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International Journal of Nursing Studies xxx (2012) xxxxxx

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httprses attitudes towards older people: A systematic review

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

Second Artillery General Hospital, Beijing, China

gs College London, Florence Nightingale School of Nursing and Midwifery, United Kingdom

What is already known about the topic?

he ageing population with their increasing functionalependency is one of the most challenging problems ofntemporary societies which has a direct effect uponlobal public health and social care systems andcreasing the demands for nursing care.egative attitudes towards older people and myths ofgeing are ubiquitous. Older adults are viewed as aurses burden and an obstacle to the more importantork of caring for younger adults.here is no previous systematic review of nursesttitudes towards older people and related variables

despite the importance of the topic and the increasingglobal migration of nurses.

What this paper adds

This review synthesizes the international researchpublished in the English and Chinese language journalsrelating to registered and student nurses attitudestowards older people and the potential underpinningvariables.

Registered and student nurses attitudes appear incon-sistent and slightly less positive since 2000. Preference towork with older people and knowledge of ageingappeared to be the most consistent variables associatedwith positive attitudes towards older people.

The review highlights the need for more well designedstudies to investigate both the attitudes of registered and

T I C L E I N F O

le history:

ived 23 April 2012

ived in revised form 22 November 2012

pted 23 November 2012

ords:

tudes

ism

r people

se

A B S T R A C T

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.

Corresponding author.

E-mail address: [email protected] (A.E. While).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ see front matter 2012 Elsevier Ltd. All rights reserved.://dx.doi.org/10.1016/j.ijnurstu.2012.11.021ease cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud.012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021

Liu et al. / International Journal of Nursing Studies xxx (2012) xxxxxx2

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NS-2141; No. of Pages 12student nurses and the associated factors, and trials ofinterventions to improve attitudes to inform workforcestrategies.

1. Introduction

The number of people in the world aged 65 years andover is increasing at an average of 870,000 each month(Kinsella and He, 2009). Europe is the greyest continentwith 23 of the worlds 25 countries with the oldestpopulations (Ofce for National Statistics, 2010). In 1995more than 60% (590 million) older people lived indeveloping countries and this distribution is expected toincrease to 70% (1.2 billion) by the year 2025 (WHO, 2000)with 81% of the worlds net gain of older people occurringin developing countries (Kinsella and He, 2009) in partreecting demographic changes and reductions in com-municable disease mortality (United Nations, 2012). In thePeoples Republic of China, for example, the percentage ofthe population aged 60 years and over increased from10.5% in 2000 to 14.0% in 2009 (China Statistical Yearbook,2010) with similar increases anticipated in other devel-oping countries (WHO, 2008).

The ageing population is one of the most challengingproblems of contemporary societies which has a directeffect upon public health and social care systems(Muangpaisana et al., 2008). Indeed the rising agedependency ratio both reduces the numbers enteringthe healthcare workforce and increases healthcare need.However, negative attitudes towards older people andmyths of ageing are ubiquitous and, while not all negativeattitudes lead to ageism (Nelson, 2005) and associatedstereotyping and discrimination, negative attitudes are aprecursor to ageism. Ageism often leads individuals to seeolder adults as unproductive, depressing and sickly, and tobelieve that cognitive impairment is a natural consequenceof ageing (Palmore, 1999). Healthcare professionals arereported to be particularly susceptible to ageist stereo-typing because of their increased exposure to ill and inrmolder people (Kearney et al., 2000). Attitudes of registerednurses appear to affect the preference for working witholder people as well as the quality of care offered to them(McDowell et al., 1999).

The important role of nurses in delivering care has beenwidely and consistently recognized (Drennan et al., 2004;Jacelon, 2002) as they are accountable for providing bothphysical and personal care including emotional support toolder adults across settings including hospitals, long-termcare facilities, and in the home (De Guzman et al., 2009). Dueto changing population demographics, there is a growingworldwide need for registered nurses who are knowledge-able and committed to working with older adults in diversesettings (Plonczynski et al., 2007). However, gerontologicalnursing is generally not considered to be popular amongnursing students and registered nurses (Happell, 2002;Soderhamn et al., 2001). Older adults are often viewed as anurses burden and an obstacle to the more important workof caring for younger adults with some nurses identifyingwith the current societal culture which does not value olderadults and nding care of confused older people frustrating(Dahlke and Phinney, 2008).

A recent UK Care Quality Commission report (CareQuality Commission, 2011) identied staff attitudes as akey variable in explaining unacceptably low care standardsfor older people in one in ve UK hospitals. While nursingsupport workers provide signicant levels of care to olderpeople, registered nurses are accountable for their caredelivery and ensuring the maintenance of care standardshighlighting the value of understanding registered nursesattitudes towards older people and related variables. Thereare two non-systematic published reviews of nursesattitudes towards older people/patients covering studiesfrom 1982 until 2005; Courtney et al. (2000) reported theliterature identied by a search of CINAHL from January1982 until December 1998 and Lovell (2006) examined theevidence of nursing students and health professionalsattitudes using four scales including Kogans Attitude Scale(1961), Facts of Aging Quiz (Palmore, 1977), AgingSemantic Differential Scale (Rosencranz and McNevin,1969) and MaxwellSullivan Attitude Scale (1980) identi-ed from searches of Medline and CINAHL 19902005. Thisreview therefore aimed to systematically examine theinternational research relating to registered and studentnurses attitudes towards older people and the potentialunderpinning variables including knowledge, experienceand self-ageing over the last decade as reported in theEnglish and Chinese language journals reecting bothChinas emergence as an important exporter of nurses todeveloped countries (Fang, 2007) and the large healthcareliterature located in Chinese language journals.

2. Methods

2.1. Study identication and selection

Both electronic and manual searches were conducted toidentify all published research studies focusing on thehealth professionals attitudes toward older people. Thesearch was completed in May 2011 and was restricted topapers published since 2000. The following databases werebroadly scanned prior to more rened electronic searches:CINAHL, MEDLINE, EMBASE, British Nursing Index (BNI),PsycINFO, Chinese Biomedical database (CBM), ChinaMedical Academic Conference (CMAC) and China Aca-demic Journal (CAJ). To maximize the sensitivity of thesearch 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 theEnglish language and 49 references in the Chinese language.Review of the titles and abstracts revealed 629 duplicatereferences, 43 were not journal papers, 1406 were notrelevant (they did not report registered or student nursesattitudes towards older people). Further information relat-ing to 15 papers was needed for their assessment but theywere unobtainable. Sixteen papers were not written in theEnglish or Chinese languages although their abstracts werein English. The full texts of the remaining 70 papers wereretrieved and assessed for eligibility. For inclusion thefollowing criteria were met: a report of primary researchinto the attitudes of registered or student nurses towardsolder people, in which attitudes were measured using aPlease 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 3

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Pl(2idated attitude scale. Papers in which nurses data were reported independently to those of other healthfessionals were excluded together with all qualitativedies. No attempt was made to access unpublished studiesther grey literature. Finally the reference lists of thected 23 papers were scanned for additional studiesich identied two papers. A total of 25 papers met thelusion criteria for the review (see Fig. 1).

Data analysis

To enable comparison across studies using differentles or the same scale utilising different point Likertles, 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 negativeto positive, 3.5 was converted to 62.5% computed by[(3.5 1)/(5 1) 100%]. But if in a 5-point scale rangedfrom positive to negative, it was reversed, and 3.5 wasconverted to 37.5% computed by [100% (3.5 1)/(5 1) 100%]. The converted data were then categorisedinto study attitudinal outcomes with percentages below40% considered as negative, neutral between 40 and 60%,or positive above 60%. There was no evidence that the dataconversion distorted any of the study ndings. The studyattitudinal outcomes were examined across time and inrelation to the reported variables across the selectedstudies.

Title and abs tracts

idened and screened

n=2179 Duplicates n=629

Not journal ar cles n=43

Not in English or Chinese n=16

Not relevant n=140 6

Full copies r etrieved and

asse ssed for eligibility

n=70

Did not meet in clusion cri teria n=48

Review of reference lists

of selected papers

n=23

Manual search idened papers n =2

Papers in cluded in the review

n=25

Fig. 1. Flow chart of study selection process.

ch terms.

cets Search terms

der people Elder; aged; older people; old people; elderly

titude Attitude(s) to/toward(s) old people/elder/aged/elderly/older people; ageism, stigma, labelling, stereotyping, prejudice,

discrimination

alth professional Nurse/s; nursing staff, nursing faculty; health professional, health care personnel; health care provider/s, physician/s;

doctor/s; medical professionalease cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud.012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021


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NS-2141; No. of Pages 122.3. Reliability of quality assessment and data extraction

Initial screening was undertaken by one researcher(YEL) and then checked by another (AW). Disagreementsabout inclusion were discussed until agreement wasreached. One researcher (YEL) extracted the followingdata from the selected studies: country of study, studydesign and setting, study sample, measurements, variablesand main results. Two reviewers (AW & IJN) veried theextracted data and made corrections as necessary andagreed the assessed study quality using the Strobechecklist (Altman et al., 2007). All three researcherscontributed to the literature synthesis.

3. Results

3.1. An overview of included papers

Of the 25 studies a third (n = 8) were conducted in NorthAmerica, a quarter in European countries (n = 6) and a sixthin Taiwan (n = 4). The remaining studies were carried out inAustralia (n = 3), Jordan (n = 2), and China (n = 1). One studywas conducted in both Australia and the UK. Most (n = 21)were cross-sectional surveys, three were trials (baselinedata used in this paper) and one was a longitudinal study.Only seven studies recruited samples from more than onesite and site selection was usually based on geographicalconvenience. Between one and three studies werepublished each year between 2000 and 2009. A furthersix were conducted in 2010 and two in 2011. The designfeatures and main ndings of the studies are reported inTable 2 together with a quality rating. No study was ratedas 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 mostfrequently used in its various translations. The KOPcomprises 17 pairs (and the revised KOP (Hilt andLipschultz, 1999) 22 pairs) of positive and negativestatements about older people which are rated on a 7-point Likert scale from strongly disagree (1) to stronglyagree (7) (Good content validity, construct validity,internal consistency and stability reliability have beenreported for both variants of the instrument (Erdemir et al.,2011)).

The Aging Semantic Differential (ASD) (Rosencranz andMcNevin, 1969) assesses attitudes toward adults ofdifferent ages (Gluth et al., 2010). It comprises 32 adjectivepairs rated on a 7-point Likert scale from positive tonegative and is reported to have robust psychometricproperties (Polizzi, 2003). The AGED Inventory (Knox et al.,1995) measures attitudes and stereotypical beliefs aboutolder adults and comprises two sub-scales of 28 adjectivepairs which are rated using a 7-point Likert scale fromnegative to positive. Its robustness has been established byKoren et al. (2008). Nolan et al.s (2001) Perceptions ofWorking with Older People (PWOP) comprises 11 state-ments with responses on a 5-point Likert scale yielding a

score of 1155. This scale is robust and reects morecontemporary views on ageing. The Facts on Aging Quiz(FAQ) (Palmore, 1988) comprises 25 multiple-choicequestions to evaluate knowledge of older people. The quizscores quantify positive or negative bias towards olderadults based upon the assumption that certain misconcep-tions about older people indicate a positive or negative bias(true, false, or dont know indicate negative bias, positivebias, or no bias). The FAQ correlates signicantly with theKAOP (Wang et al., 2010). McLafferys (2005) scalecomprises 20 items measuring nurses attitudes towardhospitalised older people with responses on a 5-pointLikert scale. It was developed using focus groups (McLaff-erty and Morrison, 2004) and reported Cronbach a 0.7 in apilot study.

3.3. Attitudes towards older people

The ndings across the 25 studies were inconsistentwith both positive, negative and neutral attitudes beingnoted across qualied and student nurses. Of the 25included studies, 21 studies data could be converted intopercentages (Table 3). The other four studies (Holroydet al., 2009; Karlin et al., 2006; Plonczynski et al., 2007;Wells et al., 2004) did not report sufcient data to allowthis calculation, but reported summary ndings.

Fig. 2 which summarises the converted scores suggeststhat there may have been a slight decrease from positive toneutral in student nurses attitudes towards older peopleover time. One study reported negative attitudes amongthree groups of Greek student nurses on the negKOP sub-scale (Lambrinou et al., 2009). Six independent samplesfrom ve studies reported neutral attitudes. Most studiesfound positive attitudes among student nurses with thehighest percentage of 71.8% and the lowest percentage of34.2% being reported by the same study (Lambrinou et al.,2009).

The same trend was observed in qualied nurses butthe trend is smaller (Fig. 2) with a wider data range. Onestudy reported that 33.8% of UK nurses held negativeattitudes (Kearney et al., 2000). Three studies foundneutral attitudes and another ve studies found positiveattitudes. The highest positive attitude was reportedamong nurse teachers (McLafferty, 2005).

3.4. Variables related to attitudes towards older people

Thirty two variables related to attitudes towards olderpeople were identied from the 25 papers. The relation-ship of these variables to positive attitudes is summarisedin Table 4. Variables were grouped under one of sixcategories and listed in order of the most investigated tothe least investigated.

Demographic variables were frequently investigated,with 3 of 11 studies reporting a signicant positiveassociation between increasing age and positive attitudes.Gender was a signicant variable in half of the studies butyielded conicting results with three studies reporting thatthe male gender was associated with positive attitudeswhile three studies reported the opposite nding. Otherdemographic variables were investigated in a smallPlease 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

Table 2

Summary of included papers.

Reference and location Design and sample Instrumentation Comments Rating

Chen and Walsh (2009)

Taiwan a

RCT 194 4th year student nurses recruited fromone nursing college (RR unclear) n = 100

intervention, n = 94 controls

Revised Kogans attitudes toward oldpeople scale (RKAOP, Kogan, 1961;

Hilt and Lipschultz, 1999)

Self-transcendence scale (STS, Reed, 1992, 2003)

Small convenience sample

based in one site

Response rate unclear

Low

Erdemir et al. (2011)

Turkey b

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%)

Attitudes towards Old People Scale

(KOP, Kogan, 1961)

Convenience sample based

in one site

Moderate response rate

Moderate

Furlan et al. (2009)

Canada c

Cross-sectional survey 15 registered nurses from an acute-careunit and 18 from a tertiary rehabilitation

centre (RR 41.7% 25.7%, respectively)

Attitudes towards Old People Scale (KOP,

Kogan, 1961)


drawn from more than one site

Low response rate

Low

Gallagher et al. (2006)

UK d

Cross-sectional survey 99 nurses, 73 assistant personnel and 15porters purposively recruited from two

hospitals (RR 69% and 57% for acute and

long-term settings, respectively)


Kogan, 1961)

Convenience sample drawn

from more than one site


Moderate

Gething et al. (2002)

Australia,UK e

Cross-sectional survey 143 Australian and 213 UK nurses workingin a range of nursing professions recruited

from two countries (average RR 70%)

Aging Semantic Differential (ASD,Rosencranz & McNevin, 1969)

Reactions to Ageing Questionnaire(RAQ, Gething, 1994)

Facts on Aging Quiz (FAQ, Palmore, 1977, 1988)

Convenience samples drawn

from two country


Moderate

Holroyd et al. (2009)

Canada f

Longitudinal study 197 student nurses recruited from a BSNprogram in a university college (RR 80%)


(KOP, Kogan, 1961)


based in one site


Low

Hweidi & Al-Hassan (2005)

Jordan g

Cross-sectional survey 143 nurses working in selected units in acutecare settings of 3 public hospitals (RR 75%)


Kogan, 1961)


drawn from multiple sites


Low

Hweidi and Al-Obeisat (2006)

Jordan h

Cross-sectional survey 243 student nurses recruited from 4 classesin one university (RR = 95.2%)


Kogan, 1961)


in one site

High response rate

Moderate

Karlin et al. (2006) USA i Cross-sectional survey 81 nursing students from a college & 108psychology students from a university

(RR unclear)

Rened Aging Semantic Differential(Rosencranz & McNevin, 1969; Polizzi, 2003)

Researcher-developed Self-Efcacy: 3 questionsmeasuring self-efcacy, efcacy

expectation and outcome value

Small convenience sample drawn

from more than one site


Low

Kearney et al. (2000) UK j Cross-sectional survey 34 medical, 102 nursing & 61 radiography staffrecruited from a regional Cancer Centre

(RR 62%, 77%, 26%, respectively)


Kogan, 1961)


in one site


Moderate

Koren et al. (2008) USA k Cross-sectional survey 200 student nurses recruited from one universityschool (RR 91.3%)

AGED Inventory (Knox et al., 1995) Researcher-developed Undergraduate NeedsAssessment 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

Small convenience sample based

in one site

High response rate

Low

Liu et

al.

/ In

ternatio

nal

Journal

of

Nursin

g Stu

dies

xxx (2

012)

xxxxxx

5

G M

odel

NS-2141;

No.

of

Pag

es 12

Please

cite th

is article

in press

as:

Liu et

al.,

Nurse

s attitu

des

towards

older

people:

A sy

stematic

review.

Int.

J. Nurs.

Stud.

(2012),

http

://dx.doi.o

rg/10.1016/j.ijn

urstu

.2012.11.021

Table 2 (Continued )

Reference and location Design and sample Instrumentation Comments Rating

Lambrinou et al. (2009)

Greece l

Cross-sectional survey Student nurses: 1st yr n = 121(RR 69.4%) & 4th yrn = 106(RR 62.35%) from one university; 1st yr

n = 112 (RR 89.6%) & 4th yr n = 79 (RR 68.2%)

from one institute

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

Facts on Aging Quiz I (Palmore, 1988)

Convenience sample drawn from

more than one site


Moderate

McLafferty (2005) UK m Cross-sectional survey 55 nurse teachers, 64 1st year student nurses, 55student nurses who had completed rst theory

module recruited from one university school

(RR 93%, 78%, 63%, respectively)

Researcher-developed questionnaire

(McLafferty & Morrison, 2004)


in one site


Low

Mellor et al. (2007)

Australia n

Cross-sectional survey 31 nurses recruited from a multi-purpose healthservice (MPHS) (RR 100%)

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

Modied Facts of Aging Quiz (PFAQ,Palmore 1988; Courtenay & Wiedman, 1985)

Researcher-developed: complimentPFAQ by adding a gerontic nursing focus


in one site

High response rate

Low

Myers et al. (2001)

Australia o

Cross-sectional survey 201 nurses working in general areas recruitedfrom one acute-care hospital (RR 29%)

Aged Semantic Differential (ASD,Rosencranz & McNevin, 1969)

Perceptions of Restraint Use Questionnaire(Strumpf & Evans, 1988)

Convenient sample based

in one site

Low response rate

Moderate

Pan et al. (2009)

Taiwan p

Cross-sectional survey 362 student nurses recruited from one university(RR 84%)

Perceptions of Working with Older

People (PWOP, Nolan et al., 2001)


in one site


Moderate

Plonczynski et al. (2007)

USA q

Cross-sectional survey 26 nursing faculty recruited from one Midwesternnursing school (RR unclear)

AGED inventory (Knox et al., 1995) Researcher-developed: 6 questionsto assess the gerontological content

of each undergraduate course,

3 questions to assess faculty

gerontological knowledge


in one site


Low

Ryan and McCauley (2004)

USA r

Cross-sectional survey 55 student nurses recruited from one universityschool (RR unclear)

Attitudes towards Old PeopleScale (KOP, Kogan, 1961)

Facts on Aging Quiz 1 (FAQ1,Palmore, 1988)


in one site


Low

Soderhamn et al. (2001)

Sweden s

Cross-sectional survey 86 1st year and 65 3rd year student nurses & 41registered nurses in post-graduate courses

recruited from one university in west Sweden

(RR 100%)


(KAOP, Kogan, 1961)


in one site

High response rate

Low

Walsh et al. (2008) USA t RCT 22 senior student nurses recruited from one school(RR unclear)

Revised Kogans attitudes toward oldpeople scale (RKOP, Kogan, 1961;

Hilt and Lipschultz, 1999)

Self-transcendence scale (STS,Reed, 1992, 2003)


in one site


Low

Wang et al. (2009)

Taiwan u

Cross-sectional survey 84 student nurses & 191 medical students recruitedfrom one school (RR 88.4%)

Attitudes towards Old People

Scale (KOP, Kogan, 1961)


in one site


Moderate

Wang et al. (2010)

Taiwan v

Cross-sectional survey 125 nursing students with at least 1-years workexperience and 95 1st year with no previous work

experience recruited from 2 different programs at

one nursing school (RR 87.4%, 77.5%, respectively)

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

Facts on aging quiz 1 (FAQ 1, Palmore, 1977)


in one site


Low

Liu et

al.

/ In

ternatio

nal

Journal

of

Nursin

g Stu

dies

xxx (2

012)

xxxxxx

6 G M

odel

NS-2141;

No.

of

Pag

es 12

Please

cite th

is article

in press

as:

Liu et

al.,

Nurse

s attitu

des

towards

older

people:

A sy

stematic

review.

Int.

J. Nurs.

Stud.

(2012),

http

://dx.doi.o

rg/10.1016/j.ijn

urstu

.2012.11.021

Wellsetal.(2004)

Cross-sectionalsurvey

FactsonAgingQuiz

(FAQ,Palm

ore,1977,1998)

Convenience

sample

drawnfrom

Moderate


G Model


Pl(2number of studies. For example, no differences in attitudeswere reported between student nurses (Hweidi and Al-Obeisat, 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/Latinostudents compared to Black students. Family incomewas not a signicant variable in Lambrinou et al. (2009)study, whereas monthly income was negatively associatedwith student nurses attitudes (p = 0.002) (Hweidi and Al-Obeisat, 2006). Nurses marital status was not associatedwith attitudes (Hweidi and Al-Hassan, 2005).

Education was the second most investigated variablewith education level being the most widely investigatedvariable and showed inconsistent ndings. Five studies(Furlan et al., 2009; Hweidi and Al-Obeisat, 2006; Karlinet al., 2006; Lambrinou et al., 2009; Soderhamn et al., 2001)reported an association between higher education leveland 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 foundno association between initial nurse training/educationand attitudes (Myers et al., 2001) while another foundmore positive attitudes in nurses with a gerontologyeducation compared to those without (Wells et al., 2004).

Several studies examined the association betweenvarious experience of older people variables and attitudeswith most nding no association. None of the studiesfound a negative association between experience andpositive attitudes except one of 4th year student nursesfrom one university (Lambrinou et al., 2009) where livingwith older people and negative attitudes was related inone but not in the other three student groups. Two of thefour studies reported that living with or having been caredfor by older people was associated with positive attitudes(Hweidi and Al-Hassan, 2005; Wu, 2011). One of threestudies found an association between positive attitudesand clinical experience (Wang et al., 2010) and anotherbetween positive attitudes and duration of nursingexperience (Hweidi and Al-Hassan, 2005). Two studiesfound no association between student nurses attitudesand their experience of working with older people(Hweidi and Al-Obeisat, 2006; Pan et al., 2009) and onefound no association between attitudes and frequency ofcaring for patients with spinal cord injury (Furlan et al.,2009).

Different work settings were associated with differentattitudes to older people. Two studies found no associationbetween attitudes and a hospital or nursing homeexperience (Koren et al., 2008; Soderhamn et al., 2001)and two studies of acute care settings yielded inconsistentndings; Furlan et al. (2009) reported that nurses workingin acute care had more ageist attitudes than those workingin a rehabilitation centre but Gallagher et al. (2006) foundno differences in attitude between nurses in the acute andlong-term settings. Area of work was not associated withattitudes in one study (Myers et al., 2001) of nursesworking in general areas from one acute-care hospital, butanother study reported that nurses working for a serviceprovider or working outside the residential care sectorwere more likely to hold positive attitudes (Wells et al.,

Australiaw

205nurses,298doctors,86otherprofessionals,

33direct

care

staff,78otherserviceproviders

&

22otherstaffrecruitedfrom

20organizations

(RR1370%)

Reactionsto

AgeingQuestionnaire

(RAQ,Gething,1994)

Researcher-developedThePracticeCostsand

RewardsQuestionnaire(PCRQ),adaptedfrom

LeCourteuretal.(1997)

multiple

sites

Low

tomoderate

response

rate

Williamsetal.(2007)

Canadax

Single

groupexperimentwithpost-test

comparator

381st

yearstudentnursesrecruited

from

twoprogramsin

oneuniversity

(RRunclear)

AgingSemanticDifferential(Rosencranz&

McN

evin,1969)

Reactionto

AgeingQuestionnaire(RAQ,

Gething,1994)

PersonalDetailsQuestionnaire

(Gething,1994)

FactsonAgingQuestionnaire

(Palm

ore,1977,1988)

Smallconvenience

sample

basedin

onesite

Response

rate

unclear

Low

Wu(2011)Chinay

Cross-sectionalsurvey

1311st

yearand823rd

yearstudentnurses

recruitedfrom

oneschool(RR100%,usable

RR91.4%)

AttitudestowardsOld

People

Scale

(KOP,Kogan,1961)

Factsonagingquiz

1(FAQ1,Palm

ore,1977)

Convenience

sample

basedin

onesite

Highresponse

rate

Moderate

Note:Ifthestudyisatrial,weusedthebaselinedata

from

trialwhere

available.ease cite this article in press as: Liu et al., Nurses attitudes towards older people: A systematic review. Int. J. Nurs. Stud.012), http://dx.doi.org/10.1016/j.ijnurstu.2012.11.021


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NS-2141; No. of Pages 122004). Only one study compared attitudinal data acrosscountries and reported that UK nurses held more negativeattitudes than Australian nurses (Gething et al., 2002).

Preference to work with older people was positivelyassociated 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 waspositively associated with attitudes in three studies ofqualied (Mellor et al., 2007) and student (Lambrinouet al., 2009; Wu, 2011) nurses.

Table 3

Nurses attitudes (positive, neutral or negative) to older people reported by the included papers.

Reference Tool Raw scores Converted score Overall attitude

a RKOP Student nurse: intervention group (a1): 77.45 12.95;control group (a2): 75.83 14.58

a1: 58% a1: Neutral

Possible range: 22154, mid-score 88, high = ve a2: 59.2% a2: Neutralb KOP Student nurse: 139.12 14.27

Possible range: 34204, mid-score 102, high = +ve68.2% Positive

c KOP Nurse: Acute-care setting (c1): +KOP = 49.67, KOP= 46.33; rehabilitation (c2): +KOP = 50.83, KOP = 55.44

c1: +KOP = 48%;KOP = 43.1%

c1: +KOP = neutral;KOP = neutral

Possible range: 1785, mid-score 51, high = +ve c2: +KOP = 49.8%;KOP = 56.5%

c2: +KOP = neutral;KOP = neutral

d KOP Nurse: acute-care seeting (d1): +KOP = 41.95, KOP= 68.13; long term (d2): +KOP = 40.37, KOP = 66.34

d1: +KOP = 63.3%;KOP = 75.2%

d1: +KOP = positive;KOP = positive

Possible range: 1785, mid-score 51, high score =ve in +KOP, reverse in KOP

d2: +KOP = 65.6%;KOP = 72.6%

d2: +KOP = positive;KOP = positive

e ASD Nurse: UK (e1): 122.31; Australia (e2): 108.79 Possible range: 32224, mid-score 128, high = ve

e1: 53% e2: 60%

e1: Neutral e2: Positive

g KOP nurse: 118.64 possible range: 34204, mid-score102, high = +ve

58.2% neutral

h KOP Student nurse: 110.6 Possible range: 34204, mid-score 102, high = +ve

54.2% Neutral

j KOP Nurse: 80 Possible range: 34170, mid-score 102, high = +ve

33.8% Negative

k AGED Student nurse: 4.35 Possible range: 17, mid-score 4, high = +ve

55.8% Neutral

l KOP 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

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%

l1: +KOP = positive;KOP = negative

l2: +KOP = positive;KOP = neutral



m RD tool 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

m1: 82.8% m2: 64% m3: 62.2%

m1: positive m2: Positive m3: Positive

n KOP Nurse: 173.4 19.18 Possible range: 34238, mid-score 136, high = +ve

68.3% Positive

o ASD Nurse: 3.61 Possible range: 17, mid-score 4, high = +ve

63.0% Positive

p PWOP Student nurse: 39.75 4.42 Possible range: 1155, mid-score 33, high = +ve

65.3% Positive

r KOP Student nurse: 142.76 15.92 Possible range: 34204, mid-score 102, high = +ve

70.0% Positive

s KOP 1st year student nurse (s1): 80; 3rd year studentnurse (s2): 72.5; registered nurse (s3): 74.8

Possible range: 34170, mid-score 102, high = ve

s1: 66.2% s2: 71.7% s3: 70%

s1: Positive s2: Positive s3: positive

t RKOP Student nurse: 74.74 Possible range: 22154, mid-score 88, high = ve

60.0% Positive

u KOP Student nurse: 156.86 Possible range: 34238, mid-score 136, high = +ve

60.2% Positive

v KOP Student nurse: with work experience (v1): 167.48;without work experience (v2): 151.23


v1: 65.4% v2: 57.5%

v1: Positive v2: neutral

x ASD Student nurse: 107.50 Possible range: 32224, mid-score 128, high = ve

60.7% Positive

y KOP 1st year student nurse (y1): 161.18; 3rd year studentnurse (y2): 159.37


v1: 62.3% v2: 61.5%

v1: Positive v2: Positive

Note: 21 studies in the table, another 4 studies data failed reported sufcient raw data; RD: researcher-developed.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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Pl(2Difference in attitudes towards older people betweenerent types of nurse was examined in three studies.erhamn et al. (2001) found that 1st year students heldre negative attitudes than registered nurses whileLafferty (2005) found that nurse teachers held moreitive attitudes than students and Mellor et al. (2007)orted that registered nurses were more positive thanolled nurses.Some studies examined the relationship of otheriables to attitudes. For example, Myers et al. (2001)orted that attitudes to restraint use and level of practicere not signicantly correlated with attitudes towardser people. Only one study investigated the associationween attitudes to self-ageing and attitudes towardser people among UK and Australia nurses and found aitive association (Gething et al., 2002). Lambrinou et al.09) reported that choosing nursing as the rst studyice was not related to students attitudes towards olderple.

iscussion

Attitudes towards older people among nurses haveacted considerable interest from researchers over time

across countries. Both registered and student nursestudes towards older people appear to have become lessitive since 2000 although the majority of studiesorted positive attitudes. The slight trend towards arease in positive attitudes among registered nursespared to student nurses, albeit with a wide data range

a few studies, is noteworthy. This attitudinalerence may impact upon the desired promotion ofitive attitudes towards older people since registeredses are the role models and mentors of student nursesing their socialisation in clinical settings. However,istered and student nurses attitudes are not indepen-t of general societal attitudes and, while one mightect healthcare professionals to espouse positivetudes towards all their potential patients, nurses arewn from the general population of their country

including migrants and are therefore subject to theinuence of prevailing attitudes of those societies andtheir cultural heritage. Interestingly the cultural back-ground of the nurse samples was not reported although itis likely most nurses reected some aspects of the countryin which the study was conducted even if they were recentmigrants. Indeed attitudes towards older people varywidely across different countries, and sometimes withincountries, reecting cultural norms.

Of the included studies, Lambrinou et al. (2009)reported conicting results with student nurses holdingpositive attitudes on posKOP but negative attitudes onnegKOP. Lambrinou offers no explanation of this ndingwhich is difcult to interpret because it indicates that thesubjects disagreed with the negative items less than theyagreed 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 potentialpredictors of nurses attitudes. Age, gender and educationlevel have been being investigated most frequently butnone appear to be consistent predictors of attitudes acrossstudies. For example, three studies found that males hadmore positive attitudes than females (Holroyd et al., 2009;Hweidi and Al-Hassan, 2005; Hweidi and Al-Obeisat,2006), but another three studies reported the oppositending. These inconsistent ndings highlight the need formore sophisticated analysis of study data.

Although investigated in a few studies only, preferenceto work with older people and knowledge of ageing appearto be associated with positive attitudes towards olderpeople. This nding suggests that education in geronto-logical nursing together with positive clinical learningexperiences can improve attitudes towards older peopleand increase the number of nurses expressing a preferenceto work with older people.

The experience of working with older people was notclearly associated with attitudes towards older people intwo studies included in this review (Hweidi and Al-Obeisat, 2006; Pan et al., 2009). This nding is in contrast

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NS-2141; No. of Pages 12to Moyles (2003) study which reported a positiveassociation between experience of working with olderpeople and attitudes. However, this study used anunvalidated attitude measure and so its ndings arequestionable.

Only one study (Gething et al., 2002) investigatednurses attitudes across countries and reported that UKnurses held more negative attitudes than Australian nursesand that views about self-ageing were correlated withattitudes towards older people. This nding may reect theimpact upon attitudes of different national policies anddifferent attitudes within different societies. The UKenacted its rst anti-age discrimination legislation in2006 following earlier legislation to outlaw discriminationrelating to race and pay in the early 1970s with equalityemerging as an important political issue from 1970onwards.

The limitations of this review include the methodolo-gical weaknesses of some of the selected studies which

recruited small non-randomly selected samples from smallgeographical areas. Additionally it was not possible todraw rm conclusions from the limited data sets derivedfrom multiple studies across time and settings. Furtherresearch using well designed studies with larger andrandom samples which examine the inter-relationshipsbetween key variables using validated instruments isneeded together with well designed trials of interventionsdesigned to improve attitudes so that there is evidenceupon which to build workforce strategies to meet futurehealth care system needs. However, cross-cultural studiesof attitudes are challenging because shared conceptualunderstanding cannot be assumed.

5. Conclusion

Global demographic trends (Kinsella and He, 2009;WHO, 2000) are creating an imperative for improvingnurses attitudes towards older people and their work

Table 4

Variables related to positive attitudes towards older people.

Category Variable Positive*

correlation

Negative*

correlation

Non-signicant correlation Total studies

Demographics Increasing age h, l3, s1 c, e, g, i, k, l1, l2, l4, o, p, r, s2 11

Gender: male f, g, h l2, l3, p, s e, i, l1,o 9

Village v. city g, h 2

Hispanic/Latino students

v. Black students

r 1

Family income l1, l2, l3, l4 1

Monthly income h 1

Marital status g 1

Education Education level c, h, i, l, s f, g, k, m, p, r, y 12

Initial training/education o 1

Gerontology education w 1

Experience Live with older people g l2 h, l1, l3, l4, p 4

Taken care by older people y 1

Clinical experience v k, p 3

Time of nursing experience g c, o 3

Working with older people h, p 2

Frequency of caring for

patients with SCI

c 1

Work setting Hospital v. nursing home k, s 2

Acute care setting c d 2

Area of work o 1

Outside the residential

care sector

w 1

Service provider w 1

Surgical v. medical units g 1

UK v. Australia e 1

Preference to work

with older people

Preference to work with

older people

h, k, p 3

Knowledge Knowledge l, n, y 3

Nurse type Registered nurse v. student s 1

Registered v. enrolled nurses n 1

Teacher v. student m 1

Other Attitudes to restraint use o 1

Level of practice o 1

Attitudes to self-aging e 1

Choose nursing as the rst

choice of studying

l1, l2, l3, l4 1

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.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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Pl(2lth care systems are to be met and high quality careivered to older people (ICN, 2006). The limited evidence

well designed studies needs urgent attention ifrkforce strategies are to be implemented. Understand- the attitudes of registered nurses and the associatedors should receive equal attention to that of studentses because registered nurses are the clinical roledels for the next generation of nurses regardless ofsdiction. However, understanding the attitudes ofdent nurses and the associated factors will providedence upon which to develop initial education curriculathat new registrants are correctly prepared fortributing to the needs of future health care systemsether they choose to remain in their home nation orer the global labour market (Kingma, 2005).

ict of interest statement

There is no conict of interest.

ding

None.

ical approval

Not required.

erences

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Nurses attitudes towards older people: A systematic review1 Introduction2 Methods2.1 Study identification and selection2.2 Data analysis2.3 Reliability of quality assessment and data extraction

3 Results3.1 An overview of included papers3.2 Instruments of included studies for measuring attitudes3.3 Attitudes towards older people3.4 Variables related to attitudes towards older people

4 Discussion5 ConclusionConflict of interest statementFundingEthical approvalReferences

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Systematic Liu, Norman & While 2013