A total of 18 studies meeting the criteria were retrieved: 14 were nonexperimental quantitative studies and 4 were qualitative studies (Table). Studies selected reflected settings in the United States and Canada. According to Whittemore and Knafl (2005), the integrative review method allows for the inclusion of diverse methods and the simultaneous inclusion of experimental and nonexperimental research to more fully appreciate the varied perspectives on a phenomenon. Study elements were compiled into a matrix (Table) for easy comparison across all primary sources. Whittemore and Knafl (2005) recommend extracting from primary data sources and compiling all data in a matrix or spreadsheet. The Table includes author, year, country of origin, study aim or purpose, study design, intervention, and sample. Studies meeting the selection criteria were evaluated for health care provider population, appropriate description of intervention used in the study, effect of the intervention, and conclusions. Descriptive synthesis of the findings revealed four major provider populations where interventions to improve ageist attitudes toward older adults were implemented: (a) nurses, (b) nursing students, (c) medical students, and (d) direct care workers.
Table: Matrix of Reviewed Studies
A commonality between all of the health care provider populations is the characteristic of exhibiting ageism toward older adults. Many of the studies reported an intervention implemented to improve ageist attitudes toward older adults (Burbank et al., 2006; Hoffman, Brand, Beatty, & Hamill, 1985; Marte, 1988; McVey, Davis, & Cohen, 1989; Menks, 1983; Menne et al., 2007; Pacala, Boult, & Hepburn, 2005; Robinson & Rosher, 2001; Stevens-Roseman & Leung, 2004; Varkey, Chutka, & Lesnick, 2006).
Health Care Provider Populations
Nurses. Nurses’ attitudes have been shown to be more negative toward older adults when compared with nursing students and volunteers (Armstrong-Esther, Sandilands, & Miller, 1989). Cooper and Coleman (2001) discovered that mentally intact patients were the “popular patients”; negative stereotypes held by nurses were related to dependence and dementia among older adults. The most common way nurses perceived older patients was in terms of mental or physical dependence (Cooper & Coleman, 2001). Lookinland and Anson (1995) compared RNs’ attitudes toward older adults with those of high school students interested in becoming nurses. Both groups exhibited negative attitudes and stereotypical views, with the high school students exhibiting the least favorable attitudes and views toward older adults (Lookinland & Anson, 1995). Some of the negative views reflected in the study included that older adults are difficult to understand, are critical of young people’s behaviors, and are emotionally dependent (Lookinland & Anson, 1995).
Nursing Students. Educators play a significant role in ensuring appropriate, equitable, and quality care for older adults. Burbank et al. (2006) studied the effects of exposing nursing students to well older adults early in the students’ didactic and clinical experiences and long-term care clinical experiences at three universities, New York University (NYU), Tuskegee University, and University of Rhode Island (URI). The strategies at NYU included placing students in high-quality long-term care settings for clinical experiences and offering senior mentoring projects to nursing students. Tuskegee University focused on successful aging and risk reduction among older adults (Burbank et al., 2006). URI included more content specific to older adults in fundamental nursing courses and included more case studies and debates specific to care of older adults. Clinical experiences with well older adults were also included at URI (Burbank et al., 2006). Students at all three universities reported a positive influence on their attitudes and an increase in their knowledge regarding older adults (Burbank et al., 2006).
Koren et al. (2008) compared attitudes and knowledge of nursing students who completed their fundamental nursing clinical experience in the nursing home setting with those completing their fundamental nursing clinical experience with ill older adults. A direct correlation between lack of knowledge regarding older adults and increased negative attitudes toward older adults was identified, and Koren et al. (2008) concluded that well-designed curricula and clinical experiences regarding older adults are key to promoting positive attitudes toward older adults.
Holroyd, Dahlke, Fehr, Jung, and Hunter (2009) evaluated nursing students’ use of Kogan’s Attitudes Toward Old People scale at different points in a baccalaureate nursing program over a 4-year period. No significant difference in attitudes was noted during this time. However, post hoc analysis revealed a decrease in positive attitudes and an increase in negative attitudes at the beginning of Years 2 and 4, when students were exposed to older adults with complex issues.
Medical Students. According to Fitzgerald, Wray, Halter, Williams, and Supiano (2003), an increasingly large body of literature suggests most medical students exhibit low interest in selecting geriatric medicine as a career. The percentage of medical schools with requirements for “geriatric exposure” is currently 98% (IOM, 2008, p. 129). Much of medical students’ exposure occurs very late in their curriculum (IOM, 2008). Over the past several decades, various studies have been conducted to assess medical students’ attitudes toward older adults (Hoffman et al., 1985; McVey et al., 1989; Menks, 1983; Pacala et al., 2005; Robinson & Rosher, 2001; Varkey et al., 2006).
The Aging Game was developed at Duke University to allow first- and second-year medical students to experience sensory deficits and functional dependency due to financial, physical, and emotional losses (McVey et al., 1989). Seventy-five percent of participants rated the experience as very good or excellent on post-game evaluations. Narrative comments by participants post-activity indicated a heightened awareness of a desire to maintain independence and an increased sensitivity to the problems associated with chronic disease and dysfunction associated with older adults (McVey et al., 1989).
Pacala et al. (2005) implemented The Aging Game at the University of Minnesota and studied the responses of medical students. Of those participants, 477 students wrote narrative comments that were analyzed for common themes, which included: (a) “Eye Opening,” (b) Attitudinal Change, (c) Raising Awareness, (d) Lasting Impact, and (e) Effectiveness of Simulated Physical/Sensory Deficits (Pacala et al., 2005, p. 147). The participants reported that the participatory learning method of the game greatly affected their attitudinal change. The students expressed that the simulation of physical and sensory deficits in the game had a lasting impact on their attitudes and care of older adults (Pacala et al., 2005).
Varkey et al. (2006) implemented a modified version of The Aging Game at the Mayo Clinic in Rochester, Minnesota for a group of 84 medical students. Participants’ attitudes toward older adults were examined before and after the intervention using the Maxwell and Sullivan questionnaire and the Aging Semantic Differential. Narrative comments were also collected and analyzed. A statistically significant improvement was noted in six of the eight attitudes toward caring for older adults as well as a statistically significant increase in empathy toward older patients following the intervention.
Menks (1983) developed The Road of Life©, a simulation board game, for medical students to increase understanding and awareness of the common psychosocial and physical experiences of older adults. Common health problems of older adults were incorporated into the game, such as hip fracture and arthritic immobility. Menks (1983) reported that the game was an effective and enjoyable way to facilitate understanding and awareness of the experiences of older adults. Hoffman et al. (1985) designed Geriatrix, a role-playing simulation game, to sensitize medical students to ethical dilemmas and perspectives of older adults. Through an informal questionnaire, 28 of the 45 students reported that their attitudes toward older adult care were positively changed by playing the game. From the data reported, it is not clear whether attitudes prior to participating in the game were more negative or positive. Data on long-term outcomes were admittedly not collected (Hoffman et al., 1985; Menks, 1983).
The Half-Full Aging Simulation Experience was a project conducted to allow medical students at Southern Illinois University School of Medicine to experience aging changes and how adaptations in the environment can improve function of older adults (Robinson & Rosher, 2001). An improvement in attitudes toward older adults was noted when pre- and posttest scores were compared. However, statistical significance was not reported (Robinson & Rosher, 2001). No set protocol or training of interventionists was reported for any of the mentioned studies.
Direct Care Workers. Virtually all direct care workers care for older adults at some point in the course of their careers, yet a large proportion continue to report feeling inadequately prepared to care for the high number of older clients (IOM, 2008). When compared with nursing and medical fields of study, little attention has been given to nursing assistants or direct care providers (Stevens-Roseman & Leung, 2004). Interventions to improve attitudes toward older adults among direct care workers include various training sessions and inservices (Marte, 1988; Stevens-Roseman & Leung, 2004) and role-playing in the care of dying residents (Schell & Kayser-Jones, 2007).
Marte (1988) introduced Into Aging, a simulation game, to increase employees’ positive attitudes toward older adults in the nursing home setting. No formal method of data collection or analysis was reported to determine effectiveness of the treatment. Marte (1988) reported only anecdotal comments that the intervention provided a valuable and exciting learning experience that was enthusiastically received by participants (Marte, 1988). This study was largely untested and has not been replicated by others.
Stevens-Roseman and Leung (2004) presented modules of information specific to the care of older adults to paraprofessionals. Information contained in the modules included relationship building, trust, communication with older adults, chronic pain, recognizing depression in older adults, family members of older adults, and self-care of the paraprofessional service provider (Stevens-Roseman & Leung, 2004). On completion, Stevens-Roseman and Leung (2004) suggested “meeting the trainees where they are” (p. 87) and empowering trainees by respecting them and encouraging participation.
Schell and Kayser-Jones (2007) explored empathy and role-taking of certified nursing assistants (CNAs) in the care of dying residents. The major, recurrent theme that emerged was the significance of role-taking and empathy skills when caring for a dying resident. CNAs discussed having an ability to use their role-taking skills to see the world from the residents’ perspective and reported a positive impact on their caregiving actions. CNAs spoke of using their empathetic skills to relate to the emotional experiences of dying residents. A finding of the study included the importance of empathy training to improve client outcomes. Schell and Kayser-Jones (2007) also suggested a supportive culture in nursing homes by providing adequate training of CNAs in regard to empathy skills as a strategy to improve quality care delivery to older adults.
Fisher and Wallhagen (2008) conducted a grounded theory study to explore CNAs’ perspectives of nursing home residents and how these perspectives influenced care provided to older adults. Three major views of residents were constructed: (a) as fictive kin, (b) as a commodity, and (c) as an autonomous person. While some CNAs primarily viewed residents as individuals with whom they shared a close relationship, others viewed residents as more of a work object. The study revealed that CNAs who were employed at a smaller, private nursing home tended to view residents as fictive kin and as an autonomous person.