Dr. Schrader is Professor and Associate Chair of RN-BS Online/Distance Completion Option, Nursing Department, Boise State University, Boise, Idaho.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. The author acknowledges the Friends of Nursing at Boise State University Nursing Department, Boise, Idaho.
Address correspondence to Vivian Schrader, PhD, RN, Professor and Associate Chair of RN-BS Online/Distance Completion Option, Nursing Department, Boise State University, 1910 University Drive, Boise, ID 83725-1840; e-mail: email@example.com.
Studies about negative attitudes toward older people by nurses and nursing students, methods to resolve them, and how to incorporate long-term care (LTC) settings as clinical sites have been reported extensively during the past 40 years (Abbey et al., 2006; Akid, 2001; Cook & Pieper, 1985; Kayser & Minnigerode, 1975; Kuhn, 1990). Nurse educators’ perceptions and experiences have not been specifically studied and integrated into this body of literature. Because nursing faculty are influential mentors of nursing students and choose their clinical sites, their perspectives could also shed light on why new nurses do not choose to care for older people or select LTC settings as a career choice.
Nearly one in five U.S. residents is expected to be age 65 or older in 2030 (U.S. Census Bureau, 2008). A growing concern related to the aging population in the United States is the increased demand for nurses to competently care for them. The U.S. Department of Health and Human Services (2009) predicted that 40% of those reaching age 65 will spend time in a LTC facility for some kind of rehabilitation service or residential care, positioning care of older people as a professional obligation for the nursing profession.
Trossman (2008) noted some improvement in nursing students’ and nurses’ negative impressions of LTC facilities since Fitch (1990) wrote about their inception in the 1930s. However, more work needs to be done because the reality persists that LTC facilities remain poorly supported with financial resources, understaffed, and essentially ignored by society at large (Abbey et al., 2006). This also raises the question of whether there will be a sufficient number of nurses to work in these facilities. Literature suggests that future nurses base their decisions to work with older people on learned attitudes and behaviors (Happell & Brooker, 2001; Lookinland & Anson, 1995; Rognstad, Aasland, & Granum, 2004).
Happell and Brooker (2001) reported that student practice preferences contribute to the nursing shortage in select practice settings. After graduation, only 1.9% of undergraduate students identified working with older people as their first nursing career choice (Happell & Brooker, 2001). Prentice and Black (2007) studied Canadian RNs working in LTC and found that they chose the setting primarily because of convenience. This also occurs with other health care providers, as similar findings were reported by junior-level medical students in their geriatric rotation (Powers, Allen, Johnson, & Cooper-Witt, 2005). LTC settings are not perceived as sites that could provide strong clinical experiences for practice.
Preparing nursing students to care for older adults begins early in their nursing curriculum, as they learn to care for adult patients across the life span. A change in the kinds of clinical experiences or decrease in the number of hours may limit or cancel a clinical rotation in LTC facilities. Chen, Witucki-Brown, Groves, and Spezia (2003) reported that since the late 1960s the nursing literature has identified and supported the benefits and importance of placing nursing students in LTC facilities, yet clinical placements in LTC facilities in the United States remain essentially underutilized.
The researcher was interested in extending the literature on attitudes related to career options in the LTC setting and the care of older people. By exploring nurse educators’ personal perspectives, contributing factors might be revealed related to the continued underutilization of these sites for clinical experiences and devaluing the care of older people.
Participants and Settings
Purposive sampling was used to recruit nurse educators representing four baccalaureate nursing programs in one geographical region convenient to the researcher’s location. The study was confined to currently employed baccalaureate nurse educators with more than 1 year of teaching experience and who had the opportunity to choose LTC facilities as clinical sites. Of a potential 48 nurse educators, 14 agreed to be interviewed.
Fourteen Caucasian female participants represented baccalaureate nurse educators in two different northwestern U.S. states. All were from nationally accredited professional nursing programs with enrollment ranging from 39 to 136 students.
Eight nurse educators taught in a large urban state-funded university; 3 in an urban fast-track nursing program; 2 in a private church-sponsored liberal arts university, and 1 in a rural nursing program. Participants had 3 to 30 years of teaching experiences and were all teaching adult health nursing topics at the time of the interviews (Table). One educator was a gerontology nurse specialist.
Nurse educator ages ranged from 33 to 62. Only 5 of the 14 faculty members (36%) had LTC facility experience in their own nursing educational process (Table). Only 1 participant currently had students in a 3-week LTC clinical rotation. Nurse educators were contacted to participate in the study through an informal method of telephone or face-to-face contact.
Approval to conduct the study was obtained from the researcher’s University Institutional Review Board prior to beginning the interview process. Written consent was obtained prior to the interviews, and pseudonyms were used to provide anonymity for participants.
A grounded theory approach was used to explore the nurse educators’ personal perceptions of LTC facilities. In-depth interviews allowed for flexibility in adapting questions and analyzing responses (Creswell, 1998). A constructivist design was used, along with a qualitative analysis of nurse educator interviews over a 6-month period in 2004.
An introductory review of the literature was used to develop interview questions. Data were collected via audio recordings using a semi-structured, open-ended question interview guide (Wimpenny & Gass, 2000) composed of two parts: 4 demographic questions and 10 topic lines of inquiry questions. Topic questions included what nurse educators remembered about their own clinical experiences in LTC, their perceptions of older people, what influenced their perspectives of LTC settings, and what influenced their career choices. Three nonparticipating nurse educators evaluated the interview guide for bias, sequence, clarity, and face validity (Marshall & Rossman, 1995). Saturation occurred when explanations, interpretations, and descriptions became recurrent.
Data analysis began with open coding. Repeated listening to the audio recordings, checking for accuracy, and a microanalysis of each interview was performed (Strauss & Corbin, 1998).
Axial coding was the next phase in which nurse educators’ responses were broken down first into 43 emergent categories that needed to be analyzed for their properties and dimensions. A Conditional Relationship Guide developed by Scott (2002) was used as a tool that operationalized Strauss and Corbin’s (1998) investigative questions of what, when, where, why, how, and with what consequences to bridge analysis to interpretation.
Significant quotations and phrases were analyzed, and emerging patterns were identified. This resulted in the reduction and refinement of four major themes. A doctoral colleague, who was not a nurse, served as another point of validation and trustworthiness in data collection and analysis processes. After completion of the interviews, the four major themes were sent back to the participants for a member check (Lincoln & Guba, 1985). All 14 study participants agreed that the themes were representative of their perspectives and experiences related to LTC settings and older people.
Analysis revealed four major themes: LTC Environment Is an Unpleasant Experience, LTC Is Not Clinically Challenging, Nurse Educators Were Influenced by Student Attitudes, and Nurse Educators Felt Fear or Discomfort about Aging. Select nurse educator quotations are included to exemplify the themes.
LTC Environment Is an Unpleasant Experience
This theme described the nurse educators’ perceptions of the LTC environment. The participants’ personal perspectives included, but were not limited to, experiences of growing up with older people, contact with relatives or friends in LTC facilities, and talking to others about their LTC experiences. Educational experience included their initial nursing education curriculum and faculty role models.
Study participants were critical of the physical appearance of LTC facilities. Many made comments such as, “It was the urine smells that got me,” “I was terrified,” “[It’s] depressing,” and “You go there to die.” Three participants described particularly moving experiences:
- “As a student, it was a learning experience and it was exciting. Then when I was in my 30s and my father ended up in a nursing home, my perspective was definitely changed because of the conditions he was placed in, the smells and the atmosphere.”
- “I’d love to tell you it was a positive experience, but it was not for me. It was a very old building. It would be one I would classify as a poor nursing home. I found my grandmother’s room and she had a bare bed, the white spread was old, only a couple of teddy bears in the room. It broke my heart.”
- “And I didn’t, you know, like the smell of urine quite frankly. And it was on my mind that these were death homes.”
Participants acknowledged they felt “forced” to use LTC as clinical sites due to dwindling clinical choices. However, a few participants explained that their impression of the LTC environment had changed after they visited the site themselves and met with the directors of nursing who had positive attitudes and made them feel welcomed. One nurse educator noted that “use of the facility depends a lot on the management staff.”
Long-Term Care Is not Clinically Challenging
Participants discussed their own experiences as nursing students in LTC. Only 5 of the 14 participants had any LTC experience in their initial nursing programs. Three participants described their student “long-term care” experiences as occurring in senior centers, assisted living facilities, and other outpatient settings where older people were generally healthier and independent. One talked about choosing her nursing program specifically because students “did not have the option” to go to LTC facilities:
I was terrified of going to the nursing homes, absolutely terrified. I was choosing between two colleges primarily. And one of my decision makers was the other college didn’t go to long-term care. I went to some of the informational meetings and the one college who didn’t go to long-term care said they throw you into acute care because that’s where you’re going to get the best learning.
Participants perceived LTC facilities as having limited clinical or learning opportunities for students due to facility nurse role modeling, low staffing levels, or high staff turnover. They spoke about wanting the best experience for students and said there were few “technical skills” available in LTC to meet clinical course outcomes.
Other responses referred to clinical site choices and fairness. Some commented “If I go there, then other faculty should go too,” “It is not my area of expertise,” “It takes a lot of extra time and energy to make it work,” “It is not my cup of tea,” and “I am overwhelmed in the setting.”
Other participants, especially the gerontology nurse specialist nurse educator, countered these negative comments with the following positive ones: “You need to be creative,” “It takes a lot of energy to create positive experiences, but worth it,” and “Working with positive staff can make a big difference.”
Concerns about choosing care of older people in LTC as a career were mentioned as factors that influenced participants’ career decisions. All participants reported being influenced by others (faculty, other nursing students, family, friends) to choose more challenging options during their own nursing education.
The gerontology nurse specialist spoke the most positively about what opportunities were available in LTC; however, she too experienced other nurses and nursing faculty trying to convince her to change her mind about working with older people. She persisted in following her passion and noted: “Students and faculty members need good role modeling”; “It can be a powerful experience for students”; and “Telling others about your positive experiences can be helpful.”
Nurse Educators Were Influenced by Student Attitudes
Participant responses revealed that taking students into the LTC environment was often not a positive experience because of the students’ preconceived negative attitudes of the setting. Participants reported that many of their students believed LTC was “beneath” them and not stimulating or worthy of the educational opportunities available to other students in an acute care setting. Several students reported to faculty that they were given the impression to “stay away” from nursing homes, that “they are not clean,” and “you only go there to die.”
One participant reported how students’ negative attitudes affected her choice to use a LTC facility as a clinical site. She reported, “I felt pressured when students complained that other students did not have to go to long-term care. They felt they didn’t learn the same things and I felt I was letting them down.”
The following are student comments that nurse educators said resonated with their own perceptions of LTC:
- “I value the stimulating environment of the hospital setting.”
- “No one is discharged from long-term care.”
- “It’s an overwhelming environment.”
- “Nurses that can’t make a go of it, go to long-term care.”
- “Students need to know they will face negative public opinion about working in long-term care.”
Nurse Educators Felt Fear or Discomfort About Aging
All 14 participants noted that aging is not a popular topic in a youth-oriented society, and students hold negative attitudes toward being assigned a clinical experience in a LTC facility. Nurse educators’ personal issues about aging and mortality were stimulated by their work in LTC settings. When asked to describe their thoughts about the possibility of living in a LTC facility, all participants expressed the hope that this would not happen to them.
Participants recognized that a range of skilled clinical services and acuity levels exist in the contemporary LTC environment, such as wound care units and rehabilitative services. However, the image of custodial care or residential care was foremost in their minds when they reflected on the LTC setting. This was demonstrated when one stated, “I told my kids they better not leave me there to die.” Several responses were summed up by the thoughts of one participant:
I will have to question about what the quality of my life will be. I want quality, not quantity. Being in a nursing home means that quality is compromised. I don’t know how to change the fact that people are getting older and will need long-term care assistance. It’s scary.
The participants shared their awareness and feelings about the losses that occur with aging. Many of them, especially those in their mid to late 50s, faced the awareness of these losses when teaching gerontology topics to students. One spoke about the reality that occurs when caring for older people:
I become more aware of aging issues when I teach about it. In the acute care or intensive care setting, people see a win as the patient leaves the unit. It’s not that way in long-term care. Students are faced with reality. Many people don’t know how to deal with this final stage of life.
One participant reflected on future nurse staffing needs and needs of older people in LTC facilities:
I hope there are going to be nurses to care for us. I hope the staff in long-term care gives excellent care.... I wish there were more registered nurses working there. Hopefully, when I get old, I can go to a place like my in-laws are in. I hope we have enough money.
Several favorable impressions related to growing old were voiced by 2 participants: “I love the elderly, they have many stories to tell” and “It was an honor to know my grandmother.”
This study provides qualitative insight into nurse educators’ perspectives of LTC settings and the care of older people. Their introspective responses revealed lingering negative feelings about their experiences. These feelings influenced and affected their valuing of placing nursing students in LTC settings. While the majority of the nurse educators’ responses were negative, the one gerontology nurse specialist nurse educator shed a more positive perspective in select responses.
The study highlighted four major themes that clearly supported the view that these nurse educators harbored many of the same negative perspectives held by nurses, nursing students, other health care providers, and society at large about LTC settings (Abbey et al., 2006; Trossman, 2008). The four emergent themes were: LTC Environment Is an Unpleasant Experience, LTC Is Not Clinically Challenging, Nurse Educators Were Influenced by Student Attitudes, and Nurse Educators Felt Fear or Discomfort about Aging. These themes converged to formulate a less than favorable composite view of the nurse educators’ perspectives of LTC settings.
These findings are noteworthy, as nurse educator perspectives have not been specifically studied in the literature. This study provides awareness that nurse educators’ perspectives must be acknowledged in discussions of caring for older people in LTC settings. This study also demonstrates a contrast of values between the 13 typical nurse educators and the 1 who was a gerontology specialist.
These findings replicated and supported what has been written about nursing students’ and nurses’ attitudes about LTC and older people (Abbey et al., 2006; Haight, Christ, & Dias, 1994; Happell & Brooker, 2001; Trossman, 2008;). Like nurses and nursing students in previous studies, these nurse educators saw the LTC work and environment as objectionable and without sufficient challenge. Happell and Brooker (2001) disagreed with this perception and recommended that nursing students acquire skilled gerontology nursing competencies and the benefits that can be gained from clinical placements in LTC.
It is widely accepted that nurse educators are influential in nursing students’ education. The findings of this study suggest that because many of the same stereotypes related to LTC were perpetuated by nurse educators, they adversely affected the progress of nursing education in elevating the care of older people.
Participants reported that they intentionally or unintentionally revealed their preferences for younger or more acute patient populations when nursing care is essentially the same despite the practice setting. While many participants recommended intensive care or pediatric care settings as preferable career choices for students, they noted that the work with these patients was similar: overwhelming environments and patients with complex or chronic diseases or who were dying. Similar care and procedures that nursing students are taught to perform on a daily basis for all patients (e.g., cleaning up bodily fluids, managing disruptive behaviors, working with chronic disease processes) are somehow seen as objectionable when working with older people.
These findings support the literature such that students and faculty who have been socialized to nursing in primarily acute care environments attribute little value to LTC nursing and thus affect nursing students’ perceptions (Abbey et al., 2006). This lack of appreciation for practice settings outside the hospital was consistent in this study where only 5 of the 14 participants had ever rotated through a LTC setting during their initial nursing program. In addition, none had chosen LTC nursing as a primary career choice after graduation.
Results also revealed that nurse educators and students influenced each other’s attitude in a reciprocal manner. This was evidenced when several nurse educators stated they were influenced by negative student attitudes and resistance to going to a LTC setting. The findings demonstrated the power of the students’ conduct that resulted in the nurse educators’ avoidance in using a LTC clinical site if at all possible. These behaviors led to the ongoing devaluing of these facilities and the older people residing within them.
It was interesting to note that none of the nurse educators articulated any changes that they personally would make to address the lack of interest or value in LTC clinical sites. Their comments, however, did support relegating the care of older people to “other faculty members” who had a passion for it.
These findings raise questions about the consequences of this lack of nurse educator interest in staying informed about the positive changes that have occurred in LTC settings. It was troubling that they did not acknowledge that changing the stereotypical impression of LTC settings or care of older people was a professional responsibility of all nurses.
Finally, although the majority of comments or experiences related to LTC were negative, there were a few positive responses. These comments essentially came from the gerontology nurse specialist. Happell and Brooker (2001) acknowledged a similar view in their research when they recommended that geriatric nurse specialists, who have a passion for this population, can challenge nursing students’ negative beliefs.
Gerontology nurse specialists, especially when they are employed in nursing education programs, can be beneficial in turning around unfavorable gerontology care opinions. In this study, the gerontology nurse specialist provided the positive role modeling and attitudes that have been discussed in the literature. However, these findings indicated she was the lone voice in gaining any significant momentum to change individuals’ values and beliefs about LTC nursing.
Although this study explores a salient topic, it does have limitations. Results must be generalized with caution as this study was conducted in a small circumscribed geographical region of the United States where a scant number of gerontology nursing specialists are employed in nursing education. To increase generalizability and transferability of the findings, future research is recommended. Studying culturally diverse nurse educator samples in different national and international nursing programs, in addition to nursing programs that employ gerontology nurse specialists, is warranted.
Implications for Nursing
Although the majority of participants reported negative perspectives of LTC, a number of suggested behaviors and processes have implications for the nursing profession. These suggestions could be implemented to improve the current resistance to using LTC facilities as clinical sites.
Several participants reported partnering and building relationships with premiere facilities, demonstrating best practices, being creative, and sharing success stories with other faculty members and students. These efforts could challenge strongly held myths about LTC settings.
Developing strategies to demonstrate best practices in LTC by developing interactive and purposeful student activities might also encourage positive feelings about the environment. Empowering faculty members and students to work on projects such as prevention of decline in activities of daily living (e.g., eating, dressing), pain, and depression are steps in the right direction to demonstrate the value of gerontology nursing. Also reported by participants was encouraging LTC facility staff to welcome and engage students and faculty, which could enhance the experience for all involved.
Several participants recommended identifying a gerontology nurse specialist in the nursing program or community who keeps older adults’ needs at the forefront. The need for gerontology specialists to be directly involved in nursing education was reported in these findings. This is an important point for nursing education administrators as they select nurse educators. Chen, Brown, Groves, and Spezia (2007) and Happell and Brooker (2001) similarly recommended this in their research, and this may be one of the more significant suggestions that will lead to sustained change in the care of older people (Ford & McCormack, 2000).
Finally, the following novel approach to improve the status of working with older people in LTC facilities might be worth considering. What if nurse educators and health care industry leaders added an economist’s point of view and acknowledged the financial aspects of providing care to older people, as older people represent 25% of ambulatory care visits, 48% of hospital patient days, and 85% of long-term care residents (Mezey, Capezuti, & Fulmer, 2004)? Older people comprise the largest numbers of the population that access health care services. For example, if older people were seen as a valued commodity, nurses, both nationally and internationally, would be aggressively recruited and sufficiently reimbursed to address the health care needs of this population. This could result in a shift in nursing practice preference by nurse educators and students.
The findings of this study report that nurse educators hold similar negative attitudes about LTC settings as nurses and nursing students. Only the gerontology nurse specialist nurse educator shed more positive perspectives on this topic. Nurse educators are also strongly influenced by nursing students’ negative attitudes. These circumstances affect their use of LTC settings in nursing programs. Nurse educators send strong messages that speak to the professional attitudes and values over the course of a nursing student’s education. This results in an educational disadvantage for nursing student opportunities and the nursing profession if LTC and the care of older people are marginalized.
Professional nurses, nurse educators, and health care leaders in all practice settings, nationally and internationally, should challenge themselves to debunk myths related to LTC settings and care of older people. If nursing education influences clinical practice, are nurse educators leading a genuine and sustained change in the care of older people? Perhaps these study findings can serve as additional evidence to add to the continuing discussions about care of older people among nurse educators, nursing students, practicing nurses, and leaders in the LTC industry. By being more informed, we may accelerate solutions for achieving the positive health care outcomes that older people deserve.
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Baccalaureate Nurse Educator Demographics
||First Nursing Degree
||Age at Graduation
||LTC in Nursing Program?
||Years as Nursing Faculty
||Type of Institution
||No. of Students in Program
||Urban state university
||Urban state university
||Leadership & management
||Urban state university
||Medical-surgical & pediatrics
||Urban state universitya
||Urban state university
||Urban state universitya
||Fundamentals & medical-surgical
||Urban state universitya
||Urban state university
||Rural state university
||Medical-surgical & pediatrics
||Urban state university
||Urban state university
||Urban state university
Table: Baccalaureate Nurse Educator Demographics