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Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

The relationship between nursing students' professional values and their

attitudes towards the elderly people: A cross-sectional study☆ ,☆ ☆
Emel Bahadir-Yilmaz
Giresun University, The Faculty of The Health Sciences, Department of Midwifery, 28340 Piraziz, Giresun, Turkey.

ARTICLEINFO ABTRACT

Keywords: Background: Professional values involve standards that are effective in solving problems, interacting with pa-
Nursing student tients, making decisions on patient care and forming the student's attitude. Throughout the course of the nursing
Ageism students' occupational education, these standards shape their attitudes, beliefs, and behaviors regarding the
Professional values provision of care for individuals.
Objective: The aim of this study was to determine the relationship between nursing students' professional values
and their attitudes towards the elderly.
Design: A cross-sectional research design was used in this study.
Settings: This study was conducted at a university in the northeast of Turkey.
Participants: 2nd-year (n = 93), 3rd-year (n = 101) and 4th-year (n = 81) nursing students.
Method: The data for the study were collected using a Personal Information Form, the Nursing Professional
Values Scale- Revised (NPVS-R) and the Ageism Attitude Scale (AAS). In the data analysis, independent samples
t-test, ANOVA and Spearman Correlation were used.
Results: The study found that the nursing students' average total NVPS-R score was 86.4 ± 16.2 and their
average total AAS score was 82.7 ± 8.8. Furthermore, a significant correlation was observed between the
professional values of the students and their attitudes towards the elderly (r = 0.407, p = 0.000). A positive,
moderately strong correlation was determined between the total NPVS-R scores and the ‘restricted life of elderly
people’ and ‘positive attitudes towards elderly people’ sub-scales of AAS (r = 0.418, r = 0.317, p < 0.005,
respectively).
Conclusion: The present study has demonstrated that the nursing students' professional values are associated
with their attitudes towards the elderly. In the light of these results, it is suggested that professional values be
taught and that courses on values be added to the curriculum in order to improve the attitudes of the students
towards ageism.

1. Introduction
The elderly population rate is gradually increasing in Turkey, just as
it is throughout the rest of the world. According to the Turkish
Statistical Institute (TSI), the elderly population in Turkey (age 65 and
over) stood at 5,682,003 in 2012 but grew by 17.1% in the last five
years, becoming 6,651,503 in 2016 (TSI, 2012). It is estimated that the
elderly population will increase to 8.6 million people by 2023 (TSI,
2013). According to the latest reported data, 23,347 elderly persons
receive services in a total of 351 nursing homes throughout Turkey -
number which seems to be inadequate (Ministry of Family and Social
Policies, 2016). In this context, it is essential to assess healthcare
providers' attitudes towards the elderly people. Because the increasing
demand for healthcare from older people with their chronic diseases
and functional impairments requires the contributions of healthcare
providers within care delivery (Liu et al., 2012). Ageist attitudes to-
wards older adult care have been linked to poor quality care, such as
reducing older adult independence and decision-making (Courtney
et al., 2000).
2. Background
In studies conducted with nursing students, it has been observed
that students are not interested in working with them following

☆
Support: No sources of any supports.
☆☆
This study is accepted as an oral presentation at the International Congress on Multidisciplinary Approach to Elderly Health and Care, Ankara, Turkey, March 22–
23, 2018.
E-mail address: emel.bahadir.yilmaz@giresun.edu.tr.

https://doi.org/10.1016/j.nedt.2018.08.007
Received 28 February 2018; Received in revised form 28 June 2018; Accepted 14 August 2018
02 60-6 917/© 2 0
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E. Bahadir-Yilmaz
graduation, they do not feel ready to work with and do not have ade-
quate knowledge about the elderly people (Bleijenberg et al., 2012;
Frost et al., 2016; Haron et al., 2013; Henderson et al., 2008;
Rathnayake et al., 2016). The studies that have aimed to determine the
attitudes of nursing students towards elderly people in Turkey have
found that generally, nursing students have negative attitudes towards
the elderly people (Ayoǧlu et al., 2014; Şenol Çelik et al., 2010), al-
though there are some studies indicating the opposite (Ayaz Alkaya and
Birimoğlu Okuyan, 2017; Demir et al., 2016).
One of the more prominent reasons nursing students do not want to
work with the elderly, as reported by various studies, has to do with
their attitudes towards elderly people (Ayoǧlu et al., 2014; Chi et al.,
2016). As a result, it is important to determine the factors that affect
students' attitudes. The some studies have reported that age, sex and
experience in working with the elderly do not affect students' desire to
work with the elderly people (Abreu and Caldevilla, 2015; Carlson and
Idvall, 2015; Demir et al., 2016); while others have indicated that age,
sex, experience in working with the elderly people and preference to-
wards working with the elderly do in fact affect students' attitudes to-
wards the elderly people (Özer and Tekeş, 2014; Özdemir and Bilgili,
2016; Rathnayake et al., 2016; Runkawatt et al., 2013; Shen and Xiao,
2012; Türgay et al., 2015).
Henderson et al. (2008) revealed that nursing students attributed
their lack of interest to the nature of the work, a fear of dealing with
death, dying and suffering, and difficulties in communicating with
older adults. A prominent issue surrounding ageism is the contribution
of university curriculum in influencing ageist attitudes (Algoso et al.,
2016). University curricula are often structured to progress students'
nursing abilities towards technically advanced skills (Abbey et al.,
2006). But nursing education has been shown to have an important role
in changing nursing students' attitudes towards the elderly people and
influencing their occupational decisions (King et al., 2013). Providing
care for the elderly people in clinical practices is mentioned as being the
most important piece of occupational education affecting the attitudes
of nursing students towards the elderly people (Chi et al., 2016). When
evaluated in this direction, certain studies have demonstrated that
nursing education is effective in changing the students' attitudes to-
wards the elderly people in a positive direction (Özer and Tekeş, 2014;
Hweidi and Al-Obeisat, 2006; Lambrinou et al., 2009; Özdemir and
Bilgili, 2016; Redfield et al., 2016). However, these studies have not
identified more of the specific components of nursing education that
affect the students' attitudes towards the elderly people. For this reason,
it is believed that ascertaining the degree to which occupational values,
which are important components of occupational education, affect the
students' attitudes towards the elderly people will significantly con-
tribute to the literature on this subject.
3. Methods
3.1. Aim and Design of the Study
The present cross-sectional study aims to better understand the re-
lationship between nursing students' professional values and their at-
titudes towards the elderly. The study sought to answer the question “Is
there a relationship between nursing students' professional values and
their attitudes towards the elderly?”
3.2. Sample and Setting
The population of the study consisted of 326 students who were
enrolled in the nursing department in the 2016–2017 academic year.
All 326 students (116 second-year, 106 third-year and 104 fourth-year
students) were included in the study and therefore, no sampling method
was used. The data for the study were collected from second-year
(n = 93), third-year (n = 101) and fourth-year (n = 81) nursing stu-
dents during the fall term of the 2016–2017 academic year. The
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inclusion criteria included a) being a second-year, third-year or fourth-
year nursing student, and b) having clinical experience with patients.
The incomplete questionnaire, unwillingness and absenteeism were
considered the exclusion criteria. However, a total of 51 students were
excluded from the study because of absenteeism or unwillingness to
participate in the study. The 1st-year nursing students were not in-
cluded in the study owing to their lack of clinical experience and pro-
vision of care to patients. The total response rate of the participants was
84.3%.
3.3. Data Collection Tools
The data for the study were collected using a Personal Information
Form, the Nursing Professional Values Scale- Revised (NPVS-R) and the
Ageism Attitude Scale (AAS).
3.3.1. Personal Information Form
This form was developed by the researcher in line with the most
recent literature and included questions on age, gender, type of family
structure, place of residence, parents' education level, parents' working
status, whether or not they gave care to older people during clinical
practice, and whether or not they wanted to work with older people
(Abreu and Caldevilla, 2015; Carlson and Idvall, 2015; Demir et al.,
2016; Özer and Tekeş, 2014; Özdemir and Bilgili, 2016; Rathnayake et
al., 2016; Runkawatt et al., 2013; Shen and Xiao, 2012; Türgay et al.,
2015).
3.3.2. Nursing Professional Values Scale-NPVS-R
The Nursing Professional Values Scale was developed by Weis and
Schank (2000). The validity and reliability of the scale was conducted
by Orak and Alpar (2012), and Acaroğlu (2014) is credited with
adapting the NPVS-R into Turkish. The scale has a total of 26 items
under three sub-scales, namely, caring (15 items), professionalism (8
items) and trust (3 items). The scale is a 5-point Likert-type scale, which
is scored as very important (5), important (4), moderately important
(3), slightly important (2), and not important (1). Total scores range
from 26 to 130, with higher scores indicating greater congruency with
professional values. Cronbach's alpha coefficient of the total scale was
found to be 0.96 (Acaroğlu, 2014). In this study, the coefficient was
determined to be 0.93.
3.3.3. Ageism Attitude Scale-AAS
The AAS, developed by Vefikuluçay Yılmaz and Terzioğlu (2011), is
a scale that consists of 23 questions under the three sub-scales of re-
stricted life of elderly people, positive attitudes towards elderly people and
negative attitudes towards elderly people. The positive attitude statements
on ageism are scored as completely agree (5 points), agree (4 points),
unsure (3 points), disagree (2 points) and absolutely disagree (1 point),
while the negative attitude statements on ageism are scored in an op-
posite manner to that of the positive statements: completely agree (1
point), agree (2 points), unsure (3 points), disagree (4 points) and ab-
solutely disagree (5 points). The highest possible score on the survey is
115 and the lowest is 23 according to this scoring scale. Cronbach's
alpha coefficient for the total scale was found to be 0.80. In this study,
the coefficient was determined to be 0.82.
3.4. Data Collection
The study data were collected between October 1 and November 30,
2017. The students were told that participation was voluntary. They
completed the survey during class, with the investigator in the room to
answer any student questions. The data collection process in each class
lasted about 30 min.
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3.5. Ethical Considerations Table 2

Nursing students' demographic characteristics and their distribution by AAS
Written approval to conduct this study was obtained from the ethics score (n = 275).
committee of Giresun University. Also, written approval was obtained Characteristics n (%) ASS mean scores Test value p value
from the Nursing Department of the Faculty of Health Sciences in
Giresun University. The verbal and written consent was received from Age
21 years and younger
the participants. It was conducted according to the ethics guidelines set 163 (59.3) 82.4 ± 8.6 t = 0.726 p = 0.469
22 years and older 112 (40.7) 83.2 ± 9.2
out in the Declaration of Helsinki.
Year of study
2 93 (33.8) 80.8 ± 7.5 F = 5.784 p = 0.003
3.6. Data Analysis 3 102 (37.1) 82.4 ± 9.3
4 80 (29.1) 85.3 ± 9.1

The data were analyzed using the SPSS 16.0, and the reliability of Gender
the scale was evaluated with Cronbach's alpha coefficients. The de- Male 53 (19.3) 81.5 ± 8.9 t = 1.105 p = 0.270
Female 222 (80.7) 83.0 ± 8.8
mographic characteristics of the nursing students were analyzed with
frequency, percentage, and mean tests. According to the Kolmogorov Type of family structure
Nuclear
Smirnov test applied, the mean scores on the NPVS-R did not show a Extended
220 (80.0) 82.8 ± 9.0 t = 0.955 p = 0.341
normal distribution (p < 0.05), whereas the mean scores on the AAS 55 (20.0) 81.5 ± 8.2
Where they came from
showed a normal distribution (p > 0.05). In the data analysis, in- Village
dependent samples t-test, ANOVA and Spearman Correlation were used. 27 (9.8) 79.2 ± 10.9 F = 6.077 p = 0.003
Town 105 (38.2) 84.8 ± 8.2
A value of p < 0.05 was considered statistically significant. City 143 (52.0) 81.8 ± 8.5

Mother's age (n = 272)

4. Results 49 years or younger 179 (65.1) 82.6 ± 9.0 t = 0.116 p = 0.908
50 yearsage
Father's or older
(n = 258) 93 (34.9) 82.7 ± 8.6
The nursing students' average total NVPS-R score was 86.4 ± 16.2,
49 years or younger 100 (38.8) 82.6 ± 8.9 t = 0.054 p = 0.957
and their mean sub-scale scores were 51.7 ± 11.0 for caring, 50 years or older 158 (61.2) 82.7 ± 8.9
26.7 ± 6.3 for professionalism, and 9.6 ± 2.2 for trust (Table 1). The Family income status
nursing students' average total AAS score was 82.7 ± 8.8, and their Income is equal to 199 (72.4) 82.9 ± 9.1 F = 0.326 p = 0.722
mean sub-scale scores were 35.5 ± 5.0 for restricted life of elderly expenses
Income is more than
people, 29.0 ± 5.1 for positive attitudes towards the elderly, and 25 (9.1) 82.4 ± 9.0
expenses
18.1 ± 3.2 for negative attitudes towards the elderly (Table 1). Income is less than 51 (18.5) 81.9 ± 7.7
The mean age of the nursing students was 21.3 ± 1.5, and more expenses
than half were 21 years old or younger (59.3%). Most of the students Living with an elderly person
were female (80.7%); 37.1% were 3rd-year students; 80.0% had a nu- Yes 32 (11.6) 81.1 ± 7.6 t = 1.052 p = 0.294
clear family structure; 52.0% came from a city; and 72.4% stated that No 243 (88.4) 82.9 ± 9.0
their family income was equal to expenses. Regarding the students' Provided care to elderly persons during clinical practices
parents, 65.1% had mothers who were 49-years-old or younger and Yes 227 (82.5) 82.9 ± 8.7 t = 0.679 p = 0.497
61.2% had fathers who were 50-years-old or over (Table 2). In terms of No 48 (17.5) 81.9 ± 9.5
the students' experience and thoughts on the elderly, 11.6% were living Willingness to work with elderly persons after graduation (n = 273)
with elderly persons, 82.5% had provided care to the elderly during Yes 192 (70.3) 83.7 ± 8.9 t = 2.889 p = 0.004
clinical practices, and 70.3% were willing to work with the elderly after No 81 (29.7) 80.3 ± 8.3

graduation (Table 2). To the question of “How old do you think one How old do you think one should be in order to be called ‘elderly’? (n = 270)
should be in order to be called ‘elderly’?”, 63.3% of the students an- 64 years or younger 99 (36.7) 81.4 ± 8.8 t = 1.968 p = 0.050
65 years or older 171 (63.3) 83.6 ± 8.7
swered, “Must be 65 years or above”.
The nursing students' scores on the AAS increased as the year of
study increased, with the highest scores obtained by 4th-year nursing
Table 3
students (p < 0.05). There was a significant difference in attitudes The correlation between the NPVS-Ra and the AASb scores of nursing students
between the students who came from a town and students who came (n = 275).
from a city and/or village (p < 0.05). Additionally, the status of
Restricted life Positive Negative Total AAS
willingness to work with the elderly after graduation influenced total
of elderly attitudes attitudes
AAS scores, with nursing students' willingness to work with the elderly people towards elderly towards elderly
obtaining higher scores (p < 0.05) (Table 2). people people

Table 1 Caring 0.407 0.298 −0.013 0.401

0.000 0.000 0.829 0.000
Mean scores for NPVS-R and AAS sub-scales (n = 275). Professionalism 0.393 0.304 −0.029 0.389
Xa ± SDb Min Max 0.000 0.000 0.632 0.000
Trust 0.353 0.299 −0.049 0.335
Restricted life of elderly people 35.5 ± 5.0 15 45 0.000 0.000 0.417 0.000
Positive attitudes towards elderly people 29.0 ± 5.1 11 39 Total NPVS-R 0.418 0.317 −0.028 0.407
Negative attitudes towards elderly people 18.1 ± 3.2 6 29 0.000 0.000 0.648 0.000
Total AAS 82.7 ± 8.8 57 107
a
Caring 51.7 ± 11.0 19 97 NPVS-R = Nursing Professional Values Scale.
Professionalism 26.7 ± 6.3 9 54 b
AAS = Ageism Attitude Scale.
Trust 9.6 ± 2.2 4 15
Total NVPS-R 86.4 ± 16.2 32 136
A positive, moderately strong correlation was found between the
a
X = mean. nursing students' average AAS scores and average NPVS-R scores
b
SD = standard deviation. (r = 0.407, p = 0.000) (Table 3). Furthermore, there was a positive,

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moderately strong correlation between the students' average scores on
the AAS and the NPVS-R care sub-scale (r = 0.401, p = 0.000), pro-
fessionalism sub-scale (r = 0.389, p = 0.000) and confidence sub-scale
(r = 0.335, p = 0.000). Lastly, a positive, moderately strong correla-
tion was determined between the total NPVS-R scores and the ‘re-
stricted life of elderly people’ and ‘positive attitudes towards elderly
people’ sub-scales of AAS (r = 0.418, r = 0.317, p < 0.005, respec-
tively).
5. Discussion
It was found that the students who participated in the study had
positive rather than good attitudes towards the elderly, with a score of
82.7 ± 8.8. Similar results have been found in studies by Ayoǧlu et al.
(2014), Bleijenberg et al. (2012), Rathnayake et al. (2016), and Türgay
et al. (2015). The attitudes of students have also been shown to vary
from culture to culture (Runkawatt et al., 2013). There are studies re-
porting that nursing students had negative attitudes towards elderly
(Abreu and Caldevilla, 2015; Chi et al., 2016; Frost et al., 2016), while
in others, it has been determined that students had more positive atti-
tudes towards the elderly and were more willing to care for and work
with elderly people (Darling et al., 2017; Faronbi et al., 2017). Certain
studies have also found that despite having positive attitudes towards
the elderly, students were still not interested in working with the el-
derly (Demir et al., 2016; Henderson et al., 2008). Identifying the fac-
tors that affect nursing students' attitudes, in either a positive or a ne-
gative manner, during the course of their occupational education,
together with these students' cultural features, will serve to significantly
aid the shaping of the nursing curriculum.
A number of studies have reported there to be various factors that
affect the students' attitudes towards the elderly, including age, sex,
experience in and preference towards working with the elderly people
(Özdemir and Bilgili, 2016; Rathnayake et al., 2016; Runkawatt et al.,
2013; Shen and Xiao, 2012; Türgay et al., 2015). In the present study, it
was found that being a 4th-year student and wanting to work with the
elderly affected the students' attitudes. That fact that 4th-year students
had more positive attitudes supports the view that occupational edu-
cation influences attitudes towards the elderly. Indeed, in the relevant
literature, occupational education is mentioned as a factor that affects
the nursing students' attitudes positively (Hweidi and Al-Obeisat, 2006;
Lambrinou et al., 2009; Özdemir and Bilgili, 2016; eRtedafil.e,ld
2016). But, Abbey et al. (2006) reported that university curricula are
often structured to progress students' nursing abilities towards techni-
cally advanced skills. According to Rogan and Wyllie (2003) time spent
caring for the older person actually assisted in integrating theory with
practice. The present study found that experience in working with the
elderly did not influence their attitudes. In this context, one of the key
factors in clinical nursing education may be closing the theory—-
practice gap.
In the present research, it was a particularly interesting finding that
living in the same house with an elderly individual and having the
experience of working with the elderly in clinical practices did not in-
fluence the students' attitudes. In contrast, other studies have shown
that the attitudes of students who are close with an elderly person or
who live in the same house with an elderly person were more positive
(Chi et al., 2016; Özdemir and Bilgili, 2016; Türgay et al., 2015). It can
be said that these factors may be associated with therapeutic relation-
ship and holistic care. In a study, students identified holism as essential
to the creation of an effective therapeutic relationship. However, some
reported that they observed patients being treated ‘all the same’ with no
respect for their individual values and beliefs (Duggan et al., 2013).
Students clearly identified challenges within the healthcare system that
affect nursing care of older adults. They reported that it is disappointing
to observe the poor standard of care, and see the neglect of the elderly
as endured by the lack of funding allocated by the government
(Baumbusch et al., 2012). It can be said that the quality and standard of
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nursing care may be affect on nursing students' attitudes towards the
elderly.
Learning and adopting professional values and applying them in
clinical care as part of nursing education are believed to be important in
helping nursing students to develop positive attitudes towards the el-
derly. Indeed, in this study, a significant correlation between the pro-
fessional values of the students and ageism has been determined.
Professional values are related to ethical principles and consist of
standards that are effective in solving problems, interacting with the
patient, making decisions on care and forming the student's attitude
(Cetinkaya Uslusoy et al., 2017; Dehghani et al., 2016; Schmidt and
McArthur, 2018). These standards shape the nursing students' attitudes,
beliefs, and behaviors regarding the provision of care for individuals
throughout their occupational education (Ghadirian et al., 2014). A
correlation between the nursing students' professional values and their
provision of care for everyone in the best and most equal way possible,
being advocates for the patients, standing up for the patients' rights and
respecting their differences has been reported in studies (Rose et al.,
2018; Yaman Aktaş and Karabulut, 2017). Therefore, education on
professional values must be included in nursing education curricula and
incorporated into clinical practices, so that the students can learn these
values by experiencing them and thereby adopt them.
5.1. Limitations
The data in this study were obtained from nursing students recruited
from one institution in Turkey. For this reason, the present findings may
not be generalizable to all nursing students in Turkey. The study did not
take into account whether the students had taken geriatric training or
not that may have influenced some of their answers related to attitudes
towards the elderly. Also, in these types of survey studies, the tendency
to answer as expected may also have influenced the results of this study.
6. Conclusion
In this study, it has been determined that being a 4th-year student,
living in a town, and volunteering to work with the elderly after
graduating were found to have a positive effect on the students' AAS
scores. However, this study revealed that there is a correlation between
nursing students' occupational values and their attitudes towards
ageism. In the light of these results, it is suggested that professional
values be taught and that courses on values be added to the curriculum
in order to improve the attitudes of the students towards ageism. Lastly,
clinical experiences should involve increased levels of interaction with
elderly persons to help foster the transferring of these values to actual
care in clinical applications, and mentorship should also be carried out.
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