S T U D E N T AT T I T U D E S

DEVELOPING POSITIVE ATTITUDES Toward Geriatric Nursing

Among Millennials and Generation Xers
BARBARA A. HEISE, VICKIE JOHNSEN, DEBORAH HIMES, AND DEBRA WING

T HE S I LV E R TSUNAMI
In the United States alone, 10,000 people a day are
IS

turning 65 years old, with this rate projected to continue for the
HERE.
next 19 years (Alliance for Aging Research, 2006). By 2030, all
of the Baby Boomer cohort (born 1946-1964) will be beyond the
65-year-old mark and will represent approximately 20 percent
of the US population, or 72.1 million people (Administration on
Aging, 2010). Coexisting with an increase of older adults is a
shortage of health care workers trained in geriatrics (Lun,
2011). Professionals trained in gerontology and geriatrics are
essential to provide care and support for older adults, allowing
them to remain independent (often called aging at home).
Despite the growing need, few nursing students specialize in
gerontology. The Institute of Medicine (2008) reports that fewer
than 1 percent of registered nurses hold a geriatric specializa-
tion or certification.
Given the high demand, why do relatively few nursing stu-
dents select this field? Many reasons have been given. Negative
or neutral attitudes toward the elderly are common in our youth-
oriented society (Koren et al., 2008; Ryan & McCauley,
2004/2005). Health care has done a great job of prolonging life,
but society has done a poor job of valuing that older life
(Holroyd, Dahlke, Fehr, Jung, & Hunter, 2009), and negative
bias (ageism) is common (Holroyd et al.; Moyle, 2003; Phelan,
2011). Anti-aging strategies thought to slow, stop, or reverse the
aging process, such as facelifts and Botox injections, may pro-
mote ageism and lead to devaluing the health care provided to
older adults (Holroyd et al.; Phelan, 2011). Allan and Johnson
(2009) found more negative ageist attitudes among males than
females. In a classic study, Slevin (1991) reported more nega-
tive attitudes toward the elderly among young nursing students
than their non-nursing counterparts.
Nursing students lack of interest in older adults may result
from a lack of awareness of the opportunities available in the
field of gerontology (Gross & Eshbaugh, 2011). Nurse educa-
tors personal negative attitudes toward aging and long-term
care facilities, as well as students negative attitudes that nurs-
ing homes were beneath RNs, affected attitudes toward clin-
ical placement in long-term care facilities (Schrader, 2009;
Sheffler, 1998).
Changing negative attitudes toward older adults and thereby
building capacity, as well as capability for gerontological health
care workers, has been the focus of research. Knowledge about
and exposure to the elderly impacts attitudes. Among social
work students, Cummings, Galambos, and DeCoster (2003)
reported that increased knowledge of the aging population
through undergraduate gerontology courses, along with
increased frequency and improved quality of older adult contact,
were positively associated with selecting aging-related careers.
At a minimum, students became aware of ageism and how their
projected area of expertise related to older adults. Exposure to
older adults through focus groups (Sandel, Cohen, Thomas, &
Barton, 2006), face-to-face meetings (Krout & McKernan,
2007), service-learning (Gutheil, Chernesky, & Sherratt, 2006),
undergraduate gerontology courses (Funderburk, Darmon-
Rodrigues, Storms, & Solomon, 2006), email pen pals (Chase,
2011), and clinical practicums (Olson, 2011; Sheffler, 1998)
have been shown to improve student attitudes toward the eld-
erly and enhance interest in working in age-related fields.
Gonzales, Morrow-Howell, and Gilbert (2010) found that social-
izing through an art program changed attitudes toward older
adults among medical students but did not influence career
plans. In a study of undergraduate college students by
Eshbaugh, Gross, and Satrom (2010), quality relationships with

A B S T R AC T Despite the increase of the older adult population, there exists a shortage of health care professionals trained to help this pop-
ulation remain independent as long as possible. ageism, common among younger adults, affects the capacity building of health care for older
adults. research has indicated that increased knowledge about older adults, as well as exposure to the elderly, may alter nursing students atti-
tudes regarding careers in gerontological nursing. however, questions remain as to what are the most effective ways to provide gerontological
content in nursing programs and enhance attitudes toward older adults. With the understanding that younger adults see a need to balance work
and play, a baccalaureate nursing program provides examples of ways to accomplish this through integration of courses, simulations, positive
images of aging, and learning activities that enhance empathy for both frail and healthy older adults.

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 S T U D E N T AT T I T U D E S
unrelated older adults and a low level of death anxiety among
young participants predicted positively the likelihood of working
with older adults. A mixed-methods study by Fox and Wold
(1996) found that with exposure, nursing students discovered
that they shared common qualities with older adults (intergener-
ational commonalities) and that older adults can contribute to
society (intergenerational sharing).
While there is no question that gerontological nursing con-
tent is vital in nursing curricula, questions arise regarding
where to place that content. Some nursing programs advocate a
stand-alone nursing course, positioned at the beginning of the
program and infused throughout the remaining courses (Jansen
& Morse, 2004), while others recommend a capstone course at
the end of the nursing program. The primary concern regarding
geriatric content integrated into already established courses is
that vital gerontology content may be minimized (Thornlow,
Latimer, Kingsborough, & Arietti, 2006).
Clinical placements for exposure to older adults have also
been examined with equivocal results. Marsland and Hickey
(2003) found that caring for the elderly in long-term care (LTC)
facilities was perceived negatively by nursing students and that
the clinical experience only served to reinforce negative percep-
tions. Some nursing programs advocate for not using LTC facili-
ties at all. Clinical experiences with healthy, community-
dwelling older adults have been shown to positively improve stu-
dent attitudes toward working with older adults and should be
part of the gerontological nursing experience (Burbank,
Dowling-Castronovo, Crowther, & Capezuti, 2006; Furze,
Lohman, & Mu, 2008). However, a concern regarding clinical
placements with only healthy older adults is that while students
may have a happier experience, their underlying negative per-
ceptions of the elderly when working with frail and ill older
adults in other settings may not change. Some studies have
shown that nursing home clinical placement has been found to
improve nursing students negative attitudes toward the elderly
when clinical placement occurred in quality LTC facilities and
clinical instructors had positive attitudes (Chen, Melcher,
Witucki, & McKibben, 2002; Hartley, Bentz, & Ellis, 1995;
Mueller, Goering, Talley, & Zaccagnini, 2011; Sheffler, 1998).
Attention to intergenerational ways of thinking may enhance
attitudinal change. Millennials (ages 16-29) and Generation Xers
(Gen Xers, ages 30-44), place a high value on work/life balance or
making time for fun, in contrast to Baby Boomers (ages 45-65),
who emphasize work as an overriding theme (Wieck, 2011). The
Pew Research Center (2010) found that most Millennials see car-
ing for an elderly parent in their home as their responsibility if the
parent should so desire. An emphasis on older adults in a healthy
play setting and in a work setting, such as LTC, may improve atti-
tudes toward older adults among Millennials and Gen Xers.
All students will encounter older adults when they become
RNs in essentially every practice location. Older adults, as
grandparents, are even involved in areas such as pediatrics and
obstetrics. Thus, common negative attitudes regarding older
adults need to change so that more students will consider geri-
atric nursing as a specialty. Clinical placements that focus on
the generational differences (Millennials, Gen Xers, Baby
Boomers) in ways of learning and perceiving may enhance atti-
tudes toward older adults.
Changes to the Curriculum This article reports on our
experience in championing gerontology in a private university
that graduates baccalaureate nurses. The College of Nursing
(CON) identified a faculty member as the gerontology content
expert for the nursing program, as well as for a university-level
Gerontology Program Committee that promotes an interdiscipli-
nary gerontology minor or certificate. Nursing successfully
identified a pathway for nursing students to be included in
obtaining the gerontology minor. Nursing students reported that
having the minor improved their marketability in obtaining jobs
they desired.
After the entire nursing faculty was surveyed to determine
the extent to which gerontology content was taught during the
nursing program, resources were mailed to all faculty to promote
such content where appropriate. Resources included case stud-
ies, PowerPoint slides, and Internet links to organizations such
as the John A. Hartford Foundation and the National League for
Nursing (NLN). (See Sidebar.) Faculty were resurveyed the fol-
lowing year to determine if they used the additional information
in their course content. Some faculty did take advantage of
these resources and even changed the medical-surgical text-
book to include one that contained a gerontology focus section
in each chapter.
A stand-alone, introductory gerontology nursing course,
Nursing Care of Older Adults, underwent major revisions
based on the AACN Older Adults: Recommended
Baccalaureate Competencies and Curricular Guidelines for the
Nursing Care of Older Adults (2010). Offered originally during
the first semester of the six-semester nursing program, the
course consisted of a didactic portion, a clinical in a LTC
facility, and a communication lab. After curricular revisions,
the gerontology course was split into three separate courses
(didactics, clinical, and lab) and moved to the second semes-
ter. The clinical course was still the nursing students first
exposure to real patients.
In an effort to provide student-centered learning, and in con-
junction with characteristics of Millennials who want to be
involved in decision-making in course development (Weick,
2011), a Course Council, with student representatives from each
May / June Vo l . 3 3 N o . 3 1 5 7
 S T U D E N T AT T I T U D E S
clinical section, was established to meet with faculty at least
monthly to discuss concerns; details are described elsewhere
(Heise & Himes, 2010). During council meetings, students
feelings about taking care of older adults were discussed; stu-
dents spoke of confusion, apprehension, and stress regarding
assignments. Based on feedback from students and faculty,
course content, both clinical and didactic, was integrated and
coordinated with a Fundamentals course taught during the same
semester; teaching similar topics often had a reinforcing effect
for student learning. A coordinated calendar was established for
all courses offered during the semester: Fundamentals, Nursing
Care of Older Adults (NCOA), the NCOA clinical component,
Communication Lab, and Introduction to Community Health.
Students are more likely to retain knowledge when they are
required to use that knowledge in a clinical setting (Benner,
Sutphen, Leonard, & Day, 2010). Therefore, faculty worked to
coordinate didactic topics with clinical exposure. The intent was
not to make the assignments burdensome but, rather, to provide
learning activities that centered on what students learned in
class. Students are given their assignment during a preconfer-
ence, prior to the beginning of the shift, and discuss their expe-
riences during the postconference time. (See Table 1.)
In an effort to engage Millennials, a number of activities were
designed to allow students to feel, in a small way, what the older
adult may be experiencing. These include the Thought for the
Day (Table 2) at the beginning of class, memory tests, reaction-
time tests, sensory kits, polypharmacy kits, and videos showing pos-
itive images of aging. Hundreds of student statements on the dis-
cussion board, midcourse evaluation, and end-of-semester evalua-
tions demonstrated new perceptions and respect for older adults.
Didactic Activities The following is a more in-depth discus-
sion for selected examples of the assignments.
SENSORY KI TS This activity was developed by Dr. Catherine
Van Son, Washington State University, School of Nursing. The
purpose is to allow students the opportunity to experience, with
their senses, some of the changes that happen as people age.
Students can experience visual changes by looking through a
sandwich bag (two layers = 20/60 vision, four layers = legally
blind), as well as changes in touch (wearing gloves and trying to
thread a needle and sew on a button) and taste (eat a piece of
chocolate while holding nose). (See Innovation Center.)
PILL SORTING ASSIGNMENT DURING POLYPHARMACY
LECTURE In this lecture, students are shown a portion of the
made-for-TV movie Where Theres a Will. The first few min-
utes of this movie clearly demonstrate the difficulty encountered
in managing medication regimens. Students then complete the
pill-sorting assignment developed by Dr. Vickie Johnsen. First,
they are each given a bag containing at least 20 pills, consist-
1 5 8 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s
ing of different sizes, shapes, and brands of candy. They must
sort their medications according to specific instructions (Table
3). Students are then told they have a particular malady (e.g., a
stroke, with loss of ability to use dominant hand; glaucoma; color
blindness) and must complete the sorting exercise one more
time. In addition, when picking up their bags of medication, stu-
dents are asked to pay the amount of money owed. These figures
are randomly generated and range from $4.00 to $4,000. The
point is to help students get a feel for the cost of medications.
LI FE WI TH BI G AL When discussing patients with dementia
and their caregivers, students are assigned to read this short
book (150 pages) by Judy Seegmiller, the widow of a man who
suffered from early onset Alzheimers disease (AD). The book
chronicles the authors view of living with Big Al, who died at
age 55 two years after the AD diagnosis. Early in the semester,
students discuss the book within their clinical groups; later, dur-
ing content on caregivers in the didactic portion of the gerontol-
ogy course, the author visits the class and answers questions
about how she dealt with the disease when caring for her hus-
band. (The author has testified before Senate committees on
Alzheimers disease.)
Clinical Activities The following is a more in-depth discussion
for selected examples of the assignments.
LI FE HI S TORY REFLECTI VE WRITI NG During clinical in
the LTC facility, students choose a patient to interview; they are
given a list of suggested questions and conversation starters.
After the interview, students write a critical reflective paper
about their experience in terms of what they learned, how it
affected them personally, and how it will affect their profession-
al career. Frequently, students comment that they were sur-
prised to find that they shared more in common with the senior
than they had thought possible. The reflective writing encour-
ages student to put the experience in perspective, personally
and professionally.
TRY THI S S ERI ES RI S K S CALES Evidence-based assign-
ments available for students through the Hartford Foundation
include general assessments for nutrition, pressure ulcers,
depression, and dementia. Additional Try This: series assess-
ments are discussed throughout the gerontology didactic class,
introducing students early in the nursing program to the impor-
tance of evidence-based practice and lifelong learning.
WORLD S ENI OR GAMES Students in this program are
exposed to healthy older adults, at least 50 years of age,
through the Huntsman World Senior Games (HWSG) in St.
George, Utah. The HWSG attracts approximately 10,000
older adults from around the world to participate in 32 com-
petitive athletic events ranging from Olympic events, like
triathlons, to events such as pickleball. During this experi-
 S T U D E N T AT T I T U D E S

Table 1.
Examples of Coordination of Fundamentals, Gerontology Didactic, and Gerontology Clinical Courses

Week Fundamentals Topic Gerontology Topic Clinical Assignment

One Hygiene Sensory Changes in the Try more than one way to provide
Elderly hygienic care for the patients.
Identify a patient with a sensory deficit and
determine how that patient has adapted to
her/his environment.
Four Medication Administration Polypharmacy Identify how many medications your
patient takes during the day.
Determine if there are any drug/drug
interactions with these medications *
Eight Diabetes Impact of Chronic Illness Identify a patient that has a diagnosis of
diabetes. Have a conversation with patient
that lasts at least 10 minutes.
Eleven Legal Issues Elders and Their Have a conversation with employee at the
Caregivers care center. How does the employee feel
about providing care to elders? Do
employees actions support these feelings?
* With some patients this could be an overwhelming task, but during the semester, the students will need to collect this
information as part of an assignment; this makes students aware before assignment is due.
!

Table
Table 2. 2. Examples
Examples of Thought
of Thought for Day
for the the Day

Quote Author
Value the old folks for what they are, not just for what Boyd K. Packer
they can do.
No matter how old we become, we can acquire Gordon B. Hinckley, Standing for Something
knowledge and use it. We can gather wisdom and profit
from it. We can grow and progress and improve and in
the process strengthen the lives of those within our
circle of influence.
Old Age Is a Culmination, NOT a Termination Unknown
People will forget what you said. Maya Angelou
People will forget what you did.
But people will never forget how you made them feel.
Respect Is Better than Food or Drink WHO/INPEA Missing Voices: Views of Older Persons on
Elder Abuse
The Little Boy and the Old Man (poem) Shel Silverstein
Between You and God (poem) Mother Teresa

Table
Table 3. Polypharmacy
3. Polypharmacy ActivityActivity

Polypharmacy Instructions: Sort pills by size, shape, color, and dosing regimen
Peanut M&Ms Plain M&Ms Skittles
Blue: Take one QID Blue: Take one every 4 hours Green: Take one PRN pain

Green: Take one TID Green: Take one ! hour after meals Purple: Take one PRN nausea
Yellow: Take one daily Orange: Take one daily Orange: Take one PRN confusion
Orange: Take one BID Brown: Take one BID Red: Take one PRN constipation
Brown: Take one ! hour before Red: Take one TID Yellow: Take one PRN diarrhea
meals
Red: Take one at HS Yellow: Take one QID
!

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 S T U D E N T AT T I T U D E S
ence, students perform health screenings, give flu shots, and
are encouraged to watch seniors as they participate in the
games. Students typically come away from the activity com-
menting that seeing active seniors gave them a completely
different perspective on aging; they enjoyed the company of
participants and are inspired to change their own lives, start-
ing now to be healthy and active.
The Senior Games are held annually only in October; to
enhance the winter semester clinical experience, students are
given an assignment to identify a person that they view as
aging successfully. The student then interviews that person
and compares and contrasts (in a written assignment) the
healthy senior with the residents they have cared for in the
LTC facility.
S I M U L A T I O N Students are exposed to other positive geri-
atric experiences through unfolding, continuing case scenarios
in the simulation/skills lab. Using medium- and high-fidelity
simulators, students are introduced to a total of five multicul-
tural, elderly patients throughout their Fundamentals and
medical-surgical courses. These simulated patients are used
weekly to reinforce subjects such as oxygenation, elimination,
pre- and postsurgical care, and hospitalization. Instructors
draw on their stories in the classroom to help situate instruc-
tion. As students revisit these patients throughout two semes-
ters, they become very familiar with them as individuals, fam-
ily members, and citizens. The psychosocial bonds they form
with these patients are reported in both midterm and end-of-
semester student evaluations. Students develop a deeper
understanding of successful aging as they receive gerontology
content simulation experiences throughout the curriculum as
well as through the medical-surgical, psychiatric, advanced
medical-surgical, community health, and the required global
health and human diversity courses.
Implications for Nursing Education The next step for the
CON is to conduct a prospective, mixed-model research study to
determine the impact of clinical experiences at an LTC facility
only versus placements in an LTC facility with two different
types of healthy aging assignments (a written assignment vs.
participation at senior athletic events) and if that attitude is sus-
tained through four additional semesters in the nursing pro-
gram. Do perceptions of seniors improve with a combined
approach to integrating LTC experiences with healthy aging
along with didactic experiences related to older adults?
Society in general needs a paradigm shift away from the
acute care focus toward preventive care and chronic care self-
management. Nurse educators, in particular, have a wealth of
resources available and must become leaders in their own
schools of nursing to help enlarge the vision, to see older adults
1 6 0 N u rsin g Edu cation Persp ectives
as people who can contribute to society through their rich his-
tory of experience. (See Sidebar for resources.) We must contin-
ue to find innovative ways to engage young nursing students
and change their perceptions, so that nursing students will see
the benefits of working with older adults. We thus will be able
to build capability and capacity to care for older adults. NLN
Sidebar.
Resources on Gerontology for Faculty
ACES (Advancing Care Excellence for Seniors),
National League for Nursing:
www.nln.org/facultyprograms/facultyresources/aces/index.htm
John A. Hartford Foundation through Hartford Geriatric
Nursing Initiative (HGNI): www.consultGeriRN.org
American Association of Colleges of Nursing. (2010).
Recommended baccalaureate competencies and curricular
guidelines for the nursing care of older adults:
www.aacn.nche.edu/geriatric-nursing/
AACN_Gerocompetencies.pdf;
and Thornlow, Latimer, Kingsborough, & Arietti, 2006:
www.aacn.nche.edu/geriatric-nursing/monograph.pdf
American Nurses Association (www.geronurseonline.org) and
Nurses Improving Care for Healthsystem Elders [NICHE]):
www.nicheprogram.org
Portal of Geriatric Online Education (POGOe.org) and other
organizations committed to improve the lives of older adults
who will remain the core business of health care systems
(Fulmer, 2006): www.jhartfound.org
Building Academic Geriatric Nursing Capacity (BAGNC)
funds Geriatric Centers of Nursing Excellence and provides
predoctoral and postdoctoral awards (Fagin & Franklin, 2005):
www.geriatricnursing.org
About the Authors The authors are faculty at the Brigham
Young University College of Nursing, Provo, Utah. Barbara A.
Heise, PhD, APRN, BC, assistant professor, teaches introductory
gerontology and end-of-life courses. Vickie Johnsen, PhD, RN, is
the clinical coordinator for Nursing Care of Older Adults.
Deborah Himes, MSN, APRN, BC, is coordinator of the
Fundamentals course. Debra Wing, MSN, RN, is assistant coor-
dinator of the Nursing Learning Center and Clinical Simulation
Laboratory. Contact Dr. Heise at Barbara-heise@byu.edu for
more information.
Key Words Ageism Nursing Student Attitudes Nursing Education
Gerontology Healthy Aging

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