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This article was downloaded by: [University of Auckland Library]On: 25 November 2014, At: 14:28Publisher: 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
Investigating the FactorStructure of an Instrumentto Measure Attitudes andPreparedness to Work withElders with Alzheimer's DiseaseMichael N. Kane PhD, MSW, MDiv aa School of Social Work , Florida Atlantic University ,USAPublished online: 25 Sep 2008.
To cite this article: Michael N. Kane PhD, MSW, MDiv (2003) Investigating the FactorStructure of an Instrument to Measure Attitudes and Preparedness to Work with Elderswith Alzheimer's Disease, Gerontology & Geriatrics Education, 24:1, 15-29, DOI:10.1300/J021v24n01_02
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Investigating the Factor Structureof an Instrument to Measure Attitudesand Preparedness to Work with Elders
with Alzheimer’s Disease
Michael N. Kane, PhD, MSW, MDiv
ABSTRACT. This study investigated the factor structure of an instru-ment to measure attitudes and preparedness of social work students towork with memory-impaired elders. Exploratory statistical proceduresto reduce data through principle component analysis identified three fac-tors with eigenvalues greater than 1.0 and a cumulative variance of65.520%. These factors include general belief in the efficacy of psycho-therapeutic services for elders with memory impairment; self-perceivedadequacy to provide services to elders with memory impairment; and be-lief in the efficacy of other ancillary services to elders with memory im-pairment. Recommendations are made for utilizing this brief self-reportinstrument in training and assessing students and other practitioners fortheir attitudes toward and greater preparedness to work with mem-ory-impaired elders. [Article copies available for a fee from The HaworthDocument Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2003 by TheHaworth Press, Inc. All rights reserved.]
Michael N. Kane is Assistant Professor in the School of Social Work at Florida At-lantic University.
Address correspondence to: Michael N. Kane, School of Social Work, Florida At-lantic University, 777 Glades Road, P.O. Box 3091, Boca Raton, FL 33431-0991(E-mail: [email protected]).
Gerontology & Geriatrics Education, Vol. 24(1) 2003http://www.haworthpress.com/store/product.asp?sku=J021
2003 by The Haworth Press, Inc. All rights reserved. 1510.1300/J021v24n01_02
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KEYWORDS. Alzheimer’s disease, memory impairment, therapeuticnihilism
Elderly populations have significantly increased since the beginningof the twentieth century, with those over 85 years being the most rapidlygrowing group (Kart & Kinney, 2001). The baby boomer cohort is ag-ing: Many will begin arriving at the age of 65 by 2010. No doubt therewill be an increasing need for practitioners of diverse disciplines to pro-vide services to these older adults. While the need for specialized practi-tioners grows, few professionals opt to specialize in the care of elders(Kane, 1999-a; Wilderom et al., 1990). Even fewer practitioners appearinterested in providing services to elders with Alzheimer’s disease andother forms of memory impairment.
Increasingly, diverse professionals will be called upon to interactwith individuals affected by Alzheimer’s disease and other forms ofmemory impairment as well as their caregivers and families. Demo-graphic evidence suggests that the prevalence of Alzheimer’s diseaseand other types of dementia will continue to increase (Kaplan & Sadock,1998). Geographic areas with large concentrations of elders may bemore affected than other areas. Kaplan and Sadock (1998) indicate thatapproximately five percent of the population over 65 years of age and15-25% of the population over 85 years of age have dementia of theAlzheimer’s type. Currently, more than half of all skilled nursing homebeds are occupied by individuals with dementia of the Alzheimer’s type(Kaplan & Sadock, 1998). In assisted-living facilities, the proportion ofindividuals with memory impairment may be even higher. While Alz-heimer’s disease is the most common type of dementia, there are othertypes of dementia which add to the numbers of memory-impaired el-ders. These other types of dementia include vascular dementia, Pick’sdisease, Lewy Body disease, Huntington’s disease, and HIV-related de-mentia (Kaplan & Sadock, 1998).
While the need for practitioners with specialized knowledge andskills grows, few professionals are interested in serving those with Alz-heimer’s disease, their families, and their care givers. Dunkelman andDressel (1994) suggest that this is a result of therapeutic nihilism amonghealth care professionals and educators: i.e., since there is little chanceof cognitive improvement or recovery, professionals may believe thereis little point in expending the energy and resources to intervene.
This study sought to develop a brief instrument that measures thera-peutic nihilism: i.e., attitudes toward working with elders affected by
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Alzheimer’s disease and perceptions of preparedness to work with thisvulnerable population. Specifically, this study sought to develop a briefinstrument which measured respondents’ beliefs in the efficacy of clini-cal service with elders affected by Alzheimer’s disease, their percep-tions about the sufficiency of their clinical knowledge and skills forwork with this population, and their general beliefs about the efficacy ofancillary services frequently used to provide intervention to elders withAlzheimer’s disease.
AGEISM AND PROFESSIONAL ATTITUDES
Ageism is a significant reality in contemporary American culture.Ageist belief purports that elders are deteriorating, useless, and unpro-ductive (Barker, 1999; Laws, 1995). From an ageist perspective, the ag-ing process is viewed as a journey that leads to incompetence andforgetfulness (Gatz & Pearson, 1988; Kane, 1998; Kane, 1999-a; Kane,2001; Laws, 1995).
A common type of contemporary ageism is the belief that older peo-ple are or will become cognitively impaired (Gatz & Pearson, 1988;Kane, 2001). This ageist belief is common in the dominant U. S. cultureas well as in many minority ethnic and cultural communities (Kane,2000). Building on this commonly held belief is the erroneous assump-tion that Alzheimer’s disease is a part of normative aging. There is am-ple evidence that suggests that memory loss is neither an inevitability ofaging nor a normative aspect of the process (Kaplan & Sadock, 1998;Schneck, Reisberg, & Ferris, 1982). Nonetheless, this erroneous beliefhas been documented among many groups, including African-Americans(Ballard, Nash, Raiford, & Harrell, 1993), Hispanics/Latinos (Henderson &Gutierrez-Mayka, 1992), and Asians/Pacific Islanders (Braun, Takamura,Forman, Sasaki, & Meininger, 1995).
While many of these ageist beliefs influence the way in which agerontophobic culture understands and perceives aging, the attitudes ofservice providers also may have a profound influence on service deliv-ery and service policy. The attitudes of various discipline-specific ser-vice providers toward elders have been studied in the literature,including the attitudes of social workers (Carmel, Cwikel, & Galinsky,1992; Rohan, Berkman, Walker, & Holmes, 1994), nursing home super-visors (Kosberg, Cohen, & Mendlovitz, 1972), institutional care-givingstaff (Solomon & Vickers, 1979; Thorson, Whatley, & Hancock, 1974),home health care workers (Weiler & Sarvela, 1993); nurses’ aides
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(Robinson, 1993), and psychiatrists (Cyrus-Lutz & Gaitz, 1972). The atti-tudes of students in professional educational programs have been reportedeven more routinely, including the attitudes of nursing students (Beall etal., 1992; Gomez, Young, & Gomez, 1991; Rowland & Shoemake, 1995),medical students (Beall et al., 1992; Beall, Baumhover, Simpson, & Pieroni,1991; Birenbaum, Aronson, & Seiffer, 1979; Green, Keith, & Pawlson,1983; Intrieri, Kelly, Brown, & Castilla, 1993; Robins & Wolf, 1989;Solomon & Vickers, 1979; Wilderom et al., 1990), social work students(Kane, 1999-a), occupational therapy students (Rosenbloom, Whitting-ton, & Wilson, 1987), and college students (Schwalb & Sedlacek,1990). Typically, respondents in these studies have neutral to negativeattitudes toward older persons.
Along with students, social workers and various other mental healthprofessionals have routinely expressed neutral to negative attitudes to-ward older populations (Geiger, 1978; Intrieri et al., 1993; Kogan,1961; Kosberg, 1973; Kosberg et al., 1972; Kosberg & Harris, 1978;Reinhardy, 1987; Rohan, Berkman, Walker, & Holmes, 1994). Someliterature suggests that many professionals like younger clients morethan older clients and prefer to work with younger clients (Rohan et al.,1994; Wilderom et al., 1990). Carmel, Cwikel, and Galinsky (1992) in-dicate that some professionals may attribute more positive characteris-tics to younger persons than older clients. Interestingly, students’attitudes across disciplines appear equivalent to those expressed bypractitioners (Beall et al., 1992; Beall et al., 1991; Birenbaum, Aronson, &Seiffer, 1979; Green et al., 1983; Intrieri et al., 1993; Kane, 1999-a;Robins & Wolf, 1989; Solomon & Vickers, 1979; Wilderom et al.,1990).
While attitudes appear in the neutral to negative range of the attitudecontinuum, many other variables have been proposed to explain thelack of interest in geriatric specialization. Wilderom et al. (1990) hy-pothesized that previous exposure to elders through family or friend-ship prior to professional education may enhance interest in pursuing acareer in geriatrics. They also indicated that other contributing variablessuch as attitude modeling of well-established professionals may influ-ence career specialization. Wilderom et al. (1990) hypothesized that(1) perceived sufficiency of financial compensation for geriatric spe-cialization, (2) perceived sufficiency of geriatric knowledge, and (3) per-ceived public attitude toward elders were other important and influencingfactors.
Among career preferences of social work students, there appeared ageneral lack of interest in working with elders with Alzheimer’s disease
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(Kane, 1999-a). Asked to rate their feelings about working with 15 vul-nerable groups, social work students were least interested in workingwith elders with Alzheimer’s disease. Other findings of this study(Kane, 1999-a) suggested that willingness to work with elders with Alz-heimer’s disease was predicated on a willingness to work with olderpersons, a preference for working with older adults over younger adults,previous exposure to elders and elders with Alzheimer’s disease, andperceived sufficiency of knowledge and skill related to aging and Alz-heimer’s disease. This is consistent with the work of Fazio, Powell, andHerr (1983), who suggest that experience with and knowledge of an at-titude object forms the most enduring attitude and encourages a moreconsistent expression of behavioral intent. Concretely, this may meanthat experience with a memory-impaired elder, as well as knowledge ofthe population, may promote a greater willingness to work with this vul-nerable group (Kane, 1999-a).
As noted previously, therapeutic nihilism appears as one of the prin-ciple factors which influences willingness to work with elders with Alz-heimer’s disease (Dunkelmann & Dressel, 1994). Therapeutic nihilismappears as a sophisticated form of ageism in that it not only is built onthe supposition that aged persons are less valuable than younger per-sons, but it also advances the belief that since memory recovery amongthe memory impaired is not currently possible there is little point in pro-viding services to this population. While there are no current interven-tions that will restore memory to elders with dementia, this is not to saythat such interventions are impossible in the future. In the interim, thereare other interventions that may bring relief, support and assistance tothe memory impaired and their caregivers. These diverse interventionsinclude individual and group therapies, recreation therapies, andcase/care management.
Elders with Alzheimer’s disease have many needs. While the diseaseis progressive in nature (Kaplan & Sadock, 1998), each individual ex-periences the disease uniquely. Elders with Alzheimer’s disease andother forms of memory impairment may need various services that canbe provided by diverse professionals. Along with medical and nursingcare, clinical interventions such as individual and group therapies maybe critically important in the early stages of the disease process (Yale,1995). Not infrequently, elders with early stage Alzheimer’s disease ex-perience depression as they become increasingly aware of their impair-ment (Kane, 1999-b; Yale, 1995). Early intervention may enhance thequality of life for these individuals and assist them in planning for theuncertain aspects of their futures (Yale, 1995). Early intervention may
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also assist in preserving their sense of self that will allow them to retaintheir identity. As the disease progresses, these same elders may experi-ence difficulty with reality testing, experience delusions and hallucina-tions, become agitated, and face the difficulties of performing activitiesof daily living and instrumental activities of daily living (Kane,1999-b). For some of these individuals, services such as case manage-ment and discharge planning following hospitalization may becomecritically important and allow them to maintain connections to past andpresent. Further along the disease process, greater intervention may berequired such as placement, conservatorship, or guardianship (Kane,2001). Those who provide these services will not only need specializedknowledge and skill of the disease process, but will need to work fromstrengths perspectives and believe in the dignity and worth of these cli-ents. This will require awareness of the effects of ageism, personalawareness of motivation for career choice, and continuing clinical su-pervision to reduce the effects of countertransference (Kane, 2002).These may effectively combat therapeutic nihilism.
Clearly, there is a significant need for professionals who will advo-cate for the needs of memory-impaired elders. These individuals will beneeded to take key positions in the delivery of services for elders withAlzheimer’s disease as well as in policy formation that will benefit thisvulnerable group. While attitudes and exposure may play a critical rolein a career specialization, tools need to be developed which will identifypreferences for this type of career specialization as well as positive atti-tudes that are the antithesis of contemporary ageist thought and thera-peutic nihilism. This study sought to develop a brief, self-reportinstrument that measures respondents’ attitudes and perceptions forwork with elders who are affected by Alzheimer’s disease.
METHOD
Sampling and Data Collection
BSW and MSW student respondents from three Florida universitiesparticipated in an anonymous, self-administered, in-class survey (N =333). Availability to survey students was based on the permission of theinstructor. Most students were enrolled in social work practice classesor field education seminars. The sample included diverse racial and cul-tural groups, reflective of Florida’s immense diversity. Table 1 pro-vides detailed sample information. Data gathered specifically for this
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Michael N. Kane 21
TABLE 1. Demographic Data
Variable Frequency Valid Percent
Gender
Male 56 16.8
Female 277 83.2
Marital Status
Single 167 50.6
In a relationship 163 49.4
Educational Program
BSW part-time (PT) 30 9.0
BSW full-time (FT) 79 23.8
MSW foundation PT 15 4.5
MSW foundation FT 30 9.0
MSW concentration PT 39 11.7
MSW concentration FT 139 41.9
Race
White 235 71.2
Black 52 15.8
Native America 2 .6
Asian/Oriental 4 1.2
Eastern Indian 1 .3
Mixed Racial 20 6.1
Other 16 4.8
Cultural Identification
Hispanic 63 20.9
Caribbean 31 10.3
Asian/Pacific Islander 4 1.3
North European 106 35.1
South European 20 6.6
African 29 9.6
Other 49 16.2
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study was attached to an instrument which investigated social work stu-dents’ willingness to specialize in a career in service of elders and elderswith Alzheimer’s disease.
Instrumentation
Based on a literature review, a pilot instrument was constructed. Ofthese items, 18 were identified as possessing face validity by a committeeof social work educators and practitioners and included in this portion ofthe instrumentation. A four-point Likert-type scale (1 = strongly agree, 2 =agree, 3 = disagree, 4 = strongly disagree) was adopted to respond to eachof the items. Demographic information was also collected.
Pre-screening of the Data
Factor analysis is a method to reduce a larger number of related itemsinto a smaller number of factors and requires the meeting of several as-sumptions. First, data must be normally distributed (Tabachnick &Fidell, 1996). Skewness and kurtosis evaluate whether the data approxi-mates normal distributions (Vogt, 1999). In this study, data approxi-mated normal distributions based on skewness and kurtosis.
Bivariate correlations for all items were examined. Because itemsthat are not related to other variables may form factors on their own andmay reduce efficient factor solution (Hutcheson & Sofronious, 1999),items which had no correlation with any other item at 0.4 or above wereremoved (Hedderson & Fisher, 1993). Using this recommendation, 7items were removed from further analysis.
Tolerance and variance inflation factor (VIF) are two statisticalmethods that can be used to assess multicollinearity. Multicollinearityis an extremely high correlation between items that are essentiallyequivalent. Hutcheson and Sofroniou (1999) indicate that tolerance sta-tistics of less than 0.2 or VIF statistics greater than 5.0 indicate multi-collinearity. In this particular study, no evidence of multicollinearitywas detected among the variables.
Sample size is a further consideration in factor analysis as in manyother statistical procedures. Statisticians indicate that the analysis tendsto be more reliable when sample sizes are large. Fewer than 150 casesare required for an acceptable solution if multicollinearity is not of con-cern (Hutcheson & Sofronious, 1999; Tabachnick & Fidell, 1996).Even though the sample size in this study was significant (N = 333), theadequacy of the sample size was evaluated using the Kaiser-Meyer-
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Olkin (KMO) statistic for both individual and multiple variables. Thesetwo procedures have score ranges from zero to one, with higher scoresmore desirable in factor analysis. The KMO statistic for multiple vari-ables was computed at 0.707; which was well within the acceptablerange. Individual scores for each item were also computed. Scoreslower than 0.5 are considered unacceptable and should be removedfrom further analysis (Hutcheson & Sofronious, 1999). All eleven re-maining items had acceptable scores well above 0.6, with many at 0.8 orabove. These statistics indicate that the sample size for this principalcomponent analysis was well above the minimal requirements.
Principal Component Analysis
Eleven items were analyzed using the statistical procedure of princi-pal component analysis with varimax rotation. This method seeks to re-duce correlated items into fewer factors or components. Eigenvaluesare one of the generated statistics in principle component analysis andindicate the amount of variation in the original items that is explainedby a particular factor (Vogt, 1999). Eigenvalues of less than 1.0 are gen-erally not significant or worth consideration (Vogt, 1999).
RESULTS
Using principle-component analysis with varimax rotation, the 11items were reduced to create a three-factor solution. Each factor had aneigenvalue greater than 1.0. The cumulative variance was calculated at65.520%. The three factors included: (a) belief in the efficacy ofpsychotherapeutic services for elders with Alzheimer’s disease, (b) self-perceived adequacy to provide services for elders with Alzheimer’s dis-ease, and (c) belief in the efficacy of ancillary services to elders withAlzheimer’s disease.
This factor solution was confirmed using the visual graphic methodof a scree plot. Based on the three factors with eigenvalues greater than1.0 and the scree plot, the three-factor solution was accepted. Factorvariance and eigenvalues for the three factors are reported in Table 2.
Principle component analysis with varimax rotation additionally re-ports factor loadings which are the correlation between each item vari-able and the factor. As with all correlations, values may range from zeroto one. Values of less than 0.4 are considered meaningless (Vogt, 1999).All 11-item loadings found in Table 3 have values greater than 0.5.
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The variance of factor 1 was calculated at 33.350%. Scores rangedfrom a minimum of 4 to a maximum of 15, with a mean value of 8.0798and a standard deviation of 2.2911. A reliability coefficient was calcu-lated at .8066.
With a minimum score of 4 and a maximum score of 16, the varianceof factor 2 was calculated to be 21.049%. The mean score was 11.4121,and the standard deviation was calculated at 2.4308. Internal consis-tency alpha was measured at .7713.
Finally, the variance of factor 3 was calculated to be 11.122%. With aminimum score of 3 and a maximum score of 10, the mean value was5.2301 and the standard deviation was 1.5667. The reliability coeffi-cient was calculated to be .8081.
CONCLUSIONS AND IMPLICATIONS
Using principle component analysis as an exploratory method, thefactor structure of a measure to determine preparedness and attitudes to-ward memory-impaired elders was investigated. The proposed instru-ment contains 11 items with a three-factor solution. These factorsprovide a framework for assessing student and practitioner perceptionsof therapeutic nihilism as it relates to working with elders with Alzhei-mer’s disease. Each of the three factors is briefly discussed.
Factor 1 concentrates on perceptions and general beliefs surroundingthe efficacy of psychotherapeutic services for elders with Alzheimer’sdisease. In particular, four items assess respondents beliefs that groupand individual psychotherapeutic services enhance the quality of life orprolong the life of an individual with Alzheimer’s disease. These fouritems appear to directly target notions of therapeutic nihilism found inthe literature (Dunkelman & Dressel, 1994; Kane, 1998; Kane, 1999-a).Lower scores indicate more positive attitudes toward the provision ofpsychotherapeutic services to memory-impaired elders. In this particular
24 GERONTOLOGY & GERIATRICS EDUCATION
TABLE 2. Eigenvalues and Variances for the Three Factors
Factor Eigenvalue Percent of Variance Cumulative Percent of Variance
1 3.668 33.350 33.350
2 2.315 21.049 54.399
3 1.223 11.122 66.520
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TA
BLE
3.R
otat
edF
acto
rM
atrix
Item
Fac
tor
Lo
adin
g
FA
CT
OR
1
Ibel
ieve
indi
vidu
alps
ycho
ther
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elde
rsw
ithA
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olon
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ality
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..8
56
Ibel
ieve
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hoth
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grou
pw
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elde
rsw
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imer
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olon
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equ
ality
ofth
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lives
..7
94
Ibel
ieve
anel
der
with
Alz
heim
er’s
dise
ase
may
bene
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dual
ther
apy
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cted
aten
hanc
ing
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rlif
e..7
60
Ibel
ieve
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der
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er’s
dise
ase
may
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omgr
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ther
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cted
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ing
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rlif
e..5
97
FA
CT
OR
2
Ibel
ieve
Ihav
ean
adeq
uate
know
ledg
eba
seto
prac
tice
with
elde
rsw
ithA
lzhe
imer
’sdi
seas
e..8
08
Ibel
ieve
[soc
ialw
ork]
educ
ator
sst
ress
the
impo
rtan
ceof
prac
tice
with
elde
rsw
ithA
lzhe
imer
’sdi
seas
e..7
86
Ibel
ieve
Ihav
eth
ene
cess
ary
skill
sto
enha
nce
the
life
expe
rienc
esof
elde
rsw
ithA
lzhe
imer
’sdi
seas
e..7
74
[Soc
ialw
ork]
Pra
ctic
ew
ithel
ders
with
Alz
heim
er’s
dise
ase
has
been
disc
usse
din
my
clas
ses.
.721
FA
CT
OR
3
Ibel
ieve
case
man
agem
entw
ithel
ders
with
Alz
heim
er’s
dise
ase
prol
ongs
the
qual
ityof
thei
rliv
es.
.840
Ibel
ieve
disc
harg
epl
anni
ngac
tiviti
esw
ithel
ders
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ase
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ityof
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.797
Ibel
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eatio
nalg
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ityof
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.726
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sample, attitudes toward the value and usefulness of psychotherapeuticservices for memory-impaired elders fell in the neutral part of the atti-tude continuum.
With four items, Factor 2 seeks to evaluate respondents’ self-perceivedadequacy to provide services to elders with memory impairment. Spe-cifically, respondents are asked to self-evaluate their clinical knowledgeand skill level to practice with elders diagnosed with Alzheimer’s dis-ease. Respondents further provide information as to whether their profes-sional education included significant content on practice with elders whohave Alzheimer’s disease. Again, lower scores on this factor indicategreater perceptions of preparedness to practice with elders with Alzhei-mer’s disease. Scores in this sample were predominantly in the neutral tonegative end of the continuum indicating that respondents did not feel ad-equately prepared to provide services to elders with Alzheimer’s disease.
Factor 3 investigates respondents’ beliefs about ancillary servicesprovided to elders with Alzheimer’s disease such as case management,discharge-planning activities, and recreational therapy services. Thisfactor taps into another dimension of therapeutic nihilism as it relates tovarious ancillary services that are offered by social workers and otherprofessionals to elders with Alzheimer’s disease. Again, lower scoresare indicative of more positive attitudes toward the provision of theseservices to elders with Alzheimer’s disease. In this particular sample,scores fell within the neutral to positive end of the continuum.
This brief self-report instrument can serve as an assessment tool to eval-uate respondents’ perceptions of therapeutic nihilism in work with elderswho have Alzheimer’s disease. Conceivably, this instrument might be usedas a pre- and post-test instrument for students in field placements whichprovide services to elders with Alzheimer’s disease or other forms of mem-ory impairment. It may further assess curriculum on aging, particularlycontent on Alzheimer’s disease in professional education programs. It mayalso be used to cue employers and agencies about the internal belief systemof potential service providers, as well as current and future employees.
The instrument will require further development through testing, es-pecially regarding validity and reliability. No doubt, there are other la-tent variables that have a bearing on the provision of services to elderswith Alzheimer’s disease. With the continuing increase in aging popu-lations and those affected by Alzheimer’s disease increase, profession-als must address the expanding needs of this population. Attention willcontinue to be needed from educators, researchers, practitioners, ad-ministrators, and policy makers as they examine the needs of elderswith Alzheimer’s disease and related populations.
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