Changing attitudes about persons with disabilities: effects of a simulation.
In general, the nursing students had relatively positive scores on the Attitudes Toward Disabled Persons scale in each testing period. The best indicator of postsimulation attitude scores was the presimulation attitude score. Personal and prior nursing experience had no statistical effects on attitude. Improvement that was significant at p = .07 level was noted in the experimental group at the six weeks delayed postsimulation when compared with the presimulation attitude scores. This study supplies data that is useful in constructing learning activities and contributes to the body of knowledge about simulation and attitudes toward persons with disabilities.
More attention is being given to issues involving persons with disabilities than ever before. In the course of our teaching, we have observed that students do not always act positively toward caring for persons with disabilities. As nursing educators, we believe that one of the purposes of education is to influence students' attitudes and thinking processes. Simulations have been used in other settings to affect student attitudes. Could the use of a teaching strategy employing simulation have a positive influence on nursing students' attitudes toward disabled persons?
To begin examination of this question, we devised a study to measure the degree and direction of the change in students' attitudes about persons with disabilities promoted by a teaching strategy which included a simulation activity. This study supplies data that could be useful in constructing learning activities for nursing students as well as contributing to the body of knowledge about simulation and attitudes toward persons with disabilities. Attitudes toward persons with disabilities can be used as indirect measures of nursing students' willingness to work with disabled persons. This study, therefore, provides information that may be used to increase the number of nurses willing to work with persons with disabilities.
Review of the Literature/Theoretical Framework
The literature on disabilities supports the fact that negative attitudes toward the disabled exist and can affect behavior. (1,10,11,21) Disabled people are viewed as different. Stereotypes include seeing them as dependent, isolated, depressed and emotionally unstable persons. These stereotypes lead to a decrease in role expectations. (12) It is the attitude of others toward the person with a disability that poses the greatest handicap to persons with a disability rather than a specific disability. (12,21) While negative attitudes are found in a variety of groups, Brellhart, Jay and Wyers found nursing faculty members to have the least positive attitudes toward the disabled when compared to beginning nursing students, graduating nursing students, registered nurses and people with disabilities. (7) Negative attitudes toward disability are expressed by avoidance, anxiety, overprotectiveness, pity, segregation, alienation and rejection. (9)
The attitudes of nurses and other health care professionals are believed to influence their interactions with people who have disabilities. (2,22) Prior work experience with persons with a disability has a significant positive effect on attitudes. (6) Positive attitudes of health care workers are likely to promote positive adaptation in persons with disabilities. Studies that investigated outcomes based on attitudes toward persons with disability indicated that outcomes for disabilities that are not prominently visible (ie, blindness and deafness) were not as affected by the attitudes of health care providers. Client outcomes were significantly improved when the health care professional had a positive attitude in dealing with disabilities that were more visible and viewed less favorably (ie, mental retardation and spinal cord injury). (16)
Duckworth believes that education of professionals should focus on ability rather than disability. (8) Because attitudes of health care workers can impact persons with disabilities, strategies that influence attitudes are important. Lindgren and Oermann found that an affective learning activity (attending a one-day educational conference) positively influenced nursing students' attitudes toward the disabled immediately postactivity and after a one month delay. (17) Personal contact with disabled people was found to promote positive attitudes. (13) Panel discussion was determined to be superior to video or audiotape presentations in changing attitudes toward disabled persons. (19) Simulation was found superior to a video/audio treatment. (18) Role playing had a positive effect on attitude. (4,15) Desensitization to working with the disabled decreases anxiety but does not improve attitudes toward the disabled. (3,5) Occupational functioning and professional accomplishments of the disabled were more influential in changing attitudes than information regarding family or social life. (20) Goddard indicated that the following strategies have shown success: using simulation or role playing, giving information about the disability and how to interact with disabled persons and providing structured, positive interactions with the disabled. (14) To change attitudes the focus should be on overcoming obstacles and positive aspects such as the abilities of the disabled person. (23)
Weaknesses noted in previous studies include lack of control groups and short time span measurement. This study, therefore, builds on prior research by inclusion of a control group and incorporation of a six month delayed posttest. Strategies for the intervention were gleaned from the literature as were categories for the demographic data.
The specific research questions addressed in this study were:
* Will Sensitivity Lab have a significant positive effect on students' attitudes toward people with disabilities immediately postintervention?
* Will Sensitivity Lab have a significant positive effect on students' attitudes toward people with disabilities that persists over six months?
* The operational hypothesis is that there will be significant differences between the experimental and control group scores on the Attitude Toward Disabled Persons (ATDP) scale immediately after Sensitivity Lab and at six weeks and six months after lab.
Design and Procedure
This quasi-experimental intervention study used a pretest, immediate and two delayed posttests design, using control and experimental groups, to explore the effect of an affective teaching strategy called "Sensitivity Lab" on nursing student attitudes toward persons with disabilities. The experimental group participated in the Sensitivity Lab and the control group did not. Students enrolled in a course on chronic illness during the spring semester when faculty had decided not to include the Sensitivity Lab served as the control group. The lab was reinstated in the fall semester and students enrolled at this time made up the experimental group. Participant confidentiality was assured by using a unique identifier code for the data.
Sensitivity Lab was an eight hour clinical activity with three major parts: (1) a simulation activity in which the students assumed various disabilities while carrying out normal activities in the community such as going to the library, shopping, catching a plane or being a tourist, (2) panel presentations by persons with a variety of disabilities and their caregivers and (3) debriefing in small clinical groups.
Students participated in pairs (one person with a disability and one observer/helper) for the simulation activity. They were assigned the community activity and the disability they were to assume prior to the day of Sensitivity Lab. Disabilities they were to assume included visual deficit, stroke with hemiplegia, paraplegia, severe respiratory impairment and arthritis. All these physical problems are part of the content for the course in which the students were enrolled. The role of the observer/helper was to observe reactions of others to the "disabled" student and to assist only when there was a potential for danger presented to the student with a "disability." Equipment such as wheelchairs, crutches, oxygen tanks, canes and special glasses was issued to the students on the day of the activity.
The panel presentations were for groups of about 40 students. Speakers included people with muscular dystrophy, multiple sclerosis, cancer, paraplegia, visual defects and asthma.
The debriefing was led by the clinical instructors for each clinical group. Clinical groups had 8-10 students. Instructors were given guidelines about what to address in the debriefing sessions. They were asked to cover the feelings the "disabled" student experienced and the perceptions of both students to the reaction of strangers in the setting. In addition, instructors were asked to have all students identify physical and other barriers encountered.
Demographic data was collected on the day of the Sensitivity Lab activity and at each subsequent administration of the ATDP scale to determine if individual experience with disability changed. This data included age, gender, ethnic group, whether the subject has a family member or friend with a disability, whether the subject has had continuing professional contact with persons with disabilities before this semester, and whether the subject has a disability. These factors may influence attitude toward persons with disabilities. Education and occupation are two additional factors that are believed to influence attitude toward persons with disabilities. These factors were controlled in the study since all subjects were baccalaureate nursing students.
Two forms of the Attitudes Toward Disabled Persons Scale (ATDP) by Yuker, Block and Young were used to measure attitude. (23) For the experimental group, the pretest using Form A was given two weeks before Sensitivity Lab (Time 1). An immediate posttest using Form B was given on the day of the Lab (Time 2) and delayed posttests using Form A were given six weeks after the lab (Time 3) and at the end of the following semester (Time 4). The control group was given the same instruments at approximately the same time frame throughout the semester immediately prior to the semester when Sensitivity Lab was held. Class activities and personnel were as consistent as possible for both groups with the exception of the addition of the Sensitivity Day activity for the experimental group.
The Attitudes Toward Disabled Persons (ATDP) scale was first developed in the late 1950s and has since undergone revisions and the development of alternate forms. (24) The ATDP scale continues to be one of the most used measures of attitude toward persons with disabilities. It is both a reliable and valid instrument. Overall reliability of the ATDP scale is approximately .80. Construct validity, established by convergent measures, is generally .54-.98 for measures with similar form and content. While measures of validity using discriminant measures are fewer in number, these yield correlations of .19-.26. (24) The conclusion is that the ATDP has sufficient validity for both disabled and nondisabled respondents to be a useful research tool.
The different forms of the ATDP scale are said to be equivalent to one another. (24) The ATDP is appropriate for group administration. Respondents indicate the extent of their agreement or disagreement according to a 6 point scale. The ATDP scale takes about 15 minutes to complete. The theoretical range of scores for Forms A and B is 0-180. High scores reflect positive, accepting attitudes in which the respondents perceive disabled persons as similar to nondisabled persons. Low scores reflect negative, rejecting attitudes in which the respondents perceive disabled persons as both different and inferior or disadvantaged to some degree.
One-hundred, twenty-one first semester seniors in a baccalaureate school of nursing were the participants. The control group (n=54) consisted of students enrolled in a course on chronic illness during the spring semester, 1994. The experimental group (n=67) consisted of the students enrolled in the same course during the fall semester, 1994. Numbers given here are for the first administration of the attitude measure. Since different numbers of students completed the instruments at each testing time, numbers vary somewhat throughout. There were 29 participants in the control group and 48 participants in the experimental group that completed the ATDP scale at times 1, 3 and 4. These 77 participants provided the data for the repeated measures ANOVA tests.
Demographic data are summarized here. The mean age was 30.0 years for the experimental group and 31.5 years for the control group. The mean age for all subjects was 30.7 years. The experimental group had 72.9% females and 27.9% males. The control group had 90% females and 10% males. Among all participants, the breakdown was 80.6% female and 19.4% male. In the experimental group, participants were 72.9% non-Hispanic white, 20% Hispanic, 1.2% African-American and 5.9% from other ethnic groups. In the control group, participants were 69.9% non-Hispanic white, 13% Hispanic, 8.7% African-American and 8.6% from other ethnic groups. Overall the participants were 71.4% non-Hispanic white, 16.9% Hispanic, 4.5% African-American and 7% from other ethnic groups. In the experimental group, 1.5% reported having a disability themselves while 3.5% in the experimental group reported having a disability. Among all participants, 2.4% reported having a disability themselves.
Design power was approximately .80 to answer questions of median group differences at the .05 level. Due to unexpected attrition and the reduced sample size that resulted, the actual power for detecting medium sized effects in this study was about .50 at alpha level of .05. Thus, it is important to cautiously examine differences with less rigid criteria for statistical significance, so that the findings can be used to understand trends in the data even though the element of chance is somewhat higher than originally intended by the design.
Scores for both the experimental and control groups on the Attitude Toward Disabled Persons Scale at each of the four times when the scale was administered are reported in Table 2. Time 1 was prior to the Sensitivity Lab. Time 2 was immediately after the lab. Time 3 was about six weeks after the lab, and time 4 was at the end of the next semester.
Repeated measures analysis of variance disclosed a group by time effect with a nonsignificant, but positive, change in ATDP scale scores in the experimental group at a .07 level (f=2.72, p=.07) for the repeated measures ANOVA. Non-Hispanic whites showed a greater increase in ATDP scale scores than Hispanics (p=0.1). Gender and prior experience with disabilities had no effect. It is clear from Figure 1 that the change in attitude occurred between times 1 and 3 and persisted through time 4, six months after the first data collection.
[FIGURE 1 OMITTED]
Simple linear regression was used to predict time three scores from time one scores. Residuals from the predicted scores at time three were examined by Chi-square tests to determine characteristics of individuals who had greater or less change than expected based on the pre-scores alone. Although differences were not statistically significant at .05 level, several trends were suggested by the data. Comparing time one and three showed the experimental group had less negative change over time than predicted. Males and non-Hispanic whites were more influenced by the experimental treatment than females and Hispanics. Among males in the experimental group, there were greater changes in both directions than predicted. Non-Hispanic white males and females had more positive changes than predicted. Prior experience (including having a disability) had no effect.
Since administration of the ATDP scale at times one and two were only one or two weeks apart, the equivalent Form B of the ATDP scale was used at time two in an attempt to decrease subjects' remembering the items. Form A of the ATDP scale was used at times one, three and four. Scores for the cases in both the control and experimental groups (n=84) at time two fell by about two points (2.4 for the control group and 2.1 for the experimental group). Despite claims of equivalency by the developers, this consistent fall in scores casts doubt on the equivalency of forms A and B. One other possible explanation for the fall in scores at time two might be annoyance at taking similar instruments in such a short time span with transfer of this annoyance to the subjects of the scale. Since form A was used at times one, three and four, comparisons among these times are believed to be valid. The general trend was for scores to become more positive over time (a 3.5 point increase for the control group and a 6.6 point increase for the experimental group). Serious doubt about the equivalence of forms A and B of the ATDP scale prevents analysis of the first research question: Will sensitivity Lab have a significant positive effect on students' attitudes toward people with disabilities immediately postintervention? The differences between times one and three in the experimental group that were significant at the .07 level support the second question: Will Sensitivity Lab have a significant positive effect on students' attitudes toward people with disabilities that persists over six months? It is clear from Figure 1 that the effect is not lost over time. The passage of several months between measurements at time three and four allows for several things. Other events in the lives of the subjects may exert influences that dilute or enhance the earlier effect of the activity. It is clear that the attitude of subjects in this study as measured by the ATDP scale did become more positive over the time covered.
[FIGURE 1 OMITTED]
The lack of statistical significance when looking at differences from the predicted values is disappointing, but the trends are encouraging. While the experimental strategy did not show strong influence, the experimental group did have less negative change, which gives support to the use of the strategy. That men and non-Hispanic whites were more influenced by the teaching strategy of Sensitivity Lab was both unexpected and interesting, since race and gender have not been cited in earlier studies as factors in success or failure of simulations. The men had greater than predicted changes in both negative and positive directions. This finding suggests that the experimental strategy could lead to undesirable attitude changes in men. The percent of men was small (19.4%), therefore studies that have larger numbers of men are suggested to see if they are more influenced by strategies such as those used in Sensitivity Lab.
The number of Hispanics was also small (16.9%), so it is difficult to make generalizations about the influence of ethnicity based on this study. Studies dealing with factors which influence attitude change among Hispanics could indicate possible reasons for the finding that they experienced less change in attitude following the strategies used in this study than non-Hispanic white students experienced.
Analysis of variance showed the same trends as did the prediction residual analysis. The significant positive changes in the experimental group support use of simulation and other experiential strategies when attempting to change attitudes of students toward people with disabilities. These strategies appear to be most effective with non-Hispanic white students. It is surprising to find that experience with people having disabilities did not show any effects on attitude change.
Normative data presented by Yuker and Block summarizes over 200 studies using the ATDP scales. (24) The reported range of scores in the 29 studies using form A is 92.7-130.8 with a median of 117.1. Females tended to score slightly higher than males. Only two studies had means equal to or higher than the nursing students. One of these studies represented rehabilitation personnel. The mean scores for nursing students in this study were considerably higher, ranging from 127.5 to 138.7, than the studies reported by Yucker and Block. Even though the nursing students had positive scores at the beginning of the study, the development of strategies to promote positive attitudes is desirable since the number of nurses choosing to work with persons having disabilities is currently low.
The findings of this study support the continued use of Sensitivity Lab and the need for further study. While outcomes were not strongly supportive, the direction of results was encouraging and students' subjective evaluations of the activity were positive. This study contributes to the general area of teaching in the affective domain as it supports the use of simulation as a strategy to influence attitudes, especially among non-Hispanic white students.
Limitations and Future Research
The fact that the experimental and control groups were made up of students enrolled in different semesters was a serious threat to the study. Choice of the design using different semesters was influenced primarily by the fact that faculty teaching the course had elected not to have the Sensitivity Lab during the spring semester and the problems of having very different clinical experiences for students in the same semester could thus be avoided. It is unfortunate that the students in the two semesters of this study were perceived as being more different than most student groups; faculty often commented that one group was quite different in general character than the other group. The different character of the two groups in the study was not evident until after the study was well underway. These uncontrolled differences allowed for situational variations and threats to the internal and external validity of results. Randomizing assignment to the experimental and control groups and having the two groups run simultaneously would be desirable in any future studies. Cross contamination would then be a potential problem, but this would probably be less of a threat than the problems encountered in this study.
Data analysis was complicated by the fact that there were only 68 students who completed the ATDP Scale at all four of the data collection periods. An incentive might have assured that a larger number of subjects would complete all data collection sessions.
Debriefing among the various clinical groups varied since eleven different faculty members were involved. Even though guidelines were available for debriefing, considerable variation may have existed. Better training of fewer faculty members and closer monitoring of the debriefing sessions are recommended for future studies. Since prior research reports negative attitudes among nursing faculty, assessment of faculty attitudes would be desirable in future studies.
Future studies using the ATDP scale should use only one form of the scale. This study casts doubt on the equivalency of forms A and B of the ATDP scale. We were unable to respond with conviction to the question of the immediate effect of the experimental treatment because of the apparent lack of equivalent test forms.
Due to difficulty providing control groups, some educational researchers accept designs without adequate controls. This study makes a strong case for educational studies having control groups. The significance of the decrease in scores between forms A and B at times one and two would have gone unnoticed had the control group not been present and had the same-decrease (Fig 1). Another positive effect the control group had on this study was to prevent an inaccurate overall conclusion that Sensitivity Lab was the sole cause of the increase in scores over time. Other design problems, particularly lack of random group assignment, proved problematic for this study. These characteristics call attention to the fact that every attempt to provide tight designs should be made in future educational research if we are to produce results that can be believed, replicated, and generalized.
While this study focused on influencing attitudes toward the disabled in an educational setting, simulation activities need to be investigated as a medium of change in other settings. In these times of cross-training, staff members need to learn new skills but also need to have positive attitudes when caring for the disabled. Simulation can be readily incorporated in training activities in the clinical setting.
Simulation as a strategy to influence attitudes about persons with disabilities was supported by this study even though statistical measures did not yield significant effects at the .05 level. The study is noteworthy because of the use of a control group which yielded important data concerning the equivalency of different forms of the ATDP scale as well as giving credibility to the findings of the study. In interpreting study data, it is important to recognize that even an effective strategy may produce only small changes when all participants begin with high scores on the measure used. The slight gains on the ATDP scale scores, while not statistically significant, are therefore viewed as important findings because the participants began the study having high scores on the ATDP scale. A unique feature of this study was the six month delayed score which showed a long-term positive effect from use of simulation.
Table 1. Demographic Data Experimental Control All subjects (N=67) (N=54) (N=121) Age 30.0 years 31.5 years 30.7 years Gender Female 72.9% 90.0% 80.6% Male 27.1% 10.0% 19.4% Ethnic Group Non-Hispanic white 72.9% 69.9% 71.4% Hispanic 20.0% 13.0% 16.9% African-American 1.2% 8.7% 4.5% Other 5.9% 8.6% 7.0% Reported having 1.5% 3.5% 2.4% a disability themselves Table 2. Scores on the Attitude Toward Disabled Persons Scale Control Group Experimental Group Time/Form Number Mean SD Number Mean SD 1/A 54 129.9 16.8 67 132.1 17.8 2/B 45 127.5 20.4 66 130.0 21.1 3/A 50 134.3 23.3 61 138.0 19.7 4/A 43 133.4 15.8 68 138.7 20.8 Note: These statistics are shown for descriptive purposes only. Comparison tests were not done at this level, but were done using repeated measures ANOVA (reported in text).
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Questions or comments about this article may be directed to: Leslie Goddard, PhD, RN, CNRN, The University of Texas Health Science Center, at San Antonio School of Nursing, 7703 Floyd Curl Drive, San Antonio, Texas 78284. She is an associate professor.
Lila Jordan, PhD, RN, CS is an associate professor, School of Nursing, The University of Texas Health Science Center at San Antonio, Texas.