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. 2021 Jan 19;16(2):e12363. doi: 10.1111/opn.12363

Registered nurses’ reflections on their educational preparation to work with older people

Sherry Dahlke 1,✉, Maya R Kalogirou 1, Nicholas L Swoboda 1,2
PMCID: PMC7988531  PMID: 33470029

Abstract

Background

Negative perceptions about working with older people within nursing contribute to the deficit of educators with expertise to teach student nurses, and nurses graduating ill‐equipped to work with the ageing population. The perceptions of nurses who have recently graduated from a nursing programme can provide insights into what they wished they knew about working with older people before they graduated.

Methods

A qualitative descriptive study design examined recently graduated registered nurses’ reflections on their education preparation to work with older people. Content and thematic analysis was used to develop the themes of first impressions and preparation to work with older people.

Results

Key findings were that nurses did not recognise the importance of learning about older people until they had graduated. Only then did they realise that the ageing population was so complex and prevalent. They perceived a lack of education particularly related to working with older people with dementia and their behaviours, as well as learning how to communicate to an older population. Participants perceived that as students, it was up to them to fit in learning about working with older people without the support of faculty.

Conclusions

Faculty need to be supported in learning how to best incorporate content about older people into their curriculum. This could include the development of learning activities that dispel negative stereotypes about ageing and facilitates interest in older people, as this is the population, students are most likely to work with when they graduate.

Implications for practice

Nurses in practice may require education on working with people with dementia as it is a deficit in nursing programmes.

Keywords: communication, dementia, nursing education

1. INTRODUCTION

Populations are ageing around the world (United Nations, 2017) and with age people are more likely to have chronic illness and/or atypical presentation of acute illnesses, all contributing to the complexity of their healthcare needs (Fedarko, 2011; Hartgerink et al., 2014). Despite recognition that specialised knowledge about older people is required since the 1950s (Dahlke, 2011), international scholars suggest that nurses are graduating from their education programmes without the necessary knowledge and skills to work with the ageing population (Baumbusch & Andrusyszyn, 2002; Deschodt et al., 2010; Gilje et al., 2007; Hirst et al., 2012; Ironside et al., 2010; Xiao et al., 2008). Research has also identified that practising nurses lack the knowledge to meet the needs of the ageing population (Cooper et al., 2017; Fox et al., 2016; Wagner et al., 2013). It is not well understood what nurses wished they had known about working with older people when they graduated – the population they are most likely to encounter.

2. BACKGROUND

A scoping review of the literature that evaluated nursing education about older people categorised the literature as either related to nursing students’ attitudes, knowledge, clinical performance, career choices or the implementation of education related to older people (Koskinen et al., 2015). They reported that despite having positive attitudes towards older people, students saw them as a burden. Students’ knowledge about the complexity of older people was inadequate, and their clinical performance (particularly as it related to communication) required improvement. Most students were not interested in working with older people as they viewed it as depressing and unchallenging. The literature also reported insufficient nursing faculty with expertise in working with older people and that nursing care of older people was poorly valued in society and among nurses. Koskinen et al. (2015) suggested the development of competency requirements for nursing older people and equipping student nurses with a broad understanding of older people. Baccalaureate competencies for working with older people had been developed in Canada and the United States (Canadian Gerontological Nurses Association, 2017; Mauro et al., 2012). However, most educational administrators, who are responsible for curriculum revisions, are unaware of these and thus they are not used to designing such curricula (Boscart et al., 2017).

The literature also identified that nursing care of older people is poorly valued in society and among nurses (Koskinen et al., 2015; Kydd et al., 2014). A review of the literature revealed that many student nurses believed working with older people was of low social status and did not require specialised knowledge or skills (Kydd et al., 2014; Kydd & Wild, 2013). Scholars have suggested that nurses’ ageist stereotypes were because they saw older people at their most vulnerable and dependent (Brown et al., 2008; Fox et al., 2016). When nurses believed that working with older people was simple (Fox et al., 2016) and held negative stereotypes of dependence with cognitive and physical decline (Palmore, 2015), they did not adequately assess and manage older peoples’ healthcare concerns. Rather nurses believed that health concerns were normal aspects of ageing and older people experience negative consequences (Boltz et al., 2013; Fox et al., 2016; Kjorven et al., 2011; Zisberg et al., 2015).

Alternatively, Wilson et al. (2017) critical review of published literature on nursing and healthcare ageism reported divergent evidence, suggesting it was uncertain whether ageism was prevalent in nursing practice. Other scholars suggested that nursing students had positive views of older people (Hammar et al., 2017; Neville & Dickie, 2014). In a critical review of the literature, Negrin and Dahlke (2019) suggested that although there is mixed evidence about whether student nurses’ perceptions towards older people is positive or negative, they were being exposed to practising nurses in their clinical settings, who exhibited negative perceptions and practices towards older people. Duggan et al. (2013) examination of UK nursing students’ perceptions about older people suggested that student perceptions were influenced by their nurse mentors’ lack of respect, poor communication, and disinterest in older people's concerns. However, student nurses who experienced positive nursing practices towards older people exhibited positive perceptions about working with older people (Brown et al., 2008).

Kagan and Melendez Torres's (2015) critical review of the literature suggested that ageism often emerged ‘insidiously, veiled in claims of “best interest,” or humor’ (p. 644), as a socially acceptable form of discrimination. Student nurses learn to work with older people through theory and clinical courses, where role models play an important role in their professional socialisations (Zarshenas et al., 2014). What practitioners say and, observations of how care is modelled, can have a lasting impact on learning and professional socialisation (Bandura, 1971). Yet, students learning to be nurses are exposed to practising nurses who demonstrate ageist perceptions and practices with older people (Brown et al., 2008; Koskinen et al., 2015). For example, nurses described older people as a ‘waste of time’ (Higgins et al., 2007; p. 10). Moreover, there was, and remains, a dearth of nurse educators with gerontological expertise who could actively dispel negative perceptions, within nursing programmes (Baumbusch & Andrusyszyn, 2002; Deschodt et al., 2010; Hirst et al., 2012; Koskinen et al., 2015). Scholars completed an integrative review to understand the factors affecting the paucity of nurse educators with the expertise to teach nursing students about the ageing population, and they found that the educational institution's budget constraints and negative attitudes of educators towards older person care both prevented educators from enhancing their knowledge about working with older people (Negrin et al., 2019). Most curricular revisions to incorporate gerontological content have involved an integrated model in which, ‘everybody is expected to do “it,” [but] nobody does “it” well’ (Ryden & Johnson, 1992, p. 351). It is reasonable to believe that integrated gerontological content will be effective only if faculty themselves can effectively teach it; this requires the necessary gerontological knowledge and an understanding about the importance of this knowledge.

Garbrah et al. (2017) conducted an integrative review that examined student nurses’ preference about working with older people. They concluded that nursing curricula hinder student nurses’ interest in choosing gerontological nursing as a career (Garbrah et al., 2017). Students’ willingness to work in gerontology declined as they progressed in their nursing programme and the more clinical placements they had with older people. This was due to perceptions about the workload in nursing homes and institutional settings as physically and psychologically demanding and working with older people's challenging behaviour in these settings was difficult. Other research has also identified the low status of gerontological nursing among student nurses and nurse educators, linking it to clinical placements (Abbey et al., 2006; Naughton et al., 2019). Brown et al. (2008) suggested that students’ perceptions of gerontological nursing were linked to ‘impoverished’ clinical settings where they were exposed to negative nursing practices with older people. Naughton et al. (2019) postulated that students’ experiences of observing ‘burnt out’ practising nurses contributed to disinterest in gerontological nursing (p. 2). Students in Naughton's study explained that even if they were paid more to work with older people, they would decline working with the ageing population. Gerontological nursing refers to evidence‐based and person‐centred practice with older people in a wide diversity of settings – such as in their homes, residential care or hospital setting (Canadian Gerontological Nurses Association, 2017; Dahlke, 2011). One wonders if student nurses are equating gerontological nursing to negative experiences in long‐term care settings, where they are exposed to people with advanced dementia.

Taken together, there are negative perceptions about working with older people within nursing that contribute to the deficit of educators with expertise to teach student nurses, and there is a lack of clarity about how best to enhance what student nurses are learning when they do work with older people. The literature is missing recently graduated nurses’ perceptions on their educational preparation, specifically as it relates to working with older people. Their perceptions can provide insights into the areas of deficit in ways that student nurses and nurse educators cannot as they are able to appreciate what they wished they knew before they graduated and can reflect back on helpful learnings. Thus, the purpose of this study was to understand recent graduate nurses’ perspectives about their educational preparation to work with older people. This study was designed to provide information about a gap in the literature related to recent graduates’ perceptions about what is needed to enhance student nurses education about older people and to guide improvements related to gerontological nursing education in one large nursing programme in Western Canada.

3. METHODS

3.1. Design

A naturalistic qualitative descriptive study design was used to examine Registered Nurses’ (RNs) reflections on their education preparation related to older people (Sandelowski, 2000). Qualitative description is a useful approach to exploring a poorly understood phenomenon and allows researchers to stay close to the data in order to report descriptions of participants’ experiences (Sandelowski, 2000).

3.2. Sample

The sample included RNs who had graduated from a nursing programme within the last 5 years. Participants included 19 RNs who had graduated from the nursing programme from 5 months to 5 years prior. The average age of participants was 30, ranging from 23 to 43. Two participants were male, and the remaining 17 were female. Three of the participants reported working with children, seven worked on medical or surgical units, four in specialty units (such as emergency), and one in home care. Only two reported their practice settings to be primarily associated with older people. All of the participants graduated from the same large nursing programme in Western Canada and reflected on their experiences of learning to work with older people, while they were in the nursing programme. The nursing programme did not have a stand‐alone course about older people. Content was threaded through theory courses, often as a special consideration of the implications for older people.

3.3. Data collection

Following ethics approval at the university on record, purposeful sampling was used to recruit RNs who had graduated from the same nursing programme in Western Canada within the past 5 years. Students who had graduated within the last 5 years were selected because it was assumed that they would be able to better recall their educational experiences. The study was advertised with posters on bulletin boards within the faculty of nursing (targeting potential participants in graduate school) and through an email invitation to alumni through the office of advancement. An experienced graduate research assistant interviewed participants via telephone. The graduate research assistant was completing a PhD, had no prior relationship with potential participants and was supported in the interview process by the first author. Prior to the interview, the participants were contacted via email and sent the consent form to review. At the time of the interview, participants were audio recorded consenting to be interviewed. The researchers developed an interview guide, and interviews followed a semi‐structured format with open‐ended questions and prompts to gather further detail. Audio recorded data were transcribed verbatim, and participants were assigned pseudonyms. Examples of the types of questions were as follows: Please describe the learning experiences related to older people that you had during your nursing programme; what made them positive, negative, or neutral? Interviews were conducted via telephone from September to November of 2019 and lasted between 20 and 40 minutes.

3.4. Data analysis

Data were analysed using conventional content analysis (Graneheim & Lundman, 2004). The coding process began by reading the data word by word and highlighting text that reflected key concepts. All three researchers coded two transcripts and then met, discussed similarities and differences and agreed on codes. A coding framework was developed based on the agreed upon codes to guide coding of the remaining transcripts. Codes could contain examples that supported the code as well as negative cases, or examples that differed from the code definition. Once coding was complete, the researchers met, discussed similarities of the codes and collapsed similar codes into categories. Categories that seemed similar were grouped together to develop themes that described the phenomenon of interest (Graneheim & Lundman, 2004). An example of how codes were collapsed into categories and then themes is in Table 1.

TABLE 1.

Examples of coding to themes

Code Definition Category Theme
Recognising ageism Participants noticed ageism in the nursing environment Recognising ageism First impression
Long‐term care, a good start for skills Participants discuss that LTC is a good place for skill development Learning thec basics First impression
Long‐term care, a good place for basics The basics or fundamentals of care are learned in LTC Learning the basics First impression
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3.5. Rigour

The trustworthiness of this study was enhanced by attending to the characteristics described by Grove, Gray, and Burns (2015). Credibility was promoted by keeping a coding framework that was agreed upon by the researchers. Thick descriptions from participants that presented a diversity of perspectives supported confirmability. Dependability was promoted through a transparent analytical decision trail (described in the analysis section) and the rigorous discussions among the co‐authors. Transferability was facilitated by providing clear descriptions of participants, data collection and analysis process. COREQ was used to ensure rigour.

4. FINDINGS

Participants’ reflections on their experiences of learning to work with older people while they were in the nursing programme are detailed in two themes: (1) first impressions and (2) preparation to work with the older population (Table 2). The first theme is comprised of two categories: learning the basics and the presence of ageism. The second theme is comprised of three categories: complexity and prevalence, quality of education and communication challenges.

TABLE 2.

Themes and categories

Themes Categories
First impressions Learning the basics
Recognising ageism
Preparation to work with older people Complexity and prevalence
Quality of education
Communication challenges
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4.1. First impressions

First impressions ranged from positive, neutral to negative and often related to the student's first clinical placement in a long‐term care (LTC) setting. Participants had a deep appreciation for the value of what they described as basic care, such as bathing, feeding and communication. Some participants recognised the presence of ageism operating in healthcare settings as part of what influenced their first impressions.

4.1.1. Learning the basics

Generally speaking, LTC was seen as a good place for nursing students to learn how to work with older people and an area where they could learn important nursing skills. Nicole stated that ‘[LTC is] where you learn basic nursing. Like how to clean people and how to give meds and everything and how to do your basic assessment, … with patients who are stable’. Although participants may not have understood the significance of their experience in LTC when they were students, as they reflected back, they recognised the value of the LTC setting for the opportunity to develop fundamental skills. For example, Jenny mentioned: ‘In the first year we did a LTC practicum, … we mostly did healthcare aide stuff … lots of people complained about that … but if you can't do healthcare aide stuff, like hands‐on care, then you can't nurse’.

Negative perceptions about older people and LTC were often associated with the challenges of working with older people who had severe dementia. Doris explained that it was ‘your first experience … helping patients with very, very severe dementia, or patients that were a constant fall risk, or were always confused,… that can affect your outlook on it throughout your education’. At the early stage of their nursing education, participants were focused on learning to manage the hygiene and mobility concerns of people and had not yet learned about behaviours associated with advanced dementia or how to manage them. Adam explained that some of his classmates quit after their first exposure to the complexity of the care requirements of older people in LTC. ‘Our very first rotation we ended up in long‐term care – some people quit. They're like, “No, this isn't for me, and I don't want to do this scope of work, so – nursing's not for me”’.

These experiences encouraged participants to associate nursing practice with older people with the managing of behaviours associated with dementia and major assistance with activities of daily living (ADL). As Amanda highlighted, the activities that students were learning in these early placements were basic skills that were often the job of a healthcare aide. ‘Doing what the healthcare aides are doing. Just getting them up, helping them with personal hygiene, and it was a very fast pace …. So, we never really got to like, interact with them’. Although Amanda was able to identify that healthcare aide work was different than RN work, it remains unclear if other students in this setting understood the RN role or how these types of experiences may have shaped their perceptions about working with older people. It is apparent that participants were aware that basic care in these settings was not the role of the RN.

In contrast, other participants reflected positively on the opportunity to talk to the older generation and understand patients, their life stories, and the impact illness and hospitalisation had on them. Janet explained that

it was quite positive getting to really get to know older adults … those first few where you get to spend the time in long‐term care and medicine settings where you have that population, you get to actually spend the time with your patients and get to know what their hospital experiences will be like, and you get to kind of talk to them, learn about their life, learn about how these things are affecting them.

Mary reflected that LTC was a good place to learn the basics of nursing care: ‘My first clinical placement … was the best experience for me, because it's the fundamentals of nursing, right? It's the hands‐on patient care, learning how to wash people, talk to people, and care for the most vulnerable population’. Similarly, Nora suggested that learning about the fundamentals was a necessary step towards making the caring experiences positive for both the nursing student and the older person: ‘To really get that fundamental as early on in the program, so that your approach to caring for older adults is not only positive for you but positive for them, I think is really important’. Thus, it seems that for some participants their first clinical experience was both a time to learn the basics and to learn communication with the ageing population.

Although participants generally valued the basics, some admitted that this was not always the case. Participants noted that learning to value the basics was also a lesson in and of itself. For example, Adam stated:

At first, you're doing this in clinical, and you're like, ‘Oh, I came to school to learn how to make a bed,’ but then you get to the hospital and you're like – ‘Oh my god, I didn't realize how important it is for somebody,’ or how you take for granted to have clean sheets every day. And if you're not doing that, nobody is.

Allan felt similarly: ‘It's certainly insulting that I didn't appreciate [it] early on in the program, but later on in the program, absolutely’. Only as their nursing programme continued or when they graduated had participants recognised that understanding the fundamentals of care (basic care) with the older population was important.

4.1.2. Recognising ageism

Some participants reflected on their experience as positive, yet either recognised or demonstrated the presence of ageism in their descriptions of working with older people. For example, Ian explained that

[Our experiences] were definitely positive, we've always heard – but for our generation, ‘Oh elderlies don't like younger people,’ but honestly, I had an absolutely amazing time in that long‐term care. Like, the staff were really good and the patients that we did communicate with, and my old patient, were all amazing. They were so good, they were so sweet. I really genuinely had an absolutely amazing time there, and I loved talking to elderlies there and I loved playing games with them, and I love how amazing they were and how sweet they were to all of us.

Ian's use of the label ‘elderlies’ and stereotypical examples about how ‘sweet’ the older people were portrayed a patronising ageist perspective, of which he seemed unaware of in his description of what he viewed as a positive experience. Doris reflected on common comments she had heard related to older people which demonstrated misconceptions and a lack of understanding of how acute conditions could impact older people's function. ‘They're a falls risk,’… ‘They're incontinent again,’ or ‘They keep forgetting what time it is,’ or ‘They take forever to take their pills’. These types of comments that participants had heard from healthcare workers while they were students suggested that working with older people was heavy and time‐consuming work. Nora also recognised that the healthcare system was institutionally ageist in design contributing to the perpetuation of negative perspectives towards the older population. ‘The healthcare system … It's designed to care for people who are you know, acutely sick, and not necessarily have multiple comorbidities and chronic diseases’.

4.2. Preparation to work with older people

Participants reflected on the importance of being prepared to work with older people due to the complexity and prevalence of the ageing population in nursing practice. Yet, they perceived their educational experiences related to older people were of minimal content and thus low quality. Communication challenges particularly with older persons who had cognitive impairment was identified as a gap as it was not formally represented in their nursing education. Of note, only three participants indicated that they felt prepared to work with older people on graduation, and their reports of being prepared lacked certainty. For example, Sam explains: ‘To a degree, yes – but I feel like there could have been more in school … around older adults because most hospital populations are generally older people’. As Sam explained, once participants graduated and started working, they began to recognise that most of the people they were working with were the older generation. Thus, when they reflected back, they recognised that their understanding about the differences related to ageing was important information they needed in their nursing practice.

4.2.1. Complexity and prevalence

Participants talked about how they had gained a greater understanding for the complexity of older people and learned to appreciate the importance of managing the care of older people due to the prevalence of this population. As Jenny relates: ‘An older person's body is much more complex … you would almost understand it better at the end [of a nursing program] when you actually understand what's happening in the body with a normal person … They don't just have one diagnosis, they have like – ten’. Lindsay explained how understanding the complexity of the ageing person could assist nurses to be alert for complications, which would ultimately result in safer care. ‘You know about these comorbidities, even just in the aging population, put them at a higher risk of – you know, coming out of anesthesia and everything else’. Nicole echoed what most of the participants explained about the prevalence of older people in nursing practice when she said: ‘General nursing, you're always going to be working with older adults … Older adults, they're usually complex patients’. Most of the participants suggested that, as graduates, they had come to recognise the complexity and prevalence of older people in their nursing practice. These reflections highlight the importance of ensuring that nursing programmes are preparing future nurses to understand the complexity of older people so they know what to expect in the real world. Moreover, seems like there is also a need to highlight to students when they are learning about older people that this is not an isolated population that only few nurses encounter, rather they are likely to encounter the ageing population in their practice.

4.2.2. Quality of education

Participants generally remembered little of their education related to older people, and what they did remember they perceived as insufficient. Several participants were able to recall some readings and modules related to older people as well as the first clinical experience in LTC. Alex explained that ‘in the classroom setting we definitely had like chapters on older adults that we had to read, and went over some information pertaining to older adults … In clinical setting we had one rotation where we were in long‐term care and most of the patients there were older adults’. However, like many participants, April remembered content related to older people ‘was just … breezed over, in a way. I’m sure they did go into it in first year and I don't remember so much’. In other words, participants did not recall details about the older population, or the importance of understanding how to care for older people. Participants did remember the focus on other populations, as Allan explains: ‘I think there was more focus put on to maternity and pediatrics than there was to older adults, despite the fact that they make up a larger portion of the people I work with in my career’. Nora found it contradictory that despite older people being the population most graduates worked with, the attention to understanding this population was ‘quite brief and [no] … course or anything that is designed specifically to address this larger area of our population’. Participants noticed the emphasis in their nursing programme on younger populations, such as maternity and paediatrics, leading them to better remember the significance of these populations. It is unclear if this was due to the ‘threaded’ approach of content related to older people in this nursing programme.

Some of the participants remembered one lesson on how to communicate with older people and another on the functional needs of older people. Those that did remember the lesson on communication described it as basic. As Kate reflected: ‘In first year … I remember, kind of just the basic communication and interaction with the elderly’. Other participants suggested that although they may have learned something about the functional needs of older people, retrospectively it was not sufficiently detailed to support their nursing practice. As Sam explains, ‘just learning about mobility and how older population – how they are different from the younger population in terms’. It would seem that participants’ recollections of the threaded content about older people was in relation to how the older population differed from younger populations. Lindsay suggested that after first year courses that may have touched on older people ‘aging across the life span wasn't well‐integrated into our lessons following that … it was just kind of assumed in our program that you would make those connections, in regards to age and increased risks, increased comorbidities’. Similarly, Jenny explained that the practicalities of what they had learned in their nursing programme relating to older people was left for them to sort out: ‘I remember learning about personal directives in school, but I don't ever remember actually understanding what that meant’. Mary suggested that learning about what is normal for the general population was not sufficient when ‘our general population is aging, then maybe the “normals” have to change’ (Mary).

4.2.3. Communication challenges

Participants described the importance of strong communication skills when working with older people. Yet, there were challenges in communication with older people particularly if they had cognitive impairment. Tyler described how as a graduate nurse he recognised that communication was integral to the relationship building process: ‘… you look after these people every single day. They have no one else. So that personal care relationship I think is really important, and it probably keeps a lot of us, like, I don't know – maybe like grounded’. Janet supported this position and built on it by describing the importance of how communication encourages nursing students to build unique relationships with older people, and how this ultimately helps students learn to identify and respect the diversity found within this population: ‘I think that a lot of people kind of generalize older adults … communicate with loud voices and slow speech’. Janet further identified how stereotypes, such as all older people being deaf, could influence how communication with the older generation occurred.

When discussing the importance of communication, participants also described some of the challenges they faced. Kate explained that communication with older people was missing: ‘I don't think we had all the education that we could've had to be able to interact with them and provide proper care in communicating’. Amanda also felt like she was ill‐prepared by her nursing programme to communicate effectively with older people: ‘we didn't really get any education on like, talking to the older adults, like what we can talk about’. It seems from Amanda's statement that she saw communication with older people as a different skillset from communicating with younger people. Moreover, it appears that the lesson on communication with older people did not provide information on what to talk about. Although some had found the communication lesson to be basic, others required even more basic information.

It is unclear if this knowledge gap was caused by discomfort with generational differences. Taylor described the difficulties communicating with an older person rather than someone closer to their own age: ‘Yeah, so that's what I found difficult … if [we] were the same age, then we just when we are talking … but to older people we have to more, you know, like the way you talk? Have to be more polite’. Ian reflected his experiences as a graduate nurse observing student nurses’ fears in trying to communicate with older people. ‘I find that students tend to get scared when they're talking to the elderly’. Finally, Alex mirrored a similar sentiment regarding different challenges when communicating with older generations, and stated: ‘we're seeing people in the hospital … at their worst, and then combined sometimes with a bit of a generational gap, I think it can be a little bit harder to communicate’. Perhaps, it is a combination of generational differences and working with ill people that created the communication challenges for participants when they were students.

Participants also discussed the difficulties communicating with older people who were experiencing cognitive impairment, such as dementia, and believed they could have been better prepared in their education programme. Ian stated: ‘… the way that you're supposed to communicate, it is a lot different – especially if the patients had like for example, dementia … – we didn't really know how to communicate with the individuals who were confused, who had dementia’. This sentiment was echoed by Adam who explained that ‘with dementia people can be hard to redirect, they can be aggressive, sexually inappropriate. Just like be dealing with people that are very confused, and that's hard to … respond to something like that – until you're doing it’. Adam was suggesting that learning occurs on the job in the moment with older people with behaviours related to dementia. Thus, communication with older people was complex; it required a younger student to know what to say to someone from a different generation, be adequately prepared to work with ill patients and be prepared to communicate with people who had dementia.

5. DISCUSSION

The novel finding from this study was that nurses did not recognise the importance of learning about older people until they had graduated and realised the ageing population was complex and prevalent, forming the majority of patients in hospitals. Other findings included a perceived lack of education related to working with older people, particularly related to working with the behaviours associated with dementia and learning how to communicate with an older person. In contrast, other scholars reported that student nurses view communication and care of older people positively (Hammar et al., 2017). Hammar et al. (2017) suggested that the students’ perceptions about communicating with older people were shaped by their early experiences in their nursing programme. A recent study of student nurses’ perceptions of working with older people supports the findings in this study that identified difficulties students have in communicating with older people, particularly those with dementia (Dahlke et al., 2020). Given the prevalence of ageism that can include negative and benevolent perspectives, both of which can be patronising (Cary et al., 2017), we wonder if studies suggesting that students have positive perspectives about older people are not capturing the possibility that benevolent ageist perspective may be present. The differing findings among these studies suggest that learning how to communicate with older people is not uniform across nursing programmes, or perhaps across all student groups. It does suggest that examining how communication with older people is taught needs to be revisited to include what to say (to help those who need more basic help), and how to best communicate with people experiencing dementia. We suggest that, given the insidious nature of ageism in nursing and health care (Kagan & Melendez‐Torres, 2015), it is best to expose ageist perceptions that are well accepted and dispel myths about ageing early on in nursing education.

In this study, participants suggested that even though there was some mention of the differences of older people to other populations, they perceived it was up to them to fit in learning about working with older people on their own. It is hard to know whether this perception of the need for self‐study was due to the increasing responsibility they were meant to assume, or if it was a reflection of faculty's perceptions that nursing practice with older people is simple (Koskinen et al., 2015) and can be self‐taught. These perceptions could also be due to participants’ reflections of what they remembered and not all that had occurred. Moreover, it is possible that when they were students, participants were focusing on what was on the next test rather than the content nurse educators were trying to impart. Moreover, practising nurses have a professional responsibility to continue their own education once they graduate and not everything a nurse will encounter can be taught in nursing school. Nonetheless, a curriculum that is designed to present the prevalence and complexity of the ageing population in a manner that seems significant to student nurses could assist nurses to graduate with the knowledge they need to look after older people.

Scholars have identified that when nurse educators are knowledgeable about the ageing population and hold positive perceptions towards older people, they can play a key and positive role in students’ decision‐making about older generations and interest in working with this population (Duggan et al., 2013; Kydd et al., 2014). When considering that participants from this study did not recognise the importance of learning to work with older people until they graduated, one wonders whether nurse educators could affect change if they portrayed the importance of this population and enthusiasm for working with them earlier on and throughout the programme. However, even though it is important that nurse educators take responsibility for ensuring that nursing students are learning the requisite knowledge and skills needed to graduate being prepared to work with older people, educators must have the knowledge about the ageing population before they can impart it. Negrin et al. (2019) integrative review of the factors influencing educators’ knowledge, skill and attitudes towards older people revealed that nurse educators are subject to the same negative perceptions about older people that are part of nursing, and they did not always receive support from their administrators to acquire the necessary gerontological knowledge. In other words, it was up to them to learn about the ageing population, much like participants in this study reflected that they perceived it was up to them as students to learn about working with older people on their own. We wonder if this is an example of what scholars suggest as a societal wide diminished importance of older people (Kagan & Melendez‐Torres, 2015; Palmore, 2015). Perhaps the first step in breaking this vicious cycle is to support nurse educators in learning about the ageing population. McCleary et al. (2009) reported on a knowledge mobilisation event with nursing educators across Canada that equipped them with tools to incorporate gerontological content into nursing curricula and a way to stay connected to support one another. Knowledge mobilisation events such as this that targets nurse educators could enhance the capacity for educating nursing students about older people.

Another way to guide knowledge about working with older people in nursing curricula is to make use of gerontology standards and competencies to guide integration of appropriate focus on older people in concepts and content areas throughout curricula. As indicated earlier, Koskinen et al.'s (2015) review suggested gerontology competencies could facilitate improvements to gerontological content in nursing curricula. Scholars examining how healthcare professionals incorporate content to facilitate gerontological competence suggested that educator gerontological expertise is necessary to bring these competencies into the curricula in a meaningful way (McCleary et al., 2017).

Participants noted specific deficits in their education preparation to communicate with the older population and to work with people with dementia (PWD) who may be exhibiting challenging behaviours. Usually participants’ experiences with PWD was in their first clinical experience in long‐term care where they were focused on learning the skills associated with fundamentals of care (hygiene, mobilisation, feeding). This type of work in the LTC settings, where students were learning these skills, was done by healthcare aides. Participants recognised this work as healthcare aide work, and did not describe the role of the RN in these settings. Their association with the work of a healthcare aide could lead to a perception that working with older people is simple. Moreover, learning to care for physical bodies was not always connected to learning to communicate and relate to these older bodies for many participants. Researchers have suggested that first clinical experiences in LTC settings where students learn fundamental skills without a corresponding recognition of the complexity of the population they are interacting with can perpetuate perceptions of working with older people as simple, and unpleasant work (Abbey et al., 2006; Gould et al., 2015). We suggest that how students are taught the basics needs to be revisited to gain an understanding that these tasks are really fundamentals of nursing practice (Kitson et al., 2010). If it is necessary to place students in LTC settings for their first clinical practice to learn the fundamentals, we suggest that open discussion about the role of the RN in LTC, the complexity of the population in LTC and guidance in managing older people with advanced dementia be considered.

There are examples in the literature of how to facilitate students’ understanding of dementia, ageing and communication. One example is an ageing educational game that simulates disabilities and physiological changes of ageing (Lucchetti et al., 2017). Other examples include clinical experiences that include exposure to a wide range of older people in a variety of clinical settings and content about older people (Dahlke & Fehr, 2010), or use of a high‐fidelity simulation to explore the complexity of older people (Abendroth & Graven, 2013). Sheets and Ganley (2011) used simulation to integrate gerontological content into a foundational nursing course. Kimzey et al. (2016) found that students’ understanding of the behaviours of PWD as communication of an unmet need increased after an online learning module about this population. These examples point to the potential to improve student nurses’ knowledge about the ageing population. Although there are many strategies to improve students’ knowledge about older people, it is unclear how widely they are being taken up, or which ones are most effective. More research into innovative learning methods that raise students’ awareness to the prevalence and complexity of the older population is still needed. It is our hope that students will graduate with the understanding that older people are the most prevalent population and feel confident in managing their care needs.

6. LIMITATIONS

This study was limited by participants representing graduates from one nursing programme in one setting. It was also limited by participants’ recollection of their experiences as nurse educators’ perspectives about what they were teaching students were not included. Although these findings cannot be generalised to other nursing programmes, research around the world identifying deficits in gerontological education in nursing programmes suggests these results may be helpful in other contexts (Deschodt et al., 2010; Gilje et al., 2007; Hirst et al., 2012; Ironside et al., 2010; Xiao et al., 2008). It is hoped that the rich descriptions within this study will aid others in identifying if there may be similarities in their own nursing programmes or in allowing nurse educators in clinical settings to think about possible gaps in knowledge related to working with older people that practising nurses might have.

7. CONCLUSIONS

Novel findings from this study were that nurses did not recognise the importance of learning about older people until they had graduated and realised the ageing population was so complex and prevalent. They perceived a lack of education related to older people, particularly related to working with the behaviours associated with dementia and learning how to communicate to an older population. We suggest that ageist perceptions and stereotypes within society need to be purposefully exposed to students as part of their learning about older people. Faculty need to be supported in learning how to best incorporate content about older people into their curriculum. This could include learning activities that dispel negative stereotypes about ageing and facilitates interest in older people, as this is the population, they are most likely to work with when they graduate.

CONFLICT OF INTEREST

The authors have no conflicts to report.

FUNDING INFORMATION

This project was funded by the McCalla Teaching Professor Award, University of Alberta.

What does this research add to existing knowledge in gerontology?

  • ●
    Nursing graduates do not recognise the importance of learning about older people, or the complexity and prevalence of the ageing population, until after they graduate.
  • ●
    There are deficits in nursing education related to persons with dementia and communication strategies with older people.

What are the implications of this new knowledge for nursing care with older people?

  • ●
    Nurse educators have a responsibility to enhance nursing education so that graduates are equipped to work with the ageing population.
  • ●
    Nurses require education to enhance their practice with persons with dementia.

How could the findings be used to influence policy or practice or research or education?

  • ●
    Research examining the effectiveness of novel learning activities related to working with older people is needed.
  • ●
    Administrators of nursing educational institutions could support nurse educators’ education and development of learning activities to teach about older people.

DATA AVAILABILITY STATEMENT

We do not wish to share data.

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Data Availability Statement

We do not wish to share data.

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