Gerontological educational interventions for student nurses: a systematic review of qualitative findings

Introduction

People worldwide are living longer and by 2030 one-in-six people will be aged 60 years or older [1] with the pace of population ageing increasing rapidly [2]. Although there is heterogeneity in ageing, there is an increased risk of accumulating chronic diseases with age, which makes older people the demographic that nurses are most likely to encounter in their practice [2, 3]. Moreover, except for the oldest old (those 90+), older people tend to experience increased hospitalization in the last year of their lives [4] leading to increased healthcare service use. While most older people live in the community with a spouse or other family members, 45 % live alone [5]. Older people living alone who become frail from chronic diseases may require assistance [6], which is often provided by unregulated health workers, such as care aides under the supervision of licensed or registered nurses. Thus, given the worldwide population ageing and older people’s increased need for healthcare services in community and healthcare settings, there is a demand for a healthcare workforce with the specific knowledge and skills to care for older people with complex health issues.

Nurses comprise the largest occupational group worldwide, accounting for close to 60 % of the healthcare workforce [7], and are pivotal to the provision of quality care and better outcomes for older people [8]. However, alarmingly, there is a global shortage of nurses (estimated to be 6.6 million in 2016) and workforce projections show that there will be an insufficient number of nurses to meet the increasing care needs of the world’s ageing population [7]. These factors – population ageing, increased likelihood of chronic diseases with age, and a projected shortage of nurses worldwide – should be signals to education providers that future nurses need to be adequately prepared and willing to care for older people. The WHO recommendations for optimising the nursing workforce worldwide to deliver healthcare includes consideration of population ageing in nursing curricula to “align with national health priorities … to prepare nurses to work effectively in interprofessional teams” (2020, p. xix).

Literature review

Systematic reviews of the literature report that nurses are graduating with inadequate education related to care of older people [9, 10]. For instance, student nurses acknoweldge that they lack knowledge about working with older people living with with dementia [11]. Furthermore, new graduates report they did not recognize that most of the patients they would be caring for would be older until they graduated and felt ill-prepared to care for this population [12]. Overall, the literature indicates that student nurses: hold ageist views [10, 13, 14]; have negative attitudes towards caring for older people [15–17]; do not consider a career working with older people to be satisfying or worthwhile [15, 18]; and that their career choices continue to reflect a preference for working in acute healthcare with younger people [18]. Neville and Dickie’s [19] literature review suggested that undergraduate nurses’ decision not to work with older people is related to their educational experiences, in particular, the curricula and experiences on clinical placements; the working conditions of specific healthcare settings, especially in nursing homes; and ageism. Similarly, Dobrowolska and colleagues [20] found that over half of nursing students had witnessed negative care practices with older people in their clinical placements.

The literature also indicates that nursing curricula tend to be acute care-focused with limited attention to chronic diseases, ageing, and ageing-specific services; content regarding older people and their care tends to be integrated across subjects rather than having standalone units specific to care of older people [21, 22]. Nurse academics and clinical educators play a significant role in shaping student nurses’ attitudes towards nursing older people (Dahlke et al. [12]). However, there are few nurse academics with expert gerontological knowledge to teach the care of older persons in nursing programs [23] and nurse educators often have negative attitudes towards older people [24].

Educational interventions aimed at providing students with ageing-related educational content and more opportunities to work with older people who are well has been shown to: increase empathy; enable students to provide care more confidently to older people; reduce students’ negative attitudes toward ageing and older people; and increase their willingness and intention to care for older people [25, 26, 27]. However, educational interventions vary in type, setting, and year of delivery and may include theoretical content (knowledge) alone, content and clinical placement experiences, and/or simulations. No previous systematic review of these interventions could be found. This paper describes findings from the qualitative component of a mixed-methods systematic review of interventions to improve student nurses’ knowledge, attitudes and/or desire to work with older people. To allow sufficient space to explicate the results of the qualitative and quantitative reviews in detail, the quantitative portion will be reported on in a separate publication.

Methods

Data analysis

After duplicates were removed, two researchers independently screened the titles and abstracts and then the full-text manuscripts, with a third researcher reviewing the decisions of the first two. Please see Figure 1 [35]. Any conflicts were resolved through discussion.

Figure 1:

PRISMA diagram.

A standardized data extraction form was used to systematically extract background information (purpose, research design, methods of data collection, findings etc.) from the 14 eligible studies (see Table 1). Directed content analysis was used to provide subjective interpretation of the content in included studies by grouping the data from the studies to answer our research aim about the knowledge, attitudes, and willingness of student nurses to work with older people [36]. This type of analysis was used as it provides the opportunity to direct analysis based on our research interests. We also grouped studies by the type of educational intervention they reported on: content (theory course), practice (clinical placement), simulation (simulation laboratory) or mixed (content and practice).

Table 1:

Qualitative data.

Title, year, country	Intervention	Aims/objectives	Study design/method	Sample	Main findings
Cao et al. 2021, China	Content A “Geriatric Nursing” course for sophomore undergraduate nursing students	To deeply understand student nurses’ experience of learning the course of “Geriatric Nursing”, in order to train more professional geriatric nursing talents	Qualitative Data collection involved semi-structured interviews and phenomenological data analysis	27 sophomore nursing students in the department of geriatric nursing (majoring in “elderly nursing”)	Themes: Lack of cognition of physiological ageing Focus on social issues and daily life care Adopting a blended teaching style to stimulate nursing students’ interest in learning Understanding the life of the elderly from a professional point of view after the class Reverence for life and realization of life values Little attention is paid to the career of the elderly in China The geriatric nursing program expands the scope of employment; and fostering nursing students’ willingness to engage with the elderly
Davies et al., 2013, United States	Placement A 16-week course ‘N352, Caring for the Older Adult’ The older adults are recruited to receive visits from a designated student every 1–2 weeks	How does a practicum involving sequential visits with an older adult accompanied by reflective journaling contribute to nursing students’ understanding of experiences of ageing?	Qualitative An illuminative evaluation of reflective journals. Interviews with students (n=32) Modified framework analysis Comparison and integration of findings from different data set	80 4th year nursing students’ journals 32 nursing students were interviewed	Themes: Becoming aware (a growing awareness of experiences related to growing older) Making connections (many students made explicit links between their learning in the theoretical component of the course and their conversations with their older adult) Seeing the unique person (a major benefit of the serial nature of the practicum visits appeared to be the way that repeated and regular contact enabled the student to view and appreciate the older person holistically)
Fox and Wold, 1996, United States	Mixed A senior capstone course on gerontological nursing emphasizing maximizing individuals capacities in the elderly and quality of life	To evaluate student-perceived learning and attitude changes towards care of the elderly population as a result of a concentrated course in selected gerontological concepts and clinical experiences at the end of the baccalaureate program	Mixed methods	144 final year nursing students	Themes: Areas of learning (increased awareness rather than knowledge of specific facts). Students reported a growth in awareness and knowledge. Subthemes included intergenerational commonalities and intergenerational sharing Perceptions of health care. Subthemes were system changes Professional development. Students perceived increase in factual knowledge, a change in awareness or values, and actual changes in the students’ professional self- concept, demeanor, or approach
Garbarino and Lewis, 2020, United States	Placement Gerontological nursing course with a service-learning component	The purpose of this study was to explore the impact of required gerontological nursing course with a service-learning component on student attitudes towards working with older adults	Convergent parallel mixed methods Two open-ended questions were used to add qualitative context to quantitative data	All students enrolled in course were invited 53 (62 %) students pre-course 59 (69 %) students post-course	Five major themes emerged from the qualitative strand of this study that emphasized the benefits of this course Students acknowledged their preconceptions about older adults prior to starting the course Students experienced a positive shift in their perceptions about older adults during their interactions Students expressed a growing interest in working with older adults Students appreciated the skills required to care for older adults Students felt that this course offered a valuable opportunity to learn nursing skills and to form connections Qualitative findings emphasized the personal impact of this course on students’ views about older adults, such as forming human connections and minimizing fears about encountering older adults, which were not captured in quantitative findings
Hsu et al., 2022, Taiwan	Content Implementation of a course on narrative medicine education	This study aims to discuss how narrative pedagogy of improving the positive attitude toward older people among nursing students and increasing students willingness to practice older peoples care	Mixed methods Qualitative-reflective journal	87 students (n=43 experimental group) (n=44 control group)	Themes: The process of change in nursing students’ attitude toward the older people Myth-breaking for the prejudice against the older people Rethinking of older people care. Reflective learning and the design of assistive devices in narrative pedagogy provide a valuable learning experience, which many students think is helpful to the idea of taking care of older people in the future
Lai et al., 2015, China	Placement A service-learning project for undergraduate nursing students	For students to Identify the needs of the older adults through observing their living environment and communicating with them Improve their problem-solving skills by learning how to develop and evaluate care plans for older adults Work as a member of a team in caring for clients Develop communication and interpersonal skills	Qualitative Data collection involved participating students keeping reflective journals of their service-learning experience analysis involved content analysis of similarities/differences in the reflective journals	52 Nursing students enrolled in “Personal and Professional Development”, a required course for all first- and second-year undergraduate nursing students at The Hong Kong Polytechnic University School of Nursing	Four themes from the four waves of data I have learned a lot – the major claim made by students about their learning, which was “a lot,” – The learning of communication skills was cited most frequently as the main learning outcome I have changed over time – summarizes the changes in students after completing this 2-year project My perception of older people has changed – before participating the students thought that older adults were difficult to get along with, passive, and had nothing much to say, however, during their visits, the students found that the older adults liked to talk I have learned through experience -although many of the students anticipated that the project would be a vehicle for their learning, some students described how they learned from various people including their teacher, social workers in the senior center, other volunteers who were also older adults, and the older adults themselves
Lin et al., 2016, Taiwan	Mixed Music therapy training	To explore whether incorporating music therapy into a practical geriatric nursing course at a nursing home cultivates positive attitudes toward older adults, raises students willingness to work with older adults, and in-creases their interest in specializing in gerontological nursing after graduation	Qualitative Focus groups were conducted to collect data from three participant groups (n=20). Verbatim transcripts of audio recorded interviews were analyzed using content analysis	Intervention Year 2 students in a 4-year baccalaureate program enrolled in an gerontological nursing elective n=20	Themes: Better appreciation and understanding of music therapy Role modeling instructors’ successful experience and positive attitude toward older adults Changing attitudes toward older adults Improving interaction skills with older adults Students’ views of older adults became more positive and they were willing to care for them in the future. Overall, the use of music may have helped provide connections between the students and older adults, thereby helping students develop more positive. Stereotypes and attitudes regarding ageing that influence how they and students perceive older adults as well as affect how they interact with them in the practice setting
Potter et al., 2013, Canada	Placement 1 h session teaching about the SPICES (sleep disorders, problems with feeding, incontinence, confusion, evidence of falls, skin breakdown) Participants then engaged in a six-week consolidated practice experience	To examine the influence of specific geriatric knowledge on 2nd and 3rd year nursing students in their provision of care to older adults, to address the paucity of research examining geriatric education for nursing students or their attitudes about working with older adults	Qualitative Data collection involved structured focus groups prior to their attendance at the 1 h teaching session on SPICES A second focus group was conducted with each participant group to gather impressions about their implementation of the assessment tools. Analysis involved thematic analysis	All 2nd and 3rd year students in the winter semester n=57	Pre-teaching focus group responses – students in both years recognized that values and beliefs about older adults were informed by numerous factors and that personal experience with the elderly affected how they viewed this age group. They were influenced by staff and the environment as well. While the program did make participants aware of negative attitudes and ageism, many felt their education did not necessarily prepare them to deal with ageing in varied ethnic cultures, on tight schedules not conducive to personalized care, or in task-oriented work environments. Theoretical knowledge about the complexity of elder care became real patient. They were also used as education tools with patients and families. Use of the tools created opportunities for relational practice and provided a chance to start a dialogue about the patient’s experience
Reitmaier, et al., 2015, United States	Placement Intergenerational placement – sequential visits with an older adult as part of a gerontological nursing course	To explore the ways in which the practicum component of a course in gerontological nursing, incorporating sequential visits with an older adult, contributes to undergraduate nursing students and older adults understanding of experiences of ageing	Qualitative Data drawn from the experiences of two cohorts of students who completed the intergenerational programme in 2010/2011	Students who had completed the intergenerational programme. The participants were divided into two classes randomly. n=43 students in experimental group and n=44 students in t control group	Four shared themes across the data sets: Becoming aware of generational experiences – the process of understanding generational experiences and stereotypes and prejudices were also contested Seeing the unique person – students also recognised how each older person ages differently Valuing the relationship – for many participants the visits had prompted a new appreciation of the relationships that formed between the older adult and student Discovering intergenerativity – some students found it difficult to bring the relationship to a close at the end of the practicum experiences and continued to communicate with their assigned older adult for a while some new insights into their respective situations
Rogan and Wyllie, 2003, Australia	Placement An educational program designed to give nursing students optimum support while attending clinical placements in nursing homes	To explore students’ perceptions of the effect of the educational program on their knowledge, skills and attitudes towards the elderly	Qualitative Data collection involved using an open-ended questionnaire and focus groups with a subset of students (n=18) to explore their responses to the questions in greater depth. All qualitative data were analyzed using a descriptive interpretative approach	112 first semester undergraduate nursing students	Five themes: Seeing the person – students’ perceptions of the resident as a unique person, an individual with their own story Appreciating the elderly person – positive attitudes expressed by students including understanding, respecting and enjoying interacting with the residents Experiencing personal growth – students’ perceptions of their personal development during the experience Becoming a nurse – students’ perceptions of their professional growth and development Learning about the elderly – factors students identified as significant in helping them learn about the elderly including: being prepared for care of the elderly
Sakamoto, 2022, United States	Placement A new clinic to provide basic health assessment and health education promotion to older community dwellers around the campus	To analyze students’ perceptions of clinical experiences at the Robust Ageing Program clinic, a community wellness outpatient senior center	Mixed methods Two open-ended questions were used to add qualitative context to quantitative data	13 nursing students	Five themes: All students indicated multiple motivations that influenced their choice to volunteer at the clinic, most commonly gaining knowledge, professional development, and values related to volunteering Views on ageing – students had a rewarding experience and gained a new respect for ageing adults Ageist attitudes – direct contact with essentially healthy seniors in the RAP clinic may reduce students’ propensity toward ageist beliefs and help them become better health professionals Influence on career development gained Importance of mentorship
Sari et al., 2020, Turkey	Simulation with the “aged simulation suit” Comprised of tools that simulate a variety of physiological changes that occur due to ageing	To explore the effect of use of an aged simulation suit on the empathy and attitudes of nursing students towards older persons	Mixed methods Data collection involved two sequential phases. Semi-structured interviews to gather information about the students’ feelings opinions and awareness regarding their experiences completing the aged simulation suit tasks. Analysis involved directed content analysis	30 nursing students in their senior year of university who registered for a Geriatric Nursing Course	Four themes: Awareness – students stated that they realized older persons have difficulties in disability-related physical activities and they will assist them if needed because they understand Worry and sadness – students stated they had a fear of falling/physical injury in relation to physical deficiencies and felt concerned about ageing and their survival in the future Empathic approach – students began to understand what older persons feel and that they should be more tolerant and helpful with older persons Helplessness/desperateness – students understand that older persons are in need of help due to their physical frailty and understand that they may feel desperate
Shellman, 2005, United States	Placement A 2-h reminiscence education program for nursing students during their community health clinical practicum	To examine baccalaureate students’ experiences of reminiscing with older adults to gain further insight into the effects of a reminiscence education program on nursing students and their ability to deliver high-quality and culturally sensitive care to this population	Qualitative Embedded in a survey design (participants answered three open-ended questions at the end of a survey)	41 senior nursing students nursing class of 2002 who had reminisced with an older adult during the clinical rotation	Three themes: Making a connection: students repeatedly noted in their descriptions of the reminiscence interaction that they felt like they were “making a connection” with their clients when they reminisced with them Seeing the world through their eyes: the older adults had such vivid memories to share that students described their reminiscence sessions in the following ways: “it allowed me to take a journey with them, wearing their shoes,” “history came alive for me,” and “I felt like I was there.” reminiscence enabled them to learn about their clients Reminiscing helps older adults: students noted that the older adults enjoyed talking about the past and that reminiscence was meaningful for them
Walton and Blossom, 2013, United States	Placement A home visiting program called healthy partners (HPs). This program paired up two nursing students with one older adult living in the community in Montana	To explore the experiences of nursing students working with older adults in rural communities, the experiences of older adults, and the development of relationships	Qualitative Phenomenological research method and data analysis. Data collection involved in-depth interviews with older adults and students	96 nursing students and older adults participating in the healthy partners program	Six themes: Welcoming presence feeling like an imposter, feeling valued, and sharing hospitality Developing a trusting relationship (creating a therapeutic relationship and developing a bond) Spending time together (nursing presence and enjoying each other) Sharing and listening to stories (learning to listen and reminiscing) Learning about growing old (breaking down stigma) Growing nursing students (applying nursing knowledge and mentoring nursing students)

The quality of the studies was also assessed, and the results of the quality appraisal are presented in Table 2.

Table 2:

Mixed methods appraisal tool (MMAT).

Qualitative studies or qualitative portion of a mixed methods study
Citation	Is the qualitative approach appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from the data?	Is the interpretation of results sufficiently substantiated by data?	Is there coherence between qualitative data sources, collection, analysis and interpretation?
Cao et al. [37]	Yes	Yes	Yes	Yes	Yes
Davies et al. [38]	No	No	Yes	Yes	Yes
Fox and Wold [39]	Yes	Yes, but limited	Yes	Yes	Yes
Garbarino and Lewis [40]	Yes	Yes	Yes	Yes	Yes
Hsu et al. [41]	Yes	Yes	Yes	Yes	Yes
Lai et al. [42]	Yes	Yes, but limited	No	No	Yes
Lin et al. [43]	Yes	Yes	Yes	Yes	Yes
Potter et al. [44]	Yes	Yes	Yes	Yes	Yes
Reitmaier et al. [45]	Yes	Yes	Yes	Yes	Yes
Rogan and Wyllie [46]	Yes	Yes, but limited	Yes	Yes	Yes
Sakamoto [47]	Yes	Yes	Yes	Yes	Yes
Sari et al. [48]	Yes	Yes, but limited	Yes, but limited	Yes, but limited	Yes, but limited
Shellman [49]	Yes, but limited	Yes	Yes	Yes	Yes
Walton and Blossom [50]	Yes	Yes	Yes	Yes	Yes

Results

Fourteen studies were ultimately included in this qualitative review [37–50]. Quality assessment using the MMAT for qualitative research revealed that some the studies were of low quality (see Table 2). Of the 14 studies included, six had significant methodological limitations: three studies partially met the quality criteria [39, 46, 49]; one was missing two of the five quality criteria [38]; one was missing three of the five quality criteria [42]; and another study was only strong in one quality criteria [48]. The countries represented in the studies numbered six; seven from the United States (US), two from Taiwan and China, and one from Australia, Canada, and Turkey, respectively. All the studies reported that the interventions they implemented improved student nurses’ knowledge about older people. All but one [44] reported improvements in student nurses’ attitudes toward older people because of their intervention. Yet only four studies reported an increase in student nurses’ increased willingness to work with older people following the intervention [37, 40, 46, 47]. Since many of the studies assessed increases in one or more of knowledge, attitudes, or willingness to work with older people and we were interested it which type of interventions are effective, we report on the studies in detail according to the type of intervention. See Table 3 for a summary of the included studies by type of intervention: content, simulation, placement, or mixed. In what follows, we report on each type of intervention in turn.

Discussion

To our knowledge this is the first review of qualitatively evaluated educational interventions for nursing students. We provide the nursing community with a valuable overview of what has been tried in various nursing programs. Our key finding is that although all the educational interventions employed in the studies in this review reported that nursing students had increased knowledge about older people and shed misconceptions about this patient population [37–50], only four reported on interventions aimed at enhancing students’ willingness to work with older people [37, 40, 46, 47].

Moreover, most of the studies reported that their interventions challenged nursing students’ negative attitudes toward older people [37–43, 45, 46, 48–50], and although the simulation helped students develop empathy, it also fostered perceptions of older people as disabled [48]. Furthermore, most of the interventions included a clinical component that was likely to be associated with students viewing older people as unique human beings, thus challenging previously held ageist views about this population and yet few students wanted to work with older people. One possible explanation may be that the student nurses were expressing unconscious ageism – unfortunately, this is unknown because none of the studies formally assessed ageist attitudes. The World Health Organization [53] suggests that ageism is prevalent around the world and often not recognized in individuals’ own culture. As well, a review of the literature examining ageism in student nurses reported that ageism directed towards older people was related to not wanting to work with this population [54].

Although clinical experiences with community-dwelling older people, either through service learning or clinical placements, resulted in nursing students’ negative stereotypes about ageing and older people being challenged as they acquired more accurate information through their experiences with this population [38, 40, 42, 45, 47, 49, 50], perhaps more is needed in order for nursing students to become willing to work with older people. We recommend addressing the ageism that many people unconscously hold towards older people early in nursing programs, and then integrating learning about older people and ageism throughout nursing curricula. The World Health Organization [53] suggests that two ways to counter ageism are education and intergenerational contact. Thus, the service learning interventions that included education and practice with community-dwelling older people would seem to be the most promising type of intervention to encourage nursing studentsto work with this population.

None of the studies in this review discussed conducting research about what was needed to enhance nursing students’ knowledge or attitudes prior to implementing their educational interventions. In other words, the interventions did not appear to have been designed based on evidence. Nor were the interventions tested to determine their effectiveness. We recommend that researchers consider using a systematic model, such as the Assessment Design Development Implementation and Evaluation (ADDIE) model to develop evidence-based educational interventions [55]. According to the ADDIE, research should first be conducted to assess gaps in student nurses’ knowledge; followed by designing an intervention using evidence to meet this gap; then further development the intervention through pilot testing; and, finally, implementing and evaluating the effectiveness of the intervention using pre-and-post measurements, as well as self-report data from student nurses. Evidence-based educational interventions developed using such a model could then be replicated by many nursing programs.

Based on our findings we recommend that student nurses be exposed to well older people, whether it be by service learning or clinical rotations in the community, to provide them with opportunities to develop their knowledge of well older people. In Canada, 85 % and in Australia, 80 %, of older people live independently in the community [56, 57], thus, learning about community-dwelling older people is essential. Many student nurses first clinical rotation is in residential/aged care; scholars have critiqued this practice because the focus is usually on body care rather than a person-centred approach to the fundamentals of nursing care [19, 58–60]. These practices also re-enforce already negative stereotypes about ageing and older people that student nurses may have held prior to entering their nursing program [61, 62].

Limitations

Given the methodological limitations of some of the studies (see Table 1), conclusions about intervention effectiveness should be made with caution. Methodical issues included lack of detailed information about the interventions, how the studies were conducted, and in some of the studies the findings appeared to be a synthesis of students’ self-report data. Due to these challenges, we were unable to do a meta synthesis of the qualitative data. As well the studies were only conducted in one educational setting; thus, they may not be suitable to all nursing programs. Moreover, we only examined studies written in English and thus could have missed some interventions included in non-English studies.

Conclusions

This systematic qualitative review provides the nursing community with an overview of research related to educational interventions that have been developed to improve student nurses’ knowledge, attitudes and/or willingness to work with older people. All the interventions improved knowledge about older people and some disrupted negative attitudes student nurses held about them, yet only a few increased their willingness to work with older people. We recommend that nursing education that disrupts negative stereotypes about older people begin early in nursing programs and continue throughout students’ education. Also, providing education and clinical experiences with community-dwelling older people may be a promising intervention to increase student nurses’ willingness to work with this population.

In terms of directions for future research, more research is needed that employs a model or systematic approach to the development and testing of educational interventions for nursing students on older people’s care.