A Pilot Study of a Creative Bonding Intervention to Promote Nursing Students' Attitudes towards Taking Care of Older People.

Abstract

Although numbers of older people are increasing, nursing students have negative attitudes towards older people and do not plan to care for them following graduation. Multiple strategies have been implemented to reverse students' attitudes with mixed results. The purpose of this pilot quasi-experimental study was to test a Creative-Bonding Intervention (CBI) with students implementing art activities with older people to promote students' willingness to take care of them. Using a self-transcendence conceptual framework, control (n = 56) and experimental (n = 14) student groups were pre- and post-tested on attitudes toward older people, self-transcendence, and willingness to serve. The CBI improved attitudes towards older people with negative attitudes significantly changed (P = .008) but with no significant differences on self-transcendence and willingness to serve. However, willingness to serve results approached significance (P = .08). The willingness measure (one question) should be expanded. Curricula changes that incorporate creative activities such as the CBI with larger and equal numbers in student groups and longitudinal follow up to determine long-term results after graduation are suggested.

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Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2011, Article ID 537634, 6 pages
doi:10.1155/2011/537634
Research Article
APilot Study of a Creative BondingInterventionto
Promote NursingStudents’ Attitudes towards Taking Care of
OlderPeople
AnnR.Lamet,Rosanne Sonshine,SandraM.Walsh, DavidMolnar,andSharonRafalko
Division of Nursing, College of Health Sciences, Barry University, 11300 NE Second Avenue, Miami Shores, FL 33161-6695, USA
Correspondence should be addressed to Sandra M. Walsh, walshmoore@aol.com
Received 15 December 2010; Revised 18 April 2011; Accepted 27 July 2011
Academic Editor: Barbara Resnick
Copyright © 2011 Ann R. Lamet et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Althoughnumbersofolderpeopleareincreasing,nursingstudentshavenegativeattitudestowardsolderpeopleanddonotplanto
care for them following graduation. Multiple strategies have been implemented to reverse students’ attitudes with mixed results.
The purpose of this pilot quasi-experimental study was to test a Creative-Bonding Intervention (CBI) with students implementing
art activities with older people to promote students’ willingness to take care of them. Using a self-transcendence conceptual
framework,control(n = 56)andexperimental(n = 14)studentgroupswerepre-andpost-testedonattitudestowardolderpeople,
self-transcendence, and willingness to serve. The CBI improved attitudes towards older people with negative attitudes significantly
changed(P = .008)butwithnosignificantdifferencesonself-transcendenceandwillingnesstoserve.However,willingnesstoserve
results approached significance (P = .08). The willingness measure (one question) should be expanded. Curricula changes that
incorporate creative activities such as the CBI with larger and equal numbers in student groups and longitudinal follow up to
determine long-term results after graduation are suggested.
1.Introduction
The pervasiveness of negative attitudes toward older people
and lack of nurses’ interest in caring for them has become
increasingly problematic as numbers of older people con-
tinue to increase worldwide [1–3]. Amid the current nursing
shortage, there is a growing demand for nurses to care for
the health care needs of older people [3]. Thirty years ago,
D. Feldbaum and M. Feldbaum [4] addressed the issue of
ageism in a United States survey of undergraduate nursing
students (n = 3,942) and registered nurses (RN’s) (n =
5,300) to describe student and RN attitudes about caring
for older people. They concluded that persons who were
interested in caring for older people were older themselves
(>55), were of minority status, and had ongoing contact
with older people at home or at work [4]. They suggested
strategies to increase nurses’ interest in older people that
included recruiting more minorities into nursing, increasing
financial incentives to nurses caring for older people, and
increasing gerontology content in curricula in schools of
nursing [4]. In an attempt to increase nursing students’ will-
ingness to care for older people after graduation, we offered
nursing students suggestions for creative bonding activities
they could share with older people.
Since the D. Feldbaum and M. Feldbaum study [4],
numerous approaches have addressed issues related to
ageism; yet, negative attitudes about older people among
nursing and other healthcare professional students persist
[3, 5, 6]. Minorities and older health professional students
andworkershavebeencitedasgroupsthatfavoredworkwith
older people [4]. Researchers have more recently reported
an inverse relationship between age of the caregiver and
better attitudes among Hispanic social work students [6].
Additionally, when geriatric didactic content has been added
to the nursing school curricula, there have been inconsistent
resultswithlittleornogaininknowledge,littleornoattitude
change, and little or no interest in caring for older people
after graduation [2, 7–9]. In a study of curricula in four
schools of nursing, the one school that had made major
curricula changes with a focus on older people reported

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changes in attitudes of students towards older people [1].
Such changes were attributed to (1) the adoption of a
“successful aging paradigm” framework throughout the cur-
ricula, (2) the provision of in-service education classes to
build faculty expertise in gerontology, and (3) the institution
of multiple student experiences with well elders living in the
community. However, students’ willingness to care for older
people post-graduation was not evaluated. In two recent
qualitative studies, medical students’ attitudes towards older
people did improve after year-long contact between medical
students and community dwelling older adults [10, 11].
Theolderadultsservedasmentors/advisorswiththemedical
students [10, 11]. Similar mentor-student programs in
schools of nursing have not been reported.
Questions remain about attitudes of students in health-
care professions and college students in general. Attitudes
and knowledge about older people have been described in
undergraduate and graduate college students (n = 125) [5].
In these college students, frequency of communication with
elders was positively correlated with better attitudes about
older people [5]. Yet, student age and knowledge about aging
hadnorelationship tostudents’attitudesaboutolderpeople.
Other researchers have measured frequency of communica-
tion, proximity to older people, and student anxiety about
aging and reported no relationship between attitudes of
college students (n = 107) and frequency of daily contact
with older people [7]. Yet, those students who resided
with older people had more anxiety about aging than
students whose sole contact with older people was in a work
environment [7]. In a survey of physician assistant students
(n = 36), students who had weekly socialization with older
people did have better attitudes towards older people than
students who had yearly contact [12]. In a small group (n =
27) of nutrition students, 1/2 of the students (n = 13) that
preferred working with older people also had better attitudes
and previous frequent contact with older people [13].
Throughout the literature, knowledge about aging [7, 8],
frequency of contact [10–13], minority status [4], age of
a student or caregiver [4–6], type of older person with whom
one communicates [7, 10, 11, 13], and implementation of
curricula changes [2, 10, 11, 13] may or may not determine
if future health professionals are willing to care for older
people. Surprisingly, in a longitudinal study of baccalaureate
nursing students, the introduction of additional knowledge
about elders and increased student contact with elders de-
creased students’ interest rather than increased their interest
in caring for older people [2]. Because nurses are the largest
health care work force that will provide care for elders [3],
researcherscontinuetofocusonwaystoincreasenursingstu-
dents’ willingness to care for older people after graduation.
2.Background Studiesfor the CurrentStudy
Researchers have reported novel approaches to address the
challenges surrounding nursing students’ knowledge, atti-
tudes, and willingness to care for older people after grad-
uation. The theory of self-transcendence [14] was used as
a conceptual framework in two studies [15, 16] to test a
creative bonding intervention (CBI) to promote positive
communication between elders and undergraduate nursing
students in the USA [15] (a pilot study) and in Taiwan [16]
(a prepost test quasi experimental study).
3.The Theory of Self-Transcendence
andRelated Studies
The theory of self-transcendence [14] guided the present
study and provided the rationale to test the CBI. In the
theory of self-transcendence, Reed [14] identified three
major concepts: self-transcendence, vulnerability, and well-
being. In the present study, older people and students
were considered vulnerable persons, the CBI was imple-
mented to “activate” self-transcendence, and well-being was
an expected outcome. Reed described self-transcendence as
a developmental trait that may be used by vulnerable popu-
lations. Self-transcendence has four dimensions: (1) intrap-
ersonal self-transcendence—within self—(2) interpersonal
self-transcendence—between self and others—(3) temporal
self-transcendence—past, present, and future time—and (4)
transpersonal self-transcendence—outside, of self, for exam-
ple, spirituality. Reed discussed that in vulnerable persons,
the introduction of creative activities might serve to promote
self-transcendence and well-being. Self-transcendence was
one outcome variable in the present study measured by
Reed’s self-transcendence scale (STS).
Inpreviousstudies[15,16],thefocusofthecommunica-
tion between the student and older person was on the inter-
personal self-transcendence (between self and others) and
temporal self-transcendence (present, past, and future time).
By self-report following the CBI, students [15, 16] reported
that they had “grown” personally after their encounters
witholderpeople(intrapersonalself-transcendence).During
the CBI activities to promote temporal self-transcendence,
students were encouraged to ask the older person to reminis-
cence about their favorite colors, favorite past experiences, or
previous hobbies during the CBI activities [15, 16].
In the two previous studies [15, 16] students attitudes
[17, 18] and self-transcendence [14] were measured before
and after a one semester course, “Care of the Older Adult.”
In the larger study [16], an experimental group of students
(n = 100) were randomly assigned to implement the CBI
while a control group of students (n = 100) implemented
a friendly visit only. Students in the CBI group increased in
self-transcendence (P < .06); however, there was significant
improvement (P < .05) in students’ attitudes towards older
people [16]. Students in the CBI group also had significantly
greater volunteer visits (P < .01) [15, 16].
4.Purpose of the Study
The purpose of the present study was to utilize the CBI to
continue to investigate the relationship of students’ attitudes
toward older people, to describe self-transcendence, and to
evaluate students’ willingness to take care of older people.
Researchers inferred that if self-transcendence increased and
attitudes towards older people improved, students would
increase their willingness to take care of older people after
graduation. The research question was, “in a group of senior

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baccalaureate nursing students, will the CBI improve atti-
tudes towards older people, self-transcendence, and willing-
nesstotakecareofolderpeople?”Onequestionto“measure”
willingness was added to the demographic data sheet. This
question asked students what age group preference they
anticipated caring for after graduation.
Hypotheses were (1) compared to the control group stu-
dents who participate in the CBI will have better attitudes
towards older people; (2) compared to the control group
students who participate in the CBI will have an increase in
self-transcendence; (3) compared to the control group, stu-
dents who participate in the CBI will have an increase in
willingness to take careof older people following graduation.
5.Methods
5.1. Settings/Participants. The collection of data occurred
during the fall of 2008 and the spring of 2009 at a Catholic
SoutheasternFloridauniversity.Thispretestposttestdescrip-
tive cross-sectional design included students from junior
and senior classes that served as controls; one section of
seniors (n = 28) was the experimental group where the CBI
was piloted. A convenience sample of two groups of junior
students and one group of senior students with no exposure
totheCBIservedasthecontrolgroup(n = 84).Therewasno
exclusioncriteria foranyoftheparticipants enrolledinselect
junior and senior nursing courses. Initially the researchers
intended the study as descriptive only, thus the small sample
and unequal size between groups. After the decision was
made to pilot the CBI, the institutional review board (IRB)
(ethics board) approved adding the intervention only in
time to include the final group of seniors in the “Care of
the Older Adult” course during their final six weeks before
graduation. Therefore, the implementation of the CBI was
limited to a final group of 14 seniors. Absences at pretesting
orpost-testingandtiming(seniorsgettingreadytograduate)
contributed to the small sample for the CBI group. Both
the CBI group and the control group of seniors had clinical
experiences with older well people living in the community.
There was a focus on well people in the “Care of the Older
Adult” course due to the literature that has supported the
need for young persons to have experiences with well older
people before these people become ill [1, 10, 11].
5.2. Materials/Tools/Instruments. The questionnaire packet
completed by the participants was comprised of a sociode-
mographic survey that included age, ethnicity, family struc-
ture, interaction with older people, living arrangements
regarding older relatives or grandparents, visitation with
older people or grandparents, volunteerism with older peo-
ple, preference among three age categories to work with after
graduation, and willingness to take care of older people. Two
instruments administered before and after intervention were
the Self-Transcendence Scale [14] and Attitudes toward Old
People Scale [17, 18]. Data were gathered the first and last
days of classes. Data were collected anonymously with vol-
unteers choosing their own identification numbers for pre-
and postdata packets.
Reed,s Self-Transcendence Scale (STS) [14] measured
self-transcendence. Participants were asked to indicate on
a 4-point Likert scale how strongly they agreed with the 15
statements (1: not at all, to 4: equals very much), resulting in
scoresrangingfrom15to60withthehigherscoresindicating
higher levels of self-transcendence. Reed reported an alpha
coefficient of .90 indicating high internal consistency for the
scale [14].
Attitude towards older people was measured using the
Attitudes toward Old People Scale [17, 18]. Participants were
asked to indicate on a 7-point Likert scale how strongly they
agreed or disagreed with the 22 items. Seventeen items were
positively worded and responses were summed to create a
positiveattitudesubscale.Fiveitemswerereversewordedand
used as a negative attitude subscale.
5.3. Ethical Considerations. The protocol and method of ob-
taining informed consent were approved by the institutional
review board (IRB) of the university where researchers were
affiliated. Anonymity was protected as no names were on any
information in the packets with a reminder on the instru-
mentsnottoputnamesonanyofthematerials.Therewasno
way to link student responses to an individual student. One
group of senior students (n = 28) enrolled in the course,
“Care of the Older Adult,” was exposed to the CBI as part
of the course content. The control group of students were
from volunteers of three groups of students from junior
and senior classes (n = 84). All information obtained was
anonymous; therefore, students were not informed of their
own scores. The course instructors were not present when
research packets were distributed. Researchers implemented
the CBI during class time with the experimental group of
senior students. Control group students completed research
instruments but did not receive the CBI.
Studentparticipationdidnotinfluenceanycoursegrades
as instructors did not know who completed research packets.
5.4.TheCreativeBondingIntervention(CBI). Tworesearcher
“interventionists” who were not involved in teaching any
didactic course content nor involved in student grading
presented a mini-CBI one-hour workshop to the senior
experimental students enrolled in the course, “Care of the
Older Adult.” Students enrolled in the course were required
to have 45 hours of clinical experience with older persons
living in the community. The interventionists also offered
additional time with interested students if students wanted
more instruction about any of the three CBI activities. The
CBI activities were (1) a monoprint, (2) a ribbon gem, and
(3) the self-image portrait. Interventionists suggested that
students might use their portrait to introduce themselves to
individuals or groups of older people when they first met,
following researchers’ suggestions from previous CBI studies
[15, 16] (see examples of photos of students completing
the self-image activities and examples of student self-image
portraits in Figures 1–3). If the older people were interested,
students would offer them the opportunity to create their
own self-portrait or create another CBI activity. A copy of
the CBI workbook was given to each of the experimental
students along with the needed art supplies to complete the

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Figure 1
Figure 2
three activities. The workbook that describes each activity
can be obtained from the third author.
6.Results
Participants were 90% women and 70% minority with a
median age of 25, including 14 in the intervention group
and 56 in the control group. At some point in their lives
half had worked or volunteered with older people and 44%
livedwitholderrelatives.Themajority(57%)interactedwith
older people at least several times per week.
Students in the control group were asked to identify their
age group preference (children, middle-aged, or older peo-
ple) to care for following graduation. Older people were the
first preference at the pretest for 18% of the respondents;
however,attheposttestonly9%oftherespondentspreferred
to take care of older people. In contrast, the proportion of
Figure 3
students that preferred the middle-aged remained constant
at 50% and the proportion that preferred children increased
from 33% to 41%. In the absence of the CBI, there was a
dramatic decrease in preference to take care of older people,
illustrating the problem the CBI was intended to address.
Although there were no statistically significant differ-
ences in baseline scores (see Table 1), the researchers used
gain scores to protect against the possible confounding influ-
ence of baseline differences A one-tail independent-samples
t-testwasconductedtoevaluatethehypothesisthatstudents’
positive attitudes toward older people would improve more
for the CBI group (M = 10.71, SD = 11.09) than the control
group (M = 3.79, SD = 11.74), t(68) = 1.99, P = .025. The
standardized difference in means (d = .57) indicated a
medium effect size. Students’ negative attitudes toward older
people improved more for the CBI group (M = −3.79, SD =
3.66) than the control group (M = −0.66, SD = 3.89), t(68)
= 2.72, P = .008. The standardized difference in means (d =
−.78) indicated a large effect size. On average, the CBI led
to important improvement in attitudes toward older people,
especially diminishing negative attitudes.
A one-tail independent samples t-test was conducted to
evaluate the hypothesis that students’ self-transcendence
would increase more for the CBI group (M =.64, SD = 5.7)
than the control group (M = .59, SD = 6.17), t(68) = .032,
P = .49. A one-tail independent samples t-test was con-
ducted to evaluate the hypothesis that students’ willingness
to take care of older people would increase more for the CBI
group (M = 1.36, SD = 2.29) than the control group (M =
.22, SD = 2.37), t(58) = 1.45, P = .08. The rejection of this
hypothesis was perhaps due to low power, .30. Low power
may be attributed to the small sample size, the unequal size
of the groups, and imprecision in the willingness measure
which was based on only one question. Although there was
a positive correlation between willingness to take care of

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Table 1: Pre-test scores between groups.
Experimental or
control
Control
Experimental
N
Mean Std. deviationStd. error mean
Willingness to care score
before intervention
56
27
6.41
6.41
2.940
2.500
.393
.481
Positive attitudes toward elderly
total score pre intervention
Control
Experimental
57
27
75.21
77.15
11.437
9.980
1.515
1.921
Negative attitudes toward elderly
total score before intervention
Control
Experimental
57
27
15.39
14.74
4.913
4.284
.651
.824
Attitudes toward elderly total
score before intervention
Control
Experimental
57
27
59.82
62.41
13.503
11.369
1.788
2.188
Self-transcendence total
score before intervention
Control
Experimental
57
27
50.12
49.04
5.587
4.895
.740
.942
older people and positive attitudes, r = .24, P = .03, the
increase in positive attitudes was not sufficient to generate a
significantincreaseinwillingness.Itisimportanttonotethat
willingness to take care of older people is uncorrelated with
negative attitudes, r = −.06, P = .33.
7.Discussion
Even though this was a pilot study, limitations should be
noted and corrected in future studies. First, the use of a con-
veniencesamplelimitedthegeneralizabilityoftheresultsand
introduced possible self-selection bias. Second, the glaring
differences in sample size between the control group and the
experimental group reduced the power of all the hypothesis
tests. To increase numbers within the CBI group, phase II
of the study is in progress implementing the CBI over two
semesters with several classes of senior students enrolled in
the “Care of the Older Adult” course. Better measurement of
willingness to take care of older people should be developed.
Finally, since differences in self-transcendence were not
found on Reed’s [14] STS, perhaps a different theoretical
framework would better explain the effects of the CBI. Reed
has acknowledged that self-transcendence changes may
occur only over long periods of time.
Regardless of the small size of the CBI group, this pilot
study provided evidence that the CBI improved students’
attitudes towards older people, with increases in positive
attitudes and even larger decreases in negative attitudes. Stu-
dents often expressed surprise that the CBI experience was
more enjoyable than they had expected. This experience
seems to be more effective in destroying negative stereotypes
than in building positive bonds. Perhaps positive bonding
requires a longer timeframe. Although not statistically sig-
nificant, there was evidence that the CBI promoted students’
willingness to take care of older people after graduation. In
the absence of the CBI there was a dramatic decrease in
preference to take care of older people after graduation, The
results suggest that interventions which promote positive
attitudes toward older people are more effective in increasing
willingness than interventions that disabuse students of the
negative stereotypes that may underlie negative attitudes.
Given the shortage of nurses in settings that serve older
persons such as skilled nursing facilities, the purpose of our
study was to facilitate students’ willingness to care for older
persons after graduation. The course, “Care of the Older
Adult,” was designed with a focus on well older persons. The
expectation was that the CBI group would rethink their
ideas about older persons if they had a positive “bonding”
experience with well older people. In a previous study [16],
when the CBI was implemented by students in a nursing
home setting, similar results were achieved with improved
attitudes towards older people.
In contrast to the previous literature [2, 7, 9] where there
was little or no attitude change in students, our study found
there were significant improvements in attitude in the CBI
group. In previous studies [2, 7, 9] willingness to care for
older people was not evaluated. Continued contact with
community-dwelling older people among nursing students
had a positive change in attitudes similar to the medical
students [10, 11] when they had multiple contacts with
community-dwelling well elders who served as mentors over
a year-long period.
8.Conclusions
From our study and previous studies, multiple interventions
with community-dwelling older people hold promise not
only to change students’ attitudes toward older people but
also to promote students’ commitment to care for an ever-
growing older population. Due to the small number of ex-
perimental students in our study and only one question
regardingwillingnesstotakecareofandpreferenceforcaring
for specific age groups following graduation, additional
questionsareneededinthesedomainstodiscovernewstrate-
gies to promote students’ interest in older people. In the
comparative study of four nursing schools [1], students in
the school that adopted major curricula changes did have
more positive attitudes, but students’ plans after graduation
were not reported.
Therefore, major curricula changes including creative
activities such as the CBI and longitudinal follow up with