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Hello and welcome to GapnaChat, an official podcast of the
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Gerontological Advanced Practice Nurses Association. GapnaChat provides interviews and discussions
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with Gapna leaders and members of the gerontological healthcare community
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and will focus on advocacy, policy, education, professional development, research,
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and clinical care for older adults. Before we get started...
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If you are an advanced practice nurse caring for older
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adults and want to further your career, GAPNA encourages you
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to sit for the Gerontological Specialist Certified Exam and earn
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your GSC credential. This expert certification distinguishes APRNs with the
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knowledge and experience to manage the complex health needs of
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older adults. Visit gerocert.org to learn more. In this episode... Dr.
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Cassandra Vaughness, a gerontological nurse practitioner and member of the
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GAPNA communication team, talks with Dr. Margaret Wolhagen, a professor
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of gerontological nursing and a geriatric nurse practitioner at the
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University of California, San Francisco. Dr. Wolhagen reflects on her
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career in gerontological nursing and her research on aging, hearing loss,
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and person-environment fit. She highlights the importance of addressing ageism
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incorporating hearing health into routine care, and promoting a lifespan
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approach to healthy aging. We are pleased to present Dr.
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Vaughness's interview with Dr. Wolhagen.
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Good morning, everyone. This is Dr.
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Cassandra Van Ness with Gap in the Chat. And today
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we have Dr. Margaret Walhagen.
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And Dr.
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Walhagen is a professor of gerontological nursing and a geriatric
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nurse practitioner at the University of California, San Francisco. She
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earned her nursing degrees from St. Luke's Hospital, UCSF, and
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the University of Washington. Her clinical experience includes critical care
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and mentoring nursing students. Joining UCSF in 1988, she has
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taught gerontological nursing at all levels.
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Dr.
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Walhagen's research focuses on caregivers, diabetes education, aging with chronic conditions, self-care,
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cross-cultural intervention, family conflict, and the effects of hearing loss
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on older adults. a four-year study analyzing how older adults
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and their partners and families experience and manage age-related hearing loss.
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This work laid the foundation for her later research on
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how hearing loss stigma affects help-seeking behaviors. In 2006, she
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became the director of UCSF John A. Hartford Center of
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Geriatric Nursing Excellence, preparing nurse leaders to care for an
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aging population.
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Dr.
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Walhagen is also the Senior Nurse Scholar for the Veterans
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Administration's Quality Scholars. Community service includes board roles at Family
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Caregiver Alliance, Bread for the World, the American Geriatric Society,
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and the Hearing Loss Association of America.
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Dr.
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Walhagen, thank you so much for joining us for Gap
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in the Chat. To begin with, what would you say
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to your younger self as you started nursing school at St.
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Luke's Hospital of Nursing in New York City, knowing now
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where your career would eventually lead?
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Well, you know, it's interesting. Thank you for the invitation
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for us to join this podcast and for the interest
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in my career. You know, when I saw this question,
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I really had to think because it really requires sort
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of a hindsight as well, forethought, if you will. And
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so much has changed since I entered nursing school. And
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my decision to attend was really significantly influenced by cost
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at that time. That said, when thinking about available career
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options at the time, they really sort of included nursing
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and teaching. I thought at the time I couldn't be
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a teacher, so I wasn't sure about that role, and
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I had received a regent scholarship. I grew up in
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New York State to attend the state university, but I
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thought the focus would be much more on the teaching,
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and I didn't think I could do that. And also, really, St.
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Luke's just seemed like, because it was a training school
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of nursing, a three-year all-around program, that it was the
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right fit for me at the time. However, during the
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time that I was there, they changed the regulations, so
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I didn't get any college credit for the three years
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I was there, the time I graduated. They sort of
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had to start over again. and go to a lot
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of evening school to get credits to go back to
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get my BS and master's. And in truth, looking back,
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I don't regret the route I took in many ways
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because St. Luke's was really an excellent program. And I
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learned so much going to evening school. I mean, it
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was just opened a whole new world for me that
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at that time. I probably was more prepared for than
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maybe when I graduated from high school. So my path
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might have been smoother going directly to the university. But
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I think the lessons that I learned and the opportunities
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I had were unique. But I would say maybe the
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one thing I would say to someone entering the school
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is really be open to opportunities. And interestingly enough, I
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would say keep a log of your experiences and how
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they fit with your goals for life's work. and seek
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out mentors who can provide guidance and support. I could
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have used a lot more mentors during my career. So
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I value mentorship a great deal. But I do think
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keeping track, looking at what your passions are makes a
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really big difference.
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It's funny how after a point in your nursing career,
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you know, you are focusing on teaching when you turned
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away from that career path that early.
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It's interesting.
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Can you share a little bit about your background, your
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clinical experiences, and then what led you to pursue gerontological nursing?
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Much of my career was, as you noted in the introduction,
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was in acute care, and especially ICU, which I love
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because I learned a great deal. But then after I finished, finally,
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my BS and master's, I ended up teaching at California
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State University, Chico. And I realized that if I wanted
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to stay in teaching, I needed to get my doctorate.
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And so I was exploring options at that time. Interestingly enough,
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I had two colleagues that we were thinking of going
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to back the doctoral programs together. But as it turned out,
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one went to UC San Francisco for sociology, another decided
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not to do anything. And I ended up in Seattle.
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So we sort of all went different ways. But when,
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at that time, I was, when I was considering the focus,
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I'd been doing, I'm very interested in neurology, very interested
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in chronic illness, because what I saw was in chronic illness,
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and that really looking at individuals who had often experienced
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what they were experiencing chronic illness, and that drew me
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increasingly to study issues of aging and gerontology and all
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the factors that influence how older adults dealt with the
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changes because I was interested in physiology, interested in neurological changes.
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And so as part of my work, what led me
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into the doctoral program was got very interested in how
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individuals interact within their environment. So the concepts of person-environment
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fit became really important to me, very much influenced by
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some of the work that M. Powell Lawton did, a
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wonderful environmental gerontologist, and also interested in concept of control
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that was introduced to me quite a bit initially by Dr.
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Fran Lewis, who's also a brilliant family researcher. My concepts,
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because I got actually very angry at the concepts, the
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idea of locus of control and so forth, probably because
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I realized in chronic illness and aging, so much of
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life is not controllable. I mean, it's not like we
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can be in control of things. So I developed sort
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of my own theoretical model around that. But that all
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really was influenced in looking at the care of older adults.
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And it's still central to my work because we do
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sort of focus a lot on being in control. And
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As I think you know, many times chronic illnesses, other
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experiences are not so easily controlled, but they can be
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managed and often giving over control to other people or
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other ways of being able to manage things. So it's
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a central piece of my work, but that's kind of
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how I got into gerontology and realizing the importance of
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looking at the environment that individuals are in and how
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that very much influences how we can age in the
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most healthy way.
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And that's an important concept for nurses to embrace, to
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return the older adult as much locus of control that
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we can provide them.
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And we don't do a very good job of that,
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especially in critical care. We don't at all.
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But thinking about it from the standpoint of manageability, because
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maybe they do need to not necessarily make the decisions themselves,
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but they want their families engaged. And so looking at
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what works for that individual, in the concept of a
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person environment fit, you know, the resources they have, the
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resources they need, and all of those kinds of things. So.
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Thank you.
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And you've conducted extensive research on the impact of hearing
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loss and identified it as a potential risk factor for
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a range of poor health outcomes in older adults. What
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drew you to this area of gerontological research?
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Well, it's a great question because as I mentioned before,
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one of my areas of research when I was in
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my doctoral program was caregivers. And I continued that in
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the theoretical concepts I just talked about. But when I graduated,
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I stayed in that area. I did work on caregivers
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of persons who have diabetes. But after one project, I
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started to wonder about my next steps. Where do I go?
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There just was a lot of work already being done
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in caregiving. And that was a long time ago. We're
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still doing a lot of that work. And I kept
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asking myself, what can I contribute to this body of work?
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And at that time I had had the opportunity of
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working with colleagues at the Alameda County study. My husband
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happened to be a project director there. And every time
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he was talking about different research things that I always,
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always say, what's the clinical implication for this epidemiological work
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that's happening. But we started looking at the data around
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hearing loss and that made me more engaged with persons
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who had hearing loss, as well as looking at those
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data and seeing the impact itself. And so I started thinking, well,
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what do nurses and physicians know about hearing loss? And
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I realized when I, especially in the area of nursing
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or when you looked at textbooks, they'd often meet just
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this little paragraph on hearing. And often it would also
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just say, make sure the hearing aids are in place.
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And so I said, well, okay. And so I asked
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nurses and others around me, I said, do you know
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how to do anything with a hearing aid? Would you
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know what to do? And all people would sort of
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say no, or they'd worry because they whistled and didn't
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realize why they whistled. And so I thought, there really
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isn't much data on this. And yet it has a
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major impact. So I started looking into that more. And
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I made a very conscious decision that I was going
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to focus my work where I thought I could maybe
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make a difference. And it may be, I have to admit,
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at that point, my career was not necessarily the wisest,
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partly because I had a lot of trouble convincing NINR
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that hearing loss was a nursing issue. And so it
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was a lonely field at that time. People, you know,
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it's not exciting to a lot of people, but I
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became very passionate and got very engaged. And the more
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I got engaged with people who had significant hearing loss
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and the impact it had, it just sort of stimulated more.
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So that's how I got here. And I'm not sorry
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I did it.
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So in your NINR-funded longitudinal study that you explained, you
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explored how older adults and their partners and families experience
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and manage age-related hearing loss. You know, we all talk
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about normal changes associated with aging and hearing is one
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of those normal part of physiologic aging.
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But why do you think the stigma around it still
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exists in aging?
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It's an interesting question in many ways, because many people
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feel that now it'll go away because so many people wear,
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you know, like earbuds, things that you're listening to all
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the time. But in truth, I think it's a different issue.
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And hearing aids are not like glasses. You don't put
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them on and hear. And I'm talking about glasses for
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normal changes that we usually expect, not things like macular degeneration.
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I would say that hearing loss is more akin to
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something like macular degeneration or something like that, because it's
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not just a decrease in sound. It's not something that's
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cured or totally fixed by hearing aids. And hearing, it's
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the meaning of hearing, I think, that is the problem,
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is that, one, people do associate it with, even if
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it occurs across the lifespan, they associate it with aging,
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and they associate it with disability. And I've had people
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tell me, you know, I have this problem, this problem,
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and now all of a sudden I have a hearing loss.
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This says I'm old. And that's unfortunate. So there's a
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piece of that. But beyond that, I think the real
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reason is that it's so central to communication. Now, there's
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lots of modes of ways of communicating. And persons who
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are deaf from birth or early on use sign language,
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which is its own language. And that's one area of communication.
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But persons who become hearing impaired don't tend to sign.
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They use captions. They use other ways of accessing communication.
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But when you're in conversation with someone, it's so key
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to being able to hear what people say to make
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it comfortable. And the person you're talking to has to
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be able to understand how to communicate in a way
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that relates. Those are both effortful activities. And some people
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with hearing loss often fade out in the background or
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get tired of saying, you know, I didn't understand what
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you say. So even if they have hearing aids, they
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don't work perfectly. You still because it's not fixing the problem.
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It's making it better, but they don't always work in
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all these situations. So I think it's really partly that
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it's this idea of its impact on communication, its impact
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on relationships. And it does because in partners, people would
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say if the person with hearing loss didn't accept it,
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didn't want to do anything about it, they'd say, OK,
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you know, they'd start information paucity. I don't want to
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take the effort to talk about this because it takes
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so much time. So it's it really does influence relationships.
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So I think that's part of it. It's the real
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impact on relationships as a central part of who the
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person is.
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You know, and we know that when hearing loss is
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added to a dynamic, it can lead to, you know,
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social isolation and, you know, you're not reaching out to
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your friends to participate like you would. Do you think
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that there's a personal perception of ageism that makes people
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reluctant to use hearing aids or to have their hearing tested,
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you know, a denial?
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It is. I think that probably the aesthetics of a
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hearing aid is much less so now because they're so small.
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That used to be a big thing in terms of
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being able to see the hearing aid and that being
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a signifier, if you will, of the loss and the
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fact that they're older. So probably the vision part of
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it is less so now, but I really do think
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it's the same thing around that because it identifies you
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as being older or they feel it is, that it
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is related to ageism. And because the person may need
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to have, you know, repeat or that is have people
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who are assumed to be cognitively impaired because they're not
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hearing the information correctly. So you're making assumptions again about
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the person being cognitively impaired or not with it all
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the time. And there's slower learning. I mean, because, you know,
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we process slower and it really takes an effort to
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try and hear and listen when you have hearing loss.
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Medicare focuses so much on cognition and we're all talking
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about brain health, but that seems like such an easy
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modifiable factor that we can address. And, you know, as
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a gerontological nurse practitioner, do you believe hearing screening should
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be a routine part of primary care?
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And what would that benefit our older patient populations?
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Yeah, well, I have to admit I'm biased, but I
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have a strong yes. I do think it's screening. But
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I think it's, you know, I know the U.S. Preventative
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Services Task Force says that there's no data that support
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the benefits of routine screening on persons who don't complain
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about hearing loss. But the data are hard to get,
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for one thing, and they only look at randomized controlled trials.
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So the data are really sparse for what they have
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to look at. Now, right from that standpoint, the data
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aren't there. But the truth is, people often don't realize
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how bad their hearing is because it comes on slowly,
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they adapt, and they don't really want to admit what
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it is. So they get used to it. So we
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miss it if you don't screen for it. Two, because
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your brain fills in They often may think they're hearing
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correctly when you're giving them information on their regimen and
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so forth. But I've had people, it's just a reason,
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you know, say that they did. That person said, you know,
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when I left, I suddenly realized I'm not sure what
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the person said. You know, it's kind of looking back
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or looking at the notes now that they like the
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notes that come out if they get them. Oh, I
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don't remember hearing that or that's different or mistaking what
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the person said about medication. So I think from a
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safety standpoint and for doing things like setting up stuff
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like an MRI, if you have hearing loss or you're
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wearing a hearing aid, you can't use them in an MRI.
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How are you going to signal? And I've had colleagues
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share their experiences trying to get being put in an
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MRI and having all their hearing aids and everything taken away.
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And they're sitting there, oh, I know what you're telling me,
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you know. And they'll say, well, we'll tell you. I
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won't hear you. So you have to have thinking about
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those things in terms of the exams or experiences or
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what happens in the ER. So if we screen for
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it and we have it in the record and we
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look at it, we use it, we can set up.
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And people are hesitant in a short visit to bring
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it up. They're sort of, you know, they know they're rushed.
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Everybody's rushed and they're thinking about the condition they've got.
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So if you want to be part of care planning,
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if you want to be part of the communication, you
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really need to have accurate information. It's a safety issue
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from my standpoint. Yeah.
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And at least part of the annual Medicare wellness visit,
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you know, incorporated into that.
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So yeah, good.
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And it should be standardized.
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Yes. You know, and available for practices.
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Yes.
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You know, it should be something that, you know, is
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easily accessible.
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And I recall dating myself with studying theories of aging
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in my gerontologic nurse practitioner program in the 1990s. And,
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you know, learning that many of the symptoms were considered
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just a normal part of the aging process. And you
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recently participated in a policy dialogue that was presented by
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the American Academy of Nursing called Ageism, Removing Stereotypes Through
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a Geroscience Lens.
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Will you share with us your current.
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Understanding of how geroscience can combat ageist stereotypes?
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Well, I think we hope that through a realization that
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the changes that we see with aging really occur across
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time and are malleable. that persons really don't all age
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in a similar way. This gets somewhat back to my
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person environment idea, because so much of what we experience
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in our cellular function is very much influenced by the
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environments that we have. And aging basically starts as people
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really do know, theoretically, as soon as we are born.
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It's a change that occurs across time. And We have
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to maximize, if you think about the changes that occur
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with aging, we talk about bone loss. You have to
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start with maximizing your bone health during your teen years
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and maybe early into your 20s. The same with respiratory problems.
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You start smoking when you're a teen, you're not going
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to have the reserves. So if you want to have
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the reserves that make a big difference in terms of
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how resilient you are as you get older, you need
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to start early. You can't start when you're 65. So
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you want to maximize your bone health and others. So
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I think incorporating concepts relating to the neuroscience in that
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we can make a difference, hopefully at the cellular level,
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that will influence our resilience It doesn't solve all the problems.
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It's not like we won't age. It's not like we
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don't want to dump a bunch of guilt on individuals
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in terms of the problems that they face. But from
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a policy perspective, from a healthcare perspective, setting up situations
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where people aren't exposed to toxins in the air, setting
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up situations where they can safely walk, all of those
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kinds of things across the lifespan. And then you can
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see that there's ways of the health span, not the
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lifespan in person, but the health span can be improved
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across time. And I think that's where the concepts of
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neuroscience can be most beneficial.
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And I like that.
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I'm going to adopt that health span, not lifespan.
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And of course, then we always have planetary health, you know,
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and living in California, you understand some of that impact.
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So hopefully, you know, upcoming generations will be able to
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answer some of these questions for us.
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Yes.
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And going back to our next question. So you have
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emphasized that aging should be understood as a continuous biological
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process across the health span, not the lifespan, rather than
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just simply a collection of age-related diseases. Yet many clinicians
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still describe symptoms as just old age. You know, I
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know even in my practice, I've heard surgeons say that
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delirium is something that they expect.
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Happening in their older adults post-operatively.
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And in nursing education, aging is often condensed into only
401
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a few slides at the end of a presentation titled,
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Age-Related Changes. How can we shift pre-licensure and graduate nursing
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education to better reflect this broader understanding of health span?
404
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Well, obviously, this has been a concern of mine for
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a long time. When we see that Again, getting back
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to this idea that there are multiple aging trajectories, I
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think that we can begin to realize we can't make assumptions.
408
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But I think that starting with a lifespan perspective in
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the early educational experiences and integrating this idea of building
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resilience early on, the critical nature of that as a
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base to aging well, if you will, You know, I
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know that there are concerns always about adding more to
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the curriculum and so forth. But if we spend a
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lot of time on peds, it's great if we think
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about and build in the fact that the actress is
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moving to where you want to make them well enough
417
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that they're going to age in a healthy way. So
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I do think we need to better incorporate the idea
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that we have an opportunity to make sure that people
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are healthy throughout their life course. And maybe starting with
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that concept of a lifespan approach, building in more cases
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in terms of looking at people across time, looking at
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how different trajectories might influence where that person will be
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down the line. That's a way of, I think, into
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right now, the integration is much more like you say,
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the same thing with make sure they're hearing a different place,
427
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this little piece that just gets in there in terms
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of it. But The fact that you can make sure
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to have people emphasize over and over that how you
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age is malleable. Not like you can solve all the problems.
431
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And because you get cancer doesn't necessarily mean you did
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something wrong. You don't want to add stigma to that.
433
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But to realize that there are ways that we can
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minimize our risk for not having resilience when we get older.
435
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So I do think they need to be built in.
436
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And I wish, I think... making physiology exciting. I love physiology,
437
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but a lot of nurses, unfortunately, sort of are afraid
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of that. And yet for me, unless you understand the
439
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process underlying the issues, it's hard for me to memorize stuff.
440
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So trying to make physiology a lot more exciting in
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terms of saying, here are ways we can actually, you know,
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potentially make this different in terms of how people function
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and looking at intrinsic capacity across the lifespan.
444
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And, you know, we focus so much on acute care
445
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in pre-licensure that we know that resilience, you know, has
446
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everything to do with an older adult's response to an
447
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acute illness or hospitalization.
448
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Yeah.
449
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So my faculty background in graduate population health. So I
450
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can imagine I can just imagine an age friendly health
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care framework. you know, from community to long-term care, being
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adapted for nursing education. And I know that you've written
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some about this, but could you share your thoughts on
454
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how that framework could be operationalized within the nursing education curriculum?
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Well, first of all, I think when we think about
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age-friendly nursing, It just says age. That could be anything.
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And again, you think of life course. It should be
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age appropriate, person friendly. Of course, I don't think health
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care should be that in general that we should always do.
460
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But I think coming at it from the idea of
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what is friendly for a person's age across the lifespan?
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How do we make settings? And I think one way
463
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to begin to look at that is it fits in
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some ways with the concepts around lifespan and universal design.
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Because universal design, again, gets at making environments friendly to everyone,
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no matter what their disability, no matter what. And I
467
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think being more aware and building into curricula in terms
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of looking at health lifespan, life trajectory, age, I want
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to call it age appropriate, friendly environments could be a
470
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way to sort of frame using case studies, using models
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of care, using whatever to sort of build that across time.
472
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So I think that's one way of looking at it.
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But I think it would be a great model for education.
474
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And it's interesting.
475
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You think about everything that we've learned about age-friendly health care.
476
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You know, we probably learned in our first semester of
477
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nursing school, you know, not really, you communication and what
478
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matters and mobility. So all of these things, you know, very,
479
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very basic, but integral to healthy lifespan.
480
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Yeah, it is.
481
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I want to thank you so much for this conversation today.
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Do you have any parting thoughts that you'd like to
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share with our audience today?
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I would say, especially in gerontological nursing and also when
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nurses think about research, Keep asking questions, never stop learning.
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But also, I think we sometimes look to NINR and
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some of the national centers to set the research agenda.
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And from my perspective, unfortunately, that misses a lot of
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the problems that we see in clinical practice. So I've
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seen nurses turn away from their research passion because they
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think they won't get funded. And I find that very sad.
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And I know it's a problem, especially early in your career.
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But we really do have a lot of issues that
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older adults deal with that influence quality of life, that
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are beyond caregiving, that are beyond some of the things
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that we tend to see as the funding priorities. And
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it would be really nice to see us take some
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of those on. And be more in charge of the
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research agenda than giving it off to some other individuals
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who have their own priorities.
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Yeah, unfortunately, we tend to be driven by other people's
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agendas and oftentimes.
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And not funding. Yes.
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Well, thank you again, Dr.
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Walhagen, and to our audience for joining us on this episode.
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of Gapna Chat. So until next time, be kind to
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others and remember to be kind to yourself.
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Thank you.
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Gapna Chat is owned and produced by the Gerontological Advanced
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Practice Nurses Association. All rights reserved. No portion of this
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00:29:59.880 --> 00:30:04.359
podcast may be used without written permission. A practical guide
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00:30:04.420 --> 00:30:08.269
for the gerontological specialist is now available for purchase in
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00:30:08.329 --> 00:30:12.069
the Gapna store. This text is a handy resource for
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00:30:12.230 --> 00:30:15.650
anyone caring for older adults and is helpful to those
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00:30:15.750 --> 00:30:23.359
preparing to sit for the gerontological specialist certified exam. Visit www.gapna.org
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00:30:23.500 --> 00:30:24.380
to get your copy.
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00:30:25.789 --> 00:30:26.130
Dr.
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Margaret Wolhagen is a professor of gerontological nursing and a
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00:30:30.230 --> 00:30:34.750
geriatric nurse practitioner at the University of California, San Francisco.
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00:30:35.470 --> 00:30:35.789
Dr.
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Wolhagen became the director of UCSF John A. Hartford Center
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for Geriatric Nursing Excellence in 2006 and is the Senior
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00:30:45.259 --> 00:30:50.829
Nurse Scholar for the Veterans Administration's Quality Scholars. Dr. Cassandra
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00:30:50.869 --> 00:30:54.450
Van Ness is the Nurses Improving Care for Health System
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00:30:54.589 --> 00:31:00.210
Elders Niche Coordinator, Geriatric Oncology at the Moffitt Cancer Center
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00:31:00.329 --> 00:31:03.829
in Tampa, Florida. She is a member of the Gerontological
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00:31:03.890 --> 00:31:08.670
Advanced Practice Nurses Association Communication Team and is a host
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00:31:08.869 --> 00:31:14.279
of the GapnaChat podcast series. For archived episodes of GapnaChat
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00:31:14.579 --> 00:31:19.119
and to learn more about the Gerontological Advanced Practice Nurses Association,
530
00:31:19.640 --> 00:31:25.079
visit gapna.org. You can also subscribe to Gapna Chat everywhere
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00:31:25.200 --> 00:31:26.380
podcasts are found.
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Hello and welcome to GapnaChat, an official podcast of the
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Gerontological Advanced Practice Nurses Association. GapnaChat provides interviews and discussions
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with Gapna leaders and members of the gerontological healthcare community
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and will focus on advocacy, policy, education, professional development, research,
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and clinical care for older adults. Before we get started...
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If you are an advanced practice nurse caring for older
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adults and want to further your career, GAPNA encourages you
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to sit for the Gerontological Specialist Certified Exam and earn
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your GSC credential. This expert certification distinguishes APRNs with the
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knowledge and experience to manage the complex health needs of
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older adults. Visit gerocert.org to learn more. In this episode... Dr.
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Cassandra Vaughness, a gerontological nurse practitioner and member of the
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GAPNA communication team, talks with Dr. Margaret Wolhagen, a professor
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of gerontological nursing and a geriatric nurse practitioner at the
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University of California, San Francisco. Dr. Wolhagen reflects on her
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career in gerontological nursing and her research on aging, hearing loss,
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and person-environment fit. She highlights the importance of addressing ageism
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incorporating hearing health into routine care, and promoting a lifespan
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approach to healthy aging. We are pleased to present Dr.
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Vaughness's interview with Dr. Wolhagen.
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Good morning, everyone. This is Dr.
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Cassandra Van Ness with Gap in the Chat. And today
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we have Dr. Margaret Walhagen.
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And Dr.
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Walhagen is a professor of gerontological nursing and a geriatric
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nurse practitioner at the University of California, San Francisco. She
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earned her nursing degrees from St. Luke's Hospital, UCSF, and
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the University of Washington. Her clinical experience includes critical care
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and mentoring nursing students. Joining UCSF in 1988, she has
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taught gerontological nursing at all levels.
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Dr.
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Walhagen's research focuses on caregivers, diabetes education, aging with chronic conditions, self-care,
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cross-cultural intervention, family conflict, and the effects of hearing loss
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on older adults. a four-year study analyzing how older adults
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and their partners and families experience and manage age-related hearing loss.
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This work laid the foundation for her later research on
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how hearing loss stigma affects help-seeking behaviors. In 2006, she
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became the director of UCSF John A. Hartford Center of
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Geriatric Nursing Excellence, preparing nurse leaders to care for an
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aging population.
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Dr.
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Walhagen is also the Senior Nurse Scholar for the Veterans
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Administration's Quality Scholars. Community service includes board roles at Family
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Caregiver Alliance, Bread for the World, the American Geriatric Society,
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and the Hearing Loss Association of America.
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Dr.
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Walhagen, thank you so much for joining us for Gap
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in the Chat. To begin with, what would you say
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to your younger self as you started nursing school at St.
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Luke's Hospital of Nursing in New York City, knowing now
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where your career would eventually lead?
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Well, you know, it's interesting. Thank you for the invitation
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for us to join this podcast and for the interest
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in my career. You know, when I saw this question,
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I really had to think because it really requires sort
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of a hindsight as well, forethought, if you will. And
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so much has changed since I entered nursing school. And
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my decision to attend was really significantly influenced by cost
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at that time. That said, when thinking about available career
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options at the time, they really sort of included nursing
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and teaching. I thought at the time I couldn't be
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a teacher, so I wasn't sure about that role, and
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I had received a regent scholarship. I grew up in
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New York State to attend the state university, but I
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thought the focus would be much more on the teaching,
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and I didn't think I could do that. And also, really, St.
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Luke's just seemed like, because it was a training school
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of nursing, a three-year all-around program, that it was the
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right fit for me at the time. However, during the
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time that I was there, they changed the regulations, so
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I didn't get any college credit for the three years
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I was there, the time I graduated. They sort of
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had to start over again. and go to a lot
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of evening school to get credits to go back to
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get my BS and master's. And in truth, looking back,
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I don't regret the route I took in many ways
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because St. Luke's was really an excellent program. And I
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learned so much going to evening school. I mean, it
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was just opened a whole new world for me that
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at that time. I probably was more prepared for than
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maybe when I graduated from high school. So my path
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might have been smoother going directly to the university. But
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I think the lessons that I learned and the opportunities
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I had were unique. But I would say maybe the
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one thing I would say to someone entering the school
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is really be open to opportunities. And interestingly enough, I
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would say keep a log of your experiences and how
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they fit with your goals for life's work. and seek
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out mentors who can provide guidance and support. I could
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have used a lot more mentors during my career. So
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I value mentorship a great deal. But I do think
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keeping track, looking at what your passions are makes a
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really big difference.
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It's funny how after a point in your nursing career,
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you know, you are focusing on teaching when you turned
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away from that career path that early.
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It's interesting.
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Can you share a little bit about your background, your
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clinical experiences, and then what led you to pursue gerontological nursing?
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Much of my career was, as you noted in the introduction,
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was in acute care, and especially ICU, which I love
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because I learned a great deal. But then after I finished, finally,
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my BS and master's, I ended up teaching at California
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State University, Chico. And I realized that if I wanted
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to stay in teaching, I needed to get my doctorate.
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And so I was exploring options at that time. Interestingly enough,
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I had two colleagues that we were thinking of going
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to back the doctoral programs together. But as it turned out,
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one went to UC San Francisco for sociology, another decided
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not to do anything. And I ended up in Seattle.
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So we sort of all went different ways. But when,
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at that time, I was, when I was considering the focus,
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I'd been doing, I'm very interested in neurology, very interested
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in chronic illness, because what I saw was in chronic illness,
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and that really looking at individuals who had often experienced
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what they were experiencing chronic illness, and that drew me
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increasingly to study issues of aging and gerontology and all
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the factors that influence how older adults dealt with the
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changes because I was interested in physiology, interested in neurological changes.
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And so as part of my work, what led me
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into the doctoral program was got very interested in how
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individuals interact within their environment. So the concepts of person-environment
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fit became really important to me, very much influenced by
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some of the work that M. Powell Lawton did, a
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wonderful environmental gerontologist, and also interested in concept of control
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that was introduced to me quite a bit initially by Dr.
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Fran Lewis, who's also a brilliant family researcher. My concepts,
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because I got actually very angry at the concepts, the
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idea of locus of control and so forth, probably because
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I realized in chronic illness and aging, so much of
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life is not controllable. I mean, it's not like we
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can be in control of things. So I developed sort
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of my own theoretical model around that. But that all
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really was influenced in looking at the care of older adults.
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And it's still central to my work because we do
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sort of focus a lot on being in control. And
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As I think you know, many times chronic illnesses, other
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experiences are not so easily controlled, but they can be
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managed and often giving over control to other people or
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other ways of being able to manage things. So it's
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a central piece of my work, but that's kind of
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how I got into gerontology and realizing the importance of
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looking at the environment that individuals are in and how
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that very much influences how we can age in the
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most healthy way.
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And that's an important concept for nurses to embrace, to
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return the older adult as much locus of control that
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we can provide them.
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And we don't do a very good job of that,
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especially in critical care. We don't at all.
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But thinking about it from the standpoint of manageability, because
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maybe they do need to not necessarily make the decisions themselves,
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but they want their families engaged. And so looking at
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what works for that individual, in the concept of a
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person environment fit, you know, the resources they have, the
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resources they need, and all of those kinds of things. So.
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Thank you.
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And you've conducted extensive research on the impact of hearing
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loss and identified it as a potential risk factor for
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a range of poor health outcomes in older adults. What
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drew you to this area of gerontological research?
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Well, it's a great question because as I mentioned before,
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one of my areas of research when I was in
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my doctoral program was caregivers. And I continued that in
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the theoretical concepts I just talked about. But when I graduated,
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I stayed in that area. I did work on caregivers
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of persons who have diabetes. But after one project, I
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started to wonder about my next steps. Where do I go?
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There just was a lot of work already being done
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in caregiving. And that was a long time ago. We're
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still doing a lot of that work. And I kept
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asking myself, what can I contribute to this body of work?
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And at that time I had had the opportunity of
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working with colleagues at the Alameda County study. My husband
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happened to be a project director there. And every time
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he was talking about different research things that I always,
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always say, what's the clinical implication for this epidemiological work
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that's happening. But we started looking at the data around
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hearing loss and that made me more engaged with persons
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who had hearing loss, as well as looking at those
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data and seeing the impact itself. And so I started thinking, well,
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what do nurses and physicians know about hearing loss? And
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I realized when I, especially in the area of nursing
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or when you looked at textbooks, they'd often meet just
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this little paragraph on hearing. And often it would also
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just say, make sure the hearing aids are in place.
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And so I said, well, okay. And so I asked
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nurses and others around me, I said, do you know
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how to do anything with a hearing aid? Would you
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know what to do? And all people would sort of
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say no, or they'd worry because they whistled and didn't
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realize why they whistled. And so I thought, there really
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isn't much data on this. And yet it has a
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major impact. So I started looking into that more. And
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I made a very conscious decision that I was going
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to focus my work where I thought I could maybe
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make a difference. And it may be, I have to admit,
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at that point, my career was not necessarily the wisest,
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partly because I had a lot of trouble convincing NINR
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that hearing loss was a nursing issue. And so it
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was a lonely field at that time. People, you know,
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it's not exciting to a lot of people, but I
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became very passionate and got very engaged. And the more
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I got engaged with people who had significant hearing loss
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and the impact it had, it just sort of stimulated more.
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So that's how I got here. And I'm not sorry
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I did it.
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So in your NINR-funded longitudinal study that you explained, you
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explored how older adults and their partners and families experience
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and manage age-related hearing loss. You know, we all talk
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about normal changes associated with aging and hearing is one
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of those normal part of physiologic aging.
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But why do you think the stigma around it still
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exists in aging?
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It's an interesting question in many ways, because many people
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feel that now it'll go away because so many people wear,
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you know, like earbuds, things that you're listening to all
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the time. But in truth, I think it's a different issue.
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And hearing aids are not like glasses. You don't put
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them on and hear. And I'm talking about glasses for
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normal changes that we usually expect, not things like macular degeneration.
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I would say that hearing loss is more akin to
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something like macular degeneration or something like that, because it's
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not just a decrease in sound. It's not something that's
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cured or totally fixed by hearing aids. And hearing, it's
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the meaning of hearing, I think, that is the problem,
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is that, one, people do associate it with, even if
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it occurs across the lifespan, they associate it with aging,
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and they associate it with disability. And I've had people
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tell me, you know, I have this problem, this problem,
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and now all of a sudden I have a hearing loss.
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This says I'm old. And that's unfortunate. So there's a
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piece of that. But beyond that, I think the real
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reason is that it's so central to communication. Now, there's
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lots of modes of ways of communicating. And persons who
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are deaf from birth or early on use sign language,
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which is its own language. And that's one area of communication.
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But persons who become hearing impaired don't tend to sign.
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They use captions. They use other ways of accessing communication.
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But when you're in conversation with someone, it's so key
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to being able to hear what people say to make
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it comfortable. And the person you're talking to has to
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be able to understand how to communicate in a way
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that relates. Those are both effortful activities. And some people
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with hearing loss often fade out in the background or
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get tired of saying, you know, I didn't understand what
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you say. So even if they have hearing aids, they
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don't work perfectly. You still because it's not fixing the problem.
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It's making it better, but they don't always work in
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all these situations. So I think it's really partly that
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it's this idea of its impact on communication, its impact
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on relationships. And it does because in partners, people would
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say if the person with hearing loss didn't accept it,
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didn't want to do anything about it, they'd say, OK,
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you know, they'd start information paucity. I don't want to
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take the effort to talk about this because it takes
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so much time. So it's it really does influence relationships.
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So I think that's part of it. It's the real
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impact on relationships as a central part of who the
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person is.
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You know, and we know that when hearing loss is
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added to a dynamic, it can lead to, you know,
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social isolation and, you know, you're not reaching out to
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your friends to participate like you would. Do you think
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that there's a personal perception of ageism that makes people
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reluctant to use hearing aids or to have their hearing tested,
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you know, a denial?
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It is. I think that probably the aesthetics of a
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hearing aid is much less so now because they're so small.
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That used to be a big thing in terms of
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being able to see the hearing aid and that being
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a signifier, if you will, of the loss and the
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fact that they're older. So probably the vision part of
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it is less so now, but I really do think
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it's the same thing around that because it identifies you
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as being older or they feel it is, that it
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is related to ageism. And because the person may need
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to have, you know, repeat or that is have people
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who are assumed to be cognitively impaired because they're not
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hearing the information correctly. So you're making assumptions again about
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the person being cognitively impaired or not with it all
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the time. And there's slower learning. I mean, because, you know,
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we process slower and it really takes an effort to
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try and hear and listen when you have hearing loss.
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Medicare focuses so much on cognition and we're all talking
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about brain health, but that seems like such an easy
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modifiable factor that we can address. And, you know, as
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a gerontological nurse practitioner, do you believe hearing screening should
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be a routine part of primary care?
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And what would that benefit our older patient populations?
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Yeah, well, I have to admit I'm biased, but I
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have a strong yes. I do think it's screening. But
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I think it's, you know, I know the U.S. Preventative
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Services Task Force says that there's no data that support
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the benefits of routine screening on persons who don't complain
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about hearing loss. But the data are hard to get,
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for one thing, and they only look at randomized controlled trials.
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So the data are really sparse for what they have
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to look at. Now, right from that standpoint, the data
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aren't there. But the truth is, people often don't realize
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how bad their hearing is because it comes on slowly,
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they adapt, and they don't really want to admit what
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it is. So they get used to it. So we
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miss it if you don't screen for it. Two, because
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your brain fills in They often may think they're hearing
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correctly when you're giving them information on their regimen and
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so forth. But I've had people, it's just a reason,
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you know, say that they did. That person said, you know,
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when I left, I suddenly realized I'm not sure what
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the person said. You know, it's kind of looking back
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or looking at the notes now that they like the
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notes that come out if they get them. Oh, I
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don't remember hearing that or that's different or mistaking what
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the person said about medication. So I think from a
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safety standpoint and for doing things like setting up stuff
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like an MRI, if you have hearing loss or you're
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wearing a hearing aid, you can't use them in an MRI.
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How are you going to signal? And I've had colleagues
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share their experiences trying to get being put in an
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MRI and having all their hearing aids and everything taken away.
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And they're sitting there, oh, I know what you're telling me,
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you know. And they'll say, well, we'll tell you. I
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won't hear you. So you have to have thinking about
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those things in terms of the exams or experiences or
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what happens in the ER. So if we screen for
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it and we have it in the record and we
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look at it, we use it, we can set up.
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And people are hesitant in a short visit to bring
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it up. They're sort of, you know, they know they're rushed.
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Everybody's rushed and they're thinking about the condition they've got.
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So if you want to be part of care planning,
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if you want to be part of the communication, you
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really need to have accurate information. It's a safety issue
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from my standpoint. Yeah.
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And at least part of the annual Medicare wellness visit,
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you know, incorporated into that.
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So yeah, good.
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And it should be standardized.
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Yes. You know, and available for practices.
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Yes.
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You know, it should be something that, you know, is
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easily accessible.
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And I recall dating myself with studying theories of aging
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in my gerontologic nurse practitioner program in the 1990s. And,
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you know, learning that many of the symptoms were considered
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just a normal part of the aging process. And you
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recently participated in a policy dialogue that was presented by
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the American Academy of Nursing called Ageism, Removing Stereotypes Through
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a Geroscience Lens.
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Will you share with us your current.
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Understanding of how geroscience can combat ageist stereotypes?
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Well, I think we hope that through a realization that
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the changes that we see with aging really occur across
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time and are malleable. that persons really don't all age
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in a similar way. This gets somewhat back to my
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person environment idea, because so much of what we experience
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in our cellular function is very much influenced by the
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environments that we have. And aging basically starts as people
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really do know, theoretically, as soon as we are born.
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It's a change that occurs across time. And We have
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to maximize, if you think about the changes that occur
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with aging, we talk about bone loss. You have to
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start with maximizing your bone health during your teen years
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and maybe early into your 20s. The same with respiratory problems.
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You start smoking when you're a teen, you're not going
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to have the reserves. So if you want to have
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the reserves that make a big difference in terms of
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how resilient you are as you get older, you need
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to start early. You can't start when you're 65. So
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you want to maximize your bone health and others. So
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I think incorporating concepts relating to the neuroscience in that
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we can make a difference, hopefully at the cellular level,
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that will influence our resilience It doesn't solve all the problems.
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It's not like we won't age. It's not like we
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don't want to dump a bunch of guilt on individuals
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in terms of the problems that they face. But from
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a policy perspective, from a healthcare perspective, setting up situations
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where people aren't exposed to toxins in the air, setting
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up situations where they can safely walk, all of those
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kinds of things across the lifespan. And then you can
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see that there's ways of the health span, not the
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lifespan in person, but the health span can be improved
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across time. And I think that's where the concepts of
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neuroscience can be most beneficial.
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And I like that.
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I'm going to adopt that health span, not lifespan.
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And of course, then we always have planetary health, you know,
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and living in California, you understand some of that impact.
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So hopefully, you know, upcoming generations will be able to
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answer some of these questions for us.
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Yes.
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And going back to our next question. So you have
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emphasized that aging should be understood as a continuous biological
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process across the health span, not the lifespan, rather than
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just simply a collection of age-related diseases. Yet many clinicians
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still describe symptoms as just old age. You know, I
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know even in my practice, I've heard surgeons say that
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delirium is something that they expect.
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Happening in their older adults post-operatively.
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And in nursing education, aging is often condensed into only
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a few slides at the end of a presentation titled,
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Age-Related Changes. How can we shift pre-licensure and graduate nursing
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education to better reflect this broader understanding of health span?
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Well, obviously, this has been a concern of mine for
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a long time. When we see that Again, getting back
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to this idea that there are multiple aging trajectories, I
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think that we can begin to realize we can't make assumptions.
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But I think that starting with a lifespan perspective in
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the early educational experiences and integrating this idea of building
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resilience early on, the critical nature of that as a
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base to aging well, if you will, You know, I
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know that there are concerns always about adding more to
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the curriculum and so forth. But if we spend a
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lot of time on peds, it's great if we think
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about and build in the fact that the actress is
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moving to where you want to make them well enough
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that they're going to age in a healthy way. So
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I do think we need to better incorporate the idea
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that we have an opportunity to make sure that people
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are healthy throughout their life course. And maybe starting with
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that concept of a lifespan approach, building in more cases
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in terms of looking at people across time, looking at
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how different trajectories might influence where that person will be
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down the line. That's a way of, I think, into
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right now, the integration is much more like you say,
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the same thing with make sure they're hearing a different place,
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this little piece that just gets in there in terms
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of it. But The fact that you can make sure
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to have people emphasize over and over that how you
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age is malleable. Not like you can solve all the problems.
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And because you get cancer doesn't necessarily mean you did
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something wrong. You don't want to add stigma to that.
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But to realize that there are ways that we can
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minimize our risk for not having resilience when we get older.
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So I do think they need to be built in.
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And I wish, I think... making physiology exciting. I love physiology,
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but a lot of nurses, unfortunately, sort of are afraid
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of that. And yet for me, unless you understand the
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process underlying the issues, it's hard for me to memorize stuff.
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So trying to make physiology a lot more exciting in
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terms of saying, here are ways we can actually, you know,
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potentially make this different in terms of how people function
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and looking at intrinsic capacity across the lifespan.
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And, you know, we focus so much on acute care
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in pre-licensure that we know that resilience, you know, has
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everything to do with an older adult's response to an
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acute illness or hospitalization.
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Yeah.
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So my faculty background in graduate population health. So I
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can imagine I can just imagine an age friendly health
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care framework. you know, from community to long-term care, being
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adapted for nursing education. And I know that you've written
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some about this, but could you share your thoughts on
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how that framework could be operationalized within the nursing education curriculum?
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Well, first of all, I think when we think about
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age-friendly nursing, It just says age. That could be anything.
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And again, you think of life course. It should be
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age appropriate, person friendly. Of course, I don't think health
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care should be that in general that we should always do.
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But I think coming at it from the idea of
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what is friendly for a person's age across the lifespan?
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How do we make settings? And I think one way
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to begin to look at that is it fits in
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some ways with the concepts around lifespan and universal design.
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Because universal design, again, gets at making environments friendly to everyone,
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no matter what their disability, no matter what. And I
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think being more aware and building into curricula in terms
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of looking at health lifespan, life trajectory, age, I want
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to call it age appropriate, friendly environments could be a
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way to sort of frame using case studies, using models
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of care, using whatever to sort of build that across time.
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So I think that's one way of looking at it.
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But I think it would be a great model for education.
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And it's interesting.
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You think about everything that we've learned about age-friendly health care.
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You know, we probably learned in our first semester of
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nursing school, you know, not really, you communication and what
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matters and mobility. So all of these things, you know, very,
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very basic, but integral to healthy lifespan.
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Yeah, it is.
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I want to thank you so much for this conversation today.
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Do you have any parting thoughts that you'd like to
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share with our audience today?
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I would say, especially in gerontological nursing and also when
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nurses think about research, Keep asking questions, never stop learning.
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But also, I think we sometimes look to NINR and
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some of the national centers to set the research agenda.
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And from my perspective, unfortunately, that misses a lot of
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the problems that we see in clinical practice. So I've
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seen nurses turn away from their research passion because they
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think they won't get funded. And I find that very sad.
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And I know it's a problem, especially early in your career.
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But we really do have a lot of issues that
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older adults deal with that influence quality of life, that
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are beyond caregiving, that are beyond some of the things
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that we tend to see as the funding priorities. And
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it would be really nice to see us take some
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of those on. And be more in charge of the
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research agenda than giving it off to some other individuals
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who have their own priorities.
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00:29:27.029 --> 00:29:30.490
Yeah, unfortunately, we tend to be driven by other people's
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agendas and oftentimes.
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And not funding. Yes.
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Well, thank you again, Dr.
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Walhagen, and to our audience for joining us on this episode.
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of Gapna Chat. So until next time, be kind to
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others and remember to be kind to yourself.
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00:29:49.319 --> 00:29:49.730
Thank you.
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Gapna Chat is owned and produced by the Gerontological Advanced
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00:29:55.700 --> 00:29:59.839
Practice Nurses Association. All rights reserved. No portion of this
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00:29:59.880 --> 00:30:04.359
podcast may be used without written permission. A practical guide
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00:30:04.420 --> 00:30:08.269
for the gerontological specialist is now available for purchase in
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00:30:08.329 --> 00:30:12.069
the Gapna store. This text is a handy resource for
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00:30:12.230 --> 00:30:15.650
anyone caring for older adults and is helpful to those
515
00:30:15.750 --> 00:30:23.359
preparing to sit for the gerontological specialist certified exam. Visit www.gapna.org
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00:30:23.500 --> 00:30:24.380
to get your copy.
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00:30:25.789 --> 00:30:26.130
Dr.
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00:30:26.170 --> 00:30:30.150
Margaret Wolhagen is a professor of gerontological nursing and a
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00:30:30.230 --> 00:30:34.750
geriatric nurse practitioner at the University of California, San Francisco.
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00:30:35.470 --> 00:30:35.789
Dr.
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00:30:35.829 --> 00:30:40.339
Wolhagen became the director of UCSF John A. Hartford Center
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00:30:40.390 --> 00:30:45.200
for Geriatric Nursing Excellence in 2006 and is the Senior
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00:30:45.259 --> 00:30:50.829
Nurse Scholar for the Veterans Administration's Quality Scholars. Dr. Cassandra
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00:30:50.869 --> 00:30:54.450
Van Ness is the Nurses Improving Care for Health System
525
00:30:54.589 --> 00:31:00.210
Elders Niche Coordinator, Geriatric Oncology at the Moffitt Cancer Center
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00:31:00.329 --> 00:31:03.829
in Tampa, Florida. She is a member of the Gerontological
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00:31:03.890 --> 00:31:08.670
Advanced Practice Nurses Association Communication Team and is a host
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00:31:08.869 --> 00:31:14.279
of the GapnaChat podcast series. For archived episodes of GapnaChat
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00:31:14.579 --> 00:31:19.119
and to learn more about the Gerontological Advanced Practice Nurses Association,
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00:31:19.640 --> 00:31:25.079
visit gapna.org. You can also subscribe to Gapna Chat everywhere
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00:31:25.200 --> 00:31:26.380
podcasts are found.
