Nurse Education in Practice xxx (2013) 1e5
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Teaching age and discrimination: A life course perspective Elizabeth Collier*, Celeste Foster 1 University of Salford, Frederick Rd Campus, Salford M6 6PU, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 3 December 2013
Age discrimination in health and social care is a universal issue with significant potential ramifications for practice, and one which should be explicitly addressed in health and social care pre-registration education. However, developing teaching and learning strategies to effectively address this subject is complex given that implicit/indirect discrimination based upon tacit beliefs and assumptions, is problematic and difficult to tackle. This paper discusses the importance of teaching age and discrimination to student nurses in the context of the development of a novel approach to this aspect of education from a life course perspective. This discussion is based personal and professional reflections of the authors on the delivery of the teaching session over a number of years with approximately 500 student mental health nurses to date. The emerging themes of this are reported here and their implications for education and practice discussed. Exploring age and discrimination in relation to children and young people and older people in particular has enabled student nurses to explore the concept as one which requires critical reflection. This promotes awareness of usually unexamined personal attitudes in relation to age in order to enhance the potential for good experiences of health services for all people in need of them. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Older people Young people Discrimination Education
Introduction Age discrimination is a worldwide concern. Internationally there is a need for nurses and health care practitioners to act fairly and in a non discriminatory way, including in respect of age, a moral principle that is explicitly enshrined in international codes of nursing practice (World Health Organisation, 2011; International Council for Nurses, 2012). However, this is not just an ethical obligation; it is also enshrined in policy and law. Rooting out age discrimination has been a common goal of international policy (Adams and Collier, 2009) which appears to have been aimed at addressing attitudes towards older people only. The UK Equality Act (2010) makes it unlawful to discriminate against people with ‘protected characteristics’, of which age is one. This paper discusses a rationale for how an education session had been developed for teaching age discrimination as a life course issue. The term life course refers to an individual’s life trajectory across the whole life span (Shanahan and Macmillan, 2008) and how at different stages, their age may impact on both their own and other people’s attitudes and perspectives. Particular periods on the * Corresponding author. Tel.: þ44 (0)161 295 2729. E-mail addresses: [email protected] (E. Collier), [email protected] (C. Foster). 1 Tel.: þ44 (0)161 295 2780.
life course, that is younger and older age groups, are used for analysis and comparison. This comparison serves to illustrate both society-imposed arbitrary margins based on chronology, and the requirement to understand phenomenological differences in an individual’s needs and subjective experience, as their development across the life course progresses. The paper is written from the perspective of UK higher education and mental health service practices and the educational session discussed is delivered in the context of student mental health nurse’s learning. The teaching session discussed has been delivered predominantly in year 2 (level 5) of a three year BSc mental health nursing programme. It has also been tested with masters level pre-registration nursing students (adult health and mental health students) and also an international multidisciplinary group of health care workers. This paper specifically discusses the session as experienced with the BSc programme. The term age discrimination is used in this paper rather than ‘ageism’, due to the connotation of an older people focus in the latter. Discrimination associated with adult interpretations of children’s needs, or assumptions of legitimacy of power to act upon children without their agreement has been termed adultism (Bell, 1995). In mental health services in the UK, people under the age of 16 are referred to child and adolescent services. Older people have traditionally been cared for in later life services (over age 65); services separately organised and managed from those for adults of
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Please cite this article in press as: Collier, E., Foster, C., Teaching age and discrimination: A life course perspective, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.12.001
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E. Collier, C. Foster / Nurse Education in Practice xxx (2013) 1e5
working age (18e64) though these divisions are slowly disappearing. Knowledge about older people and younger people is limited as there is often an exclusion of these age groups from research (Henderson et al., 1998; Cohen et al., 2000; Brewin, 2007; Collier, 2012). However, it is indirect age discrimination driven through individual attitudes that is harder to address as understanding this is complex (DH, 2002). Direct and indirect age discrimination have been defined as follows: ‘Direct age discrimination occurs if people with comparable needs are treated differently, purely on the basis of their chronological age. Indirect age discrimination occurs if people from different age groups, with different needs, are treated in the same way, with the result that the needs of the person are not fully met’ (Centre for Policy on Ageing, 2009, p13). Positive age discrimination has been used to address some health inequalities (Kings Fund, 2003) but negative age discrimination has implications for health itself. The English National Service Framework for Children (DH/DfES, 2004) highlights that discrimination is a major risk factor for the development of mental health problems for young people, but does not recognise the potential for discrimination on the basis of age. Similarly, the UN convention on rights of the child (UN General Assembly, 1989) acknowledges the risk of experiencing discrimination due to many domains but not as a result of age or by nature of being a child, apparently ignoring this aspect of experience of children and young people. The study of children and young people may be marginal in health care education because they are perceived as passive, ‘learners, rather than creators of culture’ (Berman, 2003, p.102). The education session described in this paper was developed to address the learning needs of students in relation to such issues. It aimed to provide the opportunity for critical reflection on how attitudes and beliefs may be translated in the care of people who are older or younger. Background The education session about age discrimination across the life course was initially developed following a discussion between the authors about experiences of teaching mental health in later life (EC), and mental health in children and adolescents (CF). We agreed that although there appeared to be a commitment in the preregistration nursing curriculum to include ‘life span’ perspectives in all teaching, this largely seemed to occur through asking EC & CF as specialists in their respective subjects to deliver a day’s teaching on ‘young people’ or ‘old people’. Although we understood the need for discrete teaching of this kind, we felt there was a risk that this perpetuated an idea of older and younger people as different, and potentially reinforced a view of ‘them’ as marginal. This marginalisation is exacerbated by the similar treatment of the Child and Adolescent Mental Health workforce whose training needs have always been subsumed into wider adult-centric health agendas and then ultimately lost or denigrated (Edwards et al., 2007). Although ageism in relation to older people seemed quite transparent, attitudes and understanding in both our experience demonstrated an ageism with both age ‘groups’ and there seemed to be common experiences and challenges around the application of arbitrary age based constructs, as we saw it, to our respective client groups. In addition, we recognised in our own discussions that we had learning needs in relation the other’s age group field of practice. The opportunity to explore these is important for the education of student nurses particularly as Koh (2012) indicates that older people care is the least popular choice of work area.
Each person will have a unique position regarding age and the ageing process borne out of personal experiences, but this position may never be subject to critical reflection. Individual experiences are relative and subjective, perspectives of the life course that have been found to be absent in the teaching of age discrimination (Love and Phillips, 2007). A life course perspective has the potential to remove the focus on age distinctions (Elder and Giele, 2009), as rather than considering homogenised age groups with assumed differences, it instead considers individual and cohort variations.
Aims, participants and design The aim of the session is to provide opportunity for students to examine their attitudes to people of different ages and reflect on how these can impact on their professional work. The objectives are for students to be able to: examine awareness of beliefs about age, challenge current attitudes and beliefs, increase awareness of the influence of external factors that affect attitudes and discuss the theoretical underpinnings of age discrimination. The principles underpinning the teaching session are that whilst acknowledging there are legitimate differences in relation to how nurses might need to care for young people and older people based on developmental distinctions, there is an obligation to discover which practices are based on tacit beliefs and assumptions and which on evidence. For example, older people may be stereotypically viewed as being more depressed than younger people, contrary to empirical evidence (Netuveli et al., 2008) and there is evidence that both older and younger people are more likely to have their mental health needs negated than those individuals in the middle phases of the life course (MIND, 2005). Developing practitioner understanding of the actual observed differences in the ways in which symptoms can present in children & young people and older people, for example in clinical depression, may actively contribute to reducing exclusion and inequality in health service provision for these populations. This paper focuses on one exercise in the teaching session, the Jane vignette (Box 1) as it aims to elicit and reflect upon the meaning and potential impact of personal values and beliefs. The Jane vignette is the second of three distinct exercises which scaffolds this process of self-critique. Students are first encouraged to critique the practice of institutions and apparatus of the state (through discussion of a series of statements regarding policy, procedure & articles of law) before introduction of the vignette which turns the focus towards more personal reflections. The final exercise uses a less directly challenging and more informal format Box 1 Jane vignette
Jane is a 16/30/70 year old woman who has been in a relationship for nearly 2 years/married since aged 18. She has been feeling confused lately as she is unsure about some aspects of her sexual relationship and feels uncomfortable, plus she feels that her boyfriend/husband has always been a bully and has undermined her throughout their relationship. In addition, she thinks some of her confusion arises out of her own questions about her sexuality that she has avoided all her life. Her refusal to have sex has led to arguments with her boyfriend/husband, and she thinks that maybe they should end the relationship. Her confusion and distress is too great for her to bear. She doesn’t have many friends or family and she doesn’t know where to turn but she has come to see you for help.
Please cite this article in press as: Collier, E., Foster, C., Teaching age and discrimination: A life course perspective, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.12.001
E. Collier, C. Foster / Nurse Education in Practice xxx (2013) 1e5
for large group exploration of responses to visual images, serving as an opportunity to reiterate and consolidate key points whilst concurrently giving students a ‘cool down’ period before the session ends. There are three versions of the vignette; one where Jane is 16, one where she is 30 and one where she is 70. All other aspects of the vignette are identical (the difference in relation to marriage/ relationship is dictated by the age of the younger Jane). The students are divided into groups of 4 or 5 and the groups are encouraged to sit as far apart as possible. Each group is given the vignette to discuss. Some groups (as equally distributed as possible) have 16 year old Jane, some the 30 year old Jane and some 70 year old Jane. The students are not aware of this. The task is to discuss the key issues in the scenario and list on a piece of flip chart paper all the things that could be done that could help Jane. Once this exercise is completed, the lists are posted up on the wall for all students to compare the similarities and differences between them. As facilitators, we make a note of which list relates to which aged Jane. Collecting themes The session has been conducted approximately 25 times with around 500 students in year 2 of training. Post session debriefing between EC and CF and discussion over time drew attention to some commonly occurring themes. As such, we began a cumulative collation of the themes emerging from the sessions over time. It appeared that data saturation, in terms of emergence of new themes, was reached after around the 10th session we taught. There have been some variations however, the last of which emerged in January 2013 when Jane 30 for the first time was assessed for a UTI. We therefore remain open minded about what may emerge in the future. Findings Table 1 shows the common themes discovered for the 16, 30 and 70 year old Jane with an attempt to show how the themes compare across the Jane’s. A comparison with an earlier reference to these themes (Collier, 2007) shows no substantive change from those shown here. The stability of these themes, raised by successive intakes of students over an 8 year period, serves to further strengthen the argument that addressing the issue of how underlying personal values and assumptions about age & ageing directly impact upon care provision through nurse education is of the utmost importance. However a few variations are apparent for example, informing Jane 16 of her rights has re-emerged more recently, and Jane 70 no longer seems to receive specific suggestions for distraction such as ballroom dancing and bingo which was reflected in 2007. Similarly,
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Jane 30s mood has not been questioned recently, unlike the earlier version when her experience was questioned in regard to whether the problem arose from her common perceptions of relationships or whether it was unique to this particular relationship. Four main areas of discussion are consistently raised; abuse issues, sexuality issues, sex issues and implications for age discrimination. In addition, these discussions are consistently framed round themes of consent and capacity, power and autonomy, social exclusion and language. This means that there are many other issues that get ‘accidentally’ taught. The abuse discussion arises from noting Jane’s description of her husband/partner as a bully. Despite the identification of potential abuse however Jane 16 and 70 are commonly offered relationship counselling for this reason. Jane 30 is more usually offered a variety of alternatives such as advocacy and assertiveness training. For Jane 16, the usual perspective is one of the need to protect her. She is often encouraged to finish her relationship, or her difficulties are conceptualised from a safeguarding perspective, enabling students to feel a legitimate right to act on her behalf. Similarly, Jane 30 is usually encouraged to end her relationship, unlike Jane 70 for whom this is considered an inappropriate suggestion because of the length of time she has been married. There appears to have been an avoidance of providing advice about ending the relationship for Jane 70. The discussion that follows these observations about how we hear and respond to what people in distress tell us is useful and the development of self awareness has been evident. Included in the discussion is reference to evidence regarding adolescent experiences of health care services. Young people have been found to receive health advice about issues for which they have not asked, whilst their expressed concerns are not addressed, resulting in a decision not to return for professional help (Coker et al., 2010). Freed et al. (1998) indicates that provider behaviour and perceived communication ability is an important determinant of adolescent satisfaction with health care, which in turn is highly correlated with follow-up appointment attendance. Young people’s experience of the first professional who they approach for help is pivotal in deciding whether they access further mental health care (Mental Health Foundation, 2006). This latter point is consistent with the student discussion as shown in the table where it can be seen that Jane 16, despite being confused about her sexuality and not wanting sex is offered contraception advice. Students have the opportunity to think about the need for sensitivity in recognising what is and what is not reasonable when faced with an individual’s distressing predicament and potential abuse issues. One other issue this discussion often raises is a reflection on sex and older people. The suggestion that sex is relevant for Jane 70 has on occasion caused a great deal of laughter and this has been explored with students sharing some candid views about their feelings and perceptions. Usually it is other students who can challenge their colleagues in relation to this issue.
Table 1 Themes of what will help Jane (by age). 16 Year old
30 Year old
70 Year old
Confusion due to hormones Referral to child and adolescent mental health services Protection focused Talk about sexual orientation
Confusion understood as situational
Confusion interpreted to mean cognitive impairment Medical assessments; dementia, infection, neurology
Advocacy assertiveness training Exploration of self and sexuality
Focus on birth control and safe sex within heterosexual relationships Involve parents Too young to know what she wants Refer for counselling
Link with lesbian gay bisexual transgender support
Not responding to the suggestion of abuse Sex drive gone so not an issue/beliefs that she would know by now if she was gay Sexual feelings misinterpreted as need for friendship; social outlet. Involve husband Do not consider ending relationship Refer for counselling
Peer and family involvement/women’s support group Break/end the relationship Refer for counselling
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There has generally appeared to be a more paternalistic perception of Jane 70 that is potentially invalidating of her needs: she shouldn’t end her marriage, her husband should be involved, she misinterprets the need for friendship with sexuality, and is referred for medical assessments. This perception has been less evident for the other Jane’s who are usually encouraged to talk about their sexuality. Jane 30 has been more consistently interpreted as autonomous, and for Jane 16, the picture is more mixed, with a dichotomy between respecting her need to make autonomous decisions and the desire to protect her. The tensions illustrated in the discussion about the mixed picture for Jane 16 perhaps mirrors practice where working with this age group can create complex personal and professional dilemmas, unlike for Jane 70 where there is no sense of such dilemmas reflected in the classroom. There has been a marked tendency towards a perceived age bound interpretation of the word ‘confusion’ in the vignette for Jane 70 which assumes dementia, despite reference only to confusion about sexuality. A non-pathologising understanding of the word ‘confusion’ has always been accepted without question for the other Jane’s apart from the one recent anomaly. Jane 30 was offered a test for a urinary tract infection which might demonstrate a tendency towards the medicalization of personal lives much as we see in advertising and media (Goldacre, 2008). Jane 16 and Jane 70 have commonly been referred for specialist medical or psychiatric assessment. The facilitator’s question ‘exactly what in this scenario would suggest that Jane needs specialist psychiatric intervention?’ usually results in a realisation as to how easy it can be to jump to conclusions and see what we want/expect to see. Students often acknowledge that their advice assuages their own discomfort and they can explore their need to favour risk averse approaches. Discussion The students who have participated in this education session have often been quite candid about their beliefs and assumptions. It has been important that students are reassured that we are not trying to trick or test them, that we acknowledge our own potential prejudice, but that we can learn together and would like an honest reflection on this. There has remained some defensiveness in the classroom, and the way in which this has been facilitated has been critical to the success of the aims. In addition to intentional building of teaching and learning strategies that take the student from critique of ‘other’ to critique of ‘self’ in a step wise manner, we remind the students of our role as facilitators in challenging ideas whilst accepting our own capacity to learn from the discussions. Witnessing the dawning realisation of what has happened in their interpretation of the vignette when students see us put up their lists on the wall, and write ‘16’, ‘30’ or ‘70’ in its corner, is always fascinating. The exercise introduces and makes links with psychological theories of stereotyping, labelling, protectionism and objectification and how these contribute to ageist/adultist constructs. Being in a young or older age group has been conceptualised as low status within society as a whole and age discrimination harms psychological well-being in low status groups (Garstka and Schmit, 2004). The lack of power each group ‘holds’, leads to an inability to demand support or results in lack of sensitivity. If one is older, having membership of a low status group is permanent, whereas if one is younger it is technically a temporary state that young people will leave with chronological progression (Garstka and Scmit, 2004). However, discrimination is a significant risk factor for mental ill health in children and young people (DH/DfES, 2004). Having a mental health problem risks maintaining membership of a low status group irrespective of age (Rogers and Pilgrim, 2010) as
children and young people with mental health problems will remain in a low status group with its reach and impact extending across the life course (Collier, 2012). Facilitating such discussion based on the outcomes of the exercise gives opportunity for students to engage with arguments based on the concept of intersectionality (Crenshaw, 1989), that have value and usability beyond the issue of age discrimination. Discussion has included wider knowledge of sexuality, for example challenging the view that people would have already worked out their sexuality by the time they are 70 and that this is a legitimate issue for Jane 70 to be heard. This discussion helps students appreciate life course perspectives whereby we can discuss the year Jane would have been born, when she went to school, what the likely cultural context that would have informed her opportunities to explore her sexuality or live as a gay woman when she was young, and also why she might feel that she can do this now. Arbitrary beliefs about different age groups and the values and judgements attached to these can be challenged in a safe environment. The risks of protectionism, adultism and ageism are highlighted as approaches that operate to make subordination of younger and older people appear normal, natural and inevitable and ‘essentialise’ characteristics of older and younger people to justify their subordination (Love and Phillips, 2007). The nursing workforce in the UK is underrepresented by younger people. In 2008 there were fewer than 1 in 10 people under the age of 30 on the nursing register in England (Buchan and Seccombe, 2010). One in three was aged 50 or older and there is considerable concern over the rate of retirement of nurses over the age of 50 (Buchan and Seccombe, 2010; Nursing Times, 2010). This demographic information raises some intriguing questions about whether the age profile of the workforce has a relationship to the risks that younger and older people face of misunderstanding and indirect discrimination. Certainly the age range of the students, around 18e50 with the majority in their 20s and 30s may have some influence on the discussions. Students appear to be more sensitive to the Jane most similar to their own age so it is therefore more important that they become sensitive to their own attitudes toward ageing as well as the larger cultural influences on reading others texts and lives (Ray, 1998). Conclusion The context of this paper has been the education of mental health nursing students in England. However, its focus has been on age rather than mental health which has demonstrated the integral part our beliefs and values may have in influencing the care we may give. The opportunity to explore these and to critically debate this influence enables the recognition that some people face exclusion on multiple levels, in this case, age and having mental health problems, a position that has been termed ‘double jeopardy’ (Jenkins and Laditka, 1998). There are many opportunities in an education session such as this to explore other areas of discrimination, personal attitudes and concepts with wider implications for care experiences. Ultimately it is the quality of patient experience that should drive our commitment as nurses for critical reflection and professional development in this regard. References Adams, R., Collier, E., 2009. Services for older people with mental health conditions (Chapter 56). In: Barker, P. (Ed.), Psychiatric and Mental Health Nursing. The Craft of Caring, second ed. Edward Arnold Publishers, London, pp. 486e492. Bell, J., 1995. Understanding Adultism: a Key to Developing Positive Youth-adult Relationships. Youth Build, USA. See: http://www.freechild.org/bell.htm. Berman, H., 2003. Getting critical with children: empowering approaches with a disempowered group. Adv. Nurs. Sci. 26 (2), 102e113.
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E. Collier, C. Foster / Nurse Education in Practice xxx (2013) 1e5 Brewin, C.R., 2007. Remembering and forgetting. In: Friedman, M.J., Keane, T.M., Resick, P.A. (Eds.), Handbook of PTSD. Science and Practice. Guildford Press, London, pp. 116e134. Buchan, J., Seccombe, I., 2010. Sustaining the Long View. The UK nursing labour market review 2010. RCN, London. Centre for Policy on Ageing, 2009. Ageism and Age Discrimination in Mental Health Care in the United Kingdom. A review from the literature. DH, London. Cohen, C.I., Cohen, G.D., Blank, K., Gaitz, C., Katz, I.R., Leuchter, A., Maletta, G., Meyers, B., Sakauye, K., Shamoian, C., 2000. Schizophrenia and older adults. An overview: directions for research and policy. Am. J. Geriat. Psychiat. 8 (1), 19e28. Coker, T.R., Sareen, H.G., Chung, P.J., Kennedy, D.P., Weidmer, B.A., Schuster, M.A., 2010. Improving access to and utilization of adolescent preventive health care: the perspectives of adolescents and parents. J. Adolesc. Health 47 (2), 133e142. Collier, E., 2007. Approaches to help support and care (Chapter 5). In: Older People and Mental Health Nursing. A Handbook of Care. Blackwell Publishing Ltd, Oxford, pp. 53e66. Collier, E., 2012. A Biographical Narrative Study Exploring Mental Ill Health through the Life Course. Unpublished PhD. University of Salford. Crenshaw, K., 1989. Demarginalizing the Intersection of Race and Sex: a Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Anti Racist Politics. University of Chicago Legal Forum, p. 139. Department of Health, 2002. National Service Framework for Older People: Interim Report on Age Discrimination. See: http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019556.pdf (accessed 21.01.13.). Department of Health/Department for Education and Skills, 2004. National Service Framework for Children and Maternity Services. DH, London. Edwards, R., Vostanis, P., Williams, R., 2007. Specialist CAMHS Training: Evidence Based Development of Guidelines for Providers, Commissioners and Children and Young People Who Use Services. University of Leicester/National Workforce programme CAMH. Elder, G.H., Giele, J.Z. (Eds.), 2009. The Craft of Life Course Research. The Guildford Press, New York. Equality Act, 2010. The Stationary Office Ltd., London. Freed, L.H., Ellen, J.M., Irwin Jr., C.E., Millstein, S.G., 1998. Determinants of adolescents’ satisfaction with health care providers and intentions to keep follow-up appointments. J. Adolesc. Health 22 (6), 475e479. Garstka, T.A., Schmit, M.T., 2004. How young and older adults differ in their responses to perceived age discrimination. Psychol. Aging 19 (2), 326e335.
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Goldacre, B., 2008. The Guardian. Monday 1st September. http://www.guardian.co. uk/business/2008/sep/01/pharmaceuticals.drugs (accessed 30.01.13.). Henderson, A.S., Jorm, A.F., Korten, A.E., Jacomb, P., Christensen, H., Rodgers, B., 1998. Symptoms of depression and anxiety during adult life: evidence for a decline in prevalence with age. Psycholog. Med. 28 (6), 1321e1328. International Council for Nurses, 2012. ICN Code of Ethics for Nurses. ICN, Geneva. http://www.icn.ch/images/stories/documents/publications/free_publications/ Code%20of%20Ethics%202012%20for%20web.pdf (accessed 21.01.13.). Jenkins, C.L., Laditka, S.B., 1998. Double Jeopardy. The challenge of providing mental health services to older people. Admin. Policy Mental Health 26 (1), 65e74. Kings Fund, 2003. Age Discrimination in Health and Social Care: Briefing Note. Kings Fund, London. Koh, L.C., 2012. Student attitudes and educational support for older people. A review of the literature. Nurse Educ. Prac. 12, 16e20. Love, B.J., Phillips, K.J., 2007. Ageism and adultism curriculum Design. In: Adams, M., Bell, L.A., Griffin, P. (Eds.), Teaching for Diversity and Social Justice, second ed. Routledge Taylor and Francis Group, New York. Mental Health Foundation, 2006. Truth Hurts: Final Report of National Inquiry into Self Harm Among Young People. Mental health Foundation/Camelot Foundation, London. MIND, 2005. Public Attitudes to Mental Distress. www.mind.org.uk. Netuveli, G., Wiggins., R.D., Montgomery, S.M., Hildon, S., Blane, D., 2008. Mental health and resilience at older ages: bouncing back after adversity in the British household panel survey. J. Epidemiol. Commun. Health 62, 987e991. Nursing Times, 2010. Retirement may push South East into staff crisis. Nurs. Times 106 (35), 3, 7 September. Ray, R.E., 1998. Introduction: critical perspectives on the life story. Critical gerontology. J. Aging Stud. 12 (2), 101e106. Rogers, A., Pilgrim, D., 2010. A Sociology of Mental Health and Illness. Open University Press, Berkshire. Shanahan, M.J., Macmillan, R., 2008. In: Alexander, J.C. (Ed.), Biography and the Sociological Imagination: Context and Contingencies. W.W Norton and Co., London. UN General Assembly, 1989. Convention on the Rights of the Child. http://www. unicef.org.uk/Documents/Publication-pdfs/betterlifeleaflet2012_press.pdf (accessed 21.01.13.). WHO, 2011. Human Rights Council: the Right to Health of Older Persons. http:// www2.ohchr.org/english/bodies/hrcouncil/docs/18session/A-HRC-18-37_en. pdf (accessed 21.01.13.).
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Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Teaching age and discrimination: A life course perspective Elizabeth Collier*, Celeste Foster 1 University of Salford, Frederick Rd Campus, Salford M6 6PU, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 3 December 2013
Age discrimination in health and social care is a universal issue with significant potential ramifications for practice, and one which should be explicitly addressed in health and social care pre-registration education. However, developing teaching and learning strategies to effectively address this subject is complex given that implicit/indirect discrimination based upon tacit beliefs and assumptions, is problematic and difficult to tackle. This paper discusses the importance of teaching age and discrimination to student nurses in the context of the development of a novel approach to this aspect of education from a life course perspective. This discussion is based personal and professional reflections of the authors on the delivery of the teaching session over a number of years with approximately 500 student mental health nurses to date. The emerging themes of this are reported here and their implications for education and practice discussed. Exploring age and discrimination in relation to children and young people and older people in particular has enabled student nurses to explore the concept as one which requires critical reflection. This promotes awareness of usually unexamined personal attitudes in relation to age in order to enhance the potential for good experiences of health services for all people in need of them. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Older people Young people Discrimination Education
Introduction Age discrimination is a worldwide concern. Internationally there is a need for nurses and health care practitioners to act fairly and in a non discriminatory way, including in respect of age, a moral principle that is explicitly enshrined in international codes of nursing practice (World Health Organisation, 2011; International Council for Nurses, 2012). However, this is not just an ethical obligation; it is also enshrined in policy and law. Rooting out age discrimination has been a common goal of international policy (Adams and Collier, 2009) which appears to have been aimed at addressing attitudes towards older people only. The UK Equality Act (2010) makes it unlawful to discriminate against people with ‘protected characteristics’, of which age is one. This paper discusses a rationale for how an education session had been developed for teaching age discrimination as a life course issue. The term life course refers to an individual’s life trajectory across the whole life span (Shanahan and Macmillan, 2008) and how at different stages, their age may impact on both their own and other people’s attitudes and perspectives. Particular periods on the * Corresponding author. Tel.: þ44 (0)161 295 2729. E-mail addresses: [email protected] (E. Collier), [email protected] (C. Foster). 1 Tel.: þ44 (0)161 295 2780.
life course, that is younger and older age groups, are used for analysis and comparison. This comparison serves to illustrate both society-imposed arbitrary margins based on chronology, and the requirement to understand phenomenological differences in an individual’s needs and subjective experience, as their development across the life course progresses. The paper is written from the perspective of UK higher education and mental health service practices and the educational session discussed is delivered in the context of student mental health nurse’s learning. The teaching session discussed has been delivered predominantly in year 2 (level 5) of a three year BSc mental health nursing programme. It has also been tested with masters level pre-registration nursing students (adult health and mental health students) and also an international multidisciplinary group of health care workers. This paper specifically discusses the session as experienced with the BSc programme. The term age discrimination is used in this paper rather than ‘ageism’, due to the connotation of an older people focus in the latter. Discrimination associated with adult interpretations of children’s needs, or assumptions of legitimacy of power to act upon children without their agreement has been termed adultism (Bell, 1995). In mental health services in the UK, people under the age of 16 are referred to child and adolescent services. Older people have traditionally been cared for in later life services (over age 65); services separately organised and managed from those for adults of
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.12.001
Please cite this article in press as: Collier, E., Foster, C., Teaching age and discrimination: A life course perspective, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.12.001
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working age (18e64) though these divisions are slowly disappearing. Knowledge about older people and younger people is limited as there is often an exclusion of these age groups from research (Henderson et al., 1998; Cohen et al., 2000; Brewin, 2007; Collier, 2012). However, it is indirect age discrimination driven through individual attitudes that is harder to address as understanding this is complex (DH, 2002). Direct and indirect age discrimination have been defined as follows: ‘Direct age discrimination occurs if people with comparable needs are treated differently, purely on the basis of their chronological age. Indirect age discrimination occurs if people from different age groups, with different needs, are treated in the same way, with the result that the needs of the person are not fully met’ (Centre for Policy on Ageing, 2009, p13). Positive age discrimination has been used to address some health inequalities (Kings Fund, 2003) but negative age discrimination has implications for health itself. The English National Service Framework for Children (DH/DfES, 2004) highlights that discrimination is a major risk factor for the development of mental health problems for young people, but does not recognise the potential for discrimination on the basis of age. Similarly, the UN convention on rights of the child (UN General Assembly, 1989) acknowledges the risk of experiencing discrimination due to many domains but not as a result of age or by nature of being a child, apparently ignoring this aspect of experience of children and young people. The study of children and young people may be marginal in health care education because they are perceived as passive, ‘learners, rather than creators of culture’ (Berman, 2003, p.102). The education session described in this paper was developed to address the learning needs of students in relation to such issues. It aimed to provide the opportunity for critical reflection on how attitudes and beliefs may be translated in the care of people who are older or younger. Background The education session about age discrimination across the life course was initially developed following a discussion between the authors about experiences of teaching mental health in later life (EC), and mental health in children and adolescents (CF). We agreed that although there appeared to be a commitment in the preregistration nursing curriculum to include ‘life span’ perspectives in all teaching, this largely seemed to occur through asking EC & CF as specialists in their respective subjects to deliver a day’s teaching on ‘young people’ or ‘old people’. Although we understood the need for discrete teaching of this kind, we felt there was a risk that this perpetuated an idea of older and younger people as different, and potentially reinforced a view of ‘them’ as marginal. This marginalisation is exacerbated by the similar treatment of the Child and Adolescent Mental Health workforce whose training needs have always been subsumed into wider adult-centric health agendas and then ultimately lost or denigrated (Edwards et al., 2007). Although ageism in relation to older people seemed quite transparent, attitudes and understanding in both our experience demonstrated an ageism with both age ‘groups’ and there seemed to be common experiences and challenges around the application of arbitrary age based constructs, as we saw it, to our respective client groups. In addition, we recognised in our own discussions that we had learning needs in relation the other’s age group field of practice. The opportunity to explore these is important for the education of student nurses particularly as Koh (2012) indicates that older people care is the least popular choice of work area.
Each person will have a unique position regarding age and the ageing process borne out of personal experiences, but this position may never be subject to critical reflection. Individual experiences are relative and subjective, perspectives of the life course that have been found to be absent in the teaching of age discrimination (Love and Phillips, 2007). A life course perspective has the potential to remove the focus on age distinctions (Elder and Giele, 2009), as rather than considering homogenised age groups with assumed differences, it instead considers individual and cohort variations.
Aims, participants and design The aim of the session is to provide opportunity for students to examine their attitudes to people of different ages and reflect on how these can impact on their professional work. The objectives are for students to be able to: examine awareness of beliefs about age, challenge current attitudes and beliefs, increase awareness of the influence of external factors that affect attitudes and discuss the theoretical underpinnings of age discrimination. The principles underpinning the teaching session are that whilst acknowledging there are legitimate differences in relation to how nurses might need to care for young people and older people based on developmental distinctions, there is an obligation to discover which practices are based on tacit beliefs and assumptions and which on evidence. For example, older people may be stereotypically viewed as being more depressed than younger people, contrary to empirical evidence (Netuveli et al., 2008) and there is evidence that both older and younger people are more likely to have their mental health needs negated than those individuals in the middle phases of the life course (MIND, 2005). Developing practitioner understanding of the actual observed differences in the ways in which symptoms can present in children & young people and older people, for example in clinical depression, may actively contribute to reducing exclusion and inequality in health service provision for these populations. This paper focuses on one exercise in the teaching session, the Jane vignette (Box 1) as it aims to elicit and reflect upon the meaning and potential impact of personal values and beliefs. The Jane vignette is the second of three distinct exercises which scaffolds this process of self-critique. Students are first encouraged to critique the practice of institutions and apparatus of the state (through discussion of a series of statements regarding policy, procedure & articles of law) before introduction of the vignette which turns the focus towards more personal reflections. The final exercise uses a less directly challenging and more informal format Box 1 Jane vignette
Jane is a 16/30/70 year old woman who has been in a relationship for nearly 2 years/married since aged 18. She has been feeling confused lately as she is unsure about some aspects of her sexual relationship and feels uncomfortable, plus she feels that her boyfriend/husband has always been a bully and has undermined her throughout their relationship. In addition, she thinks some of her confusion arises out of her own questions about her sexuality that she has avoided all her life. Her refusal to have sex has led to arguments with her boyfriend/husband, and she thinks that maybe they should end the relationship. Her confusion and distress is too great for her to bear. She doesn’t have many friends or family and she doesn’t know where to turn but she has come to see you for help.
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for large group exploration of responses to visual images, serving as an opportunity to reiterate and consolidate key points whilst concurrently giving students a ‘cool down’ period before the session ends. There are three versions of the vignette; one where Jane is 16, one where she is 30 and one where she is 70. All other aspects of the vignette are identical (the difference in relation to marriage/ relationship is dictated by the age of the younger Jane). The students are divided into groups of 4 or 5 and the groups are encouraged to sit as far apart as possible. Each group is given the vignette to discuss. Some groups (as equally distributed as possible) have 16 year old Jane, some the 30 year old Jane and some 70 year old Jane. The students are not aware of this. The task is to discuss the key issues in the scenario and list on a piece of flip chart paper all the things that could be done that could help Jane. Once this exercise is completed, the lists are posted up on the wall for all students to compare the similarities and differences between them. As facilitators, we make a note of which list relates to which aged Jane. Collecting themes The session has been conducted approximately 25 times with around 500 students in year 2 of training. Post session debriefing between EC and CF and discussion over time drew attention to some commonly occurring themes. As such, we began a cumulative collation of the themes emerging from the sessions over time. It appeared that data saturation, in terms of emergence of new themes, was reached after around the 10th session we taught. There have been some variations however, the last of which emerged in January 2013 when Jane 30 for the first time was assessed for a UTI. We therefore remain open minded about what may emerge in the future. Findings Table 1 shows the common themes discovered for the 16, 30 and 70 year old Jane with an attempt to show how the themes compare across the Jane’s. A comparison with an earlier reference to these themes (Collier, 2007) shows no substantive change from those shown here. The stability of these themes, raised by successive intakes of students over an 8 year period, serves to further strengthen the argument that addressing the issue of how underlying personal values and assumptions about age & ageing directly impact upon care provision through nurse education is of the utmost importance. However a few variations are apparent for example, informing Jane 16 of her rights has re-emerged more recently, and Jane 70 no longer seems to receive specific suggestions for distraction such as ballroom dancing and bingo which was reflected in 2007. Similarly,
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Jane 30s mood has not been questioned recently, unlike the earlier version when her experience was questioned in regard to whether the problem arose from her common perceptions of relationships or whether it was unique to this particular relationship. Four main areas of discussion are consistently raised; abuse issues, sexuality issues, sex issues and implications for age discrimination. In addition, these discussions are consistently framed round themes of consent and capacity, power and autonomy, social exclusion and language. This means that there are many other issues that get ‘accidentally’ taught. The abuse discussion arises from noting Jane’s description of her husband/partner as a bully. Despite the identification of potential abuse however Jane 16 and 70 are commonly offered relationship counselling for this reason. Jane 30 is more usually offered a variety of alternatives such as advocacy and assertiveness training. For Jane 16, the usual perspective is one of the need to protect her. She is often encouraged to finish her relationship, or her difficulties are conceptualised from a safeguarding perspective, enabling students to feel a legitimate right to act on her behalf. Similarly, Jane 30 is usually encouraged to end her relationship, unlike Jane 70 for whom this is considered an inappropriate suggestion because of the length of time she has been married. There appears to have been an avoidance of providing advice about ending the relationship for Jane 70. The discussion that follows these observations about how we hear and respond to what people in distress tell us is useful and the development of self awareness has been evident. Included in the discussion is reference to evidence regarding adolescent experiences of health care services. Young people have been found to receive health advice about issues for which they have not asked, whilst their expressed concerns are not addressed, resulting in a decision not to return for professional help (Coker et al., 2010). Freed et al. (1998) indicates that provider behaviour and perceived communication ability is an important determinant of adolescent satisfaction with health care, which in turn is highly correlated with follow-up appointment attendance. Young people’s experience of the first professional who they approach for help is pivotal in deciding whether they access further mental health care (Mental Health Foundation, 2006). This latter point is consistent with the student discussion as shown in the table where it can be seen that Jane 16, despite being confused about her sexuality and not wanting sex is offered contraception advice. Students have the opportunity to think about the need for sensitivity in recognising what is and what is not reasonable when faced with an individual’s distressing predicament and potential abuse issues. One other issue this discussion often raises is a reflection on sex and older people. The suggestion that sex is relevant for Jane 70 has on occasion caused a great deal of laughter and this has been explored with students sharing some candid views about their feelings and perceptions. Usually it is other students who can challenge their colleagues in relation to this issue.
Table 1 Themes of what will help Jane (by age). 16 Year old
30 Year old
70 Year old
Confusion due to hormones Referral to child and adolescent mental health services Protection focused Talk about sexual orientation
Confusion understood as situational
Confusion interpreted to mean cognitive impairment Medical assessments; dementia, infection, neurology
Advocacy assertiveness training Exploration of self and sexuality
Focus on birth control and safe sex within heterosexual relationships Involve parents Too young to know what she wants Refer for counselling
Link with lesbian gay bisexual transgender support
Not responding to the suggestion of abuse Sex drive gone so not an issue/beliefs that she would know by now if she was gay Sexual feelings misinterpreted as need for friendship; social outlet. Involve husband Do not consider ending relationship Refer for counselling
Peer and family involvement/women’s support group Break/end the relationship Refer for counselling
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There has generally appeared to be a more paternalistic perception of Jane 70 that is potentially invalidating of her needs: she shouldn’t end her marriage, her husband should be involved, she misinterprets the need for friendship with sexuality, and is referred for medical assessments. This perception has been less evident for the other Jane’s who are usually encouraged to talk about their sexuality. Jane 30 has been more consistently interpreted as autonomous, and for Jane 16, the picture is more mixed, with a dichotomy between respecting her need to make autonomous decisions and the desire to protect her. The tensions illustrated in the discussion about the mixed picture for Jane 16 perhaps mirrors practice where working with this age group can create complex personal and professional dilemmas, unlike for Jane 70 where there is no sense of such dilemmas reflected in the classroom. There has been a marked tendency towards a perceived age bound interpretation of the word ‘confusion’ in the vignette for Jane 70 which assumes dementia, despite reference only to confusion about sexuality. A non-pathologising understanding of the word ‘confusion’ has always been accepted without question for the other Jane’s apart from the one recent anomaly. Jane 30 was offered a test for a urinary tract infection which might demonstrate a tendency towards the medicalization of personal lives much as we see in advertising and media (Goldacre, 2008). Jane 16 and Jane 70 have commonly been referred for specialist medical or psychiatric assessment. The facilitator’s question ‘exactly what in this scenario would suggest that Jane needs specialist psychiatric intervention?’ usually results in a realisation as to how easy it can be to jump to conclusions and see what we want/expect to see. Students often acknowledge that their advice assuages their own discomfort and they can explore their need to favour risk averse approaches. Discussion The students who have participated in this education session have often been quite candid about their beliefs and assumptions. It has been important that students are reassured that we are not trying to trick or test them, that we acknowledge our own potential prejudice, but that we can learn together and would like an honest reflection on this. There has remained some defensiveness in the classroom, and the way in which this has been facilitated has been critical to the success of the aims. In addition to intentional building of teaching and learning strategies that take the student from critique of ‘other’ to critique of ‘self’ in a step wise manner, we remind the students of our role as facilitators in challenging ideas whilst accepting our own capacity to learn from the discussions. Witnessing the dawning realisation of what has happened in their interpretation of the vignette when students see us put up their lists on the wall, and write ‘16’, ‘30’ or ‘70’ in its corner, is always fascinating. The exercise introduces and makes links with psychological theories of stereotyping, labelling, protectionism and objectification and how these contribute to ageist/adultist constructs. Being in a young or older age group has been conceptualised as low status within society as a whole and age discrimination harms psychological well-being in low status groups (Garstka and Schmit, 2004). The lack of power each group ‘holds’, leads to an inability to demand support or results in lack of sensitivity. If one is older, having membership of a low status group is permanent, whereas if one is younger it is technically a temporary state that young people will leave with chronological progression (Garstka and Scmit, 2004). However, discrimination is a significant risk factor for mental ill health in children and young people (DH/DfES, 2004). Having a mental health problem risks maintaining membership of a low status group irrespective of age (Rogers and Pilgrim, 2010) as
children and young people with mental health problems will remain in a low status group with its reach and impact extending across the life course (Collier, 2012). Facilitating such discussion based on the outcomes of the exercise gives opportunity for students to engage with arguments based on the concept of intersectionality (Crenshaw, 1989), that have value and usability beyond the issue of age discrimination. Discussion has included wider knowledge of sexuality, for example challenging the view that people would have already worked out their sexuality by the time they are 70 and that this is a legitimate issue for Jane 70 to be heard. This discussion helps students appreciate life course perspectives whereby we can discuss the year Jane would have been born, when she went to school, what the likely cultural context that would have informed her opportunities to explore her sexuality or live as a gay woman when she was young, and also why she might feel that she can do this now. Arbitrary beliefs about different age groups and the values and judgements attached to these can be challenged in a safe environment. The risks of protectionism, adultism and ageism are highlighted as approaches that operate to make subordination of younger and older people appear normal, natural and inevitable and ‘essentialise’ characteristics of older and younger people to justify their subordination (Love and Phillips, 2007). The nursing workforce in the UK is underrepresented by younger people. In 2008 there were fewer than 1 in 10 people under the age of 30 on the nursing register in England (Buchan and Seccombe, 2010). One in three was aged 50 or older and there is considerable concern over the rate of retirement of nurses over the age of 50 (Buchan and Seccombe, 2010; Nursing Times, 2010). This demographic information raises some intriguing questions about whether the age profile of the workforce has a relationship to the risks that younger and older people face of misunderstanding and indirect discrimination. Certainly the age range of the students, around 18e50 with the majority in their 20s and 30s may have some influence on the discussions. Students appear to be more sensitive to the Jane most similar to their own age so it is therefore more important that they become sensitive to their own attitudes toward ageing as well as the larger cultural influences on reading others texts and lives (Ray, 1998). Conclusion The context of this paper has been the education of mental health nursing students in England. However, its focus has been on age rather than mental health which has demonstrated the integral part our beliefs and values may have in influencing the care we may give. The opportunity to explore these and to critically debate this influence enables the recognition that some people face exclusion on multiple levels, in this case, age and having mental health problems, a position that has been termed ‘double jeopardy’ (Jenkins and Laditka, 1998). There are many opportunities in an education session such as this to explore other areas of discrimination, personal attitudes and concepts with wider implications for care experiences. Ultimately it is the quality of patient experience that should drive our commitment as nurses for critical reflection and professional development in this regard. References Adams, R., Collier, E., 2009. Services for older people with mental health conditions (Chapter 56). In: Barker, P. (Ed.), Psychiatric and Mental Health Nursing. The Craft of Caring, second ed. Edward Arnold Publishers, London, pp. 486e492. Bell, J., 1995. Understanding Adultism: a Key to Developing Positive Youth-adult Relationships. Youth Build, USA. See: http://www.freechild.org/bell.htm. Berman, H., 2003. Getting critical with children: empowering approaches with a disempowered group. Adv. Nurs. Sci. 26 (2), 102e113.
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