The aging population, with its complex medical problems, presents an ever increasing demand for health care. This multifaceted challenge involves a burgeoning, diverse older adult population requiring specialized nursing care. For this significant population, the uncertainty of the United States (US) health care system poses additional risk of poor patient outcomes . Future projections point toward the supply of geriatric nursing not meeting the demands of this growing population . Geriatric nurses make up less than 1 percent of the current registered nurse workforce .
A challenge among today’s nurse educators is promoting student interest in the field of gerontology. Providing a dynamic, engaging, didactic experience in the classroom is vital to stimulate a vested interest for students caring for the older adult population. Due to a pervasive negative, societal attitude towards the elderly, nursing students do not often consider geriatric nursing as a career path . Studies indicate an overall lack of interest from nursing students to specialize in the care of older adults [4,5]. Ageist views of the older adult population remain a prevalent issue in today’s American society . Thus, students may devalue the older adult and show a reluctance to master the core geriatric concepts that are increasingly important as this population continues to grow and impact health care systems . The purpose of this literature review seeks to identify innovative teaching strategies that engage undergraduate nursing students in a gerontology nursing course and promote positive attitudes toward caring for the older adult population.
An electronic literature search examining peer-reviewed journal articles between 2010 and 2015 was conducted. The databases CINAHL, Medline, PubMed, EBSCOhost, PsychINFO, Scopus, and Science Direct were broadly scanned prior to an advanced, refined search using Medical Subject Heading (MeSH) keywords: “student nurse,” “older adult,” “elderly,” “old,” “geriatric,” “negative attitude,” and “ageism”. Boolean operators combined terms to narrow the subject matter to more focused areas.
All journal articles were peer-reviewed, original research available in English. The journal articles were to describe student nurse attitudes toward older adults, which included ageist, or stereotypical perceptions related to aging. All journal articles published between 2010 and 2015 within the United States and Canada were included.
Two journal articles related to ethnic characteristics of student nurses influencing attitude toward older adults were deemed not applicable to the study question. Articles that focused on registered nurses or other health care provider attitudes or perceptions related to caring for the elderly were also excluded.
Search outcomes and quality appraisal
Database search combinations yielded a total of twenty-six appropriate journal articles. Quality was ensured by examination of study rigor and merit in relation to study questions.
The literature search yielded 223 original articles identified by broadly relevant keywords. Targeted search strategies for related keywords within the articles produced 105 papers for further review. Sixty-five full-text articles were examined using inclusion and exclusion criteria, resulting in thirty articles. Four additional articles were excluded based on mixed sampling results of registered nurses and other health care providers. Twenty-six final articles were graded and included in the literature review (Appendix 1).
Factors Affecting Attitude
Attitudes and preferences
Current research continues to show that nursing students do not prefer to work in long term care settings . Several studies concluded that students felt working with older adults was unpleasant, boring, physically demanding, and monotonous [9,10]. King et al.,  report that student nurses perceptions, attitudes, and desire to work in a geriatric setting requires gerontological nursing courses which dispel ageism and promote interest in caring for older adults.
Three consistent themes emerged from the literature review investigating attitudes and preferences of undergraduate student nurses pursuing a career in geriatrics. First, Swanlund and Kujath  found students experiencing more exposure to older adults in a variety of settings had more positive attitudes and increased interest to work with older adults. Second, Nolet et al.,  found that when nursing students partnered with preceptors in long term care facilities, stereotypes of older adults were disconfirmed, thus stimulating future interest in geriatric nursing as a career choice. Third, Evers, Ploeg and Kaasalainen’s  case study identified frequent interactions and personal relationships with older adults as positively influencing student attitudes. Leung et al.,  also reported that frequent interaction and contact with older adults through intergenerational service learning projects promoted positive attitudes in student nurses.
Ageist views and stereotypes
Wurtele and Maruyama  challenged students’ negative views of older adults by introducing a classroom activity designed to identify stereotypes related to aging. Students were asked to write down how they believe older adults spend their time. The most frequent responses included socializing, watching television, exercising, reading, and playing games. To refute stereotypical perceptions, students were presented with information contrary to ageist beliefs. The results of this activity were compared to a previous longitudinal study that examined similar student classroom activity over a ten-year-period by 1,340 students . Pre and post classroom activity questionnaires assessing attitudes and beliefs about older adults were completed by students from both studies. Results showed a reduction in negative stereotype of older adults after the classroom activity. Nolet et al.,  reported that students’ stereotypical misperceptions towards the elderly changed positively after experiencing a twelve week summer internship with expert geriatric nurses caring for older adults in long-term care facilities. The internship focused on geriatric education as well as clinical, research, and leadership opportunities for undergraduate junior and senior baccalaureate students. This experince fostered positive attitudes toward older adults and stimulated interest in geriatrics as a career choice. Findings from Gallagher and Carey  found students stereotypes about aging improved after student-elderly reminiscing interviews.
Gerontological nursing knowledge
Several studies note that stand-alone nursing gerontology courses with inspirational, well-planned, supportive, learning activities play a role in influencing positive attitudes and perceptions toward caring for older adults [8,16], Baumbusch et al.,  argue that integration of older adult content with general adult coursework positively influences student’s attitudes toward caring for the elderly. Geriatric content can be strengthened by introducing case exemplars of older adults into the didactic setting [18,19] report that summer externship programs focusing on geriatric education as well as clinical, research and leadership opportunities for undergraduate junior level baccalaureate students foster positive attitudes towards older adults and stimulates interest in geriatrics as a career choice.
Tenhunen and Fizgerald  revised an undergraduate nursing gerontology course to include a variety of engaging, active teaching methods. Prior to revision, the course was delivered lecture style. Course revisions including case studies, in-class group activities, on-line media assignment, and discussion board activities were incorporated. Faculty linked class activities to the American Association of Colleges of Nursing (AACN) recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults and the National League of Nursing (NLN) Advancing Care Excellence for Seniors framework and the Geriatric Nursing Education Consortium essentials of gerontological nursing competence. The NLN framework and the AACN recommended guidelines for nurse educators who develop course work related to older adult curriculum, focusing on evidence-based practice, individualized holistic care, safety, nursing skill competencies, geriatric care models and evolving knowledge related to aging . The study results indicate that students comfort level with older adults increased.
Fostering Positive Attitude
Creative learning activities
Several studies have examined the importance of accurate gerontological curricular approaches to change knowledge and attitudes of student nurses toward older adults [5,8,21,17]. According to Chen, Kiersma, Yehle, and Plake  incorporating creative learning activities such as the Geriatric Medication Game® (GMG) into nursing curriculum allows students to experience empathy, understanding and improved knowledge of older adults’ health care challenges. “Generations as Partners in Education (GAPIE)” a service learning project facilitated intergenerational contact between elders and student nurses . Students paired with older adults and shared a 10-week period of service learning activities consisting of intergenerational contact, communication skills and discussions related to aging. Students also participated in a self-directed on-line learning program that introduced aging issues. The GAPIE project significantly increased student nurses knowledge of aging and reduced negative stereotypical perceptions related to older adults .
McCleary  found student nurses experienced improved positive attitudes and increased knowledge related to aging after viewing documentary films which addressed aging issues. Students then participated in an intergenerational panel discussion. The authenticity of this reality-based learning strategy allowed students to go beyond textbook readings and didactic learning .
The Creative Bonding Intervention (CBI) showed significant positive change in student nurse attitudes toward older adults and willingness to care for them after students implemented art activities with the elderly . Walton and Blossom  noted similar positive experiences with student nurses and older adults who partnered in a home visiting program called Healthy Partners (HP). A trusting, therapeutic bond developed between students and older adults resulting in decreased stigma related to aging. This study also found increased nursing knowledge of the aging process and allowed older adults to reminiscence and feels valued. Gallagher and Carey  relayed four emerging patterns when student nurses engaged in intentional dialogue with older adults; discovery of the value of intergenerational relationship, rejection of ageist stereotypes, overcoming painful reminiscence experiences, and gero-transcendence of wisdom and peace. Intentional dialogue facilitated speaking and listening skills of student nurses and reminiscing supports intergenerational bonding and communication.
The sound evaluation of student nurse attitudes and interest to care for older adults requires instrumentation that rigorously measures data. Neville  analyzed the strengths and weaknesses of eight instruments used to measure student nurse attitudes and perceptions of working with older adults. Within the literature review, several studies used the same instruments, while some created tools were specific to individual studies. The similar instruments included Kogan’s Attitudes Toward Old People Scale (KATOP), Attitudes Toward Old People (ATOP) questionnaire, and Aging Semantic Differential (ASD) [8,11,13,14,23,24] Neville  identified inconsistencies with psychometric characteristics of the eight instruments analyzed. Related concepts are sometimes used interchangeably and incorrectly such as the ASD scale, which interchanges the terms “attitude” with “stereotype”.
Several researchers used new tools to measure attitudes and empathy toward older adults. Kidd et al.,  created a twenty item tool known as the Multifactorial Attitudes Questionnaire (MAQ). Further development of the MAQ is needed to strengthen reliability and validity. Chen et al.,  developed the Kiersma-Chen Empathy Scale (KCES) which measures empathy, caring and attitudes of undergraduate nursing students with the validity of Cronbach’s α = 0.75. In addition, the Jefferson Scale of Empathy for Health Professional Students (JSE-HPS) was used with the reliability of Cronbach’s α = 0.78. McCleary  used an adapted version of Palmore’s Facts on Aging Quiz (Woolf’s version) which established additional validity from a panel of gerontological experts. Two studies measured ageism using the Fraboni Scale of Ageism (FSA). The FSA scale has shown potential, but lacks wide use [14,27].
Several studies within the literature review cite the use of Palmore’s Facts on Aging Quiz, a well-established, reliable, extensively used instrument to measure student learning in health care disciplines [12,17,27]. Notably, this instrument was not included in Neville’s  analysis.
Numerous studies substantiate that undergraduate nursing gerontology courses need innovative educational strategies to prompt interest and encourage positive attitudes toward older adults [8,11,19] McCann et al.,  reported that student nurses are least likely to choose geriatrics as a career choice and cite curriculum as contributing reasons. King et al.,  found that a stand-alone gerontology course helped student nurses dispel ageist views and stereotypical perceptions of aging while enhancing their knowledge of the complexities of caring for older adults. Students also reported higher desirability to work with the elderly. In contrast, Baumbusch et al.,  reported that an integrated approach of older adult content with general adult coursework promoted positively influenced student nurse attitudes toward older adults and acquisition of geriatric knowledge.
Innovative, experiential gerontological teaching strategies that engage undergraduate nursing students in active learning can bring about positive attitudes toward older adults . McCleary  reported that documentaries and older adult communities provide an authentic experience and increase the reality factor for experiential learning. Hooyman & St. Peter’s work (McCleary ) identified that strategically placing experiential learning infused with gerontology content is effective in increasing knowledge and improving attitudes toward older adults.
The United States Health Resource and Services Administration (HRSA)  and the John A. Hartford Foundation  have made substantial investments to promote gerontology education in nursing. Several key outcomes include; increasing knowledge and skills needed to care competently for the elderly and improve the number of nurses needed to care for this ever-growing population .
Older Adult Impact
The steadily growing aging population will require a knowledgeable, competent, compassionate, nursing workforce to provide individualistic, holistic and culturally sensitive care to older adults. The Institute of Medicine  has identified nurses as instrumental in meeting the health care demands of the aging population. Gerontology nurse leaders and nurse educators recognize the importance of changing how students experience gerontology in the curriculum. Key strategies to improve student nurse attitudes toward older adults have focused on stand-alone courses or integrated content throughout the nursing program [8,17]. Briscoe (King et al., ) examined several studies that compared students’ knowledge, attitude and desire to work with older adults after a stand-alone course and an integrated format. These researchers found that attitudes and knowledge of students improved with both methods; however, students rated caring for the aged as the least desirable career choice.
Gaps in the Literature
Research is inconsistent regarding the delivery of effective and innovative gerontology content within nursing curriculum. Out-of-date instrumentation scales used to measure attitudes and perceptions toward the elderly are not well understood by today’s nursing students. Innovative current instrumentation may lead to nursing students who consider a career in gerontology nursing.
In a literature review, Williams et al.,  (as reported by Neville, Dickie and Goetz) identified that despite positive responses to carefully planned clinical experiences with older adults, students remain reluctant to pursue a career in gerontology. King et al.,  reported that gerontological nursing courses have inherent value to dispel ageist views, but the type of clinical placement (acute versus long term) affected students’ preference to work with older adults upon graduation. As a supplement to a stand-alone nursing gerontology course, a didactic workshop focusing on long term care and the older adult population was developed. The workshop was created to dispel negative stereotypes related to the aging population. Students benefitted by reinforcing knowledge gained from the stand-alone course and decreasing negative connotations of long term care .
The greatest gaps in the literature include low generalizability (small, convenience, homogenous samples) and threats to internal validity, specifically instrumentation to measure attitudes and perceptions toward aging. Commonly, instruments such as Palmore’s FAQ and KATOP have been used in studies that measure knowledge and attitudes of health care disciplines. However, stronger evidence base would support increased use of these instruments . Psychometrically sound instrumentation is needed for quality research which facilitates nursing education and practice. As the older adult population continues to rapidly grow, future nurses need to be educated to provide care based on the best available scientific evidence which promotes optimal patient outcomes .
Future Research Suggestions
Several studies recommend larger more diverse sample sizes to increase generalizability of findings [5,11,12,22-24]. The literature review revealed most research to date focused on undergraduate female students. To further understand nursing student attitudes towards older adults, it would be beneficial to exclusively study a male student sample . King et al.,  and Baumbusch et al.,  compared the merits of a stand-alone gerontology course versus integrated format of older adult content respectively. Future studies need to comparatively analyze which of the formats yield the most benefits (knowledge of aging, specialized skills, dispelling myths and promoting positive attitudes toward older adults .
Nolet et al.,  examined student clinical placements in long term care with expert geriatric nurse mentors resulting in positive attitudes toward the elderly and prompting interest in gerontology as a career choice. Students revealed that long term care placements are not part of the nursing curriculum as much as acute care hospital settings . Areas of research could include: which clinical setting provides the best experiential learning, while supporting positive attitudes toward the aging population, and examination of mentorships with expert geriatric nurses.
Neville et al.,  discussed the need to further research methodological limitations, specifically, the need for psychometrically valid, reliable tools for evaluating attitudes. Several studies noted that the tools used are dated and students were unfamiliar with some phrases [8,13]. Newer, contemporary attitude questionnaires, such as the MAQ, require further development .
The literature review has identified that evaluating undergraduate nursing gerontologic curriculum, together with the incorporation of innovative teaching strategies can promote positive attitudes toward older adults, thus resulting in interest to pursue a career in geriatrics. Creative, innovative teaching approaches have greatest impact to spark interest and foster engagement in the didactic setting. Teaching strategies focusing on the themes of intergenerational contact, emotional bonding and exposure to experiential learning which dispel stereotypical views of aging show the greatest promise to address negative attitudes toward older adults. Lack of engagement in gerontology nursing courses and disinterest in pursuing a career in geriatrics are cited as common trends found in undergraduate nursing students. Nurse educators are instrumental in shaping gerontologic curriculum and must continue to pursue innovative teaching strategies that engage and inspire undergraduate nursing students to competently and compassionately care for the older adult population.