Finnish and Turkish Nursing Students’ Attitudes Toward the Elderly

Introduction: This study was aimed to compared nursing students’ attitudes toward the elderly people at two universities in Finland and Turkey. Materials and methods: A descriptive and comparative design was used. The study population included first and second year nursing students (N=1124). From this population, we selected a sample of 345 students, each of whom agreed to participate. We collected study data from a questionnaire form and the Kogan’s Attitudes Toward Older People scale. Results: The students’ mean age was 21.26 ± 4.2 and 83.5% were females. Considering the low dimensions, the Finnish students’ positive mean score was 59.3 ± 6.2 and that of the Turkish students was 60.6 ± 8.8. The mean negative score of Finnish students was 62.4 ± 5.5 and that of Turkish students was 59.1 ± 9.7. The Finnish students’ negative attitude mean score was statistically higher than that of the Turkish students (p < 0.005). Conclusion: Nursing students’ attitudes toward the elderly were moderate. Adding more curricula focused on geriatrics and geriatric patient care into the nursing education program, symposiums, panels, and conventions and increasing the available in-service training on geriatric issues is important to positively improve these students’ attitudes toward the elderly people.


Introduction
With the trend of aging population, many social problems like social care systems and the increasing caring demands has been aroused by the public concern in the world. The number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050, with most of the increase in developing countries [1]. According to Turkish Statistics Foundation's data, 65 years and over make up 8% of the society. It is expected that this percentage will rise up to 9.9% in 2025 [2]. According to the 2015 Aging Report of European Commission, those 65 years and over make up 20.2% of the society. Although more developed countries have the oldest population profiles, the vast majority of elderly are in less developed countries. Between 2010 and 2050, the number of elderly in less developed countries is projected to increase more than 250 percent, compared with a 71 percent increase in developed countries [1]. As worldwide, the increasing number of the elderly population in our country requires planning of social care services intended for configuration of elderly and elderly's health. In order to make successful planning at a national level and put it into practice, the point of view and the attitude of health personnel who will serve these groups, medicine and nursing care students need to be determined [3].

Background
Generally, the elderly is seen as a group who "occupy beds, need to stay a long time in hospitals, and reduce the effectiveness of hospitals" and are also considered failures in the health system when they cannot be treated [4]. Due to the increasing elderly population, encountering age-related problems is inevitable. Many of these problems are rooted in the physical, mental, and economic situations of the elderly.
The other part is the elderly´s outside environmental conditions [5]. The elderly people are regarded as trouble for the society because problems increase in numbers with aging. This situation is reflected in *Corresponding author: Canan Birimoglu Okuyan, Mustafa Kemal University, Public Health Nursing Turkey, Turkey, Tel: +903262160686; E-mail: cananbirimoglu@gmail.com the service and the care provided for the old, hence, the eldery´s care is an undesired working field. Living with elderly, however, is seen as unacceptable [6].
Healthcare professionals are expected to adopt a professional attitude towards all patient groups in their service offerings. However, geriatric patients, partly because of their fragility and complex needs, are at the greatest risk of experiencing negative attitudes in healthcare and social services. The negative influence on elderly people´s care and aging perception thoughts, lead to a negative attitude of nurses and nursing students towards the elderly. Knowing the attitudes of nursing students and eliminating deficiencies in this way will help the elderly person to get better health care. In line with some investigations aimed at the student nurses` attitude towards aging and elderly, it was found that students maintained a positive attitude towards the elderly [7][8][9], whereas, in some other studies they showed a negative attitude [10,11].
Cultural and individual beliefs have as much impact as a young person's fear of death and physical beauty and attraction and agerelated decreases in productivity, demoralization, and reduction in physical and mental health occurring with aging. All these factors form a negative image of the elderly [3]. Nursing care for the elderly requires an interdisciplinary group approach, where the nurse holds a central role of importance. Nursing students' attitudes toward the elderly and perceptions of working with them are of international interest to the nursing profession, governments, and service providers as there is a shortage of qualified nurses [12]. Considering that today's student nurses will be tomorrow's professional nurses, their attitude toward the elderly will affect the quality of nursing they practice.
This research was conducted to compare nursing students' attitudes toward the elderly in two different countries.

Study design and sample selection
A descriptive and comparative research design was used to compare nursing students from two universities in Southwest Finland and central Turkey. The study population included first and second year nursing students (N = 1224). With a confidence level of 95% and a confidence interval of 0.05, the sample size was calculated as 286.
The study sample included all students who agreed to participate. So, ultimately the study sample comprised 345 students (213 Turkish students and 132 Finnish students).
The inclusion criteria of the study comprised the following: the student should (a) be aged 18 or above, (b) be first and second year nursing student, (c) agree to participate in the study. Exclusion criteria were as follows: (a) unable to understand English or Turkish, (b) absence at school during the data collection process.
At a university in the middle of Turkey, the nursing program requires 184 credits for graduation. Department of Nursing trains nurses protecting, carrying out and improving the health of family and society in line with the reality and needs of the country, giving nursing care whenever it is deteriorated, adopting lifelong learning in an educational period of 4 years. In this process, the students take theoretical and practical courses as well as basic and social sciences.
However, there is no course such as geriatrics or geriatric nursing. Students learn topics regarding geriatrics for about 8-10 hours in content of some courses e.g. community health nursing.
At a university in the Southwest Finland, the nursing program requires 210 ECTS credits for graduation. The overall aim of the degree program in nursing is to educate students from the point of view of working in international and multicultural nursing contexts. Nurse education covers all the fields included in nursing care, and provides the students with skills to support individuals, families and communities in order to help them achieve favorable health and avoid illness learning in an educational period of 3.5 years. Students learn topics regarding geriatrics for about 15 ECTS in content of some courses e.g. community health nursing.

Instruments
Data was collected by a questionnaire, and "Attitude towards Elderly People" scale. The questionnaire included questions about sociodemographic characteristics of the students such as age, gender, grade, and questions related to geriatrics.
The Attitude towards Elder People Scale was developed by Kogan in 1961 in order to measure the attitudes of individuals towards the elderly. The questionnaire consists of 17 positive statements and 17 negative statements and uses a Likert scale. The response options on both the positive and negative statements range from strongly agree to strongly disagree. To obtain a positive score, the summing up of the positive answers is calculated separately from the negative ones. A higher score on the positive scale indicates a favorable attitude toward elderly adults. Before calculating the negative score, the negative statements are reversed, which means that a higher score on the negative scale indicates an unfavorable attitude toward elderly adults. A total score is obtained by adding the scores from both the 17 positive

Data collection
The research was conducted between January-April 2016. The questionnaire form was applied outside the students` class hours. Before completing the questionnaire form, the students had been informed about the objectives of the research. Students who had agreed to participate were given the questionnaire forms and asked to fill them in under the supervision of researchers. Completing the questionnaire took about 15-20 minutes.

Statistical analysis
Data was assessed by using SPSS 16.0 (Statistical Package of Social Sciences). In data analysis numbers, percentage distribution averages, standard deviations and t tests were used. Categorical variables were presented as frequencies and percentages. Continuous variables were expressed as mean and standard deviation (SD). Continuous variables were compared using the independent sample t test. Independent sample t test was used to compare the difference between mean scores of Finnish and Turkish nursing students. A two-sided p value <0.05 was considered significant for all analyses.

Ethical consideration
The approval of students was obtained from the directors of both nursing schools. The study proposal was approved by the rectorate via e-mail at the university in Finland. Ethical approval was obtained from the ethics committee in Turkey. An informed consent form was received from the students.

Results
The students' mean age was 21.26 ± 4.2, 83.5% were females (n = 288), and 63.0% (n = 208) were first-year students. Of all the students, 27.7% of Turkish students lived together with elderly at their homes, 91.1% did not participate in subjects related to geriatric care during their bachelor studies, 93% had not studied elderly outside their graduate education or practicum, 3.8% provided care to their elderly family members, 32.9% kept in touch with elderly at least once a month, and 47.9% expressed an eagerness to take care of elderly (Table 1).
Finnish students mentioned that 3.8% live together with an elder individual at home, 53% have not taken subjects about geriatric in bachelor education, 65.2% have not taken education related to elderly outside their graduated education or practicum, 18.8% expressed by visiting elder family members or rest homes, 41.7% kept in touch with elder people once a month, 46.2% were eager to take care of elderly (Table 1).
While Finnish students had a total Attitude towards Elder People Scale mean score of 121.7±5.4, Turkish students had 119.7±9.9. There was a significant difference found between groups (p<0.005). When calculating the quantity of the difference however, little impact value can be seen (Effect size=0.24).
Considering the low dimensions of the scale regarding countries, the Finnish students' positive attitude mean score was 59.3 ± 6.2 and that of the Turkish students was 60.6 ± 8.8 (p > 0.005). The Finnish students' negative attitude mean score was 62.3 ± 5.4 and that of the Turkish students was 59.1 ± 9.7. There was a significant difference between the groups (p < 0.005). Calculating the quantity of this difference, a low impact value was seen (Effect size = 0.39) ( Table 2).

Discussion
The elderly population is a special group with special healthcare service needs. They frequently require high levels of care due to chronic health problems, more complex medical treatments, multiple prescription medications, and potential interactions of those medications. Developing positive attitudes and behaviors toward the elderly is significant for offering better healthcare services to these individuals.
Negative attitudes toward the elderly are much higher as a percentage in modern societies than in traditional societies [14]. The people in the environment where the elder are living and the people´s roles are important in order to perceive the old age productively, healthily and qualitatively [15]. Especially, due to the increasing lifespan and the number of elderly in the general population, an increase in health problems, insufficiency and incompetency can be seen. Considering the practice area of nursing as human and regarding its fundamentals in people´s care, the nurse´s negative prejudices, values, beliefs and attitudes toward the elderly are reflecting the quality of healthcare [16,17]. Therefore, positive attitudes towards the elderly practiced by people making up the elder´s environment, especially today´s nursing students and tomorrow´s nurses, are essential in terms of health care quality. In our study, it was found that the attitude of Finnish and Turkish nursing students towards the elderly is positive. It can also be seen in literature, that attitudes towards the elderly are generally positive [3,[18][19][20].
Determining the need of healthy/unhealthy individuals and therefore, managing the initiative process is the fundamental philosophy of nursing. Raising and treating nursing students with this consciousness is important to make their attitudes towards the elderly positive, therefore increasing elder health care quality and making them enjoy the job after graduation [3,21]. Considering the highest point of attitude toward the elderly scale as 204, it is important for the health of the rising numbers of elderly in the population, that more effort to improve positive behavior must be shown by students. The syllabus in order to improve awareness of old age, must be reconsidered, numbers of applications in areas providing work with elder people must be increased.
Studies revealed that there are three different types of attitudes toward the elderly: positive attitude, less positive attitude, and negative attitude [20,22,23]. Analyzing the scale's results according to countries, the Finnish students exhibited significantly more negative attitude toward the elderly than the Turkish students. It is certain that a positive attitude toward the elderly would produce a higher level of care. Measures should be taken to help nursing students change their negative attitudes toward the elderly so that they will more likely take care of the elderly [9].
Education intervention could help students to change their attitudes towards elderly. Liu (2013) suggests that gerontological nursing education with positive clinical learning experiences could improve attitudes towards elderly and increase the nursing students' preference to care for elderly [21].
In many countries, health care duties are performed by professionals [24]. Because in Turkey, health care for the elderly is performed by family members, including children, it is believed that this affects Turkey's positive attitude low level positively. Therefore, determining the younger generation's attitudes toward, being together with, and working with the elderly and information regarding old age and meeting the attitudes and needs are important for developing positive attitudes toward the elderly.

Conclusion
The results of this study indicate that students in both countries had a medium level of attitude towards the elderly and that the negative attitude mean score of Finnish students towards the elderly was significantly higher. In line with this result, it is important to add more lessons about geriatrics and geriatric patient care into the nursing education program and also related to this, encouraging students to attend symposiums, panels and conventions to evaluate students' attitude towards the elderly, that activities linked with elder individuals must take place in responsibility projects in order to improve nursing students' attitude towards the elderly.
This study has some limitations. Data can only be generalized to the nursing care students studying in first and second grades. Data was limited to the information that could only be obtained from students who agreed and attended to participate and were not absent on the days instruments were applied. Attitude towards the elderly could change from one individual, culture, society to others. Therefore, it cannot be generalized. Attitude towards the elderly may vary each year within the framework of nursing education. This can affect attitude towards the elderly at different times. Attitude towards the elderly can be affected by perception of ageing.