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Publicly Available Published by De Gruyter November 30, 2023

E-learning modules to enhance student nurses’ perceptions of older people: a single group pre-post quasi-experimental study

  • Rashmi Devkota ORCID logo EMAIL logo , Sherry Dahlke ORCID logo , Mary T. Fox ORCID logo , Sandra Davidson ORCID logo , Kathleen F. Hunter ORCID logo , Jeffrey I. Butler ORCID logo , Shovana Shrestha ORCID logo , Alison L. Chasteen ORCID logo , Elaine Moody , Lori Schindel Martin and Matthew Pietrosanu



To examine whether e-learning activities on cognitive impairment (CI), continence and mobility (CM) and understanding and communication (UC) improve student nurses’ knowledge and attitudes in the care of older adults.


A quasi-experimental single group pre-post-test design was used. We included 299 undergraduate nursing students for the CI module, 304 for the CM module, and 313 for the UC module. We administered knowledge quizzes, Likert scales, and a feedback survey to measure student nurses’ knowledge, ageist beliefs, and feedback on the modules respectively.


Participants demonstrated significantly more knowledge and reduced ageist attitudes following the e-learning activities.


Findings suggest that e-learning activities on cognitive impairment, continence and mobility, and understanding and communication improve knowledge and reduce ageist attitudes among nursing students.


Populations around the world are aging [1]. As people age, they are more likely to experience chronic conditions – for example, 73 % of adults aged 65 and older have at least one of the 10 most common chronic diseases, such as depression and dementia [1]. In Canada, older adults account for 45 % of national public healthcare expenditures [2] and this proportion is projected to increase with an aging population [3]. Nurses are key healthcare providers who are ideally positioned to meet the increasing care needs of older adults, including optimizing their wellness and function, providing services, and alleviating acute and chronic illness [4], [5], [6]. Therefore, it is vital to ensure that nurses are prepared to effectively care for this population [5]. However, ageism is often insidiously ingrained in nursing culture and nursing education [7], [8], [9], [10] and influences nursing practice with older people. Ageism is defined as negative beliefs and/or behaviors towards individuals based on their age [11].

Student nurses report having insufficient knowledge of older adults’ care, hold misconceptions about caring for older adults, and prefer not to work with older people [4, 12], [13], [14]. Student nurses are the future workforce; thus, addressing their misconceptions and enhancing their knowledge and skills in the care for older adults is necessary to meet the unique needs of this population [5]. The education student nurses receive about gerontological care can play a significant role in shaping their attitudes (defined as the expression of positive or negative feelings or beliefs [15]) towards older adults [16, 17]. Moreover, student nurses receive education in various practice settings, including those where older people are a significant population, and may witness the negative attitudes and care practices of practicing nurses [18, 19]. It is important to diminish negative stereotypes about aging and older adults that student nurses may hold, as student nurses’ attitudes towards older adults are likely to affect their behaviour towards them, their preferences to work with them, and the quality of services provided to this age cohort [20], [21], [22]. Although some studies have reported positive attitudes towards older adults by student nurses [23, 24], these positive attitudes may be a reflection of benevolent ageism [25, 26] (i.e., patronizing or overly-accommodating behaviour such as doing things for older adults that they may be able to do themselves, due to the underlying belief that older people are less capable [25]).

Researchers have described student nurses’ negative attitudes towards aging and older adults’ care as consequences of a lack of adequate gerontological content in nursing education and negative experiences during clinical placements [19, 27], [28], [29], [30]. Previous studies have highlighted that student nurses see communication with older people as challenging, and do not feel competent to care for older adults with complex healthcare needs [31], [32], [33]. Many student nurses view working with older adults as depressing, boring, and unrewarding with few opportunities for advancement due to its low occupational status [26, 34, 35]. Scholars have suggested that this is because nurses typically see older adults in their most vulnerable and dependent states [36, 37].

A lack of adequately educated nurses with positive attitudes towards older adults can impact older adults’ care outcomes, such as increased hospital lengths of stay, readmission rates, and dissatisfaction of older adults and their families with care [4, 24, 38]. Moreover, avoidance of working with older adults can lead to workforce shortages in care for older people [14]. Crucially, while the prevalence of negative attitudes towards older adults and the low level of knowledge about their care among nursing students are problematic, they may be modifiable [23, 39]. The World Health Organization [40] emphasizes educational interventions as one of the most effective strategies to reduce negative attitudes towards older adults. Research has demonstrated that education about ageing and older people can diminish ageism [7, 9, 41], [42], [43]. Thus, to cultivate a nursing workforce that is able to meet the health and social care needs of an aging population, we need to enhance student nurses’ knowledge, attitudes, and willingness to care for older adults. Studies have provided evidence that student nurses’ attitudes towards older adults and the knowledge level of nursing students can be improved through knowledge-based interventions [7, 24, 27, 44]. Yet, the educational interventions that have been developed to improve student nurses’ knowledge about aging and older adults have not been rigorously tested.

Against this backdrop, we developed three e-learning modules focused on key areas of older persons’/adults’ care (understanding and communication [UC], continence and mobility [CM], and cognitive impairment [CI]), using the Analysis Design Development Implementation Evaluation (ADDIE) model and the principles of Bandura’s social learning theory [45, 46]. The ADDIE model provides a dynamic, and flexible guideline for building effective training and performance support tools [46]. Bandura posits that learning occurs through listening and observing others [45]. Thus, the modules were developed using videos and interactive activities to facilitate learning. First, the learning needs of students nurses related to providing care to older adults were identified – cognitive impairment, continence and mobility, and understanding how to communication with older adults [1332, 47]. Second, the learning modules were designed with learning objectives and content based on the literature [13, 32, 47]. Third, the modules were pilot tested [27, 48, 49] and, based on the findings, were further refined. Finally, we tested the modules with student nurses from three Canadian universities and used pre-post testing to evaluate their effectiveness. E-learning (which includes but is not limited to gamification, videos, and simulations) offers an engaging and stimulating way to acquire new knowledge and skills [50], [51], [52]. Details on the e-learning modules and the results from their pilot testing are discussed elsewhere [27, 48, 49, 53].


To examine:

  1. Changes in the knowledge levels of nursing students before and after implementing the continence and mobility (CM), and cognitive impairment (CI) e-learning modules.

  2. Changes in nursing students’ ageist beliefs and attitudes toward working with older people before and after implementing the understanding and communication (UC) with older adults e-learning module.

  3. Student nurses’ perceptions of the utility of the three e-learning modules.



  1. Nursing students will have incarease knowledge levels at post-test after implementing CM and CI e-learning modules than pre-test.

  2. Nursing students will have decrease ageist attitudes toward working with older people at post-test after implementing UC e-learning module than pre-test.

  3. Student nurses will have positive perception of the utility of the three e-learning modules.

Study design

This study is a part of a larger, ongoing project aimed at combating ageism amongst Canadian nursing students, healthcare professionals, and the general public (see [53] for the full study protocol). This paper reports on Phase I, in which we used a quasi-experimental, pre-post-test design to examine whether the three e-learning activities improve student nurses’ knowledge and attitude about assessing and managing the needs of older adults. We followed the STROBE checklist for cross-sectional studies for the reporting of this study [54].

E-learning modules

We developed the three distinct learning modules: (a) cognitive impairment (CI), (b) continence and mobility (CM), and (c) understanding and communication (UC) with evidence-based content using videos, games, formative knowledge checks, and simulations modeling positive behaviour to facilitate learning and foster engagement. These areas were selected based on research literature and team expertise. Our team included gerontological nurses, academic gerontological experts, and advocates for gerontological care. Further details on our team is described elsewhere [53]. The CI e-learning module included content on delirium, dementia, depression, and positive modeling about how to manage anxiety and aggression related to these conditions. The module was divided into eight sections and took approximately 3 h for students to complete. The CM e-learning module was divided into five sections, focused on dispelling stereotypes about older people as dependent and incontinent, and took approximately 90 min to complete. Finally, the UC module was divided into four sections and focused on addressing negative stereotypes about older adults and how to communicate with them and took approximately 90 min to complete. Our e-learning modules are freely available for use.

Sample and setting

Our sample included nursing students at the three participating universities. Undergraduate student nurses at any stage in their nursing program could volunteer to participate. Each learning module was delivered online and was offered to participants asynchronously to be completed at their own pace. The order in which the e-learning modules were presented to students was randomized to prevent ordered effects (e.g., lower participation in the last module due to participant fatigue). The modules were not linked to students’ grades, or their institutional student IDs.

We used the approach described by Cohen [55] for paired t-tests to calculate the required sample size. It was determined that a minimum of 259 participants were needed to detect an effect size of d=0.30 (i.e., a small effect in terms of Cohen’s d), a power of 1 – β=0.8 (a standard value), and a type-one error of ɑ=0.01 (a conservative Bonferroni overcorrection of ɑ=0.05 for the four planned comparisons for the CI and CM assessments and the two subscales in the UC assessment). Considering that we were able to recruit ≥299 participants (refer to result section for analytic sample), our sample size is more than sufficient to detect even small pre-post differences at a standard type-I error rate and power.

Participant recruitment

We advertised the study at the three Universities through undergraduate student association emails, social media, presentations of the study to undergraduate nursing classes, and by having faculty include the study poster on their course websites. The poster included general information about the study and a link to the informed consent and information letter, e-learning modules, and feedback survey. Students provided implied consent by completing feedback surveys following the e-learning modules. Only students who provided consent were included in our sample. We provided a $30 gift card for completing each e-learning activity. We re-advertised the study bi-weekly until our target sample size was reached and surpassed. Recruitment began in September 2021 and ended in August 2022.

Outcomes and measures

Our primary outcomes were students’ knowledge and attitudes. We assessed student nurses’ knowledge using (a) nine true-false knowledge quiz before and after they completed the CI e-learning module and (b) 18 true-false knowledge quiz before and after they completed the CM e-learning module. We designed the nine true-false knowledge quiz on older adults’ cognitive impairment based on a validated quiz on knowledge about older people [56], expert consultations, and the gerontological literature. We developed the 18 true-false knowledge quiz on older adults’ continence and mobility from a previous knowledge quiz we used in an in-person education session delivered to nurses working with hospitalized older people [57]. For both knowledge quizzes, we assessed responses from students for each question pre- and post-intervention to identify improvement. We used the validated Ambivalent Ageism Scale (AAS) [25] and Burbank’s Perceptions about Older People quiz (PCOP) [13, 58, 59] to assess student nurses’ attitudes before and after they completed the UC e-learning module. The AAS scale has 13 items, each on a 7-point Likert-type scale, which consists of two subscales measuring benevolent (AAS-B subscale: nine items) and hostile (AAS-H subscale: four items) ageism. The PCOP has nine items, each on a 5-point Likert-type scale. We reverse-coded some items in the PCOP scale, which is consistent with its development, for overall scoring. For both subscales, higher values correspond to more-ageist attitudes. Details on score derivation are provided in the statistical analysis section.

Participants were asked to provide their birth year and gender. We also assessed students’ perceptions of each of the e-learning activities using a feedback survey that invited participants to respond to four 5-point Likert-type items (1=strongly disagree and 5=strongly agree) and to respond to one open-ended question soliciting their feedback and suggestions for the module.

Statistical analyses

We used R version 3.6.3 for quantitative analysis [60]. We used descriptive statistics to summarize sample demographics and participants responses, namely frequencies and proportions for gender; means and standard deviations (SDs) for age and scale totals; and proportions for individual true-false responses. We used paired t-tests to conduct pre-post comparisons for the three e-learning activities; our approach is justified by our large sample sizes and the lack of extreme skewness or outliers in pre-post differences. Narrative data from the open-ended questions were analyzed using content analysis [61].

Ethical approval

We obtained ethics approval from the Health Research Ethics Board at the University of Alberta (certificate #Pro00110159). Informed consent was obtained from all individuals included in this study.


In total, 365 respondents completed the CI module, 370 completed the CM module, and 362 completed the UC module. After excluding respondents that did not complete both the pre- and post-tests or completed the post-test before the pre-test, our final analytic dataset included 299 respondents for the CI module, 304 for the CM module, and 313 for the UC module (Table 1). Respondents’ mean age was 23.3 (4.6) years for the CI module, 23.6 (5.0) years for the CM module, and 23.6 (4.8) years for the UC module. Most participants were female (78.9 %). We did not have any missing data.

Table 1:


Variables Cognitive impairment (CI) Continence & mobility (CM) Understanding & communication (UC)
Total 299 304 313
Age (mean, SD) 23.3 (4.6) 23.6 (5.0) 23.6 (4.8)
Gender (n, %)
Female 236 (78.9 %) 240 (78.9 %) 247 (78.9 %)
Male 59 (19.7 %) 60 (19.7 %) 62 (19.8 %)
Others 4 (1.3 %) 4 (1.3 %) 4 (1.3 %)

CI knowledge

There was a small-to-moderate improvement in the responses to each item between the pre- and post-test knowledge quiz (Table 2). Among all respondents, 50 % gave more correct answers in the post assessment. For each item, 11–28 % of respondents gave a correct response after an incorrect one, 3–29 % retained incorrect responses throughout, and 6–13 % of respondents gave an incorrect response in the post-assessment after a correct response in the pre-assessment.

Table 2:

Proportion (SD) of respondents answering each item correctly in the pre and post cognitive impairment knowledge checks and the mean number (SD) of correct responses given by respondents.

Item aA Pre Post
–Forgetfulness, concentration problems, and indecisiveness are parts of aging rather than indicators of depression. F 0.73 0.80
–Individuals with dementia are at greater risk for delirium. T 0.79 0.83
–In the case of depression, memory problems may occur. T 0.83 0.88
–The most common causes of delirium are medications and infections. T 0.83 0.84
–The Confusion Assessment Method (CAM) assesses for dementia. F 0.43 0.59
–Some treatable medical conditions can cause dementia or dementia like symptoms. T 0.82 0.90
–Responsive behaviours are gestures, words, or actions that are a form of communication. T 0.86 0.90
–Medications are an effective way of managing responsive behaviors. F 0.68 0.77
–Wandering is a psychotic responsive behaviour. F 0.46 0.60
Total (correct answers) 6.42 (1.68) 7.10 (1.63)
  1. aA=answers.

CM knowledge

We saw small-to-moderate improvements in responses between the pre- and post-test continence and mobility knowledge quiz (Table 3). Overall, 67 % of respondents gave more correct answers in the post-assessment. For each item, 11–31 % of respondents gave a correct response after an incorrect one, 2–47 % retained incorrect responses throughout, and 5–15 % of respondents gave an incorrect response in the post-assessment after a correct response in the pre-assessment.

Table 3:

Proportion of respondents answering each item correctly in the pre and post continence and mobility knowledge checks and the mean number (SD) of correct responses given by respondents.

Item aA Pre Post
–A patient who voids more often than every 2 h is experiencing urinary frequency. T 0.82 0.85
–Nocturnal enuresis is waking up to void during the night. F 0.34 0.42
–Reduced bladder sensation is associate with a lack of desire to void and no awareness of bladder filling. T 0.79 0.83
–Frail older people are more likely to be incontinent. T 0.53 0.61
–People living with dementia most often experience stress incontinence. F 0.36 0.45
–Urinary incontinence in older people has similar risk factors as other geriatric syndromes, such as falls. T 0.76 0.88
–One of the causes of nocturia in older persons is excess night-time urine production. T 0.66 0.76
–Regular toileting assistance is part of promoting continence. T 0.88 0.90
–Anticholinergic medications can impair bladder emptying and cause constipation. T 0.78 0.85
–Nocturia, urinary urgency and frequency do not increase risk of falls. F 0.70 0.78
–Overuse of absorbent products is a risk factor for urinary tract infection. T 0.80 0.87
–Use of absorbent products for patients in hospital is associated with low mobility. T 0.72 0.79
–An indwelling catheter is an appropriate way to manage urinary incontinence. F 0.52 0.70
–An indwelling urinary catheter is the best way to meet toileting needs of a patient who is receiving large doses of intravenous diuretics. F 0.50 0.68
–Constipation can make urinary incontinence worse. T 0.81 0.85
–Mobilizing older patients can improve incontinence. T 0.86 0.92
–Physical but not chemical restraints contribute to incontinence. F 0.65 0.80
–Coughing will not affect stress urinary incontinence in people with chronic obstructive lung disease. F 0.73 0.80
Total (correct answers) 12.22(2.42) 13.72 (2.76)
  1. aA=answers.

UC ageist attitudes

Items on the AAS-B and AAS-H subscale and the PCOP scale generally suggested small decreases in ageist attitudes between the pre- and post-assessments (Table 4). Overall, 66 % of respondents showed less-ageist attitudes and 23 % showed more-ageist attitude in the post assessment on the AAS scale. For each item on the AAS-B subscale, 27–51 % of participants showed a decrease in ageist attitudes, while 10–20 % showed an increase. For each item on the AAS-H subscale, 25–41 % of participants showed a decrease in ageist attitudes, while 12–24 % showed an increase. In terms of the PCOP scale overall, we saw a decrease in ageist attitudes for 62 % while for 23 % we saw an increase. For each item on the PCOP scale, 27–38 % showed less-ageist attitudes while 11–20 % showed more ageist attitudes.

Table 4:

Mean (SD) Likert scores for each item in the understanding and communication pre and post assessments.

Item Pre Post
–It is good to tell old people that they are too old to do certain things; otherwise they might get their feelings hurt when they eventually fail. 2.16 (1.51) 1.74 (1.28)
–Even if they want to, old people shouldn’t be allowed to work because they have already paid their debt to society. 2.00 (1.38) 1.74 (1.28)
–Even if they want to, old people shouldn’t be allowed to work because they are fragile and may get sick. 2.01 (1.41) 1.75 (1.28)
–It is good to speak slowly to old people because it may take them a while to understand things that are said to them. 2.85 (1.71) 2.37 (1.62)
–People should shield older adults from sad news because they are easily moved to tears. 2.11 (1.40) 1.83 (1.32)
–Older people need to be protected from the harsh realities of society. 2.10 (1.35) 1.80 (1.25)
–It is helpful to repeat things to old people because they rarely understand the first time. 2.40 (1.48) 2.00 (1.45)
–Even though they do not ask for help, older people should always be offered help. 3.31 (1.73) 2.59 (1.70)
–Even if they do not ask for help, old people should be helped with their groceries. 2.87 (1.54) 2.43 (1.59)
–Most old people interpret innocent remarks or acts as being ageist. 2.62 (1.53) 2.29 (1.48)
–Old people are too easily offended. 2.13 (1.34) 1.84 (1.24)
–Old people exaggerate the problems they have at work. 2.06 (1.32) 1.69 (1.15)
–Old people are a drain on the health care system and the economy. 1.85 (1.26) 1.62 (1.19)

AAS subtotal (B section) 21.81 (9.82) 18.26 (6.86)
AAS subtotal (H section) 8.66 (4.42) 7.44 (4.14)
AAS total 30.47 (13.44) 25.70 (13.72)

–It is frustrating caring for older patients. 2.07 (1.07) 1.78 (0.97)
aOlder patients are interesting to care for. 2.25 (1.05) 2.00 (1.00)
–Caring for older patients is less rewarding than caring for younger patients. 2.02 (1.01) 1.92 (1.07)
aCaring for older patients is usually challenging and rewarding. 2.22 (1.01) 2.09 (1.02)
aCaring for older patients is intellectually stimulating. 2.32 (1.05) 2.05 (0.96)
aAlthough caring for older patients is labor intensive, it is worth the investment of time and energy. 2.13 (1.01) 1.98 (1.01)
–Caring for older patients is often unpleasant work. 2.32 (1.06) 2.01 (0.94)
–I would not choose to attend continuing education in nursing care of older patients. 2.51 (1.18) 2.17 (1.04)
–Caring for older patients is an undesirable career choice. 2.04 (1.07) 1.79 (0.94)

PCOP total 19.89 (6.32) 17.78 (6.09)
  1. AAS-H, Ambivalent Ageism Scale-Hostile subscale; AAS-B, Ambivalent Ageism Scale-Benevolent subscale; PCOP, Burbank’s perceptions about older people quiz. aIndicates reverse-coded values.

Pre-post-test comparisons

Pre-post comparisons for the CI, CM, and UC modules using paired t-tests consistently revealed positive (i.e., towards improved knowledge and less-ageist attitudes) and statistically significant changes in total scores in our samples (Table 5). Participants gave 0.68 more correct answers on average in the post-test compared to the pre-test (p<0.001, 95 % CI 0.48–0.88) in the CI knowledge quiz and 1.51 more correct answers on average in the post-test for CM knowledge (p<0.001, 95 % CI 1.22–1.79). According to the AAS in the UC module, there was a decrease in scale totals by 4.77 (p<0.001, 95 % CI −5.76 to −3.78). On the PCOP scale, this decrease was 2.12 (p<0.001, 95 % CI −2.60 to −1.63). These results suggest roughly medium effect sizes (Table 5).

Table 5:

Comparisons between mean scores on the pre and post tests for the CI, CM, and UC modules.

E-learning modules Estimate 95 % CI Cohen’s d p-Value
CI (knowledge quiz) 0.68 (0.48, 0.88) 0.39 <0.001
CM (knowledge quiz) 1.51 (1.22, 1.79) 0.59 <0.001
UC (AAS) −4.77 (−5.76, −3.78) −0.54 <0.001
UC (PCOP) −2.12 (−2.60, −1.63) −0.50 <0.001

Feedback survey

Overall, participants reported that the three modules enhanced their knowledge about, perceptions of, and confidence in working with older people and that the activities included were enjoyable. Out of a possible score of 5, our findings indicate a mean score of at least 4.4 (and a median score of 5.0) on all items for each e-learning modules (Table 6).

Table 6:

Mean (SD) responses on the feedback survey following the learning activities.

Item CIa CMa UCa
The learning activity enhanced my knowledge about working with older people. 4.6 (0.7) 4.5 (0.7) 4.5 (0.7)
The learning activity enhanced my confidence in working with older people. 4.4 (0.7) 4.4 (0.7) 4.4 (0.7)
The learning activity was an enjoyable method of learning the material. 4.4 (0.8) 4.4 (0.8) 4.4 (0.9)
The learning activity improved my perceptions about working with older people. 4.4 (0.7) 4.4 (0.8) 4.5 (0.8)
  1. aAll median responses were equal to 5.0.

In one open-ended question, we asked students if they had any comments about the learning modules. For the Cognitive Impairment module, we had 51 comments and of those, 32 reported that the module was informative, 21 enjoyed the format and way of learning, and nine found some of the material lengthy. For the Continence and Mobility module, we had 37 comments: 22 reported the mobility module was informative, 23 enjoyed the format and way of learning, nine found the module was lengthy, and one wanted more videos. Feedback from the Understanding and Communication module included 40 comments: 15 reported the module to be informative, 18 enjoyed the format and way of learning, and eight had suggestions such as making harder distractors in the assessment questions.


The findings from this study demonstrate that the CI and CM learning modules improved student nurses’ knowledge and that the UC module decreased ageist perspectives amongst student nurses. Our findings also revealed that students found all three learning modules effective in enhancing their knowledge and perceptions about working with older adults, and they found the learning activities included enjoyable. These findings parallel those of our pilot tests of the modules [27, 48, 49]. However, in the pilot tests, students were engaging in their first clinical experiences and were all attending one university; in this study, student participants came from three universities and were in various stages of their education. Given that the ordering of the modules was randomly assigned to avoid ordered effects, the results suggest that all levels of students from different institutions may benefit from the modules. Similar to our findings, other studies have demonstrated that knowledge about aging positively influences student nurses’ perspective about older adult care [58] and decreases ageist perspectives among nursing students [7, 9] and social work students [41]. Knowledge about older adults care, coupled with the e-learning method of delivery, appears to enhance positive learning outcomes [27, 48, 49].

Ideally, student nurses would receive education about ageing and older people consistently throughout their undergraduate training [62]. Given the dearth of gerontological experts in many nursing faculties [33, 63], our modules can supplement what gerontological content is currently offered in nursing programs. The format of the e-learning modules allows them to be accessed at any time and completed flexibly at learners’ convenience [50], [51], [52]. In addition to content that is delivered in the modules, it is important that student nurses have real-world interactions with older adults to challenge negative stereotypes about aging. Nursing researchers have reported improvements in student nurses’ attitudes towards older people after an educational intervention, which typically included gerontological content, clinical experiences, or a combination of the two [6, 28, 43, 64], [65], [66], [67], [68], [69], [70], [71], [72], [73]. Of these aforementioned studies, those that included quality clinical experiences consistently disrupted students’ negative stereotypes about aging and older people. Similarly, Levy’s [42] Positive Education and Contact Experiences model emphasizes the importance of education about aging and positive role models as well as positive individualized experiences with older people to diminish ageism.

The student nurses in this study showed significant improvement in their gerontological knowledge and attitudes about working with older people. The magnitude of the pre- and post-differences for each module reveal a medium effect size in our sample. We recognize that changing ageist attitudes requires thoughtfully-placed curricular content about ageing and ageism that is continuously reinforced in order to make changes. We therefore recommend mapping content related to the hostile and ambivalent scales to entry-to-practice gerontological competencies [62, 74], to facilitate the achievement of desired learning outcomes. Given that the Canadian Association of Schools of Nursing is developing an exit exam to ensure that students have the required gerontological competencies, these modules may assist students in acquiring fundamental knowledge. Ultimately, once our e-learning modules have been revised based on students’ feedback, they will be made accessible at no cost to all nursing programs in Canada, with the hope that the modules will be one of many approaches that are employed to diminish ageism directed towards older adults.


This study captured changes in knowledge and attitudes at only one exposure point immediately after our intervention, not longitudinally. As a result, the durability of the reported effects remains unknown, and it is unclear whether they will persist in the longer term and be carried over into participants’ future nursing practice. Additionally, our ageism measure only operationalizes certain kinds of ageist behaviour (i.e., hostile, benevolent). Thus, it would be prudent to assess ageist views using other measures/behaviours (e.g., ageism rooted in vocabulary and language use that may undermine nurses’ effective communication with older adults in their care) in the future. Although our sample size is powered to detect even a small effect, we need to be cautious about the generalizability of findings as we included small number of participants from there Canadian universities and used non-probability sampling method. Finally, while we provided descriptive demographic summary of our participants, we did not conduct any sex- and gender-based analyses. As a result, the extent to which sex and gender may have influenced changes in knowledge and attitudes in our sample is unknown.


Nurses are the largest group of frontline healthcare professionals who play a key role in providing majority health care services in Canada and around the globe. Their demands to meet the care needs of older adults are increasing with an increase in aging population. Therefore, it is vital to ensure that nurses are prepared to effectively care for this population. We evaluated the impact of three e-learning modules on undergraduate student nurses’ knowledge and attitude and found that these e-learning modules could be an effective way to improve nurses’ knowledge and attitude in older adults’ care. Therefore, we recommend that every year of undergraduate nurse education should include a course in gerontology and/or gerontological concepts should be threaded throughout the nursing program to ensure that anti-ageist principles and gerontological knowledge are iteratively reinforced. Further longitudinal studies are needed to determine changes in knowledge and attitudes over time after the e-learning modules intervention, and at what point an education booster is needed.

Corresponding author: Rashmi Devkota, MScN, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton Clinic Health Academy, 11405 – 87 Ave NW, Edmonton, AB, T6G 1C9, Canada, E-mail:


We thank all the student nurses for their participation in the study.

  1. Research ethics: We obtained ethics approval from the Health Research Ethics Board at the University of Alberta (certificate #Pro00110159).

  2. Informed consent: Informed consent was obtained from all individuals included in this study.

  3. Author contributions: JB, SS, and RD contributed to the conceptualization of the study and prepared the original draft of the manuscript. MP contributed to conceptualization, statistical analysis, and review and editing. MTF, SD, KH, SS, ALC, EM, and LSM contributed to conceptualization, review and editing of the manuscript. All the authors read and approved the final version of the manuscript.

  4. Competing interests: There are no potential conflicts of interest to declare with regard to the research, authorship, and/or publication of this study.

  5. Research funding: The study has been fully funded by the Social Sciences and Humanities Research Council of Canada.

  6. Data availability: The authors confirm that the data supporting the findings of this study are available within the article.


1. World Health Organization. Ageing and health; 2022. Available from: in Google Scholar

2. Canadian Institute for Health Information. National health expenditure trends, 2021-Snapshot; 2022. Available from: in Google Scholar

3. Government of Canada. Aging and chronic disease: a profile of Canadian seniors; 2020. Available from: in Google Scholar

4. Abudu-Birresborn, D, McCleary, L, Puts, M, Yakong, V, Cranley, L. Preparing nurses and nursing students to care for older adults in lower and middle-income countries. A scoping review. Int J Nurs Stud 2019;92:121–34. in Google Scholar PubMed

5. King, BJ, Roberts, TJ, Bowers, BJ. Nursing student attitudes toward and preferences for working with older adults. Gerontol Geriatric Med 2013;34:272–91. in Google Scholar PubMed PubMed Central

6. Reitmaier, A, Davies, S, Reveling Smith, L, Mangan-Danckwart, D, Hongerholt, K, Klinkner, J. Discovering intergenerativity: an evaluation of learning partnerships between student nurses and older adults. Int J Older People Nurs 2015;10:115–26. in Google Scholar PubMed

7. Gallo, V. Ageism in nursing education: a review of the literature. Teach Learn Nurs 2019;14:208–15. in Google Scholar

8. Kagan, SH, Melendez-Torres, GJ. Ageism in nursing. J Nurs Manag 2015;23:644–50. in Google Scholar PubMed

9. McAllister, M, Ryan, C, Dodd, L, Goldenberg, M, Brien, DL. A thematic literature review of innovative strategies to prepare nursing students for aged-care. Nurse Educ Today 2020;87:104355. in Google Scholar PubMed

10. Van Wicklin, SA. Ageism in nursing. Plast Surg Nurs 2020;40:20–4. in Google Scholar PubMed

11. Butler, RN. Age-ism: another form of bigotry. Gerontologist 1969;9:243–6. in Google Scholar

12. Cheng, M, Cheng, C, Tian, Y, Fan, X. Student nurses’ motivation to choose gerontological nursing as a career in China: a survey study. Nurse Educ Today 2015;35:843–8. in Google Scholar PubMed

13. Dahlke, S, Davidson, S, Wisnesky, UD, Kalogirou, MR, Salyers, V, Pollard, C, et al.. Student nurses’ perceptions about older people. Int J Nurs Educ Scholarsh 2019;16:1–10. in Google Scholar PubMed

14. Haron, Y, Levy, S, Albagli, M, Rotstein, R, Riba, S. Why do nursing students not want to work in geriatric care? A national questionnaire survey. Int J Nurs Stud 2013;50:1558–65. in Google Scholar PubMed

15. Lee, YS. Ethnic differences in attitudes and bias toward older people comparing white and Asian nursing students. J Transcult Nurs 2015;26:202–8. in Google Scholar PubMed

16. Hovey, S, Dyck, MJ, Reese, C, Kim, MJ. Nursing students’ attitudes toward persons who are aged: an integrative review. Nurse Educ Today 2017;49:145–52. in Google Scholar PubMed

17. Koh, LC. Student attitudes and educational support in caring for older people – a review of literature. Nurse Educ Pract 2012;12:16–20. in Google Scholar PubMed

18. Attafuah, PYA, Amertil, N, Sarfo, JO, Deegbe, DA, Nyonator, D, Amponsah-Boama, C, et al.. ‘I decided to attend to him because it’s my duty’: student nurses perception and attitude towards care of older adults. BMC Med Educ 2022;22:1–7. in Google Scholar PubMed PubMed Central

19. Naughton, C, O’Shea, KL, Hayes, N. Incentivising a career in older adult nursing: the views of student nurses. Int J Older People Nurs 2019;14:1–10. in Google Scholar PubMed

20. Carlson, E, Idvall, E. Who wants to work with older people? Swedish student nurses’ willingness to work in elderly care-a questionnaire study. Nurse Educ Today 2015;35:849–53. in Google Scholar PubMed

21. Huang, CS. Undergraduate students’ knowledge about aging and attitudes toward older adults in East and West: a socio-economic and cultural exploration. Int J Aging Hum Dev 2013;77:59–76. in Google Scholar

22. Runkawatt, V, Gustafsson, C, Engström, G. Different cultures but similar positive attitudes: a comparison between Thai and Swedish nursing students’ attitudes toward older people. Educ Gerontol 2013;39:92–102. in Google Scholar

23. Cheng, WLS. Roles of knowledge and attitude in the willingness of nursing students to care for older adults in Hong Kong. Int J Environ Res Publ Health 2021;18:1–8. in Google Scholar PubMed PubMed Central

24. Neville, C, Dickie, R. The evaluation of undergraduate nurses’ attitudes, perspectives and perceptions toward older people. Nurse Educ Today 2014;34:1074–9. in Google Scholar PubMed

25. Cary, LA, Chasteen, AL, Remedios, J, Pruchno, R. The ambivalent ageism scale: developing and validating a scale to measure benevolent and hostile ageism. Gerontologist 2017;57:e27–36. in Google Scholar PubMed

26. Kalogirou, MR, Dahlke, S, Davidson, S, Hunter, KF, Pollard, C, Salyers, V, et al.. Working with older people: beginning or end of a nurse’s career? Int J Older People Nurs 2021;16:1–9. in Google Scholar PubMed

27. Dukes, C, Dahlke, S, Pietrosanu, M, Kalogirou, MR. Improving student nurses’ perspectives towards older people with an e-learning activity: a quasi-experimental pre-post design. Int J Older People Nurs 2022;17:1–9. in Google Scholar PubMed

28. Garbarino, JT, Lewis, LF. The impact of a gerontology nursing course with a service-learning component on student attitudes towards working with older adults: a mixed methods study. Nurse Educ Pract 2020;42:102684. in Google Scholar PubMed

29. Hammar, LM, Holmström, IK, Skoglund, K, Meranius, MS, Sundler, AJ. The care of and communication with older people from the perspective of student nurses. A mixed method study. Nurse Educ Today 2017;52:1–6. in Google Scholar PubMed

30. Koskinen, S, Burke, E, Fatkulina, N, Fuster, P, Löyttyniemi, E, Salminen, L, et al.. Graduating nurse students’ interest in older people nursing—a cross-sectional survey in six European countries. Int J Older People Nurs 2022;17:1–14. in Google Scholar PubMed PubMed Central

31. Celik, SS, Kapucu, S, Tuna, Z, Akkus, Y. Views and attitudes of nursing students towards ageing and older patients. Aust J Adv Nurs 2010;27:24–30.Search in Google Scholar

32. Dahlke, S, Kalogirou, MR, Swoboda, NL. Registered nurses’ reflections on their educational preparation to work with older people. Int J Older People Nurs 2021;16:1–11. in Google Scholar PubMed PubMed Central

33. Koskinen, S, Salminen, L, Stolt, M, Leino-Kilpi, H. The education received by nursing students regarding nursing older people: a scoping literature review. Scand J Caring Sci 2015;29:15–29. in Google Scholar PubMed

34. Algoso, M, Peters, K, Ramjan, L, East, L. Exploring undergraduate nursing students’ perceptions of working in aged care settings: a review of the literature. Nurse Educ Today 2016;36:275–80. in Google Scholar PubMed

35. Kydd, A, Wild, D. Attitudes towards caring for older people: literature review and methodology. Nurs Older People 2013;25:22–7. in Google Scholar PubMed

36. Dahlke, S, Phinney, A, Hall, WA, Rodney, P, Baumbusch, J. Orchestrating care: nursing practice with hospitalised older adults. Int J Older People Nurs 2015;10:252–62. in Google Scholar PubMed

37. Fox, MT, Butler, JI, Persaud, M, Tregunno, D, Sidani, S, Mccague, H. A multi-method study of the geriatric learning needs of acute care hospital nurses in Ontario, Canada. Res Nurs Health 2016;39:66–76. in Google Scholar PubMed

38. Flood, MT, Clark, RB. Exploring knowledge and attitudes toward aging among nursing and nonnursing students. Educ Gerontol 2009;35:587–95. in Google Scholar

39. Emory, J, Bowling, H, Lueders, C. Student perceptions of older adults after a music intervention: a mixed approach. Nurse Educ Pract 2021;53:103094. in Google Scholar PubMed

40. World Health Organization. Global report on ageism; 2021. Available from: in Google Scholar

41. Even-Zohar, A, Werner, S. The effect of educational interventions on willingness to work with older adults: a comparison of students of social work and health professions. J Gerontol Soc Work 2020;63:114–32. in Google Scholar PubMed

42. Levy, SR. Toward reducing ageism: PEACE (positive education about aging and contact experiences) model. Gerontologist 2018;58:226–32. in Google Scholar PubMed

43. Sakamoto, RR. Influence of “RAP” experiences on nursing students’ career choices in aging: a qualitative exploration. Nurse Educ Today 2022;109:105218. in Google Scholar PubMed

44. Martínez-Arnau, FM, López-Hernández, L, Castellano-Rioja, E, Botella-Navas, M, Pérez-Ros, P. Interventions to improve attitudes toward older people in undergraduate health and social sciences students. A systematic review and meta-analysis. Nurse Educ Today 2022;110:1–15. in Google Scholar PubMed

45. Bandura, A. Social learning theory. New York: General Learning Press; 1971.Search in Google Scholar

46. Kim, S, Choi, S, Seo, M, Kim, DR, Lee, K. Designing a clinical ethics education program for nurses based on the ADDIE model. Res Theor Nurs Pract 2020;34:205–22. in Google Scholar PubMed

47. Dahlke, S, Hunter, KF, Negrin, K, Kalogirou, MR, Fox, M, Wagg, A. The educational needs of nursing staff when working with hospitalised older people. J Clin Nurs 2019;28:221–34. in Google Scholar PubMed

48. Dahlke, S, Hunter, KF, Pietrosanu, M, Kalogirou, MR. Testing and e-learning activity designed to enhance student nurses understanding of continence and mobility. Int J Nurs Educ Scholarsh 2021;18:1–9. in Google Scholar PubMed

49. Kalogirou, MR, Dahlke, S, Pietrosanu, M, Hunter, KF. Using an E-learning activity to enhance student nurses’ understanding of cognitive impairment. Nurse Educ Today 2022;108:105167. in Google Scholar PubMed

50. Brull, S, Finlayson, S. Importance of gamification in increasing learning. J Cont Educ Nurs 2016;47:372–5. in Google Scholar PubMed

51. Dubovsky, SL, Antonius, D, Ellis, DG, Ceusters, W, Sugarman, RC, Roberts, R, et al.. A preliminary study of a novel emergency department nursing triage simulation for research applications. BMC Res Notes 2017;10:1–12. in Google Scholar PubMed PubMed Central

52. Liaw, SY, Wong, LF, Lim, EYP, Ang, SBL, Mujumdar, S, Ho, JTY, et al.. Effectiveness of a Web-based simulation in improving nurses’ workplace practice with deteriorating ward patients: a pre- and postintervention study. J Med Internet Res 2016;18:1–19. in Google Scholar PubMed PubMed Central

53. Dahlke, S, Hunter, KF, Fox, MT, Davidson, S, Perry, N, Watts, LT, et al.. Awakening Canadians to ageism: a study protocol. BMC Nurs 2021;20:1–10. in Google Scholar PubMed PubMed Central

54. von Elm, E, Altman, DG, Egger, M, Pocock, SJ, Gotzche, PC, Vandenbroucke, JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies; 2023. Available from: in Google Scholar

55. Cohen, J. Statistical power analysis for the behavioral sciences, 2nd ed. New York: Routledge; 1988.Search in Google Scholar

56. Dikken, J, Hoogerduijn, JG, Kruitwagen, C, Schuurmans, MJ. Content validity and psychometric characteristics of the “knowledge about older patients quiz” for nurses using item response theory. J Am Geriatr Soc 2016;64:2378–83. in Google Scholar PubMed

57. Hunter, KF, Dahlke, S. Nurse and health care aide knowledge of urinary continence promotion and management in hospitalized older people. J Wound Ostomy Continence Nurs 2021;48:435–9. in Google Scholar PubMed

58. Baumbusch, J, Dahlke, S, Phinney, A. Nursing students’ knowledge and beliefs about care of older adults in a shifting context of nursing education. J Adv Nurs 2012;68:2550–8. in Google Scholar PubMed

59. Burbank, PM, Dowling-Castronovo, A, Crowther, MR, Capezuti, EA. Improving knowledge and attitudes toward older adults through innovative educational strategies. J Prof Nurs 2006;22:91–7. in Google Scholar PubMed

60. R Core Team. R: a language and environment for statistical computing. R. Foundation for Statistical Computing; 2020. Available from: in Google Scholar

61. Vaismoradi, M, Jones, J, Turunen, H, Snelgrove, S. Theme development in qualitative content analysis and thematic analysis. J Nurs Educ Pract 2016;6:100–10. in Google Scholar

62. Canadian Association of Schools of Nursing. Entry-to-practice gerontological care competencies for baccalaureate programs in nursing; 2017. Available from: in Google Scholar

63. Beltran, SJ, Miller, VJ. Breaking out of the Silo: a systematic review of university-level gerontological curricula in social work and nursing programs. J Soc Work Educ 2020;56:753–78. in Google Scholar

64. Cao, Z, Wang, Y, Hu, Y, Wang, L, Wang, Y. Real experience among undergraduate nursing students in learning the course of geriatric nursing: a qualitative study. TMR Integr Nurs 2021;5:51–5. in Google Scholar

65. Davies, SM, Reitmaier, AB, Smith, LR, Mangan-Danckwart, D. Capturing intergenerativity: the use of student reflective journals to identify learning within an undergraduate course in gerontological nursing. J Nurs Educ 2013;52:139–49. in Google Scholar PubMed

66. Fox, SD, Wold, JE. Baccalaureate student gerontological nursing experiences: raising consciousness levels and affecting attitudes. J Nurs Educ 1996;35:348–55. in Google Scholar PubMed

67. Hsu, PT, Ho, YF, Chen, JJ. The effect of integrating service-learning and learning portfolio construction into the curriculum of gerontological nursing. Healthcare 2022;10:1–15. in Google Scholar PubMed PubMed Central

68. Lai, CKY, Chan, JH, Wong, IYP, Fung, JTS, Pang, PCP, Fung, KHK, et al.. Gains and development of undergraduate nursing students during a 2-year community service program. J Nurs Educ 2015;54:S21–5. in Google Scholar PubMed

69. Lin, YC, Wang, CJ, Wang, JJ. Effects of a gerotranscendence educational program on gerotranscendence recognition, attitude towards aging and behavioral intention towards the elderly in long-term care facilities: a quasi-experimental study. Nurse Educ Today 2016;36:324–9. in Google Scholar PubMed

70. Rogan, F, Wyllie, A. Engaging undergraduate nursing students in the care of elderly residents in Australian nursing homes. Nurse Educ Pract 2003;3:95–103. in Google Scholar PubMed

71. Sari, D, Taskiran, N, Baysal, E, Acar, E, Akyil, C. Effect of an aged wearing suit on nursing student’s knowledge and attitude. Euro Geriatric Med 2020;11:667–75. in Google Scholar PubMed PubMed Central

72. Shellman, J. The effects of a reminiscence education program on baccalaureate nursing students’ cultural self-efficacy in caring for elders. Nurse Educ Today 2007;27:43–51. in Google Scholar PubMed

73. Walton, J, Blossom, H. The experience of nursing students visiting older adults living in rural communities. J Prof Nurs 2013;29:240–51. in Google Scholar PubMed

74. American Association of Colleges of Nursing. Recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults; 2010. Available from: in Google Scholar

Received: 2023-06-16
Accepted: 2023-11-10
Published Online: 2023-11-30

© 2023 Walter de Gruyter GmbH, Berlin/Boston

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