The current growth in the aging population highlights the need for healthcare professionals who are willing to work with older adults. Previous studies suggest that knowledge about older adults, ageism, and personal relationships with older adults may influence career preferences in geriatric care.

To examine the direct relationship between healthcare students’ knowledge of older adults and their willingness to work with this population, as well as to explore the indirect effect of ageism as a mediator and the moderating effect of a connection with grandparents.

A cross-sectional study using a closed self-reported questionnaire.

The largest academic Faculty of Medical and Health Sciences in Israel.

Out of 350 final-year students, 241 (68.9% response rate) agreed to participate in the study, including students from nursing (47.3%), medicine (36.9%), and physiotherapy (15.8%).

The participants completed a self-administered questionnaire addressing demographic characteristics, willingness to work with older adults, knowledge, ageism, and relationships with grandparents. Mediator-moderator analyses were conducted to explore the roles of ageism as the mediator and the connection with grandparents as the moderator. The bootstrapping method (PROCESS model 5) was employed to assess indirect effects.

Positive correlations were found between willingness to work with older adults and both knowledge about older adults (r = 0.15, p < 0.05) and connection with grandparents (r = 0.16, p < 0.05), while ageism negatively correlated with both willingness to work with older adults (r = -0.18, p < 0.05) and knowledge about older adults (r = -0.19, p < 0.05). The mediation analysis revealed that knowledge about older adults significantly increases willingness to work with them, both directly and indirectly through reduced ageism. Moderation analysis revealed that the relationship between knowledge and willingness to work with older adults was significant only for those with a poor connection with grandparents.

This research underscores the crucial role of knowledge, ageism, and connection with older people in shaping healthcare students’ willingness to work with older adults. Interventions addressing social connections can foster interest and engagement in the care of the older adults, particularly among students with limited grandparental relationships.

The global population is experiencing a significant demographic shift, with an unprecedented increase in the proportion of older adults. By 2050, an estimated 22% of the world’s population will be aged 60 and over [1, 2]. This demographic transition is driving a growing demand for geriatric healthcare professionals who can provide both short-term and long-term care for older patients [3]. Quality and compassionate care should be the cornerstone of all healthcare practices, and are particularly important for older adults who are more susceptible to declining health and independence [2]. They can be provided by healthcare practitioners who possess not only a comprehensive understanding of patient conditions and needs but also have the appropriate attitude and willingness to deliver such care. Current healthcare students, excluding those specializing in younger populations, will inevitably encounter a large number of older patients with varied and often multiple biopsychosocial conditions in their future practice [4].

Research has consistently demonstrated a link between low levels of knowledge about aging and disinterest in working with older adults [5, 6]. Conversely, structured gerontological experiences can significantly improve students’ attitudes and interest in working with older adults patients [7, 8]. Despite the growing need, research indicates that geriatrics remains an uncommon career path choice for healthcare students [9]. Contributing factors include limited exposure to the field, financial considerations, perceived status, and the nature of the work [10, 11].

Given that attitudes and knowledge are closely associated with the quality of patient care [7, 12], it is crucial to investigate the willingness of future practitioners to work with older adults. This information can inform educational strategies and policy decisions aimed at addressing the growing demand for geriatric care professionals.

Willingness to work with older adults is a multifaceted concept that requires readiness and intention to engage in caregiving roles for the older adults, particularly within healthcare settings. This willingness is shaped by several factors, including attitudes toward aging, knowledge about geriatric care, personal experiences with older individuals, emotional factors such as empathy and anxiety about aging, and educational influences [13, 14]. Adequate knowledge and positive attitudes about aging are crucial, as they enhance the willingness to work with older adults [15, 7],. Additional demographic variables such as age, gender, and cultural background may alo influence the willingness to work with older adults.

Literature reports indicate that many nursing students still have limited knowledge in this area. A review by Abudu-Birresborn et al. [15], reported an insufficient to moderate level of knowledge, while Alqahtani et al. [16] concluded that only 29% of nursing students felt confident in caring for older adults. Interestingly, although both 1st year and 4th -year nursing students demonstrated only a moderate level of understanding about aging and older adults, there was an increase in the level of knowledge over the course of nursing education [17, 18]. There is also evidence suggesting that educational programs and increased knowledge are positively related to a preference for working with the older adults. This implies that enhancing knowledge about older adults might foster a greater willingness to work with this population [14].

Research has shown that students of healthcare sciences tend to have negative attitudes towards older adults, which can influence their future career choices by reducing the desire to work in this field [19, 20]. Negative attitudes towards aging [8, 21,22,23], can lead to feelings of overload, demoralization, burnout, and depression, as well as difficulties in communication. They may also discourage healthcare student from working with this population and can create barriers to providing quality care to the older adults, increase the risk of medical misdiagnoses, and may lead to poor quality care, neglect, or mistreatment of older adults, and to a lack of motivation to provide competent care [24, 25]. To address these challenges and foster positive attitudes towards aging, it is crucial for healthcare programs to provide education and training opportunities that promote empathy, understanding, and compassion for older adults [26, 27].

Negative attitudes toward aging reflect individual-level biases that, when reinforced and shared, evolve into broader ageism at the societal and institutional levels. Such ageism, grounded in stereotypes and prejudice [2], significantly influences healthcare students’ attitudes and their willingness to work with older adults.

Limited educational experiences with older adults may restrict the treatment options offered [28], or diminish the willingness to work with older adults [29]. As a corollary, personal experiences, such as caring for older adults family members, or experiential learning through gerontological field placements may contribute to a positive attitude towards old age among health and social work students [30, 31].

Although previous studies have explored the impact of knowledge and ageism on the willingness to work with older adults, our current study also considers the moderating role of relationships with grandparents, an aspect that has received limited research attention. Building on existing evidence, this study proposes a moderated mediation model in which ageism serves as a mediator, and connection with grandparents acts as a moderator in the relationship between knowledge about aging and willingness to engage in the care of older adults. Ageism is a recognized stereotype through which limited knowledge reduces the motivation to work with older adults [21,22,23], and undermines empathy, communication, and professional interest [24, 25]. Personal relationships with grandparents have been shown to moderate these effects, with closer relationships linked to greater empathy, reduced ageism, and a stronger willingness to work with older adults [30, 31]. Such contact enriches knowledge with emotional meaning, which amplifes the effect on willingness. We therefore expect knowledge about aging to influence willingness both directly and indirectly through ageism, with this relationship moderated by students’ personal connections with older adults, particularly grandparents.

Since willingness to work with older adults is reportedly higher in women than in men [32], with mixed results with respect to age [33], we controlled for these background variables in our analysis.

The aim of the current study was to examine the direct relationships between healthcare students’ knowledge of older adults and their willingness to work with this population, as well as to explore the indirect effect of ageism as a mediator with the moderating effect of connection with grandparents.

Our analysis was guided by three hypotheses:

A cross-sectional study was employed to test the study hypotheses.

Final-year students of nursing (4 year program, n = 180), medicine (6 year program, n = 120), or physiotherapy (4 year program, n = 50) were recruited from the largest academic Faculty of Medical and Health Sciences in Israel. Research assistants administered the questionnaire before class. A total of 241 students completed the questionnaires, resulting in a total response rate of 68.9%, with values of 63.3%, 74.1%, and 68.0% for the nursing, medicine and physiotherapy programs respectively. Inclusion criteria included being a final-year healthcare student and proficiency in Israel.

This study was approved on February 7, 2022, by the Institutional Review Board of Tel Aviv University (N° 0004429-1). Written informed consent was received from all the participants, who were instructed that the survey was voluntary. The data were analyzed anonymously.

According to Fritz and MacKinnon [34], a sample of 115 to 285 participants is sufficient to detect an indirect effect in mediation analysis among the variables used. As this study comprised 241 participants, the sample size met the requirements to detect an effect with a power of 0.80.

The study utilized a previously published closed self-report questionnaire consisting of five sections:

Willingness to work with older adults was assessed using a 7-point Likert single item derived from a previously used Willingness to Work with Older People scale [35]. Participants were asked: “Would you consider a future career in geriatric medicine?” The answers ranged from 7 for “strongly agree” to 1 for “strongly disagree”, thus, higher scores indicate a greater willingness to work with older adults [14].

Knowledge was evaluated by 12 out of the original 25 questions of Palmore’s FAQ1 measurement tool [36]. The main reason for not including all the original questions was to avoid burdening responders. The selected questions had been validated in a previous study conducted in Israel [37].

Ageism was assessed by the Fraboni Scale of Ageism (FSA) using the version translated by Bodner and Lazar [38]. The original FSA questionnaire, was developed by Fraboni Salstone, & Hughes [39], and included 29 statements (Cronbach’s alpha internal reliability 0.86). Five items from the original validated [40] questionnaire were omitted in a previous study in Israel due to incompatibility with Israeli culture and society [38]. The remaining 24 statements are divided into three main categories of ageism: antagonism and antipathy, avoidance, and discrimination. In the current study, we used the Fraboni Scale of Ageism (FSA) as a single composite index rather than analyzing the subscales separately. This approach is consistent with theoretical perspectives that conceptualize ageism as a unified construct [39] and is commonly used when the research focus is on general attitudes toward older adults rather than on specific dimensions. High internal reliability further justifies aggregating the items [40], and some psychometric studies have questioned the stability and distinctiveness of the original subscales across cultural contexts [41].

Students were asked to rate their agreement with each statement on a 6 point- Likert scale ranged from 6 “strongly agree” to 1 “strongly disagree”. The measuring scale of the positively worded items was reversed in order to obtain a rising scale of ageistic attitudes towards the older adults (high ageism). Cronbach’s alpha for the index was 0.79.

Grandparental Relationships were assessed by one question: “How close do you feel to your grandparents?” Responses were rated on a 5-point Likert scale, ranging from 1 (“very distant”) to 5 (“very close”), with higher scores indicating greater perceived closeness. For the purposes of analysis, responses were grouped into three ordinal categories representing the level of connection: poor (scores 1–2), moderate (score 3), and strong (scores 4–5).

Socio-demographic characteristics assessed included: age, sex, place of birth, religion, and field of study. Age was defined as a continuous measure; sex as a dichotomous variable (0 = male, 1 = female); place of birth was defined as 1 (Israel), 2 (former USSR), 3 (North America), or 4 (other); religion was defined as: 1 (Jewish), 2 (Muslim), 3 (Christian), or 4 (other); field of study was defined as 1 (nurse), 2 (medical), or 3 (physiotherapy).

Data collection utilized a structured questionnaire independently translated from English to Hebrew by bilingual speakers. The translated questionnaire was validated in a pilot study involving 10 respondents. Concerns regarding both content and clarity were addressed before data collection commenced in order to ensure full understanding of all questionnaire items. A convenience sampling strategy was employed. Questionnaires were distributed by a research assistant to all students during the first semester of their final year of studies (October 2022 to January 2023). The students were provided with both oral and written explanations regarding the study’s objectives and were requested to sign an informed consent form. Anonymity was guaranteed and the students were reassured that the questionnaire data would be used solely for the purpose of data analysis.

Descriptive statistics were used to compute the means and standard deviations for continuous variables, as well as the percentages and frequencies for categorical variables. In the second phase, bivariate analyses were conducted to assess the relationships between willingness to work with older adults, the mediator, moderator, covariates, and the dependent variable using Pearson correlation tests.

Mediator-moderator analyses were then computed in which the mediator (ageism) and moderator (connection with grandparents) were entered to test the components of the mediation- moderation model, using the bootstrapping method (PROCESS model 5) to assess the indirect effects [42]. The mediation- moderation model was examined by testing the significance of the indirect effect of the independent variable (knowledge about older adults) on the dependent variable (willingness to work with older adults) through the selected mediator and with the moderator described above. The mediator was then quantified as the product of the effect of the independent variable on the mediator (paths: a1) and the effect of the mediator on the dependent variable. This parceled out the effect of the independent variable (paths: b1, see Fig. 1), while controlling for covariates. The effect of the moderator can be seen in Fig. 2.

The mediating model depicting direct and indirect effects of knowledge (IV) on considering work with older adults (DV) tested in the current study, controlling for covariates. Notes: Graphic A depicts the total effect (C) of knowledge (IV) on considering work with older adults (DV). Graphic B depicts the direct effect (C’) of knowledge (IV) on considering work with older adults (DV) after including the mediator (MeV; connection with grandparents). Values represent unstandardized regression coefficients

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Relationship between knowledge about older adults and willingness to work with older adults among individuals with different degrees of connection to grandparents, controlling for covariates

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This approach relies on regression analysis to calculate the direct effect (weight c′, with mediator), total effect (c, without mediator), and indirect effects (a × b weights) of an independent variable on a dependent variable. The total and specific indirect effects were determined using a bootstrapping method with 5,000 samples. Confidence intervals were computed by sorting these 5,000 samples from the original dataset in ascending order to obtain a 95-percentile confidence interval (if 0 is within the confidence intervals, the effect is considered non-significant). All analyses were conducted using SPSS 28.0 with the PROCESS statistical program [42]. The effects reported by PROCESS are unstandardized regression coefficients.

As presented in Table 1, most of the participants were females (78.4%). The age of participants ranged between 21 and 53 years (Mean = 29.6, SD = 5.2) with most born in Israel and identifying as Jews. Study fields were distributed as follows: Nursing (47.3%), Medicine (36.9%), and Physiotherapy (15.8%).

Table 2 presents the outcomes of the Pearson correlations between the research variables. The results indicate a small to moderate positive correlation between willingness to work with older adults and both knowledge about older adults (r = 0.15, p < 0.05) and connection with grandparents (r = 0.16, p < 0.05). Ageism showed a negative small to moderate correlation with willingness to work with older adults (r = -0.18, p < 0.05) and knowledge about older adults (r = -0.19, p < 0.05). The finding that the mediator and moderate are not strongly related (r ≤ 0.18) indicates that there are no grounds for possible multicollinearity among the mediator and moderator in the current study.

Table 3 presents the mediation model results (PROCESS model 5; Fig. 1), showing a significant total effect (b = 4.19, p < 0.05) of knowledge about older adults on willingness to work with older adults. This includes a significant direct effect (b = 0.74, p < 0.01) and a significant indirect effect mediated through ageism (indirect effect = 0.023, 95% CI [0.7, 2.8]). Additionally, knowledge about older adults is positively associated with willingness to work with them and negatively associated with ageism (b = -1.19, p < 0.05) (path a1), which in turn significantly predicts greater willingness to work with older adults (b = -0.02, p < 0.01) (path b1). The covariates age and gender showed no significant associations with willingness to work with older adults.

A moderation analysis was conducted to explore the effect of knowledge about older adults and the connection with grandparents on willingness to work with older adults. The results indicate that the relationship between knowledge and willingness to work with older adults is positive and significant for those with a poor connection with their grandparents (b = 0.26, p = 0.009). This suggests that the willingness of individuals with limited or negative experiences with grandparents, to work with older adults, increases as their knowledge about older adults grows. In contrast, no significant relationship was observed among participants with a moderate or strong connection to their grandparents (b = 0.10, p = 0.22; b = -0.06, p = 0.57, respectively). These findings suggest that knowledge about older adults does not substantially affect the willingness of individuals who have already formed moderate or strong personal connections with grandparents, to work with this population. The moderating effect of the connection with grandparents is presented visually in Fig. 2.

The purpose of this study was to examine the direct relationship between healthcare students’ knowledge of older adults and their willingness to work with this population, as well as to explore the indirect effect of ageist attitudes as a mediator and the moderating effect of the connection with grandparents.

Our first hypothesis proposed that a higher level of knowledge about older adults among healthcare students would be associated with greater willingness to work with older adults. The findings of this study support this hypothesis, demonstrating a significant small to moderate positive relationship between knowledge and willingness to work with older adults. Moreover, these results align with previous research indicating that education and knowledge are positively associated with preference for working in older adult care [5, 6, 11, 19, 33].

Healthcare education in Israel is regulated by the Ministry of Health, which mandates a minimum educational requirement of a 4-year Bachelor of Science in a nursing or physiotherapy program for academic-based healthcare professions [43], and a 6-year program for medical education. However, the relevant curricula often lack comprehensive courses in geriatrics and gerontology, typically offering only a limited number of theoretical classes without clinical practice in geriatric care. This educational gap may contribute to the findings of the current study, which reveal a low but significant percentage of the dependent variable explained by the independent variable and a modest but significant connection between knowledge and willingness to work with older adults.

These results are in agreement with Haron et al. [11] who reported that 61% of final-year nursing students from Israel would not choose to work in aged care upon graduation. In contrast, the findings are less consistent with research by Holroyd et al. [44] and Williams et al. [45] who reported no significant improvement in students’ attitudes or willingness to work with older adults despite exposure to geriatric training and clinical experience. Several factors may explain these differences. First, cultural context may play a role; Israeli society places a strong emphasis on family ties and intergenerational relationships, which could enhance students’ receptiveness to knowledge and positively influence their attitudes toward older adults. Additionally, variations in sample characteristics, such as differences in academic programs, year of study, or prior exposure to older adults, may contribute to these divergent findings. Finally, differences in measurement tools and intervention design may also explain the discrepancies.

Our second hypothesis suggested that ageism would mediate the relationship between knowledge and willingness to work with older adults. The results confirmed this hypothesis, indicating that greater knowledge about aging is associated with reduced ageism, which in turn enhances students’ willingness to work with older adults. Although education is frequently cited as a key factor in influencing attitudes toward aging, various studies have reported positive [46], or negative [44] trends, or no change [47] in the willingness to undertake geriatric care as students progress through their academic program. The negativity of societal ageism, and association of the older adults with health issues, sickness, and the overuse of public resources may cause healthcare students to view working with older adults as routine, boring, demanding, insulting, unpleasant, or unaesthetic [48, 49]. Consequently, many students show limited interest in pursuing careers in geriatric care, perceiving such roles as uninspiring and characterized by poor working conditions [50].

Our third hypothesis proposed that the relationship between knowledge and willingness to work with older adults would be moderated by the strength of students’ connection with their grandparents. The results partially support this hypothesis, in that they detect a stronger association between knowledge and willingness among students who reported weaker connections with their grandparents. This finding aligns with previous reports that close contact with older adults positively influences attitudes toward aging among health and social work students [30, 31].

Building on this, we can conclude that individuals who are familiar with older adults through personal experiences, such as spending time with grandparents, volunteering, or living in proximity to older adults, naturally exhibit greater empathy and positive attitudes toward this population. For these individuals, personal connections may play a more dominant role, thereby reducing the relative impact of formal academic knowledge on their willingness to work with older adults. In contrast, for students who lack such close intergenerational relationships, knowledge emerges as a critical factor in shaping positive attitudes and fostering willingness to engage in geriatric care. This underscores the vital role of educational interventions in preparing future healthcare professionals to work with older adults, particularly among those without prior personal experience.

In the context of the overall model, our findings highlight educational preparation as a crucial factor in increasing healthcare students’ willingness to work with older adults. Specifically, knowledge plays a critical role among students who report poor connections with their grandparents. For these students, academic knowledge serves as a key catalyst in fostering professional interest in geriatric care. Appropriate educational preparation in older adult care not only increases knowledge but also helps translate that knowledge into reduced ageist attitudes and sustained willingness to work with this population [51, 52].

Among the most effective educational strategies are experiential and simulation-based programs, including body suit simulations, actor-based role-playing, and other interactive methods [53]. These approaches promote a more empathetic and holistic understanding of older adults’ experiences [54], ultimately enhancing healthcare students’ knowledge, reducing ageist biases, and increasing students’ motivation to pursue careers in older adult care [55]. In light of these findings, we recommend expanding the number of credits dedicated to gerontology and clinical internships, incorporating simulation-based training to foster empathy, and establishing long-term service-learning programs in collaboration with elderly care institutions.

This study has several limitations. First, it was conducted at a single university in central Israel, which, despite being the largest academic faculty of medical and health sciences in the region, may limit the generalizability of the findings. In addition, the unique family structure and cultural background of Israeli students may influence their relationships with grandparents, and potentially affecting the study results. These influences may vary in other cultural and societal contexts. Furthermore, the cross-sectional design of the study, conducted among students in their final year of studies, a period characterized by intensive clinical practice, captures data at only one time point and does not reflect potential changes in attitudes or knowledge throughout the educational process. Conducting research at different stages of the academic program might yield different insights. In addition, as the study relied on self-reported questionnaires, responses may be influenced by social desirability bias, potentially affecting the accuracy of reported knowledge, attitudes, and willingness.

An additional limitation concerns the assessment of the relationship with grandparents, which was measured using a single self-reported item. This single-item measure may not fully capture the frequency, depth, or overall quality of these relationships. Future studies should utilize multi-item validated scales to better assess this dimension. Notably, we do appreciate the existence of other potentially relevant factors, such as volunteering with older adults, prior caregiving experience, or living in proximity to older adults, which were not examined, although they may also influence willingness to work with older adults.

To address these limitations and provide a deeper understanding of the factors influencing students’ willingness to work with older adults, we recommend complementing this research with a qualitative study that includes a comprehensive questionnaire.

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A V S: Conceptualization; Methodology; Validation; Resources; Investigation, Formal Analysis, Writing - Original Draft.VR: Conceptualization; Methodology; Validation; Data Curation; Writing - Review & Editing; Visualization; Supervision.

Correspondence to Violetta Rozani.

This study was approved on February 7, 2022, by the Institutional Review Board of Tel Aviv University (N° 0004429-1). Written informed consent was received from all the participants, who were instructed that the survey was voluntary. The data were analyzed anonymously.

Not applicable.

The authors declare no competing interests.

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