Several years ago, the organization where I was employed hired a new team member. Although this new team member had much less experience than the other members of our team, I soon came to realize that this nurse had one particular qualification that made her more valuable to the organization than the rest of us. She was young. I'd never really thought much about ageism, but the preferential treatment that was given to this youngest team member, and the increasing lack of respect that was shown to the older members of the team, opened my eyes to the phenomenon of ageism, not only in the workplace but also among nurses in general.

According to the Merriam-Webster Online Dictionary (n.d.), ageism is "prejudice or discrimination against a particular age group, and especially the elderly" (Full Definition of Ageism). Common ageist stereotypes of older adults suggest that they are frail, incapable, and senile (Moody & Sasser, 2015), and as I experienced at my organization, older adults are viewed as being less competent, less savvy, lacking in creativity, and generally uninformed about technology and social media. This type of stereotypical portrayals of older adults can be harmful to any group of individuals, but when nurses display ageist attitudes, it can be harmful to older patients both physically and emotionally. In this review article, some of the literature related to ageism in nursing is described, ways that ageism can affect the quality of the care provided to older adult patients are discussed, and theories that may help explain ageism in nursing are identified.

REVIEW OF LITERATURE

Two separate searches of the medical subject headings (MeSH) in the MEDLINE/PubMed database were conducted. For the first search, the terms ageism and nurs* were used. This initial search revealed a total of 167 articles. For the second search, the terms ageism and social identity theory and terror management theory were used. This search revealed a total of three articles. The 12 most current and scholarly articles with the greatest relevance to the topic were selected for this review.

To determine whether ageism existed in health care systems, Kydd and Fleming (2015) conducted a systematic literature review of 28 articles published between 2005 and 2015 that addressed evidence of ageism or age discrimination, implications for health care systems related to ageism, and specific interventions to prevent ageism. The authors found that the literature could be sorted into three distinct categories: (1) the nature of discrimination; (2) the changing role of hospitals; and (3) social worth versus compassion. Relative to the nature of discrimination, the authors found that not all of the examples of ageism were specific to older adults and not all of the age discrimination was negative. Relative to the changing role of hospitals, the authors found there was a need for age-specific care and for specialists who were able to provide it. As well, because people are living longer, there is a need for developing services and technologies that allow older people to remain at home and live independently. Relative to social worth and compassion, the authors found that the implementation of person-centered care helped eliminate the negative perceptions associated with old age.

Polat, Karadag, Ulger, and Demir (2014) conducted a descriptive, cross-sectional study of 167 nurses (n = 110) and physicians (n = 57) working at a university hospital in Turkey. A questionnaire and the Ageism Attitude Scale were used to collect data regarding the participants' attitudes, approaches, and considerations relative to older adult patients. The researchers found that the physicians scored significantly lower than the nurses, indicating a more positive attitude toward older adults. The data revealed that the approach of nurses and physicians toward older patients was respectful and there was a tendency to allow older patients to be admitted for treatments and diagnostic tests ahead of younger patients. Notably, the data also revealed that physicians and nurses preferred to receive information about the older adult from relatives or caregivers and not directly from the patient. As well, the majority of nurses and physicians believed that mental ability, learning skills, and memory decreased in older adults, indicating that there was some level of ageism present. The researchers theorized that encouraging positive attitudes toward older people and requiring nurses and physicians to work in areas that would increase experience in working with older people could encourage positive attitudes.

Band-Winterstein (2015) conducted a qualitative study using a phenomenological approach to capture the lived experiences of nurses working in long-term care facilities and to explore how ageism functioned as a mechanism for promoting neglect of older patients. The researcher held semistructured, in-depth interviews with 30 registered nurses (RNs) from 10 long-term care facilities in Israel, all of whom had at least 2 years' experience working in long-term care facilities. Thematic analysis of the data yielded three primary themes: (1) ageism and neglect as the everyday routine; (2) the institutional system promotes neglect; and (3) from vision to reality. Relative to ageism and neglect as the everyday routine, the researcher found that neglect was built into institutional life and ageism served as its platform. This was evidenced by the older adult population being ignored and not seen, bedridden and cognitively impaired patients being treated as objects, older patients being treated according to a routine and without regard for their individual needs, a failure to perform essential tasks leading to physical neglect, and a lack of communication with the older adult leading to emotional neglect. The researcher found that institutions promoted neglect in the shadow of ageism by discouraging incident reporting, allowing health care workers to have an attitude that older patients were "past their expiration date" (p. 121), and supporting policies that encouraged paperwork over patient care. Relative to solutions for reducing and preventing neglect, the participants suggested creating multidisciplinary teams to improve communication and collaboration of care for older adults; considering the older person in the context of a life history that includes a past, present, and future; providing education and training as well as opportunities for professional discourse on neglect and ageist attitudes; promoting a professional image that encourages humanistic values (e.g., dignity, respect for human life); and cultivating a sense of mission by ensuring adequate resources are available (e.g., personnel, supplies).

In a literature review to explore emergency department nurses' knowledge and understanding of the aging process and their attitudes toward older people being treated in emergency care settings, Deasey, Kable, and Jeong (2014) reviewed 16 articles published between 2004 and 2012. The authors identified five themes that included the (1) processes of care for the older person in the emergency department, (2) emergency department nurses' knowledge of gerontological nursing, (3) impact of inadequate gerontological knowledge on older people and emergency department nurses, (4) factors that influenced nurses' attitudes toward older people, and (5) impact of nurses' attitudes on older people and emergency department nurses. The authors found that the current emergency department processes did not adequately provide for the needs of older patients. The emphasis of emergency department care was on providing lifesaving measures, and the nurses did not have enough time to attend to the psychosocial aspects of care required for older patients (e.g., emotional support). As a result of the complexity of their conditions and associated comorbidities, older patients often had multiple clinical needs that the emergency department nurses were not sufficiently educated to manage. There was a specific need for education and training for the nurses relative to managing patients with dementia. Caring for patients with dementia was enormously taxing for the nurses and enormously stressful to the patients because of the atmosphere in the emergency department (e.g., bright lights, high noise levels, rapid pace). Older patients were more vulnerable when receiving care in emergency departments because the nurses lacked the gerontological-specific skills necessary to adequately care for older patients. Notably, if the older patient also had a cognitive impairment, or dementia, this increased the complexity of patient care required. The authors found that older patients experienced negative ageist stereotypes and these negative attitudes affected the care provided to older patients and the interactions between the patients and the nurses. Some of the negativity may have been related to the nurses' perceptions that the emergency department was not the appropriate place for an older person with a non-life-threatening presentation. The nurses felt that caring for older patients added to their already high workload and, for this reason, the care of older patients was given a low priority. Caring for older patients who were frail and dependent was exasperating to the nurses because the patient could not be cured. There was a tendency for the nurses to withhold information from older patients. The tone of the nurse's voice, the mannerisms that nurses used, and the nurses' failure to provide information could have the effect of marginalizing the patient. The authors also found there was a lack of prestige associated with caring for older patients. This lack of prestige was demonstrated by belittling comments with negative undertones about older patients during nursing reports. Notably, this type of commentary and attitude passes on harmful stereotypes from one generation of nurses to the next. The authors suggested that providing education to increase knowledge and awareness of ageist attitudes and behaviors could be helpful in changing attitudes and misconceptions and promoting effective communication and interactions with older patients.

Kydd, Touhy, Newman, Fagerberg, and Engstrom (2014) conducted a quantitative study using the Multifactorial Attitudes Questionnaire to explore the perceptions of 1,587 nurses and nursing students from Scotland (nurses: n = 169; students: n = 154), Sweden (nurses: n = 243; students: n = 486), and the United States (nurses: n = 443; students: n = 92) about working with older people. Participants from Sweden were the youngest, with 53% (n = 386) in the 18-29 years age group, and participants from the United States were the oldest, with 20% (n = 107) of participants older than 50 years. The majority of participants from all three countries agreed that older people should have access to medical care and surgical procedures regardless of their age. The results of the questionnaire also showed that participants from all three countries viewed caring for older adult patients as challenging and as a subject that should receive additional emphasis in nursing education. The findings also suggested that the attitudes of nurses working with older patients influenced the attitudes of health care professionals. Participants from all three countries agreed that the working conditions associated with caring for older adults was not conducive to recruiting and retaining nurses. In addition, the participants noted that when caring for older adults there was a lack of opportunities for career advancement and a lack of respect from other health care professionals. These conditions negatively affected job satisfaction and the attitudes of nurses caring for older adults. The results of the study showed differences in attitudes toward aging and caring for older adults. Scotland had the highest scores, followed by the United States, and then Sweden. Notably, the low scores from the Swedish nurses and nursing students are telling because these are reflective of the youngest population included in the study.

In a systematic review of 25 studies conducted between 2000 and 2011 using validated attitude scales to examine the international research related to the attitudes of RNs and nursing students toward older people, Liu, Norman, and While (2013) found that attitudes toward older people had become less positive since 2000. The majority of studies reported positive attitudes; however, there was a decreasing trend in positive attitudes toward older adults among nurses and nursing students. These results were troublesome because it reflected a less positive attitude that could be imparted to future nurses. The researchers speculated that nurses' attitudes reflected the attitudes and cultural norms of the general population of their country. Preference to work with older adults and knowledge of the aging process seemed to be associated with positive attitudes toward older adults, suggesting that gerontological education and positive clinical learning experiences for nursing students could increase the number of nurses desiring to work with older adult patients.

In a descriptive, repeated-measures study conducted with third-year nursing students over a 3-year period at a nursing school in Spain, Sarabia-Cobo and Pfeiffer (2015) used the Questionnaire of Negative Stereotypes about Aging to examine the students' attitudes about older patients before and after completing an educational course on aging. The researchers found that before the educational course the students had a primarily negative perception of older adults (62%) despite having cared for older patients during the first 3 years of their clinical experience. After completing the course, negative perceptions were significantly reduced (12.3%), demonstrating that education of nursing students about the aging process and caring for older adults could help eradicate ageism and negative stereotyping of older adult patients.

Gould, Dupuis-Blanchard, and MacLennan (2015) conducted a qualitative study to explore the attitudes about older people among Canadian undergraduate student nurses. The researchers interviewed 20 students using semistructured, focus-group interviews. Analysis of the data revealed that although the students had positive reactions to caring for older adult patients, they had received strong messages from their instructors that gerontological nursing was neither prestigious nor valued. The students reported that the instructors had used disparaging words such as "lazy" to describe nurses who worked in gerontological nursing (p. 810). The students also reported being unwilling to work with patients with dementia, which they felt was synonymous with gerontological nursing. The researchers concluded that additional nursing education about caring for patients with dementia was warranted and that nurses should move beyond the stereotype that all older patients are frail and in decline and the vast majority of gerontological nursing involves caring for patients with dementia.

In a cross-sectional, descriptive study to examine the attitudes of undergraduate nursing students toward aging, Ozedemir and Bilgili (2016) surveyed 495 third- and fourth-year nursing students from four universities in Turkey. The survey was developed from the Ageism Attitude Scale. The researchers found that when the students' perception of "elderliness" was examined, the most common descriptors were "illness, charity, weakness, loneliness, adherence, dependence, and wisdom" (p. 3). Reasons provided for willingness to work with older patients included the following: additional care required for older patients (n = 81; 41.8%), personal choice (n = 58; 29.9%), considerate attitudes of older adults (n = 27; 13.9%), satisfaction derived from improving the older patient's quality of life (n = 12; 6.2%), older adults deserve more attention (n = 11; 5.7%), and everyone will someday be old (n = 5; 2.6%). Reasons provided for not being willing to work with older patients included the following: difficulties of working with older adults (n = 31; 42%), complex care required for older adult patients (n = 20; 27%), personal choice (n = 20; 27%), negative clinical practice experiences (n = 2; 2.6%), and young patients respond better to treatment (n = 1; 1.4%). The researchers concluded that the students had primarily positive attitudes related to aging, and they recommended providing education about older adults, offering opportunities for clinical care of older adults, and increasing activities for developing awareness of ageism in nursing programs.

THEORIES EXPLAINING AGEISM

There are two theories that can be used to explain ageism in nursing: social identity theory and terror management theory. Social identity theory suggests that in order to promote their own self-esteem, younger people identify more strongly with other younger people and push away those who are different (i.e., older adults; North & Fiske, 2012). Tajfel (1981, as cited in Bodner, 2009) theorized that the reason for this behavior was because the group identity was also part of the individual's sense of self and all individuals strive to maintain a positive self-perception. Being a member of the preferred social group is valued (Chonody & Teater, 2016). Social identity theory posits that when individuals are motivated to promote their own group over other groups (Bodner, 2009), the other group is viewed in negative terms (Chonody & Teater, 2016). Group membership is divided between those who are young and those who are old (Chonody & Teater, 2016). Those who belong to the young group will promote negative attitudes and stereotypes about the old group, and this promotes a more favorable perception of the young group (Harwook, 2007, as cited in Chonody & Teater, 2016). Notably, it is the physical process of aging that is viewed negatively, not old age itself (Slotterback & Sarnio, 1996, as cited in Bodner, 2009). The younger individual continues to hold negative attitudes toward older people even when presented with positive information about the older adult (Kite, Stockdale, Whitley, & Johnson, 2005, as cited in Bodner, 2009). The young group is further reinforced as being superior when youth is revered by social and cultural values (Chonody & Teater, 2016).

Terror management theory can also be used to provide an explanation for ageism in nursing. According to terror management theory, when confronted with the realization of their own mortality, people push away from reminders of their own death (i.e., older adults) and identify more closely with those who are similar (i.e., people of a like age; North & Fiske, 2012). Terror management theory provides an explanation for the impact that being afraid of death has on the individual's social behavior (Greenberg, Solomon, & Pyszczynski, 1997, as cited in Bodner, 2009). The only way to diminish the terror is to avoid situations that remind the individual that death is inevitable (e.g., interacting with an older person; Becker, 1962, 1973, 1975, as cited in Chonody & Teater, 2016). Avoidance reduces the terror by allowing the individual to believe that "death is far into the future, distracting oneself from the threat, denying ones' vulnerability to death, or physically removing oneself from salient reminders of death" (Greenberg, Schimel, & Martens, 2002, p. 36, as cited in Chonody & Teater, 2016, p. 116). According to terror management theory, people create worldviews that provide a "symbolic immortality" (i.e., an afterlife, or living on through one's children) in order to cope with the unconscious awareness of their inevitable death (p. 1006). Encounters with older adults lead to feelings of vulnerability and offer disconcerting reminders of the fragility of human life (Bodner, 2009). Younger people may adopt ageist attitudes and behaviors as a way of distancing themselves from older people in order to deny the reality that one day they may also grow old and die (Bodner, 2009).

Both social identity theory and terror management theory function to protect the ego and safeguard the individual from the threat of growing older. North and Fiske (2012) have suggested that certain interpersonal perspectives emphasizing the older person's physical appearance can also promote ageism. The older person's appearance fosters ageism through negative halo effects (i.e., older people are seen as unattractive; therefore, they must also have other negative traits); overgeneralization effects (i.e., the older people's appearance, such as having droopy eyes, implies certain traits, such as sadness, so they must be that way); and social affordances (i.e., the older people's appearance, such as wrinkled skin, and mannerisms, such as a slow gait, mean that the person is not sociable; Langlois et al., 2000; Montepare & Zebrowitz, 2004; Palmore, 2003, as cited in North & Fiske, 2012). These perspectives suggest that older adults can be devalued and stigmatized on the basis of age-related changes in physical appearance and abilities (North & Fiske, 2012).

CONCLUSIONS

Ageism is surprisingly pervasive, affecting many different areas of a society. As the review provided in this article clearly demonstrates, nursing schools do not promote gerontological nursing as a preferred career choice and, in fact, may attempt to steer students away from gerontological nursing (Gould et al., 2015). Older patients may not receive the same level of care as younger patients, their illnesses may not be treated as aggressively, and there may even be an element of acknowledged neglect of older patients (Band-Winterstein, 2015; Deasey et al., 2014). In the workplace, although job performance does not decrease with age, younger employees may be given preferential treatment and older job applicants may be rated less positively than younger applicants, even when both are similarly qualified (Avolio & Cascio, 1989; Cleveland & Landy, 1983; Liden, Stillwell, & Ferris, 1989, as cited in North & Fiske, 2012). The media representation of older adults also reflects age-related biases, as older people are underrepresented, typecast, and even precluded from leading roles (Bildtgard, 2000; Signorelli, 2001, as cited in North & Fiske, 2012). Social values that equate beauty with youth promote attitudes of reluctance to age (Chonody & Teater, 2016). Ageism allows those who are younger to distance themselves from those who are older to the extent that they no longer identify with older adults as human beings (Butler, 1975, 2009, as cited in Bodner, 2009).

Stereotypes of older adults and assumptions of old age as a time of dependency and vulnerability affect not only how older adults are perceived and treated by society but how they are treated by members of the nursing profession as well. Older adult patients should be viewed as worthy of respect. Negative and ageist attitudes can impact the physical and emotional quality of life of older adults.

As plastic and aesthetic nurses, we care for older patients on a daily basis. As advocates for our patients, we play a critical role in promoting positive, professional attitudes and ensuring that the needs of our older patients are met. Failing to do so can result in patient harm, influence the fair distribution of health services, and promote an attitude of ageism that can trickle down to student nurses and also affect the attitudes of other health care professionals.

REFERENCES