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 disorders, where issues of capacity and autonomy are central. Legislative reforms over the past 50 years have contributed to a decline in the use of physical restraints, particularly in long-term care, although rates vary significantly between countries (Liang and Huang 2023). Despite these improvements, restraint use among people with dementia remains disproportionately high, often due to ambiguous definitions and inconsistent practices (Pu and Moyle 2020), suggesting gerontological nurses have not had a strong role in this area of practice. Additionally, the expansion of palliative care and the emergence of 'right to die' policies have underscored the need for comprehensive education in dementia and palliative care for all nurses working with older adults. However, despite the availability of educational opportunities, the number of nurses with advanced specialist training in gerontological care remains low (McCleary et al. 2017; Mueller and Crogan 2020). In response to these challenges, a global movement has emerged to ensure 24/7 registered nurse (RN) coverage in long-term care. In Australia, this initiative will become mandatory for all registered long-term care facilities from 1 November 2025 (Australian Government, DoH 2025). While this policy represents a significant step forward in improving care standards for older adults, many long-term care facilities report difficulties in recruiting suitably qualified RNs. The shortage of nurses with gerontological expertise means that those employed often lack the necessary knowledge and skills to provide appropriate, high-quality care to older adults. In recent years, the establishment of the Age-Friendly Health Systems has introduced evidence-based models of care with a strong interdisciplinary foundation. Central to these systems is the 4Ms framework: What Matters (e.g., identifying and respecting individual's goals, preferences and values), Medication (e.g., minimising medication harm), Mentation (assessment and care for cognitive health) and Mobility (supporting physical function). This framework was established by the US Hartford Foundation and the Institute for Healthcare Improvement (IHI). Since its launch in 2018, more than 1000 hospitals across the US have adopted the initiative, placing older adults and their carers at the centre of care planning and delivery. The Age-Friendly Health Systems movement has also been recognised globally in countries such as Australia, Canada, New Zealand, Singapore, South Korea, Taiwan and Japan. Within these systems, staff and students are encouraged to assess, plan and communicate with patients through the 4M lens, ensuring that care is person-centred, safe and effective. This initiative has elevated the visibility and importance of gerontological care, reinforcing the need for healthcare systems to prioritise the unique needs of older adults. Technological advancements, including the development of new medications, have accelerated significantly over the past 50 years. During the peak of the COVID-19 pandemic, telehealth emerged as a vital tool for assessing and treating older adults in long-term care settings (Choi et al. 2022), while also facilitating social engagement and connection (Drazich et al. 2023). Families increasingly relied on virtual communication platforms to maintain relationships with family members in care (Moyle et al. 2020). The expansion of technologies that support functional capacity, such as dialysis, blood pressure monitoring and blood sugar monitoring, has contributed to increased longevity among older adults. Furthermore, communities are equipped to support older adults in staying at home and being discharged earlier through virtual monitoring (Angell 2025). Gerontological nurse practitioners play a critical role in promoting the health and wellbeing of both community and institutionalised older adults. They must stay abreast of advances in technology, as innovations such as social robots, for example, are gaining traction in care, particularly in care for people with dementia (Moyle 2019). Additionally, the rise of artificial intelligence and mobile health (mHealth) applications presents new opportunities for gerontological nurses to utilise and positively impact the health and wellbeing of older adults and their carers (Rathnayake et al. 2019). Growing global attention to climate change has highlighted the vulnerability of long-term aged care settings during environmental catastrophes such as earthquakes, floods and fires (Sidney et al. 2025). In these emergencies, gerontological nurses have often been required to relocate and manage large groups of older adults from long-term care under challenging conditions. Without adequate emergency preparedness, many lives could be lost. Therefore, integrating disaster management and climate-related emergency response into gerontological nursing curricula is essential, especially as such events are expected to increase in frequency and severity due to climate change. The COVID-19 pandemic further exposed the fragility of aged care systems worldwide, placing immense pressure on healthcare professionals, particularly nurses in long-term care. Older adults were disproportionately affected by the virus (Dangwa et al. 2022; Thompson et al. 2020) and the necessary preventative measures, such as isolation, led to increased risks of loneliness and social disconnection (Adepoju et al. 2022). During this time, gerontological nurses were tasked with meeting the complex needs of older adults, often while facing resource shortages and personal risk while providing care. COVID-19 revealed systemic vulnerabilities in long-term care facilities, including the spread of infection through staff working while contagious, unskilled personnel, staff employed across multiple facilities, limited access to personal protective equipment, inconsistent infection control protocols and inadequate testing procedures (Thompson et al. 2020). Despite these lessons, the global shortage of gerontological nurses remains a significant concern. Calls for mandatory staffing of qualified professionals in long-term care, such as those made in the US (Kolanowski et al. 2021), have yet to be fully realised in many countries. Although gerontological nurses can significantly benefit care provision and mitigate the negative consequences of a pandemic, the cost factor has prevented many care providers from addressing this issue (Dangwa et al. 2022; Kolanowski et al. 2021). Gerontological Nurse Practitioners (GNPs), as advanced specialists, are uniquely positioned to lead pandemic preparedness and response efforts. Their expertise can help mitigate the impact of future health crises, especially in long-term care settings. However, financial constraints continue to hinder the employment of GNPs in many care settings, despite evidence of their value in improving outcomes for older adults (Dangwa et al. 2022; Kolanowski et al. 2021). The fear of another pandemic persists among healthcare staff, underscoring the urgent need to invest in specialised gerontological nursing education and workforce development. This paper demonstrates the advancement that the nursing profession has made over the past five decades in care for older adults. However, many challenges persist. The following outlines potential strategies for addressing these challenges and guides the nursing profession on how to adapt to meet future demands. Gerontological nurses must remain committed to caring for older adults, as the challenges associated with this population will persist. To overcome such challenges, a concerted global call for action is needed from Nursing organisations, healthcare agencies, governments, the World Health Organisation, and the United Nations to address these issues. Furthermore, adopting the term 'gerontological nursing' as the exclusive term within the profession may help advance gerontological nursing as a specialty and consequently address the need for specialist education and recruitment. A higher ratio of gerontological nurse specialists is needed, particularly for adults aged 85 years and older. This is a relatively new phenomenon that we have not previously encountered, and we lack global knowledge on how to manage this old-old population growth. However, there is little doubt that we will require more nurses with specialist education to care for the growing older population. The profession must address this challenge in the undergraduate and postgraduate curricula. Alongside ageing, there has been a growth in the prevalence of cognitive impairment. However, it is unclear whether recent advances in knowledge and dementia treatments will reduce this growth or if further growth will require more specialised care across settings. Gerontological nurses will be key to developing appropriate, cost-effective and high-quality services that include family carers for this population. We continue to place older people who require assistance with care into institutionalised care despite what research has told us about the negative impact of institutional care on multiple aspects of wellbeing in late life. However, we must think beyond this type of care, as the growth in the ageing population and the current limited number of specialists available must be considered. Successful interventions for places to live, such as cluster housing and small-scale housing (Longstaff et al. 2022), should be explored to enable older adults to live at home or outside of institutional care for longer periods. Furthermore, person-centred, evidence-based care is essential for achieving quality older person care and must be delivered by knowledgeable and skilled practitioners. There is a critical need to rapidly increase the gerontological nursing workforce because of the ageing of the global population. Currently, only a small percentage of the registered nurse workforce holds qualifications in gerontological nursing. The number of registered nurses (RNs) working in long-term aged care is particularly low (Australian Government, DoH 2020; Jiang et al. 2023; Mueller et al. 2024). Furthermore, long-term care settings continue to face challenges due to staff shortages, often stemming from low morale, lower salaries, inadequate support and staff bullying (Kennedy et al. 2021; Kolanowski et al. 2021). Additionally, poor role differentiation among RNs working in long-term care fails to capitalise on the unique impact that RNs can bring, leading to difficulties in recruitment and retention (Kolanowski et al. 2021). Investment in education that involves the care of older adults, including the recruitment and training of faculty with expertise in gerontology, along with innovative strategies to recruit and retain gerontological nurses, is urgently needed to ensure an adequate current and future workforce that can deliver high-quality care to older adults. There has been a reliance on nursing assistants in long-term care to provide the mainstay of care. However, the frailty and complexity of the ageing population are demanding higher levels of specialist nurses to provide for the complexity of resident care needs. Some care providers have implemented innovative measures, such as employing highly skilled gerontological nurse practitioners (GNPs) to assess and treat residents, thereby enhancing resident care and reducing hospital admissions. Additionally, GNPs play a crucial role in educating staff. By reducing hospitalisation and improving resident care, they are cost-effective team members (Dangwa et al. 2022). Furthermore, allied health professionals have assumed a more prominent role within aged care services, suggesting that if gerontological nurses do not strengthen their role and advocate for specialisation, they will become increasingly marginalised in the system. The scope of practice for gerontological nurses needs to be reviewed, especially in long-term care, where their skills are often misused and underutilised (Resnick et al. 2022). Suppose gerontological nurses can practice to the full scope of their licence without needing to seek approval from long-term care providers for the giving of specific treatments. In that case, this will facilitate the management of common challenges and give RNs the confidence to provide quality care. The profession must advocate for policy change to ensure the full scope of practice can be achieved. Nursing students are the future of gerontological nursing, and we must help them plan their career choices and decision-making in gerontological nursing (Chai et al. 2019). Therefore, we must ensure that they are educated and possess the appropriate skills and attitudes to care for this population. Mentorship is essential for encouraging new graduates to work efficiently and with confidence in their chosen area. A recognised means to encourage students' positive attitudes toward older adults is through focused teaching strategies in the curriculum that incorporate service-learning and simulation activities (Magan et al. 2023). Furthermore, governments must invest in gerontological nursing education to expand opportunities and strengthen this workforce. There has been an increase in marginalised groups such as transgender, homosexual and refugee individuals in aged care services. Gerontological nurses must lead the way in the care and management of such groups to ensure they are provided with equitable and quality care without stigmatisation. Therefore, they need education and skills to provide such care. There is much work to be done to ensure a constant supply of RNs with gerontological nursing education ready for the future needs of the ageing population. While this manuscript demonstrates the advancement that the nursing profession has made over the past five decades, despite the challenges, we must seek innovative means to improve practice and meet workforce requirements if we are to ensure an environment that can provide appropriate care for older adults. Open access publishing facilitated by Griffith University, as part of the Wiley - Griffith University agreement via the Council of Australian University Librarians. The author has nothing to report. No patient participation within this study. The author declares no conflicts of interest. The author has nothing to report.