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This article was downloaded by: [Case Western Reserve University]On: 02 December 2014, At: 14:19Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
Gerontology & GeriatricsEducationPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wgge20
Development of anInstrument to Measure HealthProfessionals' Beliefs andOpinions About the Elderly(HPBOE)Sherry Robinson PhD, RNCS a , Anne Gunderson MSN,RNCS b , Richard Rosher MD c & John Tomkowiak MDd
a Southern Illinois University School of Medicine ,P.O. Box 19636, Springfield, IL, 62794-9622, USAb Southern Illinois University School of Medicine ,P.O. Box 19622, Springfield, IL, 62794-9636, USAc Division of Geriatrics , Southern Illinois UniversitySchool of Medicine , P.O. Box 19636, Springfield, IL,62704-9636, USAd Undergraduate Curriculum , Southern IllinoisUniversity School of Medicine , P.O. Box 19642,Springfield, IL, 62704-0642, USAPublished online: 04 Oct 2008.
To cite this article: Sherry Robinson PhD, RNCS , Anne Gunderson MSN, RNCS , RichardRosher MD & John Tomkowiak MD (2003) Development of an Instrument to MeasureHealth Professionals' Beliefs and Opinions About the Elderly (HPBOE), Gerontology &Geriatrics Education, 23:3, 39-50, DOI: 10.1300/J021v23n03_03
To link to this article: http://dx.doi.org/10.1300/J021v23n03_03
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Development of an Instrumentto Measure Health Professionals’ Beliefs
and Opinions About the Elderly (HPBOE)
Sherry Robinson, PhD, RNCSAnne Gunderson, MSN, RNCS
Richard Rosher, MDJohn Tomkowiak, MD
ABSTRACT. The purpose of the study was to explore with elders howthey would prefer to be viewed by health professionals, as an initial stepin developing an instrument to measure attitudes of health professionalsabout the elderly. Twenty-five community-dwelling elders (divided intogroups of 9, 9, and 7) and 13 elders residing in nursing homes partici-pated in focus groups designed to explore how these elders themselves wereto be viewed by medical staff of various kinds. The data were analyzedusing grounded theory. Lists of beliefs and opinions emerged and wereconstructed into 17 items. By beginning with a qualitative approach, wehave clearly identified how young elders, older elders, and elders resid-ing in nursing homes would like health professionals to view them.When fully validated, this instrument should be able to discern health
Sherry Robinson is Gerontological Clinical Nurse Specialist, Southern Illinois Uni-versity School of Medicine, P.O. Box 19636, Springfield, IL 62794-9622 (E-mail:[email protected]). Anne Gunderson is Nurse Educator, Southern Illinois Uni-versity School of Medicine, P.O. Box 19622, Springfield, IL 62794-9636 (E-mail:[email protected]). Richard Rosher is Chief, Division of Geriatrics, SouthernIllinois University School of Medicine, P.O. Box 19636, Springfield, IL 62704-9636(E-mail: [email protected]). John Tomkowiak is Director of Geriatrics, Undergrad-uate Curriculum, Southern Illinois University School of Medicine, P.O. Box 19642,Springfield, IL 62704-0642 (E-mail: [email protected]).
Gerontology & Geriatrics Education, Vol. 23(3) 2003http://www.haworthpresscom/store/product.asp?sku=J021 2003 by The Haworth Press, Inc. All rights reserved.
10.1300/J021v23n03_03 39
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professionals’ positive and negative views toward their elderly cli-ents. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-HAWORTH. E-mail address: <[email protected]>Website: <http://www.HaworthPress.com> © 2003 by The Haworth Press, Inc.All rights reserved.]
KEYWORDS. Elderly, beliefs and opinions, student evaluation, quali-tative
America is aging. In 1900, 4% of the population, or 3 million Ameri-cans were age 65 or older. Today 13% of the population, or 34 millionAmericans, are 65 or older (Administration on Aging, AARP, or 2000).In response to the aging of the population, mandates have been issuedfrom various health professional organizations and community groupsto encourage students in health professions to specialize in geriatricsand gerontology. To accomplish this, educators must inspire and sparkthe interest of more students in these areas. Curriculum developers areresponding by creating a variety of innovative learning approaches.
In order to evaluate the effectiveness of these programs, an instru-ment is needed that will appropriately measure changes in the way stu-dents view aging. Beginning with a qualitative approach can enhancethe validity of an instrument. The purpose of this study was to explorewith elders how they would prefer to be viewed by health professionalsas an initial step in the development of an instrument to measure healthprofessionals’ beliefs and opinions about the elderly. Instruments mostfrequently utilized by researchers in the health professions include TheAging Semantic Differential Scale (Rosencranz & McNevin, 1969) andthe Maxwell and Sullivan Questionnaire (Maxwell & Sullivan, 1980).Researchers have suggested that these instruments may not capturechanges in the way students view aging that are targeted through medi-cal, nursing, and health-related education. Additionally, psychometricproperties of these instruments rarely have been reported.
CURRENT INSTRUMENTS
Maxwell and Sullivan Attitude Scale
The Maxwell and Sullivan Attitude Scale (MSAS) (1980) was de-signed to measure factors that influence family physicians’ willingness
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to treat the elderly. It is a 29-item Likert-type questionnaire with itemsreflecting 5 areas: general attitudes, cost effectiveness, time and energy,therapeutic potential, and educational preparation.It was designed to beused by practicing physicians and requires experience to rate the items.A sample question is, “In my residency, problem cases in geriatrics arefrequently presented” (p. 42) This kind of wording makes it difficult touse with medical students in the early years of their education and inap-propriate for students in other health professions.
Maxwell and Sullivan (1980) reported that the overall test reliabilitywas .7836. No validity studies were reported. Reuben, Fullerton,Tschann, and Croughan-Minihane (1995) used the MSAS to examinethe attitude of 554 beginning medical students toward older persons andtheir medical care. They reported the MSAS to be unreliable on internalconsistency (.54).
Aging Semantic Differential
The Aging Semantic Differential (ASD) is the most widely used in-strument in studies to measure the presence of negative attitudes towardolder adults. Educators have evaluated the effectiveness of educationalprograms, aging simulation, and aging awareness courses (Fields,Jutagir, Adelman, Tideiksarr, & Olson, 1992; Intrieri, Kelly, Brown, &Castilla, 1993; Lorraine, Allen, Lockett, & Rutledge, 1998; Robinson &Rosher, 2001).
On the ASD, subjects respond to bipolar adjective pairs that are oppo-site in meaning, such as “busy” and “idle.” The subject rates the charac-teristic from 1 to 7 between the adjectives. The ASD was developed bycompiling a list of behavioral characteristics of several age groups:(a) males aged 20-30, (b) males aged 40-55, and (c) males aged 70-85. Var-ious authors have modified the use, some prefacing it with “most elderly”(Holtzman, Beck & Ettinger, 1981, p.196) or “most noninstitutionalizedelderly” or “those over 65” (Kelly, Knox, Gekoski, & Evans, 1987, p. 248).
Of the two instruments, the ASD has been subjected to the mostpsychometric testing. An original factor analysis resulted in threesubscales: (a) the instrumental-ineffective dimension–a high scorewould suggest that elderly are capable of pursuing goals and adapting tochange; (b) autonomous-dependent–a high score would suggest that el-derly contribute to the social system; and (c) personal acceptability-unacceptability–a high score suggests that elderly are very interactivesocially (Rosencranz & McNevin, 1969). Intrieri, von Eye, and Kelly
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(1995) determined a fourth factor, integrity, which reflects a sense ofwholeness and personal satisfaction.
Other Instruments
In an effort to capture attitudes of those involved in healthcare, someresearchers have developed their own questionnaires. Deary, Smith,Mitchell, and Maclennan (1993) piloted the Geriatric Attitude Survey.Using factor analysis, the original 33-item questionnaire was reduced to15 questions. No other psychometric testing was reported.
Wilson and Hafferty (1980) measured change in attitudes in first-yearmedical students before and one year after a 14-contact-hour seminaron aging. The authors developed their own 25-item scale adapted fromprevious scales. The new scale measured activity level, mood adapt-ability, mental status, and patient status.
In another study, fourth-year medical students attended a four-weekclinical clerkship in geriatrics. The students were evaluated using 40multiple-choice and fill-in-the-blanks questions testing knowledge and20 true-false statements measuring attitudes. These questions were vali-dated by submission to a panel of experts (Murden, Meier, Bloom, &Tideiksaar, 1986).
The forgoing review shows that problems exist with current instru-ments to measure how health professionals view the elderly. Moreover,little psychometric testing has been done to establish validity and reli-ability. Additionally, these instruments were designed from the per-spective of the professionals working with elders. A better instrumentmight be produced by inquiring of those who are aging as to how theywould like health professionals to view them. The purpose of this paperis to describe the first step of development of the instrument, HealthProfessional’s Beliefs and Opinions toward the Elderly (HPBOE).
There has been growing emphasis on blending qualitative and quan-titative approaches to instrument development. Some authors recom-mend a qualitative approach as the initial step in instrument develop-ment, where the concept to be measured is explored with the persons in-volved (Knafl & Breitmayer, 1991; Munhall & Boyd, 1993). Typically,items for instruments originate with a panel of experts. However, valid-ity is enhanced when the concept to be measured is explored with mem-bers of the population who will be subjects. Using an initial qualitativeapproach, one can be more certain that the elements most important to
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the subjects will be measured by the instrument (Knafl & Breitmayer,1991; Munhall & Boyd, 1992). In the development of this instrument,focus groups were conducted with elders with the purpose of exploringhow the elders themselves would like health professionals to viewthem.
METHODS
Insight into the relationship between the health professional and theelderly can be obtained by exploring the elderly person’s perspective.Older adults enjoy telling their stories and reminiscing about their rela-tionships with health care providers. Additionally, short-term memorydeclines with aging, and others’ comments may stimulate recall. Forthese reasons, focus group methodology was selected to help identifyhow elders would like health professionals to view them (Gray-Vickrey,1993; Krueger, 1994, McDaniel & Bach, 1994).
Participant Selection
The focus groups were composed of men and women who were(a) over 65, (b) cognitively intact, and (c) functionally able to attend a90-minute session. Twenty-five community-dwelling elders (dividedinto 3 focus groups of 9, 9, and 7) and one larger group of 13 elders re-siding in a nursing home provided the data. These 13 residents com-prised the resident’s council that had been functioning effectively as agroup. Discussions were conducted at a mid-western community-basedmedical school in a small, comfortable room. For the elders in the nurs-ing home, the discussion was conducted in the conference room in thenursing home.
Interview Guide
The interview guide was composed of 10 predetermined open-endedquestions. The faculty of the medical school who had degrees or certifi-cations in geriatrics scrutinized the interview guide. The initial questionwas, “About how many times have you seen your primary care providerover the past year?” It was designed to be answered easily to engage allparticipants. In the remaining questions, the term “health professional”was used. The participants were told to think of health professional as
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doctor, nurse, physical therapist, social worker, or any professionalwith whom they might be discussing a health issue.
Collection of Focus Group Data
Each of the elderly participants was given a nametag with his or herfirst name only and a number. Each was asked to complete a demo-graphic data form. Each focus group was conducted by a moderator anda researcher and was audiotaped. A seating diagram was constructedwhich facilitated the association of the participant with the voice later,as the researcher transcribed the tapes.
As each participant spoke, the researcher recorded the participant’snumber. Participants exhibited a variety of nonverbal behaviors, suchas head shaking or nodding in response to the participant who wasspeaking. The researcher recorded these nonverbal behaviors in the ses-sion notes to incorporate into the transcripts later.
To enhance credibility of the study, the moderator validated impor-tant points with the participants. At the conclusion of each focus group,the researcher gave a summary, and the participants were asked to con-firm the major points. Immediately following each focus group, themoderator and investigator shared what they felt were the most impor-tant views reflected by the participants.
To increase consistency and auditability, an audit trail was main-tained. Detailed notes reflected the description of each setting, the dia-grams of the focus groups and the analytical and methodologicaldecisions.
The participants of the first three focus groups were young elderly(average age of 72). Near the end of the sessions, the question wasposed to them “Would you expect health care professionals to feel anydifferent toward you if you were over 85 or living in a nursing home?”Most said “no”; however, there was some disagreement, some feelingthat persons with debilitating incurable conditions might warrant lessattention by a health care provider. To clarify this issue, an additionalfocus group was conducted with 13 older residents who lived in a nurs-ing home. The same procedure was followed as with the young elderly,except that the older elders demonstrated less energy and more fatigue.Consequently, the focus group lasted approximately 1 hour as com-pared with the other 90-minute groups. The nursing home group vali-
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dated the information provided by the young elderly, just in fewerwords.
Data Analysis Procedure
The tapes were transcribed and the researcher incorporated the non-verbal behaviors. The open coding technique was used to identify theviews which elders desired in health professionals (Strauss & Corbin,1990). The researcher and moderator separately coded the first tran-script. They then considered the label each had assigned and decided onthe most appropriate label. After coding was completed, 20 labelsemerged which reflected how older adults would like health profession-als to view them. Examples of these labels included “warm,” “recep-tive,” “unique,” “interesting,” “cherish independence,” “feel frustratedwith chronic disease,” “able to change,” “require thoroughness,” and“are reliable in judging severity and urgency of symptoms.” The labelscould not all be described as attitudes, but all indicated important waysin which these older adults would like health professionals to viewthem. Hence, these labels were categorized as opinions and beliefs.
RESULTS
Description of Participants
Demographic characteristics of the focus group participants are out-lined in Table 1. As can be seen from the table, there were differences inage, gender, marital status, hospitalizations, and number of medica-tions, reflecting the typical differences between the young old and theold old. The members of the community-dwelling group came from avariety of professions, with levels of education ranging from highschool to master’s degree. The range of levels of education for the el-ders in the nursing homes was eighth grade to completion of highschool, with one participant having attended nursing school. Seventeenof the community participants were related to someone who worked inthe health profession, while the older group reported six family mem-bers. All 25 of the community-dwelling participants felt they were“somewhat informed” about their personal medical problems, whileonly three of the nursing home residents felt they were “somewhat in-formed.”
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Opinions and Beliefs
Opinions and beliefs that were similar were assigned the same label,reducing the list to 17 labels. Items were constructed from the labels. Asan example of how items were developed from the data, one of the ques-tions asked in the focus group was, “When you tell your doctor, nurse,or other health professional that something is seriously wrong, howwould you like them to feel towards you?” Participant #4 responded,“I’d like him to feel that I’m not making something up.” Participant #11replied, “If it’s in the day, I’d like him to say, come on down and I’llwork you into the day. I want him to realize it’s urgent. I wouldn’tbother him otherwise.” The nursing home participants responded simi-larly, although they recognized that they would usually be communicat-ing to a nurse that something is wrong. Participant # 28 was adamant,saying, “They treat you like you don’t know anything. My thoughts areslower, but I can tell you when something isn’t right. I’ve lived in thisbody nearly 91 years!” During the open coding these responses were la-beled “reliable in judging severity and urgency.” The item was writtenas “Most elderly patients are reliable in judging the severity and ur-gency of symptoms.”
Another question asked was, “If your medical problem requires youto learn new information or change something that you do, how wouldyou like your doctor, nurse, or other health professional to feel towardsyou?” Participant #6 responded, “I’d like them to realize that this is go-ing to be difficult, but that I can change and I can learn how to do some-thing different.” Participant #16 responded, “It seems to me that thedoctor should be advising you fully about any condition or particular di-agnostic procedure.” Participant #30, who lived in a nursing home,commented, “I can learn, but maybe slow. The nurse or doctor needs totell me slow and clear. I can understand O.K.” Participant 32 responded,“Tell them to slow down and don’t be in a hurry. I still have my intelli-gence!” During the open coding, some of these comments were labeled“able to learn.” The item developed was “Most elderly patients canlearn new information about their health.”
In response to the question “If the health professional has bad news togive you, how would you like him or her to feel towards you?” participant#8 responded, “truthful, I want to know.” Participant #15 replied, “I thinkit is incumbent upon him to give it to you straight. You don’t want itsugar-coated, but at the same time that they are giving you news, he has togive it to you in such a way that you can have some hope.” Participant #21reflected, “I would not like to see a doctor or nurse hold back and not
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share with me the information and how I can handle the rest of my life.”In the nursing home, participant #35 summed up the feeling, “I’ve han-dled an awful lot of troubles in my life. I still like to know. If I know, I canalways pray about it, and God will comfort me.” These responses were la-beled “able to accept the truth.” The item developed from this label was“Most elderly patients are able to accept the truth.”
The focus groups had identified a potential bias that might be felt to-ward those who are over 85 or residing in nursing homes. Most commu-nity-dwelling elders felt there should be no difference regardless of ageor living arrangements. However, a small number of young elderly feltit might be acceptable for the physician to feel differently. Their ratio-nale was that the physician’s time should be devoted to younger, less illpeople with a greater potential for improvement. To clarify this issue,the question was posed to the nursing home group: “Do you think healthcare professionals feel differently towards people that live in nursinghomes?” One of the participants responded, “Yes, I think so,” and an-other responded, “If he’s a true doctor, he won’t.” Nonverbal behaviorsof other focus group participants supported this comment. It was evi-
Robinson et al. 47
TABLE 1. Demographic Characteristics of Focus Group Participants
Characteristic Community Elders Nursing Home Elders
(n = 25) (n = 13)
Age
Mean 72 88
Range 65-81 81-98
Gender
Male 8 0
Female 17 13
Marital Status
Married 13 0
Single 1 1
Widowed 7 12
Divorced 4 0
Race
African American 0 1
Caucasian 25 12
Visits to Physician in last year 6.4 6
Hospitalizations (in last 10 yrs) 1.9 3.4
# Medications presently taking
(average) 5 7.8
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TA
BLE
2.S
ampl
eQ
uest
ions
from
Hea
lthP
rofe
ssio
nals
’Bel
iefs
and
Opi
nion
sA
bout
the
Eld
erly
Circ
leth
enu
mbe
rth
atm
ostc
lose
lyco
rres
pond
sto
how
you
feel
abou
tthe
stat
emen
t.
Mos
tE
lder
lyP
atie
nts
Mos
tPat
ient
sov
er85
Mos
tPat
ient
sin
Nur
sing
Hom
es
Dis
agre
eA
gree
Dis
agre
eA
gree
Dis
agre
eA
gree
Can
bech
arac
teriz
edas
war
man
d
acce
ptin
g1
23
45
61
23
45
61
23
45
6
Are
uniq
uebe
caus
eof
the
agin
g
proc
ess
12
34
56
12
34
56
12
34
56
Che
rish
inde
pend
ence
12
34
56
12
34
56
12
34
56
Fee
lase
nse
offr
ustr
atio
nw
hen
they
have
chro
nic
dise
ases
12
34
56
12
34
56
12
34
56
48
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dent from this fourth focus group that health professionals should notfeel any different because of the elder’s age or living arrangements.Therefore in the first version of the instrument, three statements of eachitem were constructed, each with a different subject: “most elderly pa-tients,” “most elderly patients over 85,” and “most elderly patients liv-ing in a nursing home.”
A second version of the instrument was produced after review by ageriatrician, a gerontological nurse specialist, and a geriatric socialworker. Some items were removed because they always would be an-swered the same way. The instrument was then examined by 2 nurses, 2nursing students, a social worker, and 3 medical students to identify anyconfusing language. It was then revised accordingly. At this point, theinstrument was too lengthy, containing 51 items. A statistician with ex-pertise in instrument development suggested a change in format to fa-cilitate completion within a shorter period of time (Table 2). TheHPBOE is currently being tested for validity and reliability, and a factoranalysis is being conducted.
CONCLUSION
By beginning with a qualitative approach using focus group method-ology, we have clearly identified how young elders, old elders, and el-ders residing in nursing homes would like health professionals to viewthem. We have used this information to develop a potential measure ofbeliefs and opinions about elderly patients. When fully developed, thisinstrument should discern health professionals, positive and negativeviews toward the elderly. The instrument should be useful for educatorsin medicine, nursing and related health professions to measure the ef-fectiveness of their curriculum.
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