Attitudes of nursing home administrators and nurses towards people with disabilities.

Research suggests that community attitudes towards people with disabilities are negative and affect quality of life and opportunities (Gething, 1992; Wright, 1983). A negative attitude is defined as one which sets people with disabilities apart as being different from others, with the usual implication that they are deficient or inferior. This definition is based on the landmark discussion by Erving Goffman (1963) in which he applied concepts of stigma and minority group status to people with disabilities. Governments and organizations representing people with disabilities have been aware of such attitudes and have implemented strategies to promote awareness of issues, positive attitude change, and enhanced integration of people with disabilities within the community. The International Year of Disabled Persons (1981) is an example of an initiative which incorporated these strategies in many countries. Recent legislation in Australia and the United States reflects changes in government policy about discrimination, community integration, and participation of people with disabilities. The Australian Disability Services Act (1986) heralds the down-scaling of large specialist services and encourages people with disabilities to use generic services available for all citizens. It also includes strategies for enhancing equality of access to education, employment, and community life. The Americans with Disabilities Act (1990) guarantees equal opportunity for individuals with disabilities in employment, public accommodation, transportation, state and local government services, and telecommunications. These pieces of legislation have resulted in changing roles for health care providers and the creation of new job positions. They also have highlighted the need to consider prevalent attitudes among service providers and effects these may have on appropriateness of service provision.

The aim of the present study is to measure and compare attitudes of nursing staff and administrators working within the nursing home setting. It also explores the effects of demographic variables on attitudes within these two groups. Such information is useful in determining the need for interventions to promote positive and realistic attitudes, for assessing whether potential conflict may exist between two categories of staff employed in nursing homes, and for determining whether other characteristics of a service provider influence attitudes towards people with disabilities.

In the disability area, attention has been given to attitudes of nurses, teachers and of health professionals such as physiotherapists, psychologists, and rehabilitation personnel (Holmes & Karst, 1990). Most discussion has focused on attitudes of professionals who have face-to-face contact and provide direct care for people with disabilities in acute care and rehabilitation settings. Less attention has been given to people working in the nursing home setting, to administrators, or to potential conflicts that may arise from differing attitudes between professional groups.

Research into attitudes towards older clients has included nursing staffs working in nursing home settings. However this research is also characterized by neglect of administrators. Findings suggest many parallels with results of disability research: both sets of clients are devalued, seen as less competent than others and attitudes toward both are often argued to be negative. Such other findings suggest that attitudes may affect quality of life and appropriateness of treatment (Huber, Reno, & McKenney, 1993; Ingham & Fielding, 1985).

Thus evidence suggests that attitudes of nurses as health care providers are important. It is argued here that it is not sufficient to consider attitudes of these professionals alone. Also important are attitudes of other staff within an organization, including administrators.

With regards to the effects of demographic variables, previous research extending over 30 years indicates that for all variables, except amount of prior contact, evidence is inconsistent and without any clear themes emerging. Following extensive literature reviews, Yuker and Block (1986) and Shaver, Curtis, Jesuthanadas and Strong (1989) concluded that there was little consistent evidence about the effects of gender, age, occupation and education. For example, Yuker and Block (1986) concluded that of 129 studies of gender differences using the Attitudes Towards Disabled Persons Scale, 44% indicated that women scored significantly higher than men, 5% showed men to be higher and 51% revealed no statistically significant differences. In contrast, evidence for the effects of prior contact with people with disabilities has been consistent and strong, suggesting that people with higher levels of contact display more positive attitudes (e.g., Amsel & Fichten, 1988; Leonard & Crawford, 1989).

The study reported in this paper investigated attitudes of two occupational groups working within the nursing home setting: administrators and nursing staff. It also explored the effects of gender, education, age and level of prior contact with people with disabilities using a new instrument, the Interaction with Disabled Persons Scale (IDP).

The hypotheses were:

1. Occupation (administrator versus staff nurse) has a significant effect on scores on the IDP Scale.

2. Gender has a significant effect on responses on the IDP Scale.

3. Level of education has a significant effect on responses on the IDP Scale.

4. Age has a significant effect on responses on the IDP Scale.

5. Frequency of prior contact with people with people with disabilities has a significant effect on responding on the IDP Scale.

Because of the inconsistent nature of existing evidence, no hypotheses were specified for interactions between demographic variables, however, study of interactions was included in the statistical analysis.

Method

Subjects

The sample was drawn from nursing homes in the greater Los Angeles area. A list was obtained through the Los Angeles Mayor's Office for Disabled. The sample was divided into two occupational categories: 1) Administrators included managers, supervisors or business administrators; 2) Staff nurses include registered nurses, licensed vocational nurses and certified nurses aides providing direct patient care. The important difference between an administrator and a staff nurse is that major responsibilities for nurses in this study center around patient care. The administration category included people whose roles involved financial control, budgeting, staffing and facilities management. The total sample included 151 people; of these 76 were staff nurses and 75 administrators. The staff nurses sample contained 66 females and 10 males, with ages ranging from 19-69. The administrators sample contained 41 females and 34 males, with ages ranging from 19-79 years.

Instrument

The IDP Scale was devised to measure different aspects of attitudes than established instruments such as the Attitudes Towards Disabled Persons Scale (Yuker, Block, & Younng, 1970). Leonard and Crawford (1989) argue that attitudes operate on two levels, each having different implications for behavior. Most established instruments measure attitudes on the societal level which is concerned with how people with disabilities should be treated by society, their rights and whether they are different from others on non disability-related characteristics. In contrast, attitudes on a personal level refer to one's own reactions when meeting someone with disability. These two levels have different implications for behavior, as expressed in the statement: "People with disabilities have a right to live in the community (societal level), but not next door to me" (personal level). The IDP Scale was devised to tap the personal level of attitudes which have received little attention from scale constructors in the past. It measures discomfort reported in social interaction, or at the prospect of interaction with someone with disability. According to Evans (1976), such discomfort is a key factor underlying negative reactions towards people with disabilities while Simpson (1980) argues that discomfort reflects uncertainty or anxiety experience by people who are unsure of how to behave appropriately or of what to expect from the person with a disability. The IDP scale consists of twenty items relating to reactions when meeting someone with a disability. Respondents use a six-point scale ranging from "agree very much" to "disagree very much" to indicate to what extent each statement fits their reaction. Examples of items in the scale are: "I feel ignorant about disabled people"; "I feel uncomfortable and find it hard to relax"; and "I dread the thought that I could eventually end up like them."

Final development and standardization of the Scale took place between 1988 and 1990 and was based on a sample of over 6000 cases. It followed procedures outlined by Antonak and Livneh (1988) for evaluating existing instruments and developing new measures of attitudes toward people with disabilities. A detailed account of the development and standardization of the IDP Scale may be found in Gething and Wheeler (1992). However, brief details are provided here: test-retest reliability was assessed on eight occasions with coefficients ranging between +.51 for a one year period to +.82 over a two week period. Item homogeneity was assessed on 15 occasions with Cronbach's Coefficient Alpha varying between +.74 and +.86. Results for both these forms of reliability compare favorably with those reported for existing measures (Antonak & Livneh, 1988). Factor analysis was conducted for twelve data collections and indicate that items fall consistently into four major categories, the largest of which has been given the title of "Discomfort in Social Interaction".

Procedure

Respondents were contacted at their place of work and invited to complete the questionnaire and accompanying items about demographic characteristics. Participation lasted between 5 and 10 minutes. Responding was voluntary and confidential. Respondents were provided with envelopes in which to place completed forms.

Results

The staff nurses consisted f 10 (13.2%) men and 66 (86.8%) women whereas the administration groupp showed a more even balance of 34 (45.4%) men and 41 (54.6%) women. Both groups were relatively well educated with the majority of respondents in both groups haaving attained post high school and university qualifications. Of the staff nurses, 4 (5.2%) were high school graduates, 25 (32.9%) had obtained post high school diplomas, and 47 (61.8%) had obtained university degrees. With regards to the administrators, 4 (5.3%) were high school graduates, 15 (18.7%) had post high school diplomas, and 57 (76.0%), had earned or gained college degrees.

Ages foor the staff nurses ranged between 18 and 69 with the modal age range being 30-39 years. The sample of administrators was slightly older with the range being 24-79 years and the modal category being 40-49 years. Both groups had high levels of contact with peoople with disabilities with over 90% of respondents citing contact at least once a week, however administrators had higher levels of daily contact; 97.3% reported daily contact as compared with 72.5% nurses.

Analysis of variance (ANOVA) was used to test hypothesized effects of the independent variables of occupation (administrator versus staff nurse), gender, education (High School Diploma or post High School Diploma, University Degree), age (20-29, 30-39, 40-49, 50-59, 60-69, 70-79).

Of the four independent variables tested, only occupation (Hypothesis 1) produced a significant main effect. Subsequent application of an independent t test indicated that administrators had significantly more positive attitudes (t = +3.98m df = 20, p = .000). However, support was not provided for Hypotheses 2, 3, and 4 which predicted that gender, level of education and age would affect responding. Rigorous testing of Hypothesis 5 was not possible because of the relative homogeneity of the sample on the variable of contact. None of the interaction effects between demographic variables reached significance at the .05 level of probability.

Effects of Demographic Variables on IDP Scores Using ANOVA

Demographic                 Degree of
variable                    freedom        F

Gender                      1              1.203
Age                         2              0.413
Education                   1              0.190
Occupation                  1              4.136(*)

Interaction effects

Gender x Age                2              0.495
Gender x Education          1              0.011
Gender x Occupation         1              0.031
Age x Education             2              0.570
Age x Occupation            2              0.002
Education x Occupation      1              0.010

* p .05, two tailed

Table 2 contains a comparison of measures of central tendency for occupation groups. Staff nurses obtained a higher mean score on the IDP Scale (M = 64.21) than the administrators (M = 57.25), indicating that nurses providing direct patient care expressed more discomfort about interacting with people with disabilities. (A higher score indicates more discomfort in social interaction.) Since the level of contact was similar in both groups, it was concluded that even though both groups had high levels of contact, they responded differently on the IDP Scale.

Discussion

In sum, occupation within the nursing home environment emerged as having a significant influence on attitudes towards people with disabilities. Administrators were found to have more positive attitudes than nurses. Other demographic variables were not found to have an effect.

Table 2

Comparison of Measures of Central Tendency of IDP scores for Nursing and
Administrative Professionals

Measure                  Nurses       Administrators

Mean                     71.25                 66.41
Median                   71.00                 66.50
Mode                     65.00                 66.00
Standard Deviation        8.62                  9.10
Range                    49.00                 51.00
Sample size              76                    75

Even though both sets of professionals reported high levels of contact, the nature of their contact is likely to be very different and to present different kinds of experiences with people with disabilities as the nature of these interactions are likely to be different. Contact for the$staff nurse is likely to be more intensive, ongoing, personal and concerned with private bodily functions. It can be stressful for the nurse who is frequently reminded of limitations associated with disability, and it may be demanding in that it involves hard physical work and assistance with personal tasks such as toileting. In sum, contact for staff nurses enables them to get to know their clients as individuals, but heightens awareness of realities associated with disability. As mentioned above, many authors have argued that negative attitudes are reflected in health professional practice. Confirmation provided by the present findings suggests that urgent attention must be given to the impact of such attitudes on service delivery, particularly in terms of their impact on staff expectations and achievement of positive rehabilitation outcomes. In contrast, contact for an administrator often is brief and social, perhaps involving only an exchange of greetings. This difference in type between the "social" contact of administrators and "working" contact of staff nurses may be a crucial factor underlying attitude formation. Contrary to the approach taken by most previous authors, it does not appear to be sufficient to investigate amount of contact as an influence on professional attitudes. Rather type as well as quantity must be considered. Furthermore, additional research is required to determine the effect of type of nursing work on attitude formation, that is do nurses working in different settings vary in their attitudes toward people with disabilities. Evidence from the aging field suggests that working with older clients in the nursing home is viewed as one of the least preferred options for staff nurses (Downe-Wamboldt & Melansn, 1990), with an expectation that work will be unpleasant, tiresome and depressing (Armstrong-Esther, Sandilands, & Miller, 1989). Exploration of such issues is now required for staff nurses working with disabled clients.

Researchers in the aging field have gone further in specifying the aspects of occupational contact which may promote positive and negative attitudes. Their findings should be applied to the disability area to guide future studies of the effects of type of professional contact on attitudes. The following variables have been discussed: number of years of working in nursing homes, characteristics of older people with whom professionals have had contact both at work and outside work, type of work contact (whether intensive or brief) and the characteristics of the setting in which contact occurs (Ingham & Fielding, 1985). These variables should be incorporated into further research of attitudes of staff nurses and administrators which incorporates measures of type as well as amount of contact. This research will determine whether such attitudes are situation-specific (that is, whether they apply to clients with a disability within the nursing home environment or to people with disabilities in general. It should also broach the difficult issue of exploring the ways in which attitudes are expressed in behavior, in particular health professionals practice.

Such information could have important implications for enhancing effectiveness of care and quality of life for people with disabilities living in long-term care institutions such as nursing homes: it will provide directions for staff training and will also provide a basis for suggesting strategies for modifying aspects of the work environment which promote negative attitudes in nursing homes: it will provide directions for staff training and also will provide a basis for modifying aspects of the work environment which promote negative attitudes. One such strategy is disability awareness training which brings nursing staff into contact with people with disabilities who are independent, living in the community and able to demonstrate capabilities as well as limitations. This need was first recognized by Sadlick and Penta (1975) who noted that the student nurses working with severely disabled clients tended to develop more negative attitudes and argued, in a similar vein with the conclusions reached here, that this reflected the nature of their clinical experiences. Wright (1983) and Yuker (1988) argue that positive attitude change is promoted by contact with a person with a disability who is perceived as competent and socially of a similar status to others. This contact must occur in an environment in which the person can demonstrate capabilities and individuality (generally not a feature of the nursing home context). Similar conclusions were reached by Biordi and Oermann (1993) who explored the effects of contact in a rehabilitation setting on attitudes of nursing students.

Such features are incorporated into the Disability Awareness Package which has been designed for training service providers about disability (Gething, Poynter & Reynolds, 1992). The aims of this package are to promote positive attitude change and accurate beliefs about life with a disability. Personal contact with a range of people with disabilities forms the central core of workshops based on this package and is supported by provision of accurate information (a resource manual), use of trigger tapes to stimulate discussion, simulations and small group exercises. A detailed description and evaluation of this package are reported in Gething (1994).

Another strategy to address negative attitude formation involves workplace modifications such as rotation of staff between different nursing areas so that they experience contact with a range of patients and clients, not just those with severe disabilities. Furthermore, nursing homes and other health establishments should seriously consider hiring people with disabilities as staff. Such a move would provide positive role models for both nursing staff and clients and would also promote the spirit of the Americans with Disabilities Act (1990) and other legislation designed to grant equal opportunities for people with disabilities. Such steps are vital if effectiveness of service provision is to be maximized for people with disabilities. Consideration should be given to promoting positive attitude change among all service delivery personnel likely to have people with disabilities as clients, including people working in generic as well as specialist organizations.

Authors' Note

Development of the IDP Scale was conducted with funds provided by the Research and Development Committee of the Australian Department of Health, Housing and Community Services. Additional members of the Community Disability and Ageing Program who worked on the project were Felicity Reynolds and Darren Watzinger. Appreciation is expressed to Betty Wilson, Director, Mayor's Office for Disabled, Los Angeles, California for obtaining the Californian sample and for her support of the project and to Mary Kim, Psychology Department, California State University, Los Angeles for her assistance with the final drafting. The IDP Scale is available from the Community Disability and Ageing Program, University of Sydney.

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