Ageism Among Physicians and Nurses in Russia

Abstract

The phenomenon of ageism has been studied extensively in the Western world, but there is only a small number of studies among medical staff in Russia. The aim of this study was to assess the prevalence of ageism and to identify variables that can explain ageism in a sample of physicians and nurses in Russia. This is a prospective cross-sectional study of physicians and nurses who participated in a training course in the years 2016–2018 in Russia. Data collected before the start of training included the Fraboni scale of ageism (FSA) questionnaire, and sociodemographic characteristics including age, gender, profession, professional seniority, place of work, and number of older adults treated by the study participant over the past half year. In total, 903 physicians and nurses participated in the study. The mean FSA score was 2.75 ± 0.49, which indicates a moderate degree of ageism. There was a trend to higher scores among nurses compared with physicians (2.78 ± 0.50 vs. 2.76 ± 0.48, p < 0.465). There was a weak, but statistically significant, correlation between ageism and age (r = 0.157, p < 0.0001), professional seniority (r = 0.098, p < 0.003), and the number of older adult patients treated by the participant over the prior half year (r = 0.075, p < 0.025). There were no differences in other characteristics including gender, profession, work setting, or serving as main caregiver for a family member and the magnitude of ageism. The phenomenon of ageism exists among physicians and nurses in Russia. Older participants with greater professional seniority and a larger number of older patients had stronger ageism attitudes.

Introduction

Ageism is manifested in the attitudes of individuals and society, usually negative, toward the older adults.^1,2 Health care workers are an integral part of society, so expressions of ageism can be seen among physicians, nurses, and medical and nursing students,^3
–5 in medical research,⁶ and in health care policy.⁷ Negative attitudes toward the older adults on the part of the medical staff can have a negative impact on the quality of care.^8,9 In previous studies, ageism was seen among young male physicians (<30 years of age), with <10 years of professional seniority, who lacked experience working with the older adults and were not in contact with them.^10,11 The results of studies among nurses relating to predictive factors for ageism are less definitive.¹²

Demographic changes in Russia over the past decades, manifested in ageing of the population,¹³ have led to an understanding that there is a need to study the various issues related to old age in depth, so as to address the needs of the elderly population. According to an international public opinion poll conducted in 2018,¹⁴ Russian participants expressed a negative attitude toward different aspects of old age compared with participants from other countries. Eighty percent of the respondents had a negative attitude toward growing old, 65% associated old age with illness, 66% agreed that older adults are not respected sufficiently, and only 29% of the respondents thought that they could prepare for life as an old adult.

The phenomenon of ageism has been studied extensively in the Western world over recent decades, but there is only a small number of studies from Russia.^15
–17 Some of these studies included a small number of participants, some did not include physicians or nurses, and some did not use acceptable measurement tools. Gorelik & Kolpina¹⁵ conducted a survey on ageism among 207 physicians and social workers in the region of Belgorod. They reported that 65% of the participants responded that there were varied expressions of ageism in the health care system and 42% admitted that they were witnesses to it or initiated it themselves. In another qualitative study, Koplina¹⁷ surveyed attitudes toward ageism among 18 participants including specialists in gerontology, senior directors in the health care system, and a small number of physicians with at least 10 years seniority, from the region of Belgorod and selected medical institutes in Moscow. About half of the responders said that the attitude of the health care system toward the older adults was biased and most (75%) thought that health care workers were either partially aware or not aware at all of ageism. In another international study by Shpakov et al.,¹⁶ participants 70 years of age and above from Belarus, Poland, Lithuania, and Russia were asked about various aspects of ageism. The results showed that physicians were responsible for 28.9% of ageism incidents and that nurses were responsible for 44.7%.

In light of these trends, the aim of this study was to assess the prevalence of ageism and to identify variables that can explain ageism in a representative sample of physicians and nurses in Russia who participated in a training course designed to provide knowledge in the field of geriatric medicine.

Methods

This was a prospective cross-sectional study using a convenience sample that included physicians and nurses who participated in a training course. The 144-hour course was prepared and conducted by the Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University, Moskow, in the years 2016–2018 in various centers in 16 large cities throughout Russia, including Moscow. The purpose of the training program was to provide basic knowledge on ageing (including epidemiology, physiology, geriatric syndromes, and comprehensive geriatric assessment) for local physicians and nurses from various hospital wards including internal medicine, neurology, emergency room, rehabilitation, geriatric ward, nursing homes, and primary care clinics.

In the course, the participants were trained to treat older patients at work and to serve as a professional consultant for the medical staff on subjects that are relevant for treatment of older patients.

The course curriculum included face-to-face lectures, seminars, and tests. Before the start of the training program, we used the following instruments: Fraboni scale of ageism (FSA).¹⁸ The FSA was designed to measure three levels of prejudice related to ageism, from Allport's (1958)¹⁹ five levels: antilocution (e.g., “Many older adults just live in the past”), avoidance (e.g., “It is best that older adults live where they won't bother anyone”), and discrimination (e.g., “older adults should find friends their own age”). A preliminary exploratory principal component analysis supported these factors, which accounted for 23.3% (antilocution), 7.2% (avoidance), and 7% (discrimination) of the variance, with a Cronbach's coefficient of 0.86.¹⁸ The scale consists of 29 items. Participants responded to the items using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Item numbers 8, 14, and 21–24 are positive statements, and scores are reversed when calculating the total scale score. A mean score was calculated with a lower score representing a lower degree of ageism. In the absence of a Russian version of the instrument, we translated the questionnaire using the double back-translation method.²⁰

A sociodemographic questionnaire including items on age, gender, profession, professional seniority, place of work, information on the number of older adults 65 years and above treated by the study participant over the past half year, and information on whether the participant was a main caregiver for a family member aged 65 years and above.

The study was approved by the Helsinki Committee of the Russian Clinical and Research Center of Gerontology in Moscow (approval number 11.1.2016).

Statistical analysis

The data were analyzed using the SPSS Statistical Package (V. 26). Categorical variables are presented as frequencies and continuous variables are presented as mean and standard deviation. Continuous FSA scores were compared with categorical variables such as gender and profession by one-way analysis of variance tests, and with continuous variables such as age and processional seniority by Pearson correlation. Statistical significance was set at p < 0.05 for all analyses. We calculated the Cronbach's alpha score for the FSA and built three linear regression models.

Results

Characteristics of the study population

Over the study period from 2016 to 2018, 915 physicians and nurses who worked in hospital wards, nursing homes, and community clinics in 16 regions in Russia participated in the training program. Of these, 903 (98.6%) agreed to participate in the study and completed the study questionnaire, 794 (87.9%) were women, the mean age was 45.3 ± 12.4 years, 532 (58.9%) were physicians, and 371 (41.1%) were nurses, the mean professional seniority was 19.9 ± 11.4 years. The distribution of work settings was 573 (63.5%) in hospitals, 298 (33.0%) in community clinics, and 32 (3.5%) in nursing homes. In total, 380 (42.1%) said that they were main caregivers for a family member aged >65 years old (Table 1).

Table 1.

Sociodemographic Characteristics of the Study Population (N = 903)

Variable	N (%)
Gender
Male	109 (12.1)
Female	794 (87.9)
Age
Mean ± standard deviation	45.3 ± 12.4
Range	21–80
Profession
Physician	532 (58.9)
Nurse	371 (41.1)
PhD
Yes	21 (2.3)
No	882 (97.7)
Work setting
Ambulatory	298 (33.0)
Hospital	573 (63.5)
LTC	32 (3.5)
How many older adults have been treated by me during the past 6 months?
Mean ± standard deviation	440.3 ± 566.1
Range	0–3402
I have older adult relatives who I must take care of
Yes	380 (42.1)
No	523 (57.9)

Ageism among study participants

The mean FSA score for the entire study population was 2.75 ± 0.49, which indicates a moderate degree of ageism. There was a trend to higher scores among nurses compared with physicians (2.78 ± 0.50 vs. 2.76 ± 0.48, p < 0.465). There were no associations between ageism attitudes and participant characteristics such as age, gender, profession, place of work, or number of older family members, defined as 65 years of age and above (Table 2).

Table 2.

Fraboni Scale of Ageism Scores

	N	Mean ± standard deviation	p
Gender
Male	109	2.71 ± 0.49	0.135
Female	794	2.78 ± 0.49	0.135
Profession
Physician	532	2.76 ± 0.48	0.465
Nurse	371	2.78 ± 0.50	0.465
Work setting
Ambulatory	298	2.81 ± 0.47	0.076
Hospital	573	2.76 ± 0.49
LTC	32	2.61 ± 0.52
I have older adult relatives who I must take care of
Yes	380	2.78 ± 0.48	0.258
No	523	2.75 ± 0.49	0.258

In contrast, there were weak but statistically significant correlations between ageism and age (r = 0.157, p < 0.0001), professional seniority (r = 0.098, p < 0.003), and the number of older adult patients treated by the participant over the prior half year (r = 0.075, p < 0.025) (Table 3). The correlation results remained consistent among physicians in terms of age (r = 0.157, p < 0.0001), professional seniority (r = 0.143, p < 0.001), and the number older adult patients treated by the physician over the previous half year (r = 0.155, p < 0.0001), whereas among nurses the only significant correlation was between age and ageism (r = 0.162, p < 0.002).

Table 3.

Correlation Between the Fraboni Scale of Ageism Score and Different Variables

		r	p
Total	Age (years)	0.157	<0.0001
	Seniority (years)	0.098	0.003
	Seniors treated during the past 6 months	0.075	0.025
Physicians	Age (years)	0.157	<0.0001
	Seniority (years)	0.143	0.001
	Seniors treated during the past 6 months	0.155	<0.0001
Nurse	Age (years)	0.162	0.002
	Seniority (years)	0.027	0.604
	Seniors treated during the past 6 months	−0.049	0.349

The Cronbach's alpha score for the FSA questionnaire in this study was 0.801. We developed different linear regression models that included the variables age, gender, profession, years of seniority, and the number of treated patients 65 years of age and above over the past 6 months. This was conducted for all participants (general model), and for physicians and nurses separately. The general model explained only 3.3% of the variance in the sample, the physicians' model 5.2%, and the nurses' model 5.8%.

Discussion

The results of this study show that ageism exists among physicians and nurses in various regions of Russia. The unique qualities of this study, in contrast with previous studies conducted on ageism in Russia,^{13

–17,21,22} are that this is the first time that an internationally validated instrument was used to assess ageism in Russia in a large study sample that included various health care professionals in a broad geographic distribution. In addition to providing evidence of ageism among medical staff in Russia, this study raises other important conclusions that are different from those reported in previous studies in the Western world. In this study, we found a statistically significant correlation among physicians between ageism and the age of the participants, their professional seniority, and the number of older adult patients whom they treated over the past half year.

Older physicians with greater seniority who treated more elderly patients had stronger ageism attitudes. This aspect was not reported in previous studies from Russia. In articles published in the Western literature, there are inconsistent findings on associations between ageism and physicians' age and professional seniority.^3,4,11,23,24 In some of the studies,^11,23,25 an inverse correlation was found between physician's age and ageism, whereas in others no association was found.²⁶ The correlation between professional seniority and ageism was negative in previous studies^10,11 with a trend toward a change from more neutral to more positive attitudes.²³ The absence of an association between physician’ gender and ageism in this study is different from the results of other studies^5,11,24 that described more ageistic attitudes among male physicians.

The difference in the physicians' model between the present and previous studies could be related to the fact that male physicians were in a minority (12.1%) in this study, and the mean age was relatively high (45.3 ± 12.4 years) in contrast to previous studies in which the percentage of male physicians was higher and the mean age was lower.^11,23,26 Another potential explanation for the difference is that the burden of work and the level of burnout of the physicians could be higher in Russia and could be accompanied by compassion fatigue that affects their attitudes toward older patients. However, this possibility has not been evaluated and further research would be required to prove it. Another unique finding in this study is the correlation between the number of older patients treated by physicians and their attitude toward ageism. We did not find any corresponding discussion on this finding in previous studies. We think that it can be related to compassion fatigue due to prolonged exposure to elderly patients, but this contention also has to be proven in further research.

We found a correlation between age and attitudes toward ageism among nurses, but not in other variables. In previous studies from Russia, there was no discussion of factors that affect nurses' attitudes toward ageism, and corresponding results in recently published reports from the Western world were not consistent.^12,27,28 In previous studies, ageism among nurses was associated with lack of professional experience and male gender,²⁹ with work in a hospital³⁰ or in a nursing home,³¹ with extent of exposure to older adults,³⁰ and the level of knowledge on ageing.^12,27 The nurses in this study were relatively older with a high prevalence of female nurses (97.9%), which may have affected some of the results. This finding can be expected since the vast majority of nurses in Russia are female. There was no correlation between nurses' attitudes toward ageism with their place of work or exposure to elderly patients.

These results are consistent with the investigators' assumptions about the existence of ageism among health care professionals in Russia. A recent review³² on ageism used a broad definition of the concept and emphasized that this can be self-attributed or attributed to others and can be expressed at the micro and the macro level. It is our impression that to reduce the ageism phenomenon, future studies should be conducted on prejudices and stereotypes regarding the elderly in terms of self-attribution and attribution to others with intertwined qualitative and quantitative study methods. Such research can shed light on the empiric findings in this study.

This study has several strengths including the size and composition of the study population (big sample of physicians and nurses, varied work settings, and geographical regions), the study questionnaire, which is in broad use and has been validated in multiple languages for the study of ageism,^33

–36 and detailed sociodemographic data on the participants.

A significant limitation of this study is that the FSA questionnaire was translated to Russian but not validated further. We based this on the fact that the questionnaire was previously translated into various languages and found to be valid,^36
–38 but a study should be conducted to determine the validity and reliability of this instrument, and the Cronbach's alpha for each of the subscales of the Fraboni questionnaire. The study also has limitations such as noninclusion of some variables including cultural background, religion, level of knowledge on ageing and ageism, information of the personal feelings of the participants toward the older adults, and important variables such as death anxiety and anxiety over growing old, and staff burnout. The regression models explained only 3.3%–5.8%, so it is very weak and there are likely other important variables that were not taken into account.

The effect of the training course on the participants' attitudes toward ageism has not been assessed yet, but we plan to do that in the future study. Another important limitation of the study is the possibility that social desirability bias could be an additional factor that affected the results of the study. We assumed that the use of anonymous questionnaires would avert this bias,³⁹ but we will consider using a measure of social desirability in our future studies.

An intervention program was planned to provide basic data on geriatric issues and the course goals did not include a change in the participants' attitudes toward ageism, so we did not plan in advance to measure changes in these attitudes as a result of the course. This is, undoubtedly, a significant limitation of the study. We are now planning to test the effects of such a course on the attitudes of the participants toward ageism in a continuation study.

In conclusion, the phenomenon of ageism exists among physicians and nurses who work in various sectors of the health care system in modern Russia. The findings of a recent meta-analysis on the effectiveness of ageism intervention programs⁴⁰ indicated that education, intergenerational contact, and combined programs significantly reduced levels of self-reported ageism. We propose to include all of these interventional components in training programs, along with study of ageing among medical and nursing students and other professionals who work with older adult populations.

Footnotes

Author Disclosure Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

No funding was received for this article.

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