Introduction
The increase in the population of the elderly brings various consequences to societies, which must be addressed to maintain health and achieve sustainable development goals. One of the most important consequences is age discrimination [3]. Studies conducted on health professionals have shown their positive and negative attitudes toward the elderly. Prejudice, beliefs, value attitudes, and behavior of health professionals towards the elderly have been reported as the main factors affecting the quality of their care [8]. High hospitalization of the elderly in the hospital cause a decrease in the quality and quantity of care provided to the elderly compared to the care provided to other patients. The consequence is the reduction of attention to the elderly [11]. There are various reasons for the existence of discrimination in the care of elderly nurses, as the main caregivers of the elderly, such as the inefficacy of caring for the elderly, and high treatment costs [20].

Methods & Materials 
This cross-sectional study was conducted on 600 nurses in Kashan City, Iran, from July to September 2021. Sampling was conducted using a census method through face-to-face interviews. However, for nurses who were unavailable for in-person interviews due to the COVID-19 pandemic, data collection was carried out online via the Pursline platform. After obtaining the necessary permits and the approval of the Ethics committee of Isfahan University of Medical Sciences, the interviews were conducted in a quiet and suitable environment. The completion of the questionnaire was preferably done in the presence of the questioner for more accuracy and to address possible questions and problems.
The questionnaire consisted of three parts. The first part of the questionnaire gathered demographic information, including age, gender, work experience, the presence of an elderly person in the family, size of the household, whether parents are alive, ethnicity, place of residence, type of employment, and care of elderly COVID-19 patients. The second part of the questionnaire measured the attitude about old age using the Kogan attitudes toward old people scale. The third part was a questionnaire to measure discrimination against the elderly, which Ahmadi (2019) prepared [24].

Results
In this study, 600 nurses were examined, of which 434 were women and the rest were men. All people were in the age range of 17 to 68 years, with the mean and standard deviation of age equal to 31.8 and 6.3 years, respectively. The mean score of attitude and discriminatory actions in old age was 130.5±14.4 and 25.80±7.23, respectively, in women and 129.8±15.4 and 25.10±6.27 in men. Statistically, there was no significant difference in attitude (P=0.659) and behavioral discrimination (P=0.238) of male and female nurses towards old age. Meanwhile, no significant difference was observed in nurses’ attitudes (P=0.425) and behavioral discrimination (P=0.057) based on the type of employment. Statistically, there was no significant difference in attitude (P=0.052) regarding nurses’ job satisfaction, but the behavioral discrimination score of nurses based on their job satisfaction had a significant difference (P=0.004). In addition, there was no significant difference in nurses’ attitudes (P=0.348) and behavioral discrimination (P=0.068) based on the care of the elderly with COVID-19. The results show that the rate of discriminatory acts decreases with increasing age and attitude scores.
After comparing the mean score of discriminatory acts with the variables in the study, the variables of attitude score, age, and job satisfaction had a significant relationship with discriminatory acts, and the variables of type of employment and care of the elderly with COVID-19 had a P score close to the significance level. Therefore, these variables were included in the linear regression test.
The results show that except for the type of employment variable, the rest of the variables include the attitude score (P<0.001), age (P=0.013), job satisfaction (P=0.036), and caring for the elderly with COVID-19 (P=0.021) are predictors of nurses’ discriminatory behavior towards the elderly.

Conclusion
The attitude score and age have a negative and significant correlation with discriminatory behaviors in caring for the elderly. Also, the job satisfaction of nurses was effective in the discriminatory care of the elderly. Also, the results showed that discrimination in the care of the elderly was affected by attitude, age, job satisfaction, and caring for the elderly with COVID-19. Due to the rapid increase in the elderly population, nurses play an important role in meeting the specialized needs of elderly health care in hospitals. Based on the results, older nurses and nurses with more positive attitudes toward old age have fewer discriminatory acts in caring for the elderly. Also, low job satisfaction and caring for the elderly with COVID-19 were among the factors that had an impact on discriminatory care. Therefore, it is important to provide high-quality health services without discrimination by addressing nurses’ attitudes toward caring for the elderly and improving working conditions.

Ethical Considerations
Compliance with ethical guidelines
After obtaining the necessary permits and the approval of the Ethics Committee of Isfahan University of Medical Sciences (Code: IR.MUI.RESEARCH.REC.1401.062), a time for questioning the nurse was determined by the questioner, referring to each department. The interviews were conducted in a quiet and suitable environment. The questionnaire completion was preferably done in the presence of the questioner for more accuracy and to address possible questions and problems. In addition, educational content appropriate to the subject in the field of aging was prepared and presented to the people at the end of the interview so that the subjects could also benefit from this project.

Funding
This research was done with the financial support of Isfahan University of Medical Sciences.

Authors' contributions
Conceptualization, validation, investigation, resources, writing-original draft: Ameneh Baseri Arani; Methodology, software, validation, formal analysis, writing - review and editing, and supervision: Mohammad Javad Tarrahi; Conceptualization, methodology, validation, resources, writing-original draft, writing-review and editing, supervision, project administration, and funding acquisition: Majid Rahimi.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
We extend our heartfelt gratitude to all those who assisted with this study, especially the nurses, who participated patiently and clearly.


References

1. Mahmoodi R, Hassanzadeh A, Rahimi M. Health literacy and its dimensions in elderly people in Farsan city, Iran. Journal of Education and Health Promotion. 2021; 10:362. [DOI:10.4103/jehp.jehp_149_21] [PMID]
2. Shati M, Mohamadi Bolbanabad A, Zokaei M, Mohamadi Bolbanabad S, Ghaderi E, Moradi G, et al. [Challenges in the elderly care system in Iran: A qualitative study (Persian)]. Scientific Journal of Kurdistan University of Medical Sciences. 2023; 28(3):101-14. [DOI:10.61186/sjku.28.3.101]
3. Rothermund K, Klusmann V, Zacher H. Age discrimination in the context of motivation and healthy aging. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. 2021; 76(Supplement_2): S167-80. [DOI:10.1093/geronb/gbab081] [PMID]
4. Schnabel EL. Age discrimination in acute care hospital settings? focus on verbal care interactions with cognitively impaired older patients [PhD dissertation]. Heidelberg University: Heidelberg: 2021. [Link]
5. de São José JMS, Amado CAF. On studying ageism in long-term care: A systematic review of the literature. International Psychogeriatrics. 2017; 29(3):373-87. [DOI:10.1017/S1041610216001915] [PMID]
6. São José JMS, Amado CAF, Ilinca S, Buttigieg SC, Taghizadeh Larsson A. Ageism in health care: A systematic review of operational definitions and inductive conceptualizations. The Gerontologist. 2019; 59(2):e98-e108. [DOI:10.1093/geront/gnx020] [PMID]
7. Butler RN. Ageism: Another form of bigotry. The Gerontologist. 1969; 9(4):243-6. [DOI:10.1093/geront/9.4_Part_1.243] [PMID]
8. Ben-Harush A, Shiovitz-Ezra S, Doron I, Alon S, Leibovitz A, Golander H, et al. Ageism among physicians, nurses, and social workers: Findings from a qualitative study. European Journal of Ageing. 2016; 14(1):39-48. [DOI:10.1007/s10433-016-0389-9] [PMID]
9. Daniali SS, Rahimi M, Salarvand S. Age discrimination in delivery of health services to old people during COVID-19 pandemic: A scoping review study. Journal of Gerontology and Geriatrics. 2022; 70(1). [DOI:10.36150/2499-6564-N415]
10. Liu YE, Norman IJ, While AE. Nurses’ attitudes towards older people and working with older patients: An explanatory model. Journal of Nursing Management. 2015; 23(8):965-73. [DOI:10.1111/jonm.12242] [PMID]
11. Afsar B, Badir Y, Kiani IS. Linking spiritual leadership and employee pro-environmental behavior: The influence of workplace spirituality, intrinsic motivation, and environmental passion. Journal of Environmental Psychology. 2016; 45:79-88. [DOI:10.1016/j.jenvp.2015.11.011]
12. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ. Institutional ageism in global health policy. BMJ. 2016; 354:i4514.[DOI:10.1136/bmj.i4514] [PMID]
13. Melia S, Choowattanapakorn T. The relationship between nurses’ characteristics, ageism, perception of older people’s care and nursing practice in hospitalized older people. Journal of Health Research. 2016; 30(2):109-14. [Link]
14. Bowling A. Ageism in cardiology. BMJ. 1999; 319(7221):1353-5. [DOI:10.1136/bmj.319.7221.1353] [PMID]
15. Kagan SH. Ageism in cancer care. Seminars in Oncology Nursing. 2008;  24(4):246-53. [DOI:10.1016/j.soncn.2008.08.004] [PMID]
16. Hadbavna A, O’Neill D. Ageism in interventional stroke studies. Journal of the American Geriatrics Society. 2013; 61(11):2054-5. [DOI:10.1111/jgs.12537] [PMID]
17. Ayalon L, Tesch-Römer C. Introduction to the section: Ageism-Concept and origins. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. International Perspectives on Aging, vol 19. Cham: Springer; 2018. [DOI:10.1007/978-3-319-73820-8_1]
18. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting racial and ethnic disparities in health care. Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. [DOI:10.17226/12875] [PMID]
19. Mehri S, Hosseini MA, Shahbelaghi FM, Khoshknab MF, Zardkhaneh SA. Explaining nurses’ perception of the causes of ageism in hospital settings. Electronic Journal of General Medicine. 2020; 17(5):em218. [DOI:10.29333/ejgm/7881]
20. Cameron SD. A study of nurses’ attitudes toward medical ageism [PhD dissertation]. Minneapolis: Walden University; 2015. [Link]
21. Cowan DT, Fitzpatrick JM, Roberts JD, While AE. Measuring the knowledge and attitudes of health care staff toward older people: Sensitivity of measurement instruments. Educational Gerontology. 2004; 30(3):237-54. [DOI:10.1080/03601270490273169]
22. Kogan N. Attitudes toward old people in an older sample. The Journal of Abnormal and Social Psychology. 1961; 62:616-22. [DOI:10.1037/h0048356] [PMID]
23. Rejeh N, Heravi-Karimooi M, Montazeri A, Foroughan M, Vaismoradi M. Psychometric properties of the Iranian version of the Kogan’s attitudes toward older people scale. Japan Journal of Nursing Science. 2012; 9(2):216-22. [DOI:10.1111/j.1742-7924.2012.00204.x] [PMID]
24. Ahmadi P, Alavi NM, Gilasi HR, Safa A, Aghajani M. Developing a tool for evaluating ageism in nursing care of older people in Kashan/Iran. Journal of Cross-Cultural Gerontology. 2019; 34(1):25-33. [DOI:10.1007/s10823-019-09364-w] [PMID]
25. Hweidi IM, Al-Hassan MA. Jordanian nurses’ attitudes toward older patients in acute care settings. International Nursing Review. 2005; 52(3):225-32. [DOI:10.1111/j.1466-7657.2005.00434.x] [PMID]
26. Hosseini A, Nasiri F, Kermani A, Hosseini F. Assesment of nursing students and clinial nurses’ attitude toward elderly care. Iran Journal of Nursing. 2006; 19 (45): 57-67. [Link]
27. Nosek BA, Banaji MR, Greenwald AG. Harvesting implicit group attitudes and beliefs from a demonstration web site. Group Dynamics: Theory, Research, and Practice. 2002; 6(1):101-15. [DOI:10.1037/1089-2699.6.1.101]
28. Engström G, Fagerberg I. Attitudes towards older people among Swedish health care students and health Sare professionals working in elder care. Nursing Reports. 2011; 1(1):2-6. [Link]
29. Hosseini MA, Mehri S, Fallahi-Khoshknab M, Mohammadi-Shahbelaghi F, Akbari-Zardkhaneh S. The status of ageism in caring for elderly patients from nurses’ perspective. Journal of Client-Centered Nursing Care. 2020; 6(4):289-96. [DOI:10.32598/JCCNC.6.4.346.1]
30. Mion LC, Hazel C, Cap M, Fusilero J, Podmore ML, Szweda C. Retaining and recruiting mature experienced nurses: A multicomponent organizational strategy. JONA: The Journal of Nursing Administration. 2006; 36(3):148-54. [DOI:10.1097/00005110-200603000-00009] [PMID]
31. Lambrinou E, Sourtzi P, Kalokerinou A, Lemonidou C. Attitudes and knowledge of the Greek nursing students towards older people. Nurse Education Today. 2009; 29(6):617-22. [DOI:10.1016/j.nedt.2009.01.011] [PMID]
32. Chen S, Walsh SM. Effect of a creative-bonding intervention on Taiwanese nursing students’ self-transcendence and attitudes toward elders. Research in Nursing & Health. 2009; 32(2):204-16. [DOI:10.1002/nur.20310] [PMID]
33. Schroyen S, Missotten P, Jerusalem G, Gilles C, Adam S. Ageism and caring attitudes among nurses in oncology. International Psychogeriatrics. 2016; 28(5):749-57. [DOI:10.1017/S1041610215001970] [PMID]
34. Lovell M. Caring for the elderly: Changing perceptions and attitudes. Journal of Vascular Nursing. 2006; 24(1):22-6. [DOI:10.1016/j.jvn.2005.11.001] [PMID]
35. Hanson RM. ‘Is elderly care affected by nurse attitudes?’A systematic review. British Journal of Nursing. 2014; 23(4):225-9. [DOI:10.12968/bjon.2014.23.4.225] [PMID]
36. Araújo PO, Soares IMSC, Vale PRLFD, Sousa AR, Aparicio EC, Carvalho ESS. Ageism directed to older adults in health services: A scoping review. Revista Latino-Americana de Enfermagem. 2023; 31:e4019. [DOI:10.1590/1518-8345.6727.4019] [PMID]
37. Liu YE, While AE, Norman IJ, Ye W. Health professionals’ attitudes toward older people and older patients: A systematic review. Journal of Interprofessional Care. 2012; 26(5):397-409. [DOI:10.3109/13561820.2012.702146] [PMID]
38. Gonzales E, Morrow-Howell N, Gilbert P. Changing medical students’ attitudes toward older adults. Gerontology & Geriatrics Education. 2010; 31(3):220-34. [DOI:10.1080/02701960.2010.503128] [PMID]
39. Ghorbani M, Salehabadi R, Mahdavifar N, Rad M. [Factors related to nurses’ attitudes toward the elderly care: The predictive roles of altruism, moral intelligence, life satisfaction and general health (Persian)]. Salmand: Iranian Journal of Ageing. 2021; 16(2):248-59. [DOI:10.32598/sija.16.2.2767.1]
40. Hošnjak AM, Goriup J. Development of a model for the prevention of ageism in nursing practice in a team with social gerontologist. Proceedings of CBU in Medicine and Pharmacy. 2022; 3:1-5. [DOI:10.12955/pmp.v3.313]
41. Chang AY, Babb KN. One-year report of covid-19 impact on geriatric patients: A Bio-Psycho-Social Approach. Canadian Geriatrics Journal. 2022; 25(2):212-21. [DOI:10.5770/cgj.25.553] [PMID]
42. Sum S, Emamian S, Sefidchian A. Aging educational program to reduce ageism: Intergenerational approach. Elderly Health Journal. 2016; 2(1):33-8. [Link]