Joumal of Advanced Nursing, 1994, a), 382-390

Does nursing education promote ageism?

Barbara K Haight RNC DrPH FAAN
Professor of Nursmg, Medical University of South Carolina, College of Nursing,
Charleston, South Carolina

Mary Ann Chnst RNG EdD

Dean, College of Nursing, University of Mississippi Medical Center, Jackson, Mississippi

and James K Dias PhD

Assistant Professor, Department of Biostatistics, Epidemiology and System Science,
Medical University of South Carolina, Charleston, South Carolina, USA

Accepted for publication 1 December 1993

HAIGHT B K , CHRIST M A & DIAS J K (1994) Joumal of Advanced Nursing 20,

382-390
Does nursing education promote ageism?
The literature is replete with diverse studies about gerontological nursing
education on the attitudes of nursmg students This study exammed the effect
of a 3-year cumculum on ageism over all 3 years Students were exposed first to
well elderly subjects, then hospitalized older subjects, then severely ill older
subjects They were tested with the Kogan's Old People Scale and a semantic
differential scale to see how their attitudes towards older people changed
according to their experiences The Kogan scale was most sensitive and showed
that older students and those with grandparent role models had better attitudes
towards older adults Also, there were great increases in positive attitudes
towards ageing m year 1 that slowly decreased by the end of year 3

DOES NURSING EDUCATION PROMOTE '^""^P^,^* because gerontology as a speciality promotes

Ageism IS alive and well m nurses, nursmg students and
m their teachers Is ageism, this prejudice against older
people, the result of leamed behaviour in childhood, or is
It developed throughout a lifetime' When does it begm'
Why does it persist' Are we as nurse educators promulgat-
ing values that lead to negative attitudes and behaviours
or are we changmg them positively'
Gerontological nursing is m cnsis both m the Umted
States and the Umted Kmgdom In the United States gradu-
ate programmes m gerontologiccd nursmg, though well-
funded, often close because students cannot be recrmted
to enter the speciality area In the United Kingdom, I'roject
2000, a plan for the future, has no specific gerontological
Correspondence ProfessorBK Hmght, Medical University of South
Carolina, College of Nursing, 171 Ashley Avenue, Charleston, South
Carohao 29425-2403, USA
ageism (Slevm 1991) How can this be true when paediat-
ncs as a nursmg speciality has not yet prejudiced nurses
against canng for children' Perhaps nurses are developing
excuses both m the Umted States and the United Kmgdom
because they have not found ways to make this much
needed speciality attractive
And, mdeed, it is a speciality Those of us who work m
the field know there is as much defined knowledge for
genatncs as there is m other specialities Genatncs is not
an extension of a family health programme, nor is it an
extension of adult health It is a defined speciality with
defined knowledge and needs essential to the proper care
of older people Proper is the key word here, quality care
with cost-effective and efficient outcomes
Everyone knows of the growth in the aged population
In Ganada, the aged population will mcrease to 11% of
t^e total population m the next 20 years (Giardma-Roche
& Black 1990) In the Umted States the older population
eilready represents 12 6% of the total population

382

(Amencan Association of Retired Persons 1992) And m
the Umted Kmgdom as many as 48% of the total popu-
lation will be over 75 by the year 2000 (Slevm 1991)
Apparently, nursmg is not gomg to meet the needs of older
people, and smce we cannot meet the needs some of us
are gomg to say that they do not exist
REVIEW OF AGEISM AND ATTITUDES
The first, and most common, research m gerontological
nursmg was on the attitudes of nurses and students toward
canng for older people (Haight 1989) Smce then numer-
ous projects reported that education does and does not
affect ageism Underlying the assumption that education
affects ageism are the basic premises that (a) decreased
ageism will contnbute to better nursmg ceire, and (b) edu-
cation and changing the attitudes of nurses toward older
people will recruit nurses to the speciality of gerontologi-
cal nursmg To date, these basic premises are unfounded
and do not provide a foundation for the work and research
m ageism and attitudes The question then is is the work
on education and ageism prolific because it is convenient
and serves as a needed research study for faculty to gain
promotion and tenure, or is there a gut feeling among edu-
cators that education m£ikes a difference and thus we must
explore its effects on ageism''
Campbell (1971) studied the attitudes of nursing person-
nel towards tbe genatnc patient usmg the Tuckman Lorge
scale and concluded that all groups of nursing personnel
(RNs, LPNs and aides) held stereotypical attitudes toward
ageing The most educated part of tbe sample were less
stereotjrpical, but knowing the facts still prefeiTed to work
less with older people
Taylor & Hamed (1978) also examined the attitudes of
those who work with older people usmg the Kogan Old
People Scale (Kogan 1961a) Their results contramdicated
the results of Campbell m that they found those who dis-
played positive attitudes were younger, with less expen-
ence in nursing, and less experience m canng for older
people Other researchers both agreed and disagreed with
these premises Thorson et al (1974) supported the con-
cept of increased education associated with increased
positive attitudes, but also established that mcreased age
caused increased negative attitudes Gillis (1973) found
no significant differences in age groups and attitudes, but
discovered that education and expenence positively
mfiuenced attitudes
The researchers of the 1970s disagree more than support
one another, leadmg future researchers to contmue to
examine the effects of education on attitudes Auerbach &
Levenson (1977) studied the effects of shared classroom
expenence between students and older people and deter-
mined that these shared expenences promoted negative
attitudes Chamberland et al (1979) used the Tuckman
Lorge scale to examme the effects of classroom and climcal
Does nursing education promote ageism^
expenences on two groups of nursmg students They
uncovered mcrrased negative attitudes m the first group
who only attended class, but decreased negative attitudes
m the second group who expenenced class and an mter-
active project with older people
Effects of education on students
More researchers studied the effects of their educational
interventions on nursing students and perceived beneficial
effects (Hart et al 1976, Wilbite & Johnson 1976, Robb
1979, Tobiason et al 1979, Heman 1981, Langland et al
1986, Miko 1986, Olson & Logan 1986, Snape 1986, Heine
& Streit 1987) Other researchers reported specific n^ative
correlations for instance, that the functional disability of
older people was related to negative attitudes of nurses
(Elliott & Hybertson 1982), that lack of mteraction lnfiu-
enced students more negatively (Baer & Lowery 1987) and
that the social orgamzation mfiuenced attitudes (Brower
1981)
As the 1980s prc^essed, tbere were more analyses of
nurses' and nursing students' attitudes toward older
people Melanson & Downe-Wamboldt (1985) analysed the
relationships between student psycbosocial vanables and
their attitudes toward ageing Individually, the vanables
did not account for a large proportion of the variance
GreenbiU & Baker (1986) tested the effects of a leammg
expenence with well elderly adults and found no differ-
ences between the group bavmg the expenence and those
who did not, while Ross's (1985) expenence produced
converse results, students workmg with well elderly
scored higher on attitude surveys than those who worked
with the ill elderly Hooper (1981) reinforced the theory
tbat those with higher educational levels bave more posi-
tive attitudes, wbile Buschmann et al (1981) indicated
that a previous good expenence with older people contri-
buted to a more positive attitude
As the 1990s evolve, other health care professionals are
examining tbeir attitudes toward ageing Apparently this
IS not ]ust a nursmg phenomenon Using Lisrel, Belund &
Maheux (1990) examined the attitudes of medical caregiv-
ers and found that females and those who chose &mily
practice had more positive attitudes toward elderly people
Recreational therapists' attitudes were generally positive,
but they did not want to work with older people (MacNeil
1991), while respiratory therapists found that coursework
about older people improved attitudes toward older people
(Perkins 1991) In a study of physical therapists. Brown
et al (1992) determined that their coursework about older
people caused no significant differences m attitudes
toward older people
Nurses are also becoming more introspective m the
1990s Dellasega & Cumero (1991) not only looked at atti-
tude change m their students, they looked at work prefer-
ence They tested their students three times and found that
383
 BK
although their prc^amme improved students' attitudes
toward older people, the programme did not change the
students' work preference Students still chose not to work
with older people Finally, Trehame (1990), like so many
others before her, confirmed that the course she offered
ahout ageing made attitudes worse
THE STUDY
So where does that leave nursmg and nursmg education'
Does nursing education promote ageism' Perhaps,
depending on the course and other mtervemng vanahles,
it does To determme the causes of positive and/or negative
attitudes toward older people hetter, one more study fol-
lows of a model that incorporates the vanables raised as
questions m the hterature, particularly the vanable of early
exposure to good role models and well adults
Purpose
The purpose of this study was to examme the impact of
selected leaming expenences on the attitudes of baccalaur-
eate nursmg students toward older people
Sample
One hundred and eighteen baccalaureate nursmg students
began this study m year 2 of their nursmg programme
Eighty-six completed the study over a 3-year time frame,
with 57 completmg all parts of all questionnaires
Therefore, the data reported are from more than half of the
completmg class Seventy per cent of the completers were
m the 20—40 age range Fifty-two were female, five were
male Most of the sample was Caucasian (79%), 17% were
Afro-Amencan and 4% other Students filled out an
m-depth data sheet that mcluded many of the vanables
mentioned in the other studies, and that contnbuted to the
model of analysis
METHOD
The design for this study wsis test—retest with one exper-
imental group Students were tested on two attitude out-
come measures before and after each educational
experience for a total of six testings The educational
expenences acted as the mterventions or mdependent
vanables They are as follows
Interventions
Year 1 Care of the Well Elderly
This course mtroduced students to agemg through expen-
ences with well elderly people Students saw older people
on a one-to-one basis, conducted health fairs and worked
with a pnmary health care focus Individuals who had an
384
avid mterest m agemg taught the course If &culty mem-
hers were not formally educated m gerontology, they went
about acquinng the necessary mformation themselves
This group of faculty designed a course at entry level to
provide positive expenences for students with elderly cli-
ents and to emphasize health promotion and mamtenance
Year 2 Care of the 111 Elderly
This was a medical/surgical hospital-based course
Students did not receive a great deal more mformation on
ageii^ Students took care of sick patients m the hospital
and the focus of this course was secondary health care
Agemg was viewed as one vanahle that affected the disease
process and nursing care Faculty memhers were not well
versed m agemg, nor particularly interested m it, but they
were excellent faculty, well versed m disease and the nurs-
ing care of hospitalized adults
Year 3 Care of the Cntically III Elderly
In this class, students received approximately 6 more
hours of class work on the effects of hospitalization on
older people plus information on selected disease states
more common to older people A tertiary health care focus
gmded this course The client focus was on multiple dys-
function or system problems Guest gerontological experts
presented the content The faculty, though S3mipathetic to
agemg, were medical/surgical faculty, and attention was
focused on sjmthesis of the medical/surgical content
necessary to psiss the National Boards (NGLEX)
Outcome measures
Two measures tested attitudes toward agemg Though one
measure, the Kogan's Old People Scale, was used repeat-
edly by earher researchers, two measures compared to one
another provided extemal veJidity The most used measure
was also very lengthy and, if both were equally sensitive,
the shorter measure would be more useful in future
studies
Kogan's Attitude Toward Old People Scale
This IS a 34-item Lakert-type scale with 17 positive and 17
negative statements (Kogan 1961a) Six response categones
allow for a range of scores from 34 to 238 It is a self-
admimstered paper and pencil questionnaire, used exten-
sively smce 1961 (Gordon & Hallauer 1976, Thorson &
Perkins 1976)
The test ongmated with ethmc mmonty stereotype
research and then old people were substituted as referents
The stereot3rpes cover residential pattems, cogmtive style,
personal appearance, personahty and discomfort with
older people Reliability usmg odd-even Spearman-Brown
coefficients were 0 76,0 73 and 0 83 for the negative ques-
tions and 0 77,0 66 and 0 73 for the positive questions
(Kogan 1961a,b)
 Does nursing education promote ageism?

Rosencranz & McNevin

RESULTS
This semantic differential scale assesses stereotypes or per-
ceptual dispositions of subjects (Rosencranz & McNevin A vanety of categoncal vanables such as religion, income
1969) The scale mcludes 32 items with seven response and sex showed no effect on the change scores of the sub-
levels for a score ranging from 32 to 224 The scale is the jects Other vanables also had no effect, but descnbe the
result of extensive testmg of adjective scales, self- sample interestingly For example, only one student m that
administered by paper and pencil There are no reports of graduating class chose to work with older people As
reliability and validity despite extensive use (Cryns & expected, most new graduates chose to work m surgical
Monk 1973, Naus 1973) nursmg (34%) or paediatncs (22%) The students'
professional choices are shown m Figure 1
Other mterestmg variables showed that 89% of the stud-
Procedure
ents valued current relationships with older people and
The researchers persuaded the teachers who taught this 96% valued past relationships, even though 54% had very
group of students each year to allow them to test the stud- little association with older people in their past Thirty
ents At the start of each class, one investigator visited the per cent had-taken a course or senunar m agemg before
class and talked to the students about the purpose of coming to school in nursmg Eighty-two percent had pre-
the test They gave the test at the beginning (Fall) and vious expenence m long-term care, and 75% had living
end (Spring) of each semester for 3 years for a total of six grandparents, with only 12% having livmg great grand-
testings The statistician entered data mto the computer parents The number of students with previous expenence
as it was received, and at the end of 3 years statistically in long-term care seems surpnsmgly high It seems to
analysed the data reflect the potential nursing student's need to examme the
profession before entermg it Working in a nursing home
as an aide provides this opportunity
Data analysis
The most admired older person was a grandparent for
One-way ANOVA emalysed the difference scores by 53% Only 18% had older people hving m their house-
categorical vanables In this way the researchers could see hold Over 79% said they had never had a relationship
if vanables, such as age or relationships vnth older people, with an older relative Obviously, the researchers felt that
made a difference m the students' attitudes towards older the degree and type of relationships these students had
people The researchers dropped those vanables from the with older people would mfluence their athtudes towards
model that had no effect The significant vanables acted older people The variables and their significance are
as covanates m the analysis Cronbach's alpha examined indicated m Table 1
the internal vedidity of the instruments Repeated- The two mstruments, Kogan and Rosencranz &
measures ANOVA analysed the gain scores ofthe dependent McNevm, correlated significantly, as shown m Table 2
variables each year for 3 years Smce the less-used semantic differential scale.

Figure 1 Students'
professional areas of mterest

385
BJC Haight etal

Table 1 One-way ANOVA of categoncal vanables effect on

attitudes
Outcome measures
The effect on the outcome measures supported the state-
Gam ment m the hterature that read 'educational expenences
Rosencranz & with well-older people positively infiuence students' atti-
Vanable Gam Kogan McNevin
tudes toward older people The gam scores m positive
attitudes change for year 1 were notable as the students
Age XXX NS
gamed a healthy 8 points on the Kogan scale and 4 pomts
Sex NS NS
NS
on the Rosencranz & McNevin scale There was an
Race NS
Income NS NS additional gain m year 2, but by the time the students
Religion NS NS graduated they were holdmg fewer positive attitudes
Previous education NS NS towards older people The scores decreased as the stud-
Area of mterest NS NS ents' clmical expenences with more and more cntically
Long-term care NS NS ill older adults mcreased The Kogan scale seemed
Great grandparent NS NS extremely sensitive to tbe changes in the students'
Grandparent X NS attitudes over tune The gam scores are m Figure 2
Current association NS NS
Fmally, we did an analysis of the scores of those hardy
Pre-association NS NS
student subjects who not only stayed with the study for 3
years, but had properly filled out all forms These stnngent
NS P > 0 05
X P<0 05
cntena reduced the number of subjects fi-om 57 to 16 The
XX P<0 01 gain scores for this hardy group for each year of education
XXX P^OOOl fire in Figure 3, tbe anovas for tbe Kogan scale are in Table 3
and for the Rosencranz & McNevin scale in Table 4
Rosencranz & McNevin, is shorter, faster and easier to
answer, it was used with thoughts of becoming the scale
DISCUSSION
of choice for future studies However, it is not as sensitive
as the longer and more widely used Kogan scale, as seen This paper contains a large amount of information, some
m Table 1 relevant and some not so relevant However, after

Table 2 Correlations of
instrument mean scores Correlations YlSl Y2S1 Y3S1 Y1S2 Y2S2 Y3S2
(Rosencranz & McNevin)
YlSl 1 0000 0 6397 0 5087 0 5181 0 5432 0 6545
(0) (37) (40) (27) (34) (38)
P= P=0 000 P = 0 000 P = 0 003 P = 0 000 P=0 000
Y2S1 0 6397 10000 0 6074 0 5937 0 6235 0 6663
(37) (0) (42) (27) (37) (37)
P=0 000 p P=0 000 P=0 001 P=0 000 P=0 000
Y3S1 0 5087 0 6074 10000 0 6185 0 7177 0 8339
(40) (42) (0) (30) (43) (42)
P = 0 000 P=0 000 p= P=0 000 P=0 000 P = 0 000
Y1S2 0 5181 0 5937 0 6185 10000 0 5326 0 6927
(27) (27) (30) (0) (25) (24)
P=0 003 P = 0 001 P=0 000 p P = 0 003 P=0 000
Y2S2 0 5432 0 6237 0 7177 0 5326 10000 0 7527
(34) (37) (43) (25) (0) (35)
P = 0 000 P=0 000 P=0 000 P=0 003 P= P=0 000
Y3S2 0 6545 0 6663 0 8339 0 6927 0 7527 10000
(38) (37) (42) (24) (35) (0)
P = 0 000 P=0 000 P=0 000 P = 0 000 P=0 000 p

(Coefflcient/(Cases)/l-t£uledsigmficance)
" " I S pnnted if a coefficient cannot be computed
Y=year, S=semester
51 = Entry into that year (before exposure)
52 =Exit from that year (after exposure)
Most correlated significantly

386

Figure 2 Gain scores each
year
Figure 3 Gam scores hased
on ANOVA sample
Ycarl
reviewing the hterature where some of the ideas of nurses
and students are examined to leam about their attitudes
towards older people, it seemed relevant to try to gam a
more hohstic view of the students' background and expen-
ence before looking at their educational process m nursing
as a cause or byproduct of their attitudes
Does nursing education promote ageism^
Ycarl
First, It appeared that previous eissociations with older
people and the value of these associations to the student
would have a strong effect m fonnmg their attitudes That
supposition was correct m that grandparents had a strong
positive influence on student attitudes, and that grand-
parents were also the most admired older people in the
387
 BK

Table 3 Reputed-measures ANOVA - Kc^jan's scale students' hves, even more than parents Other associations
with older people did not prejudice the students' attitudes
Source SS df F-value P-value Thus, one can postulate that an influential role model for
ageing must have a close and positive relationship with
Between suhject eflFects* the student
Other expenences, such as working in long-term care
Withm cells 3947 54 15
and previous education m gerontology, had neither a posi-
Constant 226169618 1 8594 06 0000
tive nor a negative impact, neither did the personal van-
Semester withm subject efFects*
ables, such as sex and race, which differed from other
studies One student said sex was an important factor as
Within 462 84 15 females of all age groups felt more kmdly toward older
Semester 354 81 1 1150 0 004** people than males A^e was the only weighty factor, and
It had a linear effect smce attitudes unproved as age
Year within subject effects' mcreased at least up to age 40 One outlier existed m
the group over the age of 40, and this person possessed a
Withm cells 1784 38 30 negative attitude towards older people
Year 2363 81 2 19 87 0 000*** Fmally, we can look at the effect of nursmg education
on student nurses' attitudes toward ageing Exposure to
Semester x year withm subject effects* older people who are well, happy and thnving is a defimte
plus for positively influencing student nurses' attitudes
Withm cells 1706 78 30
To recruit students to work in gerontology, educators must
Semester x year 1226 01 2 10 77 0 000***
influence students at the imdergraduate level before stud-
ents become imbued with negative attitudes
**P<0 001
***P<0 0001 Graduate programmes m gerontological nursmg con-
•Number=16 tmue to close for lack of students Educators must develop
student mterest in gerontology sooner to develop a cadre
of master's-prepared nurses to take care of the increasing
number of older adults It is unhkely that undergraduate
students who do not have positive role models, chmcal
Table 4 Repeated-measures ANOVA - Resencranz & McNevm expenences with well and sick older clients, and specific
scale gerontological content, will express an mterest in the gena-
tnc-speciality graduate programme The presence of good
Source SS df F-value P-value faculty role models, also reported as important m the
hterature, probably added to the positive attitude change
Between subject effects' for yeeir 1
Withm cells 9357 77 14
Year 2 found these same students m the hospital with
Constant 1804975 22 1 2700 39 0 000** sick older people, no course content in gerontology and
no defined role models Their attitudes towards older
Semester within subject effects' people contmued to improve Based on these data, we
might venture to say that nursuig education does not pro-
Withm 1867 84 14 mote ageism Of course, these students had not practised
Semester 14 55 1 011 0 746 m a nursing home It would be mteresting to study the
effect of that expenence m a similar study to see the
Year withm subject effects' differences that the nursing home expenence makes
Fmally, the students in the last year of their educational
Withm cells 2366 69 28 expenence are canng for very ill people, and they have
Year 1352 04 2 8 10 0 002* had a little more lllness-onented content about older
people On one scale their scores fall, on another they
Semester x year within subject effects'
improve only slightly, but it should be remembered that
they are higher than when they started the programme
Withm cells 3458 67 28
Semester x year 2921 08 2 11 82 0 000**
The students are motivated, eager and ready to teike state
boards, and to start their careers One out of 57 has chosen
*P<0 05 to work with older people, the majonty are heading toward
***P<0 001 paediatncs and surgery This outcome makes sense to us
•Number=16 New graduates need to practise skills Once they are

388

comfortable with the skills, they can begm to look at the
people Perhaps, when they are ready to work hohstically
with people, they will choose the challenge of older
people
CONCLUSIONS
Several conclusions can be drawn from this study with
implications for nursmg education and for the develop-
ment of good attitudes toward ageing They are as follows
1 older nurses have improved attitudes towards older
people,
2 grandparents create positive role models for ageing,
3 exposure to well elderly people as clients has a lasting
effect on nursmg students' attitudes towards older
people,
4 nursing education does not cause ageism m fact, nurs-
ing education promotes more positive feelings towards
older people
Recommendations
Before there is more research examining the attitudes of
caregivers, nurses and nursmg students toward older
people, there needs to be an integrated review of the litera-
ture Attitude researchers need to begin their work based
on the existing body of knowledge An integrated review
will provide direction for future research, so that research
on attitudes may grow m all directions, become more valu-
able and provide more definitive answers Researchers
need to look at all mtervening vanables as well as whole
educational programmes, so that they may provide com-
plete answers to the question of the effect of nursmg edu-
cation on attitudes towards agemg The examination of
just one course on ageing will not answer the larger ques-
tion, 'What IS the effect of nursing education and educators
on ageism'''
After educators answer the larger question, they must
devote themselves to developing new cumcula to encour-
age positive a^emg attitudes New cumcula should
explore new strategies and clinical experiences should
encourage positive ageing attitudes Presently, nursing
education does not promote ageism nor does nursing
education prevent it
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