Advances in health care, technology, and information systems have contributed to the long-term survival of persons with physical disabilities and chronic illness. The added years of life are often accompanied by dependence in performing activities of daily living and fulfilling social roles. Such dependency may affect individual quality of life, family dynamics, and ultimately, society. Nurses can significantly influence the level of function and quality of life achieved by disabled individuals. Nursing students need adequate educational preparation to effectively care for the ever-growing number of disabled and chronically ill persons. This teaching involves not only acquisition of knowledge and skills essential for their care but also includes fostering positive attitudes toward them.
It is purported that negative attitudes toward the disabled exist widely in our society with its emphasis on personal appearance, productivity, achievement, and the degradation of status associated with disability (Livneh, 1982). A study of disabled adolescents by Jablin (1987) suggested the disabled were transgressed against in many ways; they were ostracized, humiliated, and denied equal job opportunity.
Negative societal attitudes, including those of health professionals, and the disabled person's responses to such attitudes are potentially significant blocks to successful rehabilitation and reintegration into society (Pederson & Carlson, 1981). Negative attitudes of nurses have the potential to jeopardize the rehabilitation and health status of the disabled. Nurses need to learn how to accept disabled persons as individuals in order to interact with them for mutual goal-setting and appropriate health care achievement. Consequently, attitudes of nursing students toward the disabled are a matter of concern to educators, particularly in undergraduate and other types of nursing programs preparing for beginning practice.
The purposes of this study were to examine the attitudes of nursing students toward the disabled and determine the effect of educational experiences on those attitudes.
Review of the Literature
The literature reviewed was divided in two categories: measures of the attitudes of health professionals toward the disabled, and studies of attempts to change or modify these attitudes. The term "disabled" was viewed to mean a variety of physical and mental dysfunctional states in the studies reviewed. There was no common, universal interpretation of this term.
Studies of professionals who have frequent contact with the disabled indicated that, in general, their attitudes were positive. Occupational therapists surveyed by Benham (1988) reported positive attitudes toward the disabled and believed that negative attitudes would adversely affect the therapeutic relationship. Elston and Snow (1986) found attitudes toward the disabled were in the average range for several types of rehabilitation professionals including rehabilitation counselors and other personnel at rehabilitation centers. In these studies, the subjects had frequent contact with the disabled in their chosen professions, and their career choices perhaps reflected positive attitudes.
Measurement of the attitudes of child psychologists in a study by Tolor and Geller (1987) indicated that the professionals' attitudes were related to the nature of the child's disability. Attitudes were assessed on three different measures: an adoption scale, a semantic differential measure, and a social distance scale. There were significant differences in the acceptability for adoption based on the various disabilities of the children. Children with problems categorized as organic and sensorimotor were significantly less acceptable to the psychologists than children with problems classified as functional and psychoeducational. The disabilities rated most positively on the semantic differential scale were AIDS, learning disabilities, sensory problems, chronic illness, and terminal illness. Delinquency, drug/alcohol/food intake problems, psychosis, autism, and hyperactivity received the least favorable ratings. On the social distance scale, the profile of the acceptability for the children's disabilities was similar across settings, with delinquency, drug and alcohol addiction, psychosis, suicide, and autism among the most frequently rejected conditions.
The nature of the disability was also found by Tripp (1988) to be related to the attitudes of physical education teachers (instructors of regular and adapted classes) toward the disabled. Subjects were more accepting of individuals with physical disabilities such as amputation, cleft palate, and epilepsy. They were less accepting of those who were mentally retarded, had cerebral palsy, or were emotionally disturbed.
Attitudes of professionals are influenced by their knowledge and perceptions of the disabled. Westbrook, Adamson, and Westbrook (1988) found numerous inaccurate perceptions of disabilities in a survey of 907 students in six health professions: physiotherapy, occupational therapy, nursing, speech pathology, medical record administration, and orthotics. Inaccuracies included overestimation of the size of the handicapped population and the number institutionalized, and exaggeration of the degree of social isolation of handicapped persons. Handicapped people's employment status and qualifications were underestimated, but community assistance received was overestimated. The main disabling conditions associated with mental retardation, paralysis, and cerebral palsy were cited far more frequently than would be expected from population morbidity data. Less visible disabilities were underreported. Findings suggested that professionals' knowledge of the handicapped is limited and professionals' perceptions of the handicapped may be biased.
Intervention studies to modify attitudes have produced mixed results. In a study with undergraduate psychology students, Evans (1976) used an experimental strategy that included counseling with a disabled individual. Findings supported the hypothesis that a structured social interaction with a disabled person would lead to the formation of positive attitudes by nondisabled participants.
Duckworth (1988) determined that medical students' attitudes toward the disabled did not change significantly from the first to the fourth year of their program, nor did they differ from the attitudes of the general public. The study suggested that the attitudes of professionals toward the disabled do not necessarily emerge from a healthrelated curriculum. This assertion was supported by the findings from Berrol's ( 1984) study of educational strategies used in a physical education certificate program. He found that a combination of information about the disability and carefully structured interaction with the disabled were the most effective strategies in developing positive attitudes toward them.
Only a few researchers have attempted intervention studies to influence the development of positive attitudes among nursing students toward patients with disabilities. Sadlick and Penta (1975) used a film about a successfully rehabilitated quadriplegic to alter attitudes of nursing students. Attitudes were more positive immediately after the intervention. Retention of these attitudes 10 weeks later was enhanced by experience with successfully rehabilitated clients.
Rosswurm (1980) studied change in nursing students' attitudes using an experimental design. The experimental group completed a learning program geared toward formation of positive attitudes toward the physically disabled. The control group received a normal course of study. At the end of the course, the experimental group expressed more positive attitudes as measured by the Attitudes Toward Disabled Persons scale (ATDP) (Yuker & Block, 1986) than the control group. Six months later, the differences between the experimental and control groups were not significant. The degree of contact that students had with the disabled in the six-month period between pre- and posttesting was not reported.
In summary, research reveals both positive and negative attitudes of professionals toward the disabled. Researchers operationalized the term "disability* in a variety of ways (Benham, 1988; Duckworth, 1988; Tolor & Geller, 1987; Westbrook et al., 1988). Findings indicate that factors influencing or related to attitudes are complex, including the nature of the disability, societal norms, a person's knowledge and perceptions of the disabled, and contact with disabled persons. This study was designed to examine the effects of didactic instruction, simulated experiences with varied aspects of care of the disabled, and contact with the disabled on students' attitudes.
The study was designed to answer the following questions:
1. Is there a difference in nursing students' attitudes toward the disabled after their participation in a one-day rehabilitation educational conference?
2. Is there a relationship between the age of nursing students and their attitudes toward the disabled before and after a one-day rehabilitation educational conference?
3. Is there a difference in attitudes toward the disabled pre- and postconference based on gender, educational level in the nursing program, type of nursing student, and prior work experience as a nurse assistant/aide/ technician, LPN, or RN?
This was a descriptive study of the attitudes of nursing students toward the disabled, as measured by the ATDP scale (Yuker & Block, 1986), and the relationship of selected demographic variables and aspects of the subject's educational background to ATDP scores. Subjects completed the ATDP and a demographic data sheet prior to and one month following a one-day educational conference on rehabilitation nursing designed to increase their knowledge and ability to care for the disabled. The independent variables were age, gender, level in the nursing program, type of nursing student, and years of prior work experience in nursing. The dependent variable was the score obtained on the ATDP.
The sample consisted of 263 nursing students enrolled in an urban university in the Midwest. The majority (JV= 195, 74.1%) were generic students. The sample was composed of sophomore, junior, and senior nursing students. The requirements for the university's Committee for the Protection of the Rights of Human Subjects were met. Participation in the study was voluntary and anonymous. All the instruments and test results were identified by code numbers.
Attitudes toward disabled persons were measured by the ATDP-Form O scale developed by Yuker, Block, and Campbell (1960). Research on its use has been reported from 1960 through 1985 (Yuker & Block, 1986). The ATDP-Form O is a 20-item Likert scale designed to measure attitudes toward the disabled. Form O is a general form, nonspecific to a certain disability. Responses range from (+3) / agree very much to (-3) / disagree very much. The ATDP takes approximately 15 minutes to complete. High scores reflect positive, accepting attitudes; low scores reflect negative, rejecting attitudes. On Form O, the range of scores is from 60 to 120.
Four procedures have been used in evaluating the reliability of the ATDP: test- retest, split-half, equivalence, and alpha. Reliability values for the ATDP range from .66 to .96 with a median of .80 (Yuker & Block, 1986). Construct validity of the ATDP was assessed by examining the relationship of ATDP scores to scores on other variables. According to Yuker and Block, the ATDP can be considered a valid measure of attitudes toward disabled persons since most of the predictions of the relationships between theory and the scale were confirmed in multiple studies.
A demographic data sheet was used to collect information on the educational background and personal characteristics of the student. Items included educational level within the program; type of nursing student; years of prior work experience in nursing as an assistant/aide/ technician, LPN, or RN; age; and gender.
The ATDP, demographic data sheet, and a letter of instruction were given to 263 nursing students prior to an educational conference on rehabilitation nursing. After completing the instruments, subjects then participated in the educational conference. The conference was a one-day rehabilitation program focused on the care of the physically handicapped person. Content included a lecture by a doctorally prepared rehabilitation nurse on enabling and empowering the disabled. All participants rotated through four intensive group sessions with qualified experts as leaders. One group session focused on the features and uses of various wheelchairs and their suitability for particular disabilities. Students had hands-on experience using the various wheelchairs. In another group session, orthotics and prosthetic devices were demonstrated and discussed. A third group included lecture, demonstration, and practice in range of motion and transfer. The fourth small-group session was on skin care and was led by a certified enterostomal therapist. The closing session of the conference was a presentation by a disabled person who was an executive in a large health care foundation. One month following the educational conference, subjects were again asked to complete the demographic questionnaire and ATDP.
Data were analyzed using descriptive statistics, £ test, Mann-Whitney U, and ANOVA. Knowledge gain was determined by comparing pre- and postconference ATDP scores using t test. Differences across groups were examined with ANOVA. Mann-Whitney U was used to compare prior work experience and ATDP scores.
Results of t Test on Pre- and Posttest ATDP Scores
The total sample consisted of 263 subjects at pretest and 125 at the one-month follow-up. The age range was from 18 to 45 years, with a mean age of 25.4 years. Forty-six subjects were male; 217 (82.5%) were female. Eighty-six (32.7%) subjects were sophomores, 74 (28.1%) were juniors, and 79 (30.0%) were senior nursing students; others were RNs and graduate students. Forty-eight subjects (18.3%) had prior experience as a student in a rehabilitation setting. The majority of students, however, had no prior experience in a rehabilitation setting.
Subjects reported various types of work experiences: 166 were nursing assistants, aides, or technicians with a mean of two years of experience; five respondents were LPNs with a mean of 1.5 years of experience; and the RNs had a mean of 3.5 years of experience in nursing. Forty-five (17.1%) subjects had prior work experience in one of these roles in a rehabilitation setting. The majority of the subjects (N= 146, 55.5%) reported no direct interaction with the physically disabled other than that associated with school or work. Of the subjects reporting interaction with the physically disabled, 11 (4.2%) indicated that a member of their immediate family was disabled. Twenty-nine subjects (11.0%) had a disabled family member not living in the same household. Fortythree subjects (16.3%) had a friend with a disability, and 13 identified other types of contact with the physically disabled.
The first research question examined the difference in scores on the ATDP following the rehabilitation conference. Of the entire sample, 73 subjects were studied from pre- to posttest; the remaining subjects at posttest did not include code numbers and could not be matched to the pretest. The mean score on the ATDP at pretest was 81.6, compared to 88.4 at posttest. A paired t test of this difference was statistically significant (£ = 5.15, df=72, p<.0001) (Table). Subjects had more positive attitudes one month following the rehabilitation conference.
Research questions 2 and 3 examined the relationships of selected demographic variables and educational background to ATDP scores. No significant correlation was found between age and pretest scores; at posttest, however, there was a significant, albeit weak, negative correlation between age and ATDP scores (r= -.22, p = 0.03). Older subjects had lower ATDP scores. A t test indicated no significant differences in ATDP scores at either pre- or posttest based on gender. A disproportionately small number of males participated in the research.
Differences in ATDP scores according to level in the nursing program were tested by ANOVA. No significant differences were found in ATDP scores based on level in the nursing program. ANOVA also was used to determine significant differences in ATDP scores among generic nursing students in a baccalaureate program (N= 195), students with previous nonnursing college degrees enrolled in the baccalaureate program CfV= 30), and RNs in the BSN-completion program (N =14). There were no significant differences in ATDP scores across groups.
The final data analysis examined the significance of prior work experience in a rehabilitation setting on ATDP scores at pre- and postconference. The mean pretest ATDP score for subjects (N= 45) with prior work experience in a rehabilitation setting was 86.6 (SD = 12.9). Subjects without this experience (JV= 182) had a mean ATDP score at pretest of 82.0 (SD = 13.7). Mann-Whitney U indicated a significant difference in ATDP scores between these two groups (U = 3084, p = .03). At posttest, however, there were no significant differences between the groups.
Despite the limited research regarding nursing students' attitudes toward the disabled, there is substantial evidence in the literature of the relationship between education and promoting a positive attitude change toward disabled individuals (Berrol, 1984; Evans, 1976; Gething, 1986). Other studies have found that working with the disabled improved the attitudes of health professionals (Benham, 1988; Evans).
In this research, students had significantly higher scores on the ATDP following a one-day educational conference, reflecting a more positive and accepting attitude toward the disabled. These findings are consistent with Rosswurm's (1980) study in which nursing students' attitudes toward individuals with physical handicaps were positively affected by an educational workshop. The importance of affective learning activities in a nursing education program cannot be underestimated. Planned educational strategies such as the conference associated with this research provided a way for students to examine their attitudes, beliefs, and values and begin to develop a value system supportive of the patient with a physical disability (Oermann & Gignac, 1991; Reilly & Oermann, 1992).
In terms of demographic and educational variables that might influence ATDP scores, there was a negative correlation between age and posttest score. Yuker and Block (1986) describe the inconsistency of findings on the relationship between age and attitudes toward the disabled. Correlational coefficients obtained in prior studies ranged from - .56 to + .30, suggesting neither a negative nor positive relationship between age and attitudes toward people with disabilities. Yuker and Block suggest that these results may be influenced by other variables such as educational level and amount and type of contact with disabled persons rather than age alone. In other studies (Berrol, 1984; Duckworth, 1988; Pederson & Carlson, 1981), the relationship of age and ATDP scores was not found to be significant. Most studies suggest that age in conjunction with other variables such as gender and experience influence attitudes toward the disabled and, thus, ATDP scores. Further empirical evidence is needed to examine age as a single variable and its effect on ATDP scores.
Gender was not found to be significant in relation to ATDP scores at either pre- or posttest. These results may be related to the significantly higher proportion of female nursing students represented in the sample. From review of 129 studies, Yuker and Block (1986) reported normative data regarding gender differences and ATDP scores. In 44% of these studies, females scored higher on the ATDP than males. In 5% of these studies, males scored higher on the ATDP. In 51% of the studies, there were no significant differences based on gender. Interaction effects of demographic variables and gender need to be determined (Yuker & Block).
Generic nursing students, students with previous nonnursing college degrees enrolled in the same program, and RNs in the BSN-completion program did not demonstrate significant differences in ATDP scores. There also were no differences in scores according to level in the nursing program. These variables may not be significant in terms of attitudes toward the physically disabled; further study is indicated.
Prior work experience as a nursing assistant/aide/ technician, LPN, or RN in a rehabilitation setting was significant at pretest. Subjects with experience in caring for the disabled had more positive attitudes toward them as indicated by higher ATDP scores. There also was a trend toward significance at posttest. One possible reason for the lack of significance at the one-month follow-up might relate to the smaller number of subjects (N=Il) with this experience who participated in the posttest. Anthony (1972) found that attitudes toward people with disabilities can be positively influenced by providing the nondisabled with an experience that includes contact with disabled persons.
Attitudes and expectations of others are a significant influence in the development of new roles and self-concept by the disabled. The attitudes of nurses involved in rehabilitation should be of particular importance and concern. Nursing personnel are likely to be in contact with a patient and the family for a greater period of time each day than with members of any single discipline on the rehabilitation team. The existence of negative attitudes toward persons with disabilities may have a profound effect on the rehabilitation process. These attitudes toward the disabled have been a central issue in the rehabilitation movement and have often been described as "invisible barriers" to rehabilitation (Chubon, 1982).
From an educational standpoint, experience with the disabled is important in influencing attitudes toward these patients as well as acquiring knowledge and skills for their care. Experiences in the clinical setting provide for cognitive and experiential learning and also add the reality dimension important in learning (Reilly & Oermann, 1992). Experiences with the disabled enable students to test beliefs and values and develop a value system supportive of the disabled person and family. Analysis of decisions made relative to care and discussion of feelings associated with caring for the disabled are important components of this clinical experience. Students' perceptions of the disabled and feelings about then- care can be explored in a conference with input from the group (Oermann & Gignac, 1991).
This research was limited to one setting, and a convenience sample was used. In addition, all students in the entire undergraduate program participated in the workshop, eliminating the use of a nonintervention control group for comparison. The size of the sample, though, was larger than many nursing education studies (Oermann, 1990).
The results of this study suggest that students' perceptions of the disabled were altered by the conference experience. However, these results must be viewed cautiously. The workshop was not a comprehensive presentation of the needs of the disabled. The workshop content emphasized the positive aspects of rehabilitation; the speaker who had a disability had become a "success." Students were not exposed to the difficult aspects of rehabilitation, such as helping patients overcome depression and discouragement. The workshop did not focus on care of those who are able to attain only small rehabilitation gains and are likely to remain dependent to some degree the rest of their lives. Exposure to mental and emotional disabilities, which are known to carry a greater stigma, was not included. Provision of a comprehensive educational experience for meeting the needs of the disabled population includes addressing these identified gaps.
Continued research is needed on students' attitudes toward the disabled. The effectiveness of different teaching methods and learning activities in improving these attitudes should be studied. Such research should be long-term because affective outcomes, such as attitudes, may change over time (Oermann, 1990).
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Results of t Test on Pre- and Posttest ATDP Scores