Nurses' Attitudes Toward Older Patients in Acute Care in Israel

Maxim Topaz, RN, MA; Israel (Issi) Doron, LL.B, LL.M, PhD


Online J Issues Nurs. 2013;18(2) 

In This Article

Abstract and Introduction


Ageism has been found to negatively affect the health care services that older persons receive, both implicitly through unfair resource allocation by the stakeholders, and explicitly, by providing offensive and poor quality treatment. In this article, the authors review the literature relating to ageing, noting that negative attitudes among caregivers toward older patients in acute care settings are a strong predictor of ageism. They describe a study in which they explored a group of Israeli nurses' knowledge of ageing and attitudes toward older people in an acute care setting and analyzed the relationship between these variables using a descriptive, correlational design method. Nurses working in one of the largest public hospital in Israel completed Kogan's Attitudes Towards Older People Scale and Palmore's Facts on Ageing Quiz. Findings indicated that the nurses' level of knowledge of ageing was relatively low. The authors discuss nurses' knowledge of ageing and nurses' ethnicity as significant predictors of ageist attitudes. They conclude by recommending that nurse educators strengthen gerontological content in the nursing curriculum and provide culturally tailored nursing education to reduce ageism among professional nurses.


Until the early 18th century, global population size was relatively static and the lives of the vast majority of people were "nasty, brutish, and short" (Bloom & Canning, 2008, p 4.). Since then, the size and structure of the global population have undergone extraordinary changes. In particular, life expectancy has increased by three decades and in the 21st century it is projected to further increase by yet another two decades (Bicket, 2002). In Israel, the population is relatively young. However, the demographic trend is similar to that found in many developed countries in that the population is ageing. Israeli life expectancy at birth is currently 80.4 years; persons over 65 years of age constitute 10.1% of the population (Israeli Agency, 2009)

This increase in the older population (65 years and older) requires that health care systems worldwide respond to new challenges (Crimmins, 2004). One prominent issue in the field of gerontology is discrimination against individuals based on their chronological age, a phenomenon that is often termed 'ageism' (Corner, Brittain, & Bond, 2007; Nelson, 2002). Ageism has been found to negatively affect the health care services that older persons receive, both implicitly through unfair resource allocation by the stakeholders, and explicitly, by providing offensive and poor quality treatment (Lothian & Philp, 2001). Negative biases and ageist attitudes among caregivers, and particularly nurses, toward older people in acute care settings, are among its more notable expressions in the health care system (Holroyd, Dahlke, Fehr, Jung, & Hunter, 2009). Identifying those attitudes constitutes the first step in understanding the many facets of interactions between nurses and older patients.

Ever since Allport's intergroup contact theory was described in the early 1950s, social and educational sciences theoreticians have maintained that attitudes have a strong influence on an individual's actual behavior (Ajzen, 2005; Allport, 1954). It is important to identify both nurses' attitudes toward older patients and the factors that correlate with those attitudes to understand, predict, and if necessary, change behaviors of nurses working with an older population, thus minimizing ageism in nursing practice.

Literature Review

In this literature review, we will consider two branches of research regarding nurses' attitudes toward older patients. First, we will summarize research addressing nurses' attitudes toward older patients in acute care; then we will consider factors affecting nurses' perceptions of old age.

Nurses' Attitudes Toward Older Patients in Acute Care

Research indicates that the quality of health care services provided to the older population is strongly influenced by caregivers' attitudes toward older people (Gallagher, Bennett, & Halford, 2006; Jacelon, 2002). Affirmative attitudes of nurses have a positive influence on the health of older patients (Courtney, Tong, & Walsh, 2000a). Nurses with constructive attitudes toward older people have been noted to listen attentively, bond deeply, assist respectfully, and engage in friendly relationships with their clients (Courtney et al., 2000a; Jacelon, 2002). In contrast, nurses that expressed negative attitudes toward older people indicated they preferred to work with younger patients. When caring for older patients, these nurses were more likely to use physical restrictions; to disrespect the patients' autonomy and dignity; and to discriminate against them (Nelson, 2004; Seedhouse & Gallagher, 2002; Wai-Tong & Lee, 2007).

Studies examining nurses' attitudes toward older, acute care patients have had inconsistent findings. For example, in the United States, positive attitudes by nurses toward older patients were reported in the geriatric and surgical departments of various hospitals (Hope, 1994). In Jordan and Australia, similar attitudes have been reported by several researchers who have studied nurses in medical-surgical wards (Hweidi & Al-Hassan, 2005; Mellor, Chew, & Greenhill, 2007). In contrast, negative attitudes toward older patients were noted in Ireland and Sweden (Gallagher et al., 2006). Because nurses' attitudes are modifiable and because there is evidence these attitudes vary from country to country (Ajzen, 2005), we believed it was important for us to assess nurses' attitudes to older, acute care patients in our country (Israel) so as to enhance the quality of health care for our older persons.

Factors Affecting Nurses' Perceptions of Older People

Current literature on attitudes toward older people tends to focus on the caregiver's education and personal characteristics, as well as the work environment. Theoretical models (Ajzen, 2005) and empirical findings have suggested that characteristics influencing a nurse's attitude towards ageing include: (a) age (Herdman, 2002; Hweidi & Al-Hassan, 2005; Soderhamn, Lindencrona, & Gustavsson, 2001); (b) gender (Cummings, Kropf, & DeWeaver, 2000; Hweidi & Al-Hassan, 2005; Soderhamn et al., 2001); and (c) education (Cummings et al., 2000; Soderhamn et al., 2001). Environmental factors affecting these attitudes include (a) the field of employment in nursing (such as acute care, long term care, or rehabilitation settings) (Courtney, Tong, & Walsh, 2000b; Hartley, Bentz, & Ellis, 1995; Hope, 1994; Hweidi & Al-Hassan, 2005; Soderhamn et al., 2001; Teeri, Leino-Kilpi, & Valimaki, 2006); (b) amount and type of exposure to older persons (Courtney et al., 2000a); and (c) type of department in which staff are employed (Courtney et al., 2000a). To date, the most important factor identified as influencing patient care is the nurse's level of knowledge of ageing (Holroyd et al., 2009).

Although each of the above factors has been correlated with nurses' attitudes toward older people, the directions of the correlations have been inconsistent. For example, Herdman (2002) found that older nurses expressed negative attitudes toward older people, whereas Murphy (2007) found that older nurses experienced positive attitudes. Other researchers have reported no significant correlation between nurses' age and attitudes toward older people (Chasteen, Schwarz, & Park, 2002; Hweidi & Al-Hassan, 2005). Previous work experience is another factor found to affect nurses' attitudes toward older people. Teeri et al. (2006) and Williams, Zimmerman, Sloane, and Reed (2005) reported that nurses working in long-term care institutions acquired paternalistic views. Other reports, however, have noted that clinical experience in chronic care institutions had a positive effect on positions regarding older people (Hartley et al., 1995; McKinlay & Cowan, 2003). Soderhamn et al. (2001) have stated that there is no clear correlation between the type of care facility and views of the elderly.

Mixed evidence also continues to be reported with regard to nurses' formal education and their attitudes toward older patients. On one hand, nurses with a higher level of formal education in geriatrics and gerontology were found to have more positive attitudes than those with little or no education in the field (Courtney, et al., 2000a). Hartley et al. (1995) have also argued that education has a major impact on these attitudes. Additionally, Furze and Pearcey (1999) have suggested that nurses with higher levels of geriatric and gerontological education demonstrate a higher degree of understanding of older person's needs and desires, and display a generally more positive attitude toward older persons. On the other hand, Buttner (2008) and Hweidi and Al-Hassan (2005) found no correlation between nurses' and nursing students' attitudes and their levels of education. Holroyd et al. (2009) from Canada identified a drop in positive attitudes and an increase in negative attitudes toward older people between first and last year nursing students.

These mixed findings are problematic, especially for nurse educators. Without solid empirical validation of the direction of the relationship between nurses' knowledge and attitudes, it remains challenging to design a nursing curriculum to meet the needs of our rapidly ageing populations. More research is needed to clarify these inconsistencies.

Since attitudes toward older people have been noted to vary between countries, some of the differences in research findings might be attributed to the effects of cultural and ethnic environments. For example, some researchers claimed that Asian cultures, based on the principles of Confucianism and Filial Piety, embrace more positive attitudes toward older people (Laidlaw, Wang, Coelho, & Power, 2010). Palmore, Branch, and Harris (2005), however, noted that Western, individualistic cultures tend to view older persons negatively, as frail and dependent members of society who become a burden after a certain age

Israeli society is notably diverse in terms of ethnic backgrounds that include Jewish immigrants from a variety of other countries and also Arab populations. A third of the Israeli Jewish population are of European or American origins, about 25% are of Asian or African origin, and 16% are Arabs (Central Bureau of Statistics, 2010). Moreover, since the dissolution of the Union of Soviet Socialist Republics, over one million Soviet Jews have immigrated to Israel (and now comprise about 14% of the Israeli population). The unique, Israeli, socio-ethnic mix makes it challenging to determine the most prevalent views of ageing. To date, only one study has empirically investigated nurses' attitudes toward older people in the Middle East. This study was conducted in Jordan, a more ethnically homogeneous country than Israel (Hweidi & Al-Hassan, 2005). Because of the differences in government structures, legal systems, and cultures, it is challenging to generalize the conclusions of the Jordanian study towards Israel or other Middle Eastern countries.

In light of the inconsistent evidence related to factors affecting nurses' attitudes toward older people, we conducted what we have found to be the first study investigating those relationships in Israel. We did so recognizing that identifying similarities and differences between health care settings in different countries is vital for improving the quality of health care provided to older persons.