Study 1: Survey
Introduction
The purpose of Study 1 was to provide baseline data for developing a gerontological education program for an intervention in Study 2. The aims of Study 1 were to:
1) validate two instruments: Nolan’s Perceptions of Work with Older People
(PWOP) and Nolan’s Knowledge of the Situation of Older People (KSOP);
2) examine the reliability of four instruments: Kogan’s (1961) Attitudes Toward Old People Scale (KOP), Perceptions of Work with Older people (Nolan, Davies et al. 2001) (PWOP), Knowledge of the Situation of Older People (Nolan, Davies et al. 2001) (KSOP), and Palmore’s (1988) Facts on Ageing Quiz 1 (FAQ1);
3) gain a greater understanding of Taiwanese nursing students’ attitudes and knowledge about older people;
4) understand the relationships between two different instruments for measuring attitudes toward older people and two different instruments for assessing knowledge about older people;
5) examine the correlations among the four instruments (two on knowledge and two on attitudes) and the demographic data; and
6) determine the factors influencing attitudes toward and knowledge about older people.
This chapter describes Study 1 and presents sections on the research methods, results, and discussion. The research method section includes: research design; descriptions of the research sample and instruments; data collection procedures; human ethical considerations and data analysis. The results section reports: sample characteristics; validity and reliability of instruments; attitudes towards and levels of knowledge about older people; correlations among measures; correlations among attitudes, knowledge and demographic variables; and factors influencing nursing
students’ attitudes and knowledge. In the discussion section, the research questions
are addressed, as well as the limitations of the research and recommendations for future research and education.
Method
Research Design
A cross sectional research design was used in this study, by means of a survey of nursing students from a university in southern Taiwan. The dependent variables in
this study were nursing students’ attitudes toward, and knowledge about, older people.
For the purpose of this study, attitudes toward older people were defined as mental views based on cumulative experience and directed toward individuals: in this study,
the students’ thoughts and feelings about older people (Kogan 1961). Knowledge
refers to useful information that can be acted upon in the course of decision making, problem solving and critical thinking: in this study, the students’ information about older people (Palmore 1998).
The independent variables in this study were identified from the literature as those likely to influence attitudes toward and knowledge about older people. These
previous work experience in nursing, contact with older people in the family, frequency of current personal contact with older people, whether or not they had lived with older people, amount of clinical and lecture time devoted to older people, and amount and type of clinical practice.
Research Questions
The specific research questions addressed in this study were:
1. What are current Taiwanese nursing students’ attitudes toward and knowledge about older people?
2. Are there relationships between two attitudinal measures, Kogan’s (1961) Attitudes Toward Older People Scale (KOP) and Nolan’s
Students’ Perceptions of Work with Older people (2001), and between two knowledge measures, Nolan’s Student Nurses’ Knowledge of the
Situation of Older People (2001) and Palmore’s (1988) Facts on Ageing Quiz: Part 1?
3. What factors are likely to influence nursing students’ attitudes toward and knowledge about older people in this sample?
Sample
The target population consisted of all undergraduate nursing students in university undergraduate nursing courses in Taiwan. The sample for this survey was nursing students from a private university located in southern Taiwan. Because the aim of Study 1 was to provide baseline data, the selection criterion for the sample was all nursing students who were studying a nursing course at the selected university. A convenience sampling frame was used to request participation by undergraduate nursing students from the four-year program, including first, third, and fourth year
students and first and second year nursing students from the two-year program. As second year students in the four-year program were to be the sample for Study 2, they were not included in Study 1. The total sample available for the survey consisted of 429 four-year program and two-year program nursing students.
Students in the four-year program apply for university entrance via three different routes: (1) the “University Joint Entrance Examination Program” by which any high school graduate who achieves the university score in the entrance examination can apply for admission; (2) the “Entrance by Application Program” by which any high school graduate who meets a particular university’s admission standards can apply for admission; and (3) the “Recommendation Screening Examination Program” which allows students to decide on majors and universities to suit their own aptitudes and talents, while the universities can select students according to their examination performance (Department of Higher Education 2003). Thus the nursing students in the four-year program can come from any area in Taiwan.
The students in the two-year program are those who take an entrance exam which is held independently by universities for working adults only; the work experience and achievements of examinees may be taken into consideration when setting up the qualification standard (Department of Higher Education 2003). Thus the nursing students in the two-year program are registered nurses and usually come from the hospital near to the university.
So the four-year nursing program serves as the general nursing education program for students who have no nursing experience, while the two-year nursing program serves as a post-registration nursing education program for students who have graduated from a nursing college and have nursing experience.
Instruments
Nursing students were asked to complete a demographic data sheet (see Appendix 7) and two instruments to measure attitudes: Kogan’s (1961) Attitudes Toward Old People Scale (KOP) (see Appendix 2); and Perceptions of Work with Older People (PWOP) (Nolan, Davies et al. 2001) (see Appendix 3); and two instruments to measure knowledge: Palmore’s (1988) Facts on Ageing Quiz: Part 1 (FAQ1) (see Appendix 4); and Knowledge of the Situation of Older People (KSOP) (Nolan, Davies et al. 2001) (see Appendix 5). Consent for the use of each of the four established research instruments was obtained from its respective author or copyright holder (see Appendix 6).
Attitudes
Kogan’s (1961) Attitudes Toward Old People Scale (KOP) was used to measure nursing students’ attitudes toward older people. This scale has been
extensively used in studying attitudes toward older people; it consists of a total of 34 statements comprising 17 paired statements about older people, one of each pair is positively framed and the other negatively framed. In the original KOP scale, some items were adapted from available ethnic minority items by the simple substitution of the “old people” referent and other statements derived from Kogan and institutions regarding stereotypes and feelings about old people in society (Kogan 1961). The Soderhamn and Lindencrona (2000) study provided support for the construct validity of the KOP scale and its internal consistency, reporting a Cronbach alpha coefficient of 0.79 for the total KOP scale (Soderhamn & Lindencrona 2000). The scale used in the KOP is a six-point Likert response category format, consisting of strongly agree
(scored 6), slightly agree (scored 5), agree (scored 4), slightly disagree (scored 3), disagree (scored 2) or strongly disagree (scored 1). Total scores for the 34 items therefore ranged from 34 (negative) to 204 (positive). The 34 statements from the original scale were used for the Taiwanese version.
The KOP scale has been extensively used in gerontological studies, including studies of the attitudes toward older people held by nursing students (Hope 1994; McCracken, Fitzwater et al. 1995; Soderhamn, Lindencrona et al. 2001); oncology health care professionals (Kearney, Miller et al. 2000); medical students (Wilderom, Press et al. 1990), and therapeutic recreation students (MacNeil 1991). However, criticism of the scale has been made in other studies; a study by Hilt (1997) indicated limitations in the KOP scale. The KOP has been described as too lengthy and using ambiguous terminology (Palmore 1977; Hilt 1997; Cowan, Fitzpatrick et al. 2004). Also, the statements are based on stereotypes, so by answering the survey respondents would be reinforcing those stereotypes (Hilt and Lipschultz 1999). Furthermore, the KOP scale was developed in 1961 and the language used in the KOP scale reflects how society viewed older people 44 years ago. Because of these limitations, the current study also used Nolan et al’s (2001) instrument, Perceptions of Work with Older People (PWOP), to reflect a more up-to-date view of older people and specifically to focus on the perception of working with older people. Furthermore using both instruments enables the comparison of the reliability of KOP and KSOP.
The instrument Perceptions of Work with Older People (PWOP) is grounded in the experiences of nurses and students. Its authors, Nolan et al. (2001) noted that a number of significant issues had been identified during interviews and focus groups with nurses and students and used these issues as the basis for this questionnaire.
From these issues, Nolan and his team developed the statements in the instrument. The instrument consists of 15 statements, and covers three broad areas addressing
students’ perceptions of: working with older people in general; personal disposition
towards work with older people; and the consequences of working with older people. To answer all these items, participants are invited to indicate the level to which they agree using a 5-point Likert format as follows: 5 = strongly agree, 4=agree, 3=neither agree nor disagree, 2=disagree and 1= strongly disagree. Scores therefore can range from 15 to 75. Nolan used the PWOP to examine 718 student nurses’ perceptions of working with older people in the UK. However, as this is a recent instrument, the psychometric properties have not yet been established. The face validity had been derived from interviews and focus groups but there were no reports of the reliability and construct validity of the questionnaire Nolan et al. (2001), so the reliability and construct validity needed to be explored in this study. For the current study, all 15 statements from the original scale were translated into Taiwanese and no content was changed. Some word changes were necessary to ensure the translated instrument could be understood by the Taiwanese students.
Knowledge
Palmore’s (1988) Facts on Ageing Quiz 1 (FAQ1) and Nolan et al’s (2001)
Knowledge of the Situation of Older People (KSOP) were adapted to measure Taiwanese students’ knowledge about older people. The Facts on Ageing Quiz 1, which was developed by Palmore (1988), has been used extensively in recent times to
measure students’ knowledge about older people. The FAQ1 consists of 25 factual
statements on ageing which deal with social, physical, and psychological facts about
coded as 3. In order to calculate the total score for FAQ 1, a correct answer was recoded as 1 and an incorrect answer or ‘don’t know’ was recorded as 0. Thus the scores on FAQ1 could range from 0 to 25. Palmore (1988) reported a high degree of face validity. The Cronbach’s alpha reliability coefficient of .57 indicates only moderate internal consistency for the FAQ1 (Norris, Tindale et al. 1987). Because the quiz contains US statistics and the current survey aimed to measure Taiwanese
students’ knowledge about older people, one item was altered in order to reflect recent
data in Taiwan. The item “Over 20% of the population is now aged 65 or over” was changed to “Over 10% of the Taiwan population is now aged 65 and over” (see Appendix 4). Other items contained data applicable to Taiwan and therefore did not need to be adapted.
Although the FAQ1 has been used by many researchers, it contains implicit sources of negative bias. The design of the questionnaire can create a negative mindset because of the age group comparisons and the focus on the physical and economic frailty of many older people (Stuart-Hamilton 2000). Moreover, the FAQ1 is considered more a measure of attitudes than a measure of knowledge (O'Hanlon, Camp et al. 1993). The existing version of the quiz is now dated due to recent changes in demography and requires updating (Nolan, Davies et al. 2001). Therefore, the KSOP (Nolan, Davies et al. 2001) that was developed following criticism of the FAQ1 was also adapted to measure Taiwanese students’ knowledge about older people.
The KSOP contains 17 statements of the most up-to-date facts about the situation of older people in the UK. The response format asks individuals to indicate
right”, coded as 2, or “too low”, coded as 3. In order to calculate the total score of
KSOP, a correct answer was recoded as 1 and an incorrect answer was recoded as 0. A
“do not know” option is not provided, because if respondents do not know the correct
answer then useful insights can be gained from the direction in which they guess, as this will provide an indication of how they perceive older people (Nolan, Davies et al. 2001). The knowledge items were obtained from two primary sources: The Age File 99 (Leather 1999, cited by Nolan et al. 2001) and the Health Education Authority Fact Sheet 1: Older People in the Population (Health Education Authority 1998, cited by Nolan et al. 2001). The knowledge quiz contains items about the demographic profile of older people, their living circumstances, their employment and expenditure, their need for help and support and use of services. It was considered important to explore
respondents’ knowledge of a wide range of issues and not just those relating to
dependency or need (Nolan, Davies et al. 2001). The face validity of the questionnaire is derived from its sources, as cited above. However, Nolan et al.(2001) did not report the reliability of this questionnaire in their project. Modifications of the instrument were needed for the current study to take account of the facts and data as well as cultural differences relating to older people in Taiwan. The statements were altered in order to match contemporary data in Taiwan. However, one of the original items could not be included due to the unavailability of the statistical information on the proportion of income spent on heating and lighting in Taiwan. Accordingly there were only 16 items for this modified Taiwanese version of the KSOP (see Appendix 5). Possible scores on KSOP therefore ranged from 0 to 16.
Demographic data
The demographic variables comprised the factors identified in the literature as potential predictors of attitudes towards older people. These included students’ age, gender, frequency of personal contact with older people, amount of clinical and lecture time devoted to older people, experience of clinical practice, educational level, year of the course, amount and type of exposure to older people and previous work experience. This demographic data sheet is attached in Appendix 7.
Translation of instruments
Quality of translation and validation of translated instruments play an important role in ensuring that the results obtained in a study are not due to errors in translation, but rather are due to real differences or similarities between cultures in the phenomena being measured (Maneesriwongul and Dixon 2004). Brislin’s (1970) report on back-translation for cross-cultural research provides guidelines for translating from English to other languages. Brislin (1970) suggested to use one or more of the following translation techniques: (1) translation and back-translation, where the original source language version is translated to a target language version and then this is translated back into the original source language in order to verify the translation (Maneesriwongul and Dixon 2004); (2) bilingual technique, the use of bilingual people to detect items yielding different responses between two language versions (Maneesriwongul and Dixon 2004); (3) the committee approach, the use of bilingual people to translate from the source to the target language; and (4) pre-test procedure, used to ensure that the users can understand all questions. There were five steps planned for the translation phase of Study 1.
data sheet were translated from English to Chinese by three bilingual people. Secondly, the Chinese version was independently back-translated into English by three other bilingual people who had not seen the original English version and who
had a master’s level qualification in nursing. Thirdly, the researcher and one English
native speaker compared the translation and back-translations with the original English versions of each instrument to look for differences in wording expression and meaning that might lead to differences in meaning while going through the translation and back-translation processes. For those words where some differences were found in the meaning, the researcher chose another more appropriate word for the Chinese version. Fourthly, ten undergraduate nursing students piloted the Chinese version of the four instruments and demographic data sheet in order to examine the understanding of the Chinese versions. Then, the researcher talked to the students as a group to check the level of understanding of each instrument. Only minimal changes of Chinese words were needed for the demographic data sheet to promote greater understandable. Finally, the researcher examined both the Chinese and English version one more time for equivalence.
Procedure
Permission to conduct the research was obtained from the university where the study was to be conducted. Then, ethical approval was obtained from the Queensland University of Technology ethics committee. The dean of the selected Taiwanese university arranged several possible dates and times for data collection. Data were collected by the researcher over a period of 3 weeks. The questionnaires were
distributed and collected during students’ lecture times. The permission of each class
lecturer was also gained. Students in each class were given a description of the study, an information sheet and informed that participation in the study was voluntary and
their study program would not be affected if they did not participate. If they agreed to participate, students were asked to sign an informed consent sheet. Some students did not complete the informed consent sheet and therefore did not complete a questionnaire or participate in the survey.
Students consenting to participate were requested to complete the following questionnaires: the demographic information sheet, KOP, PWOP, FAQ1, KSOP. Students spent about 30 minutes to complete them in class time and returned them immediately to the researcher at the end of class. The available survey sample was 429 nursing students; 302 of them completed the questionnaires, a response rate of 70%.
After a period of two weeks and taking account of their lecture schedule, students in one of the first-year classes in the four-year program were chosen for the re-testing of the instruments using the same environment and procedure. The sample size for the test-retest was 43 nursing students.
Ethical Considerations
Ethical approvals to conduct this survey were obtained from the QUT University Human Research Ethics Committee (see Appendix 8) and from the Taiwanese university (see Appendix 9). Copies of the student information sheet and consent form are attached as Appendices 10 and 11.
The main ethical considerations were confidentiality. It was important to ensure that each questionnaire would be identified by a number only. Students were assured that all information provided would be kept in strict confidence in a locked filing cabinet during the study period and would be held for five years, after which the
data would be destroyed. Data were secured on a password-protected computer file with access available only to the researcher. Full assurances were provided to all participants that all information collected was confidential and would be not disclosed to anyone other than the researcher. Students were also advised that no information about the project would be published in any form that would allow any individual or