REVIEW ARTICLE

Nurses' attitudes to hospitalized older adults

Arménio Guardado Cruz^I; Antonio Marcos Tosoli Gomes^II, Pedro Miguel Dinis Parreira^III

^I Ph.D., RN, Coordinating Professor. Nursing School of Coimbra, Portugal. Email: acruz@esenfc.pt
^II Ph.D., RN, Head Professor, Nursing School of the State University of Rio de Janeiro. Brazil. Email: mtosoli@gmail.com
^III Ph.D., RN. Adjunct Professor, Nursing School of Coimbra. Coimbra, Portugal. Email: parreira@esenfc.pt

DOI: http://dx.doi.org/10.12957/reuerj.2016.14726

ABSTRACT

Objective: to evaluate recent scientific evidence regarding nurses' attitudes to hospitalized older adults. Method: this integrative literature review was guided by the question: are nurses' attitudes to hospitalized older adults reflected in the therapeutic strategies used in promoting self-care? EBSCO online databases were searched for articles published between 2000 and 2013; a total of 14 articles were selected. The descriptors used were older patients, attitudes, nursing, hospitalization, following inclusion and exclusion criteria. Results: nurses' attitudes are inconsistent. Negative attitudes affect the promotion of autonomy and are associated with level of knowledge, age and gender. A preference for working with older people and knowledge about aging associated with positive attitudes. Conclusion: there is a lack of studies with scientific quality. It is recommended to innovate in research to evaluate specific interventions and apply appropriate strategies. New nursing training programs and models of care for the elderly and aging are suggested.

Keywords: Attitudes; nursing; elderly; hospitalization.

INTRODUCTION

The current demographic changes and trends have been accompanied by an increased risk of hospitalization among older people (OP), thus contributing to a new caring paradigm. However, clinical practices do not always reflect the changes necessary to the health-illness transition process of hospitalized older people (HOP).

Among the factors leading to the functional decline (FD) of HOP, nurses' attitudes can become a barrier to self-care promotion, contributing to FD and its consequences, namely the impact on the quality of care provision^1,2.

Attitude is defined as "a set of judgements that are developed based on our experiences and the information we have on people or groups" ^3:250; it is a behavioral predisposition, developed over the course of life, an evaluation performed by individuals that guides their everyday conduct and leads them to action³.

In a social/professional setting, nurses develop positive or negative attitudes³ towards certain objects, situations, phenomena, and/or social and human groups. Among other contributing factors, these attitudes can be changed by education, age, and communication, and influenced by certain social components⁴.

Nurses' negative vision can compromise the quality of care provision^5-7, since geriatric care is sometimes considered to be a difficult, wearing, and ungratifying experience⁸.

Empirical studies have confirmed the existence of health professionals discriminatory attitudes toward HOP, with predominantly negative feelings and an impact on care provision^9,10. Some nurses prefer to work with younger patients and tend to use physical restraints, discriminate patients, and disrespect their autonomy and dignity^11,12.

However, positive attitudes can also be developed which, despite the influence of negativism, can help to improve the relationship with older patients (respect, reciprocity, trust, etc.)⁵.

Despite the inconsistent scientific evidence on this topic, nurses' attitudes can be modifiable, thus contributing to an improved quality of the care provided to HOP¹².

This study emerged from the need to better understand this phenomenon by assessing the recent scientific evidence on nurses' attitudes towards HOP and the associated predictive factors.

METHOD

This integrative literature review (ILR) includes studies with different methodological approaches and aims at the systematic analysis of objectives, materials and methods, revealing the pre-existing knowledge on the topic under analysis^13,14. To accomplish the objectives set out, and following the Participants, Intervention, Comparisons, and Outcomes (PICO) strategy¹⁵, we formulated the following research question: Are nurses' attitudes towards hospitalized older people reflected in the therapeutic strategies used for self-care promotion?

The article search was conducted between January and March 2014 in the following databases of the Elton Brison Stephens Company (EBSCO) online research platform: Cumulative Index to Nursing and Allied Health Literature (CINAHL®) Plus with Full Text; Nursing & Allied Health; British Nursing Index; Cochrane Collection; MedicLatina (tm); Medical Literature Analysis and Retrieval System Online (MEDLINE®) with Full Text. We followed a systematic process from the selection of the search resources to the critical appraisal of the selected articles. Given the lack of scientific articles, we also conducted searches in the Biblioteca do Conhecimento Online – b-on (Online Knowledge Library), the Scientific Electronic Library Online (SciELO), and the Portuguese Open Access Scientific Repository (RCAAP).

The following English and Portuguese descriptors were used:atitudes (attitudes), pessoas idosas (older patients), enfermagem (nursing), cuidados agudos (acute care) , hospitalização (hospitalization), all connected by the Boolean operator AND.

First, the authors analyzed the titles and abstracts taking into account the research question and the objectives set out. The full version of all potentially relevant articles was analyzed with a view to confirming their eligibility. Then, the reviewers selected the articles based on the following inclusion criteria: nurses who cared for HOP aged over 65 years in an acute phase of the disease; all types of study designs ; and exclusion criteria: nurses who did not care for HOP in an acute phase of the disease; narrative reviews and opinion articles . Reviewers discussed any divergent opinion until reaching consensus.

Different instruments were used to assess the studies' methodological quality. We used the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Review and Research Syntheses in the systematic literature reviews, the JBI Critical Appraisal Checklist for Observational Studies in the observational, descriptive-correlational, and cross-sectional studies, and surveys, and, finally, the Grid for Critical Appraisal of a Qualitative Research Article in the qualitative studies. The standardized classifications were standardized, the grid scores were adapted and the studies were divided into three levels of quality: good, moderate, and weak. We classified the level of evidence of the studies according to a hierarchical system of adapted evidence^15-18.

We compiled the most relevant data from each study in a Word document: author(s), country of publication, study design, sample characterization, data collection method, and main results and conclusions.

We ensured that all principles of reliability and textual integrity were respected.

RESULTS AND DISCUSSION

The initial search provided 73 citations (EBSCO: 18; b-on: 55), of which 22 were excluded after title and abstract analysis for not complying with the question and objectives for this review and/or due to elimination of repeated citations. In a second moment, after applying the inclusion/exclusion criteria, we accessed the full-text version of 11 (100%) articles: 8 (57.2%) articles in EBSCO, and three (21.4%) articles in b-on. We added three (21.4%) master's dissertations resulting from our RCAAP search through b-on. In total, we included 14 studies ^2,18-30 (11 full-text articles and 3 dissertations) in this review (Figure 1).

FIGURE 1: Results of the online database search, 2014.

We included studies published between 2000 and 2013, five of them being published in 2007 (Figure 2)^{11,16,18,19,23}. Ten studies were conducted by nurses or nursing teachers^{2,19,20,23,24,25,26,27,28,30}, two studies were conducted by a multidisciplinary teams^22,29, and two by nurses and gerontologists^18,21. Most studies were published in international journals, except for the three Master's dissertations^2,19,20. Ten studies were written in English, having been conducted in several countries: five in Australia^{18,23,24,25,29} and one in Israel²¹, Nigeria²², Jordan²⁷, USA²⁸, and China³⁰, respectively. Four studies were written in Portuguese, conducted in Brazil²⁶ and Portugal^2,19,20.

It should be noted that 10 studies had a level of evidence 5, including: four quantitative studies (one descriptive survey²² one retrospective, descriptive and cross-sectional study²⁸, one retrospective study²⁴, and one descriptive study¹⁸; four qualitative studies (one interpretative study²⁶, and three exploratory and descriptive studies^2,19,20); two mixed-methods (qualitative and quantitative) studies (one survey^25, and one exploratory/descriptive study²³). Two quantitative descriptive and correlational studies^21,27 had a level of evidence 3, and two studies^29,30 (systematic literature reviews) had a level of evidence 1.

The samples were composed of nurses caring for HOP. Most quantitative studies used nonprobability convenience samples ranging between 31 and 14,215 participants, and two studies used a stratified random sample (130 and 231 participants, respectively). The qualitative and mixed-methods studies used nonprobability convenience samples ranging between 9 and 38 nurses. Most participants were women and had between 1 and 32 years of professional experience. Most nurses worked in medical and surgical units (acute care) of general and university public hospitals.

The semi-structured interview^2,19,20 was the data collection method most commonly used in qualitative studies, although the open interview³¹ and word recall and/or association tests were also used^2,20. Self-report questionnaires were the methods most commonly used in the quantitative studies: two developed by the researchers ^18,24, while others included already validated instruments such as the Kogan's Attitudes Towards Old People Scale (the most commonly used scale)^18,21,27, the Palmore's Facts on Aging Quiz ^18,21,24, the Caregiving Activities Scale (CAS)²⁵, and the Geriatric Institutional Assessment Profile (GIAP) database ²⁸. The mixed-methods studies used questionnaires designed by the authors and word association tests to collect quantitative and qualitative data^2,23. The systematic literature reviews used multiple descriptors and inclusion/exclusion criteria to search online databases^29,30 (Figure 2).

FIGURE 2: Characterization of the selected studies, 2014

However, high quality design studies on nurses' attitudes and associated factors are scarce, particularly taking into account the growing need for nurses to care for HOP^27,29.

Nurses' attitudes

The studies on nurses' attitudes revealed inconsistent findings. In one of the studies, nurses inconsistently showed positive, negative and neutral attitudes towards HOP, although these attitudes appear to be less positive since 2000²⁸. Older people and aging are seen from a bipolar perspective, where ageism and age-related prejudice coexist with a positive view based on concepts that characterize a successful aging process. On the other hand, nurses assign more importance to the negative physical characteristics of older people and aging, the positive psychological characteristics, as well as a certain balance between the positive and negative social characteristics².

The marginalization and oppression of OP show how nurses perceive older people, relegating them to a lower status in the definition of acute care ^21,25. In an empirical study, 73% of interviewees agreed that it is difficult to take care of older people. The negative social representation of aging was the most evident aspect, associated with situations of dependence, illness, loneliness, isolation, needs, sadness, and social burden/problems/ difficulties. This causes older people's physical, mental and psychological skills and autonomy to be undervalued ^21,24. In a qualitative study, OP were seen as dependent and lonely people who were abandoned by their families, and in need of attention. This negative view is in line with the theoretical framework, where discriminatory and negative attitudes are very frequent and have a potential impact on care quality^5-10.

We also found records of positive attitudes among nurses², although the different institutional and clinical settings are conditioning factors²⁶.

A positive clinical practice environment was associated with a positive geriatric care delivery. Resource availability, institutional values, and capacity for collaboration seem to influence care delivery to HOP ²⁸ However, despite the positive attitudes, efforts should also focus on improving them, since only then it will be possible to improve care quality²⁵.

Potential predictors of these attitudes include age, gender, level of education/knowledge, clinical experience, institutional/organizational culture, and community and geographical influence, but findings are inconsistent^20,22,25,28. Factors hampering the promotion of respect for, and autonomy of OP include motivation, OP and nurses' characteristics, and institutional constraints¹⁸.

Many negative attitudes reflect aging-related stereotypes and knowledge deficits that influence the quality of life of HOP. These results help to identify knowledge gaps in important training areas²⁷.

Another study mentions that organization in geriatric nursing has a strong impact on how the quality of geriatric care is perceived²⁶.

Suggestions for change of attitudes

It is important to reassess nurses' attitudes as well as OP level of knowledge and beliefs so as to improve nursing practice and mitigate prejudice, stereotypes, and long-lasting and harmful negative representations^2,4. Geriatric training is essential for nurses to make decisions concerning HOP and their caregivers' expectations and needs. Evidence points to the need for development of new nursing care models and new initial and postgraduate training curricula^23,24.

More than 80% of nurses agreed that they need special training², vocation, and preference to work with this social group in order to provide effective care to OP, and that the level of aging-related knowledge seems to be associated with positive attitudes towards OP^19,22,24. Academic curricula should include topics on healthy aging and avoid focusing on aging-related diseases²⁵.

Nurses should communicate more effectively with HOP and their family caregivers during hospital stay, analyzing their expectations concerning the treatment and recovery process, and the reasons for support interventions¹⁶.

The reasons for these differences must be identified, and new programs should be developed at the different levels of education to improve the quality of life of OI²⁸.

To change attitudes, managers also require a chance of paradigm. Clinical, organizational and structural measures should be developed and tested to assess the effectiveness of nursing organizational support and create flexible and feasible models of geriatric care²⁶.

Geriatric nurses should be able to inform less experienced team members. They should also advocate for OP and their needs, including the respect for their identity and specificities¹⁸.

This ILR has some methodological limitations that weaken the reported evidence, namely the lack of studies meeting the necessary prerequisites, the various types of studies and their methodological quality.

CONCLUSION

Nurses have a social mandate of leadership in the provision of quality care to HOP, and there is a growing need for commitment with the provision of care to these patients. However, studies with consistent scientific quality are scarce, both on nurses'attitudes and the associated potential factors. Therefore, further studies should be conducted to promote the assessment of the actual needs of HOP and the adoption of the best strategies and interventions. Nursing education and training programs at all levels should be restructured, and new care models focused on OP and aging should be developed.

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