Professional values, ageism, attitudes and willingness towards geriatric care among nursing students in China: a multiple path analysis

The population is aging, presenting a significant challenge for communities to proactively address. According to projections made by the World Health Organization (WHO), the number of people over 60 in the world would double to 2.1 billion by the year 2050 [1]. In China, the National Bureau of Statistics of China (NSBC) reports that there are 190 million older adults [2], with over 78% suffering from at least one chronic condition [3]. Chronic diseases often result in prolonged illness and a low recovery rate, making older adults heavily reliant on nursing care, including home and long-term care services. However, the WHO has identified a projected shortfall of over 5 million nurses and midwives by 2030 [4], a situation that is expected to be more acute in less developed countries. Furthermore, geriatric care is not commonly viewed as an attractive career path among nursing students [5, 6]. In Mainland China, only 3.6% of nursing students, and in Hong Kong, 7.7%, consider geriatric care as their preferred employment sector (5). Despite this, geriatric care education has proven to be crucial in improving students' attitudes, intentions, and knowledge in this field [7]. Thus, it is imperative to investigate the factors that influence nursing students' willingness to engage in geriatric care.

The field of geriatric care is dedicated to improving the health and quality of life for older adults. This highlights the significance of professional values and the reduction of ageism, indicating that nurses should demonstrate a greater propensity for altruistic actions and exhibit fewer prejudices and stereotypes toward older adults. Positive attitudes toward older adults have been acknowledged as indicator of a willingness to care for older adults. Consequently, we aim to investigate the mediating effect of attitudes on the relationship between professional values, ageism, and the willingness to pursue a career in geriatric care.

“Attitude” is always perceived as a complicated term, with its structure composed of cognitive, affective, and behavioral characteristics, which means it can not only influence people’ feeling and opinion but also has a substantial impact on behavior choice and information processing [8, 9]. A positive attitude toward older adults is a beneficial factor in encouraging nursing students to pursue geriatric nursing employment after graduation [10]. Nevertheless, the overall level of attitudes was low, and it varied among nations and regions, potentially due to diverse cultural contexts and distinct individual experiences [11]. The situation prompts nursing educators to explore the relevant variables to boost the changes in attitudes.

Ageism, defined as “the stereotypes, prejudice, and discrimination directed toward others or oneself based on age” [12], is pervasive in today’s society. The Global Report on Ageism published by the WHO in 2021 [13] revealed that one in every two people globally harbour ageist views. Often, ageism is implicit, with individuals holding ageist beliefs without conscious awareness. This is particularly prevalent among caregivers, leading to a diminished quality of care for older adults and an aged-unfriendly medical environment (13). Research has shown that nursing students generally possess an agism tendency toward older adults [14], which may be affected by factors such as previous negative interactions with older adults, knowledge about aging, and the quality of contact [15, 16]. The nursing curriculum has been identified as a key contributor to ageist views [17]. A lack of theoretical knowledge and practical experience in caring for older adults often leaves nursing students feeling unprepared to work with this demographic, fostering negative perceptions about aging and exacerbating the development of ageist views [17, 18].

However, even though people don’t want to convey prejudice and discrimination, they may use ageist terms unconsciously, since some language biases have been potentially internalized [19]. For example, the terms "elderly" and "senior" evoke stereotypes of older adults as frail and dependent [1, 20]. As language is powerful, which could influence the perceptions and beliefs, it is valued to reject the discriminatory linguistic encoding and unjustified stigmatization [21]. The neutral term "older adults" will be used in this article to refer to anyone 65 and older, and the word "geriatric care" will suggest nursing interventions that are focused on the issues, illnesses, and treatment of older adults.

Professional values serve as standards for action that are widely accepted within the professional community [22], providing a framework to evaluate the beliefs and attitudes influencing behaviour, and include principles such as human dignity, integrity, altruism, and justice [23]. Nursing students’ professional values are a combination of personal and organizational values derived from their culture and community [24]. Most nursing students exhibit excellent understanding of professional ethics, but show a lack of awareness in solving clinical care problems [25, 26]. In the context of geriatric care, nursing students' decisions when faced with moral dilemmas may be shaped by their robust professional values [27], which can enhance their ethical decision-making capabilities in nursing and boost their job satisfaction. Individuals with diverse educational backgrounds, genders, nationalities, and personal values may hold varying professional values [28‐30]. Furthermore, a correlation has been identified between nursing students' attitudes about older adults and their professional values [31], revealing potential ways in which nursing students may advance their intentions toward geriatric care.

Nursing students, who will be the main source of the future workforce in geriatric care, do not see geriatrics as an enticing occupation [32‐35]. One of the principal reasons for this could be attitudes toward older adults [36]. Ageist views and stereotypes, prevalent in both society and individuals, discourage nursing students from pursuing a career in geriatric care [5, 37]. Furthermore, the willingness of nursing students to provide geriatric care is associated with professional values and reduced ageism [16, 38], which are becoming increasingly significant in nursing education. Despite this, there is a scarcity of research explaining the mechanisms by which nursing students' ageism and professional values influence their readiness to provide care for older adults. Therefore, the aim of this study is to investigate nursing students' willingness to engaged in geriatric care and to examine the relationship between ageism, professional values, attitude, and willingness towards geriatric care. This research anticipates uncovering new strategies for enhancing nursing students' intention to practice geriatrics through improvements in nursing education.

To address the challenges of an aging population, a robust public health system is being developed, with a high demand for nursing professionals. Nursing students, once considered auxiliary to clinical nursing, are now key to addressing the shortage of geriatric nurses. Our study revealed that attitudes toward older adults partially mediated the relationship between professional values and willingness of geriatric care, and fully mediated the relationship between ageism and this willingness. These findings offer evidence to support the creation of a more effective nursing education system, which is essential for developing a skilled geriatric nursing workforce to respond to the evolving needs of global public health.

The study indicated that over half of the nursing students expressed a willingness to pursue geriatric care. This finding aligns with previous research conducted in Taiwan [44] and Hong Kong [45], suggesting a slight to moderate positive inclination among nursing students towards geriatric care. In contrast, only 5.1% of nursing students in Sri Lanka and 45.5% of Turkish students identified working with older adults as their preferred career choice [36, 46]. A possible explanation for this variation is that individuals raised in collectivist cultures may be more inclined to work with older adults and hold more positive attitudes toward them [37]. The persistent influence of social ideals and traditional Confucian culture may also affect the job choice of nursing students [32, 37].

This study revealed that nursing students who have participated in activities related to older adults are more likely to pursue a career in geriatric nursing care. This finding is consistent with the studies that identified previous work experience with older adults as a significant predictor of the intention to provide care for this population [37, 47]. Additionally, the study also found a significant positive correlation between nursing students' clinical practice in geriatric wards and their intention to work in geriatric care. The benefits of extending clinical placements and ensuring the presence of qualified staff to help students understand the complex role of gerontological nurses has been acknowledged in a literature review [32]. Accordingly, the suitable interventions aimed at increasing interaction with older adults and focusing on clinical practice arrangements should be considered.

This study investigated the relationship between various variables using path analysis and determined that professional values significantly and positively influenced nursing students’ willingness to engage in geriatric care. The levels of professional values among the nursing students in this study ranged from moderate to high, which aligns with findings from Korea [48]. Previous research has established professional values as a cornerstone of nursing practice, noting their role in guiding complex ethical decisions and contributing to the development of professional identity [23, 49]. Nursing students with elevated professional values are more cognizant of their caregiving roles [38], thereby focusing more on the care needs of older adults and taking responsibility for geriatric care. There is evidence to suggest that enhancing nurses' professional values can improve both the quantity and quality of nursing care [38].

This study highlighted the critical role of nursing students' attitudes toward older adults in influencing their willingness to pursue a career in geriatric care. Our findings indicated that attitude serves as a mediator between professional values and the willingness to work in geriatric care. Students with higher levels of professional values tend to score better in their attitudes toward older adults. In northern Turkey, nursing students’ attitudes toward older adults were significantly linked to their professional values [31], which are grounded in ethical principles such as altruism, justice, integrity, and human dignity, and form the foundation of the students' attitudes [23, 31]. Moreover, students with a positive attitude towards older adults are more inclined to specialize in geriatrics, making attitude emerge as the strongest predictor [45]. A positive attitude facilitates the absorption of information about aging, leading to a deeper understanding, which in turn can alter the information processing and subsequently affect behaviour [50, 51]. Consequently, nursing education should prioritize fostering positive attitudes toward older adults and instilling proper professional values in nursing students to increase their intention to enter the field of geriatric care.

In this study, attitudes fully mediated the relationship between ageism and nursing students’ willingness towards geriatric care, with no direct effect of ageism on willingness observed. This contrasts with the previous study by Gherman, which identified ageism as an indicator of nursing students' intentions to practice geriatrics and highlighted its significant role in the relationship between the quality of intergenerational contact and these intentions [16]. The difference may be attributed to the fact that participants in Gherman's study were required to finish at least one clinical rotation in geriatric care, whereas in our study, only 44.19% had clinical practice in geriatric wards. Ageism, characterized as a stereotype, prejudice, and discrimination has been confirmed to be associated with negative attitudes toward older adults [15]. Since ageism among nursing students not only degrades the standard of geriatric care but also has a detrimental effect on the physical and emotional well-being of caregivers, nursing educators are obliged to recognize and transform this situation and to provide more training on increasing awareness of older age groups.

Our findings indicate that previous involvement in activities related to older adults, such as caring for them and clinical practice in geriatric wards, positively influences nursing students' willingness to pursue geriatric care. Furthermore, the professional values of nursing students have a direct and indirect effect on their willingness to specialise in geriatric care. Ageism may also indirectly influence their willingness to engage in geriatric nursing care through its mediating effect on their attitudes toward older adults. In light of these findings, it is imperative to adopt a multifaceted approach that includes integrating professional values training into educational curricula, mitigating potential ageism among nursing students, and enhancing their exposure to geriatric care.