Saudi Arabia is one of the countries showing a dramatic increase in the number of older people. This increasing number of older people poses a serious challenge to the health care system in Saudi Arabia, and especially to the nurses who provide services to older clients as first line care providers dealing with the acute and chronic conditions experienced by this population (The medical Health sector report, 2004).

In Eastern cultures such as Saudi Arabia, which is in the focus of this study, old age is admired as a holy state of great religious significance and the aged are offered considerable respect within the family: this view is fundamental to several Eastern cultures (Alshahri, 2002). In Saudi culture, older people are regarded with great admiration and respect. Traditionally, older people are respected and listened to, and are treated accordingly: for example, it is customary for everyone to stand up when they enter a room, they are allocated the best seats and they are offered drinks and food before anyone else. They are addressed in soft voices and are not called by their first names, but instead are referred to as the father or mother of the oldest son (even if they have a daughter who is older than their son). Young Saudi people are expected to be polite and restrained, and even avoid smoking cigarettes or chewing gum when older people are present. In the home environment, an older person usually dictates to the younger family members to look after him or her and satisfy his or her needs. In a health service facility, older patients might expect no dramatic changes in the way they are accustomed to being regarded and respected. In other words, certain aspects can influence cultural issues, including but not bounded to faith, race, level of education, economic status and environmental factors (Alshahri, 2002). Furthermore, in Saudi Arabia, Islam religion, like many other religions, advocates that the Saudi population should respect and value older people and this has been illustrated in many verses in the Holy Koran (Holy Book of Islam).

The Holy Quran says,

"the Lord hath decreed that ye worship none but Him, and that ye be kind to parents .Whether one or both of them attain old age in their life, say not to them a word of contempt, nor repel them, but address them in terms of honour. And, out of kindness, lower to them the wing of humility, and say: My Lord! Bestow
on them the Mercy even as they cherished me in childhood."

An overview of the Saudi university nursing program

Nursing education in Saudi Arabia began in 1958 with the establishment of a health education institution for boys in Riyadh based on a 5–year contract between the ministry of Health (MOH) and the World Health Organization after that MOH assumed full responsibility for institution, and 15 students were enrolled. At that time, the only major being offered was health inspection. In 1960, two nursing schools for girls were established in Riyadh and Jeddah. The education program for nurses included the curriculum of fifth and sixth elementary level and nursing assistant grade.

In 1973, the Ministry of Higher Education (MOHE) established higher education programs in nursing. At King Saud University in Riyadh, under the supervision of the applied Medical Science division, a department of nursing for women was established. In 1987, a graduate program of nursing for women, including a Bachelor of Science degree was offered at King Abdul Aziz University in Jeddah in 1976 . Graduates of the baccalaureate program are qualified to practice professional nursing in a variety of health care settings as well as qualified for entrance into a graduate education program for clinical specialisation and functional areas. The program faculty believe that learning is an internal process and is evidenced by changes in behaviour of the individual (King Abdul Aziz University, 2001). Significantly, the increasing older population in Saudi Arabia calls for more nurses who are prepared to identify with the field of gerontology nursing. The purpose of this study is t o explore the impact of an integrated gerontological nursing education programme at five different academic levels on nursing students’ knowledge and attitudes, towards the care of older people in three major universities in the kingdom of Saudi Arabia.

Literature review

In reviewing the literature, it is apparent that, since the 1950s, studies on the attitudes of nursing students, staff and other health care professionals towards older people and older care have identified negative attitudes towards geriatric nursing. Significantly, Kayser and Minnigerode (1975) pointed out that in the past 30 years, student nurses have developed stereotypes and misconceptions about older people, and their study showed that nurses tended to have minimal interest in working at nursing homes caring for older people; they preferred to work with children and adult patients . The number of nurses interested in working with older people has decreased (Happel, 1999; Soderhamn et al., 2001; Herdman, 2002).

A review of the related literature shows that nurses' attitudes and knowledge of ageing may affect their expectations about their working lives and the ways in which they care for and approach their clients. Therefore, education, including gerontological nursing, is an important issue in the nursing profession, with a focus on assessing the perceptions and attitudes of student nurses towards gaining knowledge and skills in geriatric care in order to feel competent in the care of elderly people at different institutions. In addition, the literature review emphasized that in the education of nurses, goal-directed experience of care of older people is recommended in order to create positive attitudes towards and interest in older people among students .

Study objective

To describe the attitudes and knowledge of nursing students in care of older people in Saudi Arabia.

Research instruments

The instruments used in this study were the modified Kogan Attitudes Toward Old People Scale (ATOP), developed by Kogan in 1961 to measure attitudes toward older people and the modified Facts on Ageing Quiz 2 (FAQ2), developed by Palmore in 1988 to examine health professionals’ knowledge of ageing.

Methods

A descriptive cross-sectional survey design was carried out at five academic levels of nursing students’ knowledge and attitudes towards the care of older people at three major universities in the Kingdom of Saudi Arabia. The researcher carried out this study on nursing students (n=566) studying the curriculum for a five-year program leading to the degree of Bachelor of Science in Nursing (B.S.N.). Permission was obtained from the three participating nursing schools. Nursing students were informed that they did not have to participate in the study.

Results

Demographic characteristics:

The mean age of the respondents was 21.2 years. The majority (82.9% n=469) of the nursing students were single, while nearly 16.1 % (n=91) were married, 0.7 % (n=4) were divorced and 0.4% (n=2) were widowed. Tables 1 and 2 illustrate the distribution of students by marital status and number of children.

Table 1: Saudi Nursing by Marital Status.

Table 2: Saudi Nursing Students by number of children.

Gerontology courses

Table 3 illustrates the type and number of gerontology courses taken by nursing students and the number of credit hours. The results indicate that nearly 27% of the respondents (n=156) had taken one course, 12% (n=70) had taken two courses and 7% (n=45) had taken three or more courses. However, a large number of nursing students (38 %; n=220) had not taken any classes on gerontology. With regard to credit hours earned for courses on gerontology, 18% of the students (n=103) reported earning two credit hours, followed by 16% (n=93) who had earned three or more credits and 12% (n=72) who had earned one credit. These results indicate that the educational backgrounds of the students are inconsistent in terms of gerontological education.

Table 3: Saudi Nursing Students by Number of gerontology course credit hours and type of course.

Knowledge of ageing

In this study students displayed a lack of basic knowledge of ageing (physical and behavioural aspects of ageing) on The Facts on Ageing Quiz 2 (FAQ2). The mean score on the quiz for the Saudi BSN programme was 11.13 (46.37%). According to Palmore (1988), on average, undergraduate students score 14 (56%) and nurses in practice score 16.5 (66%). When the mean FAQ score of 11.13 achieved by Saudi BSN programme students was compared with that achieved by nursing students in other studies, the mean score in this study was very low.

Attitudes towards older people

This study examined Saudi nursing students’ attitudes towards older adults by using a modified Kogan Attitude Toward Old People Scale (ATOP) and it was found that the average of the attitude score was 3.18, (SD 0.29). The score indicated a favourable and positive attitude among Saudi nursing students towards older adults.

Discussion

This study has several limitations, which should be acknowledged. The participating universities offer nursing studies only to female students: thus, the sample in this study was entirely made up of female participants. Further research is needed to compare females’ and males’ attitudes towards the care of older people in Saudi Arabia. Further, the original instruments used in this study were developed in western countries, and while the researcher used versions that had been modified to be compatible with the Saudi culture, some attitude items still might not have been easy to interpret in terms of the Saudi context.

The findings in this study thus illustrate that Saudi nursing students have, in general, relatively poor knowledge of the physical and behavioural aspects of ageing. Moreover, Sheffler (1998) found that the mean score achieved by baccalaureate nursing students was 16.5, which is a borderline score. Similarly, Palmore (1988) reports mean scores ranging from 16.25 to 17.50. Other researchers have also reported mean scores in the borderline range, from 17.3 to 18.3 (Lusk et al., 1995; Greenhill & Baker, 1986; Williams et al., 1986). When the mean FAQ score of 11.13 achieved in this study by Saudi BSN program students are compared with those achieved by nursing students in other studies, they are found to be very low. Significantly, there is clear evidence from the ageing knowledge scores achieved by Saudi student nurses from this study, that they did not feel that they had undergone a valuable education experience in gerontology nursing and had little to offer in this speciality.

Similarly, Zakari, (2005) points out that ageing knowledge was very low and insufficient because the students had not taken any courses related to the care of older people. However, to throw more light on this problem, this study found that most of the BSN programmes in the kingdom with integrated gerontology content did not encourage their students to read and used a textbook specialized in gerontology nursing. In order increase students' knowledge about caring for older people, gerontology text books must be provided, as this will help nursing students to grasp knowledge about older people and how to provide for their needs in different health care settings. The findings also suggest that an integrated gerontology nursing curriculum may not significantly improve ageing knowledge (Downe-Wamboldt and Melanson,1990, 1985; Williams et al, 2007).

In addition, this study examined the attitude of nursing students toward older people and the score 3.18, (SD 0.29) indicates a favourable and positive attitude among Saudi nursing students towards older adults. However, due to the crucial role of attitudes in influencing nursing professionals to work with older people, a number of previous studies have explored nurses' attitudes towards older people, and the findings of this study support those that have found favourable attitudes among nursing students toward older people (Howeidi & Al Hassan, 2005; Zakari 2005; Mckinlay & Cowan, 2003; Nolan et al., 2002). On the other hand, several studies have shown that the number of nurses interested in working with older people has decreased significantly (Herdman, 2002; Soderhamn et al. 2001; Happel, 1999).

On a more practical note, there is clear evidence from this study that there was a high mean positive attitude when nursing students entered the BSN program after completing high school, at which point most of them were in their late teens. The majority of nursing students viewed care for older people as driven and influenced by their cultural perspectives. For that reason, Saudi nursing students regard the care of older people as a role of respect from their cultural and social perspectives. The Islamic faith is certainly the major aspect responsible for shaping the Saudi society and culture, and thus plays a significant role in nursing students’ culture and their views toward the care of older people in this study.

Socially, the extended family system prevails in Saudi Arabia, where the vast majority of older people are living in households of four or more people, and that might that affect the students’ attitudes and acceptance of older people. In keeping with this view, Howeidi and Alobeisat (2006) report that, in Jordan, where the extended family system predominates, nursing students hold positive attitudes toward older people. Similarly, Reinhardt and Quinn (1979) state that traditionally, the cultures of China, Japan, India and the Philippines have demonstrated great respect for the aged. These life experiences with living with older people outside the school context provide useful direction and understanding, helping nursing students to shape their positive attitudes and to learn how to care for older people. Similarly, these positive attitudes are strongly influenced by Saudi Arabia’s cultural, social and religious backgrounds, as well as family and women’s responsibility, which were reflected as positive significant influences on life experiences as strong foundations that students bring to bear in developing positive perceptions toward older people.

Therefore, the historical socio-economic and political conditions of Saudi Arabia are an important issue of understanding a women's role in Saudi society. In Arabic culture, women traditionally remained at home to raise children and care for older people, while men went to college and university and sometimes moved long distances in search of jobs to improve their family statue. In some instances, Saudi women were left with the primary responsibility for child-rearing and caring for older adults, which might have prevented them from pursuing education and employment opportunities. However, the younger generation in Saudi Arabia, including female nursing students, still uphold the traditional values of the family and women’s responsibility to respect old people and encourage empathy and filial responsibility.

However, this study suggests that Saudi nursing curricula should include more extensive gerontology content and clinical experience with older people in the community course in different settings. There will be a need for an increasing emphasis on rehabilitation and health maintenance rather than acute care, with a consequent need for an increased number of health care workers who are well educated in gerontology nursing. Alongside this, this study suggested that in clinical settings, staff, including faculty members and nurses, must provide students with models of the nursing role. To achieve this, it is imperative that the nursing faculty and staff nurses are aware of their own knowledge toward older people and have accurate perceptions of them, as they are role models for their students.

Conclusion and recommendation

In light of these findings, it is suggested that consideration should be given to the inclusion of more structured gerontology courses in the general nursing curriculum. This study’s results can be related to the insufficient focus on gerontologic nursing in the integrated gerontologic curriculum of the nursing schools in which data were collected.

Longitudinal studies are recommended, comparing students’ attitudes towards older people and their levels of knowledge of the ageing process after having undertaken gerontology courses. Such research may provide additional information concerning the effect of gerontological learning experiences on attitudes and knowledge change.

Furthermore, research is needed to build standardised tools for the assessment of attitudes and knowledge of older people that are specific to the Saudi community and reflect its norms and cultures. Further, qualitative research is recommended to explore the essence of attitudes toward older people and their care among nurses and staff nurses, and the ways in which these attitudes promote or interfere with the quality of patient care.

Acknowledgments

I would like to thank Professor Roger Watson and Professor Mike Nolan for support and assistance through this endeavour. They helped me to establish realistic goals for completing each phase and proved to be a valuable proponent of this research study.

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