age related changes such as wrinkles and sagging skin, as well as witnessing loss of bodily function and control of the body. A possible reason why some nurses find caring for old people difficult is their own fear of aging, of loss of bodily function, control and appearance. This issue of prematurely coping with the aging process could be dealt with in nursing education."

Other important attitudinal factors include the desire to make change, to be an advocate for patients and having a sense of social justice. Nurses also have to be able to rely on their own skills, rather than technology, and be comfortable with that.

In her final analysis, Schumacher identifies caring for the body, the act of seeing and the joy of care as emergent essences of gerontology nursing. She critiques the use of the term "basic cares" and the devaluing of essential care-giving activities that goes along with using this term, suggesting the term "primary cares" may be more appropriate. Although she does not deal with the role of caregivers in her thesis, Schumacher acknowledges that, increasingly, it is caregivers who do much of this primary care work. "Many caregivers do a very good job but it's what goes along with time care that matters, ie the developing of relationships and doing thorough assessments. The reality is there are not enough registered nurses working in gerontology. Those of us who are there need to find our place and determine what our position should be. Just being office-based and managing the medications will not bring the clients the greatest benefits. I'm not sure what the answer is but I believe nurses must discuss these professional issues outside the parameters o f economic restrictions."

The act of seeing relates directly to the title of the thesis "More than meets time eye". Although gerontology nursing is seen as the Cinderella of the profession, Schumacher believes the magic is there if nurses are willing and able to see it. Once nurses discover this magic, they will experience the joy of care and thus be helped to transcend the day-to-day demands of the job. It is the nurses' readiness and acceptance of entering into the nurse-client relationship that provides the opportunity for something magical to happen.

"The joy of care can only come about once the hard work has been done. The interpersonal relationship has to be created and nurtured, the techniques and skills mastered, and then you can take a step back and enjoy the moment for what it is, to delight in being with another person."

Schumacher urges gerontology nurses to share their insights, to make it known to the nursing profession what is so magical about gerontology nursing. She recommends more research into the art of gerontology nursing. "There is already an abundance of research into the practical details of caring for old people. What is now needed is a foundation of artistic nursing knowledge to reveal and make public the true potential of gerontology nursing."

The study also emphasises the need to explore carefully prospective employees' attitudes, not only toward old people, but also toward the actual work gerontology nurses do. "Being proficient in carrying out fundamental cares must be balanced by a desire to perform these cares in such a way that preserves the integrity of the person being nursed. Nurses also need to know more about the art of gerontology nursing. This could be encouraged through inservice training and discussed more widely in courses and seminars.

"Being more aware of the art of gerontology nursing would not only have a direct, positive outcome for patients, it would also assist in the retention of staff. I would like to see a positive focus on caring for old people right at time start of nursing education. There also needs to be greater nurturing of beginning practitioners so they learn and gain experience in a supportive and encouraging environment."

Anne Schumacher can be contacted on [e-mail].

REFERENCE

(1) Van Manen, M. (1990) Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. London, Ontario: State University of New York Press.