Dr. Pan is Assistant Professor, Department of Nursing, I-Shou University, Kaohsiung County, Taiwan, Republic of China; and Dr. Edwards is Professor, Queensland University of Technology, School of Nursing and Midwifery, Kelvin Grove, Brisbane, and Dr. Chang is Professor of Clinical Nursing and Director, Nursing Research Centre, Mater Health Services, South Brisbane, Australia.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to I-Ju Pan, PhD, RN, Assistant Professor, Department of Nursing, I-Shou University, No 8, YiDa Road, Yanchao Township, Kaohsiung County, 824 Taiwan, Republic of China; e-mail: email@example.com.
Aging is an inevitable part of life, and advanced technology and medical treatments have resulted in people living longer. There is a major demographic transformation in Taiwan, resulting in the growth of what is termed an aged population. Currently, people age 65 and older comprise 9.7% of the Taiwanese population (Department of Statistics, 2006). It is estimated that by 2030 and 2040, the proportion of older people in Taiwan will rise to 19.5% and 25% of the population, respectively (Social Affairs, 2002). Within this population, levels of disability are markedly higher. Functional disabilities due to psychological, socioeconomic, and environmental factors can have a profound impact on the health care system; this increased older adult population with its associated health care needs will represent the most common care group for the nursing profession (Happell & Brooker, 2001; Hweidi & Al-Obeisat, 2006; Paton & Sar Gerard, 2001; Sheffler, 1998).
Health care providers will play an important role in meeting the various needs of older people. Nurses, as the largest group of health care providers, will continue delivering health care to older adults; however, a number of research studies suggest that fewer health professionals are making the career choice to work with this population (Happell & Brooker, 2001; Herdman, 2002; Söderhamn, Lindencrona, & Gustavsson, 2001). Concerns have been raised about the competency and willingness of health care providers to care for this age group (Kane, 1999; McKinlay & Cowan, 2003; Mehta, Tan, & Joshi, 2000; Paton & Sar Gerard, 2001). It is also questionable whether nursing students and health care providers hold negative attitudes toward older people (Gellis, Sherman, & Lawrance, 2003; Happell, 1999; Kearney, Miller, Paul, & Smith, 2000; Knapp & Stubblefield, 2000; Paton & Sar Gerard, 2001) or positive ones (Fitzgerald, Wray, Halter, Williams, & Supiano, 2003; Hweidi & Al-Obeisat, 2006; Lookinland, Linton, & Lavender, 2002; McKinlay & Cowan, 2003; Tan, Zhang, & Fan, 2004; Yan, 2009; Yen et al., 2009). According to Jacelon (2002), the quality of care provided to older people is directly related to the attitudes of health care professionals. Consequently, because the nursing student of today is the health care provider of tomorrow, and with the burgeoning need for care for older adults, it is important for nurse educators to identify those students who have an interest in aging and encourage them. Further, it is necessary to be aware of the attitudes held by current undergraduate nursing students toward older people and to understand the implications of these attitudes. Therefore, the purpose of this study was to gain a greater understanding of Taiwanese nursing students’ attitudes toward older people and determine the factors influencing their attitudes.
Previous research has revealed conflicting views of nursing students’ attitudes toward older people. Their attitudes have been found to be influenced by nursing students’ characteristics such as gender (Gellis et al., 2003; Söderhamn et al., 2001; Yan, 2009; Yen et al., 2009), age (Gellis et al., 2003; Söderhamn et al., 2001), intention to work with older people (Gellis et al., 2003; McKinlay & Cowan, 2003; Mehta et al., 2000), and previous experience with older people (Paton & Sar Gerard, 2001)
Menz, Stewart, and Oates (2003) surveyed 81 Australian podiatry medical students: 57 third-year and 24 fourth-year students. They found no difference between male and female students with regard to attitudes toward older people. In contrast, in the United States, Gellis et al.’s (2003) study of 96 graduate social work students found that male students were less positive than female students in their attitudes toward older adults. Similarly, in Taiwan, Yen et al. (2009) studied 275 nursing and medical students and found that students had positive attitudes toward older people, but male students had less positive attitudes than female students. The students’ positive attitudes likely reflect the Chinese culture in Taiwan, with the cornerstone of the Confucian ethic: Chinese society places a high value on respect for older people. Older adults are respected and honored for their wisdom and experience. Keifer (1992) pointed out that Confucian ideals pertain to the family and the status of older people in Chinese society, in which adult children are obliged to support their older parents. Also in Chinese culture, there are different expectations of women and men. Men are supposed to earn money to support the family, and women are expected to care for family members at home. In Taiwan, a number of older people live with their adult children, perform various household chores, and contribute by taking care of their grandchildren. If the older parents live alone, the grandchildren could be asked by their parents to go to their grandparents’ home to maintain the relationship between grandparents and grandchildren.
Gellis et al. (2003) surveyed the attitudes of 172 first-year master’s-level social work students and found that younger students tended to have less favorable attitudes toward older adults. Similarly, using a convenience sample, Curl, Simons, and Larkin (2005) investigated attitudes toward older people in 125 (90 bachelor’s and 35 master’s level) social work students. The results revealed that age predicted social work students’ willingness to accept jobs in aging on graduation, with older students being more willing. On the other hand, also using a convenience sample, Tan et al. (2004) investigated attitudes toward older people in 199 university students in mainland China and found that students’ age was not correlated with their attitudes toward older people; these results were similar to those of other studies with samples of social work students (Mehta et al., 2000; Tan, Hawkins, & Ryan, 2001), university students (Prudent & Tan, 2002), medical students (Fitzgerald et al., 2003), and podiatry students (Menz et al., 2003).
Intention to work with older people has been identified as a factor that influences nursing students’ attitudes toward older people. McKinlay and Cowan (2003) conducted a study of 172 nursing students taking pre-registration nursing courses. The results showed that the students’ intentions toward working with older patients were predicted mainly by their attitudes. Similar results about intention to work with older people were found in a sample of first-year graduate social work students (Gellis et al., 2003) and in a sample of medical students (Fitzgerald et al., 2003). In all of the studies reviewed, intention to work with older people had a strong and positive relationship to attitudes.
In a study of 175 undergraduate and graduate nursing students, Paton and Sar Gerard (2001) reported that students who had previous work experience with older people expressed greater interest in working with this population than students with no such experience. The results of Paton and Sar Gerard’s (2001) study were supported by McKinlay and Cowan’s (2003) study of nursing students in a pre-registration course. However, despite a number of studies supporting a relationship between attitudes toward older people and previous experience with them, contradictory findings still exist. Studies by Hweidi and Al-Obeisat (2006) and Fitzgerald et al. (2003) found that previous experience working with older people did not correlate with attitudes about older adults.
In reviewing the literature, we found contradictory evidence regarding whether health care professionals hold more positive or negative attitudes, and whether age, gender, intention to work with older people, or previous experience with older people influence attitudes toward older people. While our review of the literature identified the factors that can influence health care providers’ and students’ attitudes toward older people, limited studies on this topic have been published in Taiwan.
Design and Sample
A cross-sectional research design was used in this study, involving a survey of undergraduate nursing students from a university in southern Taiwan. A convenience sampling frame was used to request participation from the students. The available survey sample was 429 nursing students; 362 of them completed the questionnaires, for a response rate of 84%.
The research questions addressed in this study were:
- What are current Taiwanese nursing students’ attitudes toward older people?
- What factors are likely to influence nursing students’ attitudes toward older people?
Nursing students were asked to complete a demographic data sheet including their age, gender, contact with older people in the family, clinical and lecture time devoted to older people, living with older people on permanent basis, previous work experience in nursing, clinical practice experience, nursing program, and intention to work with older people. Students’ attitudes toward older people were measured using Nolan et al.’s (2001) Perceptions of Working with Older People (PWOP), which consists of 11 statements with responses on a 5-point Likert scale ranging from 11 to 55. The Cronbach’s alpha coefficient of the PWOP was 0.73.
Permission to conduct the research was obtained from the university where the study was to be conducted. Data were collected by the researcher over a period of 3 weeks. The questionnaires were distributed and collected during students’ lecture times. The permission of each class lecturer was also gained. Students in each class were given a description of the study and an information sheet and were informed that participation in the study was voluntary and their study program would not be affected if they did not participate. If they agreed to participate, students were asked to sign an informed consent sheet. Some students did not complete the informed consent sheet and therefore did not complete a questionnaire or participate in the survey.
The main ethical consideration was confidentiality. It was important to ensure each questionnaire would be identified by a number only. The researcher approached all eligible participants and explained the purpose of the survey, data collection methods, and confidentiality issues. All participants were informed they had the right to withdraw from the survey at any time without comment or penalty. The participants were informed that no personal data that would identify them would be requested; they were assured that participation in the study would not affect their future career or study program. Full assurances were provided to all participants that all information collected was confidential and would be not disclosed to anyone other than the researcher. Students were also advised that no information about the project would be published in any form that would allow any individual or university to be identified.
SPSS version 13.0 was used to analyze the data. A Cronbach’s alpha level of 0.05 was used to test the significance of statistical differences. The sample characteristics and attitudes were identified using descriptive statistics. Standard multiple regressions were used to determine the factors predicting nursing students’ attitudes toward older people.
The convenience sample of 362 undergraduate nursing students consisted of 228 (63%) from the four-year program, including first-, third-, and fourth-year students, and 134 (37%) from the post-registration nursing program for RNs. The students’ mean age was 23.7 (SD = 6.3 years, age range = 17 to 53). The majority of students (93%) were women. Most (82%) students were single (never married). Half (50%) of the surveyed nursing students had nursing work experience. Most (91%) of the respondents acknowledged having contact with older people in their family; the majority (63%) stated that an older relative lived with their family on a permanent basis. Many (59%) respondents indicated they had not taken any subjects or programs with content related to older people. The majority (70%) had undertaken clinical practice in their nursing program. Fifty-four percent (n = 197) of all students had contact with older people during their clinical practice. The nursing students’ mean score regarding intention to work with older people was 3.21 (SD = 0.80) of a possible 5. The data indicated the majority of students were uncertain about their intention to work with older people.
Attitudes Toward Older People
The PWOP scales include negatively worded statements that were reversed so the scoring of these items coincided with that of the positively worded ones. The higher the total PWOP score, the more positive the attitude toward older people. In the total PWOP, a score of 22 indicates a neutral attitude, with possible scores ranging from 11 to 55. The nursing students who responded to this survey (n = 362) had a total mean PWOP score of 39.75 (SD = 4.42, range = 27 to 53). These data indicated these students had more positive than negative attitudes toward older people. However, although the attitudes toward older people were positive, the scores indicate the students’ attitudes could still improve.
Factors Influencing Nursing Students’ Attitudes
A multiple regression analysis related to attitudes toward older people was conducted on the PWOP scale. The multiple correlation coefficient (R) was 0.53 with all of the predictor variables accounting for 28% of the variance in PWOP scores (F9,299 = 10.97, p < 0.001). Gender and intention to work with older people were significant and independent predictors. The model indicates that nursing students who are women and have greater intention to work with older people have more positive attitudes toward older people (Table).
Table: Factors Influencing Students’ Attitudes Toward Older People: Standard Multiple Regression Using PWOP Scores
The findings of this study provide preliminary insight into Taiwanese nursing students’ attitudes toward older people and the relationship between students’ backgrounds and their attitudes. The results clearly showed that these nursing students held positive attitudes toward older people. When compared with similar studies conducted in the United Kingdom (Kearney et al., 2000), United States (Gellis et al., 2003; Prudent & Tan, 2002; Tan et al., 2001), Australia (Menz et al., 2003), and Singapore (Mehta et al., 2000), the attitudes toward older people of nursing students in this survey were more positive. While most studies of nurses’ attitudes toward older people have reported negative attitudes, some studies have reported positive attitudes consistent with the current study (Fitzgerald et al., 2003; Lin, 1993; McKinlay & Cowan, 2003; Tan et al., 2004; Wei, 1995). Reviews and critiques of studies that have examined attitudes toward older people have noted that negative attitudes may result from the kind of instruments used. The current study used a well-established and more recently developed one that reflected more contemporary views on aging. Therefore, the positive attitudes toward older people held in Chinese society were supported by the findings of this study.
The findings suggest nursing students’ intention to work with older people, as well as their gender, were important factors influencing their attitudes toward older people. A reasonable proportion of the variance in attitudes toward older people (28% of PWOP scores) could be accounted for by these variables.
In previous studies of students’ attitudes, intention to work with older people has been a consistently related factor (Gellis et al., 2003; Kane, 1999; McKinlay & Cowan, 2003; Mehta et al., 2000; Pursey & Luker, 1995). However, caution is warranted, as the results of past studies, as well as those of the current study, do not imply causality. As most studies are cross sectional in nature, it is not clear whether intention precedes positive attitudes or positive attitude precedes intention to work with older people.
As expected, gender was a predictor of positive attitudes, which is consistent with previous studies (Cammer Paris et al., 1997; Gellis et al., 2003; Gorelik, Damron-Rodriguez, Funderburk, & Solomon, 2000; Tan et al., 2004). Less positive attitudes among male students, compared with female students, have been observed in previous studies (Laditka, Fischer, Laditka, & Segal, 2004; Tan et al., 2001). This could be explained by the common expectation in Taiwanese society that men are to work hard and earn money and women are to provide a caring role in the family. In this study, female students’ attitudes toward older people could have been influenced by these expectations in Taiwanese society. Previous studies have suggested that women may be more attracted to the gerontological field because of the provision of service, as in traditional caregiving roles (Slevin, 1991). In this study, our finding is consistent with previous research, showing that women had more positive attitudes toward older people than men.
A number of limitations reduce the generalizability of the current study findings. The study was conducted using a convenience sample from a private university located in southern Taiwan. It is only 1 of 13 universities across Taiwan. The sample selection excluded second-year students, as they were to be participants in another study, so the responses may not truly reflect nursing students across Taiwan. In addition, the sample was composed of only undergraduate nursing students. Therefore, vocational school, junior college, technological school, and graduate nursing students are not represented. As the study was cross sectional, causality cannot be implied in any link between the variables examined and students’ attitudes.
Recommendations for Further Research
Further research is needed using random and larger samples to improve the generalizability of the findings. Qualitative research would be useful to gain a deeper understanding of why male students have less positive attitudes toward older people than female students. Finally, a future study could assess whether intention to work with older people is a determinant of students’ attitudes toward older people; by conducting a longitudinal study of nursing students following graduation, one could gather information on where and with what age group graduates are actually working. This would enable comparison of attitudes prior to and following a period of work in nursing.
Conclusion and Implications
The research established that Taiwanese nursing students had positive attitudes toward older people and identified the factors that influenced those attitudes. Students’ attitudes toward older adults still have room for maintenance and improvement. Therefore, for nursing education, it is important to consider what gerontological nursing content should be taught, as well as how, where, and when it should be taught.
- Cammer Paris, B.E., Gold, G., Taylor, B., Fields, S.D., Mulvihill, M.N. & Capello, C. et al. (1997). First year medical student attitudes toward the elderly: A comparison of years 1986, 1991, and 1994. Gerontology & Geriatrics Education, 18, 13–22.
- Curl, A.L., Simons, K. & Larkin, H. (2005). Factors affecting willingness of social work students to accept jobs in aging. Journal of Social Work Education, 41, 393–406.
- Department of Statistics. (2006). Report of the status of elderly long term care and nursing home institutions. Retrieved February 13, 2006, from http://www.moi.gov.tw/stat/index.asp
- Fitzgerald, J.T., Wray, L.A., Halter, J.B., Williams, B.C. & Supiano, M.A. (2003). Relating medical students’ knowledge, attitudes, and experience to an interest in geriatric medicine. The Gerontologist, 43, 849–855.
- Gellis, Z.D., Sherman, S. & Lawrance, F. (2003). First year graduate social work students’ knowledge of and attitude toward older adults. Educational Gerontology, 29, 1–16. doi:10.1080/713844235 [CrossRef]
- Gorelik, Y., Damron-Rodriguez, J., Funderburk, B. & Solomon, D.H. (2000). Undergraduate interest in aging: Is it affected by contact with older adults?Educational Gerontology, 26, 623–638. doi:10.1080/03601270050200626 [CrossRef]
- Happell, B. (1999). When I grow up I want to be a…? Where undergraduate student nurses want to work after graduation. Journal of Advanced Nursing, 29, 499–505. doi:10.1046/j.1365-2648.1999.00913.x [CrossRef]
- Happell, B. & Brooker, J. (2001). Who will look after my grandmother? Attitudes of student nurses toward the care of older adults. Journal of Gerontological Nursing, 27(12), 12–17.
- Herdman, E. (2002). Challenging the discourses of nursing ageism. International Journal of Nursing Studies, 39, 105–114. doi:10.1016/S0020-7489(00)00122-X [CrossRef]
- Hweidi, I.M. & Al-Obeisat, S.M. (2006). Jordanian nursing students’ attitudes toward the elderly. Nurse Education Today, 26, 23–30. doi:10.1016/j.nedt.2005.06.003 [CrossRef]
- Jacelon, C.S. (2002). Attitudes and behaviors of hospital staff toward elders in an acute care setting. Applied Nursing Research, 15, 227–234. doi:10.1053/apnr.2002.35958 [CrossRef]
- Kane, M.N. (1999). Factors affecting social work students’ willingness to work with elders with Alzheimer’s disease. Journal of Social Work Education, 35, 71–85.
- Kearney, N., Miller, M., Paul, J. & Smith, K. (2000). Oncology healthcare professionals’ attitudes toward elderly people. Annals of Oncology, 11, 599–601. doi:10.1023/A:1008327129699 [CrossRef]
- Keifer, C.W. (1992). Aging in Eastern cultures: A historical overview. In Cole, T.R., Van Tassel, D.D. & Kastenbaum, R. (Eds.), Handbook of the humanities and aging (pp. 96–123). New York: Springer.
- Knapp, J.L. & Stubblefield, P. (2000). Changing students’ perceptions of aging: The impact of an intergenerational service learning course. Educational Gerontology, 26, 611–621. doi:10.1080/03601270050200617 [CrossRef]
- Laditka, S.B., Fischer, M., Laditka, J.N. & Segal, D.R. (2004). Attitudes about aging and gender among young, middle age, and older college-based students. Educational Gerontology, 30, 403–421. doi:10.1080/03601270490433602 [CrossRef]
- Lin, M.-J. (1993). College student attitudes toward the elderly. Education and Psychology Research (Chinese), 16, 349–384.
- Lookinland, S., Linton, C.P. & Lavender, C. (2002). African-American nurses’ attitudes toward older persons. Journal of the National Black Nurses Association, 13(1), 6–14.
- McKinlay, A. & Cowan, S. (2003). Student nurses’ attitudes towards working with older patients. Journal of Advanced Nursing, 43, 298–309. doi:10.1046/j.1365-2648.2003.02713.x [CrossRef]
- Mehta, K.K., Tan, P.P. & Joshi, V.D. (2000). Singapore social work students: Attitudes toward older adults. Asia Pacific Journal of Social Work, 10, 40–54.
- Menz, H.B., Stewart, F.A. & Oates, M.J. (2003). Knowledge of aging and attitudes toward older people: A survey of Australia podiatric medical students. Journal of the American Podiatric Medical Association, 93, 11–17.
- Nolan, M., Davies, S., Nolan, J., Ferguson, C., Keady, J. & Grant, G. et al. (2001). AGEIN project. Unpublished paper, The University of Sheffield, School of Nursing and Midwifery, Sheffield, United Kingdom.
- Paton, R.N. & Sar Gerard, B.K. (2001). Working with older persons: Student views and experiences. Educational Gerontology, 27, 169–183. doi:10.1080/03601270151075589 [CrossRef]
- Prudent, E.S. & Tan, P.P. (2002). Caribbean students’ attitudes toward older adults. Educational Gerontology, 28, 669–680. doi:10.1080/03601270290099705 [CrossRef]
- Pursey, A. & Luker, K. (1995). Attitudes and stereotypes: Nurses’ work with older people. Journal of Advanced Nursing, 22, 547–555. doi:10.1046/j.1365-2648.1995.22030547.x [CrossRef]
- Sheffler, S.J. (1998). Clinical placement and correlates affecting student attitudes toward the elderly. Journal of Nursing Education, 37, 216–218.
- Slevin, O.D. (1991). Ageist attitudes among young adults: Implications for a caring profession. Journal of Advanced Nursing, 16, 1197–1205. doi:10.1111/j.1365-2648.1991.tb01529.x [CrossRef]
- Social Affairs. (2002). The elderly population of the Taiwan Area R.O.C. Retrieved July 27, 2009, from http://www.moi.gov.tw/dsa/
- Söderhamn, O., Lindencrona, C. & Gustavsson, S.M. (2001). Attitudes toward older people among nursing students and registered nurses in Sweden. Nurse Education Today, 21, 225–229. doi:10.1054/nedt.2000.0546 [CrossRef]
- Tan, P.P., Hawkins, M.J. & Ryan, E. (2001). Baccalaureate social work student attitudes toward older adults. The Journal of Baccalaureate Social Work, 6(2), 45–55.
- Tan, P.P., Zhang, N. & Fan, L. (2004). Students’ attitudes toward the elderly in the People’s Republic of China. Educational Gerontology, 30, 305–314. doi:10.1080/03601270490278830 [CrossRef]
- Wei, L.L. (1995). A study of knowledge about aging and attitudes toward the elderly among nursing students. Nursing Research (Taiwan), 3, 171–179.
- Yan, C.H. (2009). Medical and nursing students’ attitudes toward older people in Taiwan. Annual Academic Medicine Singapore, 38, 230–236.
- Yen, C.H., Liao, W.C., Chen, Y.R., Kao, M.C., Lee, M.C. & Wang, C.C. (2009). A Chinese version of Kogan’s Attitude Toward Older People Scale: Reliability and validity assessment. International Journal of Nursing Studies, 46, 37–43. doi:10.1016/j.ijnurstu.2008.05.004 [CrossRef]
Factors Influencing Students’ Attitudes Toward Older People: Standard Multiple Regression Using PWOP Scores
|Intention to work with older people||2.58||0.28||0.47||9.18*|
|Contact with older people in the family||0.93||0.80||0.06||1.16|
|Clinical and lecture time devoted to older people||0.51||0.58||0.06||0.88|
|Living with older people on permanent basis||0.22||0.48||0.02||0.45|
|Previous work experience in nursing||−0.20||0.79||−0.02||−0.25|
|Clinical practice experience||−0.49||0.68||−0.05||−0.72|