Carla Sílvia Fernandesa; Andreia Afonsob; Germano Coutoa
OBJECTIVE: To identify nursing students' attitudes toward older people.
METHOD: Second-year undergraduate nursing students were invited to complete a questionnaire at the beginning of the geriatric nursing curricular unit. A quantitative study was conducted by administering the validated Portuguese version of Kogan's attitudes toward old people scale (KOAP).
RESULTS: The sample included 39 students who answered the data collection instrument. The mean KOAP score was 135.56, which was slightly above the median value (119). No statistically significant relationships were found between any of the variables: gender, age, experience with older people, and living with older people.
CONCLUSIONS: The nursing students' mean score for attitude toward older people was slightly positive, which could serve as a starting point for the development of an intervention to modify their attitudes with respect to aging.
Keywords: aged; attitude; geriatric nursing; students, nursing.
OBJETIVO: Identificar as atitudes dos estudantes de enfermagem em relação à pessoa idosa.
MÉTODO: Os estudantes de enfermagem inscritos no segundo ano da licenciatura foram convidados a preencher um questionário no início da unidade curricular de enfermagem geriátrica. Recorreu-se a um estudo quantitativo através da administração da Escala de Atitudes Face aos Idosos de Kogan (KAOP), validada para a população Portuguesa.
RESULTADOS: A amostra foi constituída por 39 estudantes que responderam ao instrumento de coleta de dados. A atitude dos participantes em relação aos idosos apresentou um valor médio de 135,56; ligeiramente superior ao valor médio da escala (ponto médio = 119). Não foram evidenciadas relações estatisticamente significativas com nenhuma das variáveis em análise, nomeadamente o gênero, a idade, a experiência e a coabitação.
CONCLUSÕES: O estudo permitiu evidenciar que a atitude dos estudantes de enfermagem em relação à pessoa idosa apresenta valores médios ligeiramente positivos, o que poderá constituir um ponto de partida para o desenvolvimento de uma intervenção para modificar a atitude dos estudantes de enfermagem em relação ao envelhecimento.
Palavras-chave: idoso; atitude; enfermagem geriátrica; estudantes de enfermagem.
The phenomenon of demographic aging determines that health workers must be trained to take care of the complex needs of a population,1-3 specifically, future nurses must be prepared to care for older people.4 The current literature suggests that attitudes toward older people affect the quality of care that nurses provide4-10 as well as the quality of care that older people receive, and it is necessary to identify these attitudes and their influences.1
Nursing educators should understand how to deliver gerontological content and clinical experience that promotes positive attitudes toward older people, raising awareness about the complexity of care required for this population and attracting nurses to the field of gerontology.4 Gerontological nursing experts acknowledge the growing needs of nursing care for the elderly and stress the importance of changing the way students are exposed to gerontological education during their training to foster positive attitudes toward the elderly among those who wish to work with this population in the future.10
Hovey et al. reviewed 11 studies on student attitudes toward the elderly and emphasized that student progress toward a nursing degree had little effect on their attitudes, although incorporating experiences that actively involve students had a greater impact.4
On the other hand, in their review study on the perceptions of undergraduate nursing students about geriatric care, Algoso et al. state that universities have a responsibility to emphasize the significance of the geriatric care experience, and that this should represent the basis of nursing practice. They go on to stress that beginning nurses should be encouraged to value geriatric care when preparing for their nursing careers, incorporating positive attitudes toward aging.11
Aware of the complexity of this issue, and as the first phase of a broader intervention project to be published in future articles, this study was carried out with the purpose of identifying the general attitudes of nursing students towards the older population based on Kogan’s attitudes toward old people (KAOP) scale.12
Considering the purpose of this investigation, which was to evaluate nursing students’ attitudes toward the older people and the relationship with certain demographic and social factors, we designed a cross-sectional study with a quantitative approach. The participants were all second year nursing students at a university in the north of Portugal (n = 45). The only inclusion criteria were being enrolled in the geriatric nursing curricular unit and agreeing to participate in the study. Through non-probabilistic convenience sampling, a total of 39 students participated in the study. The results provided a descriptive representation of the nursing students’ attitudes toward the elderly. As previously mentioned, this is the first phase of a broader study that will encompass intervention and monitoring of the evolution of student attitudes. Before the study began, authorization and a positive review were obtained from the institutional ethics committee (73/2018).
Data was collected using a two-part questionnaire, one on sociodemographic characterization and another consisting of the Portuguese version of the Kogan scale,12 or KAOP.13 The KAOP was validated for the Portuguese population by Camara,13 who kindly granted us permission to use it. The instrument has been replicated in several countries, namely Portugal,13 Turkey,14 Italy,15 Peru,16 and Chile.17 The scale consists of 17 pairs of “logical opposites” (one with negative content, N, and another with content positive, P), totaling 34 items, and is formatted in Likert scales with six responses ranging from “strongly disagree” to “strongly agree.”13 To facilitate the results, the scale’s negative items were statistically inverted such that the greater the value, the more positive the attitude. Total scores on the scale can vary between 34 and 204, with a median of 119. The scale includes the following seven subscales:
residential aspects (the housing and neighborhoods of older people);
feelings caused by living with older people (discomfort, tension, satisfaction);
individuality of older people (similarity, variation);
intergenerational relationships (conflictual, healthy);
dependency (physical and emotional);
cognitive abilities and style (wisdom, adaptation);
personality and personal appearance (moods, demeanor);
economic and political power (influence of older people in society).11
The questionnaires were administered in February 2018, which coincided with the beginning of the curricular unit, during regularly scheduled class hours. Each student received written instructions and signed the informed consent form. The students were informed that participation in the study would be voluntary, that their answers would be kept anonymous and that they could opt out of the study at any time with no negative consequences. Statistical Package for the Social Sciences version 24 for Windows was used for data analysis. In addition to the descriptive statistics (calculation of the mean, median and standard deviation), the Mann-Whitney and χ2 tests were used to correlate the variables, for which a 95% confidence interval (95% CI), with a p-value < 0.05 were used.
The sample consisted of 39 second-year undergraduate nursing students, which corresponded to 86.6% of the class. The sample, of which 82.1% were female, ranged in age from 19 to 44 years, with a mean age of 23.1 years (Table 1). The majority of participants were young (mode = 19) and unmarried (97.4%). More than half of the students (74.4%) reported having experience with older people, while only 23.1% reported living with them. Most students (53.8%) reported affectionate relationships with older people. For future professional practice, 25.6% reported preferring to care for children, 20.5% preferred adults and only 7.7% reported preferring older people.
All KAOP items, both negative and positive, are scored on a Likert scale. As shown in Figure 1, the students’ mean score (135.56) was slightly higher than the scale’s median score (119) and ranged from a minimum score of 92 to a maximum of 170. The median value was 133 and the mode was 129.
Table 2 shows the mean values for each subscale. Positive values were observed regarding housing (student mean score = 25; subscale mean = 21), although for the inter-generational relationships subscale, the students’ mean score (21.7) was very close to the scale’s mean value.
Slightly positive mean values were observed for the feelings caused by living with older people subscale (student mean score = 15.5; subscale mean = 14), the dependency subscale (mean = 16.3), the personality and personal appearance subscale (mean = 16.6) and the economic and political power subscale (mean = 7.5). The mean was slightly higher for the individuality subscale (18.2). The ccognitive abilities and style subscale had the lowest mean value (14.9).
No significant correlations were found between KAOP score and gender (Mann-Whitney U = 88.000, p = 0.380), marital status (Mann-Whitney U = 8.500, p = 0.351), experience with older people (U (Mann-Whitney U = 116.500, p = 0.537), relationship with older people (χ2 = 1.642, p = 0.440), or preference to work with older people (χ2 = 1.865, p = 0.751). Interestingly, students who lived with older people scored slightly lower than those who did not (Table 3).
The overall results of the present study showed a slightly positive attitude toward older people. Different results were found by Tavares et al. in a study on Portuguese nurses.7
These authors observed low levels of geriatric knowledge and negative attitudes in relation to geriatric care, although the nurses’ attitudes were significantly associated with the hospital, type of unit, region, educational support, staff knowledge and perceived geriatric care workload. It should be pointed out that besides the different populations, the data collection instruments were also different.7
The present results are very similar to those of a study on Canadian nursing students from different years of an undergraduate course. The authors of that study also used the Kogan scale and found no significant differences among student groups. The overall mean score was 145, indicating a slightly positive attitude towards older people.18
In an American longitudinal study that used the Kogan scale, the authors found a highly positive initial attitude (149.13) that had an upward trend over time, meaning that the students generally began their nursing program with highly positive attitudes toward the elderly. However, they developed a more positive attitude over the years of the nursing course.10 Our findings are consistent with other studies of nursing students in whom slightly positive attitudes were observed.6,9,10,18,19
The authors of a review study point out that there may be large differences in cultural expectations regarding geriatric care according to geographic location. Cultural philosophies can influence the attitudes that individuals have about older people.4 In our study, perhaps due to the small sample size, no correlations were obtained with the study variables.
Four recurring themes have been identified in the literature as contributing factors to nurses’ attitudes towards geriatric care: training, work experience, work environment and demographic data.5 Nurses’ attitudes are significantly associated with the hospital, type of unit, region, educational support, staff knowledge, and perceived geriatric care burden.7 However, Carlson and Idvall found that variables such as age, gender, and previous work experience do not significantly affect geriatric care,8 which may reveal some disagreement in these measures. It should be pointed out that a positive attitude toward older people may not necessarily translate into superior care, since positive and negative feelings can coexist.5 This contradiction is evident in the findings of the present study, since despite showing slightly positive attitudes toward older people, few students indicated a desire to work with this population. King et al. observed that students prefer to work in intensive care settings, particularly in intensive care units, and that this preference was maintained throughout their course. These authors also reported that the desire to work in pediatric units decreased with time and that, despite an insignificant increase over time, nursing homes were the least preferred places to work.10
One important factor in this study is that the students had not yet completed any specific training on gerontology, since the scale was administered as they began the geriatric nursing curricular unit. This training, according to some authors, strengthens the development of positive attitudes towards the elderly,4,5,9 especially that which is acquired during an undergraduate program.7
It is crucial to improve the knowledge and attitudes of future nursing professionals toward the elderly, implementing evidence-based guidelines in their practice.7 The fact that this population group has clinical specificities which require a biopsychosocial model that involves the performance of a specially trained multidisciplinary team makes this issue even more relevant.20 Nursing schools should be able to influence their students’ perceptions about and preference for working with older people, especially gerontology courses, which should dispel myths about geriatric care.10 Nursing educators and researchers play an important role in developing strategies to expand knowledge about and improve attitudes toward older people.7
Some limitations of this study include its sample size, the variability of instruments applied in other studies (which made comparative analysis difficult), the participants’ prior experience with the elderly (74.4%) and the inclusion criteria. Selecting enrollment in a geriatric nursing curricular unit as an inclusion criterion could entail bias since the participants might be more likely to be familiar with gerontological issues.
In this sample of nursing students, the mean scores indicated a slightly positive attitude toward older people. No significant correlation was found between score and gender, age, experience with older people or living with older people.
Further research is needed to assess the impact of training strategies that foster positive attitudes toward older people with an impact on care. Longitudinal studies measuring the attitudes of nursing students over the course of their education, as well as throughout their careers, should be developed in different contexts.
Nursing educators have the opportunity and challenge of preparing prospective nurses to provide high quality geriatric care in a population expected to become increasingly aged.
1. Gibbs S, Kulig J. "We definitely are role models’: Exploring how clinical instructors' influence nursing students' attitudes towards older adults. Nurse Educ Pract [Internet], 2017 [acessado em 30 mar. 2018];26:74-81. Disponível em: https://dx.doi.Org/10.1016/j.nepr.2017.07.006
2. Lucchetti A, Lucchetti G, Oliveira I, Moreira-Almeida A, da Silva Ezequiel O. Experiencing aging or demystifying myths? - impact of different "geriatrics and gerontology’ teaching strategies in first year medical students. BMC [Internet]. 2017 [acessado em 31 mar. 2018];17(1):35. Disponível em: https://dx.doi.org/10.1186/s12909-017-0872-9
3. Chen A, Kiersma M, Yehle K, Plake K. Impact of an Aging Simulation Game on Pharmacy Students' Empathy for Older Adults. Am J Pharm Educ [Internet]. 2015 [acessado em 31 mar. 2018];79(5):1-10. Disponível em: https://dx.doi.org/10.5688/ajpe79565
4. Hovey S, Dyck M, Reese C, Kim M. Nursing students' attitudes toward persons who are aged: An integrative review. Nurse Educ Today [Internet]. 2017 [acessado em 30 mar. 2018];49:145-52. Disponível em: https://dx.doi.org/10.1016/j.nedt.2016.11.018
5. Rush K, Hickey S, Epp S, Janke R. Nurses' attitudes towards older people care: An integrative review. J Clin Nursing [Internet]. 2017 [acessado em 2 abr. 2018];26(23-24):4105-16. Disponível em: https://dx.doi.org/10.1111/jocn.13939
6. Yazdanian A, Alavi M, Irajpour A, Keshvari M. Association between nurses' personality characteristics and their attitude toward the older adults. Iran J Nurs Midwifery Res [Internet]. 2016 [acessado em 2 abr. 2018];21(1):9-13. Disponível em: https://dx.doi.org/10.4103/1735-9066.174758
7. Tavares JA, Silva A, Sá-Couto P, Boltz M, Capezuti E. Portuguese nurses' knowledge of and attitudes toward hospitalized older adults. Scand J Caring Sci [Internet]. 2015 [acessado em 2 abr. 2018];29(1):51-61. Disponível em: https://dx.doi.org/10.1111/scs.12124
8. Carlson E, Idvall E. Who wants to work with older people? Swedish student nurses' willingness to work in elderly care--a questionnaire study. Nurse Educ Today [Internet]. 2015 [acessado em 2 abr. 2018];35(7):849-53. Disponível em: https://dx.doi.org/10.1016/j.nedt.2015.03.002
9. Zhang S, Liu Y, Zhang H, Meng L, Liu P. Determinants of undergraduate nursing students' care willingness towards the elderly in China: Attitudes, gratitude and knowledge. Nurse Educ Today [Internet]. 2016 [acessado em 2 abr. 2018];43:28-33. Disponível em: https://dx.doi.org/10.1016/j.nedt.2016.04.021
10. King B, Roberts T, Bowers B. Nursing Student Attitudes Toward and Preferences for Working With Older Adults. Gerontol Geriatr Educ [Internet]. 2013 [acessado em 2 abr. 2018];34(3):272-291. Disponível em: https://dx.doi.org/10.1080/02701960.2012.718012
11. Algoso M, Peters K, Ramjan L, East L Exploring undergraduate nursing students' perceptions of working in aged care settings: A review of the literature. Nurse Educ Today [Internet]. 2016 [acessado em 30 mar. 2018136:27580. Disponível em: https://dx.doi.org/10.1016/j.nedt.2015.08.001
12. Kogan N. Attitudes towards old people: The development of a scale and examination of correlates. J Abnormal Soc Psychol. 1961;62:44-54.
13. Camara S. Atitudes de futuros Profissionais de Saúde e Serviço Social face ao trabalho com a população idosa: escala de Kogan e relaçoes intergeracionais [tese de doutorado]. Corunha: Universidade de Corunha; 2015.
14. Erdemir F, Kav S, Citak E, Hanoglu Z, Karahan A. A Turkish version of Kogan's attitude toward older people (KAOP) scale: Reliability and validity assessment. Arch Gerontol Geriatr [Internet], 2011 [acessado em 2 abr. 2018152(3):e162-5. Disponível em: https://dx.doi.org/10.1016/j.archger.2010.10.019
15. Matarese M, Lommi M, Pedone C, Alvaro R, De Marinis M. Nursing student attitudes towards older people: validity and reliability of the Italian version of the Kogan Attitudes towards Older People scale. J Adv Nurs [Internet]. 2013 [acessado em 2 abr. 2018];69(1):175-84. Disponível em: https://dx.doi.org/10.1111/j.1365-2648.2012.06055.x
16. Sampén D, Varela F, Díaz V, Tello T, Ortiz J. Validación de la Escala de Actitudes hacia el Adulto Mayor de Kogan y evaluación de las Actitudes hacia el adulto mayor por parte del personal de salud del primer nivel asistencial. Acta Méd Peruana [Internet]. 2012 [citado em 2 abr. 2018];29(3):148-54. Disponível em: http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1728-59172012000300004&lng=es
17. Fernández E, Padilla P, Monardes H, Díaz C. Actitud hacia el adulto mayor en estudiantes del pregrado de la Facultad de odontología Universidad San Sebastián, Santiago. Rev Estomatol Herediana [Internet]. 2017 [citado em 2 abr. 2018];27(1):21-9. Disponível em: http://dx.doi.org/10.20453/reh.v27i1.3099
18. Mandville-Anstey S, Ward P, Grainger P, Foley V. Nursing students' knowledge and attitudes toward caring for older adults. Perspectives. 2014;37(2):6-14.
19. Mattos M, Jiang Y, Seaman J, Nilsen M, Chasens E, Novosel L. Baccalaureate Nursing Students' Knowledge of and Attitudes Toward Older Adults. J Gerontol Nurs [Internet]. 2015 [citado em 3 abr. 2018];41(7):46-56. Disponível em: http://dx.doi.org/10.3928/00989134-20150429-01
20. Galera SC, Costa EFA, Gabriele RR. Educação Médica em Geriatria: desafio brasileiro e mundial. Geriatr Gerontol Aging [Internet]. 2017 [citado em 3 abr. 2018];11(2):88-94. Disponível em: http://dx.doi.org/10.5327/Z2447-211520171700034
July 15 2018.
Accepted em August 15 2018.