Transforming Perspective on Older Adults: Conceptualizing the “Silver Tsunami” as a Cultural Paradigm Shift

Older adults need to be seen as their own diverse group. An older adult's uniqueness comes from vast life experiences and an insidiously changing physiology that impact quality of life and health outcomes. Nurse educators in clinical and classroom settings with baccalaureate student nurses can set an example for approaching the care of older adults as a nursing specialty as is done with pediatrics, maternal/child and psychiatric nursing. Assessing, planning, and implementation of care for this special population needs to be creative and unique in order to fit the needs of the older adult. Older adults present illnesses atypically. Their physiologies often buckle under traditional health care’s ‘one size fits all’, reactive focus on care. Also the specter of ageism can cloud clinicians’ perspective and color their approach to care due to more deep seated beliefs that are reflected in American society. Simply, most elders walk into hospitals and leave on gurneys

Older adults need to be seen as their own diverse group. An older adult's uniqueness comes from vast life experiences and an insidiously changing physiology that impact quality of life and health outcomes. Nurse educators in clinical and classroom settings with baccalaureate student nurses can set an example for approaching the care of older adults as a nursing specialty as is done with pediatrics, maternal/child and psychiatric nursing. Assessing, planning, and implementation of care for this special population needs to be creative and unique in order to fit the needs of the older adult. Older adults present illnesses atypically. Their physiologies often buckle under traditional health care's 'one size fits all', reactive focus on care. Also the specter of ageism can cloud clinicians' perspective and color their approach to care due to more deep seated beliefs that are reflected in American society. Simply, most elders walk into hospitals and leave on gurneys because their complex, co-morbid conditions are misunderstood by a health care system devoted to single entity illness and a visceral fear of mortality. In order to care for this special population, health care must adopt a new think, a personalized, proactive approach. Health care needs a paradigm shift…a culture change.
Summer [1] used the [2] Pew Report's coined term "Silver Tsunami" to fittingly describe the tide of older adults rocketing toward the health care system. By 2030 it is estimated that one in every five residents in the United States will be retirement age. Older adults will outnumber children for the first time in United States history (census, 2018). Summers [1] pointed out that efforts to be ready to support the health of the growing number of older adults is underwhelming. The purpose of this paper is to describe why older adults should be considered as their own subculture. This would place the unique health needs of the older adult in its own category of population health. Population health as described by Kindig et al. [3] represents the health outcomes of a group of individuals.
Older adults experience normal changes of aging and multiple comorbid conditions that can be affected by health care, but not cured. This pushes nursing to see care for this population beyond technical skills and cures to a perspective of quality of wellness defined by each older adult. The older adult population is the perfect population to encourage development of the 'art of nursing'. The art of nursing is the intentional creative use of oneself, based upon skill and expertise, to transmit emotion and meaning to another. It is a process that is and requires interpretation, sensitivity, imagination, and active participation [4]. Wellness can only be defined by the individual. This wellness approach requires nurses to resist the impulse to treat and enter into a partnership with the older adult to determine goals and manage outcomes. The centenarian Delany sisters described that having a say in their health care improved their outcomes and quality of daily living [5]. This requires nursing education to address the older adults' health specifically, not just an extension of adulthood, to see that aging is not an illness. This shift to identify older adult subculture would help in the fight against ageism, and bring valued opportunities based on relevant criteria of health for this specific health population.
Arnold Rose [6] penned his "Subculture Theory of Aging", in which he sees older adults as a unique subculture within our society. Rose goes on to say that this subculture grew from a defensive response to society's negative attitudes and the loss of status that accompanies aging [7]. Health and well-being of older adults also need to include preservation of ability, dignity and quality of life [8].
There are numerous differences in the care of older adults than that of younger adults. Aging does have cumulative effects on health and function. Older adults are subject to multiple chronic conditions, functional declines, polypharmacy, geriatric syndromes, and an increase need for education to make appropriate decision making regarding living arrangements, insurance and financial issues as well as community resources. Nursing curricula are crowded. So nurse educators must make deliberate curriculum decisions to embed outcomes to enhance the nurses knowledge of older adults and their specific needs. In addition, complicating the national shortage of nurse educators, the profession lacks faculty trained in geriatric nursing. Campaign for Action (2016) states that less than one percent of registered nurses and three percent of advanced practice nurses are certified in gerontological nursing. Jackson [9] described the interpretive paradigm as a phenomenon through the eyes of the people that live it. Using this approach is inclusive of holistic nursing theories. Such as [10] Theory of Integral Nursing. She describes processing human experiences and perspectives to shape plans for healthy outcomes. This along with Jackson's interpretive paradigm makes room for the student to develop cultural humility to continue to build on developing cultural competency.

ISSN: 2581-3846
In [11] the AACN reported that there were only 6,741 geron-tological certified registered nurses, 3,972 gero-certified nurse practitioners and 573 gerontological clinical nurse specialists in the United States. This is a small number of nursing professionals who understand the unique care of older adults, despite a forty year effort to increase the number of certified nurses. While many baccalaureate programs state they have threaded gerontological content throughout their curriculums, and one third of nursing programs had a required course in geriatric nursing [12]. And these entry level professional nurses are the workforce expected to provide optimum nursing care to older adults.
Stand alone gerontology course for prelicensure nursing students is needed. Course participants will engage in activities that are used to immerse students in activities and learning opportunities focused on examining the experience of older adults in the present day world and in the entire spectrum of health care from wellness and health promotion to end-of-life. Through carefully designed case studies, simulations, clinical interventions, and reflective activities course participants are guided "down the rabbit hole" that is the world of older adults. Methods will be presented that challenge and force the course participants to change their perspective from treatment to prevention. They will define methods that can be used to establish themselves as agents of change and to define how each of them will work as an advocate for older adults in his/her professional practice.
From 2011 through 2017 I co-taught a stand-alone course on health care practices for the older adult with Catie Maurer Baack, MSN, CNS-BC, RN. Building on the AACN's Essentials for Baccalaureate education we successfully facilitated developing older adult health knowledge in senior level nursing students. Students learned that every older adult has a face unique to them. Experiential learning time (time spent with older adults where they live) allowed students to develop a therapeutic relationship with older adults in community settings. They learned the older adult's unique stories. This is a beginning to combating ageists' biases inherent in society. Active learning strategies were used to closely link didactic to clinical experiences. For example, completing a comprehensive geriatric assessment on an older adult without having them lay down in bed, and using technical skills. Students sharpened their observation and communication skills. Care was made in developing community partnerships so students were exposed to sites where the older adult is in the community, not just in a long term care facility. Sites such as home health, infusion clinics, wound clinics, and numerous other outpatient areas were used. Students were taught a new clinical language from the emerging science of aging such as "geriatric syndromes", "atypical presentation", iatrogenic cascade", "frail and fragile" and "comprehensive geriatric assessment". An unfolding case study using a live actor was created based on the NLN audio case study of Red Yoder.
Creative learning strategies need to be developed so novice nurses understand the culture of aging and how to care for the older adult. The Center for Disease Control [13] saw older adults as the major user of healthcare and predict by 2030, 20% of the United States population will be over 65 years of age. Case studies designed to identify how older adults maintain independence and choice as they face the challenges of again are needed. Incorporating videos, simulations, health fairs, psychosocial interviews, wellness and function-based assessments as well as resiliency should be taught in a course on older adults. There is a need to continue theory development for nursing education regarding older adults.
During the teaching of this stand-alone course student comments supported the shift of viewing the older adult as a subculture and in a positive light.
• "I can truly make a difference in an older adult's life." • "I feel like I value the client as an individual more. No one solution will work for everyone and it is important to find out what the client desires and expectations are." Page 2 of 6 ISSN: 2581-3846 • "It didn't seem like a nursing home. It felt like a community." • "I learned so much from the older adults that I can truly take with me forever. I am now open minded about the life of the older adult." • "There is always much more to an older adult than just a body. They have a past, a history full of wisdom." Almost all of us will be a member of this emerging subculture. Let's begin to evaluate older adults from a "what difference does it make" position rather than "is it true?". Designing a stand-alone prelicensure gerontology-nursing course helps to show students who older adults are, where they live and shifting the students perspective. The results bring students to see older adults as their own unique cultural paradigm.