Erasmus Intensive Programmes Focusing on Care of the Elderly: An Innovative Nursing Educational Tool?

Introduction: The Erasmus Intensive Programme (IP) is a short term programme of study lasting from 10 continuous days to a maximum of six weeks of subjec t related work by bringing together students and st aff from higher education institutions of at least three EU countries. Aim: The purpose of this paper is to describe the conte nt of a sequence of three IPs on older people’s car e and describe their relevance in contemporary nursing ed ucation. Method: This discussion paper uses reflective analysis via presentation of the key features of the three IPs i.e.: Aims, Objectives, Target groups, Main activities, L earning Outcomes and Outputs followed by a short re flective commentary on each IP by the lead participant. Results: Students and staff involved have demonstrated enth usiasm for the three EIPs ability to foster new curricula approaches and innovative educational ski lls such as open exchanges of views, cross cultural exchange of ideas, in a truly multinational classroom enviro nment. Conclusions: IPs benefited students and staff involved by broad ening their horizons concerning health care for the elderly. Also, students learned from cross-cult ura stimulation and non-conventional ways of probl em solving and subsequently gained new perspectives on their chosen professions. Similarly, tutors benefi ted from unique insights into different ways of teaching and motivation techniques.


Introduction
The rising number of elderly in all European countries is of increasing concern to both National Governments and EU Headquarters. Of vital importance is to keep these generations of aging citizens, especially those over the age of 75 in continuing good health and independent (European Commission, 2009). Their physical, mental, social, cultural and spiritual/psychic wellbeing also needs protecting within dignified and secure environments (Rechel et al., 2009;Christensen et al., 2009).
Maintaining good health through healthy lifestyles is of prime importance to nursing practice. Elderly citizens are often able to live fully active lives into ripe-old age often contributing to the daily give and take of family life or participating in out-of-house activities such as hobbies or volunteer service. These can help senior citizens to maintain their self-esteem and respected positions in society as contributing and being involved with their communities is a sign of personal well-being and social health status as well (Jonker et al., 2009;Alaphilippe, 2008).
However, there is not enough educational input to support the changing role of nurses in this context and in all European countries wide variations can be found in the role nurses play in helping older citizens in the community. Solutions to these problems exist already within Europe so what is needed is an educational tool which could be used to discuss and spread pragmatic ideas across national borders (Kotzabassaki et al., 2003).
The Erasmus Intensive Programme (IP) is an ideal tool for this as it demands a cross cultural exchange of ideas using short targeted courses.
An IP is a short programme of study which can last from a minimum of 10 continuous full days to a maximum of six weeks of subject related work by bringing together students and staff from higher education institutions of at least three EU countries. The rationale of an IP is to prepare, execute and evaluate a short course on an innovative topic, engaging multinational teaching of topics which might otherwise not be taught at all. Overall, an EIP enables participating staff to exchange views on teaching content and new curricula approaches and to test teaching methods in a truly multinational classroom environment (Enders et al., 2011;Moodie, 2008). Within the context of rising challenges regarding older people's care coupled with long-lasting austerity in Greece, three consecutive Erasmus IPs with particular focus on elderly care were organized by the Nursing Department of the Alexandrio Technological Educational Institute, Thessaloniki, Greece.
The main aim of this paper is to describe the content of a sequence of three Erasmus IPs on older people's care and describe their relevance in contemporary nursing education.

Material & Methods
The three IPs involved six institutions from five European countries, with twelve members of staff and 45 students, from 2011-2013. The generic title of the projects was Older People in Europe: New Needs (OPEN-N). Each IPs had a specific focus as follows: OPEN-N 1 (Health and Well-being of the Elderly in Europe), OPEN-N 2 (Evidence Based Practice in Elderly Care) & OPEN-N 3 (Ethical Dimensions in Older People's Care) respectively. This discussion paper uses reflective analysis via presentation of the key features of the three IPs i.e.: Aims, Objectives, Target groups, Main activities, Learning Outcomes and Outputs followed by a short reflective commentary on each IP by the lead participant (Brydges & Butler, 2012;Embree, 2011). The purpose of this reflective analysis is to provide an opportunity to examine critically our own experience from running the three IPs and to connect it to the learning objectives.

First IP -OPEN-N 1 : Health and Well-being of the Elderly in Europe
Aim: To find ways to improve and maintain good health in old age by brainstorming healthier lifestyle ideas and facilitate suggestions for improving the circumstances of this vulnerable age-group.

Objectives:
To encourage the exchange of innovative educational practises between teachers and students and share these with a multi-national classroom.
To gather and share innovative educational practises between teachers and students to be shared within multi-national classrooms.
Target groups: We looked at Elder Europeans' health and wellbeing from a broad perspective: physical, mental, social, cultural and spiritual/psychic. During six study circles preceding the IP, students compiled a portfolio that contained health and wellbeing issues regarding senior citizens in their respective countries. Participating students ranged from 1st to final year of study, were of various ages (18-28) and there was a quota of male participation of at least 20%. All shared a common interest in the field of study and showed enthusiasm for studying in a multicultural environment.

Main activities:
During the IP the students worked in transnational groups using the material in the portfolios but also other kinds of sources. Also, information technology and web-2 facilities were used to search for simple solutions concerning health improvements for the Elderly. Brainstorming cross-culturally was employed to explore innovative ideas.

Learning outcomes:
The students gained a new perspective on their chosen professions.
The staff acquired unique insights into innovative ways of teaching and motivating students.

Outputs:
The enhancement and broadening of the teaching concerning Rehabilitation and Older People's Care was achieved and a checklist of main risk factors and health issues concerning the Elderly was compiled. At the end of the IP each group presented the ideas generated for improving health outcomes of Elder Citizens in Europe, as a synthesis of the work done during the IP.

Reflective commentary
Students and staff from Finland, Greece and Lithuania participated in the first IP which involved the cross-fertilisation of ideas from a wide spectrum of students and tutors, selected from a wide range of European countries. As reported at the end of OPEN-N 1 , teachers gained insight into how to pass on, to future students, new practices and the concept of looking for simple solutions to solve sometimes complex health issues. A further benefit of this innovative approach was the initiation of close co-operation, collaboration and support between the countries involved. Students, being the core of this cooperation reported positively on their exposure and contibution to innovative ideas, good practices and pragmatic solutions. The framework of working together in a crosscultural mode enhanced the outcomes of this IP cooperation and was implemented back in their own countries.

Second IP -OPEN-N 2 : Evidence Based Practice in Elderly Care
Aim: To enable staff and students to seek viable, cost effective and most importantly evidencebased ways of improving health care delivery in European countries using lateral thinking in order to find pragmatic solutions for complex societal issues.

Objectives:
To provide an innovative forum for students and staff to find solutions to improve/maintain the health status of elderly European citizens.
To be able to work and study not only at a multinational level but in a truly cross-cultural learning environment.
Target groups: European elderly (65+) continued to be the focus of our discussions with exchange of ideas regarding their health and well-being from a broad perspective: physical, mental, social, cultural and spiritual/psychic backed by evidence based practice.

Main activities:
During the IP the students worked in transnational groups using the material in the portfolios compiled in OPEN-N 1 and other sources providing solid evidence. Moreover, IT and evidence based resources such as the Cochrane collaboration, NICE and the Joanna Briggs Institute were used to finalize the search for solutions concerning decision making in care delivery for the Elderly. Both good and poor practices were compared and discussed openly in order that participants could ascertain whether or not an innovative idea to improve services might be efficacious in their own health care system. This was also discussed considering contemporary financial, social and general constrains within each country which may influence the implementation of recommendations.

Learning outcomes:
Both staff and students learned to think 'outside the square'. This is of special value for those whose educational systems are still somewhat entrenched in rota-learning style teaching.
Both staff and students learned that cross-cultural stimulation can create unusual ways of problem solving.
Outputs: Simple solutions which were cost effective, efficacious and acceptable to old people in the current economic environment were proposed. Again, at the end of this IP each group presented their ideas to improved health outcomes of Elder Citizens, relevant to each participating country. These are summarized in a consensus statement.

Reflective commentary
Students from Finland, Greece and Portugal changed views on the notions of 'safety' and 'security' within elder populations which were explored further, with particular emphasis on falls prevention as this constitutesa a heavy burden, socially, personally and financially.
Although the main corpus of the methods remained the same as in OPEN-N1, the Finnish partner suggested that the concepts of resilience and salutogenic paradigm in elderly care could be incorporated into the programme (Antonovsky, 1987). Thus, in OPEN-N 2 , we explored key concepts within the General Resistance Resources field, i.e. innovative ways of improving elder people's lives by focusing on biological, material and psychosocial factors that can have a positive impact on their everyday lives. The reason for this is that the key content of the IP needs expanding in order to remain updated and dynamic to the international audience.

Third IP -OPEN-N 3 : Ethical Dimensions in Older People's Care
Aim: This final part of the IP continues with our innovative forums for students and staff in order to finalize with a focus on moral and ethical dilemmas pertaining to cross-cultural

Objectives:
Report on further exchanges of ideas and consolidation of innovative ideas concerning wellbeing and independence of the elderly.
Demonstrate the ability to complete a cross cultural study with all partners cooperating/contributing.

Target groups:
The primarily target group of this educational intervention remained undergraduate student nurses who partook to the third and final study phase of the OPEN-N IP series.

Main activities:
Educational activities for the project implementation included the following: At least three study circles within the students' home institution in order for the students to be more prepared at the commencement of the IP; uploading relevant material to the project's website, before, during and after the IP commences.
Learning outcomes: On completion of OPEN-N 3 , students were able to: Critically discuss ethical issues of particular concern to old people's care.
Identify nursing ethical theories influencing elder care and well-being.
Describe the moral dilemmas faced by practitioners when delivering physical, mental, social, cultural and spiritual/psychic care for the elderly Explain the health and wellbeing needs of the elderly from a broad perspective within the participating countries' health care systems.
Outputs: At the end of this IP, as an outcome of cross-cultural innovative ideas, students produced a list of main deontological and moral issues concerning the elderly. Also, key references and support material were made readily available online to the wider community. The IP's outcomes are now incorporated into the teaching of the participating institutions. Finally, further cooperation between these institutions, individual students and/or staff alike has been facilitated.

Reflective commentary
During the third phase of the OPEN-N 3 IP, run in Thessaloniki (Greece), nurse undergraduates from UΚ, Italy, Ireland, Portugal and Greece, achieved fulfillment of an innovative educational journey. Both students and teaching staff reported enhanced theoretical and practical skills concerning recognition of needs relevant to the care of ageing populations across Europe. As the main meetings were held in Greece, these European participants gained first hand insight into problems confronting those in extreme financial hardship and how essential it is to adapt and devise simple preventive strategies to ensure protective and positive health outcomes.
This programme brought considerable multilateral cooperation between staff and students from the European nursing schools involved. The exchange of problems relating to the elderly included shortcomings and strengths of each participating nursing school which encouraged greater transparency and compatibility between these educational institutions.
The notions of 'ethical care' and 'moral dilemmas' were explored further, with particular emphasis on clinical decision making. Although the main corpus of the methods remained the same as in OPEN-N 1 and OPEN-N 2 , it was suggested by the Greek partner that the concept of Deontological Ethics should be incorporated in the project. This is a prominent ethical theory which is associated with Immanuel Kant who thought that ethics should involve duty and good intent (Walford & Meerbote, 1992). Thus, this IP explored Kant's universal rules i.e..: to tell the truth, not to steal, not to kill, keep promises, and so forth.
Thus, in OPEN-N, we explored the key concepts within the Ethical paradigm of identifying innovative ways of improving elder people's lives by focusing on Deontological aspects as well as biological and psychosocial factors that have a positive impact on their everyday lives. The reason for this is that the elderly are a vulnerable section of the community who need care with a moral dimension, especially under the current economic turbulence in Europe.

Discussion
Despite minor practical organizational matters, the IPs are considered overall as a positive transcultural experience and good bonding opportunity for both students and tutors alike (Kydd et al., 2014).
The emphasis of the chosen pedagogical methods used in these IPs was to encourage the use of interactive discussions, personal creativity and multi-classroom exposure with the view of lifelong learning (LLL) and continuing education concepts. The projects also emphasized wider forms of knowledge (e.g. cultural) rather than the narrower understanding of knowledge students are expected to have, arising from more traditional methods.
In accordance with the strategy on LLL, these projects focused on systematic development of competencies, skills, learning and new thinking in education where learning in a specific organizational context does not happen in a vacuum; it evolves in a socio-cultural context. Lifelong learning per se, implies the ability to function and interact together. This is important during formal education when knowledge is created and more effectively spread if students manage to be, act, create and work together. It is a dynamic process, an interactivity in which new knowledge is generated by the cross-cultural group working together. This type of LLL is therefore not only about a single individual, concerning his/her own competence and career, but also about learning in a dynamic group.
Due to this view, the focus of all three IPs was placed on interactive didactic methods. By encouraging creative methods in the preparation of the portfolios the students were encouraged to create together, as opposed to teacher-led instruction. The LLL perspective is also seen as an ambition to bring about positive attitudes to learning and motivate to self-directed learning, so that students also later on in working life will keep up-to-date with their subject area.
In order to be able to find ways to improve and maintain good health, health care professionals require a cross-disciplinary approach where risk factors which jeopardise health can be identified and tackled. Often, this involves brainstorming healthier lifestyle ideas, creating suggestions for improving the circumstances of this vulnerable age-group. This approach should involve the cross-fertilisation of ideas from a wide spectrum of health care providers, including nurses, social workers, physiotherapists and dietitians currently attending tertiary education training. This is guaranteed to provoke an exciting forum as already the ideas are flowing from potential partners. It is anticipated that discussions of strategies for coping with various social and health problems in the participating countries would uncover practices in one country, or modifications of these, which might be of value in another. These IPs seeked pragmatic and economical ways to enhance and encourage healthy lifestyles, spiritual/psychic and physical wellbeing and independence.
Routine clinical decisions that are based on current ethical concerns that are essential for the promotion of patient safety and improved health care outcomes both within hospital and community settings. This is especially true when it comes to geriatric nursing that is rapidly expanding throughout Europe, although not yet introduced as a specific and discrete subdiscipline of nursing in many European countries.
After completion of the IP the website will remain active, available to a wider audience as there are no log-in restrictions. Students and tutors will be encouraged to feed into its content so that the website will act as a live forum for Evidence based practice.
Assessing geriatric clinical practice guidelines for their validity and incorporation of the best available evidence is critical to the safety and outcomes of care. The partnership will ensure that daily efforts throughout the IP's implementation phase will put considerable focus on learning outcomes evaluation that gathers meaningful and systematic evidence on dimensions of teaching and learning that matter to the participating institutions The concept of Deontological Ethics as this is a prominent ethical theory which is associated with Immanuel Kant who thought that ethics should involve duty and good intent. This IP will explore his universal rules i.e. to tell the truth, not to steal, not to kill, keep promises, and so forth. Thus, nurse students need to explore further the key concepts within the Ethical paradigm of identifying innovative ways of improving elder people's lives by focusing on Deontological aspects as well as biological and psychosocial factors that can have a positive impact on their everyday lives. The reason for this is that the elderly are a vulnerable section of the community who need care with a moral dimension, especially under the current economic turbulence in Europe.
The present global recession in combination with the rise in the numbers of elderly citizens in Europe requires strategies for preventive approaches which are economical and easy to implement. During all three IPs the participants visited a Centre of Open Protection for the Elderly, known throughout Greece as KAPI. This demonstrated an unusual type of support for the elderly, where coffee and board games such as backgammon are popular in a welcoming and safe environment could be implemented in other countries in Europe. Behind this popular front, is a support platform where health care services are also provided. These include medical checks, nurse led interventions, physiotherapy sessions and many more. An added advantage to the system is its remarkable cost-effectiveness.
This experience opened up new windows of opportunity to spread good practices from one country into another where such services might not be available. Likewise Greece has benefited from other countries by adopting their pragmatic solutions to current problems. Furthermore, the mere gathering of mature health care staff and young students from the participating nursing schools created an ideal forum for brainstorming innovative ideas along these lines.

Conclusions
All the students were undergraduates, studying for BA or BSc level and these IPs benefited them by broadening their horizons concerning health care for the elderly. Also, students learned from cross-cultural stimulation and non-conventional ways of problem solving.Thus, students gainned new perspectives on their chosen professions.
Similarly, tutors gained unique insights into different ways of teaching and motivation techniques.
By working with these issues the groups tried to find points of contact from different countries to create common ground. Within this pedagogical method, known as co-operative learning method, teachers had a double role in this process: they acted both as tutors and facilitators in the international groups as well as experts whom the students are expected to consult during their work. Furthermore, by use of self directed learning, students filled the gaps in their knowledge by using the expertise of the teachers.
Routine clinical decisions that are based on current ethical concerns and evidence based practice are essential for the promotion of patient safety and improved health care outcomes both within hospital and community settings. This is especially true when it comes to care of older people as geriatric nursing is rapidly expanding throughout Europe, although not yet introduced as a specific and discrete sub-discipline of nursing in many European countries. The three OPEN-N Intensive Programms, served as an innovative educational tool towards achieving this wider goal.