EJERCICIOS DE MIEMBROS INFERIORES PARA PREVENIR EL

Pawson (1996, p. 300) asserts that researchers wishing to design attitude change programmes should start by ‘considering cases where there is a positive outcome’. The studies listed in table 2.4 each report improvements in attitudes following their interventions. With regard to context, the mechanisms within these interventions were deployed within the university setting, by faculty, in all cases. Particular attention has been paid in this section to how attitudes might be changed by the reported mechanisms, through reference to Katz’ (1960) theory on attitude change.

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Table 2.4 The mechanisms used in attitude change research with pre-test/post-test design.

Author/s Theoretical

Framework

Mechanisms Chen and Walsh (2009) Self-transcendence

theory

Creative-bonding intervention versus friendly visit

Lamet, et al., (2011) Self-transcendence theory

Creative-bonding intervention Rodgers and Gilmour

(2011)

None stated Life-span focus incorporating application to older people Baumbusch, et al., (2012) Critical realism Covered common conditions of

major systems

Since 2009, the focus appears to have been upon testing the effect of integrated interventions on attitudes (Chen and Walsh, 2009; Lamet, et al., 2011; Rodgers and Gilmour, 2011; Baumbusch, et al., 2012). Improvements in attitudes are reported in each case, which involved classroom-based theoretical input, with a related clinical experience either running alongside (Chen and Walsh, 2009; Lamet, et al., 2011; Baumbusch, et al., 2012), or straight afterward (Rodgers and Gilmour, 2011).

The potential flaws of the attitudinal measurement tool used in these studies have already been highlighted (cf. section 2:5:1; pp. 65 - 68). In each of these study designs, there are additional perceived methodological weaknesses, which make it difficult to adopt any of the mechanisms used, with confidence, in this study. Table 2.4 outlines the mechanisms each used.

Many of these mechanisms appear to aim at improving nursing students’ knowledge about wellness in older people (Rodgers and Gilmour, 2011; Baumbusch, et al., 2012). This is in line with Palmore’s (1998) assertion that better knowledge will equate to better attitudes, but as Katz (1960) suggested, this can be unreliable. The mechanisms employed by Chen and Walsh (2009) and Lamet, et al., (2011) may be more applicable to modifying attitudes which serve the ego-defensive function; they

73 may be successful in allowing the student to perceive older people in a more positive way, which ‘removes the threat’ of the students’ involvement in caring for older people (Katz, 1960, p. 182). Their approach offered nursing students alternative ways of experiencing this.

Rodgers and Gilmour (2011) and Baumbusch, et al., (2012) each used a one group, pre-test/post-test design, acknowledged to be weak, because of the inability of these designs to rule out other causes for improvements in the variable being measured (Cook and Campbell, 1986). Perhaps the issue of most concern in interpreting the results of these studies is the effect of mechanisms entirely unrelated to the integrated modules; these may have had a positive impact upon attitudes. Or, the groups tested may have been changing spontaneously over time, anyway, with an associated improvement in attitude. Only longitudinal data collection, and the inclusion of a CG can account for mechanisms of this kind (Cook and Campbell, 1986). A longitudinal study design also allows judgements to be made about the longevity of any reported attitude changes, which is acknowledged by Baumbusch, et al., (2012).

Both Chen and Walsh (2009) and Lamet, et al., (2011) used a pre-test/post-test design, but included comparison and control groups, respectively. Although this additional study design feature represents an improvement in approach, it is still impossible to discern whether the improvements they each reported were really down to their ‘creative-bonding interventions’, or whether the improvements were sustained. Only repeated pre and post-intervention measurements can provide support to their assertion that the improvements in attitudes were caused by their interventions4, both of which were lacking (Wagner, et al., 2002). For example,

4

How repeated measurements can provide support to a study which tests the effects of programmes is discussed in chapter three.

74 students may have been measured at the pre- intervention test when they were having a bad day, making their pre-intervention scores seem worse, and consequently, the post-intervention scores show a marked improvement.

In addition, each used the revised version of KAOPS (Hilt and Lipschultz, 1999). The use of this tool to measure attitudes within attitude change research related to the nursing profession has been criticised, because it takes no account of the context in which nurses work with ill older people (McLafferty, 2007). Hence, the improvements reported in each of these studies should be viewed cautiously.

The importance of knowledgeable and enthusiastic faculty within attitude change programmes, and in nurse education, in general was acknowledged (Chen and Walsh, 2009; Rodgers and Gilmour, 2011; Baumbusch, et al., 2012). The importance of faculty ‘role-modelling positive attitudes and behaviours towards older people’ is also put forward by Rodgers and Gilmour (2011, p. 19). Baumbusch, et al., (2012, p. 7) report the need to ‘build capacity’ among nurse educators, in order that they are enabled to positively integrate and promote content related to older people. It is of interest that Baumbusch, et al., (2012) cite critical realism as their theoretical framework. After a review of their work, it is difficult to discern how critical realism guided their study design, and analysis of data, as they make no mention of it in their discussion.

Table 2.4 also outlined the guiding theoretical frameworks followed in these studies. This does imply a positive change in approach, when compared with attitude change research carried out before the turn of the century; it is no longer ‘a-theoretical’, as it had been in the past (Schigelone, 2003, p. 37). However, the improvements reported in each of these studies should be viewed tentatively. As already suggested, a lack of detail, and poor attempts to rule out the effect of other possible

75 explanatory mechanisms causing improvements in attitude make it difficult for researchers to adopt them, with confidence, in future work. In addition, all used an attitudinal measure which has been criticised for failing to take context into account.

2:8 Summary

Part I of the review of the literature clarified that nursing students still report negative experiences caring for ill older people. It has also emphasised that nursing students appear to hold negative attitudes toward the care of ill older people, for a variety of reasons; existing structures, such as supernumerary status, and mechanisms, like the poor status of this field of nursing, seem to compound the negativity that students report (Kydd, 2012). Although unintentionally, key agents such as faculty and registered nurses also appear to contribute to the development and maintenance of negative attitudes.

In part II, the review identified a paucity of evidence in three key areas. First, there is a lack of methodologically sound research into the effect of educational programmes and interventions upon the attitudes of nursing students, which are so briefly reported on that it is difficult to build upon the successes of studies reporting positive outcomes. In addition, the review has also identified that the findings of research into the effects of pre-registration nurse education upon attitudes appears to be inconclusive; there was little evidence which outlined how the contexts in which nursing students learn affect their attitudes. Secondly, the review also identified that many of these studies used attitudinal measures which were ignorant of the context in which nurses work with ill older people. Acknowledgement of context is a central feature of critical realist research, and requires that an attitude measurement tool that takes context into account is used. Lastly, there was a lack of nursing research

76 which cited critical realism as its philosophical base; there are few examples of its use, from study design to study completion.

In summary, the review was suggestive of gaps in knowledge and in the evidence base about if and how education can influence the attitudes of nursing students toward this field of nursing. The review facilitated the development of the study’s research hypothesis, and secondary questions (cf. section 1:6; pp. 34 - 37). Because critical realism promotes exploration beneath the surface of what has been observed, this study, which follows a critical realist approach, is intended to fill these gaps, in the following ways:

 Critical realism prompts the use of a methodologically sound approach to data collection, which attempts to account for alternative explanations for programme effects;

 Detailed information is given about the programme, to facilitate its use by others;

 Exploration below the surface of observed effects will be conducted, to find out about how context influences attitudes;

 A contextually-sensitive attitude measurement tool is used, and  It will provide an example of a study which claims critical realism as

its philosophical base, from design through to completion.

In reporting this study’s findings, the intention is to contribute in an original way to the body of knowledge concerning the effects of education, and how it influences the attitudes of nursing students toward the care of ill older people.

Chapter three will discuss the design of the study in detail, expanding upon themes identified for further discussion within chapter one, outlining in detail how this study attempts to address the gaps identified within the review of the literature.

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Chapter Three