Nurse Education Today 35 (2015) 183–188
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Review
Undergraduate nurse attitudes toward older adults and perceptions of working with older adults: An analysis of measurement instruments Christine Neville ⁎ Ipswich Clinical School, School of Nursing and Midwifery, The University of Queensland, 11 Salisbury Road, Ipswich, QLD 4305, Australia
a r t i c l e
i n f o
Article history: Accepted 4 September 2014 Keywords: Attitudes Perspectives Perceptions Aged Nursing Students Scales Measurement
s u m m a r y Background: An undergraduate nurse's attitude toward older adults or their perception of working with older adults can influence the quality of care provided and their career choice, respectively. As such, it is important to conduct research that contributes to the evaluation of attitudes and perceptions. In the conduct of comprehensive and rigorous research, it is necessary to make the right choice of an instrument to measure outcomes. The identification of a valid and reliable instrument to suit a specific research question is a complex process. Objective: In order to deal with this complexity, this paper reviews instruments that have been used to measure undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. Data Sources: Data were sourced from Medline, CINAHL, Healthsource/Academic Edition, PsycINFO and PubMed for the years 2008–2013. Results: Eight readily available instruments were identified and their characteristics analyzed for their purpose, number of items, design, reliability and validity. The strengths and weaknesses of each of the instruments and recent use are also discussed. Conclusion: The choice of a suitable instrument is likely to be critical to the testing of intervention strategies such as curriculum activities, which target attitude improvements to enhance the quality and effectiveness of nursing care provided to older adults. © 2014 Elsevier Ltd. All rights reserved.
Introduction If an undergraduate nurse has a poor attitude toward older adults, this can seriously impact on the care provided and the ability to staff an aged care workforce (Flood and Clark, 2009). Such a concern will be magnified in the coming decades given the aging of the population. Globally, the proportion of people aged over 60 years will increase from 11% to 22% between 2000 and 2050 (World Health Organization, 2012). Aligned with this increase will be a greater demand for nursing care because older adults have more hospitalization days and use the largest portion of health services (Gilje et al., 2007; Institute of Medicine, 2008). It is necessary for those involved in nursing education to determine undergraduate attitudes toward older adults and their perceptions of working with older adults. A review of 32 studies of undergraduate nurses attitudes and perspectives toward older people and perceptions of working with older people found that these are positive in the majority, but through the detailed analysis of the limitations of the reviewed studies, it was determined that researchers should be more discriminant with their selection of measurement instruments (Neville and Dickie, 2014). Within Neville and Dickie's review were nine studies that used a variety ⁎ Tel.: +61 7 33811182; fax: +61 7 33811166. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.nedt.2014.09.001 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
of measurement instruments to evaluate the effectiveness of educational strategies such as course work and clinical practicum activities developed to improve attitudes and perceptions. Once again, it was found that the intervention positively changed student attitudes and perceptions in the majority of the studies. However, it was determined that a methodological weakness of these studies was the lack of a strong rationale for the chosen measurement instrument. Therefore, the aim of this review is to describe and analyze the properties of the instruments that are available to assess undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. Attitude is defined as “a settled opinion or way of thinking; behaviour reflecting this” and perception as “an interpretation or impression based on one's understanding of something” (The Oxford Dictionary, 1999). In the context of this paper, this means that the attitude of an undergraduate nurse can influence how they think about and behave towards an older adult. A fundamental part of nursing practice is the development of a relationship with the care recipient that is built on trust, strong communication, common goals and collaboration. All of this can be markedly influenced in either a positive or negative way by one's attitude. So it is vitally important to identify and evaluate the attitudes undergraduate nurses have toward older adults and understand their perceptions of work in the field of gerontological nursing so that they can be prepared for competent and professional nursing practice.
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For nursing to be credible as a profession, it must have a strong evidence base developed from research that is conceptually and methodologically sound. For quantitative studies, this involves the choice of an instrument/s to measure variables. Rigorous research uses psychometrically sound instruments that have been tested for reliability and validity. Currently, there are no reviews of the instruments available to measure undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. This review addresses this need and will be of great benefit to researchers in this area. Method The search strategy involved peer-reviewed, English language, research studies (2008–2013) to identify what instruments have been in recent use. Databases included Medline, CINAHL, Healthsource/ Academic Edition, PsycINFO and PubMed. The search syntax and limiters were as follows: (aged care OR nursing homes OR care homes OR elderly) AND (undergraduate nurse OR nursing student) AND (attitudes OR perspectives OR perceptions OR views OR thoughts OR values). Yielded and reviewed papers are detailed in Table 1. Inclusion criteria were quantitative studies. Qualitative studies and systematic reviews were excluded. A hand search of the reference lists of the 40 retrieved papers was conducted to determine if there were other relevant papers that fitted the inclusion criteria. Three studies were extracted using the reference list hand search with two found suitable as outlined in Table 1. The original papers describing the development of the instruments were sourced and included in this review. Instruments that measured related concepts, for example, perspectives and perceptions were included to demonstrate the necessity for conceptual clarity. Overall, eight instruments were analyzed for purpose, number of items, design, sample size (and if sample included undergraduate nurses), validity and reliability information. Validity reflects the extent to which an instrument measures what it is intended to measure and reliability is concerned with the amount of error inherent in the instrument (Polit and Beck, 2004). Results Since 2008, eight original instruments were identified from the 42 relevant publications. Of these, seven instruments have been used to measure undergraduate nurse attitudes toward older adults and one for perceptions of working with older adults. Characteristics of each of these are detailed in Table 2, and each instrument will be discussed in detail. Kogan's Attitudes Toward Old People scale The most commonly used scale to measure undergraduate nurses' attitude toward older people is the Kogan's Attitudes Toward Old People scale (KATOP) (Kogan, 1961). It was developed to assess attitudes toward older people with respect to both norms and individual differences. Initially, a set of items expressing negative sentiments about
older adults was constructed, and then a second set of items was then devised, the content of which was the reverse of the first set resulting in matched positive–negative paired statements. Some of the items were adapted from other scales that determined attitudes toward other minority groups (e.g., different ethnic backgrounds) by the simple substitution of the “old people” referent. Other statements were derived from Kogan and other intuitions regarding stereotypes and feelings about old people in North American society in the 1960s. Initial testing was undertaken with three samples of college undergraduates enrolled in introductory classes in psychology. Two male samples (n = 128 and 186) were obtained from Northeastern University and one sample (n = 168, 87 males and 81 females) was obtained from Boston University. The result was a 34-item scale (17 positive statements + 17 negative statements). It is a self-administered, summed Likert scale with six response categories for all of the items: “strongly disagree,” “disagree,” “slightly disagree,” “slightly agree,” “agree” and “strongly agree.” These categories are scored 1, 2, 3, 5, 6 and 7, respectively, with a score of 4 assigned in the rare case of failure to respond to an item. Scores on the negative statements are reversed scored with a possible total ranging between 34 and 204. Higher scores indicate a more positive attitude with 102 registering as a neutral attitude. The KATOP has been in consistent use since its development over 50 years ago. In recent times, although it has been criticized for not being reflective of current societal contexts such as changed views toward aging, advancing medical technologies and social and community environments (King et al., 2013; Rodgers and Gilmour, 2011; Runkawatt et al., 2013). Despite these criticisms, a number of translated versions of the KATOP have been developed and tested with undergraduate nurses in different cultural contexts. To date, these have been for Sweden (Soderhamn et al., 2000), China (Yen et al., 2009), Italy (Matarese et al., 2013), Greece (Lambrinou et al., 2005) and two from Turkey (Erdemir et al., 2011; Kucukguclu et al., 2011). Studies that have used the KATOP have been primarily of two kinds. Predominantly, it has been cross-sectional studies to assess undergraduate nurse attitudes toward older adults (Ayoglu et al., 2013; Bleijenberg et al., 2012; Erdemir et al., 2011; Kucukguclu et al., 2011; Lambrinou et al., 2009; Matarese et al., 2013; Runkawatt et al., 2013; Wang et al., 2009, 2010; Yen et al., 2009; Zverev, 2013). Second, the KATOP has been used to test the impact of curriculum activities on attitudes (Holroyd et al., 2009; King et al., 2013; Rodgers and Gilmour, 2011). In these studies, the KATOP was reported to have reliably detected attitude change.
Revised Kogan's Attitudes Toward Old People scale In 1999, Hilt and Lipschultz undertook a revision of Kogan's Attitudes Toward Old People scale (RKATOP) in response to criticism that the original scale was too long and that the statements were stereotypes, and by answering the survey, respondents would be verifying those stereotypes. Therefore, their purpose was to test a revised and shortened Kogan's Attitudes Toward Old People scale. This was done with three key occupational groups in television news—general managers, news directors and
Table 1 Strategy for literature search and process of rejection and acceptance of papers for inclusion in the literature review. Database
Total number of papers reviewed
Number following title and abstract review
Duplicates removed
Papers retrieved and examined
Papers that fit inclusion criteria
CINAHL Medline PubMED PsycINFO Healthsource/Academic Edition Hand Search Total
9 4 646 1 78 0 738
9 4 24 0 10 0 47
0 0 7 0 0 0 7
9 4 17 0 10 3 43
9 4 17 0 10 2 42
Table 2 Characteristics of measures of undergraduate nurse attitudes toward older adults and perceptions of working with older adults. Validity
Dimension
Spearman–Brown (+items 0.66 to −0.77, − items 0.73 to 0.83). Pearson (0.46 to 0.52) CA = 0.79
Not reported
Uni
FA
Uni
84*
CA = 0.82
CVI = 0.92
Uni
34
1637*
CA = 0.76
CVI = 0.81
Uni
6-point Likert
34
277*
CA = 0.80
Not reported
Uni
Assess attitudes
6-point Likert
34
177*
CVI = 0.94
Uno
Assess attitudes
6-point Likert
34
237*
FA
Uni
Assess attitudes
6-point Likert
22
87
CA = 0.84 Test–retest = 0.73 CA = 0.89 Test–retest = 0.83 CA = 0.79
Not reported
Uni
Assess attitudes
6-point Likert
22
194
CA = 0.88
Face
Uni
Assess attitudes
5-point Likert
20
290*
5-point Likert
20
20*
FA Content Not reported
Uni
Assess attitudes
Reported as reliable but no more details given Test–retest = 0.79
Assess attitudes
5-point Likert
20
162*
CA = 0.70
Content
Uni
Assess attitudes
Semantic Differential
32
287
Not reported
FA
Uni
Assess attitudes
Semantic Differential
32
286*
CA = 0.87
Not reported
Uni
Assess age stereotypes and attitudes
Semantic Differential
28
1400
FA
Multi
Assess stereotypes
Yes/no statements
137 40
147 124
Test–retest positiveness r = 0.57 Vitality r = 0.75 Goodness r = 0.72 Maturity r = 0.73 Test–retest = 0.36 to 0.62 Spearman–Brown = 0.82
Not reported Not reported
Uni Uni
Assess perceptions of working with older adults
5-point Likert
15
718*
CA = 0.73
Not reported
Uni
Scale/developer/country
Purpose
Design
1
Kogan's Attitudes Toward Old People scale (KATOP) Kogan (1961), USA
Assess attitudes
6-point Likert
34
482
1a
KATOP Soderhamn et al. (2000), Sweden KATOP Yen et al. (2009), China KATOP Matarese et al. (2013), Italy KATOP Lambrinou et al. (2005), Greece KATOP Erdemir et al. (2011), Turkey KATOP Kucukguclu et al. (2011), Turkey Revised Kogan's Attitudes Toward Old People scale (RKATOP) Hilt and Lipschultz (1999), USA RKATOP Chen and Walsh (2009), Taiwan Nursing Students' Attitudes Towards the Elderly Questionnaire (NSATE) Johnson, (1992), Australia NSATE (Chinese version) Xiao et al., (2013), Australia/China Attitudes Towards Hospitalized Older People (ATHOP) McLafferty, (2005), UK Aging Semantic Differential (ASD) Rosencranz and McNevin (1969), USA ASD Beullens and Martens (2000), The Netherlands Age Group Evaluation and Description Inventory (AGED Inventory) Knox et al., (1995), Canada
Assess attitudes
6-point Likert
34
319*
Assess attitudes
6-point Likert
34
Assess attitudes
6-point Likert
Assess attitudes
Attitudes Toward Old People questionnaire (ATOP) Tuckman and Lorge, (1953), USA Students' Perceptions of Working with Older People (SPWOP) Nolan et al., (2006), UK
1b 1c 1d 1e 1f 2 2a 3 3a 4 5 5a 6
7
8
No. of items
Sample size for psychometric testing (*included undergraduate nurses)
Uni
C. Neville / Nurse Education Today 35 (2015) 183–188
Reliability
No.
CA, Cronbach's alpha; CVI, Content Validity Index, computed by using the proportion of experts who are in agreement about item relevance (Polit and Beck, 2004); FA, factor analysis.
185
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producers to determine how their attitudes affected news coverage of older adults given the media's influence on societal attitudes toward older adults. In the revised version, the number of statements was reduced to 22. Seventeen statement scores were reversed. The Likert format was retained with scores ranging from 22 to 154. Lower scores indicate more positive attitudes (Hilt and Lipschultz, 1999). The RKATOP was used by Walsh et al. (2008) to test the impact of a creative-bonding intervention and a friendly visit with older adults in a group of undergraduate nurses (n = 28). The RKATOP was translated into Mandarin Chinese for a similar study (n = 194) conducted in Taiwan (Chen and Walsh, 2009). Nursing Students' Attitudes Towards the Elderly questionnaire In 1992, Johnson reported on the development of a questionnaire to measure undergraduate nurse attitudes towards older adults. The Nursing Students' Attitudes Towards the Elderly questionnaire (NSATE) has 20 items with a five-point Likert scale. Ten items are positive statements and ten items are negative statements, in random order. “Strongly agree” responses are scored one, and “strongly disagree” responses are scored five, with three being undecided. The NSATE was developed from Johnson's personal experience, a literature review and discussions with persons concerned with aged care. Content validity was established by two gerontic nurse specialists who indicated the NSATE was consistent with the conceptual definition of attitudes. Confirmatory factor analysis established that the positive and negative statements were discrete constructs. Content validity was further supported through pilot work with 16 undergraduate nurses (Johnson, 1992). The NSATE has been translated into Chinese (Xiao et al., 2013). Attitudes Towards Hospitalized Older People questionnaire The rationale for designing the Attitudes Towards Hospitalized Older People questionnaire (ATHOP: McLafferty, 2005) was based on the notion that nurses view older adults differently due to the context in which they meet the majority of older adults such as a hospital whereas other commonly used questionnaires such as Tuckman and Lorge (1953) and Kogan (1961) are generic and better used to measure broader societal attitudes (McLafferty, 2005). The items for the ATHOP were developed from six focus group interviews exploring nurses' attitudes toward older adults who were hospitalized. It is a 20-item, five-point Likert scale (strongly agree to strongly disagree), and higher scores indicate more positive attitudes. Other than McLafferty (2005), Goncalves et al. (2011) used the ATHOP to measure the attitudes of Portuguese undergraduate nursing students (n = 141). Aging Semantic Differential The Aging Semantic Differential (ASD) was developed by Rosencranz and McNevin (1969) to measure stereotypic attitudes toward populations of all ages including older adults. It consists of 32 pairs of polar adjectives and was categorized into three dimensions through factor analysis: (1) Instrumental–Ineffective (9 pairs) is related to a person's selfdetermination and ability to adapt to changes in life, for example, progressive/old-fashioned; (2) Autonomous–Dependent (9 pairs) measures attitudes about a person's social development and independence, for example, organized/disorganized; and (3) Personal Acceptability– Unacceptability (14 pairs) relates to social acceptability and interaction, for example, hopeful/dejected. Respondents are asked to indicate on a 7-point Likert scale in which social object in their judgment best describes the age-group in question. Scores can range from 32 to 224 with lower scores indicating more positive attitudes with 128 considered a neutral attitude. The instrument was tested with 287 undergraduate students at the University of Missouri in the United States of America. Beullens and Martens (2000) created a Dutch Version of the ASD. The ASD has been used in two cross-sectional studies to measure
undergraduate nurse attitudes toward older adults: Bernardini Zambrini et al. (2008) (n = 57) and Bleijenberg et al. (2012), who used the Dutch version (n = 113). Knox et al. (1995) commend the ASD for its brevity, multidimensionality, response range from positive to negative and flexibility with respect to target age-group specification. However, they also criticized it for a lack of conceptual clarity as Rosencranz and McNevin (1969), in their description of the ASD's development, interchangeably use the terms “attitude” and “stereotype” and do not define either term which arguably are different. Furthermore, through a number of tests, Knox et al. (1995) were unable to replicate the factor structure reported by Rosencranz and McNevin (1969) and have concerns about the ASD on psychometric grounds. Age Group Evaluation and Description Inventory The Age Group Evaluation and Description Inventory (AGED Inventory) was designed to overcome the shortcomings of the ASD identified in the previous paragraph by Knox et al. (1995). Its purpose is to assess both age stereotypes and attitudes towards age-specified targets. This 28-item semantic differential scale has seven points and two subscales. The evaluative subscale (includes the dimensions of goodness and positiveness) and the descriptive subscale (includes the dimensions of vitality and maturity) have 14 items each and are anchored by bipolar adjectives such as satisfied/unsatisfied. Before rating each bipolar adjective pair, respondents are asked to think about a person in a specific age-group; for example, if the focus of the study is older adults, the instruction would be “with a typical 65 year old person in mind.” The total score for each subscale is the mean of item responses and, therefore, ranges from 1 to 7 with higher scores indicating more positive attitudes. Only one study was found to have used this scale to assess undergraduate nurse attitudes toward older adults (Koren et al., 2008). Within this crosssectional study (n = 200), Cronbach's alpha for the evaluative subscale was 0.85, but the descriptive subscale only achieved 0.63 indicating some weakness in this subscale. Attitudes Toward Old People questionnaire The Attitudes Toward Old People questionnaire (ATOP) was developed by Tuckman and Lorge (1952, 1953). It examines the incidence of “yes” and “no” responses to a set of 137 statements reflecting stereotypes and misconceptions about older adults. These were obtained through unstructured interviews with 15 adults aged 21 to 65 years, by discussion with social workers and directors of aged care facilities, case records and a review of the literature. The statements are classified into 13 categories: Conservatism, Activities and Interests, Financial, Physical, Family, Personality Traits, Attitude Toward the Future, Best Time of Life, Insecurity, Mental Deterioration, Sex, Interference and Cleanliness. The instrument was tested with 147 graduate students (92 men, 55 women; mean age, 31 years). Lower scores reflect a more positive attitude. A shorter 40-item questionnaire is also available (Tuckman and Lorge, 1952). Swanlund and Kujath (2012) used this questionnaire to examine attitudes of undergraduate nurses (n = 50). This scale was criticized by Kogan (1961) because they did not “make use of attitude scaling procedures and paid little attention to psychological correlates of attitudes toward old people” (p. 44). Knox et al. (1995) rejected the ATOP because it only contains predominantly negatively worded items to which the respondent indicates their degree of agreement and it does not readily capture positive attitudes toward older adults. Students' Perceptions of Working with Older People questionnaire The Students' Perceptions of Working with Older People (SPWOP) questionnaire (Nolan et al., 2006) assesses students' perceptions of working with older adults in general, students' personal disposition
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towards or intention to work with older adults and students' perceptions of the consequences of working with older adults. The higher the total SPWOP score, the more positive the perception of working with older adults. The SPWOP consists of 15 statements with responses on a 5-point Likert scale. A score of 45 in the total SPWOP indicates a neutral attitude, with possible scores ranging from 15 to 75. Nolan et al. (2006) did not report any specific psychometric data, but in a study that examined undergraduate nurse perceptions of working with older adults, a Cronbach's alpha coefficient for the SPWOP was reported as 0.73 (Pan et al., 2009).
Discussion The review has examined the psychometric characteristics of eight instruments designed to measure the attitudes of undergraduate nurses with regard to older adults and their perceptions of working with older adults. In the conduct of rigorous research, it is very important to define the concept of interest and ensure that the purpose of the outcome measure is closely aligned. This review has identified that related concepts have sometimes been used interchangeably. The term “attitude” has been interchanged with “stereotype” in the theoretical development of the Aging Semantic Differential (Rosencranz and McNevin, 1969). Furthermore, Pan et al. (2009) undertook a study with the Students' Perceptions of Working with Older People (SPWOP) questionnaire (Nolan et al., 2006) but used the term “attitude” to report their study results. In these examples, these terms are clearly different and need to be used correctly and consistently. Of the eight instruments, internal consistency using Cronbach's coefficient was documented for all the instruments either by the developers or other researchers. Test–retest was less common with no inter-rater reliability assessed for any of the instruments. Internal construct validity of three instruments was assessed using factor analysis but for some instruments validity information was not reported. If psychometric property information is incomplete, it may restrict the usefulness of the instrument. The instruments reported here have been used by at least one other independent researcher/s, which imbues more confidence in the utility of the instrument. However, more independent testing will greatly improve the evidence base for the use of these instruments. A limitation of work in this field is the lack of older adult input into scale development. Kogan's Attitudes Toward Old People scale (Kogan, 1961) continues to be the most commonly used instrument despite some serious comments about its current relevancy. The other instruments are well worth consideration for use in this field of research as they bring different conceptual development aspects.
Conclusions This review provides comprehensive information about eight quantitative instruments currently available for research evaluating undergraduate nurse attitudes toward older adults and perceptions of working with older adults. A number of implications can be drawn from this review. First, it is important to have conceptual clarity in regard to what outcome is to be measured. Second, aside from Kogan's Attitudes Toward Old People scale (Kogan, 1961), more effort could be contributed to develop a stronger evidence base to support increased use of these instruments. The availability of a broad range of instruments for assessing attitudes and perceptions is required to advance the field, especially given the rapid growth of the aging population and the implications this will have for the nursing discipline. As this field of study continues to grow, researchers need to choose instruments that are conceptually and psychometrically sound so that good quality research is carried out to develop education and practice innovations in the care of older adults.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Undergraduate nurse attitudes toward older adults and perceptions of working with older adults: An analysis of measurement instruments Christine Neville ⁎ Ipswich Clinical School, School of Nursing and Midwifery, The University of Queensland, 11 Salisbury Road, Ipswich, QLD 4305, Australia
a r t i c l e
i n f o
Article history: Accepted 4 September 2014 Keywords: Attitudes Perspectives Perceptions Aged Nursing Students Scales Measurement
s u m m a r y Background: An undergraduate nurse's attitude toward older adults or their perception of working with older adults can influence the quality of care provided and their career choice, respectively. As such, it is important to conduct research that contributes to the evaluation of attitudes and perceptions. In the conduct of comprehensive and rigorous research, it is necessary to make the right choice of an instrument to measure outcomes. The identification of a valid and reliable instrument to suit a specific research question is a complex process. Objective: In order to deal with this complexity, this paper reviews instruments that have been used to measure undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. Data Sources: Data were sourced from Medline, CINAHL, Healthsource/Academic Edition, PsycINFO and PubMed for the years 2008–2013. Results: Eight readily available instruments were identified and their characteristics analyzed for their purpose, number of items, design, reliability and validity. The strengths and weaknesses of each of the instruments and recent use are also discussed. Conclusion: The choice of a suitable instrument is likely to be critical to the testing of intervention strategies such as curriculum activities, which target attitude improvements to enhance the quality and effectiveness of nursing care provided to older adults. © 2014 Elsevier Ltd. All rights reserved.
Introduction If an undergraduate nurse has a poor attitude toward older adults, this can seriously impact on the care provided and the ability to staff an aged care workforce (Flood and Clark, 2009). Such a concern will be magnified in the coming decades given the aging of the population. Globally, the proportion of people aged over 60 years will increase from 11% to 22% between 2000 and 2050 (World Health Organization, 2012). Aligned with this increase will be a greater demand for nursing care because older adults have more hospitalization days and use the largest portion of health services (Gilje et al., 2007; Institute of Medicine, 2008). It is necessary for those involved in nursing education to determine undergraduate attitudes toward older adults and their perceptions of working with older adults. A review of 32 studies of undergraduate nurses attitudes and perspectives toward older people and perceptions of working with older people found that these are positive in the majority, but through the detailed analysis of the limitations of the reviewed studies, it was determined that researchers should be more discriminant with their selection of measurement instruments (Neville and Dickie, 2014). Within Neville and Dickie's review were nine studies that used a variety ⁎ Tel.: +61 7 33811182; fax: +61 7 33811166. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.nedt.2014.09.001 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
of measurement instruments to evaluate the effectiveness of educational strategies such as course work and clinical practicum activities developed to improve attitudes and perceptions. Once again, it was found that the intervention positively changed student attitudes and perceptions in the majority of the studies. However, it was determined that a methodological weakness of these studies was the lack of a strong rationale for the chosen measurement instrument. Therefore, the aim of this review is to describe and analyze the properties of the instruments that are available to assess undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. Attitude is defined as “a settled opinion or way of thinking; behaviour reflecting this” and perception as “an interpretation or impression based on one's understanding of something” (The Oxford Dictionary, 1999). In the context of this paper, this means that the attitude of an undergraduate nurse can influence how they think about and behave towards an older adult. A fundamental part of nursing practice is the development of a relationship with the care recipient that is built on trust, strong communication, common goals and collaboration. All of this can be markedly influenced in either a positive or negative way by one's attitude. So it is vitally important to identify and evaluate the attitudes undergraduate nurses have toward older adults and understand their perceptions of work in the field of gerontological nursing so that they can be prepared for competent and professional nursing practice.
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For nursing to be credible as a profession, it must have a strong evidence base developed from research that is conceptually and methodologically sound. For quantitative studies, this involves the choice of an instrument/s to measure variables. Rigorous research uses psychometrically sound instruments that have been tested for reliability and validity. Currently, there are no reviews of the instruments available to measure undergraduate nurse attitudes toward older adults and their perceptions of working with older adults. This review addresses this need and will be of great benefit to researchers in this area. Method The search strategy involved peer-reviewed, English language, research studies (2008–2013) to identify what instruments have been in recent use. Databases included Medline, CINAHL, Healthsource/ Academic Edition, PsycINFO and PubMed. The search syntax and limiters were as follows: (aged care OR nursing homes OR care homes OR elderly) AND (undergraduate nurse OR nursing student) AND (attitudes OR perspectives OR perceptions OR views OR thoughts OR values). Yielded and reviewed papers are detailed in Table 1. Inclusion criteria were quantitative studies. Qualitative studies and systematic reviews were excluded. A hand search of the reference lists of the 40 retrieved papers was conducted to determine if there were other relevant papers that fitted the inclusion criteria. Three studies were extracted using the reference list hand search with two found suitable as outlined in Table 1. The original papers describing the development of the instruments were sourced and included in this review. Instruments that measured related concepts, for example, perspectives and perceptions were included to demonstrate the necessity for conceptual clarity. Overall, eight instruments were analyzed for purpose, number of items, design, sample size (and if sample included undergraduate nurses), validity and reliability information. Validity reflects the extent to which an instrument measures what it is intended to measure and reliability is concerned with the amount of error inherent in the instrument (Polit and Beck, 2004). Results Since 2008, eight original instruments were identified from the 42 relevant publications. Of these, seven instruments have been used to measure undergraduate nurse attitudes toward older adults and one for perceptions of working with older adults. Characteristics of each of these are detailed in Table 2, and each instrument will be discussed in detail. Kogan's Attitudes Toward Old People scale The most commonly used scale to measure undergraduate nurses' attitude toward older people is the Kogan's Attitudes Toward Old People scale (KATOP) (Kogan, 1961). It was developed to assess attitudes toward older people with respect to both norms and individual differences. Initially, a set of items expressing negative sentiments about
older adults was constructed, and then a second set of items was then devised, the content of which was the reverse of the first set resulting in matched positive–negative paired statements. Some of the items were adapted from other scales that determined attitudes toward other minority groups (e.g., different ethnic backgrounds) by the simple substitution of the “old people” referent. Other statements were derived from Kogan and other intuitions regarding stereotypes and feelings about old people in North American society in the 1960s. Initial testing was undertaken with three samples of college undergraduates enrolled in introductory classes in psychology. Two male samples (n = 128 and 186) were obtained from Northeastern University and one sample (n = 168, 87 males and 81 females) was obtained from Boston University. The result was a 34-item scale (17 positive statements + 17 negative statements). It is a self-administered, summed Likert scale with six response categories for all of the items: “strongly disagree,” “disagree,” “slightly disagree,” “slightly agree,” “agree” and “strongly agree.” These categories are scored 1, 2, 3, 5, 6 and 7, respectively, with a score of 4 assigned in the rare case of failure to respond to an item. Scores on the negative statements are reversed scored with a possible total ranging between 34 and 204. Higher scores indicate a more positive attitude with 102 registering as a neutral attitude. The KATOP has been in consistent use since its development over 50 years ago. In recent times, although it has been criticized for not being reflective of current societal contexts such as changed views toward aging, advancing medical technologies and social and community environments (King et al., 2013; Rodgers and Gilmour, 2011; Runkawatt et al., 2013). Despite these criticisms, a number of translated versions of the KATOP have been developed and tested with undergraduate nurses in different cultural contexts. To date, these have been for Sweden (Soderhamn et al., 2000), China (Yen et al., 2009), Italy (Matarese et al., 2013), Greece (Lambrinou et al., 2005) and two from Turkey (Erdemir et al., 2011; Kucukguclu et al., 2011). Studies that have used the KATOP have been primarily of two kinds. Predominantly, it has been cross-sectional studies to assess undergraduate nurse attitudes toward older adults (Ayoglu et al., 2013; Bleijenberg et al., 2012; Erdemir et al., 2011; Kucukguclu et al., 2011; Lambrinou et al., 2009; Matarese et al., 2013; Runkawatt et al., 2013; Wang et al., 2009, 2010; Yen et al., 2009; Zverev, 2013). Second, the KATOP has been used to test the impact of curriculum activities on attitudes (Holroyd et al., 2009; King et al., 2013; Rodgers and Gilmour, 2011). In these studies, the KATOP was reported to have reliably detected attitude change.
Revised Kogan's Attitudes Toward Old People scale In 1999, Hilt and Lipschultz undertook a revision of Kogan's Attitudes Toward Old People scale (RKATOP) in response to criticism that the original scale was too long and that the statements were stereotypes, and by answering the survey, respondents would be verifying those stereotypes. Therefore, their purpose was to test a revised and shortened Kogan's Attitudes Toward Old People scale. This was done with three key occupational groups in television news—general managers, news directors and
Table 1 Strategy for literature search and process of rejection and acceptance of papers for inclusion in the literature review. Database
Total number of papers reviewed
Number following title and abstract review
Duplicates removed
Papers retrieved and examined
Papers that fit inclusion criteria
CINAHL Medline PubMED PsycINFO Healthsource/Academic Edition Hand Search Total
9 4 646 1 78 0 738
9 4 24 0 10 0 47
0 0 7 0 0 0 7
9 4 17 0 10 3 43
9 4 17 0 10 2 42
Table 2 Characteristics of measures of undergraduate nurse attitudes toward older adults and perceptions of working with older adults. Validity
Dimension
Spearman–Brown (+items 0.66 to −0.77, − items 0.73 to 0.83). Pearson (0.46 to 0.52) CA = 0.79
Not reported
Uni
FA
Uni
84*
CA = 0.82
CVI = 0.92
Uni
34
1637*
CA = 0.76
CVI = 0.81
Uni
6-point Likert
34
277*
CA = 0.80
Not reported
Uni
Assess attitudes
6-point Likert
34
177*
CVI = 0.94
Uno
Assess attitudes
6-point Likert
34
237*
FA
Uni
Assess attitudes
6-point Likert
22
87
CA = 0.84 Test–retest = 0.73 CA = 0.89 Test–retest = 0.83 CA = 0.79
Not reported
Uni
Assess attitudes
6-point Likert
22
194
CA = 0.88
Face
Uni
Assess attitudes
5-point Likert
20
290*
5-point Likert
20
20*
FA Content Not reported
Uni
Assess attitudes
Reported as reliable but no more details given Test–retest = 0.79
Assess attitudes
5-point Likert
20
162*
CA = 0.70
Content
Uni
Assess attitudes
Semantic Differential
32
287
Not reported
FA
Uni
Assess attitudes
Semantic Differential
32
286*
CA = 0.87
Not reported
Uni
Assess age stereotypes and attitudes
Semantic Differential
28
1400
FA
Multi
Assess stereotypes
Yes/no statements
137 40
147 124
Test–retest positiveness r = 0.57 Vitality r = 0.75 Goodness r = 0.72 Maturity r = 0.73 Test–retest = 0.36 to 0.62 Spearman–Brown = 0.82
Not reported Not reported
Uni Uni
Assess perceptions of working with older adults
5-point Likert
15
718*
CA = 0.73
Not reported
Uni
Scale/developer/country
Purpose
Design
1
Kogan's Attitudes Toward Old People scale (KATOP) Kogan (1961), USA
Assess attitudes
6-point Likert
34
482
1a
KATOP Soderhamn et al. (2000), Sweden KATOP Yen et al. (2009), China KATOP Matarese et al. (2013), Italy KATOP Lambrinou et al. (2005), Greece KATOP Erdemir et al. (2011), Turkey KATOP Kucukguclu et al. (2011), Turkey Revised Kogan's Attitudes Toward Old People scale (RKATOP) Hilt and Lipschultz (1999), USA RKATOP Chen and Walsh (2009), Taiwan Nursing Students' Attitudes Towards the Elderly Questionnaire (NSATE) Johnson, (1992), Australia NSATE (Chinese version) Xiao et al., (2013), Australia/China Attitudes Towards Hospitalized Older People (ATHOP) McLafferty, (2005), UK Aging Semantic Differential (ASD) Rosencranz and McNevin (1969), USA ASD Beullens and Martens (2000), The Netherlands Age Group Evaluation and Description Inventory (AGED Inventory) Knox et al., (1995), Canada
Assess attitudes
6-point Likert
34
319*
Assess attitudes
6-point Likert
34
Assess attitudes
6-point Likert
Assess attitudes
Attitudes Toward Old People questionnaire (ATOP) Tuckman and Lorge, (1953), USA Students' Perceptions of Working with Older People (SPWOP) Nolan et al., (2006), UK
1b 1c 1d 1e 1f 2 2a 3 3a 4 5 5a 6
7
8
No. of items
Sample size for psychometric testing (*included undergraduate nurses)
Uni
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Reliability
No.
CA, Cronbach's alpha; CVI, Content Validity Index, computed by using the proportion of experts who are in agreement about item relevance (Polit and Beck, 2004); FA, factor analysis.
185
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producers to determine how their attitudes affected news coverage of older adults given the media's influence on societal attitudes toward older adults. In the revised version, the number of statements was reduced to 22. Seventeen statement scores were reversed. The Likert format was retained with scores ranging from 22 to 154. Lower scores indicate more positive attitudes (Hilt and Lipschultz, 1999). The RKATOP was used by Walsh et al. (2008) to test the impact of a creative-bonding intervention and a friendly visit with older adults in a group of undergraduate nurses (n = 28). The RKATOP was translated into Mandarin Chinese for a similar study (n = 194) conducted in Taiwan (Chen and Walsh, 2009). Nursing Students' Attitudes Towards the Elderly questionnaire In 1992, Johnson reported on the development of a questionnaire to measure undergraduate nurse attitudes towards older adults. The Nursing Students' Attitudes Towards the Elderly questionnaire (NSATE) has 20 items with a five-point Likert scale. Ten items are positive statements and ten items are negative statements, in random order. “Strongly agree” responses are scored one, and “strongly disagree” responses are scored five, with three being undecided. The NSATE was developed from Johnson's personal experience, a literature review and discussions with persons concerned with aged care. Content validity was established by two gerontic nurse specialists who indicated the NSATE was consistent with the conceptual definition of attitudes. Confirmatory factor analysis established that the positive and negative statements were discrete constructs. Content validity was further supported through pilot work with 16 undergraduate nurses (Johnson, 1992). The NSATE has been translated into Chinese (Xiao et al., 2013). Attitudes Towards Hospitalized Older People questionnaire The rationale for designing the Attitudes Towards Hospitalized Older People questionnaire (ATHOP: McLafferty, 2005) was based on the notion that nurses view older adults differently due to the context in which they meet the majority of older adults such as a hospital whereas other commonly used questionnaires such as Tuckman and Lorge (1953) and Kogan (1961) are generic and better used to measure broader societal attitudes (McLafferty, 2005). The items for the ATHOP were developed from six focus group interviews exploring nurses' attitudes toward older adults who were hospitalized. It is a 20-item, five-point Likert scale (strongly agree to strongly disagree), and higher scores indicate more positive attitudes. Other than McLafferty (2005), Goncalves et al. (2011) used the ATHOP to measure the attitudes of Portuguese undergraduate nursing students (n = 141). Aging Semantic Differential The Aging Semantic Differential (ASD) was developed by Rosencranz and McNevin (1969) to measure stereotypic attitudes toward populations of all ages including older adults. It consists of 32 pairs of polar adjectives and was categorized into three dimensions through factor analysis: (1) Instrumental–Ineffective (9 pairs) is related to a person's selfdetermination and ability to adapt to changes in life, for example, progressive/old-fashioned; (2) Autonomous–Dependent (9 pairs) measures attitudes about a person's social development and independence, for example, organized/disorganized; and (3) Personal Acceptability– Unacceptability (14 pairs) relates to social acceptability and interaction, for example, hopeful/dejected. Respondents are asked to indicate on a 7-point Likert scale in which social object in their judgment best describes the age-group in question. Scores can range from 32 to 224 with lower scores indicating more positive attitudes with 128 considered a neutral attitude. The instrument was tested with 287 undergraduate students at the University of Missouri in the United States of America. Beullens and Martens (2000) created a Dutch Version of the ASD. The ASD has been used in two cross-sectional studies to measure
undergraduate nurse attitudes toward older adults: Bernardini Zambrini et al. (2008) (n = 57) and Bleijenberg et al. (2012), who used the Dutch version (n = 113). Knox et al. (1995) commend the ASD for its brevity, multidimensionality, response range from positive to negative and flexibility with respect to target age-group specification. However, they also criticized it for a lack of conceptual clarity as Rosencranz and McNevin (1969), in their description of the ASD's development, interchangeably use the terms “attitude” and “stereotype” and do not define either term which arguably are different. Furthermore, through a number of tests, Knox et al. (1995) were unable to replicate the factor structure reported by Rosencranz and McNevin (1969) and have concerns about the ASD on psychometric grounds. Age Group Evaluation and Description Inventory The Age Group Evaluation and Description Inventory (AGED Inventory) was designed to overcome the shortcomings of the ASD identified in the previous paragraph by Knox et al. (1995). Its purpose is to assess both age stereotypes and attitudes towards age-specified targets. This 28-item semantic differential scale has seven points and two subscales. The evaluative subscale (includes the dimensions of goodness and positiveness) and the descriptive subscale (includes the dimensions of vitality and maturity) have 14 items each and are anchored by bipolar adjectives such as satisfied/unsatisfied. Before rating each bipolar adjective pair, respondents are asked to think about a person in a specific age-group; for example, if the focus of the study is older adults, the instruction would be “with a typical 65 year old person in mind.” The total score for each subscale is the mean of item responses and, therefore, ranges from 1 to 7 with higher scores indicating more positive attitudes. Only one study was found to have used this scale to assess undergraduate nurse attitudes toward older adults (Koren et al., 2008). Within this crosssectional study (n = 200), Cronbach's alpha for the evaluative subscale was 0.85, but the descriptive subscale only achieved 0.63 indicating some weakness in this subscale. Attitudes Toward Old People questionnaire The Attitudes Toward Old People questionnaire (ATOP) was developed by Tuckman and Lorge (1952, 1953). It examines the incidence of “yes” and “no” responses to a set of 137 statements reflecting stereotypes and misconceptions about older adults. These were obtained through unstructured interviews with 15 adults aged 21 to 65 years, by discussion with social workers and directors of aged care facilities, case records and a review of the literature. The statements are classified into 13 categories: Conservatism, Activities and Interests, Financial, Physical, Family, Personality Traits, Attitude Toward the Future, Best Time of Life, Insecurity, Mental Deterioration, Sex, Interference and Cleanliness. The instrument was tested with 147 graduate students (92 men, 55 women; mean age, 31 years). Lower scores reflect a more positive attitude. A shorter 40-item questionnaire is also available (Tuckman and Lorge, 1952). Swanlund and Kujath (2012) used this questionnaire to examine attitudes of undergraduate nurses (n = 50). This scale was criticized by Kogan (1961) because they did not “make use of attitude scaling procedures and paid little attention to psychological correlates of attitudes toward old people” (p. 44). Knox et al. (1995) rejected the ATOP because it only contains predominantly negatively worded items to which the respondent indicates their degree of agreement and it does not readily capture positive attitudes toward older adults. Students' Perceptions of Working with Older People questionnaire The Students' Perceptions of Working with Older People (SPWOP) questionnaire (Nolan et al., 2006) assesses students' perceptions of working with older adults in general, students' personal disposition
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towards or intention to work with older adults and students' perceptions of the consequences of working with older adults. The higher the total SPWOP score, the more positive the perception of working with older adults. The SPWOP consists of 15 statements with responses on a 5-point Likert scale. A score of 45 in the total SPWOP indicates a neutral attitude, with possible scores ranging from 15 to 75. Nolan et al. (2006) did not report any specific psychometric data, but in a study that examined undergraduate nurse perceptions of working with older adults, a Cronbach's alpha coefficient for the SPWOP was reported as 0.73 (Pan et al., 2009).
Discussion The review has examined the psychometric characteristics of eight instruments designed to measure the attitudes of undergraduate nurses with regard to older adults and their perceptions of working with older adults. In the conduct of rigorous research, it is very important to define the concept of interest and ensure that the purpose of the outcome measure is closely aligned. This review has identified that related concepts have sometimes been used interchangeably. The term “attitude” has been interchanged with “stereotype” in the theoretical development of the Aging Semantic Differential (Rosencranz and McNevin, 1969). Furthermore, Pan et al. (2009) undertook a study with the Students' Perceptions of Working with Older People (SPWOP) questionnaire (Nolan et al., 2006) but used the term “attitude” to report their study results. In these examples, these terms are clearly different and need to be used correctly and consistently. Of the eight instruments, internal consistency using Cronbach's coefficient was documented for all the instruments either by the developers or other researchers. Test–retest was less common with no inter-rater reliability assessed for any of the instruments. Internal construct validity of three instruments was assessed using factor analysis but for some instruments validity information was not reported. If psychometric property information is incomplete, it may restrict the usefulness of the instrument. The instruments reported here have been used by at least one other independent researcher/s, which imbues more confidence in the utility of the instrument. However, more independent testing will greatly improve the evidence base for the use of these instruments. A limitation of work in this field is the lack of older adult input into scale development. Kogan's Attitudes Toward Old People scale (Kogan, 1961) continues to be the most commonly used instrument despite some serious comments about its current relevancy. The other instruments are well worth consideration for use in this field of research as they bring different conceptual development aspects.
Conclusions This review provides comprehensive information about eight quantitative instruments currently available for research evaluating undergraduate nurse attitudes toward older adults and perceptions of working with older adults. A number of implications can be drawn from this review. First, it is important to have conceptual clarity in regard to what outcome is to be measured. Second, aside from Kogan's Attitudes Toward Old People scale (Kogan, 1961), more effort could be contributed to develop a stronger evidence base to support increased use of these instruments. The availability of a broad range of instruments for assessing attitudes and perceptions is required to advance the field, especially given the rapid growth of the aging population and the implications this will have for the nursing discipline. As this field of study continues to grow, researchers need to choose instruments that are conceptually and psychometrically sound so that good quality research is carried out to develop education and practice innovations in the care of older adults.
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