Journal of Nursing Management, 2015, 23, 644–650
Ageism in nursing SARAH H. KAGAN
PhD, RN
1
and G.J. MELENDEZ-TORRES
MPhil, RN
2
1
Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA and 2Departmental Lecturer in Evidence-based Social Intervention, Centre for Evidence-based Intervention, University of Oxford, Oxford, UK
Correspondence Sarah H. Kagan Claire M. Fagin Hall Room 313 418 Curie Boulevard Philadelphia PA 19104-4217 USA E-mail: [email protected]
KAGAN S.H. & MELENDEZ-TORRES G.J.
(2015) Journal of Nursing Management 23,
644–650. Ageism in nursing Aim Ageism in health care delivery and nursing poses a fundamental threat to health and society. In this commentary, implications of age discrimination are presented to generate an agenda for action in nursing management. Background In nations like the United States and the United Kingdom, nursing is an ageing profession caring for an ageing society where age discrimination takes many forms and has broad impact. Evaluation This commentary critically synthesizes the literature on ageism and relevant data on ageing societies for nurse managers and other leaders. Key issues Investigations of ageism suggest that discrimination negatively affects health and results in poor health care experiences. Age discrimination is present in nursing, exacerbating workforce shortages and limiting the use of expertise within the profession. Conclusion Nursing faces a future for which understanding ageing societies and ageism is essential. An agenda for the future is proposed. Implications for nursing management Nurse managers possess the power to enact an agenda for combating ageism in health care and nursing. Keywords: ageism, gerontology, health care disparities, nurse administrators, nursing staff, social justice Accepted for publication: 13 September 2013
Introduction Despite overt concern about consequences of our ageing societies stated in research reports and editorial commentaries, ageism persists as a dominant form of social oppression in those societies and in the workplace. Ageism is perhaps the last socially acceptable form of discrimination (Kagan 2008, 2012, Binstock 2010). It commonly emerges insidiously, veiled in claims of ‘best interests’ or in humour. In health care and nursing, ageism is sustained through a variety of mechanisms that range from social stereotypes that support poor knowledge to policies that enforce neglect. Importantly for nursing, ageism contributes to poor health care for older adults and to workforce short644
ages through the exclusion of ageing nurses from many settings (Bongaarts 2009, Cherubini et al. 2010, J€ onson 2013). Unlike many other instances of ageism, patterns of discrimination in health care and nursing are intertwined. In health care, evidence to guide the care of older adults lags well behind need, largely because of persistent, systematic age biases in scientific investigations (Kagan 2008, Cherubini et al. 2010). Similarly, the evidence-based practice and best practices for elder care that do exist feature less prominently than expected in institutional agendas and policies in ageing societies, except when regulatory mandates intervene, as they do in the Centers for Medicare and Medicaid Services Value Based Purchasing Program in the USA (Leipzig et al. 2009, Carver & Parsons 2012, Werner DOI: 10.1111/jonm.12191 ª 2013 John Wiley & Sons Ltd
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& Dudley 2012). Nursing education may socialize students away from interests in elder care by prioritizing other specialties and often fails to actively promote positive attitudes and knowledge (Haight et al. 1994, Chan & Chan 2009, Marshall 2010, Shen & Xiao 2012). Care for older people tends to be devalued, regardless of setting (Elwer et al. 2010, Maben et al. 2012), with this devaluation compounded by poor social status and low compensation, specifically in long-term care settings (Palmer & Eveline 2012). Additionally, while the ageing nursing workforce is well described in the literature, few remedies for its consequences are well tested and even fewer are widely disseminated (Buchan & Aiken 2008, Beverly et al. 2010, Hill 2011). Ageism in health care and in the nursing profession creates oppression for patients and for nurses, with deleterious implications for both groups (Hopkins & Pain 2007, Moore 2009). Ageism in nursing and health care are outlined here to better understand its consequences. In the service of a more just and equitable workforce and health care system, an agenda for change is presented for nursing leaders.
Ageism, ageing societies and ageing workforce Ageism presents itself in several forms across societies and cultures. Age-based discrimination does not accurately reflect the realities of ageing communities, aged societies and ageing workforces. As an emotionally derived, socially constructed phenomenon, ageism often occurs without apparent logic (Cohen 2001). However, ageism may be more marked in contexts where older people are more prominent or more numerous in certain settings (Binstock 2010).
Ageism Despite social and professional demographics, ageism manifests as social and interpersonal discrimination and as stereotypes based on advancing age. Butler links ageism to other forms of bigotry, such as sexism and racism (Butler 2009). These parallels mean that ageism is easily apprehended and understood by professionals and lay individuals alike (Butler 1969, Palmore & Manton 1973). The most familiar form of ageism is negative judgement and hurtful, or even violent, actions against another based on perceptions of advanced age. This openly offensive form of bigotry, sometimes termed ‘granny bashing’, is also frequently associated with psychological and physical abuse of older people (Kagan 2008, Mysyuk et al. 2013). Such ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
discrimination can be labelled ‘negative ageism’ in order to facilitate comparison with other types of oppression and to avoid judgemental labels in favour of rigorous analysis (Kagan 2008). Unlike social and individual constructions of race and ethnicity, age advances and changes continually across an individual’s life span. As a result, advancing age presents both opportunities for, and possible threats to, self and identity. Watching others age provides the observer with a window into a personal future, but this future image may elicit worry or outright fear, thus triggering hostility or disparagement (Nelson 2005). Moreover, negative ageism may intersect multiplicatively with racism and sexism, leaving those elders perceived as being from so-called minority groups and older women of colour especially vulnerable to societal assault (Nuessel 1982, Collins 1998, Hopkins & Pain 2007). Binstock’s discussion of compassionate ageism calls up the way in which old age interacts with other characteristics commonly associated with overt and covert discrimination. In this context, the curtain of compassion may be drawn back to show that far more negative forms of intersecting discrimination are at hand. Current understandings of ageing increasingly invoke uncertainty and vulnerability in both a personal image of an indeterminate future and a complicated, competitive future society. For example, the term ‘oldest old’, which is favoured by many gerontologists, creates a catch-all category. The ‘oldest old’ captures a huge group of individuals, overtly clustered by age and labelled by the association of frailty and vulnerability (Binstock 1985). Importantly, Binstock first noted the risk of compassionate ageism in his treatise on labelling those aged 85 and over the ‘oldest old’. He noted that the ‘oldest old’ are commonly taken to be part of the deserving poor, those vulnerable and disadvantaged in society deemed deserving of assistance. More recently, he posited that further damage done by this label results in escalating competition for scarce resources, with resulting intergenerational conflict (Binstock 2010). Contemporary ageism is increasingly expressed in protective, parental terms. A rise in this positively intended ageism likely stems from two sources (Kagan 2008, Papadaki et al. 2012). First, in many societies, negatively expressed discrimination is frowned upon and branded as politically incorrect. Second, in ageing societies, younger generations are regularly charged with care for their elders. This role is associated with responsibility and protection and may provoke a parental attitude toward elders, with younger people superseding elder voices (e.g. ‘I know what is best for 645
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you, Mom’) and compensatory action (e.g. ‘Let me do that for you, sir’). At a societal level, positive ageism often veils discrimination in humorous or protective stereotypes, often through jokes lampooning diminished capacity and myths involving protecting older people from themselves (Palmore 2005). Self-stereotyping is the form of ageism most difficult to address. Self-stereotyping is the intra-individual process of discriminating against oneself in thought and action because of negative images of being old. Levy and colleagues identify the extent to which older people judge themselves ‘too old’ or incapable and suffer negative consequences in health and function as a result (Hausdorff et al. 1999, Levy 2000, 2001, Levy et al. 2009, 2012). Such judgements likely represent processes of learned and internalized oppression. Older people engage in self-stereotyping in different ways. Most simply, they may actively refuse help and express ill-considered fatalism about being old, or exclude themselves from desired relationships and activities. Importantly, as Levy and colleagues reveal, older people who self-stereotype incur the consequences of unexpressed and seemingly inconsequential negative beliefs in diminished function and disease (Levy et al. 2009).
Nursing is widely acknowledged as a profession with an ageing workforce, with the additional hindrance of an ageing professoriate delaying restoration of balance in the workforce (Buerhaus 2008, Beverly et al. 2010, Hill 2011, McDermid et al. 2012). Among other factors, the emergence of this aged workforce is a result of many nurses ageing out of active work while not being replaced by younger members of the profession (Rother & Lavizzo-Mourey 2009). To a certain extent, then, the aged nursing workforce, the aged nursing professoriate and ageing societies together create a self-sustaining cycle that proves difficult to break. Ageing societies face heightened consequences of an ageing nursing workforce, even as these societies require more nursing care. Specifically, the rise in chronic non-communicable disease with advancing age requires more nurses at the population level and more intensive nursing care at the individual level, possibly intensifying at end-of-life because of practice patterns and resource use (Olshansky et al. 2009, Beverly et al. 2010, Beaglehole et al. 2011, Kelley et al. 2011).
Summing up the challenges The first challenge: ageism in health care
Ageing societies and ageing workforce Ageing societies are commonly misunderstood by nurses and other health professionals. Nurses tend to see care for older people as their charge and draw the conclusion that increasing numbers of older people make for an ageing society. Increased life expectancy and greater numbers of people who are considered old and needful constitute only one part of ageing societies (Bongaarts 2009). Declining fertility and decreasing numbers of children and younger adults – especially those counted in the general workforce of a nation – constitute the primary force that creates an old society (Bongaarts 2009). Taken together, increasing life expectancy and declining birth rates result in an altered ratio of those older people who need care to those younger people who can provide it (Binstock 1985). This ratio is the elder dependency ratio, which increases as societies age (Bongaarts 2009). Elder dependency is the crux of ageing societies as defined by demographers, the basis for concern in terms of economics, finance, institutions, businesses, families and workforce groups (Binstock 1985, Bongaarts 2009). However, the translation of this conceptual ratio into terms of actual care delivery is difficult. 646
Ageism in health care is clearly documented, existing both in the clinical research that generates evidence for practice and across health care settings (Peake et al. 2003, Kagan 2008, Levy et al. 2009, Pascoe & Smart Richman 2009, Cherubini et al. 2010, Royal College of Surgeons 2012). Even in diseases and conditions associated with advanced age, evidence suggests that the ‘oldest old’ in a given society may incur what Binstock referred to as ‘compassionate ageism’, where very advanced age alone may be related to unacceptable patterns of care (Binstock 1985, 2010, Kagan 2008, Saposnik et al. 2009, Wallace 2012). Conversely, an ironic ageism also occurs when a person is judged too old to have a disease associated with youth, such as HIV/AIDS (Emlet 2006). Socially ascribed race, gender, sexual orientation and poverty appear to aggravate ageism in health care, increasing the jeopardy an older person may face in a particular situation (Palmore & Manton 1973, Palmore 2005, Emlet 2006, Hopkins & Pain 2007, Moore 2009, Wallace 2012). The relation of old age and health status represents a reciprocal effect in which age surmounts or exacerbates the influence of other characteristics, driving inequity at societal and individual levels (Williams 2010, Wallace 2012). Indeed, Wallace ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
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valuably argues that ageism is a social determinant of health, creating disparate access, care and outcomes for older individuals. Ageism in nursing care is detailed in a variety of works throughout our professional literature (Beverly et al. 2010). Authors take varied perspectives on ageism, including the misrepresentation of ageism in our profession (Herdman 2002), the educational experience and attitudes of nursing students (Haight et al. 1994, Shen & Xiao 2012), the nurse–patient relationship (Maben et al. 2012) and nurses’ understanding of ethical issues in care for the aged (Rees et al. 2009). Most importantly, evocative qualitative as well as quantitative evidence attests to the twinned scourges of the undesirability of nursing the aged and the poor care experienced by older patients (Jacobson 2009, Marshall 2010, Maben et al. 2012, Palmer & Eveline 2012, Shen & Xiao 2012). Initiatives such as Nurses Caring for Health System Elders (NICHE programme) and the Hospital Elder Life Programme (HELP programme) acknowledge the need for improved contemporary knowledge, attitudes and beliefs among nurses and their interdisciplinary team colleagues to advance care for older people across the health care continuum (Rubin et al. 2011, Capezuti et al. 2012). Nonetheless, persistent patterns of poor care for older people, coupled with the low status of caring for these individuals, underscore the very real presence of ageism in nursing care. Ageism’s impact is especially troubling, as nursing is a particularly consequential element of care for older people. Indeed, regardless of the frequency with which poor care and low satisfaction with care are experienced, any ageism in our care is ethically untenable, at odds with our history of care for the vulnerable and limiting of our power to positively influence health care and society.
The second challenge: ageism in nursing Ageism within the profession of nursing is often ambiguously represented and difficult to grasp. As a profession and an academic discipline, nursing maintains a sizeable discourse on an aged workforce and professoriate. Discrimination based on age in our ranks is generally hidden beneath rationale emphasizing the nature of our work. An example is found in the common attribution of the physical demands of practice and in systems that are rigorously maintained, such as staffing patterns and shift times. Nursing endures an implicitly and paradoxically jeunist culture to our collective detriment, promoting implicit ageism ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
in our work life. Jeunism, discrimination against older people in favour of those who are younger, is imbedded within the culture of nursing, although generally unacknowledged. Different practice environments are associated with youth and physicality, although often without evidence, to support perception and myth (Elwer et al. 2010, Harris et al. 2010). Oddly, while nursing emphasizes youth and physical work in many settings such as acute care, we paradoxically elevate the position of seniority in a duplicitous system of ‘paying your dues’ for students and young nurses. The jeunist paradox is best seen in examination of nursing’s hidden curriculum, through which divides between results, education and practice appear (Allan et al. 2011). While young nurses may be dissatisfied with career opportunities and represent a large portion of position turnover in hospitals, older nurses may maintain employment over the long term against odds that make their work and work environment more difficult (Buerhaus et al. 2003, Buerhaus 2008, Harris et al. 2010). Similarly, jeunism may account for the lack of adequate education about ageing and care of older people in nursing. When the knowledge of how to care for older people is not privileged equally through coursework and clinical placements, we implicitly value knowledge of how to care for younger individuals over those who are aged. Combating ageism in nursing is not a popular topic for discussion and action. In many ways, the stock response to workforce concerns is to address increasing educational capacity (Buchan & Aiken 2008, Rother & Lavizzo-Mourey 2009). Authors who report research on age-friendly nursing workforce management acknowledge the phenomenon of older nurses leaving practice settings and the resultant risks of worsening shortage and constrained expertise (Moseley et al. 2008, Wray et al. 2009, Graham & Duffield 2010, Harris et al. 2010). Factors undergirding ageism in nursing are, however, less well explored. The role of gender in ageism is particularly problematic for nursing. Nursing workforces around the world are composed largely of women. Gender inequity in nursing most often mirrors society as a whole. For example, men continue to earn more as nurses in a variety of roles, especially leadership positions (Kaplan & Brown 2009, Hader 2010a,b, Moran et al. 2011). Ageism specific to the nursing professoriate is even more difficult to define and remedy. Salary inequities, heavy workload, and poor role preparation may discourage younger individuals considering an academic 647
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career (Allan & Aldebron 2008, McDermid et al. 2012). Other issues, such as attainable measures of success and workplace characteristics such as incivility, may also interact with age in attracting and retaining nurses in academic careers (Clark 2008, McDermid et al. 2012). Amongst the variety of strategies posed in the literature to address the nursing faculty shortage, the role of ageism remains unexplored (Allan & Aldebron 2008, Yucha & Witt 2009). This critical oversight leaves unutilized a key line of attack for ending critical shortages in nursing education and the entire workforce.
Agenda for action Ageism in nursing threatens our collective and individual selves in myriad ways. We can mitigate threats and capitalize on opportunities by changing our culture, shifting our values, reframing our education and reshaping our practices. It is up to nursing to transform the menace of ageism into a paradigm of power and dignity. This requires frame-breaking change in perspective, strategy and action. Enacting any agenda for change requires a professional stance and actions counter to many sociocultural forces and traditions within nursing and across societies. In order to change culture, values, education and practice, the following actions warrant consideration: Alter the language of nursing to represent the value of advancing age and the positive characteristics, like wisdom, often associated with it. For example, chronological age is one of the most commonly used pieces of data in practice and research. Yet, chronological age is almost never of consequence in and of itself. It is a proxy variable that we should avoid in favour of describing what we truly mean (Kagan 2011). Explicitly value differential contributions to nursing work and, simultaneously, highlight the integrity and dignity of the person in our practice and research. No person is adequately represented by one characteristic, whether that is age, gender or another aspect of personhood. Similarly, no one person does anything in any domain equally well and, conversely, everyone may make viable contributions, given opportunity. Create and implement a research agenda that aims to fully describe, interpret and intervene in ageism within health care and in nursing. Current research lacks sufficient power to fully describe, interpret and alter the consequences ageism begets in many nations, communities and health care systems. 648
Dispel myths and misinformation about ageing and its implications in the biological, physical, psychological, cultural, social and spiritual domains. Specifically, we must align curricula with the phenomena of an ageing society, including by addressing care needs resulting from chronic non-communicable diseases and functional dependency. Education must similarly address needs for improved knowledge, ethical and moral attitudes and better nursing skill in elder care. Redefine nursing practice to correspond to the realities of ageing societies. Redefinition must be sweeping, capturing details and connotations such as misrepresentation of long-term care as low-status work, stereotyping geriatric nursing as only care of institutionalized elders, and use of myths such as normative cognitive decline in ageing as a rationale for not providing evidence-based care.
Implementing the agenda for action Nurse managers hold the power to rethink the workplace and management strategies and to shape new practices among their clinical nurses. Creating new or more flexible interpretations of traditions in nursing, including staffing models, shift design and mentorship, imply real rewards for nurses of all ages and their patients and clients (Moseley et al. 2008, Harris et al. 2010, Maben et al. 2012). Changing practices need not be unwieldy and require all-encompassing initiatives. Simple strategies and small interventions may prove effective in altering attitudes and beliefs that result in improved care practices. Two examples are challenging clinical nurses to describe patients without using age, and creating campaigns celebrating effective and compassionate care for older patients. While this review speaks primarily to nurse managers and administrators, educators and researchers share equally advantaged positions to influence necessary change. Several authors outline the imperative of partnerships to resolve the nursing and nursing faculty shortages, amend workplace concerns, enhance job satisfaction and advance career options in nursing (Allan & Aldebron 2008, Graham & Duffield 2010, Moran et al. 2011, Chan & Perry 2012). Clearly, partnerships among nurse managers, educators and researchers offer potential to understand and define ageism in nursing care and the workforce, and to develop feasible interventions that abolish it. While the challenges of ageism persist, significant peril faces nursing and society. Seizing opportunity for action ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
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that redresses this threat offers unparalleled potential for nurse managers.
Funding This is a review paper and was not funded in any way through any source.
Ethical approval Ethical approval was not required for this paper.
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ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
Ageism in nursing SARAH H. KAGAN
PhD, RN
1
and G.J. MELENDEZ-TORRES
MPhil, RN
2
1
Lucy Walker Honorary Term Professor of Gerontological Nursing, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA and 2Departmental Lecturer in Evidence-based Social Intervention, Centre for Evidence-based Intervention, University of Oxford, Oxford, UK
Correspondence Sarah H. Kagan Claire M. Fagin Hall Room 313 418 Curie Boulevard Philadelphia PA 19104-4217 USA E-mail: [email protected]
KAGAN S.H. & MELENDEZ-TORRES G.J.
(2015) Journal of Nursing Management 23,
644–650. Ageism in nursing Aim Ageism in health care delivery and nursing poses a fundamental threat to health and society. In this commentary, implications of age discrimination are presented to generate an agenda for action in nursing management. Background In nations like the United States and the United Kingdom, nursing is an ageing profession caring for an ageing society where age discrimination takes many forms and has broad impact. Evaluation This commentary critically synthesizes the literature on ageism and relevant data on ageing societies for nurse managers and other leaders. Key issues Investigations of ageism suggest that discrimination negatively affects health and results in poor health care experiences. Age discrimination is present in nursing, exacerbating workforce shortages and limiting the use of expertise within the profession. Conclusion Nursing faces a future for which understanding ageing societies and ageism is essential. An agenda for the future is proposed. Implications for nursing management Nurse managers possess the power to enact an agenda for combating ageism in health care and nursing. Keywords: ageism, gerontology, health care disparities, nurse administrators, nursing staff, social justice Accepted for publication: 13 September 2013
Introduction Despite overt concern about consequences of our ageing societies stated in research reports and editorial commentaries, ageism persists as a dominant form of social oppression in those societies and in the workplace. Ageism is perhaps the last socially acceptable form of discrimination (Kagan 2008, 2012, Binstock 2010). It commonly emerges insidiously, veiled in claims of ‘best interests’ or in humour. In health care and nursing, ageism is sustained through a variety of mechanisms that range from social stereotypes that support poor knowledge to policies that enforce neglect. Importantly for nursing, ageism contributes to poor health care for older adults and to workforce short644
ages through the exclusion of ageing nurses from many settings (Bongaarts 2009, Cherubini et al. 2010, J€ onson 2013). Unlike many other instances of ageism, patterns of discrimination in health care and nursing are intertwined. In health care, evidence to guide the care of older adults lags well behind need, largely because of persistent, systematic age biases in scientific investigations (Kagan 2008, Cherubini et al. 2010). Similarly, the evidence-based practice and best practices for elder care that do exist feature less prominently than expected in institutional agendas and policies in ageing societies, except when regulatory mandates intervene, as they do in the Centers for Medicare and Medicaid Services Value Based Purchasing Program in the USA (Leipzig et al. 2009, Carver & Parsons 2012, Werner DOI: 10.1111/jonm.12191 ª 2013 John Wiley & Sons Ltd
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& Dudley 2012). Nursing education may socialize students away from interests in elder care by prioritizing other specialties and often fails to actively promote positive attitudes and knowledge (Haight et al. 1994, Chan & Chan 2009, Marshall 2010, Shen & Xiao 2012). Care for older people tends to be devalued, regardless of setting (Elwer et al. 2010, Maben et al. 2012), with this devaluation compounded by poor social status and low compensation, specifically in long-term care settings (Palmer & Eveline 2012). Additionally, while the ageing nursing workforce is well described in the literature, few remedies for its consequences are well tested and even fewer are widely disseminated (Buchan & Aiken 2008, Beverly et al. 2010, Hill 2011). Ageism in health care and in the nursing profession creates oppression for patients and for nurses, with deleterious implications for both groups (Hopkins & Pain 2007, Moore 2009). Ageism in nursing and health care are outlined here to better understand its consequences. In the service of a more just and equitable workforce and health care system, an agenda for change is presented for nursing leaders.
Ageism, ageing societies and ageing workforce Ageism presents itself in several forms across societies and cultures. Age-based discrimination does not accurately reflect the realities of ageing communities, aged societies and ageing workforces. As an emotionally derived, socially constructed phenomenon, ageism often occurs without apparent logic (Cohen 2001). However, ageism may be more marked in contexts where older people are more prominent or more numerous in certain settings (Binstock 2010).
Ageism Despite social and professional demographics, ageism manifests as social and interpersonal discrimination and as stereotypes based on advancing age. Butler links ageism to other forms of bigotry, such as sexism and racism (Butler 2009). These parallels mean that ageism is easily apprehended and understood by professionals and lay individuals alike (Butler 1969, Palmore & Manton 1973). The most familiar form of ageism is negative judgement and hurtful, or even violent, actions against another based on perceptions of advanced age. This openly offensive form of bigotry, sometimes termed ‘granny bashing’, is also frequently associated with psychological and physical abuse of older people (Kagan 2008, Mysyuk et al. 2013). Such ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
discrimination can be labelled ‘negative ageism’ in order to facilitate comparison with other types of oppression and to avoid judgemental labels in favour of rigorous analysis (Kagan 2008). Unlike social and individual constructions of race and ethnicity, age advances and changes continually across an individual’s life span. As a result, advancing age presents both opportunities for, and possible threats to, self and identity. Watching others age provides the observer with a window into a personal future, but this future image may elicit worry or outright fear, thus triggering hostility or disparagement (Nelson 2005). Moreover, negative ageism may intersect multiplicatively with racism and sexism, leaving those elders perceived as being from so-called minority groups and older women of colour especially vulnerable to societal assault (Nuessel 1982, Collins 1998, Hopkins & Pain 2007). Binstock’s discussion of compassionate ageism calls up the way in which old age interacts with other characteristics commonly associated with overt and covert discrimination. In this context, the curtain of compassion may be drawn back to show that far more negative forms of intersecting discrimination are at hand. Current understandings of ageing increasingly invoke uncertainty and vulnerability in both a personal image of an indeterminate future and a complicated, competitive future society. For example, the term ‘oldest old’, which is favoured by many gerontologists, creates a catch-all category. The ‘oldest old’ captures a huge group of individuals, overtly clustered by age and labelled by the association of frailty and vulnerability (Binstock 1985). Importantly, Binstock first noted the risk of compassionate ageism in his treatise on labelling those aged 85 and over the ‘oldest old’. He noted that the ‘oldest old’ are commonly taken to be part of the deserving poor, those vulnerable and disadvantaged in society deemed deserving of assistance. More recently, he posited that further damage done by this label results in escalating competition for scarce resources, with resulting intergenerational conflict (Binstock 2010). Contemporary ageism is increasingly expressed in protective, parental terms. A rise in this positively intended ageism likely stems from two sources (Kagan 2008, Papadaki et al. 2012). First, in many societies, negatively expressed discrimination is frowned upon and branded as politically incorrect. Second, in ageing societies, younger generations are regularly charged with care for their elders. This role is associated with responsibility and protection and may provoke a parental attitude toward elders, with younger people superseding elder voices (e.g. ‘I know what is best for 645
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you, Mom’) and compensatory action (e.g. ‘Let me do that for you, sir’). At a societal level, positive ageism often veils discrimination in humorous or protective stereotypes, often through jokes lampooning diminished capacity and myths involving protecting older people from themselves (Palmore 2005). Self-stereotyping is the form of ageism most difficult to address. Self-stereotyping is the intra-individual process of discriminating against oneself in thought and action because of negative images of being old. Levy and colleagues identify the extent to which older people judge themselves ‘too old’ or incapable and suffer negative consequences in health and function as a result (Hausdorff et al. 1999, Levy 2000, 2001, Levy et al. 2009, 2012). Such judgements likely represent processes of learned and internalized oppression. Older people engage in self-stereotyping in different ways. Most simply, they may actively refuse help and express ill-considered fatalism about being old, or exclude themselves from desired relationships and activities. Importantly, as Levy and colleagues reveal, older people who self-stereotype incur the consequences of unexpressed and seemingly inconsequential negative beliefs in diminished function and disease (Levy et al. 2009).
Nursing is widely acknowledged as a profession with an ageing workforce, with the additional hindrance of an ageing professoriate delaying restoration of balance in the workforce (Buerhaus 2008, Beverly et al. 2010, Hill 2011, McDermid et al. 2012). Among other factors, the emergence of this aged workforce is a result of many nurses ageing out of active work while not being replaced by younger members of the profession (Rother & Lavizzo-Mourey 2009). To a certain extent, then, the aged nursing workforce, the aged nursing professoriate and ageing societies together create a self-sustaining cycle that proves difficult to break. Ageing societies face heightened consequences of an ageing nursing workforce, even as these societies require more nursing care. Specifically, the rise in chronic non-communicable disease with advancing age requires more nurses at the population level and more intensive nursing care at the individual level, possibly intensifying at end-of-life because of practice patterns and resource use (Olshansky et al. 2009, Beverly et al. 2010, Beaglehole et al. 2011, Kelley et al. 2011).
Summing up the challenges The first challenge: ageism in health care
Ageing societies and ageing workforce Ageing societies are commonly misunderstood by nurses and other health professionals. Nurses tend to see care for older people as their charge and draw the conclusion that increasing numbers of older people make for an ageing society. Increased life expectancy and greater numbers of people who are considered old and needful constitute only one part of ageing societies (Bongaarts 2009). Declining fertility and decreasing numbers of children and younger adults – especially those counted in the general workforce of a nation – constitute the primary force that creates an old society (Bongaarts 2009). Taken together, increasing life expectancy and declining birth rates result in an altered ratio of those older people who need care to those younger people who can provide it (Binstock 1985). This ratio is the elder dependency ratio, which increases as societies age (Bongaarts 2009). Elder dependency is the crux of ageing societies as defined by demographers, the basis for concern in terms of economics, finance, institutions, businesses, families and workforce groups (Binstock 1985, Bongaarts 2009). However, the translation of this conceptual ratio into terms of actual care delivery is difficult. 646
Ageism in health care is clearly documented, existing both in the clinical research that generates evidence for practice and across health care settings (Peake et al. 2003, Kagan 2008, Levy et al. 2009, Pascoe & Smart Richman 2009, Cherubini et al. 2010, Royal College of Surgeons 2012). Even in diseases and conditions associated with advanced age, evidence suggests that the ‘oldest old’ in a given society may incur what Binstock referred to as ‘compassionate ageism’, where very advanced age alone may be related to unacceptable patterns of care (Binstock 1985, 2010, Kagan 2008, Saposnik et al. 2009, Wallace 2012). Conversely, an ironic ageism also occurs when a person is judged too old to have a disease associated with youth, such as HIV/AIDS (Emlet 2006). Socially ascribed race, gender, sexual orientation and poverty appear to aggravate ageism in health care, increasing the jeopardy an older person may face in a particular situation (Palmore & Manton 1973, Palmore 2005, Emlet 2006, Hopkins & Pain 2007, Moore 2009, Wallace 2012). The relation of old age and health status represents a reciprocal effect in which age surmounts or exacerbates the influence of other characteristics, driving inequity at societal and individual levels (Williams 2010, Wallace 2012). Indeed, Wallace ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
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valuably argues that ageism is a social determinant of health, creating disparate access, care and outcomes for older individuals. Ageism in nursing care is detailed in a variety of works throughout our professional literature (Beverly et al. 2010). Authors take varied perspectives on ageism, including the misrepresentation of ageism in our profession (Herdman 2002), the educational experience and attitudes of nursing students (Haight et al. 1994, Shen & Xiao 2012), the nurse–patient relationship (Maben et al. 2012) and nurses’ understanding of ethical issues in care for the aged (Rees et al. 2009). Most importantly, evocative qualitative as well as quantitative evidence attests to the twinned scourges of the undesirability of nursing the aged and the poor care experienced by older patients (Jacobson 2009, Marshall 2010, Maben et al. 2012, Palmer & Eveline 2012, Shen & Xiao 2012). Initiatives such as Nurses Caring for Health System Elders (NICHE programme) and the Hospital Elder Life Programme (HELP programme) acknowledge the need for improved contemporary knowledge, attitudes and beliefs among nurses and their interdisciplinary team colleagues to advance care for older people across the health care continuum (Rubin et al. 2011, Capezuti et al. 2012). Nonetheless, persistent patterns of poor care for older people, coupled with the low status of caring for these individuals, underscore the very real presence of ageism in nursing care. Ageism’s impact is especially troubling, as nursing is a particularly consequential element of care for older people. Indeed, regardless of the frequency with which poor care and low satisfaction with care are experienced, any ageism in our care is ethically untenable, at odds with our history of care for the vulnerable and limiting of our power to positively influence health care and society.
The second challenge: ageism in nursing Ageism within the profession of nursing is often ambiguously represented and difficult to grasp. As a profession and an academic discipline, nursing maintains a sizeable discourse on an aged workforce and professoriate. Discrimination based on age in our ranks is generally hidden beneath rationale emphasizing the nature of our work. An example is found in the common attribution of the physical demands of practice and in systems that are rigorously maintained, such as staffing patterns and shift times. Nursing endures an implicitly and paradoxically jeunist culture to our collective detriment, promoting implicit ageism ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
in our work life. Jeunism, discrimination against older people in favour of those who are younger, is imbedded within the culture of nursing, although generally unacknowledged. Different practice environments are associated with youth and physicality, although often without evidence, to support perception and myth (Elwer et al. 2010, Harris et al. 2010). Oddly, while nursing emphasizes youth and physical work in many settings such as acute care, we paradoxically elevate the position of seniority in a duplicitous system of ‘paying your dues’ for students and young nurses. The jeunist paradox is best seen in examination of nursing’s hidden curriculum, through which divides between results, education and practice appear (Allan et al. 2011). While young nurses may be dissatisfied with career opportunities and represent a large portion of position turnover in hospitals, older nurses may maintain employment over the long term against odds that make their work and work environment more difficult (Buerhaus et al. 2003, Buerhaus 2008, Harris et al. 2010). Similarly, jeunism may account for the lack of adequate education about ageing and care of older people in nursing. When the knowledge of how to care for older people is not privileged equally through coursework and clinical placements, we implicitly value knowledge of how to care for younger individuals over those who are aged. Combating ageism in nursing is not a popular topic for discussion and action. In many ways, the stock response to workforce concerns is to address increasing educational capacity (Buchan & Aiken 2008, Rother & Lavizzo-Mourey 2009). Authors who report research on age-friendly nursing workforce management acknowledge the phenomenon of older nurses leaving practice settings and the resultant risks of worsening shortage and constrained expertise (Moseley et al. 2008, Wray et al. 2009, Graham & Duffield 2010, Harris et al. 2010). Factors undergirding ageism in nursing are, however, less well explored. The role of gender in ageism is particularly problematic for nursing. Nursing workforces around the world are composed largely of women. Gender inequity in nursing most often mirrors society as a whole. For example, men continue to earn more as nurses in a variety of roles, especially leadership positions (Kaplan & Brown 2009, Hader 2010a,b, Moran et al. 2011). Ageism specific to the nursing professoriate is even more difficult to define and remedy. Salary inequities, heavy workload, and poor role preparation may discourage younger individuals considering an academic 647
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career (Allan & Aldebron 2008, McDermid et al. 2012). Other issues, such as attainable measures of success and workplace characteristics such as incivility, may also interact with age in attracting and retaining nurses in academic careers (Clark 2008, McDermid et al. 2012). Amongst the variety of strategies posed in the literature to address the nursing faculty shortage, the role of ageism remains unexplored (Allan & Aldebron 2008, Yucha & Witt 2009). This critical oversight leaves unutilized a key line of attack for ending critical shortages in nursing education and the entire workforce.
Agenda for action Ageism in nursing threatens our collective and individual selves in myriad ways. We can mitigate threats and capitalize on opportunities by changing our culture, shifting our values, reframing our education and reshaping our practices. It is up to nursing to transform the menace of ageism into a paradigm of power and dignity. This requires frame-breaking change in perspective, strategy and action. Enacting any agenda for change requires a professional stance and actions counter to many sociocultural forces and traditions within nursing and across societies. In order to change culture, values, education and practice, the following actions warrant consideration: Alter the language of nursing to represent the value of advancing age and the positive characteristics, like wisdom, often associated with it. For example, chronological age is one of the most commonly used pieces of data in practice and research. Yet, chronological age is almost never of consequence in and of itself. It is a proxy variable that we should avoid in favour of describing what we truly mean (Kagan 2011). Explicitly value differential contributions to nursing work and, simultaneously, highlight the integrity and dignity of the person in our practice and research. No person is adequately represented by one characteristic, whether that is age, gender or another aspect of personhood. Similarly, no one person does anything in any domain equally well and, conversely, everyone may make viable contributions, given opportunity. Create and implement a research agenda that aims to fully describe, interpret and intervene in ageism within health care and in nursing. Current research lacks sufficient power to fully describe, interpret and alter the consequences ageism begets in many nations, communities and health care systems. 648
Dispel myths and misinformation about ageing and its implications in the biological, physical, psychological, cultural, social and spiritual domains. Specifically, we must align curricula with the phenomena of an ageing society, including by addressing care needs resulting from chronic non-communicable diseases and functional dependency. Education must similarly address needs for improved knowledge, ethical and moral attitudes and better nursing skill in elder care. Redefine nursing practice to correspond to the realities of ageing societies. Redefinition must be sweeping, capturing details and connotations such as misrepresentation of long-term care as low-status work, stereotyping geriatric nursing as only care of institutionalized elders, and use of myths such as normative cognitive decline in ageing as a rationale for not providing evidence-based care.
Implementing the agenda for action Nurse managers hold the power to rethink the workplace and management strategies and to shape new practices among their clinical nurses. Creating new or more flexible interpretations of traditions in nursing, including staffing models, shift design and mentorship, imply real rewards for nurses of all ages and their patients and clients (Moseley et al. 2008, Harris et al. 2010, Maben et al. 2012). Changing practices need not be unwieldy and require all-encompassing initiatives. Simple strategies and small interventions may prove effective in altering attitudes and beliefs that result in improved care practices. Two examples are challenging clinical nurses to describe patients without using age, and creating campaigns celebrating effective and compassionate care for older patients. While this review speaks primarily to nurse managers and administrators, educators and researchers share equally advantaged positions to influence necessary change. Several authors outline the imperative of partnerships to resolve the nursing and nursing faculty shortages, amend workplace concerns, enhance job satisfaction and advance career options in nursing (Allan & Aldebron 2008, Graham & Duffield 2010, Moran et al. 2011, Chan & Perry 2012). Clearly, partnerships among nurse managers, educators and researchers offer potential to understand and define ageism in nursing care and the workforce, and to develop feasible interventions that abolish it. While the challenges of ageism persist, significant peril faces nursing and society. Seizing opportunity for action ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 644–650
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that redresses this threat offers unparalleled potential for nurse managers.
Funding This is a review paper and was not funded in any way through any source.
Ethical approval Ethical approval was not required for this paper.
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