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Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Nurses attitudes towards older people: A systematic review

Yun-e Liu a, Ian J. Norman b, Alison E. While b,*
a b

PLA Second Artillery General Hospital, Beijing, China Kings College London, Florence Nightingale School of Nursing and Midwifery, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history: Received 23 April 2012 Received in revised form 22 November 2012 Accepted 23 November 2012 Keywords: Attitudes Ageism Older people Nurse

Background: The population is ageing globally. Older people are more likely to have chronic diseases and disabilities and have contact with health services. Attitudes of healthcare professionals affect the quality of care provided and individual career preferences. Aim: To examine the international research relating to registered and student nurses attitudes towards older people and the potential underpinning variables. Methods: A systematic search of 8 databases covering English and Chinese language publications since 2000 was undertaken which identied 25 papers. Findings: Reported attitudes towards older people were inconsistent with positive, negative and neutral attitudes being noted across registered and student nurses and appear to be slightly less positive since 2000. A range of variables have been examined as potential predictors of nurses attitudes with age, gender and education level being investigated most frequently but none were consistent predictors. Preference to work with older people and knowledge of ageing appeared to be associated with positive attitudes towards older people. Conclusions: There is a growing need for registered nurses committed to working with older people, however, there is a dearth of well designed studies which investigate both the attitudes of registered and student nurses and the associated factors, and test interventions to inform workforce strategies. 2012 Elsevier Ltd. All rights reserved.

What is already known about the topic?  The ageing population with their increasing functional dependency is one of the most challenging problems of contemporary societies which has a direct effect upon global public health and social care systems and increasing the demands for nursing care.  Negative attitudes towards older people and myths of ageing are ubiquitous. Older adults are viewed as a nurses burden and an obstacle to the more important work of caring for younger adults.  There is no previous systematic review of nurses attitudes towards older people and related variables

despite the importance of the topic and the increasing global migration of nurses. What this paper adds  This review synthesizes the international research published in the English and Chinese language journals relating to registered and student nurses attitudes towards older people and the potential underpinning variables.  Registered and student nurses attitudes appear inconsistent and slightly less positive since 2000. Preference to work with older people and knowledge of ageing appeared to be the most consistent variables associated with positive attitudes towards older people.  The review highlights the need for more well designed studies to investigate both the attitudes of registered and

* Corresponding author. E-mail address: alison.while@kcl.ac.uk (A.E. While). 0020-7489/$ see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

Please cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud. (2012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

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student nurses and the associated factors, and trials of interventions to improve attitudes to inform workforce strategies. 1. Introduction The number of people in the world aged 65 years and over is increasing at an average of 870,000 each month (Kinsella and He, 2009). Europe is the greyest continent with 23 of the worlds 25 countries with the oldest populations (Ofce for National Statistics, 2010). In 1995 more than 60% (590 million) older people lived in developing countries and this distribution is expected to increase to 70% (1.2 billion) by the year 2025 (WHO, 2000) with 81% of the worlds net gain of older people occurring in developing countries (Kinsella and He, 2009) in part reecting demographic changes and reductions in communicable disease mortality (United Nations, 2012). In the Peoples Republic of China, for example, the percentage of the population aged 60 years and over increased from 10.5% in 2000 to 14.0% in 2009 (China Statistical Yearbook, 2010) with similar increases anticipated in other developing countries (WHO, 2008). The ageing population is one of the most challenging problems of contemporary societies which has a direct effect upon public health and social care systems (Muangpaisana et al., 2008). Indeed the rising age dependency ratio both reduces the numbers entering the healthcare workforce and increases healthcare need. However, negative attitudes towards older people and myths of ageing are ubiquitous and, while not all negative attitudes lead to ageism (Nelson, 2005) and associated stereotyping and discrimination, negative attitudes are a precursor to ageism. Ageism often leads individuals to see older adults as unproductive, depressing and sickly, and to believe that cognitive impairment is a natural consequence of ageing (Palmore, 1999). Healthcare professionals are reported to be particularly susceptible to ageist stereotyping because of their increased exposure to ill and inrm older people (Kearney et al., 2000). Attitudes of registered nurses appear to affect the preference for working with older people as well as the quality of care offered to them (McDowell et al., 1999). The important role of nurses in delivering care has been widely and consistently recognized (Drennan et al., 2004; Jacelon, 2002) as they are accountable for providing both physical and personal care including emotional support to older adults across settings including hospitals, long-term care facilities, and in the home (De Guzman et al., 2009). Due to changing population demographics, there is a growing worldwide need for registered nurses who are knowledgeable and committed to working with older adults in diverse settings (Plonczynski et al., 2007). However, gerontological nursing is generally not considered to be popular among nursing students and registered nurses (Happell, 2002; derhamn et al., 2001). Older adults are often viewed as a So nurses burden and an obstacle to the more important work of caring for younger adults with some nurses identifying with the current societal culture which does not value older adults and nding care of confused older people frustrating (Dahlke and Phinney, 2008).

A recent UK Care Quality Commission report (Care Quality Commission, 2011) identied staff attitudes as a key variable in explaining unacceptably low care standards for older people in one in ve UK hospitals. While nursing support workers provide signicant levels of care to older people, registered nurses are accountable for their care delivery and ensuring the maintenance of care standards highlighting the value of understanding registered nurses attitudes towards older people and related variables. There are two non-systematic published reviews of nurses attitudes towards older people/patients covering studies from 1982 until 2005; Courtney et al. (2000) reported the literature identied by a search of CINAHL from January 1982 until December 1998 and Lovell (2006) examined the evidence of nursing students and health professionals attitudes using four scales including Kogans Attitude Scale (1961), Facts of Aging Quiz (Palmore, 1977), Aging Semantic Differential Scale (Rosencranz and McNevin, 1969) and MaxwellSullivan Attitude Scale (1980) identied from searches of Medline and CINAHL 19902005. This review therefore aimed to systematically examine the international research relating to registered and student nurses attitudes towards older people and the potential underpinning variables including knowledge, experience and self-ageing over the last decade as reported in the English and Chinese language journals reecting both Chinas emergence as an important exporter of nurses to developed countries (Fang, 2007) and the large healthcare literature located in Chinese language journals. 2. Methods 2.1. Study identication and selection Both electronic and manual searches were conducted to identify all published research studies focusing on the health professionals attitudes toward older people. The search was completed in May 2011 and was restricted to papers published since 2000. The following databases were broadly scanned prior to more rened electronic searches: CINAHL, MEDLINE, EMBASE, British Nursing Index (BNI), PsycINFO, Chinese Biomedical database (CBM), China Medical Academic Conference (CMAC) and China Academic Journal (CAJ). To maximize the sensitivity of the search Boolean operators were used to combine the terms (older people and attitude and health professional). Specic search terms used are listed in Table 1. The electronic search produced 2130 references in the English language and 49 references in the Chinese language. Review of the titles and abstracts revealed 629 duplicate references, 43 were not journal papers, 1406 were not relevant (they did not report registered or student nurses attitudes towards older people). Further information relating to 15 papers was needed for their assessment but they were unobtainable. Sixteen papers were not written in the English or Chinese languages although their abstracts were in English. The full texts of the remaining 70 papers were retrieved and assessed for eligibility. For inclusion the following criteria were met: a report of primary research into the attitudes of registered or student nurses towards older people, in which attitudes were measured using a

Please cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud. (2012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

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Liu et al. / International Journal of Nursing Studies xxx (2012) xxxxxx Table 1 Search terms. Facets Older people Attitude Health professional Search terms Elder; aged; older people; old people; elderly Attitude(s) to/toward(s) old people/elder/aged/elderly/older people; ageism, stigma, labelling, stereotyping, prejudice, discrimination Nurse/s; nursing staff, nursing faculty; health professional, health care personnel; health care provider/s, physician/s; doctor/s; medical professional 3

validated attitude scale. Papers in which nurses data were not reported independently to those of other health professionals were excluded together with all qualitative studies. No attempt was made to access unpublished studies or other grey literature. Finally the reference lists of the selected 23 papers were scanned for additional studies which identied two papers. A total of 25 papers met the inclusion criteria for the review (see Fig. 1). 2.2. Data analysis To enable comparison across studies using different scales or the same scale utilising different point Likert styles, the raw mean score was converted to a percentage

so that the whole potential score ranged from 0% to 100%. For example, in a 5-point scale which ranged from negative to positive, 3.5 was converted to 62.5% computed by [(3.5 1)/(5 1) 100%]. But if in a 5-point scale ranged from positive to negative, it was reversed, and 3.5 was converted to 37.5% computed by [100% (3.5 1)/ (5 1) 100%]. The converted data were then categorised into study attitudinal outcomes with percentages below 40% considered as negative, neutral between 40 and 60%, or positive above 60%. There was no evidence that the data conversion distorted any of the study ndings. The study attitudinal outcomes were examined across time and in relation to the reported variables across the selected studies.

Title and abstracts idened and screened n=2179 Duplicates n=629 Not journal arcles n=43 Not in English or Chinese n=16 Not relevant n=1406

Full copies retrieved and assessed for eligibility n=70

Did not meet inclusion criteria n=48

Review of reference lists of selected papers n=23

Manual search idened papers n=2

Papers included in the review n=25

Fig. 1. Flow chart of study selection process.

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2.3. Reliability of quality assessment and data extraction Initial screening was undertaken by one researcher (YEL) and then checked by another (AW). Disagreements about inclusion were discussed until agreement was reached. One researcher (YEL) extracted the following data from the selected studies: country of study, study design and setting, study sample, measurements, variables and main results. Two reviewers (AW & IJN) veried the extracted data and made corrections as necessary and agreed the assessed study quality using the Strobe checklist (Altman et al., 2007). All three researchers contributed to the literature synthesis. 3. Results 3.1. An overview of included papers Of the 25 studies a third (n = 8) were conducted in North America, a quarter in European countries (n = 6) and a sixth in Taiwan (n = 4). The remaining studies were carried out in Australia (n = 3), Jordan (n = 2), and China (n = 1). One study was conducted in both Australia and the UK. Most (n = 21) were cross-sectional surveys, three were trials (baseline data used in this paper) and one was a longitudinal study. Only seven studies recruited samples from more than one site and site selection was usually based on geographical convenience. Between one and three studies were published each year between 2000 and 2009. A further six were conducted in 2010 and two in 2011. The design features and main ndings of the studies are reported in Table 2 together with a quality rating. No study was rated as high quality using the Strobe checklist (Altman et al., 2007). 3.2. Instruments of included studies for measuring attitudes Six scales were employed in the selected studies. Kogans Old People Scale (KOP) (Kogan, 1961) was the most frequently used in its various translations. The KOP comprises 17 pairs (and the revised KOP (Hilt and Lipschultz, 1999) 22 pairs) of positive and negative statements about older people which are rated on a 7point Likert scale from strongly disagree (1) to strongly agree (7) (Good content validity, construct validity, internal consistency and stability reliability have been reported for both variants of the instrument (Erdemir et al., 2011)). The Aging Semantic Differential (ASD) (Rosencranz and McNevin, 1969) assesses attitudes toward adults of different ages (Gluth et al., 2010). It comprises 32 adjective pairs rated on a 7-point Likert scale from positive to negative and is reported to have robust psychometric properties (Polizzi, 2003). The AGED Inventory (Knox et al., 1995) measures attitudes and stereotypical beliefs about older adults and comprises two sub-scales of 28 adjective pairs which are rated using a 7-point Likert scale from negative to positive. Its robustness has been established by Koren et al. (2008). Nolan et al.s (2001) Perceptions of Working with Older People (PWOP) comprises 11 statements with responses on a 5-point Likert scale yielding a

score of 1155. This scale is robust and reects more contemporary views on ageing. The Facts on Aging Quiz (FAQ) (Palmore, 1988) comprises 25 multiple-choice questions to evaluate knowledge of older people. The quiz scores quantify positive or negative bias towards older adults based upon the assumption that certain misconceptions about older people indicate a positive or negative bias (true, false, or dont know indicate negative bias, positive bias, or no bias). The FAQ correlates signicantly with the KAOP (Wang et al., 2010). McLafferys (2005) scale comprises 20 items measuring nurses attitudes toward hospitalised older people with responses on a 5-point Likert scale. It was developed using focus groups (McLafferty and Morrison, 2004) and reported Cronbach a 0.7 in a pilot study. 3.3. Attitudes towards older people The ndings across the 25 studies were inconsistent with both positive, negative and neutral attitudes being noted across qualied and student nurses. Of the 25 included studies, 21 studies data could be converted into percentages (Table 3). The other four studies (Holroyd et al., 2009; Karlin et al., 2006; Plonczynski et al., 2007; Wells et al., 2004) did not report sufcient data to allow this calculation, but reported summary ndings. Fig. 2 which summarises the converted scores suggests that there may have been a slight decrease from positive to neutral in student nurses attitudes towards older people over time. One study reported negative attitudes among three groups of Greek student nurses on the negKOP subscale (Lambrinou et al., 2009). Six independent samples from ve studies reported neutral attitudes. Most studies found positive attitudes among student nurses with the highest percentage of 71.8% and the lowest percentage of 34.2% being reported by the same study (Lambrinou et al., 2009). The same trend was observed in qualied nurses but the trend is smaller (Fig. 2) with a wider data range. One study reported that 33.8% of UK nurses held negative attitudes (Kearney et al., 2000). Three studies found neutral attitudes and another ve studies found positive attitudes. The highest positive attitude was reported among nurse teachers (McLafferty, 2005). 3.4. Variables related to attitudes towards older people Thirty two variables related to attitudes towards older people were identied from the 25 papers. The relationship of these variables to positive attitudes is summarised in Table 4. Variables were grouped under one of six categories and listed in order of the most investigated to the least investigated. Demographic variables were frequently investigated, with 3 of 11 studies reporting a signicant positive association between increasing age and positive attitudes. Gender was a signicant variable in half of the studies but yielded conicting results with three studies reporting that the male gender was associated with positive attitudes while three studies reported the opposite nding. Other demographic variables were investigated in a small

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Table 2 Summary of included papers. Reference and location Chen and Walsh (2009) Taiwan a Design and sample  RCT  194 4th year student nurses recruited from one nursing college (RR unclear) n = 100 intervention, n = 94 controls  Cross-sectional survey  177 nursing students, 108 nutrition students, 88 physical therapy students, 63 health management students, 99 social worker students and sports students recruited from one university (RR 71%)  Cross-sectional survey  15 registered nurses from an acute-care unit and 18 from a tertiary rehabilitation centre (RR 41.7% 25.7%, respectively)  Cross-sectional survey  99 nurses, 73 assistant personnel and 15 porters purposively recruited from two hospitals (RR 69% and 57% for acute and long-term settings, respectively)  Cross-sectional survey  143 Australian and 213 UK nurses working in a range of nursing professions recruited from two countries (average RR 70%)  Longitudinal study  197 student nurses recruited from a BSN program in a university college (RR 80%)  Cross-sectional survey  143 nurses working in selected units in acute care settings of 3 public hospitals (RR 75%)  Cross-sectional survey  243 student nurses recruited from 4 classes in one university (RR = 95.2%)  Cross-sectional survey  81 nursing students from a college & 108 psychology students from a university (RR unclear)  Cross-sectional survey  34 medical, 102 nursing & 61 radiography staff recruited from a regional Cancer Centre (RR 62%, 77%, 26%, respectively)  Cross-sectional survey  200 student nurses recruited from one university school (RR 91.3%) Instrumentation  Revised Kogans attitudes toward old people scale (RKAOP, Kogan, 1961; Hilt and Lipschultz, 1999)  Self-transcendence scale (STS, Reed, 1992, 2003) Attitudes towards Old People Scale (KOP, Kogan, 1961) Comments Small convenience sample based in one site Response rate unclear Convenience sample based in one site Moderate response rate Rating Low

Please cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud. (2012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

Erdemir et al. (2011) Turkey b

Moderate

Furlan et al. (2009) Canada c

Attitudes towards Old People Scale (KOP, Kogan, 1961)

Small convenience sample drawn from more than one site Low response rate Convenience sample drawn from more than one site Moderate response rate

Low

Liu et al. / International Journal of Nursing Studies xxx (2012) xxxxxx

Gallagher et al. (2006) UK d

Attitudes towards Old People Scale (KOP, Kogan, 1961)

Moderate

Gething et al. (2002) Australia,UK e

Holroyd et al. (2009) Canada f Hweidi & Al-Hassan (2005) Jordan g Hweidi and Al-Obeisat (2006) Jordan h Karlin et al. (2006) USA i

 Aging Semantic Differential (ASD, Rosencranz & McNevin, 1969)  Reactions to Ageing Questionnaire (RAQ, Gething, 1994)  Facts on Aging Quiz (FAQ, Palmore, 1977, 1988) Attitudes towards Old People Scale (KOP, Kogan, 1961) Attitudes towards Old People Scale (KOP, Kogan, 1961) Attitudes towards Old People Scale (KOP, Kogan, 1961)  Rened Aging Semantic Differential (Rosencranz & McNevin, 1969; Polizzi, 2003)  Researcher-developed Self-Efcacy: 3 questions measuring self-efcacy, efcacy expectation and outcome value Attitudes towards Old People Scale (KOP, Kogan, 1961)

Convenience samples drawn from two country Moderate response rate

Moderate

Small convenience sample based in one site Moderate response rate Small convenience sample drawn from multiple sites Moderate response rate Convenience sample based in one site High response rate Small convenience sample drawn from more than one site Response rate unclear

Low

Low

Moderate

Low

Kearney et al. (2000) UK j

Convenience sample based in one site Moderate response rate Small convenience sample based in one site High response rate

Moderate

Koren et al. (2008) USA k

 AGED Inventory (Knox et al., 1995)  Researcher-developed Undergraduate Needs Assessment Form: 1. Current knowledge of gerontology as well as their comfort and condence in caring for older adults. 2. Intent to pursue gerontological knowledge. 3. Interest in learning more about 15 specic gerontology topics

Low

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Table 2 (Continued ) Reference and location Lambrinou et al. (2009) Greece l Design and sample  Cross-sectional survey  Student nurses: 1st yr n = 121(RR 69.4%) & 4th yr n = 106(RR 62.35%) from one university; 1st yr n = 112 (RR 89.6%) & 4th yr n = 79 (RR 68.2%) from one institute  Cross-sectional survey  55 nurse teachers, 64 1st year student nurses, 55 student nurses who had completed rst theory module recruited from one university school (RR 93%, 78%, 63%, respectively)  Cross-sectional survey  31 nurses recruited from a multi-purpose health service (MPHS) (RR 100%) Instrumentation  Attitudes towards Old People Scale (KOP, Kogan, 1961)  Facts on Aging Quiz I (Palmore, 1988) Comments Convenience sample drawn from more than one site Moderate response rate Rating Moderate

Please cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud. (2012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

McLafferty (2005) UK m

Researcher-developed questionnaire (McLafferty & Morrison, 2004)

Small convenience sample based in one site Moderate response rate

Low

Mellor et al. (2007) Australia n

Myers et al. (2001) Australia o

 Cross-sectional survey  201 nurses working in general areas recruited from one acute-care hospital (RR 29%)  Cross-sectional survey  362 student nurses recruited from one university (RR 84%)  Cross-sectional survey  26 nursing faculty recruited from one Midwestern nursing school (RR unclear)

Pan et al. (2009) Taiwan p Plonczynski et al. (2007) USA q

 Attitudes towards Old People Scale (KOP, Kogan, 1961)  Modied Facts of Aging Quiz (PFAQ, Palmore 1988; Courtenay & Wiedman, 1985)  Researcher-developed: compliment PFAQ by adding a gerontic nursing focus  Aged Semantic Differential (ASD, Rosencranz & McNevin, 1969)  Perceptions of Restraint Use Questionnaire (Strumpf & Evans, 1988) Perceptions of Working with Older People (PWOP, Nolan et al., 2001)  AGED inventory (Knox et al., 1995)  Researcher-developed: 6 questions to assess the gerontological content of each undergraduate course, 3 questions to assess faculty gerontological knowledge  Attitudes towards Old People Scale (KOP, Kogan, 1961)  Facts on Aging Quiz 1 (FAQ1, Palmore, 1988) Attitudes towards Old People Scale (KAOP, Kogan, 1961)

Small convenience sample based in one site High response rate

Low Liu et al. / International Journal of Nursing Studies xxx (2012) xxxxxx

Convenient sample based in one site Low response rate Convenience sample based in one site Moderate response rate Small convenience sample based in one site Response rate unclear

Moderate

Moderate

Low

Ryan and McCauley (2004) USA r

 Cross-sectional survey  55 student nurses recruited from one university school (RR unclear)  Cross-sectional survey  86 1st year and 65 3rd year student nurses & 41 registered nurses in post-graduate courses recruited from one university in west Sweden (RR 100%)  RCT  22 senior student nurses recruited from one school (RR unclear)

Small convenience sample based in one site Response rate unclear Small convenience sample based in one site High response rate

Low

derhamn et al. (2001) So Sweden s

Low

Walsh et al. (2008) USA t

Wang et al. (2009) Taiwan u Wang et al. (2010) Taiwan v

 Cross-sectional survey  84 student nurses & 191 medical students recruited from one school (RR 88.4%)  Cross-sectional survey  125 nursing students with at least 1-years work experience and 95 1st year with no previous work experience recruited from 2 different programs at one nursing school (RR 87.4%, 77.5%, respectively)

 Revised Kogans attitudes toward old people scale (RKOP, Kogan, 1961; Hilt and Lipschultz, 1999)  Self-transcendence scale (STS, Reed, 1992, 2003) Attitudes towards Old People Scale (KOP, Kogan, 1961)  Attitudes towards Old People Scale (KOP, Kogan, 1961)  Facts on aging quiz 1 (FAQ 1, Palmore, 1977)

Small convenience sample based in one site Response rate unclear

Low

Convenience sample based in one site Moderate response rate Small convenience sample based in one site Moderate response rate

Moderate

Low

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number of studies. For example, no differences in attitudes were reported between student nurses (Hweidi and AlObeisat, 2006) or nurses (Hweidi and Al-Hassan, 2005) living in villages or in the city. Ryan and McCauley (2004) reported more positive attitudes in Hispanic/Latino students compared to Black students. Family income was not a signicant variable in Lambrinou et al. (2009) study, whereas monthly income was negatively associated with student nurses attitudes (p = 0.002) (Hweidi and AlObeisat, 2006). Nurses marital status was not associated with attitudes (Hweidi and Al-Hassan, 2005). Education was the second most investigated variable with education level being the most widely investigated variable and showed inconsistent ndings. Five studies (Furlan et al., 2009; Hweidi and Al-Obeisat, 2006; Karlin derhamn et al., 2001) et al., 2006; Lambrinou et al., 2009; So reported an association between higher education level and positive attitudes and the other six (Holroyd et al., 2009; Hweidi and Al-Hassan, 2005; Koren et al., 2008; McLafferty, 2005; Pan et al., 2009; Ryan and McCauley, 2004; Wu, 2011) reported no association. One study found no association between initial nurse training/education and attitudes (Myers et al., 2001) while another found more positive attitudes in nurses with a gerontology education compared to those without (Wells et al., 2004). Several studies examined the association between various experience of older people variables and attitudes with most nding no association. None of the studies found a negative association between experience and positive attitudes except one of 4th year student nurses from one university (Lambrinou et al., 2009) where living with older people and negative attitudes was related in one but not in the other three student groups. Two of the four studies reported that living with or having been cared for by older people was associated with positive attitudes (Hweidi and Al-Hassan, 2005; Wu, 2011). One of three studies found an association between positive attitudes and clinical experience (Wang et al., 2010) and another between positive attitudes and duration of nursing experience (Hweidi and Al-Hassan, 2005). Two studies found no association between student nurses attitudes and their experience of working with older people (Hweidi and Al-Obeisat, 2006; Pan et al., 2009) and one found no association between attitudes and frequency of caring for patients with spinal cord injury (Furlan et al., 2009). Different work settings were associated with different attitudes to older people. Two studies found no association between attitudes and a hospital or nursing home derhamn et al., 2001) experience (Koren et al., 2008; So and two studies of acute care settings yielded inconsistent ndings; Furlan et al. (2009) reported that nurses working in acute care had more ageist attitudes than those working in a rehabilitation centre but Gallagher et al. (2006) found no differences in attitude between nurses in the acute and long-term settings. Area of work was not associated with attitudes in one study (Myers et al., 2001) of nurses working in general areas from one acute-care hospital, but another study reported that nurses working for a service provider or working outside the residential care sector were more likely to hold positive attitudes (Wells et al.,

Low

 Cross-sectional survey  205 nurses, 298 doctors, 86 other professionals, 33 direct care staff, 78 other service providers & 22 other staff recruited from 20 organizations (RR 1370%)

 Cross-sectional survey  131 1st year and 82 3rd year student nurses recruited from one school (RR 100%, usable RR 91.4%) Wu (2011) China y

 Facts on Aging Quiz (FAQ, Palmore, 1977, 1998)  Reactions to Ageing Questionnaire (RAQ, Gething, 1994)  Researcher-developed The Practice Costs and Rewards Questionnaire (PCRQ), adapted from Le Courteur et al. (1997)  Aging Semantic Differential (Rosencranz & McNevin, 1969)  Reaction to Ageing Questionnaire (RAQ, Gething, 1994)  Personal Details Questionnaire (Gething, 1994)  Facts on Aging Questionnaire (Palmore, 1977, 1988)  Attitudes towards Old People Scale (KOP, Kogan, 1961)  Facts on aging quiz 1 (FAQ 1, Palmore, 1977) Note: If the study is a trial, we used the baseline data from trial where available. Williams et al. (2007) Canada x Wells et al. (2004) Australia w  Single group experiment with post-test comparator  38 1st year student nurses recruited from two programs in one university (RR unclear)

Please cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud. (2012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

Convenience sample based in one site High response rate

Small convenience sample based in one site Response rate unclear

Convenience sample drawn from multiple sites Low to moderate response rate

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Table 3 Nurses attitudes (positive, neutral or negative) to older people reported by the included papers. Reference a Tool RKOP Raw scores  Student nurse: intervention group (a1): 77.45 12.95; control group (a2): 75.83 14.58  Possible range: 22154, mid-score 88, high = ve  Student nurse: 139.12 14.27  Possible range: 34204, mid-score 102, high = +ve  Nurse: Acute-care setting (c1): +KOP = 49.67, KOP = 46.33; rehabilitation (c2): +KOP = 50.83, KOP = 55.44  Possible range: 1785, mid-score 51, high = +ve  Nurse: acute-care seeting (d1): +KOP = 41.95, KOP = 68.13; long term (d2): +KOP = 40.37, KOP = 66.34  Possible range: 1785, mid-score 51, high score = ve in +KOP, reverse in KOP  Nurse: UK (e1): 122.31; Australia (e2): 108.79  Possible range: 32224, mid-score 128, high = ve  nurse: 118.64  possible range: 34204, mid-score 102, high = +ve  Student nurse: 110.6  Possible range: 34204, mid-score 102, high = +ve  Nurse: 80  Possible range: 34170, mid-score 102, high = +ve  Student nurse: 4.35  Possible range: 17, mid-score 4, high = +ve  Sample 1: Student nurse from one university: 1st year (l1): +KOP = 68.62, KOP = 65.02; 4th year (l2): +KOP = 71.28, KOP = 62.28  Sample 2: Student nurse from one institute: 1st year (l3): +KOP = 70.38, KOP = 67.10; 4th year (l4): +KOP = 72.63, KOP = 64.32  Possible range: 17102, mid-score 51, high = +ve, reverse in KOP  Nurse teacher (m1): 4.31; 1st year student nurse (m2): 3.487; another student group (m3): 3.56  Possible range: 15, mid-score 3, high = +ve  Nurse: 173.4 19.18  Possible range: 34238, mid-score 136, high = +ve  Nurse: 3.61  Possible range: 17, mid-score 4, high = +ve  Student nurse: 39.75 4.42  Possible range: 1155, mid-score 33, high = +ve  Student nurse: 142.76 15.92  Possible range: 34204, mid-score 102, high = +ve  1st year student nurse (s1): 80; 3rd year student nurse (s2): 72.5; registered nurse (s3): 74.8  Possible range: 34170, mid-score 102, high = ve  Student nurse: 74.74  Possible range: 22154, mid-score 88, high = ve  Student nurse: 156.86  Possible range: 34238, mid-score 136, high = +ve  Student nurse: with work experience (v1): 167.48; without work experience (v2): 151.23  Possible range: 34238, mid-score 138, high = +ve  Student nurse: 107.50  Possible range: 32224, mid-score 128, high = ve  1st year student nurse (y1): 161.18; 3rd year student nurse (y2): 159.37  Possible range: 34238, mid-score 136, high = +ve Converted score  a1: 58%  a2: 59.2% 68.2%  c1: +KOP = 48%; KOP = 43.1%  c2: +KOP = 49.8%; KOP = 56.5%  d1: +KOP = 63.3%; KOP = 75.2%  d2: +KOP = 65.6%; KOP = 72.6%  e1: 53%  e2: 60% 58.2% 54.2% 33.8% 55.8%  l1: +KOP = 67.3%; KOP = 36.3%  l2: +KOP = 71.8%; KOP = 40.3%  l3: +KOP = 69%; KOP = 34.2%  l4: +KOP = 71%; KOP = 36.9%  m1: 82.8%  m2: 64%  m3: 62.2% 68.3% 63.0% 65.3% 70.0%  s1: 66.2%  s2: 71.7%  s3: 70% 60.0% 60.2%  v1: 65.4%  v2: 57.5% 60.7%  v1: 62.3%  v2: 61.5% Overall attitude  a1: Neutral  a2: Neutral Positive  c1: +KOP = neutral; KOP = neutral  c2: +KOP = neutral; KOP = neutral  d1: +KOP = positive; KOP = positive  d2: +KOP = positive; KOP = positive  e1: Neutral  e2: Positive neutral Neutral Negative Neutral  l1: +KOP = positive; KOP = negative  l2: +KOP = positive; KOP = neutral  l3: +KOP = positive; KOP = negative  l4: +KOP = positive; KOP = negative  m1: positive  m2: Positive  m3: Positive Positive Positive Positive Positive  s1: Positive  s2: Positive  s3: positive Positive Positive  v1: Positive  v2: neutral Positive  v1: Positive  v2: Positive

b c

KOP KOP

KOP

e g h j k l

ASD KOP KOP KOP AGED KOP

RD tool

n o p r s

KOP ASD PWOP KOP KOP

t u v

RKOP KOP KOP

x y

ASD KOP

Note: 21 studies in the table, another 4 studies data failed reported sufcient raw data; RD: researcher-developed.

2004). Only one study compared attitudinal data across countries and reported that UK nurses held more negative attitudes than Australian nurses (Gething et al., 2002). Preference to work with older people was positively associated with attitudes towards older people in three

studies (Hweidi and Al-Obeisat, 2006; Koren et al., 2008; Pan et al., 2009) and knowledge relating to ageing was positively associated with attitudes in three studies of qualied (Mellor et al., 2007) and student (Lambrinou et al., 2009; Wu, 2011) nurses.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Fig. 2. Student and qualied nurses converted scores of the included studies.

m-teacher s2,s3 s1 o e2 e1 r m2 m3 k d1d2d2+ n d1+ x h l2+,l4+ l1+,l3+ p v1 u a1,a2 c2- v2 c1+,c2+ c1l2l4-, l1l3-

Converted score of student nurse (reference)

b y1,y2
Converted score of qualied nurse (reference) Linear trend line of student nurse

t k

Linear trend line of qualied nurse

Difference in attitudes towards older people between different types of nurse was examined in three studies. derhamn et al. (2001) found that 1st year students held So more negative attitudes than registered nurses while McLafferty (2005) found that nurse teachers held more positive attitudes than students and Mellor et al. (2007) reported that registered nurses were more positive than enrolled nurses. Some studies examined the relationship of other variables to attitudes. For example, Myers et al. (2001) reported that attitudes to restraint use and level of practice were not signicantly correlated with attitudes towards older people. Only one study investigated the association between attitudes to self-ageing and attitudes towards older people among UK and Australia nurses and found a positive association (Gething et al., 2002). Lambrinou et al. (2009) reported that choosing nursing as the rst study choice was not related to students attitudes towards older people. 4. Discussion Attitudes towards older people among nurses have attracted considerable interest from researchers over time and across countries. Both registered and student nurses attitudes towards older people appear to have become less positive since 2000 although the majority of studies reported positive attitudes. The slight trend towards a decrease in positive attitudes among registered nurses compared to student nurses, albeit with a wide data range from a few studies, is noteworthy. This attitudinal difference may impact upon the desired promotion of positive attitudes towards older people since registered nurses are the role models and mentors of student nurses during their socialisation in clinical settings. However, registered and student nurses attitudes are not independent of general societal attitudes and, while one might expect healthcare professionals to espouse positive attitudes towards all their potential patients, nurses are drawn from the general population of their country

including migrants and are therefore subject to the inuence of prevailing attitudes of those societies and their cultural heritage. Interestingly the cultural background of the nurse samples was not reported although it is likely most nurses reected some aspects of the country in which the study was conducted even if they were recent migrants. Indeed attitudes towards older people vary widely across different countries, and sometimes within countries, reecting cultural norms. Of the included studies, Lambrinou et al. (2009) reported conicting results with student nurses holding positive attitudes on posKOP but negative attitudes on negKOP. Lambrinou offers no explanation of this nding which is difcult to interpret because it indicates that the subjects disagreed with the negative items less than they agreed with statements praising older people. Moreover, this nding is inconsistent with the results of Kogans (1961) study of three samples used to develop the KOP. A range of variables have been examined as potential predictors of nurses attitudes. Age, gender and education level have been being investigated most frequently but none appear to be consistent predictors of attitudes across studies. For example, three studies found that males had more positive attitudes than females (Holroyd et al., 2009; Hweidi and Al-Hassan, 2005; Hweidi and Al-Obeisat, 2006), but another three studies reported the opposite nding. These inconsistent ndings highlight the need for more sophisticated analysis of study data. Although investigated in a few studies only, preference to work with older people and knowledge of ageing appear to be associated with positive attitudes towards older people. This nding suggests that education in gerontological nursing together with positive clinical learning experiences can improve attitudes towards older people and increase the number of nurses expressing a preference to work with older people. The experience of working with older people was not clearly associated with attitudes towards older people in two studies included in this review (Hweidi and AlObeisat, 2006; Pan et al., 2009). This nding is in contrast

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Table 4 Variables related to positive attitudes towards older people. Category Demographics Variable Increasing age Gender: male Village v. city Hispanic/Latino students v. Black students Family income Monthly income Marital status Education level Initial training/education Gerontology education Live with older people Taken care by older people Clinical experience Time of nursing experience Working with older people Frequency of caring for patients with SCI Hospital v. nursing home Acute care setting Area of work Outside the residential care sector Service provider Surgical v. medical units UK v. Australia Preference to work with older people Knowledge Registered nurse v. student Registered v. enrolled nurses Teacher v. student Attitudes to restraint use Level of practice Attitudes to self-aging Choose nursing as the rst choice of studying Positive* correlation h, l3, s1 f, g, h r c, h, i, l, s w g y v g Negative* correlation l2, l3, p, s h l2 Non-signicant correlation c, e, g, i, k, l1, l2, l4, o, p, r, s2 e, i, l1,o g, h l1, l2, l3, l4 g f, g, k, m, p, r, y o h, l1, l3, l4, p k, p c, o h, p c Total studies 11 9 2 1 1 1 1 12 1 1 4 1 3 3 2 1

Education

Experience

Work setting

w w g h, k, p

c e

k, s d o

2 2 1 1 1 1 1 3

Preference to work with older people Knowledge Nurse type

l, n, y s n m e

o o l1, l2, l3, l4

3 1 1 1 1 1 1 1

Other

Note: *p < 0.05; s1: student nurse, s2: registered nurse; l: both student groups from two sites, l1: 1st year student nurses from one university, l2: 4th year student nurses from one university, l3: 1st year student nurses from one institute, l4: 4th year student nurses from one institute.

to Moyles (2003) study which reported a positive association between experience of working with older people and attitudes. However, this study used an unvalidated attitude measure and so its ndings are questionable. Only one study (Gething et al., 2002) investigated nurses attitudes across countries and reported that UK nurses held more negative attitudes than Australian nurses and that views about self-ageing were correlated with attitudes towards older people. This nding may reect the impact upon attitudes of different national policies and different attitudes within different societies. The UK enacted its rst anti-age discrimination legislation in 2006 following earlier legislation to outlaw discrimination relating to race and pay in the early 1970s with equality emerging as an important political issue from 1970 onwards. The limitations of this review include the methodological weaknesses of some of the selected studies which

recruited small non-randomly selected samples from small geographical areas. Additionally it was not possible to draw rm conclusions from the limited data sets derived from multiple studies across time and settings. Further research using well designed studies with larger and random samples which examine the inter-relationships between key variables using validated instruments is needed together with well designed trials of interventions designed to improve attitudes so that there is evidence upon which to build workforce strategies to meet future health care system needs. However, cross-cultural studies of attitudes are challenging because shared conceptual understanding cannot be assumed. 5. Conclusion Global demographic trends (Kinsella and He, 2009; WHO, 2000) are creating an imperative for improving nurses attitudes towards older people and their work

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preference for caring for older people if the needs of global health care systems are to be met and high quality care delivered to older people (ICN, 2006). The limited evidence from well designed studies needs urgent attention if workforce strategies are to be implemented. Understanding the attitudes of registered nurses and the associated factors should receive equal attention to that of student nurses because registered nurses are the clinical role models for the next generation of nurses regardless of jurisdiction. However, understanding the attitudes of student nurses and the associated factors will provide evidence upon which to develop initial education curricula so that new registrants are correctly prepared for contributing to the needs of future health care systems whether they choose to remain in their home nation or enter the global labour market (Kingma, 2005). Conict of interest statement There is no conict of interest. Funding None. Ethical approval Not required. References
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