1 │ Introduction

The proportion of the world’s population over the age of 60 will increase from 12% to 22% by the year 2050 [1]. The older adult population is a large percentage of health care consumption and there will be an increased need for nurses to care for older adults in their living environment such as home, inpatient, outpatient, or long-term care settings. It has been found that a significant number of nurses, as well as nursing students, are unwilling to work with this population, highlighting the importance of dispelling age-related myths and fostering more positive attitudes, which, in turn, can lead to improved health outcomes [2].

Nursing students often feel that they cannot communicate effectively with older adults. Many baccalaureate nursing students recognize that they have preconceived ideas and unfavorable biases toward older adults [3]. Some feel that caring for older adults is depressing and futile, and they express a reluctance to work in such an environment. Lack of knowledge and preconceived notions often deter students from their willingness to work with this population after graduation. Compared to other populations, nursing students ranked working with older adults among their least preferred career choices [4]. Nurse educators must be attentive to students' attitudes and perceptions regarding older adults [5] because negative attitudes can have a substantial impact on the provision of gerontology nursing care.

1.1 │ Significance and aim

Previous studies have indicated students have a negative connotation when it comes to working with older adults [2]. None of these studies have indicated why students feel this way or included educational interventions to address this significant finding.  Investigators hope to identify gaps in knowledge and dispel negative connotations nursing students have as it relates to working with the older adult population upon graduation. With the information obtained from this study, researchers will develop an educational intervention to address the knowledge gap and in turn, increase confidence in assessment and communication skills with the older adult population.

This pilot study aims to examine the nursing students' perceptions towards older adult care, anxiety levels, and confidence in nursing care skills before and after their initial clinical rotation in a long-term care facility. The primary goal of this study is to gather preliminary evidence that can be used to inform the development of future supportive educational programs and research initiatives.

1.2 │ Background

1.2.1 │ Communication/Assessment skills

Communication is an essential nursing concept and plays a pivotal role in patient care. Quality care and positive outcomes are dependent on effective communication.  Students have reported a lack of confidence in their physical assessment and communication skills prior to their first clinical rotation [6, 7]. Nursing students must successfully master communication skills to improve relationships with patients and coworkers for positive patient outcomes. Good communication and advocacy skills are necessary in today’s complex and rapidly changing healthcare system.   Communication is the foundation for patient-centered care and creates rapport and trust with patients to ensure their voice is heard and dignity respected [8]. Effective communication is the key to a thorough holistic patient assessment.

In addition to effective communication, it is important for students to develop strong assessment skills while in nursing school.  During foundational nursing courses, students learn health assessment skills in the classroom, lab, or simulation prior to the initiation of clinical.  During lab, students are allowed to practice, obtain feedback from faculty, and demonstrate competency during validations. Clinical experiences are necessary for students to assimilate theory into practice and to help reduce fear and anxiety.

1.2.2 │ Understanding physiological changes

Though each older adult is unique, there are typical physiological changes related to normal aging. For example, sensory impairments experienced by older adults such as a loss of high frequency tones can affect communication during the provision of care [9]. The changes are not pathological but can make older adults more susceptible to common clinical conditions and diseases [9]. Additionally, cognitive status, chronic diseases, and medications can add complexity to the assessment of the older adult [9]. Therefore, it is necessary for nursing students to recognize the psychosocial changes that accompany life transitions, including role changes, retirement, financial adjustments, housing, and social isolation. Students should evaluate attitudes toward older adults, acquire a solid understanding of common physiological and psychosocial changes, and prioritize the independence and quality of life for older adults [9].

2 │ Methods

2.1 │ Study design and procedures

This descriptive pilot study aims to identify variances in communication and assessment skills, anxiety levels, and perceptions of older adults before and after a long-term care clinical rotation. The study is designed to evaluate the effectiveness of the current clinical rotation and to furnish foundational evidence for the development of future education programs and studies. The study included 70 first-semester baccalaureate nursing students in their initial clinical course at a nursing college in AL, USA. Students were assigned a long-term care clinical rotation in groups of six, during which they completed a total of 48 clinical hours, distributed across eight-hour shifts at seven different facilities. Each facility had a dedicated clinical instructor to facilitate the care of the residents. Data were collected anonymously by using online survey methods before and after the long-term care clinical rotation. The online survey facilitated quick and easy responses from students. Students were informed that they were under no obligation to answer questions if they experienced any discomfort or inconvenience. Additionally, it was made clear that there would be no disadvantages associated with choosing not to participate. The study received approval from the Institutional Review Board (No. 22-535 EX 2212).

2.2 │ Measures

A total of researcher-made five questions were asked before and after the long-term care rotation. Questions were researcher-made to explore variations in several key concepts, including attitudes towards care for older adults, assessment skills, communication skills, anxiety levels, and the likelihood of working with older adults upon graduation. These questions were intended to serve as a preliminary step to inform the selection of validated tools for future research. For sentiments towards older adult care, we asked students to list up to three words when thinking about older adult care. The remaining four questions were asked using a Likert scale to assess: 1) assessment skills (range: 0 to 10), 2) communication skills (range: 0 to 10), 3) anxiety level (range: 0 to 10), and 4) the likelihood of working with older adults upon graduation (range: 0 to 5).  Higher scores indicate greater competency in skills, higher anxiety levels, and a higher likelihood of working with older adults upon graduation.

2.3 │ Statistical analysis

The scores were calculated using descriptive statistics, independent t-tests, and chi-squared tests. Chi-square analysis was employed to investigate the correlation between clinical time and sentiments related to caring for older adults. A sentimental analysis was utilized to categorize the word data into negative, positive, and neutral categories. From this data, one hundred words were extracted to generate a word cloud, with bigger words representing higher frequencies.

3 │ Results

Table 1 shows the survey questions and scores of pre- and post-clinical. Before the long-term care rotation, students reported a competence level of 5.60 (SD=1.76) for assessment skills and 7.87 (SD=1.74) for communication skills, indicating greater confidence in their communication skills than in their assessment skills. The anxiety level of students before clinical was 5.72 (SD=2.64), and the majority responded that their likelihood of working with older adults upon graduation was 'probably not' to 'possibly', with a score of 2.41 (SD=1.03).

After clinical, students exhibited a statistically significant increase in confidence in assessment skills (t= -7.58, P< 0.001) and communication skills (t= -2.58, P= 0.11) and a statistically significant decrease in anxiety levels (t= 5.61, P< 0.001). However, students' likelihood of working with older adults upon graduation showed no statistical difference before or after clinical (t= 0.94, P= 0.351), and the score after clinical was lower than pre-clinical, with a score of 2.25 (SD=0.94).

Table 2 shows the sentiments of words about caring for older adults. The positive sentiments were dominant both before and after clinical (pre: 68.9%, post: 74.5%), followed by negative sentiments (pre: 23.7%, post: 22.8%), and a smaller proportion of neutral sentiments (pre: 7.4%, post: 2.7%). Specifically, the positive sentiment related to caring for older adults increased by 5.6%, while the negative sentiment decreased by 0.9%, and the neutral sentiment decreased by 4.7%. However, the differences in sentiments between the pre-and post-clinical periods were not statistically significant (χ² = 3.84, P= 0.147).

The most frequently mentioned words before clinical were 'patience', 'gentle', and 'difficult', whereas after clinical, included 'rewarding', 'difficult', and 'sad'.

Table 1. Survey question results.

Table 2. Sentimental analysis result.

4 │ Discussion

The findings of this study align with previous research that has explored the perceptions of nursing students prior to their first clinical experience and their hesitation to work with older adults.  Students expressed concerns about their lack of knowledge regarding essential skills and a fear of effective communication with patients and family members [6]. Specifically, these communication concerns revolved around the fear of not having answers to questions posed by patients, family members, or instructors [6]. Additionally, students expressed concerns about appearing inexperienced or feeling embarrassed [6].

However, students were not opposed to working with the older adult population due to those reasons; rather, it was more about not wanting to work in a long-term care facility [10]. Therefore, there is the need for further research such as in-depth interviews to gain a deeper understanding of student perceptions regarding older adults. Such interviews could help identify knowledge gaps and deficiencies in curricular content and clinical site placement. Once these gaps and deficits are identified, faculty members can develop educational programs and foster clinical partnerships aimed at altering student perceptions of working with older adults upon graduation.

4.1 │ Limitations

The study involved a single cohort of first-semester nursing students, and it's important to note that the findings may have limited generalizability due to the relatively low number of clinical hours spent in long-term care facilities.

4.2 │ Implications for nurse educators

Nurse educators should develop evidence-based teaching strategies to encourage positive sentiments towards older adults and foster a desire to work with the gerontological population. These strategies could include the use of an “aged simulation suit” to enhance the realism of the aging process and promote empathy. An “aged simulation suit” could add more realism to the didactic lecture content and increase empathy in the student when it comes to working with the older adult. Additionally, nurse educators should consistently assess the impact of long-term care clinicals both before and after the clinical experience to enhance the quality of these educational experiences. This evaluation can help identify areas where supplemental education may be needed to strengthen the understanding and dispel myths of the older adult population.

4.3 │ Recommendations for future research

In future studies, conducting a demographic analysis to assess the knowledge and experience each student brings to their first long-term care clinical could be valuable. In order to support the findings from this pilot study and to ensure robust findings, the use of validated tools of variables in future studies is imperative. Further research focused on long-term care clinical is essential for obtaining a more profound insight into students' perceptions, dispelling misconceptions, and enhancing curricula pertaining to older adults.

5 │ Conclusions

Nursing students need to examine their thoughts and emotions concerning older adults to be prepared in their clinical, and this study provides preliminary data to create meaningful clinical experiences and to develop education programs. Working with this population in clinical settings can offer students valuable insights into the aging process. Effective communication and proficient assessment skills are crucial. To enhance confidence, it is recommended that students are exposed to positive role models and receive guidance from clinical instructors regarding communication and assessment skills. The overarching goal is to impart knowledge and competency in assessment skills while encouraging students to approach careers involving older adults with an open mind, ultimately improving care for older adults.

Acknowledgements

Not applicable.

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: AC, LB, HS; Drafting the work or revising it critically for important intellectual content: AC, LB, HS; Final approval of the version to be published: AC, LB, HS; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: AC, LB, HS.

Funding

Self-funded.

Ethics approval and consent to participate

The study received approval from the Institutional Review Board (No. 22-535 EX 2212). Verbal informed consent was obtained from participants.

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

Using artificial intelligent chatbots

None.