A local study confirms research evidence that education and clinical placements are not increasing knowledge or promoting positive attitudes in older people’s care
Both student nurses and registered nurses may lack sufficient knowledge and positive attitudes to care for an ageing population, and education programmes are not addressing this. This research review, which includes a small study by the author, found that neither education nor clinical placements significantly improved students’ knowledge about or attitudes towards older people. This review also explores the evidence and suggests how this issue could be addressed.
Citation: Welford C (2014) Attitudes and knowledge in older people’s care. Nursing Times; 110: 34/35, 22-24.
Author: Claire Welford is national practice development facilitator, Mowlam Healthcare, Ireland.
- This article has been double-blind peer reviewed
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An ageing population requires nurses to be fully equipped to care for their specialist needs (Abendroth and Graven, 2013; Kerridge, 2008). Health professionals’ values, beliefs and attitudes towards older people affect how they view and approach those in their care, which affect the quality of care that older people experience (Liu et al, 2013; Randers and Mattiasson, 2004).
Several researchers have linked professionals’ level of knowledge about ageing with positive attitudes (Mandy et al, 2007; Wells et al, 2004), while others have suggested negative attitudes arise out of work associated with caring for older people, such as providing constant physical care and managing cognitive impairment and its challenges (Abendroth and Graven, 2013; Wells et al, 2004; Pursey and Luker, 1995; Hope, 1994). This raises three questions:
- Do nurses’ attitudes towards and/or knowledge about ageing and older people affect the care they provide?
- Do the work-based experiences of caring for older people affect nurses’ future behaviour and/or career choices?
- What is being done to address negative attitudes and poor learning environments in older people’s care?
A number of scales to quantify or score staff attitudes towards older people have been developed (Palmore, 1977; Rosencranz and McNevin, 1969; Kogan, 1961).
Using the KAOP scale, Hope (1994) found that attitudes varied not only across countries but also across care sectors. The main finding was that nurses working in acute care for older people had significantly higher or more positive attitude scores than those in acute medical care. Hope (1994) suggested this may be because nurses with a positive attitude towards older people find themselves working with older people. Hope (1994) also found patient dependency may influence staff attitudes. This study is 20 years old and had a small sample size (n=86) but it paved the way for further research.
Recently, Liu et al (2013) reported from a systematic review that nurses’ and student nurses’ attitudes have become less positive since 2000; whether this is linked to dependency rising with age is not clarified or stated. Liu et al (2013) said doctors often have more positive attitudes than nurses and suggest this may be down to the greater educational investment in medical students.
Several researchers have found links between healthcare staff’s education levels and the level of positive attitudes towards older people (Doherty et al, 2011; Mandy et al, 2007).
Wells et al (2004) explored the prevalence of negative attitudes towards ageing among nurses working with older adults. In addition to education and work environment factors, they found nurses were more likely to hold positive attitudes if they:
- Had worked for a service provider rather than an employment agency;
- Had studied gerontology;
- Had worked outside residential care.
They also found that nurses:
- Had not as much accurate knowledge of ageing as other health professionals;
- Expressed a higher anxiety about ageing;
- Were more likely than other health professionals to believe that working with older adults was held in low esteem by their profession.
Pursey and Luker (1995) challenged the assumption that nurses’ lack of desire to work with older people was due solely to negative attitudes they held towards this group. They researched four educational institutions in north-west England to examine nurses’ experiences of working with older people to draw out the differences in attitudes. They found older people’s high dependency and the structure of nursing work with older people in hospitals meant that few nurses made this area a positive career choice. They said one would have expected this to have changed with the development of individual patient-centred care and public awareness of this, but this was not the case. Recent research has reported similar findings (Liu et al, 2013; Murphy and Welford, 2012; Doherty et al, 2011; Wells et al, 2004).
Doherty et al (2011) measured healthcare workers’ attitudes towards older people in a rural Irish population. They aimed to explore the attitudes held by nurses, healthcare assistants, ward managers, student nurses and public health nurses who were on duty over a 24-hour data-collection period. Using the KAOP scale, they found no significant difference in attitude scores by gender, job title or length of service in current role. However, graduates held more positive attitudes than those without a university education. While there was no difference in attitudes between care environments, public health nurses had the most positive attitudes.
Education on older people’s care
I conducted a small study in an Irish university to explore the attitudes of student nurses towards older people before and after theoretical education and clinical placement. The findings of the unpublished study (Box 1) identify two key areas for development in nursing:
- The methods by which theoretical education is delivered to increase students’ knowledge about ageing;
- The quality of clinical placement experiences to affect career choice.
Working with older people requires specific competencies. McCormack (2001) describes these as listening, negotiating, enabling opportunities and choice, and enabling decision making. Interpersonal skills and commitment to the job can ultimately affect and improve an older person’s quality of life (McCormack and McCance, 2006). Nurses working with older people should be motivated to take flexible and innovative approaches to care, as well as being committed to understanding the person (Welford et al, 2010; Reed et al, 2007; McCormack and McCance, 2006).
Leadership permeates all aspects of care, with a lack of leadership resulting in fragmented, task-based approaches to the care of older people that reduces its quality (Forbes-Thompson and Gessert, 2005; Swagerty et al, 2005).
Transformational leadership theory suggests leaders use charisma to provide vision and direction and, ultimately, transform organisations. Encouragement and praise for achievement are essential to the success of this leadership style, and can help to gain trust and respect from staff, thereby improving motivation and morale. Leaders in gerontological nursing should be recruited on their ability to transform.
Practice development can help staff integrate their knowledge and apply their specialist skills to benefit older patients, and can role model best practice to students.
Both Abendroth and Graven (2013) and Welford (2007) suggested new approaches to gerontological education that may pave the way for further developments. Recalling the link that Pursey and Luker (1995) found between high dependency in older people and the structure of nursing work with older people, nurse educators need to consider how student nurses can be best equipped to cope with the demands of this type of placement. Furthermore, Wells et al (2004) reported that different service providers yielded nurses with more positive attitudes in relation to their work.
Placements sites should be rigorously selected for taking innovative and modern approaches to gerontological care. Kerridge (2008) recognised the value of practice-based learning in nursing but said the quality of clinical learning environments must meet the needs of older people in diverse settings.
Whitaker (2004) described nursing homes as both a place where older people were living the last days of their life and a workplace for staff; this is interesting because it highlights that staff are in a hurried or pressed culture while residents are living in a waiting or expecting culture. Whitaker (2004) said these two cultures never interacted. Practice development is just one way in which this can be addressed through its ability to blend research and knowledge with practice-based innovations and change management projects.
There appears to be a dichotomy between the view that nursing education is equipping student nurses with the specialist knowledge and skills to care for older people and the reality that in many settings older people do not receive specialist care and students do not have positive placements.
This discussion has focused on three strategies to promote change:
- Recruiting people with the right interpersonal skills;
- Fostering a transformational leadership culture;
- Maximising practice development to bridge the theory-practice gap.
Care needs to be organised in line with best practice, and the needs and wants of older people should drive this. The complexity of changing practice, however, cannot be overestimated and a detailed, systematic approach is required when analysing barriers and agreeing actions.
Older people’s nursing is an emerging specialty as a result of the ageing population but the quality of the clinical and theoretical experiences of students may determine whether it will be fully recognised by nursing boards and chosen as a career pathway. Therefore, a systematic approach that takes into account personal and organisational factors along with the social and cultural context of the practice environment, is more likely to succeed.
As the number of older people continues to rise, a change in the ethos of care and how that care is structured and organised, is required.
- Negative attitudes towards caring for older people may be adversely affecting care
- Nursing education needs to be developed from current clinical issues and demands
- Organisations need to recruit people with the interpersonal skills to work with older people
- Positive placement experiences in the older people’s care are important for an understanding of this speciality
- Nursing boards need to consider the future of older people’s nursing and recognise it as a specialty
Abendroth M, Graven LJ (2013) Integrating care of older adults into the nursing curriculum: a case exemplar project. Journal of Nurse Education; 52: 9, 529-532.
Doherty M et al (2011) Attitudes of healthcare workers towards older people in a rural population: a survey using the Kogan scale. Nursing Research and Practice; 2011: 1-7.
Forbes-Thompson S, Gessert C (2005) End of life in nursing homes: Connections between structure, process and outcomes. Journal of Palliative Medicine; 8: 3, 545-555.
Hope KW (1994) Nurses’ attitudes towards older people: a comparison between nurses working in acute medical and acute care of elderly patient settings. Journal of Advanced Nursing; 20: 605-612.
Kerridge JL (2008) Supporting student nurses on placement in nursing homes: the challenges for the link-tutor role. Nurse Education in Practice; 8: 6, 389-396.
Kogan N (1961) Attitudes toward old people: the development of a scale and an examination of correlates. Journal of Abnormal and Social Psychology; 62: 1, 44-54.
Liu Y et al (2013) Nurses’ attitudes towards older people: a systematic review. International Journal of Nursing Studies; 50: 9, 1271-1282.
Mandy A et al (2007) Clinical educators’ reactions to ageing. International Journal of Allied Health Sciences and Practice; 5: 4, 1-14.
McCormack B (2001) Negotiating Partnerships with Older People: a Person-Centred Approach. Farnham: Ashgate.
McCormack B, McCance (2006) Development of a framework for person-centred nursing. Journal of Advanced Nursing. 56: 5, 472-479.
Moseley A, Paterson J (2008) The retention of the older nursing workforce: a literature review exploring factors that influence the retention and turnover of older nurses. Contemporary Nurse. 30: 1, 46-56.
Murphy K, Welford C (2012) Agenda for the future: enhancing autonomy for older people in residential care. International Journal of Older People Nursing; 75-80.
Palmore E (1977) Facts on aging: a short quiz. The Gerontologist; 17: 315-320.
Pursey A, Luker K (1995) Attitudes and stereotypes: nurses’ work with older people. Journal of Advanced Nursing; 22: 547-555.
Randers I, Mattiasson AC (2004) Autonomy and integrity: upholding older patients’ dignity. Journal of Advanced Nursing; 45: 1, 63-71.
Reed J et al (2007) Specialist nurses for older people: implications from UK development sites. Journal of Advanced Nursing; 58: 4, 368-337.
Rosencranz HA, McNevin TE (1969) A factor analysis of attitudes toward the aged. The Gerontologist; 9: 55-59.
Swagerty DL et al (2005) The context for nursing home resident care. Journal of Gerontological Nursing; February, 40-48.
Welford C (2007) Preparing undergraduates for practice placements in gerontological nursing. Journal of Nursing Older People; 19: 9, 33-36.
Welford C et al (2010) A concept analysis of autonomy for older people in residential care.Journal of Clinical Nursing; 19, 1226-1235.
Wells Y et al (2004) Nurses’ attitudes toward ageing and older adults. Journal of Gerontological Nursing; 30: 9, 5-13.
Whitaker A (2004) The Last Home: Family Ties, Ageing and Death in a Nursing Home. Stockholm: Stockholm University.