This study was a cross-sectional study investigating the associations among gerontological nursing knowledge, ageism, and therapeutic communication competency among outpatient nurses working in general hospitals. Our study findings show that the significant factors of therapeutic communication competency were ageism toward older adults rather than gerontological nursing knowledge. Additionally, clinical experience of over 10 years and the absence of overtime work were positively associated with higher therapeutic communication competency. Our study findings can serve as fundamental information to improve the therapeutic communication skills of outpatient nurses and contribute to the development of competency-based training programs tailored to outpatient nursing practice.

In this study, the most significant factor associated with therapeutic communication competency was ageism toward older adults. Ageism negatively impacts the ability of older adults to receive adequate healthcare and nursing services [21]. It also hinders the formation of therapeutic trust relationships with older adults, ultimately reducing the quality of healthcare services provided [21]. Nurses who have negative attitudes toward older adults struggle to establish trusting relationships, which can adversely affect patient health outcomes [21]. Specifically, ageism among healthcare providers is negatively associated with therapeutic communication for patient care [21]. Our study findings confirm that preventing ageism toward older adults is essential to enhancing therapeutic communication in outpatient settings, rather than relying solely on knowledge-based education.

To reduce ageism, developing training programs to promote value changes for better and healthy aging should be prioritized in tertiary settings. For example, prior research has introduced simulation-based education programs to address ageism by allowing nurses and nursing students to experience the challenges of aging through role-play [22,23]. Participants in these programs wore aging simulation suits and participated in communal activities resembling the daily lives of older adults. Through shared experiences and reflection, both nurses and nursing students reported improved understanding, behaviors, and attitudes toward older adults, along with a reduction in discriminatory attitudes [22,23].

To develop the specific contents of an attitude-changing program, our correlational results provide some suggestions. Among the three subdomains of ageism toward older adults, discriminatory attitudes showed significant negative correlations with all subdomains of therapeutic communication competency. Additionally, the emotional avoidance subdomain was negatively correlated with most subdomains of therapeutic communication competency. Discriminatory attitudes reflect a willingness to engage in actions that directly obstruct the rights of older adults [19]. In contrast, emotional avoidance represents prejudice characterized by negative emotions that lead to maintaining distance from older adults [19]. Previous studies have found that factors influencing discriminatory attitudes are commonly associated with negative social interactions with older adults, which shape ageism toward them [24,25]. Therefore, discriminatory attitudes and emotional avoidance need to be changed to improve outpatient care for older adults.

There are several reasons that may explain the discrepancies among the three subdomains. First, the emotional avoidance items were designed to assess responses to similar emotional situations, thereby likely eliciting more consistent responses across participants. In contrast, the items within the discriminatory attitudes and stereotypes subdomains addressed more abstract and cognitively complex constructs. These may have been subject to varying interpretations among respondents, or influenced by social desirability bias, potentially reducing internal consistency. In addition, the relatively small number of items in these subdomains may have contributed to lower Cronbach’s ⍺ values, as the coefficient is sensitive to the number of items in a scale. Lastly, cultural and linguistic differences introduced during the Korean translation process may have influenced how the content of certain subdomains was interpreted, thereby affecting their internal reliability.

Dissimilar to previous studies [26,27], gerontological nursing knowledge was not a significant factor in therapeutic communication competency after considering other factors. Typically, increasing gerontological nursing knowledge is the first step toward improving gerontological care competency, such as therapeutic communication [27]. Our unexpected finding may result from the indirect effect of knowledge. The previous studies found that enhancing nursing knowledge influences ageism toward older adults, which in turn affects the quality of care in practice [22,23,27]. This suggests that attitude serves as a mediator between knowledge and care, similar to the knowledge-attitude-practice model [28].

Our study also found the significance of other factors, such as overtime work and nurses' clinical experience. First, overtime work is a negative factor that reduces therapeutic communication. Prolonged overtime work contributes to physical, mental, and emotional fatigue, which results in burnout, work overload, and insufficient rest, all of which decrease job satisfaction [29]. Nurses with low job satisfaction experience reduced motivation for patient care, and this leads to diminished enthusiasm and commitment in nurse-patient interactions, ultimately compromising the quality of nursing care [29]. Strategies should focus on workload adjustments, implementing predictable work schedules, and maintaining consistent shift patterns to reduce fatigue and improve working conditions. Second, the therapeutic communication competency of nurses was higher among those with longer clinical experience. Experienced nurses develop communication strategies through hands-on practice with a diverse range of patients. Previous studies also indicate that repeated experience increases confidence when interacting with patients, which in turn enhances communication skills [26,30]. Experienced nurses can serve as role models for less experienced nurses, offering guidance on communication techniques and strategies for new or less prepared nurses.

This study has several limitations. First, participants were recruited through online advertisements, and eligibility was based on self-identification as registered nurses working in general hospitals. However, this classification relied solely on self-reported data, and no independent verification of the participants' institutional affiliation was conducted. As a result, there is a possibility that some respondents may have misclassified their healthcare setting, leading to classification bias. This may have affected the accuracy of subgroup analyses related to institutional characteristics and limited the generalization of the findings. Future research should include nurses from a broader range of healthcare institutions using more representative sampling strategies. Second, the therapeutic communication competency instrument used in this study was not specifically designed for gerontological care. The limitations of the research instrument may have led to the omission of specific competencies required for interactions with older patients, such as addressing the physical and psychological characteristics associated with aging. Therefore, future research should focus on developing tools that are specifically designed to measure competencies in therapeutic communication with older patients. Applying such tools in studies would contribute to a more accurate understanding of these competencies. Additionally, patterns of communication with older patients may vary depending on the healthcare provider’s working environment and cultural context. It is crucial to account for factors such as patient demographics within the hospital, organizational support for geriatric nursing, and resources allocated for elderly care. Incorporating these aspects into future research would provide a more comprehensive framework for understanding and improving therapeutic communication with older adults. Lastly, most instruments in this study were self-reported. There is also a potential for response bias due to varying levels of comprehension of survey items among participants, which may distort the results. Future research should incorporate behavioral observation, structured interviews, and in-depth qualitative methods to supplement self-reported data and address these limitations.

Based on the discussion above, the following clinical implications of the research findings are proposed: First, a structured educational program should be developed to reduce ageism. To implement this, systematic educational programs should be designed, including simulation-based education, aging experience programs (e.g., wearing aging simulation suits), role-playing, and case-based learning. All outpatient nurses should be institutionalized to regularly participate in these programs. Additionally, the changes in ageism attitudes and therapeutic communication competency should be evaluated before and after the education to verify the effectiveness of the program. Survey questionnaires, behavioral observations, and feedback systems should be used to assess attitude changes and promote continuous improvement. Second, a mentoring program utilizing clinical experience should be introduced. Experienced nurses should be paired with novice nurses, with the experienced nurses mentoring the novices and providing practical guidance on effective communication skills and patient relationship building. For example, regular case-sharing sessions should be organized, allowing experienced nurses to share successful communication cases and positive interactions with older adults. Third, the work environment should be improved, and overtime should be reduced. Work schedules should be adjusted to reduce overtime and provide predictable schedules to decrease nurses’ physical and mental fatigue. Adequate rest areas should be provided within the hospital, and rest periods during shift changes should be strictly ensured. Furthermore, stress management workshops, work environment improvements reflecting nurses' feedback, and activities promoting communication among colleagues should be introduced to enhance job satisfaction.

Finally, measures to accurately measure therapeutic communication competency with older adults should be developed. Based on the evaluation results, educational and practical opportunities should be provided to help nurses improve areas of deficiency. Additionally, patient feedback should be collected from older patients and their families to assess communication satisfaction and incorporate it into practical improvements.

This study highlights the importance of fostering a nonageist attitude to enhance therapeutic communication competency among nurses working in outpatient care settings. The findings suggest that, when caring for older adults, efforts to improve ageism toward aging should be prioritized over knowledge-based gerontological education. Emphasizing the reduction of ageism and promoting awareness can better support nurses in delivering effective care. The results of this study provide a foundational framework for developing gerontological nursing competency programs in outpatient practice. Finally, fostering positive nurse-patient interactions contributes to the delivery of higher-quality care and improves patient outcomes.