Nurse perception of care of hospitalized older adults - a comparative study between northern and central regions of Portugal

Resume Objective: to analyze the relationship between the perceptions of nurses about geriatric care (GC) environment and geriatric nurses’ knowledge and attitudes according to unit type considering the northern and central regions of Portugal. Method: a cross-sectional study was developed among 1068 Portuguese’s nurses in five hospitals. The instrument was Geriatric Institutional Assessment Profile - Portuguese version. The independent samples t-test was when the assumption of normality was verified, otherwise, the Mann-Whitney U test was used. The level of significance was 5%. Results: the profile of perceptions of GC showed a relatively homogeneous pattern (no statistically significant results were found). For the geriatric care environment scale, only the CC/ED units presented significant differences in all considered subscales (resource availability; aging-sensitive care; institutional values; and continuity of care), with more positive perceptions among nurses in the northern region. In Professional Issues scales, only the scale perception of burden related with upsetting behaviors revealed significant differences between regions in all specialties. Conclusion: the findings suggest the need for increased investment by hospital leaders to promote a geriatric nursing practice environment that supports the specialized needs of hospitalized older adults.


Methods
This study utilized a quantitative, exploratorydescriptive, cross-sectional and correlational approach.

Data and sample
This study was conducted in five hospitals; two located in the northern region (Oporto) and three in the center of the country (Coimbra and Aveiro). Of these hospitals, three are hospital centers and two are academic hospitals. In order to ensure a diverse sample, the selection of these hospitals was based on bed size as well as the number of inpatients and nurses (14) . The Tavares JP, Silva AL, Sá-Couto P, Boltz M, Capezuti E. geographical proximity of these hospitals was also considered in order to optimize data collection (14) .
The method of sampling was nonprobability convenience and included all registered nurses who worked in medical or surgical specialty units, critical care units (CCUs) and emergency departments (ED).
We excluded nurses who worked on units serving primarily younger adults or children, and nurses who did not provide direct care (including nurse managers and supervisors). The project was submitted to and approved by the ethics committees of each of the 5 hospitals; all of the participants signed an informed consent form.

Data collection
The researcher, in partnership with the nurse manager of the units, conducted the data collection.
The steps taken in this process are described in the article of validity of the GIAP (14) . Among the 2271 surveys distributed, 1173 were returned, representing a 52% response rate, which is considered acceptable (16) .
However, 105 were not completed and were excluded.
Thus, the final sample included 1,068 registered nurses.

The survey
The GIAP is a 152-item self-completed survey that examines unit/hospital and respondent demographic/ their implications for geriatric nursing practice (6) .The translation, adaptation, and validation of the GIAP scales to Portuguese (12) were based on the standards of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force for Translation and Cultural Adaptation (17) . The internal consistency reliability (Cronbach's alpha) ranges from 0.601 to 0.919, and thus shows good to very good internal consistency, similar to other studies (7)(8) .

Data analysis
Descriptive and inferential statistics were used to systematize and enhance the information provided by

Sites and samples
The sample (n=1068) was mostly comprised of female nurses (79.7%) who were single (45.4%) or divorced (34.3%). The mean age of the nurses was 34. had a master's or doctoral degree. The majority of the nurses (N=922; 86.3%) reported not having received any gerontological education or training; 94 (8.8%) had participated in short courses (continuing education), and 52 (4.9%) had received training in an academic program (master's or doctoral degree) (14) .

Geriatric nursing knowledge and attitudes
The results indicated in Table 1 demonstrate no significant differences (p>0,05) for both total score and subscales on Geriatric Knowledge and Attitudes between regions in the three units considered.

Geriatric Care Environment
The results concerning the GCE -extrinsic factors (

Professional issues
The results on the overall score of GCE -intrinsic factors (Professional Issues scales, Table 1) Table 1).
Nurses who worked in the center of the country were less likely to perceive upsetting behaviors among older patients, and these behaviors did not represent significant barriers to providing 'good' quality of care.
Regarding medical units (Professional Issues scales,   Table 1). Nurses who worked in the northern region reported fewer disagreements among staff compared to those from the central region.

Discussion
Studies of GNPE have emerged in the literature over the last decade, driven by research conducted in North America. In Portugal, studies demonstrate that the perception of the geriatric milieu among nurses is considered unsatisfactory (11)(12) . Analyzing the differences between the northern and central regions, this study found that nurses who work in the CCU/ED units in the northern region have more positive perceptions of the geriatric care environment, the extrinsic factors of the GNPE. Thus, these nurses had a more positive perception about the organizational commitment to quality geriatric care. A younger population and a higher patient to nurse ratio in this region could influence their perceptions of the geriatric care environment, especially in these units (12) . Aspects such as the emphasis on teamwork In contrast, a study performed in North America found that the responses to this scale were the most negative, constituting one of the main barriers to providing quality of care among the nurses (11) . Sociocultural differences, professional regulation, and the legal system, could explain the different perceptions of nurses in these two countries.
The findings showed no significant regional Another limitation is that all data were collected by self-report and could be subject to respondent bias (e.g., nurses who are more dissatisfied may be more likely to respond negatively to the GNPE scales). Furthermore, these results could be influenced by the specific and It is expected that these results will contribute to the developing, planning, and implementation of geriatric care models or programs to promote the quality of care in these two regions of Portugal.