Case histories are utilized as examples of how integrating concepts from anthropology, sociology, and the behavioral sciences such as entry, rapport, and social class Influence can enrich nursing students' learning experience in gerontology. It is stressed that this knowledge base is necessary in order for students to identify and implement meaningful interventions as practitioners.
Undergraduate Nursing Students and Their Experience in Gerontology Gwendolyn Safier, RN, PhD2
This paper discusses and illustrates how concepts from anthropology and sociology as applied to a required nursing course benefit the students' learning experience in gerontology. The nursing students and the program were in the School of Nursing, University of California, San Francisco. The students had previously completed at least 2 years of undergraduate courses from a general curriculum stressing the physical, social, biological sciences, and the humanities. The students, in addition, had completed I year of nursing courses.3 Briefly, there were approximately 124 nursing students enrolled in the required course with five faculty members teaching the Geriatrics course. The students also had, during the same school year, an intensive course in physiology, in chronic and acute illnesses, taught outside the framework of the course described here. The over-all objective of the course was to enable the students to learn about the aged, whether living within an institution or out in the community, in today's society. A means of attempting to reach this objective was by assigning one student to one elderly individual for the entire length of the course. Geriatrics is defined here as a field devoted to the aged. The conceptualization is meant to be broad and to encompass multilevel such as sociocultural, physiological, and psychological. The course 1. Paper presented at the 33rd Annual Meeting of the Society for Applied Anthropology, Boston, March 14, 1974. 2. Assistant Professor, School of Nursing, Univ. of California, San Francisco, Third & Parnassus Aves., San Francisco 94143. 3. At the time the course was given, the baccalaureate program was 5 years. The curriculum has subsequently been revised to 4 years.
April 1975
lasted three school quarters, or from September to June. In addition to being assigned to one geriatric client (age 65 years or more) whom the student was expected to see approximately at least once every 2 to 3 weeks, the course also consisted of formal lectures, required and recommended readings, and conferences with students and faculty. A t the end of the course, the student was expected to have developed the specific nursing skills relevant to her specific assigned client. The expectations were: (I) to study the cultural setting in which the individual lived. This included looking at the process by which the student enters into the client's culture and the student's own role in establishing and maintaining rapport with the individual; (2) to identify the interrelationships of the client and the community; (3) to evaluate self as part of the sociocultural interaction with the client and reassess and readjust role accordingly. The clients were chosen from many diverse agencies in the San Francisco Bay Area. The San Francisco Area population is known for its ethnic and cultural diversity. Some clients live in institutions and some live (by themselves) out in the community. There is a great deal of heterogeneity in cultural and ethnic background in both the students and in the clients. For example, there are blacks, whites, Chicanos, Japanese, Chinese, Filipinos, and many former immigrants from different countries with their diverse cultures. The emphasis of this paper will be on the students' conferences and how some theoretical concepts from anthropology and sociology were
165
tained in each case was different; that is, there was variability, but on the whole rapport in general led to a v/orking relationship. Social class is defined as a category of people within a system of social stratification who have a similar socioeconomic status. One's social class is usually determined by one's income, education, occupation, residence, and prestige. All of the aforementioned are usually positively correlated with each other. One's social class usually includes cultural values and orientations. The following case histories are presented to illustrate the three concepts.
Rapport is defined as a harmonious relationship between the student and his/her assigned client. How the rapport was achieved and main-
The nursing student, a 23-year-old white married male from a middle-class background, had a client assigned to him from the University of California Comprehensive Clinics.8 This facility is a comprehensive medical clinic which deals with as many medical problems as possible (in some cases, the patients are referred to special clinics such as the Gl, ENT, Orthopedics, or Ob-Gyn when the condition requires more intense treatment). The clinic is made up of medical interns, resident nurses, nursing students, pharmacy students, a dietician, and two social workers. In the morning hours, the medical, nursing, and pharmacy students see patients together and plan follow-up care. Different sets of physicians come in each day of the week; every doctor on the medical team comes in once a week. The patients see the same doctor on every visit except cases of emergencies when a doctor might come in while their own doctors are off duty. The frequency of patients' visits depends on the condition of the patients and' varies from daily, weekly, to monthly. Patients are encouraged to call in if they have any problems. They may be sent to the Screening Clinic, while arrangements are being made for their doctors' visits. The dietician assists the doctors in planning the patients' diets. The clinic works as a team and consults with the different health professionals with any problems. The client, Mr. K., was a 93-year-old white male who had immigrated to the United States from Russia when he was a young man. At the time of the study, he lived by himself in the same house in a middleclass neighborhood in which he had reared his family. His 3 children were all married, and he had 8 grandchildren. He had I daughter who lived near by and with whom he had close contact. Mr K. himself was the oldest of 8 and had I surviving brother, who lives in the USSR. The student contacted Mr. K. first by telephone and found that he had a very difficult time making himself understood and even more difficulty understanding what Mr. K. said. Mr. K. spoke broken English and had1 a very heavy accent. He had been diagnosed at the U. C. Clinic as having emphysema and made periodic visits to the clinic for the condition. Mr. K.'s income was minimal; he received no Social Security but only a small pension of $52 a month. He lived on the top floor of a building he owned and rented out the lower part. He had had many occupations.
4. "Client" and "resident" are used interchangeably throughout this paper; the former usually, however, refers to an individual living by self in the community and the latter refers to an individual living in an institution.
5. The clients were selected by the social workers and the chief nurse on the unit. Guidelines and criteria for selection had been agreed upon jointly with the instructor before the class began.
Instructor and second-year undergraduate nursing students at Univ. of California, San Francisco.
integrated into the analysis of the data the students brought in. The students had regularly scheduled conferences v/ith their instructor. Four to 6 students, each one having a client from a different setting, participated. Prior to the conference, the student was expected to write a 2-page summary and analysis of her/his last visit with the client.4 The student also identified short- and long-term nursing goals. The aim of the conferences was to get the students, in a general discussion, to raise problems that they might have been having, share materials, learn from the experiences of the other students, and relate readings from the anthropological-sociological literature. In particular, the students were expected and encouraged to put their concrete specific data into higher levels of abstraction and conceptualizations. There are many anthropological and sociological concepts which are quite relevant to the discussion here, but consideration will be limited to three concepts, entry, rapport, and social class. Entry is defined as the student's entry into a new, usually different, cultural setting with its values, norms, and role expectations. The student had to go through the process of making entry into the following: Old Age—"Geriatrics," the individual geriatric client, his cultural background, and the place where he lived. There also was a reciprocal entry of the client into the student's world, which will not be discussed here.
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The Gerontologist
In Russia he had been a machinist who made tools. When he came to San Francisco in 1907, he worked at various jobs. Mr. K. cooked his own meals, and for breakfast every morning he fixed a green salad with onions. For his other meals he ate mostly potatoes and eggs and sometimes his daughter brought him a pot of soup. He stated very emphatically that he did not want to see a student nurse and that h© was in "fine shape." Mr. K., however, could not walk very much because his legs got tired and' he was short of breath. The student assessed Mr. K.'s basic immediate problems as poor diet, lack of exercise, and loneliness due to his social isolation. After the student made his evaluation, he set the nursing goals and interventions of discussing Mr. K.'s present diet with him and some ways of supplementing it and of talking with him about how his energy might increase if he would eat the right things. The student thought that if he could get Mr. K. out of his apartment more, he would not be so lonely. About 2 weeks later, the student came in to see me, the instructor, discouraged because when he (the student) telephoned him (the client) to set a time for their next meeting, Mr. K. refused to see him again. "What have I done wrong?" asked the student. He stated that he was going to try telephoning again or even stopping by Mr. K.'s house and would report to the conference group what happened. At the conference group, the student related the story of his client, and the discussion which followed threw light on many factors of which the student had not been aware. For example, here was a 93-year-old man of foreign birth. He probably thought he was near death's door for a nurse to be coming to his house to see him. Also, a male nurse? Who ever heard of such a thing? (today's broader conceptualization of nursing is still not accepted' by everyone, not even sophisticated physicians). He must really be sick, for that is what nurses do—take care of the sick—take temperatures, give pills, and so on. Mr K.'s language difficulty also added to the problem. Mr. K. it seemed tried to establish some rapport with "this young man" by showing him photographs. It also may have been a way of relieving his (the client's) anxiety. The cultural differences in expectations also came out in the diet; for example, the client had greens and onions for breakfast, and the student expected him to have something like orange juice and eggs. The student in this case had a conceptualization of geriatrics and nursing which was quite broad. However, he was limited in his experience with people from different cultural backgrounds, and an immigrant from Russia was just as difficult for him to understand as a person from China. The conference ended with peer support for the student, insight into the total situation, and a decision to get another new geriatric client as soon as possible for the student.
student arrived, the new client told him he did not want any nurse. The student was really dejected, and the instructor intervened and asked the social worker to try to find a client on the other side of town for the student. This time, the student was given a 78-year-old, upper middle-class former lawyer, a widower, who lived in a comfortable apartment, was not of foreign background, in good health, and very independent. The student, at first, had a hard time getting an initial appointment because the man was so busy on committees and traveling that his calendar was full. The student stated that if this client did not work out, he wanted another one and the instructor to come with him to see what he was doing wrong. As it turned' out, the student had a fruitful learning experience with the former lawyer, who showed considerable interest in the nursing profession and males in it. He took the student with him to various Senior Citizen Centers and cooperated with the student fully. The client was in excellent physical health, had the financial resources to live moderately well and seemed to be adjusting to aging by an active involvement in community activities. At the end of the school year, the client, who had been a widower for 4 years, was seriously considering remarriage. The Jewish Home' for the Aged (JHA) is a health care facility that has a capacity of 335 beds and is located in the outer Mission District of San Francisco. At its founding in 1871, it served primarily the indigent and infirm aged. With time and changed needs, it expanded to meet the growing demand for greater nursing care for the vastly increasing numbers of elderly in the community seeking admission. The residents are served by over 200 employees, who include specialists in every area of health care, and the stress is on the rehabilitative aspects of care. There are five sections in the JHA ranging from the care for independent residents to those completely dependent. The Medical and Psychiatric Services work closely with the Nursing and Social Services through a continuous program of staff education. The staff prepares summaries of residents' problems for weekly discussion and there is a continuous feedback to all of staff to carry out the recommendations arrived at throughout these staff conferences. There is a social service staff which consists of six social workers with many years of experience in the mental health field. The nursing department consists of a director, an assistant director, registered nurses, aides, orderlies, and nursing coordinators. The efforts in nursing and social service and all of the staff is to help the residents utilize whatever strengths they have for a satisfying life in the JHA. The nursing student in the second example was a 21-year-old Japanese-American, born in the United States, but whose parents came from Japan. She came from a lower social class background; her father was a janitor and her mother a seamstress. The student was the first one in her family who was able to pursue a university education. Her definition of geriatrics was that it was "a course dealing with old people." Her cultural orientation toward "old" people is that "we take care of our old." Also the Japanese culture is known to generally value the old, and they occupy a place of dignity and respect in the Japanese society. She had a difficult time grasping the fact that some elderly people actually choose to live in a residence
The social worker at the University of California reassigned the student, who, again, went through the same procedure of telephoning, identifying himself, and making an appointment to meet his new client at his home. As it turned out, the new client lived down the street from the student's first client, and they were "good friends of long standing." In the interval of time between when the student had telephoned and when he actually turned up, the former client and the new client had talked, and when the
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for the elderly. This was the first time the student had any direct experience with the Jewish culture. She heard of it before, but did not know that Jewish could mean many different things, such as a formal religion, cultural values, and orientation. In many respects the Japanese and Jewish are similar in that they both care for the elderly and value education. The students first met with the client's assigned social worker. In this way, the case was discussed, with the object of helping the student know something about her client's background and present status. The social worker had previously explained the nature of the student nurse's role and asked the client if she would object to having a student nurse. The social worker accompanied the stud'ent nurse to the client and introduced them to one another. The student then worked out the "contract" arrangement with her client. After her visit, the student wrote a brief summary and analysis of her visit and met again with the social worker. Rapport in most instances at the JHA was relatively easy to establish and maintain. For one thing, the residents were accustomed to having students of various kinds—medical, social workers, and others. In this case, the student was Japanese and her demeanor was mild. She described her initial experience with the home as "being a warm, friendly, cheerful place, and . . . that the attitude of everyone there was a loving, caring attitude toward the elderly." Born into a family of 10 children in Hungary, Mrs. C. came to the USA in 1906, at the age of 15. She had a difficult life, full of ups and downs, and developed a tough, somewhat flamboyant exterior to deal with her problems. This exterior at times alienated people, and Mrs. C. then went into a depression that revealed how vulnerable she- really was. At JHA, which she entered in 1971 because of loneliness, Mrs. C. was an active well resident and derived great satisfaction from using her Ethel Merman-like voice in the annual Chanukah show. Otherwise she was not especially involved in life here, not particularly popular with other residents, and from time to time she became "sick," usually from overeating (she was very obese), in this way receiving the attention she craved. Given this background, it became obvious how meaningful the visits of Mrs C.'s student nurse could be and also what dangers were inherent in such a relationship. Mrs. C. was initially resistant, then pleased and accepting of Ms. T. Before long she was also extremely demanding and1 manipulative, requesting in a coercive way that Ms. T. drive her places, take her shopping, and many other things. Ms. T. needed encouragement to set firm limits with Mrs. C, but she was eventually able to say "no" to Mrs. C. and, more importantly, to appreciate the positive value of this action. In the conference group this particular student was in, there was a girl who was Jewish and able to clarify and amplify certain points pertaining to Judaism. The other four students did not know much about the Jewish culture, and one black girl said she did not know there were so many different religious groups and that the JHA certainly sounded different from the institution (a large county one) where her client was located. The San Francisco Council of Churches operates Senior Citizen Activities Centers staffed with social workers and trained volunteers. The number of Senior
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Centers in San Francisco is constantly increasing, and the churches pay the cost of equipment. The centers, which are all interdenominational and' interracial, provide recreational and social support to the senior citizens and' opportunities for personal relationships. The student in this case was an intelligent black 20-year-old woman from a lower-middle-class background. Her father left the family when she was small, and her mother supported the family by doing housework. Her client, Mrs. W., was a black woman who was a member of the Senior Citizen's group at the old First Presbyterian Church. Mrs. W. lived in one of San Francisco's most elite residences for the elderly. The residence is operated by the Presbyterians but is not limited to Presbyterians. One of the admission policies of the Home is than an applicant must be 62 years of age, or older, have sufficient financial assets to pay necessary costs, and be in a normal state of health at the time of admission. The fees are expensive by any standards and range from an "accommodation fee" of a minimum $15,000 to $58,000 with respective monthly care fees of $260 to $650 a month. Mrs. W., an unmarried woman of 65, became ill with chronic arthritis. Her sister, who could no longer care for her, with the aid of a friend, set out to find an apartment for Mrs. W. The following is the story of how Mrs. W. came to live at the Home on July 2, 1970: Mrs. W.'s sister was the president of a missionary body of the Missionary Society of San Francisco. She had a black friend who was a real estate man and found out the Home was built with the aid of government funds and that no black people lived there. He put an ad in a San Francisco paper addressed to the elderly of San Francisco telling that the Home was renting and that apartments were available. Mrs. W.'s niece sent her to the office with the paper, and an appointment for the interview was made. She stated that there were other black people there for interviews, and', out of all of them, she was glad to be chosen, as the only black. She talked about the interview in these words: They asked me how I would feel living in an all-white community. I told them that I raised white people all my life. I know how to get along with them; I have no choice. I was notified after my interview I was chosen because I was best fit for the community. Most people cannot live without a kitchen and they don't like the lack of complete privacy and a high security. I have nothing to hide. I can have my little meetings out in the parlor. I know how to talk to white people. Mrs. W. and one male black tenant were the Home's two blacks, which the student saw as tokenism. Mrs. W.'s loneliness was manifested by her desire to participate in numerous social activities outside of the Home. She did not go to the get-togethers at the home; instead, she usually was "busy" and had other engagements. Her favorite seat in the dining room was at the small table by the window where she ate her meals alone. The stud'ent stated that they had lunch together in the dining room, which has seating arrangements much like a college dormitory, but lacking in vitality and cross-group chatter. The student stated that everyone in the dining room, with the exception of one waitress, was white and that the "territory" seemed "very strange." Mrs. W. talked a lot about her relationship with whites in Texas. She said that "white and blacks" knew their places. Racial segregation was still an implicit
The Gerontologist
and accepted rule by Mrs. W. and many other elderly people. The aged, with their conservative ideas, which is a symptom of normal anxiety, have less desire for change because changes become too much of a burden. They help maintain what used to be the status quo, racial segregation. The problem of racial segregation that has resulted in social segregation at the Home will not be eased until the residential standards at the Home are altered to attract the ethnic population of San Francisco and the Home begins to serve as a model for the community. Mrs. W. has not stated this as a problem but merely as a concern. "It would be nice having other blacks living here." Certainly it would be nice and surely it is necessary. My intervention in this situation was to encourage Mrs. W. to go to her other social contacts, for she already knew its importance and she knew how to handle the problem of racial segregation best for herself. She has succeeded in her adjustments; the problem of racial segregation for Mrs. W. was not a problem for her but a way of life. The student did not seem to have any difficulty establishing and maintaining rapport with Mrs. W. However, what emerged in the conferences was that the student's entry into such a world as this practically all-white elite institution was a strong reenforcement of the student's view that the blacks were definitely discriminated against and treated "like dirt." The student, because of the difference in her age and her client's, could not accept what she considered to be the client's somewhat passive view of her living in the Home and how she was deliberately left out of social activities
Conference Calendar
Alcohol Problems Among Older Per-
sons, summer course. At Rutgers Univ., Summer School of Alcohol Studies, Rutgers, New Brunswick, NJ 08903.
April 1975
These case histories have been examples of how integrating concepts from anthropology and other social sciences such as entry, rapport, and social class influence can enrich the students' learning experience in the field of gerontology. This basic understanding is necessary for students before they can identify and implement meaningful interventions.
(Continued from p. 154)
June 2-5. Old Ago Policy: Social, Medical, and Economic Aspects, 6th international course of social gerontology. In Paris. Centre International de Gerontologie Sociale, 3 Place des Etats-Unis, 75116 Paris. June 5-7. Crime Against the Elderly National Conference. At Statler Hilton Hotel, Washington. Dr. Jack Goldsmith, College of Public Affairs, American Univ., Washington 20016. June 9-13. Workshop on Novels of Adolescence and Age. At Miami Univ., Dept. of English. The Dept., Oxford, OH 45056. June 19-21. Physical Exercise and Activity for the Aging. At Wingate Inst. for Physical Education and' Sport, Israel. Raymond Harris, Ctr. for the Study of Aging, 706 Madison Ave., Albany 12208. June 21-22. Third Conference, International Federation on Ageing. In Jerusalem. Federation Secretariat, 1909 K St., NW, Washington 20006. June 22-27. 10th International Congress of Gerontology. In Jerusalem. Congress Secretariat, POB 16271, Tel Aviv, Israel, or Dr. Carl Eisdorfer, Chairman, American Executive Committee, Univ. of Washington, Seattle 98105. June 22-July I I .
and left alone in the dining room. The other students in the group pointed out that there was, indeed, snobbery in the Home among the different social classes of the whites themselves. The entry into such a Home was thought by the white students to be foreign to them, since they considered themselves middle-class, and this place was high class. The student found it somewhat more difficult to maintain rapport with her peer group than with her client. She experienced culture conflict, in that she admitted liking some of the things about the Home, such as the physical attractiveness, the doorman, who incidentally was not black, and the panoramic Bay view from the windows. She found it very difficult to accept the idea that Mrs. W. would have nothing to do with the one and only other black resident, a man, but Mrs. W. stated that he was "much too low class for me." The students again attempted to use this as an example of how blacks among themselves may show a certain preference which could be inferred by others as snobbery.
June 23-Aug. I. Summer Institutes, Ctr. for Studies in Aging, North Texas State Univ. At Denton. Prof. Cora Martin, the Ctr., Denton 76203. June 23-Aug. I. 1975 Summer Institute on Gerontology. At Univ. of Michigan. Summer Institute, Institute of Gerontology, 543 Church St., Ann Arbor 48104. July 7-Aug. I. Summer Institutes, Univ. of Chicago Ctr. for Continuing Education. At Univ of Chicago. The Ctr., 1307 E. 60th St., Chicago 60637. July 7-18 and July 21-Aug. I. Summer Institutes, Univ. of Michigan-Wayne State Univ. Inst. of Gerontology. At Ann Arbor. The Institute, 543 Church St., Ann Arbor 48104. July 27-31. 1st North American Symposium on LongTerm Care Administration. At Prince Hotel, Toronto. Chairman, Education & Research Committee, American College of Nursing Home Administrators, 8641 Colesville Rd., Silver Spring, MD 20910. Aug. 13-15. Seminar, Biomechanics of Tissue Viability and Clinical Applications. At Univ. of Strathclyde, Glasgow. Prof. R. M. Kenedi, Bioengineering Unit, Wolfson Ctr., the University, Glasgow G4 ONW. Oct. 26-30. Aging and Research. 28th Annual Scientific Meeting of Gerontological Society (with American Geriatrics Society). At Gait House, Louisville. The Society, # 1 Dupont Circle, Washington 20036.
169
Undergraduate Nursing Students and Their Experience in Gerontology Gwendolyn Safier, RN, PhD2
This paper discusses and illustrates how concepts from anthropology and sociology as applied to a required nursing course benefit the students' learning experience in gerontology. The nursing students and the program were in the School of Nursing, University of California, San Francisco. The students had previously completed at least 2 years of undergraduate courses from a general curriculum stressing the physical, social, biological sciences, and the humanities. The students, in addition, had completed I year of nursing courses.3 Briefly, there were approximately 124 nursing students enrolled in the required course with five faculty members teaching the Geriatrics course. The students also had, during the same school year, an intensive course in physiology, in chronic and acute illnesses, taught outside the framework of the course described here. The over-all objective of the course was to enable the students to learn about the aged, whether living within an institution or out in the community, in today's society. A means of attempting to reach this objective was by assigning one student to one elderly individual for the entire length of the course. Geriatrics is defined here as a field devoted to the aged. The conceptualization is meant to be broad and to encompass multilevel such as sociocultural, physiological, and psychological. The course 1. Paper presented at the 33rd Annual Meeting of the Society for Applied Anthropology, Boston, March 14, 1974. 2. Assistant Professor, School of Nursing, Univ. of California, San Francisco, Third & Parnassus Aves., San Francisco 94143. 3. At the time the course was given, the baccalaureate program was 5 years. The curriculum has subsequently been revised to 4 years.
April 1975
lasted three school quarters, or from September to June. In addition to being assigned to one geriatric client (age 65 years or more) whom the student was expected to see approximately at least once every 2 to 3 weeks, the course also consisted of formal lectures, required and recommended readings, and conferences with students and faculty. A t the end of the course, the student was expected to have developed the specific nursing skills relevant to her specific assigned client. The expectations were: (I) to study the cultural setting in which the individual lived. This included looking at the process by which the student enters into the client's culture and the student's own role in establishing and maintaining rapport with the individual; (2) to identify the interrelationships of the client and the community; (3) to evaluate self as part of the sociocultural interaction with the client and reassess and readjust role accordingly. The clients were chosen from many diverse agencies in the San Francisco Bay Area. The San Francisco Area population is known for its ethnic and cultural diversity. Some clients live in institutions and some live (by themselves) out in the community. There is a great deal of heterogeneity in cultural and ethnic background in both the students and in the clients. For example, there are blacks, whites, Chicanos, Japanese, Chinese, Filipinos, and many former immigrants from different countries with their diverse cultures. The emphasis of this paper will be on the students' conferences and how some theoretical concepts from anthropology and sociology were
165
tained in each case was different; that is, there was variability, but on the whole rapport in general led to a v/orking relationship. Social class is defined as a category of people within a system of social stratification who have a similar socioeconomic status. One's social class is usually determined by one's income, education, occupation, residence, and prestige. All of the aforementioned are usually positively correlated with each other. One's social class usually includes cultural values and orientations. The following case histories are presented to illustrate the three concepts.
Rapport is defined as a harmonious relationship between the student and his/her assigned client. How the rapport was achieved and main-
The nursing student, a 23-year-old white married male from a middle-class background, had a client assigned to him from the University of California Comprehensive Clinics.8 This facility is a comprehensive medical clinic which deals with as many medical problems as possible (in some cases, the patients are referred to special clinics such as the Gl, ENT, Orthopedics, or Ob-Gyn when the condition requires more intense treatment). The clinic is made up of medical interns, resident nurses, nursing students, pharmacy students, a dietician, and two social workers. In the morning hours, the medical, nursing, and pharmacy students see patients together and plan follow-up care. Different sets of physicians come in each day of the week; every doctor on the medical team comes in once a week. The patients see the same doctor on every visit except cases of emergencies when a doctor might come in while their own doctors are off duty. The frequency of patients' visits depends on the condition of the patients and' varies from daily, weekly, to monthly. Patients are encouraged to call in if they have any problems. They may be sent to the Screening Clinic, while arrangements are being made for their doctors' visits. The dietician assists the doctors in planning the patients' diets. The clinic works as a team and consults with the different health professionals with any problems. The client, Mr. K., was a 93-year-old white male who had immigrated to the United States from Russia when he was a young man. At the time of the study, he lived by himself in the same house in a middleclass neighborhood in which he had reared his family. His 3 children were all married, and he had 8 grandchildren. He had I daughter who lived near by and with whom he had close contact. Mr K. himself was the oldest of 8 and had I surviving brother, who lives in the USSR. The student contacted Mr. K. first by telephone and found that he had a very difficult time making himself understood and even more difficulty understanding what Mr. K. said. Mr. K. spoke broken English and had1 a very heavy accent. He had been diagnosed at the U. C. Clinic as having emphysema and made periodic visits to the clinic for the condition. Mr. K.'s income was minimal; he received no Social Security but only a small pension of $52 a month. He lived on the top floor of a building he owned and rented out the lower part. He had had many occupations.
4. "Client" and "resident" are used interchangeably throughout this paper; the former usually, however, refers to an individual living by self in the community and the latter refers to an individual living in an institution.
5. The clients were selected by the social workers and the chief nurse on the unit. Guidelines and criteria for selection had been agreed upon jointly with the instructor before the class began.
Instructor and second-year undergraduate nursing students at Univ. of California, San Francisco.
integrated into the analysis of the data the students brought in. The students had regularly scheduled conferences v/ith their instructor. Four to 6 students, each one having a client from a different setting, participated. Prior to the conference, the student was expected to write a 2-page summary and analysis of her/his last visit with the client.4 The student also identified short- and long-term nursing goals. The aim of the conferences was to get the students, in a general discussion, to raise problems that they might have been having, share materials, learn from the experiences of the other students, and relate readings from the anthropological-sociological literature. In particular, the students were expected and encouraged to put their concrete specific data into higher levels of abstraction and conceptualizations. There are many anthropological and sociological concepts which are quite relevant to the discussion here, but consideration will be limited to three concepts, entry, rapport, and social class. Entry is defined as the student's entry into a new, usually different, cultural setting with its values, norms, and role expectations. The student had to go through the process of making entry into the following: Old Age—"Geriatrics," the individual geriatric client, his cultural background, and the place where he lived. There also was a reciprocal entry of the client into the student's world, which will not be discussed here.
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The Gerontologist
In Russia he had been a machinist who made tools. When he came to San Francisco in 1907, he worked at various jobs. Mr. K. cooked his own meals, and for breakfast every morning he fixed a green salad with onions. For his other meals he ate mostly potatoes and eggs and sometimes his daughter brought him a pot of soup. He stated very emphatically that he did not want to see a student nurse and that h© was in "fine shape." Mr. K., however, could not walk very much because his legs got tired and' he was short of breath. The student assessed Mr. K.'s basic immediate problems as poor diet, lack of exercise, and loneliness due to his social isolation. After the student made his evaluation, he set the nursing goals and interventions of discussing Mr. K.'s present diet with him and some ways of supplementing it and of talking with him about how his energy might increase if he would eat the right things. The student thought that if he could get Mr. K. out of his apartment more, he would not be so lonely. About 2 weeks later, the student came in to see me, the instructor, discouraged because when he (the student) telephoned him (the client) to set a time for their next meeting, Mr. K. refused to see him again. "What have I done wrong?" asked the student. He stated that he was going to try telephoning again or even stopping by Mr. K.'s house and would report to the conference group what happened. At the conference group, the student related the story of his client, and the discussion which followed threw light on many factors of which the student had not been aware. For example, here was a 93-year-old man of foreign birth. He probably thought he was near death's door for a nurse to be coming to his house to see him. Also, a male nurse? Who ever heard of such a thing? (today's broader conceptualization of nursing is still not accepted' by everyone, not even sophisticated physicians). He must really be sick, for that is what nurses do—take care of the sick—take temperatures, give pills, and so on. Mr K.'s language difficulty also added to the problem. Mr. K. it seemed tried to establish some rapport with "this young man" by showing him photographs. It also may have been a way of relieving his (the client's) anxiety. The cultural differences in expectations also came out in the diet; for example, the client had greens and onions for breakfast, and the student expected him to have something like orange juice and eggs. The student in this case had a conceptualization of geriatrics and nursing which was quite broad. However, he was limited in his experience with people from different cultural backgrounds, and an immigrant from Russia was just as difficult for him to understand as a person from China. The conference ended with peer support for the student, insight into the total situation, and a decision to get another new geriatric client as soon as possible for the student.
student arrived, the new client told him he did not want any nurse. The student was really dejected, and the instructor intervened and asked the social worker to try to find a client on the other side of town for the student. This time, the student was given a 78-year-old, upper middle-class former lawyer, a widower, who lived in a comfortable apartment, was not of foreign background, in good health, and very independent. The student, at first, had a hard time getting an initial appointment because the man was so busy on committees and traveling that his calendar was full. The student stated that if this client did not work out, he wanted another one and the instructor to come with him to see what he was doing wrong. As it turned' out, the student had a fruitful learning experience with the former lawyer, who showed considerable interest in the nursing profession and males in it. He took the student with him to various Senior Citizen Centers and cooperated with the student fully. The client was in excellent physical health, had the financial resources to live moderately well and seemed to be adjusting to aging by an active involvement in community activities. At the end of the school year, the client, who had been a widower for 4 years, was seriously considering remarriage. The Jewish Home' for the Aged (JHA) is a health care facility that has a capacity of 335 beds and is located in the outer Mission District of San Francisco. At its founding in 1871, it served primarily the indigent and infirm aged. With time and changed needs, it expanded to meet the growing demand for greater nursing care for the vastly increasing numbers of elderly in the community seeking admission. The residents are served by over 200 employees, who include specialists in every area of health care, and the stress is on the rehabilitative aspects of care. There are five sections in the JHA ranging from the care for independent residents to those completely dependent. The Medical and Psychiatric Services work closely with the Nursing and Social Services through a continuous program of staff education. The staff prepares summaries of residents' problems for weekly discussion and there is a continuous feedback to all of staff to carry out the recommendations arrived at throughout these staff conferences. There is a social service staff which consists of six social workers with many years of experience in the mental health field. The nursing department consists of a director, an assistant director, registered nurses, aides, orderlies, and nursing coordinators. The efforts in nursing and social service and all of the staff is to help the residents utilize whatever strengths they have for a satisfying life in the JHA. The nursing student in the second example was a 21-year-old Japanese-American, born in the United States, but whose parents came from Japan. She came from a lower social class background; her father was a janitor and her mother a seamstress. The student was the first one in her family who was able to pursue a university education. Her definition of geriatrics was that it was "a course dealing with old people." Her cultural orientation toward "old" people is that "we take care of our old." Also the Japanese culture is known to generally value the old, and they occupy a place of dignity and respect in the Japanese society. She had a difficult time grasping the fact that some elderly people actually choose to live in a residence
The social worker at the University of California reassigned the student, who, again, went through the same procedure of telephoning, identifying himself, and making an appointment to meet his new client at his home. As it turned out, the new client lived down the street from the student's first client, and they were "good friends of long standing." In the interval of time between when the student had telephoned and when he actually turned up, the former client and the new client had talked, and when the
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for the elderly. This was the first time the student had any direct experience with the Jewish culture. She heard of it before, but did not know that Jewish could mean many different things, such as a formal religion, cultural values, and orientation. In many respects the Japanese and Jewish are similar in that they both care for the elderly and value education. The students first met with the client's assigned social worker. In this way, the case was discussed, with the object of helping the student know something about her client's background and present status. The social worker had previously explained the nature of the student nurse's role and asked the client if she would object to having a student nurse. The social worker accompanied the stud'ent nurse to the client and introduced them to one another. The student then worked out the "contract" arrangement with her client. After her visit, the student wrote a brief summary and analysis of her visit and met again with the social worker. Rapport in most instances at the JHA was relatively easy to establish and maintain. For one thing, the residents were accustomed to having students of various kinds—medical, social workers, and others. In this case, the student was Japanese and her demeanor was mild. She described her initial experience with the home as "being a warm, friendly, cheerful place, and . . . that the attitude of everyone there was a loving, caring attitude toward the elderly." Born into a family of 10 children in Hungary, Mrs. C. came to the USA in 1906, at the age of 15. She had a difficult life, full of ups and downs, and developed a tough, somewhat flamboyant exterior to deal with her problems. This exterior at times alienated people, and Mrs. C. then went into a depression that revealed how vulnerable she- really was. At JHA, which she entered in 1971 because of loneliness, Mrs. C. was an active well resident and derived great satisfaction from using her Ethel Merman-like voice in the annual Chanukah show. Otherwise she was not especially involved in life here, not particularly popular with other residents, and from time to time she became "sick," usually from overeating (she was very obese), in this way receiving the attention she craved. Given this background, it became obvious how meaningful the visits of Mrs C.'s student nurse could be and also what dangers were inherent in such a relationship. Mrs. C. was initially resistant, then pleased and accepting of Ms. T. Before long she was also extremely demanding and1 manipulative, requesting in a coercive way that Ms. T. drive her places, take her shopping, and many other things. Ms. T. needed encouragement to set firm limits with Mrs. C, but she was eventually able to say "no" to Mrs. C. and, more importantly, to appreciate the positive value of this action. In the conference group this particular student was in, there was a girl who was Jewish and able to clarify and amplify certain points pertaining to Judaism. The other four students did not know much about the Jewish culture, and one black girl said she did not know there were so many different religious groups and that the JHA certainly sounded different from the institution (a large county one) where her client was located. The San Francisco Council of Churches operates Senior Citizen Activities Centers staffed with social workers and trained volunteers. The number of Senior
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Centers in San Francisco is constantly increasing, and the churches pay the cost of equipment. The centers, which are all interdenominational and' interracial, provide recreational and social support to the senior citizens and' opportunities for personal relationships. The student in this case was an intelligent black 20-year-old woman from a lower-middle-class background. Her father left the family when she was small, and her mother supported the family by doing housework. Her client, Mrs. W., was a black woman who was a member of the Senior Citizen's group at the old First Presbyterian Church. Mrs. W. lived in one of San Francisco's most elite residences for the elderly. The residence is operated by the Presbyterians but is not limited to Presbyterians. One of the admission policies of the Home is than an applicant must be 62 years of age, or older, have sufficient financial assets to pay necessary costs, and be in a normal state of health at the time of admission. The fees are expensive by any standards and range from an "accommodation fee" of a minimum $15,000 to $58,000 with respective monthly care fees of $260 to $650 a month. Mrs. W., an unmarried woman of 65, became ill with chronic arthritis. Her sister, who could no longer care for her, with the aid of a friend, set out to find an apartment for Mrs. W. The following is the story of how Mrs. W. came to live at the Home on July 2, 1970: Mrs. W.'s sister was the president of a missionary body of the Missionary Society of San Francisco. She had a black friend who was a real estate man and found out the Home was built with the aid of government funds and that no black people lived there. He put an ad in a San Francisco paper addressed to the elderly of San Francisco telling that the Home was renting and that apartments were available. Mrs. W.'s niece sent her to the office with the paper, and an appointment for the interview was made. She stated that there were other black people there for interviews, and', out of all of them, she was glad to be chosen, as the only black. She talked about the interview in these words: They asked me how I would feel living in an all-white community. I told them that I raised white people all my life. I know how to get along with them; I have no choice. I was notified after my interview I was chosen because I was best fit for the community. Most people cannot live without a kitchen and they don't like the lack of complete privacy and a high security. I have nothing to hide. I can have my little meetings out in the parlor. I know how to talk to white people. Mrs. W. and one male black tenant were the Home's two blacks, which the student saw as tokenism. Mrs. W.'s loneliness was manifested by her desire to participate in numerous social activities outside of the Home. She did not go to the get-togethers at the home; instead, she usually was "busy" and had other engagements. Her favorite seat in the dining room was at the small table by the window where she ate her meals alone. The stud'ent stated that they had lunch together in the dining room, which has seating arrangements much like a college dormitory, but lacking in vitality and cross-group chatter. The student stated that everyone in the dining room, with the exception of one waitress, was white and that the "territory" seemed "very strange." Mrs. W. talked a lot about her relationship with whites in Texas. She said that "white and blacks" knew their places. Racial segregation was still an implicit
The Gerontologist
and accepted rule by Mrs. W. and many other elderly people. The aged, with their conservative ideas, which is a symptom of normal anxiety, have less desire for change because changes become too much of a burden. They help maintain what used to be the status quo, racial segregation. The problem of racial segregation that has resulted in social segregation at the Home will not be eased until the residential standards at the Home are altered to attract the ethnic population of San Francisco and the Home begins to serve as a model for the community. Mrs. W. has not stated this as a problem but merely as a concern. "It would be nice having other blacks living here." Certainly it would be nice and surely it is necessary. My intervention in this situation was to encourage Mrs. W. to go to her other social contacts, for she already knew its importance and she knew how to handle the problem of racial segregation best for herself. She has succeeded in her adjustments; the problem of racial segregation for Mrs. W. was not a problem for her but a way of life. The student did not seem to have any difficulty establishing and maintaining rapport with Mrs. W. However, what emerged in the conferences was that the student's entry into such a world as this practically all-white elite institution was a strong reenforcement of the student's view that the blacks were definitely discriminated against and treated "like dirt." The student, because of the difference in her age and her client's, could not accept what she considered to be the client's somewhat passive view of her living in the Home and how she was deliberately left out of social activities
Conference Calendar
Alcohol Problems Among Older Per-
sons, summer course. At Rutgers Univ., Summer School of Alcohol Studies, Rutgers, New Brunswick, NJ 08903.
April 1975
These case histories have been examples of how integrating concepts from anthropology and other social sciences such as entry, rapport, and social class influence can enrich the students' learning experience in the field of gerontology. This basic understanding is necessary for students before they can identify and implement meaningful interventions.
(Continued from p. 154)
June 2-5. Old Ago Policy: Social, Medical, and Economic Aspects, 6th international course of social gerontology. In Paris. Centre International de Gerontologie Sociale, 3 Place des Etats-Unis, 75116 Paris. June 5-7. Crime Against the Elderly National Conference. At Statler Hilton Hotel, Washington. Dr. Jack Goldsmith, College of Public Affairs, American Univ., Washington 20016. June 9-13. Workshop on Novels of Adolescence and Age. At Miami Univ., Dept. of English. The Dept., Oxford, OH 45056. June 19-21. Physical Exercise and Activity for the Aging. At Wingate Inst. for Physical Education and' Sport, Israel. Raymond Harris, Ctr. for the Study of Aging, 706 Madison Ave., Albany 12208. June 21-22. Third Conference, International Federation on Ageing. In Jerusalem. Federation Secretariat, 1909 K St., NW, Washington 20006. June 22-27. 10th International Congress of Gerontology. In Jerusalem. Congress Secretariat, POB 16271, Tel Aviv, Israel, or Dr. Carl Eisdorfer, Chairman, American Executive Committee, Univ. of Washington, Seattle 98105. June 22-July I I .
and left alone in the dining room. The other students in the group pointed out that there was, indeed, snobbery in the Home among the different social classes of the whites themselves. The entry into such a Home was thought by the white students to be foreign to them, since they considered themselves middle-class, and this place was high class. The student found it somewhat more difficult to maintain rapport with her peer group than with her client. She experienced culture conflict, in that she admitted liking some of the things about the Home, such as the physical attractiveness, the doorman, who incidentally was not black, and the panoramic Bay view from the windows. She found it very difficult to accept the idea that Mrs. W. would have nothing to do with the one and only other black resident, a man, but Mrs. W. stated that he was "much too low class for me." The students again attempted to use this as an example of how blacks among themselves may show a certain preference which could be inferred by others as snobbery.
June 23-Aug. I. Summer Institutes, Ctr. for Studies in Aging, North Texas State Univ. At Denton. Prof. Cora Martin, the Ctr., Denton 76203. June 23-Aug. I. 1975 Summer Institute on Gerontology. At Univ. of Michigan. Summer Institute, Institute of Gerontology, 543 Church St., Ann Arbor 48104. July 7-Aug. I. Summer Institutes, Univ. of Chicago Ctr. for Continuing Education. At Univ of Chicago. The Ctr., 1307 E. 60th St., Chicago 60637. July 7-18 and July 21-Aug. I. Summer Institutes, Univ. of Michigan-Wayne State Univ. Inst. of Gerontology. At Ann Arbor. The Institute, 543 Church St., Ann Arbor 48104. July 27-31. 1st North American Symposium on LongTerm Care Administration. At Prince Hotel, Toronto. Chairman, Education & Research Committee, American College of Nursing Home Administrators, 8641 Colesville Rd., Silver Spring, MD 20910. Aug. 13-15. Seminar, Biomechanics of Tissue Viability and Clinical Applications. At Univ. of Strathclyde, Glasgow. Prof. R. M. Kenedi, Bioengineering Unit, Wolfson Ctr., the University, Glasgow G4 ONW. Oct. 26-30. Aging and Research. 28th Annual Scientific Meeting of Gerontological Society (with American Geriatrics Society). At Gait House, Louisville. The Society, # 1 Dupont Circle, Washington 20036.
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