1. Introduction
Increased life expectancy and the growing population of the elderly are the important outcomes of the 21st century (Hosseini et al., 2016; Liu, Norman & While 2015). According to the 2016 census of the Statistical Center of Iran, adults older than 65 years comprise 6.1 million of the 80 million people in Iran (Statistical Center of Iran 2017). It is predicted that the population older than 60 years will constitute more than 10% and 20% of the Iranian population in 2021 and 2050, respectively (Hosseini et al., 2016). Following this increase, the older adult’s health has become a challenge for healthcare systems in developing and developed countries (Adib-Hajbaghery, Mohamadghasabi & Masoodi 2014). Therefore, managing problems related to older adults requires planning and policy-making (Amini & Nosratabadi 2019).
Older adults used to receive more respect, but they receive less respect because of difficult living conditions and changes in the family structure (Liu, Norman & While 2015). Negative attitudes and stereotypes, such as viewing older adults as weak, sensitive, and dependent people are prevalent worldwide (Butler 1969). Besides, this problem is exacerbated in hospitals with a high number of visits from older adults (Liu, Norman & While 2013). In healthcare centers, the lack of attention to care for older adults partly results from an increased number of patients and staff shortage (Ben-Harush et al., 2017); this reduces the quality and quantity of care provided to older adults, compared with that provided to other patients (Officer et al., 2016). It also makes older adults be viewed as barriers to economic growth and responsible for increasing healthcare costs (Allen 2016; Mehri et al., 2020b).
In addition to reducing respect for the elderly, these factors understate the care of the elderly with a more inadequate prognosis (Lioyd-Sherlock et al., 2016). Ageism is the major cause of this neglect in older adult care (São José & Amado 2017; São José et al., 2019). Ageism was first defined by Butler and means discrimination or prejudice against one age group compared with other age groups (Butler 1969). São José and Amado introduced ageism as follows: “Ageism is defined as negative or positive stereotypes, prejudice and/or discrimination against (or to the advantage of) us on the basis of our chronological age or on the basis of a perception of us as being ‘old’, ‘too old’, ‘young’, or ‘too young.’ Ageism can be self-directed or other-directed, implicit or explicit, and expressed on a micro, meso, or macro-level” (São José & Amado 2017). Studies on health professionals demonstrate both positive and negative attitudes toward older people (Ben-Harush et al., 2017; Butler 1969; Liu Norman & While 2015). The prejudice, beliefs, values attitudes, and behaviors of health professionals toward older people are important, as they impact the quality of care (Mehri et al., 2020b).
Nurses are the largest group of healthcare providers to older adults in hospitals (Melia & Choowattanapakorn 2016). Moreover, studies report the existence of ageism in older adult care (Liu, Norman & While 2015; Mehri et al., 2020a). Studying ageism in hospitals can increase the nurses’ knowledge and awareness of ageism (Cowan et al., 2004), and facilitates the identification of discrimination and planning for its resolving. Thus, this study aimed to investigate the status of ageism in caring for elderly patients from nurses’ perspective.

2. Materials and Methods
Setting and sample
This descriptive cross-sectional study was conducted between January and May 2019, in three teaching hospitals (Imam Reza, Dr Fatemi, and Imam Khomeini with overall 693 beds) affiliated to the Ardabil University of Medical Sciences. The study population included all 650 nurses working in these hospitals. It is worth mentioning that the citizens of the Ardabil province have Azeri ethnicity and speak the Azeri Turkish language. The inclusion criteria were willingness to participate and having a minimum of two years of work experience in older adult care.

Instruments
The Ageism Scale in Hospital Care (Mehri et al., 2019), was used to collect the data. This scale includes two parts. The first part examines demographic information, including age, gender, ward, work experience, education level, and employment status. The second part examines ageism in the hospital care setting. This scale has 20 items, with six items evaluating self-directed ageism and 14 items evaluating other-directed ageism. Also, responses are scored on a 6-point Likert scale from “completely disagree”= 1 to “completely agree”= 6. The scores range from a minimum of 20 to a maximum of 120. The score ranges of 20 to 53, 54 to 87, and 88 to 120 respectively indicate weak, moderate, and severe ageism in the provision of care to older adults. This scale has a content validity index of 0.89, the Cronbach alpha of 0.90, and an intracluster correlation of 0.98 (Mehri et al., 2019). In this study, the Cronbach alpha was calculated as 0.91.
 
Procedure
After obtaining the required permissions, the objectives of the study were explained to the participants, and informed and verbal consent was obtained from them upon visiting the study setting. All the nurses met the inclusion criteria, thus, the data collection tool was distributed to all 650 nurses, and 550 of them returned the completed questionnaire; 68 questionnaires were unusable, and finally, 482 questionnaires were analyzed. 


Data analysis 
The data were analyzed by descriptive (frequency, percentage, mean, and standard deviation) and inferential statistics (the Pearson correlation coefficient, independent t-test, one-way ANOVA, and Scheffe post hoc test) using SPSS V. 20.

3. Results
The Mean±SD age of the subjects was 33±6 years. Table 1 represents the relationship between ageism and the demographic information of the study participants.

In this study, 159, 259, and 31 participants (33%, 60.6%, and 6.4%, respectively) respectively showed weak, moderate, and severe ageism when providing care to older adults. Table 2 shows the mean and SD of the scores in each subscale.

The Pearson correlation coefficient was used to examine the correlation between ageism and the nurses’ age and work experience. According to Table 1, ageism is negatively correlated with the nurses’ age (P=0.002, r= -0.142).
Table 1 also reveals a 2-tailed significance level of 0.032 for the Pearson correlation test between ageism and nurses’ work experience; this value is less than 0.05 (the minimum significance level). Thus, ageism is significantly and negatively associated with the nurses’ work experience. To examine the relationship between ageism and the nurses’ gender, an independent t-test was performed; the calculated t value was significant at the 0.05 level (P≤0.05; Table 1). Therefore, the level of ageism differs by gender; the mean score was higher among male nurses (66.33), compared with female nurses (58.62).
Moreover, according to the 1-way ANOVA results (Table 3), ageism is significantly related to the admission ward.

Specifically, the minimum value of ageism in one ward differs from that in the others. The Scheffe post hoc test was run to find the source of this difference, i.e. to identify the ward, the mean score of which differs from those of the rest.
Table 4 shows a significant difference in the mean score of ageism between the nurses working in the internal medicine ward and those working in the surgery ward.

Also, the mean score of ageism significantly differs between nurses working in the internal medicine ward and those working in the intensive care unit. However, the differences were insignificant in other comparisons.

4. Discussion
This study aimed to investigate the status of ageism in caring for elderly patients from nurses’ perspective. Based on the results, most of the nurses showed moderate ageism when providing care to older adults. This finding was consistent with another study that indicated a moderate level of ageism among nurses who worked in a clinical setting. As members of society, nurses are not protected from this ageist attitude, which may influence the professional practice for elder people (Melia & Choowattanapakorn 2016). Moreover, ageist attitudes toward the elderly would negatively affect the care provision for the elderly patients (Hanson 2014). A study conducted at the University of South Australia in Queensland examined the attitudes of final-year nursing students towards aging to emancipate them to cope with these issues and prevent the recurrence of aging in their future performance as registered nurses. The social critical theory together with the Stringer participatory action research model guided the theoretical directions of this study. Nine final-year students volunteered. Data were collected through focus group meetings and clinical diary for six months. The findings of this study showed acute self-awareness about the meaning of aging and personal fear of the aging process (De la Rue et al., 2003). Since older adults constitute the majority of patients admitted to hospitals, these results highlight the importance of paying attention to the provision of high-quality care without discrimination for this age group.
Based on the findings, as the nurses’ age increased, their level of ageism decreased, and vice versa. This result is consistent with studies expressing that older caregivers provide better care to older adults (Blegen, Vaughn & Goode 2001; Mion et al., 2006). Also, compared with younger nurses, older and more experienced nurses provide better care (Melia & Choowattanapakorn 2016). Moreover, older participants provided better care to older adults (Lambrinou et al., 2009; Chen & Walsh 2009; Söderhamn, Lindencrona & Gustavsson 2001). In a study conducted in Iran, negative attitudes toward elderly people were more severe in high school students, compared with university students (Sum, Emamian& Sefidchian 2016). However, some other studies reported no significant difference between the nurses’ attitudes towards older patients and their demographic characteristics, such as age, gender, and work department (Polat et al., 2014; Sahin et al., 2012).
Results of this study showed that as the work experience of nurses increased, their degree of ageism decreased. Similar studies also reported that those with an experience of working with older adults had a positive attitude towards their care (Melia & Choowattanapakorn 2016; Özer & Terkeş, 2014; Sum, Emamian& Sefidchian 2016). Results of some other studies are congruent with our findings (Hughes et al., 2008; Wilkinson, Gower & Sainsbury 2002; Mclafferty & Morrison 2004). Similarly, Leung and colleagues determined that nurses with experience in elderly patient care held significantly more positive attitudes than those with no experience. Nurses who have experience in working with elderly patients demonstrate positive behavior, because of increased knowledge concerning older patients’ care, the development of communication with elderly patients, and an increased awareness of issues specific to older patients care and the process of aging (Leung et al., 2011). While some studies found no association between ageism and the experience of working with older people (Hweidi & Al-Obeisat 2006; Pan, Edwards & Chang 2009).
Based on the results of the present study, the degree of ageism in hospital care differs between men and women. The findings showed that ageism for older adults had a better and more satisfactory status in female nurses than in male nurses. In this regard, female university students have shown a more positive attitude towards older adult care, compared with their male counterparts (Deary et al., 1993; Fitzgerald et al., 2003; Wang et al., 2009). Also, in studies by Özer and Terkeş (2014) and Mcconatha et al. (2004) women showed less ageism for older adult care, compared with men. The results of these studies are in line with the present findings, which may be related to the caregiving role played by women in families. However, this result is inconsistent with some other studies reporting that gender weakly affects older adult care (Melia & Choowattanapakorn 2016).
In the present study, ageism in the provision of care to older adults significantly differed considering the ward in which the nurses worked; the highest degree of ageism was reported in the internal medicine ward. On the other hand, the lowest level of ageism was found in the surgery ward, in which the length of stay is short. Some similar studies reported that ageism is more severe in clinical nurses and some wards compared with others (Brown et al., 2008; Melia & Choowattanapakorn 2016). This result may be due to the working conditions of nurses providing care to older patients, eg, the number of nurses per patient, the chronic conditions of the patients, and their long-term stay in this ward.

5. Conclusion
The findings revealed the existence of ageism in the study hospitals and showed that the severity of ageism decreases as the nurses’ age and work experience increase. Moreover, the degree of ageism in older adult care is lower in women than in men. Also, the highest level of ageism was seen in the internal medicine ward, in which older adults stay for a longer time. The main limitation of this study was the self-report nature of the data collection tool. The emotional and psychological status of the nurses at the time of filling in the questionnaire could have affected the results of the study; this factor could not be controlled by the researcher. Besides, the present study was carried out on nurses working in a specific region in Iran. Therefore, these findings may not be generalizable to all nurses. 
It is recommended to further investigate the factors influencing ageism against the elderly people among nurses. It is also suggested to conduct a similar study in other provinces and countries, so more reliable and valid conclusions can be drawn by the comparison of the results of different studies. Future studies are also suggested to examine the factors affecting ageism in hospital care. Moreover, interventional studies are suggested to be planned to improve the attitude of nurses working with elderly people in nursing homes, hospitals, and community health care settings.

Ethical Considerations
Compliance with ethical guidelines
This article was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.2018.263). Besides, all the subjects signed the informed consent.

Funding
The present paper was extracted from the PhD. dissertation of the corresponded author in the Department of Nursing, University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
All authors contributed in preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Deputy of Research and Technology, Department of Nursing at the University of Social Welfare and Rehabilitation Sciences, and the nursing participants for their valuable cooperation.


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