The numbers and proportion of elderly people in the population are gradually increasing.1 This means that the development of effective and costefficient educational programs to prevent illness and promote health among the elderly has become an important task for nurses and other health professionals.
Programmed learning is one method of education that has been effective with children and in military settings, but has been seldom used with the elderly.2·3 In addition, the use of social reinforcement, such as praise, as an adjunct to programmed learning, has not been tried with elderly persons.
This study attempted to determine whether the use of praise in conjunction with programmed learning would result in greater learning among the elderly, compared to programmed learning used without praise. However, it was estimated that the addition of praise to a programmed learning method would not affect all elderly learners equally. Rather, elderly persons with a high level of emotional dependence might be expected to respond to learning accompanied by praise more than their less emotionally dependent counterparts.
Emotional dependence has been described as help-seeking, approvalseeking behavior. Some writers propose that a certain degree of emotional dependence is part of the normal personality. Murray uses terms such as succorance (a marked need for affection and approval), and deference (tendency to subordinate one's self to the influence of another) to describe emotional dependence. He includes these in his system of human needs.4
Emotional dependence is often viewed as a negative characteristic, especially in cultures that value individualism and independence. But emotional dependence can also be seen as a very positive force in interpersonal relationships. Moses states that dependency is:
"probably the most cohesive force in our culture, providing the basis for sexualization, marriage, child-rearing, and creativity by expanding our efforts to please others and win recognition."5
Unfortunately, the elderly in our society often feel ambivalent, if not negative, about emotional or physical dependence.6,7 This was shown in a case study by Pease in which an elderly woman who felt ambivalent about her emotional dependence sent mixed messages to her nurse.8 This placed the nurse in a "double-bind" situation. Whether the nurse responded to the need for dependence or independence, she was wrong. She was in a "no- win" position. Clark and Anderson found that one of the most important criteria for self esteem among a group of urban aged was to maintain complete autonomy.9
To what extent does emotional dependence exist among the aged, compared to other age groups? Strother and Schaie compared college graduates aged 20 to 28 to college graduates aged 70 to 88. They found that the older age group's need for deference (subordinating one's self to another's influence) was greater than that of the younger age group.10 A sex difference in the older age group was also found, with older women having a greater need for succorance (affection and approval of others) than older men. However, a 17family, three-generational study by Kastenbaum and Cameron found no greater level of emotional dependence in the older age group. " Thus, the studies measuring emotional dependence in the elderly are few, with inconsistent findings.
What has been found regarding the influence of emotional dependence on learning? Flanders measured emotional dependence in elementary school-aged children, and found that students high in emotional dependence wanted more support and approval during learning sessions, compared to students with low emotional dependence.12 Cairns and Lewis found that college freshmen with a high level of self-assessed dependence also showed a high degree of sensitivity to verbal reinforcement.13 But no studies were found that measured the relationship of emotional dependence to any form of learning in the elderly.
A promising question to investigate, then, is whether some form of social reinforcement, such as praise, would increase learning in elderly persons, particularly among the emotionally dependent who might be more susceptible to such praise.
The specific hypotheses to be tested in this study were:
1. There will be no difference in knowledge gained from programmed study when praise is used compared to when praise is not used.
2. Persons high in emotional dependence will learn more when praise is used, compared to when it is not used.
3. Persons low in emotional dependence will learn just as well whether praise is used or not.
One hundred and twenty-nine persons aged 60 and older from eight randomly selected senior citizen centers and nutrition sites in the New Orleans area completed the first section of the study. The ages of these volunteers ranged from 60 to 87, with an average age of 70. There were 82 women and 47 men, with an ethnic grouping of 35 black and 94 white. Sixteen percent of the participants had a sixth-grade education or less, 56% completed from eight to 12 grades, and 28% completed one or more years of study past high school. In order to be included in the study, volunteers had to speak English as a first language, read and write, and be able to follow instructions.
After agreeing to take part in the study and signing a consent form, the participants were interviewed to obtain personal data. Next they completed the Holmes and Rahe Life Change Index, which measured life stress experienced in the previous six months. ,4 The purpose of this testing was to eliminate persons whose recent stress might cause a temporary increase in dependence, called "state" dependency. However, no volunteers scored higher than 300 points; thus none had to be eliminated.
The participants next completed a modified form of the Edwards Personal Preference Schedule (EPPS), which yielded a deference and succorance score, the two measures of emotional dependence used in the study. ,5 Deference is defined as wanting others to provide help, encouragement, sympathy and understanding, while succorance is defined as seeking suggestions and decisions from others, and doing what is expected. This selfadministered test took participants an average of 35 minutes to complete.
The second part of the study was conducted at a second session. Each participant was randomly assigned to study a programmed lesson under one of two conditions, either with or without the use of praise. The participants for which praise was used completed the lesson pretest, and then were taught how to use the programmed lesson. As they proceeded through the lesson, the investigator, sitting beside them, gave praise for correct responses. The participants for which praise was not used similarly completed the pretest and were taught how to use the programmed lesson. However, these participants completed the programmed lesson independently. After completing the lesson, the final steps in the procedure were similar for all participants. Each completed the post-test, received immediate feedback on the results of the post-test, and were given an opportunity to discuss questions with the investigator.
The 11 -page programmed lesson used in this study was designed by the investigator, and titled "Protecting Your Money and Health at the Drug Store." It focused on common misuses of two non-prescription drugs, cold medicines and "first-aid" antiseptics. The pre- and post-tests were identical, and measured the learning that occurred. The lesson and accompanying tests were pilot-tested and revised several times to assure reliability and validity.
One hundred and twenty-nine participants completed the first session, but 30 of these dropped out of the study before completing the second session due to continually missed appointments (16), illness (6), complaints that the lesson took too long (5), dislike of testing (2), and death (1). The remaining 99 subjects completed both sessions.
All three hypotheses were tested with analysis of covariance, using pretest scores as covariants. The first hypothesis, that there would be no difference in learning when a programmed lesson with praise was compared to a programmed lesson without praise, was supported by the findings. Participants were found to learn equally well under either learning method when only the methods themselves were compared, as was expected.
For analysis of the second hypothesis, the deference and succorance scores were combined. If participants' scores fell in the top 25% of the combined scores, they were considered emotionally dependent. When the learning of this group of participants was analyzed, it was found that there was no significant difference in learning when the two teaching techniques were compared.
The second hypothesis was further analyzed by examining the two measures of emotional dependence, succorance and deference, separately. When the learning scores of participants in the top 25% of succorance scores were subjected to analysis of covariance, a main effect for teaching method was shown to be significant: participants high in succorance learned significantly more when programmed learning was accompanied by praise than when no praise was used (p = .05). However, when the top 25% of deference scores were analyzed, no significant difference in learning occurred when the two methods of teaching, with and without praise, were compared.
Thus, the second hypothesis was not supported when emotional dependence was defined as succorance and deference combined. However, when succorance was examined separately, significantly greater learning occurred under the teaching method using praise. The third hypothesis proposed that participants low in emotional dependence would learn equally under either learning method. With deference and succorance scores combined, the lowest 25% of scorers showed no difference in learning under the two teaching methods. Likewise, when deference and succorance scores were analyzed separately, the lowest 25% of scorers for both succorance and deference showed no significant difference in learning when the two teaching methods were compared. Thus, the third hypothesis was supported.
The findings were further analyzed to determine if characteristics such as sex, marital status, education, or ethnic grouping were related to participants' level of emotional dependence. Only sex showed a significant finding, with women showing a higher level of emotional dependence than men, when the top quarter and lowest quarter of scores were compared, using the chi-square statistic. An additional analysis showed that subjects with higher levels of education tended to learn more, regardless of method of learning or other personal characteristics.
The findings of this research suggest that, when emotionally dependent older persons are learning in a structured situation similar to the one used in this study, they are likely to learn more if praise is included in the teaching method. However, emotionally independent older persons' learning is not likely to be greater if praise is used, supporting the idea that praise is less meaningful to the less emotionally dependent person. It should be noted that this implication for teaching applies only when emotional dependence is measured by succorance scores.
The finding that women have higher levels of emotional dependence than men supports earlier studies of older persons. Strother and Schaie found a sex difference among college-educated elderly, and this study shows that women of lower socio-economic levels also differ from their male counterparts in emotional dependence.
It is recommended that nurses and other health educators who offer programmed lessons on health topics to older persons will find that learners who have higher levels of emotional dependence, defined as succorance, will leam more if praise is incorporated into the teaching methods used. In addition, older women are more likely to be emotionally dependent than older men, and persons who have completed more formal education will, in general, learn more from programmed learning than those with less education.
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