The Effect of the “Geriatric Nursing” Course on Nursing Students’ Attitudes toward Old Age and Aging: A Comparative Study

Background: Negative approaches to aging and elderly care may also negatively affect nursing students’ attitudes towards the elderly. Therefore, it is important to determine the attitudes of student nurses towards elderly individuals. This study was carried out to find out the attitudes of nursing students taking geriatric nursing course and those not taking the course in two different universities towards old age and aging. Methods: The study was conducted with nursing students receiving education in two universities according to their status of taking the “Geriatric Nursing” course. In the study which was conducted with 181 participants based on voluntariness, “Attitude Scale Toward Aging and Elderliness” and “Socio-Demographic Information Form” which was prepared by the researcher, were used. Results: It was determined that total mean score obtained by students taking the “Geriatric Nursing” course from the “Attitude Scale Toward Aging and Elderliness” was 2.95 ± 0.47; whereas, total mean score obtained by the students not taking the course was 3.07 ± 0.56. The difference between them was not statistically significant (p > 0.05). In addition, it was determined that the Difficulty of Coping with Life” subscale mean scoreofthe students taking the “Geriatric Nursing” course was 3.04 ± 0.60; whereas, the mean scoreofthe students, not taking the course, for this subscale was 3.34 ± 0.57. The difference between them was statistically significant (p < 0.05). Conclusions: It was determined that the students not taking the “Geriatric Nursing” course had more negative attitudes toward old age and aging and experienced a greater difficulty of coping with life, compared to the students taking the course.


Introduction
The World Health Organization explains old age as the population group aged 65 years and over [1]. As a result of medical and technological developments, prevention of diseases and exploration of effective treatment methods, mortality rates have decreased, life expectancy at birth has prolonged and the number of elderly individuals has also increased in Turkey as in almost every country [2]. According to the population projections in Turkey, the elderly rate within the total population is estimated to be 9.5% by 2020 and 11% by 2025 [3].
Although old age is not an illness, health problems that increase with old age and decline in functional abilities are potential problems of old age [4] and these problems increase care needs of the elderly [5]. Gradually increase of elderly individuals' healthcare need also increases the need for healthcare professionals who will provide elderly care [6]. Thus, it is envisaged that a great part of nursing students would work with elderly individuals after graduation [7]. Knowledge, skills, beliefs, and attitudes of nursing students toward aging and the elderly influence the effectiveness and quality of healthcare service provided to the elderly [8].
When examining the studies conducted to determine nursing students' attitudes toward the elderly; it is seen that there are some studies reporting that students have positive attitudes toward the elderly [9][10][11], some other studies have reported negative attitudes [7,12].
Attitudes toward old age are affected by factors such as age, gender, ethnic origin, living with an elderly and geriatric training [5,13]. In the study by Zhang, et al., it was reported that students who did not have adequate theoretical knowledge and on elderly care,were more reluctant to give care to these patients [14]. In their study, Danis and Kara recommended to include subjects and practices related to old age and elderly care more often in the content of undergraduate study, for the purpose of increasing positive attitudes toward the elderly before graduation and sustaining care [15]. In addition, the studies have stressed that students' attitudes toward the elderly can be altered more positively by trainers [16,17]. Due to all these reasons, the geriatric nursing course which is involved in nursing undergraduate education process, becomes more and more important. Geriatric nursing is a course examining the diseases and care needs of elderly individuals. It is a theoretical course provided within the scope of elective courses in only a few faculties in Turkey and is not applied.
This study was carried out to find out the attitudes of nursing students taking geriatric nursing course and those not taking the course in two different universities towards old age and aging.

Design
This study is a descriptive, cross-sectional type study.

Population and sample of the study
The population of the study consisted of fourth year students studying in nursing faculties of 2 different universities, one from Eastern Anatolia Region (n = 360), and one from Central Anatolia Region (n = 128) between January and March 2020, depending on whether they took "Geriatric Nursing" course. The sample of the study consisted of nursing students who met the inclusion criteria and were selected via the simple random sampling method, which is among probabilistic sampling methods. The data of the study were collected with the participation of a total of 181 students (79 students taking the "Geriatric Nursing" course and 102 students not taking the course).

Data collection
The data were collected using the "Socio-Demographic Information Form" and "Attitude Scale toward Aging and Elderliness (ASTAE)" between the aforementioned dates.

Socio-demographic information form:
Includes questions about variables such as students' class, age, school of graduation, residence, and parents' educational background.

Attitude Scaletoward Aging and Elderliness (ASTAE):
The scale was developed in Turkish by Otrar in 2016 to evaluate the attitude towards aging and aging in individuals aged 18 and over [18]. A validity and reliability study was conducted for the scale which consists of 45 items and four subscales (Cronbach's Alpha Reliability Coefficient α = 0.97 and between 0.90-0.93 for the scales). The four subscales were evaluated and named in the context of their own questions. These subscales were named as: "Difficulty of Accepting Old Age", "Social Exhaustion Perception", "Difficulty of Coping with Life", and "Negative Image" and the scale was named as "Attitude Scale Toward Aging and Elderliness". Higher score indicates increase of the quality after which the dimension is named. Increase of the general mean score obtained from the scale also signifies the increase of negative attitudes toward old age and aging.
While applying the data collection tools in the study, each class was visited in different times and the students were informed about the study and the scale. It was stressed that participation in the study was based on voluntariness. The data were collected by one of the researchers (HTP) in the group taking the "Geriatric Nursing" course and by the other researchers (BC and GBT) in the group not receiving the course.

Data analysis
Descriptive statistics for the variables from the study were given as numbers, percentages, arithmetic mean and standard deviation. The normal distribution of the study was evaluated according to the Skewness and Kurtosis values (between -2 and +2). It was determined that the study showed a normal distribution. For this reason, independent sample t-test was used in twogroup comparisons. Statistical analyzes were made with the SPSS 22 program and the level of significance was taken into account as 0.05 (p-value) in statistical analyzes.

Ethics committee of the study
Before starting the study, the approval from the Ethics Committee Presidency of X University Y Faculty (numbered 14567952-050/66) and verbal consents from the relevant faculties and students were obtained.

Limitation of the study
The study was limited to students who studied in the aforementioned faculties in 2020. The results obtained from the study can be generalized to the aforementioned units and to nursing students studying between them was not statistically significant (p > 0.05). It was found that the students taking the "Geriatric Nursing" course experienced the difficulty of accepting old age more than those not taking the course (Table 2).
It was found that total mean scoreof the "Social Exhaustion Perception" subscale was 2.92 ± 0.46 for the students taking the "Geriatric Nursing" course and 3.02 ± 0.56 for those not taking the course. The difference between them was not statistically significant (p > 0.05). The students not taking the "Geriatric Nursing" course experienced the social exhaustion perception more than those taking the course (Table 2).
It was determined that total mean scoreof the "Difficulty of Coping with Life" subscale was 3.04 ± 0.60 for students taking the "Geriatric Nursing" course and 3.34 ± 0.57 for those not taking the course. The difference between them was statistically significant (p < 0.05). The students not taking the "Geriatric Nursing" course experienced the difficulty of coping with life more than those taking the course ( Table 2).
It was determined that total mean scoreof the "Negative Image" subscale was 2.89 ± 0.52 for the students taking the "Geriatric Nursing" course and 3.04 ± 0.64 for those not taking the course. The difference between them was not statistically significant (p > 0.05).
between the aforementioned dates. In addition, the fact that the study did not have pre-test and no repeated measurements were made due to Covid-19 pandemic is another limitation of the study.

Results
In the study examining the effect of the geriatric nursing course on students' attitudes toward old age and aging through comparative method, a total of 181 students participated (102 students not taking the "Geriatric Nursing" course (56.4%) and 79 students taking the "Geriatric Nursing" course (43.6%)). It was determined that age average of the students was 21.64 ± 1.72 years (min: 20 -max: 35) and 60.8% were in the age range of 20-21 years, 80.7% were female, 97.8% were single, and 64.1% had an income equal to expenditure. In addition, it was found that 62.4% of the students who participated in the study desired to live with an elderly, 19.3% lived with an elderly, 42.5% communicated with the elderly from time to time and 48.6% were undecided whether they would desire to provide care to the elderly after graduation or not (Table 1).
It was found that total mean score of the "Difficulty of Accepting Old Age" subscale was 2.94 ± 0.54 for the students taking the "Geriatric Nursing" course and 2.92 ± 0.73 for those not taking the course. The difference aging. This expected situation provesthe positive effect of the "Geriatric Nursing" course on nursing students.
It was determined that the students not taking the "Geriatric Nursing" course had a higher mean score from the difficulty of coping with life subscale, compared to the students taking the course. It was seen that students taking the "Geriatric Nursing" course had a more positive perception, which shows that the students taking the course thought that aging is not disturbing and itdoes not require to stop living life or enclose to novelties. Numerous studies have revealed that nursing curriculum with an important gerontological content positively affects students' attitudes toward the elderly. In addition, these studies suggest that formal trainings and experiences in the field of gerontology enable students to acquire knowledge via personal experiences rather than stereotyped experiences [19][20][21]. In their study, Liu, et al., recommended for students to take the clinical education and geriatric nursing course together, in order to develop positive attitudes toward the elderly and increase the desire of conducting studies with them [5]. In the study conducted by MacDowell, et al. with hospital staff members, they determined that employees' knowledge and attitudes toward the elderly developed effectively after the gerontology training [22]. Wells, et al., stated that inadequate training on normal aging process negatively affected their attitudes toward old age [23]. Harrison and Novak determined that short-term training programs related to old age positively affected nurses' knowledge and attitudes toward old age [24]. In another study, it was indicated that education and role models were important determinants to develop medical and nursing students' knowledge and attitudes toward elderly care [25]. In the literature, it was determined that geriatric nursing education and clinical practices positively affected students' knowledge and attitudes toward the elderly [26][27][28]. In addition, it is recommended that gerontological nursing education including theoretical and clinical practices should be compulsory in nursing programs [26,29,30]. The results obtained from this study were found to be similar with the literature.
The students not taking the "Geriatric Nursing" course experienced the negative image more than those taking the course (Table 2).
It was found that total mean score of the ASTAE was 2.95 ± 0.47 for the students taking the "Geriatric Nursing" course and 3.07 ± 0.56 for those not taking the course. The difference between them was not statistically significant (p > 0.05). The students not taking the "Geriatric Nursing" course had more attitudes toward old age and aging than those taking the course ( Table 2).

Discussion
Considering that problems and chronic illnesses related to old age and thus care burden would increase as a result of the increase of the elderly population, it becomes more important for nursing students to have knowledge about gerontology. However, gerontological nursing has not become a popular field of specialization in Turkey, yet. Thus, the effect of the "Geriatric Nursing" course on nursing students' attitudes toward old age and aging was assessed in this study. In the study, it was determined that the students not taking the "Geriatric Nursing" course obtained a higher mean score from Attitude Scale Toward Aging and Elderliness and the social exhaustion perception and negative image subscales, compared to the students taking the course; however, there was no significant difference between the subscales. Lack of this significant difference might have been caused by the fact that Turkish people, due to cultural structure of the Turkish society spend more time with their family or the elderly in their immediate surroundings and consider elderly care a family responsibility. On the other hand, considering that as the total and subscale scores of the scale increased, negative perception of old age and aging increased, it was seen that students not taking the "Geriatric Nursing" course had a more negative perception on old age and aging. In addition, it can be asserted that the students not taking the "Geriatric Nursing" course had a higher perception that social exhaustion will increase with age and had a more negative image regarding