Art & science | research
Attitudes towards caring for older people in Scotland, Sweden and the United States Angela Kydd and colleagues compare data from three countries to assess what staff think about working in the specialty Correspondence [email protected] Angela Kydd is senior lecturer in research, Institute of Older Persons’ Health and Wellbeing, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton Theris Touhy is emeritus professor, Florida Atlantic University, United States David Newman is statistician, Florida Atlantic University, United States Ingegerd Fagerberg is professor, Ersta Sköndal University College, Sweden Gabriella Engstrom is associate professor, Florida Atlantic University, United States Date of submission November 15 2013 Date of acceptance January 8 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
NURSING OLDER PEOPLE
Abstract Aim To explore the attitudes of nurses and nursing students in Scotland, Sweden and the US towards working with older people. Method This quantitative study used the 20-item Multifactorial Attitudes Questionnaire (MAQ) to elicit attitudes on ageism, resources, working environment, education and professional esteem. Researchers from each country distributed the questionnaires to nursing students and nurses, giving a convenience sample of 1,587 respondents. Data were entered on the Statistical Package for Social Sciences version 18 and merged into one large dataset. Results Scottish participants had the highest (positive) and Swedish participants the lowest mean MAQ score. The Kruskal-Wallis test showed significant differences in mean scores across the countries in 18 THE GLOBAL shortage of nurses, combined with the fact that the population in the West is ageing, mean that there is a need to recruit gerontological nurses and to attract students to work in health and social care settings for older people (British Geriatrics Society (BGS) 2011, American Association of Colleges of Nursing (AACN) 2014). This article presents the results of an international study that examined the attitudes of registered nurses (RNs) and nursing students towards caring for older people. A Multifactorial Attitudes Questionnaire (MAQ) was used to explore the attitudes of participants from Scotland, Sweden and the US (Kydd and Wild 2013, Kydd et al 2013). The countries were conveniently chosen by researchers who worked together and had an interest in the topic. Although the health and social care
of the 20 statements, even when controlling for age and experience. Most participants gave positive responses, but agreed that negative attitudes towards working with older people pervade among peers due to working conditions, poor career prospects and a perceived lack of professional esteem. Conclusion Inspirational educators, excellent clinical placements and increasing the professional esteem of those working with older people are required to promote the specialty as an attractive career option. Keywords Ageism, attitudes to older people, gerontological nursing, nurse attitudes, professional esteem, quantitative research systems in these countries are different, as are their methods of care and cultural and societal attitudes towards ageing, the researchers wanted to explore commonalities and differences in attitudes towards working with older people.
Background One in nine people in the world is aged 60 years or over and this figure is projected to increase to one in five by 2050 (United Nations Population Fund and HelpAge International 2012). The need for adequate numbers of healthcare professionals to care for the growing number of older people is of critical concern across the globe (European Economic and Social Committee 2013). However, this need is compromised by pervasive ageism and increased care costs (Silcock and Sinclair 2012), a lack of March 2014 | Volume 26 | Number 2 33
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Art & science | research interest in working in this field (BGS 2011, AACN 2014) and a shortage of specialist staff (Fahlström and Hellner 2010, Bardach and Rowles 2012). Nurses, including educators and students, have negative attitudes towards working with older people (Engström and Fagerberg 2011, Jöhnemark et al 2012) and these attitudes can adversely affect the quality of care they provide (Natan et al 2013). Studies have also reported that working with older people is viewed as a lowly profession, which does not make it an attractive career option (Cornwell 2012).
Aim The aim of this study was to explore the attitudes of nurses and nursing students in Scotland, Sweden and the US towards working with older people.
Method This quantitative study used the MAQ, designed by Kydd et al (1999), then revised (Kydd and Wild 2013) and used for a study with nurses, healthcare assistants and nursing students in Scotland (Kydd et al 2013). The MAQ includes a variety of factors that may influence attitudes towards older people and working in care of older people. It was deemed suitable for use in this three-country study because it covered five different themes derived from a global literature search on attitudes towards older people and to working in the field of ageing. The original themes were ageism, learning environment, working environment, professional esteem, and specialist status. The MAQ includes 20 statements. Demographic information was also sought, which included age and time spent working with older people. The authors acknowledge that this instrument was developed in Scotland, by researchers familiar with the Scottish, that is, UK, healthcare system, and that wording and implicit understanding of the statements might be different for participants in other countries where the social and cultural conditions differ. To address this issue, in Sweden the MAQ was translated to Swedish and then translated back to English (Råholm et al 2010) by a professional translator and the terminology used in Scotland was checked with the lead researcher in the US for mutual understanding. The convenience sample was recruited from a variety of acute hospitals, healthcare settings for older people, long-term care facilities and five universities in the west of Scotland, the Mälardalen region of Sweden and South Florida, US. Inclusion criteria were that participants were employed as nurses or nursing students. As the 34 March 2014 | Volume 26 | Number 2
countries have different types of nurses, it is important to note that for the purposes of this article, the term ‘nurse’ is used for someone working with the title RN. Nursing students were considered to be any participants studying to become an RN. Data collection occurred in all three countries between 2009 and 2010. University/faculty staff distributed the questionnaires in classes for undergraduate and master’s nursing students, and managers in hospitals and long-term care settings were recruited to distribute the questionnaires in their facilities. In Scotland, in addition to distribution in person, the MAQ was distributed by post and email. Researchers in each country collected the completed questionnaires and entered the data on the Statistical Package for Social Sciences version 18 (Pallant 2010). The data from each country were merged into one large dataset and a factor analysis performed to show the correlations between variables in this dataset (Pallant 2010). The themes derived from the factor analysis were ageism, resources, working environment, education, and professional esteem. These differed from the themes of the Scottish study (Kydd and Wild 2013), which came from the literature. The 20-statement MAQ required participants to respond to each statement on a five-point Likert-type scale. Seven of the 20 statements were scored as 1 = strongly disagree; 2 = disagree; 3 = unsure; 4 = agree; 5 = strongly agree. The remaining 13 statements were scored in reverse order, 1 = strongly agree to 5 = strongly disagree, meaning that a higher score for each statement indicated a more positive attitude versus a lower score indicating a more negative attitude. A total MAQ score ranging from 20 to 100 was obtained by adding all of the scores from the 20 statements. Since the data violated the assumption of homogeneity of variance, that is, that the variance in each of the populations was equal, and was an ordinal scale, the first set of hypotheses that investigated differences in the perceptions of healthcare professionals on ageing across the three countries used a Kruskal-Wallis one-way analysis of variance. A post-hoc test using Mann-Whitney U with Bonferroni correction was used to further examine the items that were statistically significant (Kruskal and Wallis 1952, Corder and Foreman 2009). Ordinal regression was further used to investigate differences between countries while controlling for age and time spent working with older people. To investigate reliability of the MAQ, Rasch analyses were conducted using WINSTEPS 3.75.1 software (Linacre 2013). Summary statistics NURSING OLDER PEOPLE
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Table 1 Age groups of nurses and nursing students in Scotland, US and Sweden Age group Country
Profession
Scotland
Nurse
25
(15)
28
(17)
67
(40)
35
(21)
6
Nursing student
86
(56)
39
(25)
19
(12)
3
(2)
0
Nurse
68
(15)
89
(20)
95
(21)
93
(21)
13
Nursing student
60
(65)
12
(13)
9
(10)
1
(1)
0
Nurse
36
(15)
42
(17)
55
(23)
60
(25)
26
350
(72)
84
(17)
37
(8)
3
(1)
0
US
Sweden
18-29 n (%)
Nursing student
30-39 n (%)
were calculated for the 20 MAQ items across the three countries with 1,587 respondents. Person separation raw scores reliability = 1.29. The Mean Outfit Zstd 1.0 for person and 0.01 for items are expected values that indicate the data fit the model. The Outfit Zstd 0.1 for person and 0.1 for items were also within the expected value of 1 (Smith and Suh 2003). Outliers (2% of participants) were removed during the analysis. The person to raw score measure had a correlation of 0.97 with a Cronbach’s alpha of 0.61 and a person reliability of 0.63. These results indicate a low but acceptable level of reliability. It should be noted that personal reliability increases to an average of 0.69 when considering the countries individually, suggesting that the differences between countries might exist not only on an item level but also have difference in the underlying constructs. Conformity construct validity was assessed using confirmatory factor analysis; an adequate model fit was obtained with confirmatory factor analysis 0.89, root mean square error of approximation 0.80. The Chi-square test was 2720.8 df 155, P3, 2>3
20.
Other health professionals do not seem to appreciate that care of the older person is a highly skilled specialty.
1.85 (0.87)
2.31 (0.91)
2.07 (0.94)
58.3
0.000
1>2, 1>3, 2>3
NB Bold statements are scored strongly disagree (1) to strongly agree (5). All other statements are scored strongly agree (1) to strongly disagree (5)
NURSING OLDER PEOPLE
March 2014 | Volume 26 | Number 2 37
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Art & science | research Table 4 Ordinal regression testing for differences on the Multifactorial Attitudes Questionnaire while controlling for age and working with older people Statement
Chi-square
Sig
R2 Cox Snell
1.
Older people should have access, if appropriate, to medical and surgical procedures regardless of their age.
17.21
0.002
2.
As older people become increasingly old they become more irritable, touchy and unpleasant.
70.65
Attitudes towards caring for older people in Scotland, Sweden and the United States Angela Kydd and colleagues compare data from three countries to assess what staff think about working in the specialty Correspondence [email protected] Angela Kydd is senior lecturer in research, Institute of Older Persons’ Health and Wellbeing, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton Theris Touhy is emeritus professor, Florida Atlantic University, United States David Newman is statistician, Florida Atlantic University, United States Ingegerd Fagerberg is professor, Ersta Sköndal University College, Sweden Gabriella Engstrom is associate professor, Florida Atlantic University, United States Date of submission November 15 2013 Date of acceptance January 8 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
NURSING OLDER PEOPLE
Abstract Aim To explore the attitudes of nurses and nursing students in Scotland, Sweden and the US towards working with older people. Method This quantitative study used the 20-item Multifactorial Attitudes Questionnaire (MAQ) to elicit attitudes on ageism, resources, working environment, education and professional esteem. Researchers from each country distributed the questionnaires to nursing students and nurses, giving a convenience sample of 1,587 respondents. Data were entered on the Statistical Package for Social Sciences version 18 and merged into one large dataset. Results Scottish participants had the highest (positive) and Swedish participants the lowest mean MAQ score. The Kruskal-Wallis test showed significant differences in mean scores across the countries in 18 THE GLOBAL shortage of nurses, combined with the fact that the population in the West is ageing, mean that there is a need to recruit gerontological nurses and to attract students to work in health and social care settings for older people (British Geriatrics Society (BGS) 2011, American Association of Colleges of Nursing (AACN) 2014). This article presents the results of an international study that examined the attitudes of registered nurses (RNs) and nursing students towards caring for older people. A Multifactorial Attitudes Questionnaire (MAQ) was used to explore the attitudes of participants from Scotland, Sweden and the US (Kydd and Wild 2013, Kydd et al 2013). The countries were conveniently chosen by researchers who worked together and had an interest in the topic. Although the health and social care
of the 20 statements, even when controlling for age and experience. Most participants gave positive responses, but agreed that negative attitudes towards working with older people pervade among peers due to working conditions, poor career prospects and a perceived lack of professional esteem. Conclusion Inspirational educators, excellent clinical placements and increasing the professional esteem of those working with older people are required to promote the specialty as an attractive career option. Keywords Ageism, attitudes to older people, gerontological nursing, nurse attitudes, professional esteem, quantitative research systems in these countries are different, as are their methods of care and cultural and societal attitudes towards ageing, the researchers wanted to explore commonalities and differences in attitudes towards working with older people.
Background One in nine people in the world is aged 60 years or over and this figure is projected to increase to one in five by 2050 (United Nations Population Fund and HelpAge International 2012). The need for adequate numbers of healthcare professionals to care for the growing number of older people is of critical concern across the globe (European Economic and Social Committee 2013). However, this need is compromised by pervasive ageism and increased care costs (Silcock and Sinclair 2012), a lack of March 2014 | Volume 26 | Number 2 33
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Art & science | research interest in working in this field (BGS 2011, AACN 2014) and a shortage of specialist staff (Fahlström and Hellner 2010, Bardach and Rowles 2012). Nurses, including educators and students, have negative attitudes towards working with older people (Engström and Fagerberg 2011, Jöhnemark et al 2012) and these attitudes can adversely affect the quality of care they provide (Natan et al 2013). Studies have also reported that working with older people is viewed as a lowly profession, which does not make it an attractive career option (Cornwell 2012).
Aim The aim of this study was to explore the attitudes of nurses and nursing students in Scotland, Sweden and the US towards working with older people.
Method This quantitative study used the MAQ, designed by Kydd et al (1999), then revised (Kydd and Wild 2013) and used for a study with nurses, healthcare assistants and nursing students in Scotland (Kydd et al 2013). The MAQ includes a variety of factors that may influence attitudes towards older people and working in care of older people. It was deemed suitable for use in this three-country study because it covered five different themes derived from a global literature search on attitudes towards older people and to working in the field of ageing. The original themes were ageism, learning environment, working environment, professional esteem, and specialist status. The MAQ includes 20 statements. Demographic information was also sought, which included age and time spent working with older people. The authors acknowledge that this instrument was developed in Scotland, by researchers familiar with the Scottish, that is, UK, healthcare system, and that wording and implicit understanding of the statements might be different for participants in other countries where the social and cultural conditions differ. To address this issue, in Sweden the MAQ was translated to Swedish and then translated back to English (Råholm et al 2010) by a professional translator and the terminology used in Scotland was checked with the lead researcher in the US for mutual understanding. The convenience sample was recruited from a variety of acute hospitals, healthcare settings for older people, long-term care facilities and five universities in the west of Scotland, the Mälardalen region of Sweden and South Florida, US. Inclusion criteria were that participants were employed as nurses or nursing students. As the 34 March 2014 | Volume 26 | Number 2
countries have different types of nurses, it is important to note that for the purposes of this article, the term ‘nurse’ is used for someone working with the title RN. Nursing students were considered to be any participants studying to become an RN. Data collection occurred in all three countries between 2009 and 2010. University/faculty staff distributed the questionnaires in classes for undergraduate and master’s nursing students, and managers in hospitals and long-term care settings were recruited to distribute the questionnaires in their facilities. In Scotland, in addition to distribution in person, the MAQ was distributed by post and email. Researchers in each country collected the completed questionnaires and entered the data on the Statistical Package for Social Sciences version 18 (Pallant 2010). The data from each country were merged into one large dataset and a factor analysis performed to show the correlations between variables in this dataset (Pallant 2010). The themes derived from the factor analysis were ageism, resources, working environment, education, and professional esteem. These differed from the themes of the Scottish study (Kydd and Wild 2013), which came from the literature. The 20-statement MAQ required participants to respond to each statement on a five-point Likert-type scale. Seven of the 20 statements were scored as 1 = strongly disagree; 2 = disagree; 3 = unsure; 4 = agree; 5 = strongly agree. The remaining 13 statements were scored in reverse order, 1 = strongly agree to 5 = strongly disagree, meaning that a higher score for each statement indicated a more positive attitude versus a lower score indicating a more negative attitude. A total MAQ score ranging from 20 to 100 was obtained by adding all of the scores from the 20 statements. Since the data violated the assumption of homogeneity of variance, that is, that the variance in each of the populations was equal, and was an ordinal scale, the first set of hypotheses that investigated differences in the perceptions of healthcare professionals on ageing across the three countries used a Kruskal-Wallis one-way analysis of variance. A post-hoc test using Mann-Whitney U with Bonferroni correction was used to further examine the items that were statistically significant (Kruskal and Wallis 1952, Corder and Foreman 2009). Ordinal regression was further used to investigate differences between countries while controlling for age and time spent working with older people. To investigate reliability of the MAQ, Rasch analyses were conducted using WINSTEPS 3.75.1 software (Linacre 2013). Summary statistics NURSING OLDER PEOPLE
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Table 1 Age groups of nurses and nursing students in Scotland, US and Sweden Age group Country
Profession
Scotland
Nurse
25
(15)
28
(17)
67
(40)
35
(21)
6
Nursing student
86
(56)
39
(25)
19
(12)
3
(2)
0
Nurse
68
(15)
89
(20)
95
(21)
93
(21)
13
Nursing student
60
(65)
12
(13)
9
(10)
1
(1)
0
Nurse
36
(15)
42
(17)
55
(23)
60
(25)
26
350
(72)
84
(17)
37
(8)
3
(1)
0
US
Sweden
18-29 n (%)
Nursing student
30-39 n (%)
were calculated for the 20 MAQ items across the three countries with 1,587 respondents. Person separation raw scores reliability = 1.29. The Mean Outfit Zstd 1.0 for person and 0.01 for items are expected values that indicate the data fit the model. The Outfit Zstd 0.1 for person and 0.1 for items were also within the expected value of 1 (Smith and Suh 2003). Outliers (2% of participants) were removed during the analysis. The person to raw score measure had a correlation of 0.97 with a Cronbach’s alpha of 0.61 and a person reliability of 0.63. These results indicate a low but acceptable level of reliability. It should be noted that personal reliability increases to an average of 0.69 when considering the countries individually, suggesting that the differences between countries might exist not only on an item level but also have difference in the underlying constructs. Conformity construct validity was assessed using confirmatory factor analysis; an adequate model fit was obtained with confirmatory factor analysis 0.89, root mean square error of approximation 0.80. The Chi-square test was 2720.8 df 155, P3, 2>3
20.
Other health professionals do not seem to appreciate that care of the older person is a highly skilled specialty.
1.85 (0.87)
2.31 (0.91)
2.07 (0.94)
58.3
0.000
1>2, 1>3, 2>3
NB Bold statements are scored strongly disagree (1) to strongly agree (5). All other statements are scored strongly agree (1) to strongly disagree (5)
NURSING OLDER PEOPLE
March 2014 | Volume 26 | Number 2 37
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Art & science | research Table 4 Ordinal regression testing for differences on the Multifactorial Attitudes Questionnaire while controlling for age and working with older people Statement
Chi-square
Sig
R2 Cox Snell
1.
Older people should have access, if appropriate, to medical and surgical procedures regardless of their age.
17.21
0.002
2.
As older people become increasingly old they become more irritable, touchy and unpleasant.
70.65
