ORIGINAL ARTICLE
Korean nurses’ attitudes towards older people with dementia in acute care settings Yun Kang
MAP (Gerontology), BN, RN
Lecturer, Department of Nursing, Cheju Halla College, Jeju Special Self-Governing Province, South Korea
Wendy Moyle
PhD, MHSc, BN (Ed.), Dip App Sci, RN
Professor and Deputy Director, RCCCPI, Griffith Health Institute, Griffith University, Nathan Campus, Brisbane, Qld, Australia
Lorraine Venturato
PhD, BBus (Hlth Admin), BN (Hons), RN
Research Fellow, RCCCPI and RSL Care, Griffith Health Institute, Griffith University, Nathan Campus, Brisbane, Qld, Australia
Submitted for publication: 21 May 2010 Accepted for publication: 30 July 2010
Correspondence: Wendy Moyle Professor and Deputy Director RCCCPI Griffith Health Institute Griffith University 170 Kessels Road Nathan Campus Brisbane, Qld Australia Telephone: +61 7 3735 5526 E-mail:
[email protected]
Korean nurses’ attitudes towards older people with dementia in acute care settings. International Journal of Older People Nursing 6, 143–152 doi: 10.1111/j.1748-3743.2010.00254.x Aim. To identify and describe Korean nurses’ attitudes towards older people with dementia in acute care settings and to examine the effect of selected socio-demographics and nursing work characteristics on attitudes. Background. In Korea, older people receive health care services in acute care settings because long-term care settings are not the norm. Culturally, it is considered shameful to place parents or relatives in a long-term care facility. Design. A descriptive survey design. Method. Attitudes towards older people with dementia were measured in Korean registered nurses (n = 100) working in acute care settings of two hospitals in southern Korea in 2009. The Attitudes toward the Elderly with Dementia (AED) and the Approaches to Dementia Questionnaire (ADQ) were administered to participants. Results. Moderately positive attitudes towards older people with dementia in the acute care setting were found. Two-thirds of the nurse participants (n = 65, 65.7%) working in medical wards demonstrated significantly more positive attitudes than those working in surgical wards (n = 34, 34.3%). Demographics including years of experience in the current unit and in the service, and nurses’ position did not correlate significantly with their attitudes. Conclusion. The environment, work routine and technology may influence the likelihood of negative attitude towards people with dementia. Implications for practice. There may be conflict between nurses’ cultural values and care practices in acute care settings. Therefore, there is a need for ongoing education of nurses in dementia care that may reduce the potential of such conflicts. KANG Y., MOYLE W. & VENTURATO L. (2011)
Key words: acute care, attitudes, dementia, nurse, older people, survey
2010 Blackwell Publishing Ltd
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Introduction In 2008 in Korea, the number of older people aged 65 years and above was 5 016 026, or 10.3% of the total population (Korean Statistical Information Service, 2008). The proportion of persons with dementia is thought to constitute 8.3% of older people aged 65 years and above and it is predicted that this number will rise to 9% within the next 13 years as the growth in the older population continues (Ministry of Health and Welfare, 2008). Providing care for older people with dementia can be challenging. The quality of care that older people with dementia receive can be significantly influenced by the attitudes, knowledge, and practices of the nurses caring for them (Soderhamn et al., 2001; Baumann, 2007). In particular, the attitudes of acute care nurses towards older people with dementia in their care is of great concern, as usually such people are admitted with an acute condition outside of their dementia, and their special needs as a result of their cognitive impairment may readily be forgotten in the busy acute environment (Borbasi et al., 2006).
Korean culture Nurses’ attitudes are affected by societal and cultural factors. In Korea, older people generally enjoy more respect, because older age is recognised as a source of prestige and honour influenced by Confucian tradition (Tsai, 2001). However, there are increasing tensions from younger Koreans in relation to whether they will be able to continue to care for older family members. A number of reasons contribute to this perception. Firstly, there has been a decline in the extended family and an increase in nuclear families, leaving many older parents alone. In addition, industrialisation has brought the younger population to cities, further increasing the physical distance between many parents and children (Byun, 1997). Furthermore, the number of women working outside the home has steadily increased. Traditional social structures in Korea dictate that the care of parents is predominantly the responsibility of women, in particular the daughter-in-law. Filial piety based on the Confucian philosophy of respect for both the living and dead has greatly influenced the care system between parents and children and relationships among people (Tsai, 1999). However, such a system is not without its challenges as approximately 43–70% of daughters-in-law who provide the majority of care for older parents often experience stress, including physical and mental burnout (Kim et al., 2006). Therefore, they perceive caring for older parents as a negative experience associated with physical and mental challenges 144
and they feel competing tensions from their filial responsibility (Lee & Sung, 1997; Lee & Farran, 2004). As a consequence of such tensions and changing family values it is becoming more difficult to take care of older Korean people in the home (Choi, 1996). The demands of employment in a competitive world economy may also pressure families to pass over their caregiving role and place an older family member or spouse in a care facility. Such a decision can cause Korean families to experience intense feelings of shame and discomfort. Currently in Korea there are about 0.40% of institutionalised people aged 65 years and above with dementia (Ministry of Health and Welfare, 2008) and this number will continue to increase if families give up the tradition of filial piety. Because of the shame associated with placing a family member into long-term care, Korean families may place an older family member requiring ongoing care into an acute care setting. Nurses in acute care settings are in an ideal position to not only teach families how best to assist family members with dementia but also how to find meaning in caregiving. However, unless nurses have positive attitudes towards older people with dementia opportunities to assist families may be missed (Bramble et al., 2009).
Nurses’ attitudes The quality of care older people receive in acute care settings is directly dependent on positive attitudes. Positive nurses’ attitudes have been found to have a positive effect on the care of older people in areas such as attentiveness, connectedness, friendliness, helpfulness, unobtrusiveness, and respectfulness, while negative attitudes towards older people may result in harmful nursing behaviours (Jacelon, 2002). Such research supports the need for further exploration of staff attitudes and their impact on care of older people and in particular older people who have cognitive impairment. There are a number of factors considered to influence nurses’ attitudes. A majority of studies have focused on the characteristics of nurses and their work environment to explain nurses’ attitudes towards older people with dementia. The most frequent correlates presented are age (Astrom et al., 1991; Slevin, 1991; Myers et al., 2001; Soderhamn et al., 2001; Herdman, 2002; Hweidi & Al-Obeisat, 2006), gender (Astrom et al., 1991; Slevin, 1991; Kwan & Law, 1994; Soderhamn et al., 2001; Hweidi & Al-Obeisat, 2006), level of education of nurses (Astrom et al., 1991; Salmon, 1993; Kwan & Law, 1994; Myers et al., 2001; Lookinland et al., 2002; Kim, 2006), health status of the older person with dementia (Ryynanen et al., 2000; Sourial et al., 2001; Eriksson & Saveman, 2002; Fessey, 2007), work environment 2010 Blackwell Publishing Ltd
Korean nurses’ attitudes towards older people with dementia
To identify and describe Korean nurses’ attitudes towards older people with dementia in acute care settings and to examine the effect of selected socio-demographics and nursing work characteristics on attitudes.
distribute research questionnaires and information sheets to registered nurses (RNs) at their unit meetings. Participants were sought according to the following inclusion criteria: (i) RNs working in medical–surgical units and (ii) unit nursing managers. Unit managers were included in this sample because they have the potential to influence the provision of care of people with dementia. The researcher aimed to distribute questionnaires with demographic information that included gender, age and years of experience to RNs working in the selected units of both hospitals. In the private hospital, a potential sample of 70 RNs worked in the medical wards and 50 RNs in the surgical wards (n = 120). In the public hospital, there was a potential sample of 48 RNs in the medical wards and 32 RNs from the surgical wards (n = 80).
Design
Data collection
The study used a survey design. The University and Institutions human research ethics committees gave ethics approval. The data were collected in 2009.
Participants were asked to complete selected demographics and work characteristic information. In order to explore attitudes towards older people with dementia, two selfadministered questionnaires were used: the Kaduszkiewicz et al. (2008) Attitudes toward the Elderly with Dementia (AED) and the Lintern et al. (2000) Approaches to Dementia Questionnaire (ADQ). In the original Kaduszkiewicz et al. questionnaire, 24 items out of 49 items developed for use with physicians were deemed by an expert panel to be appropriate for use with acute care nurses and only these items were collected and analysed. The questionnaire consists of positively or negatively worded attitudinal statements on a 6-point Likert-type scale from 1 to 6 (1 = minimum, 6 = maximum). The scores were partly grouped to rank the degree of agreement/disagreement (1, 2 = do not agree at all; 3, 4 = partially agree; 5, 6 = strongly agree). Kaduszkiewicz et al. (2008) did not report the questionnaire reliability in their paper. The second questionnaire is a standardised 19-item self-administered questionnaire, titled the Approaches to Dementia Questionnaire (ADQ) and used to measure nurses’ attitudes. This instrument explores the correlational link between attitudes and behaviour. The instrument uses a 5-point Likert-type scale, which is scored from 1 to 5 (1 = strongly disagree; 2 = disagree; 3 = unsure; 4 = agree; 5 = strongly agree) so that higher scores reflect more positive attitude. The test–retest for reliability performed during the development of the ADQ reflecting nursing staff’s attitudes towards people with dementia indicated the two factors, as well as total scores were both internally consistent and stable over time. In terms of reliability coefficient, the ADQ total was 0.76, ADQ factor 1 (hope) was 0.70 and ADQ factor 2 (recognition of personhood) was 0.68 (P > 0.001) (Lintern et al., 2000).
(Helmuth, 1995; McIntosh et al., 1999; Myers et al., 2001; Amador et al., 2007), and amount and type of exposure to older people with dementia (Kwan & Law, 1994; Pursey & Luker, 1995; Soderhamn et al., 2001; McLafferty & Morrison, 2004; Higgins et al., 2007).
Methods Aim
Settings Jeju Special Self-Governing Province, in the southern part of Korea, and a 1-hour flight from Seoul was chosen as the location to collect the data, as it is the home of the researcher and was therefore convenient and feasible for data collection. The population of Jeju Island is approximately 565 519 being equivalent to 1.15% of the total population of South Korea. The population is ageing with 12 in 100 of the population of Jeju Special Self-Governing Province aged 65 years or above (Jeju Special Self-Governing Province, 2008). A convenience sample of two largest acute hospitals (one private hospital and one public hospital) in Jeju Special Self-Governing Province was selected. The private hospital has 613 beds and offers comprehensive surgical, medical, and emergency services supported by state-of-art diagnostic and treatment facilities. The 450 bed public hospital also located in Jeju si is National University owned and has a medical and nursing school. They provide the same care and treatment as above and offer continual staff development and patient improvement in care through education and research. The selection of the units within each hospital was based on provisional data provided by the department of nursing about the percentage of older people admitted to these units.
Participants Information about the study was presented to the nursing directors and unit managers. Nursing unit managers agreed to 2010 Blackwell Publishing Ltd
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The English version questionnaires were translated into Korean by a bilingual researcher and reviewed by a bilingual expert who specialises in cultural studies, together with two nurses and two unit nurse managers. The back translation was obtained independently through a professional translator. The translation–back translation cycle was repeated until the researcher was satisfied with the equivalence of the form. In this study, an internal consistency reliability of the AED questionnaire was 0.75. In the exploratory factor analysis of the items (AED), each factor loading was more than 0.40 so it met an absolute value of 0.40. Consequently, the validity of AED items was accepted. In addition, Cronbach’s a of the ADQ questionnaire was 0.81 as a good internal consistency for the total and each of the factor scores. All the factors were found to be uncorrelated and each factor loading was more than 0.40 so it met an absolute value of 0.40. Consequently, the validity of ADQ items was accepted. In order to explore the relationship between the AED and ADQ instruments in Korean correlation was performed. The probability value was 0.04 (P < 0.05), which is statistically significant. Therefore, the reliability between AED and ADQ was accepted.
Data analysis The Statistical Package for the Social Sciences version 16.0 (SPSS Inc., Chicago, IL, USA) was used to analyse the data collected. Central tendencies were applied to identify nurses’ attitudes towards older people with dementia in acute care settings. Descriptive statistics were used to describe nurses’ characteristics in each nursing department and for each nursing position to examine the effects on their attitudes. An independent t-test was used for gender and martial status to examine the effects of nurses’ characteristics and nursing department and nursing position of the effects of nursing work characteristics in the two instruments. The effects of other types of nurses’ characteristics and nursing work characteristics were examined using a one-way analysis of variance (A N O V A ) for variables, which have more than two groups in each characteristic. In addition, Levene’s test was performed to determine whether the two questionnaires have homogeneity of variance, before conducting both t-test and ANOVA.
Findings Of the potential 200 RNs, 100 RNs completed the questionnaires, resulting in a 50% response rate. However, due to missing data 99 responses were analysed. As shown in Table 1, the majority of participants were female (99%, n = 98). Approximately 90% (n = 88) of participants were 146
aged between 20 and 30 years. Two-thirds (65.7%, n = 65) of the sample were single. Over half of the sample (57.6%, n = 57) had been working as RNs between 1 and 5 years. Two-thirds (65.7%, n = 65) were working in medical wards and the remainder (34.3%, n = 34) were in surgical wards. Predominantly 67.7% (n = 67) graduated from a 3-year college-nursing program, whereas 30.3% (n = 30) had a Bachelor’s degree. There was only one respondent who held a Master’s degree and one respondent with a 3-year associate degree in nursing studies. All participants (100%, n = 99) were in full-time employment. Of the respondents, 11.1% were managers (n = 11), and 88.9% were clinical nursing staff (RNs) (n = 88).
Attitudes This sample of Korean nurses reported moderately positive attitudes towards older people (Table 2). As shown in Tables 2 and 3, the nurses working in medical wards (65.7%, n = 65) demonstrated significantly more positive attitudes than those working in surgical wards (34.3%, n = 34). Age, gender, marital status, type of nursing degree, years of experience in the current unit and in the health service, and nurses’ position, however, did not correlate significantly with their attitudes (Table 4).
Discussion This study identified that Korean RNs reported moderately positive attitudes towards older people with dementia in acute care settings. This finding is consistent with Tsai’s (2001) findings, which indicated that older age is recognised as something to be respected and honoured and influenced by Confucian tradition in Korea. A comparison of results between Korea and Western countries may help to identify if Korean nurses’ attitude towards older people in acute care settings are influenced in part by the social system structure. Kong (2007) reported that daughters-in-law in Korea who are the majority of primary caregivers reported filial obligation as a major care-giving motivation, while Caucasian American caregivers reported filial affection as a major motivator. The majority of daughters-in-law taking care of older parents with dementia experience stress, including physical and mental burnout, because of the 24-hour care demands often required to care for a person with dementia (Lee & Sung, 1997; Kong, 2007). Such demands can result in a gradual dislike for the parent. Therefore, they perceive caring for older parents as a negative experience associated with physical and mental challenges and they feel competing tensions from their filial responsibility (Lee & Farran, 2010 Blackwell Publishing Ltd
Korean nurses’ attitudes towards older people with dementia Table 1 Sample characteristics
Variance
Nurse characteristics
Frequency
Percentage (%)
Gender
Male Female 20–24 25–29 30–34 35–39 40–44 45–49 Single Married 3-year associate degree Bachelor degree Master degree Other (RN to BSN degree) Full-time
