Nursing students' willingness to work in geriatric care: An integrative review

Abstract Aims This integrative review aims to explore the willingness of nursing students to work in geriatric care over the past 10 years and to explore the factors influencing nursing students to work in geriatric care. Design An integrative review. Methods Studies investigating nursing students’ willingness in gerontological nursing work and related influencing factors published in English in Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL between 2010–2020 were included. Data collected in April 2020. Results Twenty‐four studies were analysed. Most studies presented a contradictory or negative attitude about the willingness of nursing students to engage in gerontological nursing work. In most studies that rank the intention to work in nursing fields, gerontological care received the lowest or a relatively low ranking. The main factors affecting work related to gerontological nursing include prior experience caring for older adults, attitudes towards geriatrics, anxiety about ageing, clinical practice environment and living experience with older family members.

Therefore, this integrative review aims to analyse and criticize the current literature on nursing students' intention towards gerontological nursing work and on factors that influence the willingness of nursing students to pursue careers as gerontological nursing practitioners and to provide relevant evidence regarding this phenomenon.

| ME THODS
An integrative review of the literature was conducted using the framework provided by Whittemore and Knafl (2005); this approach allows for the inclusion of diverse methodologies (i.e., experimental and non-experimental research) and contains five stages, including problem identification, literature search, data evaluation and analysis and presentation. This method can use diverse data sources, thereby developing a holistic understanding of the topic of interest (Hopia et al., 2016).

| Literature search
The following databases were searched for articles published between 2010-2020: the Cochrane Library, Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica dataBASE (Embase), PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The following three groups of search terms (text words and Medical Subject Headings (MeSH) terms, if available) were used in combination: (a) geriatric nursing, aged care, gerontology nursing, old people, elderly, old age, older adults, older population or elder care; (b) willingness to work, job intention, work, employment intention, employment intent or preference of employment; and (c) nursing students, student nurses or undergraduate student nurses. The reference lists of all included studies were hand-searched to identify any potentially relevant studies, and the authors were contacted to access additional relevant publications.

| Eligibility criteria
All studies investigating nursing students' attitudes towards gerontological nursing work and related influencing factors and that were published in English were included. To analyse up-to-date results on this research topic, only articles published in recent ten years were included. In addition, both qualitative studies and quantitative surveys were included.

| Study selection and data extraction
Two reviewers independently assessed the studies for eligibility.
After eliminating the duplicates, the studies were first selected based on the title and abstract; then, the full-text publications were examined. Disagreements were resolved by discussion or referral to a third review author. Any differences were discussed, and agreement among the researchers was achieved. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram was presented to outline the screening process used in the literature search.
The data extracted included the author, year, the country where the study was conducted, purpose, data collection and analysis methods, sampling and main results. One researcher extracted all the data from the included studies.

| Quality appraisal
The quantitative studies were assessed using the Center for Evidence-Based Management (CEBM) appraisal of a survey checklist (CEBM, 2014), and the mixed-methods studies were assessed using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018). Two reviewers were independently involved in the appraisal process; disagreements were resolved by discussion or referral to a third review author.

| Data analysis
Data analysis was initially undertaken by the primary author and later scrutinized by other authors to ensure accurate interpretation and credibility. As suggested by Whittemore and Knafl (2005), four phases were constituted in this stage: (a) Data reduction. In this phase, the primary sources are divided into subgroups according to the logical system to facilitate analysis; (b) Data display. In this phase, data display matrices and graphs are developed to enhance the visualization of patterns and relationships with and across primary data sources; (c) Data comparison. In this phase, data are iteratively compared with examine data displays to identify patterns, themes or relationships. Specifically, in comparing data, the authors searched for common and unusual patterns, contrasted and compared the patterns and themes, clustered similar themes together and subsumed these themes into more general themes and alternated between the literature and the conclusions drawn to verify the findings and test for plausibility and (d) Drawing conclusions and verification. In this phase, the important elements and conclusions of each subgroup are synthesized into an integrated summation of the phenomenon.

| Search results
The electronic database search yielded 427 titles and abstracts.
After the duplicates were removed, 246 titles and abstracts were screened according to the inclusion and exclusion criteria. This process yielded 35 manuscripts for full-text review. Fourteen manuscripts were unavailable and were, therefore, excluded. In some studies, the themes focused on students with employment intentions in various departments rather than specifically gerontological care, but these studies also investigated the students' attitude towards becoming gerontological care practitioners; thus, we included these studies. Overall, 24 publications were included as follows: 19 quantitative publications reporting surveys and five mixed-method studies; no qualitative study was searched ( Figure 1).

| Study characteristics
Twenty-four studies were included in the final review, and the main characteristics of the included studies were extracted (Table 1). Most of the studies were conducted in Australia (N = 3), Mainland China (N = 3), Sri Lanka (N = 1), Sweden (N = 1), Taiwan (N = 1), Turkey (N = 1) and the United States (N = 6); additionally, one of the studies was conducted in Australia and China and another one was conducted in both Korea and the United States.
Regarding the participant characteristics, overall, 8,892 participants were involved in the study and the average sample size was 370 (range: 50-1,462).

| Nursing students' willingness to work in gerontological care
In two studies, the willingness of nursing students to engage in gerontological care was positive (Chi et al., 2016;Zhang et al., 2016). In two other studies, the nursing students' choice of gerontological care as a career and the nursing students' motivation was at a moderate level (Che et al., 2018;Cheng et al., 2015). However, in two studies, the nursing students had a contradictory attitude. On the one hand, they had a moderate or positive attitude towards older people; on the other hand, the nursing students had no interest in working in gerontological care (Neville, 2016;Rathnayake et al., 2016). In addition, one study showed that the nursing students' attitudes towards working in geriatrics were negative (Natan et al., 2015). King et al. (2013) found that the negative attitude was related to working in nursing homes rather than to working with older people. In five studies ranking the intention to work in many nursing fields, gerontological care received the lowest or a relative low ranking (King et al., 2013;McCann et al., 2010;Shen & Xiao, 2012;Swanlund & Kujath, 2012;Yildirim et al., 2011). Stevens (2011 indicates that due to the accumulation of the process and experience of nursing education, the willingness to work in gerontological care gradually decreases.

| Factors influencing nursing students' willingness to work in geriatric nursing
Twenty-seven variables were identified from the 24 papers. The relationship between these variables and nursing students' willingness to work in geriatric nursing is summarized in Table 4. The variables were grouped into one of six categories and listed in the order of the most investigated to the least investigated.

| Demographics
Five demographic variables that affect nursing students' willingness to work in geriatric nursing are mentioned. Three studies showed that younger students were more active in gerontological nursing work (Shen & Xiao, 2012;Xiao et al., 2013). However, Neville (2016) showed that young participants were less active than those in the older age group. Carlson and Idvall (2015) and Che et al. (2018) found the willingness to care for older people did not significantly differ among students of various ages.
There is also a difference in the impact of the gender of nursing students. While two studies showed that males were more likely to work in gerontological care (Che et al., 2018;Natan et al., 2015), another study showed that females were more active than males (Neville, 2016). Moreover, two studies showed no significant correlation between the different sexes (Carlson & Idvall, 2015;Mattos et al., 2015).
Neville (2016) Che et al. (2018) and Zisberg et al. (2015) showed the opposite results. Swanlund and Kujath (2012) showed that the willingness to work with elders was not significantly related to the year of study.
Further, religious students were more inclined than secular students to intend to work in geriatrics (Natan et al., 2015). Zisberg et al. (2015) showed that ethnicity was a predictor of intentions to work in geriatric care, and the Arab students demonstrated higher intention to work with older people than Jewish students.

| Education
In three studies, an enriched clinical practice environment more positively affected students' selection of gerontological care (Carlson & Idvall, 2015;Cheng et al., 2015;Stevens, 2011). Haron et al. (2013) showed that the type and place of training made a difference; approximately half the diploma students were prepared to consider working in geriatrics, but only a third of the college students and less than a quarter of the university students were prepared to do so. However, Che et al. (2018) andMattos et al., (2015) showed that the willingness to work with older people did not differ significantly by the type of training programme. Mattos et al., (2015) showed that, compared with a gerontological nursing course that was integrated into other nursing courses, a stand-alone gerontological nursing course yielded students with higher intention levels. Che et al. (2018) showed that the approach used by the gerontological nursing course did not significantly af-

| Experience
In our synthesis, nine studies determined that prior experience in caring for older people was positively related to nursing students' desire to pursue a career in geriatric care after graduation ( Cheng et al. (2015) and Rathnavake et al. (2016) revealed that having a living experience with older family members was a positive factor in geriatric career intention, while Che et al. (2018) showed that there was no significance. Cheng et al. (2015) also indicated that having parents that have good attitudes towards older people and having a close relationship with elder relatives positively affected students' intention to work with older people.
Similarly, Shen and Xiao (2012) and Xiao et al. (2013)  In addition, nursing students who had empathy for older people had a high willingness to care for them Jang, Oh, et al., 2019). Zhang et al. (2016) discovered that gratitude was a mediator between knowledge about gerontological adults and the willingness to care for them.

| Others
In our study, we included several influencing factors that are only mentioned in individual studies and cannot be grouped in the above categories. Cheng et al. (2015) showed that investigators believe that personal interest is an important factor affecting work in gerontological care. The results from Haron et al. (2013) revealed that significantly most of the participants who had planned to consider working in gerontological nursing cited the expansion of the management powers and the creation of the clinical nurse specialist role. Natan et al. (2015) found that normative and control beliefs were predictors of nursing students' intention to work in geriatrics on graduation.

| D ISCUSS I ON
This study reviewed the willingness of nursing students to work in geriatric nursing care over the past ten years. The results indicated that although some studies showed the willingness of nursing students engaged in gerontological was at a positive or moderate level, more studies presented a contradictory and negative attitude.
Furthermore, in most studies where nursing fields were ranked according to the intention to work in these fields, gerontological care was ranked the lowest or ranked relatively low.
A few decades ago, students did not prefer geriatric care. Heller and Walsh (1976) showed that nursing students tend to treat older people with a negative attitude and that negative emotions render these students reluctant to engage in geriatric nursing work; Feldbaum and Feldbaum (1981), Kayser and Minnigerode (1975) demonstrated, in comparing students' willingness to work in other areas, that most students were unwilling to work in a "nursing home"; Happell ' (1999) also showed that, among students who wanted to work in psychiatry, gerontology was the lowest ranked in terms of willingness to work.
Unfortunately, despite decades of effort, students' willingness to work in gerontological care has not significantly changed or improved. Swanlund and Kujath (2012) suggested that students prefer to work in a fast-paced working environment, such as acute care   , 2006;Neville, 2016;Neville et al., 2008). In an Israeli study, university students' willingness to work in gerontological care was lower than that of college-and diploma-qualified students (Haron et al., 2013) and this finding is similar to the willingness of Chinese nursing students to work in the gerontological care setting. In China, highly educated nursing students are more reluctant to work in a gerontological ward or other institutions care for older people. Hence many institutions care for older people can provide only basic life care, the professional nursing services such as chronic disease management, rehabilitation nursing and palliative care are inadequate. In particular, older people often have multiple chronic diseases, self-function degradation and decreased self-care ability; therefore, gerontological care is more complex than simple daily life care and the support and guidance of a more professional and personalized caregiver are needed. Like paediatric and intensive care nursing, the gerontological care specialty requires professional high-quality nursing personnel.
Regarding the demographic characteristics of the subjects, studies show contradictory results. In terms of age, younger students were more positively engaged than older students in gerontological care work (Shen & Xiao, 2012;Xiao et al., 2013) and senior students hold a negative attitude on geriatric working intention (Che et al., 2018;Zisberg et al., 2015). These findings are inconsistent with the rules of education; it is generally presumed that as the level of students' education increases, the students' knowledge of  gerontological nursing and willingness towards gerontological nursing work will both improve. The level of engagement should demonstrate an increasing trend.
Concerning gender, female students working in geriatric nursing are more positive (Neville, 2016); however, Che et al. (2018) and Natan et al. (2015) showed the opposite result. Neville (2016) provided an analysis showing that women are more likely to be set up as "role caregivers" in the traditional sense. In an analysis conducted by Natan et al. (2015), the male nurses indicated that they could assist older people with meeting their fitness goals, such as rotation and activities; therefore, gerontological care provided by male nurses is in high demand. In addition, the role of male nurses in traditional women's work is a feature of certain departments, such as maternity wards and finding a related job can be challenging. We believe that promote the attractiveness of lectures so that students will more readily accept geriatric nursing courses. Furthermore, as were evidenced to be the effective learning approaches to improve students' theoretical knowledge and skills, more education methodologies such as flipped classroom pedagogy, and simulation-based learning (Hu et al., 2018;Torkshavaned et al., 2020) are encouraged to be explored in designing gerontological nursing programmes.
In clinical training, nursing education regarding gerontological care promotes a positive clinical learning experience that can improve attitudes towards older people and motivate nursing students to prioritize their intentions to engage in gerontological nursing work (Abbey et al., 2006;Brown et al., 2008;Chenoweth et al., 2010;King et al., 2013;Liu et al., 2013;Robinson et al., 2008). Clinical practice includes the clinical ward environment, staff, patients, nurses, teachers and interactions with student tutors (Papp et al., 2002). Schools and hospitals should carefully screen for knowledgeable and caring teachers, train teachers, provide adequate medical supplies and equipment in the internship section and develop a comprehensive internship programme for students (Chi et al., 2016). In particular, regarding the role of teachers during internship, it is important for high-quality nursing centres to create a harmonious relationship between nurses and patients, provide a good environment and establish a high-quality nursing service consciousness. As stated by Che et al. (2018), the clinical learning setting is critical for cultivating students' interest in geriatric care; therefore, nursing programmes should ensure that both the training environment and assigned mentors work to promote positive attitudes towards caring for older people.
In addition, in the past, the treatment and care of the older people were mainly distributed in other disease-centred specialties de- Concerning family education and its impact on working intention, the experience of living and interacting with older people in daily life includes both the experience of caring for and the experience of understanding older people. Living with the older members in a family can promote nursing students' understanding of the lifestyle involved with interacting with older people. Compared with students without relevant experience, experienced students have more confidence and skills in caring for older people (Zhang et al., 2016). Students' concern and sympathy for older people can be easily simulated (Pan et al., 2009) and interactions with older people can reduce the anxiety of nursing students regarding ageing (Yan et al., 2011).
Furthermore, young persons who live with older people are more likely to be enthusiastic about people who need help because such young persons are more likely to take care of older people (Zhang et al., 2016). The role of parents is vital; parents should be filial to their parents and set a good example for their children to encourage respect for older people.

| Limitations
Because of the limitation of language, we included only articles published in English; this restriction may have led to language bias, and some significant findings published in other languages might have been overlooked. Second, although the search strategy was extensive and inclusive, we did not search the unpublished literature, and hence, the related data might be missed. Moreover, the inclusion criteria did not clearly distinguish among gerontological care workplaces, such as geriatrics departments, nursing homes, rehabilitation centres, or general wards at gerontological care pension institutions; the nursing students' work tendency in different workplaces of geriatric nursing may have differed. Further studies are needed to clarify these issues.

| CON CLUS ION
This paper reviewed 24 studies reporting on the willingness of nursing students to work in geriatric nursing over the past ten years and the relevant influencing factors. The results showed that although in recent years, governments, educational systems and professional nursing associations have initiated efforts to promote gerontological care services, nursing students' willingness to work in gerontological care services is still not promising. And the main factors affecting work related to gerontological nursing include prior experience caring for older adults, attitudes towards geriatrics, anxiety about ageing, clinical practice environment and living experience with older family members.
This finding suggests that continued and dedicated work towards improvements can be achieved by government policies, public opinion, school programmes, clinical practice education, family atmosphere and many other efforts. Given the global ageing population has reached a serious level and the demand for geriatric nurses is expected to increase dramatically, further research on the subject is desirable and timely.

ACK N OWLED G EM ENTS
We would like to thank The National Social Science Fund of China for their support.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author(s).

DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets generated for this review are available on reasonable request to the corresponding author.