Journal of Nursing Management, 2015, 23, 965–973
Nurses’ attitudes towards older people and working with older patients: an explanatory model YUN-E. LIU
BSN, MSN, PhD
1
, IAN J. NORMAN
BSc, MSc, PhD, RN
2
and ALISON E. WHILE
RN, BSN, MSN, PhD
2
1
Nurse-in-Charge, PLA Stroke Care and Research Centre, The Second Artillery General Hospital PLA, Beijing, China, and 2Professor, Florence Nightingale School and Midwifery, King’s College London, London, UK
Correspondence Yun-e Liu PLA Stroke Care and Research Centre The Second Artillery General Hospital PLA 16 Xinjiekouwai Street Beijing 100088 China E-mail: [email protected]
LIU Y.-E., NORMAN I. J., WHILE A. E.
(2015) Journal of Nursing Management 23, 965–973. Nurses’ attitudes towards older people and working with older patients: an explanatory model Aim To establish an explanatory model of registered nurses’ attitudes towards older people and working with older patients. Background Increasing demands for health-care from an ageing population will require a higher proportion of nurses who have positive attitudes towards older people and like working with older patients. Method A convenience sample of registered nurses (n = 579; 79.3% response rate) attending continuing professional education courses within a large university in London was surveyed from October to December 2011. Results Registered nurses expressed positive attitudes towards older people and 89.7% reported positive attitudes towards working with older patients. The variables of self-ageing anxiety, attitudes towards health-care resource allocation, knowledge of ageing, ethnic group, job title, attitudes towards older patients and interaction between ethnic group and attitudes towards working with older patients explained 42.6% of the variance in attitudes towards older people. Factors, including attitudes towards older people, self-ageing anxiety, commitment to nursing, attitudes towards health-care resources allocation among older people and clinical specialty explained 16.7–34.3% of the variance in attitudes towards older patients. Conclusion The models identified several related factors that may help in the selection and management of nurses for caring older people. Implications for Nursing Management Our findings highlight the importance of investing in continuing education related to gerontological nursing and the ageing process so that there is a growing pool of registered nurses who wish to care for older patients. Keywords: attitudes, nurses, older patient, older people, working with nurse
Accepted for publication: 14 April 2014
Introduction Global population ageing is associated with a growing prevalence of non-communicable diseases (United Nations 2012) and chronic disease burden (World Health Organisation 2008) placing heavy demands DOI: 10.1111/jonm.12242 ª 2014 John Wiley & Sons Ltd
upon health-care systems and adding to the global challenge of the growing shortage of registered nurse (RN) (Kingma 2007). However, health-care professionals are reported to be particularly susceptible to ageist stereotyping because of their increased exposure to elderly and infirm people (Kearney et al. 2000). 965
Y-E. Liu et al.
Health-care professionals’ attitudes about the ageing population may influence the treatment that they deliver to older people, particularly in terms of their behaviour, interactions and offering health care and other services (Knowles & Sarver 1985, Pedersen et al. 2008). Indeed, the study of ageism is important because a negative attitude may influence the pursuance of a diagnosis and the subsequent treatment of the older patient (Uncapher & Arean 2000, Dale 2003). The tendency to dismiss many abnormal disease processes as a normal part of ageing has been frequently described in the literature (Uncapher & Arean 2000). In addition, attitudes of nurses seem to affect the preference for working with older people as well as the quality of care offered to them (International Council of Nurses 2006).
Overview of the literature Nurses are the largest occupational group in healthcare and have an important role in delivering highquality care (Jacelon 2002, Drennan et al. 2004) with their accountability for providing both physical and personal care, as well as health education and emotional support to older adults across settings that include hospitals, long-term care facilities and in the home (Guzman et al. 2009). Owing to the changing population demographics, there is a growing worldwide need for RNs 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 a popular area of nursing and tends to be viewed as unchallenging and unrewarding. For example, Happell (2002) examined the attitudes of a random sample of 793 of Australian undergraduate nursing students and found that working with older people was the least desirable choice. The six reasons underpinning their choice were: negative nature of the work; negative environment; less diversity; not personally suited; fear of or discomfort with older people; and previous negative experience. Dahlke and Phinney (2008) have also reported similar views expressed by 12 nurses working in medical or surgical units of a mid-sized regional hospital in western Canada. Older adults were viewed as a nurse’s burden and an obstacle to the more important work of caring for younger adults. Further, most of the nurses reported that working with confused elders was frustrating and that the current societal culture did not value older adults. With population ageing, understanding nurses’ attitudes towards older people (ATOP) and attitudes 966
towards working with older patients (ATWWOP) are becoming increasingly important. Several studies of nurses’ ATOP have reported varied results. For example, Mellor et al. (2007) reported strongly positive attitudes towards older people among Australian nurses as did Lookinland and Anson (1995) among British nurses but Kearney et al.’s (2000) survey of nurses from a British regional cancer centre reported negative attitudes. Surveys of ATWWOP also show inconsistent findings. Choowattanapakorn et al. (2004) found that Thai nurses perceived talking with older people as a waste of time, with some preferring to care for children after they had experienced several years of caring for older people. In contrast Nordam et al. (2005) reported that Norwegian male nurses working in gerontology wards perceived working with older patients as exciting, challenging and valuable, and felt responsible for providing good care for older patients. A positive relationship between ATOP and ATWWOP has been reported among student nurses (Hweidi & Al-Obeisa 2006, Pan et al. 2009). However, few studies have reported the attitudes and the related variables among RNs, with the literature consistently reporting upon student nurses and their career intentions regarding workplace and patient group preferences (Hayes et al. 2006). This study therefore explores the attitudes of RNs towards older people and the relationships between their attitudes, personal profile variables and whether they like working with older patients.
The study The study aimed to establish an explanatory model of RNs’ attitudes towards older people and working with older patients.
Design A cross-sectional questionnaire survey was conducted to explore the inter-relationships between the study variable (Burns & Grove 2009) with data collection from October to December 2011.
Respondents A convenience sample of RNs attending continuing professional education courses within a large university in London was recruited with the assistance of module leaders acting as sample gatekeepers. Seven hundred and thirty questionnaires were distributed ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 965–973
Model of nurses’ attitudes towards older people
and 579 were returned completed (79.3% response rate), although the item response varied as indicated in Table 1.
●
Data collection Data were collected using self-administered questionnaires. The development of the questionnaire drew upon extensive literature reviews of Cowan et al. (2004) and Liu et al. (2013) and comprised the following: ●
Kogan’s Attitudes towards Old People (KAOP) scale (Kogan 1961): 17 pairs of positive and negative statements about older people using a sevenpoint Likert scale from ‘strongly disagree’ (1) to ‘strongly agree’ (7), (i.e. scores of 1, 2, 3, 5, 6 or 7, with a score of 4 assigned in the rare case of failure to respond to an item). We reversed the negative frame so that a higher overall score indicates more
●
●
● Table 1 Respondents’ demographics and work related characteristics
Age (years)(n = 550) 20–29 30–39 40–49 50 or older Gender (n = 537) Male Female Ethnic group (n = 540) Any Caucasian background Any Asian background Any Black background Live with older people (n = 547) Yes No Place of work (n = 542) Hospital Community Educational level (n = 531) Diploma of Higher Education Bachelor degree Postgraduate Speciality (n = 537) Medical Surgical Mental health Ambulatory care Older people Paediatrics Primary care Job title (n = 547) Staff nurse Sister/charge nurse Ward manager/senior nurse Clinical nurse specialist
n
%
175 203 132 40
31.8 36.9 24.0 7.3
56 481
10.4 89.6
349 82 109
64.6 15.2 20.2
56 491
10.2 89.8
440 102
81.2 18.8
214 261 56
40.3 49.2 10.5
169 174 34 20 23 56 61
31.5 32.4 6.3 3.7 4.3 10.4 11.4
313 71 86 77
57.2 13.0 15.7 14.1
n-values indicate item response. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 965–973
positive attitudes. The Cronbach’s alpha was 0.823 in this study, indicating good internal consistency. Facts on Aging Quiz (FAQ) (Palmore 1998): 25 multiple-choice questions to evaluate knowledge of ageing (true, wrong, don’t know). The Cronbach’s alpha was 0.787 in this study, indicating acceptable internal consistency. The Ageing Anxiety Scale (AAS) (Lasher & Faulkender 1993): 20 statements to assess overall selfageing anxiety on a four-point Likert scale ranging from strongly agree (1) to strongly disagree (4), with higher scores indicating higher anxiety. The Cronbach’s alpha was 0.774 in this study, indicating acceptable internal consistency. Professional Commitment Scale (Brown et al. 1986): 10 items on a five-point Likert type scale (1 = never, 5 = very often) with higher scores indicating higher levels of commitment to nursing. The Cronbach’s alpha was 0.807 in this study, indicating good internal consistency. Healthcare resources allocation scale: We developed this short-scale by reviewing literature, expert consultation and a pilot study to explore attitudes relating to the distribution of increasingly scarce health-care resources and the potential willingness to prioritise the needs of older people within resource allocation. The scale has eight items with both positive and negative items to assess attitudes towards the distribution of resources on a six-point Likert type scale from strongly agree (1) to strongly disagree (6). After converting the negative frame, higher scores indicate more positive attitudes towards health-care resources allocation among older people. In this study, the Cronbach’s alpha was 0.604, indicating acceptable internal consistency (Cronbach’s alpha values are lower for shorter scales; Nunnally 1978).
Demographic and professional data including age, gender, ethnicity, whether living with an older person, place of work, educational level, clinical specialty, job title and response to the statement ‘I like working with older patients’ using a four-point Likert type scale from strong agree to strongly disagree (ATWWOP) were also collected.
Ethical considerations Permission to undertake the study was obtained from the university ethics committee (PNM/10/11-149). The researchers explained the study to potential participants after which the questionnaires were distributed
967
Y-E. Liu et al.
to those willing to participate together with envelopes for the return of completed questionnaires. Participation was anonymous.
mean = 170.65 (SD 18.88)] with only 10.3% reporting negative attitudes. The majority (89.7%; n = 477/ 532) of the respondents reported positive ATWWOP.
Data analysis
ATOP Model
A general linear model–univariate analyses (analysis of covariance) was used to establish a model of ATOP. Ordinal data were treated as rank data to conduct this analysis (Pallant 2007). Regarding the ATWWOP, very few nurses strongly disliked working with older patients so we categorized them with nurses who disliked working with older patients into the negative group. A two-stage binary logistic analysis (Bewick et al. 2005) was used to establish the model of ATWWOP (see Figure S1). For each binary logistic analysis, a backward selection was used to determine which variables were included in each model. The variables were removed from the model one at a time, using a conservative significance level of 0.05, until all variables in the model were statistically significant. The process was replicated until all the variables had been processed.
The variables included in the final attitudinal model are presented in Table 2. The results showed that 42.6% of the variance in attitudes could be explained by this set of variables. More positive attitudes were significantly associated with less anxiety regarding self-ageing (AAS; Lasher & Faulkender 1993), more positive attitudes towards health-care resource allocation
Validity and reliability Data were collected using validated scales with a carefully considered approach to data analysis in light of the data set. The data collection instrument was tested in a small pilot study using 50 RNs who were attending continuing professional education courses within the study site, which confirmed the adequacy of the data collection method and instrument. Minor modifications were made to the instrument to improve its presentation and question wording.
Results General characteristics and attitudes The demographic and professional characteristics of the respondents are shown in Table 1. Most of the respondents were Caucasian (64.6%), women (89.6%), aged 20–29 years (31.8%) or 30–39 years old (36.9%), did not live with an older person (89.8%), worked in a hospital (81.2%), were Diploma (40.3%) or bachelor’s degree (49.2%) qualified, worked in medical (31.5%) or surgical wards (32.4%) and were staff nurses (57.2%). The respondents had been qualified for a mean of 9.61 years (SD 8.21) and reported positive attitudes towards older people (ATOP) on KAOP (Kogan 1961) [median = 172.00; 968
Table 2 Model of Kogan’s attitudes towards older people: F-statistic and mean rank and 95% confidence interval for each level and P-value for the variables Variables
F df
F-value
P-value
Anxiety on self-ageing Attitudes towards healthcare resources allocation Knowledge of ageing
F(1.515) F(1.515)
13.049 60.474
Nurses’ attitudes towards older people and working with older patients: an explanatory model YUN-E. LIU
BSN, MSN, PhD
1
, IAN J. NORMAN
BSc, MSc, PhD, RN
2
and ALISON E. WHILE
RN, BSN, MSN, PhD
2
1
Nurse-in-Charge, PLA Stroke Care and Research Centre, The Second Artillery General Hospital PLA, Beijing, China, and 2Professor, Florence Nightingale School and Midwifery, King’s College London, London, UK
Correspondence Yun-e Liu PLA Stroke Care and Research Centre The Second Artillery General Hospital PLA 16 Xinjiekouwai Street Beijing 100088 China E-mail: [email protected]
LIU Y.-E., NORMAN I. J., WHILE A. E.
(2015) Journal of Nursing Management 23, 965–973. Nurses’ attitudes towards older people and working with older patients: an explanatory model Aim To establish an explanatory model of registered nurses’ attitudes towards older people and working with older patients. Background Increasing demands for health-care from an ageing population will require a higher proportion of nurses who have positive attitudes towards older people and like working with older patients. Method A convenience sample of registered nurses (n = 579; 79.3% response rate) attending continuing professional education courses within a large university in London was surveyed from October to December 2011. Results Registered nurses expressed positive attitudes towards older people and 89.7% reported positive attitudes towards working with older patients. The variables of self-ageing anxiety, attitudes towards health-care resource allocation, knowledge of ageing, ethnic group, job title, attitudes towards older patients and interaction between ethnic group and attitudes towards working with older patients explained 42.6% of the variance in attitudes towards older people. Factors, including attitudes towards older people, self-ageing anxiety, commitment to nursing, attitudes towards health-care resources allocation among older people and clinical specialty explained 16.7–34.3% of the variance in attitudes towards older patients. Conclusion The models identified several related factors that may help in the selection and management of nurses for caring older people. Implications for Nursing Management Our findings highlight the importance of investing in continuing education related to gerontological nursing and the ageing process so that there is a growing pool of registered nurses who wish to care for older patients. Keywords: attitudes, nurses, older patient, older people, working with nurse
Accepted for publication: 14 April 2014
Introduction Global population ageing is associated with a growing prevalence of non-communicable diseases (United Nations 2012) and chronic disease burden (World Health Organisation 2008) placing heavy demands DOI: 10.1111/jonm.12242 ª 2014 John Wiley & Sons Ltd
upon health-care systems and adding to the global challenge of the growing shortage of registered nurse (RN) (Kingma 2007). However, health-care professionals are reported to be particularly susceptible to ageist stereotyping because of their increased exposure to elderly and infirm people (Kearney et al. 2000). 965
Y-E. Liu et al.
Health-care professionals’ attitudes about the ageing population may influence the treatment that they deliver to older people, particularly in terms of their behaviour, interactions and offering health care and other services (Knowles & Sarver 1985, Pedersen et al. 2008). Indeed, the study of ageism is important because a negative attitude may influence the pursuance of a diagnosis and the subsequent treatment of the older patient (Uncapher & Arean 2000, Dale 2003). The tendency to dismiss many abnormal disease processes as a normal part of ageing has been frequently described in the literature (Uncapher & Arean 2000). In addition, attitudes of nurses seem to affect the preference for working with older people as well as the quality of care offered to them (International Council of Nurses 2006).
Overview of the literature Nurses are the largest occupational group in healthcare and have an important role in delivering highquality care (Jacelon 2002, Drennan et al. 2004) with their accountability for providing both physical and personal care, as well as health education and emotional support to older adults across settings that include hospitals, long-term care facilities and in the home (Guzman et al. 2009). Owing to the changing population demographics, there is a growing worldwide need for RNs 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 a popular area of nursing and tends to be viewed as unchallenging and unrewarding. For example, Happell (2002) examined the attitudes of a random sample of 793 of Australian undergraduate nursing students and found that working with older people was the least desirable choice. The six reasons underpinning their choice were: negative nature of the work; negative environment; less diversity; not personally suited; fear of or discomfort with older people; and previous negative experience. Dahlke and Phinney (2008) have also reported similar views expressed by 12 nurses working in medical or surgical units of a mid-sized regional hospital in western Canada. Older adults were viewed as a nurse’s burden and an obstacle to the more important work of caring for younger adults. Further, most of the nurses reported that working with confused elders was frustrating and that the current societal culture did not value older adults. With population ageing, understanding nurses’ attitudes towards older people (ATOP) and attitudes 966
towards working with older patients (ATWWOP) are becoming increasingly important. Several studies of nurses’ ATOP have reported varied results. For example, Mellor et al. (2007) reported strongly positive attitudes towards older people among Australian nurses as did Lookinland and Anson (1995) among British nurses but Kearney et al.’s (2000) survey of nurses from a British regional cancer centre reported negative attitudes. Surveys of ATWWOP also show inconsistent findings. Choowattanapakorn et al. (2004) found that Thai nurses perceived talking with older people as a waste of time, with some preferring to care for children after they had experienced several years of caring for older people. In contrast Nordam et al. (2005) reported that Norwegian male nurses working in gerontology wards perceived working with older patients as exciting, challenging and valuable, and felt responsible for providing good care for older patients. A positive relationship between ATOP and ATWWOP has been reported among student nurses (Hweidi & Al-Obeisa 2006, Pan et al. 2009). However, few studies have reported the attitudes and the related variables among RNs, with the literature consistently reporting upon student nurses and their career intentions regarding workplace and patient group preferences (Hayes et al. 2006). This study therefore explores the attitudes of RNs towards older people and the relationships between their attitudes, personal profile variables and whether they like working with older patients.
The study The study aimed to establish an explanatory model of RNs’ attitudes towards older people and working with older patients.
Design A cross-sectional questionnaire survey was conducted to explore the inter-relationships between the study variable (Burns & Grove 2009) with data collection from October to December 2011.
Respondents A convenience sample of RNs attending continuing professional education courses within a large university in London was recruited with the assistance of module leaders acting as sample gatekeepers. Seven hundred and thirty questionnaires were distributed ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 965–973
Model of nurses’ attitudes towards older people
and 579 were returned completed (79.3% response rate), although the item response varied as indicated in Table 1.
●
Data collection Data were collected using self-administered questionnaires. The development of the questionnaire drew upon extensive literature reviews of Cowan et al. (2004) and Liu et al. (2013) and comprised the following: ●
Kogan’s Attitudes towards Old People (KAOP) scale (Kogan 1961): 17 pairs of positive and negative statements about older people using a sevenpoint Likert scale from ‘strongly disagree’ (1) to ‘strongly agree’ (7), (i.e. scores of 1, 2, 3, 5, 6 or 7, with a score of 4 assigned in the rare case of failure to respond to an item). We reversed the negative frame so that a higher overall score indicates more
●
●
● Table 1 Respondents’ demographics and work related characteristics
Age (years)(n = 550) 20–29 30–39 40–49 50 or older Gender (n = 537) Male Female Ethnic group (n = 540) Any Caucasian background Any Asian background Any Black background Live with older people (n = 547) Yes No Place of work (n = 542) Hospital Community Educational level (n = 531) Diploma of Higher Education Bachelor degree Postgraduate Speciality (n = 537) Medical Surgical Mental health Ambulatory care Older people Paediatrics Primary care Job title (n = 547) Staff nurse Sister/charge nurse Ward manager/senior nurse Clinical nurse specialist
n
%
175 203 132 40
31.8 36.9 24.0 7.3
56 481
10.4 89.6
349 82 109
64.6 15.2 20.2
56 491
10.2 89.8
440 102
81.2 18.8
214 261 56
40.3 49.2 10.5
169 174 34 20 23 56 61
31.5 32.4 6.3 3.7 4.3 10.4 11.4
313 71 86 77
57.2 13.0 15.7 14.1
n-values indicate item response. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 965–973
positive attitudes. The Cronbach’s alpha was 0.823 in this study, indicating good internal consistency. Facts on Aging Quiz (FAQ) (Palmore 1998): 25 multiple-choice questions to evaluate knowledge of ageing (true, wrong, don’t know). The Cronbach’s alpha was 0.787 in this study, indicating acceptable internal consistency. The Ageing Anxiety Scale (AAS) (Lasher & Faulkender 1993): 20 statements to assess overall selfageing anxiety on a four-point Likert scale ranging from strongly agree (1) to strongly disagree (4), with higher scores indicating higher anxiety. The Cronbach’s alpha was 0.774 in this study, indicating acceptable internal consistency. Professional Commitment Scale (Brown et al. 1986): 10 items on a five-point Likert type scale (1 = never, 5 = very often) with higher scores indicating higher levels of commitment to nursing. The Cronbach’s alpha was 0.807 in this study, indicating good internal consistency. Healthcare resources allocation scale: We developed this short-scale by reviewing literature, expert consultation and a pilot study to explore attitudes relating to the distribution of increasingly scarce health-care resources and the potential willingness to prioritise the needs of older people within resource allocation. The scale has eight items with both positive and negative items to assess attitudes towards the distribution of resources on a six-point Likert type scale from strongly agree (1) to strongly disagree (6). After converting the negative frame, higher scores indicate more positive attitudes towards health-care resources allocation among older people. In this study, the Cronbach’s alpha was 0.604, indicating acceptable internal consistency (Cronbach’s alpha values are lower for shorter scales; Nunnally 1978).
Demographic and professional data including age, gender, ethnicity, whether living with an older person, place of work, educational level, clinical specialty, job title and response to the statement ‘I like working with older patients’ using a four-point Likert type scale from strong agree to strongly disagree (ATWWOP) were also collected.
Ethical considerations Permission to undertake the study was obtained from the university ethics committee (PNM/10/11-149). The researchers explained the study to potential participants after which the questionnaires were distributed
967
Y-E. Liu et al.
to those willing to participate together with envelopes for the return of completed questionnaires. Participation was anonymous.
mean = 170.65 (SD 18.88)] with only 10.3% reporting negative attitudes. The majority (89.7%; n = 477/ 532) of the respondents reported positive ATWWOP.
Data analysis
ATOP Model
A general linear model–univariate analyses (analysis of covariance) was used to establish a model of ATOP. Ordinal data were treated as rank data to conduct this analysis (Pallant 2007). Regarding the ATWWOP, very few nurses strongly disliked working with older patients so we categorized them with nurses who disliked working with older patients into the negative group. A two-stage binary logistic analysis (Bewick et al. 2005) was used to establish the model of ATWWOP (see Figure S1). For each binary logistic analysis, a backward selection was used to determine which variables were included in each model. The variables were removed from the model one at a time, using a conservative significance level of 0.05, until all variables in the model were statistically significant. The process was replicated until all the variables had been processed.
The variables included in the final attitudinal model are presented in Table 2. The results showed that 42.6% of the variance in attitudes could be explained by this set of variables. More positive attitudes were significantly associated with less anxiety regarding self-ageing (AAS; Lasher & Faulkender 1993), more positive attitudes towards health-care resource allocation
Validity and reliability Data were collected using validated scales with a carefully considered approach to data analysis in light of the data set. The data collection instrument was tested in a small pilot study using 50 RNs who were attending continuing professional education courses within the study site, which confirmed the adequacy of the data collection method and instrument. Minor modifications were made to the instrument to improve its presentation and question wording.
Results General characteristics and attitudes The demographic and professional characteristics of the respondents are shown in Table 1. Most of the respondents were Caucasian (64.6%), women (89.6%), aged 20–29 years (31.8%) or 30–39 years old (36.9%), did not live with an older person (89.8%), worked in a hospital (81.2%), were Diploma (40.3%) or bachelor’s degree (49.2%) qualified, worked in medical (31.5%) or surgical wards (32.4%) and were staff nurses (57.2%). The respondents had been qualified for a mean of 9.61 years (SD 8.21) and reported positive attitudes towards older people (ATOP) on KAOP (Kogan 1961) [median = 172.00; 968
Table 2 Model of Kogan’s attitudes towards older people: F-statistic and mean rank and 95% confidence interval for each level and P-value for the variables Variables
F df
F-value
P-value
Anxiety on self-ageing Attitudes towards healthcare resources allocation Knowledge of ageing
F(1.515) F(1.515)
13.049 60.474
