ageism in nursing education a review of the literature

• DOI: 10.1016/J.TELN.2019.04.004
• Corpus ID: 182699424

Ageism in nursing education: A review of the literature

• Published in Teaching and Learning in… 1 July 2019
• Education, Medicine

41 Citations

Factors associated with nursing students’ attitudes toward older people: a scoping review.

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Development of Gerontological Learning Objectives to Enhance Nursing Educational Curricula.

Gerontological educational interventions for student nurses: a systematic review of qualitative findings, ageism against older patients in nursing: conceptual differentiations and the role of moral sensitivity.

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Ageism, moral sensitivity and nursing students' intentions to work with older people - A cross-sectional study.

E-learning modules to enhance student nurses’ perceptions of older people: a single group pre-post quasi-experimental study, willingness to care for older people and associated factors in pre-registered student nurses: a multi-country survey study., effects of an age suit simulation on nursing students’ perspectives on providing care to older persons, assessing attitudes and intention to work with older adults by american and israeli nursing students: adapting and testing a measure., gerontological nursing competencies: a scoping review., 22 references, attitudes of nursing students about ageism and the related factors, the relationship between nursing students' professional values and their attitudes towards the elderly people: a cross-sectional study., nursing students and geriatric care: the influence of specific knowledge on evolving values, attitudes, and actions., the continuation of prejudice: addressing negative attitudes in nurse training and continuing professional education, the effect of first clinical assignments on prelicensure nursing students’ attitudes toward older people: an observational study, promoting student learning and increasing organizational capacity to host students in residential aged care: a mixed method research study., why do nursing students not want to work in geriatric care a national questionnaire survey., teaching caring and competence: student transformation during an older adult focused service-learning course., assessing ageist behaviours in undergraduate nursing students using the relating to older people evaluation (rope) survey, nursing students' intentions to work in dementia care: influence of age, ageism, and perceived barriers, related papers.

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Ageism in nursing education: students’ views of ageing.

1. Introduction

2. materials and methods, 3.1. ageism of nursing students—quantitative analysis, 3.1.1. ageism and gender, 3.1.2. ageism and age, 3.1.3. ageism and contact with older adults, 3.2. ageism of nursing students—qualitative analysis, 3.2.1. positive view.

“An accumulation of experiences and knowledge, a path travelled and lived”; “Lifelong acquisition of wisdom and knowledge”; “We become wiser and wiser as we collect life experiences”; “Lifelong acquisition of wisdom and knowledge”.

“Is more than age”; “Drawing a story”; “Create memories”.

“Mindset change. Young people are more impulsive, maybe due to lack of experience”; “Become more aware of attitudes and behaviours”.

“Life experiences that prepare us to educate the new generations”; “Teach them values”.

“Gain of skills”; “Adapting skills to everyday life”;

“Consolidation of identity and reflection on the events and actions carried out in the course of life”; “It is a phase in which people reflect on what they have done throughout life, achievements and defeats, creating new goals and dreams”.

“Means maturing, new responsibilities and new challenges”; “Ability to decide what to do with one’s life”.

“Gain of offspring, grandchildren, and great-grandchildren, which bring happiness”; “See the family grow and meet many people”; “Meet and interact with many people”.

3.2.2. Negative view

“Closer to the end”; “Is to die slowly. I am born like spring; I live like summer; I feel myself decaying in autumn to be winter forever”.

“Greater vulnerability to certain health problems”; “Condition that can lead to pathologies”.

“Become dependent on other people”; “Need for attention”; “Forgetfulness and confusion”.

“Lose certain functions and undergo physical changes”; “Loss of functionality progressively and at a slow pace”.

“Decreased motor skills”; “Greater motor difficulties and more illness”; “Loss of some movements, difficulties in carrying out daily activities”; “Inability to perform certain actions”.

“Weakening of the body over time”; “Become weaker and in pain”.

“It is an age of extreme vulnerability when it is more difficult to feel happiness”; “Feeling of frustration at losing physical and mental faculties”; “Mood swings, such as loss of patience and, in some cases, increased stubbornness”.

“Loneliness”; “Loneliness, non-recognition, and abandonment are often present”.

4. Discussion

5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Cerqueira, A.F.; Ramos, A.L.; Palma, J. Ageism in Nursing Education: Students’ Views of Ageing. Soc. Sci. 2023 , 12 , 142. https://doi.org/10.3390/socsci12030142

Cerqueira AF, Ramos AL, Palma J. Ageism in Nursing Education: Students’ Views of Ageing. Social Sciences . 2023; 12(3):142. https://doi.org/10.3390/socsci12030142

Cerqueira, Andreia Ferreri, Ana Lúcia Ramos, and José Palma. 2023. "Ageism in Nursing Education: Students’ Views of Ageing" Social Sciences 12, no. 3: 142. https://doi.org/10.3390/socsci12030142

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A Critical Review of Published Research Literature Reviews on Nursing and Healthcare Ageism

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Interventions to Reduce Ageism Against Older Adults: A Systematic Review and Meta-Analysis

D. Burnes and K. Pillemer were involved in study conceptualization and design, supervised search strategy and data collection, and contributed to results interpretation and article writing. C. Sheppard contributed to study design, data collection, data preparation, and article writing. C. R. Henderson Jr contributed to study design, conducted analysis, and contributed to results interpretation and article writing. M. Wassel contributed to study design, data collection, and data preparation. R. Cope contributed to data collection, data preparation, and article preparation. C. Barber contributed to data collection.

Background. Research has found a strong link between ageism, in the form of negative stereotypes, prejudice, and discrimination toward older people, and risks to their physical and mental health. Little is known, however, about the effectiveness of strategies to reduce ageism.

Objectives. To assess the relative effects of 3 intervention types designed to reduce ageism among youths and adults—education, intergenerational contact, and combined education and intergenerational contact—by conducting a systematic review and meta-analysis.

Search Methods. We searched PubMed, PsycINFO, AgeLine, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Index Medicus, Database of Abstracts of Reviews of Effects (DARE), Epistemonikos, Cochrane Database of Systematic Reviews, Campbell Collaboration, PROSPERO, GreyLit, and OpenGrey. We identified additional records by hand-searching reference lists of relevant review articles as well as records included in the meta-analysis. Two independent reviewers completed the search and screening process.

Selection Criteria . Eligible studies were those that (1) evaluated an intervention designed to reduce ageism, (2) examined at least 1 ageism outcome in relation to older adults, (3) used a design with a comparison group (randomized or nonrandomized), and (4) were published after 1970, when the ageism concept was developed.

Data Collection and Analysis. Two independent reviewers extracted study-level data from records using a common data collection spreadsheet. They also assessed study quality by using the Cochrane Risk of Bias Tool, and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool to assess quality of outcome evidence. Primary outcomes were attitudes toward older people and accuracy of knowledge about aging and older people. Secondary outcomes included comfort with older adults, anxiety about one’s own aging, and interest in working in the field of geriatrics or gerontology. We carried out meta-analyses with statistical mixed models.

Main Results. We identified 63 eligible studies (1976–2018) with a total sample of 6124 participants. Ageism interventions demonstrated a strongly significant effect on attitudes (differences of standardized mean differences [d D ] = 0.33; P  < .001), knowledge (d D  = 0.42; P  < .001), and comfort (d D  = 0.50; P  < .001), but no significant effect on anxiety (d D  = 0.13; P  = .33) or working with older adults (d D  = −0.09; P  = .40). Combined interventions with education and intergenerational contact showed the largest effects on attitudes. We found stronger effects for females and for adolescent and young adult groups.

Authors’ Conclusions. Interventions are associated with substantial reduction in ageism and should be part of an international strategy to improve perceptions of older people and the aging process. Additional research using more rigorous designs to examine the effects of interventions is strongly recommended.

Public Health Implications. Ageism has well-established negative effects on the physical and mental health of older people. Findings suggest that relatively low-cost, feasible strategies involving education and intergenerational contact can serve as the basis of effective interventions to reduce ageism.

PLAIN-LANGUAGE SUMMARY

Ageism is the stereotyping, prejudice, and discrimination against people on the basis of their age. Research has shown that ageism directed toward older adults has a negative impact on their health, well-being, and quality of health care received. The scope of ageism is expected to expand in the context of a growing aging population around the world. Despite the scope and health-related consequences of ageism against older adults, the relative effectiveness of common intervention strategies designed to reduce ageism has not been established. We sought to conduct a systematic review and meta-analysis examining the relative effectiveness of ageism interventions characterized by education, intergenerational contact, or both. Our findings showed that interventions significantly reduced ageism outcomes related to attitudes, knowledge, and comfort toward older adults. Interventions that combined elements of both education and intergenerational contact had the largest effect on people’s attitudes toward older adults. Furthermore, interventions had a stronger effect on females as well as adolescent and young adult age groups. This study suggests that relatively low-cost, feasible interventions should be adopted as a part of an international strategy to reduce ageism. Further investigation using rigorous intervention study designs is strongly recommended for future research.

Ageism, defined as stereotyping, prejudice, or discrimination toward people on the basis of age, is a mounting international concern with important health implications. 1 A substantial and growing body of research shows that ageism toward older adults is highly prevalent across countries, 2 and the scope of this problem is expected to grow with global population aging. Furthermore, compelling findings have emerged demonstrating that negative attitudes toward aging pose a significant risk to health and well-being in the later years. 3,4 Adoption of widespread negative attitudes toward aging contributes to mortality risk, poor functional health, and slower recovery from illness. 5 Holding negative perceptions of aging also predicts poor mental health. 6–8

Not only do pervasive ageist attitudes and stereotypes contribute to negative health outcomes, but ageism among health care professionals can also result in discriminatory practices that place older people at risk. Studies have found widespread negative attitudes toward older people and old age among physicians, medical students, and nurses. 9 Such ageist attitudes can lead to practical consequences for older patients, as assumptions regarding functional and cognitive decline lead to more limited provision of medical information, withholding certain treatment options, and exclusion from clinical trials. 10–13 Ageist attitudes have also been found among mental health practitioners and trainees (such as assuming that symptoms such as depression are normal among the aged), which in turn may restrict access to treatments. 14 Thus, age stereotyping and prejudice among health providers can affect the quality and quantity of care older people receive and in turn lead to negative health outcomes. 15

Ageism also promotes other forms of discrimination including the social exclusion of older persons from meaningful roles and relationships. 16 The experience of social exclusion related to unfavorable stereotypes has been identified as a chronic stressor for older people that can compromise health. 17 Age-related prejudices lead to discrimination and institutional norms based on stereotypes that limit the participation of older adults. 18 At an institutional level, ageist attitudes also inhibit the development of health policies that would benefit older individuals. 19–21

Given the extent of ageist attitudes and stereotypes and the negative consequences of ageism for health and quality of care, developing effective interventions to reduce ageism is a priority. Support for this view is provided by growing evidence that reducing ageism can promote positive health behaviors among older people. 22 Thus, developing interventions to combat ageism is increasingly viewed as a critical component of healthy aging. 23 Interventions include educating professionals and the general public, fostering contact between older individuals and young people (e.g., school-aged children, university students), and experimental attempts to change attitudes.

Despite this promise, the effectiveness of interventions to reduce or prevent ageist stereotypes, prejudice, or discrimination has not been established. 24 To date, no systematic review and meta-analysis has been conducted, to our knowledge, that addresses the effectiveness of interventions across age groups to reduce ageism toward older adults. Although the extensive literature on ageism and health outcomes sheds light on the scope and impact of the problem, there is no clear guidance about how to reduce negative views of older adults through targeted interventions.

As part of a larger initiative coordinated by the World Health Organization (WHO) to understand and address the issue of ageism, we conducted a systematic review and meta-analysis of relevant experimental and quasi-experimental intervention studies to examine the relative effectiveness of major types of ageism interventions. On the basis of previous research, 25 we categorized interventions into 3 types: educational interventions that provide instruction of some kind designed to reduce ageism, intergenerational contact interventions that feature an opportunity for contact between younger people and older people, and combined interventions that pair the 2 approaches.

We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 26 Eligible studies met the following inclusion criteria: (1) evaluated an intervention designed to reduce ageism, (2) examined at least 1 ageism outcome in relation to older adults, (3) used a design with a comparison group (randomized or nonrandomized), and (4) was published after 1970, when the ageism concept was developed. 27

Literature Search Strategy and Selection Criteria

We searched the following electronic databases (academic, gray literature) up until December 2017 by using translations of a comprehensive “ageism” search strategy developed in consultation with information specialists: PubMed, PsycINFO, AgeLine, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Index Medicus, Database of Abstracts of Reviews of Effects (DARE), Epistemonikos, Cochrane Database of Systematic Reviews, Campbell Collaboration, PROSPERO, GreyLit, and OpenGrey. The search strategy combined key terms related to “ageism,” “age discrimination,” “age prejudice,” “age stereotype,” or “social exclusion” with terms related to “elder” or “older adults” (Figure A, available as a supplement to the online version of this article at http://www.ajph.org ). We identified additional records by hand-searching reference lists of relevant review articles 25,28 and the reference lists of the studies included in this meta-analysis. Following an initial phase of removing duplicates and completely irrelevant records, 2 independent reviewers (among C. S., M. W., and C. B.) screened records for potentially eligible titles and abstracts and subsequently reviewed full texts to determine inclusion in the meta-analysis. Disagreements were resolved with a third reviewer (D. B. or K. P.) via consensus. We used Covidence systematic review management software (Veritas Health Innovation Ltd, Melbourne, Australia) to facilitate the screening process. We assessed study eligibility against a systematic review and meta-analysis protocol registered with PROSPERO (ID: CRD42018088349).

Data Analysis

Extraction..

Two reviewers (among C. S., M. W., and R. C.) independently extracted the following study-level data from records by using a common data collection spreadsheet, which was pilot-tested with an initial sample (n = 10) of records: publication year, country, intervention type and duration, research design, participant inclusion and exclusion criteria, sample size, and participant characteristics (e.g., age, gender, race/ethnicity, educational group). For each ageism outcome measure, we extracted mean and SD data for treatment and control groups. If SDs were not provided in the article or available after contacting authors (n = 15), we derived them by using other information provided in the article (i.e., means, Ns, t or F statistics). In some cases, it was necessary to assume equal SDs for control and intervention groups or for baseline and follow-up in the derivation.

Many studies had only 1 follow-up assessment point (n = 51), and the remaining studies (n = 12) varied greatly in the timing of subsequent follow-up assessments (ranging from several weeks to 5 years). For this reason, we used the first follow-up assessment (range = 1–104 weeks; mean = 15 weeks) for all studies in the analysis. We compared data collection sheets from independent reviewers on all data elements, and we resolved discrepancies through consensus.

Studies with multiple intervention arms.

Several studies contained multiple intervention arms. We selected or combined intervention groups to create a single intervention group for each study. All cases of combined arms involved, for example, identical outcomes and protocols (timing of intervention and follow-up) and comparable goals, not requiring modeling of dependence between arms. We selected the original researchers’ “combined” intervention arm when more than 1 of the 3 intervention types were represented in a study. This selection rule aligned with the theoretical expectation that a combined intervention strategy would be more impactful than an approach involving only 1 mode of intervention.

We organized the ageism measures used across studies (Table A, available as a supplement to the online version of this article at http://www.ajph.org ) into 5 outcome categories through research team consensus that reflect common categories of ageism found in the literature 25 and represent both self-directed and other-directed dimensions of the construct. 29 The meta-analysis examined 2 primary outcomes: attitudes toward aging, including aging stereotypes, perceptions, and prejudice toward older people, and knowledge on aging, including information and misconceptions on the aging process. We examined 3 additional secondary outcomes: comfort and types of behavioral interactions with older adults, anxiety about one’s own aging process, and interest in working in the field of geriatrics or gerontology. If a study reported more than 1 measure for a given outcome category, we selected the measure most commonly used within the pool of included studies. We determined this by selecting the measure that was used most commonly across the studies that considered the outcome in question.

Risk of bias and quality of evidence assessments.

Two reviewers (among C. S., M. W., and R. C.) independently appraised the risk of bias for individual intervention studies by using the Cochrane Risk of Bias Tool, which assesses studies as low or high risk for the following forms of bias: selection, performance, detection, attrition, reporting, and other. 30 We resolved discrepancies between reviewers in assessing risk of bias through consensus within the study team. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool to assess the quality of the body of evidence across studies for each ageism outcome. 31

Methods of analysis.

We carried out meta-analyses by using statistical mixed models. The dependent variables were the standardized mean differences (SMDs) over time (baseline to postintervention) for control and for intervention (outcome mean differences divided by the SD of the difference).

The primary model included treatment (control vs intervention), time of assessment (a repeated measure: baseline vs first follow up upon treatment completion) as fixed classification factors, the interaction between these factors, and studies as levels of a random classification factor. We specified an unstructured error. Random effects help to model heterogeneity among studies. We examined the effect of the intervention on study outcomes by the treatment multiplied by time interaction in this model. Results are reported in terms of differences of SMDs, denoted d D , because of the numerous measurement instruments and scale ranges used by the studies for each outcome.

We examined additional independent variables, including type of intervention (intergenerational contact–only, educational-only, combined intergenerational contact and education), educational age group (preschool or primary-school students, high-school students, university students), year of publication, country of study, randomized controlled trial versus quasi-randomized, mean age of study participants, participant percentage female, participant percentage White, and participant percentage African American. We added each of these variables to the primary model (as a fixed classification factor for categorical variables and as a covariate for quantitative variables; separate models for each variable) as well as its interaction with treatment and time. To examine whether, for example, specific study-level methodological characteristics moderated treatment effects—whether effects were stronger for or limited to certain levels of these characteristics—the focus was on the interaction with treatment, including examination of homogeneity of regressions for the covariates. 32 These examinations of moderator variables were limited to the primary outcomes, attitudes, and knowledge because of the limited number of studies assessing the secondary outcomes. We examined a measure of intervention dosage—number of weeks—in a separate model in which we regressed outcomes on these variables for the intervention group only.

In this type of meta-analysis, it is clear that an assumption of studies as fixed (a single true effect size for all studies) is inappropriate. True effect sizes will vary by studies owing not just to sampling error but also to differences in sample composition (e.g., age, ethnicity, education), methods of assessment and study protocol, variable definitions, overall study quality, and numerous other factors. We used mixed models in which we assumed studies to be random (sampled from a population of studies). We assumed effect sizes to differ by studies.

We examined the question of publication bias by constructing funnel plots with sample size plotted against SMD. 33

The database and hand searches identified 29 702 total articles, and we identified 238 records for full-text review following removal of duplicates and irrelevant records. We excluded 174 full-text records for several reasons, such as studies lacking a comparison group, pre–post assessment, ageism outcome, and usable data for the purpose of meta-analysis. Exclusions resulted in 63 34–96 studies eligible for meta-analysis with a total sample of 6124 participants ( Figure 1 ). Included studies were published between 1976 and 2018. Interventions comprised intergenerational contact–only (33.3%), education-only (36.5%), and combined intergenerational contact and education (30.2%) programs with mean duration of 12.6 weeks (SD = 16.6). Studies included both experimental (8.0%) and quasi-experimental (92.0%) designs. Participants were mostly female (67.2%) and White (66.7%) with mean age 22.4 years (SD = 9.0) across preschool and primary-school (20.7%), high-school (15.9%), undergraduate (20.6%), and graduate or professional (36.5%) educational age groups. The most common ageism outcome category was attitudes toward aging (n = 53) followed by knowledge about aging (n = 19), comfort with older adults (n = 9), interest in working with older adults (n = 6), and anxiety about own aging (n = 5; see Table A for study characteristics).

PRISMA Flow Diagram for Systematic Review of Interventions to Reduce Ageism

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Meta-analyses of the overall effect of ageism interventions for all outcomes are shown in Table 1 and for primary outcomes in Figures 2 and ​ and3. 3 . Ageism interventions demonstrated a strongly significant effect on attitudes (d D  = 0.33; P  < .001), knowledge (d D  = 0.42; P  < .001), and comfort (d D  = 0.50; P  < .001), but no significant effect on anxiety (d D  = 0.13; P  = .33) or working with older adults (d D  = −0.09; P  = 0.40).

TABLE 1—

Mixed Model Meta-Analyses of Ageism Interventions for Primary and Secondary Outcomes: Worldwide, 1976–2018

Note. CI = confidence interval; d D  = differences of standardized mean differences.

Examination of Overall Effect of Ageism Interventions on Primary Attitudes Outcome: Baseline to Posttreatment

Note. CI = confidence interval; d D  = differences of standardized mean differences; wt = weight. In 2b, the 4 rightmost columns show, in order, d D for each study (which is d D ), the lower confidence limit, the upper confidence limit, and the weight given to each study in the pooled analysis.

Examination of Overall Effect of Ageism Interventions on Primary Knowledge Outcome: Baseline to Posttreatment

Note. CI = confidence interval; d D  = differences of standardized mean differences; wt = weight. The 4 rightmost columns show, in order, d D for each study (which is d D ), the lower confidence limit, the upper confidence limit, and the weight given to each study in the pooled analysis.

In the moderator analysis (Table B, available as a supplement to the online version of this article at http://www.ajph.org ), each intervention type showed a strong effect on primary outcomes of attitudes (intergenerational-only: d D  = 0.18; P  = .026; education-only: d D  = .34; P  < .001; combined: d D  = 0.43; P  < .001) and knowledge (intergenerational-only: d D  = 0.53; P  = .005; education-only: d D  = 0.41; P  < .001; combined: d D  = 0.36; P  < .08). The combined and intergenerational contact–only intervention types demonstrated the strongest effects on the attitudes and knowledge outcomes, respectively. Gender was a significant moderating factor for attitudes (d D  = 0.01; P  = .009) and knowledge (d D  = 0.01; P  < .001), with interventions having a greater positive effect on females.

Ageism interventions had significant effects on both primary outcomes among high-school (attitudes: d D  = 0.36; P  < .001; knowledge: d D  = 0.50; P  < .027) and university-level (attitudes: d D  = 0.39; P  < .001; knowledge: d D  = 0.42; P  < .001) educational age groups. The relation between intervention dosage (number of weeks) and the attitudes outcome was positive but not significant ( P  = .09); intervention dosage was not related to knowledge ( P  = .69). There was no significant difference between ageism intervention studies using randomized controlled trials versus non–randomized controlled trial designs on the attitudes outcome. There were too few randomized controlled trials with data on the knowledge outcome to examine this effect. There was also no significant difference on primary outcomes between intervention studies from the United States versus non-US countries.

In general, studies included in this meta-analysis were found to be at high risk of bias according to the Cochrane Risk of Bias Tool (Table C and Figure B, available as supplements to the online version of this article at http://www.ajph.org ). The majority of studies used a quasi-experimental design and, therefore, demonstrated shortcomings related to randomization, allocation concealment, and blinding of participants, personnel, and outcome assessors. Using the GRADE tool, we rated the quality of evidence supporting each outcome as low–moderate, largely downgraded because of the limitations in study design (Table D, available as a supplement to the online version of this article at http://www.ajph.org ).

Although we would use a mixed model in the analysis regardless of the I 2 , the I 2 values were 78.09 for attitudes and 81.11 for knowledge. The funnel plots for attitudes, knowledge, comfort, and anxiety outcomes showed no clustering of studies in the lower-right portion of the funnel that would indicate lack of publication of smaller or nonsignificant studies; the work outcome showed some evidence of bias (Figures C and D, available as supplements to the online version of this article at http://www.ajph.org ).

Ageism, in the forms of stereotyping, prejudice, and discrimination toward people on the basis of age, has well-established negative effects on the physical and mental health of older people. However, global health strategies have not considered ageism as a modifiable risk factor. This situation is changing as the WHO has identified reducing ageism as a key target for improving human health. 23 Although numerous interventions have addressed ageism, the overall effectiveness of such programs is unknown. 24 To fill this knowledge gap, we completed the first meta-analysis, to our knowledge, of interventions designed to reduce ageism toward older people.

Our study provides a comprehensive systematic review and meta-analysis of available experimental and quasi-experimental ageism trials. In this meta-analysis, interventions significantly reduced levels of self-reported ageism among treatment participants versus controls. The size of these proportional reductions was broadly consistent across 3 intervention types, indicating that education, intergenerational contact, and combined programs provide broadly generalizable benefits. The data also suggest that interventions to reduce ageism are particularly effective among females and among adolescent and younger adult educational groups.

This study has several limitations. Given the nature of the available evidence, we were unable to rely primarily on randomized controlled studies. In the meta-analysis, 5 of the studies were randomized controlled trials and 58 employed quasi-experimental designs. Our approach was consistent with a general consensus in the field that inclusion of quasi-experimental studies is justified when more rigorous trials are lacking. As has been recommended, 97 we excluded the weakest designs (including observational studies and single-group before-and-after studies) and only included studies that employed an analysis of a treatment and a comparison group with pre and post assessments on each group. The inclusion of non–randomized controlled trials that used comparison group designs is justified because it allows us to address outcomes from pragmatic implementations of ageism interventions that have not been sufficiently studied in randomized controlled trials. 98 Our analysis comparing studies using randomized controlled trial versus non–randomized controlled trial designs found no significant differences on the primary outcome (attitudes) with enough studies to conduct such an analysis. However, findings reported in this article should be interpreted with caution because of the methodological limitations of the studies included. This observation points to the need for future studies to employ randomized controlled designs.

Our review also uncovered 2 important gaps in the ageism intervention literature. First, the majority of ageism intervention studies were from the United States, which may contribute to location bias; future research is necessary in other contexts throughout the world to understand whether the effect of certain interventions varies across different cultures and age-related social norms. Second, studies that examined the effect of ageism interventions among older adults themselves were lacking. Such research is critical given evidence of internalized ageism among older adults and their implicit preferences for younger adults. 7

The most important implication of this meta-analysis, however, is the encouraging potential for interventions to reduce ageist stereotyping and prejudice. Furthermore, most of the interventions included in this review were small-scale, low-cost programs. Positive effects were found in intervention over comparison groups in most studies, and negative effects of interventions were rare. Interventions that included both educational and intergenerational contact components demonstrated particularly strong effects, especially for combating negative attitudes toward aging, suggesting that such combined programs should be a high priority for rigorous testing and dissemination. Furthermore, given that ageism constitutes a global crisis, interventions must be developed that are adapted for different national and cultural contexts. Our findings suggest that intervention research will lead to substantial progress in combating ageism and, in turn, improving the health and well-being of older people.

ACKNOWLEDGMENTS

This study was funded by the Bronfenbrenner Center for Translational Research at Cornell University and the Social Sciences and Humanities Research Council of Canada (435-2017-0578). K. P. acknowledges support from a Roybal Center Grant from the National Institute on Aging (P30AG022845).

We thank Vânia de la Fuente-Núñez and Alana Officer for overall guidance and coordination, and for developing the search strategy together with Kavita Kothari and Tomas Allen. We thank Gražina Rapolienė, Sarmite Mikulioniene, Justyna Stypinska, Joana Mendonça, and João Mariano for their assistance in the removal of completely irrelevant records. We also thank Cary Reid for assistance in manuscript review and feedback.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to report.

HUMAN PARTICIPANT PROTECTION

Institutional review board approval was not needed because human participants were not involved.

See also Nelson, p. 1066 .

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Ageism in the Nursing Care of Older Adults

A concept analysis.

Hammouri, Ammar MSN, RN; Taani, Murad H. PhD, MPH, RN; Ellis, Julie PhD, RN

College of Nursing, University of Wisconsin-Milwaukee.

Correspondence: Ammar Hammouri, MSN, RN, College of Nursing, University of Wisconsin-Milwaukee, 1921 East Hartford Ave, Milwaukee, WI 53211 ( [email protected] ).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Despite the high prevalence of ageism worldwide, it is still underestimated and unrecognized by many nurses. Concept clarification is required to delineate the meaning of the word “ageism” in nursing. The purpose of this concept analysis is to clearly define the concept of ageism relative to nursing discipline using the Walker and Avant method. Defining the concept of ageism will provide nurses with a better understanding of its causes and consequences. It will aid policy makers in developing policies and interventions to help decrease ageism in health care environments.

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Ageism and age discrimination in health care: Fact or fiction? A narrative review of the literature

Affiliations.

• 1 School of Health Nursing and Midwifery, University of the West of Scotland, Hamilton Campus, Almada Street, Hamilton, Lanarkshire, Scotland, United Kingdom. Electronic address: [email protected].
• 2 School of Health Nursing and Midwifery, University of the West of Scotland, Hamilton Campus, Almada Street, Hamilton, Lanarkshire, Scotland, United Kingdom.
• PMID: 26044073
• DOI: 10.1016/j.maturitas.2015.05.002

Ageism and age discrimination are terms used in best practice statements and in the literature to define negative attitudes towards older people and towards people because of their age (whether old or young). However, 'old age' is a nebulous concept with definitions ranging from the over 50s to the over 85s. In seeking to explore ageism and age discrimination within health care, this paper discusses the concept of 'old' and discusses the findings of a narrative review of the literature on these two concepts. Results show that negative attitudes have been perceived by users of health care services, but the reasons are not clear. Such attitudes are usually reported in acute health care settings, where targets and quick turnover are encouraged. Thus people, usually those with complex needs, who require longer periods of recuperation and rehabilitation following an episode of ill health, are troublesome to staff working in a system geared up for early discharges. This type of service user is usually over the age of 85. Recommendations from this paper include the need for acute frailty units, with well trained staff, where frail older people can be comprehensively assessed, receive timely and targeted care, followed by a supported discharge.

Keywords: Age discrimination; Ageism; Health care; Old age; Person centred.

Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

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• Published: 30 August 2024

Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial

• Raziyeh Ghafouri 1 ,
• Vahid Zamanzadeh 1 &
• Malihe Nasiri 2  

BMC Medical Education volume  24 , Article number:  949 ( 2024 ) Cite this article

Metrics details

Since effective education is one of the main concerns of every society and, in nursing, can lead to the education of successful people, the development of learning and teaching methods with greater effectiveness is one of the educational priorities in every country. The present study aimed to compare the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment.

The present study was a Parallel randomized clinical trial study. The participants were 166 nursing students. The clinical trial data was collected from December 14, 2023, to February 20, 2024. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. The participants were allocated to four groups with colored carts. In the first group, teaching was performed via gamification in a flipped learning environment; in the second group, teaching was performed via the gamification method. A flipped class was implemented in the third group. In the fourth group, the usual lecture method was used. The practical performance to assess the physical health assessment with 10 questions using the key-feature questions, along with the satisfaction and self-efficacy of the students, was also checked with questionnaires.

In this study, 166 nursing students, (99 female and 67 male), with an average (standard deviation) age of 21.29 (1.45) years, participated. There was no statistically significant difference in the demographic characteristics of the participants in the four intervention groups ( P  > 0.05). Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). In the comparison of the four groups, the ANOVA results for the comparison of the average scores of knowledge evaluation and satisfaction after intervention among the four groups indicated a statistically significant difference ( P  < 0.001). When the knowledge evaluation scores of the groups were compared, the scores for gamification in the flipped learning environment were significantly different from the other methods ( P  < 0.05), and there was no significant difference between the scores for the flipped class and lecture methods ( P  = 0.43). According to the ANOVA results, when comparing the satisfaction scores of the groups, the students in the flipped learning environment and gamification groups were more satisfied than the flipped class and lecture groups ( P  < 0.01).

Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

Peer Review reports

Introduction

Effective education is one of the main concerns of every society [ 1 ]. Because the traditional methods of teaching, learning and management have little effectiveness [ 2 ], multiple learning strategies of active learning and the use of technologies [ 3 , 4 , 5 ], it is helpful to integrate the classroom approach among these methods. The reverse is the use of a playful method [ 6 , 7 ]. The flipped classroom was presented in 2007 by Bergmann and Sams, two chemistry teachers at Woodland Park High School in Colorado (USA). Their goal was to ensure that students who could not attend class for various reasons could proceed at the pace of the course and not be harmed due to not attending class [ 8 ]. Bergmann and Sams videotaped and distributed instructional content and found that this model allowed the teacher to focus more attention on the individual learning needs of each student [ 5 , 8 ].

In 2014, the Flipped Learning Network (FLN) was introduced, in which flipped learning was defined as “an educational approach in which direct instruction is transferred from the group learning dimension to individual learning, and in a dynamic and interactive learning environment, where the instructor guides students in applying concepts and engaging creatively with course content”. The four pillars of flexible environment, learning culture, purposeful content and professional instructor have been described in opposite directions [ 9 , 10 ]. In addition to the ever-increasing complexity of the healthcare environment and the rapid advancement of healthcare technology, a global pandemic (COVID-19) has affected educational structures. The pandemic has caused a global educational movement toward blended learning to meet students’ technological and hands-on learning needs. Indeed, at no time in history has there been such a sudden transition to this type of learning [ 11 ], where the flipped classroom was widely used [ 9 ].

In nursing education, the use of flipped classrooms [ 9 , 12 ] and technologies [ 3 , 5 ] has been emphasized. The results obtained in the systematic review of the effect of the flipped classroom on academic performance in nursing education indicated its positive effect, and the opinions of most students about this method included aspects such as its usefulness, flexibility, greater independence or greater participation [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. According to the cognitive bases related to the Bloom’s taxonomy, with the flipped classroom method, the student works in the first stage of the learning process at home, which is the simplest stage, and in the second stage, through active learning with the help of the teacher and classmates, in class time, which is used to increase and empower more [ 20 , 21 ]. In addition, the flipped classroom method has certain advantages over traditional learning. The flipped classroom is student-centered and makes students responsible for their own learning [ 22 ], and its use in nursing has been emphasized in systematic review studies [ 3 , 23 , 24 ].

One of the interactive teaching methods using computers is the gamification method. Gamification in education includes the use of game elements to increase motivation and participation and to involve students in the personal learning process [ 1 , 25 ]. Gamification is an active education method. The gamification system increases the level of engagement and motivation of learners by provoking excitement and creating challenges for them. Additionally, with this method, it is possible to provide an opportunity for testing, and in that test, in addition to creating a challenge, learners are given the opportunity to display their achievements through competition [ 26 ].

Nursing education institutions are obliged to improve the ability of nursing students to make correct clinical judgments through various educational programs and the use of new teaching methods [ 27 , 28 ] so that when nursing students enter the clinic, they can fulfill their role as members of the medical team [ 27 ]. Therefore, it is necessary to carry out more research regarding the identification of effective teaching methods that can improve the attractiveness of education and its satisfaction among nursing students [ 1 , 27 ].

This study addresses the lack of comparative research on the effectiveness of flipped classrooms and gamification in nursing education, an area that has not been sufficiently explored. The advantages of combining education methods are that they can be used together [ 6 , 7 ]. For example, by combining education using the flipped class with gamification, more study time is provided by using the flipped class, and the attractiveness of the method is provided by gamification [ 7 ]. Therefore, considering the attractiveness of the new application that is prepared in a flipped class, the current research was conducted aimed at comparing the effects of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in terms of client health assessment.

The present study was a parallel randomized clinical trial research aimed at comparing the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment. The clinical trial data was collected from December 14th, 2023, until February 20th, 2024.

Participants

First, in a call, 247 nursing students registered to participate in the study. After checking the entry criteria, 188 people met the entry criteria for the study. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. Exclusion criteria were: miss the mobile and drop out of study, for example, because of transferring, migration or do not like to continue participating in the study. So, 18 students were excluded from study for unwillingness to continue, 2 students because of migration were excluded, and 2 people were excluded for missing their mobile (Fig.  1 ).

Study and sampling process

The participants were allocated to four groups with using colored carts. Before sampling, 188 carts in 4 blue, red, black and white colors (from each color, 45 carts) were prepared in one enveloped pocket. After completing the informed consent and pre-test questionnaires, each student took a colored card from the enveloped pocket. Then, with the lottery, it was determined that the participants with the blue card participated in the gamification in a flipped learning environment, the red cart in the gamification, the black cart in the flipped class, and the white cart in the lecture method. The study and sampling process is shown in Fig.  1 .

Intervention

The education course was 4 class in 60 min of health status assessment in 4 weeks. Each group has a classroom weekly. Education content was health assessment and clinical examination courses of the Bachelor of Nursing Education curriculum. Course plan was developed based on the curriculum.

For intervention, the application was designed using the cascade model (initial analysis, system analysis, design, programming, testing (alpha and beta), implementation and modification) [ 29 , 30 ]. In the initial analysis stage, the need or the desired problem, which is the issue of education improvement, is raised, and can technical solutions be provided for it? If there are possible solutions, the practicality is evaluated, and in the analysis of the visual appeal system, the up-to-date information, simple language, and comprehensiveness of the information provided in the educational content are checked. In the design phase, the design of the desired system was written, and a program was written by the programmers according to the initial design of the system.

The educational content of the application was prepared based on the health assessment and clinical examination courses of the Bachelor of Nursing Education Program, approved by an expert panel. The application was designed in two parts: education and scenario-based games. In the education section of the application, the content of the education was presented, and in the scenario base game section, the 10 scenarios of health status assessment and clinical examination were designed based on real situations.

In the scenario base game section of the application, the application was embedded as a game in such a way that the student, at the first, observes the chief compliance of the patient, and they must complete patient examinations and choose the correct answer. If they choose correctly, they will take a green cart, and if they make a mistake, they will take a red cart. They could take 4 green carts in each scenario. A yellow cart was shown when the answer was not incorrect, but it was not an exact answer. In each scenario, they must find the correct nursing diagnosis. They must provide a nursing diagnosis based on the priority of care in the scenario.

The fundamental elements of gamification are mechanics (motivating students through points, budgets and rewards), dynamics (engaging users through stories and narratives), and aesthetics (user experiences from applications about being user-friendly and attractive) [ 31 , 32 , 33 ]. The mechanics element was considered in the application, with green carts in each stage. The dynamic element was considered in the scenarios. The aesthetic element was considered and checked in alpha and beta tests.

In the test phase, the Application was checked for errors, and it was tested for user acceptance in two parts, the alpha and beta tests. In the alpha test, the program was used by the designers (four academic nurses and 4 IT men) as users, and in the beta test, a group of users (20 nursing studentsThe fundamental elements of a flipped class are that the students must read the content before the class and do the assignment in the class. In this study, this element was considered, and the provided content was given to participants at first. The students read content for each class before the class, and they solved the assignment in the class. The provided content for the flipped class group was designed in the PowerPoint files, and for the gamification in the Flipped Learning Environment group was designed in the application.

It was improved based on their opinions, and in the next stage, the approved application by the designer and user was used in this study.

Lecture group

In the Lecture group, the content of the education was held in the lecture method, and in each section, at the end of class, a scenario of the designed was given to the students as an assignment. They must solve it by next week. At the end of the study, four scenarios were performed by the students as assignments in this group.

Flipped class group

In the Flipped class group, the content was prepared in the four voiced PowerPoints and presented them to the students in the first session. Students read the content of each class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were discussed by the students as assignments in this group.

Gamification group

In the Gamification group, in each class, after the educational content was presented, the homework was presented, and students played a scenario of application in the class. Four scenarios were performed by the students as assignments in this group.

Gamification in the flipped learning environment group

In the Gamification in the Flipped Learning Environment group, the designed mobile application was presented in the first session of the course. Students must read the content of the session before the class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were performed as homework by students in a gamification environment.

Data collection tools

In this study, a questionnaire with 10 key-feature questions (KFQs) was designed by an expert panel of 10 academic nurses. After designing a KFQ questionnaire, its validity and reliability were examined. Validity was confirmed with a content validity ratio (CVR) of 14 expert (academic nurses) and qualitative validity with 7 academic and 7 clinical nurses; reliability was checked by test-retest. The CVR of the questionnaire was 0.96 and was confirmed. All seven academic and seven clinical nurses confirmed the qualitative validity of the questionnaire. The content validity coefficient based on the number of participating professors (at least 10 people) is 0.49 as the minimum acceptable according to the Lauwshe Tables (18, 19) and the necessity of the items of tools was confirmed.

For the test-retest of KFQ questionnaire, 10 nursing students participated. They filled out the questionnaire twice, with an interval of two weeks. The correlation coefficient between their answers was 0.93 with Spearman’s correlation coefficient. The correlation coefficient above 0.7 is good [ 34 , 35 ].

Additionally, education satisfaction was investigated with the Measuring Student Satisfaction Scale from the Student Outcomes Survey [ 27 ], which includes 20 items. The validity of it was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.91 and was confirmed. Cronbach’s alpha was 0.69. Cronbach’s alpha coefficient above 0.7 is good, 0.3–0.7 is good, and less than 0.3 is poor [ 34 , 35 ]. The overall Cronbach’s alpha was appropriate reliability.

The Sherer questionnaire tool was used to assess the self-efficacy of the nursing students [ 36 ]. This tool contains 17 items on a five-point Likert scale. Sherer et al., confirmed the reliability of the questionnaire with Cronbach’s alpha 0.76 [ 36 ]. Also, for this questionnaire, the validity was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.90 and was confirmed. Cronbach’s alpha was 0.45.

Data analysis

The analysis of the research data was performed using the Statistical Package for Social Sciences version 20. The Kolmogorov-Smirnov test was used to assess the normality of the data. Data analysis was performed by using descriptive tests, such as percentage, mean and standard deviation, and statistical tests, such as the chi-square test, paired t test, and ANOVA. In all statistical tests, a significance level was considered less than 0.05.

In the present study, 166 nursing students, 99 women and 67 men, with an average (standard deviation) age of 21.29 (1.45) years, were participated. The demographic characteristics of the participants are shown in Table  1 . The homogeneity of the intervention and control groups was checked with statistical methods, and the results are reported in Table  1 . There was no statistically significant difference in the demographic characteristics of the participants in the groups ( P  > 0.05).

Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). Table  2 shows the results of paired t tests.

The ANOVA showed that a statistically significant difference between the mean scores of knowledge and satisfaction after intervention in the four groups ( P  < 0.001). The result of the ANOVA was not significant difference between the mean of the self-efficacy after intervention in the four groups ( P  = 0.101).

In the analysis of the groups, there was a significant difference in the comparison of the knowledge evaluation scores, such that there was a significant difference between the average of the gamification methods in the flipped learning environment group and the gamification compared to the inverted class and lecture, considering equal variance ( P  < 0.001). There were significant differences at the 0.05 level between the two gamification methods in the flipped learning environment group and the gamification group ( P  = 0.03). Gamification and flipped classes had no significant difference ( P  = 0.054). There was no significant difference between the two methods of flipped class and lecture ( P  = 0.43).

According to the ANOVA results, when comparing the satisfaction scores of the groups, there was no significant difference between the means of gamification in the flipped learning environment and the gamification method ( P  = 0.49); however, there was a significant difference between the gamification in the flipped learning environment and the gamification with the flipped class and the lecture. Additionally, there were significant differences between the flipped class and the lecture method ( P  < 0.01).

Discussions

This study aimed to compare the effects of the lecture method, flipped class and gamification in a flipped learning environment on the performance of nursing students in assessing the health status of clients. The demographic characteristics of the participants (gender, age, academic semester, grade point average and theory course score) had the same distribution among the four groups, and there was no statistically significant difference ( P  < 0.05).

Comparing the results before and after the training, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P  < 0.001). The results indicate that all four teaching methods effectively affected the learning, satisfaction and self-efficacy of students in evaluating the health status of their clients. However, in the comparison of the 4 groups, ANOVA revealed a statistically significant difference ( P  < 0.001). In the analysis comparing the knowledge evaluation scores of the gamification group with those of the other methods group, there were significant differences ( P  < 0.05), and there was no significant difference between the two methods (Flipped class and lecture) ( P  = 0.439). According to the ANOVA results, the satisfaction scores of the groups were greater for the gamification in the flipped learning environment and gamification groups than for the flipped class and lecture groups ( P  < 0.01). The results of the present research indicate that teaching methods have an effect on students’ learning and satisfaction.

Rachayon and his colleagues also used a task-based learning method in combination with digital games in a flipped learning environment to develop students’ English language skills, and their results also indicated the success of combining the above methods [ 7 ]. Muntrikaeo and his colleagues also used a similar model of task-based learning in combination with games in a reversed environment for teaching English, and their findings were also successful [ 6 ]. The results of the current research, which involved the integration of the gamification in the flipped learning environment for teaching health status assessment to nursing students, are similar to those of the above research.

Zou et al., in their systematic review, found that success in the flipped classroom is related to teachers’ creativity in making the classroom interactive, students’ readiness, and the use of technology [ 37 ]. In the present study, the flipped class, along with the use of gamification in the flipped learning environment, increased learner satisfaction and learning. Therefore, their findings are similar to the findings of the present study.

Hernon and his colleagues reported that the use of technology plays a significant role in the development of nursing students’ skills [ 4 ]. Regarding the use of educational applications for health assessment, the results of their research are the same as the current research, and the use of technology not only plays a role in learning but also it has role in education satisfaction. Considering the results of the present study and similar studies, we can conclude that the use of gamification in the flipped learning environment is an interactive teaching method and can be used to improve nursing education. Gamification can increase the attractiveness of education and promote education. If a good application is designed as a flipped enviroment, it provides more time in the classroom for discussion, interaction, and scenario-based education and promotes education satisfaction.

In this study, the satisfaction with education had a significant difference between the groups, but the students’ self-efficacy, despite the significant difference before and after the intervention, did not have a significant difference between the groups. Since all three studied methods were effective in students’ learning and self-efficacy, it can be said that teachers can improve educational effectiveness and satisfaction by using different methods and combining them in educational situations by considering resources and conditions.

The gamification method was associated with higher satisfaction, but it requires more resources, equipment, and skilled personnel. The flipped class method requires fewer resources, is more cost-effective, and provides more time for practice and group discussion. By combining these two methods, the advantages of both can be used, which is confirmed by the results of the present study. It seems that the upside-down environment provides a good opportunity for life-long training, including the promotion of interaction and teamwork, and along with other methods, it is also associated with more effectiveness and benefits.

In this study, knowledge and satisfaction of education had significant differences between groups, but students’ self-efficacy had not significant difference between groups. Maybe it was due to the fact that we participated in the second and third semesters of nursing students, and the interactive skills of students were not assessed. So, the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using gamification in a flipped environment.

Therefore, this method is helpful in nursing education as well as other medical fields. It is suggested that this method could be combined with other educational methods, such as task-based and team-based methods, to develop the possibility of developing team-based education and task-based education. Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction with effective education, and with the use of appropriate applications, it is necessary to create a sense of competition and learning. But, in this study, the interactive skills of students were not assessed. Finally it is emphasized that teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

The teaching method has an effect on students’ satisfaction with the teaching method, and the use of gamification in the flipped learning environment is more effective than the flipped class method, gamification, and the lecture method. Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

Limitations

Not installing the program on IOS phones made it impossible for these users to use the application and drop out study, so we recommended that designed application for android and IOS. The ability of the professor to teach with the method of gamification in the flipped learning environment and his mastery of the application are necessary to provide necessary training to the teachers regarding the above methods.

Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction. But, in this study, the interactive skills of students were not assessed. So the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using the gamification method in an upside-down environment.

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

The authors also wish to thank all the participants and those who helped us in carrying out the research especially all the staffs of Department of Medical Surgical Nursing of School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences.

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VZ and RG formulates the research question that represents the systematic review objective. VZ and RG provide proposal and reports. RG collected the data. MN: Data analysis. All authors read and approved the final manuscript.

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This study was approved by the ethics committee of Shahid Beheshti University of Medical Science (IR.SBMU.PHARMACY.REC.1402.152), and all methods were carried out in accordance with the research ethical codes of the Iran National Committee for Ethics in Biomedical Research. The authors guarantee that they have followed the ethical principles stated in the Declaration of Helsinki (to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information of research subjects) in all stages of the research. This is the online certificate of the research ethical code: https://ethics.research.ac.ir/ProposalCertificateEn.php?id=404003&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true . This study was registered in the Iranian Registry of Clinical Trials ( https://irct.behdasht.gov.ir ) on 14/12/2023, with the IRCT ID: IRCT20210131050189N7. To observe ethical considerations, School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences agreed to participate in the study; the research goals and procedures were elucidated to the participants, the participants were assured of information anonymity and confidentiality, and informed written consent was obtained from each participant and documented. They participated in the study voluntarily and could leave the study at any stage.

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Ghafouri, R., Zamanzadeh, V. & Nasiri, M. Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial. BMC Med Educ 24 , 949 (2024). https://doi.org/10.1186/s12909-024-05966-2

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Received : 15 March 2024

Accepted : 28 August 2024

Published : 30 August 2024

DOI : https://doi.org/10.1186/s12909-024-05966-2

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