Several experiences in the author's Gerontological Clinical Nurse Specialist (GCNS) program provided preliminary work for this project. First, for the clinical component of the GCNS course, the author developed and presented health education programs in collaboration with the Newark Senior Center (NSC). To prepare these programs, it was necessary to assess what the NSC staff believed were the needs of the their members and work within their goals, objectives and specified structure. Program development included careful planning and implementation, but unfortunately there were very few opportunities for implementing Knowles' (1984) principles of adult learning and concepts of transition as suggested by Schumacher and Meleis (1994). These programs usually followed a rather traditional format of a lecture on a health-related topic followed by discussion. Subjective observations led to the conclusion that the participants learned the most during the discussion period when they were able to apply information presented to their own situation.

A second experience which provided preliminary work for the project occurred during the spring of 1997 when the author had the opportunity to use the concepts of transitions as suggested by Schumacher and Meleis (1994) more completely by assisting with the nursing elective, the Adult Health and Development Program (AHDP). In the course, students learn about the aging process and work one-on-one with an older adult partner, as well as in groups with the other students and their partners. It was from this work that concepts related to transition (Schumacher and Meleis, 1994) were delineated into a model for health promotion programs consisting of the four steps of (a) assessment of readiness, (b) education, (c) role supplementation, and (d) evaluation.

In the AHDP, step one, assessment of readiness, was accomplished by baseline physical and psychological assessments of the older adults made by the students. Further assessments of readiness were provided when students and the older adults jointly defined short and long-term health-related goals. Step two, education, was provided through individual and group activities, including weekly educational sessions on a variety of health-related topics. Step three, role supplementation, was provided in the form of individual teaching, counseling and support, both during the regular Saturday morning program and by student contact with their partners during the week through activities such as phone calls, lunch dates or walks.

This one-on-one contact between the students and partners augmented input from instructors and helped students provide interventions for many types of transitions. For example, a common developmental transition for older adults is dealing with losses. The older adults in this group were no exception; losses were represented in may forms, such as loss of health, family and friends, or function. There were many developmental and situational transitions being experienced by the older participants in this program. Examples of illness to health transitions were numerous. One member was dealing with limitations imposed by a craniotomy to stop a bleeding cerebral aneurysm. The AHDP facilitated her transition by providing a place in which she got approval and affirmation for regaining her active lifestyle, including tournament bowling; for openly sharing how she resumed an active love life; and for reaching out to another member whose limited mobility was causing her a great deal of distress.

For evaluation, which is step four, Schumacher and Meleis (1994) recommend evaluating outcomes at intervals by looking at subjective well-being, role mastery, and the well-being of relationships. Students talked with their partners each week about their subjective well-being, and checked with them about their role mastery as demonstrated by their goal attainment. Measurement of well-being of relationships was also a frequent topic of conversation.

The author took a third preliminary step in model building during the summer of 1997 through an independent study course for the purpose of exploring current efforts in health promotion and the older adult population. It was during this course that the Health Belief Model and the principles of adult learning were explicated and integrated with the concepts related to transition. A component of the summer course was spending time with Rob Simmons, the Chief of Health Education and Promotion of the Physical Medicine and Rehabilitation Institute (PMRI) at Christiana Care Health System to determine the types of health promotion programs that are the most successful. Simmons shared that the staff of PMRI incorporate concepts of the health belief model and the principles of adult learning as they design programs. They use concepts of the Health Belief Model to stimulate behavioral change when individuals seek out a specific health promotion activity. Simmons invited the author to present a health-promotion program for the local Mallwallers group. The Mallwalkers are a group of older adults who use the mall facility to walk for exercise. Christiana Mall and Christiana Care Health System's PMRI support this organization by providing a breakfast meeting quarterly where a health promotion topic is presented. The program became a precursor of the prototype medication use program for this project.

A program concerning chronic pain management and prevention was developed and presented at the NSC during this course. Chronic illness and thus chronic pain have been characterized as a transition (Schumacher & Meleis, 1994). Steps to support or make this transition as easy as possible were presented during this program. Several of the older adults in attendance did not seem to engage with the lecture component and only became interested when they were able to express their personal struggles with pain management. This observation supports the basic premise of the Health Belief Model. This model is based on the theory that people will engage in certain health behaviors to avoid disease or illness. The desired health behavior is contingent on perceived susceptibility to a health problem, the seriousness of the health problem, perceived benefits of taking action, perceived barriers to taking action, and perceived factors that trigger the health behavior (Rosenstock, Strecher & Becker, 1988).

Some of the key principles of adult learning as described by Knowles (1989) are (a) adults are willing to put forth the effort required to learn things that they are convinced that they need to know to continue to be responsible for their own lives, (b) adult orientation to learn has a life-centered or problem solving focus and, (c) adult learners are more responsive to intrinsic factors such as desire for a better quality of life, increased self esteem, or job satisfaction. Participants who attended health promotion programs received specific information that could help them with the transitions in which they are currently engaged.

By the fall of 1997, the author believed the concepts supporting the four-step model had been developed sufficiently and operationalized in enough health education programs to involve graduate and undergraduate students in use of the model.

The graduate nursing students' role was primarily the development and presentation of two educational programs for members of the Newark Senior Center. Mentoring this group included coordinating the promotional and other supportive activities of the undergraduate students and sharing information such as literature reviews. This self-motivated, highly accountable group needed very little help to complete the objectives of program development and presentation.

An evaluation of this clinical experience was developed and completed by the undergraduate students at the end of their rotation (Appendix B). The undergraduate students reported that they received the appropriate amount of information and direction about their responsibilities for the health promotion activities. They felt that this experience would help them in the future when they facilitate health promotion programs. The undergraduate nursing students reported that they found this to be a helpful clinical experience and that they especially profited from their contact with the graduate nursing students. The highlights of this clinical experience as reported by these students was the success of the health promotion strategies as demonstrated by the attendance at the health promotion programs. When asked how to improve this experience they indicated they would have liked to have been more involved with planning the date and time of the health promotion activities so that they could have attended. They would have also liked to participate in program presentation with the support of the graduate students.

The interview questionnaire tool was developed by the undergraduate students and the health promotion program coordinator. A draft questionnaire was developed and then sent to the Community Health faculty member, the Gerontological faculty member and the pharmacist involved in this project to be reviewed. The program coordinator then made revisions based on the comments of the reviewers, obtaining additional feedback from the reviewers until all agreed that the tool was satisfactory. A copy of the completed medication use assessment tool is in Appendix D. The undergraduate students were initially disappointed the final survey differed significantly from the original draft after feedback from the reviewers was integrated; after reviewing the survey objectives, they concluded the revised questionnaire would generate better data than the original tool.

The undergraduate students conducted the medication interviews with members the senior center where the medication program was scheduled to be presented. The undergraduate students then compiled the survey results and these results were incorporated into the medication use program by the graduate student and the pharmacist presenting this program. Thirty-six older adults were interviewed. The survey revealed that these 36 individuals are taking 52 different types of prescription and non-prescription medications. The most commonly repeated prescription medications were those classified as "heart pills," "blood pressure pills," and "water pills." The most common non-prescription medications as identified by this survey were Tylenol, aspirin, and vitamins.

Most (88%) of the respondents reported that there were no or they did not know of any side effects associated with the medications they were taking. Seventy-two percent of the individuals interviewed responded that they received adequate information about their medications from their pharmacist or the person who prescribed the medication. Eighty-three percent of those who responded reported that they take their medications as prescribed. This data indicates a lack of knowledge related to what questions to ask before taking any new medication, thus reinforcing the need for a medication program. A particular concern was that most of the older adults interviewed believed they had adequate information about their medications even though they were unaware of the potential adverse effects associated with the medications.

The results of the survey were used to prepare an educational program as directed by the second therapeutic intervention suggested by Schumacher and Meleis (1994), preparing for transition. The objectives selected for the program pertained to knowledge and one objective pertained to level of planning, i.e. what they would do if side effects occurred. Plans were also made to assess level of planning in the program evaluation by asking participants to list changes they will make in medication-taking behaviors as a result of attending the program.

Attendance is of utmost importance to the success of any health promotion program. Therefore, the next readiness step was to determine what additional ways to market and promote this program. The medication use survey was used as a program-marketing tool for those older adults who were surveyed. Three publications have proven to be successful spots to advertise health promotion programs: The Newark Senior Center Newsletter, The News Journal and the Newark Post. Program announcements were written, edited and submitted to these publications (Appendix E). Finally, a poster and flyers were developed (Appendix F) and displayed in the lobby of the NSC and at adult residential communities in the surrounding area. A fall bazaar was scheduled for the NSC the weekend prior to the medication program; hundreds of older adults come to the bazaar to have breakfast or shop at the white elephant sale. The promotional materials were displayed in time to capture this audience. The Social Director at the NSC also promoted the program during a radio spot on the local radio station WNRK.

Reducing medication-usage problems of older adults has an enormous potential to improve quality of life and decrease costly health care interventions (Haber, 1994). The primary goal of this program on medication use was to encourage the participants to become conscientious and competent medication users. The program's objectives were to inform the participants of (a) the questions they should ask with any new prescription, (b) why when a medication is taken matters, (c) what should be watched for when mixing prescription and non-prescription medications, (d) potential adverse medication reactions, and (e) how aging affects the medication's function. This program was developed to not only include the participant's individual learning needs as assessed by the pre-program questionnaire but also to incorporate presentation strategies based on principles of adult learning.

Older adults report that they prefer to attend programs that allow for peer interaction and discussion. To add the peer interaction component to this program Think, Pair and Share strategies as described by Dr. Eric Mazur in Peer Instruction (1997) were included. This educational strategy takes place in four steps. First, a concept such as a type of adverse physical response to a medication is explained and a question is then posed to the participants. Second, the participants are given a short period of time to think quietly and determine how they would answer the question. Third, after the think time, the group is asked to find a partner and discuss their response to the question. The pairs are given a second brief period of time to talk about the question and share their answers. Finally, the facilitator reviews the question, polls the participants for their understanding of the concept and provides the correct answer. When the majority of the participants do not grasp the concept, which is demonstrated by indicating the incorrect response, more information can then be provided.

A video presentation entitled To Lead a Better life (National Public Education Program, 1996) was shown at the end of the program to reinforce the key concepts of this program. The To Lead A Better Life (1996) National Public Education program on compliance for older Americans has been developed to help health care professionals provide information to seniors on the importance of taking medications correctly. This 17-minute video is narrated by and contains a personal message from Walter Cronkite, a former anchorman and a well-respected journalist. This program offers advice to older Americans on the importance of taking medicine correctly (Appendix G). This video production reinforced and supported the most important message of this program, which was that the health care consumer is the most important member of the health care team.

One of the recurrent messages in this program was to keep track of all of the medications that are being used. The members of the National Council on Patient Information and Education (1992) suggest making a list of prescription and nonprescription medications, keeping this list by the phone and taking it to all health care appointments, and adding notes about the purpose and appearance of medications. Program participants were provided a form to compile this information (Appendix K).

1. The medication's name and purpose;
2. How, when and for how long the medication is to be taken;
3. What food, drinks and other medications or activities should be avoided while taking this medication;
4. Side effects and what to do if they occur;
5. Will this new medication work safely with other prescription medications; and
6. Written information that is available about the medication. (National Council on Patient Information and Education, 1992)

Comments when asked to list one new thing that was learned from this program included:

• Carefully read non-prescription drug directions even those you have taken for many years
• Misuse of medications may cause dementia
• Ibuprofen causes stomachache in some people and that you should consult with your doctor if stomachache occurs
• Sudafed shrinks blood vessels
• Eat foods when taking Motrin
• Taking multiple medications at one time rarely causes difficulties
• All the side effects from Ibuprofen
• There are many different side effects from Advil, not just stomach upset
• To make sure to ask questions when getting medications

This question was a sensitive one to answer because the nurse and pharmacist wanted to preserve confidence in both the hospital and the health care providers while, at the same time, providing information for the participant to develop safe medication use skills. The pharmacist replied that the hospital's computerized pharmacy profile recognizes and reports all known drug to drug interactions so that the nurse could be notified if the medications were not safe to be taken together. From this answer, this participant concluded that, "taking multiple medications at one time rarely causes difficulties." The nurse presenter emphasized that nurses are responsible for (a) checking for potential drug interactions before administering medication, (b) clarifying medication orders, which may cause drug interactions with pharmacists and physicians, and (c) providing information about optimal ways of taking medications. An important part of the model is to provide mechanisms for follow-up in order to correct misconceptions.

The second narrative question on the evaluation form was, "What changes will you make in your health-related activities based on the information you learned in the program"? Written comments are as follows:

• Ask physician when I am prescribed a new medication, what precautions I should take and what to expect
• I will try to educate about the medications that I am distributing so people know what they are taking and what adverse affects to look for
• Will avoid taking medications with food at mealtime
• Call Doctor if have any side effects
• Get more exercise
• I will make sure I get all the information I can get about my prescription at the time it is prescribed to me
• Always ask and get correct directions

The comment regarding patient education was asked by one of the undergraduate nursing students who attended and participated in this program. During the question and answer portion of the program, a student asked if hospitalized or nursing home patients were made aware of the purpose of the medications they were having administered and if they knew of the potential side effects. This question offered an excellent opportunity to discuss the professional nurses' role in medication administration. This role includes patient education and follow-up assessment as well as accurately administering and documenting the medication.

A recurring message of this program was for the participants to open the lines of communication with their health care provider. The participants were encouraged to ask questions with any new prescription and to contact their provider again if they experience side effects from medications. A program participant asked what should be done when he was unable to contact his health care provider. He stated that he was currently a member of an HMO and was frequently unable to reach a physician. He then added that this inability to contact a health care provider is becoming a joke among his associates who are also members of an HMO. When asked if he had filed a complaint to this organization for poor response time, he indicated he had not. At this point in the program, the participants were encouraged to be advocates for themselves and to inform their health care insurance system when services are not meeting their expectations or their needs.

Comments, suggestions, or requests to ud-geriteach@udel.edu. "http://www.udel.edu/geriteach/project/watson-chap3.html" Last updated July 12, 1998. Copyright Norine Watson, 1998.