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The Chinese version of the facts on aging quiz scale: Reliability and validity assessment
International Journal of Nursing Studies 47 (2010) 742–752
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The Chinese version of the facts on aging quiz scale: Reliability and validity assessment Cheng-Ching Wang a,b, Wen-Chun Liao a,b, Pi-Chao Kuo a,b, Su-Chuan Yuan a,b, Hsiao-Ling Chuang a, Hao-Chang Lo c, Hui-Yen Liao d, Miller Elaine e, Meng-Chih Lee b,f,g, Chi-Hua Yen b,f,g,* a
College of Nursing, Chung Shan Medical University (CSMU), Taiwan Center for Education and Research on Geriatrics and Gerontology, CSMU, Taiwan General Education Center, CSMU, Taiwan d Department of Nursing, Buddhist Tzu Chi General Hospital, Taiwan e University of Cincinnati College of Nursing, USA f Institute of Medicine, CSMU, Taiwan g Department of Family and Community Medicine, Chung Shan Medical University Hospital (CSMUH), Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 April 2009 Received in revised form 2 November 2009 Accepted 7 November 2009
Background: The use of health care services by older adults is increasing with the aging of the population. It is therefore essential that health care workers are current in their knowledge about gerontology; thus, educational programs regarding the care of elders are essential. Chinese-language assessments to measure knowledge about gerontology and aging and attitudes toward older adults are lacking. Objective: This study was designed to measure the reliability and validity of a Chineselanguage version of Palmore’s facts on aging quiz (FAQ 1). Method: Cronbach’s alpha, construct validity, content validity and convergent validity of the Chinese version of the FAQ 1 were assessed. A sample of 220 student nurses was recruited. Part of the sample (n = 125; Group A) was comprised of experienced nurses who had returned to school for advanced degrees. The remaining 95 participants were firstyear undergraduate students without prior work experience (Group B). The FAQ 1 was administered to all participants. The Chinese-language version of Kogan’s Attitudes toward Older People (KAOP) was also administered to assess convergent validity of the FAQ 1. Results: Cronbach’s alpha of the FAQ was 0.68, content validity was 0.82, and construct validity and convergent validity were acceptable. Group A had more correct answers on each item than Group B, indicating that students with prior work experience with the elderly were more knowledgeable regarding older people and aging. Conclusions: Based on the results of the assessment, the Chinese version of FAQ 1 is a valid and reliable instrument for measuring students’ or health care providers’ knowledge about older people. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Palmore Facts on aging quiz Gerontological education Instrument validation
What is already known about the topic?
* Corresponding author at: No. 110, Sec.1, Jianguo N.Rd., Taichung, 402, Taiwan. Tel.: +886 4 24730022x11733; fax: +886 4 23248137. E-mail address: [email protected] (C.-H. Yen). 0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.11.009
The FAQ 1 is a 25-item tool used to test knowledge of and attitudes toward older people. It can also be used to assess learning as a pre/post-test for education programs.
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What this paper adds The Chinese version of the FAQ 1 is a reliable and valid measure of knowledge of and attitudes toward older Chinese adults. The Chinese version of the FAQ 1 is applicable in the Chinese culture. The Chinese version of the FAQ 1 will be useful in assessing knowledge about older people among health science students and professionals. 1. Introduction Nations throughout the world are experiencing rapid increases in their elderly populations. In the United States and Taiwan, there is a shortage of healthcare providers specializing in geriatrics, a problem that has important implications for workforce planning (AGS Fact and Sheet, 2006). It is essential that all healthcare providers improve their knowledge, attitudes and skills relating to geriatric care as contact with older patients becomes more commonplace. It is equally important that medical and nursing students are adequately prepared to care for the growing population of older adults. Unfortunately, not enough students of the health professions are choosing to specialize in geriatrics as a career path. Few Chinese studies have investigated nurses’ knowledge of and attitudes toward older people. To address this issue, a self-report questionnaire was translated and trialed in a sample of nurses and compared to findings from Palmore’s FAQ I (Palmore, 1977). Preliminary findings suggested that nurses’ attitudes toward older people were predominately negative (Kwan and Law, 1994). The formal study of health professionals’ and students’ knowledge of the aging process, and their attitudes toward older adults, has been ongoing for the past 5 decades (Palmore, 1998; Tuckman and Lorge, 1953; Yen et al., 2009). Palmore (1977) designed the FAQ 1 to assess knowledge of physical, psychological, social, and economic factors related to aging, and to measure misconceptions regarding elderly people. Compared to other tests and scales, the FAQ 1 has the advantages of brevity (only 25 items) and the use of fact-based questions rather than questions and statements regarding attitudes. Palmore proposed four purposes for the FAQ 1: to educate, to measure learning, to test knowledge, and to measure attitudes. The test has been used in more than 1200 studies (Obiekwe, 2001; Palmore, 1998). Data from multiple studies that used the instrument suggested that groups of subjects matched on education level had similar mean scores, suggesting that the FAQ has face validity (Palmore, 1977, 1981). Previous studies have suggested that healthcare providers do not enjoy caring for the elderly. It has been suggested that the main reasons for this are ignorance and poor attitude (Kwan and Law, 1994). Palmore (1988) indicated that the only variables consistently related to knowledge regarding aging are level of education and attitudes toward older adults.
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Successful nursing interactions and interventions with older patients appear to be important in fostering positive attitudes (Haight et al., 1994; Tagliareni and Boring, 1988). Previous studies have found that education about geriatric care and interaction with older patients resulted in better knowledge about geriatrics as well as more positive attitudes toward elders (Cowan et al., 2004). A UK report (King’s Fund, 2002) indicated that the attitudes of health care staff needed improvement and recommended development of programs to educate staff and to focus attention on the way elders are treated by healthcare professionals. With the rapid aging of the population, it is important to have a way to assess nurses’ and nursing students’ knowledge about geriatrics. Formal studies of nurses’ and nursing students’ knowledge about older people has not yet been carried out in Taiwan. A valid and reliable assessment tool is needed to determine the effectiveness of interventions designed to improve knowledge about elders and elder care. The FAQ 1 has been used in several studies. For example, Hawk et al. (2001) used the FAQ to assess changes in students’ knowledge of geriatrics after a geriatrics course and found positive changes after the course. In Lusk et al. (1995) used FAQ 1 and FAQ 2 to assess knowledge and to measure misconceptions regarding the elderly and compared results on the FAQ 1 and FAQ 2 administered to nursing students. Knapp and Stubblefield (2000) administered the FAQ 1 to assess students’ knowledge before and after a geriatrics course and found that students who completed the course did benefit from the instruction. This finding is consistent with the work of Palmore (1980) who concluded that individuals who received training in gerontology consistently scored higher on a post-test then they had done on a pretest. In addition, Harris and Changas (1994) have noted that more than 100 studies have been conducted using the FAQs since their initial appearance in the empirical literature. However, the Chinese version of the assessment has not been translated and validated. 1.1. Purpose and research hypotheses The main purpose of this study was to assess the reliability and validity of the Chinese version of FAQ 1. Convergent validity, content validity, known-group validity, and internal consistent reliability were assessed. The research hypotheses were: 1. The content validity of the Chinese version of FAQ 1 will exceed .80. 2. The internal consistent reliability of the Chinese version of FAQ 1 will exceed .80. 3. There will be a significant difference in scores on the Chinese version of the FAQ between nursing students who are older and have previous work experience and undergraduate nursing students without such experience. 4. The convergent validity will be adequate, based on a positive correlation between the Chinese version of FAQ
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1 and the Kogan’s Attitudes toward Older People (KAOP) assessment. 2. Methods 2.1. Design and participants A cross-sectional comparison study was conducted. The questionnaires included a cover letter that addressed the purpose and importance of the study. A questionnaire was given to each participant by a teaching assistant during one of the class times during the first week of the 2008 academic year. Written and verbal instructions were explained to students by the instructor who then left the classroom. Teaching assistants remained to handle questions from students. 2.2. Ethical considerations The study was conducted in a Baccalaureate College of Nursing, which is a part of a medical university in the central Taiwan. The study was approved by the institutional review board of the university hospital. Informed consent was obtained from each participant, and participants were assured of strict confidentiality. Participants were instructed to retain a copy of the informed consent form for their records. If a participant chose to withdraw from the study, that participant’s completed assessment was located by code number and destroyed. Participants were informed that study participation involved no harm or discomfort, that participants would receive no direct benefit from their participation, and that the data they provided would be used in the evaluation and improvement of the instrument. 2.3. Instruments Palmore’s facts on aging quiz (FAQ 1; Palmore, 1977) was completed by each participant. The instrument is comprised of 25 questions with possible answers of ‘‘true’’, ‘‘false’’ or ‘‘don’t know’’. The FAQ 1 was originally intended to help stimulate discussion about and reflection on misconceptions about aging, but it has since been used to assess knowledge and bias toward the elderly in a variety of settings (Palmore, 1988). The quiz is short, designed to cover the basic physical, mental, and social facts about aging, has been empirically documented, and has been tested for validity and reliability internationally. The assessment is scored as follows: starting with a score of 25, .5 is subtracted for each incorrect answer. ‘‘Don’t know’’ responses are assigned zero points. This scoring system was designed to focus on the number of correct answers given without penalizing respondents for using the ‘‘don’t know’’ option (Knapp and Elder, 1998). Total scores can range from 0 to 25, with higher scores reflecting greater knowledge about aging. Palmore (1977, 1981) classified 16 items as indicating a negative bias toward the elderly if answered incorrectly and 5 items indicating a positive bias if answered incorrectly. The remaining 4 items were considered bias-neutral. Based on responses, a positive
bias score, a negative bias score, and a net bias score were determined. Kogan’s attitudes toward older people (KAOP; Kogan, 1961): The convergent validity of the FAQ 1 was assessed using the KAOP, which consists of 34 statements regarding older adults. Half of the items are negatively-worded statements (KAOP ), and the other half are positivelyworded statements (KAOP+). Statements are presented in random order. The KAOP is a summed Likert scale with 7 response categories ranging from ‘‘strongly disagree’’ (1) to ‘‘strongly agree’’ (7). In scoring, responses to negatively worded items are reversed (e.g. a score of 7 became 1). Thus, a higher total score indicates a more positive attitude towards older persons. The reliability of the Chinese version of the KOAP has been established. For the Chinese version, the Cronbach’s alpha was 0.82 for the total scale. Two factors were extracted and explained a total variance of 54.7% (Yen et al., 2009). 2.4. Translation The standard forward-backward procedure was used to translate the FAQ I from English into Chinese. Two bilingual nursing and geriatric professionals translated the questionnaire into Chinese, and back-translation of the scale was performed independently by a bilingual language expert. The wording in the last statement was changed from ‘‘2000’’ to ‘‘2020’’ so that the question read: ‘‘The health and socioeconomic status of older people (compared to younger people) in the year 2020 will probably be about the same as now.’’ 2.5. Data analysis 2.5.1. Demographic data Demographic data including age and number of working years was collected. Differences in these variables and in scores of KAOP and FAQ 1 were compared between Group A and Group B using t-tests. Percentage correct score on the FAQ 1 was used as the measure of student knowledge of older people. Pearson correlation was used to measure the association between KAOP and FAQ 1. SPSS 14.0 for Windows was used for all statistical analyses. Statistical analyses associated with each study hypothesis are presented below: 2.5.2. Hypothesis one Content Validity is the extent to which a measurement reflects the specific intended domain of content (Carmines and Zeller, 1991). The content validity of the Chinese FAQ 1 was assessed by a panel of geriatric experts that included five general geriatricians, one faculty member from the Department of Family Medicine, two gerontological experts and one school administrator. The experts were asked to rate each item of the Chinese version of the FAQ 1 based on relevance, clarity, and simplicity as 1 (not relevant), 2 (somewhat relevant), 3 (relevant), or 4 (very relevant). A content validity index (CVI) was computed using the proportion of experts who were in agreement about item relevance. The expectation was that content validity would exceed .80.
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Fig. 1. Flow chart of participants through each stage of the study.
2.5.3. Hypothesis two The reliability of the FAQ 1 and its relevant subscales were measured using internal consistency (Cronbach’s alpha). Internal consistency refers to the degree of homogeneity of items measuring the same dimension (Streiner and Norman, 2003). To assess reliability, a Cronbach’s alpha equal to or greater than .70 was considered adequate (Polit and Beck, 2004; Nunnally and Bernstein, 1994; Nunnally, 1978).
convergent validity was used to determine the extent to which the FAQ 1 score correlated with the KAOP score (Pearson correlation). Based on Kwan’s criteria (1983), the KAOP subscale was used as the criterion for the FAQ negative subscale since they both purported to measure negative attitude, and the KAOP+ subscale was used as the criterion for the FAQ positive subscale.
2.5.4. Hypothesis three An independent t-test was used to assess differences in the total Chinese FAQ 1 scores between older nursing students with previous work experience (Group A) and first-year undergraduate nursing students without work experience (Group B). Construct validity was used to measure relationships predicted on the basis of theoretical considerations by using the known-group technique to compare differences in the critical attributes of the FAQ 1 (Schneider et al., 2008). The known-group validity refers to how scores on FAQ 1 will discriminate among different groups at a high level of significance (Kline, 2000). In this study, knowngroup validity was assessed by comparing FAQ 1 scores between Group A and B. FAQ 1 scores were expected to be higher among participants in Group A.
3.1. Demographic data
2.5.5. Hypothesis four Convergent validity is the degree to which an operation is similar to other operations to which it should theoretically be similar (Polit and Beck, 2004). In the present study,
3. Results
A convenience sample of 263 student nurses was recruited from two different educational programs (a 3year program and a 4-year program) at one nursing school in Taichung, Taiwan. Informed consent was obtained from each subject. Forty-three participants did not finish the questionnaire due to absenteeism, tardiness, or unwillingness to cooperate, leaving a total sample of 220 student nurses who completed the questionnaire (Fig. 1). Slightly more than half the sample (57%) were licensed nurses with associate nursing degrees who were enrolled in a 3-year baccalaureate nursing program (Group A). Participants in Group A ranged in age from 21 to 42 years (Table 1), and all had more than 1 year of clinical experience in a hospital or clinic. The remaining 95 participants (Group B) were firstyear undergraduate nursing students with no previous work experience. Their average age was 18 (Table 1). Compared to Group B, Group A was older and had more work experiences (Table 1). Group A had higher mean scores on FAQ 1 and KAOP than did Group B.
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Table 1 Summary of mean age, mean working years, mean of KAOP, mean of FAQ 1, and p-value of KAOP and FAQ 1 between Group A and B. Subjects (n = 220)
Group Aa (n = 125)
Group Ba (n = 85)
Age Working years Mean of KAOP** Mean of FAQ 1***
28.63 4.5 167.48**** (SD: 15.04) 17.84**** (SD: 3.52)
18.78 0 151.23 (SD: 15.72) 13.35 (SD: 4.89)
SD: standard deviation. a Group A and Group B: see Fig. 1. ** Kogan’s attitudes toward older people scale. *** Palmore’s facts on aging quiz. **** P < 0.05, by using independent t-test.
3.3. Content validity Palmore (1981) suggested that an analysis of errors made on his knowledge quiz items might serve as an indirect measure of bias against older adults. Sixteen items in FAQ 1 may be classified as indicating a negative bias if answered incorrectly and 5 items may be classified as indicating a positive bias if answered incorrectly. In this study, the 25 translated items were submitted to a panel of geriatric experts for ratings of content validity. The content validity index (CVI) was used to determine item validity. The average CVI was .82 in the final version indicating adequate content validity (>.80; Polit and Beck, 2004). 3.4. Internal consistent reliability
3.2. Performance on specific test items Group A had a higher percentage of correct answers on each item of FAQ 1 than Group B (Table 2). Item 19 ‘‘Over 15% of Taiwanese population is over 65’’ had the highest percentage of correct answers in both groups (Group A: 98%; Group B: 84%). Item 5 (‘‘Feel miserable most of the time’’) had the second highest percentage of correct answers in both groups. The three items with the lowest percentages of correct answers were item 12 (‘‘Take longer to learn something new’’), item 15 (‘‘All are pretty much alike’’), and item 23 (‘‘Become more religious with age’’) in Group A and item 8 (‘‘Drivers have similar proportion of car accidents’’), item 15 (‘‘All are pretty much alike’’), and item 23 ‘‘Become more religious with age’’ in Group B.
Cronbach’s alpha was .68. Compared to previous studies, the reliability of the English version of FAQ 1 in the United States was .45 (Obiekwe, 2001) and .28 (Harris et al., 1996). Thus, the Chinese version of the FAQ 1 appears to be more highly reliable. 3.5. Construct validity Known-group comparison was conducted to assess how well the questionnaire discriminated among the subgroups of participants who differed in FAQ 1 scores. An independent t-test was used to compare the differences of FAQ 1 scores between Group A and B. FAQ 1 scores were significantly higher in Group A (Table 1) indicating that the older, more experienced nurses who made up Group A had a higher level of knowledge about the elderly than Group B.
Table 2 Ranking of items on true–false versions of the first facts on aging quiz (N = 220). Itema
1. Majority are senile +2. All five senses decline 3. No interest in/capacity for sex +4. Lung capacity declines 5. Feel miserable most of the time +6. Physical strength declines 7. At least 10% of the aged are living in long-term care 8. Drivers have similar proportion of car accidents 9. Work less effectively than young 10. About 80% have normal health 11. Set in ways/unable to change +12. Take longer to learn something new 13. Impossible to learn something new +14. Reaction time shows down 15. All are pretty much alike 16. Seldom bored 17. Majority socially isolated/lonely 18. Fewer worker accidents than young 19. Over 15% of Taiwanese population is over 65 20. Medical doctors give old low priority 21. Majority have income below poverty 22. Majority are working (including around the house) 23. Become more religious with age 24. Seldom irritated or angry 25. Expect same health and SES in 2020 a
% Correct Group A (n = 120)
Group B (n = 95)
90 82 75 84 91 87 80 78 78 72 78 61 81 87 60 73 81 72 98 67 79 87 65 84 88
78 79 60 74 84 81 62 55 65 61 67 59 68 81 50 58 74 63 84 56 66 73 53 75 73
Even-numbered items are true; odd-numbered items are false. Errors on items marked + and
indicate positive and negative bias, respectively.
C.-C. Wang et al. / International Journal of Nursing Studies 47 (2010) 742–752 Table 3 Pearson’s correlation coefficient between the Chinese version of the FAQ 1 and KAOP. FAQ 1 negative items KAOP KAOP+ *
*
.48 –
FAQ 1 positive items – .38*
Correlation is significant at the .05 level (two-tailed).
Therefore, the construct validity of the Chinese version of the FAQ 1 was supported. 3.6. Convergent validity Based on Pearson’s correlation, the KAOP was significantly correlated with the FAQ negative subscale and the KAOP+ was positively correlated with the FAQ positive
Table 4 (Palmore’s facts on aging quiz I; Palmore, 1977) Palmore the BEST response alternative for each of the questions below.
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subscale, indicating adequate convergent validity (Tables 3 and 4). 4. Discussion This research had some limitations to consider when interpreting the results. First, the groups were not randomly assigned, so they were not equivalent. Second, the results cannot be generalized due to the small sample size of the two groups. This study demonstrated that the Chinese version of the FAQ 1 is a reliable and valid measure. We found that internal consistent reliability, construct validity, content validity, and convergent validity were all acceptable. Our finding of an internal consistency of .68 is higher than the findings of a Canadian study, which found an internal consistency of .52 (Kwan, 1983). Luszcz (1982) found that
, directions: select
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the third-year Australian psychology students scored 64% correct, whereas first-year students scored 58% correct. This finding is consistent with our results, as well as Palmore’s (1980), and Pennington’s (2001) reports that level of education effects overall performance. However in the present study, this difference may be due to the fact that our more highly educated participants also had former work experience with the elderly. Our finding of higher scores on the FAQ 1 among participants with more education and work experience is consistent with previous studies. Studies by Heller and Walsh (1976), Giardina-Roche and Black (1990) and Stewart et al. (2005) all found that students with prior work experience with older adults were more knowledgeable about the elderly, and had more positive attitudes toward them than did students without this experience. If experience alone with the elderly population can result in increased knowledge and thus improved attitudes, programs that expose health professionals to older adults could potentially enhance the care of elderly patients. For example, some schools have introduced activities whereby students come in contact with healthy and active older people living in the community, and several studies have employed a pre/ post-test methodology to gauge the change in children’s attitudes after some form of interaction with older people (Cowan et al., 2004). Palmore (1991) suggested that nursing students enter nursing education programs with predetermined beliefs and attitudes about older people; however, education and exposure to older adults might facilitate a change in students’ perspectives. Haight et al. (1994), Stewart et al. (2005), and Wang et al. (in press) found that educational experiences with older people positively influenced students’ attitudes towards older people. King’s Fund (2002) has also recommended that the level of knowledge and the attitude of health care staff could be improved via educational programs. In the present study, both participant groups demonstrated a low percentage of correct answers on Items 15 and 23. This finding is consistent with previous study (Mellor et al., 2007), which found a high percentage of incorrect answers on items regarded as fundamental nursing knowledge (items pertaining to age-related sensory changes, age-related changes in lung capacity, and age-related changes in learning). The apparently poor knowledge on the part of nursing students in these areas is a major concern and deserves further exploration. As is the case with most developed countries, Taiwan is facing the dilemma of a rapidly growing elderly population, and there is a perceived need for greater gerontological education for health care professionals. Educators in many academic programs, including medical and nursing curricula, must do better in preparing students to care for the booming elderly population. In order to provide useful and sufficient information to increase students’ knowledge, the development of a reliable and valid assessment instrument is essential for determining students’ strengths and weaknesses.
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5. Conclusion This study confirmed the reliability and validity of the Chinese version of FAQ 1 scale in a sample of student nurses. Results of FAQ 1 assessments may be used to improve the content of Gerontology courses to better address deficiencies in knowledge, skills, and attitudes toward the elderly. The Chinese version of the FAQ 1 is an important tool that can now be confidently used by educators to assess the students’ and/or health care providers’ knowledge about the elderly. Acknowledgements The authors wish to express their appreciation to Dr. Erdman Palmore and Dr. Carol Deets for their advice. Conflict of interest: None declared. Ethical approval: This study has approved by the institutional review board of the Chung Shan Medical University Hospital. Funding: This study did not received funding from other affiliations. References AGS Fact Sheet, 2006. American Geriatrics Society. Available at: http:// www.americangeriatrics.org/news/ags_fact_sheet.html (accessed 01/03/08). Carmines, E.G., Zeller, R.A., 1991. Reliability and Viability Assessment. Sage, CA. Cowan, D.T., Roberts, J.D., Fitzpatrick, J.M., While, A.E., Baldwin, J., 2004. Nutritional status of older people in long term care settings: current status and future directions. International Journal of Nursing Studies 41, 225–237. Giardina-Roche, C., Black, M., 1990. Attitudes of diploma student nurses toward adult clients. Journal of Nursing Education 29, 208– 214. Haight, B.K., Christ, M.A., Dias, J.K., 1994. Does nursing education promote ageism? Journal of Advanced Nursing 20, 382–390. Harris, D.K., Changas, P.S., 1994. Revision of Palmore’s second facts on aging quiz from a true–false to a multiple-choice format. Educational Gerontology 20, 741–754. Harris, D.K., Changas, P.S., Palmore, E.B., 1996. Palmore’s first facts on aging quiz in a multiple-choice format. Educational Gerontology 22, 575–589. Hawk, C., Byrd, L., Killinger, L.Z., 2001. Evaluation of a geriatrics course emphasizing interdisciplinary issues for chiropractic students. Journal of Gerontological Nursing 27, 6–12. Heller, B., Walsh, F., 1976. Changing nursing students’ attitudes toward the aged: an experimental study. Journal of Nursing Education 15, 9– 17. King’s Fund, 2002. Old Habits die Hard: Tackling Age Discrimination in Health and Social Care. Author, London. Kline, P., 2000. Handbook of Psychometrical Testing. Routledge, New York. Knapp, J.L., Elder, K.B., 1998. Assessing prison personnel’s knowledge of the aging process. Journal of the Oklahoma Criminal Justice Research Consortium 4. Knapp, J.L., Stubblefield, P., 2000. Changing students’ perceptions of aging: the impact of an intergenerational service learning course. Educational Gerontology 26, 611–621. Kogan, N., 1961. Attitudes toward old people: the development of a scale and an examination of correlates. Journal of Abnormal Social Psychology 64, 44–54. Kwan, Y.H., 1983. An examination of the validity of Palmore’s facts on aging quiz. HKInCHiP 39, 31–35. Kwan, A., Law, B.K., 1994. Attitudes of student/pupil nurse toward the aged in Hong Kong: implications for nursing education. Hong Kong Journal of Gerontology 8, 43–51. Lusk, S.L., Williams, R.A., Hsuing, S., 1995. Evaluation of the facts on aging quizzes I & II. Journal of Nursing Education 34, 317–324.
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Luszcz, M.A., 1982. Facts on aging: an Australian validation. The Gerontologist 22, 369–372. Mellor, P., Chew, D., Greenhill, J., 2007. Nurses’ attitudes toward elderly people and knowledge of gerontic care in a multi-purpose health service (MPHS). Australian Journal of Advanced Nursing 24, 37–41. Nunnally, J.O., 1978. Psychometric Theory. McGraw-Hill, New York. Nunnally, J.O., Bernstein, I.H., 1994. Psychometric Theory. McGraw-Hill, New York. Obiekwe, J.C., 2001. An item response theory analysis of Palmore’s facts on aging quiz (FAQ) using the three parameter model. In: Paper presented at the Annual Conference of the Association for Gerontology in Higher Education, San Jose, CA. Palmore, E.B., 1977. Facts on aging quiz: a short quiz. The Gerontologist 17, 315–320. Palmore, E.B., 1980. The facts on aging quiz: a review of findings. The Gerontologist 20, 669–672. Palmore, E.B., 1981. The facts on aging quiz: part two. The Gerontologist 21, 431–438. Palmore, E.B., 1988. The Facts on Aging Quiz. Springer, New York. Palmore, E.B., 1991. Ageism Negative and Positive. Springer, New York. Palmore, E.B., 1998. The Facts on Aging Quiz: A Handbook of Uses and Results, 2nd ed. Springer, New York. Pennington, H.R., Pachana, N.A., Coyle, S.L., 2001. Use of the facts on aging quiz in New Zealand: validation of questions, performance of a student sample, and effects of a don’t know option. Educational Gerontology 27, 409–416.
Polit, D.F., Beck, C.T., 2004. Nursing Research: Principles and Methods, 7th ed. Lippincott Williams and Wilkins, Philadelphia. Schneider, Z., Whitehead, D., Elliott, D., LoBiondo-Wood, G., Haber, J., 2008. An overview of research theory and process. In: Nursing & Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 3rd ed. Elsevier, Sydney. Stewart, J.J., Giles, L., Paterson, J.E., Butler, S.J., 2005. Knowledge and attitudes towards older people: New Zealand students entering health professional degrees. Physical and Occupational Therapy in Geriatrics 234, 25–36. Streiner, D.L., Norman, G.R., 2003. Health Measurement Scales: A Practical Guide to their Development and Use, 3rd ed. Oxford University Press, Oxford. Tagliareni, E., Boring, G., 1988. Faculty, student, caregiver attitudes toward the Aged. In: National League for Nursing, Associate Degree Nursing and the Nursing Home, pp. 99–112. Tuckman, J., Lorge, I., 1953. Attitudes toward old people. Journal of Social Psychology 37, 249–260. Wang, C.C., Yen, C.H., Liao, W.C., Yuan, S.C., Chen, Y.R., Lee, M.C., Lu, H.J., Bloom, P., in press. Evaluating outcomes of Taiwan’s first gerontology certification program. Archives of Gerontology and Geriatrics. doi:10.1016/j.archger.2009.04.002. Yen, C.H., Liao, W.C., Chen, Y.J., Kao, M.C., Lee, M.C., Wang, C.C., 2009. A Chinese version of Kogan’s attitude toward older people scale: reliability and validity assessment. International Journal of Nursing Studies 46, 37–43.
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The Chinese version of the facts on aging quiz scale: Reliability and validity assessment Cheng-Ching Wang a,b, Wen-Chun Liao a,b, Pi-Chao Kuo a,b, Su-Chuan Yuan a,b, Hsiao-Ling Chuang a, Hao-Chang Lo c, Hui-Yen Liao d, Miller Elaine e, Meng-Chih Lee b,f,g, Chi-Hua Yen b,f,g,* a
College of Nursing, Chung Shan Medical University (CSMU), Taiwan Center for Education and Research on Geriatrics and Gerontology, CSMU, Taiwan General Education Center, CSMU, Taiwan d Department of Nursing, Buddhist Tzu Chi General Hospital, Taiwan e University of Cincinnati College of Nursing, USA f Institute of Medicine, CSMU, Taiwan g Department of Family and Community Medicine, Chung Shan Medical University Hospital (CSMUH), Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 April 2009 Received in revised form 2 November 2009 Accepted 7 November 2009
Background: The use of health care services by older adults is increasing with the aging of the population. It is therefore essential that health care workers are current in their knowledge about gerontology; thus, educational programs regarding the care of elders are essential. Chinese-language assessments to measure knowledge about gerontology and aging and attitudes toward older adults are lacking. Objective: This study was designed to measure the reliability and validity of a Chineselanguage version of Palmore’s facts on aging quiz (FAQ 1). Method: Cronbach’s alpha, construct validity, content validity and convergent validity of the Chinese version of the FAQ 1 were assessed. A sample of 220 student nurses was recruited. Part of the sample (n = 125; Group A) was comprised of experienced nurses who had returned to school for advanced degrees. The remaining 95 participants were firstyear undergraduate students without prior work experience (Group B). The FAQ 1 was administered to all participants. The Chinese-language version of Kogan’s Attitudes toward Older People (KAOP) was also administered to assess convergent validity of the FAQ 1. Results: Cronbach’s alpha of the FAQ was 0.68, content validity was 0.82, and construct validity and convergent validity were acceptable. Group A had more correct answers on each item than Group B, indicating that students with prior work experience with the elderly were more knowledgeable regarding older people and aging. Conclusions: Based on the results of the assessment, the Chinese version of FAQ 1 is a valid and reliable instrument for measuring students’ or health care providers’ knowledge about older people. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Palmore Facts on aging quiz Gerontological education Instrument validation
What is already known about the topic?
* Corresponding author at: No. 110, Sec.1, Jianguo N.Rd., Taichung, 402, Taiwan. Tel.: +886 4 24730022x11733; fax: +886 4 23248137. E-mail address: [email protected] (C.-H. Yen). 0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.11.009
The FAQ 1 is a 25-item tool used to test knowledge of and attitudes toward older people. It can also be used to assess learning as a pre/post-test for education programs.
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What this paper adds The Chinese version of the FAQ 1 is a reliable and valid measure of knowledge of and attitudes toward older Chinese adults. The Chinese version of the FAQ 1 is applicable in the Chinese culture. The Chinese version of the FAQ 1 will be useful in assessing knowledge about older people among health science students and professionals. 1. Introduction Nations throughout the world are experiencing rapid increases in their elderly populations. In the United States and Taiwan, there is a shortage of healthcare providers specializing in geriatrics, a problem that has important implications for workforce planning (AGS Fact and Sheet, 2006). It is essential that all healthcare providers improve their knowledge, attitudes and skills relating to geriatric care as contact with older patients becomes more commonplace. It is equally important that medical and nursing students are adequately prepared to care for the growing population of older adults. Unfortunately, not enough students of the health professions are choosing to specialize in geriatrics as a career path. Few Chinese studies have investigated nurses’ knowledge of and attitudes toward older people. To address this issue, a self-report questionnaire was translated and trialed in a sample of nurses and compared to findings from Palmore’s FAQ I (Palmore, 1977). Preliminary findings suggested that nurses’ attitudes toward older people were predominately negative (Kwan and Law, 1994). The formal study of health professionals’ and students’ knowledge of the aging process, and their attitudes toward older adults, has been ongoing for the past 5 decades (Palmore, 1998; Tuckman and Lorge, 1953; Yen et al., 2009). Palmore (1977) designed the FAQ 1 to assess knowledge of physical, psychological, social, and economic factors related to aging, and to measure misconceptions regarding elderly people. Compared to other tests and scales, the FAQ 1 has the advantages of brevity (only 25 items) and the use of fact-based questions rather than questions and statements regarding attitudes. Palmore proposed four purposes for the FAQ 1: to educate, to measure learning, to test knowledge, and to measure attitudes. The test has been used in more than 1200 studies (Obiekwe, 2001; Palmore, 1998). Data from multiple studies that used the instrument suggested that groups of subjects matched on education level had similar mean scores, suggesting that the FAQ has face validity (Palmore, 1977, 1981). Previous studies have suggested that healthcare providers do not enjoy caring for the elderly. It has been suggested that the main reasons for this are ignorance and poor attitude (Kwan and Law, 1994). Palmore (1988) indicated that the only variables consistently related to knowledge regarding aging are level of education and attitudes toward older adults.
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Successful nursing interactions and interventions with older patients appear to be important in fostering positive attitudes (Haight et al., 1994; Tagliareni and Boring, 1988). Previous studies have found that education about geriatric care and interaction with older patients resulted in better knowledge about geriatrics as well as more positive attitudes toward elders (Cowan et al., 2004). A UK report (King’s Fund, 2002) indicated that the attitudes of health care staff needed improvement and recommended development of programs to educate staff and to focus attention on the way elders are treated by healthcare professionals. With the rapid aging of the population, it is important to have a way to assess nurses’ and nursing students’ knowledge about geriatrics. Formal studies of nurses’ and nursing students’ knowledge about older people has not yet been carried out in Taiwan. A valid and reliable assessment tool is needed to determine the effectiveness of interventions designed to improve knowledge about elders and elder care. The FAQ 1 has been used in several studies. For example, Hawk et al. (2001) used the FAQ to assess changes in students’ knowledge of geriatrics after a geriatrics course and found positive changes after the course. In Lusk et al. (1995) used FAQ 1 and FAQ 2 to assess knowledge and to measure misconceptions regarding the elderly and compared results on the FAQ 1 and FAQ 2 administered to nursing students. Knapp and Stubblefield (2000) administered the FAQ 1 to assess students’ knowledge before and after a geriatrics course and found that students who completed the course did benefit from the instruction. This finding is consistent with the work of Palmore (1980) who concluded that individuals who received training in gerontology consistently scored higher on a post-test then they had done on a pretest. In addition, Harris and Changas (1994) have noted that more than 100 studies have been conducted using the FAQs since their initial appearance in the empirical literature. However, the Chinese version of the assessment has not been translated and validated. 1.1. Purpose and research hypotheses The main purpose of this study was to assess the reliability and validity of the Chinese version of FAQ 1. Convergent validity, content validity, known-group validity, and internal consistent reliability were assessed. The research hypotheses were: 1. The content validity of the Chinese version of FAQ 1 will exceed .80. 2. The internal consistent reliability of the Chinese version of FAQ 1 will exceed .80. 3. There will be a significant difference in scores on the Chinese version of the FAQ between nursing students who are older and have previous work experience and undergraduate nursing students without such experience. 4. The convergent validity will be adequate, based on a positive correlation between the Chinese version of FAQ
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1 and the Kogan’s Attitudes toward Older People (KAOP) assessment. 2. Methods 2.1. Design and participants A cross-sectional comparison study was conducted. The questionnaires included a cover letter that addressed the purpose and importance of the study. A questionnaire was given to each participant by a teaching assistant during one of the class times during the first week of the 2008 academic year. Written and verbal instructions were explained to students by the instructor who then left the classroom. Teaching assistants remained to handle questions from students. 2.2. Ethical considerations The study was conducted in a Baccalaureate College of Nursing, which is a part of a medical university in the central Taiwan. The study was approved by the institutional review board of the university hospital. Informed consent was obtained from each participant, and participants were assured of strict confidentiality. Participants were instructed to retain a copy of the informed consent form for their records. If a participant chose to withdraw from the study, that participant’s completed assessment was located by code number and destroyed. Participants were informed that study participation involved no harm or discomfort, that participants would receive no direct benefit from their participation, and that the data they provided would be used in the evaluation and improvement of the instrument. 2.3. Instruments Palmore’s facts on aging quiz (FAQ 1; Palmore, 1977) was completed by each participant. The instrument is comprised of 25 questions with possible answers of ‘‘true’’, ‘‘false’’ or ‘‘don’t know’’. The FAQ 1 was originally intended to help stimulate discussion about and reflection on misconceptions about aging, but it has since been used to assess knowledge and bias toward the elderly in a variety of settings (Palmore, 1988). The quiz is short, designed to cover the basic physical, mental, and social facts about aging, has been empirically documented, and has been tested for validity and reliability internationally. The assessment is scored as follows: starting with a score of 25, .5 is subtracted for each incorrect answer. ‘‘Don’t know’’ responses are assigned zero points. This scoring system was designed to focus on the number of correct answers given without penalizing respondents for using the ‘‘don’t know’’ option (Knapp and Elder, 1998). Total scores can range from 0 to 25, with higher scores reflecting greater knowledge about aging. Palmore (1977, 1981) classified 16 items as indicating a negative bias toward the elderly if answered incorrectly and 5 items indicating a positive bias if answered incorrectly. The remaining 4 items were considered bias-neutral. Based on responses, a positive
bias score, a negative bias score, and a net bias score were determined. Kogan’s attitudes toward older people (KAOP; Kogan, 1961): The convergent validity of the FAQ 1 was assessed using the KAOP, which consists of 34 statements regarding older adults. Half of the items are negatively-worded statements (KAOP ), and the other half are positivelyworded statements (KAOP+). Statements are presented in random order. The KAOP is a summed Likert scale with 7 response categories ranging from ‘‘strongly disagree’’ (1) to ‘‘strongly agree’’ (7). In scoring, responses to negatively worded items are reversed (e.g. a score of 7 became 1). Thus, a higher total score indicates a more positive attitude towards older persons. The reliability of the Chinese version of the KOAP has been established. For the Chinese version, the Cronbach’s alpha was 0.82 for the total scale. Two factors were extracted and explained a total variance of 54.7% (Yen et al., 2009). 2.4. Translation The standard forward-backward procedure was used to translate the FAQ I from English into Chinese. Two bilingual nursing and geriatric professionals translated the questionnaire into Chinese, and back-translation of the scale was performed independently by a bilingual language expert. The wording in the last statement was changed from ‘‘2000’’ to ‘‘2020’’ so that the question read: ‘‘The health and socioeconomic status of older people (compared to younger people) in the year 2020 will probably be about the same as now.’’ 2.5. Data analysis 2.5.1. Demographic data Demographic data including age and number of working years was collected. Differences in these variables and in scores of KAOP and FAQ 1 were compared between Group A and Group B using t-tests. Percentage correct score on the FAQ 1 was used as the measure of student knowledge of older people. Pearson correlation was used to measure the association between KAOP and FAQ 1. SPSS 14.0 for Windows was used for all statistical analyses. Statistical analyses associated with each study hypothesis are presented below: 2.5.2. Hypothesis one Content Validity is the extent to which a measurement reflects the specific intended domain of content (Carmines and Zeller, 1991). The content validity of the Chinese FAQ 1 was assessed by a panel of geriatric experts that included five general geriatricians, one faculty member from the Department of Family Medicine, two gerontological experts and one school administrator. The experts were asked to rate each item of the Chinese version of the FAQ 1 based on relevance, clarity, and simplicity as 1 (not relevant), 2 (somewhat relevant), 3 (relevant), or 4 (very relevant). A content validity index (CVI) was computed using the proportion of experts who were in agreement about item relevance. The expectation was that content validity would exceed .80.
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Fig. 1. Flow chart of participants through each stage of the study.
2.5.3. Hypothesis two The reliability of the FAQ 1 and its relevant subscales were measured using internal consistency (Cronbach’s alpha). Internal consistency refers to the degree of homogeneity of items measuring the same dimension (Streiner and Norman, 2003). To assess reliability, a Cronbach’s alpha equal to or greater than .70 was considered adequate (Polit and Beck, 2004; Nunnally and Bernstein, 1994; Nunnally, 1978).
convergent validity was used to determine the extent to which the FAQ 1 score correlated with the KAOP score (Pearson correlation). Based on Kwan’s criteria (1983), the KAOP subscale was used as the criterion for the FAQ negative subscale since they both purported to measure negative attitude, and the KAOP+ subscale was used as the criterion for the FAQ positive subscale.
2.5.4. Hypothesis three An independent t-test was used to assess differences in the total Chinese FAQ 1 scores between older nursing students with previous work experience (Group A) and first-year undergraduate nursing students without work experience (Group B). Construct validity was used to measure relationships predicted on the basis of theoretical considerations by using the known-group technique to compare differences in the critical attributes of the FAQ 1 (Schneider et al., 2008). The known-group validity refers to how scores on FAQ 1 will discriminate among different groups at a high level of significance (Kline, 2000). In this study, knowngroup validity was assessed by comparing FAQ 1 scores between Group A and B. FAQ 1 scores were expected to be higher among participants in Group A.
3.1. Demographic data
2.5.5. Hypothesis four Convergent validity is the degree to which an operation is similar to other operations to which it should theoretically be similar (Polit and Beck, 2004). In the present study,
3. Results
A convenience sample of 263 student nurses was recruited from two different educational programs (a 3year program and a 4-year program) at one nursing school in Taichung, Taiwan. Informed consent was obtained from each subject. Forty-three participants did not finish the questionnaire due to absenteeism, tardiness, or unwillingness to cooperate, leaving a total sample of 220 student nurses who completed the questionnaire (Fig. 1). Slightly more than half the sample (57%) were licensed nurses with associate nursing degrees who were enrolled in a 3-year baccalaureate nursing program (Group A). Participants in Group A ranged in age from 21 to 42 years (Table 1), and all had more than 1 year of clinical experience in a hospital or clinic. The remaining 95 participants (Group B) were firstyear undergraduate nursing students with no previous work experience. Their average age was 18 (Table 1). Compared to Group B, Group A was older and had more work experiences (Table 1). Group A had higher mean scores on FAQ 1 and KAOP than did Group B.
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Table 1 Summary of mean age, mean working years, mean of KAOP, mean of FAQ 1, and p-value of KAOP and FAQ 1 between Group A and B. Subjects (n = 220)
Group Aa (n = 125)
Group Ba (n = 85)
Age Working years Mean of KAOP** Mean of FAQ 1***
28.63 4.5 167.48**** (SD: 15.04) 17.84**** (SD: 3.52)
18.78 0 151.23 (SD: 15.72) 13.35 (SD: 4.89)
SD: standard deviation. a Group A and Group B: see Fig. 1. ** Kogan’s attitudes toward older people scale. *** Palmore’s facts on aging quiz. **** P < 0.05, by using independent t-test.
3.3. Content validity Palmore (1981) suggested that an analysis of errors made on his knowledge quiz items might serve as an indirect measure of bias against older adults. Sixteen items in FAQ 1 may be classified as indicating a negative bias if answered incorrectly and 5 items may be classified as indicating a positive bias if answered incorrectly. In this study, the 25 translated items were submitted to a panel of geriatric experts for ratings of content validity. The content validity index (CVI) was used to determine item validity. The average CVI was .82 in the final version indicating adequate content validity (>.80; Polit and Beck, 2004). 3.4. Internal consistent reliability
3.2. Performance on specific test items Group A had a higher percentage of correct answers on each item of FAQ 1 than Group B (Table 2). Item 19 ‘‘Over 15% of Taiwanese population is over 65’’ had the highest percentage of correct answers in both groups (Group A: 98%; Group B: 84%). Item 5 (‘‘Feel miserable most of the time’’) had the second highest percentage of correct answers in both groups. The three items with the lowest percentages of correct answers were item 12 (‘‘Take longer to learn something new’’), item 15 (‘‘All are pretty much alike’’), and item 23 (‘‘Become more religious with age’’) in Group A and item 8 (‘‘Drivers have similar proportion of car accidents’’), item 15 (‘‘All are pretty much alike’’), and item 23 ‘‘Become more religious with age’’ in Group B.
Cronbach’s alpha was .68. Compared to previous studies, the reliability of the English version of FAQ 1 in the United States was .45 (Obiekwe, 2001) and .28 (Harris et al., 1996). Thus, the Chinese version of the FAQ 1 appears to be more highly reliable. 3.5. Construct validity Known-group comparison was conducted to assess how well the questionnaire discriminated among the subgroups of participants who differed in FAQ 1 scores. An independent t-test was used to compare the differences of FAQ 1 scores between Group A and B. FAQ 1 scores were significantly higher in Group A (Table 1) indicating that the older, more experienced nurses who made up Group A had a higher level of knowledge about the elderly than Group B.
Table 2 Ranking of items on true–false versions of the first facts on aging quiz (N = 220). Itema
1. Majority are senile +2. All five senses decline 3. No interest in/capacity for sex +4. Lung capacity declines 5. Feel miserable most of the time +6. Physical strength declines 7. At least 10% of the aged are living in long-term care 8. Drivers have similar proportion of car accidents 9. Work less effectively than young 10. About 80% have normal health 11. Set in ways/unable to change +12. Take longer to learn something new 13. Impossible to learn something new +14. Reaction time shows down 15. All are pretty much alike 16. Seldom bored 17. Majority socially isolated/lonely 18. Fewer worker accidents than young 19. Over 15% of Taiwanese population is over 65 20. Medical doctors give old low priority 21. Majority have income below poverty 22. Majority are working (including around the house) 23. Become more religious with age 24. Seldom irritated or angry 25. Expect same health and SES in 2020 a
% Correct Group A (n = 120)
Group B (n = 95)
90 82 75 84 91 87 80 78 78 72 78 61 81 87 60 73 81 72 98 67 79 87 65 84 88
78 79 60 74 84 81 62 55 65 61 67 59 68 81 50 58 74 63 84 56 66 73 53 75 73
Even-numbered items are true; odd-numbered items are false. Errors on items marked + and
indicate positive and negative bias, respectively.
C.-C. Wang et al. / International Journal of Nursing Studies 47 (2010) 742–752 Table 3 Pearson’s correlation coefficient between the Chinese version of the FAQ 1 and KAOP. FAQ 1 negative items KAOP KAOP+ *
*
.48 –
FAQ 1 positive items – .38*
Correlation is significant at the .05 level (two-tailed).
Therefore, the construct validity of the Chinese version of the FAQ 1 was supported. 3.6. Convergent validity Based on Pearson’s correlation, the KAOP was significantly correlated with the FAQ negative subscale and the KAOP+ was positively correlated with the FAQ positive
Table 4 (Palmore’s facts on aging quiz I; Palmore, 1977) Palmore the BEST response alternative for each of the questions below.
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subscale, indicating adequate convergent validity (Tables 3 and 4). 4. Discussion This research had some limitations to consider when interpreting the results. First, the groups were not randomly assigned, so they were not equivalent. Second, the results cannot be generalized due to the small sample size of the two groups. This study demonstrated that the Chinese version of the FAQ 1 is a reliable and valid measure. We found that internal consistent reliability, construct validity, content validity, and convergent validity were all acceptable. Our finding of an internal consistency of .68 is higher than the findings of a Canadian study, which found an internal consistency of .52 (Kwan, 1983). Luszcz (1982) found that
, directions: select
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the third-year Australian psychology students scored 64% correct, whereas first-year students scored 58% correct. This finding is consistent with our results, as well as Palmore’s (1980), and Pennington’s (2001) reports that level of education effects overall performance. However in the present study, this difference may be due to the fact that our more highly educated participants also had former work experience with the elderly. Our finding of higher scores on the FAQ 1 among participants with more education and work experience is consistent with previous studies. Studies by Heller and Walsh (1976), Giardina-Roche and Black (1990) and Stewart et al. (2005) all found that students with prior work experience with older adults were more knowledgeable about the elderly, and had more positive attitudes toward them than did students without this experience. If experience alone with the elderly population can result in increased knowledge and thus improved attitudes, programs that expose health professionals to older adults could potentially enhance the care of elderly patients. For example, some schools have introduced activities whereby students come in contact with healthy and active older people living in the community, and several studies have employed a pre/ post-test methodology to gauge the change in children’s attitudes after some form of interaction with older people (Cowan et al., 2004). Palmore (1991) suggested that nursing students enter nursing education programs with predetermined beliefs and attitudes about older people; however, education and exposure to older adults might facilitate a change in students’ perspectives. Haight et al. (1994), Stewart et al. (2005), and Wang et al. (in press) found that educational experiences with older people positively influenced students’ attitudes towards older people. King’s Fund (2002) has also recommended that the level of knowledge and the attitude of health care staff could be improved via educational programs. In the present study, both participant groups demonstrated a low percentage of correct answers on Items 15 and 23. This finding is consistent with previous study (Mellor et al., 2007), which found a high percentage of incorrect answers on items regarded as fundamental nursing knowledge (items pertaining to age-related sensory changes, age-related changes in lung capacity, and age-related changes in learning). The apparently poor knowledge on the part of nursing students in these areas is a major concern and deserves further exploration. As is the case with most developed countries, Taiwan is facing the dilemma of a rapidly growing elderly population, and there is a perceived need for greater gerontological education for health care professionals. Educators in many academic programs, including medical and nursing curricula, must do better in preparing students to care for the booming elderly population. In order to provide useful and sufficient information to increase students’ knowledge, the development of a reliable and valid assessment instrument is essential for determining students’ strengths and weaknesses.
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5. Conclusion This study confirmed the reliability and validity of the Chinese version of FAQ 1 scale in a sample of student nurses. Results of FAQ 1 assessments may be used to improve the content of Gerontology courses to better address deficiencies in knowledge, skills, and attitudes toward the elderly. The Chinese version of the FAQ 1 is an important tool that can now be confidently used by educators to assess the students’ and/or health care providers’ knowledge about the elderly. Acknowledgements The authors wish to express their appreciation to Dr. Erdman Palmore and Dr. Carol Deets for their advice. Conflict of interest: None declared. Ethical approval: This study has approved by the institutional review board of the Chung Shan Medical University Hospital. Funding: This study did not received funding from other affiliations. References AGS Fact Sheet, 2006. American Geriatrics Society. Available at: http:// www.americangeriatrics.org/news/ags_fact_sheet.html (accessed 01/03/08). Carmines, E.G., Zeller, R.A., 1991. Reliability and Viability Assessment. Sage, CA. Cowan, D.T., Roberts, J.D., Fitzpatrick, J.M., While, A.E., Baldwin, J., 2004. Nutritional status of older people in long term care settings: current status and future directions. International Journal of Nursing Studies 41, 225–237. Giardina-Roche, C., Black, M., 1990. Attitudes of diploma student nurses toward adult clients. Journal of Nursing Education 29, 208– 214. Haight, B.K., Christ, M.A., Dias, J.K., 1994. Does nursing education promote ageism? Journal of Advanced Nursing 20, 382–390. Harris, D.K., Changas, P.S., 1994. Revision of Palmore’s second facts on aging quiz from a true–false to a multiple-choice format. Educational Gerontology 20, 741–754. Harris, D.K., Changas, P.S., Palmore, E.B., 1996. Palmore’s first facts on aging quiz in a multiple-choice format. Educational Gerontology 22, 575–589. Hawk, C., Byrd, L., Killinger, L.Z., 2001. Evaluation of a geriatrics course emphasizing interdisciplinary issues for chiropractic students. Journal of Gerontological Nursing 27, 6–12. Heller, B., Walsh, F., 1976. Changing nursing students’ attitudes toward the aged: an experimental study. Journal of Nursing Education 15, 9– 17. King’s Fund, 2002. Old Habits die Hard: Tackling Age Discrimination in Health and Social Care. Author, London. Kline, P., 2000. Handbook of Psychometrical Testing. Routledge, New York. Knapp, J.L., Elder, K.B., 1998. Assessing prison personnel’s knowledge of the aging process. Journal of the Oklahoma Criminal Justice Research Consortium 4. Knapp, J.L., Stubblefield, P., 2000. Changing students’ perceptions of aging: the impact of an intergenerational service learning course. Educational Gerontology 26, 611–621. Kogan, N., 1961. Attitudes toward old people: the development of a scale and an examination of correlates. Journal of Abnormal Social Psychology 64, 44–54. Kwan, Y.H., 1983. An examination of the validity of Palmore’s facts on aging quiz. HKInCHiP 39, 31–35. Kwan, A., Law, B.K., 1994. Attitudes of student/pupil nurse toward the aged in Hong Kong: implications for nursing education. Hong Kong Journal of Gerontology 8, 43–51. Lusk, S.L., Williams, R.A., Hsuing, S., 1995. Evaluation of the facts on aging quizzes I & II. Journal of Nursing Education 34, 317–324.
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Luszcz, M.A., 1982. Facts on aging: an Australian validation. The Gerontologist 22, 369–372. Mellor, P., Chew, D., Greenhill, J., 2007. Nurses’ attitudes toward elderly people and knowledge of gerontic care in a multi-purpose health service (MPHS). Australian Journal of Advanced Nursing 24, 37–41. Nunnally, J.O., 1978. Psychometric Theory. McGraw-Hill, New York. Nunnally, J.O., Bernstein, I.H., 1994. Psychometric Theory. McGraw-Hill, New York. Obiekwe, J.C., 2001. An item response theory analysis of Palmore’s facts on aging quiz (FAQ) using the three parameter model. In: Paper presented at the Annual Conference of the Association for Gerontology in Higher Education, San Jose, CA. Palmore, E.B., 1977. Facts on aging quiz: a short quiz. The Gerontologist 17, 315–320. Palmore, E.B., 1980. The facts on aging quiz: a review of findings. The Gerontologist 20, 669–672. Palmore, E.B., 1981. The facts on aging quiz: part two. The Gerontologist 21, 431–438. Palmore, E.B., 1988. The Facts on Aging Quiz. Springer, New York. Palmore, E.B., 1991. Ageism Negative and Positive. Springer, New York. Palmore, E.B., 1998. The Facts on Aging Quiz: A Handbook of Uses and Results, 2nd ed. Springer, New York. Pennington, H.R., Pachana, N.A., Coyle, S.L., 2001. Use of the facts on aging quiz in New Zealand: validation of questions, performance of a student sample, and effects of a don’t know option. Educational Gerontology 27, 409–416.
Polit, D.F., Beck, C.T., 2004. Nursing Research: Principles and Methods, 7th ed. Lippincott Williams and Wilkins, Philadelphia. Schneider, Z., Whitehead, D., Elliott, D., LoBiondo-Wood, G., Haber, J., 2008. An overview of research theory and process. In: Nursing & Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 3rd ed. Elsevier, Sydney. Stewart, J.J., Giles, L., Paterson, J.E., Butler, S.J., 2005. Knowledge and attitudes towards older people: New Zealand students entering health professional degrees. Physical and Occupational Therapy in Geriatrics 234, 25–36. Streiner, D.L., Norman, G.R., 2003. Health Measurement Scales: A Practical Guide to their Development and Use, 3rd ed. Oxford University Press, Oxford. Tagliareni, E., Boring, G., 1988. Faculty, student, caregiver attitudes toward the Aged. In: National League for Nursing, Associate Degree Nursing and the Nursing Home, pp. 99–112. Tuckman, J., Lorge, I., 1953. Attitudes toward old people. Journal of Social Psychology 37, 249–260. Wang, C.C., Yen, C.H., Liao, W.C., Yuan, S.C., Chen, Y.R., Lee, M.C., Lu, H.J., Bloom, P., in press. Evaluating outcomes of Taiwan’s first gerontology certification program. Archives of Gerontology and Geriatrics. doi:10.1016/j.archger.2009.04.002. Yen, C.H., Liao, W.C., Chen, Y.J., Kao, M.C., Lee, M.C., Wang, C.C., 2009. A Chinese version of Kogan’s attitude toward older people scale: reliability and validity assessment. International Journal of Nursing Studies 46, 37–43.