queensland university of technology school of nursing...
TRANSCRIPT
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Queensland University of Technology
School of NursingCentre for Nursing Research
“THE EFFECT OF AN EXPERIENTIAL LEARNING STRATEGYON NURSING STUDENTS’ KNOWLEDGE AND ATTITUDESTOWARD OLDER PEOPLE IN TAIWAN”
Student： I-Ju PanPrincipal Supervisor： Prof Helen EdwardsAssociate Supervisor： Prof Anne Chang
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KEY WORDS
Older people
Attitudes
Knowledge
Undergraduate nursing students
Gerontological nursing
Experiential learning
Lecture
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RELATED PRESENTATIONS
Conference paper abstract
The 3rd Pan-Pacific Nursing Conference & The 5th Hong Kong Nursing Symposium
on Cancer Care 11-12 November 2005
The abstract of presentation as below:
Title: Factors influencing the development of an experiential gerontological course
Authors: I-Ju Pan, Helen Edwards, Anne Chang
Institution: Queensland University of Technology (QUT)
In Taiwan the percentage of the population aged 65 years and over has increased to
9% and as in other countries is predicted to continue to increase. While this growth is
reflected in the increasing number of positions for nurses, gerontological nursing is
often not a preferred career option. Inadequate knowledge and negative beliefs about
older people have been linked to the reluctance to choose gerontological nursing as a
career. A survey was conducted for the purpose of gaining greater understanding of
nursing students’ attitudes and knowledge about older people. This material would
provide a baseline for developing a gerontological nursing course. Questionnaire data
on attitudes and knowledge were collected from 302 nursing students in baccalaureate
nursing programs in Southern Taiwan. Nurses’ attitudes towards older people were
positive (mean=130, SD=14.59) and their level of knowledge was moderate at 50.4%.
Multiple regression analysis indicates that work experience, intention to work with
older people and type of nursing program are significant factors influencing students’
attitudes toward older people. The findings of this study indicate the need to maintain
and further improve nursing students’ attitudes and to enhance their knowledge about
ageing. The provision of experiential gerontological nursing courses placing more
emphasis on attitudes as well as knowledge about ageing and that take account of
students’ working experience and their career intention will lead to a higher quality of
care for older patients. Further research is needed to compare the effects of
experiential and existing gerontologic courses on students’ attitudes, knowledge and
career intention.
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ABSTRACT
The aim of the research was to improve Taiwanese undergraduate nursing students’
attitudes toward and knowledge about older people in order to encourage them to
work with older people. People aged 65 and over currently make up 9.7% of the
Taiwanese population (Department of Statistics 2006). With the increasing population
of older people, health care professionals will have more experiences of caring for
older people. However, an increasingly large body of literature suggests that most
health care professionals have negative attitudes toward older people and little
knowledge about older people. Studies from Western countries have indicated that
attitudes toward and knowledge about older people can be improved through a variety
of educational efforts .
Two studies were conducted to examine these issues. Study 1 involved a cross
sectional survey of 302 nursing students from four-year and two-year programs in a
university in southern Taiwan. Overall, the results showed that nursing students held
positive attitudes toward older people but had poor knowledge about older people.
Moreover, the findings suggested that nursing students’ intention to work with older
people and gender were important factors influencing their attitudes toward older
people. Age, nursing program, and living with older people were the variables which
made independent contributions to knowledge about older people.
Study 2 was a quasi-experimental design using pre-post tests with an intervention
(experiental based learning) and control group (usual lecture based learning) (n = 60)
to test the impact of a gerontological educational subject. Focus group data were also
collected to examine students’ reactions to the gerontological nursing subject and the
experiential learning strategies used in an experiential-based learning group. The
sample was students in the second semester of their second year from the same
university used for Study 1. All 60 students were randomly assigned into either
experiential-based learning or lecture-based learning groups for their gerontological
nursing subject. The data were collected across three time points (pre-test, week 16
and week 20) using 2 validated instruments from Study 1. Qualitative data were also
collected from the experimental group after students’ clinical practice at week 20. In
order to test for the effect of the intervention over time, repeated measures analysis of
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variance was used to determine the effectiveness of the experiential learning approach
and clinical practice on each of the dependent variables of attitudes and knowledge.
The results of Study 2 indicated that students’ attitudes toward and knowledge about
older people did not differ between the two groups In addition, there was no change
in attitudes following the completion of the gerontological nursing subject. Students
in both groups had improved their level of knowledge at the end of the gerontological
subject. Therefore, the study hypotheses were not supported. Several factors such as
lack of linkage between theoretical concepts and experience, the dominant ‘exam
culture’, students’ usual learning style and the structure of the program may explain
the results.
This was the first study which had introduced experiential learning into the selected
university. It was necessary to conduct this initial study to understand the students’
reaction to it. Therefore, based on the research findings from both the quantitative and
qualitative results, the study indicates that additional studies are needed to continue
exploring how experiential learning strategies may be used to improve students’
attitudes toward and knowledge about older people.
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TABLE OF CONTENTS
KEY WORDS ........................................................................................................... iiRELATED PRESENTATIONS................................................................................. iiiABSTRACT............................................................................................................. ivTABLE OF CONTENTS.......................................................................................... viLIST OF TABLES.................................................................................................... xiLIST OF FIGURES................................................................................................. xiiSTATEMENT OF ORIGINAL AUTHORSHIP ...................................................... xiiiDECLARATION OF ENROLMENT ......................................................................xivACKNOWLEDGEMENTS......................................................................................xvCHAPTER ONE ....................................................................................................... 1
Introduction........................................................................................................... 1Background and Significance............................................................................. 1Purpose and Objectives...................................................................................... 6Research Questions............................................................................................ 9Definition of Terms...........................................................................................11Structure of the Thesis ......................................................................................12
CHAPTER TWO......................................................................................................14Literature Review: Attitudes toward and Knowledge about Older People..............14
Attitudes toward Older People ..........................................................................16Negative Attitudes towards Older People ......................................................16Positive Attitudes toward Older People .........................................................18
Knowledge about Ageing..................................................................................22Factors Influencing Attitudes toward Older People ...........................................25
Demographic Characteristics .......................................................................25Gender ......................................................................................................26Age ...........................................................................................................27Intention to work with older people...........................................................29
Knowledge about Ageing ..............................................................................30Previous Experience with Older People ........................................................31
Factors Influencing Knowledge about Older People..........................................33Limitations of Studies.......................................................................................34Instruments Used to Measure Attitudes and Knowledge Related to Ageing .......36Summary ..........................................................................................................39
CHAPTER THREE..................................................................................................41Literature Review: Gerontological Nursing Education ..........................................41
Overview of Educational Programs...................................................................42Findings of Studies........................................................................................43
Attitudes toward older people....................................................................43Knowledge about older people ..................................................................46Limitations of the studies ..........................................................................49
Types of Educational Programs.....................................................................50Traditional lecture-based learning .............................................................50Intergenerational service-learning .............................................................51Experiential learning .................................................................................52
Conclusion....................................................................................................53Experiential Learning Model ............................................................................55
Concrete experience......................................................................................57Reflective observation ...................................................................................57
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Abstract conceptualisation ............................................................................58Active experimentation..................................................................................58
Factors Influencing Experiential Learning Outcomes........................................60Experience with Well Older People ...............................................................60Relationship with Older People.....................................................................64Experience in Clinical Settings .....................................................................66
Summary ..........................................................................................................71CHAPTER FOUR....................................................................................................72
Study 1: Survey ....................................................................................................72Introduction ......................................................................................................72Method .............................................................................................................73
Research Design ...........................................................................................73Research Questions.......................................................................................74Sample ..........................................................................................................74Instruments ...................................................................................................76
Attitudes ...................................................................................................76Knowledge................................................................................................78Demographic data .....................................................................................81Translation of instruments.........................................................................81
Procedure .....................................................................................................82Ethical Considerations..................................................................................83Data Analysis................................................................................................84
Results..............................................................................................................85Sample Characteristics .................................................................................86
Level of education ....................................................................................87Work experience in nursing.......................................................................87Contact with older people .........................................................................87Gerontological course ...............................................................................88Clinical practice ........................................................................................90Intention to work with older people...........................................................91Summary ..................................................................................................91
Validity of Instruments ..................................................................................91Perceptions of Working with Older People (PWOP)..................................91Knowledge of the Situation of Older People (KSOP) ................................95
Reliability of Instruments ..............................................................................98Kogan’s Attitude toward Old People Scale (KOP) .....................................98Perceptions of Working with Older People (PWOP)..................................98Palmore’s Facts on Ageing Quiz: Part 1 (FAQ1)........................................98Knowledge of the Situation of Older People (KSOP) ................................99
Attitudes toward Older People ......................................................................99Kogan’s Attitudes toward Old People (KOP) scale ....................................99Perceptions of Working with Older People (PWOP)................................100
Knowledge about Older People...................................................................100Palmore’s Facts on Aging Quiz: Part 1 ....................................................100Knowledge of the Situation of Older People (KSOP) ..............................101
Correlations among Measures of Attitudes and Knowledge .........................101Correlations among Attitudes, Knowledge and Demographic Variables ......103
Attitudes toward older people..................................................................104Knowledge about older people ................................................................106
Factors Influencing Nursing Students’ Attitudes and Knowledge .................107
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Discussion ......................................................................................................113Validity and Reliability of Instruments.........................................................114Attitudes .....................................................................................................114Knowledge ..................................................................................................116Factors Influencing Nursing Students’ Attitudes toward and Knowledge aboutOlder People...............................................................................................117
Limitations of the Study..................................................................................120CHAPTER FIVE....................................................................................................122
Gerontological Nursing Education Program........................................................122Introduction ....................................................................................................122
Overview of Gerontological Nursing Subject in Lecture-Based LearningGroup .........................................................................................................126
Aim and objectives .................................................................................126Classroom situation.................................................................................127Content ...................................................................................................128Teaching approach ..................................................................................129Assessment .............................................................................................131
Overview of Educational Intervention Program in Experiential-BasedLearning Group ..........................................................................................131
Aim and objectives .................................................................................132Classroom situation.................................................................................132Content ...................................................................................................133Teaching approach ..................................................................................134
Experience in a Senior Apartment .......................................................135Group discussion.................................................................................136Journal writing ...................................................................................137Debriefing. ..........................................................................................137Lecture. ...............................................................................................138Textbook reading .................................................................................138Simulation game..................................................................................138Role play .............................................................................................139Skills practice in the laboratory...........................................................140
Assessment .............................................................................................145Summary ........................................................................................................145
CHAPTER SIX ......................................................................................................147Study 2: Evaluation of Educational Intervention .................................................147
Method ...........................................................................................................147Research Design .........................................................................................147Variables.....................................................................................................148Research Questions and Hypotheses ...........................................................149Sample ........................................................................................................151
Sample size.............................................................................................153Instruments .................................................................................................154
Attitudes .................................................................................................154Knowledge..............................................................................................155Demographic data ...................................................................................156
Procedure ...................................................................................................156Ethical Considerations................................................................................159Educational Intervention.............................................................................162
Control group..........................................................................................162
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Experimental group.................................................................................163Data Analysis..............................................................................................164
Quantitative Results........................................................................................169Attitudes .....................................................................................................172Knowledge ..................................................................................................176Summary of Quantitative Results ................................................................181
Qualitative Results..........................................................................................181Benefits of the gerontological nursing subject .............................................183
Improving communication ......................................................................183Ability to assess older people ..................................................................183Improving knowledge about older people................................................184Practice in a real experience ....................................................................184
Views on Experiential Learning ..................................................................185Bridging theory and practice ...................................................................185‘Feel the feeling’ of older people .............................................................186Practice in Senior Apartment...................................................................187Perceptions of older people .....................................................................189Benefits of discussion .............................................................................190
Factors Influencing Experiential Learning..................................................191Learning preference ................................................................................191Attitudes to reading and examination ......................................................192‘Doing differently’ in experiential learning..............................................194
Discussion ......................................................................................................195CHAPTER SEVEN................................................................................................208
Conclusion .........................................................................................................208Summary of Findings .....................................................................................208Discussion of Findings....................................................................................215Strengths and Limitations of the Research ......................................................221Implications for Nursing Education ................................................................223Recommendations for Research......................................................................225Summary ........................................................................................................226
REFERENCES.......................................................................................................228APPENDIXces.......................................................................................................242
Appendix 1—Review of Educational Program....................................................243Appendix 2—KOP (Study 1) (English Version) ..................................................250Appendix 2—KOP (Study 1) (Chinese Version)..................................................253Appendix 3—PWOP (Study 1) (English Version) ...............................................256
Students’ perceptions of the consequences of ......................................257Appendix 3—PWOP (Study 1) (Chinese Version)...............................................258Appendix 4—FAQ 1 (Study 1) (English Version) ...............................................259Appendix 4—FAQ 1 (Study 1) (Chinese Version)...............................................261Appendix 5—KSOP (Study 1) (Original English Version) ..................................263Appendix 5—KSOP (Study 1) (Taiwanese English Version)...............................265Appendix 5—KSOP (Study 1) (Chinese Version) ...............................................267Appendix 6— Consent for the use of the four established research instruments ..269Appendix 7—Demographic data sheet (English Version)....................................270Appendix 7—Demographic data sheet (Chinese Version) ...................................274Appendix 8—Ethical Approval from QUT..........................................................277Appendix 9—Ethical Approval from study university.........................................278Appendix 10—Participant information sheet (Study 1) (English Version) ...........279
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Appendix 10—Participant information sheet (Study 1) (Chinese Version)...........282Appendix 11—Consent form (Study 1) (English Version)...................................284Appendix 11—Consent form (Study 1) (Chinese Version) ..................................285Appendix 12—PWOP (English Version).............................................................286Appendix 12—PWOP (Chinese Version)............................................................287Appendix 13—KSOP (Taiwanese English Version) ............................................288Appendix 13—KSOP (Chinese Version).............................................................289Appendix 14— Five highest and lowest statements of KOP................................290Appendix 15— Five highest and lowest statements of KSOP .............................291Appendix 16— Five highest and lowest statements of FAQ1..............................292Appendix 17— Five highest and lowest statements of KSOP .............................293Appendix 18—Questions for focus group interview............................................294Appendix 19—Participant information sheet (Study 2) (English Version) ...........295Appendix 19—Participant information sheet (Study 2) (Chinese Version)...........297Appendix 20—Consent form (Study 2) (English Version)...................................299Appendix 20—Consent form (Study 2) (Chinese Version) ..................................300Appendix 21—Gerontological Nursing Education Program................................301
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LIST OF TABLES
Table 3.1 Advantages and disadvantages of three teaching/learning strategies ..........54Table 4.1 Comparison of contact with older people according to type of nursing
program ....................................................................................................89Table 4.2 Comparison of gerontological nursing courses undertaken by students,
according to type of nursing program........................................................90Table 4.3 Varimax Rotated Factor Loadings for the Students’ Perceptions of Working
with Older People (PWOP) .......................................................................94Table 4.4 Varimax Rotated Factor Loadings for the Knowledge of the Situation of
Older People (KSOP)................................................................................97Table 4.5 Pearson correlation coefficients for attitude and knowledge scales ..........103Table 4.6 Pearson Correlations among demographics, KOP, PWOP, FAQ1, and KSOP
...............................................................................................................104Table 4.7 Biserial Correlations among Demographics, KOP, PWOP, FAQ1, and KSOP
...............................................................................................................106Table 4.8 Standard Multiple Regression on Kogan Attitudes toward the Older People
(KOP) .....................................................................................................109Table 4.9 Standard Multiple Regression on Perceptions of Working with Older People
(PWOP) ..................................................................................................109Table 4.10 Standard Multiple Regression with subscale of PWOP in intentions to
work with older people............................................................................110Table 4.11 Standard Multiple Regression with Nolan’s Knowledge of the Situation of
Older People (KSOP).............................................................................. 111Table 4.12 Standard Multiple Regression with subscale of KSOP in daily activities of
older people ............................................................................................112Table 5.1 Content of gerontological nursing in lecture-based learning group...........130Table 5.2 Overview of gerontological nursing program in experiential-based learning
group ......................................................................................................141Table 6.1 Quasi-experimental design for the study..................................................148Table 6.2 Stage of thematic content analysis (Burnard, 1991) .................................165Table 6.3 The transcript extract: an example of open data coding of a focus group
interview.................................................................................................168Table 6.4 Comparison of contact with older people according to learning strategy..170Table 6.5 Mean PWOP scores for experiential-based learning group and lecture-based
learning group.........................................................................................173Table 6.6 Mean intention to work with older people scores for experiential-based
learning group and lecture-based learning group .....................................174Table 6.7 Mean career prospects of working with older people scores for experiential-
based learning group and lecture-based learning group............................176Table 6.8 Mean KSOP scores over time for experiential-based learning group and
lecture-based learning group ...................................................................177Table 6.9 Mean daily activities of older people scores for experiential-based learning
group and lecture-based learning group...................................................178Table 6.10 Mean Demography of older people scores for experiential-based learning
group and lecture-based learning group...................................................179Table 6.11 Mean Vulnerability of older people scores for experiential-based learning
group and lecture-based learning group...................................................180Table 6.12 Theme development from open coding of focus group interview...........182
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LIST OF FIGURES
Figure 3.1 Kolb’s Experiential Learning Cycle .........................................................56Figure 5.1 Learning activities based on the experiential learning model..................134Figure 6.1 Graph of interaction of intention to work with older people ...................174Figure 3.1 Kolb’s Experiential Learning Cycle .........................................................56Figure 5.1 Learning activities based on the experiential learning model..................134Figure 6.1 Graph of interaction of intention to work with older people ...................174
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ACKNOWLEDGEMENTS
I express my appreciation to my Principal Supervisor, Professor Helen Edwards for
her guidance, support and patience. Her invaluable input into the design,
implementation and analysis of this research project, together with her ongoing
encouragement, attention to detail and ability to challenge and inspire more ideas, was
instrumental to the successful completion of my study.
I would also like to express my gratitude to my Associate Supervisor, Professor Anne
Chang. Her ability provides a realistic perspective on the ability to deliver the
research outcomes. Anne’s enthusiasm and support were essential, and greatly
appreciated throughout this process.
I wish to thank Ray Duplock for his technical and statistical support. I am also
indebted to the teachers and students who volunteered for this study and all workers
and older people in the “Senior Apartment”. Without them and their willingness to
support, this study would not have been possible.
Special thanks to my colleagues in QUT and I-Shou University and others who made
this experience such a pleasure.
Finally, I would like to express my sincere gratitude to my family for their
understanding, patience and enduring support during the difficult time of studying.
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CHAPTER ONE
Introduction
Background and Significance
Gerontological education is currently one of the most important aspects of
nursing education. As the steady advance of medical treatment and technology allows
people to live longer, there is an increasing need for those who can work with and
help this ageing population. Nurses, as the largest group of health care providers, will
carry on delivering health care to older people, however, a number of research studies
suggest that fewer health professionals are making the career choice to work with
them (Happell and Brooker 2001; Soderhamn, Lindencrona et al. 2001; Herdman
2002). Concerns have been raised about the competency and willingness of health
care providers to care for this age group (Kane 1999; Mehta, Tan et al. 2000; Paton,
Sar et al. 2001; McKinlay & Cowan 2003). It is questionable whether nursing students
and health care providers hold negative attitudes toward older people (Happell 1999;
Kearney, Miller et al. 2000; Knapp & Stubblefield 2000; Paton, Sar et al. 2001; Gellis,
Sherman et al. 2003) or positive ones (Lookinland, Linton et al. 2002; Fitzgerald,
Wray et al. 2003; McKinlay and Cowan 2003; Tan, Zhang et al. 2004; Hweidi & Al-
Obeisat 2006). According to Jacelon (2002), the quality of care provided for older
people is directly related to the attitudes and knowledge of health care professionals.
Consequently, since the student nurse of today is the health care provider of tomorrow,
and with the burgeoning need for care for older people, it is important for nursing
educators to identify those students who have an interest in ageing and to encourage
them. Furthermore, it is necessary to be aware of the attitudes held by current
undergraduate nursing students toward older people and their knowledge about them,
and to understand the implications of these attitudes and knowledge.
Ageing, the process of growing older, is an inevitable part of life. In many
countries, such as Australia, USA and Taiwan, reaching the age of 65 has been the
marker for compulsory retirement; in this study, the term “older people” refers to
people 65 years and over. In the developed world the size and proportion of this
population is increasing; ageing of the population involves greater numbers of older
people as well as consequent changes in the demographic structure of the population
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as a whole (Mathur 1996); this presents a challenge for the community through the
loss of their potential social-economic contribution. Furthermore, the proportion of
people aged 75 and over will increase during this century and this group is the most
intensive user of health and aged care services (Fagerberg, Winblad et al. 2000). Thus
the structure of the aged population is an important indicator of the potential need for
health care services.
Advanced technology and medical treatments have resulted in people living
longer. In Australia, the proportion of the population aged 65 years and over increased
from 10.3% to 13.1% between 30 June 1985 and 30 June 2005 (Australian Bureau of
Statistics 2005). It is projected to rise from around 12% today to 18% by the year
2021, and to 25% by the year 2051 (Commonwealth Department of Health and Aged
Care 2000). In the United States of America, persons 65 years and older currently
make up 12.4% of the population and by 2030 they will constitute 20% (U.S. Bureau
of the Census 2000). As in western industrial countries, there is a major demographic
transformation in Taiwan, resulting in the growth of what is termed an “aged
population”. Currently, people aged 65 and over make up 9.7% of the Taiwanese
population (Department of Statistics 2006). It is estimated that by 2030 and 2040, the
proportion of older people in Taiwan will rise to 19.5% and 25% of the population,
respectively (Social Affairs 2002). Within this growing aged population, levels of
disability are markedly higher for those 65 and over. Functional disabilities with
psychological, socioeconomic, and environmental factors can have a profound impact
on the health care system; this increased aged population with its associated health
care needs will represent the most common care group for nursing (Sheffler 1998;
Happell and Brooker 2001; Paton, Sar et al. 2001; Hweidi and Al-Obeisat 2006).
Health care providers will play an important role in meeting the various needs of older
people.
Some studies suggest that generally people believe that growing old is
associated with frailty and an inevitable decline in function, such as fading memory,
reduced learning skills, and being slower in general (Treharne 1990; Hawkins 1996;
Gellis, Sherman et al. 2003). Older people have also been viewed as burdensome
throughout western society (Woolf 1998) and it has been suggested that society has
negative attitudes toward older people (Laditka, Fischer et al. 2004). Nurses, as
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members of society, are not immune from holding negative, pessimistic views that can
influence professionals’ understanding of the needs of older people (Reed and Clarke
1999). Negative attitudes toward older people have been investigated in nurses
(Kearney, Miller et al. 2000), undergraduate nursing students (Happell 1999; Knapp
and Stubblefield 2000; Happell and Brooker 2001), and social work students (Gellis,
Sherman et al. 2003).
On the other hand, a number of studies in Taiwan have found that students
hold positive attitudes toward older people (Lin 1993; Liou and Hsu 1994; Wei 1995).
In Taiwan, 63% of older people aged 65 years and over live with their children
(Department of Statisics 2000). Strong and often close relationships with grandparents
could explain why students’ attitudes toward older people are positive in Taiwanese
studies.
With the increasing population of older people, health care professionals will
gain more experience in caring for older people; however, an increasingly large body
of literature suggests that most health care professionals have little knowledge about
older people, such as their demographic characteristics and physical status, (Nolan,
Davies et al. 2001; Kaempfer, Wellman et al. 2002; Fitzgerald, Wray et al. 2003;
Fajemilehin 2004). The issue of low levels of knowledge about older people is
relevant to nursing education programs; to increase students’ knowledge about older
people, gerontological education needs to be included in general professional nursing
education courses.
A number of studies support the notion that nurses and nursing students have
been influenced by pessimistic views and hold negative attitudes toward older people
(Happell 1999; Kearney, Miller et al. 2000; Knapp and Stubblefield 2000; Paton, Sar
et al. 2001; Gellis, Sherman et al. 2003) and have little knowledge about them (Nolan,
Davies et al. 2001; Kaempfer, Wellman et al. 2002; Fitzgerald, Wray et al. 2003;
Fajemilehin 2004). From a pedagogical perspective, in order to address these issues,
many universities and colleges have offered gerontological education programs to
prepare students to work with older people (Wei 1995; Gorelik, Damron-Rodriguez et
al. 2000; Fajemilehin 2004). Exposure to gerontological content has been shown to
modify stereotypical attitudes toward older people, instil knowledge, and develop
skills (Shoemake, Bowman et al. 1998; Knapp and Stubblefield 1999; Langer 1999;
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Weaver 1999; Berenbaum 2000; Alford, Miles et al. 2001; Wilkes and LeMiere 2001).
Gerontological courses can assist nursing students to gain knowledge about older
people, to increase students’ commitment to anticipating the needs of older people,
and to use their knowledge in new situations (Knapp and Stubblefield 2000; Ragan
and Bowen 2001; Wilkes and LeMiere 2001; Gallagher, Dobrosielski-Vergona et al.
2005; Moriello, Smey et al. 2005). However in Taiwan there are concerns with
currently existing gerontological nursing courses. Firstly, the subject is optional in
nursing programs, leading to student perceptions that it is not as important as other
compulsory units. Secondly, in the four-year nursing program, students start clinical
practice in acute hospitals in their second year, when they experience and learn how to
care for ill patients, including older patients. During such nursing education programs
and clinical training, students receive few positive messages about caring for older
people. The main messages they get consist of information that focuses more on
caring for ill older people and less on positive aspects of the ageing process (Liou and
Hsu 1994). Thirdly, in Taiwan, traditional didactic lecture-based learning is the most
common teaching method used to deliver nursing courses, including gerontological
subjects. It is usual for teachers to transmit their knowledge, and for students to be
passive information receivers; students memorise the information which the teacher
gives during the lecture in order to pass examinations. During the class, there is no
active interaction between students and teachers, no real experience or interaction
with older people during the gerontological nursing subject, and no opportunity for
reflection on students’ experiences with older people. These factors highlight some
important issues in gerontological nursing courses in Taiwan.
A number of researchers have reported that nursing students’ attitudes toward
and knowledge about older people can be improved by a variety of educational means
(Brown and Roodin 2001; Ragan and Bowen 2001; Wilkes and LeMiere 2001;
O'Hanlon and Brookover 2002; Dorfman, Murty et al. 2004; Moriello, Smey et al.
2005). For example, courses that have been shown to promote nursing students’
attitudes toward and knowledge about older people have included the use of an
intergenerational service-learning approach (Knapp and Stubblefield 2000; Blieszner
and Artale 2001; Nichols and Monard 2001; Weinreich 2003; Dorfman, Murty et al.
2004; O'Quin, Bulot et al. 2005) and an experiential learning approach (Bullard,
Fleischer et al. 1996; Karner, Rheinheimer et al. 1998; Anderson-Hanley 1999;
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O'Hanlon and Brookover 2002; Moriello, Smey et al. 2005). Intergenerational service-
learning is an innovative approach to teaching and learning that integrates community
service activities that focus on the interactions between younger and older adults into
academic curricula (Newman and Smith 1997; McCrea, Nichols et al. 2000).
Although participating in service activities with older people is one way to deliver
gerontological education, two issues that need consideration are time commitment and
implementation of service-learning (Bringle and Kremer 1993; Blieszner and Artale
2001). For example, in terms of time commitment, students need to spend more time
in community service to achieve the requirements of the course; but when placing
students in the community, practical considerations such as travel and effective
monitoring need to be taken into account so as to promote the most effective learning
experience.
According to earlier studies, an alternative method is the experiential learning
approach, which has been used in gerontological nursing courses to promote positive
attitudes and increase nursing students’ knowledge about older people. In this
approach, the teacher interacts with students about a particular concept using a variety
of activities; for gerontological courses these activities might include exercises such
as experience with older people, group discussion, journal writing, lecture, role play,
simulation games, and skills practice in the laboratory (Potgieter and Phil 1999; Wood
2002). A few studies have documented evidence on the effectiveness of experiential
learning approaches in improving attitudes toward and enhancing knowledge about
older people in gerontological nursing (Karner, Rheinheimer et al. 1998; Kropf 2002;
O'Hanlon and Brookover 2002; Wood 2002). Although experiential teaching
approaches have been introduced as a teaching method for gerontological education in
earlier studies, it is interesting to note that no published studies have reported on this
area in Taiwan. Thus research is required in this area.
Kolb’s (1984) experiential learning model provides a conceptual framework
for guiding the design of a gerontological nursing course and was used in the study
reported in this thesis. Kolb’s experiential learning model is a four-stage cycle. The
stages are: concrete experience (CE), reflective observation (RO), abstract
conceptualization (AC), and active experimentation (AE). The first stage in Kolb’s
model is concrete experience, which enables individuals to become immersed in
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actual situations (Kolb 1984). By having contact with healthy older people, students
can gain positive feedback and experience. Reflective observation of ideas and
situations by carefully observing them from different perspectives, and impartially
describing them, can facilitate students’ understanding of their meaning (Kolb 1984).
Group discussion, journal writing, and debriefing could also be used to engage
students at this stage. Abstract conceptualisation is used to develop explanations of
what has been experienced; lecture and textbook readings might be used as teaching
strategies at this stage. The last stage is active experimentation, active doing;
simulation games, role play, and practice in the laboratory might be used as teaching
strategies at this stage.
The overall model emphasises learning rather than teaching; the learner is
prepared for learning outcomes through activities that promote active involvement
rather than by being a passive receiver of information. Moreover, experiential learning
denotes learning activities that engage the learner directly in experiencing real
situations. Application of the experiential learning approach to an educational
program, with a variety of teaching strategies, provides students with opportunities to
see the more positive aspects of older people and to receive positive feedback from
them (O'Hanlon and Brookover 2002). It also provides a real-world model to
reinforce their gerontological concepts and knowledge about older people (O'Hanlon
and Brookover 2002); students’ self-confidence in their interactions with older people
could consequently be increased, improving their attitudes toward them.
Purpose and Objectives
The overall purpose of the research reported in this thesis was to improve
undergraduate nursing students’ attitudes toward and knowledge about older people in
order to encourage them to work with older people in Taiwan. To achieve this purpose,
a three-phase process was used (Figure 1.1).
7
Phase 1: Study 1—Survey Phase 2: Development of gerontologicalnursing education program
Phase 3: Study 2—Evaluation ofEducational Intervention
Table 0:1
Figure1.1 Framework for the proposed studies
Development of gerontologicalnursing program with experientiallearning approach
(Kolb 1984)
Changes in:
Attitudestoward olderpeople
Knowledgeabout olderpeople
Attitudestoward olderpeople
Knowledgeabout olderpeople
Students’ characteristics Age Gender Nursing program Work experience Living with older
people Contact with older
people Previous studies
related to older people Clinical practice Intention to work with
older people
Experientialeducationintervention
8
Phase 1: Study 1 focused on establishing current Taiwanese nursing students’ attitudes
toward and knowledge about older people. It was an exploratory study on the
relationships between students’ demographic variables and attitudes toward
older people and knowledge about them.
Phase 2: Informed by the results of Study 1, this phase was the planning and
development of a nursing education program including gerontological content
and activities for teaching and learning.
Phase 3: Study 2 examined changes in knowledge and attitudes regarding older people
among undergraduate nursing students following their participation in the
planned educational gerontological course.
The specific objectives of Study 1 were to:
1. Validate two instruments: Perception of Working with Older People (PWOP) and
Knowledge of the Situation of Older people (KSOP);
2. Examine the reliability of four instruments: Kogan’s (1961) Attitudes toward Old
People Scale (KOP), Nolan et al.’s (2001) Perception of Working with Older
People (PWOP), Palmore’s (1988) Facts on Ageing Quiz 1 (FAQ 1), and Nolan et
al.’s (2001) Knowledge of the Situation of Older people (KSOP);
3. Gain a greater understanding of Taiwanese nursing students’ attitudes toward and
knowledge about older people;
4. Understand the relationships between two different instruments measuring
attitudes toward older people and two different instruments assessing knowledge
about older people;
5. Examine the correlations among two knowledge and two attitude instruments and
9
demographic data;
6. Determine the factors influencing Taiwanese nursing students’ attitudes toward
and knowledge about older people.
The specific objectives of Study 2 were to:
1. Evaluate the effect of an experiential-based learning strategy on nursing students’
attitudes toward and knowledge about older people compared to lecture-based
learning in Taiwan;
2. Examine students’ reactions to the gerontological nursing subject and the
experiential learning strategies used in the experiential-based learning group.
Research Questions
In order to achieve the objectives of Study 1, the following research questions were
pursued:
1. What are current Taiwanese nursing students’ attitudes toward and knowledge
about older people?
2. What are the relationships between two attitudinal measures, Kogan’s (1961)
Attitudes Toward Older People Scale (KOP) and Nolan’s Students’ Perceptions of
Work with Older people (2001), and between two knowledge measures, Nolan’s
Student Nurses’ Knowledge of the Situation of Older People (2001) and Palmore’s
(1988) Facts on Ageing Quiz (FAQ 1)?
3. What factors are likely to influence Taiwanese nursing students’ attitudes toward
and knowledge about older people?
In order to achieve the objectives of Study 2, the following research questions were
pursued:
10
4. Does the use of an experiential learning approach in a selected gerontological
nursing course improve Taiwanese nursing students’ attitudes toward older people
when compared to a usual lecture based approach?
5. Does the use of an experiential learning approach in a selected gerontological
nursing course improve Taiwanese nursing students’ knowledge about older
people when compared to a usual lecture based approach?
6. What were students’ perceptions of the experiential learning strategies after the
gerontological nursing educational program (experiential-based learning group
only)?
The following research hypotheses were formulated to examine research questions 4
and 5:
Research question 4. Students studying a gerontological course who received an
experiential-based learning strategy would have more positive attitudes toward older
people than students who received the usual lecture-based learning strategy.
It was specifically expected that:
Students studying a gerontological course who received an experiential-based
learning strategy would report greater intention to work with older people than
students who received the usual lecture-based learning strategy.
Students studying a gerontological course who received an experiential-based
learning strategy would rate their career prospects of working with older people
higher than students who received the usual lecture-based learning strategy.
Research question 5. Students studying a gerontological course who received an
experiential-based learning strategy would have a higher level of gerontological
knowledge than students who received the usual lecture-based learning strategy.
11
It was specifically expected that:
Students studying a gerontological course who received an experiential-based
learning strategy would have more knowledge about older people’s daily activities
than students who received the usual lecture-based learning strategy
Students studying a gerontological course who received an experiential-based
learning strategy would have more knowledge about the demography of older
people than students who received the usual lecture-based learning strategy
Students studying a gerontological course who received an experiential-based
learning strategy would have more knowledge about the vulnerability of older
people than students who received the usual lecture-based learning strategy
Definition of Terms
In order to clearly understand the study, key terms need to be explained. The
following terms are defined in the context in which they are used in the studies
reported in this thesis.
Older people refers to individuals who are 65 years of age and older.
Ageing is a gradual process of individual physical, psychological and social
change over the course of time. (Polizzi and Millikin 2002).
Ageism has been defined by Butler (1975) as a “process of systematic
stereotyping of and discrimination against people because they are old, just as
racism and sexism accomplish this with skin colour and gender. Older people are
categorised as senile, rigid in thought and manner, old-fashioned in morality and
skills… ageism allows the younger generations to see older people as different
from themselves; thus they subtly cease to identify with their elders as human
beings” (p.12).
Stereotypes refer to sets of cognitive beliefs which describe typical members of a
12
category of people, objects, or ideas (Bowd 2003).
Attitudes toward older people refers to mental views based on cumulative
experience and directed toward individuals; in this case, attitude refers to student’s
thoughts and feelings about older people (Kogan 1961).
Knowledge refers to useful information that can be acted upon in the course of
decision making, problem solving and critical thinking; in this case, knowledge
refers to information about older people (Palmore 1998).
Gerontology refers to the study of ageing.
Experiential learning refers to “the process whereby knowledge is created through
the transformation of experience” (Kolb, 1984, p.38)
Gerontological nursing educational intervention is defined as a nursing course
consisting of 32 hours in a 16 week semester. It includes didactic presentations
which address the biopsychosocial needs of older people, simulation game
experiences which focus on sensitivity training, contact with healthy older people
in a community setting, and clinical practice in a hospital setting.
Students are defined as those male and female students enrolled in an
undergraduate program of nursing in a particular university in Taiwan.
Structure of the Thesis
The thesis is presented in seven chapters.
Chapter 1 provides the background to the research study, the purpose,
objectives, research questions, and definition of terms.
Chapter 2 presents a review of the literature, including attitudes toward and
knowledge about older people, factors influencing attitudes and knowledge, and
instruments used to examine attitudes and knowledge.
Chapter 3 presents a review of the literature regarding the impact of
13
gerontological educational interventions and experiential learning. The experiential
learning model to be used in the study is also outlined in this chapter.
Chapter 4 describes the method used to conduct Study 1, including research
design, research questions, hypotheses, outcome and explanatory variables, data
collection procedure, instruments, data analysis and ethical considerations. The
discussion of Study 1 findings, as well as the limitations of the research and
recommendations for future research and education is also outlined in Chapter 4.
Chapter 5 presents the gerontological nursing educational program that was
developed and evaluated in Study 2. The chapter includes an overview of the
gerontological nursing subject and of teaching and learning activities in the usual
lecture-based learning group, followed by a description of the educational
intervention program and teaching and learning activities in the experiential-based
learning group.
Chapter 6 outlines the method used to conduct Study 2, sample characteristics,
quantitative results of attitudes towards and knowledge about older people, qualitative
results of focus group interviews and discussion of findings.
Chapter 7 concludes the thesis by reviewing the findings reported in Chapters
Four and Six. The limitations of the current studies, implication of their findings for
nursing education, and recommendations for further research are discussed.
14
CHAPTER TWO
Literature Review: Attitudes toward and Knowledge about Older People
This chapter will firstly examine the literature dealing with current health care
professionals’ and students’ attitudes toward older people and their knowledge about
them. Then it will examine the factors influencing these attitudes and knowledge, and
the limitations of previous studies that have been identified. Finally, the chapter will
conclude with an overview of instruments used to measure attitudes and knowledge
related to ageing.
Ageing is a natural process; society, however, is generally seen to be youth
oriented. In a society where older people are not highly valued, everybody prefers
being young rather than ageing or old; many people fear growing old and try to cover
up their ageing. The negative perceptions of ageing and older people are apparent in
our media, language, and humour (Moody, 2000). For example, the word “old” is
associated with a decline in physical characteristics, such as impotence, reduced
function, and withered appearance. The term “old” often indicates a negative bias
against older people, which is common to many cultures and is true of the Chinese
language.
Negative attitudes toward older people are reinforced by myths and
misinformation about the ageing process and the state of being old (Cowan,
Fitzpatrick, Roberts, & While, 2004; Harris & Dollinger, 2001). Myths about ageing
include the belief that all older people are alike (Fajemilehin, 2004). Older people are
often described in society as disagreeable, dependent, inactive, economically
15
burdensome, dull and generally ill and frail (Thornton, 2002). In the 19th century, the
medical community began to preface physical conditions with the term “senile” to
link diseases to older individuals (Lookinland & Anson, 1995). In many countries,
reaching the age of 65 and over has been a reason for compulsory retirement and
categorisation into the “old” age group. The medical labelling of “senile” combined
with categorisation as “old” led to acceptance of the concept of “old” into society
(Moody, 2000). Moody (2000) has argued that societal institutionalisation provided
the structure to form stereotypes about older people in society, encouraging
prejudicial behaviour. These negative beliefs can be held by society in general, as well
as by health care providers. Research has illustrated that negative and stereotypical
attitudes toward older people are held by both nurses (Gething et al., 2002; Kearney,
Miller, Paul, & Smith, 2000) and social work and nursing students (Gellis, Sherman,
& Lawrance, 2003; Happell & Brooker, 2001).
In order to review attitudes toward and knowledge about older people, a
search of data bases such as CINAHL, ERIC, MEDLINE, and PsysINFO was
undertaken. The terms used to limit the search were students, nursing students, nurses,
attitudes, knowledge, and older people. The researcher found 25 quantitative studies
published between 2000 and 2006. Fourteen of these studies had examined nursing
students’ and nurses’ attitudes toward older people; four had examined knowledge
about older people related to nursing students and nurses, and the remaining studies
had examined attitudes toward and knowledge about older people in relation to
students from social work, medicine, podiatry, dietetics, psychology, and general
university courses. However, the researcher could not locate studies over the same
period through the above databases related to attitudes and knowledge about older
people in Taiwan. Threrfore, the search was extended to the period from 1990 to 2006.
16
Three Taiwanese studies were found including two studies related to nursing students
and nurses and one related to general university students. Hence this study has
reviewed a total of 28 studies including 25 studies from 2000 to 2006 and three
Taiwanese studies from 1990 to 2006.
Attitudes toward Older People
In the studies reviewed, 14 out of 28 studies related to nursing students’ and
nurses’ attitudes toward older people. Out of these 14 studies, four did not directly
identify whether nursing students’ or nurses’ attitudes toward older people were
positive or negative, so only the remaining 10 studies are reviewed in this section.
This section will firstly examine studies that have reported negative attitudes toward
older people held by nurses and nursing students; studies from Taiwan will be
reported first, followed by studies from other countries. This will be followed by a
similar section on positive attitudes; again, studies on other countries will follow
those on Taiwan.
Negative Attitudes towards Older People
In similar ways to western countries, Taiwan has reported negative beliefs
toward older people. In Taiwan, Liou and Hsu (1994) surveyed 333 nurses and 189
fourth year college nursing students to evaluate their attitudes and stereotypes toward
older people. The results revealed that generally both groups stereotyped them, but
nurses’ attitudes were more negative and stereotypical than those of nursing students.
The reasons cited for this were that, in clinical settings, nurses have to face real
situations such as shortages of staff, lack of self-care ability of older people, lack of
care facilities, and lack of self-preparation in caring for older people (Liou & Hsu,
17
1994). However, in the study by Liou and Hsu’s (1994), the sample of nurses was
derived from one veterans’ hospital, where, because the older patients are disabled
and without family to help them, the nurses’ workload was increased, a factor which
may have contributed to the negative attitudes toward the older patients.
Persistently negative attitudes toward older people were found in the study by
Kearney et al. (2000) which measured attitudes toward older people in the United
Kingdom (UK) held by 119 registered nurses working within a cancer centre. Using
Kogan’s Attitudes toward Old People Scale (KOP), the results of the study revealed
that attitudes were more negative than neutral. However, the older people in a cancer
centre would be those suffering different stages of physical or psychological illnesses.
Caring for these older patients was likely to affect the healthcare professionals’
attitudes toward them, so the results should not be generalised beyond this type of
setting. Also, the KOP scale was not designed to examine attitudes toward older
people in a specific health care context.
In Australia, Happell and Brooker (2001) surveyed the attitudes of 793 year
one undergraduate nursing students in Victoria toward their future career options. The
study indicated that they did not have a favourable attitude toward employment in the
care of older people because of their overwhelmingly negative views and
misconceptions. However, in this study, the sample was limited to nursing students in
Victoria, so results cannot be generalised to students in other locations.
In a study of 143 Australian and 213 British nurses currently working in
nursing, particularly in gerontology, Gething et al.(2002) explored the question of
attitudes about older people among nurses across these two countries. The results
18
revealed that, overall, negative stereotyping among nurses in regard to ageing and
older people occurred across both countries, and suggested that nurses in the sample
devalued and underestimated the capabilities of older people (Gething et al., 2002).
However, the majority of these nurses worked in aged care. The characteristics of the
older people in the aged care settings were not reported but the context of the care
setting could be a factor affecting the nurses’ attitudes toward older people.
A Swedish study by Soderhamn, Lindencrona, and Gustavsson (2001), using
Kogan’s Attitudes toward Older People (KOP) Scale, explored the attitudes toward
older people among 151 first, third and final year nursing students, and 41
experienced registered nurses in post-graduate courses. The study found that the
attitudes among nursing students and registered nurses were quite negative. However,
demographic characteristics, such as work experience with older people or amount of
contact with older people, were not reported in the study. These aspects of experience
with older people could have been an important factor influencing the students’ and
nurses’ attitudes toward older people.
Positive Attitudes toward Older People
In Taiwan, Wei (1995) examined attitudes toward older people in 911 senior
nursing students with clinical practice experience, including those studying at
universities, 2-year and 5-year junior college courses, and 3-year vocational high
school courses. Wei (1995) found that the attitudes of nursing students were positive
in contrast to studies in other countries (Gething et al., 2002; Happell & Brooker,
2001; Kearney et al., 2000; Liou & Hsu, 1994; Soderhamn et al., 2001). However, in
Taiwan, the family often stay with patients in the hospitals and students often only
19
take care of one patient during their clinical practice. The students often view older
patients as similar to their grandparents (Wei, 1995) and so having positive attitudes
toward older patients is not unexpected.
Several studies in other countries have reported positive attitudes held by
students and nurses. Using the Perceptions of Working with Older People (PWOP)
instrument, Nolan et al. (2001) explored the perceptions of UK students and qualified
nurses toward older people. They found both students and nurses were quite
favourably disposed toward working with older people. For example, the majority of
students and nurses disagreed that working with older people was a dead-end job. The
vast majority of respondents disagreed with the sentiment that it was difficult to gain
satisfaction from working with older people. However, in the student group, most
students had contact with older people, such as caring for a family member, voluntary
work or school experience; this prior experience might have influenced students’
attitudes toward older people in the study. Moreover, in the nurse group, the majority
were registered nurses, which might have influenced the degree to which they liked to
work with older people. But nurses’ work experience with older people was not
mentioned in the study and may have influenced their perception of older people or
attitudes toward older people.
Lookinland, Linton, and Lavender (2002) collected data using Kogan’s
Attitude Toward Older People (KOP) Scale with a group of 385 African-American
nurses to explore their attitudes towards older clients. The results indicated that
African-American nurses expressed overall positive attitudes. However, this study
was focused only on African-American nurses; although controlling for ethnicity can
be viewed as a strength, cultural differences could be a factor and it may be
20
inappropriate to generalise its results to other ethnicities.
McKinlay and Cowan (2003) examined attitudes toward older patients among
172 student nurses undertaking pre-registration nursing courses in Scotland. They
found that student nurses displayed positive attitudes and intentions toward working
with older patients; however, this study explored attitudes and intentions toward
working with older patients, rather than with older people in general. As student
nurses, they may not have been fully aware of the reality of working with older
patients in a clinical setting and this may explain their positive attitudes.
Similarly, a study by Hweidi and Al-Obeisat (2006), using Kogan’s Attitudes
toward Older People (KOP) Scale, surveyed the attitudes of 243 Jordanian nursing
students at one government university. The students were selected from four different
classes: two were first and second year classes and the other two were third and fourth
year classes. The study noted that these Jordanian nursing students reported slightly
positive attitudes. However, more than half of the students had no previous experience
in working with older people either in acute care or long-tern care settings. Also, half
of the students had lived with one or more older people. The study did not investigate
the relationship between attitudes and demographic factors such as students’ prior
experience with older people and living with older people. Such demographic
characteristics could be factors influencing students’ attitudes toward older people.
To summarise, several studies have investigated attitudes among students and
nurses. The results of the studies are inconsistent or contradictory. Five studies have
indicated the presence of ageist stereotypes and negative attitudes toward older people
(Gething et al., 2002; Happell & Brooker, 2001; Kearney et al., 2000; Liou & Hsu,
21
1994; Soderhamn et al., 2001) in nurses and nursing students. However, five other
studies have found positive attitudes (Hweidi & Al-Obeisat, 2006; Lookinland et al.,
2002; McKinlay & Cowan, 2003; Nolan et al., 2001; Wei, 1995). The negative
attitudes toward older people held by nurses and nursing students may have arisen
because, by the time they were studied, they had had increased exposure to older
individuals with physical problem in acute clinical settings. According to Fishbein and
Ajzen (1975), what we believe about a person influences our attitude toward that
person, which in turn affects our intention to behave and then how we actually behave
toward that person. Therefore, it can be assumed that the attitudes and stereotypical
beliefs of nurses and nursing students toward the ageing process and older people can
be influenced by their experience with them in acute institutional settings, where the
older people are more likely to present with negative than with positive aspects of
ageing.
Interestingly, two studies were conducted on Taiwanese nursing students’ and
nurses’ attitudes toward older people: one study revealed positive attitudes and the
other revealed negative attitudes, so they are contradictory. Because little research has
been done in the area of nursing students’ attitudes toward older people in Taiwan, a
need for further research in the Taiwanese setting is indicated. Presumably, the further
research could be expected to reveal more positive attitudes held by nursing students
because of the Chinese culture. In the Chinese culture, old people prefer to live with
their children, to keep the family as the primary focus of their social interaction, and
find much of the meaning of their lives and their hope for the future in their close
relationships with children and grandchildren (Sokolovsky, 1997; Tan, Zhang & Fan,
2004). In Taiwan, 63% of people 65 years and over live with their children
(Department of Statistics, 2000). Also, older people are respected and honoured for
22
their wisdom and experience; the Confucian ideals of respect for older people and
their high status generally apply to the family in Chinese cultures (Tan et al., 2004).
Older people in the family act as the role model for younger generations, while the
younger generation have respect for the wisdom of older people. Therefore, the close
relationship between grandparents and students as well as the role model of older
people in the family is reflected in the students’ positive attitudes toward older people
as reported in Taiwanese studies.
Knowledge about Ageing
With the growing population of older people, health care professionals will
have more experiences of caring for older people. However, an increasing body of
literature suggests that most health care professionals have little knowledge about
older people, such as the demographics of older people or the ageing process. In a
search of the literature, only four out of the 28 reviewed studies mentioned nurses’
and nursing students’ knowledge about older people. Because of the limited number
of studies, this section also included three studies that involved students of other
health professions. The following section will first examine four studies that have
reported on levels of knowledge about older people by nurses and nursing students,
and then three studies from other professional areas. As before, the discussion will
address studies from Taiwan first and then focus specifically on studies from other
countries.
In Taiwan, Wei’s (1995) survey of 911 nursing students’ knowledge
demonstrated low levels of knowledge of ageing and older people. However, the
instrument used mainly focused on physical changes, without examining the
gerontological content that participants had learnt; a specific focus that limits the
23
ability to generalise from these findings.
Using the Knowledge of the Situation of Older People (KSOP) measure,
Nolan et al.(2001), in the UK, explored students’ and qualified nurses’ knowledge of
older people. They found both groups lacked understanding about demographic
projections of ageing, such as: identifying future population trends in those over 85,
the numbers of people in nursing homes, or accidental deaths over the age of 75.
However, in this study, no information was reported about those nurses and students
who had ever attended any subject or program related to older people that might have
influenced their level of knowledge of older people. Also, lack of information about
the reliability and validity of the instrument raises concerns about the validity of the
findings.
Fajemilehin (2004) used a descriptive approach by using the Facts on Ageing
Quiz 1 (FAQ1) to measure knowledge about ageing among 14 nursing students, 41
diploma-nursing students and 25 medical students. The study revealed that students
demonstrated a high level of stereotypic misconceptions and poor knowledge of
ageing and older people. The statements in FAQ1 tend to address the normal ageing
process, but the students in this study had not taken any courses in normal growth,
development, or ageing before they began their clinical practice with ill older people.
Until such courses are undertaken, students may not realise the facts related to the
ageing process, and the positive aspects of healthy older people.
Using Facts of Ageing Quiz 2 (FAQ2), a study by Lee, Wong, and Loh (2006)
in Hong Kong examined 219 nursing students including pre-registration and post-
registration undergraduate nursing students. The study demonstrated that nursing
24
students had 57% correctness in FAQ 2, lower than the 65% to 70% average found for
other professional groups (Gibson, Choi, & Cook, 1993; Palmore, 1988; Stuart-
Hamilton & Mahoney, 2003). However, the majority of nursing students were from
Year 1, had never studied gerontology before and had no experience of caring for
older people. Not having care experiences with older people or gerontological
education may be key factors influencing the results from this study.
In another professional area, using the Facts on Ageing Quiz 1 (FAQ1) and
Facts on Ageing Quiz 2 (FAQ2) in a study with dietetics students, Kaempfer, Wellman,
and Himburg (2002) found that these students’ level of knowledge about older people
was low, with only 40% giving correct answers; however, without students having
taken any subjects related to older people, these low scores could be expected.
In a study of 171 commencing medical school students, Fitzgerald et al. (2003)
found that incoming medical students had limited knowledge about older people.
Similarly, Gellis et al. (2003) studied 96 first year graduate social work students’
knowledge about older people using the Facts on Ageing Quiz 2 (FAQ2). They also
found that students had little knowledge about ageing. As the students in both these
studies were commencing their studies, it was not unexpected for them to have low
levels of knowledge about older people.
Menz et al. (2003) examined knowledge of ageing in 81 Australian podiatry
students completing the third and fourth year of a bachelor’s degree. Contrary to
previous studies, these results revealed that students had an accurate understanding of
older people. However, students completed the questionnaire at the end of a lecture
series on geriatrics. Also, students had some experience in dealing with older people
25
during their clinical rotations. The specific influence on knowledge of the lecture
series and the experience was not examined in the study.
To summarise, several studies have investigated the level of knowledge about
older people among students and health care providers. The majority of studies have
reported minimal levels of knowledge about older people (Fajemilehin, 2004;
Fitzgerald et al., 2003; Gellis et al., 2003). This may be because of limited experience
with older people or that few study participants had taken courses related to older
people in their studies. For increasing students’ and health care providers’ knowledge
about older people by means of a dedicated gerontological education curriculum, it is
important to establish their current level of knowledge.
Factors Influencing Attitudes toward Older People
Broadly, factors that influence students’ and nurses’ attitudes toward older
people can be contradictory. The factors influencing attitudes will be examined from
three major perspectives: demographic characteristics such as gender, age, and
intention to work with older people; knowledge about ageing; and previous
experience with older people.
Demographic Characteristics
Fifteen of the 28 studies being reviewed had explored the relationship between
demographic characteristics and attitudes. Six studies related to nursing students’ and
nurses’ attitudes toward older people, and nine related to students from social work,
medicine, podiatry and from general university courses. Studies related to nursing
students and nurses will be reported first, followed by studies related to students from
other areas. This section will firstly examine studies that have reported relationships
26
between gender and attitudes toward older people and then will focus on the influence
of age, and intention to work with older people.
Gender
In addition to its genetic basis, gender is a social construct, through which
social life is organised at the level of the individual, the family, and society (Connell,
1993). Most people recognise there are differences in women’s and men’s lives. Men
are expected to provide for and protect their families (Farrell, 1993; Philpot, 2000);
they should be strong, brave and less sympathetic. Women are expected to develop a
nurturing role, caring for children, older people, and family (Huston, 1988; Nicolson,
1996), and are expected to be softer and have more caring attitudes than men. These
expectations by society of males and females influence students’ views about career
choice. In addition, women tend to enter female-orientated professions, such as
teaching and nursing, and males tend to enter male-orientated professions, such as
engineering and medicine (Philpot, 2000). Therefore, women are more likely than
men to take on a role of caring for people, including children and older people. In
studies, there is evidence that male students have more negative attitudes toward older
people than do female students (Gellis et al., 2003; Soderhamn et al., 2001).
The Kogan’s Attitude toward Older People (KOP) scale was used by
Soderhamn et al. (2001) to measure the attitudes of 151 undergraduate first-year and
third-year students and 42 registered nurses toward older people in Sweden. More
negative feelings were present in male than in female students. This was consistent
with the results of the study of 204 undergraduate social work students conducted by
Tan, Hawkins et al. (2001), who also found that male students were less positive than
27
female students in their attitudes toward older people.
In other health professional areas, Gellis et al. (2003) examined the
relationship between gender and attitude towards older people of 96 first year
graduate social work students using the Ageing Semantic Differential (ASD) in the
USA. They found that being male was associated with less favourable attitudes
toward older people. A study by Fitzgerald et al. (2003) surveyed 171 commencing
medical school students, and found that female students had more positive attitudes
toward older people than male students.
Although gender was thought to be a factor influencing nursing students’
attitudes toward older people, a study by Kearney et al. (2000) found no relationship
between gender and attitudes toward older people. However, male staff represented
only 9% of the respondents; it is not known whether that figure is close to the overall
proportion of male health professionals in UK where the study was conducted. Also,
as the sample was only from cancer wards or units the findings could not be
generalized to health care professionals working in other fields. A study by Menz et al.
(2003) surveyed 81 Australian podiatry medical students, comprising 57 third year
and 24 fourth year students. They found no difference between male and female
students with regard to attitudes toward older people.
Age
Age, in some studies, has been identified as a factor influencing attitudes
toward older people. In the study of Soderhamn et al.(2001) in Sweden, they found
that more negative feelings were present in nursing students aged < 25 compared to
28
those aged > 25 years. Older students had more positive attitudes toward older people.
In the area of social work, a study by Gellis et al. (2003) surveyed the attitudes
of 172 first year masters level social work students. They also found that younger
students tended to have less favourable attitudes. Similarly, Curl, Simons, and Larkin
(2005), using a convenience sample of attendees at the Social Work Student Policy
Practice Forum, investigated 126 social work students’ attitudes toward older people
including 90 bachelors students and 35 masters students. The results from this study
revealed that age predicts social work students’ willingness to accept jobs in ageing
upon graduation; older students being more willing.
On the other hand, several studies with nursing and other professional students
have found no correlation with attitudes toward older people. Using a convenience
sample of 175 undergraduate and graduate nursing students, Paton, Sar, Barber, and
Holland (2001) found that there was no statistically significant relationship with age
in students’ interest in working with older people. A study by Lookinland et al. (2002)
investigated 385 African-American nurses’ attitudes toward older people. This study
confirmed that nurses’ age had no correlation with their attitudes. Similarly, using a
convenience sample, Tan et al. (2004) investigated 199 Mainland China university
students’ attitudes toward older people, including those with majors in political
science or law, social work, and Chinese language . They found that students’ age was
not correlated with their attitudes toward older people; these results were similar to
other studies with samples of social work students (Mehta, Tan, & Joshi, 2000; Tan et
al., 2001), university students (Prudent & Tan, 2002), medical students (Fitzgerald et
al., 2003), and podiatry students (Menz et al., 2003).
29
Intention to work with older people
In the studies reviewed on attitudes toward older people, intention to work
with older people was consistently related to attitudes (Fitzgerald et al., 2003; Gellis
et al., 2003; Liou & Hsu, 1994; McKinlay & Cowan, 2003; Mehta et al., 2000; Wei,
1995). For example, in Taiwan, a study by Liou and Hsu (1994) found that nurses and
nursing students who had greater intention to care for older people had more positive
attitudes toward them. Similar results have been reported in a study by Wei (1995) of
a sample of nursing students.
McKinlay and Cowan (2003) conducted a study on 172 student nurses
undertaking pre-registration nursing courses at three higher education institutions in
Scotland. The results showed that student nurses’ intentions toward working with
older patients were mainly predicted by their attitudes. However, in that study,
students had a variety of previous experiences of working with older people, which
could have had a significant influence on their intention.
Mehta et al. (2000) examined the attitudes of 201 undergraduate social work
students in Singapore. They found that students who planned to work primarily with
older people after they graduated had more positive attitudes. Similar results about the
intention to work with older people were obtained from the Gellis et al.(2003) study
of a sample of first year graduate social work students and the Fitzgerald et al. (2003)
study with a sample of medical students. In all the studies reviewed, intention to work
with older people had a strong and positive relationship to attitudes.
30
Knowledge about Ageing
Level of knowledge about ageing is likely to influence attitudes toward older
people. The following section will firstly examine those studies that found
relationships between knowledge about ageing and attitudes toward older people. The
following section will examine those that have reported no such relationships.
With 81 podiatry students in their third and fourth year of study at two
institutions in Australia, Menz et al.(2003) found that those with a greater knowledge
of ageing had more favourable attitudes toward older people. In a study of first year
graduate social work students, Gellis et al. (2003) found students with more
knowledge about older people rated them as more acceptable than did those students
with less knowledge. However, the majority of the students had experience with older
people either through living or working with them. Experience with older people
could provide a positive impact on students’ attitudes toward older people. It is
difficult to conclude that students with greater knowledge about older people had
more positive attitudes toward older people without taking into account their
experience with them. But, since the study was limited to students in one school,
results cannot be generalised to the whole student population.
On the other hand, a Taiwanese study by Liou and Hsu (1994) found that 78%
of the sample of nurses who had taken a gerontological course had negative attitudes.
However, the majority of the study participants had graduated from a college in which
the gerontological nursing subject mainly focused on the technical skills of caring for
ill older people in acute institutional settings. The results of the study could also have
been influenced by other factors, such as the characteristics of the older people in that
hospital, the workload of nurses, or the self-care ability of older people.
31
Similarly, Wei (1995) in Taiwan, found there was no relationship between
nursing students’ knowledge and attitudes toward older people. However, in this study,
students had only positive attitudes toward older people, with no negative responses
reported. The gerontological content in their course had been integrated into other
subjects so that it might have been difficult for students to distinguish it from other
content. The lack of clearly identifiable gerontological content may have made it
difficult for their education to have influenced their attitudes toward older people.
It is clear that attitudes toward older people are likely to be influenced by
knowledge about older people. However the findings from studies are inconsistent or
contradictory. As most studies were cross-sectional in nature, it is not clear whether
knowledge about older people precedes attitudes or attitudes precede the acquisition
of knowledge. Moreover, study samples were derived from one or two schools, which
limited generalisation of these respondents’ views to those populations. Also, a
number of variables appear to affect nursing students’ attitudes toward older people,
with no single dominant variable (Aday & Campbell, 1995).
Previous Experience with Older People
Personal contact and previous work experience with older people has been
another focus of studies about attitudes toward older people (Hartley, Bentz, & Ellis,
1995; Kane, 1999; Lin, 1993; Paton et al., 2001; Robert & Mosher-Ashley, 2000;
Schwartz & Simmons, 2001; Sheffler, 1995; Tan et al., 2004). However, findings
about the influence of these variables on attitudes toward older people have
sometimes been contradictory. The following section will firstly examine studies that
reported relationships between experience with older people and attitudes toward
32
older people; the section after that will examine studies that reported no such
relationships.
Previous working experience with older people has been highlighted in
relation to health workers’ interest in ageing. In Taiwan, Lin (1993) examined
Taiwanese college students’ attitudes, to find whether or not contact with older people
influenced their attitudes. The study found that students who had experience with
older people were more positive than students who had none. Lin’s study was
supported by another Taiwanese study by Wei (1995) who examined nursing students’
contact experience with older people.
In a study of 175 undergraduate and graduate nursing students, Paton et al.
(2001) reported that students with previous work experience with older people
expressed greater interest in working with older people than students with no such
experience. The results of the Paton et al. (2001) study was supported by a study by
McKinlay and Cowan (2003) of nursing students in a pre-registration course.
However, despite a number of studies supporting a relationship between
attitudes toward older people and previous experience with older people,
contradictory findings still exist. A study by Hweidi and Al-Obeisat (2006) found that
students’ previous experience of working with older people did not correlate with
their attitudes concerning older people; a similar result had been found in a study by
Fitzgerald et al. (2003) of a sample of medical students.
To summarise, the results of previous studies provide some evidence that there
is a relationship between previous experience with older people and attitudes toward
33
them (Lin, 1993; McKinlay & Cowan, 2003; Paton et al., 2001; Wei, 1995). However
the results of the studies were at times contradictory and most studies used
convenience sampling, which limits their generalizability. Furthermore, the studies
provided limited information regarding the type or amount of work experience with
older people; the extensiveness and exclusiveness of the involvement with older
people; the timing of the experience of caring for older people; and the type of care
provided. Without such detail, it is difficult to interpret the influence of that
experience on attitudes.
Factors Influencing Knowledge about Older People
Only a few studies have examined how students’ characteristics influence their
knowledge about older people. Five of the 28 studies reviewed had explored the
relationship between demographic characteristics and knowledge: two studies related
to nursing students’ knowledge about older people and three studies related to
students from social work, medicine, and podiatry.
Only three out of the five studies examined the influence of gender. A study by
Fitzgerald et al. (2003) surveyed 171 commencing medical school students, finding
that their gender did not correlate with knowledge about older people. Similar results
were found by Menz et al. (2003) who surveyed 81 Australian podiatry students.
Another Australian study by Hughes and Heycox (2006) evaluated 55 final-year
social work students’ knowledge of older people’s issues. They found no significant
relationships between students’ gender and their scores on the knowledge instrument.
In Taiwan, Wei (1995) examined 911 students’ knowledge about older people.
This study found that age was correlated with knowledge about older people; older
34
students reported higher levels of knowledge about older people than younger
students. However, without considering other factors in the study design, such as
experience with older people, the findings need to be viewed with caution. Lee et al.
(2006) surveyed 219 nursing students, including pre-registration and post-registration
students, finding that final year students had significantly higher scores than junior
year (year 1 to year 3) students regarding knowledge of community resources for
older people. On the other hand, the study by Fitzgerald et al. (2003) found that
knowledge about older people did not correlate with the ages of commencing medical
school students. Similar results were found by Menz et al. (2003) with a sample of
podiatry students and by Hughes and Heycox (2006) with social work students.
Only one study had examined course attendance on ageing issues influencing
students’ knowledge about older people. Using a convenience sample of 55 final-year
social work students, Hughes and Heycox (2006) found that significant relationships
were identified between exposure to a course on ageing issues and students’ results on
the knowledge score. Students who had attended a course on ageing issues had higher
average scores than students who had not attended such a course.
To summarise, although age could be a factor influencing knowledge about
older people, there have been few studies about such factors; moreover, the use of
convenience sampling and the lack of consideration of other factors, such as
experience with older people, may affect their findings.
Limitations of Studies
In reviewing the studies, some issues of research design that could have
influenced the results have been noted. Most of the studies used convenience samples
35
(Curl et al., 2005; Fitzgerald et al., 2003; Gellis et al., 2003; Hughes & Heycox, 2006;
Hweidi & Al-Obeisat, 2006; Lee et al., 2006; Liou & Hsu, 1994; Mehta et al., 2000;
Menz et al., 2003; Paton et al., 2001; Prudent & Tan, 2002; Soderhamn et al., 2001;
Tan et al., 2001; Tan et al., 2004). The use of convenience sampling can introduce
bias, as the subjects chosen could be atypical of the target population with respect to
the critical variables being measured. Since the students for the studies were not
selected randomly, this limits the statistical chances that the responses of these
students reflect the opinions and responses of the target population—it is quite likely
that there were systematic differences between those chosen to be in the study and
those who were not. This raises concerns about the generalizability of the findings.
Also, in some studies, the sample was limited to social work students or medical
students so it is difficult to generalise to students in other disciplines (Curl et al., 2005;
Fitzgerald et al., 2003; Gellis et al., 2003; Hughes & Heycox, 2006; Mehta et al., 2000;
Menz et al., 2003; Tan et al., 2001). Moreover, all of the studies used cross-sectional
designs that do not imply causality; for example, they cannot show whether the
intention to work with older people precedes attitudes toward them, or the attitudes
precede the intention. Caution is needed in inferring causality from the studies that
used cross-sectional designs. Lastly, for the studies reviewed, the instruments that
were used are quite old, such as KOP from 1961 and FAQ from 1977. The
contemporary instruments used in the Nolan et al. (2001) study lacked psychometric
testing of the reliability and validity of the instruments. Using measures not tested for
validity and reliability (Nolan et al., 2001) weakens confidence in the findings, and
hence results must be interpreted cautiously.
To summarize, the results of the studies reviewed were often contradictory.
Five studies found that nurses and nursing students held negative attitudes toward
36
older people, while five studies found that they held positive attitudes. Six studies
revealed that health professionals, including nurses and nursing students,
demonstrated limited knowledge about the ageing process, while only one study
found that students had an accurate understanding of older people. Some studies
found that participants’ demographic characteristics, such as gender, age, previous
experience with older people, intention to work with older people, having attended a
course on ageing issues, could be factors influencing attitudes and knowledge,
however, some studies did not support these findings. On the other hand, although the
reliability and validity of the attitudinal and knowledge instruments in the Nolan et al.,
(2001) study were not reported, those instruments are more contemporary and
relevant to current nursing practice. These instruments require psychometric testing so
they can be used in future studies.
Instruments Used to Measure Attitudes and Knowledge Related to Ageing
Out of the studies reviewed, two instruments were most commonly used:
Kogan’s Attitude toward Older People (KOP) scale to measure attitude toward older
people and the Facts on Ageing Quiz (FAQ) to measure knowledge about older people.
Although the KOP and FAQ have been used extensively there are some limitations
with each of them. This section will examine the KOP and FAQ instruments.
The KOP scale has been extensively used in gerontological studies, including
studies of the attitudes toward older people held by nursing students and nurses
(Hweidi & Al-Obeisat, 2006; Kearney et al., 2000; Lambrinou, Sourtzi, Kalokerinou,
& Lemonidou, 2005; Lookinland et al., 2002; McKinlay & Cowan, 2003; Soderhamn
et al., 2001). Kogan (1979) reported that the KOP had a high internal consistency
(Cowan et al., 2004), which was confirmed by the findings of Soderhamn and
37
Lindencrona (2000), who tested the Swedish version of the KOP scale for reliability
and validity in a sample consisting of students and various health-care professionals.
The results revealed that the KOP scale was a reliable instrument and the instrument’s
construct and convergent validity were also verified.
Moreover, Lambrinou et al. (2005) tested the Greek version of the KOP scale
for reliability and validity in a sample consisting of 390 nursing students. The result
of the study showed that the KOP scale is an instrument with adequate reliability
coefficients, although the validity of the instrument was only partially supported by
the results.
Criticism of the scale has, however, been reported in some studies. A study by
Hilt (1997) indicated limitations in the KOP scale, such as being too lengthy and
using ambiguous terminology. Also, the items are statements based on stereotypes, so
by answering the survey respondents would be verifying those stereotypes (Hilt &
Lipschultz, 1999). Furthermore, the KOP scale can be seen to be outdated as it was
developed in 1961 and the language used in the KOP scale reflects how society
viewed older people over 40 years ago. Moreover, although the KOP is a validated
and reliable instrument, it deals with attitudes toward older people in general, and
may not be valid for older patients in hospital (Courtney, Tong, & Walsh, 2000). The
KOP scale excludes items which have a caring dimension and it was felt that this is an
important aspect of the context of the clinical setting (Slevin, 1991).
With regard to knowledge about older people, as Palmore (1977) has noted,
the problems with previous measures were their length, their use of ambiguous
wording, and their lack of correct answers. To address these issues, Palmore (1977)
38
developed the Facts on Aging Quiz (FAQ), a factual 25-item “true-false” and “do not
know” format with correct answers for each item. Palmore (1977; 1988) proposed that
the FAQ could be used for measuring learning, to test knowledge, and indirectly to
measure attitudes. However, some researchers have argued that the FAQ included
items that have an equivocal factual base (Miller & Dodder, 1980), or that the FAQ as
a whole is sensitive to respondents’ attitudinal biases toward older people (Klemmack,
1978). The attitudinal biases may inflate or deflate scores on the test (O'Hanlon,
Camp, & Osofsky, 1993). Klemmack (1978) claimed that the FAQ was more a
measure of attitudes than a measure of knowledge. However, Palmore (1981) stated
the FAQ was not an instrument based on “psychometry”, which deals with the theory
and development of the instruments or measurement techniques (Beanland &
Schneider, 2000; Palmore, 1978), and held that one use of the FAQ was an indirect
assessment of attitudes (Kline, Scialfa, Stier, & Babbitt, 1990). However, the FAQ has
often been used as though it were an index of knowledge alone, while it was intended
to demonstrate students’ misconceptions and their lack of awareness of many
interesting facts about ageing (Palmore, 1977, 1998). The FAQ scale has been
extensively used in gerontological studies including studies of the knowledge about
older people held by nursing students (Fajemilehin, 2004); student dieticians
(Kaempfer et al., 2002); social work students (Gellis et al., 2003); medical students
(Fitzgerald et al., 2003); and also other students without a health background
(Pennington, Pachana, & Coyle, 2001).
Pennington et al. (2001) designed a study to compare the results of the “Don’t
Know” (DK) version and “True-False” (T-F) version in FAQ1. The two versions were
compared using 218 undergraduate students enrolled in either a first-year or third-year
psychology course in New Zealand. The internal consistencies of the T-F and DK
39
versions were compared using Cronbach’s alpha. Respective alpha levels were found
of .40 for T-F version and .83 for DK version. Fajemilehin (2004) also pilot tested and
retested the FAQ; the results indicated that the FAQ had a high reliability, ranging
from .73 to .88. However, no details were provided about the pilot study, such as the
length of time between testing and retesting, who it was tested on and how many
people were included. To summarise, although the KOP and FAQ scales have been
extensively used in previous studies, the psychometrics differ across studies. Although
the KOP was developed in 1961, it has established validity and reliability and is still
commonly used. Although only one study showed that the DK version of the FAQ had
higher reliability than the T-F version, the DK version appeared to be a more stable
measure.
Summary
The review of the literature identified the factors that can influence attitudes
toward and knowledge about older people held by health care providers and students.
In reviewing the literature, contradictory evidence exists as to whether health care
professionals hold more positive or negative attitudes; and whether age, gender,
intention to work with older people, previous experience with older people, or
knowledge level influence attitudes toward older people. Gerontological nursing
education may play an important role in the formulation of more positive attitudes and
increased knowledge levels. Also, the KOP and FAQ scales were most commonly
used to measure attitudes toward and knowledge about older people.
The implications from the review of the literature relate directly to the
educational experience of nursing students. Gerontological nursing curricula need to
focus more on creative learning strategies and more experience with older people in
40
order to promote the formation of more favourable attitudes. The literature also
suggests a need to focus on the normal ageing process as well as on the positive
aspects of older people in the community, rather than only on institutionalised settings
in the students’ first clinical placement. The following chapter provides a literature
review of gerontological nursing education, with a view to identifying the educational
opportunities that exist or that need to be developed in order to build favourable
attitudes toward and knowledge about older people.
41
CHAPTER THREE
Literature Review: Gerontological Nursing Education
Currently, one of the most important areas of concern in nursing education is
gerontological education. Exposure to gerontological content has been shown to
positively influence nurses’ and nursing students’ attitudes toward older people and
knowledge about them (Gallagher, Dobrosielski-Vergona, Wingard, & Williams, 2005;
Knapp & Stubblefield, 2000; Moriello et al., 2005; Ragan & Bowen, 2001; Wilkes &
LeMiere, 2001). Gerontological nursing courses are not popular in the development of
gerontological nursing in Taiwan, where only 35% of nursing schools have introduced
gerontological nursing (Huang & Lin, 1996). A search of nursing education curricula
in universities found that over the last ten years, gerontological nursing courses have
become part of curricula, but remain as elective subjects in the majority of cases.
Lecture based learning is the major teaching methodology and there is a lack of
clinical experience with healthy older people in the community (Wei, 1995).
Moreover, in Taiwan, nurses in geriatric wards are often considered to be lacking in
caring ability, less competent than colleagues in acute hospital settings, or preparing
for their own retirement (Liou & Hsu, 1994). Also, here are issues related to
gerontological nursing courses in Taiwan, including deficiencies in the quantity and
quality of understanding about older people, with the major focus of concern being on
caring for ill, rather than well, older people (Liou & Hsu, 1994).
Lack of preparation in gerontological nursing, traditional didactic lecture-
based learning approaches, with the lecturer in complete control of the learning
42
situation (Griffin, 2002), and lack of experience with well older people in the
community are important issues in gerontological nursing curricula in Taiwan.
Consequently, a gerontological nursing curriculum that focuses on normal ageing and
more creative teaching methodologies, as well as providing experience with well
older people, could be a key to influencing nursing students’ attitudes toward and
knowledge about older people (O'Hanlon & Brookover, 2002; Shoemake et al., 1998).
Moreover, in taking care of older people in the clinical setting in Taiwan, the
main concerns for health care providers (Yeh et al., 2001) are physiological issues,
due to the influence of the medical model, which overemphasises the role of
pathology and the treatment of illness rather than the provision of holistic care (Koch
& Webb, 1996); because of this influence health care providers feel that they have to
solve physical issues first in order to alleviate the discomfort of patients. Besides, a
shortage of gerontological nursing staff, a lack of preparation in gerontological
nursing, and a focus upon older people’s physical abilities could affect nurses’
willingness to care for them. Therefore, as a reflection of the health care providers’
needs in the clinical settings, the present priority in gerontological nursing education
focuses on physical issues of older people, rather than psychological or social issues.
This chapter will firstly overview gerontological education, findings of studies
reviewed and three major educational strategies. Then the experiential learning model
will be described; and finally, the factors influencing that model’s outcomes examined.
Overview of Educational Programs
In order to review gerontological education programs that had been
implemented for students, a search of databases such as CINAHL, ERIC, MEDLINE,
43
PsysINFO was undertaken. The terms used to limit the search were gerontology,
students and nursing students. The researcher found 15 studies dating from 1990 to
2005, 14 quantitative studies and one qualitative study. However, only 12 quantitative
studies had examined students’ attitudes toward and knowledge about older people
after a gerontological education program (see Appendix 1), while three studies had
examined the teaching strategies used to deliver such programs.
Findings of Studies
Attitudes toward older people
Of the 12 studies reviewed, seven reported that a gerontological educational
program had improved attitudes toward older people. Using volunteer students,
Bringle and Kremer (1993) undertook a study on three groups of students: fourteen
students who were enrolled in an Intergenerational Service-Program (Group One)
received training and didactic instruction and made weekly visits to older people
during an 8-week period; 10 students in a Seminar on Adulthood and Ageing (Group
Two) as a course requirement, met at least twice with an older person for at least 3
hours at each visit; twenty-one students who were enrolled in an upper-level social
psychology class (Group Three) were not exposed to course content on ageing,
training, or visitation experiences (and so were selected as the comparison group).
Using a pre-test post-test research design, Bringle and Kremer (1993) found more
positive attitudes toward older people among those students exposed to the training
and visitation in Groups One and Two than in the comparison group.
Aday and Campbell (1995) collected data over 2 years from a nursing program
that was designed to integrate the concepts of ageing and the aspects of the older
44
client throughout the nursing curriculum. Using a pre-test post-test, one group only
design, nursing students’ perceptions of older people, and preferences for working
with them, were examined. Participants scored significantly higher on the post-test
than the pre-test, indicating that they significantly changed their preconceived notions
about older people.
Using an Into Aging game, Karner, Rheinheimer et al. (1998) examined the
impact of participation in an experiential learning educational program concerning
older people on the knowledge and attitudes of hospital personnel in the USA.
Participants scored significantly higher on the post-test than the pre-test, indicating
that there were differences in attitudes toward older people following the education
program.
Ragan and Bowen (2001) measured the changes of attitudes toward older
people using a pre-post test and one-month follow-up test. Using volunteer students, a
total of 99 college students participated in one of three groups: information only;
information plus a discussion group; and information plus a reinforcement-to-change
discussion group. The study results revealed that information alone produced initial
improvements in attitude toward older people in all groups. However, only students in
the reinforcement-to-change group had maintained positive attitudes changes at the
one-month follow-up.
An Australian study by Wilkes and LeMiere (2001) investigated whether
education over a 12-month period affected attitudes of 47 staff at an aged care facility.
Using a pre-test post-test, one group only, the study revealed that staff who attended
the specific aged care education sessions showed more positive attitudes toward older
45
people at the end of the 12 months.
In another study, O’Hanlon and Brookover (2002) investigated 55 students
enrolled in a gerontology course in the USA. They found that by using many
classroom activities, such as lectures, discussions, demonstrations, simulations, case
studies, and examinations as well as an interview assignment with active and
community-dwelling older people, positive attitudinal change was achieved in the
students from pre-test to post-test. However, lack of a control group makes it hard to
confidently attribute the attitudinal change to the various educational activities.
Using a one-group design, Dorfman, Murty et al. (2004) collected data over
five semesters and examined attitudinal change in five successive cohorts of
intergenerational service-learning students (n=59) enrolled in an introductory
gerontology course. Using open-ended questions and a pre-test post-test on the
General Attitudes Toward the Elderly scale, positive attitudinal change at post-test
was found across the cohorts.
On the other hand, two studies reported no change in participants’ attitudes
toward older people following an educational program (Dorfman et al., 2004;
Moriello et al., 2005). Interestingly, one of the studies (Dorfman et al., 2004)
incorporated two attitudinal measurements. Improvements were focused on students’
attitudes toward older people, but interestingly, no significant change was found at
post-test on the other measurement, the Working with Older People scale.
Using a post-test only, control group design, the central purpose of the study
by Moriello et al.(2005) was to assess the influence of an educational intervention on
46
the attitudes of allied health students toward older adults. The students in the
intervention group participated in a six-hour multi-modal workshop consisting of
didactic lecture, group activities, and simulation activities. KOP scales were used to
measure attitudes toward older adults within the week following the completion of the
intervention and at 10 weeks after the workshop. The study results provided no
evidence of group differences for the KOP scale at one week and 10 weeks.
Knowledge about older people
Of the 12 studies reviewed, six reported that a gerontological educational
program had improved participants’ knowledge about older people. Using an aspect of
Kolb’s experiential learning theory, Bullard, Fleischer et al. (1996) used a one group
research design and a variety of teaching methods combined with traditional didactic
lectures to enhance the knowledge base of 155 nursing assistants who participated in
workshops. The variety of teaching methods allowed for role-plays, simulations of
age-related situations, videotapes, and discussion of key concepts. The study showed
that the intervention had a significant impact on the knowledge gained and that it was
retained for at least 8 weeks.
Using volunteer students, Knapp and Stubblefield (1998) used Facts on
Ageing Quizzes I and II to assess the extent to which students’ knowledge of the
ageing process increased as a result of successfully completing a one-semester course
in gerontology. Using a pre-test post-test comparative study (27 students in the control
group and 28 students in the experimental group), the results revealed that students in
the experimental group significantly improved their knowledge of the ageing process.
47
Using an Into Aging game, Karner, Rheinheimer et al. (1998) used a one-
group research design and examined the effect on the knowledge of hospital personnel
in USA of participation in an experiential learning educational program about older
people. They found that participants scored significantly higher on the post-test than
the pre-test, indicating that the program was effective in achieving the program goal
of increasing knowledge of the issues and needs of older people.
Using a pre-test post-test, control group design, the central purpose of the
study by Knapp and Stubblefield (2000) was to assess the instructional effectiveness
of intergenerational service learning, by examining the impact of a one semester
ageing course on students’ knowledge of the ageing process. The term
intergenerational service learning was coined for an innovative method of teaching
and learning that integrates community service activities focusing on the interactions
between younger and older adults into academic curricula (McCrea et al., 2000;
Newman & Smith, 1997). Students (n=22) in the control group received the lecture-
exam format, while students (n=22) in the experimental group received the
intergenerational service-learning format. Knapp and Stubblefield (2000) found that
the intergenerational service learning course had a positive influence on student’s
knowledge and perceptions of ageing. However, the mean age of students in the
experimental group was older than students in control group. Also there were ten
students aged over 55 who had a background in social gerontology; these students
probably had more experience with older people than students in the control group.
As mentioned previously, Wilkes and LeMiere (2001) investigated whether
education over a 12-month period affected knowledge of 47 staff at an aged care
facility. Using a pre-test post-test, one group design, the study revealed that staff who
48
attended the specific aged care education sessions showed greater knowledge of older
people at the end of the 12 months.
Using a post-test only, control group design, Moriello et al. (2005) assessed
the influence of an educational intervention on the knowledge of allied health students
toward older adults. FAQ scales were used to measure knowledge about older adults
within one week of the completion of the intervention and 10 weeks after the
workshop. The study result revealed that students in the intervention group scored
higher on knowledge than the comparison group at one week, but not at 10 weeks.
In contrast, of the 12 studies reviewed, two studies found that the educational
interventions did not have an impact on students’ knowledge about older people. In
Kline and Kline’s (1991) study in Canada, 42 students in a formal gerontology course
were compared at the beginning and end of an academic term and with non-
gerontology students on both the Facts on Ageing Quiz (FAQ) and the Knowledge of
Ageing and the Elderly (KAE) questionnaire. Using a pre-test post-test, control group
design, Kline and Kline found that neither the FAQ and KAE scores changed as a
result of the formal course training received over the 10-week period.
As mentioned previously, Bringle and Kremer (1993) used three groups to
conduct their study: an Intergenerational Service-Program (Group One); students in a
Seminar on Adulthood and Ageing (Group Two); and a comparison group (Group
Three). Bringle and Kremer (1993) found that intergenerational experience and
didactic instruction made no difference to knowledge between the intervention groups
and the comparison group.
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Limitations of the studies
In reviewing the studies, some limitations and issues were noted which could
have influenced the results. Some of the studies used volunteer students who self-
selected to do the educational program (Bringle & Kremer, 1993; Knapp &
Stubblefield, 1998; Ragan & Bowen, 2001). These students were likely to be biased
because they were interested in doing the type of program in the study. The
investigators cannot be sure if the course increased students’ attitudes toward and
knowledge about older people or if only highly motivated individuals joined the
program. Also, many of the studies used a one-group only design (Aday & Campbell,
1995; Bullard et al., 1996; Dorfman et al., 2004; Karner et al., 1998; O'Hanlon &
Brookover, 2002; Wilkes & LeMiere, 2001); in such cases, there were no
opportunities for the educational program to be compared to either a control or
comparison group. In other words, it is difficult to be confident that the outcomes
described are the result of the nursing program or because of the students’
characteristics or differences in students’ experiences. Also, as no mention was made
of how the course was delivered in these two studies, it is hard to be confident in
drawing conclusions as to whether or not the formal course training changed students’
attitudes toward or knowledge about older people (Kline & Kline, 1991; Knapp &
Stubblefield, 1998). The use of a post-test only research design reduced the strength
of the study conducted by Moriello et al.(2005) and it is hard to assess the degree to
which the program itself contributed to students’ results. Also, such designs weaken
the confidence the researchers can have in assuming that the experimental and control
groups were similar at the beginning of the study. Finally, in Bringle and Kremer’s
(1993) study, the lack of reliable and validated instruments raise questions about the
findings of the study.
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To summarize, the results of the studies reviewed were inconsistent or
contradictory. Seven studies found that a gerontological educational program could
positively influence attitudes toward older people and six studies led to improvement
in knowledge about older people; however, other studies did not support these
findings. The majority of the study designs used one-group designs and used
volunteer students as the sample. One study used a post-test only design, while
another did not report the reliability of the measurements; in addition, two studies did
not mention the details of the course delivery. Such design issues can reduce the
strength and findings of a study.
Types of Educational Programs
In the studies reviewed, three major educational strategies were used. These
were: traditional lecture-based learning; intergenerational service-learning; and
experiential learning. They are described below.
Traditional lecture-based learning
The lecture is a major teaching method in almost all institutions of higher
education, primarily because they are seen as necessary for providing background
information and ideas, basic concepts, and methods required by students before they
can learn on their own and become effective participants in classroom discussion (Fry,
Ketteridge, & Marshall, 2003). The lecture is effective as a means of transmitting
information, however traditional lecturing is often viewed as an example of passive
learning, in which the only activities students engage in during a lecture are listening
and note taking and where there is little opportunity for active learning (Exley &
Dennick, 2004). Hence the lecture method has often been linked with other methods
51
such as service-learning (Brown & Roodin, 2001; Dorfman et al., 2004; Knapp &
Stubblefield, 2000), or experiential learning (Anderson-Hanley, 1999; Bullard et al.,
1996; Moriello et al., 2005; O'Hanlon & Brookover, 2002).
Intergenerational service-learning
Service-learning has recently received increased attention as a pedagogical
experience to be incorporated into curricula in higher education (O'Quin et al., 2005).
Service-learning is defined as a course-based, credit-bearing educational experience in
which students participate in an organised service activity that meets identified
community needs and actively engages students in reflection to increase
understanding of course content, provide broader appreciation of the discipline, and
enhance students’ sense of civic responsibility (Bringle & Hatcher, 1995; Eyler &
Giles, 1999; Zolotkowski, 1998). Unlike community service, in which individuals
commit their time and energy to a worthy cause without engaging in a structured
learning process, service-learning is a structured learning process. According to recent
gerontological education literature, service-learning has been used for
intergenerational programming in gerontological education (Blieszner & Artale, 2001;
Dorfman et al., 2004; Knapp & Stubblefield, 2000; Nichols & Monard, 2001; O'Quin
et al., 2005; Weinreich, 2003). Intergenerational service-learning is an innovative
method of teaching and learning that focuses on the interactions between younger and
older adults while integrating community service activities into academic curricula
(McCrea et al., 2000; Newman & Smith, 1997). It is a cyclical process: providing
service; reflecting on that experience; linking it to course content through classroom
discussion; and translating the experience into new understandings that improve the
services provided and lead to continuing learning (Cone & Harris, 1996; Fisher &
Finkelstein, 1999; Kolb, 1984). Osborne, Penticuff, and Norman (1997) distinguished
52
experiential learning as doing from service-learning as engaging in activities that are
personally meaningful and have a positive impact on others. Two of the studies
reviewed were of intergenerational service-learning used as a teaching method to
deliver a gerontological course. For example, Knapp and Stubblefield (2000) showed
that an intergenerational service-learning course had a positive influence on student’s
knowledge and perceptions of ageing. Also, Dorfman, Murty et al. (2004) found that
students improved their attitudes toward older people after an educational program
using intergenerational service-learning.
Experiential learning
Experience gained through life, work and education plays a central role in the
process of learning, and this perspective on learning is called experiential learning or
learning by doing (Fry et al., 2003). Evaluations of experiential learning methods and
techniques have consistently found that students’ responses to these techniques are
generally positive and that students believe their learning is enhanced (Anderson-
Hanley, 1999; Bullard et al., 1996; Karner et al., 1998; Moriello et al., 2005;
O'Hanlon & Brookover, 2002). As an example of a study using experiential learning,
a group of students took part in one-semester gerontology course using experiential
learning activities. They completed an attitudinal measurement instrument (Ageing
Semantic Differential Scale, ASD) at the beginning and end of the course, and a self-
report on beliefs after completing the course (O'Hanlon & Brookover, 2002). The
experiential activities consisted of interviewing an older person in the community,
discussions, demonstrations, simulations, and case studies. Findings were that positive
attitudinal change and an overall positive shift in the students’ beliefs about older
adults were achieved.
53
Conclusion
To summarise this review, there is some evidence that nursing education in
gerontology has fostered positive attitudes in nursing students and increased their
knowledge about older people. However, future studies need to overcome common
limitations of previous studies and use more rigorous research designs, rather than one
group only, or post-test only designs and to use random selection procedures rather
than volunteers. As for the teaching methods, although lecture-based learning has
benefits for transmitting knowledge from teacher to students, students tend to be
passive learners. Intergenerational service-learning contributes a great deal to
students’ understanding of the ageing process, their attitudes toward older people, and
their familiarity with community services for older people and their families.
Although participating in service activities with older people is an alternative method
to deliver gerontological education, several issues need to be considered, such as time
commitment and practical issues of implementing service-learning (Blieszner &
Artale, 2001; Bringle & Kremer, 1993). In relation to time commitment, students need
to spend more time on community service in order to achieve the requirements of the
course; how they can fit service-learning into their already busy timetable needs to be
considered. Transportation to community service could also be a problem. Further,
with service-learning, the importance of the interactions between the students and
older people requires the attention of a person who has the time and ability to monitor
and work with the students on their reactions for each community service visit. These
issues need to be overcome to implement service-learning. On the other hand, in
experiential learning, understanding is formed and re-formed through experience,
which plays a central role in the learning. An appreciation of experiential learning is
necessary to underpin many of the different types of teaching activities, including
placement learning, practical work, role play, group discussion, reflective practice,
54
simulation games, and laboratory practice sessions. However, since the learner needs
to resolve the tensions of various learning activities, this will have an effect on their
outcomes. Also, the learner’s learning style and background can influence the degree
to which they accept experiential learning. Therefore, considering the advantages and
disadvantages of the three different teaching methods (see Table 3.1), the experiential
learning approach appears appropriate to use as a conceptual framework for teaching
gerontology content. To expand on this, the next section introduces Kolb’s
experiential learning model.
Table 3.1
Advantages and disadvantages of three teaching/learning strategies
Teaching strategies Advantages Disadvantages
Lecture-basedlearning(Light & Cox,2001; Murphy,1998)
More effective than other methodsin transmitting facts andinformation
Efficiencies to teach in largegroups
Explain things better Help students make connections Give students an overview of a
course or a topic Share with students the lecturer’s
research findings Provide students up-to-date
information
Ineffective for teachingbehavioural skills
Not as effective as discussionmethods in promoting thought
Ineffective for teaching valuesassociated with subject matter,inspiring interest in a subjector for personal and socialadjustment
Not suitable for changingstudents’ attitudes
Hierarchical structure-- lecturerclearly identified as an expertand the students clearlyidentified as the audience
IntergenerationalService-learning(Blieszner &Artale, 2001;Bringle & Kremer,1993; Weinreich,2003)
Collaborative learning: distributedleadership, heterogeneous grouping,positive interdependence andindividual accountability, socialskills acquisition, and groupautonomy
Better understanding for text materialMore knowledge in specific content
areasMembers of both generations can get
to know on anotherIntroduced students to other older
people than their grandparentsStudents learn to adapt to situations in
which they initially are
Difficulty with fitting students’already busy timetable intoservice-learning
Transportation to thecommunity service
Hard to select a sensitive andcapable person who worked inthe service and has the timeand ability to monitor andwork with the reactions of thestudents on each communityservice visit
Difficulty with coordinatingstudents’ available time withthe site’s needs
55
Teaching strategies Advantages Disadvantages
uncomfortableIncrease acquisition of professional
experienceMore knowledgeable about
community resources and humanservice systems
Mutual cooperation between studentsand community
Well-structured and meaningfulexperiential components
Students are more responsible fortheir own learning
Becoming too attached to olderpeople
Becoming depressed about thesituations in which some olderpeople live
Experientiallearning (Gillis,1991; Pulsford,1993; Spier, 1992)
Experiential activities are interactive,involve the learner physically andpsychologically, allow role-play insafe environment, and stimulatecreativity.
Experiential activities allow theparticipants to gain insight intobehaviour associated withinteractions and to practice handlinginterpersonal conflict in a safeenvironment.
Clinical experience with well olderpeople increases students’ self-confidence
Students rewarded by their interactionwith well older people
No thrusting environment for thebeginning students in role plays orsimulation games
Bridging the gap between theclassroom and clinical experience
Information is more meaningful andmore likely to be retained if it can beapplied soon after it is taught
Promotes learning as an activeprocess
Reflects the experience into theleaning
Doing rather than just listening
Students need to solve thetension of variety of teachingstrategies
Students’ learning style andlearning background couldinfluence the outcomes ofexperiential learning
Group size limitationsTeacher should ensure that they
are skilled and confident in theuse of experiential learningmethods
Experiential learning are not‘real life’—the situationspractices are trivial andartificial
Experiential Learning Model
The Experiential Learning Cycle proposed by Kolb (see Figure 3.1) will be the
conceptual framework for the study and will be used when examining the nursing
students’ attitudes and knowledge toward older people (Kolb, 1984).
56
Figure 3.1 Kolb’s Experiential Learning Cycle.
Kolb’s model of experiential learning is a conceptual framework that is useful
for guiding the design of a gerontological nursing curriculum is. Kolb (1984) stated
that learning was viewed as a life-long process in which transactions occurred
between the learner and the environment. Experiential learning theory integrates
affect, perception, cognition and behaviour, providing a holistic framework of the
learning process for viewing adult development that is consistent with what is known
about how people learn, grow and develop (Baker, Jensen, & Kolb, 2002).
Experiential learning emphasises the central role of experience in the learning process,
“the process whereby knowledge is created through the transformation of experience”
(Kolb, 1984, p.38). Experiential learning well reflects the nature of professional
nursing with its blend of action, experience and cognition (Cavanagh, Hogan, &
Ramgopal, 1995). Experience is the central role of experiential learning, and provides
the emphasis that distinguishes it from other learning theories. The term experiential
is used therefore to differentiate it from both cognitive learning theories, which
emphasise cognition over affect, and behavioural learning theories, which deny any
role for subjective experience in the learning process (Kolb, Boyatzis, & Mainemelis,
2001).
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Kolb’s experiential learning model is a four-stage cycle. As shown in Figure
3.1, the stages are: concrete experience (CE), reflective observation (RO), abstract
conceptualisation (AC), and active experimentation (AE). This cycle shows how
immediate concrete experience followed by reflective observation is translated into
abstract concepts; these concepts then serve as guides for testing the implications of
concepts in new situations (Holbert & Thomas, 1988).
Concrete experience
The experiential learning model emphasises the crucial role that experience
plays in the learning process. The first stage in Kolb’s model is concrete experience
that enables individuals to become immersed in actual situations (Laschinger, 1990).
According to Kolb, the importance of this stage is that it is involved in experiences
and deals with immediate human situations in a personal way (Kolb, 1984). Teaching
methods in this stage should provide students with real-life experience; in a
gerontological program this would require encouragement of students’ understanding
of their own feelings and those of older people by providing them with opportunities
to talk with positive and well older adults, and to focus on healthy life styles and
health promotion, which can encourage students to focus on their feelings.
Reflective observation
The second stage in Kolb’s model stresses reflection and observation. The
focus is on understanding the meaning of ideas and situations by careful observation
from different perspectives and impartially describing them (Kolb, 1984). The learner
reflects on the experience from many aspects, seeking to find its meaning (Svinicki &
Dixon, 1987). A discussion would follow the students’ experiences of talking with
58
well older adults; it would emphasise students’ observations and encourage them to
describe what they have experienced with older people. Students would also be
encouraged to reflect on their professional and personal reasons for needing to learn
more about caring for older people. Diary writing could help students through the
journaling phase of the learning process, enabling them not only to elaborate on and
to identify the nature of the feelings encountered during the observation and interview,
but also to reflect on the strategies selected for resolving the feelings. Subsequent
classes for the unit could focus on the assessment of and communication skill with
older people, the role of the nurse in their health promotion, and in providing nursing
care for older people with illness and disability.
Abstract conceptualisation
In Stage Three, abstract conceptualisation is used to develop explanations of
what has been experienced. This stage focuses on the use of logical concepts and
ideas and puts an emphasis on thinking (Potgieter & Phil, 1999). Presenting
information through lectures and assigned reading, and discussing the selected
concepts and theories and their implications, are the main teaching strategies in this
stage (Holbert & Thomas, 1988). Lectures and discussion could focus on cognitive
content related to the ageing process. During this stage, students complete their
assigned readings and attend a series of classes designed to expand both their
cognitive and affective knowledge bases (Potgieter & Phil, 1999).
Active experimentation
The last stage is active experimentation, which is active doing. Individuals
attempt to solve practical problems by using previously developed theoretical
explanations. Students apply their knowledge in simulated and real-life situations.
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Feelings of hopelessness and despair toward older people can interfere with the
students’ motivation for learning about caring for older people and influence their
attitudes toward them; this conceptual framework will give a basis for improving the
students’ attitudes toward older people. It provides an approach to develop the
capabilities of students and enhances the contribution of students to the class; this
framework also offers nurse educators opportunities to prepare students to integrate
humanistic caring, expert knowledge, and technological competence.
The experiential learning model provides a functional framework for a
gerontological course design and classroom activities. This model takes into account
the varying perspectives of the learner’s role in the learning process. This process
emphasises learning rather than teaching; the learner is prepared for learning
outcomes through activities that promote active involvement rather than being a
passive information receiver. Moreover, experiential learning refers to learning
activities that engage the learner directly in experiencing the real situation. Learners
can reflect on the experience themselves from many perspectives, drawing logical
conclusions and solving problems in the real world. Many experiences that a learner
brings to a situation or that occur during a period of learning have the potential to
influence learning outcomes. Therefore, various teaching methods and activities were
planned based on the four-phase cycle in the experiential learning model. For example,
in the phase of CE, experience in a Senior Apartment was planned to provide students
with real life experiences with older people. In the phase of RO, journal readings,
discussions, and debriefings were designed to help students reflect on their experience
with older people. In the phase of AC, lectures and textbook readings were planned
for students to develop their conceptual understanding of older people. Finally, role
plays, simulation games, and practice sessions in the laboratory were designed to
60
develop students’ capabilities and their participation in the class. More details are
discussed in Chapter 5. The next section discusses factors that are likely to influence
learning outcomes in an experiential nursing context.
Factors Influencing Experiential Learning Outcomes
Experience with Well Older People
Nursing education consists of two major components: the accumulated
knowledge from classroom content and the application of this content in clinical
learning sessions. Experiential learning in clinical practice is vital in nursing
education; it can reflect the nature of professional nursing with its blend of action,
experience and cognition (Cavanagh et al., 1995). In the theory of experiential
learning, Kolb (1984) describes learning as a lifelong process of person-environment
interaction; knowledge derived from experience with the environment and then
enhanced by critical analysis results in new knowledge (Hiebert, 1996). Success in a
discipline is more likely when personal and environmental variables are congruent
(Shin, 2000).
Attitude change is very difficult to achieve unless the individual is exposed to
an experience that places the learning situation on a very personal level (Marte, 1991).
Experiential learning activities can encourage individuals to integrate concepts into
their practice; activities that require individuals to formulate value judgments are
claimed to be particularly valuable (Kirkpatrick, Brown, & Koldjeski, 1997).
However, the problems with gerontological education programs arise not only
from the content of scientific knowledge and skills, but also from the limited
61
experience for students with “well” older people that they typically offer. As students’
clinical practice is predominantly in acute hospital settings, their experience of
working with older people is based on those who are ill and frail. The lack of personal
contact with “well” older people can reinforce the students’ negative beliefs about
older people; hence direct contact with well older people could provide students with
a more accurate view and experience of what it means to age.
A consistent emphasis on the rewards of direct experience with well older
people throughout the educational program can foster movement toward a more
positive influence on the way nursing students view older people. A number of studies
have indicated that introducing students to well older people before requiring them to
work with critically ill older people can have a positive effect (Aday & Campbell,
1995; Shoemake et al., 1998). Through this strategy of integrating contact with well
older people into an educational program, students have been provided with
opportunities to see the more positive aspects of older people and receive positive
feedback from them. It also provides a real-world model to reinforce classroom
concepts (O'Hanlon & Brookover, 2002). Students’ self-confidence could increase,
nourishing positive attitudes toward older people, helping them develop more
confidence and feel more comfortable in caring for ill older people (Aday &
Campbell, 1995). Moreover, it could reduce the prevalence of stereotypical beliefs
that have been suggested by some researchers (Davis-Berman, 1995 ; Gorelik et al.,
2000; Ragan & Bowen, 2001; Rowland & Shoemake, 1995; Schwartz & Simmons,
2001).
A number of studies have examined the importance of student experience in
developing positive attitudes (Dellasega & Curriero, 1991; Gorelik et al., 2000;
62
Heliker et al., 1993; Rowland & Shoemake, 1995). Some studies have found support
for experience while others found no improvement following student experience.
Dellasega and Curriero (1991) collected data over a 15-week period from 39
students in an undergraduate nursing program on nursing care of older people, in an
effort to evaluate the impact of their experience with older people in institutional and
community settings. This course involved 2½ hours per week of didactic content on
nursing of older people and 6 hours per week of structured clinical experience with
them. The first 7 weeks of clinical experience was in a skilled care facility and the
second 7 weeks was in providing care for an older person living independently in a
high-rise apartment. The data revealed that, while more students’ attitudes toward the
older people become more positive, they still preferred not to work with them.
However, in this study, students’ contact was with ill older people first and then well
older people later, which could have influenced their perceptions of older people.
Several studies have argued it is better that students have experience with well older
people before contact with ill older people (Aday & Campbell, 1995; Angiullo,
Whitbourne, & Powers, 1996).
A pre-test, post-test design was used to explore the difference in the attitudes
of 34 students, including medical, nursing, dental, and dental hygiene students, toward
older people, following a non-threatening experience with “well” older people
(Heliker et al., 1993). They found interaction with “well” older people influenced
students’ attitudes in a positive manner. However, the request for volunteers in the
study may have attracted people who were interested in research and may have
produced a skewed representation. Also, the non-random procedure could further
minimise representativeness and limit the ability to generalise to other populations
63
(Heliker et al., 1993).
In a cross-sectional and quasi-experimental study using a stratified random
comparison group, Gorelik, Damron-Rodriguez et al. (2000) surveyed 382
gerontology students and 769 non-gerontology students. Gerontology students
reported significantly more frequent interaction with older family members and more
contact with extended family such as great aunts and uncles. The findings showed that
contact with older people is significantly related to initial interest in ageing. However,
without a pre-test for gerontology students, it was not possible to draw conclusions
regarding causality. Moreover, the gerontological students were self-selected as those
taking an aging course; this could have created a confounding bias.
On the other hand, using Kogan’s Attitude Toward Old People (KOP) scale
and Palmore Facts on Aging (FAQ), Greenhill and Baker’s (1986) study, using a pre-
test, post-test design, failed to support the idea that experiences with “well” older
people would make a difference in their attitude and knowledge base. Of 78 senior
students enrolled in Advanced Family Care and Long-Term Care courses, half were
given experience with well older people while the others had no experience with this
population. Greenhill and Baker (1986) found that no significant differences in
attitudes or knowledge were found between the treatment and control groups.
Moreover, all students, regardless of group, increased their knowledge. Students who
initially had negative attitudes significantly improved their attitudes, regardless of the
type of clinical experience, but there was no difference in students already assessed as
having positive attitudes. The researchers concluded that knowledge and attitude
changes are not dependent upon a particular type of clinical learning. The clinical
experience should not only provide contact with “well” older people but also should
64
be integrated with well planned curriculum experiences related to older people, which
can positively influence attitudes toward this group and increase the knowledge base
of nursing students. However, students were manipulated and assigned into
experimental or control group based on their KOP means; this lack of randomisation
limits the generalizability of the result. Furthermore, students’ characteristics could be
the factors influencing the results, but without reporting them, it is hard to assess the
degree to which the program itself contributed to their results.
In summary, in relation to experience with well older people, the majority of
the literature revealed that a positive experience with well older people was likely to
influence students’ attitude toward older people. During planned and integrated
contact with older people, students could discover that older people are unique and
active, with many interests. It could change their negative, stereotypical and
misconceived notions of older people. However, the contradictory results of these
studies could have been influenced by the limitations of the study designs.
Relationship with Older People
In Taiwan, 63% of older people 65 years and over live with their children
(Department of Statistics, 2000). It is recognised that students would come to a
gerontological nursing course with a variety of experience with older people in their
family. Studies found that students’ relationships with older people had a direct
positive influence on their attitudes toward them (Hawkins, 1996; Mehta et al., 2000;
Robert & Mosher-Ashley, 2000; Tan et al., 2004). Hawkins (1996) sampled the
attitudes of 420 undergraduate students, 171 males and 249 females, and found that
students who felt close to older relatives or non-relatives were more likely to have
positive attitudes toward older people. However, the sample was from an
65
undergraduate health course at a university and is thus limited as to the
generalisations that can be made to other populations, such as postgraduate students
or students in other professional areas.
Robert and Mosher-Ashley (2000) investigated the factors influencing 282
college students’ desire to work with older people. They found that while a close
relationship to older people may influence attitudes toward this population, it did not
affect the desire to pursue a career specialising in work with older people. However,
the older person’s mental and physical conditions were not reported in the study; these
additional factors could be an important influence on students’ experience with older
people.
Mehta et al. (2000) examined the attitudes of 201 undergraduate social work
students in Singapore. They found that students who felt close to an older relative had
more positive attitudes toward older people; however, as the sample was not random,
these views may not be reflective of the population of social work students. Similarly,
Tan et al. (2004) investigated 199 Mainland China university students’ attitudes
toward older people. They found that students who felt close to older relatives or non-
relatives were more likely to have positive attitudes toward older people. The result
was consistent with the studies by Prudent and Tan (2002) and Mehta et al. (2000);
however, using students from one university who were volunteers may not reflect the
student population as a whole.
Despite those studies that support the association between contact with older
people and attitudes toward them, contrary findings exist. Living with older people
was found not to influence students’ attitudes toward older people, by Mehta et al.
66
(2000), who found that living with an older adult did not correlate with students’
attitudes toward older people. Prudent and Tan (2002) also found there was no
correlation between having lived with older people and students’ attitudes toward
them. However, the majority of these students were first years, and views may not be
reflective of the other years of the student population. Similarly, Tan et al. (2004)
found that there was no correlation between having lived with older people and
students’ attitudes toward them.
In summary, the majority of the literature revealed that a close relationship
with older people can influence students’ attitudes toward older people; contrary
findings, however, do exist. As most studies were cross sectional in nature, it is not
clear whether a close relationship with older people precedes positive attitudes or a
positive attitude precedes a close relationship. Thus caution is needed in making
generalisations from these studies, as causality has not been studied. Moreover, most
study samples were not randomly selected so they could reflect biased populations.
Experience in Clinical Settings
Nursing students develop personal realities based on assumptions that emanate
from their experiences, and from information, attitudes, and values learned from
family, peers, and teachers (Rowland & Shoemake, 1995). Students often find the
clinical practice environment to which they are exposed is different from their
personal understanding of the reality of older people and from their knowledge gained
at university. Students in Taiwan are usually placed for the practice in their nursing
course in acute hospitals. In the acute clinical environment, older people often present
with more complex physical problems. Nursing students are likely to find a
substantial contrast between what they have learnt about normal human development
67
and their experience of working with sick older patients. Students’ realisation that
practice in the clinical setting is quite different from what they had imagined can have
a great impact on them (Shin, 2000). Also, because they lack a variety of experiences
of life, the clinical practice seems difficult and mentally stressful. Consequently,
facing unpredictable situations and contact with ill older people in the acute hospital
can be frightening and can impact on students’ attitudes toward them (Stevens &
Crouch, 1992; Stevens & Crouch, 1995). Therefore, in recognition of this and to
ensure that clinical placement with older people is a positive experience for students,
a community setting is considered a better placement for the first gerontological
clinical practice. In community settings, where the clients are not as acutely ill and the
pace is slower and more predictable, nursing students have more time to develop the
skills pertaining to communication, basic nursing assessment, and health teaching
(Spier, 1992). These settings provide a relaxed atmosphere where positive
relationships can be established; in this positive environment, students can gain self-
confidence and learn to identify the age-related changes of older people before
dealing with complex, disease-related changes (Hogstel, 1988). Relationships with
active well older people who function independently and maintain a positive outlook
in spite of health changes contribute to the development of positive attitudes among
nursing students (Spier, 1992).
However, a contradictory view was found by a number of studies that have
investigated the effect of clinical placement in nursing home settings and the
correlates affecting students’ positive attitudes toward older people (Gorelik et al.,
2000; Langland et al., 1986; Rowland & Shoemake, 1995; Sheffler, 1998). They argue
that the nursing home setting is a supportive and unhurried environment that may
have contributed to the building of student confidence.
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The central purpose of the study by Langland, Raithel et al. (1986) was to
examine whether or not a clinical experience in a nursing home would influence the
attitudes of basic nursing students toward older people. The subjects for the study
were 50 students from one Introduction to Nursing Methods class. The program
provided experiences for nursing students in a nursing home. The KOP scale was used
to determine students’ attitudes before and after their nursing home experience. The
authors concluded that an initial clinical experience with institutionalised older people
was helpful, not only in completing basic nursing skills, but also in fostering positive
attitude change toward older people. However, the nursing program in this study
focused more on the positive perspectives of older people. Also the nursing home
experience focused on those older people who had more self-care abilities, rather than
disabled or demented older people. Students’ characteristics were not reported in this
study. It is hard to know that whether the nursing home experience influenced their
attitudes, or other factors influenced their attitudes toward older people. Also, the lack
of a control group reduces the strength of the study. It is hard to be confident that the
outcomes described are the result of the change in nursing home experience rather
than being due to other variables such as participant’s experience or characteristics.
Rowland and Shoemake, in their 1995 research on the impact of a nursing
home experience on 169 nursing students in first semester of final year nursing
students, reported that students indicated they enjoyed the practicum very much. Also,
after the practicum, nearly 30% reported that they “would really like” to work
professionally with older people. However, caution is needed when interpreting their
results, as the response rate was unknown. Again, the lack of a control group reduces
the strength of the study.
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In a study of second year nursing students who had enrolled in a fundamentals
of nursing course, Sheffler (1998) hypothesised that undergraduate nursing students’
attitudes toward older people would change following a clinical experience with older
people in a nursing home. In her study, 42 nursing students completed the pre-test but
only 35 of them completed the post-test. The author noted that the students’ scores on
Kogan’s Attitudes Toward Older People (KOP) scale reflected a significant
improvement, thus supporting her hypothesis. As indicated by this study’s findings,
the author suggested that positive attitudes toward older people could occur as a result
of clinical experience in a nursing home. However, in this study, only one group was
studied; the lack of a control group meant there was a failure to control for many
possible extraneous factors such as age, sex, and previous experience.
Although clinical placement in nursing home settings and the correlates
affecting students’ positive attitudes toward older people have been supported by the
above studies, these students were final year nursing students who had experience
with well older people early in their nursing course. Although students had experience
in a nursing home setting, they were caring for older people with self-care abilities
rather than disabilities. Therefore, for beginning nursing students, as Rowland and
Shoemake (1995) recommended, combining theory and practice is a way to improve
teaching and learning processes in nursing schools. A gerontological nursing
curriculum is needed that increases the knowledge base and provides nursing students
with multiple experiences first with well, and later with ill, older people (Rowland &
Shoemake, 1995). Such programs need to present a breadth of information about older
people and avoid presenting biased views, and should enable students to record their
thoughts and feelings about their practice to promote self-awareness. A well-planned
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learning experience with older people in community settings would be an advantage.
Although nursing home placement could be an excellent place for beginning nursing
students to begin learning about the nursing process, skills, and assessment, several
authors have argued that a nursing home experience is not appropriate for nursing
students in a beginning nursing course because of the complex needs of older people
in these settings (Hogstel, 1988; Spier, 1992). Of the studies which reported a positive
impact on clinical placements in nursing homes, it is noted that the most recent one
was published in 2000. The current global status of residential aged care is generally
considered to be a system under pressure with high acuity residents, understaffing and
under-skilled workers. So the current context of residential aged care may not be an
appropriate setting for initial learning. Also, the residents with complex needs in long-
term settings may produce an initial negative impression and discourage students
from working in gerontological nursing.
On the other hand, using a pre-test, post-test, with control group design,
Wilkinson, Gower et al. (2002) examined all 186 second year medical students’
attitudes toward older people in the community and in rest homes. They found that the
effect on attitudes was more pronounced in those students who saw older people in
the community rather than in rest homes. However, the lack of comment on the
reliability of the questionnaire raises concerns about validity of the results.
In summary, most literature revealed that clinical experience in nursing homes
is likely to influence students’ attitude toward older people. However, these studies
could be influenced by the limitations of the study designs. For example, using a one-
group study could fail to control for other factors such as sample characteristics. Also,
many students were in the last year of their nursing program and they may have had
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different experiences with older people compared with commencing students.
Therefore, experience in nursing homes may have had different impacts on students’
attitudes according to various characteristics such as age or year of students’ nursing
program. Without considering these factors, it is difficult to be confident about the
findings.
Summary
The implications from this review of the literature relate directly to the
educational experience of nursing students. Gerontological nursing curricula need to
focus more on creative teaching strategies and more experiences with well older
people in order to promote the formation of more favourable attitudes. Although
nursing homes could influence students’ attitudes toward older people, the literature
suggests the need to focus on the normal ageing process as well as positive aspects of
older people in the community, rather than using institutionalised settings in the
students’ beginning clinical placement.
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CHAPTER FOUR
Study 1: Survey
Introduction
The purpose of Study 1 was to provide baseline data for developing a
gerontological education program for an intervention in Study 2. The aims of Study 1
were to:
1) validate two instruments: Nolan’s Perceptions of Work with Older People
(PWOP) and Nolan’s Knowledge of the Situation of Older People (KSOP);
2) examine the reliability of four instruments: Kogan’s (1961) Attitudes Toward
Old People Scale (KOP), Perceptions of Work with Older people (Nolan,
Davies et al. 2001) (PWOP), Knowledge of the Situation of Older People
(Nolan, Davies et al. 2001) (KSOP), and Palmore’s (1988) Facts on Ageing
Quiz 1 (FAQ1);
3) gain a greater understanding of Taiwanese nursing students’ attitudes and
knowledge about older people;
4) understand the relationships between two different instruments for measuring
attitudes toward older people and two different instruments for assessing
knowledge about older people;
5) examine the correlations among the four instruments (two on knowledge and
two on attitudes) and the demographic data; and
6) determine the factors influencing attitudes toward and knowledge about older
people.
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This chapter describes Study 1 and presents sections on the research methods,
results, and discussion. The research method section includes: research design;
descriptions of the research sample and instruments; data collection procedures;
human ethical considerations and data analysis. The results section reports: sample
characteristics; validity and reliability of instruments; attitudes towards and levels of
knowledge about older people; correlations among measures; correlations among
attitudes, knowledge and demographic variables; and factors influencing nursing
students’ attitudes and knowledge. In the discussion section, the research questions
are addressed, as well as the limitations of the research and recommendations for
future research and education.
Method
Research Design
A cross sectional research design was used in this study, by means of a survey
of nursing students from a university in southern Taiwan. The dependent variables in
this study were nursing students’ attitudes toward, and knowledge about, older people.
For the purpose of this study, attitudes toward older people were defined as mental
views based on cumulative experience and directed toward individuals: in this study,
the students’ thoughts and feelings about older people (Kogan 1961). Knowledge
refers to useful information that can be acted upon in the course of decision making,
problem solving and critical thinking: in this study, the students’ information about
older people (Palmore 1998).
The independent variables in this study were identified from the literature as
those likely to influence attitudes toward and knowledge about older people. These
included the students’ gender, age, educational level, course undertaken, marital status,
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previous work experience in nursing, contact with older people in the family,
frequency of current personal contact with older people, whether or not they had lived
with older people, amount of clinical and lecture time devoted to older people, and
amount and type of clinical practice.
Research Questions
The specific research questions addressed in this study were:
1. What are current Taiwanese nursing students’ attitudes toward and
knowledge about older people?
2. Are there relationships between two attitudinal measures, Kogan’s
(1961) Attitudes Toward Older People Scale (KOP) and Nolan’s
Students’ Perceptions of Work with Older people (2001), and between
two knowledge measures, Nolan’s Student Nurses’ Knowledge of the
Situation of Older People (2001) and Palmore’s (1988) Facts on
Ageing Quiz: Part 1?
3. What factors are likely to influence nursing students’ attitudes toward
and knowledge about older people in this sample?
Sample
The target population consisted of all undergraduate nursing students in
university undergraduate nursing courses in Taiwan. The sample for this survey was
nursing students from a private university located in southern Taiwan. Because the
aim of Study 1 was to provide baseline data, the selection criterion for the sample was
all nursing students who were studying a nursing course at the selected university. A
convenience sampling frame was used to request participation by undergraduate
nursing students from the four-year program, including first, third, and fourth year
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students and first and second year nursing students from the two-year program. As
second year students in the four-year program were to be the sample for Study 2, they
were not included in Study 1. The total sample available for the survey consisted of
429 four-year program and two-year program nursing students.
Students in the four-year program apply for university entrance via three
different routes: (1) the “University Joint Entrance Examination Program” by which
any high school graduate who achieves the university score in the entrance
examination can apply for admission; (2) the “Entrance by Application Program” by
which any high school graduate who meets a particular university’s admission
standards can apply for admission; and (3) the “Recommendation Screening
Examination Program” which allows students to decide on majors and universities to
suit their own aptitudes and talents, while the universities can select students
according to their examination performance (Department of Higher Education 2003).
Thus the nursing students in the four-year program can come from any area in Taiwan.
The students in the two-year program are those who take an entrance exam
which is held independently by universities for working adults only; the work
experience and achievements of examinees may be taken into consideration when
setting up the qualification standard (Department of Higher Education 2003). Thus the
nursing students in the two-year program are registered nurses and usually come from
the hospital near to the university.
So the four-year nursing program serves as the general nursing education
program for students who have no nursing experience, while the two-year nursing
program serves as a post-registration nursing education program for students who
have graduated from a nursing college and have nursing experience.
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Instruments
Nursing students were asked to complete a demographic data sheet (see
Appendix 7) and two instruments to measure attitudes: Kogan’s (1961) Attitudes
Toward Old People Scale (KOP) (see Appendix 2); and Perceptions of Work with
Older People (PWOP) (Nolan, Davies et al. 2001) (see Appendix 3); and two
instruments to measure knowledge: Palmore’s (1988) Facts on Ageing Quiz: Part 1
(FAQ1) (see Appendix 4); and Knowledge of the Situation of Older People (KSOP)
(Nolan, Davies et al. 2001) (see Appendix 5). Consent for the use of each of the four
established research instruments was obtained from its respective author or copyright
holder (see Appendix 6).
Attitudes
Kogan’s (1961) Attitudes Toward Old People Scale (KOP) was used to
measure nursing students’ attitudes toward older people. This scale has been
extensively used in studying attitudes toward older people; it consists of a total of 34
statements comprising 17 paired statements about older people, one of each pair is
positively framed and the other negatively framed. In the original KOP scale, some
items were adapted from available ethnic minority items by the simple substitution of
the “old people” referent and other statements derived from Kogan and institutions
regarding stereotypes and feelings about old people in society (Kogan 1961). The
Soderhamn and Lindencrona (2000) study provided support for the construct validity
of the KOP scale and its internal consistency, reporting a Cronbach alpha coefficient
of 0.79 for the total KOP scale (Soderhamn & Lindencrona 2000). The scale used in
the KOP is a six-point Likert response category format, consisting of strongly agree
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(scored 6), slightly agree (scored 5), agree (scored 4), slightly disagree (scored 3),
disagree (scored 2) or strongly disagree (scored 1). Total scores for the 34 items
therefore ranged from 34 (negative) to 204 (positive). The 34 statements from the
original scale were used for the Taiwanese version.
The KOP scale has been extensively used in gerontological studies, including
studies of the attitudes toward older people held by nursing students (Hope 1994;
McCracken, Fitzwater et al. 1995; Soderhamn, Lindencrona et al. 2001); oncology
health care professionals (Kearney, Miller et al. 2000); medical students (Wilderom,
Press et al. 1990), and therapeutic recreation students (MacNeil 1991). However,
criticism of the scale has been made in other studies; a study by Hilt (1997) indicated
limitations in the KOP scale. The KOP has been described as too lengthy and using
ambiguous terminology (Palmore 1977; Hilt 1997; Cowan, Fitzpatrick et al. 2004).
Also, the statements are based on stereotypes, so by answering the survey respondents
would be reinforcing those stereotypes (Hilt and Lipschultz 1999). Furthermore, the
KOP scale was developed in 1961 and the language used in the KOP scale reflects
how society viewed older people 44 years ago. Because of these limitations, the
current study also used Nolan et al’s (2001) instrument, Perceptions of Work with
Older People (PWOP), to reflect a more up-to-date view of older people and
specifically to focus on the perception of working with older people. Furthermore
using both instruments enables the comparison of the reliability of KOP and KSOP.
The instrument Perceptions of Work with Older People (PWOP) is grounded
in the experiences of nurses and students. Its authors, Nolan et al. (2001) noted that a
number of significant issues had been identified during interviews and focus groups
with nurses and students and used these issues as the basis for this questionnaire.
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From these issues, Nolan and his team developed the statements in the instrument.
The instrument consists of 15 statements, and covers three broad areas addressing
students’ perceptions of: working with older people in general; personal disposition
towards work with older people; and the consequences of working with older people.
To answer all these items, participants are invited to indicate the level to which they
agree using a 5-point Likert format as follows: 5 = strongly agree, 4=agree, 3=neither
agree nor disagree, 2=disagree and 1= strongly disagree. Scores therefore can range
from 15 to 75. Nolan used the PWOP to examine 718 student nurses’ perceptions of
working with older people in the UK. However, as this is a recent instrument, the
psychometric properties have not yet been established. The face validity had been
derived from interviews and focus groups but there were no reports of the reliability
and construct validity of the questionnaire Nolan et al. (2001), so the reliability and
construct validity needed to be explored in this study. For the current study, all 15
statements from the original scale were translated into Taiwanese and no content was
changed. Some word changes were necessary to ensure the translated instrument
could be understood by the Taiwanese students.
Knowledge
Palmore’s (1988) Facts on Ageing Quiz 1 (FAQ1) and Nolan et al’s (2001)
Knowledge of the Situation of Older People (KSOP) were adapted to measure
Taiwanese students’ knowledge about older people. The Facts on Ageing Quiz 1,
which was developed by Palmore (1988), has been used extensively in recent times to
measure students’ knowledge about older people. The FAQ1 consists of 25 factual
statements on ageing which deal with social, physical, and psychological facts about
ageing, to which respondents answer ‘yes’ coded as 1, ‘no’ coded as 2 or ‘don’t know’
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coded as 3. In order to calculate the total score for FAQ 1, a correct answer was
recoded as 1 and an incorrect answer or ‘don’t know’ was recorded as 0. Thus the
scores on FAQ1 could range from 0 to 25. Palmore (1988) reported a high degree of
face validity. The Cronbach’s alpha reliability coefficient of .57 indicates only
moderate internal consistency for the FAQ1 (Norris, Tindale et al. 1987). Because the
quiz contains US statistics and the current survey aimed to measure Taiwanese
students’ knowledge about older people, one item was altered in order to reflect recent
data in Taiwan. The item “Over 20% of the population is now aged 65 or over” was
changed to “Over 10% of the Taiwan population is now aged 65 and over” (see
Appendix 4). Other items contained data applicable to Taiwan and therefore did not
need to be adapted.
Although the FAQ1 has been used by many researchers, it contains implicit
sources of negative bias. The design of the questionnaire can create a negative
mindset because of the age group comparisons and the focus on the physical and
economic frailty of many older people (Stuart-Hamilton 2000). Moreover, the FAQ1
is considered more a measure of attitudes than a measure of knowledge (O'Hanlon,
Camp et al. 1993). The existing version of the quiz is now dated due to recent changes
in demography and requires updating (Nolan, Davies et al. 2001). Therefore, the
KSOP (Nolan, Davies et al. 2001) that was developed following criticism of the
FAQ1 was also adapted to measure Taiwanese students’ knowledge about older
people.
The KSOP contains 17 statements of the most up-to-date facts about the
situation of older people in the UK. The response format asks individuals to indicate
whether a series of statistics about older people are “too high”, coded as 1, “about
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right”, coded as 2, or “too low”, coded as 3. In order to calculate the total score of
KSOP, a correct answer was recoded as 1 and an incorrect answer was recoded as 0. A
“do not know” option is not provided, because if respondents do not know the correct
answer then useful insights can be gained from the direction in which they guess, as
this will provide an indication of how they perceive older people (Nolan, Davies et al.
2001). The knowledge items were obtained from two primary sources: The Age File
99 (Leather 1999, cited by Nolan et al. 2001) and the Health Education Authority Fact
Sheet 1: Older People in the Population (Health Education Authority 1998, cited by
Nolan et al. 2001). The knowledge quiz contains items about the demographic profile
of older people, their living circumstances, their employment and expenditure, their
need for help and support and use of services. It was considered important to explore
respondents’ knowledge of a wide range of issues and not just those relating to
dependency or need (Nolan, Davies et al. 2001). The face validity of the questionnaire
is derived from its sources, as cited above. However, Nolan et al.(2001) did not report
the reliability of this questionnaire in their project. Modifications of the instrument
were needed for the current study to take account of the facts and data as well as
cultural differences relating to older people in Taiwan. The statements were altered in
order to match contemporary data in Taiwan. However, one of the original items
could not be included due to the unavailability of the statistical information on the
proportion of income spent on heating and lighting in Taiwan. Accordingly there
were only 16 items for this modified Taiwanese version of the KSOP (see Appendix
5). Possible scores on KSOP therefore ranged from 0 to 16.
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Demographic data
The demographic variables comprised the factors identified in the literature as
potential predictors of attitudes towards older people. These included students’ age,
gender, frequency of personal contact with older people, amount of clinical and
lecture time devoted to older people, experience of clinical practice, educational level,
year of the course, amount and type of exposure to older people and previous work
experience. This demographic data sheet is attached in Appendix 7.
Translation of instruments
Quality of translation and validation of translated instruments play an
important role in ensuring that the results obtained in a study are not due to errors in
translation, but rather are due to real differences or similarities between cultures in the
phenomena being measured (Maneesriwongul and Dixon 2004). Brislin’s (1970)
report on back-translation for cross-cultural research provides guidelines for
translating from English to other languages. Brislin (1970) suggested to use one or
more of the following translation techniques: (1) translation and back-translation,
where the original source language version is translated to a target language version
and then this is translated back into the original source language in order to verify the
translation (Maneesriwongul and Dixon 2004); (2) bilingual technique, the use of
bilingual people to detect items yielding different responses between two language
versions (Maneesriwongul and Dixon 2004); (3) the committee approach, the use of
bilingual people to translate from the source to the target language; and (4) pre-test
procedure, used to ensure that the users can understand all questions. There were five
steps planned for the translation phase of Study 1.
Firstly, the four instruments (KOP, PWOP, FAQ1, KSOP) and demographic
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data sheet were translated from English to Chinese by three bilingual people.
Secondly, the Chinese version was independently back-translated into English by
three other bilingual people who had not seen the original English version and who
had a master’s level qualification in nursing. Thirdly, the researcher and one English
native speaker compared the translation and back-translations with the original
English versions of each instrument to look for differences in wording expression and
meaning that might lead to differences in meaning while going through the translation
and back-translation processes. For those words where some differences were found
in the meaning, the researcher chose another more appropriate word for the Chinese
version. Fourthly, ten undergraduate nursing students piloted the Chinese version of
the four instruments and demographic data sheet in order to examine the
understanding of the Chinese versions. Then, the researcher talked to the students as a
group to check the level of understanding of each instrument. Only minimal changes
of Chinese words were needed for the demographic data sheet to promote greater
understandable. Finally, the researcher examined both the Chinese and English
version one more time for equivalence.
Procedure
Permission to conduct the research was obtained from the university where the
study was to be conducted. Then, ethical approval was obtained from the Queensland
University of Technology ethics committee. The dean of the selected Taiwanese
university arranged several possible dates and times for data collection. Data were
collected by the researcher over a period of 3 weeks. The questionnaires were
distributed and collected during students’ lecture times. The permission of each class
lecturer was also gained. Students in each class were given a description of the study,
an information sheet and informed that participation in the study was voluntary and
83
their study program would not be affected if they did not participate. If they agreed to
participate, students were asked to sign an informed consent sheet. Some students did
not complete the informed consent sheet and therefore did not complete a
questionnaire or participate in the survey.
Students consenting to participate were requested to complete the following
questionnaires: the demographic information sheet, KOP, PWOP, FAQ1, KSOP.
Students spent about 30 minutes to complete them in class time and returned them
immediately to the researcher at the end of class. The available survey sample was
429 nursing students; 302 of them completed the questionnaires, a response rate of
70%.
After a period of two weeks and taking account of their lecture schedule,
students in one of the first-year classes in the four-year program were chosen for the
re-testing of the instruments using the same environment and procedure. The sample
size for the test-retest was 43 nursing students.
Ethical Considerations
Ethical approvals to conduct this survey were obtained from the QUT
University Human Research Ethics Committee (see Appendix 8) and from the
Taiwanese university (see Appendix 9). Copies of the student information sheet and
consent form are attached as Appendices 10 and 11.
The main ethical considerations were confidentiality. It was important to
ensure that each questionnaire would be identified by a number only. Students were
assured that all information provided would be kept in strict confidence in a locked
filing cabinet during the study period and would be held for five years, after which the
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data would be destroyed. Data were secured on a password-protected computer file
with access available only to the researcher. Full assurances were provided to all
participants that all information collected was confidential and would be not disclosed
to anyone other than the researcher. Students were also advised that no information
about the project would be published in any form that would allow any individual or
university to be recognised.
The researcher approached all eligible participants and explained the purpose
of the survey, data collection methods, and confidentiality issues. All participants
were informed that they had the right to withdraw from undertaking the survey at any
time without comment or penalty. The participants were informed that no personal
data would be requested that would identify them; they were assured that participation
in the study would not impact on their future career or study program.
Data Analysis
The Statistical Package for the Social Science (SPSS) version 12.0 was used to
analyse the data. An alpha level of .05 was used to test the significance of statistical
differences. The sample characteristics were summarised by using mean and standard
deviations for continuous variables with normal distribution, and median, minimum
and maximum for continuous variables with non-normal distribution. Also the sample
characteristics were summarised by frequency for categorical variables. The t-test, for
continuous variables, and chi-square for categorical variables, was used to determine
whether or not there was a significant difference between the nursing students in the
four-year and two-year programs. Means and standard deviations were used to
summarise the attitudes and knowledge scale scores. Factor analysis was chosen to
determine factorial validity, a type of construct validity, for the PWOP and KSOP. An
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exploratory factor analytic technique was used to determine the interrelationships
among items and to determine the items that “go together” as unified concepts (Polit
and Hungler 1999) among all items in the PWOP and KSOP. Principal Components
Analysis (PCA), which was used to determine the factorability of the variables and to
estimate the number of factors in the solution, was performed on the 15 questionnaire
items in the PWOP and 16 questionnaire items in the KSOP. Alpha coefficients for all
scales were calculated to determine the internal consistency of the scales. The stability
of the four scales was derived using procedures that evaluated test-retest reliability.
Correlation coefficients were used to determine the inter-relationships among the four
scales using the product-moment correlation coefficient, referred to as Pearson’s r.
For most variables of a social or psychological nature, correlations between variables
of a psychosocial nature are typically in the .10 to .40 range (Polit & Hungler, 1999).
Furthermore, the Pearson’s product-moment correlation was used to determine the
relationships between the continuous dependent variables and continuous independent
variables. The relationship between the continuous dependent variables and
independent variables with dichotomous data was assessed by biserial correlations.
Then, standard multiple regressions were used to determine the factors predicting
nursing students’ attitudes towards older people and knowledge about ageing. These
regressions were used to develop a set of independent variables that could predict the
dependent variable, and to eliminate those independent variables that did not provide
additional prediction to the independent variables already in the analysis (Tabachnick
and Fidell 2001b).
Results
The questionnaires were completed by 302 undergraduate nursing students
studying in a university located in southern Taiwan. Descriptions of the sample as
86
well as the results of analyses on the validity of the PWOP and KSOP, the reliability
of the four instruments, descriptive statistics of the four instruments (KOP, PWOP,
FAQ1, and KSOP), correlations between instruments and demographic data, and
multiple regressions are presented in the following sections.
Sample Characteristics
The convenience sample of 302 undergraduate nursing students consisted of
168 (56%) from the four-year program including first, third, and fourth year students
and 134 (44%) from the two-year program that included first and second year students.
Second year students from the 4-year program were excluded because they were
going to be involved in the second study.
The mean age of students in the four-year program was 19.68 years and
ranged from 17 to 26 years. The mean age of students in the two-year program was
30.55 years ranging from 20 to 53 years. As expected, the mean age was significantly
higher for students in the two-year program (M=30.55, SD= 5.52) than students in the
four-year program (M=19.68, SD= 1.83) (t (300) =-23.95, p<.001).
The majority of students (93%) were female, 149 from the four-year program
and 134 from the two-year program. Most students (82%) were single (having never
married), however, as expected, more students 168 (56%) from the four-year program
were single compared with 79 (26%) from the two-year program. Almost two thirds
of students were either undergraduate first year nursing students in the four-year
program (31%) or first year students in the two-year program (32%). The other one
third of students were third year nursing students (10%), forth year nursing students
(15%) in the four-year program and second year nursing students (12%) in the two-
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year program.
Level of education
The majority of students had graduated from general senior high school (48%).
In the four-year program, the majority of students (86%) had graduated from general
senior high school, and the majority of students (72%) in the two-year program had
graduated from nursing junior college. As expected, more students who had graduated
from nursing junior college were in the two-year program (96) compared to the four-
year program (12) (²(3)=254.84, p<.001).
Work experience in nursing
Work experience in nursing refers to any nursing experience, either paid or
unpaid work, which students had carried out in clinical settings. Half of the surveyed
nursing students had nursing work experience (50%) and 88% of these had paid work
experience (median = 4.9 years, range = 0.2 to 21.6 years). As expected, more
students who had nursing work experience were from the two-year program (128)
than from the four-year program (24) (²(1)=196.78, p<.001). The mean score of
nursing students’ satisfaction with work experience in nursing was 3.43 (SD = .62)
out of a possible range from one to five. The finding indicated that the majority of
students were neither satisfied nor dissatisfied with work experience in nursing.
Interestingly, there was no significant difference between the two groups in their
satisfaction with experience in nursing (t (149) =1.89, p=.06).
Contact with older people
Most of the respondents (91%) acknowledged having contact with older
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people in their family at least occasionally (33%), and spent at least 30 minutes to an
hour (27%) with older people on each contact. The majority of students (63%) stated
that an older relative lived with them and their family on a permanent basis. The mean
score of nursing students’ satisfaction of living with older people was 3.57 (SD = .70)
out of a possible range from one to five. The finding indicated that the majority of
students were neither satisfied nor dissatisfied with living with older people. There
was no significant difference between students in the two-year and four-year program
regarding satisfaction with the experience of living with older people (t (188) =1.43,
p=.16). Further, comparison between the two groups (See Table 4.1) revealed that more
students in the four-year program did not live with older relatives permanently than
students in the two-year program.
Gerontological course
Many nursing students (59%) indicated that they had not taken any subjects or
programs with content related to older people. Of the 41% of students who had taken
subjects or programs related to older people, only 27 (22%) of these students said that
the subjects or programs had more than 32 hours of content on older people in one
semester. The majority of students (70%) stated that less than 12 hours were spent on
programs related to older people (Table 4.2). Comparison of the students across the
two programs indicated that significantly more students from the 2-year program
(n=94) than the four-year nursing program (n=28) had studied gerontological courses
(Table 4.2).
89
Table 4.1
Comparison of contact with older people according to type of nursing program
4-year
program
(n=168)
2-year
program
(n=134)
²
f % f %
Contact with older people in your family
Yes 154 51.0 120 39.7
No 14 4.6 14 4.6 .40 NS
Contact with older people in family before
commencing course
Everyday 41 14.6 39 13.9 7.58 NS
Once a week 21 7.5 12 4.3
Twice a week 8 2.8 6 2.1
Three times a week 7 2.5 6 2.1
Once a fortnight 4 1.4 10 3.6
Once a month 16 5.7 12 4.3
Occasional 62 22.1 37 13.2
Time spent with older person on each contact
Less than 30mins 47 16.7 30 10.6 6.87 NS
30 minutes to 1 hour 37 13.1 46 16.3
1 to 2 hours 29 10.3 17 6.0
2 to 3 hours 15 5.3 11 3.9
More than 3 hours 31 11 19 6.7
Older relative living with student and family
on a permanent basis
Yes 97 32.1 93 30.8 4.35*
No 71 23.5 41 13.6
NS= not significant * p < 0.05
90
Table 4.2
Comparison of gerontological nursing courses undertaken by students, according to
type of nursing program
4-year
program
(n=168)
2-year
program
(n=134)
²
f % f %
Study of subjects or programs which had
content related to older people
Yes 28 9.3 94 31.1 91.02**
No 140 46.4 39 12.9
Time spent on subjects or programs about
older people
0 to 12 hour 18 14.5 69 55.6 6.87 NS
12 to 32 hours 3 2.4 7 5.6
More than 32 hours 8 6.5 19 15.3
NS= not significant; **p < .001
Clinical practice
Clinical practice refers to nursing practice under supervision in clinical
settings. The majority of nursing students (70%) had undertaken clinical practice in
their nursing program. Sixty-five percent (n=197) of all students had contact with
older people during their clinical practice. The mean score of nursing students’
satisfaction with their contact with older people during clinical practice was 3.40 (SD
= .64) out of a possible range from one to five. The data indicated that the majority of
students were neither satisfied nor dissatisfied with contact with older people during
clinical practice. There was a significantly greater number of students who undertook
clinical practice in the two-year program (n=134) than in the four-year nursing
program (n=78) (²(1)=102.26, p<.01). There was no significant difference in the
91
percentage of students in the two-year program (n=123) and 4-year program (n=74)
who had contact with older people during their clinical practice (²(1) =.08, p=.78).
Intention to work with older people
The mean score of nursing students’ intention to work with older people was
3.21 (SD = .80) out of a possible range from one to five. The data indicated that the
majority of students were uncertain about their intention to work with older people.
Comparison between students in the 4-year and 2-year programs indicated there was
no significant difference in intention to work with older people by students in these
two programs (t (299)=.83, p=.41).
Summary
The majority of nursing students were female and had undertaken clinical
practice in their nursing program. Half of the students had work experience in nursing,
while most students either had contact or lived with older people. Many of them had
not taken any study with content related to older people. The majority of students
were uncertain about their intention to work with older people.
Validity of Instruments
Exploratory fac1tor analysis was conducted to explore the underlying
dimensions, and to test construct validity of two scales: PWOP and KSOP.
Perceptions of Working with Older People (PWOP)
An exploratory factor analysis was performed on data from 302 undergraduate
nursing students. For the 15-item PWOP scale, Bartlett’s test of sphericity revealed a
92
chi-square value of 997.86 (p<.001). The Kaiser-Meyer-Olkin (KMO) measure of
sampling adequacy was .79 which is above the value of .50 required for deciding
whether factor analysis is appropriate (Tabachnick & Fidell, 2001b). The anti-image
correlation matrix, another requirement for factor analysis, was greater than .50 for
the 15 items. Bartlett’s test of sphericity, the KMO measure of sampling adequacy and
the anti-image correlation matrix confirmed that the data were suitable for factor
analysis.
The eigenvalues had four factors greater than one and the Cattell scree plot
suggested a four-factor solution. The four-factor solution, with and without varimax
rotation, was examined. In the four-factor solution, only one variable loaded on the
fourth factor, which is below the recommended number of two variables per factor
(Tabachnick & Fidell, 2001a). A three-factor solution with varimax rotation was
therefore undertaken which was also supported by Nolan, Davies et al’s use of three
areas in the construction of the original 15 item PWOP (Nolan, Davies et al. 2001).
However, in the three-factor solution, only two variables with the required factor
loading of .4 or more (Comrey & Lee, (1992) loaded on the second factor.
Interpretation of factors defined by only one or two variables is not recommended
(Tabachnick & Fidell, 2001a). Therefore, a two-factor solution with varimax rotation
was considered. The two-factor solution with varimax rotation, which accounted for
38% of the explained variance, was considered to provide an acceptable interpretation.
With a cut off of .4 for inclusion of a variable in the interpretation of a factor, four out
of 15 variables did not load on any factor. Table 4.3 shows the factor loadings for the
chosen solution.
93
The first factor, which contained 5 items reflecting intention to work with
older people, had a Cronbach alpha coefficient of .81. The second factor contained 6
items regarding career prospects and had a Cronbach alpha coefficient of .68. Four
items, “Nursing older people is challenging and stimulating”, “The older you are the
easier it is to have a good rapport with older people”, “Nursing older people is a
highly skilled job”, and “I am really anxious/I was really anxious about my first
placement with older people”, were not retained because of low factor loadings.
Therefore, two subscales with a total of 11 items “Intention to work with older
people” (5 items) and “Career Prospects of work with older people” (6 items) were
formed as measures of undergraduate nursing students’ attitudes toward older people.
Participants’ responses to these items ranged from strongly agree (5) to strongly
disagree (1). The scale included negatively worded statements that were reversed to
coincide with positively worded ones. Possible scores therefore ranged from 11 to 55
which differed from the original 15-item PWOP with possible scores ranging from 15
to 75, (Appendix 12). A total score was calculated by averaging the responses for the
items on the relevant subscale. Possible mean scores therefore ranged from one to five
with a high score indicating the nursing students held more positive attitudes toward
older people.
94
Table 4.3
Varimax Rotated Factor Loadings for the Students’ Perceptions of Working with OlderPeople (PWOP)
Intention to
work with
older people
Career Prospects
of work with
older people
I think older people are really interesting to
nurse
.832 .028
I would definitely consider working with older
people when I qualify
.822 -.039
I am really looking forward/I really looked
forward to my first placement with older
people
.804 -.012
Working with older people does not appeal to
me at all
.666 .311
Working with older people has a high status .534 .043
Once you work with older people it is difficult
to get a job elsewhere
-.001 .712
Working with older people is a dead-end job .205 .699
Working with older people is not a good career
move
.247 .690
Nurses work with older people because they
cannot cope with hi-tech care
.112 .654
Nursing older people provides little satisfaction
as they rarely get better
.084 .431
Nursing older people is mainly about basic
care - it does not require much skill
-.016 .400
Nursing older people is a highly skilled job .355 .139
Nursing older people is challenging and
stimulating
.197 .133
I am really anxious/I was really anxious about
my first placement with older people
.223 .283
The older you are the easier it is to have a good
rapport with older people
-.218 .283
95
Knowledge of the Situation of Older People (KSOP)
An exploratory factor analysis was performed on data from 302 undergraduate
nursing students for the 16 items of the KSOP scale. The anti-image correlation for 14
items was greater than .50. The two items, “The percentage of people currently over
the age of 100 is about 0.003% in the general population” and “People aged 65 years
and over are 2.6 times more likely to die of an accidental death than the middle aged
population” had an anti-image correlation less than .50. Therefore, these two items
were removed, resulting in a total of 14 items comprising the Taiwanese version of the
KSOP questionnaire. Bartlett’s test of sphericity revealed a chi-square value of 831.17
(p<.001). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for the
overall correlation matrix was .73 which is above the recommended value of .50
required for factor analysis (Tabachnick & Fidell, 2001a). The anti-image correlation
matrix was greater than .50 for the 14 items, another requirement for factor analysis.
Bartlett’s test of sphericity, the KMO measure of sampling adequacy and the anti-
image correlation matrix confirmed that the data for the 14 remaining items were
suitable for factor analysis.
The eigenvalues suggested a four-factor solution with four values greater than
1, while the Cattell scree plot suggested a three-factor solution. The four and three
factor solutions, with and without varimax rotation, were examined. In the four-factor
solution, only one variable loaded on the fourth factor. Interpretation of factors
defined by only one variable is not recommended (Tabachnick & Fidell, 200a).
Therefore, a three-factor solution with varimax rotation, accounting for 46% of the
explained variance, was considered. As factor loadings of .4 and above are considered
acceptable (Comrey & Lee, (1992) for inclusion of a variable in a factor, one of the 14
variables was not retained because of low factor loadings: “The percentage of people
96
over the age of 65 in some form of paid employment is about 11%”. Table 4.4 shows
the factor loadings for the chosen solution.
The first factor containing 6 items reflected daily activities and had a
Cronbach’s alpha coefficient of .79. The second factor containing 3 items reflected the
demography of older people and had a Cronbach’s alpha coefficient of .61. The third
factor containing 4 items related to the vulnerability of older people had a Cronbach’s
alpha coefficient of .53. Although the second factor was formed by only 3 items, it was
still included because it met another criterion for forming factors, that is it was
considered as theoretically appropriate (Tabachnick & Fidell, 2001a). However,
analyses of this subscale need to be interpreted with caution.
Therefore, the three subscales of Daily Activities (six items), Demography of
Older People (three items) and Vulnerability of Older People (four items), with a total
of 13 items, were formed in the measurement of undergraduate nursing students’
knowledge about older people. The response format asked individuals to indicate
whether a series of statistics about older people are “too high”,” about right”, or “too
low”. For data entry, “too low” was recorded as 1, “about right” was recorded as 2,
and “too high” was recoded as 3. However, in order to calculate the total score, the
correct answer to each item was recoded as 1 and the incorrect answer was recorded
as 0. Total possible scores therefore ranged from 0 to 13 (see Appendix 13), which
differed from the original 17-item KSOP with possible scores ranging from 0 to 17. A
high score on the KSOP indicated greater levels of nursing students’ knowledge about
older people.
97
Table 4.4
Varimax Rotated Factor Loadings for the Knowledge of the Situation of Older People
(KSOP)Daily
Activities
Demography of
Older People
Vulnerability of
Older People
The percentage of people over theage of 65 who need help with thefollowing activities:Using the toilet .804 .078 .016
Washing all over .768 .125 .118
Dressing .732 .049 .082
Assistance with eating .722 .005 .045
Get up to bed and get down frombed
.679 -.029 .030
Assistance with making a phone call .411 .303 -.105
The percentage of people over theage of 65 in Taiwan is about 9 %
.043 .823 -.017
Between now and 2030 thepercentage of people over the age of65 is expected to increase by about20%
.016 .790 .032
The percentage of people inAboriginal group who are currentlyover the age of 65 years in theTaiwan is about 6 %
.019 .618 .245
Of women over the age of 65 about40% will live alone
-.105 .094 .714
In any one year the percentage ofpeople aged 65+ who have an in-patient stay in hospital is about 7times more than other population
.052 .156 .632
Of people aged 65 years and overabout 56% report chronic illness ordisability
.162 -.010 .630
The percentage of people over theages 65 living in residential ornursing home is about 10%.
.187 .204 .480
The percentage of people over theage of 65， in some from of paidemployment is about 11%
.011 .060 .042
98
Reliability of Instruments
The internal consistencies of the KOP, PWOP, FAQ1, and KSOP for the 302
survey sample were examined. A test-retest was performed on a sample of nursing
students (n=43) with a 2-week interval between testing, as a test for temporal stability.
Kogan’s Attitude toward Old People Scale (KOP)
The Cronbach’s alpha coefficient for this sample was .83 for the total KOP
score. The test-retest reliability coefficient of .92 was obtained for the total KOP score.
These data indicate that the KOP for this sample was internally consistent and stable
over a too-week period. The level of the Cronbach’s alpha coefficient for this sample
was equal or higher compared with data from other studies (Kogan 1961; Kearney,
Miller et al. 2000; Soderhamn & Lindencrona, 2000).
Perceptions of Working with Older People (PWOP)
The Cronbach’s alpha coefficient was .75. The two-week test-retest reliability
coefficient was .86. These data indicate that the PWOP for this sample was internally
consistent and stable over a two-week period. As there are no published data on the
reliability of the PWOP, it is not possible to compare with other studies.
Palmore’s Facts on Ageing Quiz: Part 1 (FAQ1)
The Cronbach alpha coefficient for this sample for the FAQ1 was .71. The
test-retest reliability coefficient was .76. These data indicate that the FAQ1 for this
sample was internally consistent and stable over a two-week period. The level of the
Cronbach’s alpha coefficient for this sample was higher than data from other studies
(Palmore 1980; Norris, Tindale et al. 1987; Lusk, Williams et al. 1995)
99
Knowledge of the Situation of Older People (KSOP)
A coefficient alpha was computed for this newly formed instrument to
determine the internal consistency of the 13 items (n=302). The Cronbach’s alpha
coefficient was .72. The test-retest reliability coefficient was .82. These data indicate
that the KSOP for this sample was internally consistent and stable over a two-week
period. As there are no published data on the reliability of the KSOP, it is not possible
to compare this with other studies.
These analyses confirmed that the instruments were appropriate to use in the
current study. The findings for the KOP, PWOP, FAQ1 and KSOP scales were used to
describe the students’ attitudes towards and knowledge about older people.
Attitudes toward Older People
Kogan’s Attitudes toward Old People (KOP) scale
The nursing students who responded to this survey had a total mean KOP score
of 130 (SD=14.58), with scores ranging from 80 to 171 from a possible range of 34 to
204. The scale included negatively worded statements that were reversed to coincide
with positively worded ones. The higher the KOP score, the more positive the attitudes
held toward older people. As a score of 102 indicates a neutral attitude (Kearney, Miller
et al. 2000), the results for this study indicate that the nursing students in this study held
more positive than neutral attitudes toward older people. The statement with the highest
overall mean score was the item “When you think about it, old people have the same
faults as anybody else” (M=5.16, SD=0.68). The statement with the lowest overall
mean score was the item “Most old people need no more love and reassurance than
anyone else” (M=2.45, SD=0.90). The five highest and lowest statements ranked by
nursing students are listed in Appendix 14.
100
Perceptions of Working with Older People (PWOP)
The PWOP scales included negatively worded statements that were reversed
so that the scoring coincided with positively worded ones. The higher the total PWOP
score, the more positive the attitudes held toward older people. In the total PWOP, a
score of 22 indicates a neutral attitude with possible scores ranging from 11 to 55. The
nursing students who responded to this survey (n=302) had a total mean PWOP score
of 39.75 (SD=4.42) with scores ranging from 27 to 53. For the subscale of Intention,
students had a mean score of 15.72 (SD=2.94) with scores ranging from 6 to 24 out of
a possible range of 5 to 25. For the subscale of Career Prospects, students had a mean
score of 22.51 (SD=2.36) with scores ranging from 12 to 28 out of a possible range of
6 to 30.
These data indicated that the students had more positive than negative
attitudes toward older people. The statement with the highest mean score, indicating a
more positive attitude, in this survey was a reversed score statement “Nurses work
with older people because they cannot cope with hi-tech care” (M=4.19, SD=0.70).
The statement with the lowest overall mean in this survey was “I am really looking
forward/I really looked forward to my first placement with older people” (M=2.79,
SD=0.77). The five highest and lowest statements ranked by nursing students are
listed in Appendix 15. Consistent with the results from the KOP, the attitudes of
nursing students toward older people in this survey were quite positive.
Knowledge about Older People
Palmore’s Facts on Aging Quiz: Part 1
The mean level of knowledge for the nursing students who responded to this
25-item quiz was 12.61 (SD = 3.03) with scores ranging from 6 to 20 from a possible
range from 0 to 25, which is just lower than the mean of 16.25 to 17.5 average found
101
for other professional groups (Palmore 1988; Gibson, Choi et al. 1993; Stuart-
Hamilton and Mahoney 2003). The five highest and lowest ranked statements by
nursing students are listed in Appendix 16. Therefore, the results of the FAQ1 scale
indicate that nursing students had a low to moderate level of knowledge about ageing.
Knowledge of the Situation of Older People (KSOP)
For the overall 13-item scale, the nursing students who responded to this
survey had a mean total score of 7.20 (SD = 2.69) with scores ranging from 0 to 13.
For the 6-item subscale of Daily Activities, the students had a mean score of 3.47
(SD=1.86) with scores ranging from 0 to 6. For the 3-item subscale of Demography of
Older People, students had a mean score of 1.53 (SD=.81) with scores ranging from 0
to 3. For the 4-item subscale of Vulnerability of Older People, the students had a mean
score of 1.08 (SD=1.86) with scores ranging from 0 to 4. It therefore seems that the
students had just over 50% accuracy about certain facts relating to older people in
Taiwan today. The five highest and lowest statements ranked by nursing students are
listed in Appendix 17. Therefore, from the KSOP scale, the data showed that while the
nursing students had some knowledge of the ageing situation in Taiwan there was also
much that they did not know.
Correlations among Measures of Attitudes and Knowledg
Correlations were examined among the four measurements: Kogan’s Attitudes
toward Older People (KOP), Nolan’s Perceptions of Working with Older People
(PWOP), Palmore’s Facts on Ageing1 (FAQ1), and Nolan’s Knowledge of the
Situation of Older People (KSOP). Table 4.5 presents the correlations between
instruments. The survey data revealed that scores on the KOP had a significant
positive correlation (p < 0.01) with the PWOP, which is not surprising as both tests
102
are designed to measure attitudes toward older people. Moreover, there were
significant positive correlations (p < 0.01) between the FAQ1 and KOP, and between
the FAQ1 and PWOP. As Palmore (1977; 1988) noted, the FAQ1 can generate an
indirect measure of attitudes toward ageing, on the assumption that misconceptions
about older people can indicate positive or negative bias. Also, Klemmack (1978)
claimed that the FAQ was more a measure of attitudes than a measure of knowledge.
The significant and positive correlations between FAQ1, KOP, and PWOP indicate
possible similarity between these instruments, as measurements of attitudes toward
older people.
The survey data did not reveal a significant correlation between the FAQ1 and
KSOP, although both tests are designed to measure knowledge of ageing. This
supports the claims that FAQ1 is a measure of attitudes not knowledge. The KSOP
was not correlated with the other two attitudes instruments, which indicates that the
KSOP is a different type of instrument and clearly does not measure attitudes. These
data confirmed that the KSOP is a measure of knowledge and that the FAQ1 is more
likely to measure attitudes.
103
Table 4.5
Pearson correlation coefficients for attitude and knowledge scales
KOP PWOP FAQ1
PWOP .53** -
FAQ1 .44** .33** -
KSOP .04 .05 -.02
KOP=Kogan’s Attitudes toward Older People;
PWOP=Nolan’s Perceptions of Working with Older People;
FAQ1=Palmore’s Facts on Ageing: Part 1;
KSOP=Nolan’s Knowledge of the Situation of Older People
** p < 0.01
Correlations among Attitudes, Knowledge and Demographic Variables
Analyses of correlation coefficients were conducted to investigate the
potential interrelationships between the demographic variables as independent
variables and the two attitudes and two knowledge instruments as dependent variables.
Point biserial correlation coefficients were calculated to determine the relationships
between the categorical independent variables, such as program, gender, marital status,
working with older people, living with older relatives, contact with older people,
clinical practice, and taking courses related to older people, with the continuous
dependent variables of KOP, PWOP, FAQ1, and KSOP. Pearson product moment
correlations were used to analyse the relationship between the continuous independent
variables, such as age, length of working experience, satisfaction of working
experience, satisfaction of living with older relatives, length of clinical practice,
satisfaction of contact with older people in clinical practice, and intention to work
with older people, with the continuous dependent variables of KOP, PWOP, FAQ1,
104
and KSOP.
Attitudes toward older people
Consistent with the literature, several demographic variables were correlated
with attitudes toward older people. The KOP was found to have a low, negative but
significant correlation with age, the length of work experience and the length of
clinical practice. Satisfaction with living with older relatives, satisfaction with contact
with older people during clinical practice, and intention to work with older people had
moderate and significant positive relationships with KOP (Table 4.6).
Table 4.6
Pearson Correlations among demographics, KOP, PWOP, FAQ1, and KSOP
KOP PWOP FAQ1 KSOP
Age¹ -.15** .00 -.08 -.03
Length of working experience² -.17** .01 -.10 -.00
Satisfaction of work experience² .07 .16 .02 .03
Satisfaction of living with older
relatives³
Length of clinical practice
Satisfaction of contact with older
people during clinical practice
Intention to work with older
people
.43**
-.13*
.35**
.21**
.37**
-.03
.35**
.47**
.21**
-.04
.21**
.10
-.03
.02
.04
.05
** p < .01 level
* p < .05 level
¹n=299, ²n=148, ³n=187, n=193, n=298
With point biserial correlation coefficients, the KOP had low, positive but
105
significant correlations with type of nursing program, work experience, and clinical
practice (Table 4.7). Therefore, the data suggested that younger nursing students with
less work experience in nursing and less clinical practice tended to have more positive
attitudes toward older people. Students in the two-year program had more positive
attitudes than students in the four-year program. Students who had work experience
and experience of clinical practice had more positive attitudes than those who did not
have. However, when students had work experience and experience of clinical
practice, students who worked longer and had longer clinical practice had more
negative attitudes toward older people than those who had shorter work experience
and experience of clinical practice. Also, students with greater satisfaction with
contact with older people during clinical practice and living with older relatives as
well as intention to work with older people had more positive attitudes toward older
people.
The Pearson product moment correlations (r) indicated that the PWOP had a
moderate and significantly positively correlation with intention to work with older
people. Satisfaction with living with older people and satisfaction with contact with
older people during clinical practice also had a moderate and significantly positive
relationship with the PWOP (Table 4.6). Point biserial correlation coefficients
indicated that the PWOP had a low, negative but significant relationship with gender
(rpbis = -.13, p = .03) (Table 4.7). So the data suggested that students who had high
satisfaction with living with older people and were satisfied with contact with older
people during clinical practice and had a high intention to work with older people had
positive perceptions of working with older people. Also, female students had more
positive perceptions of working with older people than male students.
106
Table 4.7
Biserial Correlations among Demographics, KOP, PWOP, FAQ1, and KSOP
(N=302)
KOP PWOP FAQ1 KSOP
Nursing program .17** .11 .11 -.14*
Level of education .18 .00 .07 .12
Gender .02 -.13* .02 -.01
Martial status .06 -.05 .01 .05
Working experience .19** .01 .04 .09
Live with older people on permanent
basis
.02 -.06 -.01 -.05
Contact with older people in family -.10 -.08 .03 .03
Clinical practice .14* .03 .01 .03
Taking subject related older people .09 -.04 .02 .11
*p < .05, **p < .01
Knowledge about older people
The Pearson product moment correlations (r) indicated that the FAQ1 was
positively and significantly correlated with satisfaction of living with older relatives
and contact with older people during clinical practice (Table 4.6). The point biserial
correlation coefficients indicated that the FAQ1 had no significant relationship with
any dichotomous demographic variables (Table 4.7). Therefore, the data suggested
that students with greater satisfaction with living with older relatives and who were
satisfied with contact with older people during clinical practice had higher knowledge
about older people.
The Pearson product moment correlations (r) indicated that the KSOP had no
significant relationship with any continuous demographic variables (Table 4.6). Point
107
biserial correlation coefficients indicated that the KSOP had a low, positive but
significant relationship with type of nursing program (Table 4.7). Therefore, the data
suggested that students in the four-year program had greater knowledge of older
people than students in the two-year program.
Hence these data indicated that attitudes were correlated with several of the
independent variables but knowledge was only correlated with the different type of
program, satisfaction of living with older relatives, and satisfaction of contact with
older people during clinical practice.
Factors Influencing Nursing Students’ Attitudes and Knowledge
In order to explore which demographic factors were predictive of nursing
students’ attitudes toward older people and knowledge about ageing, standard
multiple regressions were performed. The criteria for including independent variables
in the multiple regression analysis were selected by the researcher based on three
sources: 1) the correlations with the dependent variables; 2) the related literature; and
3) the demographic data provided by all nursing students. For example, the
demographic question of the length of work experience in nursing was only answered
by those students who had work experience in nursing, so this variable was not
entered into a standard multiple regression. Next, checking collinearity diagnostics
between independent variables from the multiple regression models indicated there
was no multicollinearity between independent variables. Finally, the nine independent
variables which were selected for the regression analysis were: students’ age, gender,
nursing program, work experience in nursing, living with older relatives on a
permanent basis, contact with older people in the family, completion of subjects or
programs which had content related to older people, completion of a period of clinical
108
practice in their course, and intention to work with older people. Categorical predictor
variables were dummy coded as 0 and 1. The dependent variables were the four scales
and their subscales: two attitude scales (KOP and PWOP with its related two
subscales); and two knowledge scales (FAQ1 and KSOP with its three related
subscales). Standard multiple regressions were conducted and all predictor variables
were entered into each regression equation at the same time to evaluate the impact of
the predictor variables. The unique amount of variance that the predictor variables
added to the dependent variable was assessed.
In the multiple regression on the KOP attitude scale, all the predictor variables
accounted for 10% of the variance (R = .33, F 9,296 = 3.48 p<.001). The only
independent variable that contributed significantly to the prediction of attitudes
toward older people was intention to work with older people (p<.005). The model
indicates that nursing students with greater intention to work with older people had
more positive attitudes toward them (Table 4.8).
A multiple regression related to attitudes towards older people was conducted
on the PWOP scale. The multiple correlation coefficient (R) was .53 with all the
predictor variables accounting for 28% of the variance in PWOP, (F 9,299 = 10.97,
p<.001). Gender and intention to work with older people were significant and
independent predictors. The model indicates that nursing students who are female and
have greater intention to work with older people have more positive attitudes towards
older people (Table 4.9).
109
Table 4.8
Standard Multiple Regression on Kogan Attitudes toward the Older People (KOP)
B Std. Error β t
Program
Age
Gender
Work experience in nursing
Living with older people on permanent basis
Contact with older people in the family
Taking subject related to older people
Having clinical practice
Intention to work with older people
-.72
-.03
-3.36
-4.95
-1.27
5.09
.41
-1.10
3.96
3.56
.24
3.48
2.88
1.76
2.91
2.14
2.48
1.02
-.02
-.02
-.06
-.17
-.04
.10
.01
-.03
.22
-.20
-.15
-.96
-1.72
-.72
1.75
.19
-.44
3.86*
* p<.001
Table 4.9
Standard Multiple Regression on Perceptions of Working with Older People (PWOP)
B Std. Error Beta t
Program
Age
Gender
Work experience in nursing
Living with older people on permanent basis
Contact with older people in the family
Taking subject related to older people
Having clinical practice
Intention to work with older people.
-.63
.01
-2.87
-.20
.22
.93
.51
-.49
2.58
.97
.06
.96
.79
.48
.80
.58
.68
.28
-.07
.01
-.16
-.02
.02
.06
.06
-.05
.47
-.66
.14
-3.00*
-.25
.45
1.16
.88
-.72
9.18*
* p<.05
The multiple regression conducted on the PWOP subscale of intention to work
with older people resulted in a multiple correlation coefficient (R) .62 with all
predictor variables accounting for 39% of the variance (F 9,299 = 20.28, p<.001).
110
Similarly to the regression on the full PWOP scale, gender and intention to work with
older people were significant and independent predictors. The model indicates that
nursing students who are female or have greater intention to work with older people
have more positive intention to work with older people (Table 4.10).
Table 4.10
Standard Multiple Regression with subscale of PWOP in intentions to work with older
people
B Std. Error Beta t
Program
Age
Gender
Work experience in nursing
Living with older people on permanent basis
Contact with older people in the family
Taking subject related to older people
Having clinical practice
Intention to work with older people.
-.08
.02
-1.29
-.42
.21
.20
.12
.11
2.23
.58
.04
.58
.48
.29
.48
.35
.41
.17
-.01
.05
-.11
-.07
.03
.02
.02
.02
.61
-.14
.59
-2.23*
-.87
.73
.41
.33
.28
13.10**
* p<.05, **p<.001
The multiple regression on the PWOP subscale of career prospects of work
with older people, found a multiple correlation coefficient (R) of .22. The predictor
variables explained only 5% of the variance and no direct significant relationship was
found between the predictor variables and career prospects of work with older people
(F 9, 299 = 1.66 p=.10).
In the multiple regression on the knowledge scale of Palmore’s Facts on
Ageing Quiz: Part 1 (FAQ1), the resulting multiple correlation coefficient (R) was .19.
The predictor variables explained only 4% of the variance and no direct significant
111
relationship was found between the predictor variables and the FAQ (F 9, 295 = .94
p=.49).
In the multiple regression on Nolan’s Knowledge of the Situation of Older
People (KSOP), the multiple correlation coefficient (R) was .25 with all predictor
variables accounting for 7% of the variance (F 9,299 = 2.38, p=01). Type of program
and age were significant and independent predictors. The model indicates that nursing
students who are older or in the four-year program had greater knowledge about older
people (Table 4.11).
Table 4.11
Standard Multiple Regression with Nolan’s Knowledge of the Situation of Older
People (KSOP)B Std. Error Beta t
Program
Age
Gender
Work experience in nursing
Living with older people on permanent basis
Contact with older people in the family
Taking subject related to older people
Having clinical practice
Intention to work with older people.
-2.47
.09
-.20
.82
.51
-.54
-.41
.29
.18
.66
.04
.65
.54
.33
.55
.39
.46
.19
-.45
.22
-.02
.15
.09
-.06
-.07
.05
.05
-3.76*
2.18*
-.32
1.51
1.54
-.98
-1.04
.62
.96
* p<.005
A multiple regression was performed on each of the three KSOP subscales to
further explain possible relationships. The results of the multiple regression on the
KSOP subscale of daily activities indicated a multiple correlation coefficient (R) .30
with all predictors variables accounting for 9% of the variance (F 9,299 = 3.30, p=.001).
Type of program, age and living with older people were significant and independent
112
predictors. The model indicates that nursing students in the four-year program had
greater level of knowledge about daily activities of older people than students in the
two-year program. Also, students who lived with older people had greater knowledge
about daily activities of older people than students who did not live with older
relatives. Older students also had more knowledge about daily activities than younger
students (Table 4.12).
Table 4.12
Standard Multiple Regression with subscale of KSOP in daily activities of older
people
B Std. Error Beta t
Program
Age
Gender
Work experience in nursing
Living with older people on permanent basis
Contact with older people in the family
Taking subject related to older people
Having clinical practice
Intention to work with older people.
-1.86
.07
.01
.28
.47
-.18
-.24
.29
.29
.45
.03
.45
.37
.22
.37
.27
.32
.13
-.49
.26
.00
.07
.12
-.03
-.06
.07
.08
-4.13**
2.61*
.01
.76
2.10*
-.47
-.87
.92
1.43
* p<.05 **p<.001.
In the multiple regression on the KSOP subscale of demography of older
people, the resulting multiple correlation coefficient (R) was .10. The predictor
variables explained only 1% of the variance and no direct significant relationship was
found between the predictor variables and the demography of older (F 9, 298 = .36
p=.95).
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In the multiple regression on the KSOP subscale of vulnerability of older
people, the resulting multiple correlation coefficient (R) was .22. The predictor
variables explained only 5% of the variance and no direct significant relationship was
found between the predictor variables and vulnerability of older people (F 9, 298 = 1.67
p=.09).
So attitudes, as measured by the KOP and PWOP scales, and knowledge, as
measured by FAQ1 and KSOP, could be predicted by the independent variables.
Intention to work with older people was the independent variable that could predict
both attitude scales of KOP and PWOP scales, while PWOP was also predicted by
gender. Knowledge scale of KSOP was predicted by type of nursing program, age and
living with older relatives. The results indicated that female nursing students and
those with greater intention to work with older people had more positive attitudes
toward older people. Students in the four-year program, older students and students
who have lived with older relatives had greater knowledge about older people than
students in two-year program and younger ones.
Discussion
The general aim of this study was to provide the baseline data of attitudes
toward and knowledge about older people for developing a gerontological educational
program for an intervention in Study 2. Study 1 was undertaken to validate the
instruments, to examine the reliability of instruments, to gain a greater understanding
of Taiwanese nursing students’ attitudes toward and knowledge about older people, to
understand the relationship between the instruments, and to determine the factors
influencing the attitudes toward and knowledge about older people. This section
presents a discussion of Study 1.
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Validity and Reliability of Instruments
The KOP and FAQ1 scales had been used in previous studies. When compared
to similar studies, the reliability of KOP in this study was similar to that of other
studies (Kearney, Miller et al. 2000; Soderhamn and Lindencrona 2000), while the
reliability of FAQ1 was higher compared to what was found in others’ studies
(Palmore 1980; Norris, Tindale et al. 1987; Lusk, Williams et al. 1995). These data
support these two scales as reliable instruments to test the attitude toward and
knowledge about older people.
Because of the limitations of KOP and FAQ1, as described in the method
section, the instruments of Perceptions of Working with Older People (PWOP) and
Knowledge of the Situation of Older People (KSOP) were also used in this study.
However, the psychometric properties of the PWOP and KSOP had not been
established previously. Factor analysis was performed to establish the construct
validity and reliability. Factor analysis confirmed the validity of the PWOP and KSOP
scales. Internal consistency and test-retest of all four instruments were satisfactory.
These data provided support for the PWOP and KSOP as valid instruments and
indicated that the reduced versions of PWOP and KSOP can be used for measuring
students’ attitudes toward and knowledge about older people in Taiwan.
Attitudes
The baseline findings provided preliminary insights into the nursing students’
attitudes towards older people and the relationship between students’ backgrounds and
attitudes. The results of this study clearly showed that these nursing students held
positive attitudes toward older people. When compared to similar studies conducted in
115
United Kingdom (Kearney, Miller et al. 2000), United States (Tan, Hawkins et al.
2001; Prudent and Tan 2002; Gellis, Sherman et al. 2003), Australia (Menz, Stewart et
al. 2003), and in Singapore (Mehta, Tan et al. 2000), the nursing students’ attitudes
toward older people in this survey were more positive. While most studies of nurses’
attitudes toward older people have reported negative attitudes, there are some studies
that have reported positive attitudes consistent with the current study (Lin 1993; Wei
1995; Fitzgerald, Wray et al. 2003; McKinlasy and Cowan 2003; Tan, Zhang et al.
2004). Reviews and critiques of studies that have examined attitudes toward older
people have noted that negative attitudes may result from the type of instruments used.
The current study used a well-established instrument and a more recently developed
one that reflected more contemporary views on ageing. The students’ attitudes were
consistently positive across both instruments. This suggests that their positive
attitudes were consistent and not influenced by the type of instrument used.
The positive attitudes of the students are likely to reflect the Chinese culture of
Taiwan. As a cornerstone of the Confucian ethic, Chinese society is held to place a
high value on respect for older people. Older people are respected and honoured for
their wisdom and experience. Keifer (1992) points out that Confucian ideals pertain to
the family and the status of older people in Chinese society. There are mutual
obligations between older parents and adult children with adult children being obliged
to support their older parents. Also older people might live with their adult children,
perform various household chores and contribute by taking care of their grandchildren.
If the older parents live alone, the grandchildren could be asked by their parents to go
to their grandparents’ home in order to maintain the relationship between
grandparents and grandchildren. Therefore, the positive attitudes towards older people
held in Chinese society were supported by the finding of this study. However,
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although the attitudes toward older people were positive, the attitude scores indicate
there is still scope for the students’ attitudes to improve.
Knowledge
The students’ average knowledge scores on the FAQ1 and the KSOP were
12.61 and 7.2, respectively. Previous research using the FAQ1 has reported average
knowledge scores of 16.25 to 17.50 (Palmore 1988; Gibson, Choi et al. 1993; Paton,
Sar et al. 2001; Fitzgerald, Wray et al. 2003; Menz, Stewart et al. 2003; Stuart-
Hamilton and Mahoney 2003). This indicates that the students in the current study had
poorer knowledge than that found in previous research using FAQ1. Also, the KSOP
scores were just on the midpoint level. These results indicate that the knowledge of
the students was halfway between positive and negative and indeed lower than
expected. There is no previous research that has used the KSOP for comparing these
findings.
In Taiwan, in the early 90s, only 35% of nursing schools had introduced
gerontological nursing subjects (Huang and Lin 1996) and they were only offered as
elective subjects. A search of nursing education curricula in universities found that,
over the last ten years, gerontological nursing courses have become part of nursing
curricula, but still as elective subjects in the majority of universities. The majority of
students in the current study had not taken a subject or program with any content
related to older people. Therefore, limited knowledge about older people could be
expected. The issue of poor gerontological knowledge is disturbing and suggests that
there is little or no gerontological content included in any fundamental nursing or
introductory subjects. Gerontological content needs to be introduced in the early
stages of nursing programs to increase students’ knowledge about older people and
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their needs.
Factors Influencing Nursing Students’ Attitudes toward and Knowledge about Older
People
The findings suggest that nursing students’ intention to work with older people,
as well as gender, were important factors influencing their attitudes toward older
people. Nursing program, age, and living with older relatives were important factors
influencing their knowledge about older people. A reasonable proportion of the
variance in attitudes toward older people (10% KSOP and 28% PWOP) could be
accounted for by these variables. A smaller proportion of the variance (KSOP 7%;
FAQ1 4%) in knowledge about older people was accounted for by these variables.
Intention to work with older people, and gender, were the variables that made
an independent contribution to attitudes toward older people. In previous studies on
students’ attitudes, intention to work with older people has been a consistently related
factor (Pursey and Luker 1995; Kane 1999; Mehta, Tan et al. 2000; Gellis, Sherman et
al. 2003; McKinlay & Cowan, 2003). However, caution is needed, as these past
studies, as well as the current study, do not imply causality. As most studies are cross-
sectional in nature, it is not clear whether intention precedes positive attitudes or that
positive attitude precedes intention to work with older people.
As expected, gender was a predictor of positive attitudes, which is consistent
with previous studies (Cammer-Paris, Gold et al. 1997; Gorelik, Damron-Rodriguez
et al. 2000; Gellis, Sherman et al. 2003; Tan, Zhang et al. 2004). Less positive
attitudes among male students compared with female students have been observed in
previous studies (Tan, Hawkins et al. 2001; Laditka, Fischer et al. 2004). This could
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be explained by the common expectation in Chinese society that females are to
provide a caring role in the family. Previous studies have suggested that women may
be more attracted to the gerontological field because of the provision of service, as in
traditional caregiving roles (Slevin 1991). In this study, the finding is consistent with
previous research, showing that females had more positive attitudes than males.
Age, nursing program, and living with older people were the variables that
made independent contributions to knowledge about older people. In previous studies
on students’ knowledge, age has been a factor consistently related to knowledge about
older people (Wei 1995; Wan 1997; Yeh, Lin et al. 2001), with older students having
more knowledge about older people than younger students. It might be that as
university gerontological nursing subjects were usually elective subjects, and
therefore given in the later years of the program/course, the students are older when
they study and gain knowledge in the area. Also, older students might have more
experience of clinical practice or work experience in nursing, which increases the
chance of exposure to older people. The students could learn about older people
through their general life experience, which might increase their knowledge about
older people.
Type of nursing program contributed as a predictor influencing students’
knowledge about older people. Students in the four-year program had more
knowledge about older people than those in the two-year program. Looking at
students’ background, the majority in the two-year nursing program were from
nursing junior colleges. In the nursing junior college, the course places more emphasis
on practical nursing issues rather than theoretical ones. The education at junior
colleges aims at teaching students applied sciences and technology, so as to cultivate
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personnel with intermediate technical or managerial skills (Ministry of Education
2005). In the two-year nursing program at the university where the study was
undertaken, the course design focused on how to improve the students’ existing
knowledge, in order to help them to deal with their nursing work in the acute care
setting. Therefore, subjects tended to include more advanced scientific and research
knowledge. It was rare for subjects relating to older people to be presented to students.
However, in the four-year nursing program, the nursing course focuses more on
theoretical nursing issues rather than practical nursing skills. The course design
focuses on how to create the students’ nursing knowledge in order to increase their
nursing experience, so students needed to experience different nursing fields; the
gerontological nursing subject was one of these. Also, content related to older people
is integrated into other subjects in the four-year program. Hence it can be seen that
students in the four-year nursing program were likely to have more theoretical
knowledge about older people than those in the two-year nursing program because of
the differences in purpose of the nursing training between these two nursing programs.
Living with older relatives was also a predictor of students’ knowledge about
older people. Students who lived with older relatives had higher knowledge levels
than students who did not live with older relatives. This is not unexpected, as living
with older relatives could increase the chance of interaction with older people. During
the interaction with older people, they could pass on their experiences and knowledge
to the students. Students also could observe physical and psychosocial changes in
older people. So more exposure and direct observation might increase students’
knowledge about gerontology.
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Limitations of the Study
A number of limitations reduce the generalisability of the findings in the
current study. The study was conducted from a convenience sample in a private
university located in southern Taiwan. It is only one of thirteen universities across
Taiwan. The sample selection excluded second year students, since those were to be
participants in Study 2, so the responses may not truly reflect nursing students across
Taiwan.
In addition, the sample was comprised only of undergraduate nursing students.
Therefore, vocational school, junior college, technological school, and graduate
nursing students are not represented. Thus the results of the study can only be
generalised to undergraduate nursing students. As the study was cross-sectional,
causality cannot be implied in any link between variables examined and attitudes and
knowledge.
It is also acknowledged that the effect of concurrently administering two
scales measuring the same concept (e.g. attitudes) has not been examined in this study.
It is possible that completing the first presented scale may have influenced responses
to the second presented scale. The order of presented scales was kept constant in this
study. In future studies the order could be reversed for half the sample so the effect of
presentation order could be examined.
Despite these limitations, the study does have implications for nursing
education and future research. These will be discussed in the final chapter along with
the discussion of findings of Study 2. Study 1 was to provide baseline data on
attitudes toward and knowledge about older people for the purpose of developing a
121
gerontological educational program for an intervention in Study 2. Using the Study 1
results as baseline data, the following chapter presents the gerontological nursing
educational program that was developed and evaluated in Study 2.
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CHAPTER FIVE
Gerontological Nursing Education Program
Introduction
The results of Study 1 revealed that the attitudes of nursing students were
more positive than negative toward older people, when measured by Kogan’s
Attitudes toward Older People (KOP) and Perception of Working with Older People
(PWOP) scales. The Facts of Ageing Quiz: Part 1 (FAQ1) showed that the nursing
students had a moderate to low level of knowledge about ageing; and also the
Knowledge of the Situation of Older People (KSOP) showed they had some
knowledge of the ageing situation in Taiwan but that there was also much that they
did not know. Therefore, it is clear that students’ attitudes toward older people still
have room for improvement, also that significant improvements are needed in the
level of students’ knowledge about older people. In order to improve students’
knowledge and attitudes, it was decided to revise and restructure the existing
gerontological nursing subject in the four-year undergraduate nursing program of the
selected university.
The existing gerontological nursing subject offered at that university was an
elective subject conducted in the second semester of third year of the four-year
program. Students in the third year had experience with ill older people in their
clinical practice in an acute hospital. The issues of the lack of contact with healthy
older people before contacting ill older people and lack of experience with older
people during gerontological nursing subjects were identified in literature reviews and
needed to be considered. For these reasons, the researcher negotiated with the nursing
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faculty to shift the gerontological nursing subject from second semester in third year
to second semester in second year. In the second year of their nursing course the
majority of students have not yet started clinical practice. Also, second year students
had basic knowledge about nursing and had started to learn the fundamental nursing
skills, so the gerontological nursing subject was not only shifted to second year but
also changed from a free choice elective to a compulsory subject, to ensure all second
year students studied it. In addition, the focus of the gerontological nursing subject
was changed from caring for ill older people to caring for healthy ones; consequently,
the objectives and content of the gerontological nursing subject were revised.
Therefore, two different programs were developed and offered; one using
experiential-based learning (EBL); the other using lecture-based learning (LBL).
Because the study was designed to test the specific learning methodology, the
objectives and content needed to be similar between the groups, but the approach to
delivering the subject was different.
In the selected university in Taiwan, the gerontological nursing subject had
traditionally been conducted through didactic lecture-based learning (LBL). Although
didactic lecture-based learning may have great value in terms of gaining knowledge, it
focuses mainly on students’ conceptual understanding (Ramsden, 2003). In Taiwan, it
is usual for teachers to transmit their knowledge; the student is a passive receiver of
that knowledge and they memorise the information that the teacher gives during the
lecture in order to pass the examination. During the class, there are no active
interactions between students and teachers, and there is no experience or interaction
with older people during the gerontological nursing subject, and no reflection on
students’ experiences with older people. Thus, gerontological nursing courses in
Taiwan need to be designed so that students not only obtain knowledge about older
124
people but also gain experience with older people. Also students need to actively
participate in their classes so that improved the interaction between students and
teachers occurs. Therefore, it was proposed that introducing practical experience with
older people into the gerontological nursing subject would result in improved
students’ attitudes toward and knowledge about older people.
A new approach to deliver gerontological nursing content using Kolb’s
experiential learning model was suggested by other authors (Bullard et al., 1996;
Gillis, 1991; Marte, 1991; Spier, 1992). Kolb (1984) stated that learning was viewed
as a life-long process in which transactions occurred between the learner and the
environment. Experiential learning is a holistic framework of the learning process and
integrates affect, perception, cognition, and behaviour; it emphasises the central role
of experience in the learning process, “the process whereby knowledge is created
through the transformation of experience” (Kolb, 1984, p.38), so it can reflect the
nature of professional nursing with its blend of action, experience and cognition
(Cavanagh et al., 1995). For these reasons, students need to be introduced to
experiential learning not only to focus on their conceptual understanding of older
people but also to gain experience from interacting with older people and reflecting
on the experience so as to enhance positive attitudes towards and knowledge about
them.
In the second semester of second year in the four-year program, there are three
core subjects, three free choice elective subjects, and one compulsory subject. The
major core subjects are:
1. Fundamentals of Nursing and its related clinical practice, which provides
opportunities for students to understand basic human needs and human
125
responses to stress situations, to help them to develop common knowledge
and skills in the nursing care of patients in an acute hospital;
2. Nursing Process, which assists students to understand the concept of
nursing process and to apply the nursing process to evaluate patients’
needs, assess patients’ health problems and solve them; and
3. Pharmacology, which provides students with the basic concepts of
pharmacological function and theory.
The elective subjects are:
1. Human Relationships, which provides the concept of the interaction
between human and environments;
2. Therapeutic Nutrition, which assists students to apply the knowledge of
nutrition to care for patients with different types of diseases; and
3. Parasitology, which introduces the concept of parasites and the relationship
between humans and parasites.
The one compulsory subject was gerontological nursing.
This chapter presents the gerontological nursing educational program that was
developed and evaluated in Study 2. It includes an overview of the gerontological
nursing subject and activities of teaching and learning in the usual lecture-based
learning group, followed by a description of the educational intervention program and
activities of teaching and learning in the experiential-based learning group. A
summary concludes the chapter.
126
Overview of Gerontological Nursing Subject in Lecture-Based Learning Group
The gerontological nursing subject was offered over one semester, over 16
weeks in the second semester of the second year. The regular class was 2 hours a
week in the university setting. The class activities included lectures.
The teaching method used for the gerontological nursing subject was based on
didactic lectures; no class activities and discussions were carried out in the class.
There were no demonstrations of nursing skills and experience with older people
during the class. Questions were asked by lecturers at the end of lectures but were
rarely answered by students. Students received all information through the lecture and
were asked to read a textbook and memorise all information in order to pass the
examination. This style of teaching is the usual method for all teaching in the nursing
program in the study university. The lecturers were not asked to make any changes to
their teaching styles.
Aim and objectives
The aim of the gerontological nursing subject for students in the selected
university was to improve students’ attitudes toward and knowledge about older
people by using the usual lecture-based learning strategy.
As the existing gerontological nursing subject was delivered in the third year,
the content and objectives of the subject was designed not only to introduce
gerontological nursing but also to help students care for older people in an acute
hospital. It focused on the issues of caring for ill older people rather than for healthy
ones. Therefore, in order to focus on well older people, the existing gerontological
127
nursing subject was changed; its objectives were reset so as to focus on well older
people. One group addressed these objectives through LBL; the other group addressed
these objectives through EBL.
The objectives of the gerontological nursing subject were to enable students to:
describe the concept of ageing;
understand the natural changes related to ageing and the role of nurses in
response to these changes;
describe gerontological nursing;
carry the knowledge of gerontological nursing into practice;
recognise the roles of gerontological nurses in caring for older people;
explore positive and negative attitudes toward older people;
identify mismatched values between older people and self and determine
relationships among values;
discuss current gerontological issues related to older people.
Classroom situation
The gerontological nursing subject in the lecture-based learning (LBL) group
was not conducted by lecturers from the selected university but was delivered by two
lecturers from other universities. It is common practice for lecturers to be brought in
when the teaching cannot be covered by the university staff. In order to ensure that the
two lecturers in LBL group delivered the program in the way it was designed, the
researcher discussed with the two lecturers the teaching strategies to be used.
Although the two lecturers were not lecturers in the selected university, they were
128
lecturers in other universities teaching gerontological nursing subjects and had
expertise in the gerontological nursing area. Also, these two lecturers did not have any
exposure to experiential learning or experience in it.
Content
Because the study was designed specifically to test the methodology, the
content of the subject was the same as in the experiential-based learning group. The
content of lectures covered normal physical, psychological, and social changes due to
ageing and theories of ageing. The social, emotional, and cognitive needs of older
people, and preventing disease and maintaining and promoting well being, were also
included. Challenges to effective care provision and the allocation of resources were
also presented. The concepts of physical, psychological and social assessments and
communication with older people were included. Ethical issues and challenges of the
future of the nursing role in providing service to older people and the future
perspectives of gerontological nursing were also included in the content. Reading
from a gerontological nursing textbook was also required, to assist students in
understanding the concepts that had been presented during the lecture. The topics for
each week are shown in Table 5.1. The content of the gerontological nursing subject
was delivered through didactic lectures only. There was a two hour class each week
for 16 weeks; in weeks 1 to 7, the class had regular two-hour lectures each week;
weeks 8 and 9 were for students to prepare for their mid-term examination; weeks 10
to 14 continued the regular lectures of 2 hours a week; and in weeks 15 and 16
students prepared for their final examination.
129
In the second semester of second year, the students also studied fundamental
nursing and related clinical practice. Three hours of class lectures each week were
taught by a team of faculty members (usually four to five lecturers), followed by 5
hours of nursing skills practice in the nursing laboratory. In the nursing laboratory,
students were allocated into five or six groups. Nursing skills practice was supervised
by another team of faculty members (usually five to six teachers) in the university
setting. One teacher demonstrated a nursing skill to the class; students imitated the set
of procedures for their teacher. At the end of semester, students undertook clinical
practice, consisting of a total of 40 hours in the acute hospital. The content of clinical
practice was the same across the two groups. Students needed to engage in physical
nursing activities, such as measuring vital signs and nursing assessment in the
hospitals. They needed to complete fundamental nursing procedures under the
supervision of their clinical instructors.
Teaching approach
As mentioned in the previous section, the didactic lecture was the only
teaching method used in the lecture-based learning group. There was no class activity
involvement during class time. The lecturers gave students information that they
required for their assessments; brief and readable lecture notes and handouts were
given out before each lecture to confirm and reinforce the main point of a lecture.
Questions, such as ‘any questions for this section’, were asked by the lecturers at the
end of sections.
130
Table 5.1
Content of gerontological nursing in lecture-based learning group
Topic Teaching
method
Week 1 Introduction of gerontological nursing Lecture
Week 2 Older people and physical ageing
Life expectancy and the demographics of ageing
Lecture
Week 3 Ageing theory Lecture
Week 4 Communication
—theory of communication
Lecture
Week 5 Changes of biological ageing Lecture
Week 6 Changes of biological ageing Lecture
Week 7 The psychology of ageing: theories of adult development Lecture
Week 8 Preparation for Mid Examination Lecture
Week 9 Midterm Examination
Week
10
Social perspectives in ageing Lecture
Week
11
Nursing assessment of older people
—functional assessment
Lecture
Week
12
Nursing assessment of older people
—psychosocial assessment
Lecture
Week
13
Ethical issues in gerontological nursing Lecture
Week
14
The future perspectives of gerontological nursing Lecture
Week
15
Preparation for final Examination Lecture
Week
16
Final Examination/Evaluation
Week
20
Clinical practice related to fundamental nursing
131
Assessment
There were two assessments for the gerontological nursing subject, including a
mid-term examination and a final examination to assess the students’ learning
outcomes. There were 33 multiple-choice questions in the mid-term examination.
Twenty multiple-choice questions and two short answer questions were included in
the final examination. Each assessment was worth 50%.
There were 30 students in the lecture-based learning group; they completed
the research instruments: the demographic data sheet; Perceptions of Working with
Older People (PWOP); and Knowledge of the Situation of Older People (KSOP). The
research instruments were completed three times. At the beginning of the
gerontological nursing subject, the students were invited to complete the research
instruments. At the end of the gerontological nursing class in week 16, and also on the
last day of clinical practice in week 20, students were again invited to complete the
research instruments.
Overview of Educational Intervention Program in Experiential-Based Learning
Group
Using Kolb’s experiential learning model as described in Chapter Three, the
experiential learning approach was fully implemented throughout the whole
gerontological nursing subject for the EBL group. The new approach for the
gerontological nursing subject was offered in one semester, over 16 weeks with a total
of 32 hours, in the second semester of the second year of the nursing course. It had the
same contact hours as the LBL group. The gerontological nursing subject for the EBL
group had a reduced didactic lecture time, increased interactions between students and
lecturer and had real life experiences with older people introduced. A range of
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teaching activities were introduced, such as lectures, group discussions, visits to a
Senior Apartment, journal writings, debriefings, a simulation game, and a role play.
Students received gerontological nursing knowledge through a lecture and
lecture notes and were encouraged to search for information that they needed. By
reducing the didactic lecture time, it was possible to increase class activities,
including small group and class discussions which are crucial in encouraging students
to participate and in increasing the interaction between the teacher and students.
Experience is the central theme of experiential learning, so an experience in a Senior
Apartment was an important way to bridge theory and practice and increase the
students’ experience with healthy older people. Journal writing and debriefings were
used with each activity to allow students to express their feelings.
Aim and objectives
The aim of the educational intervention program for second year students in
the selected university was to improve students’ attitudes toward and knowledge
about older people by using experiential-based learning strategies. The gerontological
nursing objectives in the experiential-based learning group were the same as for the
lecture-based learning (LBL) group. The content was also the same as for the LBL
group.
Classroom situation
The experiential-based learning approach for the gerontological nursing
subject was conducted by the researcher. Participants were 30 second year nursing
students. The subject was delivered for 16 weeks for a total of 32 hours. The subject
was conducted in two settings: the classroom and a Senior Apartment in a community
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setting. In the EBL group, the subject format included a total of 11 hours of lecture
time followed by a total of 6 hours of small group discussion and class discussion, 2
hours of a simulation game, 1 hour of a role play in the university setting and a total
of 8 hours experience with healthy older people in a Senior Apartment plus 4 hours
for examinations.
Content
As mentioned in the content section in LBL group, the content for EBL group
was the same as LBL group. Reading from a gerontological nursing textbook was also
required to assist students in understanding the concepts that had been derived from
the lecture. The topic for each week is shown in Table 5.2 and details are shown in
Appendix 21. The content for the EBL group was delivered through many types of
teaching strategies that are discussed in detail in the next section on teaching approach.
The conceptual understanding of gerontological nursing content was presented
through 11 hours of lectures. The perceptions of older people and experience with
well older people were facilitated through class activities such as group discussions,
simulation games, role play, visiting a Senior Apartment, and journal writing and
debriefing. The class activities did not directly relate to increases in knowledge,
however, as the concrete experience phase of the experiential learning model, they
played an important role in providing experience with older people. Such activities
explore the learner’s personal involvement in the learning situation and can be
effective in promoting positive behaviour toward older people (Karner et al., 1998).
Moreover, they can promote collaboration, as participants meet and discuss the
special needs of older people, clarify misconceptions about them and develop an
understanding at their difficulties. For all the other subjects undertaken during the
semester, the students in the EBL group attended the same lectures as the lecture-
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based learning group.
Teaching approach
The teaching methods and activities were planned around the different phases
of the experiential learning model. Figure 5.1 lists the learning activities that were
used in this study to engage the students in each of the four poles of the learning
model. As described in Chapter Three, Kolb’s experiential learning model is a four-
phase cycle. The phases are: concrete experience (CE), reflective observation (RO),
abstract conceptualisation (AC), and active experimentation (AE). CE enables
students to experience and dealing with human situations in a personal way while RO
is focused on understanding the meaning of ideas and situations by careful
observation from different perspectives and impartially describing them (Kolb, 1984).
AC is used to develop explanations of what has been experienced and lastly, AE
emphases active doing. These four learning phases of the cycle were used
simultaneously in delivering the gerontological nursing subject to the EBL group.
CONCRETE EXPERIENCE
Experience in Senior Apartment
Previous personal experience
ACTIVE EXPERIMENTATION REFLECTIVE OBSERVATION
Role play Discussion
Simulations game Journal
Skill practice in the laboratory Debriefing
ABSTRACT CONCEPTUALIZATION
Lecture
Textbook reading
Figure 5.1 Learning activities based on the experiential learning model
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Below is a description of the activities that were used to engage students in
each of the four learning phases.
Experience in a Senior Apartment. This experience with healthy older
people in a Senior Apartment in the community setting served as a concrete
experience (CE) in the experiential learning cycle, giving students the opportunity to
explore their attitudes. For example, active involvement was utilised by allowing
students to observe, assess, and communicate directly with older people in order to
make their learning meaningful; these experiences were developed and guided by the
lecturer. The Senior Apartment in the community setting was chosen because the
majority of well older people stay in the community. It was 30 to 40 minutes’ drive
from the university, an apartment located in the community, reserved for older people
who are aged 60 and over and can fully and independently care for themselves. Many
kinds of leisure activities are provided to older people every day in the Senior
Apartment in order to increase the interaction among them; participation in these
activities is voluntary. Chinese and Western medical doctors regularly visit the
apartment; nursing care consultants and pharmacological and nutritional consultants
are also provided for the older people. All students in the EBL group were placed in
the same setting and worked with one or two of these older people. For each visit to
the Senior Apartment, students were provided with guidelines on a different selected
topic to allow them to apply knowledge to the real situation.
There were four visits to the Senior Apartment, in weeks 2, 5, 10, and 13. In
week 2, the first visit, students were divided into three groups and guided by the three
staff who worked in the apartment. This provided students an opportunity to
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understand the environment of a Senior Apartment and its function for older people.
Then, students were asked to work as a pair and to talk with at least one older person
in the apartment using the guidelines. A practice communication skill with older
people in the Senior Apartment was carried out in week 5. Students had to conduct an
interview with a healthy older person, using guidelines provided, in order to learn
general and therapeutic communication and interpersonal skills, the positive and
negative aspects of ageing, and as a foundation for assessing older people. The third
experience in the apartment was conducted in week 10. Students were still provided
with a guideline sheet before conducting an interview, however, in this case,
questions were not to be asked directly from the sheet; they did not take it with them
when they conducted their interview. For the final visit in week 13, students had to
assess and evaluate a well older person’s health status, medication, exercise routine,
and diet with the goal of assessing how older people maintain their current health
status and promote their well-being. Immediately after the completion of each visit
there was debriefing and discussion. Students were asked to write a reflective journal
after each visit.
Group discussion. Discussion sessions served as the reflective observation
(RO) in the experiential learning cycle; providing an opportunity for students to think,
talk, and share their ideas with other members of the group. It also encouraged
students to reflect on their experience and the experiences of others. In the group
discussion sessions, thirty students were divided into five to six small groups. Groups
were given a set of questions related to the topic of each lecture and activities. The
discussions took place after each lecture and the activity lasted for 15 to 20 minutes.
Each student was expected to think about the questions and share the answer with
other members in the small group. A leader for each group was asked to summarise
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their ideas to the whole class. Each individual student was expected to lead the small
group once during the gerontological nursing subject.
Journal writing. Writing a journal was also offered as a reflective
observation (RO) in the experiential learning circle. Students were asked to write a
reflective journal after each activity and each contact with well older people. There
were seven journal entries due on weeks 3, 5, 6, 8, 11, 14, and 15. In order to provide
guidelines to students, they were provided with key questions to consider for their
journal entries, which could include their own feelings encountered during the
observation and interview with older people and strategies to deal with them. Journal
writing can encourage students to reflect on their experience and the experiences of
others.
Debriefing. Immediately after the completion of each activity there was a
debriefing session. The debriefing session served as a further reflective observation
(RO) in the experiential learning cycle; it promoted collaboration as participants met
and discussed the special needs of older people and clarified misconceptions about
them. Positive feedback or reinforcement was given by relating a student’s
performance to a desired goal to facilitate learning. Debriefing periods followed each
visit to the Senior Apartment in weeks 2, 5, 10, and 13 and allowed students to
discuss their feelings for each contact with older people. A debriefing period followed
the simulation game in week 7 to allow students to discuss their feelings about being
an older person, identify myths exposed in the game, and think about possible nursing
actions to help older people cope with their limitations.
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Lecture. Lectures were offered as class learning activities for abstract
conceptualisation (AC) in the experiential learning cycle. (The content of lectures has
been listed in an earlier section.) All the material was presented in a logical and
organized manner, and content proceeded from simple to complex. In order to assist
students’ retention, repetition of the concepts and facts and summarizing of content
was used.
There were nine lectures covering eight topics in weeks 1, 3, 4, 6, 8, 11, 12, 14,
and 15, for a total of 11 hours. They were carried out in the university setting; the
lecturer gave students the information that they needed for their assessments. Brief
and readable lecture notes and handouts were given before each lecture to confirm
and reinforce the main points. The lecturer asked students questions related to topics
raised during the lecture in order to check on their understanding.
Textbook reading. Reading was offered as a learning activity for the abstract
conceptualisation (AC) phase of the experiential learning cycle. Reading from a
gerontological nursing text was required, to assist students in understanding the
concepts that had been presented in lectures. Students were given selected chapter
readings for each topic and were expected to read the chapter before undertaking a
lecture in order to get general ideas beforehand and to raise questions from the pre-
reading. They were also expected to read a textbook after the lecture in order to get
better understanding from their reading. Also, students were encouraged to do further
reading or to do searches for themselves, in order to find out more about older people.
Simulation game. A simulation game was offered as active experimentation
(AE) in the experiential learning circle; it was carried out in week 7 in the laboratory.
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The “Into Aging” simulation game was adapted from Marte (1991) and used as a class
activity. It allows students to experience, vicariously, the daily struggles in the lives of
older people. The simulated life events engaged in by the students are those that are
most likely to happen in the real world (Marte, 1991). The game required about one
and half hours to complete; students were asked to work in pairs. As the activity
progressed, the students experienced the lives of older people and types of physical
losses that older people experience in their daily activities. The activity provides the
experiences of physical limitation such as hearing, vision, taste, smell, tactile sense,
and mobility. For example, students were asked to put cotton wool into both their ears
in order to imitate hearing problems and were then asked to talk with other students.
Using yellow transparent film to cover their eyes, students could experience blurred
and yellow vision. With dry corn kernels taped under students’ feet, they could feel
the pain of the corns. To simulate the limitations of mobility, students were asked to
bandage up their elbow and knee joints, and then walk around and climb the stairs
with limited joint movement. The students had to carry on the game with these
obvious physical limitations; each student was asked to experience all of them. At the
completion of the activity, a debriefing and discussion were immediately carried out.
Students were asked to write a reflective journal after the activity.
Role play. Role play serves as active experimentation (AE) in the
experiential learning cycle. A role play was carried out in week 15 in the classroom.
Students were divided into six groups and encouraged to imitate a problem situation
arising from their previous experience with older people in the Senior Apartment, or
from observation of older people in their daily life. For the role play, students were
provided an opportunity to integrate the concepts that they had learned during the
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gerontological nursing subject and apply these concepts to solve the problems. At the
completion of the activity, a debriefing and discussion were immediately carried out.
Skills practice in the laboratory. Gerontological skills practice, such as
communication and physical and psychological assessment skills of older people, was
provided in the university laboratory setting as active experimentation (AE). The
practice sessions were carried in week 4 and week 12. There were two major skills
including communication skills and assessment skills. Before practicing assessment
and communication skills with older people in the Senior Apartment, students were
asked to practice in pairs with their classmates in the laboratory. Students were given
guidelines to follow for the communication skills and physical and psychological
assessments.
Therefore, in the EBL group, lectures were not the only teaching strategy.
Other strategies included simulation games, role play, experience with healthy older
people in the community, discussion sessions, and writing journals during class time.
There were eight topics. The topics were the same as for the LBL group and are
outlined in Table 5.2
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Table 5.2
Overview of gerontological nursing program in experiential-based learning group:
Date Topic Learning Activities andTeaching method
Stage ofexperientiallearning
Week1
Introduction to gerontologicalnursing
--Discuss previousexperience with olderpeople--Discuss course outlineand explain activities--Discuss how to studygerontological nursing--Give brief lecture abouttopic: Introduction togerontological nursing--Small group discussion--Class discuss thequestions
CE
AC
AC
ACRORO
Week2
Visiting the Senior Apartment--Assessment 1
--Group visiting theapartment--Observations of theapartment--Talk with older people--Debrief of students’thoughts and questions--Discuss individualpaper assessment #1
CE
ROCE
RO
ROWeek3
1. The demographic and lifeexpectancy of ageing2. Ageing Theory
--Homework to searchthe demographic data ofolder people--Small group discussionof the data--Discuss previousknowledge of the dataand ageing theory--Lecture the topic:demographic data ofolder people and ageingtheory--Small group discussionin the activity--Class discuss thequestions-- Individual paperassessment #1 due
AC
RO
CE
AC
RORO
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Date Topic Learning Activities andTeaching method
Stage ofexperientiallearning
Week4
Communication--Assessment 2
--Previouscommunicationexperience with olderpeople--Discuss the experience--Lecture topic:communication witholder people--Practicecommunication skillswith classmate--Discuss individualpaper assessment #2
CERO
AC
AE
RO
Week5
Practice communication skillsin Senior Apartment--Assessment 3
--Previouscommunicationexperience with olderpeople--Practicecommunication skill witholder people guidelines--Observations whilepracticing in the seniorapartment--Debrief of students’thoughts and questions-- Individual paperassessment #2 due--Discuss individualpaper assessment #3
AC
CE
RO
RO
Week6
Changes of biological ageing --Previous knowledge--Discuss the experience--Lecture: changes ofbiological ageing--Class discuss thequestions--The individual paperassessment #3 due
CERO
ACRO
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Date Topic Learning Activities andTeaching method
Stage ofexperientiallearning
Week7
Simulation game--Assessment 4
--Discuss the previousexperience of physicallimitations--Simulation game--Observation and realexperience of biologicalageing--Discussion of students’thoughts and questions--Discuss the individualpaper assessment #4
ACCE
RO
RO
Week8
1. The psychology of ageing:theories of adult development2. Social perspectives in ageing
--Previous experience--Group discussion: thelate life crisis--Lecture: Psychology ofageing and socialperspectives in ageing-- Individual paperassessment #4 due
CE
RO
AC
Week9
Mid-term Exam-- Assessment 5
Week10
Practice in Senior Apartment--Assessment 6
--Discuss the previousexperience in assessment--Practicecommunication skillswith older people usingguidelines--Observations whilepracticing in the seniorapartment--Debrief on students’thoughts and questions--Discuss the individualpaper assessment #6
AC
CE
RO
RO
Week11
Nursing assessment of olderpeople--functional assessment
--Discuss the previousexperience of physicalassessments--Discuss the experience--Lecture: functionalassessments--Class discuss thequestions-- Individual paperassessment #6 due
CERO
ACRO
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Date Topic Learning Activities andTeaching method
Stage ofexperientiallearning
Week12
Nursing assessment of olderpeople--psychosocial assessment
--Discuss the previousexperience ofpsychological assessment--Discuss the experience--Lecture: Psychologicalassessment--Practice with classmate--Class discussion thequestions
CERO
ACAE
ROWeek13
Clinical Activities--Assessment 7
--Discuss the previousexperience of functionaland psychologicalassessment--Practice physical,psychological and socialassessment skills witholder people usingguidelines--Observations whilepracticing in the seniorapartment--Debrief on students’thoughts and questions-- Discuss individualpaper assessment #7
AC
CE
RO
RO
Week14
Ethical issues in gerontologicalnursing
--Discuss the previousexperience of ethicalissues--Discuss the experience--Lecture: ethical issuesrelated to older people--Small group and classdiscussion the questions--Individual paperassessment #7 due
CERO
AC
RO
Week15
--Nursing role in providingservice to older people--The future perspectives ofgerontological nursingperspectives of gerontologicalnursing--Assessment 8 (role play)--Assessment 9
--Discuss the thinking ofgerontological nursesrole--Lecture: futureperspectives ofgerontological nursingand nursing role--Role play--Discuss individualpaper assessment #9
RO
AC
AE
Week16
Final Examination/Evaluation--Assessment 10
--Individual assessment#9 due
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Assessment
In order to follow the experiential learning model, the EBL assessment was
different from the lecture-based learning group. There were ten assessments,
including two examinations and eight journal entries. In the examinations, the
students had the same examination papers as the students in the lecture-based learning,
in the same classroom with the same schedule for examinations, in weeks 9 and 16.
The examinations were to help lecturers to understand the students’ knowledge level
about older people; journal entries followed each of the eight activities, in order to
understand the students’ thoughts and feelings. There was 10% allocated to each
journal entry with a total weight of 80%. Also, there was 10% allocated to each
examination with a total weight of 20%. These assessment weightings were quite
different from the LBL group which had 50% allocated to each examination.
Thirty students in the EBL group completed the research instruments: the
demographic data sheet, Perceptions of Working with Older People (PWOP), and
Knowledge of the Situation of Older People (KSOP) at the beginning of the
gerontological nursing subject in the classroom, at week 16 in the classroom, and on
the last day of clinical practice in week 20 in the clinical practice setting in the
hospital.
Summary
This chapter outlined the overview of the LBL gerontological nursing program
and its related aim and objectives, class situation, content, teaching approaches and
assessment as well as the EBL gerontological nursing educational program and its
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related experiential learning strategies. The gerontological nursing educational
program was designed to be used in Study 2. The following chapter will describe
Study 2 and present its findings.
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CHAPTER SIX
Study 2: Evaluation of Educational Intervention
The purpose of Study 2 was to evaluate a gerontological nursing education
intervention designed to reinforce positive attitudes and improve knowledge related to
older people and the ageing process, with a sample of second-year undergraduate
nursing students. The aims of Study 2 were: (1) to evaluate the effect of an
experiential learning strategy on nursing students’ attitudes towards and knowledge
about older people compared to lectured-based learning in Taiwan; and (2) to examine
students’ reactions to the gerontological nursing subject and the experiential learning
strategies used in the experiential-based learning group. This chapter outlines the
method used to conduct the study, sample characteristics, quantitative results,
qualitative results of the focus group and a discussion of the findings.
Method
Research Design
A quasi-experimental design using pre- and post-tests with intervention and
control groups was selected for the study. The experimental group received an
experiential-based learning (EBL) strategy and the control group received the usual
lecture-based learning (LBL) method. Both groups had a pre-test at the beginning of
the course, a post-test at the end of the course during lecture time in week 16. Then,
both groups had a second post-test after the end of their clinical practice in week 20.
The specific notation for the design is outlined in Table 6.1.
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Table 6.1
Quasi-experimental design for the study
GroupPre-test
(week1)
Program
Intervention
Post-test
(week16)
Clinical
practice
(week20)
Post-test
(week20)
Control Group Usual Lecture
Based Learning
Experimental
Group
New Experiential
Based Learning
In order to get feedback from students on the experiential learning strategies, a
qualitative aspect was also included. Qualitative data were collected from a focus
group interview, as the researcher was interested in feedback from students who
participated in the experiential-based learning. A focus group is a form of group
interview through which data are generated from the interactions between research
participants (Kitzinger, 1995). It encourages people to talk to one another, asking
questions, exchanging anecdotes and commenting on each others’ experiences and
opinions (Kitzinger, 1994, 1995). Therefore, this method is particularly useful for
exploring people’s experiences and knowledge and can be used to examine not only
what people think, but how they think and why they think that way (Kitzinger, 1995).
The purpose of the focus group in this study was to evaluate the gerontological
nursing education program and the students’ reactions to the experiential learning
strategies.
Variables
Consistent with the design and purpose of the study, the dependent variables in
this study were nursing students’ attitudes toward, and knowledge about, older people.
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For the purpose of this study, attitudes toward older people were defined as mental
views based on cumulative experience and directed toward individuals; in this case,
attitude refers to student’s thoughts and feelings about older people (Kogan, 1961).
Knowledge refers to useful information that can be acted upon in the course of
decision making, problem solving and critical thinking; in this case, knowledge refers
to information about older people (Palmore, 1998). The concepts were measured with
two instruments: Perception of Working with Older People (PWOP) and Knowledge
of the Situation of Older People (KSOP). A more detailed description of the
instruments is included later in this chapter. The independent variable in this study
was the type of learning experience the students received: either the usual lecture-
based approach or the experiential-based learning approach.
Research Questions and Hypotheses
Consistent with the aims of this study, the following primary research
questions were asked:
1. Does the use of an experiential learning approach in a selected gerontological
nursing course improve students’ attitudes toward older people when compared to
the usual lecture based approach?
2. Does the use of an experiential learning approach in a selected gerontological
nursing course improve students’ knowledge about older people when compared
to the usual lecture based approach?
To achieve the aim of examining the students’ perceptions of experiential
learning strategies in the experiential-based learning group, the following primary
research question was asked:
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3. What were students’ perceptions of the experiential learning strategies after the
gerontological nursing educational program (asked of the experiential-based
learning group only)?
The following research hypotheses were formulated to examine research
questions 1 and 2:
Students studying a gerontological course who receive an experiential-based
learning strategy will have more positive attitudes toward older people than students
who receive the usual lecture-based learning strategy.
It was specifically expected that:
1a. Students studying a gerontological course who receive the experiential-
based learning strategy will report greater intention to work with older people than
students who receive the usual lecture-based learning strategy.
1b. Students studying a gerontological course who receive an experiential-
based learning strategy will rate the career prospects of working with older people
higher than students who receive the usual lecture-based learning strategy.
1c. Students studying a gerontological course who receive an experiential-
based learning strategy will have a higher level of gerontological knowledge than
students who receive the usual lecture-based learning strategy.
It was specifically expected that:
2a. Students studying a gerontological course who receive an experiential-
based learning strategy will have more knowledge about older people’s daily activities
than students who receive the usual lecture-based learning strategy
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2b. Students studying a gerontological course who receive an experiential-
based learning strategy will have more knowledge about the demography of older
people than students who receive the usual lecture-based learning strategy
2c. Students studying a gerontological course who receive an experiential-
based learning strategy will have more knowledge about the vulnerability of older
people than students who receive the usual lecture-based learning strategy
Sample
The target population consisted of all the nursing students in university
undergraduate nursing courses in Taiwan at the time of the study (February 2004 to
July 2004). The population of this research study therefore consisted of all nursing
students from the selected university, a total of approximately 489 nursing students at
the time of the study.
The sample for Study 2 was students in the second semester of their second
year in a faculty of nursing in a private university located in Southern Taiwan. A
convenience sampling frame was used. As mentioned in Study 1, the university
provides two different nursing programs: a two-year program and a four-year program.
To reduce possible confounding variables to the evaluation of the educational
intervention, it was desirable to limit any experience students had in nursing practice;
furthermore, it was considered desirable that students should have completed a
systematic program of studies in basic and advanced sciences, introductory nursing
and physical assessments in order to understand the content of the gerontological
nursing subject. Accordingly, students in the two-year program were not considered
eligible for Study 2 as they had had at least one year working experience in nursing
and the third year and fourth year students in the four-year program were not eligible
152
for inclusion as they were required to undertake clinical practice in institutional
settings. The first year students in the four-year program were not included as they
had yet to complete the systematic program in basic and advanced science, physical
assessments and introductory nursing. Thus the students chosen for Study 2 were the
second year students from the four-year program.
The majority of students in the sample had graduated from general senior high
school. Most of these graduates had no previous experiences with older people who
were ill and had not yet undertaken any clinical practice in institutionalised settings.
However, because of the policy of the university and nursing faculty, some students
could be accepted into the four-year program from vocational high school and
therefore could have had some nursing background. Also, the university could recruit
students with certification from junior colleges of nursing into the second year of the
four-year program. These various entry points are used by the university to ensure
each class has 60 students. Therefore, some second year students might have had
some experience or contact during clinical practice with older people in hospital
settings in their previous vocational high school or junior college. It was expected that
there would not be a large number of these students.
The students in the sample had therefore completed a systematic program of
study in the basic and advanced sciences, introductory nursing, physical assessment
and human development before entering the nursing major in the second year. In the
second semester of second year, as mentioned in the previous chapter, students were
taking three core subjects including Fundamental Nursing and its related clinical
practice, Nursing Process, and Pharmacology. Fundamental Nursing provides
opportunities for students to understand basic human needs and human responses to
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stress situations. Its related clinical practice is designed to help students develop
common knowledge and skills in the nursing care of patients in acute hospitals.
Nursing Process enables students to understand the concept of the nursing process and
to apply it to evaluate patients’ needs, examine patients’ health problems, and solve
those health problems. Pharmacology provides students with the basic concepts of
pharmacological function and theory. Also, because the gerontological nursing subject
was a compulsory subject, students were also expected to take it at the same time as
the other three subjects.
All 60 students from second year were randomly assigned, by drawing
numbers, into either the experiential-based learning or lecture-based learning groups.
Thirty students were randomly assigned to each group; the details of the random
assignment are explained later, in the procedure section.
The 30 students in the experiential-based learning group were invited to
participate in a focus group interview. Participation was voluntary and 10 students
agreed to take part; so one focus group was conducted with students from the
experiential-based learning group.
Sample size
Previous studies on the effects of gerontological educational programs on
attitudes and knowledge related to older people had mainly used one group, pre- and
post-test designs. Also, the instruments of Perception of Working with Older People
(PWOP) and Knowledge of the Situation of Older People (KSOP) had only been used
in the cross-sectional research conducted by the researcher and explained in Chapter
Four. Therefore, there were no similar previous studies to provide guidance for
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estimating sample size. Moreover, in the selected university, there were only a total of
60 students in the second year so the researcher could only get 30 students in each
group. Instead of calculating the sample size and effect size before conducting Study
2, the researcher was able to calculate statistical power only at the conclusion of the
study.
Instruments
Nursing students’ attitudes towards older people were measured using the
instrument of Nolan et al. (2001): Perceptions of Work with Older People (PWOP)
(see Appendix 12) and Nolan’s (2001) Knowledge of the Situation of Older People
(KSOP) was used to measure students’ knowledge about older people (see Appendix
13). Students also completed a demographic data sheet (see Appendix 7). Consent
procedures for the use of the two established research instruments was referred to
earlier in Study 1.
Attitudes
The PWOP was selected for this study as it reflects an up-to-date view of older
people and because it specifically focuses on perceptions of working with older
people. Although Kogan’s Attitudes Toward Old People Scale (KOP) scale has been
used extensively in measuring attitudes toward older people, the language used in the
KOP scale reflects how society viewed older people 44 years ago. In Study 1, the
KOP scale was found to be correlated with Perceptions of Work with Older People
(PWOP). Therefore, instead of using both KOP and PWOP to measure attitudes
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toward older people, the PWOP alone was chosen to measure these attitudes in Study
2.
The refined Perceptions of Work with Older People (PWOP) scale from Study
One was used in Study 2. It consists of 11 statements and includes two subscales:
intention to work with older people and career prospects of working with older people.
To respond to these statements, students were invited to indicate the level to which
they agreed using a 5-point Likert format as follows: 5 = strongly agree, 4 = agree,
3 = neither agree nor disagree, 2 = disagree and 1 = strongly disagree. Scores can
range from 11 to 55. Cronbach’s alpha coefficients derived from Study One
were .75, .81, and .68, and from Study Two were .73, .72, and .60 for the total PWOP
score, and the subscales: intention to work with older people, and career prospects of
working with older people, respectively.
Knowledge
Although the Ageing Quiz: Part 1 (FAQ1) has been used extensively to
measure knowledge about ageing, it is considered more a measure of attitudes than of
knowledge (O'Hanlon, Camp, & Osofsky, 1993). The similarity between FAQ1, KOP,
and PWOP, as measurements of attitudes toward older people, was reported in the
result of Study 1. Also, the Knowledge of the Situation of Older People (KSOP)
reflects more up-to-date knowledge of facts about the situation of older people in
Taiwan; so the KSOP scale was chosen to measure students’ knowledge about older
people in Study 2.
The refined KSOP from Study One contains 13 statements that are the most
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up-to-date data about the situation of older people in Taiwan. The response format
asked students to indicate whether a series of statistics about older people were “too
high”,” about right”, or “too low”. In order to calculate the total score, the correct
answer was recoded as 1 and incorrect answers were recorded as 0. Total possible
scores therefore ranged from 0 to 13. The knowledge quiz contains 3 subscales: daily
activities; demography of older people; and vulnerability of older people. Cronbach’s
alpha coefficients derived from Study One were .72, .79, .61 and .53 and from Study
Two were .63, .65, .50, and .52 for the total KSOP score and the subscales: daily
activities, demography of older people, and vulnerability of older people, respectively.
Demographic data
The demographic variables comprised the factors identified from Study One as
those that could influence attitudes toward and knowledge about older people. These
were age, gender, level of education, living with older people, contact with older
people, as well as intention to work with older people. Therefore, these factors were
included in the demographic data sheet (see Appendix 7).
Procedure
Permission was obtained from both the university in Taiwan and the
Queensland University of Technology. Once consent had been obtained from the
university in Taiwan, the researcher negotiated with nursing faculty to shift the
gerontological nursing subject from second semester in third year to second semester
in second year. This change was intended to minimise contamination from clinical
practice, by decreasing the likelihood that students would have had work experience
in nursing, or any clinical practice in their course. The students do not do any clinical
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practice until the end of second semester of second year, while in third and fourth year
they undertake subjects such as Fundamental Nursing, Paediatric Nursing, or
Medical-Surgical Nursing that have clinical practice in institutional settings. After the
purpose of the study was explained to all members of the nursing faculty, the
gerontological nursing subject was shifted to second semester in second year. Then
the dean of the nursing faculty arranged for the gerontological nursing subject to be
conducted on Wednesday mornings from 10:20 to 12:20 for the experimental group,
and on Thursday mornings from 8:20 to 10:20 for the control group.
In a scheduled class, the researcher spent 30 minutes giving the students a
description of the study. An information sheet was distributed and students were
invited to participate, to sign the consent form and to return it at the end of the class.
Students were advised that their participation in the study was voluntary and that their
result from the gerontological nursing subject would not be affected if they did not
participate. They were advised that students agreeing to participate in the study would
be randomly allocated, by drawing numbers, to one of the two classes mentioned in
the previous section. They were also told that if they were reluctant to participate in
the study, they would be allocated to the Thursday group, since in any case it was
necessary to complete the gerontological nursing subject. Because students needed to
know which class they had to enrol in before the second semester started, they were
notified of the date of the course one week later, via the faculty notice-board.
As mentioned in the previous section, all 60 second year students were
randomly assigned into either the experiential-based or lecture-based learning group
by drawing numbers. In order to randomly assign the students, the researcher obtained
a list of students and their university numbers from the nursing faculty. Following the
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procedure from Polit and Hungler (1999), the researcher created a new list of numbers,
from 1 to 60, matched with the students’ university numbers. The numbers were
written on slips of paper that were put into a bag, and then drawn out by the researcher.
As each of the first 30 numbers was drawn out, the researcher put the student who
matched that number into the experiential-based learning group. The remaining 30
students were assigned to the lecture-based learning group.
Data were collected by the researcher over a period of a semester from
February to July 2004. There were three data collection times; the questionnaires were
distributed and collected by the researcher during the first class of the gerontological
nursing subject in week 1, during the last class in week 16, and on the last day of their
clinical practice in the hospital. Students were requested to complete the demographic
information sheet and the PWOP and KSOP scales on the first occasion to set a
baseline, and the PWOP and KSOP scales again at the two remaining data collection
periods. The students spent about 30 minutes of class time completing the
questionnaires. The same data collection process was used for both groups.
Qualitative data were collected from focus group interviews at the end of the
clinical practice period. The researcher was interested in feedback from students in the
experiential-based learning group; the purpose of the focus group was to understand
students’ perceptions of experiential learning strategies. The researcher explained the
purpose of the focus group to the 30 students in the experiential-based learning group
on the last day of lectures before they commenced their clinical practice. Participation
in the focus group was voluntary and there were 10 students who agreed to take part.
The researcher contacted the clinical teacher to arrange a time and place for
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the group interview; it was conducted at 4 pm on the last day of the students’ clinical
practice, in the staff meeting room in the hospital. The interview lasted appropriately
one hour. Because the researcher was the only person who taught the gerontological
nursing subject to the EBL group, she knew what content had been taught, how it had
been delivered, and what students’ reactions in the class had been, so it was decided
that the focus group interview should be led by the researcher. Before commencing
the interview, she briefly explained the aims of the study, issues concerning
confidentially, and how the focus group data were to be used and stored. The
researcher obtained consent forms from each student permitting her to record the
interview with a tape recorder, in order to ensure the information was documented and
also to help the data analysis process. Brief notes were taken throughout the interview
to help the researcher in providing feedback to students on the main points that were
raised in response to questions.
The focus group interview was guided by four key questions, focused upon
eliciting students’ thoughts about what they had learnt in their gerontological nursing
subject (Appendix 18). For example, students were asked about how the
gerontological nursing subject had been helpful to them in their clinical practice and
what their thoughts were about the experiential learning strategies. The researcher
asked follow-up questions to clarify any issues that were unclear.
Ethical Considerations
Ethical approval to conduct the research was obtained from the QUT
University Human Research Ethics Committee (Appendix 8) and from the study
university in Taiwan (Appendix 9). Copies of the student’s information sheet and
consent form are attached as Appendices 19 and 20.
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The main ethical consideration was confidentiality of data collection, which
was ensured by each questionnaire being identified by a number only. The researcher
created a list of study numbers for each student in order to match up the data for
different stages of data collection. Students were assured that these numbers and all
information provided would be kept in strict confidence in a locked filing cabinet
during the study period and would be held for five years, after which the data would
be destroyed. Data were secured on a password-protected computer file with access
available only to the researcher. Full assurances were provided to all students that all
information collected was confidential and would be not disclosed to anyone other
than the researcher. Students were also advised that no information about the project
would be published in any form that would allow any individual to be recognised.
The researcher approached all eligible students and explained the purpose of
the study, data collection methods, and confidential issues. The students were assured
that non-participation in this study would not impact on their future career or study
and also they had freedom to decide not to participate without any consequences.
Once students decided to participate in the study, they were informed that the
gerontological nursing subject in both classes had the same lecture topics and
objectives in order to achieve the required level of knowledge of gerontology. They
were also informed that the gerontological nursing subject was a compulsory subject
and one of the core requirements for completing their nursing program. Although they
had the right to withdraw from undertaking the study at anytime without comment or
penalty, they had to complete the gerontological nursing subject.
161
Explanations were given to the students about the possible risks of taking part
in this study such as feeling stress in studying a gerontological nursing subject and
becoming upset when remembering the difficult times they had experienced in
relationships with their deceased grandparents or older friends. If this should occur at
any time during the study, the students should stop their activities immediately; they
would be given the option of continuing after a short break, or continuing on another
occasion. The students were recommended to visit the student counsellor in the
university or the subject co-coordinator, as needed. The researcher provided ongoing
support during the study and was freely available to answer all students’ questions
related to the study.
Because the researcher was the only person who had any knowledge about
experiential learning, it was decided that the gerontological nursing subject for the
EBL group would be taught by her. Also, as she was the only person who knew what
content had been taught and how it had been delivered, and what had been the
students’ reactions to the experiential learning teaching strategies, the researcher
conducted the focus group. It was important for the leader of the focus group to be
accepted by students. However, the researcher had to be aware of the bias that she
would have as the lecturer who taught the gerontological nursing subject for the EBL
group and the mediator of the focus group interview. To minimise bias, the focus
group interview was guided by a semi-structured interview schedule with four key
questions; the researcher kept to the questions in the schedule. Students had been
assured that their responses would not have an impact on their study.
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Educational Intervention
As described in Chapter Five, Study 2 focused on comparison between two
teaching approaches to the implementation of the gerontological curriculum,
experiential-based learning and lecture-based learning, based on the results of the
Study One survey and suggestions from previous relevant literature. The researcher
used Kolb’s experiential learning framework to deliver the gerontological nursing
subject to the experiential-based group and the other gerontological nursing educators
used the usual lecture approach for the lecture-based group. These educators had
experience in delivering this subject before.
The gerontological nursing subject was a compulsory subject in the second
semester of second year, consisting of 32 hours over 16 weeks of classes held on the
campus. The objectives of the gerontological nursing were outlined in Chapter Five.
Control group
The control group addressed the gerontological education topics and
objectives through the usual didactic lecture method for all classes, as described in
Chapter Five. There were no class activities such as simulation games, role-plays, or
experience with healthy older people in the Senior Apartment, discussion sessions, or
writing journals during class time. The didactic lecture was the only teaching method
used with this group. Two examinations, the same as for the experimental group, were
used to evaluate the students’ learning outcomes.
Clinical practice was part of the students’ Fundamental Nursing subject and
was facilitated by faculty lecturers. The clinical practice consisted of a total of 40
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hours. The content of clinical practice was the same for the two study groups.
Students needed to engage in physical nursing activities such as measuring vital signs
and other nursing assessments in acute hospitals; they had to complete these
fundamental nursing procedures under the supervision of their clinical instructors.
Experimental group
The experimental group addressed the same gerontological education topics
and objectives as the control group. Utilising Kolb’s experiential learning model, the
experiential learning approach was fully implemented throughout the whole
gerontological nursing subject, outlined in Chapter Five. The way chosen to deliver
the gerontological nursing subject was to reduce the didactic lecture time and increase
the interaction between students and lecturer and the real experiences with older
people. So lectures, group discussions, four visits to the Senior Apartment, followed
by journal writing and debriefing, a simulation game, and a role-play were introduced
in the class. Eight journal writing assignments and two examinations were used to
evaluate the students’ learning outcomes.
During the clinical practice at the end of the semester all students were
involved in caring for older patients in acute hospital settings. This clinical practice
was part of their Fundamental Nursing program and was facilitated by faculty
members. It consisted of five days with eight hours per day of clinical contact with
patients, including older people. Students socialised with patients while engaging in
physical nursing care activities. They had to measure patients’ vital signs and
complete nursing assessments of the patients’ status; they also had to assist patients in
164
their activities of daily living, determine their priority needs, and meet those needs
under the supervision of their clinical instructors.
Data Analysis
The Statistical Package for the Social Science (SPSS), version 12.0, was used
to analyse the quantitative data. Several types of statistical analyses were performed
to determine the relationship between the variables. An alpha level of .05 was used to
test for statistical significance. Descriptive statistics were used to describe the sample
characteristics. The t-test and chi-square were used to determine whether there were
any significant differences between groups at baseline, according to the level of
measurement. Means and standard deviations were used to summarise the scores of
each scale and subscale. Repeated measures analysis of variance was used to
determine the effectiveness of the experiential learning approach and clinical practice
on each of the dependent variables of attitudes and knowledge, and their subscales,
over time. Group (experiential-based learning versus lecture-based learning) was the
between-subject factor and time (pre-test, week 16, week 20) was the within-subject
factor.
The focus group interview tapes were transcribed, verbatim, by the researcher
and entered into her computer. Each sentence was placed on a separate line in order to
assist with sorting and coding. Qualitative data obtained from the focus group
interviews were analysed by using the guidelines of thematic content analysis that
were proposed by Burnard to identify emerging themes (Burnard, 1991). Burnard
developed the method from Glaser and Strauss’ grounded theory approach, from
various works on content analysis, and from other sources concerned with the analysis
of qualitative data (Babbie, 1979; Berg, 1989; Bryman, 1988; Couchman & Dawson,
165
1990; Field & Morse, 1985; Fox, 1982; Glaser & Strauss, 1967; Strauss, 1986). The
method provides a step-by-step approach to coding and categorising the focus group
transcripts. These stages of analysis are summarised in table 6.2.
The technique of thematic content analysis enabled core constructs related to
students’ perceptions of experiential learning to be produced from the textual data
through a process of reduction and analysis (Burnard, 1991; Woods, Priest, & Roberts,
2002). The aim of the analysis was to produce a detailed and systematic recording of
the themes and issues addressed in the focus group interviews and to link these
themes so that they maintained a conceptual link with interview data (Burnard, 1991;
Harrison & Zohhadi, 2005). A thematic content analysis of categories was used to
166
explore basic concepts arising out of the interview. The steps taken to analyse the
qualitative data, modified from the 14 stages of Burnard (1991), are outlined below.
Step 1: interview tapes were transcribed verbatim in Chinese by the researcher
and then entered into the researcher’s computer. Each sentence was placed on a
separate line in order to assist with sorting and coding.
Step 2: the transcripts of Chinese version were translated to English by the
researcher.
Step 3: the transcripts were read through, and notes and highlights were made
throughout the reading.
Step 4: the transcripts were read through again — many headings were written
down to capture the content, excluding extraneous matter. Open coding was
undertaken in order to identify categories from the text in this stage.
Step 5: similar categories were grouped together into higher order headings in
order to reduce the numbers of categories.
Step 6: the researcher worked through the list of headings and removed and
grouped similar headings again. Similar categories were grouped again to produce the
final heading. The result of open coding data analysis was a list of codes and
categories that were extracted from the data. This process is exemplified by an extract
of data in Table 6.3.
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Step 7: two researchers were invited to discuss and adjust the final headings in
order to achieve the agreement of categories. The aim of this step is to attempt to
enhance the validity of the categories.
Step 8: transcripts were re-read alongside the final list of categories and sub-
headings to check that the categories covered all aspects of the interviews.
Step 9: the transcript was reviewed and a coloured highlight pen was used to
distinguish between each piece of the transcript allocated to categories and
subcategories. For example, using orange coloured pen highlighted the benefits of
gerontological nursing; using green coloured pen highlighted the views on
experiential learning; and blue coloured pen highlighted the factors influencing the
experiential learning.
Stage 10: the transcripts were then ‘cut’ according to each code. All items of
each code were collected together.
Stage 11: the ‘cut’ sections were ‘pasted’ together under the appropriate
categories and subcategories.
Stage 12: during the writing up of the findings, copies of the complete
interview transcript were kept to hand, to help the researcher clarify unclear points by
referring directly back to the transcript.
Stage 13: the researcher selected the examples of data for each section.
168
Stage 14: the researcher wrote up the findings, using verbatim examples of
interviews in the various sections.
Table 6.3
The transcript extract: an example of open data coding of a focus group interview
Line Transcript Code
1 R: What have you gain from gerontological
2 Nursing for your clinical practice?
3 S: We had learned the concept about the physical and Knowledge about older people
4 psychological changes in older people. In here, we
5 really see them. That is reality. It can connect with Bridge theory and practice
6 textbook.
7 S: In technical, yes, in the aspect of communication with Communication skills
8 older people and the knowledge about older people about Knowledge about older people
9 the problem of older people
10 R: What do you think about the experiential activities?
11 S: I felt that our body really becomes not flexible. We can
12 feel the feeling of older people. Feel the feeling of older people
13 S: Game is good…Without experience it, you can not
14 realise the difficulties of older people in their daily life. Feel the feeling of older people
15 S: I like the discussion because it stimulates me to think. Benefits from discussion
16 S: The discussion can share the opinions because Benefits from discussion
17 everyone is different. Sometimes, during the discussion,
18 we found the new questions and increase the discussion
19 level.
20 S: I felt it is really important. I gained a lit from Senior Practice in Senior Apartment
21 Apartment. Communication and asking question about
22 information.
23 S: Bai Bai and grandmother were so cute and energised. Perceptions of older people
24 They knew what they want and planned for their life, so
25 brave. We needed to learn from them.
26 S: the grandmother tole me that some people group Perception of older people
27 themselves as rich and poor. The rich group does not talk
28 to the poor group. They also told something behind
29 peoples’ back. The behaviour is so boring
30 S: I felt it is so trouble in the way of going there so Practice in Senior Apartment
31 probably feel tired.
R = researcher; S = student
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Quantitative Results
Sample characteristics
The sample for the study was comprised of all second year nursing students
(n=60). The total valid study sample was 58 nursing students. Thirty students in the
experiential-based learning group and 28 students in the lecture-based learning group
completed the questionnaires in the first data collection period, and 30 students in
each group completed the questionnaires in the second and third data collection
periods. The two students who did not complete the questionnaires were absent at the
first data collection time; as complete data sets were not available for them, their data
were not included in the analysis.
The mean age of the students in the experiential-based learning group was
19.83 (SD=.99), ranging from 19 to 24 years; in the lecture-based learning group the
mean age was 20.20 (SD=1.19), ranging from 19 to 23. There was no significant
difference in age between the two groups (t (58) = 1.30, p=.20). Across both groups, the
majority of nursing students were female (80%). There were five males in the lecture-
based learning group and seven males in the experiential-based learning group
(²(1)=.10, p=.75).
The majority of students had graduated from general senior high school
(73.3%). There were four who had graduated from a vocational high school in both
the experiential-based and the lecture-based learning groups. One student had
graduated from a nursing junior college in the experiential-based learning group and
there were seven junior college students in the lecture-based learning group. As
expected, there was no significant difference between the two groups in the level of
170
education (²(2)=.5.32, p=.07).
The majority of students (75%) said that they had contact with older people in
their family: 23 students in the lecture-based learning group and 22 students in the
experiential-based learning group. These students acknowledged having contact with
older people at least occasionally (41.7%), and spent less than 30 minutes (30%) with
older people on each contact. As expected, there was no significant difference
between the students in the experiential-based and lecture-based learning groups in
terms of their contact with older people, time of contact with older people, and time
spent with the older person on each contact (Table 6.4).
Table 6.4
Comparison of contact with older people according to learning strategyLecture-based
learning
(n=23)
Experiential-
based
learning
(n=22)
²
f % f %
Contact with older people in family before
commencing course
Everyday 6 20 1 3 4.38 NS
Once a week 2 7 3 10
Twice a week 3 10 5 17
Occasionally 12 40 13 43
Time spent with older person on each
contact
Less than 30 min 10 33 8 27 .65 NS
30 min to 1 hour 6 20 8 27
More than 1 hour 7 23 6 20
NS= not significant
171
The majority of students (65%) indicated that they had no older relative living
with them and their family on a permanent basis. In terms of satisfaction with living
with older relatives, those students who lived with older relatives had a mean score of
3.55 (SD = .73), with a possible range of scores of 1 to 5, in the experiential-based
learning group and 3.42 (SD = .79) in the lecture-based learning group. These data
indicated that the majority of students rated their satisfaction as neutral. Comparison
of students in the experiential-based learning and lecture-based learning groups
indicated there was no significant difference in terms of living with older relatives
(²(1)=.66, p=.59) and satisfaction of living with older people (t (19)=-.41, p=.68).
A five-point Likert scale format was used for students to indicate their
intention of working with older people (definitely yes = 5; probably yes = 4;
uncertain = 3; probably no = 2; definitely no = 1). The students in the experiential-
based learning group had mean scores of 3.07 (SD = .58) and those in the lecture-
based group had mean scores of 3.10 (SD =.71), indicating that the majority of
students were uncertain about their intention to work with older people. Comparison
of students in the experiential-based and lecture-based learning groups indicated there
was no significant difference in their intention to work with older people (t (58)=.20,
p=.84).
In summary, the majority of students were female, with a similar mean age of
20. They had no work experience in nursing. Also, the students had contact with older
people in their family at least occasionally, and spent less than 30 minutes with older
people on each contact. The majority of students had no older relative living with
them and their family on a permanent basis. There were no significant differences
172
between the two groups at the beginning of the gerontological nursing subject
regarding students’ intention to work with older people.
Attitudes
In order to check differences between the experiential-based learning group
and lecture-based learning group at Time 1, a t-test was conducted. The data revealed
that there was no statistically significant difference at Time 1 between the two groups
(t (56)=.08, p=.94). To test the hypothesis that students studying a gerontological
nursing course who receive an experiential-based learning will have more positive
attitudes toward older people than students who receive the usual lecture-based
learning strategy, a repeated measures analysis of variance was conducted for the
Perception of Working with Older People (PWOP) Scale. Group was the between-
subject factor and time of test was the within-subject factor (pre-test, post-test in week
16, post-test in week 20).
Due to the small sample size, a check of the assumptions of the statistical test
was conducted. The Mauchly’s Test is sensitive not only to sphericity but also to
non-normality of the dependent variable as well as to heterogeneity of covariance
(Tabachnick & Fidell, 2001b). The Mauchly’s Test of Sphericity was not significant
(p=.15), hence sphericity was acceptable. Also, Box’s M test (F=.47, p=.83) was used
to check homogeneity of variance assumptions. The conditions of Box’s M test for
homogeneity were met. The F test for the routine repeated measures ANOVA was
therefore appropriate.
Table 6.5 shows the mean attitude scores for the experiential-based learning
group and lecture-based learning group at the three data points as measured by the
PWOP scale. Possible scores ranged from 11 to 55; therefore the data indicated
173
students had slightly positive attitudes toward older people over the period of the
gerontological nursing subject.
The repeated measures ANOVA revealed no interaction effect for time by
group (F (2,112) = 2.66, p = .07). Similarly, there was no significant main effect for time
(F (2,112) = .34, p = .71) or for group (F (1,56) = 2.78, p = .10).
Table 6.5
Mean PWOP scores for experiential-based learning group and lecture-based learning
groupExperiential-based
learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 38.67 4.02 38.75 3.92
Post-test (Week 16) 37.17 5.04 39.46 4.07
Post-test (Week 20) 37.23 4.30 39.43 3.77
ª = Range: 11-55
These results revealed that students’ attitudes toward older people did not
differ between the two groups of students. In addition, there was no change in
attitudes following the completion of a gerontological nursing subject. Therefore, the
hypothesis that students who received an experiential-based learning strategy would
have more positive attitudes toward older people than students who received the usual
lecture-based learning strategy was not supported.
In order to test the hypotheses related to the subscale scores, two further
repeated measures ANOVA analyses were conducted. Table 6.6 shows the means of
students’ scores for the intention to work with older people subscale and Table 6.7
174
shows the means of students’ scores for the career prospects of working with older
people subscale.
The repeated measures ANOVA on intention to work with older people
revealed a significant interaction effect for time by group (F (2,112) = 12.03, p = .01). A
graph of the interaction is shown in Figure 6.1. There was no significant main effect
for time (F (2,112) = 1.56, p = .21) or group (F (1,56) = 3.57, p = .06).
Table 6.6
Mean intention to work with older people scores for experiential-based learning group
and lecture-based learning groupExperiential-based
learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 15.27 2.59 15.18 1.91
Post-test (Week 16) 14.07 2.86 15.46 2.44
Post-test (Week 20) 14.47 2.11 16.04 2.08
ª = Range: 5-25
Figure 6.1 Graph of interaction of intention to work with older people
Mea
ns o
f in
tent
ion
to w
ork
with
old
er p
eopl
e
0
5
10
15
20
25
30
Week1
Week16
Week20
Experiential Šbased learning
Lecture-based learning
175
In order to examine significant interactions, a series of t-tests was conducted
to compare the means of both groups at each time point. The results showed there was
no significant difference between groups at the pre-test in week 1 (t (58) = -.15, p
= .88). However, students in the lecture-based learning group reported greater
intention to work with older people than students in experiential-based learning group
in the post-tests in week 16 (t(58) = 2.01, p = .04) and week 20 (t (58) = 2.39, p = .02).
The result revealed that there was a statistically significant difference between
students in the experiential-based learning group and lecture-based learning group
regarding the score of intention to work with older people, so that the results of the
study did not support the hypothesis that students who underwent experiential
learning would report greater intention to work with older people than those who
underwent the usual lecture-based learning.
So, interestingly, this result revealed a contrary position to what was expected,
with students in the lecture-based learning group reporting greater intention to work
with older people over the course of their gerontological nursing subject, while
students in the experiential-based learning group stating a reduced intention to work
with older people.
The repeated measures ANOVA conducted on the career prospects subscale
revealed no interaction effect for time by group (F (2,112) = .22, p = .80). In addition,
there was no significant main effect for time (F (2,112) = .71, p = .49) or a group (F (1,56)
= .95, p = .33).
The results of the study therefore did not support the hypothesis that students
who received an experiential learning strategy would rate the career prospects of
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working with older people higher than students who received the usual lecture-based
learning strategy.
Table 6.7
Mean career prospects of working with older people scores for experiential-based
learning group and lecture-based learning group
Experiential-based learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 19.50 1.76 19.86 2.19
Post-test (Week 16) 19.60 2.25 20.29 2.32
Post-test (Week 20) 19.43 2.43 19.75 2.33
ª = Range: 6-30
Knowledge
In order to check differences in gerontological knowledge between the
experiential-based group and the lecture-based group at Time 1, a t-test was
conducted. The data revealed that there was no statistically significant difference at
Time 1 between the two groups (t (56)=.52, p=.60). To test the hypothesis that students
studying a gerontological nursing course who receive an experiential-based learning
strategy will have a higher level of gerontological knowledge than students who
receive the usual lecture-based learning strategy, a repeated measures analysis of
variance was conducted for the knowledge Knowledge of Situation of Older People
(KSOP) Scale. Group was the between-subject factor and time of test was the within-
subject factor (pre-test, post-test in week 16, post-test in week 20).
Due to the small sample size, a check of the assumptions of the statistical test
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was conducted. The Mauchly’s Test is sensitive not only to sphericity but also to
non-normality of the dependent variable as well as to heterogeneity of covariance
(Tabachnick & Fidell, 2001b). Mauchly’s Test of Sphericity was not significant
(p=.52) therefore sphericity was acceptable. Also, Box’s M test (F=.1.76, p=.10) was
used to check homogeneity of variance assumptions. The conditions of Box’s M test
for homogeneity were met. The F test for routine repeated measures ANOVA was
therefore appropriate.
Table 6.8 shows the mean knowledge scores for the experiential-based
learning group and lecture-based learning group at the three data points as measured
by the KSOP scale. With possible scores ranging from 0 to 13, the data indicated
students from both groups had improved their knowledge about older people over the
period of the gerontological nursing subject.
Table 6.8
Mean KSOP scores over time for experiential-based learning group and lecture-based
learning group
Experiential-based learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 7.30 2.82 7.64 2.11
Post-test (Week 16) 10.00 3.31 9.21 2.01
Post-test (Week 20) 10.40 3.39 10.29 2.98
ª = Range: 0-13
The repeated measures ANOVA revealed no interaction effect for time by
group (F (2,112) = 1.02, p = .36). There was a significant main effect for time (F (2,112) =
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28.09, p < .001). The data indicated that both groups improved their knowledge
following the completion of the gerontological nursing subject (see Table 6.8). There
was no main effect for group (F (1,56) = .10, p = .75).
The results from the study showed no statistically significant difference in
scores for the Knowledge of Situation of Older People (KSOP) for the experiential-
based learning students when their scores were compared to those of the lecture-based
learning group. Therefore, results of the study did not support the hypothesis that
students in the experiential learning group would have a higher level of knowledge
about older people than students in the usual lecture-based learning group. Contrary to
expectations, both group of students improved their knowledge about older people.
In order to test the hypotheses related to the subscale scores, three further
repeated measure ANOVA analyses were conducted. Table 6.9 shows the means of
students’ scores in the daily activity of older people subscale; Table 6.10 shows the
means of students’ score in the demography of older people; and Table 6.11 shows the
mean of students’ scores in the vulnerability of older people.
Table 6.9
Mean daily activities of older people scores for experiential-based learning group and
lecture-based learning group
Experiential-based learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 3.48 1.84 3.50 1.32
Post-test (Week 16) 5.03 1.68 4.61 1.50
Post-test (Week 20) 4.83 1.75 4.79 1.62
ª = Range: 0-6
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There was no interaction effect for time by group (F (2,110) = .46, p = .63). The
result for the daily activities revealed a significant main effect for time (F (2,110) =
18.24, p < .001). The data indicated that both groups improved their knowledge
following their respective educational program (see table 6.9). There were no main
effects for group (F (1, 55) = .22, p = .64). The results of the study did not support the
hypothesis that students who received an experiential-based learning strategy would
have higher knowledge scores about older people’s daily activities than students who
received the usual lecture-based learning strategy.
Table 6.10
Mean Demography of older people scores for experiential-based learning group and
lecture-based learning groupExperiential-based learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 1.72 .65 1.89 .73
Post-test (Week 16) 2.24 .87 2.00 .82
Post-test (Week 20) 2.45 .78 2.39 .83
ª = Range: 0-3
There was no interaction effect for time by group (F (2,112) = .23, p = .79) for
the demography subscale. The result revealed a significant main effect for time (F
(2,112) = 13.32, p < .001). The data indicated that both groups improved their
knowledge following their respective educational program (see Table 6.10). There
were no main effects for group (F (1,56) = .60, p = .44).
The results of the study did not support the hypothesis that students who
received an experiential-based learning strategy would have higher knowledge scores
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about the demography of older people than students who received the usual lecture-
based learning group.
There was no interaction effect for time by group (F (2,110) = .60, p = .32) for
the vulnerability subscale. The result revealed a significant main effect for time
(F (2,110) = 5.34, p < .001). The data indicated that both groups improved their
knowledge following their respective educational program (see Table 6.11). There
was no main effect for group (F (1,55) = .10, p = .75).
Table 6.11
Mean Vulnerability of older people scores for experiential-based learning group and
lecture-based learning groupExperiential-based learning
(n=30)
Lecture-based learning
(n=28)
Meanª SD Meanª SD
Pre-test (Week 1) 2.27 1.01 2.25 .97
Post-test (Week 16) 2.87 1.31 2.61 .96
Post-test (Week 20) 3.30 1.18 3.11 1.20
ª = Range: 0-4
The results of the study did not support the hypothesis that students who
received an experiential-based learning strategy would have higher knowledge scores
about the vulnerability of older people than students who received the usual lecture-
based learning group.
The result of the overall knowledge and subscale analysis indicated that both
groups of students improved their knowledge as they progressed through their
respective gerontological subject. Therefore, the hypotheses related to knowledge
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were not supported.
Summary of Quantitative Results
To summarise the results, the data indicated that, after their respective courses,
students in the lecture-based learning had a greater intention to work with older
people compared with students in the experiential-based learning group. Moreover,
the students in the experiential-based group did not differ from the lecture-based
group in respect to overall attitudes toward older people or career prospects of
working with older people. Regardless of group, knowledge scores improved across
time. Therefore, the results of the study did not support the hypotheses that students
who received the experiential-based learning strategy would have improved attitudes
toward and knowledge about older people than students who received the usual
lecture-based learning strategy.
Qualitative Results
The results of the focus group interview of students in the experiential-based
learning (EBL) group are presented in terms of the research question: What were
students’ perceptions of the experiential learning strategies after the gerontological
nursing education program?
In examining students’ perceptions of the gerontological nursing subject and
the experiential learning strategies, analysis of the transcripts revealed three major
themes. These were the benefits of gerontological nursing subjects, views on
experiential learning, and factors influencing experiential learning (Table 6.12).
The benefits of the gerontological nursing subject fell into a number of
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categories. These were coded as: improving communication, ability to assess older
people, improving knowledge about older people and practice in real circumstances.
The views on experiential learning also had a number of categories. There were coded
as: bridging theory and practice, ‘feel the feeling’ of older people, practice in Senior
Apartment, perceptions of older people, and benefits of discussion. The factors
influencing experiential learning had three categories. These were coded as: learning
preference, attitudes to reading and examination, and doing differently in experiential
learning.
Table 6.12
Theme development from open coding of focus group interviewTheme Category
Benefits of gerontological nursing
subject
Improving communication
Ability to assess older people
Improving knowledge about older people
Practice in real circumstances
Views on experiential learning Bridging theory and practice
‘Feel the feeling’ of older people
Practice in Senior Apartment
Perceptions of older people
Benefits of discussion
Factors influencing experiential learning Learning preference
Attitudes to reading and examination
‘Doing differently’ in experiential
learning
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Benefits of the gerontological nursing subject
The categories of the theme benefits of the gerontological nursing subject are
outlined below.
Improving communication
Many students reported that what they had learned had improved their
communication skills that they were able to use when talking to older people. The
notion of learning during the gerontological nursing subject to improve
communication was identified by a number of students.
“She [nurse] used the high pitch volume and the Bai Bai [male older
person] cannot understand. Then I thought what I was taught from
subject [gerontological nursing subject] and then I used low pitch and
close to his ear…… Bai Bai [male older people] could understand. “
“Yes, better communication with older people. We had practice in the
gerontological nursing subject, hadn’t we? I wasn’t scared to ask them[older people] questions…”
“I felt that the communication between him [older patient] and mewas good. I can know what he wants from his facial expression.”
“Because of real practice, my communication with older people isgood. I can ask questions to older people directly.”
“I do not feel scared to talk with them [older people].”
Ability to assess older people
Students revealed that they could apply their knowledge of assessment skills
of older people into the real situation because of practice undertaken during the
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gerontological subject. The notion of ability to assess older people was identified by a
number of students.
“The nurse asked me if I had ever done the assessment of mini mental
status to assess older people. I said yes…There is no problem to do theassessments, because I had done them in the class and in the senior
apartment...In the class, I did the physical and psychological
assessment and no problems to identify their needs…”
“I knew how to do the assessment to older people. I was not scared toassess older people here [clinical setting] because we had practiced
during the subject. It is not so difficult.”
Improving knowledge about older people
Students reported that what they had learned through the gerontological
nursing subject had improved their knowledge about older people.
One student supported this by stating:
“We had learnt from content [gerontological nursing subject] about
physical ageing process.”
Another student supported this by adding:
“I felt in gerontological nursing lecture, we had learnt the conceptsabout the physical and psychological changes in older people.”
Practice in a real experience
Practice in a real situation allowed students to have real experiences with older
people in order to help them to enhance what they had leaned from the subjects. The
following students’ statements highlight this code:
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“…real practice with older people is important.”
“I think practice in both of them [older people and ill older people] isnecessary…”
“I think to practice with well older people first and then for clinicalpractice for fundamental nursing later. In fundamental nursing related
clinical practice, you only can see ill older people not well older
people.”
“I felt that I had real experience of communication. Real practice is sodifferent…you did not felt nervous because you had experience andthen you knew what they [older people] thought.”
In the students’ responses from the above themes, it was clear that students not
only improved their communication and knowledge about older people but also had
practice in the class to apply this knowledge into a real situation.
Views on Experiential Learning
Through the students’ reflections on the experiential-based teaching strategies
more aspects emerged from feedback. The categories of the theme views on
experiential learning are outlined below.
Bridging theory and practice
The experiential learning activities helped the students to integrate the theory
of physical ageing into practice, but also enhanced students’ interest and involvement
in the learning process.
For this theme one student stated:
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“We can take care of them [older people] and really see the differences
between reality and imaginations [from textbook] of older people.”
Another student supported this by adding:
“…in here [clinical setting], we really see them [older people]. That isreality. It can connect with textbook.”
Another student identified this theme by stating:
“It was quiet interesting to go to see the differences between thetextbook and real older people. I liked this kind of learning and
activities. It bridged the textbook and reality.”
Experiential learning is an active rather than passive form of learning. Many
researchers have noted the importance of experiential ‘learning through doing’
(Fazzone, 2001; Hitchcock & Murphy, 1999; Welch, Jeffries, Lyon, & Boland, 2001;
Wilkison et al., 1998). The actual performance of an activity can connect students’
knowledge that has been taught in the lecture to the real situation. This study
confirmed that this bridging of knowledge, and practice and reflection from doing
were important issues in the experiential learning.
‘Feel the feeling’ of older people
The simulation game allowed students to experience learning on a personal
basis and formulate value judgements (Kirkpatrick, Brown, & Koldjeski, 1997). The
game also provided active learning in a relaxed environment, putting students in a
position where they could identify the experience of problems, losses, sensory deficits
associated with ageing, by becoming involved in activities that are closely related to
ageing. The following student statements highlight this:
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“I felt good in the game [simulation game]. I felt that our body reallybecomes not flexible. I can feel that feeling of older people. I can have
a real experience of their feeling. I can understand that they really can
not be that. Then, it can induce our empathy. I feel that it is not bad.”
“…game [simulation game] is good. I like it. Without experience them[physical limitations], you can’t realise the difficulties of older people
in their daily life. For example, in the limitation of vision, I knew why
my grandmother always asked me to pass the cotton knit through
needle for her to sew. It was hard to do this job without a good vision.”
“I understand why my grandmother walked so slowly especially when
she climbed the stairs. When my elbow and knee were limited by
bandage and my vision was blurred, it was hard to walk especially you
[teacher] asked me to climb the stairs. I was so scared to fall down.
When I didn’t have good vision, I really need my partner to help me
otherwise I will fall down really. Climbing stairs took me a lot of time
to finish this task.”
The experience of being an older person during this simulation game helped
the students to understand physical limitations of older people and create empathy
toward them. The game not only helped students to integrate the theory of physical
ageing into practice, but also enhanced students’ interest and involvement in the
learning process. Attention will next focus on practice in the Senior Apartment.
Practice in Senior Apartment
The student group could be divided into those who thought the practice in
Senior Apartment was useful and those who did not. It became clear that the students
felt that they learnt most about older people from the Senior Apartment activity. This
was often more important to them than were the lectures carried out in the class.
Students reported that:
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“I felt that it [practice in Senior Apartment] is really important. Igained a lot from Senior Apartment such as communication and asking
question to older people about information.”
Another student supported this by adding:
“I felt it [visiting Senior Apartment] was the easier part of thecourse.”
The practice in Senior Apartment was important to help students build up their
interpersonal skills such as communication with older people before they cared for ill
older people in hospitals.
However, practice in Senior Apartment seemed to contain a negative
evaluation from some students. They were quite clear that this activity did not impress
them. The following student statements highlight different aspects of this:
“I felt it was trouble in the way of going there [Senior Apartment] soprobably felt tired.”
“It is so tired to go there [Senior Apartment].”
“We had to ask questions to Bai Bai [male older people] orgrandmother [female older people], then after that nothing to talk
about…I felt so uncomfortable”
“I felt that we usually talked to one individual older people. Then inthe end of conversation, we ran out of ideas to talk.”
These students expressed negative feelings about practice in the Senior
Apartment. It is interesting to compare their statements with those of other students. It
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seemed that talking with older people was a challenge to them, because they were not
used to talking with older people without guiding questions.
Perceptions of older people
The experiential learning activities helped many students to develop more
positive perceptions about older people. However, some students seemed to focus
more on the negative aspects that they experienced.
The following student statements highlight this:
“Bai Bai [male older people] and grandmother [female older people]were so cute and energized… They knew what they want and planed
for their life, so brave. We needed to learn from them... “
“I felt that they [older people in Senior Apartment] enjoy their life.”
“They [older people in Senior Apartment] still learnt new stuff such ascomputer although they are old and need more time to deal with.”
“The grandmother [female older people] is so active. She attended alot of activities in the Senior Apartment.”
“Bai Bai [male older people] and Nai Nai [female older people] inSenior Apartment are so happy and willing to teach.”
The contact with older people helped students to see the positive aspects of
older people in order to enhance positive attitudes toward them. Many studies have
confirmed that prior exposure to, and experience with, older people exerted a positive
influence on nursing students’ attitudes (Aday & Campbell, 1995; Dellasega &
Curriero, 1991; Shoemake, Bowman, & Lester, 1998).
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However, contact with older people seemed to contain a negative evaluation
from some students. They were quiet clear that this activity did not impress them with
older people. The following students’ statements highlight this:
“The grandmother [the students’ way to refer to female older people]told me that some people group themselves as rich and poor. The rich
group does not talk to the poor group... They [rich and poor group]
also told something behind people’s back… The behaviour is soboring.”
“The grandmother [female older people] does not participate in anyactivities, she only stays in her room. Her life is so boring here.”
“The grandmother always told me about money money money and how
important about money. Why shouldn’t she just forget the money andenjoy rest of her life?”
“… she [female older people] complains a lot…?”
“Some older people are strange.”
These students expressed negative feelings toward older people. It is
interesting to compare their statements with other students. It seemed that some
students made personal criticism of the personalities of older people.
Benefits of discussion
The discussion session was designed for students to think about the topics and
to participate actively in the class group. Students were asked to discuss a set of
questions, which were given by the lecturer and related to lecture topics. The students
appeared to enjoy the discussion section as it stimulated them and helped to develop
191
their confidence. The following student statements highlight this:
“I am very shy to talk in the class but I finally can put my hand up toanswer and ask the questions...’
“I liked the discussion because it stimulates me to think.”
“The discussion can share the opinions because everyone is different.”
“I can learn a lot from discussion...”
Because students were used to passively receiving information and being
silent listeners, active participation in the class discussion could be a challenge for
them. For some students, calling them up to answer a question is a necessary strategy
to motivate them to participate in the class. Giving students questions to think about,
to talk about, and to share is another discussion technique to use in the class, rather
than only having them receive information from the lecturer. Students are encouraged
to think deeply, widely, and critically in order to organize and integrate the lecture
content into their experience. Also, students were expected to share their thinking with
other group members; this helped them to know the experience of others and
recognise other perspectives.
Factors Influencing Experiential Learning
The categories influencing experiential learning are outlined below.
Learning preference
Although active participation and gaining experience through actual doing was
the core of the experiential learning, it still challenged the students’ usual learning
style. Lecture learning appeared to be the preferred learning style for students, who
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liked listening rather than doing. Some students appeared to be more comfortable with
the traditional teacher centred approach; they did not enjoy the change in teaching
style, as it was quite different from what they saw as the usual teachers’ role. The
following student statements highlight this code:
“Why didn’t we do just like Thursday class [lecture-based learning
group] just sat in the class, didn’t need to go somewhere else...it is sotiring.”
“…they [students in lecture-based learning] didn’t need to do those[activities], the teacher taught them everything.”
“…we didn’t need to do the search in the internet because yousupposed to tell us or other students will do it.”
“You [teacher] should provide us the right answer in each questionwhich you ask. Although sometimes there is no exactly right answer for
the question such as using euthanasia while caring for older people,
you still had to provide us your thought otherwise I had no ideas about
the answer.”
From the information received, it appeared that the method most frequently
used and accepted by the students was the lecture. When students had been introduced
to the experiential-based learning in the gerontological nursing subject, they became
information givers and active participants in the class rather than passive information
receivers. This was a contrast to their preferred learning style, which was listening
and receiving information passively.
Attitudes to reading and examination
Most students did not see the need to read in addition to the experiential
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activities as they felt they learned through the activities. Also, as their examination
was only worth 10%, they did not feel the pressure to study for the examinations. The
following student statements highlight this:
“I can gain the sense from the activities such as in Senior Apartment
or class discussion. I do not need to read… They were so boring.”
“I can learn from discussion and activities, why should I read?”
“Sometimes it is common sense. You knew it then [textbook] describethem into words. Then [I] felt that what I need to read.”
“…read textbook, remember it and forget it. So do not need to read”
“The students in Thursday class [Lecture-based learning] had to read
lots and listened to lecture and feel boring but must read and listen,
because the worth of examination is so heavy, 50%. Then, [we] in
Wednesday class [experiential-based learning] do not need because
the examination is only 10%.”
“It is too easy to get the grade than Wednesday class [lecture-based
learning group]...only 10% in each assignment, including
examinations...”
“…no exam, no reading…”
“Taking exam, read textbook, memorise the content, then I forgot all ofthem. Now 10% for each exam mean I don’t need to read and studyhard. I would not be failed if I did not perform well in the exam.”
The students seemed not to realise the limitations of learning through
experience and did not acknowledge that theoretical and factual knowledge are
important as well as experiential knowledge. Also, students’ view of examinations
was passing subjects without recognising that the reading and lecturing still were
194
important parts of gaining understanding. The students appeared to take a more
pragmatic view of learning by doing rather than elaborating the concepts of
experiential learning with reference to theory of the subject content.
‘Doing differently’ in experiential learning
Most students said that they liked having fewer lectures and less theory. They
wanted to keep the activities and practice in Senior Apartment. Overall, students said
that they enjoyed doing it differently. The following student statements highlight this
code:
“We can have less class lectures”
“We can have less theory part.”
“We can have health teaching in group in Senior Apartment.”
“We can talk to our case [older people], and should added the group
teaching or group activities with older people. It could increase their
participation and then it is very easy to communicate with them after
group teaching or activities.”
“Older people can also prepare some activities and through these
activities, they [older people] could teach us their experience and
knowledge. I think through their [older people] teaching, it can
increase their confidence.”
“Senior Apartment must keep. Go there more times.”
Here, the acknowledgements were made by students that increasing the
frequency of activities with older people was useful to enhance the interaction with
them and to encourage their participation.
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To summarise the qualitative results, students tended to view the experiential
learning strategies in more practical terms. They also saw it positively as an active
and personal method to gain experience through actual doing. However, they did not
recognise that the balance between theoretical knowledge and personal experience
was important. Students’ opinions suggested reducing lectures and increasing
interactions with older people.
Discussion
The aims of Study 2 were to evaluate the effect of an experiential learning
strategy on nursing students’ attitudes towards and knowledge about older people
compared to lectured-based learning in Taiwan, and to examine students’ reactions to
the gerontological nursing subject and the experiential learning strategies used in the
experiential-base learning group. This section presents a discussion of the quantitative
and qualitative findings.
Contrary to the two hypotheses, students in the experiential-based learning
(EBL) group did not have more positive attitudes or a higher level of knowledge after
the program compared to students in the lecture-based learning (LBL) group. In fact,
students in the LBL group had greater intention to work with older people when
compared to students in the EBL group. Students in each group had improved their
level of knowledge by the end of their program.
The results of this study are similar to some studies that also found that an
experimental group did not have more positive attitudes or a higher level of
knowledge after a gerontological nursing program (Bringle & Kremer, 1993; Kline &
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Kline, 1991; Moriello, Smey, Pescatello, & Murphy, 2005). However, the findings of
the current study conflict with some other studies that did demonstrate more positive
attitudes or a higher level of knowledge after a gerontological nursing program in an
experimental group (Aday & Campbell, 1995; Anderson-Hanley, 1999; Brown &
Roodin, 2001; Bullard et al., 1996; Dorfman, Murty, Ingram, Evans, & Power, 2004;
Gallagher, Dobrosielski-Vergona, Wingard, & Williams, 2005; Karner, Rheinheimer,
& Due, 1998; Knapp & Stubblefield, 2000; Knapp & Stubblefield, 1998; O'Hanlon &
Brookover, 2002; Ragan & Bowen, 2001; Wilkes & LeMiere, 2001). The conflicting
results could be explained by some differences between the previous studies and the
current one. For example, the length of gerontological nursing programs in some
studies were shorter than in the current study (Bringle & Kremer, 1993; Bullard et al.,
1996; Karner et al., 1998; Moriello et al., 2005). A one-group design without a
comparison group was frequently used in previous studies and was therefore different
from the current study (Anderson-Hanley, 1999; Bullard et al., 1996; Dorfman et al.,
2004; Karner et al., 1998; O'Hanlon & Brookover, 2002; Wilkes & LeMiere, 2001).
The lack of a control or comparison group may explain why many previous studies
have reported improvement in attitudes and knowledge. Using volunteer students to
participate in an educational program without randomisation could attract certain
students who may be highly motivated individuals before joining a program and
therefore different from the students in the current study (Bringle & Kremer, 1993;
Knapp & Stubblefield, 1998; Ragan & Bowen, 2001).
Despite the lack of support for the hypotheses, students in both groups did
increase their knowledge about older people. It appears that the content of the
gerontological nursing program covered information that increased students’
knowledge about older people in both the EBL and LBL groups. Although there was
197
no statistical difference in attitudes toward older people between the two groups, in
fact, students’ attitudes in the EBL group became more negative with respect to their
intention to work with older people. However, data from the focus group interview
revealed that, even although the hypotheses were not confirmed, students enjoyed the
experiential learning and gave positive feedback about it. There are several
possibilities related to the EBL program and research design that could explain why
students’ attitudes toward and knowledge did not change as expected.
Firstly, in order to change attitudes it is important to link theoretical concepts
with experience; these are crucial elements in experiential learning. However, from
the focus group categories of views on experiential learning and factors influencing
experiential learning, it appears that students enjoyed and focused on the experiential
learning activities but did not engage with the underlying theoretical concepts.
According to Kolb (1984) learning occurs in four ways: concrete experience,
reflective observation, abstract conceptualisation and active experimentation; to learn
at the highest level, abilities must be developed in all four areas. In relation to this
model, it appears that students focused more on the stages of active experimentation
and concrete experience, which emphasise practical and real-life experience, rather
than the stage of abstract conceptualisation that emphasises gaining a cognitive and
affective knowledge base. If students focussed only on the experience, without
developing increased conceptual understanding, it is not surprising that changes in
their attitudes did not occur. Increased cognitive understanding may have occurred if
the students had engaged in different types of activities with the older people and for
longer periods. It may be that the treatment effect of the real life experience was low
because of the nature of the activities and the time constraints.
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Moreover, the examination culture in the university of the study may have
influenced students’ motivation to link their experience and theory. The exams take a
certain form, and so students develop strategies they think are appropriate for dealing
with them (Kennedy, 2002). Studying hard, reading a required textbook, and listening
to the lecture in the classroom are the common strategies to pass exams in Taiwan.
The fact that these tendencies existed was confirmed by the focus group theme of
attitudes to reading and examination, which indicated that the students rely on
memorisation and reproduction of material, often without a real understanding of
meaning or of how the new information relates to previous knowledge. It is not
common for students to seek further connections, meaning, or the implication of what
is learned. Such learning promotes and encourages a surface approach to learning
which is characterised by only acquiring sufficient knowledge to compete the task
(Nijhuis, Segers, & Gijselaers, 2005; Watkins & Biggs, 1996). In the qualitative
results, the EBL students mentioned that, as the examination was only worth 10% for
each examination, they did not need to study for it. If the researcher, as was possible,
had made each examination worth 50%, as for the LBL group, and made the writing
assignments compulsory but with no weighting, then the students would have focused
only on the examinations; they would have had no motivation to do the writing tasks
or activities. Therefore, to ensure the EBL students would do them, it was necessary
to weight the writing assignments more highly (80%) than the exams (20%). However,
students in the EBL group did not see reading as the connection between their
experience and understanding of meaning — because the examinations were only
worth 20%. Without seeking the connection between experience and theoretical
concepts, it is hard for students to achieve deep learning, which is associated with an
interest in the learning task, searching for meaning in the task and integration of task
aspects into a whole (Nijhuis et al., 2005; Watkins & Biggs, 1996). Therefore, as the
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students seemed to lack motivation to connect their experiences with theoretical
concepts, it would be difficult for them to improve their attitudes toward older people.
Secondly, in the previous studies conducted in the USA, the experiential
learning methods were confined to changing students’ attitudes toward nursing
research (Pugsley & Clayton, 2003), student’s willingness and perceived preparedness
to provide HIV-patient care (Cornelius, 2004), attitudes toward and knowledge about
system-based care (O'Connell & Mechaber, 2004), and gaining knowledge about
ageing (Bullard et al., 1996). These studies demonstrated that experiential-based
learning methods worked well in Western cultures and were well suited to
overcoming the gap between classroom and real world practice. Cultural values
encourage students to learn by doing, participate in class, develop their own ideas,
offer options in discussion, and even sometimes disagree with the teacher (Speece,
2002). However, Akande (1998) noted that learning is different across cultures.
Cultural differences might explain limits to the use of experiential-based learning,
since cultural issues may influence students’ behaviour in the class. Students in the
current study do not usually speak up and offer opinions in class; they are likely to
feel shy or fear losing face in the class if their answer is wrong. Although students in
the focus group said that they got benefits from the discussion, the majority of
students still kept quiet in the class, contrary to the concept of active participation in
experiential learning. In experiential learning, students are expected to actively
participate in activities such as small group discussion, class discussion, simulation
games, and practice, like in the Senior Apartment. However, the researcher found that
at the beginning of the gerontological nursing subject there was very often one vocal
member in the group, while the other members were very quiet. In addition, students
were reluctant to answer questions in the class unless the researcher called on
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someone to answer. At the end of the program, the students in the focus group said
that they felt positive and enjoyed the experiential learning. It is likely, however, that
many of the students did not engage or participate in the activities to a level likely to
create a change in their attitudes. Taiwan, as a Chinese culture, is a collectivist culture
with a strong sense of belonging to a social group and a preference for working
together in groups to solve problems (Gieve & Clark, 2005; Kennedy, 2002; Park,
1997). Reticence and humility are highly valued, and Chinese culture is rooted in the
Confucian tradition. The concept of face is important; students do not want to show
off what they know nor do they want to lose face if their answers are not correct; also
wasting other students’ class time by expressing individual opinions is seen as selfish,
issues attributed to the significance of face.
Moreover, students might feel that it is impolite to criticize a teacher’s answer,
because teachers are regarded highly in the social hierarchy (Speece, 2002). There is a
saying in Chinese about the relationship between students and teachers: if someone
has been your teacher for one day, you should respect him as your father for the rest
of your life (Wang, 2001). Therefore, influenced by the strong social hierarchy, the
students would behave themselves without questioning the teacher in the class; the
teachers are always right, even if the students may not truly believe it. So this is likely
to influence students’ behaviour in the class; they prefer to keep quiet and wait for the
teacher to provide them with information, contrary to the concepts of active
participation in experiential learning. Students’ apparent reluctance to express
opinions in class may be related to the Confucian ethic of filial piety, and a strong
sense of hierarchy in social structures. It may also reflect an emphasis on strictness of
discipline and proper behaviour (Kennedy, 2002). Proper respect is also to be given to
teachers whose wisdom and knowledge is not to be questioned (Kennedy, 2002).
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To the contrary, in experiential learning students should take responsibility for
their own learning and should contribute to discussions and activities. However, the
majority of students in the current study came from general senior high school, where
the lecture method is the usual teaching method, as it is believed to be most
economical and to best prepare students for the university entrance exanimation. As a
result, the majority of students prefer the traditional method such as lectures, as they
mentioned under the focus group theme of learning preference. The students have
become conditioned to this type of learning, and are more predisposed towards
lecture-based methodologies that provide concrete information (Vaughan, 1990). Also,
in the traditional education system in the university of this study, learning in the
subjects in the nursing faculty was more passive. From the teachers’ perspective, they
are responsible for telling students the right answers and providing them with the
information and details that they think they need. Students expect the teacher to
provide the information and correct answers to questions, as mentioned under the
theme of learning preference. Students memorise any information, wherever it comes
from, in order to pass every examination; they are not responsible for contributing to
the development of an answer (Speece, 2002); this is contrary to the concept of
students being responsible for their own learning.
Although active participation and gaining experience through actual doing is
the core of experiential learning, it still challenged the students’ usual learning style,
with the consequence that lecture-based learning appeared to be the preferred learning
style for students. From the information received from the focus group theme of
learning preference, it appeared that the method most frequently used and accepted by
the students was the lecture. When students were introduced to the experiential-based
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learning in the gerontological nursing subject, they became information givers and
active participants in the class, rather than passive information receivers. This was a
contrast to their preferred learning style, which was listening and passively receiving
information. Also, the majority of subjects in the nursing faculty are delivered through
lectures; only the gerontological nursing subject was delivered through experiential
learning. It was hard for students to adapt to experiential learning under these
circumstances. The point here is that, to use methodologies that inevitably involve
students’ participation, it is important to make sure that the students are familiar with
and accept such methodologies (Cheng, 2000). Students might need to be given time
and support to gradually make the transition to new forms of learning, taking into
account the students’ usual learning style and faculty circumstances.
Thirdly, the activity of contact with older people has been shown to be
beneficial by previous studies in western countries (Aday & Campbell, 1995;
Dellasega & Curriero, 1991; Gorelik, Damron-Rodriguez, Funderburk, & Solomon,
2000; Heliker et al., 1993; O'Hanlon & Brookover, 2002; Schwartz & Simmons, 2001;
Shoemake et al., 1998). However, in Taiwan, the Asian values of Confucianism and
filial piety have a positive influence on the intergenerational relations (Lin &
Harwood, 2003). In the current study, the majority of students had contact with older
people in their family but the contact was for less than 30 minutes at a time. The
students’ contact with the older people, such as grandparents, was for a short time and
therefore during this brief contact, the older people might dote on them. The students
might not fully understand older people and what they think during such a short
period of contact. That doting behaviour, on grandchildren by grandparents, could be
the reason for the students’ positive image of older people. Therefore, when students
in EBL group had contact with older people in Senior Apartment for more than one
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hour in each visit to work with and complete an assignment, the negative aspects of
these non-family older people may have become more salient to them. Thus, it is
possible that this contact with non-family older people might have actually created the
negative attitudes that the course had set out to combat.
The students in EBL were exposed to a variety of teaching methods in addition
to lecture material, especially the visits to the Senior Apartment to interact with older
people. However, in the gerontological nursing subject design, students had their first
visit in the second week of the course. Although the majority of older people in the
Senior Apartment were fairly healthy physically, it was still quite hard for students
who did not have sufficient knowledge about older people to avoid focussing on the
negative aspects of some of the older people. If the students had had more lectures or
class activities before contact with older people, in order to understand their reality,
the results might have been more favourable.
Fourthly, for the students in the LBL group, the lecture approach was the only
teaching method used, mainly focused on students’ conceptual understanding
(Ramsden, 2003). Although there were no other learning activities in the
gerontological nursing content, didactic lecture-based learning may still have had a
greater value in terms of gaining knowledge, especially as the Chinese culture regards
the teacher as the provider of knowledge. Also, even for the students in the EBL group,
the lecture approach was one of the range of teaching strategies used, so students
could increase their knowledge about older people through didactic lecture learning,
which is consistent with past studies which found that formal didactic lectures were a
effective way of transmitting knowledge about older people (Angiullo, Whitbourne, &
Powers, 1996; Carmel, Cwikel, & Galinsky, 1992). This could be why the students in
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LBL group increased their knowledge as well as those in the EBL group.
Fifthly, in the gerontological nursing program, debriefing and journal writing
after each activity were important parts of the experiential learning, so that students
could reflect and explore their feelings while being given support. However, under the
focus group theme of perceptions of older people, students revealed two sides of their
perceptions of older people at the end of the program. This result could challenge the
functions of debriefing and journal writing; how to use debriefing and discussion
groups more effectively to explore students’ negative attitudes is a challenge for
program design and for the person who delivers the program. Also, the traditional role
of the teacher was perceived to be as an authoritative source whose job is to take
students systematically through a set of tasks, step by step, varying the pace according
to students’ understanding — rather than elaboration, application or critique of
foundational knowledge (Kennedy, 2002). This traditional teacher’s role could have
influenced the researcher’s teaching performance while using experiential learning
strategies such as debriefing. The researcher, who was the lecturer in the EBL group,
had some experience and knowledge about experiential learning; however, her
background was similar to the students’ traditional teachers. It is a challenge for such
researchers/teachers to be able to facilitate learning from an approach that is very
different and that pulls against the traditional culture of the usual learning context in
which they normally teach.
Finally, the rigorous research design used in the study may explain why the
findings of this study are different from other published studies. The current study
used a quasi-experimental design using a randomisation process, and pre-, post- and
follow up tests, with intervention and comparison groups, and a relatively
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homogenous sample. Ragan & Bowen (2001) used pre- and post-tests and follow up
tests and a comparison group design and found that the intervention group had more
positive attitude changes than the comparison group; however they used volunteer
students who self-selected to do the educational program, therefore, it is still not clear
whether the course increased students’ attitudes toward and knowledge about older
people or that this occurred because highly motivated individuals joined the program.
Many other studies used either one group only, or post-test only design. So the strong
design of the current study could explain the differences with previous studies.
Moreover, diffusion of the intervention may have occurred between the two
groups. The EBL and the LBL groups would have had contact during all their other
subjects and the students in the EBL may have shared some of their information and
experiences with students in the LBL group. As mentioned in the method section,
students came from the same year. Students were taking three core subjects together
including Fundamental Nursing and its related clinical practice, Nursing Process, and
Pharmacology. Although students in the LBL group not have been able to have the
direct experiences of students in the EBL group, the students in the EBL group could
still share their experiences with students in the LBL group. In other words, the
sharing experience may have occurred unbeknown to the researcher. This might have
influenced the LBL students’ attitudes and knowledge. The possibility of diffusion
could have been explored in focus groups with both groups. The decision was made,
however, to conduct the focus group with the EBL group only so an in-depth
exploration of the educational intervention could be undertaken. In addition, the focus
group was done to determine the integrity of the EBL intervention.
The small sample size may have had an impact on the findings and could
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account for the lack of confirmation of the hypotheses. As noted earlier in the method
section, it was not possible to calculate a sample size with appropriate power before
conducting the study. No published studies had used the same instruments as the
current study. Therefore, there was no relevant data to use to estimate expected
differences in attitudes and knowledge scores and effect size. Such data is necessary
to calculate sample size prior to conduct the study. In addition, the sample size of 60
was fixed and could not be increased; it was recognised that the sample size may not
be large enough to have sufficient power to detect statistically significant differences.
In the selected university, only 60 second year students were available to participate in
the study. Also, small sample sizes can be expected in educational research on
experiential learning and group interaction and so its nature limits the sample size
(Quinn, 1988). Consequently, the small sample size is a limitation of the study.
In summary, the current study did not support the hypotheses that students
who received the experiential-based learning strategy would have improved attitudes
toward and knowledge about older people than students who received the usual
lecture-based learning strategy. However, several possibilities could explain the
results, such as lack of linkage between theoretical concepts and experience, level of
engagement in experiential learning, students’ preferred learning style, different
experiences with older people between family and non-family members, the function
of lecture, and research design of the current study. These possibilities should be
considered as factors that could influence the results of the current study.
It is recognised that the Study 2 had some strengths in the research design such
as randomly allocated students to either EBL or LBL group, using pre-test, post-test,
and follow-up test design, and using the experiential learning model as a conceptual
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framework. The limitations of the study are also recognised, such as the issue of
generalizability of the findings, the weighting of the examination in the EBL group,
the usage of various teaching strategies, and the physical location of the Senior
Apartment. Taking into consideration its strengths and limitations, the study has
implications for nursing education and provides recommendations for future research.
These will be discussed in the final chapter.
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CHAPTER SEVEN
C onclusion
Summary of Findings
The general aim of this RESEARCH was to improve undergraduate nursing
students’ attitudes toward and knowledge about older people, in order to encourage
them to work with older people in Taiwan. To achieve this aim, the research was
conducted in two parts. Study 1 focused on exploring current Taiwanese nursing
students’ attitudes toward older people and knowledge about them, and establishing
the reliability and validity of contemporary attitudinal and knowledge measures.
Study 2 examined changes in attitudes and knowledge among undergraduate nursing
students following their participation in a specially developed educational
gerontological course. This chapter summarises the findings from the two studies. The
strengths and limitations of the studies and their implications for nursing education
are discussed, and recommendations for future research are outlined.
These studies contribute to gerontology literature in several ways. Firstly,
Study 1 makes a major contribution on establishing the validity and reliability of two
instruments that were developed by Nolan et al. (2001): Perceptions of Work with
Older People (PWOP) and Knowledge of Situation of Older People (KSOP). In
previous studies, the Kogan’s Attitudes Toward Old People Scale (KOP) and Ageing
Quiz: Part 1 (FAQ1) scales have been used extensively to measure attitudes (Hope,
1994; Kearney, Miller, Paul, & Smith, 2000; McCracken, Fitzwater, Lockwood, &
Bjork, 1995; Soderhamn, Lindencrona, & Gustavsson, 2001) and knowledge
(Fajemilehin, 2004; Gellis, Sherman, & Lawrance, 2003; Kaempfer, Wellman, &
Himburg, 2002). However, many criticisms of the KOP and FAQ1 scales have been
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made in the literature, as described in Chapters Two and Four. For example, the
language used in the KOP scale reflects how society viewed older people 45 years ago
and the FAQ1 is considered more a measure of attitudes than a measure of knowledge
(O'Hanlon, Camp, & Osofsky, 1993). Because of the criticisms of KOP and FAQ, this
research conducted psychometric testing of the PWOP and KSOP as additional
options; they are more contemporary instruments for measuring attitudes toward and
knowledge about older people. The original PWOP and KSOP instruments are in
English; they were translated into Taiwanese and hence are now available in English
and Taiwanese versions. Moreover, the research also examined the relationship
between the two attitudinal scales (KOP and PWOP) and the two knowledge scales
(FAQ and KSOP). The use of the four scales enabled a comparison of two older and
well-established scales with two contemporary but untested scales. The PWOP and
KSOP were evaluated with a large sample of nursing students in Taiwan, so are now
available to be used in Taiwan.
Secondly, this research, as reported in Chapter 4, explored current Taiwanese
nursing students’ attitudes toward and knowledge about older people, the relationships
between two attitudinal measures and two knowledge measures, and the factors
influencing nursing students’ attitudes and knowledge. The results clearly showed that
the nursing students held positive attitudes toward older people. These results are
consistent with other studies that have reported positive attitudes (Hweidi & Al-
Obeisat, 2006; Lookinland, Linton, & Lavender, 2002; McKinlay & Cowan, 2003;
Nolan et al., 2001; Wei, 1995), however, they contradict studies reporting negative
attitudes (Gething et al., 2002; Happell & Brooker, 2001; Kearney et al., 2000; Liou
& Hsu, 1994; Soderhamn et al., 2001). As described in Chapter Two, in Taiwan, 63%
of older people 65 years and over live with their children (Department of Statistics,
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2000). The Confucian ideals of respect for older people in the family, and their high
status, generally apply to the family in Chinese cultures (Tan, Zhang, & Fan, 2004).
Older people are respected and honoured for their wisdom and experience. Older
people in the family act as the role model for younger generations while the younger
generation have respect for the wisdom of older people. It follows that the close
relationship between grandparents and students and the role models provided by older
people in the family are likely to be reflected in students’ positive attitudes toward
older people, as reported in the current study.
Moreover, the findings of the research indicate that nursing students’ gender
and their intention to work with older people were important factors influencing their
attitudes. Intention to work with older people and gender were the variables that made
independent contributions to attitudes toward older people. In previous studies on
students’ attitudes, intention to work with older people has been a consistent factor
influencing attitudes toward older people (Fitzgerald, Wray, Halter, Williams, &
Supiano, 2003; Gellis et al., 2003; Liou & Hsu, 1994; McKinlay & Cowan, 2003;
Mehta, Tan, & Joshi, 2000; Wei, 1995). Gender as a predictor of positive attitudes,
which is also consistent with previous studies with less posititve attitudes found
among male students (Fitzgerald et al., 2003; Gellis et al., 2003; Soderhamn et al.,
2001).
Thirdly, compared with previous research using the FAQ1 (Fitzgerald et al.,
2003; Gibson, Choi, & Cook, 1993; Menz, Stewart, & Oates, 2003; Palmore, 1988;
Paton, Sar, Barber, & Holland, 2001; Stuart-Hamilton & Mahoney, 2003), the students
in this study had poorer knowledge. Also, the KSOP scores indicated that the
knowledge of the students was indeed lower than expected. The findings indicated
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that there is a need to improve the knowledge base of nurses about the ageing process.
Moreover, age, nursing program, and living with older people were the variables that
made independent contributions to knowledge about older people. In previous studies
on students’ knowledge, age has been a consistent predictor of knowledge about older
people (Wei, 1995; Yeh, Lin, Wang, & Ho, 2001). Students in the four-year program,
older students and students who have lived with older relatives had greater knowledge
about older people than students in the two-year program and those who were younger.
These findings highlight the influence of education programs and experience on
understanding about ageing.
Fourthly, the gerontological education program evaluated in the second study
had a strong theoretical framework, since it was developed from Kolb’s experiential
learning model. Kolb’s experiential learning model is a four-stage cycle. This cycle
shows how immediate concrete experience is translated through reflective observation
into abstract concepts; these concepts then serve as guides for testing the implications
of concepts in new situations (Holbert & Thomas, 1988). This model provided a
holistic framework for the learning process that is consistent with what we know
about how people learn, grow and develop (Baker, Jensen, & Kolb, 2002). Experience
is the central role of experiential learning, which is what distinguishes it from other
learning theories. The term experiential is used, therefore, to differentiate experiential
learning both from cognitive learning theories, which emphasise cognition over affect,
and behavioural learning theories, which deny any role for subjective experience in
the learning process (Kolb, Boyatzis, & Mainemelis, 2001). The overall model
emphasises learning rather than teaching; the learner is prepared for learning
outcomes through activities that promote active involvement rather than by being a
passive receiver of information. Moreover, experiential learning denotes learning
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activities that engage the learner directly in experiencing real situations. It provides a
real-world model to reinforce students’ gerontological concepts and knowledge about
older people (O'Hanlon & Brookover, 2002); students’ self-confidence in their
interactions with older people could consequently be increased, improving their
attitudes toward them. While this experiential learning model is seen to have some
limitations (see Chapter Three) such as tension between various learning activities
and students’ preferred learning styles and background, it nevertheless provided a
conceptual framework for the gerontological curriculum evaluated in this research.
The educational intervention was therefore underpinned by a strong and contemporary
learning theory. This is a major strength of this research, as most other studies that
have evaluated gerontological programs have not used a learning theory as a
framework for their programs.
However, using an experiential leaning approach in a nursing course was a
new and innovative concept in the university of the study in Taiwan. The students’
reactions to the experiential learning strategies were identified from the themes
emerging from the focus group. Three major themes were revealed as described in
Chapter Six: the benefits of gerontological nursing subjects, views on experiential
learning, and factors influencing experiential learning. The benefits of the
gerontological nursing subject were categorised as: improving communication, ability
to assess older people, improving knowledge about older people and practice in a real
experience. The views on experiential learning also had a number of categories:
bridging theory and practice, ‘feel the feeling’ of older people, practice in Senior
Apartment, perceptions of older people, and benefits of discussion. The factors
influencing experiential learning were: learning preference, attitudes to reading and
examination, and doing differently in experiential learning. The findings of the focus
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groups indicated that students quite enjoyed the experiential learning strategies; they
tended to view them in practical terms and saw them positively as active and personal
methods of gaining experience through actual practice. However, students did not
recognize or achieve a balance between theoretical knowledge and their personal
experiences that is important in the experiential learning model. This may have been
because the experiential component was so novel for students, indicating they may
need more time and assistance in learning how to link experience with the cognitive
component.
Lastly, this research investigated whether using an experiential learning
approach to gerontological education could improve Taiwanese undergraduate nursing
students’ attitudes and knowledge in comparison to lecture-based learning. Although
the benefits of using experiential learning to increase students’ attitudes and
knowledge has been acknowledged (Anderson-Hanley, 1999; Bullard et al., 1996;
Karner, Rheinheimer, & Due, 1998; Moriello, Smey, Pescatello, & Murphy, 2005;
O'Hanlon & Brookover, 2002), there is minimal documented evidence to demonstrate
that experiential learning could improve attitudes and knowledge compared to lecture-
based learning in gerontological education. This educational intervention research
was therefore progressive and innovative for nursing education in Taiwan.
The evaluation of the educational intervention was discussed in Chapter 6. In
general, the results indicated that students’ attitudes toward and knowledge about
older people did not differ between the two groups. In addition, there was no change
in attitudes following the completion of the gerontological nursing subject between
the two groups. Students in both groups had improved their level of knowledge at the
end of the gerontological education program. Therefore, the findings did not support
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the hypotheses that students who received an experiential-based learning (EBL)
strategy would have more positive attitudes toward and greater knowledge about older
people than students who received the usual lecture-based learning (LBL) strategy.
Contrary to expectations, the average scores for attitudes toward older people
decreased over the 20-week period in the group who received the EBL strategy
compared with the LBL group. Both groups’ means were similar at the outset.
However, the EBL group showed a slight drop from pre-test to follow up test and the
control group scores showed a slight increase from pre-test to follow up test. However,
these changes did not produce a significantly different outcome. In relation to the two
subscales of PWOP, the results revealed no significant difference between the EBL
and LBL groups in career prospects of working with older people, but there was a
significant difference between the groups regarding intention to work with older
people. Again, contrary to expectations, the LBL students reported a greater intention
to work with older people. Moreover, the average scores for knowledge increased
over the 20-week period in the both groups; both groups’ means were similar at the
outset, however, both EBL and LBL groups showed an increase in knowledge from
pre-post to follow up test. Effects on both groups were significant; in looking at the
three subscales of KSOP, the results revealed that students in both groups increased
their scores in the KSOP subscales of Daily activities of older people, Demography of
older people, and Vulnerability of older people. However, no significant differences
were found between the EBL and LBL groups. These findings suggest that both the
experiential based and lecture based programs were useful in increasing students’
knowledge about ageing, however, they did not support the expectation that an
experiential based learning approach would increase students’ engagement with the
experiences and the theory, that would, in turn, improve their attitudes and knowledge
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related to ageing. There are several possible explanations for these findings and these
are discussed in the next section.
Discussion of Findings
The findings of this research conflict with other studies which have
demonstrated more positive attitudes or a higher level of knowledge in students after
gerontological nursing programs (Aday & Campbell, 1995; Anderson-Hanley, 1999;
Brown & Roodin, 2001; Bullard et al., 1996; Dorfman, Murty, Ingram, Evans, &
Power, 2004; Gallagher, Dobrosielski-Vergona, Wingard, & Williams, 2005; Karner et
al., 1998; Knapp & Stubblefield, 2000; Knapp & Stubblefield, 1998; O'Hanlon &
Brookover, 2002; Ragan & Bowen, 2001; Wilkes & LeMiere, 2001). The conflicting
results can be explained from two perspectives: first, from the nature of the
educational intervention implemented in the current study, for instance the current
study was conducted over 20 weeks, while the length of gerontological nursing
programs in previous studies was shorter than that. Secondly, from the perspective of
research design, the intervention study used a stringent design developed in response
to methodological issues identified from previous studies. One-group designs, without
a comparison group, or post-test only designs were used predominantly in previous
studies. In addition, many previous studies had volunteer students undergo the
educational programs and did not randomise groups. Lack of randomisation could
have encouraged certain students, who may have been highly motivated individuals,
to join the programs. Also noted as methodological issues in previous studies were the
use of instruments with questionable or unreported psychometric properties, and the
absence of details on how the gerontological nursing courses were delivered. All these
methodological issues weaken the designs of previous studies and therefore their
positive findings may not have held up had they used a more rigorous design, as in the
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current research.
In reaction to these methodological issues from previous studies, this research
used a quasi-experimental design which randomised students into experimental and
comparison groups. Using a comparison group provided an opportunity for the
educational program to be compared between the experimental and comparison
groups, hence increasing confidence in the conclusions on whether or not the
education intervention changed students’ attitudes toward or knowledge about older
people. Random assignment to groups helps to eliminate systematic bias and to ensure
that groups will be similar on important variables, so that differences in the dependent
variable may be attributed to the experimental treatment alone (LoBiondo-Wood &
Haber, 1998), Using a pre-test, post-test design also enabled testing for differences
between the groups that may have existed despite randomisation. In contrast to other
post-test studies, the current research used two post-tests to examine changes over
time and after a period of clinical practice. In addition, the sample was relatively
homogeneous, since the sample was drawn from students in one course at one
university. Moreover, the research conducted psychometric testing on contemporary
attitudinal and knowledge instruments to ensure the validity and reliability of the
Taiwanese versions of the selected instruments. These design features helped to limit
the effects of any extraneous or confounding variables, so that any detected
differences could be confidently attributed to the intervention. While these design
features are strengths of the current research, issues related to the intervention itself
may also have contributed to the unexpected findings.
The validity of the educational intervention was promoted by basing it on
Kolb’s experiential learning model (Kolb, 1984) where experience is seen to play a
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central role in students’ learning. Understanding is formed and re-formed through
experience. An appreciation of experiential learning is necessary to underpin many of
the different types of teaching activities, including placement learning, practical work,
role play, group discussion, reflective practice, simulation games, and laboratory
practice sessions. So the experiential learning approach was an appropriate conceptual
framework for teaching the gerontology content. To further ensure the validity of the
intervention program, each teaching strategy was carefully considered for its fit with
each stage of the experiential leaning model. For example, as described in Chapter
Five, experience in a Senior Apartment served as a concrete experience (CE); group
discussion, journal writing, and debriefing served as reflective observation (RO);
lecturing and textbook reading provided learning activities for abstract
conceptualisation (AC); and role play, a simulation game, and practice in the
laboratory served as active experimentation (AE) in the experiential learning cycle.
However, several aspects of the educational intervention may explain why the
hypotheses were not confirmed. These aspects are discussed from two perspectives:
intrinsic factors related to the students; and extrinsic factors related to the educational
and teacher/researcher context. Firstly, while students in the experiential-based
learning (EBL) group had contact with well older people and completed an
assignment in a Senior Apartment, the intense and personal contact with non-family
older people may have been confronting to students, so that they may have focused on
the negative aspects of ageing that they observed. Another aspect of the ‘Senior
Apartment’ visit was that is was located 40 minutes away from the university; the
time taken to travel to it may have affected students’ willingness and motivation to go
there; this in turn may have influenced their reactions to the older people living in the
apartment. Secondly, consistent with the principles of experiential learning, students
218
were expected take responsibility for their own learning and actively participate in
class activities. In the traditional learning environment in Taiwan, students expect the
teacher to provide information and correct answers to questions, and are not
responsible for contributing to the development of an answer (Speece, 2002); this is
contrary to the concept in Kolb’s model of students engaging with their own learning.
So the dominance of the students’ traditional learning style may have limited their
ability to adapt to the new learning strategies; insufficient consideration of students’
usual learning style and preference may have limited their changes in attitudes and
knowledge. Thirdly, cultural differences might explain limitations on the use of
experiential-based learning, as cultural issues influence students’ behaviour in the
class. In respecting the Confucian ethic of filial piety, it is impolite to critique the
teacher’s answer, because of the teachers’ hierarchical position in the social context.
Students’ difficulty in changing their classroom behaviours may be attributed to the
importance of face in the Chinese cultural context (Valentine, 2002). Students do not
want to show off what they know, nor do they want to lose face if their answers are
not correct. Also, wasting other students’ class time by expressing individual opinions
is seen as selfish. Lastly, it was not possible to blind the students to the intervention;
they knew they were getting a different learning experience and, as they had to mix
with the students in other subjects, it was possible that they discussed and compared
their experiences. As the intervention was quite different from the usual teaching
style, there was likely to be an attention effect. It is usual for an attention effect to
have a positive influence on participants as they respond to what is expected of them
(Polit & Hungler, 1999; Portney & Watkins, 1993). However, as the learning style
was challenging the students’ usual style it may be that the students did not respond
positively to the experience and the attention effect may have had a negative influence
on the students that may have hindered changes in the students’ attitude and
219
knowledge.
With respect to extrinsic factors related to the intervention, several
possibilities could explain why the hypotheses were not confirmed. Firstly, in the
educational context, in order to ensure validity of the intervention, the teaching
strategies were based upon the experiential learning model, to help students not only
to gain experience, but also enable them to reflect on the experience and to connect
their experience with conceptual theories of ageing. However, the examination culture
in the selected university may have influenced students’ motivation, or lack of it, to
link their experience with theory. As mentioned in Chapter Six, the university required
students in the intervention group to complete the same examination as students in the
comparison group. To encourage students to attend to the experiential activities most
of the assessment weighting (80%) was given to these activities. Only a 10%
weighting was given to each of the examinations that the students had to do. With
such a low weighting on these examinations, they may not have been motivated to do
the readings for the examinations, which would have engaged them more with the
program and assisted with the development of abstract conceptualisation. This then
may have made it hard for students to develop a higher level of conceptual
understanding of older people. Secondly, a diverse range of learning strategies was
used and there may have been too many activities for the students to engage with and
reflect on each type; they may not have had enough time to explore their reactions and
experience with each of them. It may have been better to introduce fewer strategies to
give students the opportunity to experiment and develop a sense of mastery with one
strategy before introducing another one. An incremental approach over a longer
period of time would be necessary to achieve this.
220
Finally, the teacher/researcher context has to be considered; this was the first
time that experiential learning had been used in the selected university. No one knew
any more about experiential learning than the researcher/teacher, who was also the
lecturer who presented the intervention to the EBL group, as well as being the
interviewer for the focus group, and the data collector, and this could have introduced
bias to the study. As there were no other teachers in the university who had any
knowledge or experience about experiential learning it was not possible to get an
independent person to conduct the program, hence the researcher/teacher came to the
situation with some bias. Certain strategies were put in place to limit the impact of
this including: a detailed plan of how the gerontological nursing course would be
delivered through the whole semester, the details of each assignment, and the weight
of each assignment and examination; a detailed plan of how the course would be
conducted in each week including the topic, objectives, methods of teaching, details
of class activity, and discussion questions; teaching and lecture handouts on the
content of each topic presented; how the content was delivered each week; and
detailed plans for each activity. While it would have been desirable to have a different
person conduct the focus group with the EBL group, the person doing so needed to
have some understanding of focus group processes. Because of the absence of such a
person, the researcher needed to conduct the focus groups. Again, possible bias was
addressed by developing a question guide to be following during the focus group.
Although the researcher/teacher had some knowledge and experience about
experiential learning, her usual teaching style followed the didactic lecturing style
traditionally used in Taiwan, so the challenge for her was to provide learning that was
different from her usual style and from that of the students. The teacher’s skills and
competency at experiential learning may not have been enough to create the expected
221
change in student learning. These issues need to be considered in the context of
implementing a progressive and innovative learning strategy within a strong
traditional didactic teaching context. Two lecturers, from two other universities,
delivered the course to the comparison group; although they used only lectures to
deliver the program, the style and quality of these teachers was unknown and beyond
the control of the researcher. They could have made the content come alive for the
students and may have influenced the outcomes of the study.
Strengths and Limitations of the Research
Many of the design and intervention features discussed above can be seen as
strengths and weaknesses of the current research; however, there are others that also
need to be acknowledged. A major strength of the research is that it documented
current attitudes and knowledge of Taiwanese nursing students using contemporary
and psychometrically sound instruments that, as a result, are now available in
Taiwanese versions and can be used in future research. Also the research identified
important influencing factors for attitudes and knowledge about older people that can
be used when planning gerontological nursing education programs.
The educational intervention developed a program based on Kolb’s
experiential learning framework and the students in the focus groups said that they
enjoyed the new way of learning. Experiential learning enabled students to focus on
their personal involvement with older people, to reflect on their experience and
develop explanations of what was experienced. Because of the personal involvement
with older people and participation in class activities, students increased their
understanding of the positive aspects of older people and changed their attitudes
toward them. The main emphasis for experiential learning was on personal
222
involvement through reflection on each activity, and this was the first time such an
approach had been used in Taiwan. The experiential learning strategies were also
more flexible and learner-centred. The research has therefore provided new
knowledge and insights into how new learning approaches could be implemented in
Taiwan. These findings will be important to nurse academics and those implementing
gerontology programs.
In addition to some limitations outlined in the discussion of findings,
limitations about the generalizability of the findings need to be acknowledged. The
research was conducted with a convenience sample in a private university located in
southern Taiwan. It is only one of thirteen universities across Taiwan. The sample was
comprised only of undergraduate nursing students, so vocational school, junior
college, technological school, and graduate nursing students were not represented.
Consequently, the results of the study can only be generalised to undergraduate
nursing students, so the responses may not truly reflect all students studying nursing
across Taiwan.
Although a rigorous research design was used to evaluate the intervention, the
sample size was small. As mentioned in Chapter Six, the PWOP and KSOP scales had
been used only in cross-sectional research designs and the majority of previous
studies on the effects of gerontological educational programs on attitudes and
knowledge related to older people had used one-group, pre-test, post-test designs.
Therefore, there were no similar previous studies to provide guidance for estimating
sample size before conducting this study. Also, there was a total of only 60 students in
the second year, so only 30 students could be randomly assigned to each group.
Therefore, the sample was finalised with 60 students. Consequently, the power of the
223
sample size could not be calculated before the study and the finite sample resulting
may have been underpowered to detect the expected differences.
Implications for Nursing Education
Overall, the research established that nursing students had positive attitudes
and had some knowledge of the ageing situation in Taiwan but there was also much
about older people that they did not know. So students’ attitudes toward older people
still have room for improvement and significant improvements are also needed in
their level of knowledge about older people. Therefore, for nursing education, it is
important to consider what gerontological nursing content should be taught, how it
should be taught, where it should be taught, and when it should be taught. Also it is
recommended that gerontological subjects become part of the core nursing curriculum
and should no longer be offered as elective subjects.
Gerontological nursing education should be designed, not only to teach
students about older people, but also to try to create opportunities for contact with
older people, so as to encourage students’ intention to work with them. This study has
shown how a non-traditional learning approach could be used in nursing education.
Although the results did not support the hypotheses, the qualitative results suggest
students enjoyed the experiential learning activities and found them helpful for their
clinical practice. Therefore, experiential learning activities with older people could be
integrated into gerontological nursing education.
As students in the four-year nursing program had greater knowledge about
older people than two-year program students, nursing education needs to examine
programs of differing length and how the gerontology content is delivered in them. As
224
students’ previous experience with older people is likely to influence their interest in
aged care, nurse academics need to consider how they can build upon previous
experiences in positive and stimulating ways.
While the students enjoyed the experiential learning activities, their dominant
learning style needs to be considered, and students need to be assisted in a gradual
manner to adjust to experiential learning and to shift their learning style from being
passive information receivers to active learners. Students could be introduced to one
type of experiential activity and gain mastery and confidence with that, before being
introduced to the next one. Moreover, considering Taiwanese students’ learning style,
which focuses on didactic lectures and examinations, it may have been more
appropriate for the course to start with didactic lectures to let students understand
more about older people, giving them time to adjust to the new learning strategies.
Because of the examination culture, students do not study unless they have
examinations. Therefore, the weightings of the examinations need to re-considered
and possibly increased to encourage students to read the required readings.
Also, having some class activities prior to contact with older people would be
useful in order to avoid the possible effects of negative images of non-family older
people. It is therefore recommended that experiential learning strategies be introduced
sequentially and incrementally across a longer period of time.
Before experiential learning can be introduced as a major learning strategy in
nursing education, nurse academics will need to be prepared. Nurse academics in
Taiwan have come from the traditional didactic lecture method and therefore need to
develop their own skills in experiential learning. However, many have gained post-
225
graduate qualifications in Western countries and are therefore aware of the benefits of
student-centred learning. Nurse academic leaders in Taiwan are encouraged to
develop professional development programs for academics, so they can develop skills
and competence in experiential learning. The preparation of nurse academics to
implement experiential learning is a critical element for its success.
Recommendations for Research
In view of the findings of this study and for the further examination of
attitudes toward and knowledge about older people by underg raduate nursing
students, several recommendations are proposed as follows:
The survey of nursing students’ attitudes and knowledge should be
repeated across the whole range of nursing programs, undergraduate and
postgraduate, in order to provide additional information regarding how
different educational levels and nursing programs might influence
students’ attitudes and knowledge.
Qualitative research would be useful to gain a deeper understanding of
why male students have less positive attitudes toward older people than
females.
A future study could assess if intention to work with older people is a
determinant of students’ attitudes toward older people, by conducting a
longitudinal study of nursing students following graduation, to gather
information on where they are actually working and the ages of the
patients they work with. This would enable comparison of attitudes prior
to and following a period of work in nursing.
Research should explore Taiwanese students’ learning preference and
learning styles, using quantitative and qualitative study designs.
226
A stronger educational intervention needs to be developed and tested. This
may involve: a longer intervention with more focused experiential learning
strategies; a gradual introduction of contact with older people; systematic
and incremental introduction of each new learning strategy; consistency
between learning strategies and assessment methods; inclusion of students’
grades as an outcome measure.
An evaluation of an experiential based educational intervention, using a
larger sample size.
A comparison of students’ reaction to experiential learning with to lecture-
based learning.
In future research, that the intervention of experiential learning for a
gerotnological nursing course be delivered by teachers skilled in this
method, and that independent researchers need to collect the data.
Summary
This was the first research of its kind to be done in a Taiwanese university; no
published study has ever reported the introduction of experiential learning into an
undergraduate nursing course. It therefore provides a contemporary description of
student nurses’ attitudes and knowledge about ageing, and highlights the need for
gerontology to be a core subject in nursing curricula. Although the hypotheses were
not supported, the results can be explained from the perspectives of a stringent
research design and the introduction of an innovative and progressive intervention. It
was necessary to conduct this initial study to understand the students’ reaction to it,
and to explore how a student-centred learning approach could be integrated into
nursing curricula. Based on the research findings, students showed that they quite
enjoyed the experiential learning approach and found it helpful and practical. The
227
study has provided many insights into how such a learning approach could be
implemented into nursing education. Nursing academics are encouraged to learn
more about experiential learning, as it is an appropriate approach to ensure that nurses
of the future are well-prepared and interested in working with older people.
228
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APPENDIXCES
243
Appendix 1—Review of Educational Program
Authors &Year
Sample Methodology Variable measure Findings Strategies
1. Kline & Kline(1991)
UndergraduateN=42
Pre-Post test Control group (no
gerontology) Experimental group
(having gerontology) 10 weeks period
Attitudes (KAE) Knowledge (FAQ)
No significantdifferences werefound betweenmean scoresobtained at time 1and time 2 in eitherthe FAQ or theKAE
No mention
2. Bringle & Kremer(1993)
UndergraduateGroup 1: n=14Group 2: n=10Group3; n=20
Pre-Post test 8 weeks period 3 groups
Attitudes Knowledge
More positiveattitudes towardolder people in G1and G2 than G3
No differencebetween theinterventiongroups and thecomparison groupon knowledge ofageing.
G 1: receivedtraining andinstruction and madeweekly visits duringan 8-week period
G2: meet at leasttwice with an olderperson for at least 3hours at each visit
G3: were notexposed to coursecontent on aging,training, orvisitationsexperiences
244
Authors &Year
Sample Methodology Variable measure Findings Strategies
(comparison group)
3. Aday & Campbell(1995)
Undergraduaten=45
1. One group2. Pre-post test
Attitudes towardolder people (PAEI)
Attitudes aboutcaring for the olderpeople (EPCI)
1. Positiveattitudinalchange
2. greater sentimentfor working witholder people
Integrate the conceptsof ageing and aspectsof the older clientsthrough the nursingcurriculum (4semesters)
Class (lecture??) Clinical experience in
acute hospital4. Bullard &Fleischer (1996)
NursingassistantsN=155
Pre-post test, follow-uptest (8 weeks)
One group
Knowledge (FAQ 1) Intervention had asignificant impacton the knowledgegained
Workshop (8 hours) Didactic lectures
along with simulatedexercises
5. Knapp &Stubblefield (1998)
UndergraduateN=55
Pre-post test Control group (n=27) Experimental group (n=28)
Knowledge (FAQ 1 &FAQ 2)
Student wereenrolled in thegerontology coursedid benefit fromthe instruction
No mention
6. Kaner,Rheinheimer, DeLisi& Due (1998)
Hospital staffN=96
Pre-post test One group only
Attitudes (FAQ 1) Knowledge (FAQ1)
An experientiallearningeducationalprogram forhospital personnelcan be effective in
experiential learning into ageing game file: Images of Ageing
245
Authors &Year
Sample Methodology Variable measure Findings Strategies
increasingknowledge aboutand influencingattitudes towardolder adults.
7. Anderson-Hanley(1999)
UndergraduateN=9
Quantitative— Post-testQualitative-- Writing comments
regarding each activity
Rating of theactivity’susefulness
Open-end questions
Activities to behelpful infacilitatingstudents’ learning
12 experientialactivities (integratedwith traditionallectures anddiscussions)
8. Knapp &Stubblefield (2000)
UndergraduateN=55
Pre-post test Control group (n=27) Experimental group (n=28)
Knowledge (FAQ 1 &FAQ 2)
Student wereenrolled in thegerontology coursedid benefit fromthe instruction
Service learning
9. Ragan & Bowen(2001)
UndergraduateN=112
Pre-Post test and follow uptest
3 groups G1: Information only G2: information and
reinforcement G3: information and
campus life
Attitudes (ASD) The interactionbetween group andtime wassignificant, as werethe main effects forgroup, and time
Each group,attitudes weresignificantly morepositive
G1: watchingvideotape
G2: watchingvideotape, discussionthe videotape, verbalreinforcement forappropriate remarksand ignored any off-task comments
G3: watching
246
Authors &Year
Sample Methodology Variable measure Findings Strategies
immediately afterobserving thevideotape thantheir pre-test.There was nosignificantdifference betweentheir pretest and 4-week follow-upscores
videotape, discussionthe current events atthe university, verbalreinforcement forcomments related tothese topics, ignoreany references toother issues such asvideotapes
10. Wilkes &LeMiere (2001)
Staff workingin aged carefacilityN=47
Pre-post test A series of educational
program One group
Attitudes Knowledge
Increasingknowledge of olderpeople
More positiveattitudes if the staffworking in an agedcare facility towardolder people
No mentioned
11. Brown & Roodin(2001)
Undergraduaten=104
Qualitative—contentanalysis
Students’ initialreactions to service-learning
Students’ finalreactions to service-learning
Six themes Service-learning Discussion of their
experience as aregular part of class
Classroom lecturesand reading
Small groupdiscussion during
247
Authors &Year
Sample Methodology Variable measure Findings Strategies
class time Weekly journal
writing assignments Assigned short paper
dealing with issues12. O’ Hanlon&Brookover (2002)
1.Undergraduate n= 462.Graduate
n= 93.total N=55
1.Quantitative andQualitative researchdesign
2.One group3.Pre-post test
Attitudes (ASD) Self-reported beliefs
1.Positiveattitudinalchange
One semester-longgerontology course
Experiential learningactivity—a personalinterview with a olderadult
13. Dorfman, Murty,Ingram, Evans&Power (2004)
Undergraduate5 CohortsTotal N= 59
Quantitative— Pre-post testQualitative-- Open-end questions
Students’ attitudinalchange
Mean difference inattitudes among thefive student cohorts
At posttest,positiveattitudinal changeacross cohorts onthe GeneralAttitudes Towardthe Elderly scale
No significantchange at posttestin either theWorking withOlder Peoplescale
Intergenerationalservice-learning
14. Gallzgher, Undergraduate 1. Two group Comparison of Web-based Web-based v.s.
248
Authors &Year
Sample Methodology Variable measure Findings Strategies
Dobrosielski-Vergona, Wingard&Williams (2005)
Web-based n= 12 Traditional
classroomn= 32
2. Pre-post test studentcharacteristics
Instructionaloutcomes
Student retention ofcourse material sixmonths aftercompletion of thegerontology course
students wereolder thantraditionalclassroomstudents
The majority ifstudents in web-based hadprevious taken anonline course.Traditionalstudents were not
Web-basedstudents hadgreater success inaccomplishing thecourse
Retention ofinformation washigher in web-based students
Traditional classroom
15. Moriello, smey,Pescatello & Murphy(2005)
41 pre-alliedhealthstudents-Intervention(n=19)-Comparison
Quasi-experiementaldesign over time
Post test only (1 weekand 10 weeksfollowing theworkshop)
Attitudes (KOP) Knowledge
(FACTS)
Interventionimprovedknowledge in theshort term, but bitat 10 weeks
No significant
Intervention group:didactic lecture, groupactivities, andsimulation activities
249
Authors &Year
Sample Methodology Variable measure Findings Strategies
(n=22) Two group A six-hour multi-modal
workshop
difference wasnoted between thetwo groups ionthe attitudinalscale
250
Appendix 2—KOP (Study 1) (English Version)
Kogan’s Attitudes Toward Old People Scale (KOP)
For each of following questions, circle the answer that best expresses your “true”
feelings. Response range from（1）strongly disagree to（7）strongly agree. It is
important that you give your own personal judgment and not how you feel others
might react or hoe you think you should react. Please answer all questions.
Strongly Agree（7）
Agree （6）
Slightly Agree（5）
Slightly Disagree（3）
Disagree（2）
Strongly Disagree（1）
1. It would probably be better if most old people lived in 1 2 3 5 6 7
residential units with people of their own age.
2. It would probably be better if most old people lived in 1 2 3 5 6 7
residential units that also housed younger people.
3. There is something different about most old people: it 1 2 3 5 6 7
is hard to figure out what makes them sick.
4. Most old people are really no different from anybody 1 2 3 5 6 7
else: they are as easy to understand as younger people.
5. Most old people get set in their ways and are unable to 1 2 3 5 6 7
change.
6. Most old people are capable of new adjustment when 1 2 3 5 6 7
the situation demands it.
7. Most old people would prefer to quite work as soon as 1 2 3 5 6 7
251
pensions or their children can support them.
8. Most old people would prefer to continue working just as 1 2 3 5 6 7
long as they possible can rather than be dependent on
anybody.
9. Most old people tend to let their homes become shabby 1 2 3 5 6 7
and unattractive.
10. Most old people can generally be counted on to maintain 1 2 3 5 6 7
a clean, attractive home.
11. It is foolish to claim that wisdom comes with older ages 1 2 3 5 6 7
12. People grow wiser with the coming of old age. 1 2 3 5 6 7
13. Old people have too much power in business and 1 2 3 5 6 7
politics
14. Old people should have more power in business and 1 2 3 5 6 7
politics
15. Most old people make one feel ill at home. 1 2 3 5 6 7
16. Most old people are very relaxing to be with. 1 2 3 5 6 7
17. Most old people bore others by their insistence on talking 1 2 3 5 6 7
about the “good old days”.
18. One of most interesting and entertaining qualities of 1 2 3 5 6 7
most old people is their accounts of their past experiences.
19. Most old people spend too much time prying into the 1 2 3 5 6 7
affairs of others and giving unsought advice unattractive.
20. Most old people tend to keep to themselves and give 1 2 3 5 6 7
advice only when asked.
21. If old people expect to be liked, their first step is to try 1 2 3 5 6 7
to get rid of their irritating faults.
252
22. When you think about it, old people have the same 1 2 3 5 6 7
faults as anybody else.
23. In order to maintain a nice residential neighborhood, 1 2 3 5 6 7
it would be best if too many old people did not live in it.
24. You can count on finding a nice residential neighborhood 1 2 3 5 6 7
when there is a sizeable number of old people living in it.
25. There was a few exceptions, but in general most old 1 2 3 5 6 7
people are pretty much alike.
26. It is evidence that most old people are very different 1 2 3 5 6 7
from one another.
27. Most old people should be more concerned with their 1 2 3 5 6 7
personal appearance: they are too untidy.
28. Most old people seem to be quite clean and neat in 1 2 3 5 6 7
their personal appearance.
29. Most old people are irritable, grouchy, and unpleasant. 1 2 3 5 6 7
30. Most old people are cheerful, agreeable, and good 1 2 3 5 6 7
humored.
31. Most old people are constantly complaining about the 1 2 3 5 6 7
behavior of the younger generation.
32. One seldom hears old people complaining about the 1 2 3 5 6 7
behavior of the younger generation.
33. Most old people make excessive demands for love 1 2 3 5 6 7
and reassurance.
34. Most old people need no more love and reassurance 1 2 3 5 6 7
than anyone else.
253
Appendix 2—KOP (Study 1) (Chinese Version)
對於『老人』之 Kogan態度評量 (KOP)
請詳讀以下陳述以及指示,並以打勾()的方式選出認為最能夠表達自己意見的
選項:
非
常
同
意
同意 一點
點同
意
一點
點不
同意
不同
意
非常
不同
意
1.大部分的老年人最好與其他年齡相仿的老年
人一同居住在安養住宅內
2.大部分的老年人所居住的安養住宅，最好也
有年輕人共同生活在安養住宅內
3.大部分老年人總是有一些不同：但很難去了
解是什麼使他們被厭惡的
4.大部分的老年人和其他人沒有什麼不同：他
們和年輕人一樣很容易被了解
5. 大部分的老年人都固守自己的原則，沒有
辦法改變的
6.應情況的要求，大部分的老年人都有能力去
調適或適應新的狀況
7.大部分的老年人都希望一旦有退休金或是他
們的小孩有能力撫養他們時就辭職
8.大部分的老年人如果可以的話寧願持續工作
而非仰賴他人
9.大部分的老年人們傾向讓住家變的陳舊和不
吸引人注意的
10.大部分的老年人們能夠維持一個整齊清潔
和美觀的住家
11. 越老越有智慧是一種愚蠢的說法
12. 年紀越大越有智慧
13. 老年人擁有過多商場上或政治上的權利
14. 老年人在商場或政治圈中應要有更多的權
利
15. 在家時，大部分的老年人讓人覺得不舒服
254
非
常
同
意
同意 一點
點同
意
一點
點不
同意
不同
意
非常
不同
意
16. 大多數的老年人讓人覺得和他們在一起是
很自在的
17.大部分的老年人們總是喜歡不斷的陳述一
些讓人覺得無趣的往事
18.大部分老年人最令人感到有趣及有興趣的
特質是他們講述他們所經歷過的歲月點滴
(過去經驗)19.大多數的老年人常七嘴八舌地談論別人的
事情，並給予無建設(無吸引力)的建議
20.大多數的老年人並不管別人的閒事，且只
在別人要求時提出他們的看法與建議
21.假如老年人希望被喜愛，第一步就是改掉
令他人厭煩的毛病
22. 其實你想一想之後，老年人們犯的錯我們
也會犯
23.為了要保有好的住家環境，必須不能有太
多老年人住在裡頭
24.我們可以發現好的住家環境，通常都擁有
適當比例的老年人居住人口
25. 除了少數幾個之外，大多數的老年人都很
像
26. 我們常可以發現老年人們彼此是很不同的
27.老年人們須注意一下自己的外觀：他們實
在是太不修邊幅了
28. 大多數老年人的外觀給人印象是整齊清潔
的
29. 大多數的老年人是易惱怒的、愛抱怨和令
人不愉快的
30.大多數的老年人是令人高興的、能與人和
睦相處以及具有好的幽默感的
31. 大多數的老年人總是不斷抱怨年輕一輩行
為的不是
32. 我們很少聽到老年人們在抱怨年輕人行為
的不是
33. 大多數的老年人過度要求關愛與再保證
255
非
常
同
意
同意 一點
點同
意
一點
點不
同意
不同
意
非常
不同
意
34. 大多數的老年人較不需要更多的關愛與再
保證
256
Appendix 3—PWOP (Study 1) (English Version)
Perceptions of Working with Older People (PWOP)
Please read the statements and indicate how much you agree with each by
circling the number that best reflects your opinion:
Strongly Agree (5)
Agree (4)
Neither Agree nor Disagree (3)
Disagree (2)
Strongly Disagree (1)
Stro
ngly
Agr
ee
Agr
ee
Nei
ther
agre
eno
rdi
sagr
ee
disa
gree
Stro
ngly
disa
gree
Students’ perceptions of working witholderPeople in general1. Nursing older people is mainly aboutbasic care—it does not requiremuch skill2. Nursing older people is challenging andstimulating3. Nurses work with older people becausethey cannot cope with hi-tech care4. The older you are the easier it is to havea good rapport with older people5. Nursing older people is a highly skill job6. I think older people are really interestingto nurseStudent’s personal disposition towardworkWith older people7. I would definitely consider working witholder people when I qualify8. I am really looking forward/I reallylooked forward to my first placement witholder people9. I am really anxious/ I was really anxiousabout my first placement with older people
257
Stro
ngly
Agr
ee
Agr
ee
Nei
ther
agre
eno
rdi
sagr
ee
disa
gree
Stro
ngly
disa
gree
10. Working with older people does notappeal to me at all
Students’ perceptions of the consequences ofworking with older people11. Work with older people is a dead- endjob12. Working with older people has a highstatus13. Once you work with older people it isdifficult to get a job elsewhere14. Nursing older people provides littlesatisfaction as they rarely get better15. Working with older people is not agood career move
258
Appendix 3—PWOP (Study 1) (Chinese Version)
Perceptions of Working with Older People (PWOP)
請詳讀以下陳述以及指示,並以打勾()的方式選出認為最能夠表達自己意見的
選項:
非常
同意
同意尚可不同意非常不同意
一般而言,學生照護老年的觀點
1.照護老年人主要是基本的照護—這不需要
太多的技能
2.照護老年人是個挑戰與激勵
3.會選擇照護老年人的護士,是因為他們無
法適應高技術層面的照護工作
4.年紀越長,越容易跟老年人有不錯的交流互動
5.照護老年人是一個很高技能的工作
6.我想照護老年人真的是很有趣的工作
對照護老年人學生的個性傾向
7.當我有執照後,我確定我會考慮照護老年人的工作
8.我真的期待/我已期待我的第一個場所是照護老年人
9.我真的覺的焦慮/我已經覺得焦慮我的第一個場所是照護老年人
10.與老年人一起工作一點都不吸引我
學生對照護老年人的結果的觀點
11.和老年人有關的工作是沒有前途的職業
12.和老年人有關的工作是有很高的地位
13.只要你做過一次和老年人有關的工作, 就很難在其他地方找到工作
14.照護老年人只能提供一點點的滿足,因為他們病情很少會好轉
15.老人照護不是一個很好的生涯職業進展
259
Appendix 4—FAQ 1 (Study 1) (English Version)
Facts on Ageing Quiz
Please answer the following questions. Make “x” for False and “o” for True. DO
NOT PLACE YOUR NAME IN QUESTIONNAIRES.
1. The majority of old people are senile（i.e., defective memory, disoriented or
demented）.
2. All five sense tend to decline in old age.
3. Most old people have no interest in, or capacity for, sexual relations.
4. Lung capacity tends to decline in old age.
5. Majority of old people feel miserable most of the time.
6. Physical strength tends to decline in old age.
7. At least, one-twentieth of the aged are living in long-stay institution（i.e.,
nursing home, home for the aged, etc.）.
8. Aged drivers have fewer accidents per person than drivers under 65.
9. Most older workers cannot work as effectively as younger workers.
10. About 80% of the aged are healthy enough to carry out their normal activities.
11. Most older people are set in their ways and unable to change.
12. Old people usually take longer to learn something new.
13. It is almost impossible for most old people to learn new thing.
14. The reaction time of most old people tends to be slower than the reaction time
of younger people.
15. In general, most old people are pretty much alike.
16. The majority of old people are seldom bored.
260
17. The majority of old people are socially isolated and lonely.
18. Older workers have fewer accidents than younger workers.
19. Over 10% of Taiwan population are now age 65 and over.
20. Major medical practitioners tend to give low priority to old people.
21. The majority of older people have incomes below poverty level (as defined by
the Government).
22. The majority of old people are working or would like some kind of work to do
(including housework and volunteer work).
23. Older people tend to become more religious as they age.
24. The majority of old people are seldom irritated or angry.
25. The health and socioeconomic status of older people (compared to younger
people) in the year 2020 will probably be about the same as now.
261
Appendix 4—FAQ 1 (Study 1) (Chinese Version)
Facts on Ageing Quiz
請詳讀以下陳述以及指示,並以打勾()的方式回答以下的問題。請注意!不要留
下名字在問卷上.
對 錯 不
知
道
1.大多數的老年人都是老態龍鍾的（例如:不健全的記憶,迷失
方向或是 心智障礙的）
2.在年老後五官會傾向於衰弱
3.大多數的老年人對於性關係都是沒興趣及沒能力的
4.肺活量在老年時期會傾向於衰退
5.在大多數時間，大多數的老年人感到自己是不幸的
6.老年時期身體體能會傾向於衰退
7.至少有10%的老年人住在長期照護機構（如:護理之家,老人
之家 ,…等等）
8.每個年長的駕駛人都比65歲以下的駕駛人較少發生意外
9.大多數的年長工作者無法工作的像年輕工作者般一樣有效力.
10.大約有80%老年人都有足夠的健康去執行日常的活動.
11.大多數的老年人都是固執自己的原則以及不知變通的.
12.老年人通常要用比較長的時間在學習新的事物上.
13.對大多數的老年人而言要學習新事物幾乎是不可能的.
14.大多數老年人反應時間都比年輕人趨於緩慢.
15.一般而言,大部分的老年人看起來都很相似
16.大多數的老年人很少是無聊的
17.大多數的老年人都是很孤獨的並且和社交隔離的
262
對 錯 不
知
道
18.年長的工作者較年輕的工作者少有意外事故
19.台灣人口中，9%以上的是 65歲或是 65以上的老年人
20.大多數的醫療人員傾向給予老年人比較少的優先權
21.大多數老年人的常態收入是在貧窮階級以下(政府的定義)
22.大多數的老年人都有在工作或是會想有一些工作做(包括家事
和志願性的工作)
23.隨著他們的年齡增長,老年人更趨向成為宗教信仰虔誠的人
24.大多數的老年人是很少發怒或是生氣
25.老年人的健康與社會經濟的狀況(跟年輕人做比較)在2020 年
將有可能會大概與目前相同
263
Appendix 5—KSOP (Study 1) (Original English Version)
Knowledge of Situation of Older People
Below are some statements about older people in the UK today. Please indicate
whether you think each of the following statistics is either too high, about right, or too
low by placing a tick in the appropriate box:
I think this figure is:
Too About Too
High Right Low
1. The percentage of people currently over the age of 65
in the UK is about 17%
2. The percentage of people in ethnic minority group who
are currently over the age of 65 years in the UK is about 10%
3. Between now and 2034 the percentage of people over
the age of 85 is expected to increase by about 60%
4. By 2016 the number of people aged over 100 will treble
5. Of women over the age of 75 about 60% live alone
6. The percentage of people between the ages of 60-74 living
in residential or nursing home is about 5%
7. People aged 75 years and over are 3 times more likely to
die an accidental death than the general population
8. Of people aged 75 years and over about 50% report
long-term illness or disability
9. The percentage of people over the age of 65 who need help
with the following activities is about
Washing all over 20%
264
Dressing 12%
Using the toilet 10%
Climbing steps/ stairs 30%
Hearing someone talk 20%
Reading a newspaper even with glasses 15%
10. The percentage of people between the ages of 65-74 in
some from of paid employment is about 5%
11. In any one year the percentage of people aged 75+ who
have an in-patient stay in hospital is about 30%
12. On average people aged over 75 spend about 15% of
their income on hearing and lighting
265
Appendix 5—KSOP (Study 1) (Taiwanese English Version)
Below are some statements about older people in the Taiwan today. Please indicate
whether you think each of the following statistics is either too high, about right, or too
low by placing a tick in the appropriate box:
9. The percentage of people over the age of 65 who need help with the following
activities is aboutI think this figure is
Toohigh
Right Toolow
Washing all over 2.5%Dressing 2.1%Using the toilet 2.0%Get up to bed and get down from bed 1.8%Assist with making phone call 4.6%Assist with eating 1.2%
I think this figure is:Toohigh
Right Toolow
1. The percentage of people over the age of 65 in the Taiwan isabout 9 %.
2. The percentage of people in Aboriginal group who are currentlyover the age of 65 years in the Taiwan is about 6 %
3. Between now and 2030 the percentage of people over the age of65 is expected to increase by about 20%
4. The percentage of people currently over the age of 100 is about0.003% in the general population
5. Of women over the age of 65 about 40% will live alone6. The percentage of people over the ages 65 living in residential or
nursing home is about 10%
7. People aged 65 years and over are 2.6 times more likely to die anaccidental death than the middle age population
8. Of people aged 65 years and over about 56% report chronicillness or disability
266
I think the figure isToohigh
Right Toolow
10. The percentage of people over the age of 65， in some from ofpaid employment is about 11%
11. In any one year the percentage of people aged 65+ who have anin-patient stay in hospital is about 7 time than other population
12.The economic supply of the age 65 elderly is about 47% incomefrom their kids.
267
Appendix 5—KSOP (Study 1) (Chinese Version)
Knowledge of Situation of Older People
下列的陳述是有關於今日台灣的老年人。請在下述的陳述問卷中，針對你的想
法來表示每一個統計數據值的適切性，並在太高、正確及太低的專屬空格中打
勾作記號。
9.年齡等於或大於 65歲的人，需要下列的日常生活完全的協助我認為這個數字是
太高 正確 太低
日常盥洗（含全身） 2.5%
穿衣服 2.1%
廁所使用 2.0%
上下床 1.8%
打電話 4.6%
進食 1.2%
我認為這個數字是
太高 正確 太低
1.在台灣，年齡大於 65歲的人口比例約為 9 %2.在台灣，年齡大於 65歲的台灣原住民人口佔台灣人口比例
約為 6 %3.從現在到 2030年，年齡大於 65歲的人口比例將提昇至
20%4.現今年齡大於 100歲的老年人口佔台灣總人口比例約
0.003%。
5.約有 40%，年齡超過 65歲的女性將獨自居住。6.約有 10%居住在安養院或療養院的人，年齡超過 65歲的老
年人
7.年齡等於或大於 65歲的人，死於意外的比例是少於中年人
(45-64歲)的 2.6倍。8.約有 56%長期受到疾病侵犯或是殘疾的人，年齡是等於或大於 65歲。
268
我認為這個數字是
太高 正確 太低
10.約 11%有酬勞被雇用的人口比例，其年齡大於 65歲以上
11.每年住院費用比例中，年齡大於 65歲的老年人的住院費用是非老年人的 7倍
12.年齡 65歲的老年人的經濟來源，47%來自於子女的奉養
269
Appendix 6— Consent for the use of the four established research instruments
270
Appendix 7—Demographic data sheet (English Version)
DEMOGRAPHIC INFORMATION
(Please circle the appropriate response unless otherwise asked)
1. Age at last birthday
(Please insert the number of years)
…………….years2. Gender
Male……………………..1Female…………………..2
3. Martial status
Single (never married) …………………..1Single (divorced) …………………………2
Married/Defacto…………………………3
4. Qualification
General Senior High School…………………..1Vocational high school (3years) ………………2Junior College (5years) ……………………….3Other (Please specify) …………………………4………………………..
5. Which year of your course are you in?
Four year program:
First Year…………………..1Second Year………………..2Third Year………………….3Forth Year…………………..4
Two year program:
First Year…………………..1Second Year………………..2
6. Do you have any work experience in nursing?
Yes…………………………..1No……………………………2If yes, please continue with this question, if no please go to Question 7
If you have had work experience, how long was this for? ………………..
271
What type of experience was it? (Please tick)
Paid work………… Work experience without payment……………. Volunteer work…….……….
How satisfying/dissatisfying did you find the experience? (Please circle)
1 2 3 4 5
Extremely Satisfying Neutral Dissatisfying Extremely
Satisfying Dissatisfying
7. Before you commenced your course, did an older relative live with you and
your family on a permanent basis?
Yes…………………………1, go to question 11
No………………………….2, go to question 8
8. Had you had any contact with older people in your family before you
commenced your nursing course?
Yes……………………..1, go to question 9
No……………………...2, go to question12
9. How often did you have contact with older people in your family before you
commenced your course?
Everyday………………………..….. 1Once a week…………………………2Twice a week…………………………3Three times a weeks………………….4Every 2 weeks………………………..5Once a month…………………………6Occasionally………………………….7
10. On average how much time long did you spend with the older person in
your family on each contact?
Less than 30 minutes …………………...130 minutes – 1hour………………….…..21 – 2 hours………………………………3
272
2 – 3 hours…………………………..…..4More than 3 hours………………….……5
11. Following your contact with older people, how satisfying/dissatisfying did
you find the experience?
(Please circle)
1 2 3 4 5
Extremely Satisfying Neutral Dissatisfying Extremely
Satisfying Dissatisfying
12. Have you ever taken any subjects or programs which have had content
related to older people?
Yes…………………..1, go to question 13 No…………………...2, go to question 14
13. How much time did the subjects or programs spend on older people?
Less than 1 hour…………………...1Between 1 – 2 hours……………….2Between 2 – 6 hours……………….3Between 6 – 12 hours……………...4Between 12 – 16 hours…………….5Between 16 – 32 hours…………….6More than 32 hours………………..7
14. Have you undertaken any clinical practice in your course?
Yes……………………….1 No………………………2
If yes, how much time did you have on clinical? ………………If yes, did you have any contact with older people during this clinical
practice?
Yes……………………….1No………………………..2
How satisfied did you feel related to the clinical experience of the contact
with older people while on clinical?
(Please circle)
273
1 2 3 4 5
Extremely Satisfying Neutral Dissatisfying Extremely
Satisfying Dissatisfying
15. After you finish your nursing course, do you intend to work with older
people?
1 2 3 4 5
Definitely Probably will Undecided Probably will not Definitely not
274
Appendix 7—Demographic data sheet (Chinese Version)
DEMOGRAPHIC INFORMATION
(請以打勾選擇最適當的答案)
4. 實際年齡 …………….歲(足歲)
5. 性別 男 …………………
女... ……………….
6. 婚姻狀況 單身(沒結過婚) …………. 單身(離婚) ………………. 已婚/同居…………………
7. 教育程度(已畢業的最高學歷) 普通高中……...…….…高級職業學校(3年) ….. 專科(5年)... ……………其他 (請說明) .…………
8. 你現在是在那一學制中?
四年學制…………………..(請打勾)
一年級…………………..二年級…………………..三年級.………………….四年級…………….…….
兩年學制…………………..(請打勾)
一年級…………………..二年級…………………..
9.你有沒有護理的工作經驗? (請打勾)
6a.你這護理工作經驗有多久?
6b.那是那一類的經驗? (請打勾)
沒有………………………
有…………………………
假如你回答沒有，請回答第 7題
假如你回答有，請回答第 6 a, b & c題 :
………月
有付酬勞的……….…………
有工作經驗但沒酬勞的(含實習及家人的看護經驗)………………..……義工…...…………….……….
6c.你對這工作經驗的滿意度為何? (請打勾)
非常滿意 滿意 尚可 不滿意 非常不滿意
275
16. 在你開始護理課程前，家中有無老
年人或年老的親戚和你們長久住在一
起?
有………………………… ,請回答問題 8
無………………………. ,請回答問題 9
8. 依據你和老年人的接觸經驗，你的滿意度為何? (請打勾)
非常滿意 滿意 尚可 不滿意 非常不滿意
9. 在你開始護理課程前，你有無和家中老年人或年老親戚接觸的經驗（ie,沒和你住在一起的老年人）?
有…………………….. ,請回答問題 10
無…………………... ,請回答問題 12
10. 在你開始護理課程前，你平均多久
和家族裡的老年人接觸一次?每天………….……………..….. 一星期一次…..…………………一星期兩次……..………………一星期三次……….…………….每兩星期一次…………………..一個月一次…………..…………偶爾一次………………..……….
11. 一般而言，在每一次接觸中，你花
多少時間和老年人相處?少於 30分鐘 …………………...30分鐘 – 1小時…………….…..1小時 – 2小時….………………2小時– 3小時……..………..…..3小時以上………………….……
12. 你曾經修習過任何有關於老年人的
科目或研習課程嗎?有……………………. … ,請回答問題 13
沒有…………………. … ,請回答問題 14
13. 在這門科目或是研習裡，合計花多
少時間在老年人身上?少於 1小時……………….….……...1小時到 2小時之間……………….2小時到 6小時之間……………….6小時到 12小時之間……………...12小時到 16小時之間…………….16小時到 32小時之間…………….32小時以上……….……….………..
14. 在你的課程中，你曾經修過任何臨
床實習的課程(含任何護理的課程)?
14a.你在臨床實習的時間有多少?
14b.你曾經在這個臨床實習期間裡有接
有………………………….沒有………………………
假如你回答沒有，請回答問題 15
假如你回答有，請回答問題 14 a, b & c :
………………天
有………………………. 請回答問題 14c
276
觸過任何老人嗎? 沒有………………….. 請回答問題 15
14c. 在這臨床實習期間，你對這接觸老年人的經驗的滿意度為何? (請打勾)
非常滿意 滿意 尚可 不滿意 非常不滿意
15. 當你結束護理課程之後，你會打算從事有關於護理老年人的工作嗎?
確定會 可能會 還沒決定 可能不會 確定不會
277
Appendix 8—Ethical Approval from QUT
278
Appendix 9—Ethical Approval from study university
279
Appendix 10—Participant information sheet (Study 1) (English Version)
CENTRE FOR HUMAN RESEARCH
INFORMATION SHEET FOR SURVEY PARTICIPATION
STUDY TITLE: The effect of an experiential learning strategy onnursing students’ knowledge and attitudes toward olderpeople in Taiwan
Purpose of the Survey:
Little is known about nursing students’ knowledge and attitude toward older people in
Taiwan. This survey aims to identify factors influencing Taiwanese nursing students’
attitudes and knowledge toward older people. Based on the results of this survey, a
new gerontological curriculum will be developed.
Participant Involvement
As student nurses of today are the health care providers of tomorrow, your
input into this study is greatly valued. You are being invited to take part in a survey on
your attitudes toward old people and your knowledge about facts on ageing. If you
agree to be involved, you will be asked to complete a questionnaire. This
questionnaire will ask you about issues such as your attitudes toward older people and
your knowledge about ageing. The questionnaire should take approximate 15-20
minutes to complete.
Expected outcomes
Possible benefits include devising a gerontology curriculum for future nursing
students. We cannot guarantee or promise that you will receive any direct benefits
from this survey.
280
Risks
No risks to you have been identified. Your decision to participate will in no way
impact on your present or future study.
Confidentiality
Please do not write your name or university on the questionnaire, as we do not wish
any individual or university to be identified by the data collected. Each questionnaire
will be identified by a number. All information you provide will be kept in strictest
confidence and locked in a filing cabinet during the study period and for five years
after which the data will be destroyed. No information about the project will be
published in any form that would allow any individual or university to be recognized.
Data will be secured on a password-protected computer file with access available only
to the researcher.
Voluntary Participation
Your participation in the survey is entirely voluntary and you are free to withdraw
from undertaking the survey at anytime without comment or penalty. Your decision
will in no way impact upon your future study.
Feedback
All participants have the right to ask questions about the survey, and feedback on the
survey will be supplied on request. If you have any questions or concerns, or if you
request additional information, you may contact I-Ju Pan at any time during or
following the survey. If you have any ethical concerns, you may contact Pai Mei Lin,
phone 07-6577711-5764
Thank you for considering participation in this survey. Your participation is greatly
appreciated.
The person to contact is:
I-Ju Pan
PhD student in Queensland University of Technology;
Victoria Park Road Kelvin Grove QLD 4059 Australia
Telephone:61-7-3864 3882
Lecturer in I-Shou University
No 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung Xien, Taiwan
Telephone: 886-7-6577711-5752
Email: [email protected]
Queensland University of Technology, University Human Research Ethics Committee
(UHREC)
281
Email: [email protected]
Pai Mei Lin,
Associate Professor in I-Shou University
No 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung Xien
Telephone: 07-6577711-5764
282
Appendix 10—Participant information sheet (Study 1) (Chinese Version)
研究主題:來自經驗學習策略對於在台灣護理系學生對老年人的知識及態度影
響。
研究之目的:主題是有關台灣的護理學生對老年人的知識及態度。這個調查報告
主要是去發現影響台灣護理學生對老年人態度及老化知識以及其影響的因素。
這份調查報告的結果將是發展新的老人護理學的基礎。
參予者之牽連
今日的護理學生的你將是明日健康照顧的提供者。你對這研究的參與是具有極
大的價值。你正被邀請加入參予這關於你對老年人的態度及你面對老化的知識
的研究。假如你同意加入，你將會被要求去完成一份問卷。這問卷大概會詢問
你一些關於你對老年人的態度及面對老化的知識。這問卷大約花費你 15~20分
鐘來完成。
預期的結果
有可能益處包含對未來的護理學生而言發展一門老年的專業科目。我們不能保
證及承諾你將會從這調查報告中得到直接的好處。
風險
對你而言，尚無任何風險被發現。你的決定參與將不會對你的現在及未
來有任何的影響。
機密
在這研究問卷中請不要寫下你的姓名及大學，就如我們不希望個人或大學在資
料收集中被發現。每份問卷只會被數據所證明。在研究期間，所有你所提供的
資料將會以最嚴密的機密而保存在一個上鎖的檔案櫃中並且這些資料將會在五
年後被摧毀。即使是被個人或大學所允許，任何有關這主題的資料將不會以任
何形式被出版。這數據會被一個有密碼保護及只有研究者可開啟電腦檔案所保
護著。
在此份調查中，你的參與是完全的出於自願。此外你也可以在任何時間
283
內自由的退出這研究調查活動並且沒有任何的影響及懲罰。你的決定將不會對
你未來的學習有任何的影響。
回饋
所有的參與者都有權利詢問有關這研究的問題且此份調查報告也會對此要求提
共回覆。假如你有任何的問題或顧慮，或者你有要求額外的資料，你可以在此
調查時間內的任何的時間與潘怡如聯絡。假如你有任何道德上的顧慮，你可以
與林柏美電話聯絡07-6577711-5764。
感謝你考慮加入此次調查，你的參予將會被大大的感激。
聯絡人:
潘怡如
昆士蘭科技大學博士班學生
Victoria Park Road Kelvin Grove QLD 4059 Australia
電話: 61-7-3864 3882
E-mail:[email protected]
義守大學講師
高雄縣大樹鄉學成路一段一號
電話: 07-6577711-5752
Queensland University of Technology, University human Research Ethics Committee(UHREC)Email: [email protected]
林柏每
義守大學副教授
No 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung Xien
電話: 07-6577711-5764
Email: [email protected]
284
Appendix 11—Consent form (Study 1) (English Version)
PARTICIPANT CONSENT FORMSTUDY TITLE: The effect of an experiential learning strategy on nursing
students’ knowledge and attitudes toward older people in Taiwan
Statement of consentI, consent to participate in the above named project. I have beengiven information about the survey, as well as an information sheet outlining detailsof the survey. I understand that any information collected for the survey will remainstrictly confidential.
By signing below, you are indicating that you:
1. have read and understand the Participant Information Sheet about this survey;2. understand the nature and purpose of the study;3. have been given the opportunity to ask questions regarding the research study;4. understand that the confidentially of all information you provide will be
safeguarded;5. understand that participation is voluntary, and I am free to withdraw from the
study at any time without comment or penalty;6. I understand results from this study will be published however I will not be
identified in any way;7. I agree to participate in this study.
DATE:……………………….PARTICIPANT NAME………………………….( Signature)……………………I have explained the nature and purpose of this study to the above participant and haveanswered their questions.
NAME OF INVESTIGATOR……………………(Signature)…………………….
DATE: ………………………
285
Appendix 11—Consent form (Study 1) (Chinese Version)
參予者的同意書
研究主題:經驗學習策略對於在台灣的護理學生對老年人的知識及態度的影響。
同意之聲明
我， 同意參予以上所陳列之研究。我已被給予任何有關
此次研究的任何資訊，那些資訊與此研究中資料表單內所列之細節相同。我了
解任何關於此份調查報告中所收集的數據將會以最嚴密的機密所保存著。
藉由以下之簽名，你正表示出你:
1.你已經讀過並了解調查報告中參與資訊。
2. 了解這研究的本質及目的。
3.已經被給予機會問一些關於這研究的問題。
4.了解所有你所提供機密的資訊將會被安全的保護著。
5.參與者是完全的出於自願並且我也可以在任何時間內自由的退出此研究活動
並且沒有任何的議論及懲罰。
6.我了解這研究結果將會被出版不管我是否將被告知。
時間﹔
參予者名稱﹔ (簽名)
我已經解釋這研究之本質及目的給以上之參予者並且已經回答他們的問題。
研究人之姓名: (簽名)
日期:
286
Appendix 12—PWOP (English Version)
Perceptions of Working with Older People (PWOP)
Please read the statements and indicate how much you agree with each bycircling the number that best reflects your opinion:
Strongly Agree (5)Agree (4)
Neither Agree nor Disagree (3)Disagree (2)
Strongly Disagree (1)
Stro
ngly
Agr
ee
Agr
ee
Nei
ther
agre
eno
rdi
sagr
ee
disa
gree
Stro
ngly
disa
gree
Intention to work with older people1. I think older people are really interestingto nurse2. I would definitely consider working witholder people when I qualify3. I am really looking forward/I reallylooked forward to my first placement witholder people4. Working with older people does notappeal to me at all5. Working with older people has a highstatusCareer prospects of work with olderpeople6. Once you work with older people it isdifficult to get a job elsewhere7. Work with older people is a dead- endjob8. Working with older people is not a goodcareer move9. Nurses work with older people becausethey cannot cope with hi-tech care10. Nursing older people provides littlesatisfaction as they rarely get better11. Nursing older people is mainly aboutbasic care—it does not requiremuch skill
287
Appendix 12—PWOP (Chinese Version)
Perceptions of Working with Older People (PWOP)
請詳讀以下陳述以及指示,並以打勾()的方式選出認為最能夠表達自己意見的選項:
非常
同意
同意尚可不同意 非常
不同
意
Intention to work with older people1.我想照護老年人真的是很有趣的工作2.當我有執照後,我確定我會考慮照護老年人的工作
3.我真的期待/我已期待我的第一個場所是照護老年人
4.與老年人一起工作一點都不吸引我
5.和老年人有關的工作是有很高的地位
Career prospects of work with older people
6.只要你做過一次和老年人有關的工作,就很難在其他地方找到工作
7.和老年人有關的工作是沒有前途的職業
8.老人照護不是一個很好的生涯職業進展
9.會選擇照護老年人的護士,是因為他們無法適應高技術層面的照護工作
10.照護老年人只能提供一點點的滿足,因為他們病情很少會好轉
11.照護老年人主要是基本的照護—這不需要太多的技能
288
Appendix 13—KSOP (Taiwanese English Version)
Below are some statements about older people in the Taiwan today. Please indicatewhether you think each of the following statistics is either too high, about right, or toolow by placing a tick in the appropriate box:
The percentage of people over the age of 65 who need help with the followingactivities is about
I think this figure is
Daily activitiesToohigh
Right Toolow
1.Using the toilet 2.0%2. Washing all over 2.5%
3. Dressing 2.1%
4. Assist with eating 1.2%
5.Get up to bed and get down from bed 1.8%
6.Assist with making phone call 4.6%
I think this figure is:Toohigh
Right Toolow
Demography of older people
7. The percentage of people over the age of 65 in the Taiwan is about9 %.
8. Between now and 2030 the percentage of people over the age of65 is expected to increase by about 20%
9. The percentage of people in Aboriginal group who are currentlyover the age of 65 years in the Taiwan is about 6 %
Vulnerability of older people
10. Of women over the age of 65 about 40% will live alone
11. In any one year the percentage of people aged 65+ who have anin-patient stay in hospital is about 7 time than other population
12. Of people aged 65 years and over about 56% report chronicillness or disability
13. The percentage of people over the ages 65 living in residential ornursing home is about 10%
289
Appendix 13—KSOP (Chinese Version)
Knowledge of Situation of Older People
下列的陳述是有關於今日台灣的老年人。請在下述的陳述問卷中，針對你的想
法來表示每一個統計數據值的適切性，並在太高、正確及太低的專屬空格中打
勾作記號。
年齡等於或大於 65歲的人，需要下列的日常生活完全的協助我認為這個數字是
太高 正確 太低
1.廁所使用 2.0%
2.日常盥洗（含全身） 2.5%
3.穿衣服 2.1%
4.進食 1.2%
5.上下床 1.8%
6.打電話 4.6%
我認為這個數字是
Daily activities 太高 正確 太低
7.在台灣，年齡大於 65歲的人口比例約為 9 %8.從現在到 2030年，年齡大於 65歲的人口比例將提昇至
20%9.在台灣，年齡大於 65歲的台灣原住民人口佔台灣人口比例約為 6 %Vulnerability of older people
10.約有 40%，年齡超過 65歲的女性將獨自居住。
11.每年住院費用比例中，年齡大於 65歲的老年人的住院費用是非老年人的 7倍
12.約有 56%長期受到疾病侵犯或是殘疾的人，年齡是等於或
大於 65歲。13.約有 10%居住在安養院或療養院的人，年齡超過 65歲的老
年人
290
Appendix 14— Five highest and lowest statements of KOP
The five highest statements of KOP ranked by nursing students are listed table, in
highest to lowest order:
Statement Mean StandardDeviation
When you think about it, old people have the same faults as anybodyelse.
5.16 0.68
One of the most interesting and entertaining qualities of most oldpeople is their accounts of their past experiences.
4.73 0.87
It is foolish to claim that wisdom comes with old age.* 4.69 1.01
Most old people would prefer to continue working just as long as theypossibly can rather than be dependent on anybody.
4.66 0.96
In order to maintain a nice residential neighbourhood, it would be bestif too many old people did not live in it.*
4.60 1.10
*Reversed scoresPossible score 1-6
The five lowest statements of KOP ranked by nursing students are listed table, in to
lowest to highest order:
Statement Mean StandardDeviation
Most old people need no more love and reassurance than anyoneelse.
2.45 0.90
Most old people get set in their ways and are unable to change.* 2.86 1.22
Most old people are constantly complaining about the behaviourof the younger generation.*
2.90 1.07
One seldom hears old people complaining about the behaviour ofthe younger generation.
2.96 0.94
Most old people make excessive demands for love andreassurance.*
2.99 1.05
* Reversed scoresPossible score 1-6
291
Appendix 15— Five highest and lowest statements of KSOP
The five highest ranked statements by nursing students are listed in table, in highest to
lowest order:
Statement Mean StandardDeviation
Nurses work with older people because they cannot cope with hi-tech care. *
4.19 0.70
Work with older people is a dead-end job. * 4.15 0.67
Once you work with older people it is difficult to get a jobelsewhere. *
4.09 0.60
Working with older people is not a good career move. * 4.03 0.71
Nursing older people provides little satisfaction as they rarely getbetter. *
3.83 0.88
*Reversed scores
The five lowest statements ranked by nursing students are listed in table, in lowest to
highest order:
Statement Mean StandardDeviation
I am really looking forward/ I really looked forward to my firstplacement with older people.
2.79 0.77
Working with older people has a high status. 2.96 0.72
I would definitely consider working with older people when I qualified. 3.17 0.78
I think older people are really interesting to nurse. 3.39 0.81
Working with older people does not appeal to me at all. * 3.43 0.85
* Reversed scores
292
Appendix 16— Five highest and lowest statements of FAQ1
The five items of FAQ1 that the students were most likely to answer correctly are in
table, from highest to lowest order:
Statement N %Physical strength tends to decline in old age. 295 97.7
All five senses tend to decline in old age. 272 90.1
Lung capacity tends to decline in old age. 268 88.7
The reaction time of most old people tends to be slower than thereaction time of younger people.
268 88.7
Old people usually take longer to learn something new. 261 86.4
The five items of FAQ1 that the students were most likely to answer incorrectly are
listed table, in lowest to highest order:
Statement N %Older people tend to become more religious as they age. 284 94.0
At least, one-twentieth of the aged are living in long-stayinstitution (i.e., nursing home, home for the aged, etc.).
283 93.7
Over 10% of Taiwanese population are now age 65 andover.*
270 89.4
The majority of old people are seldom bored. 234 77.5
Most older workers cannot work as effectively as youngerworkers.
227 75.2
* The statement refers to Taiwanese data
293
Appendix 17— Five highest and lowest statements of KSOP
The five items of KSOP that the students were most likely to answer correctly are
listed below, in highest to lowest order:
Statement N %Between now and 2030 the percentage of people over theage of 65 is expected to increase by about 20%. *
206 68.2
Of people aged 65 years and over about 56% reportchronic illness or disability. *
202 66.9
The percentage of people over the age of 65 who need helpwith the following activities is about:Using the toilet 2.0% *
195 64.6
The percentage of people over the age of 65 who need helpwith the following activities is about:Assist with eating 1.2% *
192 63.6
The percentage of people over the age of 65 who need helpwith the following activities is about:Dressing 2.1% *
174 57.6
* The statement refers to Taiwanese data
The five items of KSOP that the students were most likely to answer incorrectly are
listed below, in to lowest to highest order:
Statement N %Of women over the age of 65 about 40% will live alone. * 178 58.9
The percentage of people over the age of 65 in the Taiwanis about 9 %. *
175 57.9
The percentage of people over the age of 65 who need helpwith the following activities is about:Assist with making phone call 4.6% *
172 57.0
The percentage of people in Aboriginal group who arecurrently over the age of 65 years in the Taiwan is about 6%. *
171 56.6
The percentage of people over the ages 65 living inresidential or nursing home is about 10%. *
130 43.0
* The statement refers to Taiwanese data
294
Appendix 18—Questions for focus group interview
Interview questions:1. Tell me how things are going?2. How much have you gained?3. What has been helpful to you?4. What would you like to have included on the program that we have not covered or
is not planned? Such as: Simulation game Class discussion Group discussion
5. What other comments do you have regarding the program?6. What one or two changes might be considered by your to improve your
involvement in this program?7. What components/features would you especially want to retain in the content of
the presentation in future program?8. What one or two factors (such as experience of participant, increase presentation
time, facilities) should not be changed for you to maintain the quality of program?9. How might the program be improved so that your involvement would have greater
impact?
295
Appendix 19—Participant information sheet (Study 2) (English Version)
CENTRE FOR HUMAN RESEARCH
INFORMATION SHEET FOR STUDY PARTICIPATION
STUDY TITLE: The effect of an experiential learning strategy onnursing students’ knowledge of and attitudes toward olderpeople in Taiwan
Purpose of the Study:As little is known about nursing students’ knowledge and attitude toward older peoplein Taiwan, this study aims to examine the effect of an experiential learning approachon Taiwanese nursing students’ knowledge of and attitudes toward older people.
Participant InvolvementAs a student nurse of today is the health care provider of tomorrow, your input
into the study is greatly valued. You are being invited to take part in a study on your
attitudes toward old people and your knowledge about facts on ageing. In this study,
you will be asked to attend the gerontological nursing course. This course will provide
the issues related to older people in order to increase your ageing knowledge and
attitudes toward older people. The gerontological nursing should take approximately
32 hours in a 16 week to complete.
Expected outcomesPossible benefits include increased knowledge about facts on ageing and skills
to communicate with and assess older people from the gerontological curriculum.
RisksNo risks to you have been identified. Your participation will in no way impact on your present or future study.
ConfidentialityPlease do not write your name or university on the questionnaire, as we do not wishany individual or university to be identified by the data collected. Each questionnairewill be identified by a number only. All information you provide will be kept instrictest confidence in a locked filing cabinet during the study period and for five
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years afterwards until which time the data will be destroyed. No information about theproject will be published in any form that would allow any individual or university tobe recognized. Data will be secured on a password-protected computer file withaccess available only to the researcher.
Voluntary ParticipationThis program is part of your nursing course. Your participation in the study does notallow withdrawing from undertaking the study at anytime due to faculty policy.However, you have right to withdraw from one learning approach to another one.
FeedbackAll participants have the right to ask questions about the study, and answers toquestions or any feedback on the survey will be supplied on request. If you have anyquestions or concerns, or if you request additional information, you may contact I-JuPan or Paimei Lin at any time during or following the survey.Thank you for considering participation in this study. Your participation is greatlyappreciated.The person to contact is：I-Ju PanPhD student in Queensland University of Technology;Victoria Park Road Kelvin Grove QLD 4059 AustraliaTelephone:61-7-3864 3882Lecturer in I-Shou UniversityNo 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung Xien, TaiwanTelephone: 886-7-6577711-5752Email: [email protected]
Queensland University of Technology, University Human Research Ethics Committee(UHREC)Email: [email protected]
Pai Mei Lin,Associate Professor in I-Shou UniversityNo 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung XienTelephone: 07-6577711-5764
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Appendix 19—Participant information sheet (Study 2) (Chinese Version)
CENTRE FOR NURSING RESEARCHINFORMATION SHEET FOR STUDY PARTICIPATION
研究主題:來自經驗學習策略對於在台灣護理系學生對老年人的知識及態度影
響。
研究的目的:僅有少數的研究是有關於台灣的護理學生對老年人的知識及態度，所以這研究
的目標是調查大學護理系學生在參與一個有規畫性的老人護理學課程後其對老
人的態度及知識的改變。
參與者之參與
今日的護理學生的你將是明日健康照顧的提供者。你對這研究的參與是
具有極大的價值。你正被邀請加入參予這關於你對老年人的態度及老化的知識
的研究。在這研究中，你將會被邀請參與老人護理學課程。這個課程將呈現有
關於老年人的議題以增加你對老年人的態度及老化的知識。這老人護理學的課
程需要16週32個小時內完成。
預期的結果
可能的益處包含從老人護理學的課程中你可增加老化知識，和老年人溝
通技巧，及對老年人評估的技巧。
風險
對你而言，尚無任何風險被發現。你的決定參與將不會對你的現在及未來有任
何的影響。
機密
在這研究問卷中請不要寫下你的姓名及大學，就如我們不希望個人或大學在資
料收集中被發現。每份問卷只會被數據所證明。在研究期間，所有你所提供的
資料將會以最嚴密的機密而保存在一個上鎖的檔案櫃中並且這些資料將會在五
年後被摧毀。即使是被個人或大學所允許，任何有關這主題的資料將不會以任
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何形式被出版。這數據會被一個有密碼保護及只有研究者可開啟電腦檔案所保
護著。
參與
假如你同意參與這次的研究，你會被要求被隨機分配到兩班中的其中一班。依
據教學講述及個別指導活動，這兩班的教學方式是不同的。你的參與是自願性
的，你有權利在任何時間從這研究撤離。但是老人護理學是屬於你護理課程的
一部分，你必須要參與其中的一個班。假如你不希望參與這個研究，你仍會被
分配到以講述教學為基準的班級。你的決定將不會影響你的教育課程也不會在
其他方面對你有任何的不利。
回饋
所有的參與者都有權利詢問有關這研究的問題且此份研究報告也會對此要求提
共回覆。假如你有任何的問題或顧慮，或者你有要求額外的資料，你可以在此
研究時間內的任何的時間與潘怡如聯絡。假如你有任何道德上的顧慮，你可以
與林柏每電話聯絡07-6577711-5764。
感謝你考慮加入此次研究，你的參予將會被大大的感激。
聯絡人:
潘怡如
昆士蘭科技大學博士班學生
Victoria Park Road Kelvin Grove QLD 4059 Australia
電話: 61-7-3864 3882
E-mail:[email protected]
義守大學講師
高雄縣大樹鄉學成路一段一號
電話: 07-6577711-5752
Queensland University of Technology, University human Research Ethics Committee(UHREC)Email: [email protected]
林柏每
義守大學副教授
No 1, Xue-Chen Road, Dah-Shu Xian, Kaohsiung Xien
電話: 07-6577711-5764
Email: [email protected]
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Appendix 20—Consent form (Study 2) (English Version)
PARTICIPANT CONSENT FORMSTUDY TITLE: The effect of an experiential learning strategy on nursing
students’ knowledge and attitudes toward older people in Taiwan
Statement of consentI, consent to participate in the above named project. I have beengiven information about the survey, as well as an information sheet outlining detailsof the survey. I understand that any information collected for the survey will remainstrictly confidential.
By signing below, you are indicating that you:
1. have read and understand the Participant Information Sheet about this survey;2. understand the nature and purpose of the study;3. have been given the opportunity to ask questions regarding the research study;4. understand that the confidentially of all information you provide will be
safeguarded;5. understand that gerontological nursing is part of faculty nursing curricula, and I do
not allow to withdraw from this course at any time;6. I understand results from this study will be published however I will not be
identified in any way;7. I agree to participate in this study.
DATE:……………………….PARTICIPANT NAME………………………….( Signature)……………………I have explained the nature and purpose of this study to the above participant and haveanswered their questions.
NAME OF INVESTIGATOR……………………(Signature)…………………….
DATE: ………………………
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Appendix 20—Consent form (Study 2) (Chinese Version)
參予者的同意書
研究主題:經驗學習策略對於在台灣的護理學生對老年人的知識及態度的影響。
同意之聲明
我， 同意參予以上所陳列之研究。我已被給予任何有關
此次研究的任何資訊，那些資訊與此研究中資料表單內所列之細節相同。我了
解任何關於此份調查報告中所收集的數據將會以最嚴密的機密所保存著。
藉由以下之簽名，你正表示出:
7.我已經讀過並了解調查報告中參與資訊;
8. 我了解這研究的本質及目的;
9.我已經被給予機會問一些關於這研究的問題;
10.我了解所有你所提供機密的資訊將會被安全的保護著;
11.我了解老人護理是護理課程的一部分;
12.我將會被隨機被分配到兩個不同的班級;
13.我可以隨時退出這個研究但是也將要繼續在以講述為主的班級繼續老人護理
學的課程;
14.我了解這研究結果將會被出版但是我將並不會被認出;
15.我同意參與此次的研究。
時間﹔
參予者名稱﹔ (簽名)
我已經解釋這研究之本質及目的給以上之參予者並且已經回答他們的問題。
研究人之姓名: (簽名)
日期:
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Appendix 21—Gerontological Nursing Education Program
Gerontological NursingInstructor:I-Ju PanNursing DepartmentI-Shou University
Purpose of the Course:This course will introduce the gerontological nursing concepts and theory to studentsin order to help them to understand that the ageing process could impact the olderpeople in their physical, psychological and social aspect. Based on experientiallearning, this course will connect the theory and practice to discuss these aspects.Therefore, student could have more understood how individual, family, andcommunity deal with the process of ageing.
Required Text & Additional Reading:1. 王世俊,林麗嬋,蔡娟秀等人 (2003) 老人護理學(四版), 偉華書局, 台北
2. 楊怡君,許淑敏,莊宇慧等人 (2002) 老人護理學, 華騰文化, 台北3. Chop, C.W. &Robnett, R.H. (1999) Gerontology: for the health care professional,
F.A. Davis Company, Philadelphia.4. Eliopoulos (1997) Gerontological Nursing, Lippincott, New York.5. Burk M.M. & Walsh M.B. (1997) Gerontological Nursing: Wholistic care of the
Older Adult, Mosby, London.6. Koch, S. & Garratt, S. (2001) Assessing Older People: a practical guild for health
preofessionals, Maclennan & Petty, London.7. Pickering, S. & Thompson, J. (1998) Promoting Positive Practice in Nursing
Older People, Bailliere Tindall, London.8. Nelson, T. (2002) Ageism: Stereotyping and Prejudice against Older People, A
Bradford Book, London.
Course Structure and Expectation:1.) Grading:
Activity 1: Week 3 Monday (1/3) 10%Activity 2: Week 4 Monday (8/3) 10%Activity 3: Week 5 Monday (15/3) 10%Activity 4: Week 6 Monday (22/3) 10%Activity 5: Week 8 Monday (5/4) 10%Activity 6: Week 11 Monday (26/4) 10%Activity 7: Week 14 Monday (17/5) 10%Activity 8: Week 15 Wednesday (26/5) 10%
2.) Examinationa. Based on the content in lecture and textbookb. Middle examination on Week 9 (14/4) 10%c. Final Examination on Week 16 (2/6) 10%
3.) Exercise:a. Every report needs to hand in on time.
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b. Every report needs to follow the format which is required by course.c. Every report needs to hand in; otherwise, the subject will be recoded as fail.
4.) Participationa. Students need to participate in each activity in order integrate the theory and
clinical practice.b. Students are expected to do the pre-reading and rise the questions or issues
during the classc. Students are expected to do the reviewing and getting more understanding
from lectures.
Schedule of Class Topics
Overview of gerontological nursing program in experiential-based learning group:Date Topic Learning Activities and Teaching
methodWeek1
Introduction to gerontologicalnursing
--Discuss previous experience witholder people--Discuss course outline and explainactivities--Discuss how to study gerontologicalnursing--Give brief lecture about topic:Introduction to gerontological nursing--Small group discussion--Class discuss the questions
Week2
Visiting the Senior Apartment--Assessment 1
--Group visiting the apartment--Observations of the apartment--Talk with older people--Debrief of students’ thoughts andquestions--Discuss individual paper assessment#1
Week3
1. The demographic and lifeexpectancy of ageing2. Ageing Theory
--Homework to search thedemographic data of older people--Small group discussion of the data--Discuss previous knowledge of thedata and ageing theory--Lecture the topic: demographic dataof older people and ageing theory--Small group discussion in theactivity--Class discuss the questions-- Individual paper assessment #1 due
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Date Topic Learning Activities and Teachingmethod
Week4
Communication--Assessment 2
--Previous communication experiencewith older people--Discuss the experience--Lecture topic: communication witholder people--Practice communication skills withclassmate--Discuss individual paper assessment#2
Week5
Practice communication skills inSenior Apartment--Assessment 3
--Previous communication experiencewith older people--Practice communication skill witholder people guidelines--Observations while practicing in thesenior apartment--Debrief of students’ thoughts andquestions-- Individual paper assessment #2 due--Discuss individual paper assessment#3
Week6
Changes of biological ageing --Previous knowledge--Discuss the experience--Lecture: changes of biologicalageing--Class discuss the questions--The individual paper assessment #3due
Week7
Simulation game--Assessment 4
--Discuss the previous experience ofphysical limitations--Simulation game--Observation and real experience ofbiological ageing--Discussion of students’ thoughts andquestions--Discuss the individual paperassessment #4
Week8
1. The psychology of ageing:theories of adult development2. Social perspectives in ageing
--Previous experience--Group discussion: the late life crisis--Lecture: Psychology of ageing andsocial perspectives in ageing-- Individual paper assessment #4 due
Week9
Mid-term Exam-- Assessment 5
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Date Topic Learning Activities and Teachingmethod
Week10
Practice in Senior Apartment--Assessment 6
--Discuss the previous experience inassessment--Practice communication skills witholder people using guidelines--Observations while practicing in thesenior apartment--Debrief on students’ thoughts andquestions--Discuss the individual paperassessment #6
Week11
Nursing assessment of older people--functional assessment
--Discuss the previous experience ofphysical assessments--Discuss the experience--Lecture: functional assessments--Class discuss the questions-- Individual paper assessment #6 due
Week12
Nursing assessment of older people--psychosocial assessment
--Discuss the previous experience ofpsychological assessment--Discuss the experience--Lecture: Psychological assessment--Practice with classmate--Class discussion the questions
Week13
Clinical Activities--Assessment 7
--Discuss the previous experience offunctional and psychologicalassessment--Practice physical, psychological andsocial assessment skills with olderpeople using guidelines--Observations while practicing in thesenior apartment--Debrief on students’ thoughts andquestions-- Discuss individual paper assessment#7
Week14
Ethical issues in gerontologicalnursing
--Discuss the previous experience ofethical issues--Discuss the experience--Lecture: ethical issues related toolder people--Small group and class discussion thequestions--Individual paper assessment #7 due
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Date Topic Learning Activities and Teachingmethod
Week15
--Nursing role in providing service toolder people--The future perspectives ofgerontological nursing perspectivesof gerontological nursing--Assessment 8 (role play)--Assessment 9
--Discuss the thinking ofgerontological nurses role--Lecture: future perspectives ofgerontological nursing and nursingrole--Role play--Discuss individual paper assessment#9
Week16
Final Examination/Evaluation--Assessment 10
--Individual assessment #9 due