Abstract
“Given the plight of persons with psychiatric disorders and the problems of staff recruitment and retention in psychiatric occupational therapy, we need to explore innovations in occupational therapy curricula that will enhance student attitudes toward persons with psychiatric and other disabilities” (Lyons & Hayes, 1993 p. 547). This aim is particularly important for mental health occupational therapy education in the United States, because only 2.4% of occupational therapists and 1.4% of occupational therapy assistants reported that their primary work setting was a mental health setting (American Occupational Therapy Association [AOTA], 2015).
Despite the small number of occupational therapy practitioners working in mental health settings, key official documents from AOTA and the Accreditation Council for Occupational Therapy Education® (ACOTE®) highlight the importance of psychosocial factors in influencing engagement in occupation (ACOTE, 2011; AOTA, 2010a, 2010b, 2014). With the likelihood that few students will have Level II fieldwork opportunities in traditional mental health care settings, one challenge for academic programs is ensuring students’ entry-level competence in mental health skills and knowledge. Moreover, current fieldwork placements often do not provide opportunities for students to develop practice skills such as self-reflection, ethical reasoning, and compassionate care. As McAllister, Tower, and Walker (2007) noted, citing Ironside (2004), “in the time-constrained, complex, specialized field of clinical practice . . . there may be a tendency to emphasize the technical skills and overlook the humanities and ethic of care. Technical skill acquisition serves the interests of health service efficiency and management, but it may not always serve the interests of a caring community” (p. 305).
Student skills indicative of sensitivity to the “interests of a caring community” (McAllister et al., 2007, p. 305) include increased critical self-reflection; the ability to describe new understanding regarding self, service users, and the value of the service being provided; increased interpersonal communication abilities and professional behaviors; changes in assumptions about members of the population receiving services and their families; and increased professional activity in response to specific interactions with service users (Edmonds-Cady & Sosulski, 2012; Gelman, 2012; Mallory, 2003; Rush, 2008). This skill growth directly addresses two ACOTE (2011) accreditation standards for occupational therapy education programs at all levels:
B.2.9: The student will be able to express support for the quality of life, well-being, and occupation of the individual, group, or population to promote physical and mental health and prevention of injury and disease considering context (e.g., cultural, personal, temporal, virtual) and environment.
B.2.6: Analyze the effects of heritable diseases, genetic conditions, disability, trauma, and injury to the physical and mental health and occupational performance of the individual.
Given these standards, it is essential for educators to identify pedagogical methods that maximize learning and personal growth in these skills.
Evidence across domains of allied health practice literature indicates that students who experience planned learning activities about disability awareness may be more likely to adopt caring practices and attitudes (Gelman, 2012; Gitlow & Flecky, 2005; Knecht-Sabres, 2013; Lyons & Hayes, 1993; Mallory, 2003; McAllister et al., 2007; Rush, 2008). Experts in higher education worldwide recommend that activities to enhance students’ caring and positive attitudes should be intentionally incorporated into curricula for diverse disciplines, for a variety of reasons, including increased economic advantages to society and advocacy for people with disabilities (Chan, Lee, Yuen, & Chan, 2002; Gelman, 2012; Mallory, 2003; McAllister et al., 2007; Moroz et al., 2010; Rush, 2008; Stachura & Garven, 2007).
No studies to date have described the attitudes of occupational therapy students toward people with intellectual disabilities (IDs). Moreover, studies of occupational therapy student attitudes toward people with disabilities either have been qualitative in nature, not used standard assessment measures, not used comparison groups, not provided means for assessing the relative merit of different instructional methods, relied on one-factor measures, or been survey-based exclusively or not measured intervention-oriented change over time (i.e., Chan et al., 2002; Gitlow & Flecky, 2005; Knecht-Sabres, 2013; Lyons & Hayes, 1993; Stachura & Garven, 2007).
This study was designed to examine the effect of a Level I fieldwork program on student attitudes toward people with IDs and to answer two research questions: (1) Do health professional students’ perceptions of people with IDs change after listening to a lecture on disability awareness? and (2) Do occupational therapy students’ perceptions of people with IDs change after participation in fieldwork with this population? Understanding educational approaches that improve attitudes of students toward people with disabilities is essential because bias can interfere with maximizing positive outcomes through treatment (Chan et al., 2002).
Method
This study used a nonrandomized, pretest–posttest design that included in sequence a pretest, Intervention 1 (a traditional lecture), Posttest 1 (following Intervention 1), Intervention 2 (an experiential fieldwork), and Posttest 2 (following Intervention 2 for the groups who completed the fieldwork activity). Age, major, year of study, gender, ethnicity, highest level of education achieved, marital status, household income, the lecture, and the fieldwork experience were the independent variables. Attitude toward people with IDs was the dependent variable. Institutional review board approval was obtained before study inception.
Participants
The purposive sample for this study was recruited from 62 first- and second-year occupational therapy students and 40 public health students at American International College, Springfield, MA. First-year occupational therapy students (n = 32) did not have any fieldwork or coursework specifically related to disability awareness before this study. Second-year occupational therapy students (n = 30) participated in this study’s lecture and fieldwork for the first time in the summer after the first-year students completed it. Although these second-year students had been exposed to the concept of disability awareness and had encountered children with IDs during fieldwork in other courses, this study was their first time receiving a lecture on this topic and engaging in more than a daylong fieldwork activity with adults with IDs. The study’s public health students (n = 6) were in the first year of their program and did not have any fieldwork as a component of their coursework. Table 1 presents participant characteristics.
Participant Characteristics by Program Type and Year
Note. OT 1 = first-year occupational therapy student group; OT 2 = second-year occupational therapy student group; PH = first-year public health student group.
Intervention
Intervention 1 was a recorded lecture on disability awareness delivered online by means of a link on Blackboard (Perkins, 2014). Although the focus of the lecture was not specific to people with IDs, it was selected because of its focus on the social model of disability and its significance for people with IDs and because the speaker is a recognized expert in mental health education. Students listened to the 117-min lecture during class and were asked to complete the posttest immediately after the lecture.
Intervention 2 was the fieldwork experience, which was included as a component of a 3-credit course in the Master of Science in Occupational Therapy curriculum, Foundations of Occupational Therapy. Because the public health students received only Intervention 1 and were not involved in Intervention 2, they were not retested after Posttest 1.
Local public health initiatives were reviewed to explore options to create a meaningful fieldwork experience. In the aftermath of a damaging tornado in 2011, Springfield, MA, followed a redevelopment plan that recommended promoting citizens’ healthy living by enhancing neighborhood recreation opportunities (Springfield Redevelopment Authority, 2012). Studies of exercise programs for adults with IDs have indicated that members of this marginalized population could benefit from increased access to fitness facilities (Bazzano et al., 2009; Chapman, Craven, & Chadwick, 2005, 2008; Ewing, McDermott, Thomas-Koger, Whitner, & Pierce, 2004; Marshall, McConkey, & Moore, 2003; Melville et al., 2011; Saunders et al., 2011).
On the basis of this research, and in collaboration with a local day program for adults with IDs and developmental disabilities, the fieldwork program was developed. Four groups of 15 or 16 students participated in, and reflected on, a group activity program that took place in the college gymnasium for 1 hr/wk for 5 wk. Fifteen to 25 adults with significant IDs and developmental disabilities, supervised by the fieldwork instructor, participated in the program. Activities were structured for participants’ ability level and included walking around the perimeter of the gym to music, shooting basketballs, and kicking soccer balls. During activities, students were encouraged to interact with program attendees, model active behaviors for them, and practice professional communications skills by talking to day program staff.
Instrument
The Attitudes Toward Intellectual Disabilities (ATTID) questionnaire (Morin, Crocker, Beaulieu-Bergeron, & Caron, 2013) was used in this study to capture the multidimensional nature of peoples’ attitudes toward people with IDs. The questionnaire consists of 67 items on a Likert scale ranging from 1 (completely agree) to 5 (completely disagree). It is divided into three components: cognitive, affective, and behavioral. The cognitive component consists of two factors: knowledge of capacity and rights and knowledge of causes. The affective component also consists of two factors: discomfort as well as sensitivity and compassion. The behavioral component consists of one factor: interactions. The ATTID questionnaire was found to have excellent content validity, adequate construct validity, and excellent reliability, with a Cronbach’s α of .92 for the overall questionnaire (Morin et al., 2013). Table 2 presents sample ATTID questionnaire test items grouped by factor.
Sample of Test Items by Factor for Attitudes Toward Intellectual Disabilities Questionnaire
Note. ID = intellectual disability.
Procedures
After receiving approval from the institutional review board, faculty from the public health and occupational therapy programs explained the purpose of the study to the participants, distributed the consent forms, and answered questions. Participants were given an identification number known only to them on their hard copy of the informed consent that allowed them to access the ATTID questionnaire online. Participants completed the questionnaire first during the first week of the semester (pretest), a second time after listening to the recorded lecture on disability awareness (Posttest 1), and a third time (occupational therapy students only) after the conclusion of fieldwork (Posttest 2). Demographic data (i.e., gender, age, ethnicity or race, family income, work status, the frequency and context of contact with people with IDs, and whether they or a family member or a friend had a disability) were collected when participants first completed the questionnaire.
The following steps were taken to reduce experimenter bias: Student participants were anonymous, no grade was attached to student participation in any step of the study process, participant consent forms were presented and collected by faculty not involved in the study, the recorded lecture was by a scholar who was not affiliated with the college where the study took place, and fieldwork supervision was limited to participant safety. Students were instructed to spend time reflecting on their experience, but there was no guided class discussion during or after fieldwork sessions.
Analysis
Data were analyzed using IBM SPSS Statistics (Version 21; IBM Corp., Armonk, NY). Data were organized by the three components of attitude (cognitive, emotion, and behavior) and the five factors within these three components (knowledge of capacity and rights, knowledge of causes, discomfort, sensitivity and compassion, and interactions). Analyses of variances were run to evaluate differences in the five factors between the three time points (pretest, Posttest 1, and Posttest 2). Age, major, year of study, gender, ethnicity, highest level of education achieved, marital status, and household income were used as within-subjects variables.
Results
There were 68 total participants at the start of this study. Each study group had different characteristics, including numbers of participants, average ages, gender representation, ethnic makeup, and marital status. Family income was reported by participants to range from less than $20,000/yr to more than $100,000/yr. There were 32 participants in the first-year occupational therapy group (OT 1). Their average age was 23, with 9% of the sample identifying as males, 34% as non-White, and 12.5% as married. There were 30 participants in the second-year occupational therapy group (OT 2). Their average age was 24, with 33% of the sample identifying as males, 43% as non-White, and 13.3% as married. There were 6 participants in the public health group (PH). Their average age was 20, with 16.7% of the sample identifying as males, 50% as non-White, and 16.7% as married.
After Intervention 1, the dropout rate was 4%, with 31 participants remaining in OT 1, 29 in OT 2, and 5 in PH. After Intervention 2, which involved only OT 1 and 2, the dropout rate was 8%, with 30 participants in OT 1 and 25 participants in OT 2 completing Posttest 2. For reasons that are unclear, some of the participants chose not to answer a variety of questions on Posttest 2, thus their responses were dropped from the final factor analyses, which accounts for the differences in samples.
Gender, ethnicity, and household income were found to have no significant effect on the magnitude of change in attitudes within any of the groups studied, regardless of the intervention. From pretest to Posttest 1, no significant differences were found in change of attitude between OT 1, OT 2, and PH regarding factors of discomfort, knowledge of rights and capacities, knowledge of causes, and sensitivity and compassion. However, for the interactions factor, regardless of class year and program type, students who answered yes to the question “Are the people with ID you know neighbors?” (n = 15) were more likely to express less positivity on this component from pretest to Posttest 1 than those who answered no (n = 50; F = 4.69, p < .05). After the occupational therapy students completed the fieldwork, between-groups analyses revealed significant attitude changes on each of the five factors for selected participant variables (Table 3). Because many analyses were conducted for each variable, Table 3 presents a condensed version of the study results highlighting significant changes.
Comparison of Significant Attitude Changes and Participant Variables Within Factors
Note. df = degrees of freedom; ID = intellectual disability; OT = occupational therapy.
p < .05.
For sensitivity and compassion, the younger the students, the more compassionate they became from pretest to Posttest 2, F = 4.16, p < .05. For knowledge of causes, students who answered “very often” (n = 3), “sometimes” (n = 28), or “often” (n = 4) to the question “How often have you had contact or interactions during your lifetime with people with ID” became significantly more positive from pretest to Posttest 2 than the student who answered “never,” n = 1; F = 3.13, p < .05. One subgroup, those who answered yes to knowing people with IDs through school (n = 2), demonstrated a more negative change in attitude. As for knowledge of rights and capacities, these two students were more likely to express a negative attitude regarding knowledge of causes after fieldwork than students who answered “no” to the same question. n = 32; F = 31.02, p < .05.
From Posttest 1 to Posttest 2, for discomfort, regardless of program year, occupational therapy students who had volunteer work experience with people with IDs were more likely to be significantly more comfortable with people with ID compared with all other occupational therapy students, F = 4.32, p < .05. For knowledge of rights and capacities, after fieldwork, OT 2 demonstrated a significantly greater improvement in this factor compared with OT 1, F = 5.05, p < .05.
One subgroup within the combined OT 1 and 2 demonstrated a negative change in attitude on this factor. Students who answered yes to the question “Are the people with ID you know students in your child’s day care or school?” (n = 2) were more likely to express a negative attitude after fieldwork than students who answered no to the same question, n = 33, F = 4.15, p < .05. This trend was reversed, however, between the lecture and the end of fieldwork; for interactions, students who answered yes (n = 13) demonstrated significantly more positive changes compared with students who answered no, n = 39, F = 4.91, p < .05. Additionally, students who answered yes to the question “Are the people with ID you know people for whom you do work?” (n = 30) were significantly more positive after fieldwork than students who answered no, n = 22, F = 6.81, p < .05.
Discussion
Results of this study indicate that although the traditional educational approach (lecture) did not yield meaningful differences in changing attitudes of students in two different years and two different types of programs, fieldwork significantly improved components of attitudes in each of the five factors measured on the ATTID questionnaire across several participant variables in occupational therapy students. These findings support the results of investigations yielding positive changes in attitudes toward people with disabilities as a result of implementing curriculum activities for this purpose (Chan et al., 2002; Gelman, 2012; Mallory, 2003; McAllister et al., 2007; Moroz et al., 2010; Rush, 2008; Stachura & Garven, 2007). The younger the students were when they experienced fieldwork, the more likely they were to become significantly more compassionate by its conclusion. Students who had volunteer or work experiences with people with IDs were more likely than those who did not to demonstrate more positive attitudes on knowledge of rights and capacities, and they professed greater comfort in interactions with this population after fieldwork. Greater quantities of interactions were also correlated to improvements in knowledge of causes after fieldwork. Thus, familiarity may be the single greatest factor in improving attitudes toward people with IDs.
The finding that gender, ethnicity, and household income were not significant variables in how participants responded to this intervention suggests that fieldwork of this nature may have a positive impact on students regardless of their culture of origin, sexual orientation, or socioeconomic status. This result therefore may be generalizable for a variety of program types.
This study had limitations. Small sample sizes and participant dropout for Posttest 2 resulted in decreased power for analyzing differences and limited generalizability. Despite participant dropout, there were significant differences in the sample that remained. This study explored only the relationship between fieldwork and attitude toward people with IDs at one college in the Northeast. Currently, it is not possible to determine whether positive attitude changes generated through fieldwork would be retained through ensuing fieldwork or after participants begin practicing.
Future studies should determine whether improvements in student attitudes demonstrated after this fieldwork can be replicated. Educational interventions for students who demonstrate negative changes in attitude after fieldwork need to be identified. Changes to student attitudes through subsequent fieldwork need to be identified.
There is insufficient evidence at this time to conclude that any one approach is the most effective to maximize student attitudes toward people with IDs. What is known, however, is doing nothing almost guarantees that students will maintain less positive attitudes toward people with disabilities, and this outlook represents a risk factor for poor quality interventions and outcomes for people with disabilities who receive treatment. Given the complexity of promoting safe, effective, client-centered, sustainable health outcomes for people with disabilities, health professional educators must continue to develop opportunities and adopt practices that maximize student learning.
Implications for Occupational Therapy Education
The results of this study have the following implications for occupational therapy education:
Fieldwork may be more effective than lecture in yielding meaningful improvements in student attitudes toward people with IDs.
Student attitudes toward people with IDs improved with increased experience with this population, suggesting that fieldwork with members from this population should be offered early in educational programs and be followed by subsequent experiences as students progress through their education.
Footnotes
Acknowledgments
We thank the faculty of the Temple University Occupational Therapy Doctoral Program and Cathy Dow-Royer for their role in bringing this study to fruition; Yu-Bo Wang for his assistance in analyzing its results; and all study participants, without whom this study would not have been possible.