Reflections on Gerontological Nursing Over the Past 50 Years

Fifty years ago, I began hospital-based nursing training with aspirations far removed from caring for older adults. My early career ambitions were centred on high-intensity clinical environments such as intensive care, emergency departments and adolescent mental health, where I believed my clinical skills would be most challenged and utilised. However, following a brief period in adolescent mental health, I was required to undertake a placement in cardiology prior to transitioning into intensive care. This experience proved pivotal to my career. Most patients in cardiology were older adults, and concurrently, I was assisting with the care of my grandfather in our home. His stories and presence profoundly influenced my perspective, leading me to discover a deep professional and personal connection to the care of older people. Although the average age of cardiology patients at that time was closer to 60, the complexity of their care revealed a compelling and meaningful path, one that would shape the trajectory of my career. This invited commentary, part of the Journal of Advanced Nursing's 50th Anniversary Special Issue, provides an opportunity to reflect on the evolution of gerontological nursing over the past five decades. It highlights significant advancements, ongoing challenges and future priorities for the profession as we respond to the needs of an ageing global population. Looking forward, concerns are raised that gerontological nursing may be in danger of extinction unless we invest in and value it more. Without investment, care for older adults will not achieve the quality of care required. The global demographic landscape is undergoing a profound transformation. Life expectancy continues to rise, and the proportion of older adults within the population is increasing rapidly. The World Health Organisation (WHO 2024) defines older adults as individuals aged 60 years and above, with those aged 80 and older representing the fastest-growing subgroup. By 2030, one in six people globally will be aged 60 or older, and by the late 2070s, individuals aged 65 and above will outnumber those under 18 (United Nations 2024). While many older adults remain active and engaged, ageing is often accompanied by increased frailty, multimorbidity and complex care needs (Howlett et al. 2021; Tazzeo et al. 2021). These trends have significant implications for healthcare delivery, resource allocation and workforce planning. Historically, older adults were primarily cared for in long-term care settings or so-called geriatric wards set aside for older people. However, over the past three decades, the ageing of the population has resulted in older people having a substantial presence across all healthcare environments, including acute and specialist units such as intensive care. Advancements in public health and medicine have extended life expectancy and shifted the demographic profile of patients in acute care. Today, the average age of patients in intensive care units (ICUs) is 65 years or older, with an increasing number of admissions among individuals over 80 (Flaatten et al. 2017; Lee et al. 2024; Rai et al. 2023). Furthermore, there were once age limits placed on admission to specialist units, such as the ICU, thereby diminishing the need for specialist gerontological nurses in these units. Such changes have led to the need for adjustments in health policies and practices to meet the evolving care needs of an ageing population. Alongside this, as women tend to live longer than men, there has been an increase in older females admitted to ICUs (Flaatten et al. 2017), suggesting the need for gender-specific health policies and care practices allocated to gender-specific treatments and education. The ageing population has created an urgent demand for nurses with specialised expertise in gerontological care. Despite the increasing complexity of care environments, the number of nurses with advanced certification in gerontological nursing remains insufficient to cope with the increasing demands (Fulmer 2020; Johnson et al. 2023). This shortage poses a significant challenge for healthcare systems that strive to deliver high-quality, evidence-based care to older adults. In contrast to paediatric care, where the value and complexity of children's health needs are widely recognised and addressed by qualified professionals, older adults are often cared for by underqualified or unlicensed staff, particularly in long-term care settings. Ageist attitudes within society and the healthcare profession contribute to disparities in treatment, staffing, assessment and access to advanced care (Shimizu et al. 2023; Whitley Jr. and Kite 2006). However, recent efforts to reform nursing education, challenges to ageist language and promotion of the empowerment of older adults have led to improvements in care quality (WHO 2021). Despite these advances, workforce data consistently indicate a shortage of nurses equipped to manage the growing demands of gerontological care. Even in countries with substantial investment in gerontological education, nurses report burnout due to increasing care complexity and limited resources (Resnick et al. 2022). Addressing these challenges requires sustained commitment to workforce development, education and policy reform if gerontological nursing is to survive. The terminology used to describe the complex nursing care required for older adults has evolved over time. Historically referred to as ‘geriatric nursing’, the term has largely been replaced by ‘gerontological nursing’ to reflect the broader scope of practice. Gerontological nursing encompasses the physical, psychological and social dimensions of ageing across diverse care settings (Tohmola et al. 2022). In contrast, ‘geriatric’ fell out of favour in the late 1970s as a term for nurses to use, as it is recognised as a medical subspecialty focused on disease treatment (Burggraff and Mueller 2020). Despite this evolution, the term ‘aged care nursing’ remains prevalent, often implying a narrow focus on long-term care and inadvertently diminishing the complexity and expertise inherent in gerontological nursing. A global call to action is needed to standardise the use of ‘gerontological nursing’ within the profession, thereby affirming its identity as a sophisticated and essential nursing specialty. Recent years have seen emphasis placed on the importance of language, particularly as it can perpetuate ageism and stigma. For example, in 2020, the American Psychological Association (APA 2020) reported the need for the use of bias-free language. They recognised the term ‘elderly’ as being disrespectful, lacking precision regarding age and perpetuating negative stereotypes. Authors were encouraged to use terms such as ‘older persons’ or ‘older adults’ rather than ‘elderly’. While journals that adhere to APA guidelines are unlikely to accept the term ‘elderly’ in publications, it is still commonly seen in the nursing and medical literature. The nursing profession must take the lead in stopping the advancement of stigmatising language and promoting positive views of older adults. Language in care use has improved significantly over the last 50 years. It used to be standard practice for nurses to call patients, especially older adults, ‘love’, ‘dear’, ‘sweetie’, etc. Older people told us this language was disrespectful. Society, including the nursing profession, has become aware of the importance of avoiding disrespectful language, and it is now standard practice to address patients by their preferred name. Historically, nurses were trained primarily in hospital-based apprenticeship models. This approach has largely been replaced by university-based nursing degrees, which place greater emphasis on developing knowledge, skills and capabilities. The nursing degree typically spans 3–4 years; however, the limited duration constrains the breadth and depth of content that can be covered. Currently, there is no globally mandated nursing curriculum, resulting in significant variation in content and duration. Consequently, while nursing academics often claim that the care of older adults is integrated into curricula, topics related to other population groups are frequently prioritised (Fetherstonhaugh et al. 2022; Rayner et al. 2023). Moreover, the notion of ‘integration’ has been critiqued, as it may suggest that content is delivered by academics with limited interest or expertise in gerontology, thereby diminishing its perceived importance (Nay et al. 1999), which would further diminish the significance of older adult care. In many Bachelor of Nursing programmes, clinical care for older adults is introduced in the first year, typically within the context of foundational nursing skills, such as hygiene care. However, theoretical content on ageing is typically deferred until the second year, which can lead to the undervaluing of early practical experiences with older adults. Despite the increasing specialisation of clinical practice, nursing curricula continue to adopt a generalist approach to caring for older adults. As a result, many nurses report graduating with insufficient preparation to care for this population (Dahlke et al. 2021; Garbrah et al. 2017). This issue is compounded by a shortage of academic faculty with gerontological expertise (McCleary et al. 2017) and by persistent stigma within the profession that suggests caring for older adults requires no specialised knowledge. Such attitudes contribute to the marginalisation of gerontological nursing and discourage new graduates from pursuing it as a specialty. Traditionally, specialisation in gerontological nursing occurs at the postgraduate level, placing additional financial and time burdens on students who seek to undertake advanced education. These barriers have contributed to the low number of nurses pursuing advanced education in gerontology (McCleary et al. 2017). To address this, it is essential to engage new graduates in both work and study within the field of interest. Although recent studies indicate that attitudes toward older adults are improving, the number of graduates intending to work in gerontology remains low (Ho et al. 2023a, 2023b; Magan et al. 2023; Smith et al. 2022). The timing and quality of gerontological education and clinical placements can significantly influence students' career choices. For instance, positive experiences with knowledgeable instructors and placements in the later years of study have been shown to increase interest in working with older adults (Smith et al. 2022). In contrast, early exposure, often limited to basic care, may reinforce negative perceptions of care of older adults. While there is no consensus on how best to integrate gerontological content into nursing curricula, increasing its presence has been shown to influence students' career intentions positively (Lee et al. 2018). Furthermore, delivering gerontological education in settings where older adults receive care can enhance both the quality and appeal of this specialty (Salin et al. 2020). Over the past five decades, alongside advances in medicine, significant developments in nursing have shaped the practice and education of gerontological nursing. One of the most notable advancements has been the establishment of gerontological nursing competencies, designed to ensure nurses possess the advanced knowledge and skills necessary to provide quality care for older adults. These competencies serve not only to guide clinical practice but also to inform nursing education and training. The first US nursing competencies were published in 1976 by the American Nurses' Association, Division of Gerontological Nursing Practice (Mueller and Crogan 2020). More recently, the John A. Hartford Foundation has played a pivotal role in advancing gerontological nursing by developing and promoting core competencies for nurses caring for older adults. These competencies are intended to be embedded across all levels of nursing education, from entry-level to advanced practice. Over the past four decades, the Hartford Foundation has been instrumental in establishing centres of gerontological excellence across the US (Johnson et al. 2023), and its influence has extended internationally, contributing to the formation of gerontological networks in Australia and Asia. The US Hartford Foundation's efforts have led to a substantial increase in the integration of geriatric content in nursing curricula, from 63% of programs in 1997 to 92% in 2003, and the inclusion of ageing and older adult care in the curricular guidelines of nursing, social work and medical programs (Isaacs et al. 2019). The Foundation has also recognised and celebrated the contributions of visionary leaders in gerontological nursing (Burggraff and Mueller 2020), a practice that has not been widely adopted in other countries. While each of the above frameworks claims to define the competencies required for caring for older adults, their scope and applicability vary. For instance, Traynor et al. (2024) note that their competencies were explicitly developed for aged care services, which may limit their relevance to broader healthcare contexts. This diversity raises important questions for the global gerontological nursing community, such as: How should competency development be approached to foster harmonisation and strengthen both national and international recognition of the specialty? Could a unified, collaborative effort have produced a global competency framework with greater influence on leadership and practice, similar to developments in other specialised fields, such as intensive care nursing? As demonstrated by the US experience, without the support of strong professional organisations and visionary leadership, it is unlikely that gerontological nursing competencies will be effectively integrated into nursing curricula and clinical practice. A coordinated global approach may be essential to elevate gerontological nursing as a respected and influential speciality worldwide. Without this, gerontological nursing as a speciality is likely to continue to be eroded. Alongside an ageing population and an increase in complex ageing syndromes, the field has shifted from treating individual medical conditions to focusing on nursing care for complex syndromes, such as frailty, sarcopenia and cognitive impairment. This shift has led to the emergence of subspecialities within gerontological nursing, including dementia care and palliative care, alongside a growing emphasis on public health initiatives, particularly the role of exercise in promoting healthy ageing. According to the WHO (2025), 57 million people were living with dementia in 2021, with nearly 10 million new cases diagnosed annually. This growing prevalence has intensified the demand for person-centred nursing care that respects individual preferences and promotes dignity. Gerontological nursing practice and education are increasingly grounded in person-centred care principles, which have also driven the advancement of ethical standards in care delivery. These standards are particularly relevant in the care of older adults with neurocognitive where of and are over the past 50 years have contributed to a in the use of particularly in long-term care, significantly countries and 2023). Despite these use among people with dementia remains often due to and practices and 2020), suggesting gerontological nurses have not a strong role in this of practice. the of palliative care and the emergence of to policies have the need for education in dementia and palliative care for all nurses working with older adults. However, the of the number of nurses with advanced specialist training in gerontological care remains low (McCleary et al. 2017; Mueller and Crogan 2020). In to these a global has to ensure in long-term care. In this will become for all long-term care from While this policy a significant in care standards for older adults, many long-term care report in qualified The shortage of nurses with gerontological expertise that those often the necessary knowledge and skills to provide care to older adults. In recent the establishment of the Health has introduced evidence-based of care with a strong to these systems is the and preferences and and care for cognitive and This framework was by the US Hartford Foundation and the for its in than across the US have adopted the placing older adults and their at the of care and delivery. The Health has also been recognised globally in countries such as and these and students are encouraged to and with patients the that care is and This has the and importance of gerontological care, the need for healthcare systems to the needs of older adults. advancements, including the development of new have significantly over the past 50 years. the of the as a for and treating older adults in long-term care settings et al. while also social and connection et al. 2023). increasingly on to with in care et al. 2020). The of that support such as and has contributed to increased among older adults. Furthermore, are equipped to support older adults in at and being Gerontological a role in promoting the health and of both and older adults. They must of advances in as such as social for example, are in care, particularly in care for people with dementia 2019). the of and health new for gerontological nurses to and positively the health and of older adults and their et al. 2019). global to has the of long-term aged care settings such as and et al. In these gerontological nurses have often been required to and manage groups of older adults from long-term care under Without emergency many be and emergency into gerontological nursing curricula is especially as such are to increase in and due to The further the of aged care systems placing on healthcare professionals, particularly nurses in long-term care. Older adults were by the et al. 2022; et al. 2020) and the necessary such as led to increased of and social et al. 2022). this gerontological nurses were with the complex needs of older adults, often while resource and personal while care. revealed in long-term care including the of working while across limited access to personal and et al. 2020). Despite these the global shortage of gerontological nurses remains a significant for of qualified in long-term care, such as those in the US et al. have to be in many countries. Although gerontological nurses can significantly care and the negative of a the has many care from this issue et al. 2022; et al. 2021). Gerontological as advanced are to lead and expertise can the of future health especially in long-term care settings. However, financial continue to the of in many care of their value in for older adults et al. 2022; et al. 2021). The of among healthcare staff, the urgent need to invest in specialised gerontological nursing education and workforce This the advancement that the nursing profession has over the past five in care for older adults. However, many challenges The following for these challenges and the nursing profession on how to to meet future Gerontological nurses must remain to caring for older adults, as the challenges with this population will To such a global call for action is needed from Nursing healthcare the World Health and the Nations to address these Furthermore, the term ‘gerontological nursing’ as the term within the profession may gerontological nursing as a specialty and address the need for specialist education and A of gerontological is particularly for adults aged years and This is a new that we have not and we global knowledge on how to manage this population However, there is that we will nurses with specialist education to care for the growing older population. The profession must address this challenge in the and postgraduate Alongside there has been a in the prevalence of cognitive impairment. However, it is recent advances in knowledge and dementia treatments will this or if further will specialised care across settings. Gerontological nurses will be to developing and that for this population. continue to place older people who with care into care has told us the negative of care on of in late However, we must this of care, as the in the ageing population and the limited number of must be for to such as and et al. should be to older adults to live at or of care for longer Furthermore, evidence-based care is essential for quality older care and must be delivered by knowledgeable and is a need to increase the gerontological nursing workforce of the ageing of the global population. Currently, only a of the workforce in gerontological nursing. The number of nurses working in long-term aged care is particularly low 2020; et al. 2023; Mueller et al. 2024). Furthermore, long-term care settings continue to challenges due to often from low support and et al. 2021; et al. 2021). role among working in long-term care to on the that can leading to in and et al. 2021). in education that the care of older adults, including the and training of faculty with expertise in gerontology, with to and gerontological is needed to ensure an and future workforce that can deliver care to older adults. has been a on nursing in long-term care to provide the of care. However, the and complexity of the ageing population are levels of specialist nurses to provide for the complexity of care care have such as gerontological to and thereby care and a role in By and care, are et al. 2022). Furthermore, health have a role within aged care services, suggesting that if gerontological nurses not strengthen their role and for will become increasingly in the The scope of practice for gerontological nurses needs to be especially in long-term care, where their skills are often and (Resnick et al. 2022). gerontological nurses can practice to the scope of their without to seek from long-term care for the of In that this will the of challenges and the to provide quality care. The profession must for policy to ensure the scope of practice can be Nursing students are the future of gerontological nursing, and we must their career and in gerontological nursing et al. 2019). we must ensure that are and possess the skills and attitudes to care for this population. is essential for new graduates to work and with in their A recognised to students' positive attitudes toward older adults is focused in the that and et al. 2023). Furthermore, must invest in gerontological nursing education to and strengthen this has been an increase in groups such as and individuals in aged care Gerontological nurses must lead the in the care and of such groups to ensure are with and quality care without need education and skills to provide such care. is work to be to ensure a of with gerontological nursing education for the future needs of the ageing population. While this the advancement that the nursing profession has over the past five decades, the we must seek to practice and meet workforce if we are to ensure an that can provide care for older adults. access by as part of the the of The has to within this The no of interest. The has to