Ageism is a form of discrimination that impedes access to effective and equitable health care, reduces the quality of life, and negatively impacts the personal health of older adults (Chang et al., 2020). Ageism is universal and "refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or oneself based on age" (World Health Organization [WHO], 2021, p. ix). Older adults who experience ageism have poorer physical and mental health outcomes, shorter life spans, and increased social isolation and loneliness (Genderon, 2022; WHO, 2021). Beliefs about aging powerfully determine how aging occurs. Viewing aging as decline and suffering can become a self-fulfilling prophecy (Jenkins, 2016; Zweig, 2021). Older adults who believe and conform to negative views of aging are more likely to experience adverse health conditions, including cognitive decline and cardiac events (Levy, 2022).
Ageism impacts a person's health on three different levels: individually, when negative beliefs and actions are assimilated/internalized and perceived by older adults as true; socially, during interpersonal interactions in health care settings; and structurally, within health care institutions that perpetuate ageism through policies and practices that limit services because of age (Ehni & Wahl, 2020; Van Wicklin, 2020). Nurses can educate themselves and older adults about aging; however, it is likely that ageism will be present in their interactions with older patients and colleagues. The prevalence of ageism in health care prevents nurses from providing the best care to older adults. Nursing education can prepare nurses to proactively dismantle their own ageist views as well as ageist practices within health care settings.
The good intentions and skilled training of nurses may be hampered by unconscious bias that begins in early childhood. Bombarded by images of aging that are absorbed as early as three to four years old, nurses can inadvertently perpetuate ageism in nursing practice (Dahlke & Hunter, 2021; Levy, 2022). For example, nurses may bring with them inaccurate stereotypes about aging, negative perceptions of older adults, and actions that exclude older adults from fully participating in their own care. Nurses cannot fairly assess and care for patients if they base their actions on stereotypical assumptions about how older patients feel, think, and expect to age.
NURSING EDUCATION TO COMBAT AGEISM
Nursing education is a key strategy to combat ageism. Existing nursing curricula commonly attribute the current population surge in older adult patients to the baby boom generation and increased longevity (WHO, 2021). Available information about older adults and gerontology nursing differentiates between the aging process, factors that have an impact on health, and diseases most common in old age.
The concept of ageism is introduced to nursing students by debunking myths that are detrimental to aging and completing aging scales and self-perception assessments (Demirtas & Basak, 2021; Van Wicklin, 2020). The emphasis on identifying personal bias and discriminatory ageist views aptly includes self-reflection, which enables nursing students to grapple with their own beliefs and recognize that ageism and implicit bias are universal. However, the tendency to focus on personal attitudes and feelings does not specifically address how to change behaviors within nursing practice or within the interpersonal and institutional manifestations of ageism in health care settings. Knowledge of ageism, along with self-reflection, is foundational to reducing ageism, but skill and practice are necessary to foster changes within the three levels of ageism. It is essential for nurses to not only become self-aware of their own attitudes and beliefs that contribute to ageism but also to become proactive and proficient in recognizing and challenging ageism in health care.
Tools and approaches to combat other forms of discrimination, such as racism and sexism, can be helpful in eliminating ageism in nursing practice and in promoting equality, equity, and inclusion in the personal, social, and institutional arenas of health care (Auger-Dominguez, 2022; Fuller et al., 2020; Singh, 2019; Williams, 2021). Approaches such as acknowledging power dynamics and providing psychological safety involve actively listening to and believing the voices of those who have experienced discrimination. The use of open-ended questions facilitates interactions that foster awareness, empathy, and support for the experiences of older adults. "Collaborageism" is an approach that specifically encourages intergenerational conversations to fight ageism collaboratively (Haserot, 2021).
Efforts to deconstruct and reduce ageism through nursing education can be modeled based on the strategies of diversity, equity, and inclusion training that specifically confront and challenge racism and sexism through intersectionality (Bryant & Arrington, 2022). The intersectionality of various characteristics of individuals, such as gender and sexual orientation, are applicable to ageism (Lytle et al., 2018). The "Prism of Age" framework is useful for nursing students to address types of aging and variables that intersect and influence well-being and attitudes toward aging (e.g., chronological age, occupational age, life events age, generational age, physical and cognitive age, social age, and subjective age; Pitt-Catsouphes et al., 2012).
It is appropriate for nursing education to focus on the role of the professional nurse as an anti-ageism advocate (American Nurses Association, 2021). Once nursing students learn about types of ageism, they proceed to learn how to be advocates for change. However, if a patient describes experiences of ageism, what can the nursing student do? If the student sees or hears ageist behaviors or disrespectful comments by a health care worker, how can the student be an ally and constructively bring these behaviors or comments to a person's attention?
Nursing students should be prepared to stand alongside patients and be advocates for them. This is a critical step beyond identifying personal attitudes of stereotypes and bias toward older adults. Changing one's attitudes and behaviors can be difficult, but nursing students can become proficient through practice. It is vital to provide students with opportunities to develop skills that will challenge and change inappropriate behaviors and patterns of speech. For example, if a nursing student is given a scenario to problem-solve and role-play what to do, the behavior becomes internalized, just as technical and communication skills are practiced before using them in the clinical setting. Opportunities for students to build on their knowledge of ageism through simulation, role-play, and case studies can result in becoming more empathetic and confident in the anti-ageist care of older patients.
Role-play in the development of anti-ageism skills can address each level of ageism. For example, specific scenarios can be created that highlight situations in which older adults demonstrate that they have internalized myths of aging. The nursing student in such a scenario interacts with the patient in ways that encourage active aging based on accurate knowledge of aging. Other scenarios can involve interactions with other nurses and team members in health care settings, such as situations that involve inappropriate language, falsely attributing limitations to aging rather than to pathology or social determinants of health, or dismissing and ignoring the older patient's comments. Examples of institutional ageism in scenarios can include the practice of meeting and planning with family members, without the involvement of the older patient; sharing information about the older patient with family members without permission; and the allocation of resources because of parameters of age rather than based on comprehensive assessment or likelihood of survival.
All these situations are intended for learning with the expectation that mistakes will be made. Support by peers during debriefing discussions following each session will reinforce positive actions for students to try in similar circumstances.
CONCLUSION
Nelson Mandela said, "Education is the most powerful weapon which you can use to change the world" (Weil, 2021). Anti-ageism nursing education can be instrumental in changing the care of older adults for the better. Providing nursing students with skills to challenge and oppose ageism supports the scope and standards of nursing practice to be anti-ageist and advance equity in health care (American Nurses Association, 2021). Older patients will be afforded autonomy and self-determination, individualized and patient-centered care, respect, dignity, and healthier outcomes.
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