Attitudes towards the Elderly among Nursing Students in Poland – Initial Findings

Background: Similarly to many developed countries, the demographic tendency in Poland is that of a systematic increase in the number of elderly persons in the general population structure. In 2013 in Poland the percentage of people over 65 equalled 14.7%, where the average life expectancy for women was 81.1 and 73.1 for men. It is estimated that by 2020 the percentage of elderly citizens in the Polish society will have increased by 18.2%. The aim of the research was the assessment of the nursing students’ attitudes towards the elderly in Poland. Methods: The tool used for the assessment of the attitudes towards the elderly in Poland was the KAOP scale (Kogan’s Attitudes Toward Old People Scale) first used in 1961 by N. Kogan. Statistical analysis shows that there is a correlation between the attitude towards the elderly and the type of the programme of studies (the day-programme vs. extramural programme), sex of the subjects, age and education. However, the analysis does not indicate a link between the subjects’ attitude and their marital status, place of residence, family model and the frequency of contacts with the elderly. Results: According to the Kogan scale, among 360 subjects 133 (36.9%) of them presented a positive attitude towards the elderly, and 227 (63.1%) had a negative viewpoint. 44 students (34.6%) who were raised by their parents and did not have everyday contact with older members of their families presented a positive attitude, and 83 of them (65.4%) showed a negative one. Conclusions: Longitudinal research is necessary in order to evaluate the students’ attitude towards the elderly. In order to assess the attitudes towards the elderly, it is crucial to gather country-specific tools taking into account social, cultural and religious features.


Introduction
The human population is ageing on a global scale. Similarly to many developed countries, the demographic tendency in Poland is that of a systematic increase in the number of elderly persons in the general population structure. In 2013 in Poland the percentage of people over 65 equalled 14.7%, where the average life expectancy for women was 81.1 and 73.1 for men. It is estimated that by 2020 the percentage of elderly citizens in the Polish society will have increased by 18.2% [1].
The growing number of the elderly, usually chronically ill and dependent on others, constitutes a serious challenge both for the Polish national health service and for social services. What constitutes a major concern is financial deficits and the payment of long-term benefits. Nevertheless, the problem which seems to be constantly overlooked is bias against old age (ageism), based on creating prejudice, stereotypes and negative attitudes [2]. In fact, stereotypical assumptions concerning the psychophysical features of the elderly are usually negative. Attitude is a way of perceiving and judging a person or an object [3] and can be positive, negative or neutral. Research shows [4], that the quality of medical services for the elderly depends on the government. As it is in the case of the entire population, the employees of the national health service frequently present negative views and attitudes towards the elderly, which is reflected in their behaviour [5]. Identifying these attitudes and the associated factors constitutes a crucial step in understanding and improving the relations between health service employees and elderly patients.
Unfortunately, stereotypes and the erroneous picture of seniors lead to a tendency where there is a decrease both in the number of nursing students and nurses on the very threshold of their professional careers who work at the geriatric wards. What is more, such a trend is visible not only in Poland [6]. In fact, graduates of nursing would rather work with children or adults, especially in the intensive care units or surgical wards than in internal or long term care departments. Bancroft [7] agrees stating that the majority of students of nursing of West Midlands University (UK) would prefer working with young people and children which may be a decision stemming from the influence of the media and their tutors' attitudes. In fact, Happle [8], Soderhamn [9], Herdman [10], pointed out that within the last 30 years, the number of nurses interested in working with the elderly has significantly dropped.
As far as Polish universities are concerned, there number of classes devoted to geriatrics and geriatric nursing in the nursing curriculums is sufficient. Therefore, the students have a chance to professionally prepare and shape the correct professional attitude. In spite of this, it is the students themselves who admit they do not feel prepared well enough for the task, especially in terms of working with people with dementia where communication and the routine are particularly difficult. Thus, it is reflected in their negative attitude.
The aim of the research was the assessment of the nursing students' attitudes towards the elderly in Poland.

Research material
360 nursing students at the Bachelor of Nursing level took part in the research, all of whom were members of two nursing students groups; part of them were day students (n = 199; 53%), and the other part consisted of extramural students (n = 161; 44.7%) -as the control group. All students at the moment of taking the test were at their final year of studies, having taken part in the obligatory classes concerning geriatrics and geriatric nursing.

Research method
The reprospective study assessing the attitudes of nursing students towards the elderly was conducted at Poznan University of Medical Sciences between October 2012 and June 2014. All qualified participants had signed written consents beforehand.

Measurements
The tool used for the assessment of the attitudes towards the elderly in Poland was the KAOP scale (Kogan's Attitudes Toward Old People Scale) first used in 1961 by Kogan [11]. Its reliability has been confirmed by a number of researchers [4,12,13]. The KAOP scale consist of 34 sentences resembling the six-point Likert scale divided into 17 positive and 17 negative statements concerning the elderly. It describes attitudes ranging from "I definitely disagree" [1] to "I definitely agree" [6]. For the purpose of this study, the official permission of professor Nathan Kogan has been obtained. In addition, in order to adapt the scale to the Polish conditions, the tool was translated and the pilot study was conducted.

Statistical analysis
The collected data was gradually entered into a specially developed Excel database; and all the calculations were done using the statistical software of Statistica PL 10.0 by StatSoft and StatXact 8.0 by Cytel. For the comparison of two independent variables Mann-Whitney's test was used, and for more than two Kruskal-Wallis test was employed. When Kruskal-Wallis test pointed to crucial differences between the tested variables, a post hoc Dunn test was engaged. In order to determine the dependence between the variables Spearman's rank correlation coefficient was used. Th incidence rate of positive results in the analysed groups was compared by means of Chi-square test or the Fischer's exact test depending on the size of the analysed group. The given analysis data were statistically relevant at p<0.05.

Results
The socio-demographic features of the analysed group (Table 1).
Women constituted a predominant group among the students participating in the study, adding up to 341 people (95%). The majority of subjects, i.e. 179 people (49.7%) were between 20-25 years of age. Day students turned out to be younger, whereas extramural students tended to be older. In the remaining age groups, the age of the subjects was comparable and presented as follows: 26-30 years of age -17 subjects (4.7%), and 31-36 years of age -12 subjects (3.3%). As far as the marital status of the subjects is concerned, 127 students were single (35.5%), whereas 233 declared being in a relationship (64.7%). What is more, 308 subjects (85.6%) had secondary education, and 52 students had higher education (14.4%). The largest group, amounting to 124 subjects (34.4%), consisted of people living in a city with fewer than 100 000 inhabitants, whereas 119 subjects (33.2%) lived in the country. The remaining 80 subjects (22.2%) lived in a city with more than 500 000 inhabitants, and 37 students (10.2%) lived in a city with more than 100000 inhabitants.
Taking into account the family model in which the subjects were raised, 127 students (35.5%) were brought up by parents without any contact with older family members. On the other hand, 122 subjects (33.9%) grew up in extended families, 103 students (28.6%) were raised by parents with frequent contact with grandparents, and 8 subjects (2.2%) were brought up exclusively by their grandparents.
The majority of subjects, i.e. 323 students (89.7%), claimed that both in their professional careers and in everyday lives they have frequent contact with the elderly.
The determinants of the subjects' attitudes Statistical analysis shows that there is a correlation between the attitude towards the elderly and the type of the programme of studies (the day-programme vs. extramural programme), sex of the subjects, age and education. However, the analysis does not indicate a link between the subjects' attitude and their marital status, place of residence, family model and the frequency of contacts with the elderly.
According to the Kogan scale, among 360 subjects 133 (36.9%) of them presented a positive attitude towards the elderly, and 227 (63.1%) had a negative viewpoint. In fact, positive attitude was shown by 84 subjects (42.2%) of the day-programme students, and by 49 students (30.4%) of the extramural programme. It was more common for the extramural students to present a negative attitude (112 subjects, 69.6%), and the same attitude was visible in 155 day-programme students (57.5%). It is vital to notice that the difference was statistically relevant (p<0.05) ( Figure 1).
The presented correlation between sex and the attitude towards the elderly (p<0.05%) stemmed probably from the evident predominance of women in the subject group. In fact, 131 women subjects (98.5.4%) showed a positive attitude, whereas 210 female students (92.5%) had a negative viewpoint.
In terms of the relation between age and attitude, it turned out that subjects from the youngest and the oldest age groups showed both positive and negative standpoint. As far as 20-25-year-olds are concerned, 72 of them (40.2%) were positive towards the elderly, whereas 107 students (59.8%) had a negative attitude. In the group of students aged 36 and older, 44 of them (28.9%) had a positive attitude, and 108 subjects (71.1%) had a negative viewpoint. The difference was statistically relevant (p<0.05) ( Figure 2). Moreover, a correlation between the level of education and attitude was observed as well (p<0.05). 113 students (36.7%) with secondary level of education and 20 subjects (38.5%) with higher education were positive towards the elderly. Conversely, the negative attitude was presented by 195 students (63.3%) with secondary level of education and 32 subjects (61.5%) with higher education (Figure 3).
What is more, the negative attitude was more frequent in subjects who were in a relationship (155 subjects, i.e. 66.2%) and in those who were single (72 subjects, i.e. 56.7%), (statistically insignificant).   44 students (34.6%) who were raised by their parents and did not have everyday contact with older members of their families presented a positive attitude, and 83 of them (65.4%) showed a negative one. 48 subjects (39.3%) from extended families were positive towards the elderly, and 74 of them (60.7) had a negative viewpoint. In terms of students brought up by their parents, but who had contact with grandparents, 40 subjects (38.8%) showed positive attitude and 63 (61.2%) presented a negative one. Finally, as far as the students raised exclusively by their grandparents, there was 1 subject (12.5%) who had a positive attitude towards the elderly and 7 students (87.5%) showed a negative standpoint, (statistically insignificant), (Figure 4).

Figure 4:
The attitude towards the elderly and family type.
It is worth noticing that the negative attitude was predominant even after the analysis of the frequency of contact between the students and the elderly on an everyday basis and in their professional work (statistically insignificant). It was observed in 200 subjects (61.9%) who had frequent contact with the elderly, and in 27 students (73%) who did not have a frequent contact with the elderly. The latter were in fact less numerous (n = 37; 10.3%), (statistically insignificant), ( Figure 5). Analysis of the selected statements from the Kogan scale concerning the adopted attitude towards the elderly and the aforementioned determinants (Table 2).
It has been shown that, according to the subjects, the majority of the elderly has their embedded habits which they are unable to change. What is more, a relation between such a statement and both the age and the level of education of the subjects has also been demonstrated. In fact, that thesis was more often supported by the youngest and the oldest subjects (r=-0.17, p<0.001), as well as by those with a higher level of education (r=-0.16, p<0.01). 116 of the subjects (32%) agreed that the majority of the elderly would prefer to stop working when they retire or to be supported by their children (p<0.05). Furthermore, 125 students (35%) claimed that the elderly should not influence the world of business and politics (p<0.05). Such a view was shared especially by subjects between 20-25 years if age (r=0.13, p<0.01). In addition, 70 subjects (46%) aged 20-25 (r=0.11, p<0.05) stated that "the majority of the elderly made them feel uncomfortable". On the other hand, 125 students (34%) did not agree that "an are is attractive to live in if a lot of seniors live there", (r=0.19, p<0.001). Moreover, 104 subjects (28.8%) disagreed with the statement saying that "staying with the majority of the elderly is relaxing", (r=-0.12, p<0.001). In fact, there was a correlation between the abovementioned statement and age (p<0.05) as well as with sex (p<0.01). 108 (35.1%) subjects with higher education claimed that the elderly are mostly annoying, grumpy and unpleasant (r=-0.10, p<0.05). Another 151 subjects (42%), mostly women 141 (41%), (p<0.01), claimed that "the majority of the elderly need more love, support and sympathy than others" (r=-0,10, p<0.01). However, 133 of the students (37%) disagreed with the statement that "if an elderly person wanted to be likeable, he or she would need to get rid of their irritating qualities" (r=0.15, p<0.05).
Having analysed the results of the positive statements according to Kogan, it turned out that 114 subjects (32%) from both day and extramural programme said that "it would probably be better if most of the elderly lived with younger generations" (p<0.05). In fact, this statement was more common for 20-25-year olds (r=-0.11, p<0.05). The subjects did not agree that "most of the elderly are no different than the younger people and it is equally easy to understand the elderly and the younger people" (p<0.01).
It is possible that this statement may depend on the age of the subjects, because it was mainly the youngest students who shared this opinion (r=0.19, p<0.001). On the other hand, 157 (43.6%) subjects agreed that "the elderly are diversified" (r=0.13, p<0.05), 154 students (43%) claimed that the elderly have the same faults as other age groups do (r=0.19, p<0.05); and 55 younger subjects (30.7%) stated that "people become wiser with age" (r=-0.10, p<0,05). However, 166 women (48.7%) and 84 subjects (55.3%) aged 36 and older claimed that one of the greatest features of the elderly is their ability to talk about the past (r=-0.11, p<0.05).
A correlation was observed between education and the statement that "most of the elderly keep their opinion to themselves and give advice only if they are asked to do so"; in fact, 111 subjects (36%) with higher education disagreed with it (r=0.11, p<0.05). 120 students (33.3%), the majority of whom were women -117 (34.3%) -(p<0.01) claimed that the elderly are usually smiling, kind and cheerful (p<0.05). Furthermore, 95 women (28%) stated that most of the elderly are clean and looked-after (p<0.05). 126 subjects (35%) rather opposed the claim that the elderly rarely complain about the behaviour of the younger generations (r=0.12, p<0.05).

Discussion
Research shows that age, sex, education, contact with a given patient group, as well as the area of practice and specialty influence the attitude of the health service employees [3]. According to Holroyd et al. [14], the most crucial factor that can change the professional attitude is the level of education; although Topaz et al. [3] also stress the personal qualities and working conditions. It has also been observed that some of the aforementioned factors were linked with the attitude of the nurses included in the research; however, the directions of correlations were not cohesive. Taking into account age, it was pointed out that older nurses more often presented a negative attitude towards the elderly, which is analogous with what Herdman claims, but it is not supported by Murphy [15]. Other scientists did not see any connection between age and the attitudes of nurses towards the elderly [16,17].  Table 2: Analysis of the selected statements from the Kogan scale concerning the adopted attitude towards the elderly and the aforementioned determinants.
Education and the influence it has on the nurses' attitudes in their professional work constitute yet another aspect. In theory, nurses with higher education, greater knowledge of geriatrics and gerontology should present more positive attitudes, as they are better at understanding the elderly and identifying their needs than those without any professional knowledge in this area [2]. In the research in question, a correlation between the level of education of the nursing students and their attitudes was shown. It was more common for subjects with higher level of education or those taking part in the extramural programme to present the negative attitude. It seems possible that in terms of extramural students, frequently having a longterm professional experience, their attitude stems from the difficult working conditions of nurses in Poland, overloading with professional duties or simply from job burnout. Nevertheless, Hweidi and Al-Hassan [17] do not support the correlation between education and attitude.
Professional experience that the extramural students mainly presented did not exert positive influence on their attitude. According to, Teeri et al. [18], professional experience constitutes a crucial determinant in terms of attitude. However, Kang et al. [6] claim that even a long-term professional experience is not in any way linked with attitude.
Similarly to the research in question, Hanson [19] observed a generally negative attitude of both nursing students and nurses towards the elderly. In fact, he stated that the most important reason for the negative attitude is the lack of knowledge concerning the process of growing old. His theory is supported by the Australian [5] and Israeli research [2] conducted among the nurses working at the Emergency departments. The abovementioned authors used the Kogan scale and showed little knowledge of the staff concerning the process of growing old, and stressed the negative attitudes claiming that they constitute strong predictors of ageism. The authors believed that the negative attitude stemmed from the lack of time devoted to the care of the elderly, as well as from the tedious character of care. The negative attitudes of nurses towards the elderly were also observed in Ireland and Sweden [4] where the percentage of the elderly is high. In fact, Lambrinou et al. [20] showed that the Western culture has the tendency to perceive the elderly in a negative manner, i.e. they are usually seen as weaker, dependent and burdensome members of society.
Contrary to the reports mentioned above, a research using a modified Kogan scale conducted in Saudi Arabia showed a favourable and positive attitude of the nursing students towards the elderly [21]. It is vital to notice that the outcome of the research may stem from the position of the elderly in the Eastern culture, e.g. China, Japan or the Philippines where the elderly are in the centre of family life, they are appreciated and respected. Nevertheless, in the Chinese research [22,23] with the use of analogical tools of attitude assessment, only 50.1% of subjects presented a positive attitude towards the elderly. What is more, Neville et al. [24] from the United Kingdom have completed a vast overview of the literature concerning attitudes and the perception nursing students have about the elderly. In fact, the analysis of their research pointed to the positive attitudes towards this age group. Holroyd et al. [14] also attempted evaluating the nursing students' attitudes at the time of studying. They noticed a crucial difference which was based on the increase of negative attitudes of nursing students between the first and the last year of studying. An opposite outcome with the use of the Kogan scale was presented in Greece and New Zealand. Lambrinou et al. [20] pointed out that the last year students had a more positive attitude towards the elderly. Furthermore, similarly to the research in question, it was shown that females had a positive influence on the overall attitude towards the elderly. In addition, in New Zealand [25] a positive change was observed at the very beginning and ant the very end of the studies. The abovementioned results support the thesis that education concerning the process of growing old influences the attitude, and constructive experience gathered at the time of professional internship reinforces the result. The outcome of the research in question is not parallel with the abovementioned facts, as the attitude at the last year of the studies was assumed.
In Scotland, Sweden and the USA the assessment of attitudes of nurses towards the elderly was performed using the Multifactorial Attitudes Questionnaire where the subject group consisted of 1587 people. The majority of subjects, especially in Scotland, presented a positive attitude, but at the same time they claimed that the negative standpoint passed from their peers, and stems mainly from poor working conditions and the lack of professional perspectives in the area of geriatrics [26].
It is worth comparing the research concerning the attitudes of students of other medical courses. Nochajski et al. [27] used the Aging Semantic Differential (ASD) to assess 311 dentistry students who presented positive attitude only in formal contacts with the elderly patients. Moreover, the research conducted among the medical students showed a negative change at the end of the studies [28], and little interest in the area of geriatrics [29].
The limitation of the research is the lack of specific, separate for each country, tools taking into account social, cultural and religious features. It is necessary to understand the attitudes to the elderly and it is highly worrying that with the still growing number of the elderly, care and social interest taken in them is on the not decrease. In conclusion should be considered, that longitudinal research is necessary in order to evaluate the students' attitude towards the elderly, because there are too few.

Conclusion
Positive attitude was presented by 133 subjects (36.9%), with 227 subjects (63.1%) showing the negative attitude. Day programme students more frequently showed positive attitude, and the students of the extramural programme presented mostly the negative one.
In order to assess the attitudes towards the elderly, it is crucial to gather country-specific tools taking into account social, cultural and religious features.
It is necessary to promote a positive attitude and to present advantages of working with the aging people, which can be achieved with the help of teachers and all national health service employees. It is highly worrying that with the still growing number of the elderly, care and social interest taken in them is on the decrease.