ABSTRACT
Background
Nursing students encounter older people in all health care sectors; however, few choose a career primarily focused on older person's care.
Aim
To explore the challenges to teaching older person's care to Bachelor of Nursing students and how pre-registration nursing students are prepared to care for older people, part of a large study investigating content on care of older people in Australian nursing curricula.
Methods
A purposive sample of Australian nurse academics involved in Bachelor of Nursing curriculum development or delivery completed a telephone-assisted survey. Qualitative content analysis of two open-ended questions was undertaken.
Results
All Australian schools of nursing participated, and 45 nurse academics were interviewed. Reflecting on the challenges of teaching older person's care to nursing students, most participants felt the curriculum was too crowded and some called for a 4 year degree. In addition, students’ ageist attitudes, fuelled by unrealistic portrayals of nursing in popular culture, were reinforced by curricula being acute care focused and the ageist attitudes of some nurse academics.
Conclusions
Teaching older person's care in Australian nursing curricula is challenged by insufficient time and ageism among students and academics. Regulatory bodies need to urgently provide direction so that nursing curricula content aligns with emerging Australian health care priorities, in particular the health care needs of older people.
Keywords
Summary of relevance
Problem or Issue
Most care recipients in Australian health care settings are older people, yet the nursing workforce, the largest health care workforce, is insufficient in number, and unprepared to provide high quality care to older adults.
What is already known
International and national research show that graduate nurses do not actively choose a gerontological nursing career.
What this paper adds
Teaching older person's care to Australian nursing students is a challenge because a three-year degree does not allow for the inclusion of fundamental content and experiences relevant to older peoples care in curricula that are already too crowded. In addition, students commence their degree with unrealistic expectations of nursing roles and patient populations. Many have ageist attitudes, reflective of the general population attitudes, and are taught by academics who may also have ageist attitudes. All these issues impact graduates’ career choices and their work readiness.
1. Introduction
Australia has no national Bachelor of Nursing curriculum (Schwartz, 2019), and the mandated curricula inclusions are Aboriginal and Torres Strait Islanders’ health needs and a minimum of 800 hours of clinical placement (
Australian Nursing and Midwifery Accreditation Council (ANMAC) 2019
). All Australian nursing curricula are accredited every three to 5 years by ANMAC, in line with the standards for nurses developed by the Nursing and Midwifery Board of Australia. Currently, there are no accepted gerontological competencies for Australian Bachelor of Nursing curricula (Poulos et al., 2020
), despite the projections of an increasing number of older people with chronic illnesses using health care services (Australian Institute of Health and Welfare 2021
; Australian Institute of Health and Welfare 2019
) and a shortage of nurses to provide care (Health Workforce Australia 2014
).Health Workforce Australia. (2014). Australia's Future Health Workforce – Nurses Overview. DoH, Canberra. Accessed 2 September 2021. Available at: https://www.health.gov.au/sites/default/files/documents/2021/03/nurses-australia-s-future-health-workforce-reports-overview-report.pdf.
Graduate nurses need to be work-ready; they should have the appropriate skills, and knowledge, beyond technical competency, to adapt to the challenges of clinical workplaces (
Rogers et al., 2021
). Nurses require specific knowledge and skills to care for older people with complex health care issues (Australian Government, DoH 2020
), and they must also be confident and capable of working with older people. However, over two decades of international literature suggests, that nurses are graduating with little preparation to work with older people (Dahlke et al., 2021
), particularly those with dementia (Khait et al., 2022
). They also hold ageist views (Sarabia-Cobo and Pfeiffer, 2015
; Koskinen et al., 2015
); and do not consider a career working with older people to be satisfying or worthwhile (Hunt et al., 2020
; Hebditch et al., 2020
).An exploration of how care for the older person is taught in Australian nursing curricula, may provide some understanding of graduate nurses’ work readiness and career choices.
2. Literature review
The literature suggests that nursing students’ attitudes to caring for older people are negative (
Hunt et al., 2020
; Liu et al., 2013
) and that their career choices continue to reflect a preference for working in acute health care with younger people (Hebditch et al., 2020
). Neville et al., 2014
found that undergraduate nursing students’ decisions not to work with older people was related to their educational experiences, in particular the curricula and experiences on clinical placements; the working conditions of specific health care settings, especially in residential aged care facilities (RACF); and ageism. Undergraduate nursing curricula remain acute-care focused with limited attention to chronic diseases, ageing and ageing-specific services (; Calma et al., 2019
). Content on the older person's care tends to be integrated (; Garbrah et al., 2017
), and there are few nurse academics with expert gerontological knowledge to teach this content (; Fulmer, 2020
). Most Australian nursing students undertake their first clinical placement in a RACF (Parker et al., 2021
; Rayner et al., 2022
). They commonly report these placement experiences in negative terms related to feeling unprepared (Keeping-Burke et al., 2020
) and unsupported (Forber et al., 2016
), having limited interaction with registered nurses (RNs) (Hunt et al., 2020
), and poor working conditions in the sector (Kydd et al., 2014
). These negative clinical experiences can perpetuate nursing students’ ageism and influence their career choices (- Kydd A.
- Engström G.
- Touhy T.A.
- Newman D.
- Skela-Savič B.
- Touzery S.H.
- et al.
Attitudes of nurses, and student nurses towards working with older people and to gerontological nursing as a career in Germany, Scotland, Slovenia, Sweden, Japan, and the United States.
International Journal of Nursing Education. 2014; 6: 182-190
Naughton et al., 2019
).This paper reports findings associated with the challenges of teaching care of the older person content in Australian nursing curricula, and how pre-registration nursing students are prepared to care for older people, part of a larger study investigating care of older person content in nursing curricula.
3. Method
3.1 Study design
An exploratory study investigated the how care of older people content is incorporated and taught in Australian undergraduate nursing curricula ().
3.2 Ethical considerations
Ethical approval was obtained from the La Trobe University Human Research Ethics Committee in 2018 and where required from the institutional ethics committee of other research team members universities. All respondents gave informed consent.
3.3 Settings and participants
All Australian Schools of Nursing (SoN) offering a Bachelor of Nursing in 2019 were eligible to participate. Heads of the SoN were asked to nominate one or more academics who had an in-depth knowledge of the undergraduate curriculum, and the qualifications and/or expertise to teach the care of older people content (Table 1, ).
3.4 Data collection
A semistructured survey developed, piloted, and reviewed by the Australian Hartford Consortium for Gerontological Nursing Excellence (Aus-HCGNE) was completed as a telephone interview (
Rayner et al., 2022
). Participants from three SoN elected to undertake the survey as a small group interview (two interviews with two participants and one with three participants). This approach enabled questions to be answered by the participant with the knowledge to do so, e.g., questions about clinical placements were answered by academics who organise them such as Lead of Professional Practice.3.5 Data analysis
Responses to open-ended questions were analysed using qualitative content analysis, a method that reduces data into manageable representations through clustering data that are ‘connected…or have common meanings’ into sub and then whole themes (
Krippendorff, 2013
, p.205). Two authors analysed the data manually, individually identified clusters which were then cross-checked by both with consensus determining themes and sub-themes.Strategies to establish rigour included analysis by two authors and the use of the Consolidated Criteria for Reporting Qualitative Data (COREQ) (
Tong et al., 2007
). Direct quotes illustrative of the categories were utilised to provide the context in reporting.4. Results
All 35 (100%) Australian SoN participated, including 33 universities, a Technical and Further Education (TAFE) organisation and an Institute of Advanced Education. Forty-five nurse academics, mainly women (n = 41, 91%) with at least one from each SoN, were interviewed. Most were co-ordinators of the undergraduate degree (n = 21, 60%).
The findings reported here are from an analysis of two open-ended questions: what are the challenges of teaching older person's care in Australian undergraduate nursing curricula? Furthermore, how pre-registration nurses are prepared to care for older people? The analysis produced two discrete themes – the curriculum and the ageist attitudes of students and nurse academics.
4.1 The curriculum
Respondents spoke at length about why they could not include more content on older person's care in their curriculum. The discussion focused on where and when to include this content as the curricula are already full, leaving very little time to include additional content.
When we look at everything that must be in the curriculum, and everyone wants a fast-tracked pathway. There is just not enough time to get nurses on graduation to be workforce ready (SoN 28).
We have to have governance, we have got to have risk management, quality and safety, patient safety, all of the standards that need to be addressed now in an undergraduate curriculum make it very packed (SoN 6).
It's what we are required to have - we must have a mental health unit, an Indigenous unit, an evidence-based/research unit. There is so much required in the curriculum. (SoN 1).
Some respondents, acknowledging that there was insufficient content on older person care despite nurses being most likely to care for older people in all health care settings, reported that their current curriculum was poorly designed. The curricula were criticised for being acute care focused. The content on older person's care emphasised bodily care, with little content on healthy ageing, older peoples’ specific needs or communication with people with dementia. In addition, respondents noted that clinical experiences associated with older people were generally undertaken in RACFs in the first year of the degree, which further reinforced students’ perceptions of the care of older people.
We've got serious problems about how we conceptualise older person care in the curriculum. We consistently conceptualise clinical placements about older people as aged care facility placements, ignoring the fact that older people are in every area of health service (SoN 2).
We are very much into the pathology behind ageing as opposed to the human side, which impacts the quality of care provided (SoN 31).
The lack of time to teach the care of the older person content, despite acknowledging the need and value of this for nursing students, prompted some respondents to suggest the Bachelor of Nursing should be extended to a four-year degree, with curriculum renewal focusing on the care of the older person in line with national health care priorities.
We need more time to do this teaching. I would definitely be an advocate for the four-year degree because there actually isn't enough time. I don't think you can take out what we've currently got, but it would be great if we had more time to really go into the physiology of ageing and to bring it back in the later years. It's fine to introduce it in first year, but you introduce a whole lot of foundation concepts that can't be built, there's not time to build on all of them (SoN 30).
Others spoke about the difficulties in (re)designing a curriculum while adhering to the ANMAC standards. They felt this made it very difficult to introduce new content or expand on existing areas. Some thought ANMAC should provide guidance to SoN.
If there was some guidance around what needs to be incorporated in undergraduate curriculum, that would be helpful. When you're trying to put a curriculum together, trying to think of everything is difficult (SoN 13).
Participants supported standalone gerontological subjects in nursing curricula and acknowledgement that gerontological nursing needed to be genuinely promoted as a legitimate career path.
Universities are too quick to incorporate older person care into the entire curriculum. I think that the standalone subject is really necessary for the student's better understanding of older person care. They're the largest population (SoN 5).
I think [gerontological nursing] needs to be promoted to undergraduate as a legitimate career because they gravitate towards health care that is more acute, and they look for graduate programs within those. I think we need to encourage them. It is a legitimate, challenging career pathway (SoN 15).
Within the curriculum theme, nurse academics reported that scheduling clinical experiences in RACF for first year students was a challenge.
The biggest challenge is sending out first year nurses into aged care placements because of who they're buddied up with - carers (SoN 30).
Many respondents felt that RACF settings were unsuitable for first-year students due to the complex nature of the care required by residents, especially those with dementia, and because there were insufficient numbers of RNs available to supervise students. In addition, respondents felt these experiences reinforced students' existing ageist views and negatively influenced their attitudes toward pursuing a gerontological career.
4.2 The ageist attitudes of students and nurse academics
The second challenge to teaching care of the older person in Australian undergraduate degrees was the ageist attitudes of students and nurse academics. Respondents spoke at length about the stereotypical attitudes about older people held by nursing students. Some added that this was more evident among graduate-entry students who currently or previously worked in RACFs. Respondents reported that ageist attitudes influenced students’ engagement with older person care content and their clinical experiences with older people. However, they acknowledged that it was difficult to counter these attitudes, which reflective the wider society.
I think one of the challenges is that ageism does exist, and you've got to really challenge that with students (SoN 27)
It is ageism. Some students email me about it ‘It's my third time to go to aged care facilities or look after someone who's older, I think it is enough’ (SoN 4).
Further, respondents stated that some nurse academics also held negative attitudes and biases about nursing older people or preferred acute care nursing over gerontological nursing. The ageist attitudes of academics can influence students’ pre-existing ageist views, a challenge acknowledged by respondents to teaching content on older person care.
We have many staff who worked in aged care or did placements themselves. That experience of aged care is predominantly their memory, and sometimes they can be quite negative (SoN 22).
Our biggest challenge is attitudes. I don't necessarily mean attitudes of the students. It's more the attitudes of the people teaching them (SoN 34).
Finding the right clinical teacher who isn't someone who just dismisses aged care and already has those negative views. I think staff do hold ageist views (SoN 16).
Coupled with ageist attitudes, respondents reported that students had unrealistic ideas about nursing and who they would be caring for. According to respondents, popular culture, particularly social media and television, significantly influenced whom students imagined they would be nursing and in what health care settings. At odds with the reality of health care settings and patient cohorts, television programs depicted nurses caring for young, acutely ill people in highly technical settings such as intensive care units (ICU) or emergency departments (ED). Respondents reported that popular culture was often the driver for some students to start a nursing degree and that it was difficult to counter these perceptions, especially in the first year.
We're battling against the differing motivations to doing nursing now. It's about fighting against their preconceived ideas about what nursing is, and television is killing us (SoN 23).
It's the perceptions that students have, how they view nursing. They want to perform venepuncture and all the things they see on TV that have formed their image of nursing (SoN 15).
Others spoke about how students conflate care of the older person with care of people living in RACFs; and of the impact of the negative media coverage about RACFs, especially that related to the coverage of the Australian Royal Commission into Quality and Safety in Aged Care, which intensified student's negative views of the care of older people.
The majority of people that students will care for are over 65, regardless of where they work. I don't think students realise that. Even when I've said that you get this surprised look on students’ faces, and you think, “I don't know who you're thinking you're going to be caring for”. It's going to be a very long battle because, unfortunately, even in the media, there's never a nice light shone on aged care (SoN 16).
When asked about how their SoN advertised their Bachelor of Nursing degree, many added that their websites perpetuated the inaccurate image of nursing and patient cohorts, as very few websites included older people as recipients of care.
Most of our websites tend to be lovely young people with stethoscopes and white coats in labs, which drives us crazy because that doesn't really describe nursing (SoN 34).
On the website, when you see it, it's really the students that are the focus. I mean there is one image of a person who's in bed, and the person is very young, and it's a nice pretty patient (SoN 17).
As a result of these widely accepted yet often inaccurate images of nursing, health care settings and patient cohorts, participants reported that student nurses preferred and valued the acute care content over other areas, especially content on older person's care. They added that students also sought acute care areas for their graduate positions.
They [students] gravitate towards acute health care facilities, and they look for graduate programs in those (SoN 15).
Our biggest challenge is that students see care of the older person as in residential care. Not understanding the complexities of chronic and acute health changes. I think that is associated with the ageist view (SoN 17).
Normally they all want to go and work in ED, or ICU, or midwifery (SoN 35).
All respondents spoke about the limited number of nurse academics in their school with gerontological qualifications, expertise and experience to teach the content on older person's care adequately (). This lack of expertise also extended to clinical teachers. In addition, respondents acknowledged that older person care was now more complex than previously understood, which was lost on students and some nurse academics. This added to the challenge of finding academics who could teach the content effectively and authoritatively.
One of the challenges is the lack of [academic staff] experience or expertise or being too specialist in another field and getting across to the students the importance of, and differences in, caring for the aged across a variety of settings and the complexities that this entails (SoN 3).
I think one of the challenges is that some academics sometimes have a bit of a blind spot to older people. They want to just give the acute medical ICU type sessions, and they want that biological, biomedical type curriculum to be at the forefront of the nurse, and that's not the reality of what students are going to be seeing now or into the future (SoN 13).
5. Discussion
The changing dynamics of the Australian health care sectors, including the ageing of the population, the increased complexity of care, innovations in health care technologies and restrained spending (), means nursing graduates need to be work-ready. However, the literature suggests that the current preparation of nurses is inadequate, and graduate nurses are not ‘work-ready’ (
Missen et al., 2015
). In particular, they are insufficiently prepared to care for older people (), a population cohort they will increasingly encounter in all health care settings.These findings highlight the challenges in teaching content on older person's care in Australian undergraduate nursing degrees, which may impact student nurses’ career choices, as has been found elsewhere (
Hunt et al., 2020
). Career choices are often made as an undergraduate, with many factors influencing the decision, including the factors identified in this research. While there was consensus concerning the importance of teaching care of the older person in all SoN, there was little indication of a systematic approach to delivering this content because of the challenges reported.As this study found, international reviews suggest that nursing curricula are overcrowded (
Deschodt et al., 2010
), and nurse academics admit that they have no time to comprehensively cover content on older person's care (Dahlke et al., 2020
). Content on older person's care in Australian undergraduate nursing programs is generally delivered as a combination of standalone subjects and integrated across the curricula, with a small number of SoN reporting the content is included in electives (). Offering content on older person's care as an elective subject may not provide the attention it deserves. It has been suggested that electives attract fewer students (Grocki and Bert Fox, 2004
) especially if the subject matter does not align with their career goals (Babad, 2001
). More than 20 years ago, Nay et al., 1999
argued that the integration of content on older person's care devalues it; however, more research is required as there is a lack of evidence of the effectiveness of offering standalone subjects over embedding or integrating content on older person's care across the curriculum. Some respondents suggested that a four-year degree was required as current curricula are ‘full’ reiterating Recommendation 12 (exploring ways to extend the current three-year degree) from the recent review of nursing education in Australia (Schwartz, 2019
, p. xv). This would also bring the degree in line with nursing degrees in Canada, Ireland, the United States, and many European countries.The acute care focus of nursing curricula in Australia (0 and elsewhere (
Garbrah et al., 2017
) also influences nursing students’ career choices. Students value nursing that involves more technical skills, so their career preferences are for highly technical health care settings such as emergency departments (EDs) and intensive care units (ICUs) (Neville et al., 2014
). Academics in this study reported that students come into nursing with an expectation and desire to work in technical areas of health care which may reflect their exposure to images of nurses in popular culture and inherent ageism. Ageism is ‘pervasive, widely accepted, and normative in many societies and is a form of prejudice that goes unchallenged’ (Sargent-Cox, 2017
, p. 5). Ageist attitudes are most common among younger people (Australian Human Rights Commission 2021
), including among student nurses internationally (Sarabia-Cobo and Pfeiffer, 2015
; Koskinen et al., 2015
; Kydd et al., 2014
) and in Australia (- Kydd A.
- Engström G.
- Touhy T.A.
- Newman D.
- Skela-Savič B.
- Touzery S.H.
- et al.
Attitudes of nurses, and student nurses towards working with older people and to gerontological nursing as a career in Germany, Scotland, Slovenia, Sweden, Japan, and the United States.
International Journal of Nursing Education. 2014; 6: 182-190
Frost et al., 2016
; McKenzie and Brown, 2014
). Neville et al., 2014
argue that this valuing of technical health care reflects the pervasive ageism inherent in societies.Attitudes to nursing older people are reinforced by popular culture, particularly portrayals of nurses working and the people they are nursing, which is commonly set in highly technical acute care settings with younger people (
van Iersel et al., 2016
). These portrayals influence understandings of nursing in particular contexts and in turn, students career choices (Albudaiwi, 2018
; Terry and Peck, 2020
) because nursing students start their degree with a ‘predominantly lay-informed conceptualisation of nursing’ (McCann et al., 2010
, p. 34), reinforced through popular culture. (Terry and Peck, 2020
) found that medical television programs such as Grey's Anatomy and Offspring were strong motivators for close to a third of students to commence a nursing degree (p.354).Ageist attitudes held by nursing students not only influence their career choice but may affect their behaviour toward the care of older people, so identification of negative attitudes towards older people should be a concern for nurse academics (). However, as this study found, nursing academics and clinical supervisors have also been found to have negative attitudes toward the care of older people, which reinforce and support students’ ageist attitudes (
Garbrah et al., 2020
; Simpkins-Gibbs and Kulig, 2017
). The literature highlights the importance of having positive role models and enthusiastic academic teaching staff with sufficient knowledge and experience in older person care. Further, gerontological nursing education has been shown to foster the development of positive attitudes towards nursing older people (Hovey et al., 2017
). To moderate the effects of inaccurate portrayals of nursing, academics, and accrediting and professional bodies must actively work to promote what nursing involves. SoN can address this issue by including images of nurses working with older people on their websites advertising the Bachelor of Nursing programs, which are currently missing.Australian nurses will encounter older people in acute care settings, community care, home care, and residential aged care. Recognition of the importance of gerontological competencies and incorporating care of the older person content into educational programs for health care professionals, including nurses, has been a major priority for the Hartford Consortium in the United States for the last thirty years (
Isaacs et al., 2019
). In Australia, competency in gerontological nursing is required now in all health care settings and is going to become even more essential as the Australian population ages (Aged Care Workforce Strategy Taskforce. A matter of care. Australia's aged care workforce strategy 2018
). As Australian undergraduate nursing programs undergo curricula review and revision, SoN need to consider a more comprehensive approach to including gerontological content to prepare work-ready graduates.Aged Care Workforce Strategy Taskforce. A matter of care. Australia's aged care workforce strategy. Report of the aged care workforce strategy taskforce, (2018). Accessed 2 September 2021. Available at: https://www.health.gov.au/sites/default/files/a-matter-of-care-australia-s-aged-care-workforce-strategy.pdf.
6. Limitations
Sampling bias limits the findings, as nurse academics who participated may have had different knowledge and experiences from others teaching Australian undergraduate nursing degrees. The group interview structure for a small number of respondents may also have limited disclosure of opinions. However, the research design, including the selection of respondents, the response rate (100%), and rigorous data analysis, contributed to the reliability of the findings and increased the likelihood that the findings accurately represented the respondents’ information.
7. Conclusion
Comprehensive undergraduate nurse education should provide nursing students with the tools they will need to adapt to future health care changes. Including more content on older person care in undergraduate nursing curricula may be challenging but it is necessary to produce work-ready graduates who are capable and confident to work with older people in any health care setting. Curricula changes may include increasing the degree length to four years and removing clinical placements from the first year. Ensuring that SoN staff assigned to teach older adult care are well prepared for the role is a critical consideration.
Authorship contribution statement
All authors were involved in survey design, discussion of findings and drafts of paper writing. JR wrote and submitted the ethics application and any modifications. DF and JR were involved in recruitment and data collection. JR and DF undertook the qualitative data analysis.
Ethical statement
This manuscript reports findings from research project involving human subjects. The project was fully reviewed by La Trobe University Research Ethics Committee. Approval was obtained on 18 December 2018; approval number: HEC18492. Reciprocal ethics approval was obtained from Curtin University on 15th February 2019, approval number: HRE2019-0061; and from Griffith University on 11th March 2019, protocol approval number: 2019/149.
Conflict of interest
None.
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Article info
Publication history
Published online: September 13, 2022
Accepted:
August 25,
2022
Received in revised form:
July 6,
2022
Received:
May 18,
2022
Identification
Copyright
© 2022 Australian College of Nursing Ltd. Published by Elsevier Ltd.
