Attitudes and work preferences toward older people among Malay undergraduate nursing students

Background: The aging population is increasing globally and requires a high demand for healthcare services in several countries. As a way of preparing future nurses in aged care, substantial incorporation of gerontology courses in the nursing program to meet future needs is required. The present study aimed to investigate the association between attitudes and work preferences toward older people among undergraduate nursing students. Methods: A cross-sectional study was conducted involving 291 nursing students at a Malaysian public university. A set of questionnaires was used that comprised the following three parts: (1) Part A: Sociodemographic background, (2) Part B: Attitudes toward older people, and (3) Part C: Nursing students’ work preferences. Results: Most of the participants (80.4%) demonstrated slightly positive attitudes on older people. Only 2.4% selected older people group as their work preference. There were no significant associations between attitudes with sex (p = 0.84), year of study (p = 0.30), living status (p = 0.77), and work preferences (p = 0.81). Conclusion: Overall, the majority of participants had slightly positive attitudes on older people. Although they had positive attitudes on older people, working in aged care setting is not their first preference after their graduation.


Introduction
The United Nations report warned that the aging population has increased dramatically, and an increase in the number of aging population from 901 million in 2015 to 1.4 billion in 2030 is anticipated. 1 Malaysia, which is located in the southeastern region, also showed an increasing trend of aging population, which increased from 10% in 2018 to 10.3% in 2019. 2 Considering the rapid increase in the number of the older population, better healthcare services are required and demand for health services for older people increases.
Despite the increase in the number of aging population worldwide, several nurses are not interested to work in the field of aged care. Several issues that could influence the decision to work in aged care include low wages working as geriatric nurses, 3 less skilled area, 4 stressful working environment, 5,6 and low opportunity for future career development. 5,7 One of the actions that could increase the interest of future nurses working in aged care is improving the nursing curriculum with stand-alone gerontology nursing courses in all undergraduate nursing programs 6 and using more innovative educational strategies to increase the interest of undergraduate nurses. 4,6 Good experience in gerontological nursing education is also reported to be associated with the choice to work in aged care. [7][8][9][10] Therefore, determining the nursing students' attitudes toward older people and their work preferences is considered crucial. Attitudes toward older people can be defined as individual judgments of the older people that may be influenced by the cause of aging. 11 Previous studies reported inconsistent results with positive and negative attitudes on older people in nursing students. Most studies found that nursing students reported positive attitudes toward older people. 4,[12][13][14][15] It showed that males were less positive than females, 16,17 and senior students demonstrated better attitudes on older people than junior students. 16 Undergraduate nursing students reported the lowest positive attitude at the beginning of the program and the highest positive attitude at the end of the nursing program. However, the association between these two was not significant. 18,19 Meanwhile, another study found that there was no significant association between year of study and attitudes. 13,14 The experience of staying with older people is believed to cultivate a positive attitude to aging and older people. 20 However, conflicting findings were found regarding the association between living with older people and their attitudes toward older people. Working in aged care may not be the first preference for undergraduate nursing students. Preference for working with older people can be defined as individual intention to work with older people. 14 A recent study has reported that 5.1% of undergraduate nursing students considered the older people as their main preferred group. 13 Another study involving Malaysian nursing students reported an average level of work preferences in aged care. 12 On the contrary, other studies involving Turkish nursing students reported that higher than 50% of the undergraduate nursing students were willing to engage in geriatric nursing upon graduation. 14,21 It is anticipated that undergraduate students in nursing course who showed a positive attitude on the elderly might be interested working in aged care setting.
Previous studies on the association between attitudes and work preferences with older people produced different findings. A positive association between attitudes and work preferences with older people was reported in some studies. 13,14,[21][22][23] However, several studies have reported that there was no significant association between attitudes and work preferences toward older people. 24,25 It was reported that although nursing students have a positive attitude toward older people, they are not interested in aged care. 26,27 The conflicting findings might be attributable to methodological differences such as various ethnicities in prior research studies.
Considering Malaysia's setting, a previous study by Che, Chong, and Hairi on attitudes and work preferences involved all undergraduate students enrolled in either diploma or bachelor in nursing, in which 90% of the participants are diploma nursing students. 12 Interestingly, their study found that diploma nursing students reported more willingness to work in aged care than those studying a bachelor in nursing at universities. The differences in ethnicities were also found with Malay nursing students having a plan to work in aged care compared to the Chinese nursing students. Although the concept of caring for the older people is one of the important elements in Chinese culture, the younger generation including Chinese nursing students may not be interested in taking on such responsibilities due to lack of family support. Meanwhile, caring for the older people is one of the important values in Islam, with all Malays considered as Muslims. 28 It can be concluded that religion, such as Islam, may play an important role in the issue of caring for the older people. 29 Due to limited studies assessing the association between attitudes and work preferences toward older people among Malaysia population 12 and different findings from previous studies, 13,14,21,22,24,25 it is important to further explore on this topic. Thus, this study aimed to examine the association between attitudes and work preferences focusing on Malay undergraduate nursing students. to set the appointment of gathering data. Once the date was agreed, the researcher screened the participants based on their inclusion and exclusion criteria. Participants who agreed to participate were provided with the consent form and a set of questionnaires.

Methods
Data analysis. Data analysis was performed using the statistical analysis program, the Statistical Package for the Social Sciences version 20. Descriptive analysis was performed to describe the sociodemographic background, attitudes, and work preferences of nursing students. Inferential analysis such as independent t-test, analysis of variance (ANOVA), and correlation test were used to analyze the association between sociodemographic data, attitudes, and work preferences. In the present study, p < 0.05 was considered statistically significant. The results show that there were no statistically significant between all variables that were tested in this study ( Table 2).

Discussion
Generally, most of the students (80.4%) reported slightly positive attitudes on older people. This finding was consistent with that of a previous study, which showed that undergraduate students enrolled in nursing course reported positive attitudes toward older people. 4,[12][13][14] Regarding work preference upon graduation, it was noted that only 2.4% of nursing students indicated older people as their first option of age group to work with. Similarly, a previous study also reported elderly group as the least chosen age group to work with; however, the percentage was relatively higher than that in the present study (5.1%). 13 This finding is not surprising as the current nursing program focuses more on clinical care in hospitals. Students perform more clinical training in hospitals than in nursing homes or community health clinics, which are more appropriate places for clinical training exposure related to the care of older people. In fact, there are nursing programs that place clinical practice in nursing homes as elective courses. Nursing students may choose a different workplace if they have clinical experience in a nursing home. 24 In the present study, it was observed that male nursing students reported a more positive attitude than female nursing students, although the differences were not significant. The finding was different from that of the previous study. 16 The study finding also revealed that the year of study among undergraduate nursing students is not associated with the attitudes toward older people. Nevertheless, the final year nursing students reported a higher positive attitude toward older people than those in year one, year two, and year three undergraduate nursing students. It might be because the final year nursing students have completed a geriatric nursing course before the enrolment of year four study. The finding was similar to that of the previous study, 18,19 which found that nursing students who were in the last year of the study reported positive attitudes toward older people.
This study also revealed that there was no significant association between attitudes and living with older people. Generally, it was found that nursing students staying with older family members reported a slightly positive attitude. The present study found that more than 50% of students were living with older family members. Considering that all participants in the present study were Malays, it can be inferred that most Malay families are still more living in the extended family compared to the nuclear families. The finding was similar to that of Söylemez et al.'s study, reporting that there was no significant association between staying together with older people and positive attitudes toward older people. 14 Findings from the present study reported that there was no association between attitudes and work preferences. The finding was not consistent with those of earlier studies, which found a significant association between work preferences and attitudes. 13,14,21,22 However, the finding was similar to those of previous studies. 24,25 It might be due to limited exposure to aged care in the clinical setting that has influenced their work preference in aged care, although the students may have a positive attitude toward older people.
Although previous studies found that Malay nursing students prefer to work with older people, 12 the present studies found a conflicting finding. It can be suggested that working with older people remains the least preferred area regardless of ethnicities and religions. This study had few limitations. This study involved one public university; thus, the results may not represent other undergraduate nursing schools and cannot be generalized to the general population. The study design may also limit the understanding of study results. Future studies may use a mixed-method approach to add participants' voices regarding their attitudes and work preferences.

Conclusion
This study found that most undergraduate Malay nursing students reported a positive attitude toward older people. However, they were not interested to work in geriatric care. Future nursing bachelor's degree programs should emphasize more on clinical experience with the older people, specifically in nursing homes, to increase their interest in working in the field of geriatric care. The recent coronavirus disease 2019 (COVID- 19) pandemic indicates that more geriatric nurses are needed in the field of geriatric care because older people are more likely to be infected with the COVID-19 virus.

Funding
This study received no specific grant from any funding agency.