Nurse Education Today 29 (2009) 617–622

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Nurse Education Today

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Attitudes and knowledge of the Greek nursing students towards older people

Ekaterini Lambrinou a, Panayota Sourtzi b,*, Athena Kalokerinou b, Chrysoula Lemonidou b

a Nursing Department, Faculty of Health Sciences, Cyprus University of Technology, 215 Lemessos Ave, 2252 Latsia, Nikossia, Cyprusb Faculty of Nursing, University of Athens, 123 Papadiamantopoulou Street, 11527 Athens, Attica, Greece

a r t i c l e i n f o

Article history:Accepted 26 January 2009

Keywords:AttitudesKnowledgeOlder peopleNursing students

0260-6917/$ - see front matter � 2009 Elsevier Ltd. Adoi:10.1016/j.nedt.2009.01.011

* Corresponding author. Tel.: +30 2107461474; faxE-mail address: psourtzi@nurs.uoa.gr (P. Sourtzi).

s u m m a r y

Background: The proportion of older people has increased worldwide and so are the health problemsrelated with ageing, such as cardiovascular diseases and cancer that often need long-term nursing care.Nurses therefore, have a pivotal role in the care of older people.Aim: To evaluate the effects of education on nursing students’ knowledge and attitudes towards olderpeople in Greece.Method: Two hundred and twenty seven first and final year nursing students at a university and 191 firstand final year nursing students at a Technological Education Institute completed a questionnaire, includ-ing demographic questions, the Kogan’s Old People Scale and the Palmore’s Facts on Aging Quiz I.Results: Attitudes towards older people were more positive in final year students in comparison to firstyear ones in both schools. Knowledge was found better only in relation to physical health in the final yearstudents, in both schools. Age and female gender were found to influence both attitudes and knowledgepositively.Conclusions: Nursing education in Greece seems to influence the attitudes and knowledge of nursing stu-dents towards older people. However, revisions and improvements in curricula are needed if nursing stu-dents are to gain a more holistic perspective of older people.

� 2009 Elsevier Ltd. All rights reserved.

Introduction

The ageing of the population is one of the most complicatedproblems of contemporary societies. The population of Greece isageing rapidly, a common phenomenon in most of the developedcountries. Persons aged 65 years or older represented 18% of theGreek population in 2005 and this percentage is expected to in-crease to over 30% by the year 2050. Similar trends are observedin most European countries (Eurostat, 2006).

The ageing of the population has a direct effect on health caresystems as it is presented with higher incidence of chronic diseasesthat often require long-term care. Nurses are the main profession-als that provide the required services; therefore, their role on thecare of older people is of great importance (Drennan et al., 2004).In order to respond to the needs resulting from the trends de-scribed above, nursing education has responded by developinggerontological nursing specialisation. However, this does not seemto be a popular one because nurses declare that they do not find itchallenging and interesting (McKinlay and Cowan, 2003).

Attitudes of nurses seem to affect the preference for workingwith older people as well as the quality of care offered to them(McDowell et al., 1999). Education plays an important role in thedevelopment of professional cultures and seems to have either a

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positive or a negative influence to the attitudes of health care giv-ers. Even more, culture, age and sex seem to affect the develop-ment of attitudes towards older people (Fagerberg et al., 1997;McDowell et al., 1999; Soderhamn et al., 2001).

Until now there have been no published studies in Greece thatevaluate nursing education in relation to the care of older people.Only a small exploratory qualitative study that described nursingstudent’s attitudes toward the care of older people has been per-formed, which concluded that there is a need for further explora-tion (Kotzabassaki et al., 2002).

Background

Attitude expresses the perception of a person towards a humanbeing, an object or a condition, which is developed by the person’sexperiences and defines his or her reactions, while knowledge is toknow something by studying, exercise, education; it is the experi-ence of things and wisdom (Chountoumadi and Pateraki, 1997).Attitude contains three parameters: emotions, knowledge andthe way of acting and all three parameters can change (Joy et al.,2000; Soderhamn et al., 2001). Several factors such as culture,age, gender, education, experience and previous relationships witholder people, have been studied and seem to influence nurses’ atti-tudes toward older people (McDowell et al., 1999; Hweidi and Al-Obeisat, 2006).

618 E. Lambrinou et al. / Nurse Education Today 29 (2009) 617–622

Education can have either a positive or negative influence onnurses’ attitudes (McDowell et al., 1999; Davies et al., 1999; Soder-hamn et al., 2001). It is the main variable that has been found tomake a significant and consistent positive difference to overall lev-els of knowledge (Palmore, 1998) and on changing social influ-ences about ageing to a positive direction (Ford and McCormack,2000; Brymer et al., 2001; Fagerberg and Kihlgren, 2001). High le-vel of knowledge on gerontological nursing, as well as experienceon older people’s care seems to influence positively nurses’ atti-tudes towards older people (Fagerberg and Kihlgren, 2001; McKin-lay and Cowan, 2003; Wallace et al., 2006; Ryan et al., 2007).Clinical experience with older people of nursing students seemsvery important in shaping students’ orientation towards nursingthem (Alabaster, 2007). Equally important is continuing educationin order to alleviate social misconceptions about ageing (Davieset al., 1999).

Nursing education in Greece is offered at higher education levelby Universities and Technological Education Institutes (TEI). Allcandidates have completed 12 years of education and have takenpart in the national general entrance exams. Universities award aB.Sc. after a 4-year academic programme that includes 50% of the-ory classes and 50% skills laboratory work and clinical practice. Ba-sic science and nursing courses that include knowledge andexperience on ageing and older people’s care are taught through-out the study programme. In addition to these, an elective courseon gerontology nursing is included. The TEI 4-year professionalprogramme also includes 50% clinical practice. The organisationof the study programme includes 3.5 years of theoretical and clin-ical study and at the end students are required to work for sixmonths under the supervision of clinical staff, before registrationis awarded. The content of the programme includes compulsorycourses on geriatrics and gerontology nursing (Lambrinou, 2005).

The main difference between the two ways of studying nursingin Greece is that the TEI programme focuses on professional skills,while the university programme equips students with strongertheoretical knowledge. In addition to those there is a differencein the admission scores of the candidates, with university studentsachieving much higher ones. Both programmes satisfy the Euro-pean guidelines for the education of a general nurse and are re-viewed from time to time to be relevant with contemporaryhealth and nursing issues. As there is no evaluation of effectivenessof the curricula on knowledge and attitudes to older people, thefindings of the study presented here could be used in future curric-ula development.

Aim

The aim of the study was to evaluate the effect of Greek nursingeducation on students’ knowledge and attitudes towards olderpeople and assess if there were any differences between TEI anduniversity prepared nursing students. This study also sought to as-sess possible relationships between knowledge and attitude scoresand other variables such as age, gender and previous experiencewith older people.

Methods

Study design, setting, sample

The study was designed as a cross-sectional survey. It was per-formed in the Faculty of Nursing of one university and in the Nurs-ing Department of a TEI in Greece.

The study population consisted of all first and final year stu-dents in both schools. The first year students were selected be-cause it was thought that they would not have prior organisedknowledge and experience on older people’s care, while the final

year students were expected to have acquired all knowledge thatwas available throughout their education. The university students’sample consisted of the total population, as at the time of the studythere was only one university programme in Greece. As for the TEIsample, again the total population of students of the respectiveyears of one TEI was included. The specific department was se-lected between the seven operating in the country randomly. AllTEI departments follow the same curriculum and candidates havesimilar entrance scores (Lambrinou, 2005). It was thereforethought that the specific student’s population could be representa-tive of all TEI students. The total sample number consisted of 418students – 121 first year and 106 final year students of the univer-sity (response rate 69.14% and 62.35%, respectively) and 112 firstyear and 79 final year TEI students (89.6% and 68.2%, respectively).

Instrument

The students were given a self-completed questionnaire inGreek. The questionnaire included demographic questions, the Ko-gan’s Old People Scale (Kogan, 1961) and the Palmore’s Facts onAging Quiz I (Palmore, 1998). Both questionnaires were translatedinto Greek following permission by the respective authors.

Kogan’s Old People Scale (1961) is a Likert scale and measuresattitudes toward the older people. This consists of 17 positivestatements (positive subscale, OP+), e.g. ‘‘More old people are capa-ble of new adjustments when the situation demands it” and 17 nega-tive statements (negative subscale, OP�), e.g. ‘‘Most old people tendto let their homes become shabby and unattractive” on a six-pointscale ranging from strongly agree to strongly disagree. A higherscore on the positive scale (score of all positive items) indicates afavourable disposition towards older people, while a higher scoreon the negative scale (score of all negative items) represent anunfavourable disposition (Kogan, 1961). The instrument’s internalconsistency measured by Cronbach’s a has been found to rangefrom 0.66 to 0.77 for the positive subscale and 0.73–0.83 for thenegative subscale (Kogan, 1961; Soderhamn et al., 2000), whilefor the whole scale it was found 0.79 (Soderhamn et al., 2000).Validity of the instrument has been found adequate (Kogan,1961; Soderhamn et al., 2000). Kogan’s Old People Scale was trans-lated into Greek and was found to possess adequate reliability –a = 0.73 for the OP� scale, a = 0.65 for the OP+ scale and 0.80 forthe total scale – and validity (Lambrinou et al., 2005).

Facts on Aging Quiz I (FAQ I) contains 25 true/false statementsabout ageing. The statements cover the basic physical [e.g. Lung vi-tal capacity tends to decline in old age], mental [e.g. Depression ismore frequent among the elderly than among younger people], socialfacts [e.g. At least one tenth of the aged are living in long-term insti-tutions] and the most frequent misconceptions about ageing [e.g. Ingeneral older people look alike] (Palmore, 1998). The instrument’sreliability has been found to range from a = 0.50 to 0.80 (Palmore,1998). The Greek version of FAQ I was found to possess adequatereliability with a = 0.68 (Lambrinou, 2005).

Ethical considerations

Appropriate ethical approvals were sought and granted by therelevant authorities in each school, following explicit informationon the aim of the study. School authorities were also assured thatthey would be informed on the study results, as well as for theintention to publish them in the scientific press.

All students were asked to participate voluntarily after havingreceived information on the study. Questionnaires were distrib-uted and collected by the principal researcher during allocatedclass time. The questionnaire was anonymous and there were nohints to identify the students. The completion and return of thequestionnaires were perceived as consent giving to participate in

Table 2Kogan’s Old People Scale scores for the UOA students.

Kogan’s subscales Students Mean SD t p

Negative subscale’s total score First year 65.02 12.93 1.75 0.08Final year 62.28 10.60

Positive subscale’s total score First year 68.62 10.60 �1.99 0.04Final year 71.28 9.30

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the study. Following the analysis and presentation of results, com-pleted questionnaires were stored in a secure locker to which onlythe principal researcher had access.

Analysis

Questionnaires were coded according to the directions given byKogan (1961) and Palmore (1998) and analysis was performed bythe Statistical Package for the Social Sciences, SPSS 10.0. For totalscale and subscale scores of Kogan’s Old People Scale the t-testwas used because mean values of the sample were normally dis-tributed. Pearson chi-square test was used for the analysis ofFAQ I data. Relationships between knowledge and attitudes werestudied by Spearman correlation coefficients (rs) and for variablessuch as age and gender linear regression was used (Burns andGrove, 1997). Statistical significance level was at 0.05.

Results

University, Faculty of Nursing

Demographic characteristicsStudents (n = 227) who were present in class participated in the

study. These consisted of 121 first year nursing students and 106final year students. The results showed that final year studentshad more working experience with older people (13.5%) than thefirst year students (3.4%). Most students had older people in theirfamilies and many had the experience of living with them (see Ta-ble 1).

Attitudes towards older peopleFinal year students had a lower total score than the first year

students for the Kogan’s negative subscale (mean scores 62.28and 65.02, respectively) but not at a statistically significant level.For the positive subscale final year students had statistically signif-icant higher total score than the first year ones (mean scores 71.28and 68.62, respectively) (Table 2).

Knowledge about ageing and older peoplePalmore’s FAQ I scores were similar for the final and first year

students. No statistical difference was observed. However, all stu-dents had high scores in the physical facts part of the questionnaireand there was also a statistically significant difference in favour ofthe final year ones (Table 3).

Demographic variables were examined to see whether theyinfluence the direction or magnitude of changes in scores. Linear

Table 1Demographic characteristics of the UOA students (n = 227).

Demographic characteristics Answers First year n

Gender Male 18 (14.9)Female 103 (85.1)

Age Mean (SD) 18.67 (2.20Nursing science-first choice for studying Yes 36 (29.8)

No 85 (70.2)Work experience Yes 4 (3.3)

No 116 (96.7)Work experience with older people Yes 4 (3.4)

No 115 (96.6)Family condition Married 3 (2.5)

Not married 118 (97.5)Other

Older people in the family Yes 78 (64.5)No 43 (35.5)

Have lived with older people Yes 18 (14.9)No 66 (54.5)Occasionally 37 (30.6)

regression was performed to check if gender, age, previous experi-ence with older people, family condition and choosing nursing asthe first choice of studying, influence students’ attitude and knowl-edge towards the older people. None of these were found to affectfirst year students’ attitudes. FAQ I score was found to be influ-enced by age (p < 0.05), where a significant increase in the scorewas observed as the students’ age grew older. Final year students’results seem to be related with more independent variables. Ko-gan’s negative subscale score was related with gender and whetherthere were older people in the family. Girls were found to have lessnegative attitudes than boys and students whose family did not in-clude older people also have had less negative attitudes. Kogan’spositive subscale score seems to be related with gender, wheregirls seem to have a more positive attitude than boys. No signifi-cant differences were found in the knowledge score.

Correlation coefficients were calculated between total score ofknowledge and the scores of Kogan’s attitude subscale. For firstyear students correlation coefficient between the negative subscaleand knowledge was rs = �0.34, p < 0.01, and between the positivesubscale and knowledge was rs = 0.31, p < 0.01. For the final yearstudents the findings were similar (rs = �0.33, p < 0.01, andrs = 0.21, p < 0.01, respectively).

TEI nursing department

Demographic characteristicsFirst (112) and final year (79) nursing students who were pres-

ent in class participated in the study. As shown in Table 4 many ofthe students had older people in their families and also had theexperience of living with them.

Attitudes towards older peopleFinal year students had a lower total score than the first year

students for the Kogan’s negative subscale but not at a statisticallysignificant level. For the positive subscale, final year students had ahigher total score than the first year ones but not in a statisticallysignificant level (Table 5).

= 121 (%) Final year n = 106 (%) v2 p

21 (19.8) 0.65 0.4285 (80.2)

) 23.13 (3.76) t = �11.05 0.0016 (15.1) 6.07 0.0190 (84.9)15 (14.2) 7.21 0.0191 (85.8)14 (13.5) 6.33 0.0190 (86.5)5 (4.7) 2.00 0.37100 (94.3)1 (4.0)75 (70.8) 0.75 0.3931 (29.2)21 (19.8) 0.94 0.6356 (52.8)29 (27.4)

Table 3Palmore’s Facts on Ageing Quiz I results for the UOA students.

Palmore’s facts Students Mean SD t p

Physical facts First year n = 116 5.22 0.99 �2.30 0.022Final year n = 103 5.50 0.69

Mental facts First year n = 117 1.67 1.12 1.42 0.16Final year n = 104 1.47 0.99

Social facts First year n = 117 2.20 0.11 0.019 0.98Final year n = 99 1.17 0.12

Most frequent misconceptions about ageing First year n = 114 2.29 1.35 1.06 0.29Final year n = 101 2.09 1.41

Palmore’s total score First year n = 112 11.41 2.82 0.49 0.62Final year n = 97 11.23 2.54

Table 4Demographic characteristics of the TEI students (n = 191).

Demographic characteristics Answers First year n = 112 (%) Final year n = 79 (%) v2 p

Gender Male 20 (17.7) 9 (11.5) 0.92 0.34Female 92 (82.3) 70 (88.5)

Age Mean (SD) 20.82 (5.11) 23.05 (2.81) t = �3.86 0.00Nursing science-first choice for studying Yes 56 (49.6) 17 (21.8) 13.91 0.00

No 57 (50.4) 61 (78.2)Work experience Yes 21 (18.6) 11 (14.3) 0.34 0.56

No 92 (81.4) 66 (85.7)Work experience with older people Yes 19 (16.8) 11 (14.3) 0.07 0.79

No 94 (83.2) 66 (85.7)Family condition Married 6 (5.3) 3 (3.8) 0.29 0.87

Not married 106 (93.8) 74 (94.9)Other 1 (0.9) 1 (1.3)

Older people in the family Yes 72 (63.7) 52 (66.7) 0.07 0.79No 41 (36.3) 26 (33.3)

Have lived with older people Yes 27 (23.9) 17 (21.8) 0.79 0.67No 72 (63.7) 54 (69.2)Occasionally 14 (12.4) 7 (9.0)

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Knowledge about ageing and older peopleMean scores in Palmore’s FAQ I were similar for the first and fi-

nal year students. The highest scores were observed in the physicalpart, in which final year students had a higher score at a statisti-cally significant level. It was also observed a statistically significantdifference in favour of the first year students in the part concerning‘‘most frequent misconceptions about ageing” (Table 6).

Additional analyses using linear regression were conducted toassess whether independent demographic variables influence thedirection or magnitude of changes in scores. Age was found to af-fect first year students’ attitudes, where older students had morepositive attitudes towards older people in both subscales, as wellas gender, where girls had more positive attitudes than boys. Gen-der was found to affect final year student’s knowledge scores. Boyswere found to have a higher score, meaning they had better knowl-edge than girls.

Correlation coefficients between knowledge and attitudes werefor first year students rs = �0.34, p < 0.01 for the negative subscaleand rs = 0.08, p > 0.05 for positive subscale. For final year studentsbetween the negative subscale and knowledge was rs = �0.41,p < 0.01, and between the positive attitude subscale and knowl-edge was rs = 0.29, p < 0.01.

Table 5Kogan’s Old People Scale scores for the TEI students.

Kogan’s subscales Students Mean SD t p

Negative subscale’s total score First year 67.10 11.57 1.63 0.10Final year 64.32 11.43

Positive subscale’s total score First year 70.38 10.21 �1.46 0.14Final year 72.63 10.76

Discussion

The care of older people will have an increasingly importantpart in the remit of health care professionals, especially nurses(McKinlay and Cowan, 2003; Ryan et al., 2007). Therefore, thepreparation of nurses in order to respond to the health care needsof older people is of great importance. Nursing curricula in Greecehave been changing from time to time although there have notbeen evaluated in order to determine if they are adequate in pre-paring students to be able to work with older people.

The key findings emerged from this study are related to the atti-tudes towards older people and knowledge of older people of nurs-ing students in Greece and are discussed below. Students’demographic characteristics were comparable in both schools, anexpected finding as all young persons – including nurses – starttheir higher education immediately after they graduate from highschool.

The results of Kogan’s Old People Scale for both nursing pro-grammes were comparable. All measurements showed more posi-tive attitudes towards older people at the end of nursing education,a finding that agrees with McDowell et al. (1999), with universityfinal year students showing the most positive attitudes towardsolder people. These results agree with authors who support thatnurses with higher level of knowledge and education also acquiremore positive attitudes toward older people (Fagerberg et al.,1997; McKinlay and Cowan, 2003; Wallace et al., 2006). It is diffi-cult to argue that this is only due to the curriculum or the quality ofstudents; therefore further investigation into the process of learn-ing by using the same students at different points of their studymay help reveal if this is a fact.

The results of Palmore’s FAQ I total score did not show differ-ences between first and final year students knowledge of older

Table 6Palmore’s Facts on Ageing Quiz I results for the TEI students.

Palmore’s facts Students Mean SD t p

Physical facts First year n = 108 5.12 0.95 �1.94 0.05Final year n = 71 5.40 0.99

Mental facts First year n = 110 1.41 0.92 1.76 0.81Final year n = 73 1.15 1.05

Social facts First year n = 108 2.36 1.32 �1.37 0.17Final year n = 73 2.63 1.24

Most frequent misconceptions about ageing First year n = 108 2.07 1.41 3.14 0.002Final year n = 72 1.44 1.15

Palmore’s total score First year n = 103 10.93 2.80 0.89 0.38Final year n = 68 10.56 2.49

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people in either school. Furthermore, their knowledge was averagein both schools. This finding although disappointing for this partic-ular group of students, it seems that is quite common in similarstudies (Lee et al., 2006; Mellor et al., 2007). Students in both pro-grammes had high scores in the physical facts part of the question-naire and final year students had statistically significant higher.This finding may show that existing curricula give emphasis onbiomedical aspects of ageing and not the psychosocial ones, a find-ing that is in accordance with McDowell et al. (1999) and Lee et al.(2006). It is therefore necessary to discuss how curricula could beimproved in order that students are able to care for the older per-son as a whole.

Previous studies have presented several independent variablesthat influence students’ attitudes and knowledge, such as cul-ture, age, gender and education (Fagerberg et al., 1997; McDo-well et al., 1999; Soderhamn et al., 2001). In this study, themost consistent moderating variables that were found to influ-ence attitudes and knowledge were age and gender. Female stu-dents in both schools have had more positive attitudes towardolder people. Final year students also had more positive atti-tudes, with older female students showing the most positiveattitudes and knowledge towards older people. Previous studieshave also presented similar results, which may mean that wo-men are more caring than men irrespective of cultural influences(Fagerberg et al., 1997; Soderhamn et al., 2001; Lee et al., 2006).Experience, although it did not produce significant findings by it-self in the present study, seems that improves both attitudes andknowledge, something that has been discussed by Alabaster(2007) as an important factor in helping students to choose theirfuture career.

Finally, the relationship between knowledge and attitudes seemvery strong in all students, a finding that may show that if studentsget better education in all aspects of ageing their attitudes may be-come ever more positive and therefore, their preference for work-ing with older people may increase. Therefore, the findings couldbe used as a guide in order to revise the curricula in both pro-grammes in a way that will promote positive attitudes through fur-ther clinical experience not only with older people in hospitals andnursing homes, but also with those living in the community, sothat misconceptions about ageing will be diminished (Alabaster,2007; Ryan et al., 2007). Reorganisation of theoretical content sothat it will not emphasise only on the biomedical aspects of ageing,could also be made so that there would be improved knowledge inall aspects of ageing and not only physical health.

Conclusions

The main conclusion of this study is that while education is pos-sibly making a difference more needs to be done in relation to pro-moting a more holistic curriculum related to caring for olderpeople. Therefore, it would be useful to investigate how the educa-tional programmes affect the same groups of students at different

times during their study. In addition to that, it would be importantto see how gerontology courses influence students’ attitudes andknowledge toward the older people.

The ageing population in Greece increases the need of appro-priate nursing care services. The preference of nurses to workwith older people and the quality of nursing care is influencedby nurses’ attitudes and knowledge toward the older people.Students’ attitudes of both Greek nursing programmes seem tobe influenced in a positive way but misconceptions about ageingpersist. Therefore, nursing curricula should develop in such away as to promote more positive attitudes towards older people,as well as to diminish misconceptions about ageing and empha-size the potential for job satisfaction arising from working witholder people.

Limitations of the study

One limitation of this study is the difficulty to compare directlythe two groups of students because of the different content andorganisation of their study. However, both programmes showedsimilar strengths and weaknesses and this could be used as a ref-erence for future curricula changes. Another limitation is the selec-tion of the sample, as it is difficult to support that first yearstudents had not any experience in caring for older people, asmany of them have had family experience or had lived with them.This prevents us from concluding that the observed differences inattitudes and knowledge was due to education only.

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