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Nurses' Attitudes Toward Older Patients in Acute Care in Israel

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Maxim Topaz, RN, MA
Israel (Issi) Doron, LL.B, LL.M, PhD

Abstract

Ageism has been found to negatively affect the health care services that older persons receive, both implicitly through unfair resource allocation by the stakeholders, and explicitly, by providing offensive and poor quality treatment. In this article, the authors review the literature relating to ageing, noting that negative attitudes among caregivers toward older patients in acute care settings are a strong predictor of ageism. They describe a study in which they explored a group of Israeli nurses’ knowledge of ageing and attitudes toward older people in an acute care setting and analyzed the relationship between these variables using a descriptive, correlational design method. Nurses working in one of the largest public hospital in Israel completed Kogan’s Attitudes Towards Older People Scale and Palmore’s Facts on Ageing Quiz. Findings indicated that the nurses’ level of knowledge of ageing was relatively low. The authors discuss nurses’ knowledge of ageing and nurses’ ethnicity as significant predictors of ageist attitudes. They conclude by recommending that nurse educators strengthen gerontological content in the nursing curriculum and provide culturally tailored nursing education to reduce ageism among professional nurses.

Citation: Topaz, M., Doron, I., (April 15, 2013) "Nurses' Attitudes Toward Older Patients in Acute Care in Israel" OJIN: The Online Journal of Issues in Nursing Vol. 18 No. 2.

DOI: 10.3912/OJIN.Vol18No02PPT01

Keywords: Ageism, gerontological knowledge, gerontological education of nurses, attitudes toward ageing, Kogan’s Attitudes Towards Older People Scale, Palmore’s Facts on Ageing Quiz, Israel

Ageism has been found to negatively affect the health care services that older persons receive, both implicitly through unfair resource allocation by the stakeholders, and explicitly, by providing offensive and poor quality treatment. Until the early 18th century, global population size was relatively static and the lives of the vast majority of people were “nasty, brutish, and short” (Bloom & Canning, 2008, p 4.). Since then, the size and structure of the global population have undergone extraordinary changes. In particular, life expectancy has increased by three decades and in the 21st century it is projected to further increase by yet another two decades (Bicket, 2002). In Israel, the population is relatively young. However, the demographic trend is similar to that found in many developed countries in that the population is ageing. Israeli life expectancy at birth is currently 80.4 years; persons over 65 years of age constitute 10.1% of the population (Israeli Agency, 2009)

This increase in the older population (65 years and older) requires that health care systems worldwide respond to new challenges (Crimmins, 2004). One prominent issue in the field of gerontology is discrimination against individuals based on their chronological age, a phenomenon that is often termed ‘ageism’ (Corner, Brittain, & Bond, 2007; Nelson, 2002). Ageism has been found to negatively affect the health care services that older persons receive, both implicitly through unfair resource allocation by the stakeholders, and explicitly, by providing offensive and poor quality treatment (Lothian & Philp, 2001). Negative biases and ageist attitudes among caregivers, and particularly nurses, toward older people in acute care settings, are among its more notable expressions in the health care system (Holroyd, Dahlke, Fehr, Jung, & Hunter, 2009). Identifying those attitudes constitutes the first step in understanding the many facets of interactions between nurses and older patients.

Ever since Allport’s intergroup contact theory was described in the early 1950s, social and educational sciences theoreticians have maintained that attitudes have a strong influence on an individual’s actual behavior (Ajzen, 2005; Allport, 1954). It is important to identify both nurses’ attitudes toward older patients and the factors that correlate with those attitudes to understand, predict, and if necessary, change behaviors of nurses working with an older population, thus minimizing ageism in nursing practice.

Literature Review

Negative biases and ageist attitudes among caregivers, and particularly nurses, toward older people in acute care settings, are among its more notable expressions in the health care system. In this literature review, we will consider two branches of research regarding nurses’ attitudes toward older patients. First, we will summarize research addressing nurses’ attitudes toward older patients in acute care; then we will consider factors affecting nurses’ perceptions of old age.

Nurses' Attitudes Toward Older Patients in Acute Care

Research indicates that the quality of health care services provided to the older population is strongly influenced by caregivers’ attitudes toward older people (Gallagher, Bennett, & Halford, 2006; Jacelon, 2002). Affirmative attitudes of nurses have a positive influence on the health of older patients (Courtney, Tong, & Walsh, 2000a). Nurses with constructive attitudes toward older people have been noted to listen attentively, bond deeply, assist respectfully, and engage in friendly relationships with their clients (Courtney et al., 2000a; Jacelon, 2002). In contrast, nurses that expressed negative attitudes toward older people indicated they preferred to work with younger patients. When caring for older patients, these nurses were more likely to use physical restrictions; to disrespect the patients’ autonomy and dignity; and to discriminate against them (Nelson, 2004; Seedhouse & Gallagher, 2002; Wai-Tong & Lee, 2007).

Affirmative attitudes of nurses have a positive influence on the health of older patients. Studies examining nurses’ attitudes toward older, acute care patients have had inconsistent findings. For example, in the United States, positive attitudes by nurses toward older patients were reported in the geriatric and surgical departments of various hospitals (Hope, 1994). In Jordan and Australia, similar attitudes have been reported by several researchers who have studied nurses in medical-surgical wards (Hweidi & Al-Hassan, 2005; Mellor, Chew, & Greenhill, 2007). In contrast, negative attitudes toward older patients were noted in Ireland and Sweden (Gallagher et al., 2006). Because nurses’ attitudes are modifiable and because there is evidence these attitudes vary from country to country (Ajzen, 2005), we believed it was important for us to assess nurses’ attitudes to older, acute care patients in our country (Israel) so as to enhance the quality of health care for our older persons.

Factors Affecting Nurses’ Perceptions of Older People

To date, the most important factor identified as influencing patient care is the nurse’s level of knowledge of ageing. Current literature on attitudes toward older people tends to focus on the caregiver’s education and personal characteristics, as well as the work environment. Theoretical models (Ajzen, 2005) and empirical findings have suggested that characteristics influencing a nurse’s attitude towards ageing include: (a) age (Herdman, 2002; Hweidi & Al-Hassan, 2005; Soderhamn, Lindencrona, & Gustavsson, 2001); (b) gender (Cummings, Kropf, & DeWeaver, 2000; Hweidi & Al-Hassan, 2005; Soderhamn et al., 2001); and (c) education (Cummings et al., 2000; Soderhamn et al., 2001). Environmental factors affecting these attitudes include (a) the field of employment in nursing (such as acute care, long term care, or rehabilitation settings) (Courtney, Tong, & Walsh, 2000b; Hartley, Bentz, & Ellis, 1995; Hope, 1994; Hweidi & Al-Hassan, 2005; Soderhamn et al., 2001; Teeri, Leino-Kilpi, & Valimaki, 2006); (b) amount and type of exposure to older persons (Courtney et al., 2000a); and (c) type of department in which staff are employed (Courtney et al., 2000a). To date, the most important factor identified as influencing patient care is the nurse’s level of knowledge of ageing (Holroyd et al., 2009).

Although each of the above factors has been correlated with nurses’ attitudes toward older people, the directions of the correlations have been inconsistent. For example, Herdman (2002) found that older nurses expressed negative attitudes toward older people, whereas Murphy (2007) found that older nurses experienced positive attitudes. Other researchers have reported no significant correlation between nurses’ age and attitudes toward older people (Chasteen, Schwarz, & Park, 2002; Hweidi & Al-Hassan, 2005). Previous work experience is another factor found to affect nurses’ attitudes toward older people. Teeri et al. (2006) and Williams, Zimmerman, Sloane, and Reed (2005) reported that nurses working in long-term care institutions acquired paternalistic views. Other reports, however, have noted that clinical experience in chronic care institutions had a positive effect on positions regarding older people (Hartley et al., 1995; McKinlay & Cowan, 2003). Soderhamn et al. (2001) have stated that there is no clear correlation between the type of care facility and views of the elderly.

Mixed evidence also continues to be reported with regard to nurses’ formal education and their attitudes toward older patients.  On one hand, nurses with a higher level of formal education in geriatrics and gerontology were found to have more positive attitudes than those with little or no education in the field (Courtney, et al., 2000a). Hartley et al. (1995) have also argued that education has a major impact on these attitudes. Additionally, Furze and Pearcey (1999) have suggested that nurses with higher levels of geriatric and gerontological education demonstrate a higher degree of understanding of older person’s needs and desires, and display a generally more positive attitude toward older persons. On the other hand, Buttner (2008) and Hweidi and Al-Hassan (2005) found no correlation between nurses’ and nursing students’ attitudes and their levels of education. Holroyd et al. (2009) from Canada identified a drop in positive attitudes and an increase in negative attitudes toward older people between first and last year nursing students.

These mixed findings are problematic, especially for nurse educators. Without solid empirical validation of the direction of the relationship between nurses’ knowledge and attitudes, it remains challenging to design a nursing curriculum to meet the needs of our rapidly ageing populations. More research is needed to clarify these inconsistencies.

Since attitudes toward older people have been noted to vary between countries, some of the differences in research findings might be attributed to the effects of cultural and ethnic environments. For example, some researchers claimed that Asian cultures, based on the principles of Confucianism and Filial Piety, embrace more positive attitudes toward older people (Laidlaw, Wang, Coelho, & Power, 2010). Palmore, Branch, and Harris (2005), however, noted that Western, individualistic cultures tend to view older persons negatively, as frail and dependent members of society who become a burden after a certain age

Israeli society is notably diverse in terms of ethnic backgrounds that include Jewish immigrants from a variety of other countries and also Arab populations. A third of the Israeli Jewish population are of European or American origins, about 25% are of Asian or African origin, and 16% are Arabs  (Central Bureau of Statistics, 2010). Moreover, since the dissolution of the Union of Soviet Socialist Republics, over one million Soviet Jews have immigrated to Israel (and now comprise about 14% of the Israeli population). The unique, Israeli, socio-ethnic mix makes it challenging to determine the most prevalent views of ageing. To date, only one study has empirically investigated nurses’ attitudes toward older people in the Middle East. This study was conducted in Jordan, a more ethnically homogeneous country than Israel (Hweidi & Al-Hassan, 2005). Because of the differences in government structures, legal systems, and cultures, it is challenging to generalize the conclusions of the Jordanian study towards Israel or other Middle Eastern countries.

In light of the inconsistent evidence related to factors affecting nurses’ attitudes toward older people, we conducted what we have found to be the first study investigating those relationships in Israel. We did so recognizing that identifying similarities and differences between health care settings in different countries is vital for improving the quality of health care provided to older persons.

Method and Analysis

In this section, we will describe our study’s aims, design and participant selection process, research instruments, and data analysis. This study maintained required ethical standards of voluntary informed consent and confidentiality. It was approved by the Helsinki Ethics Committee of the hospital at which it was conducted.

Aims

The goals of this study were (a) to explore nurses’ level of knowledge related to ageing and the attitudes of nurses toward older people in acute care; and (b) to examine the association between nurses’ attitudes toward aging and their socio-demographic (sex, ethnic group, age, place of birth) and work characteristics (professional training, academic education, hospital unit, geriatric experience, working experience, shift). These associations have not been previously investigated among Israeli nurses. In particular, in our study the association between nurses' socio-demographic factors, professional characteristics, and nurses’ attitudes toward older people were examined. For the purposes of this study and in agreement with our research instruments, we defined an older person as a person who is 65 years of age or older.

Design and Selection of Participants

A descriptive correlation design was used to identify acute care nurses' views of the elderly as well as their knowledge of ageing. Potential participants were nurses working in medical-surgical and surgical units of the largest public hospital in northern Israel. This hospital is located in Haifa. Data collection took place in six surgical units (general surgery, thoracic surgery, vascular surgery, neurosurgery, orthopedics, and urology) and six medical-surgical units. The inclusion criterion was being a nurse in one of the twelve-targeted units. Nurses were chosen on a convenience basis, approached during their hospital shift by one of the researchers and were asked to dedicate 25 to 30 minutes to completing the research instruments. Out of 210 study questionnaires distributed during all three eight-hour shifts (morning/evening/night) in September and October of 2009, 170 were completed and returned to the researchers (either by internal hospital mail or in-person). The response rate was 81%. The importance of providing complete responses was presented in the explanation letter and in person and there was no missing data in the collected questioners.

Research Instruments

The three instruments administered in the study questionnaire package are described below:

  1. Information Survey requesting selected demographic and work characteristic information. This survey consisted of a checklist and fill-in-the-blank questions.


  2. Kogan’s Attitudes towards Older People Scale (KOP) (Kogan, 1961). This instrument, consisting of 34 statements, assessed nurses’ attitudes toward older people. Half of the statements represented negative attitudes and the other half positive attitudes toward older individuals. This scale is a self-administered, paper and pencil questionnaire. It takes approximately 15–20 minutes to complete, and assesses attitudes toward older people regarding social norms, individual differences, stereotypes, and misconceptions. Participants were asked to evaluate the statements on a 5-point Likert scale ranging from 1 “strongly disagree,” to 5 “strongly agree.” The scores on negatively worded items were reversed prior to analysis. Following are two examples of statements presented in the KOP survey: “Most old people are irritable, grouchy and unpleasant” and “Most old people tend to let their homes become shabby and unattractive.” The average score for each participant was calculated, with high scores indicating more positive attitudes. The KOP scale is a widely used instrument for measuring attitudes toward older people, and has been shown to be very reliable in previous studies (Lambrinou, Sourtzi, Kalokerinou, & Lemonidou, 2009; Soderhamn, Gustavsson, & Lindencrona, 2000). The KOP scale initially was translated into Hebrew for use in the Healthcare Professionals’ Attitudes Study; in this study its internal consistency reliability was 0.81 (Barzilai, 2004). In our study, an internal consistency reliability of 0.75 was demonstrated.


  3. The participants’ knowledge of ageing was measured by the Palmore’s Facts on Ageing Quiz 1 (FAQ1) (Palmore, 1977). The FAQ1 is a 25-item knowledge scale requiring a ‘Yes, No, or Don’t Know’ response from participants to statements related to their knowledge of older people. Following are two examples of the FAQ1 statements: “Physical strength tends to decline with age” and “The majority of older people are socially isolated.” The instrument has been widely used and found to be reliable and valid in a variety of populations (Palmore, 1977). The reliability reported for the instrument ranges from 0.50 to 0.80 (Cowan, Fitzpatrick, Roberts, & While, 2004; Kaempfer, Wellman, & Himburg, 2002). The FAQ1 was previously translated to Hebrew during another study in which its internal consistency reliability was 0.76 (Eagleshtain & Weisenberg, 1986). In our study, an internal consistency reliability of 0.72 was demonstrated.

These research instruments were selected because they have demonstrated reliability and validity in similar recent studies conducted among international health care professionals (Cheong, Wong, & Koh, 2009; Cowan et al., 2004; Furlan, Craven, Ritchie, Coukos, & Fehlings, 2009; Kaempfer et al., 2002; Kucukguclu, Mert, & Akpinar, 2011; Lambrinou et al., 2009; Lui, & Wong, 2009). Also, these instruments had already been were translated and validated in Hebrew for previous studies (Barzilai, 2004; Eagleshtain & Weisenberg, 1986). Additionally, the use of these instruments provided us with the unique opportunity to compare Israeli nurses’ attitudes to those of their international counterparts.

Data Analysis

Questionnaires were coded according to the directions given by Kogan (1961) and Palmore (1977), and analysis was performed using the STATA Data Analysis and Statistical Software, version 11.1 (2010). STATA is an analytical software program for managing, analyzing, and graphing data. First, we performed a bivariate analysis of attitudes with all study variables using the t-test for continuous data, the chi-square test for categorical data, and the one-way ANOVA for categorical variables with more than two categories. Furthermore, we created a multiple regression model to predict nurses’ attitudes toward older people. Only variables found to be significant at p<.05 in the bivariate comparisons were included in the models.

Findings

This section will describe our findings. Results regarding socio-demographic characteristics, bivariate comparisons, and multivariate regression analysis will be presented.

Socio-Demographic Characteristics

The study sample (N=170) was relatively young, with 75 nurses between the ages of 36 and 45 years of age, and 65 nurses between the ages of 26 and 35. Two-thirds of the participants (61%) were female nurses. On average, the participants had been working as registered nurses for 14 years (SD = 8.58), and almost one third (27.6%) had worked in a geriatric facility at some point of their career. Two-thirds of the sample (64.7%) had a Bachelor of Arts degree in nursing, about one-fifth (18.2%) graduated from a 3-year non-degree RN program, and 10% possessed a Master of Arts degree in nursing. Eleven percent were Registered Practice Nurses. Sixty-three percent of the nurses worked in internal medicine units; the rest were in surgical units. The majority of the participants defined their ethnicity as Jewish (62%) while the rest defined themselves as Arabs. A significant portion of nurses had been born in Russia (48%).

This sample of Israeli nurses reported moderately positive attitudes toward older people (M=3.32 out of 5, SD = 0.33); however, their level of knowledge of ageing was relatively poor (M=12.77 out of 25, SD = 2.9). Descriptive statistics are summarized in Table 1.

Table 1: Socio-demographic and Occupational Characteristics of the Sample.

Characteristics

Nurses sample (N=170)

Age categories n(%)

 

20-25

9 (6%)

26-35

65 (38%)

36-45

75 (44%)

46+

21 (12%)

Gender (female), n (%)

103 (61%)

Ethnic background, n (%)

 

Jewish

105 (62%)

Arab

65 (38%)

Place of birth, n (%)

 

Israel

87 (52%)

Russia

81 (48%)

Work experience with older people, average number of year (SD)

12.8 (8.3)

Working shift, n (%)

 

Morning (7:00 AM- 3:00 PM)

64 (37.7%)

Afternoon (3:00 PM- 11:00 PM)

34 (20%)

Night (11:00 pm- 7:00 AM)

72 (42.3%)

Home-care experience with older people, in (%)

106 (62.3%)

Worked in med-surgical wards, n (%)

108 (64%)

Education

 

Registered Practice Nurse (RPN), n (%)

11 (7%)

Registered Nurse (RN) without BA, n (%)

31 (18%)

RN with BA, n (%)

110 (64%)

RN with MA or MSN, n (%)

18 (11%)

Palmore’s total score (Knowledge), mean ± SD

12.77 (2.9)

Kogan Attitudes Toward Old People, mean ± SD

3.32 (0.33)

Bivariate Comparison

Table 2 shows the relationship between nurses’ characteristics and their attitudes toward older people. Significant relationships (p<.05) were found between these characteristics and their knowledge of ageing (r = 0.18, p = 0.02), ethnic background (t(df169) = 3.7, p = 0.02), age (F(df169) = 2.7, p = 0.04), and education (F(df169) = 8.51, p < 0.00). Because a significant difference was noted between nurses’ attitudes during different shifts (F(df169) = 3.2, p = 0.04), the shift variable was included in our final regression model. Due to the significant variances in attitudes between ethnic groups and in order to allow better understanding of the effect of knowledge on attitudes among the two ethnic groups, we created a variable showing the correlation between knowledge and attitudes separately for Jews and Arabs in the multivariate regression model (Allison, 1999). Finally, we validated our findings with a post hoc analysis that showed that our power of rejecting a false null hypothesis was sufficient (our power ranged from 76% to 100% for different types of bivariate comparisons).

Table 2: Bivariate Correlations of Nurses’ Characteristics and Attitudes toward Older People.

Significance (p)

Statistic

Kogan Attitudes Toward Old People score, mean

Characteristics

r

Pearson’s r

0.02

.18*

Palmore’s total score (Knowledge)

0.31

0.06

Experience

0.3

0.11

Years of geriatric experience other than acute care

F

ANOVA

0.04

2.7*

Age categories

14.11

20-25

12.55

26-35

12.73

36-45

13

46+

0.00

8.51*

Education

11.54

Registered Practice Nurse (RPN)

13.32

Registered Nurse (RN) without BA

12.64

RN with BA

13.33

RN with MA or MSN

0.04

3.2*

Shift

14.03

Morning

12.26

Afternoon

11.89

Night

t

t-tests

0.02

3.7*

Ethnic background

3.41

   Jewish

3.15

Arab

0.26

1.12

Gender

3.36

Male

3.3

   Female

0.73

.33

Place of birth

3.32

Israel

3.34

Russia

0.25

1.16

Home-care experience with older people

3.38

Yes

3.21

No

0.55

0.59

Med-surgical vs. Surgical ward

3.34

Med-surgical wards

3.31

Surgical wards

* Significant at p<.05 comparisons included in the regression model

Multivariate Regression

Multivariate analysis applying a regression model included all variables found to be significant in the bivariate comparison and the interaction term between knowledge of ageing and ethnicity (see Table 3). Dummy variables were created for ethnic background, level of interaction and shift. Age was an ordinal variable with categories presented in Table 1. The regression model explained 30% of the variance in attitudes toward older people. Only the level of knowledge of ageing (b = 0.042, p = 0.01) and ethnic background (p = 0.01) were significantly associated with attitudes toward older people in the regression model, including the level of education, shift, age, and interaction between ethnic background and knowledge of ageing. We also verified that our data fits the linear regression assumptions by plotting the observed versus predicted values (linearity assumption); checking the autocorrelation plot of the residuals (independence assumption); and generating the normal probability plot of the residuals (normality assumption). Because of the presence of dummy variables in our model, we assumed that relationships are additive- that is, that the partial effect of each explanatory variable is the same regardless of the specific value at which the other explanatory variable is held constant. One exception was made for the interaction term between knowledge of ageing and ethnicity, based on our findings from bivariate comparisons (Allison, 1999).

Table 3. Multivariate Regression Analysis of Attitudes toward Older People

Factors

Standardized Coefficient (b)

Standard Error

95 % confidence interval

t-value

p-value

R²= 30%, F =5.53, df= 156, p<.0001

Age

1.84

.16

Palmore’s total score (Knowledge)

.04

.015

.012-.07

2.92

.01

Jewish ethnic background

.81

.19

1.18-.44

2.87

.01

Level of education

1.9

.12

Shift

1.62

.2

Interaction between knowledge and ethnicity

-1.05

.62

-2.2-.29

-1.3

.19

 

Discussion

The aim of this study was to explore nurses’ level of knowledge related to ageing and their attitudes of nurses toward older people in acute care, and to examine the association between the nurses’ socio-demographic characteristics and nursing work characteristics and their attitudes. These relationships, along with the limitations of this study, will be presented below.

Nurses’ Knowledge of Ageing

The level of knowledge of ageing was examined using Palmore's FAQ1 quiz (Palmore, 1977). The average score was 12.77 out of 25 (51% correct answers). This score is slightly lower than results obtained in similar studies in other countries, as assessed by Palmore’s FAQ1, and also in studies conducted among allied health professionals in Israel reporting 60% - 70% correct answers. These lower scores point to a relatively low level of knowledge of ageing (Barzilai, 2004; Giles, Patrson, Butler, & Stewart, 2002; Horowitz & Bressler, 2000).

There are several possible explanations for the lower scores among Israeli nurses compared with both their colleagues abroad and Israeli allied health professionals. First, most of the studies examining the level of knowledge among nurses were conducted in North America, where nursing education is often characterized by an extensive focus on geriatric nursing and gerontology. Accrediting bodies for these North American nursing schools frequently mandate the inclusion of gerontology content in the curriculum (Wallace, Greiner, Grossman, Lange, & Lippman, 2006). Until recently, nursing education in Israel lacked this content, although the four largest Israeli academic nursing programs have now begun to include gerontological topics in their nursing curriculum (Ben-Gurion University, 2009; Tel-Aviv University, 2009; The Hebrew University of Jerusalem, 2009; The University of Haifa, 2009). Participants in this study were thus not exposed to these topics during their nursing education. In fact, until recently, the nursing curriculum focused on pathologies and illnesses related to old age, while almost completely ignoring psycho-social aspects of healthy ageing (content measured by the FAQ1) (Golandeer & Levy, 2010). We suggest this may account for the lower FAQ1 findings in this study.

Furthermore, in an Israeli study examining the level of knowledge of ageing among physical therapists, the average score of FAQ1 was 68% correct answers (Barzilai, 2004), appreciably higher than that among nurses. This finding may be partially explained by the differences in study programs. In Israel, most of the physical therapy academic programs include content and specific courses on gerontology and geriatrics, thus providing basic knowledge on the subject of old age. This might explain the gap in knowledge between the two health professions (Barzilai, 2004).

Nurses’ Attitudes Toward Older People

Nurses' attitudes toward older people were measured using the KOP questionnaire. The average score of the participants was 3.32 out of 5. These results place Israeli nurses in an intermediate spot when compared with the findings (also measured by the KOP) from other countries. The attitudes of acute care nurses in Western Europe (Soderhamn et al., 2001) and Arab countries (Hweidi & Al-Hassan, 2005) were found to be more negative, and those of nurses in the US (Jacelon, 2002) and Australia (Mellor et al., 2007) to be more positive, than those of the Israeli nurses.

...the level of knowledge of old age was a significant predictor of nurses' attitudes toward older people. In the regression model, the level of knowledge of old age was a significant predictor of nurses' attitudes toward older people. This finding is extremely important as it empirically validates the effect knowledge bears on nurses’ attitudes. In agreement with similar evidence from diverse international studies (Courtney, et al., 2000a; Furze & Pearcey, 1999; Hartley et al., 1995), our results suggest that the more people know about old age and old people, the more positive are their attitudes towards them.

Another significant predictor of attitudes toward older people is ethnic background: Jewish nurses scored significantly higher than their Arab colleagues. One possible explanation of this finding is the exposure to older persons; the percentage of individuals over 65 years old among Arabs is 3%, whereas in the Jewish population it is about 12% (Israeli Agency, 2009).

... our results suggest that the more people know about old age and old people, the more positive are their attitudes towards them. Note that most of the Jewish nurses are immigrants who immigrated to Israel after the collapse of the USSR in early 1990s (as part of one of the largest immigration inflows in Israel's history). Literature suggests that because of the shift in social values towards productivity and the impoverishment of older people, attitudes toward old age became very negative in post-Soviet Russia (Zabelina, 2006). In our study, however, Jewish (of mostly Russian origin) nurses’ attitudes were significantly more positive when compared with their Arab peers. In light of these unexpected findings, further research is needed to better understand the influence of ethnicity and culture on nurses’ attitudes.

The results of our analysis suggest that, especially in the absence of appropriate education, attitudes toward older people do not change over time and are unrelated to the nurses’ socio-demographic or environmental factors... Unlike the findings of other studies examining the impact of various factors on attitudes toward old age among health professionals, this study found that other nurses’ work-related factors and socio-demographic characteristics were unrelated to these attitudes. The results of our analysis suggest that, especially in the absence of appropriate education, attitudes toward older people do not change over time and are unrelated to the nurses’ socio-demographic or environmental factors as measured in this study. In Israel, nurses' attitudes are consistent with the general population’s attitudes toward old age (Doron, 2009). Interestingly, in our study, attitudes toward old age were not affected by occupational features, such as work experience with older persons. Finally, although the level of nurses’ education was identified as a factor significantly correlated with nurses’ attitudes toward old age in the bivariate analysis, its effect disappeared when controlling for other factors. This finding is not surprising in light of the lack of appropriate gerontological and age-related content in any of the nursing education programs in Israel.

Limitations

The study sample was a convenience sample that included 170 nurses working in the acute care wards of one public hospital. Also, our sample was relatively young compared to the general nursing population. Therefore, the ability to draw conclusions regarding the general population of nurses is limited. Additionally, using a self-reporting questionnaire always involves the risk of social desirability bias; people’s responses might be idealized to conform to socially accepted norms. Finally, the level of participants’ religiosity might have influenced the attitudes towards old age. Future studies should collect more data on the levels of religiosity, for example religious versus secular.

Conclusions

In rapidly ageing, modern societies, nursing curriculum should include topics related to healthy ageing and avoid focusing only on the pathologies and illnesses associated with old age. The findings of this study strengthen the results of the growing body of research that suggests that knowledge of ageing is indeed a significant predictor of the attitudes toward older people. In our study, there was no significant correlation between the level of nurses’ education and knowledge of ageing, probably because until recently, nursing education in Israel lacked old-age-related content. In rapidly ageing, modern societies, nursing curriculum should include topics related to healthy ageing and avoid focusing only on the pathologies and illnesses associated with old age. Increased knowledge of ageing is necessary to improve nurses’ attitudes, thus reducing the degree of ageism in our modern, interdependent health care systems. We recommend that in Israel, nursing educators and other health care stakeholders allocate more resources to bridge this identified knowledge gap and incorporate old-age-related content into nursing education. Moreover, there is a critical need to understand the best strategies to increase the levels of knowledge of old age among practicing nurses in acute care settings.

...there is a difference in the levels of knowledge of ageing among nurses from different ethnic groups. The developing of cultural competence among nursing students can be an effective strategy to address the needs of ethnically diverse nursing students. According to our findings, there is a difference in the levels of knowledge of ageing among nurses from different ethnic groups. The developing of cultural competence among nursing students can be an effective strategy to address the needs of ethnically diverse nursing students (Carter & Xu, 2007; Stewart, 2005). To address knowledge disparities, Israeli nursing educators should pay more attention to creating culturally tailored educational programs that meet the needs of ethnically diverse body of students.

The present study also suggests several notable considerations for further exploration. In light of this study’s findings regarding the positive significant correlation of nurses’ knowledge and attitudes toward older people, it is important to further investigate the influence of education on the care provided to older individuals, using advanced qualitative and quantitative methods. Also, more studies are needed to estimate, and possibly quantify, the effect of nurses’ knowledge and attitudes on older peoples’ outcomes. A possible study in this domain might assess the effect of nurses’ knowledge and attitudes on older patients’ satisfaction with nursing care in acute care settings. Another venue for research is to further explore the factors affecting knowledge of old age. A possible study in this domain might examine the effect of age, work-related factors (such as type of health care facility or work experience) on the knowledge. Finally, further research is needed to identify the best strategies to providing culturally appropriate geriatrics and gerontology education to a diverse body of Israeli nurses and nursing students. A possible study might compare the effect of several education strategies used to teach old-age-related content on practicing nurses’ or nursing students’ knowledge and attitudes.

In summary, we have found it very profitable to assess Israeli nurses’ knowledge of, and attitudes toward older persons. We encourage all of our international colleagues to make these assessments in their countries, if they have not already done so, to guide their curriculum development.

Authors

Maxim Topaz  RN,  MA
E-mail: mtopaz@nursing.upenn.edu

Maxim Topaz earned his baccalaureate degree in nursing and his master’s degree in gerontology from the University of Haifa, Israel. He is currently a Fulbright fellow and a PhD candidate at the School of Nursing, University of Pennsylvania, Philadelphia, PA. Maxim’s research focuses on gerontology and the implementation of new technologies in health care education, practice, and research. He has had diverse clinical experiences in acute care settings at one of the largest hospitals in Israel. Maxim has participated on, and managed, several research grants and has published and presented widely in a variety of academic institutions within the United States and internationally. He is actively involved in both policy making, as a member of American Medical Informatics Association Public Policy Committee, and in health care services and educational leadership, as a Co-President of the Doctoral Student Organization and a Graduate Fellow for Teaching Excellence at the Center for Teaching and Learning at University of Pennsylvania.

Israel (Issi) Doron, PhD, LL.B.
E-mail: idoron@univ.haifa.ac.il

Dr. Doron is the Head of the Department of Gerontology, University of Haifa, and the President of the Israeli Gerontological Society.  He specializes in the fields of law and ageing, social policy and aging, and ageism. Dr. Doron has written extensively on topics such as law and aging and human rights of older persons. He is the editor of key books in the field, including Theories on Law and Aging: The Jurisprudence of Elder Law and Beyond Elder Law: New Directions in Law and Aging. Dr. Doron received his LL.B. degree from the Hebrew University of Jerusalem, Israel; his LL.M. degree from the Washington College of Law, Washington DC, USA; and his PhD from Osgoode Hall Law School, Toronto, Ontario, Canada.

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© 2013 OJIN: The Online Journal of Issues in Nursing
Article published April 15, 2013


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