Self Determination in the Elderly

Self-Determination in the Elderly 1

Nursing Students’ Perceptions of
Self-Determination in Elderly People

Maritta Valimaki, Helena Haapsaari, Jouko Katajisto and Ritta Suhonen

Research and Design Professor Pollack April 10, 2007

Nursing Students’ Perceptions of Self-Determination in Elderly People:
A Critique

ABSTRACT

Self-Determination in the Elderly 2
This research study shows different nursing students’ perceptions of variables that affect elderly patients’ self-determination before and after a clinical studies program. The researchers found that the studies program does in fact have an influence on the students’ perceptions.

TOPIC CONTENT
This article was published on March 15, 2008 in the Journal of Nursing Ethics. The topic discussed is whether Nursing Student’s perceptions of the Elderly would change after being given an Ethics course. The article falls within the bounds of the journal as this is a publication centering on Nursing Ethics, which is clearly the subject of the periodical itself. No masthead description is attached to the article.
STYLE
The manuscript does conform to APA style in its major aspects. Each page of the journal does contain a page header; however it alternates with the author’s name and the title of the publication. All information is cited correctly using footnotes. The structural differences in which the paper deviates from APA style is the lack of a Title Page, and variation in formatting. Instead of the four major sections being shown as Title Page, Abstract, Main Body and References, the paper is organized as a Research study in the format of Introduction, Background, Aims, research questions and hypothesis, Method, Analysis, Results, Discussion, Conclusion, and References.
INTRODUCTION
The beginning of this article concisely describes in two paragraphs the nature of the study. The introduction serves its purpose by highlighting the importance of patients’ self- determination as a crucial value to grasp in nursing. The first paragraph identifies the ever growing need of nurses who understand this value due to the boom in older patients. In the second paragraph, the author points out the problem which is the basis for the research study: that although the need for care is increasing, a less than favorable perception of working with these older patients exists with many nursing students, and practitioners. The writers further bring to light the need for action by defining this as an ethical problem. To solve the problem and conclude the introduction, the writers bring in this idea of a study geared to indentify the impact of ethics education on the topic of nursing students’ negative attitudes towards gerontology.

An explicit hypothesis is stated in the Method section 1. It reads “In this study, we set a hypothesis that the content in nursing studies would have a positive effect on nursing students’ perceptions of self determination in elderly patients in long term care settings.”
The origin of this hypothesis has not been made explicit however has been linked to research evidence during previous studies on the same topic. For example “studies have also demonstrated that gerontological content can have a
Self-determination in the elderly 3 positive effect on student nurses’ attitudes towards older patients.” The hypothesis was correctly derived from the theory cited.
METHOD
The method is so described that a replication is not possible without further information. The setting is given as “the nursing ethics course offered at the nursing college during the time of data collection.” The exact location of the school or the name of the course is not given. If this information is granted however, it is likely that the study would be replicable. The instrument used was a modified self-administered questionnaire that the new researchers would once again have to take into consideration when replicating the experiment. The researchers found this study to be accurate and they themselves will be replicating the study to “investigate further any changes that can be identified in student nurses’ conception of the self determination in older people in Finland”.
The subjects were not sampled randomly from the population to which the results will be generalized. The sample has three inclusion criteria; being a student nurse, having undertaken theoretical studies in geriatric nursing, and undergoing a period of clinical training in geriatric nursing.
Informed consent was obtained by participants of this research study. The respondents were “informed about the voluntary and confidential nature of the data gathering and analysis”. The probable biases in sampling that exist are that the sample content is highly skewed because 90% of the 120 subjects used were women. The controls used for experimenter influence and expectancy effects were that the questionnaire was administered to the participant anonymously, they filled it out on their own, information sessions were organized for the students by the researcher and students were given oral and written information about the study. In addition, pilot testing did not show any reason to revise the questionnaire.
Special variables affecting the subjects that were not part of the experimenter manipulation were participant variables such as age, ethnic background, gender, and experience in the nursing field. According to studies, “ nurses who have previous experience working with older adults have been shown to be very positive about their work and limited experience, young age, and being male were factors for showing less favorable feelings towards elderly people.
The control groups were appropriate. The subjects in the pretest group served as the control group. They were given the questionnaire, before taking the ethics seminar to see what their raw attitudes elderly patients and self-determination were. Then the variable of the ethics seminar was introduced and the effect of the independent variable- the seminar, on the dependent variable-the attitudes of the students, was measured. Three different studies were organized. Using the first study as an example, the following is how validity and reliability were established. This study was the nursing students’ perceptions of elderly patients’ willingness to
Self-determination in the elderly 4 exercise their self determination. Utilizing Cronbach’s alpha, which is an internal consistency measure or reliability, the researchers calculated the correlation of willingness to exercise their self-determination with the following other variables: receiving information on their own care, to be asked for their permission for nursing interventions, to exercise their right of refusal during care, and to make decisions about their own care. The overall alpha value in the pre-test of the extent to which elderly patients are willing to exercise self determination was 0.63 at pre-test and 0.77 at post-test, with an increase of 0.14. 11. This shows a reliable level of internal consistency, and that the ethics seminar increased this reliability level.
To measure construct validity we must consider the adequacy of the operational definition of variables. The study has face validity. It is measuring what it is supposed to measure; the perceptions nursing students have towards the elderly self-determination level.
The research shows a predictive validity that is stronger as far as nursing student’s knowledge on the self-determination of their elderly patients. The study revealed that after the seminar more students thought that elderly patients had good opportunities to control their treatment, limited willingness to exercise their self-determination, and more of a perception on whether the elderly had any insight into their own medical treatment. The numerical values are not explicitly stated but the study does say “our results confirm earlier findings related to positive attitudes towards elderly patients” 13 (356)
The measures are free from biases regarding how the questionnaire was set up, every person given the questionnaire had the opportunity to ask a researcher if there was something they did not understand. As far as correlations with general responsivity, the students were not given any knowledge as to what trends the researchers were looking for, and the chosen subjects were not a random sample, so as already stated some of the findings could be affected by the narrow population used.
Interrater reliability is not used. Blind administration is not used. Foreign-language translations were not used. Correlation designs were not used.
REPRESENTATIVE DESIGN
When the stimulus is human, in clinical judgments of clients of differing race, sex, etc. there is not a good sample of stimuli. The only information provided about the sample is that the participants were 90% female. Technically, one could say there is a sample, but 90% female is clearly skewed heavily. The researchers did not state their race.
The statistics were used with appropriate assumptions fulfilled by the data. In all three research tables the researcher used a perception scale with intervals defined as to a great extent, to some extent, don’t know, to a limited
Self-determination in the elderly 5 extent, and not at all. The researcher used Pearson’s Chi squared, degrees of freedom, P-value, mean, Standard deviation, a two sample t-test, and P-values for all three studies as well.
The P-value is the probability of obtaining by chance alone, results at least extreme as those obtained equivalently. In other words, the P-value is the probability of getting an extreme result by pure chance. The P-values are quite low on all the five variables compared in Tables 1,2, and 3 which suggest little common variance. The exception is Table 1 when asking about the nursing students’ perceptions on the elderly’s consent to nursing interventions when the P-value is .56. The second exception is when asking about the nursing students’ perceptions about whether the elderly can make decisions about their own treatment. Perhaps this measure was so strong because of the strong emotional evocation related to this particular variable s that skewed the nursing student’s responses.
The mean is the average of all the responses, which out of 120 students on the pretest came out to 4.22 with a standard deviation of .52 which means that the range of the mean that 98% of the entire scores wall within is from 3.7 to 4.74.
Statistical significance levels have been followed by an analysis of practical significance levels. The practical analysis is in the Results section of the research study. The data analysis shows that the students in both pre and post test agreed that self-determination is an important value for elderly patients. No difference was located for mean values.
The elderly patients’ knowledge level results were very different after pre and post tests. Of the students questioned before the seminar experience 28.3% of them didn’t know whether the elderly had information regarding the medications they were taking. Afterwards only 6.1% said they were unsure, so the clinical experience helped the students answer this question for them. Interestingly, as said before this result does not show up in the statistics. 14
Finally in 6 of the 15 categories surveyed, the students changed their perceptions. Afterwards more students tended to agree that they support the elderlys’ self-determination, with more positive perceptions in the statistics as well.
FACTOR ANALYTIC STATISTICS
The proportion of yes and no responses for each variable are divided into categories on a scale from Very Important to Not At All. One example of this breakdown is the Extent to which elderly patients can control their treatment through the information they receive, Pre-test: To a great extent-2.5%, to some extent-22.5%, don’t Know-30.8%, to a limited extent-42.5%, Not at all-1.7%.
The sample size is given both for the pre-test and post test as 120, and 115. This is more than an appropriate size, with twenty to thirty being sufficient (text). The five less is due to people dropping out for one reason or another.
Self-determination in the elderly 6
FIGURES AND TABLES
The figures and tables are self-explanatory and necessary. There are only three tables each of which list one variable, and its correlation to five different variables. In total there are fifteen different relationships being assessed. The first chart in Table 1 compares the Importance of self-determination despite possible cognitive failure to receiving information about own treatment, their consent to nursing interventions is asked, they can exercise their right of refusal in care, they can express their own opinions about their treatment, they can make decisions about their own treatment. The second and third charts are arranged similarly. All of the variables are measured by different instruments which show their validity and reliability. The information in the Tables also corresponds with the information in the text, with the exception of the difference in knowledge level.
DISCUSSION AND CONCLUSION The discussion concludes that the study found nursing students to have positive views of older people’s self-determination, before their clinical training period. It then also contradicts this claim by saying that opposing results have been documented, but does not say by who. Still the evidence shows that in 6 of the 15 areas, the perceptions of the students did change. The discussion however seems wishy-washy by including the contradictory evidence, and then further weakening its’ argument by saying these findings are localized to only this particular Finnish institution.
Some findings in the discussion do strengthen the hypothesis such as the evidence that particularly regarding the student’s perceptions about patients’ self-determination on their ability to have a say in their treatment, and to talk about what kind of support they received from nurses to help them exercise their self-determination, became more positive after clinical experience.
The discussion goes on to state that the data is from the 1990’s and many structural changes have been made to the clinical system since then, and that the researchers still stress that ethical seminars are a way to influence nursing student’s perceptions.
The author has accepted the null hypothesis with some conditions, and the limitations of generalization are clear which stress that the ethical seminar only changed perceptions in some areas, and that the curriculum could still use much work in order to have a widespread effect.
The conclusion of this study showed that the students had positive views of elderly peoples’ self determination, and the attitudes stayed positive after clinical training In addition, different variables considered in the study as they relate to the elderly and self-determination and the nursing students’ perceptions are: importance, control, willingness, knowledge and support on certain aspects.

REFERENCES

1. Valimaki, Maritta, Haapsaari Helena, Katajisto, Jouko and Suhonen, Riitta Nursing Students’ Perceptions of Self-Determination on Elderly People (Nu