Ageism was defined by Dr. Butler in 1969 as the "prejudice by one age group towards other age groups." The negative perceptions towards seniors are culturally driven and evident in health care culture, where seniors are considered frail and helpless. These age-related stigma and discrimination have been linked to neglect as older patients are less likely to receive preventative medicine and life-saving treatments. Older adults, especially those who are bed-bound and lack cognitive capabilities, are not seen as humans and are not deemed worthy of resource-intensive therapies. Based on the Critical Theory Paradigm, it is essential to acknowledge the power differences between health care workers and geriatric patients. Awareness of this social inequality then leads us to action. This paper has presented two evidence-based actions: Critical reflexivity and gerontological education. More education in gerontological care and increasing intergenerational contact opportunities are essential to decrease ageism in health care providers and improve the quality of care that older adults receive. Further studies are encouraged to include seniors in facilitating ways to dismantle the power inequalities between health care and seniors, as seniors have been silenced.
Keywords: ageism, health care, critical reflexivity, gerontological education, intergenerational contact
Ageism in Health Care
Despite the known stereotyping and discrimination against the elderly since 1969, ageism is still the most socially condoned and institutionalized form of prejudice in the health care system (Allen, 2016). Ageism was first defined in 1969 as a concept for social reform by Dr. Robert Butler, the first director of the National Institute on Aging (Wilson et al., 2017). Dr. Butler defined ageism as "prejudice by one age group towards other age groups" (Mehri et al., 2020). Ageism can be expressed in three levels: the individual (micro), the institutional (mezzo), and the societal (macro) level (Band-Winterstein, 2015). Like any other prejudice, ageism is based on negative stereotypes, viewing the older person as senile, a burden, useless, and invisible (Band-Winterstein, 2015). 91% of Canadians above the age of 60 have reported experiencing ageism. Although there are positive stereotypes (e.g., older adults are wise), negative stereotypes are more pervasive and increase with age (Cooney, Minahan, & Siedlecki, 2020). The World Health Organization also stated that "ageism may now be more pervasive than sexism or racism" (as cited in Levy & Macdonald, 2016, p. 7). In this paper, the critical paradigm's assumptions are used to explore the social processes, power relations, and consequences of ageism. This paper will provide two evidence-based actions that can address ageism and promote equity.
The Problem
All of the articles reviewed in Assignment One have concluded that ageism in healthcare exists and is problematic. As ageism is the systematic stereotyping or discrimination against older adults (Wilson et al., 2017), older adults are considered less powerful and oppressed. Interestingly, Ozel Bilim and Kutlu (2021) stated that ageism leads to young individuals' views that the elderly are different from themselves. Greenberg's terror management theory attributes ageism to the human desire to dissociate from any reminder of our own inevitable personal death (as cited in Ben-Harush, 2016). This situation increases fear of and trepidation toward ageing by eliminating the fact that the elderly are people. Ben-Harush et al. (2017) has demonstrated that ageism exists among physicians, nurses, and social workers in various therapeutic settings.
Band-Winterstein (2015) described how ageism in health care is expressed in four ways:
1. Professional workers' overwhelming preference to work with the younger people as working with the elderly is less prestigious and attractive, hence the shortage in human capital.
2. Ageism is manifested in paternalistic behaviours by doing things for older adults that they can do well.
3. Viewing older people as not human beings, which leads to failure to refer them to specialists.
4. The perception of older patients as senile undermines their abilities. It might lead them to live up to the disabilities expected of them.
Critical Theory Paradigm
The dominant paradigm that was discussed in my first assignment was the Critical Theory Paradigm. The essence of critical theory is to "combine philosophy with the empirical study" to change the world in "an emancipatory direction" (Akella, 2020). The Critical Theory Paradigm asserts that power relations influence multiple subjective realities in society; that knowledge is subjective and co-constructed between individuals and groups; aims to understand community organization and action; knowledge is acquired by interviews, focus groups, open-ended questionnaires (Dueñas, 2020). The goal is to examine oppression and routes to challenging oppression, focusing on the exploitation of parts of society (alienation) and society's view of people as political or other objects (reification) (Ryan, 2018).
The Consequence
Like racism, classicism, and sexism, ageism is a social inequality that affects everyone regardless of age. Both younger and older adults experience ageism, but negative associations and behaviors are directed towards the older adult. Stereotypes about ageing become internalized over one's life, consequently developing into negative expectations that manifest via psychological, physiological, and behavioral pathways (Cooney et al., 2020).
Personal/Professional Consequence
I have experienced ageism where my young age seems to be a barrier to performing my Unit Manager role. Many have commented that I was "too young" to be a manager and "did not have enough life experience" to lead, despite my history of being in leadership positions. I also had patients who would refuse their medications because I was "too young" to be a nurse. This experience highlights that it is the older adult who experiences ageism. However, I acknowledge that ageism in older adults is more rampant and has more significant consequences (Burnes et al., 2019).
As a nursing student, friends and I discussed which clinical area we would like to preceptor in. I mentioned cardiology, the emergency department, and the operating room. None in my group mentioned long-term care or a nursing home. Nurses often assign a lower status to geriatric nursing (Ben-Harush et al., 2016), and no one wants to work in long-term care as they had the fear that "they would lose their skills." On the contrary, research has identified gaps in practicing nurses' knowledge about caring for older adults. Some nursing programs have less than five percent of gerontological content in their curriculum, producing newly graduated nurses that can provide evidence-based care to seniors (Negrin & Dahlke, 2019). I did not envision myself to be working in geriatric psychiatry. However, my career led me to it due to opportunities that opened up. I quickly realized that what I know about the general adult population does not readily transfer to the older adult's care. I was not readily aware of the geriatric syndromes. I quickly realized that I needed to improve my knowledge and skills. My interest and passion for caring for the older-adult increased. I worked towards getting a certification with the Canadian Nurses Association in Gerontological Nursing and Psychiatric & Mental Health Nursing.
Patients/Health Care System Consequence
Older adults can internalize ageist beliefs and begin to believe and behave that they are no longer independent, healthy, and vibrant adults (Allen, 2014). Becca Levy (2009) presented the theory of stereotype embodiment where she states that the ageing process is, in part, a social construct. This twenty-three-year longitudinal study had identified that those older adults who held positive stereotypes about their health lived longer than those who held negative stereotypes as they became older (Levy & Macdonald, 2016). Unsurprisingly, older adults who have held negative stereotypical beliefs and have experienced ageism have poorer functional health (increased chronic diseases), recover from disease slowly, and have a shorter lifespan (Allen, 2014).
There is a strong connection between ageism and elder neglect in the provision of health care. Elder neglect is defined as elder mistreatment. It can either be omission – unintentional or passive acts, or commission – intentional or active deprivation of basic needs and services (Band-Winterstein, 2013). Several studies have linked ageism in health care workers and shortcomings in their care, leading to early loss of independence, increased inability, and death; despite the older individual having the functional capacity and lived healthy lives (Mehri et al., 2020). Ageism in health care professionals can result in discriminatory practices such as assuming that physical and cognitive decline is "normal." Older adults are provided limited medical information and restrict treatment options (Burnes et al., 2019). Problems that can be treated with medications are considered a natural part of ageing. Health care providers can ignore these problems due to their stereotypical belief that older adults complain more as "they" age (Levy & Macdonald, 2016). Paternalistic behaviours are common in the treatment of older adults; in particular, withholding invasive medical procedures can be considered as compassionate care rather than as under treatment due to the need to provide quality of life over longevity, regardless of what the older adult wants (Ben-Harush et al., 2016).
The health care workers have the power to dictate how an older person should live, what their activities for the day would be, and when they can go to the bathroom, especially when the older adult lives in a nursing home. At an institutional level, ageist attitudes also inhibit the development of health policies that would benefit older individuals (Brunes et al., 2019). Ageism in health care settings leads to a reduction in communication and lack of communication to facilitate understanding in the elderly, reducing their awareness; reduces preventive health services; leads to shortages of prescriptions; and decreasing prescribing experiments and treatment for the elderly (Mehri et al., 2020). On the other hand, when older individuals want to participate and make decisions for their care, they are labelled as "difficult" and "demanding" as they want to manage their treatment plan, once again showcasing the paternalistic behaviours of health care professionals towards older adults (Ben-Harush et al., 2016).
Community Consequence
The COVID-19 pandemic is a prime example of how ageism is endangering society by dividing generations when solidarity is most important. Fraser et al. (2020) point to issues such as the lack of preparation for such a crisis in long-term care homes, how some "protective" policies can be considered patronizing, and how the perception of the public is that the COVID-19 pandemic is only an issue for older people and not the younger population who are "invincible" to COVID-19. The message that we all need to stay at home to protect older people is ageistic. It divides the young and the old; it classifies the older individuals to be blamed for the lockdown and that all older adults are frail and vulnerable (Abramson, 2020).
The pandemic's current discourse highlights how older people are misrepresented and undervalued in society, upholding that older people are not human beings (Fraser et al., 2020).
Ageism in the Workplace
I am proud to say that both of my organizations, Alberta Health Services (AHS) and Covenant Health, embrace diversity and are committed to creating an environment where staff, patients, and families are treated with respect and dignity. Alberta Health Services (2016) has released a report on "Creating Diversified, Respectful and Inclusive Teams" that aims to promote diversity in the workforce and eliminate ageism.
Both organizations have also sponsored the Elder Friendly Care Project (AHS, n.d.) that brought together many stakeholders and knowledgeable health care providers in Alberta to share learnings and discover new techniques and approaches towards improving care for seniors, specifically for the following domains: Reduce restraints (pharmacologic, physical, mechanical & environmental), prevent delirium and falls, increase mobility, enhance sleep and support more effective and timely discharge. The Elder Friendly Care project has presented the concept of "frailty," and not everyone above sixty-five years old is frail. Frailty is "a medical syndrome with multiple causes and contributors characterized by diminished strength, endurance and reduced physiologic function that increases an individual's vulnerability for developing increased dependency or death" (Jankowska-Polanska, 2019). It is objectively measured with tools such as the Edmonton Frailty Scale.
My participation in the Elder Friendly Care projects triggered my desire to seek certification in Gerontological Nursing. The concepts of Elder Friendly Care are practiced by staff on the units that I manage. I also ensure that my nursing practice is evidence-based as I work as a frontline Registered Nurse.
Evidence-based Actions
Just like any other form of systemic oppression and discrimination, eliminating ageism is not straightforward, nor is it easy. However, this paper will present two evidence-based actions that will create awareness and decrease ageism in health care workers.
Critical Reflexivity
The first action presented to overcome ageism is critical reflexivity for gerontology practice, as presented by Flores-Sandoval and Kinsella (2020). Critical reflexivity is crucial for individuals who work with older adults as it encourages health care professionals to examine taken-for-granted assumptions, values and belief around the ageing process; while being cognizant of how these assumptions shape their practice and how they use their position of power to improve the quality of care that they provide to older adults (Flores-Sandoval & Kinsella, 2020). There are three ways that health care professionals and students can be engaged in critical reflexivity: Observation, narrative, and writing.
Observation. Through observation, students can use their senses to challenge their own beliefs and values of ageing and understand emotional factors, both internal and external. They can better appreciate power dynamics and ageism through observation of how staff interact with the patients.
Narrative. It is essential to hear older adults' narratives and how their identity as an older adult affects them, and how they cope and be resilient in the face of ageism. These narratives are humanizing and challenge healthcare professionals to make sense of their practice and resist dominant discourse by offering counter-narratives.
Writing. Students were encouraged to write about their thoughts and feelings when interacting with older adults. Students can safely express their thoughts, negative or positive, allowing teachers to provide a safe place for dialogue to improve students' confidence when working with older adults and promote empathy and respect. However, the interaction between the older adult and student promotes a perspective transformation as they have "bonded" with their patients (Flores-Sandoval & Kinsella, 2020).
Gerontological Education
It is estimated that by 2030, an additional 3.5 million geriatric health care professionals will be needed to meet the rapidly expanding population of those age sixty-five and older (Nelson, 2016). There is a need for health care professionals trained specifically for the care of older adults and are aware of ageism and its negative impact on older adults. Negrin and Dahlke (2019) state that society's negative perceptions about ageing influence nursing practice, but there was a significant improvement in knowledge and positive perceptions towards older adults by nursing students after a gerontological theory and clinical placement course. However, the clinical placement needs to be done in a facility where preceptors modelled "respectful perceptions of older adults and enthusiasm for their work" (Negrin & Dahlke, 2019). Empathy is a learnable skill. This skill must be taught to students as emphatic skills can help understand disadvantaged patients and establish a caring relationship, which is the foundation for providing good quality care (Kaplan Serin & Tülüce, 2021).
Nursing educators, nursing leadership, and researchers must come together in ways that support the integration of gerontological entry-to-practice competencies into nursing curricula to ensure students have the requisite preparation to care for older adults. The faculty member who will be teaching Gerontological content needs to be certified through the Canadian Nurses Association. This will ensure that educators have the requisite knowledge and had the specialized education to ensure that the new nursing graduates both have the necessary gerontological knowledge, skills, and positive attitudes towards older adult care need to break the cycle of institutional ageism that is prevalent in health care (Negrin & Dahlke, 2019).
The two actions, critical reflexivity and gerontological education highlight the importance of education to challenge the perceptions of ageing. The biomedical model and the current systemic structures that health care professionals work in unintentionally promote the idea that the ageing process is negative and is all about the decline and wear and tear (Flores-Sandoval & Kinsella, 2020). While not overtly stated, the two studies by Flores-Sandoval and Kinsella (2020) and Negrin and Dahlke (2019) discuss intergenerational contact benefits. A long-standing and extensive body of research has demonstrated that positive contact with older adults has led to lower ageism levels (Lytle, Nowacek, & Levy, 2020). However, as Negrin and Dahlke (2019) mentioned, the interactions need to be positive. The staff working with the older adults should embody a positive perspective with caring for an older adult and ageing.
Conclusion
Ageism has been a discourse since 1969 when Dr. Butler coined the term and provided a spotlight on negative perceptions that have alienated an age group (older people) that had led to poor-quality health care and, at times, neglect. Unfortunately, ageism is still pervasive and has further been highlighted during the COVID-19 pandemic. The older adults are acceptable collateral damage with the push to re-open the economy. The culture of ageism needs to be explored using a Critical Theory Paradigm for health care professionals and leaders to highlight the roots of ageism in the health care system and focus on ways to address it. There is a need to actively find ways to challenge existing powers and provide a culture shift towards inclusion and mutual respect for older adults, improving their health outcomes. Critical reflexivity and gerontological education have been identified as two evidence-based actions to address ageism in health care. Increased knowledge in ageing and how to provide appropriate care and increased intergenerational contact will hopefully decrease the negative stereotypes and attitudes that health care providers have towards ageing.
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