Wisdom of the Elders: Narratives Enhancing Trainees’ Attitudes Towards Aging

James S. Powers ^{1, 2, *}, Destiny O. Birdsong ³, Kemberlee R. Bonnet ⁴, Neena R. Kapoor ⁴, Jamaria J. Southward ⁴, Ifeoma Nwankwo ³, David G. Schlundt ⁴

1. Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA

2. Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center, Nashville, Tennessee 37232, USA

3. Department of English, Vanderbilt University, Nashville, Tennessee 37232, USA

4. Department of Psychology, Vanderbilt University, Nashville, Tennessee 37232, USA

This work was selected for presentation at the 2019 Annual Meeting of the Gerontological Society of America.

* Correspondence: James S. Powers

Academic Editor:  Donatella R. Petretto

Received: April 25, 2019 | Accepted: August 20, 2019 | Published: August 26, 2019

OBM Geriatrics 2019, Volume 3, Issue 3, doi:10.21926/obm.geriatr.1903072

Recommended citation: Powers JS, Birdsong DO, Bonnet KR, Kapoor NR, Southward JJ, Nwankwo I, Schlundt DG. Wisdom of the Elders: Narratives Enhancing Trainees’ Attitudes Towards Aging. OBM Geriatrics 2019; 3(3): 072; doi:10.21926/obm.geriatr.1903072.

© 2019 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Background

Healthcare professionals’ understanding of older adults is vitally important in optimizing the health outcomes of elderly patients. Enhancing attitudes towards aging among early medical trainees has been achieved through personal contact [1], with demonstration of improved comfort and socially skilled behaviors toward older adults [2,3,4]. Empathy-building tasks have included art and storytelling [5] as well as simulation experiences [6]. Another helpful tool is narrative medicine, which is defined by written reflection exercises with an emphasis on patients’ stories and the recognition that patients are people, and not merely their symptoms.

Narrative medicine has the potential to offer valuable insights into trainees’ thinking and learning profiles [7,8]. In addition to highlighting their strengths in listening to older adults, narratives have the potential to identify weaknesses and vulnerabilities that might negatively impact care for aging patients. Additionally, trainees who elicit patients’ stories and develop narratives from these encounters form relationships with patients that validate their identities, and address emotional, spiritual, and social needs [9]. Story-telling can also play a role in the personal healing process of patients. Sharing narratives is therapeutic because patients are not often allowed the opportunity to speak about themselves without interruptions or time constraints [10]. Narratives based on interviews of older adults can also provide helpful information about coping strategies, including successful aging, resilience, and reflection on life events; how individuals derive meaning, pleasure, satisfaction, and a sense of purpose; their concerns, hopes, and fears about aging; and how individuals perceive themselves as they get older. When individuals share their stories, we glean further insight into their lives [10].

Narratives can help build a stronger relationship between individuals, including empathizing with a patient’s struggle with illness and generating compassion [11].

Narrative competence includes the ability to “recognize, absorb, interpret, and be moved by the stories one hears or reads” [12]. If preclinical trainees interview patients and write about these interviews, these trainees are building their narrative competence, and also contributing to the field by providing a body of knowledge about elderly patients that could be useful to other providers. Written reflections on patients has been found to improve the communication skills and professionalism of surgical trainees [13], and emphasizes a person-centered approach that personalizes care [14].

Analyzing life stories requires a theoretical perspective that incorporates personal history, historical contexts, and change over time. Examining how elders adapt to change in health, cognition, and environment as they get older will be facilitated by using an appropriate theoretical lens. Life Course Theory is a framework well suited for making sense of life-stories told by elders [15,16]. The Life Course approach is an attempt to study people’s lives as they change over time, with an emphasis on explicitly understanding the influence of personal, environmental, and historical context. People’s lives are viewed across domains such as work, leisure, neighborhood, social institutions, and family. Generations or age-specific cohorts (e.g., Baby Boomers, Millennials) are important because individuals within those cohorts share common historical events and engage with each other through social networks.

We created the opportunity to practice narrative medicine and introduce awareness of aging among trainees previously given insight into aging by introducing graduate student Discovery & Learning Fellows to hospitalized elders, similar to that of early medical trainees with no prior clinical training. Since attempts to analyze electronic documents with general purpose computational linguistics has had limited success due to the unified medical language systems’ (UMLS) inadequate context and vocabulary for concept identification related to psychosocial domains [17,18], we utilized qualitative analysis of trainees’ narratives to detect aging and intergenerational themes. We describe the feasibility of a pilot project for preclinical trainees given guidance on age – friendly concepts and exposed to a medical environment with vulnerable elders and report the on the possibility of yielding positive results. Our goal was to use qualitative methods to understand the content of the students’ written narratives and to identify the topics and themes discussed by the patients during the interviews.

This project grew out of the 2012 Wisdom of the Elders [19] community-engaged research, a service–learning partnership on intergenerational relations consisting of interviews, workshops, and life-story documentation. This project utilizes qualitative methods to detect intergenerational themes in narratives among trainees exposed to hospitalized elderly veterans.

2. Methods

The subjects were Discovery & Learning Fellows: three female graduate students in Health Policy, English, and Psychology, all in their mid-20s, with no prior medical training. They received a small stipend and volunteered to participate in the Wisdom of the Elders project. A 90-minute training curriculum was developed and delivered by an interdisciplinary team, including a humanities scholar (DB), a psychologist and interdisciplinary team educator (DS), and a physician (JP). The training emphasized a positive introduction to the healthcare system, an overview of aging and illness, and patient confidentiality. The training promoted the hospital as a clinical laboratory, explained the role of the Discovery & Learning Fellows, promoted empathy for patients, and demonstrated how trainees help to provide patient-centered care. The Reframing Aging Program [20] was used to identify aging-related topics for data collection and analysis, including: intergenerational themes, inclusiveness, the value of life stories, independence and resilience, social context and participation in society, stereotypes, and public views of aging. Fundamentals of interviewing included an open-ended approach and adapting to patient needs [21]. Fellows were provided readings, scenarios of case examples, and role-playing opportunities before conducting interviews.

Discovery & Learning Fellows were asked to perform a semi-structured interview lasting 30 to 90 minutes, asking patients to: 1) tell the fellow about themselves; 2) talk generally about their medical conditions; 3) tell about their life experiences; and 4) to self-reflect. Narratives were developed focused on interviews with their senior partners.

3. Subjects and Setting

Discovery & Learning Fellows interviewed older hospitalized veterans receiving care on an acute care for elderly (ACE) unit. Patients received a comprehensive, multi-dimensional assessment and development of a plan of care undertaken by an interdisciplinary team of healthcare professionals for a target a group of high-risk, high-need patients who were likely to benefit from these services. A review of program elements comprising ACE Units identified three key concepts: 1) geriatric medical review, 2) early rehabilitation, and 3) patient-centered care. These individual, focused interventions appear to have a greater effect than either discharge planning processes, or the environment of care [22]. Fellows were included during rounds, and patients gave verbal consent to be interviewed.

Interviews were performed over a six-month period in 2017. No recording was permitted; however, reflections were written within 48 hours of the interview. These were electronically uploaded to a secure site for coding and qualitative analysis. Discovery & Learning Fellows contributed a total of 17 narratives—Health Policy [1], English [9], and Psychology [7]—with a mean length of 1.4 (.75-2) pages.

This work was supported by the Andrew W. Mellon Foundation, the Meharry-Vanderbilt Community Engaged Research Program, and the Vanderbilt University Chancellor’s Higher Education Fellows Program. The Tennessee Valley Healthcare System Institutional Review Board acknowledged this project as a quality improvement initiative.

4. Results

4.1 Participant Characteristics

Discovery & Learning Fellows rounded with the geriatric interdisciplinary team, and 17 patients (15 males, 2 females) verbally agreed to participate. Senior partners had a mean age of 66.9 (51-85) years, with many comorbidities (6 sepsis, 5 paraplegia, 2 congestive heart failure, 2 hemodialysis, 1 stroke, and 1 myocardial infarction).

4.2 Coding Schemata

The coding schemata was developed based on the Discovery Fellow curriculum and self- reflection, and included ten categories:

1. Time Orientation: Time frame that was discussed (past, present, future);
2. Self: When the participant spoke about himself/herself. Sub-categories reflected a range of thoughts and reflections about the patients’ thoughts, feelings, and experiences;
3. Emotions: Discussion of emotional experiences. These were often paired with other categories in order to identify the root cause of the emotions;
4. People: Discussions about family, friends, and other important individuals in their lives;
5. Personal Experiences: Discussion centered on personal experiences and defining life events;
6. Medical Condition: Discussions about past and present illnesses, as well as current medical conditions;
7. Health Maintenance: Discussions about how each patient maintained their health;
8. Comments from Interviewers: Interviewers’ impressions of both the patient and the interview;
9. Comments from Others Who Were Present: Comments provided by other people present during the interview (e.g., spouses and other loved ones);
10. VA Experience: Discussions about the positive and negative experiences in the VA hospital.

Secondary themes were derived from faculty review of the narratives, including specific categories of subject and Discovery & Learning Fellows’ self-reflections.

4.3 Qualitative Analysis

Each statement was treated as a separate quote, and each quote was coded using a hierarchical coding system. This system was developed based on the overall purpose of the study, and a preliminary review of the student narratives. Each major category was subdivided, and the subcategories were further expanded to describe the information related to the study question [23,24,25]. Quotes could be assigned up to five different codes in addition to the time orientation code. A file management system was used to sort all identified codes and their associated quote, and was then sorted by coding category. Analysis consisted of an iterative inductive-deductive approach that involved using our theoretical frameworks and filling in details from the coded data. This approach allowed us to create a conceptual framework which was used to summarize the data and support the summary with specific quotes. The coded data were then used to summarize the quotes and identify the significant themes that were extracted from the data. A total of 774 codes were used to describe the themes present in 582 quotes.

4.4 Conceptual Framework

Based on the coding system, frequency of codes, and a review of the quotes sorted by category, we developed a model that encompassed the major themes and topics salient within the interviews and analysis (Figure 1). “Self” is presented as the focal point, incorporating self-evaluation and discussion of values, religion/spirituality, and goals and aspirations. “Self” also extends into other themes that are presented over time (lifespan). “People” consists of the important individuals in the patients’ lives who have had a significant impact, either presently or in the past. “Personal experience” includes topics such as job/career, hobbies/pastimes, education, military, and trauma/hardships. Personal experiences mostly occurred in the past, but affected present-day themes, “medical conditions,” and “health maintenance.” “Medical conditions” included hospital experiences, chronic illnesses, past and present symptoms, and physical function. “Health maintenance” describes health-promoting behaviors, such as rehabilitation, diet, and regular physical activity.

Figure 1 Conceptual framework: Narrative themes derived from older hospitalized patients.

4.4.1 Personal Experience

Senior partners discussed a wide range of life experiences and occupations. Many of them were retired, but a few of them still performed minimal work. Some expressed regret about not attending college or pursuing passions, while others discussed the possibility of re-enrollment. Their advice to younger generations included, “Become as well educated as possible and choose your occupation very carefully.”

Senior partners disclosed both positive and negative military experiences in their youth. Positive military experiences stemmed from the opportunities enlistment offered for education and travel. Negative military experiences included combat in wars such as the Vietnam War, and the public scrutiny that came with it. In one reflection, a Discovery Fellow noted that the patient said he “became desensitized to death. When he came back, he felt that nobody could understand him.” Other lasting effects of desensitization, health issues, and trauma were also discussed. One veteran reflected, “He said going to Vietnam was a waste of time, and remembered having bottles thrown at him when he returned home. He lost a lot of friends there.”

In addition to military trauma, the interviewers lauded the senior partners’ abilities to cope with their health conditions and multiple personal losses, such as the deaths of spouses. As one patient’s spouse (one of the seventeen patient interviews included a spouse present) noted, “I was surprised to learn about his past trauma experience and how he was able to cope without professional assistance.” Some of the patients turned to pastimes to cope with their past and present lives, and such activities included spending time with their families (spouses, children, and grandchildren), and attending church. As one reflection described, “He uses music to block out the memories, saying, ‘it calms me down and brings me peace.’ Sometimes he’d wake up in the middle of the night, get out of bed, put on his headphones and play the piano.”

4.4.2 People

The people in the patients’ lives were described as both a support system and a motivation to improve health. Spouses and siblings visited often, and played a major role in patients’ daily lives as well as in their health maintenance. One of the fellows observed that a senior partner “lives with his sister, and she comes to visit him often.” Children and grandchildren were an additional source of happiness, and many senior partners were deeply attached to them. One patient told a fellow that, “if she [his granddaughter] wants something, all she has to do is call.”

Other senior partners drew a sense of community from their church congregations, and often used religious fellowship as an opportunity to participate in favorite hobbies. For several of them, their church communities were considered quasi-familial and an “outlet of entertainment.” Several expressed goals of improving their health in order to participate in activities with their families and communities. Since most of the patients’ parents had passed away, most had close relationships with friends and neighbors who provided a network of people to turn to in times of need. One fellow noted that a patient highlighted his dependence on “the help and support of a neighbor couple, who buy groceries for him.”

4.4.3 Self

Senior partners who self-identified as individuals whose lives were difficult lived without regrets and had great optimism for the future. They often described themselves as carefree young people, but they matured as they began feeling the effects of old age. Some patients expressed their current values through advice to the fellows about topics such as the importance of education, staying true to oneself, and taking advantage of one’s youth. Religion and spirituality were also highlighted as important; many patients felt that these concepts helped them cope with life, loss, illness, and hospitalizations: “Throughout our conversation [he] would seamlessly offer parts of his philosophy. At one point he asked me, ‘What is the opposite of love?’ I said, ‘I would guess hate, but I don’t think that’s the answer.’ He replied, ‘The opposite of love is indifference.’”

The senior partners reflected on their own life choices and experiences, sometimes describing their appreciation of learning opportunities, but also identifying what they would have done differently in various situations. They offered advice to the fellows based on these life experiences. One Discovery Fellow recorded this example of a senior partner’s describing his values and advice for others: “His advice to younger people in his community, like his daughters and the young men at his church, is to focus on a good character and maturity. He said to know who you are and be who you are and don’t apologize, adding, ‘You’ve got to stand up for you.’ [He] believes that ‘young people need to find out what they want out of life.’ He suggested setting goals because you can’t achieve your goals if you don’t set them. He also suggested that young people should get a profession, not just a job, because they won’t have a way to retire jumping from job to job.”

Some of the senior partners also shared goals and aspirations of continuing personal growth, such as returning to school, trying new careers, or spending more time with friends and family. As one fellow recorded: “When asked to describe himself in a few words, he said, ‘I’m a grown man who is still growing,’ but he believes he’s closer than he used to be.”

4.4.4 Medical Conditions

Each of the senior partners discussed in detail their current reason for hospitalization at the VA. They described their interaction with staff and their treatment, and shared both positive and negative experiences liberally. In addition to their reasons for hospitalization, many had chronic conditions ranging from addiction to diabetes. In fact, some had medical conditions that limited their physical function, and they discussed how this affected their everyday lives. About one of the senior partners, a fellow wrote, “For the past year, he hasn’t been able to do much for his health and does not feel in control of his health, especially because he can’t walk. He has rods and pins in one leg, and the other foot has elephantiasis.”

However, the patients discussed mortality, morbidity, and prognosis much less frequently than other aspects of their medical condition. Many of them were much more concerned with their current quality of life. For example, one senior partner “was offered a pacemaker one year ago and turned it down, but he now needs it in order to have surgery. He’s not worried about dying on the table during surgery, but rather, he is worried about being able to walk.”

4.4.5 Health Maintenance

Many of the senior partners were involved in rehabilitative activity because either their current or past medical conditions affected their physical function. They also discussed diet and exercise as something they hoped to improve upon, and recommended it to the fellows as a way to avoid later health problems. One senior partner told a fellow that “some of the staff said he was the only patient already trying to lose weight. His advice to others is to keep a good and healthy attitude, exercise, and eat right. He noted that Oprah has kept her weight off, but that she can pay someone to help her.”

5. Discussion

Self-reflective narratives of interviews with older patients produced by young trainees provided insight and rich material for analysis of coping strategies for successful aging. The narratives provided insight into the ways older adults stay emotionally positive and engaged with the world; how they derive meaning, pleasure, satisfaction, and sense of purpose; their concerns, hopes, and fears about aging; and how they see themselves and change as they get older.

Many of the Discovery Fellow-reported patient narrative themes corroborate the concept of wisdom, which includes aspects of self-reflection, openness, compassion, and morality [26]. These narratives appear to enable older individuals to use their intelligence and experience for the sake of a common good [27]. Wisdom is defined as a positive developmental quality that is the product of life changes, reflection, and insight [28,29]. Wisdom teaches younger generations how to live and age well and how to learn from life’s experiences. Narratives permit self-reflection as a mechanism through which wisdom is constructed from life experiences, especially relationship events in life-threatening occurrences such as illness [30]. Reflective wisdom is associated with subjective well-being and may strengthen older adults’ ability to cope with aging-related losses [31].

This work advances the field of narrative medicine by analyzing both the form and content of participants’ narratives, contributing to new understanding that can be used to craft training in intergenerational communication. The skills will be useful to healthcare practitioners, as well as to humanities scholars by promoting the commonality of life experiences, shared purpose and respect for people, the value of advice derived from elders, and the rich insight gained from interpersonal relationships. Requiring students to write reflective narratives of their interviews encourages them to listen carefully, process what they are being told, and organize it into coherent stories. Narrative medicine adds to wisdom research by providing insight on individual and contextual factors related to reflection on life experiences. Senior partners who are interviewed may benefit from reflecting on life’s experiences.

6. Limitations

Discovery & Learning Fellows all volunteered to participate in the program and were thus unlikely to have negative views toward older adults. Also, they were trained to focus on aging concerns; however, the subjects provided unique responses based on their life experiences, which did not always yield clear information specifically about health concerns. In this study, we coded and analyzed the written reflections of the Discovery & Learning Fellows, and therefore cannot be certain that they accurately portrayed the stories told by their patients. Nonetheless, our analysis offered a comprehensive understanding of the shared experience between the Fellows and older adults.

7. Conclusions and Implications

Our experience suggests that creative outcomes can result from trainees given insight into aging. Contact with older adults combined with a written reflection exercise is a feasible way to introduce awareness of aging to young trainees. The older participants responded by sharing life experiences, reflecting on their life trajectories, and offering advice and wisdom to the young trainees. Trainees who are given guidance to appreciate aging themes can create positive narratives reflecting on inclusive, intergenerational exchange and wisdom derived from lived experiences.

Author Contributions

Conceptualization: Nwankwo, Powers, Birdsong, Schlundt; Implementation: Powers, Birdsong; Analysis: Birdsong, Bonnet, Kapoor, Southward, Schlundt; Manuscript Preparation: Powers, Birdsong, Bonnet, Nwankwo, Schlundt.

Competing Interests

The authors have declared that no competing interests exist.