Literature review

‘Is elderly care affected by nurse attitudes?’ A systematic review Ruth M Hanson

T

riumphant advances in medicine combined with economic and social development are resulting in increased longevity in the world’s population. Six hundred million people worldwide are aged over 60 years, a figure that is predicted to double by 2025 (World Health Organization, 2013b). This increase necessitates a growth in healthcare provision for this group of the population (Stuart-Hamilton, 2006). Consequently, nurses are and will continue to be, primarily caring for older people, both in the hospital and community and will require expertise in gerontology and the ageing process (Pope, 2012). This systematic review examined original research relating to the attitudes of nurses and whether care needs are being met. Five research papers were chosen to review, portraying similar themes in relation to nurses’ attitudes and how these affect the care received by older people. It was not possible to attain exact matches to form a comparison, and therefore this paper provides a review predominantly based on thematic evidence.

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Literature review The literature review, although non-exhaustive, revealed numerous variables relating to older people. These individual characteristics appear to contribute towards moulding the nurse’s attitude towards the elderly. These attitudes subsequently affect the behaviour of nurses and the willingness to learn the skills required to care for older people, impacting on the quality of care provided (Holroyd et al, 2009). Caring for older people can also be complicated by a range of multiple morbidities. Bracewell et al (2009) comment that ageing can result in increased pathologies, including hypertension, dementia, immobility and vascular problems, often resulting in chronic illness. However, morbidities are not gender-specific and illnesses can vary according to a person’s culture or social class (Victor, 2010). Culture can significantly influence views and attitudes towards caring for older people. Obligation and reciprocity can be prevalent, with the expectancy that care will be provided without question (del-Pino-Casado et al, 2011). An understanding of cross-cultural norms is paramount to aid care provision for older people, especially in multicultural societies. Within western cultures, old age is considered a ‘problem’ and as such ageism becomes evident (Tanner and Harris, 2008). The awareness of ageism has become more widespread, and so legislation has been implemented to address the issue. The Department of Health (DH) (2001) has incorporated guidelines within the National Service Framework for Older People to ensure older people are not discriminated against

British Journal of Nursing, 2014, Vol 23, No 4

Abstract

Background: The world’s population of older people is increasing, The World Health Organization (WHO) (2013a) defines ‘elderly’ as those 65 years and older. Currently there are deficits in good basic care, partially resulting from the negative attitudes of some nursing staff. Method: This systematic review was conducted by searching the CINAHL and MEDLINE databases, which produced 119 results. Three original research papers were extracted, the fourth was obtained from a reference list and the final paper was taken from the internet. Results: Both student and qualified nurses can portray a negative attitude towards older people, thus negatively affecting care. The reasons for these negative attitudes are numerous, although lack of knowledge of the ageing process and gerontology prevail. Conclusion: Further research is required and in-depth interviews to establish why some nurses portray negative attitudes. Strategies need to be implemented to address these issues, so encouraging better care provision. Key words: Elderly ■ Attitudes ■ Student nurses ■ Knowledge deficit

because of their age. Bracewell et al (2009) emphasise that stereotypical signs and health symptoms are often attributed to ‘old age’, potentially leaving the older person vulnerable to illness. Stereotyping older people is common and they are often portrayed negatively. Ill-health is often thought of as a stereotype of ageing, with the accompanying physical and mental decline (Bond et al, 2007). If nurses hold these views, this could have a detrimental effect on the care they provide. Victor (2010) argues that when older people are perceived to be alike in their experiences of illness this leads to a universal response, removing the holistic individuality of care. Communicating with older people can be difficult, due to a variety of complications. Common challenges are hearing, ability and understanding (Redfern and Ross, 2006). These issues can create negativity when attempting to communicate with older people. Bond et al (2007) observe that a patronising approach can be adopted, depicting a loud voice and a childish way of speaking.

Ruth M Hanson is Staff Nurse, Complex Care, Medical Elderly, Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire Accepted for publication: February 2014

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Records identified through database searching (n=119)

Additional records identified through other resources (n=2)

01/01/2006–31/12/2013 and those aged 65 years and over were implemented. This methodology was also critiqued by peers.

Inclusion criteria ■■ All

journal articles were to be the original research journal articles were to portray the attitudes of student or qualified nurses ■■ All journal articles were published between 2006 and 2013. ■■ All

Records after duplications removed (n=121)

Exclusion criteria

Full-text articles assessed for eligibility (n=5)

Full-text articles excluded (n=0)

Studies included (n=5)

Figure 1. Flow diagram of review process.

Caring for older people requires nurses to adopt specialist knowledge. Burbank et al (2006) comment that as ageing occurs a person’s needs change and so nurses must have a good understanding of gerontological nursing. Aside from this, nurses need to be aware of the normal ageing process and differentiate it from illness (Hindle and Coates, 2011). Providing care for older people can take place in a variety of settings. Care provision in any environment can be a positive or negative experience for the caregiver (Nicholl et al, 2007). Older patients require assistance with multiple conditions, including mobility. Hayes and Ball (2012) argue there is a high level of physical dependency on nursing staff, which can be compounded by inadequate staffing levels. This literature review has explored factors that may potentially influence the attitudes of nurses. Generally, there appears to be a negative attitude, which is having an impact, as the care being delivered can be inadequate, making the older person feel invisible and a drain on the economy (Chambers and Ryder, 2009). This inadequacy of care is further emphasised by the low priority afforded to elderly care provision and time constraints placed on nurses (Bond et al, 2007). Consequently, this systematic review from 2006 to present aims to determine whether ‘Elderly care is affected by the attitudes of nurses’.

Methodology An extensive search of the CINAHL, MEDLINE and Internurse databases was conducted. As the research was conducted with specific guidelines, limitations were in place regarding the use of further databases. The terms ‘Geriatrics’, ‘Geriatric nursing’, ‘Frail elderly’, ‘Care of the elderly’, ‘Older people’ and ‘Nurse attitudes’ were used singly or in combination. Limiters of published date from:

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■■ One

paper referred to the development of a questionnaire to determine nurses’ attitudes (this was not suitable and although referred to the questionnaire being implemented, to date no evidence was found) ■■ Articles reviewing student or qualified nurses’ attitudes.

Outcome of the search A number of database search combinations were conducted. All the titles were read and three relevant articles were extracted that met the search criteria. The fourth original research article was obtained from the reference of a review article. The final original research article was obtained from an internet search when researching the ‘Kogan’s Scale’. A total of five original research articles were reviewed from 01/01/2006 to present (see Figure 1).

Appraisal of the quality Quality was ensured by using relevant and up-to-date original articles. The final five articles were chosen on their merit in relation to discussing the attitudes towards caring for older people by nurses. There were no specific quantitative or qualitative measures required.

The critique of data Data was critiqued using the Roe (1993) critiquing framework tool, to judge the quality following a structured and objective systematic evaluation of each research article.

Synthesis Synthesis of the findings was based on the overarching themes which emerged from data extraction. The themes included culture, ageism, staff working conditions, communication difficulties and morbidity issues to include lack of knowledge.

Findings The findings from the journal articles are summarised in Table 1. The journal articles were similar in content referring to the attitudes of nurses towards older people. They related to studies conducted globally. A number of articles focused on the attitudes of student nurses, others related to qualified nurses. Some of the studies incorporated how knowledgeable the participants were in the ageing process and gerontology. The studies used a variety of methods to obtain both quantitative and qualitative data, from questionnaires to interviews and longitudinal cohort studies.

Culture Celik et al (2010) portrayed culture as having a significant influence on older people, declaring that co-habiting with

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Records screened (n=121)

Full-text articles included (n=5)

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Literature review

Table 1. Key outcomes of research First author (year)

Number of participants

Setting population

Aim measurement method

Research design validity

Summary

Mellor (2006)

31

Rural Multi-purpose Health Service (MPHS), Northern Queensland, Australia.

Exploration of nurse’s attitudes working in MPHS and their understanding of gerontic care.

Descriptive, non-experimental quantitative research design using KOPS, PFAQ and NKEPQ. KOPS and PFAQ are validated, NKEPQ authors confirm validity.

Strong positive attitudes towards elderly / knowledge deficits in gerontic nursing and ageing need addressing.

Holroyd (2009)

197

Student nurses, Canadian university college.

Measurement of student nurse attitudes at different points in their nursing programme.

Comparative cross-sectional quantitative study adapting KOPS. KOPS is validated. Internal consistency is validated by Cronbach’s alpha.

Study found no difference +/- in attitude. Knowledge and attitude are interlinked / lack of knowledge negatively influences attitude.

Celik (2010)

42

Student nurses from a nursing school in Ankara, Turkey.

Determine the views and attitudes of nursing students towards ageing and older patients.

Qualitative semi-structured focus group interviews. Transcribed data was validated by moderator and investigator.

More than half had negative attitudes towards ageing, but behaved positively towards older patients. Communication problems.

Higgins (2007)

9

Nurses from acute medical and surgical ward in a teaching hospital in New South Wales, Australia.

Exploration of negative attitudes of nurses towards older people in acute care setting.

Descriptive qualitative subsample of single interviews from a larger study. No reference made to validating data from interviews.

Thematic and negative relating to marginalisation, oppression and stereotyping the older person. Negative attitudes due to being underresourced and ill-equipped.

Bleijenberg (2012)

113

Dutch bachelor of nursing students, Hogeschool Utrecht (HU), University of Applied Sciences.

Investigate students’ knowledge of and attitudes towards older people. Willingness to work with older people and how this changes after three years education.

Longitudinal cohort study with follow-up using quantitative PFAQ, ASDS and KOPS in the student’s 1st and 4th year. No reference to validity, although PFAQ and KOPS are validated.

Students need better preparation to work with older people. There are negative attitudes. Correlation between knowledge deficit and negative attitude.

Key: KOPS – Kogan’s Old People’s Scale; PFAQ – Palmore’s Facts of Ageing Quiz; NKEPQ – Nurses’ Knowledge of Elderly Patients Quiz; ASDS – Ageing Semantic Differential Scale

older adults was the norm, encouraging a positive attitude. Culture can also influence views on ageism, stereotypes or labelling individuals (Higgins et al, 2007).

Higgins et al (2007) revealed that older people may not be admitted to be cured and the nurse’s attitude may perceive care as being a waste of time.

Ageing/ageism

Communication issues

Celik et al (2010) said ageing encompasses traits, for example sickness, dependency and loneliness—predominantly negative characteristics. Higgins et al (2007) referred to ageism as promoting enablement for a younger person to mobilise, against an older person who was returning to a nursing home.

Mellor et al (2006) suggested the nurse could overestimate the ability of older people to communicate effectively, resulting in problems with care provision. Communicating with older people can expose visual, hearing and mental health problems (Celik et al, 2010). Patients with mental health issues can have problems understanding and providing consent (Celik et al, 2010).

Stereotypes

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Celik et al (2010) commented that nurses’ attitudes towards older people could be stereotypical, treating them as fragile and attending to all their needs, thus endangering their independence. This is evidenced by the way older people are disregarded, ignored or how their care is delayed or of a lower priority (Higgins et al, 2007).

Morbidities Mellor et al (2006) suggested there was a deficit in knowledge relating to gerontic nursing and aetiology of disease. Celik et al (2010) support these findings, commenting that difficulties arise with chronic diseases that older patients experience.

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Knowledge deficits Mellor et al (2006) indicated that nurses have a significant deficit in knowledge of gerontology. Bleijenberg et al (2012) commented that a positive attitude towards the elderly resulted in a positive attitude towards learning. Further research indicated that student nurses perceive knowledge to be fundamental when providing nursing care (Celik et al, 2010).

Staff, working conditions and workload Holroyd et al (2009) argue that staff aged 26-33 years expressed positive attitudes, but younger students portrayed

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n The

article aims to establish nurses’ attitudes towards older people.

n Overall n Are n Is

there is a negative attitude and as a result is care affected?

the elderly stereotyped in healthcare?

there a lack of knowledge in caring for older people?

n Is

there a lack of understanding of what gerontology can contribute to poor care provision?

n Is

the ageing process considered in care provision?

a negative attitude; while a positive attitude was conveyed by students who had previously cared for older people. Similarly, those with less exposure to caring for older people portrayed a negative attitude (Holroyd et al, 2009). The findings suggest that generally there is a negative attitude towards older people by predominantly student nurses, as the ratio of evidence was 3:2, students versus qualified nurses. Mellor et al (2006) indicate that care is compromised and an improvement in staff knowledge would be beneficial to older people. This is further evidenced by Holroyd et al (2009) and Celik et al (2010), who comment that a lack of knowledge negatively affects nurses’ attitudes, but not specifically confirming whether this affects the care that is given. Bleijenberg et al (2012) suggest that negative attitudes are an historical problem originating from ageism and stereotypes, suggesting that improvement will enhance patient care.

Discussion The research articles evidenced several variables which are attributable to the nurse’s attitude to older people, interestingly highlighting a strong correlation between a negative attitude and insufficient knowledge. Numerous studies have identified multiple factors that contribute towards nurses’ attitudes, none of which are dominant or accountable in isolation (Cozort, 2008). Conversely, a fundamental theme that emerged was inadequate knowledge of gerontology and the ageing process. Funderburk et al (2006) discovered that a curriculum high in gerontological content enhances knowledge and improves attitudes. Tutors and nursing staff need to facilitate an environment that is conducive to learning (Cozort, 2008), thereby providing a positive influence (Latimer and Thornlow, 2006). Kydd et al (2009) argue that patients require care from competent nurses experienced in gerontology. It was evident there was an emerging theme relating to how older people are portrayed in different cultures, some positive, others negative. Wang et al (2009) argue that some studies portray a positive cultural attitude towards older people. The concept of ageing and ageism was portrayed negatively and compassion in elderly care has been a recent focus. The Parliamentary and Health Service Ombudsman (2011), comments in its Care and Compassion? report that problems exist across the NHS in attitudes towards older people. This is further supported by Mullen (2012), who comments that

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ageism still prevails in care provision for the elderly. Preconceived ideas about older people were often expressed within the studies. Lovell (2006) comments that ageism is a form of stereotyping and that discrimination is often rooted in a negative attitude. Higgins et al (2007) comment that stereotypical views foster negative attitudes in nurses. Multiple morbidities are common with older people and nursing staff require a range of knowledge and expertise (Allan and Johnson, 2009). Interestingly, Liu et al (2012) argue that in comparison, doctors’ attitudes towards older people have become positive over time. Gonzales et al (2010) attribute this to a greater investment in the training and education of doctors in gerontology and the ageing process, compared to nurses. Communication difficulties ranged from patients being unable to hear instructions or communicate their health needs, to mental health impairments and forgetfulness. Fredman et al (2010) suggest that adjusting the pace and method of communication facilitates interaction by the patient and the nurse. Staff working conditions and workload reflect negatively on attitudes. The Royal College of Nursing (2012) argues in its report, Safe Staffing for Older People’s Wards, that increasing staff numbers alone will not improve care; nurses’ attitudes and skill levels also need addressing. Hayes and Ball (2012) agree and suggest that recruitment of staff with the right attitude and knowledge is imperative. This systematic review emphasised several limitations that prevented the results from being generalisable. Mellor et al (2006) suggested that the participants gave socially acceptable responses, therefore questioning a true reflection. Small sample sizes prevented generalisability (Holroyd et al, 2009). Different cultures portray different attitudes towards older people (Celik et al, 2010). The study conducted by Higgins et al (2007) requested negative data, eliminating positive responses. Data was also collected from nurses at varying points in their career (Bleijenberg et al, 2012). The research has evidenced certain issues that cause nurses to have a negative attitude towards older people, which may lead to poor care. This appears to be an automatic process and the more issues that are present, i.e. low staffing levels, lack of knowledge and poor communication, in any given circumstance, the more prevalent the poor care is the more prevalent the poor care is. As the elderly care workload increases, it is imperative that a collaborative caring environment is encouraged. Recently poor elderly care has been portrayed in The Mid Staffordshire NHS Foundation Trust Public Inquiry, which has emphasised the negative attitudes of nurses (Francis, 2013). The media has also reported inadequacies in care, further questioning nurse’s attitudes. Underpinning the NHS is the Care Quality Commission (2013) whose role is to ensure standards are being met, arguably there is a deficit in this area.

Conclusion It is evident, from the systematic review of the research, that predominantly student nursing staff portray a negative attitude towards older people rather than a positive one that negatively affects care. This is primarily due to a lack

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Key points

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Literature review of knowledge of the gerontological and ageing process of older people. In addition, there are a number of other variables contributing towards this negative attitude, including culture, working conditions and staff levels. Caring for older people can have a negative effect on nurses, due to the complex nature of multiple morbidities. The general historic view of ageism and stereotypical influences also contribute to a negative attitude. Further research is required using a broader spectrum of unbiased data, as this research was small in size and thus limited. In addition, an individual in-depth interview technique asking nurses if and why they have a negative attitudewww towards older people would be appropriate. Having conducted this systematic review, which established how prevalent nursing older people is both currently and for future years, a resolution to this problem is required, in order to prevent older people from being subjected to continued BJN poor care.  Conflict of interest: none Allan LJ, Johnson JA (2009) Undergraduate attitudes towards the elderly: the role of knowledge, contact and aging anxiety. Educ Gerontol 35(1) 1-14. http://tinyurl.com/njsbzre (accessed 17 February 2014) Bleijenberg N, Jansen MJM, Schuurmans MJ (2012) Dutch nursing students’ knowledge and attitudes towards older people – A longitudinal study. J Nurs Educ Prac 2(2): 1-8 Bond J, Peace S, Dittmann-Kohli F, Westerhof G (2007) Ageing in Society. Sage Publications, London Bracewell C, Gray R, Rai GS (2009) Essential Facts in Geriatric Medicine. Radcliffe Publishing, Oxford Burbank PM, Dowling-Castronovo A, Crowther MR, Capezuti EA (2006) Improving knowledge and attitudes toward older adults through innovative educational strategies. J Prof Nurs 22(2): 91-7 Care Quality Commission (2013) About Us. www.cqc.org.uk/about-us (accessed 17 February 2014) Celik SS, Kapucu S, Tuna S, Akkus Y (2010) Views and attitudes of nursing students towards ageing and older patients. Aust J Adv Nurs 27(4): 24-30 Chambers C, Ryder E (2009) Compassion and Caring in Nursing. Radcliffe Publishing, Abingdon Cozort R (2008) Student nurses’ attitudes regarding older adults: strategies for fostering improvement through academia. Teach Learn Nurs 3(1): 21-5 del-Pino-Casado R, Frias-Osuna A, Palomino-Moral PA (2011) Subjective burden and cultural motives for caregiving in informal caregivers of older people.J Nurs Scholarsh 43(3): 282-291 Department of Health (2001) National Service Framework for Older People. http://tinyurl.com/qg3cou9 (accessed 18 February 2014)

Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Enquiry Final Report. www.midstaffspublicinquiry.com/report. (accessed 17 February 2014) Fredman G, Anderson E, Stott J (2010) Being with Older People: A Systematic Approach. Karnac Books, London Funderburk B, Damron-Rodriguez J, Storms LL, Solomon DH (2006). Endurance of undergraduate attitudes toward older adults. Educ Gerontol 32: 447−62 Gonzales E, Morrow-Howell N, Gilbert P (2010) Changing medical students’ attitudes toward older adults. Gerontol Geriatr Educ 31(3): 220–34 Hayes H, Ball J (2012) Achieving safe staffing for older people in hospital. Nurs Older People 24(4): 20-4 Higgins I, Van der Riet P, Slater L, Peek C (2007) The negative attitudes of nurses towards older patients in the acute hospital setting: a qualitative descriptive study. Contemp Nurs 26(2): 225-37 Hindle A, Coates A (2011) Nursing Care of Older People: A Textbook for Students and Nurses. Oxford University Press, Oxford Holroyd A, Dahlke S, Fehr C (2009) Attitudes toward aging: implications for a caring profession. J Nurs Educ 48(7): 374-80 Kydd A, Duffy T, Raymond Duffy FJ (2009) The Care and Wellbeing of Older People. Reflect Press, Exeter Latimer DG, Thornlow DK (2006) Incorporating geriatrics into baccalaureate nursing curricula: laying the groundwork with faculty development. J Prof Nurs 22(2): 79-83 Lovell M (2006) Caring for the elderly: changing perceptions and attitudes. J Vasc Nurs 24(1): 22-6 Liu Y, While AE, Norman IJ,Ye W (2012) Health professionals’ attitudes toward older people and older patients: a systematic review. J Interprof Care 26(5): 397-409 Mellor P, Chew D, Greenhill J (2006) Nurses’ attitudes toward elderly people and knowledge of gerontic care in a multi-purpose health service (MPHS). Aust J Adv Nurs 24(3): 37-41 Mullen C (2012) Poor care of the elderly – is it inevitable? British Journal of Healthcare Assistants 6(2): 84-7 Nicholl C, Wilson KJ, Webster S (2007) Elderly Care Medicine. Blackwell Publishing, Oxford Parliamentary and Health Service Ombudsman (2011) Care and Compassion? Report of the Health Service Ombudsman on Ten Investigations into NHS Care of Older People. http://tinyurl.com/3rpp7no (accessed 17 February 2014) Pope T (2012) How person-centred care can improve nurses’ attitudes to hospitalised older patients. Nurs Older People 24(1): 32-6 Redfern SJ, Ross FM (2006) Nursing Older People. Churchill Livingstone, London Roe B (1993) Undertaking a critical review of the literature. Nur Res 1(1): 38-9 Royal College of Nursing (2012) Safe Staffing for Older People’s Wards. http://tinyurl.com/6n65wuc (accessed 17 February 2014) Stuart-Hamilton I (2006) The Psychology of Ageing. Jessica Kingsley Publishers, London Tanner D, Harris J (2008) Working with Older People. Routledge, Oxford Victor CR (2010) Ageing, Health and Care. The Policy Press, Bristol Wang C, Liao W, Kao M et al (2009) Taiwanese medical and nursing student interest levels in and attitudes towards geriatrics. Ann Acad Med Singapore 38(3): 230-6 World Health Organization (2013a) Definition of an Older or Elderly Person. http://tinyurl.com/q8l8ovm. (accessed 17 February 2014) World Health Organization (2013b) Older People and Primary Health Care (PHC). http://tinyurl.com/yaxc72w (accessed 17 February 2014)

Support and care for patients with long-term conditions Helen McVeigh

About the book

§ Each chapter presents learning points, using a reflective approach

Like other books in this series, Fundamental Aspects of Long-Term Conditions provides a succinct, useful basis from which both student nurses and adult nurses can extend their knowledge and skills.

§ Essential guide to long-term conditions, exploring the key principles of About the author

practice, skills and policy

Helen McVeigh is a Senior Lecturer in Primary Care at De Montfort University Leicester. She is a qualified District Nurse. She has over 20 years experience of working in Primary Care working in both rural and inner city practices.

Other titles in the Fundamental Aspects of Nursing series: Children & Young Peoples Nursing Procedures Community Nursing Complementary therapies Finding Information Mental Health Nursing

§ Case history examples included to illustrate issues discussed

Nursing Adults with Respiratory Disorders Nursing the Acutely Ill Adult Pain Assessment & Management Palliative Care Nursing 2nd edition Research for Nurses

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Editor: John Fowler ISBN-13: 978-1-85642-392-2; 234 x 156 mm; paperback; 280Seriespages; publication 2010; £24.99

Fundamental Aspects of

Fundamental Aspects of Long-Term Conditions

Providing support and care for individuals with a long-term condition is an essential feature of modern health care. Over 15 million people in England currently have a long-term condition, and it is predicted that these numbers will continue to rise. Treating the range of long-term conditions that affect the population will therefore play an important role for health professionals. This book is an essential guide to long-term conditions, exploring the key principles of practice, skills and policy. The chapters in this book can be read as stand-alone chapters, or the book can be read in sequence. Full references are provided.

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'Is elderly care affected by nurse attitudes?' A systematic review.

The world's population of older people is increasing,The World Health Organization (WHO) (2013 a) defines 'elderly'as those 65 years and older. Curren...
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