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 Nurse Education Today 108 (2022) 105161

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Review

How does geriatric nursing education program change the knowledge,

attitude and working intention among undergraduate nursing students? A
systematic literature review
Zhoumei Yan a, Hui-Chen (Rita) Chang a, b, *, Jed Montayre c, Mu-Hsing Ho a, b
a
School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia
b
Illawarra Health and Medical Research Institute (IHMRI), Northfields Ave, Wollongong, NSW 2522, Australia
c
School of Nursing and Midwifery, Western Sydney University, Campbelltown Campus, NSW 2751, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: This review aimed to examine the changes of knowledge, attitude and working intention in nursing
Geriatric nursing students after an undergraduate geriatric nursing education.
Nursing education Design: A systematic review of the literature.
Knowledge
Data sources: Five databases which included CINAHL, MEDLINE, PubMed, Scopus and Web of Science were
Attitude
Working intention
searched for this literature review from January 2010 to October 2020.
Review methods: The review was registered in PROSPERO registry with registration number CRD42020215703.
The review examined undergraduate nursing education programs in terms of knowledge, attitude and working
intention towards geriatric care among undergraduate nursing students as outcomes. We used JBI critical
appraisal tools and Mixed Methods Appraisal Tool to evaluate and assess the quality of the retrieved research
papers.
Results: The search yielded 19 studies included in the final review, 14 of which were quantitative studies and five
were qualitative studies. Four types of education programs were identified. These were type 1, a four-year un­
dergraduate gerontology program consisting of geriatric theory and geriatric care clinical placement; type 2,
stand-alone geriatric subject and geriatric clinical placement program; type 3, integrated geriatric subject and
geriatric clinical placement program; type 4, solely geriatric clinical placement program. The review found that
the type 2 program demonstrated the best educational outcomes in undergraduate students.
Conclusions: This review provided the most recent literature evidence pertaining to undergraduate geriatric
education program and its educational outcomes. Future research should focus on the evaluating the content of
each type of geriatric education program to inform the development of undergraduate geriatric nursing
education.

1. Introduction et al., 2010). However, the traditional undergraduate nursing curricu­

lum design focuses on acute, medical, and surgical care settings, while
Geriatric education is one of the most discussed components of the geriatric subjects are often disregarded (Bednash et al., 2011; Hesselink
nursing education curricula in terms of its necessity and practicality for a et al., 2019). Many scholars have recognised that undergraduate geri­
nursing career (Michael et al., 2019). The content of Geriatric nursing atric nursing education plays a critical role in providing academic and
education includes generalised registered nursing programs including professional training to ensure that students are equipped with knowl­
geriatric theory or advanced geriatric specialist training such as geron­ edge, skills and a positive attitude for caring for older adults to meet the
tology, and geriatric clinical placement in a variety of settings (for need of the increasing aged population (Hsu et al., 2019; Pepper, 2014).
example, acute care, community care and residential care) (Deschodt However, it is also evident that geriatric nursing education contents

* Corresponding author at: School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, NSW 2522,
Australia.
E-mail addresses: [email protected] (Z. Yan), [email protected] (H.-C.(R. Chang), [email protected] (J. Montayre), mhh838@
uowmail.edu.au (M.-H. Ho).

https://doi.org/10.1016/j.nedt.2021.105161
Received 15 April 2021; Received in revised form 17 September 2021; Accepted 27 September 2021
Available online 30 September 2021
0260-6917/© 2021 Elsevier Ltd. All rights reserved.
Z. Yan et al. Nurse Education Today 108 (2022) 105161

were offered inadequately and inconsistently across undergraduate from American Association of Colleges of Nursing (AACN) in 2019
geriatric nursing curricula (Deschodt et al., 2010; Pepper, 2014). For (AACN, 2019). In contrast, the American Geriatric Society claimed that
example, it could consist of a short geriatric simulation workshop less than 1% of registered nurses and less than 3% of the advanced
(Cheng et al., 2020; Cheng et al., 2015), a stand-alone geriatric subject practice registered nurses are qualified as geriatric nurses (Robert Wood
containing geriatric theory and geriatric clinical placement (Lowey, Johnson Foundation, 2012). Thus, the scarcity of geriatric training leads
2018), geriatric theory content integrated with other nursing subjects (e. to the weakness of knowledge, interest, and attitude in caring for older
g., acute nursing) and geriatric clinical placement (Sarabia-Cobo and adults among nursing students (Che et al., 2018).
Castanedo Pfeiffer, 2015), or geriatric clinical placement only (Evers Nevertheless, a study reported that geriatric nursing was an elective
et al., 2011). subject in most institutions and the clinical placement hours are less
The inadequacy and inconsistency of geriatric education has a sig­ than 50% of the curricular time in Mainland China (Cai, 2020). Besides,
nificant impact on the quality and safety of geriatric care (Royal Com­ working environment, anxiety about ageing and negative attitudes to­
mission into Aged Care Quality and Safety, 2019). A survey from the wards geriatric care, individual life experience with seniors were rea­
Curtin University in 2017 found that in residential aged care facilities, sons for low preferences among nurses for working with older adults
while more than 70% of staff had at least a TAFE certificate, associate (Cheng et al., 2015). Geriatric care knowledge, negative views about
diploma or postgraduate certificate in geriatric training, the remaining ageing and the inability to communicate with older adults were dis­
30% of the geriatric care staff had an education level equal to or below cussed by Dionigi (2015) as important factors influencing undergradu­
year 12 (Burgess et al., 2018). ate nursing students to pursue their career choice in geriatric care.
The Curtin study found that inadequacy of geriatric nursing educa­ Robust evidence-based geriatric education is warranted to enhance
tion led to high stress levels in staff, poor quality of care and job satis­ undergraduate nursing students’ knowledge, attitude and working
faction, and limited opportunities for promotion resulting in more than intention towards geriatric care. A systematic review found that high
70% of the participants (N = 72) having the intention to leave geriatric intention to take care of older adults and knowledge about ageing were
care (Burgess et al., 2018). Besides, lack of mandatory competencies and positively associated with the attitude towards older people among
the absence of compulsory accreditation standards relative to geriatric nurses and nursing students (Liu et al., 2013). Abudu-Birresborn et al.
care are the key factors weakening the current Australian geriatric ed­ (2019) conducted a scoping review examining the preparedness of
ucation (Australian Nursing and Midwifery Board, 2021; Royal Com­ nurses and nursing students caring for older adults in lower and middle-
mission into Aged Care Quality and Safety, 2019). Although the income countries. The findings showed that both nurses and nursing
Universities Australia (2018) introduced ten key recommendations to students had a positive attitude towards geriatric care, but the miscon­
address the future needs of geriatric care workforce. However, these ception about caring for older adults. Besides, nursing students also
recommendations tend to be more flexible and linen, and they were reported a low working intention towards geriatric care (Abudu-Bir­
often neglected by academy providers (Royal commission into Aged resborn et al., 2019). Although these studies were the most recent re­
Care Quality and Safety, 2019; Universities Australia, 2018). Yet, we views, the limitations of these studies were focused on English and
cannot ignore the significance of these recommendations. Particularly, it Chinese languages, low and middle-income countries only. To our
highlights the needs of developing high quality of undergraduate geri­ knowledge, there has been no systematic review that gathers the un­
atric nursing education in enhancing the knowledge, attitude, and dergraduate nursing education program with geriatric nursing compo­
intention of nursing students to meet the needs of increasing ageing nent and its effect on knowledge, attitude and working intention
population (Aged Care Crisis Inc, 2019). Given the limited focus on how towards geriatric care among undergraduate students. Therefore, a
the current undergraduate geriatric education changes the knowledge, broad and inclusive review that highlighted the significance of geriatric
attitude and working intention among students, this review aimed to education is needed.
examine the changes of knowledge, attitude and working intention to­
wards geriatric care in undergraduate nursing students after the nursing 3. Methods
education program which includes geriatric nursing component.
3.1. Study design
2. Background
This systematic review aimed to investigate undergraduate nursing
The rapid growth of the ageing population results from declining education program in terms of its educational outcomes in knowledge,
birth rates, mortality rates, and increasing longevity (World Health attitude and working intention towards geriatric care among under­
Organisation [WHO], 2011). The rapidly ageing population suggests an graduate nursing students. This review protocol was guided by the
increased demand for primary and long-term healthcare services (WHO, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
2020). However, WHO (2020) projects a shortfall of 9 million nurses and (PRISMA) 2020 Checklist to enhance the rigor of this review (Page
midwives by 2030 and the situation is worst in less developed countries et al., 2021). Key steps in this framework are including study selection,
(WHO, 2020). Even though developed countries have a strong economic search strategy, critical appraisal and data extraction, and data
body and a significant amount of healthcare workforces, yet the synthesis.
Australian Nursing Federation (2011) articulated that the nursing
workforce shortage in geriatric care is getting more severe with a pre­ 3.2. Study selection
diction of 60 thousand shortage by 2050. Concurrently, geriatric care
nurses take only 14% of the total nursing workforce and respond to 1.2 Based on the review object and questions, we believed that the
million senior Australians’ healthcare demands in residential facilities included studies using diverse methodologies would contribute to a
care and community care (The Hon Greg Hunt, 2020). As a result, the comprehensive understanding of the geriatric education program
shortage of the nursing workforce fail to meet the standards of geriatric changes the knowledge, attitude and working intention among under­
care quality and safety needs (Aged Care Quality and Safety Commis­ graduate nursing students. Therefore, the inclusion criteria for article
sion, 2021). selection were as follows: (1) studies explore the outcome of knowledge,
In the United States, Hartford Institute for Geriatric Nursing stated attitudes and working intention after expose to undergraduate geriatric
that only one third of the American undergraduate nursing education nursing education (including geriatric theory and/or geriatric clinical
required geriatric subjects in 2005 (Robert Wood Johnson Foundation, placement); (2) studies explore associate factors (e.g., knowledge, atti­
2012). While the number of registered nurses work in acute care hos­ tude, geriatric education program) in relationship with geriatric work­
pitals raised from 44% in 2004 to 57% in 2013 according to a report ing intention among undergraduate nursing students; (3) written in the

2
Z. Yan et al. Nurse Education Today 108 (2022) 105161

English language or translated in English; (4) published in peer- help us to capture the dynamics of the topic and enrich the data (Pearson
reviewed journal articles. The exclusion criteria included: (1) studies et al., 2015). The synthesis knowledge could further inform, explain and
examined a mixed of interdisciplinary participants (e.g., medical stu­ strengthen the findings and final result in a valid and rigorous conclu­
dents, dental students, and social work students) or staff (e.g., teaching sion (Pearson et al., 2015).
staff, clinical working staff) attitudes towards older adults or geriatric There are three steps of data synthesis. First, after data extraction, we
care; (2) focused on non- undergraduate and no details about geriatric compared the quantitative data by converting the original score (raw
curriculum design; (3) focused on ageism and/or stereotype towards score) into percentages due to the inconsistency of standardised metrics
older adults; (4) systematic review, opinion paper, dissertations, and used in the included studies. The same method was used by Liu et al.
theses. (2013) to compare the attitude score in a literature review. Specifically,
the overall score was categorized into three groups based on the per­
3.3. Search strategy centages of original score: namely, low (< 39.9%), medium (40% - 60%)
and high (> 60.1%). A p - value less than 0.05 was considered statisti­
The review protocol was registered on the International prospective cally significant. Similar to the data synthesis method in the previous
register of systematic reviews (PROSPERO) registry and the registration literature (Liu et al., 2013), predetermined themes of the types of edu­
number is CRD42020215703. Five electronic bibliographic databases, cation program, variables and measurement tools, raw score, converted
namely Medline, CINAHL, PubMed, Web of Science, and Scopus were score, overall score and statistically significant were used to abstract the
searched to identify the published studies that meet the selection table (Table 2). Second, the qualitative data extracted from mixed
criteria. We confirmed the key terms by consulting with librarian and method studies and qualitive studies were also presented separately, to
aligned with the review object and questions. The key search terms enhance the rigor and reliability of the synthesis of data. The key items
including (undergraduate nursing students or college nursing students such as type of education program and education outcome in relation to
or university nursing students); AND (Geriatric or gerontology or the knowledge, attitude and working intention were presented in
gerontological nursing education and clinical placement); AND Table 3. Third, we conducted an insight screen at the result of different
(knowledge, attitude or perception, working intention or working geriatric education program by comparing the quantitative result of
intention or care willingness towards older adults or elderly or seniors or knowledge, attitude and working intention among different types of
geriatrics or geriatric care or aged care). The search strict to the English education programs. In particular, we categorized the education
language, peer reviewed, research paper, abstract and full text available. outcome into four levels, namely: low, medium, medium to high and high.
The timeframe was limited from January 2010 until October 2020. The Also, we highlighted the number and percentage of each type of edu­
reference lists of included studies that entered the eligibility phase were cation program and its educational outcome in different levels. Items
reviewed to identify other relevant studies. like type of education program, level of knowledge, attitude and
working intention were demonstrated in Table 4. A narrative synthesis
was used to report the results.
3.4. Critical appraisal and data extraction
4. Results
Two independent reviewers used Joanna Briggs Institute (JBI) Crit­
ical Appraisal Checklists and Mixed Methods Appraisal Tool (MMAT) to
A preliminary search yielded 254 articles, and one study was added
assess the methodological quality of the included studies (Aromataris
from a reference list. Five were removed due to duplication, 201 were
and Munn, 2020; Pluye et al., 2011). JBI Data Extraction Instrument was
removed by screening the title and abstract, resulting in 49 papers fully
used to pool out data from included studies that were relevant and
retrieved and examined. 30 irrelevant records were excluded for specific
significant (Aromataris and Munn, 2020). We preliminary identified the
reasons: 13 studies examined multidisciplinary participants, three
types of geriatric education programs and categorized them into four
studies focused on ageism, one study focused on simulation learning,
groups, as shown in Table 1. Furthermore, we extracted the data from
two studies focused on details of geriatric curriculum design, six studies
the included studies. The following data were collected: the first author
had no geriatric education as intervention, and five studies did not focus
of the study, year of publication, country, study aim, study design,
on nursing students. Ultimately, 19 full-text papers were included; de­
participants, type of intervention, standardised metrics, and the findings
tails of these are given in Fig. 1.
of the study.
4.1. Results of critical appraisal
3.5. Data synthesis
Two independent reviewers aligned the review objects and the in­
An integrated synthesis was used to summarise the findings of clusion criteria to select the studies to be included. The critical appraisal
included studies. The collected data from qualitative studies, quantita­ results revealed that all selected studies had adequate methodological
tive studies and mixed-method studies were analysed separately. This is rigor (Appendix 1 and 2). Although two mixed-method studies showed a
because an integration of the quantitative and qualitative data could low response rate, we decided to include them because the small sample
size (N = 43 and N = 80, respectively) will not affect the validity and
Table 1 rigor of review results (Baumbusch et al., 2012; King et al., 2013).
Definition of each type of geriatric nursing education program (GNEP). Therefore, no study was further excluded after the critical appraisal.
Type of geriatric Definition
education 4.2. Definition of each type of geriatric nursing education program
Type 1 Four-year undergraduate gerontology program consisting of (GNEP)
two-year of geriatric theory (second year and third year) and
two-year of geriatric clinical placement caring for older Table 1 shows the definition of each type of GNEP. Type 1 had a four-
adults (third year and fourth year).
year undergraduate gerontology program including two years of geri­
Type 2 Stand-alone geriatric subject and geriatric clinical placement
caring for older adults. atric theory and two years of geriatric clinical placement (Zisberg et al.,
Type 3 Geriatric theory integrated with other nursing subjects, 2015). Type 2 program included a stand-alone geriatric subject and
including geriatric clinical placement caring for older adults. geriatric clinical placement in various settings (e.g., nursing home,
Type 4 No geriatric theory study, only geriatric clinical placement hospital, or home care). Geriatric theory was included in the stand-alone
caring for older adults.
geriatric subject, and most of the stand-alone geriatric subjects ranged

3
Z. Yan et al. Nurse Education Today 108 (2022) 105161

Table 2
The knowledge, attitude and working of each type of geriatric nursing education program in quantitative findings (N = 14).
Reference and Variables and measurement tools Raw scores Converted score Overall Statistically
type of education score* significant
program. (P value)

1. Zisberg et al., Attitude: KAOP (5-Point Scale) Mean attitude score in Jewish group A:65.2% A: High NS
2015. Type 1. (A):3.26 ± 0.34; Arabic group (B): 2.97 ± B:59.4% B: Medium
0.27.
Knowledge: FAQ (total score 25) Total knowledge score: A:49.9% A: Medium p = 0.005
A: 12.48 ± 2.65. B:44.9% B: Medium
B: 11.23 ± 2.86.
Working intention: self-formulate Mean Working intention score: A:57.8% A: Medium p = 0.05
question (5-Point Scale) A: 2.89 ± 1.11. B:65.0% B: High
B: 3.25 ± 1.08.
2. Zhang et al., Attitude: KAOP (7-Point Scale) Total attitude score in intervention group A:51.0% A: Medium NS
2016. Type 2. (A): 121.43 ± 16.66; control group (B): B: 51.0% B: Medium
121.48 ± 14.96.
Knowledge: FAQ Total knowledge score: A: 36.8% A: Low NS
A: 9.20 ± 3.05. B: 36.2% B: Low
B: 9.06 ± 2.79.
Working intention: Nursing students’ Mean working intention: A: 70.2% A: High NS
care willingness to the elderly scale (5- A: 3.51 ± 0.69. B: 71.5% B: High
Point Scale). B: 3.59 ± 0.76.
4. Koehler et al., Attitude: Students’ Perceptions of Mean score: Pre-test:76.6% Pre-test: P < 0.00 1
2016. Type 2. Working with Older Adults Scale (5- Per-test: 3.83 ± 0.43. Post-test: 80.2% high
Point Scale). Post-test: 4.01 ± 0.41. Post–test:
high
Pre-test mean score of students had previous Pre-test: Pre-test: P < 0.001
working experience with older people (A): Pre-test: A: High
3.88 ± 0.42; without prior experience group A:77.6% B: High
(B): 3.57 ± 0.43 B:71.4%
Post-test mean score: Post-test:
A: 4.04 ± 0.41. Post-test: A: High
B: 3.88 ± 0.37. A:80.8% B: High
B:77.6%
Working intention: self-formulated Pre-test: 22 participants changed towards Pre-test: shit towards aged Pre-test: Pre-test: p =
questionnaire to ask students most prefer aged care, 7 shifts away from aged care, 227 care: 8.3%; shit away from Low 0.004
and least prefer to work with aged group. unchanged. aged care: 3.1%. Post-test: Post-test: p =
Post-test: 17 participants changed towards Post-test: shift towards aged Low 0.001
aged care, 42 shifts away from aged care, care:6.4%; shift away from
194 unchanged. aged care: 15.8%
5. Hsu et al., Attitude: KAOP (6-Point Scale) Total attitude score: 168.44 ± 18.38 82.4% High NA
2019. Type 2.
6. Che et al., Working intention: Intention to work Total working intention score: 39.72 ± 4.38 72.2% High NA
2018. Type 2. with Older People Scale (total score 55).
Attitude: KAOP (7-Point Scale) Total attitude score: 145.12 ± 12.99 61.0% High NA
7. King et al., Attitude: KAOP (6-Point Scale) Total attitude score:149.13 73.1% High p < 0.05
2013. Type 2.a Working intention: self-formulated Intention to work in different aged group Working with older people Medium p < 0.008
questionnaire to measure intention to ranking: younger adult group, adults, and ranked the third preferable
work in different aged group. adults aged 65-85 in-sequence. aged group among in a total
of seven groups.
8. Cheng et al., Working intention: The Motivation Total expectancy score: 20.11 ± 3.28. Expectancy score: 67.0%. High NA.
2015. Type 2. Questionnaire (Including aged care Total value score:44.93 ± 6.33 Value score: 64.2%
expectancy and value parts; total score of
expectancy is 30, total value score is 70).
Knowledge: FAQ Total score: 20.51 ± 1.70 82.0% High NA.
Attitude: Geriatric Attitude Scale (5- Mean score: 3.54 ± 0.34 70.8% High NA.
Point Scale)
9. Boutin et al., Knowledge: Revised version of FAQ Total score: pre-test:23-38; post-test:25-40. Post-test: 50%-80% Medium to p < 0.05
2019. Type 2. (total score 50) high
Attitude: Multifactorial Attitude The study result has not present total NA NA Only 3 items
Question. attitude score. The frequencies and statistically
percentages for pre-test and post-test significant.
attitudes showed similar positive results for
both pre-test and post-test for the majority of
the statements. 3 out of 20 items statistically
significant.
10. Garbarino Attitude: Senses Framework Survey. The finding did not present overall attitude NA NA 11 out of 15 items
and Lewis, score, only present the mean score of each statistically
2020. Type 2.a item in the survey. significant.
11. Baumbusch Knowledge: FAQ Total knowledge score: pre-test: 13.4 ± 2.15; Pre-test:53.6% Pre-test: p < 0.001
et al., 2012. post-test: 16.83 ± 2.28. Post-test: 67.3% Medium
Type 2. a Post-test:
High
Attitude: perceptions of caring for older Total score: pre-test: 69.07 ± 12.53; post- Pre-test:69.1% Pre-test: p = 0.001
people scale (total score:100) test: 76.78 ± 7.19. Post-test:76.8% High
(continued on next page)

4
Z. Yan et al. Nurse Education Today 108 (2022) 105161

Table 2 (continued )
Reference and Variables and measurement tools Raw scores Converted score Overall Statistically
type of education score* significant
program. (P value)

Post-test:
High
12. Haron et al., Attitude: self-formulated questionnaire Consider working in geriatric care group (A): A:65.7% A: High NA
2013. Type 3. (7-Poit Scale) 4.6 (mean score). B:62.3% B: High
Decided against geriatric care group (B):
4.36 (mean score).
Working intention: self-formulated 61% of students have no intention to work in 39% of participants would Low NA
questionnaire aged care consider geriatric care under
certain conditions.
13. Koskinen Working intention: self-formulated Total working intention score: 45.05 ± 45.1% Medium NA
et al., 2012. questionnaire (total score:100) 22.70
Type 3.
14. McCloskey Knowledge: FAQ (24 total score) Total knowledge score: Pre-test: 64.1% Pre-test: NS
et al., 2020. Pre-test:15.39 Post-test:64.4% High
Type 3 Post-test:15.45 Post-test:
High
Attitude: KOAP (6 Points Scale) Total attitude score: Pre-test:69.8% Pre-test: NS
Pre-test:142.48 Post-test: 73.0% High
Post-test:148.94 Post-test:
High
Working intention: self-formulated Working intention: Pre-test:23.9% Pre-test: NS
question. Pre-test: gerontology ranked at the fourth Post-test:23.1% Low
place among six different nursing career Post- test:
choice (23.9% participants chose Low
gerontology care)
Post-test: gerontology ranked at the third
place among six different career choice
(23.1% participants chose gerontology care).
15. Rodgers et al., Attitude: KAOP (6-Point Scale) Total attitude score: Pre-test:80.4% Pre-test: p < 0.0005
2011. Type 3. Pre-test: 164 Post-test: 86.5% High
Post-test:176.50 Post-test:
High

Note: *1. If the converted score was lower than 39.9% of the total score of the standardised metrics, then the result categorized as low; If the converted score ranged
from 40.0%-60.0% of the original measurement scale, then the result categorized as medium; if the converted score above 60.1% of the original standardised metrics,
then the result categorized as high. 2. NS: no significant; NA: not applicable because of cross-sectional study or partially significant. 3. a: quantitative findings from a
mixed method study.

disclosure of the length of the geriatric theory or clinical placement

Table 3
(Haron et al., 2013). Type 4 program had solely geriatric clinical
The knowledge, attitude and working intention of each type of geriatric nursing
placement without any geriatric theory content, and the length ranged
education program in qualitative findings (N = 8).
from 18 days (Gould et al., 2015) to 13 weeks (Moquin et al., 2018).
Reference and types of Outcomes
education program
4.3. An overview and characteristics of the included studies
3. Mattsson and Pietilä Both positive and negative perceptions about
Rosendahl, 2017. Type 2. ageing and older people, increased working
intention. Supplement file 1 demonstrates the characteristics of the included
7. King et al., 2013. Type 2. b Increased attitude and working intention towards studies. Details included the first author of the study, year, country,
geriatric care. study aim, design, sample, type of GNEP, standardised metrics, and
10.Garbarino and Lewis, Positive shift perception and increase working
findings. Of the 19 included studies, only one study (5.2%) was identi­
2020. Type 2. b intention towards geriatric care.
11. Baumbusch et al., 2012. Students preferred to work with older people in fied as a type 1 four-year undergraduate gerontology program, ten
Type 2. b hospital setting, enjoy spending time with older studies (52.6%) were identified as type 2 stand-alone geriatric subject
adults and wish to have more time in clinical and geriatric clinical placement program, four studies (21.1%) were
placement to work with elderly. identified as type 3 integrated geriatric subject and geriatric clinical
16. Augustin and Freshman, Increased knowledge and attitude, working
2016. Type 4. intention are relative to the preparedness of career
placement program and four as type 4 solely geriatric clinical placement
development. program (21.1%). In terms of methodology, eleven studies (57.9%) re­
17. Duggan et al., 2013. Type Students felt knowledge deficit, underprepared to ported quantitatively, five studies (26.3%) reported qualitatively, and
4. work older people in acute care and critical care three (15.8%) reported as mixed method. A total of eight studies
settings.
explored geriatric care knowledge, 17 studies examined the attitude or
18. Gould et al., 2015. Type 4. Negative attitude towards geriatric care.
19. Moquin et al., 2018. Type Positive perception towards older adults and perception towards geriatric care/ older adults, and 11 studies investi­
4. geriatric care. gated the working intention towards geriatric care among undergradu­
ate nursing students. Regarding the most frequently used standardised
Note: b. qualitative findings from a mixed method study.
metrics, six studies employed Palmore's Facts on Aging Quiz (FAQ) to
measure the geriatric care knowledge score (Palmore, 1977), and seven
from five weeks (Mattsson and Pietilä Rosendahl, 2017) to one semester
studies employed Kogan's Attitude towards Old People Scale (KAOP) to
in length (Hsu et al., 2019), but little information was provided about
measure the attitude score (Kogan, 1961). However, nearly half of the
the length of the geriatric clinical placement. In type 3 program, geri­
study employed a self-formulated questionnaire to measure working
atric theory was integrated with other nursing subjects (e.g., acute care),
intention among participants.
and geriatric clinical placement was included but there was no
A total of 5083 participants were involved in this review. The sample

5
Z. Yan et al. Nurse Education Today 108 (2022) 105161

Table 4
Variables outcome comparison in different types of geriatric education programs.
Type of geriatric education Knowledge (N = 6) Attitude (N = 11) Working intention (N = 9)
program

Type 1 (#1) n % n % n %
Low Low Low
Medium 1 (#1) 16.7% Medium Medium
Medium to Medium to 1(#1) 9.1% Medium to 1(#1) 11.1%
high high high
High High High
Type 2 n % n % n %
(#2-#11) Low 1 (#2) 16.7% Low Low 1 (#4) 11.1%
Medium Medium 1 (#2) 9.1% Medium 1 (#7) 11.1%
Medium to 1 (#9) 16.7% Medium to Medium to
high high high
High 2 (#8, 33.3% High 6 (#4, #5, #6, #7, #8, 54.5% High 3 (#2, #6, # 33.3%
#11) #11) 8)
Type 3 n % n % n %
(#12-#15) Low Low Low 2 (#12, #14) 22.2%
Medium Medium Medium 1 (#13) 11.1%
Medium to Medium to Medium to
high high high
High 1 (#14) 16.7% High 3 (#12, #14, #15) 27.3% High
Total 6 100% 11 100% 9 100%

Note: 1. This table only consider quantitative data with overall score of a standardised metrics not the individual items of a measurement scale.
2. The variables outcomes only illustrated the post-test outcomes and/or intervention group outcomes from quantitative evidence.

Records idenfied through Addional records idenfied

database searches: Medline, through other sources, eg. hand
Idenficaon

CINAHL, PubMed, Web of Science searching the reference lists.

& Scoups
(n = 254 ) (n=1)

Records aer duplicates removed

(n = 250)
Screening

Title and abstract Records excluded because

screened unrelated to the topic
(n = 250) (n =201 )

Full text arcles excluded due to

(n =30):
Full text arcles assessed Muldiscplinary
for eligibility parcipants=13
(n = 49) Study focus on
agesm=3
Eligibility

Simulaon program=1
Study focus on geriatric
curriculum design=2
Studies have no geriatric
educaon intervenon
n=6
Risk of bias assessment Parcipants are not
(n = 19) nursing students=5

Studies excluded aer risk of

bias assessment
(n =0 )
Included

Studies included in the

literature review
(n = 19 )

Fig. 1. PRISMA flow diagram.

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Z. Yan et al. Nurse Education Today 108 (2022) 105161

sizes varied from 15 (Moquin et al., 2018) to 1462 (Che et al., 2018). indicated that type 2 stand-alone geriatric subject and geriatric clinical
Nine studies (47.4%) were undertaken in North America, six (31.6%) in placement program achieved a better attitude outcome than the other
Asia, three (15.7%) in Europe, and one (5.3%) in Oceania. In terms of types of programs.
the settings, fourteen (73.7%) studies were conducted in a single higher
education institution, the remaining five (26.3%) studies were under­ 4.6. Geriatric working intention outcome
taken in multiple higher education institutions.
Two studies (type 2 program) reported statistically significant
4.4. Geriatric knowledge outcome change of working intention in post-intervention. One study reported a
significant (p < 0.008) increase in working intention (Koehler et al.,
Three studies showed statistically significant improvement in post- 2016), whereas the other reported a significant (p = 0.001) decrease in
intervention knowledge scores (Table 2). One was a type 1 (four-year working intention (King et al., 2013) (Table 2). A total of nine quanti­
undergraduate gerontology program) study (p = 0.005) (Zisberg et al., tative studies compared the level of working intention scores among
2015) and two were type 2 (stand-alone geriatric subject and geriatric different types of programs; these results are presented in Table 4. The
clinical placement program) studies (p < 0.05) (Baumbusch et al., 2012; type 1 four-year undergraduate gerontology program reported a medium
Boutin et al., 2019). Six quantitative studies reported geriatric knowl­ to high in working intention score (Zisberg et al., 2015). In type 2 pro­
edge scores (Table 4). The type 1 program reported a medium level gram, one study reported a low level working intention score (Koehler
knowledge score (Zisberg et al., 2015). Of the type 2 program, one study et al., 2016), one in medium (King et al., 2013) and three in high level
reported a low level knowledge score (Zhang et al., 2016), one study working intention scores (Che et al., 2018; Cheng et al., 2015; Zhang
reported a medium to high knowledge score (Boutin et al., 2019) and two et al., 2016). In the type 3 integrated geriatric subject and geriatric
studies reported high knowledge scores (Baumbusch et al., 2012; Cheng clinical placement program, two studies reported a low level working
et al., 2015). One type 3 (integrated geriatric subject and geriatric intention score (Haron et al., 2013; McCloskey et al., 2020) and one
clinical placement program) study reported a high level knowledge score reported a medium level working intention score (Koskinen et al., 2012).
(McCloskey et al., 2020). Two qualitative studies explored students’ A total of five qualitative studies scrutinizing the changes of working
perception of a change in their geriatric care knowledge; they were both intention, reported an increasingly geriatric working intention in post-
type 4 (solely geriatric clinical placement program) studies (Table 3). intervention (Table 3). Among these five studies, four were type 2 pro­
One study reported students’ geriatric care knowledge increased gram (Baumbusch et al., 2012; Garbarino and Lewis, 2020; King et al.,
(Augustin and Freshman, 2016), while the other reported students felt 2013; Mattsson and Pietilä Rosendahl, 2017) and one was type 4 solely
deficient in geriatric knowledge and felt underprepared for caring for geriatric clinical placement program (Augustin and Freshman, 2016).
older adults in an acute and critical care setting (Duggan et al., 2013). Overall, the type 2 stand-alone geriatric subject and geriatric clinical
Irrespective of differences in types of geriatric education programs, the placement program outperform (n = 3, 33.3%) than other types of
overall geriatric care knowledge outcome was good. In particular, the programs in enhancing the working intention outcome.
findings indicated that a higher number of the type 2 (stand-alone
geriatric subject and geriatric clinical placement program) studies (n = 5. Discussion
2, 33.3%) reported a high level knowledge scores.
Our study gathered the most relevant literature research from 2010
4.5. Geriatric attitude outcome to 2020, aimed to find the best undergraduate geriatric nursing educa­
tion program that could effectively enhance the educational outcomes in
Eleven quantitative studies were examined the attitude score; three terms of knowledge, attitude, and working intention towards geriatric
of these studies showed statistically significant (p < 0.05) score after care among undergraduate nursing students. The finding showed that
geriatric education (Table 2). Of those three studies, two were type 2 the stand-alone geriatric subject and geriatric care clinical placement
(stand-alone geriatric subject and geriatric clinical placement program) program achieved better educational outcomes than other types of
studies (Baumbusch et al., 2012; King et al., 2013) and one was type 3 geriatric nursing education programs.
(integrated geriatric subject and geriatric clinical placement program) Changes in knowledge, attitude, and working intention based on the
study (Rodgers and Gilmour, 2011). Additionally, two studies (type 2 type of geriatric nursing education program.
program) reported some items of the attitude scale had statistically
significant changed in post-test rather than the overall attitude score 5.1. Geriatric knowledge outcome
changed (Boutin et al., 2019; Garbarino and Lewis, 2020). Nine of the 11
quantitative studies reported a high level attitude score (Table 4). Among The type 2 stand-alone geriatric subject and geriatric clinical place­
these nine studies, six (54.5%) were type 2 program (Baumbusch et al., ment program presents the best knowledge outcome of the four types of
2012; Che et al., 2018; Cheng et al., 2015; Hsu et al., 2019; King et al., geriatric education programs examined (Augustin and Freshman, 2016;
2013; Koehler et al., 2016) and three (27.3%) were type 3 integrated Baumbusch et al., 2012; Boutin et al., 2019; Cheng et al., 2015; Zhang
geriatric subject and geriatric clinical placement program (Haron et al., et al., 2016). Quantitative studies, such as Baumbusch et al. (2012)
2013; McCloskey et al., 2020; Rodgers and Gilmour, 2011). The type 1 found a combination of stand-alone geriatric theory study and geriatric
four-year undergraduate gerontology program reported a medium to high clinical placement program is the key to achieve a high knowledge score,
level attitude score (Zisberg et al., 2015). A total of six qualitative claiming this type of program enables students to apply their knowledge
studies summarised the changes in geriatric attitudes post-intervention; into practice and therefore, enhance their confidence and experience
their results presented in Table 3. Two studies (type 2 program) reported with older people. The qualitative evidence also supports increased
positive attitudes shifting towards geriatric care (Garbarino and Lewis, geriatric care knowledge after type 2 program (Augustin and Freshman,
2020; King et al., 2013), whereas one study (type 2) reported a mixed 2016). However, one type 2 study reported a low knowledge score, and
attitude (Mattsson and Pietilä Rosendahl, 2017). Similar, two studies it was related to gratitude, while some students showed less gratitude
which employed type 4 program (solely geriatric clinical placement) towards older adults (Zhang et al., 2016). In this case, geriatric knowl­
also reported attitudes changed positively towards geriatric care edge is influenced by personal attitudes rather than the weakness of the
(Augustin and Freshman, 2016; Moquin et al., 2018), while one study education program itself. In the type 1 program, Zisberg et al. (2015)
(type 4 program) reported students showed negative attitudes towards indicated that geriatric care knowledge was clearly related to progres­
geriatric care (Gould et al., 2015). The evidence mentioned above makes sion through the degree (for example, first year, second year), and the
it clear that more than half of the quantitative studies (n = 6, 54.5%) higher the year level the better the knowledge score. However, despite

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Z. Yan et al. Nurse Education Today 108 (2022) 105161

students in the type 1 four-year undergraduate gerontology program et al., 2015). Unexpectedly, the type 3 integrated geriatric subject and
spending two years in geriatric theory study and two years in geriatric geriatric clinical placement program overall presented a low geriatric
clinical placement, the final knowledge score was not the highest among working intention (Haron et al., 2013; Koskinen et al., 2012; McCloskey
the other types of programs (Zisberg et al., 2015). However, in the type 3 et al., 2020). Just as Koskinen et al. (2012) explained student preferred
integrated geriatric subject and geriatric clinical placement program, geriatric subject delivery as a stand-alone subject rather than integrated
McCloskey et al. (2020) found that a high knowledge score was due to with other nursing subjects. Haron et al. (2013) argued geriatric care has
students received necessary of geriatric theory and clinical training never been a population career choice among undergraduate nursing
through an integration of other nursing subjects, such as acute care and students and the education program does not influence their future
health assessment. With adequate of knowledge and clinical experience, career choice. In addition, McCloskey et al. (2020) articulated although
it is reasonable that students who received the type 3 geriatric education slightly increased in working intention after geriatric clinical placement,
program demonstrated a high knowledge score (McCloskey et al., 2020). the clinical placement place at the beginning of the undergraduate
In terms of type 4 solely geriatric clinical placement program, it is not nursing program does not make many efforts in enhancing the geriatric
surprising that a mixed knowledge result was found, due to a lack of learning outcome. Admittedly, that is no surprise the type 3 program
geriatric theory study and inadequate time allocated for geriatric reported low geriatric working intention. However, in type 4 solely
learning (Augustin and Freshman, 2016; Duggan et al., 2013). Overall, geriatric clinical placement program, only one study explored students
the efficacy of the type 2 stand-alone geriatric subject and geriatric geriatric working intention and the overall results reported increased
clinical placement program was found to exceed other types of programs working intention (Augustin and Freshman, 2016). By comparing both
in improving geriatric knowledge outcome. quantitative and qualitative studies, a valid conclusion can be drawn
from these evidence that the type 2 stand-alone geriatric subject and
5.2. Geriatric attitude outcome geriatric clinical placement program is superior to other types of pro­
grams in strengthening geriatric working intention outcome.
Surprisingly, regardless of the types of programs, the overall attitude In summary, the four-year undergraduate gerontology program did
score was medium to high in all included studies. However, the type 2 not meet the expectation of high educational outcomes as we expected
stand-alone geriatric subject and geriatric clinical placement program although it takes the longest time in geriatric learning. The four-year
outperformed the other types of programs in intensifying geriatric care gerontology program is more applicable for education providers that
attitude results. Six out of eleven type 2 studies reported a high level equip with substantial educational resources (e.g., experience staff,
attitude score (Baumbusch et al., 2012; Che et al., 2018; Cheng et al., time, funding). In contrast, the stand-alone geriatric subject and geri­
2015; Hsu et al., 2019; King et al., 2013; Koehler et al., 2016). Addi­ atric clinical placement achieved the best educational outcomes than the
tionally, three type 2 qualitative studies confirmed students’ attitudes other programs. The Integrated geriatric subject and geriatric clinical
changed positively towards geriatric care and the desire to have a longer placement program demonstrated higher knowledge and attitude out­
geriatric clinical placement (Baumbusch et al., 2012; Garbarino and comes but low working intention. This model is particular suitable for
Lewis, 2020; King et al., 2013). Although reporting a medium to high education providers that are encounter with resource shortage but
level attitude score, the type 1 four-year gerontology program recog­ needed geriatric education to address the healthcare needs of growing
nised the differences of culture and ethnicity could also influence geri­ ageing population. At last, if the geriatric education program contents
atric care attitude. The type 3 integrated geriatric subject and geriatric have geriatric clinical placement only, it is not surprising leads to the
clinical placement program reported a high level attitude score, how­ poor education outcomes. However, the results might be limited due to
ever, the evidence was less convincing than that for the type 2 program the small sample size.
due to a lack of qualitative evidence support (Haron et al., 2013;
McCloskey et al., 2020; Rodgers and Gilmour, 2011). On the other hand, 5.4. The impacts of clinical placement
the type 4 solely geriatric clinical placement program reported negative
attitudes towards geriatric care, because students were negatively Clinical placement plays a key role in enhancing the knowledge,
influenced by their clinical mentors and perceived geriatric care as skills, confidence as well as promoting a positive attitude and increasing
routine work, less valued and less challenging (Gould et al., 2015). working intention for nursing students (Donnelly, 2012; Goodwin et al.,
Overall, the type 2 stand-alone geriatric subject and clinical placement 2016). It allows students actively engaging with the environment, care
program is more cogent than other types of programs in leading students recipients and the clinical mentors and therefore, strengthen personal
generate a positive attitude towards geriatric care. experimental learning, changing their own stereotype and growing in­
terest in geriatric care (King et al., 2013; Garbarino and Lewis, 2020;
5.3. Geriatric working intention outcome Goodwin et al., 2016; Gould et al., 2015). However, poor clinical
placement experience could make students feeling frustrated and
The type 2 stand-alone geriatric subject and geriatric clinical place­ intimidating by the working experience and have no intention to work in
ment program displays an outstanding performance in increasing stu­ geriatric care again (Gould et al., 2015). Students’ working intention
dents’ geriatric care working intention. Three out of five quantitative towards geriatric care is never a single aspect of the educational result,
studies (type 2 program) reported high level working intention (Che rather than a complex combined effect that encompasses ethnicity,
et al., 2018; Cheng et al., 2015; Zhang et al., 2016). However, one type 2 knowledge, attitude, working experience and personal factors (Augustin
study reported a low working intention score, and it was related to and Freshman, 2016; Koskinen et al., 2012; Zisberg et al., 2015). Posi­
students’ individual career preference, stereotype and perceived geri­ tive clinical learning would enhance students’ experience with for older
atric care as routine work and less challenge (Koehler et al., 2016). adults and result in choosing geriatric nursing as their future career.
Although the causation has been explained by the authors, again, it is Hence, a scientific design of the geriatric clinical placement and magnify
not about the drawbacks of type 2 program itself, rather a mixed of series the role of clinical mentor would be helpful to foster a positive clinical
complex factors such as personal career preferences and negative atti­ learning environment to actively engage students in practicum learning.
tude towards geriatric care (Koehler et al., 2016). Importantly, all the
type 2 qualitative studies revealed students demonstrated an increasing 5.5. The necessity of geriatric education guidelines in improving
geriatric working intention after education (Baumbusch et al., 2012; educational outcomes
Garbarino and Lewis, 2020; Mattsson and Pietilä Rosendahl, 2017; King
et al., 2013). However, the type 1 four-year undergraduate gerontology The Recommended Baccalaureate Competencies and Curricular
program only shows a medium to high level working intention (Zisberg Guidelines for the Nursing Care of Older Adults are the principles of

8
Z. Yan et al. Nurse Education Today 108 (2022) 105161

undergraduate geriatric nursing education program. A Supplement to nursing students for the purpose of improving geriatric education
the Essentials of Baccalaureate Education for Professional Nursing outcomes.
Practice is the essential guidelines for education providers to develop an
effective evidence-based undergraduate curriculum (AACN, 2010). The
AACN guidelines set the foundation of evidence-based curriculum 5.8. Limitations
design as it highlighted twenty geriatric care competencies (e.g., using
assessment tools, implementing strategies and guidelines) and nine es­ The study has several limitations. First, most of the studies (14 out of
sentials (e.g., liberal education, quality care and patient safety) that 19) were only examined within one institution, and nearly half (nine out
aimed to strengthen the knowledge and skills of nursing students of 19) of the studies were undertaken in North America. Thus, the
(AACN, 2010). The University of San Francisco adhered to the AACN generalisability of the current review is limited. Second, the diversity of
guidelines and developed a six-week stand-alone geriatric curriculum of standardised metrics among different studies makes it hard to compare
which encompassed 1-2 h of theory and nine and half hours of clinical the outcomes of each type of education program. However, the mea­
placement per week in geriatric care settings (Andrade, 2016). Their surement scales have been proved their reliability and validity. Third,
pilot test results showed the knowledge score increased by 30%, raised the type 4 (solely geriatric clinical placement program) studies were all
from 66.18% to 97.09%, and a more positive attitude and higher qualitative studies, it is hard to quantify the qualitative studies and make
working intention towards geriatric care (Andrade, 2016). The result is the comparison with quantitative studies due to the small sample size.
consistence with our findings that stand-alone geriatric subject and
geriatric clinical placement could significantly increase the educational 6. Conclusion
outcomes among undergraduate nursing students. Andrade (2016)
suggested that evidence-based undergraduate geriatric education pro­ This literature review aimed to examine the changes of knowledge,
gram should not only focuses on enhancing geriatric care knowledge, attitude and working intention of four types of undergraduate geriatric
skills and competencies, but also helping students to cultivate a positive nursing education programs among undergraduate nursing students.
attitude towards geriatric care. Besides, education providers are Our review synthesis quantitative and qualitative evidence proved that
encouraged to collaborate with healthcare organisations to ensure the most promising education program appeared to be the type 2 stand-
nursing students could have a continuously fluence junction between alone geriatric subject and geriatric clinical placement program. The
theory and clinical learning but not being interrupted (Andrade, 2016). evidence showed that students have significant improvement in
knowledge, attitude, and working intention towards geriatric care if
5.6. The impacts of the variation in standardised metrics they attend the stand-alone geriatric subject and geriatric clinical
placement in their undergraduate nursing education program. Despite
The standardised metrics are various among the included studies, to the considerable number of published articles focus on type 2 education
some extent, they might affect the rigorous and validation of the results. program, the evidence supporting the efficacy of type 2 program is
Although the raw score of quantitative studies (type 1[four-year un­ limited due to the generalizability and the inconsistency of standardised
dergraduate gerontology program], type 2 [stand-alone geriatric subject metrics use cross the included studies. Future research should focus on
and geriatric clinical placement program] and type 3[integrated geri­ the evaluating the content of each type of geriatric education program to
atric subject and geriatric clinical placement program]) were converted inform the development of undergraduate geriatric nursing education.
into percentages, it is hard to quantify and compare the outcomes of Supplementary data to this article can be found online at https://doi.
qualitative studies as all type 4 (solely geriatric clinical placement org/10.1016/j.nedt.2021.105161.
program) studies were report qualitatively. Besides, the difference in
measurement tools could cause discrepancy between the results of the Funding
variables. Each measurement tool will take the unique perspective to
measure the result of the variable, but it is unlikely that the measure­ No funding.
ment tools could agree exactly with one and other (Griffiths and Mur­
rells, 2010). For example, we using tool A and tool B to measure the Ethical approval
geriatric care knowledge of nursing students. Tool A measures acute care
geriatric care knowledge while tool B measures the residential geriatric Not applicable.
care knowledge. Even though acute care knowledge and residential care
knowledge are all geriatric care knowledge, the items of these two Availability of data and materials
measurements are vary, so it is hard to make comparison among each
other. Not applicable.

5.7. The implication for nursing education CRediT authorship contribution statement

Based on the review results, there are implications for nursing edu­ Zhoumei Yan: Methodology, Validation, Formal analysis, Data
cation. First, education providers must adhere to discipline guidelines in curation, Writing – original draft. Hui-Chen (Rita) Chang: Conceptu­
building up evidence-based geriatric nursing education program. Indi­ alization, Methodology, Validation, Supervision, Writing – review &
vidual institution is fully entitled to revise or update the geriatric cur­ editing. Jed Montayre: Methodology, Validation, Writing – review &
riculum according to discipline guidelines, resources, and the needs of editing. Mu-Hsing Ho: Conceptualization, Methodology, Validation,
students. Second, the core of developing undergraduate nursing cur­ Writing – review & editing.
riculum should focus on increasing the geriatric care knowledge and
competencies that enables students to cope with daily working tasks in
different geriatric care settings. Third, geriatric care clinical placement Declaration of competing interest
plays a crucial role in enhancing the practical experience in geriatric
care, fostering a positive attitude and increasing the working intention We are here to declare that our team members (Zhoumei Yan; Hui-
towards geriatric care among undergraduate nursing students. Thus, it is Chen (Rita) Chang; Jed Montayre; Mu-Hsing Ho) have no financial
suggested that education provider should collaborate with the health­ and personal relationship with other people or organisations that could
care organisation to scientifically arrange the clinical placement for inappropriately influence (bias) our work.

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Z. Yan et al. Nurse Education Today 108 (2022) 105161

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