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Factors influencing the intention of students to work with individuals with intellectual disabilities
Research in Developmental Disabilities 32 (2011) 2502–2510
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Research in Developmental Disabilities
Factors influencing the intention of students to work with individuals with intellectual disabilities Shirli Werner *, Alina Grayzman The Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Mount Scopus, Jerusalem, 91905, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 July 2011 Accepted 11 July 2011 Available online 3 August 2011
Providing adequate care to individuals with intellectual disability (ID) requires the willingness of students in various health and social professions to care for this population upon completion of their studies. The aim of the current study was to examine the factors associated with the intentions of students from various fields to work with individuals with ID, using the framework of the Theory of Planned Behavior. A structured selfadministered questionnaire was completed by 512 social work, occupational therapy, speech and language therapy, special education, and nursing students. The questionnaire measured students’ attitudes toward individuals with ID and toward working with this population, as well as their perceptions of subjective norms, controllability, self-efficacy, prior acquaintance with individuals with ID, and subjective knowledge about ID. Structural equation modeling showed that the students’ intentions to work with individuals with ID were predicted by their attitudes and perceptions of subjective norms. Field of study and subjective knowledge were also found to be predictive of behavioral intention. The TPB proved to be a useful framework for examining students’ intentions to work with persons with ID. Given the lack of education in the field of ID, as well as the prevailing stigmatic attitudes toward this population, university departments should develop programs aimed at increasing knowledge, promoting positive contact, and reducing the fear attached to working with persons with intellectual disability. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Intellectual disability Theory of Planned Behavior Behavioral intention Attitudes Knowledge
1. Introduction The ‘‘deinstitutionalization’’ movement has brought about a shift in the treatment and care for people with intellectual disability (ID), moving away from predominantly institutional care to less restrictive community-based approaches (Cleary, Friedman, Hunt, & Walter, 2006). This shift, along with the complex needs of individuals with ID in relation to cognitive difficulties, multiple medical conditions, and communication limitations (Taua & Farrow, 2009), have brought about the need for intensive, specialized, integrated, and long-term treatment (Davis, Barnhill, & Saeed, 2008) provided by trained professionals in various fields of specialization. In order to provide adequate care, a multidisciplinary approach is warranted, requiring the participation and willingness of professionals in all health and social care specialties to work with this population. The main aim of the current study was to identify the predictors of the intentions of students from various professions to work with individuals with ID, using the Theory of Planned Behavior (TPB) as a theoretical framework.
* Corresponding author. Tel.: +972 2 5881377; fax: +972 2 5883927. E-mail addresses: [email protected] (S. Werner), [email protected] (A. Grayzman). 0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2011.07.010
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1.1. The role of different professions in the care of individuals with ID Studies have pointed to the importance of several professional groups for the care of individuals with ID. Social workers, for example, function as primary care coordinators for these individuals (Claiborne & Vandenburgh, 2003) and their family members (Davis et al., 2008). Nurses are in charge of their activity management, nutrition, medication administration, physiological and psychological comfort, behavioral-cognitive therapy, communication and coping, and family-caregiver support (Sheerin, 2008). The role of occupational therapists lies in helping individuals to function in everyday life while providing them with the ability to perform Activities of Daily Living (Hallgren & Kottorp, 2005). The role of speech and communication disorder therapists is to improve the various aspects of communication in order to enable individuals with ID to affect the environment, make choices and state their needs (Sigafoos et al., 2000). Finally, special education professionals focus on training individuals to use self-care skills in functional daily living tasks, as well as providing reading and arithmetic instruction and assistance with transportation, recreation, and social skills (Kauffman & Hung, 2009). Researchers have shown that each of these professional groups makes its unique contribution, but it seems that some professionals have a clearer understanding of their role (Werner, 2011). For example, recent findings have suggested that students in more practical fields, such as special education, occupational therapy, and speech and language therapy, may have a clearer understanding of their role because their training includes direct and specific practical interventions with individuals with ID (Cascella, 2005; Hallgren & Kottorp, 2005; Kauffman & Hung, 2009; Sigafoos et al., 2000). For other professionals, their role in working with individuals with ID might be more obscured. For example, nurses and social workers may be trained in a holistic, all-inclusive approach (Rosen & Zlotnik, 2001) without clear guidelines as to their role in working with this specific population. 1.2. The intention to work with individuals with ID and its predictors Although the socialization and training of each and all of these professionals is important to the treatment and quality of life of individuals with ID, it is known that recruiting professionals to work with this population can be difficult. Studies have found that working with this population is not the first occupational choice of newcomers to the health and social professions (Crowe & Mackenzie, 2002; Krumer-Nevo & Weiss, 2006; Limb & Organista, 2006; Stevens & Dulhunty, 1997; Werner, 2011) owing to the difficulties involved in caring for people with ID (Fang et al., 2009). Nursing students were found to hold the least positive opinion toward this population relative to medical students and other health care profession students (Tervo, Palmer, & Redinius, 2004). Another study found that a higher proportion of occupational therapy students, as compared with physiotherapy students, chose to work with people with disabilities (Stachura & Garven, 2007). Studies have also tried to map the factors that influence the occupational choices of students. Fieldwork experience and knowledge have been identified as important factors that can influence students’ preferences for their future area of practice. Studies in occupational therapy (Crowe & Mackenzie, 2002), social work (Russo-Gleicher, 2008), and nursing (Matziou, Galanis, Tsoumakas, Gymnopoulou, & Brokalaki, 2009) suggest that the desire to work with individuals with ID may be increased by an enhanced focus on both the fieldwork and the coursework in this area, as well as by carefully designed curricula. Personal attitudes and perceptions play another important role in the reluctance of professionals to work with individuals with ID. For example, the reluctance of social work students to work with individuals with ID has been attributed to their perceptions that this group lacks potential for change (Jack & Mosley, 1997), that psychotherapy is inappropriate for these individuals, and that indirect practice is technical and professionally unchallenging (Aviram & Katan, 1991). Despite the importance of all these findings, no study has yet examined, within a theoretically-driven empirical framework, the specific factors that are related to the intentions of students from various professional groups to work with individuals with ID following the completion of their studies. 1.3. The Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) was developed by Ajzen (1991) to account for the process by which individuals decide on a particular course of action (Ajzen, 1985). This theory asserts that the best predictor of behavior is the intention to perform the behavior. Behavioral intention is influenced by three factors: (1) personal attitudes toward the behavior, which are the individuals’ beliefs about the outcomes of the target behavior (McKinlay & Cowan, 2003); (2) subjective norms, which are the beliefs held by the individual about significant others’ attitudes toward the behavior (McKinlay & Cowan, 2003); and (3) perceived behavioral control, which refers to the perceived ease or difficulty of performing the behavior. It has been suggested that perceived behavioral control should be split into two constructs: controllability and self-efficacy. Self-efficacy refers to the confidence that one feels about performing a particular behavior (Bandura, 1986), and controllability refers to the beliefs about the extent to which performing the behavior is up to the actor (Ajzen, 2002). According to the TPB, external factors, such as demographic characteristics, knowledge, and previous experience, have no direct effect on intention, but may influence the direct antecedents of intention. Thus, based on the TPB and the above literature, it was hypothesized that intentions to work with individuals with ID would be higher among individuals with more positive attitudes, more positive subjective norms, and stronger perceived
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behavioral control. Furthermore, it was assumed that individuals who have more positive attitudes toward, prior acquaintance with and greater knowledge about individuals with ID would have a higher intention to work with this group. Finally, it was assumed that intentions to work with individuals with ID would be relatively low across students from all professional groups and lowest for students in the nursing and social work professions. 2. Materials and methods 2.1. Participants Students from 17 school programs participated in the study (4 social work programs, 4 special education programs, 4 occupational therapy programs, 3 nursing programs, and 2 speech therapy programs). These fields of study were selected to represent those fields in which professionals are most likely to have a role in the care of individuals with DD. Within these school programs, 667 students were available during class time. Of the available students, 512 completed the questionnaire, representing a 76.8% response rate. Thirty-four participants (6.6%) were removed from the statistical analyses because they did not complete the data on all TPB constructs. Thus, the present analysis is based on data collected from 478 students. The main participants’ background characteristics are shown in Table 1. As can be seen, the majority of participants were female and the mean age was 25.6 (SD = 3.9). 2.2. Procedure Information about the aim of the study was sent to the heads of all relevant university and college programs in Israel. Arrangements were then made for a research assistant to administer the questionnaire in a mandatory class for students in the final year of their Bachelor’s degree program. In the class, the research assistant explained the study’s aims and procedures and the students were asked to complete the questionnaire within class time. 2.3. Ethical considerations The study’s protocol was approved by the Ethics Committee of the School of Social Work and Social Welfare at the Hebrew University. 2.4. Instruments The TPB questionnaire: Following the procedure described by Conner and Sparks (2005), a structured self-administered questionnaire was designed on the basis of the Theory of Planned Behavior in order to measure the variables of the TPB in relation to students’ intentions to work with individuals with ID.
Table 1 Participants’ background characteristics. Characteristic Mean age (SD) Gender (%) Female Male Place of birth (%) Israel Former Soviet Union Asia/Africa Europe/America Other Marital status (%) Single Married Divorced Widowed Professional study group Social work Occupational therapy Special education Nursing Speech therapy Prior acquaintance with individuals with ID No Yes
N = 478 25.6 (3.9) 422 (88.3) 56 (11.7) 415 40 3 16 1
(87.4) (8.4) (0.6) (3.4) (0.2)
339 132 6 1
(70.9) (27.6) (1.3) (0.2)
138 83 126 84 47
(28.9) (17.4) (26.4) (17.6) (9.8)
174 (36.4) 304 (63.6)
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Dependent variable: Behavioral intentions were measured using three items rated on a 7-point scale, ranging from 1 = definitely disagree to 7 = definitely agree. For example, ‘‘I intend to treat people with ID in my professional work as a social worker in the future, at least part of the time.’’ A composite index of the average of all items was created (Cronbach a = 0.94). Independent variables: Attitudes were measured using nine semantic differentials preceded by the sentence ‘‘If I were to work with individuals with ID, my work would be. . .’’ Each of the nine items was rated on a scale ranging from 1 to 7. After reversing three of the items, a composite index of the average of all items was created (Cronbach a = 0.73), with 1 representing a more negative attitude (e.g., harmful, boring) and 7 representing a more positive attitude (e.g., beneficial, challenging). Subjective norms were measured using three items rated on a 7-point scale, ranging from 1 = not true to 7 = true. For example, ‘‘Most people who are important to me think that I should treat people with ID.’’ A composite index of the average of the items was created after removing the second item (‘‘People who are important to me will support my decision to work with individuals with ID’’), which showed a low correlation with the other two items (Cronbach a = 0.83). Perceived behavioral control was assessed using two subscales: controllability and self-efficacy, with each composed of two items rated on a 7-point scale ranging from 1 = definitely disagree to 7 = definitely agree. For example, ‘‘For me, treating people with ID is an easy task.’’ A composite index of the average of the items was created for each aspect of perceived behavioral control, with controllability demonstrating a decent internal reliability (Cronbach a = 0.65) and self-efficacy a low internal reliability (Cronbach a = 0.44). Subjective knowledge in the field of intellectual disabilities was measured with one item asking the participants to rate their perceived level of knowledge on a scale from 1 to 5, with 5 representing a higher degree of perceived knowledge. Attitudes toward individuals with intellectual disability were measured using the Hebrew translation of Yuker’s Attitude Toward Disabled Persons Scale – ATDP (Yuker, Block, & Younng, 1966). Participants were asked to rate 20 items on a 6-point scale, ranging from 1 = do not agree at all to 6 = agree very much. The scale score was obtained by the mean of the 20 items after reverse coding of 17 items, with a higher mean representing more positive attitudes (Cronbach a = 0.82). Background characteristics included information on participants’ age, gender, and marital status, as well as their field of study. Additionally, respondents were asked to report if they had any prior acquaintance with individuals with ID. 2.5. Statistical analyses Descriptive statistics were used to describe the sample and the main variables. Pearson correlations between the main study variables were examined. Independent t-tests were utilized to examine differences in the behavioral intentions to treat individuals with ID according to different fields of study. Post-hoc analyses were conducted using the Scheffe test. T-tests were utilized for binary variables. Model testing was done using structural equation modeling (SEM) by means of the AMOS program. Fig. 1 provides a drawing of the theoretical model that was examined in the current study. This figure maps the relationship between the independent and the dependent variables in the study. Multiple indices of fit were used to assess the fit of the data to the model. An overall chi-square index was used to assess the degree of fit between the estimated and the observed matrices. Lower values indicate better fitting models. Additional model fit indices used included the normed goodness-of-fit (NFI), for which a value of .90 is the lowest acceptable value (Loehlin, 1998); the Tucker-Lewis Index (TLI), which is scaled from 0 (no fit) to 1 (perfect fit) (Schumacker & Lomax, 1996); and the root mean square error of approximation (RMSEA), for which a value equal to or less than .08 indicates a good fit of the model (Loehlin, 1998).
Attitudes External variables: - Gender - Field of study - Prior acquaintance - Subjective knowledge - Attitudes toward individuals with ID
+
Behavioral intention (treating people with intellectual disability)
Subjective norms
+
Perceived behavioral control: - Controllability - Self-efficacy
+
Fig. 1. Theoretical model of the relationship between attitudes, subjective norms, and perceived behavioral control and the intention to treat people with intellectual disability.
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Table 2 Means, standard deviations, and correlations of main study variables. Variables
Behavioral intention
Attitudes
Subjective norms
Behavioral intention Attitudes Subjective norms Controllability Self-efficacy Subjective knowledge Prioracquaintance ATDP
1.00
0.41*** 1.00
0.57*** 0.35*** 1.00
Controllability 0.07 0.06 0.01 1.00
Selfefficacy 0.29*** 0.31*** 0.36*** 0.02 1.00
Subjective knowledge 0.34*** 0.24*** 0.31*** 0.05 0.35*** 1.00
Prior acquaintance
ATDP
Mean
Standard deviation
0.18*** 0.14** 0.24*** 0.03 0.25*** 0.23*** 1.00
0.04 0.13** 0.09* 0.17*** 0.04 0.08 0.09* 1.00
4.10 4.90 3.96 5.61 3.36 2.56
1.74 0.97 1.36 1.41 1.14 0.96
4.18
0.62
*
p <. 05. ** p <. 01. *** p <. 001.
3. Results Table 2 shows the means and standard deviations of the main study variables as well as the Pearson correlation values between these constructs. As can be seen from the means, behavioral intentions, subjective norms and subjective knowledge were all around the midpoint of the scale, while controllability was rated more positively. Furthermore, with the exception of controllability and attitudes toward individuals with ID, all of the constructs in the extended TPB model were correlated with the intention to treat individuals with DD. The strongest positive correlation observed was with subjective norms, followed by attitudes and self-efficacy. Fig. 2 shows the differences in the main study variables between the students of the various professional groups. For these and the following analyses, the social work and the nursing students were grouped together and compared to the occupational therapy, the speech and language therapy, and the special education students because it was found that the main differences in the scores on all constructs were between these groups. As shown in Fig. 2, lower levels for all of the variables, with the exception of ATDP, were observed for the social work and the nursing students as compared to the other groups, though the differences were not statistically significant for controllability and self-efficacy. 3.1. Model testing The structural equation analysis model was run on all hypothesized paths except for age, given that 95% of the participants were in the age range of 21–31. Controllability was not used in the structural equation analysis, as it was not found to be associated with intention at the bi-variate level. The model showed a good fit of the data (x2/df = 3.00, p = .00; NFI = .917, CFI = .942, TLI = .921, RMSEA = .065) and explained 42% of the variance. As can be seen in Fig. 3, the strongest
Fig. 2. Difference in study variables between professional groups. Note: All variables range from 1 to 7 except for subjective knowledge, which ranges from 1 to 5.
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Fig. 3. Final structural model of the pathway for intention to work with individuals with intellectual disability.
predictors of intention were subjective norms, followed by attitudes. Self-efficacy did not show a direct impact on intention, but rather was related to attitudes and through them to intention. Subjective knowledge was found to have a statistically significant association with subjective norms and self-efficacy, as well as a direct, albeit weak, association with behavioral intention. Field of study was also found to be associated with attitudes and subjective norms, as well as directly with intentions, showing that the students from the fields of occupational therapy, speech and language therapy, and special education were more positive about working with individuals with ID than were the social work and the nursing students. Regarding the external variables, gender was found to have a direct impact on attitudes, with women showing more positive attitudes. Prior acquaintance with individuals with ID was associated with subjective norms and self-efficacy. Finally, attitudes toward individuals with ID were positively related to attitudes toward working with this group. However, these attitudes were not associated in a direct path to behavioral intention. 4. Discussion This study examined an extended TPB model to explore the determinants of the intentions of various groups of students to work with individuals with ID after the completion of their studies. Several interesting findings emerged from the data. First, it was found that despite the overall low level of intention reported by the participants, differences were found between
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the various professional groups. Across almost all of the TPB constructs, the nursing and the social work students reported the lowest scores as compared with the other professional groups. These findings suggest that, as hypothesized, students in more practical fields, such as special education, occupational therapy, and speech and language therapy, might hold a clearer understanding of their role with this population (Cascella, 2005; Hallgren & Kottorp, 2005; Kauffman & Hung, 2009; Sigafoos et al., 2000) than do nursing and social work students (Rosen & Zlotnik, 2001). It is interesting to note that while the social work students scored the highest on their attitudes toward individuals with ID, they nevertheless scored low on their attitudes toward and intentions of working with this population. These findings are surprising, as social workers are taught values of rights, dignity, individual uniqueness, self-determination, and client access to resources ((National Association of Social Workers, approved 1996 revised 2008). It might be that they feel the need to verbally express positive attitudes toward a population in need, even when they are not inclined to work with such individuals. The proposed model incorporating additional variables (subjective knowledge, attitudes toward individuals with ID, and prior acquaintance) with the standard TPB constructs (attitudes, subjective norms, controllability, and self-efficacy) provided a good fit for the data. Specifically, among the standard TPB constructs, subjective norms were found to be the strongest predictor of intentions to work with individuals with ID. This finding may be attributable to the fact that young students in the first stages of their professional socialization are more likely to be influenced in their decision-making process by the perceptions of other relevant persons or groups. The second strongest predictor of intention was the students’ own personal attitudes toward working with individuals with ID, suggesting that students who perceived working with such individuals as beneficial, challenging, enjoyable, and important also reported a higher intention to work with this population. These findings are in accordance with the assumptions of the TPB (Ajzen, 2002) and suggest that in order to increase future professionals’ willingness to work with persons with ID, there is a need to develop interventions aimed at changing students’ and others’ attitudes toward working with this group. The finding that the attitudes toward individuals with ID ranked higher than the attitudes toward working with this group may also be the effect of explicit versus implicit attitudes (Wilson, Lindsey, & Schooler, 2000). Implicit attitudes are considered to be stable evaluative representations, while explicit attitudes are more recently acquired and coexist with the presumptively stable implicit attitudes (Petty, Tormala, Brinol, & Jarvis, 2006). On an explicit level, people might feel the need to express positive attitudes, while on an implicit level they may not want to work with this population. In any case, interventions should focus not only on changing overall attitudes toward individuals with ID, but also on changing attitudes toward working with these individuals. A final alternative explanation for these results is that the lack of knowledge and the low feelings of self-efficacy related to individuals with ID bring about a low level of intention toward working with this population. If this is the case, then greater focus should be placed on providing knowledge and improving feelings of self-efficacy through education and field training experience. Contrary to the hypothesized TPB relationships, self-efficacy was not directly associated with intention, but its impact was mediated by the attitudes construct. This finding suggests that confidence is important in order to bring about more positive attitudes. Subjective knowledge and prior acquaintance were found to be strongly associated with self-efficacy, reinforcing previous findings that the lack of face-to-face experience with people with ID is likely to influence confidence in treating this population (Moyle, Iacono, & Liddell, 2010). These findings are especially worrisome in regard to the health and social professions, as it has been suggested that when the lack of experience and confidence are combined with a lack of knowledge, people with ID and their families are likely to be left with unmet health and emotional needs (Moyle et al., 2010). Moreover, professionals’ lack of confidence may negatively impact on individuals with ID and their families and lead to a distrust of practitioners (Baxter, Cummins, & Yiolitis, 2000). This assertion speaks to the need for immediate attention to increase the level of knowledge among medical professionals about persons with ID among practitioners in the health and social professions in an effort to raise their self-assurance in treating this group. It is also interesting to note that subjective knowledge and prior acquaintance were predictive of subjective norms. It is possible that students with a greater degree of knowledge, which may also be gained through their prior acquaintance, are able to influence their significant others by transferring important information to them as well as by reducing possible stigmatic feelings and fear held by their significant others. 4.1. Practical implications The findings of the present study call for the development of several avenues to increase future professionals’ willingness to work with persons with ID. Given that both the attitudes of the students themselves and those of significant others were found to be important factors, attitude change programs should be aimed at both the individual students as well as at society at large. Within the university setting, academic programs should refocus their curricula in such a way that will be conducive to promoting the intentions of students to work with individuals with ID. Such efforts should include the provision of mandatory classes and field experience with this population in order to reinforce positive attitudes, knowledge, and skills in the area. Furthermore, meetings between young professionals and professionals working in the field may be useful in bringing about positive attitude formation and result in increased interest and intention to work in this area. These encounters might raise the awareness that working with individuals with ID requires similar professional skills as those used with other populations (Russo-Gleicher, 2008). Besides implementing interventions at the student level, the results of our study stress
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the need to implement attitude change programs for the students’ significant others via effective educational approaches and positive contact opportunities (Seccombe, 2007). 4.2. Study limitations The results of the current study need to be interpreted in light of several limitations. First, the data employed were crosssectional. Consequently, conclusions regarding causality are tentative and should be treated with caution. Additionally, relationships with behavior were not examined. Future longitudinal studies should examine the relationships between intentions and actual behavior. Finally, the study sample consisted of a convenience sample, which may affect the generalizability of the findings. Despite these limitations, the current research suggests that the decision-making process of students in various professional groups to work with individuals with ID is influenced by a range of personal (attitudes, knowledge) and social (subjective norms) forces. Thus, future efforts targeted toward increasing the number of professionals willing to work with this population may benefit by adopting a TPB-based perspective that will guide the development of interventions focused on changing attitudes and increasing knowledge at both the university and societal levels.
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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Factors influencing the intention of students to work with individuals with intellectual disabilities Shirli Werner *, Alina Grayzman The Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Mount Scopus, Jerusalem, 91905, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 July 2011 Accepted 11 July 2011 Available online 3 August 2011
Providing adequate care to individuals with intellectual disability (ID) requires the willingness of students in various health and social professions to care for this population upon completion of their studies. The aim of the current study was to examine the factors associated with the intentions of students from various fields to work with individuals with ID, using the framework of the Theory of Planned Behavior. A structured selfadministered questionnaire was completed by 512 social work, occupational therapy, speech and language therapy, special education, and nursing students. The questionnaire measured students’ attitudes toward individuals with ID and toward working with this population, as well as their perceptions of subjective norms, controllability, self-efficacy, prior acquaintance with individuals with ID, and subjective knowledge about ID. Structural equation modeling showed that the students’ intentions to work with individuals with ID were predicted by their attitudes and perceptions of subjective norms. Field of study and subjective knowledge were also found to be predictive of behavioral intention. The TPB proved to be a useful framework for examining students’ intentions to work with persons with ID. Given the lack of education in the field of ID, as well as the prevailing stigmatic attitudes toward this population, university departments should develop programs aimed at increasing knowledge, promoting positive contact, and reducing the fear attached to working with persons with intellectual disability. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Intellectual disability Theory of Planned Behavior Behavioral intention Attitudes Knowledge
1. Introduction The ‘‘deinstitutionalization’’ movement has brought about a shift in the treatment and care for people with intellectual disability (ID), moving away from predominantly institutional care to less restrictive community-based approaches (Cleary, Friedman, Hunt, & Walter, 2006). This shift, along with the complex needs of individuals with ID in relation to cognitive difficulties, multiple medical conditions, and communication limitations (Taua & Farrow, 2009), have brought about the need for intensive, specialized, integrated, and long-term treatment (Davis, Barnhill, & Saeed, 2008) provided by trained professionals in various fields of specialization. In order to provide adequate care, a multidisciplinary approach is warranted, requiring the participation and willingness of professionals in all health and social care specialties to work with this population. The main aim of the current study was to identify the predictors of the intentions of students from various professions to work with individuals with ID, using the Theory of Planned Behavior (TPB) as a theoretical framework.
* Corresponding author. Tel.: +972 2 5881377; fax: +972 2 5883927. E-mail addresses: [email protected] (S. Werner), [email protected] (A. Grayzman). 0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2011.07.010
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1.1. The role of different professions in the care of individuals with ID Studies have pointed to the importance of several professional groups for the care of individuals with ID. Social workers, for example, function as primary care coordinators for these individuals (Claiborne & Vandenburgh, 2003) and their family members (Davis et al., 2008). Nurses are in charge of their activity management, nutrition, medication administration, physiological and psychological comfort, behavioral-cognitive therapy, communication and coping, and family-caregiver support (Sheerin, 2008). The role of occupational therapists lies in helping individuals to function in everyday life while providing them with the ability to perform Activities of Daily Living (Hallgren & Kottorp, 2005). The role of speech and communication disorder therapists is to improve the various aspects of communication in order to enable individuals with ID to affect the environment, make choices and state their needs (Sigafoos et al., 2000). Finally, special education professionals focus on training individuals to use self-care skills in functional daily living tasks, as well as providing reading and arithmetic instruction and assistance with transportation, recreation, and social skills (Kauffman & Hung, 2009). Researchers have shown that each of these professional groups makes its unique contribution, but it seems that some professionals have a clearer understanding of their role (Werner, 2011). For example, recent findings have suggested that students in more practical fields, such as special education, occupational therapy, and speech and language therapy, may have a clearer understanding of their role because their training includes direct and specific practical interventions with individuals with ID (Cascella, 2005; Hallgren & Kottorp, 2005; Kauffman & Hung, 2009; Sigafoos et al., 2000). For other professionals, their role in working with individuals with ID might be more obscured. For example, nurses and social workers may be trained in a holistic, all-inclusive approach (Rosen & Zlotnik, 2001) without clear guidelines as to their role in working with this specific population. 1.2. The intention to work with individuals with ID and its predictors Although the socialization and training of each and all of these professionals is important to the treatment and quality of life of individuals with ID, it is known that recruiting professionals to work with this population can be difficult. Studies have found that working with this population is not the first occupational choice of newcomers to the health and social professions (Crowe & Mackenzie, 2002; Krumer-Nevo & Weiss, 2006; Limb & Organista, 2006; Stevens & Dulhunty, 1997; Werner, 2011) owing to the difficulties involved in caring for people with ID (Fang et al., 2009). Nursing students were found to hold the least positive opinion toward this population relative to medical students and other health care profession students (Tervo, Palmer, & Redinius, 2004). Another study found that a higher proportion of occupational therapy students, as compared with physiotherapy students, chose to work with people with disabilities (Stachura & Garven, 2007). Studies have also tried to map the factors that influence the occupational choices of students. Fieldwork experience and knowledge have been identified as important factors that can influence students’ preferences for their future area of practice. Studies in occupational therapy (Crowe & Mackenzie, 2002), social work (Russo-Gleicher, 2008), and nursing (Matziou, Galanis, Tsoumakas, Gymnopoulou, & Brokalaki, 2009) suggest that the desire to work with individuals with ID may be increased by an enhanced focus on both the fieldwork and the coursework in this area, as well as by carefully designed curricula. Personal attitudes and perceptions play another important role in the reluctance of professionals to work with individuals with ID. For example, the reluctance of social work students to work with individuals with ID has been attributed to their perceptions that this group lacks potential for change (Jack & Mosley, 1997), that psychotherapy is inappropriate for these individuals, and that indirect practice is technical and professionally unchallenging (Aviram & Katan, 1991). Despite the importance of all these findings, no study has yet examined, within a theoretically-driven empirical framework, the specific factors that are related to the intentions of students from various professional groups to work with individuals with ID following the completion of their studies. 1.3. The Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) was developed by Ajzen (1991) to account for the process by which individuals decide on a particular course of action (Ajzen, 1985). This theory asserts that the best predictor of behavior is the intention to perform the behavior. Behavioral intention is influenced by three factors: (1) personal attitudes toward the behavior, which are the individuals’ beliefs about the outcomes of the target behavior (McKinlay & Cowan, 2003); (2) subjective norms, which are the beliefs held by the individual about significant others’ attitudes toward the behavior (McKinlay & Cowan, 2003); and (3) perceived behavioral control, which refers to the perceived ease or difficulty of performing the behavior. It has been suggested that perceived behavioral control should be split into two constructs: controllability and self-efficacy. Self-efficacy refers to the confidence that one feels about performing a particular behavior (Bandura, 1986), and controllability refers to the beliefs about the extent to which performing the behavior is up to the actor (Ajzen, 2002). According to the TPB, external factors, such as demographic characteristics, knowledge, and previous experience, have no direct effect on intention, but may influence the direct antecedents of intention. Thus, based on the TPB and the above literature, it was hypothesized that intentions to work with individuals with ID would be higher among individuals with more positive attitudes, more positive subjective norms, and stronger perceived
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behavioral control. Furthermore, it was assumed that individuals who have more positive attitudes toward, prior acquaintance with and greater knowledge about individuals with ID would have a higher intention to work with this group. Finally, it was assumed that intentions to work with individuals with ID would be relatively low across students from all professional groups and lowest for students in the nursing and social work professions. 2. Materials and methods 2.1. Participants Students from 17 school programs participated in the study (4 social work programs, 4 special education programs, 4 occupational therapy programs, 3 nursing programs, and 2 speech therapy programs). These fields of study were selected to represent those fields in which professionals are most likely to have a role in the care of individuals with DD. Within these school programs, 667 students were available during class time. Of the available students, 512 completed the questionnaire, representing a 76.8% response rate. Thirty-four participants (6.6%) were removed from the statistical analyses because they did not complete the data on all TPB constructs. Thus, the present analysis is based on data collected from 478 students. The main participants’ background characteristics are shown in Table 1. As can be seen, the majority of participants were female and the mean age was 25.6 (SD = 3.9). 2.2. Procedure Information about the aim of the study was sent to the heads of all relevant university and college programs in Israel. Arrangements were then made for a research assistant to administer the questionnaire in a mandatory class for students in the final year of their Bachelor’s degree program. In the class, the research assistant explained the study’s aims and procedures and the students were asked to complete the questionnaire within class time. 2.3. Ethical considerations The study’s protocol was approved by the Ethics Committee of the School of Social Work and Social Welfare at the Hebrew University. 2.4. Instruments The TPB questionnaire: Following the procedure described by Conner and Sparks (2005), a structured self-administered questionnaire was designed on the basis of the Theory of Planned Behavior in order to measure the variables of the TPB in relation to students’ intentions to work with individuals with ID.
Table 1 Participants’ background characteristics. Characteristic Mean age (SD) Gender (%) Female Male Place of birth (%) Israel Former Soviet Union Asia/Africa Europe/America Other Marital status (%) Single Married Divorced Widowed Professional study group Social work Occupational therapy Special education Nursing Speech therapy Prior acquaintance with individuals with ID No Yes
N = 478 25.6 (3.9) 422 (88.3) 56 (11.7) 415 40 3 16 1
(87.4) (8.4) (0.6) (3.4) (0.2)
339 132 6 1
(70.9) (27.6) (1.3) (0.2)
138 83 126 84 47
(28.9) (17.4) (26.4) (17.6) (9.8)
174 (36.4) 304 (63.6)
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Dependent variable: Behavioral intentions were measured using three items rated on a 7-point scale, ranging from 1 = definitely disagree to 7 = definitely agree. For example, ‘‘I intend to treat people with ID in my professional work as a social worker in the future, at least part of the time.’’ A composite index of the average of all items was created (Cronbach a = 0.94). Independent variables: Attitudes were measured using nine semantic differentials preceded by the sentence ‘‘If I were to work with individuals with ID, my work would be. . .’’ Each of the nine items was rated on a scale ranging from 1 to 7. After reversing three of the items, a composite index of the average of all items was created (Cronbach a = 0.73), with 1 representing a more negative attitude (e.g., harmful, boring) and 7 representing a more positive attitude (e.g., beneficial, challenging). Subjective norms were measured using three items rated on a 7-point scale, ranging from 1 = not true to 7 = true. For example, ‘‘Most people who are important to me think that I should treat people with ID.’’ A composite index of the average of the items was created after removing the second item (‘‘People who are important to me will support my decision to work with individuals with ID’’), which showed a low correlation with the other two items (Cronbach a = 0.83). Perceived behavioral control was assessed using two subscales: controllability and self-efficacy, with each composed of two items rated on a 7-point scale ranging from 1 = definitely disagree to 7 = definitely agree. For example, ‘‘For me, treating people with ID is an easy task.’’ A composite index of the average of the items was created for each aspect of perceived behavioral control, with controllability demonstrating a decent internal reliability (Cronbach a = 0.65) and self-efficacy a low internal reliability (Cronbach a = 0.44). Subjective knowledge in the field of intellectual disabilities was measured with one item asking the participants to rate their perceived level of knowledge on a scale from 1 to 5, with 5 representing a higher degree of perceived knowledge. Attitudes toward individuals with intellectual disability were measured using the Hebrew translation of Yuker’s Attitude Toward Disabled Persons Scale – ATDP (Yuker, Block, & Younng, 1966). Participants were asked to rate 20 items on a 6-point scale, ranging from 1 = do not agree at all to 6 = agree very much. The scale score was obtained by the mean of the 20 items after reverse coding of 17 items, with a higher mean representing more positive attitudes (Cronbach a = 0.82). Background characteristics included information on participants’ age, gender, and marital status, as well as their field of study. Additionally, respondents were asked to report if they had any prior acquaintance with individuals with ID. 2.5. Statistical analyses Descriptive statistics were used to describe the sample and the main variables. Pearson correlations between the main study variables were examined. Independent t-tests were utilized to examine differences in the behavioral intentions to treat individuals with ID according to different fields of study. Post-hoc analyses were conducted using the Scheffe test. T-tests were utilized for binary variables. Model testing was done using structural equation modeling (SEM) by means of the AMOS program. Fig. 1 provides a drawing of the theoretical model that was examined in the current study. This figure maps the relationship between the independent and the dependent variables in the study. Multiple indices of fit were used to assess the fit of the data to the model. An overall chi-square index was used to assess the degree of fit between the estimated and the observed matrices. Lower values indicate better fitting models. Additional model fit indices used included the normed goodness-of-fit (NFI), for which a value of .90 is the lowest acceptable value (Loehlin, 1998); the Tucker-Lewis Index (TLI), which is scaled from 0 (no fit) to 1 (perfect fit) (Schumacker & Lomax, 1996); and the root mean square error of approximation (RMSEA), for which a value equal to or less than .08 indicates a good fit of the model (Loehlin, 1998).
Attitudes External variables: - Gender - Field of study - Prior acquaintance - Subjective knowledge - Attitudes toward individuals with ID
+
Behavioral intention (treating people with intellectual disability)
Subjective norms
+
Perceived behavioral control: - Controllability - Self-efficacy
+
Fig. 1. Theoretical model of the relationship between attitudes, subjective norms, and perceived behavioral control and the intention to treat people with intellectual disability.
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Table 2 Means, standard deviations, and correlations of main study variables. Variables
Behavioral intention
Attitudes
Subjective norms
Behavioral intention Attitudes Subjective norms Controllability Self-efficacy Subjective knowledge Prioracquaintance ATDP
1.00
0.41*** 1.00
0.57*** 0.35*** 1.00
Controllability 0.07 0.06 0.01 1.00
Selfefficacy 0.29*** 0.31*** 0.36*** 0.02 1.00
Subjective knowledge 0.34*** 0.24*** 0.31*** 0.05 0.35*** 1.00
Prior acquaintance
ATDP
Mean
Standard deviation
0.18*** 0.14** 0.24*** 0.03 0.25*** 0.23*** 1.00
0.04 0.13** 0.09* 0.17*** 0.04 0.08 0.09* 1.00
4.10 4.90 3.96 5.61 3.36 2.56
1.74 0.97 1.36 1.41 1.14 0.96
4.18
0.62
*
p <. 05. ** p <. 01. *** p <. 001.
3. Results Table 2 shows the means and standard deviations of the main study variables as well as the Pearson correlation values between these constructs. As can be seen from the means, behavioral intentions, subjective norms and subjective knowledge were all around the midpoint of the scale, while controllability was rated more positively. Furthermore, with the exception of controllability and attitudes toward individuals with ID, all of the constructs in the extended TPB model were correlated with the intention to treat individuals with DD. The strongest positive correlation observed was with subjective norms, followed by attitudes and self-efficacy. Fig. 2 shows the differences in the main study variables between the students of the various professional groups. For these and the following analyses, the social work and the nursing students were grouped together and compared to the occupational therapy, the speech and language therapy, and the special education students because it was found that the main differences in the scores on all constructs were between these groups. As shown in Fig. 2, lower levels for all of the variables, with the exception of ATDP, were observed for the social work and the nursing students as compared to the other groups, though the differences were not statistically significant for controllability and self-efficacy. 3.1. Model testing The structural equation analysis model was run on all hypothesized paths except for age, given that 95% of the participants were in the age range of 21–31. Controllability was not used in the structural equation analysis, as it was not found to be associated with intention at the bi-variate level. The model showed a good fit of the data (x2/df = 3.00, p = .00; NFI = .917, CFI = .942, TLI = .921, RMSEA = .065) and explained 42% of the variance. As can be seen in Fig. 3, the strongest
Fig. 2. Difference in study variables between professional groups. Note: All variables range from 1 to 7 except for subjective knowledge, which ranges from 1 to 5.
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Fig. 3. Final structural model of the pathway for intention to work with individuals with intellectual disability.
predictors of intention were subjective norms, followed by attitudes. Self-efficacy did not show a direct impact on intention, but rather was related to attitudes and through them to intention. Subjective knowledge was found to have a statistically significant association with subjective norms and self-efficacy, as well as a direct, albeit weak, association with behavioral intention. Field of study was also found to be associated with attitudes and subjective norms, as well as directly with intentions, showing that the students from the fields of occupational therapy, speech and language therapy, and special education were more positive about working with individuals with ID than were the social work and the nursing students. Regarding the external variables, gender was found to have a direct impact on attitudes, with women showing more positive attitudes. Prior acquaintance with individuals with ID was associated with subjective norms and self-efficacy. Finally, attitudes toward individuals with ID were positively related to attitudes toward working with this group. However, these attitudes were not associated in a direct path to behavioral intention. 4. Discussion This study examined an extended TPB model to explore the determinants of the intentions of various groups of students to work with individuals with ID after the completion of their studies. Several interesting findings emerged from the data. First, it was found that despite the overall low level of intention reported by the participants, differences were found between
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the various professional groups. Across almost all of the TPB constructs, the nursing and the social work students reported the lowest scores as compared with the other professional groups. These findings suggest that, as hypothesized, students in more practical fields, such as special education, occupational therapy, and speech and language therapy, might hold a clearer understanding of their role with this population (Cascella, 2005; Hallgren & Kottorp, 2005; Kauffman & Hung, 2009; Sigafoos et al., 2000) than do nursing and social work students (Rosen & Zlotnik, 2001). It is interesting to note that while the social work students scored the highest on their attitudes toward individuals with ID, they nevertheless scored low on their attitudes toward and intentions of working with this population. These findings are surprising, as social workers are taught values of rights, dignity, individual uniqueness, self-determination, and client access to resources ((National Association of Social Workers, approved 1996 revised 2008). It might be that they feel the need to verbally express positive attitudes toward a population in need, even when they are not inclined to work with such individuals. The proposed model incorporating additional variables (subjective knowledge, attitudes toward individuals with ID, and prior acquaintance) with the standard TPB constructs (attitudes, subjective norms, controllability, and self-efficacy) provided a good fit for the data. Specifically, among the standard TPB constructs, subjective norms were found to be the strongest predictor of intentions to work with individuals with ID. This finding may be attributable to the fact that young students in the first stages of their professional socialization are more likely to be influenced in their decision-making process by the perceptions of other relevant persons or groups. The second strongest predictor of intention was the students’ own personal attitudes toward working with individuals with ID, suggesting that students who perceived working with such individuals as beneficial, challenging, enjoyable, and important also reported a higher intention to work with this population. These findings are in accordance with the assumptions of the TPB (Ajzen, 2002) and suggest that in order to increase future professionals’ willingness to work with persons with ID, there is a need to develop interventions aimed at changing students’ and others’ attitudes toward working with this group. The finding that the attitudes toward individuals with ID ranked higher than the attitudes toward working with this group may also be the effect of explicit versus implicit attitudes (Wilson, Lindsey, & Schooler, 2000). Implicit attitudes are considered to be stable evaluative representations, while explicit attitudes are more recently acquired and coexist with the presumptively stable implicit attitudes (Petty, Tormala, Brinol, & Jarvis, 2006). On an explicit level, people might feel the need to express positive attitudes, while on an implicit level they may not want to work with this population. In any case, interventions should focus not only on changing overall attitudes toward individuals with ID, but also on changing attitudes toward working with these individuals. A final alternative explanation for these results is that the lack of knowledge and the low feelings of self-efficacy related to individuals with ID bring about a low level of intention toward working with this population. If this is the case, then greater focus should be placed on providing knowledge and improving feelings of self-efficacy through education and field training experience. Contrary to the hypothesized TPB relationships, self-efficacy was not directly associated with intention, but its impact was mediated by the attitudes construct. This finding suggests that confidence is important in order to bring about more positive attitudes. Subjective knowledge and prior acquaintance were found to be strongly associated with self-efficacy, reinforcing previous findings that the lack of face-to-face experience with people with ID is likely to influence confidence in treating this population (Moyle, Iacono, & Liddell, 2010). These findings are especially worrisome in regard to the health and social professions, as it has been suggested that when the lack of experience and confidence are combined with a lack of knowledge, people with ID and their families are likely to be left with unmet health and emotional needs (Moyle et al., 2010). Moreover, professionals’ lack of confidence may negatively impact on individuals with ID and their families and lead to a distrust of practitioners (Baxter, Cummins, & Yiolitis, 2000). This assertion speaks to the need for immediate attention to increase the level of knowledge among medical professionals about persons with ID among practitioners in the health and social professions in an effort to raise their self-assurance in treating this group. It is also interesting to note that subjective knowledge and prior acquaintance were predictive of subjective norms. It is possible that students with a greater degree of knowledge, which may also be gained through their prior acquaintance, are able to influence their significant others by transferring important information to them as well as by reducing possible stigmatic feelings and fear held by their significant others. 4.1. Practical implications The findings of the present study call for the development of several avenues to increase future professionals’ willingness to work with persons with ID. Given that both the attitudes of the students themselves and those of significant others were found to be important factors, attitude change programs should be aimed at both the individual students as well as at society at large. Within the university setting, academic programs should refocus their curricula in such a way that will be conducive to promoting the intentions of students to work with individuals with ID. Such efforts should include the provision of mandatory classes and field experience with this population in order to reinforce positive attitudes, knowledge, and skills in the area. Furthermore, meetings between young professionals and professionals working in the field may be useful in bringing about positive attitude formation and result in increased interest and intention to work in this area. These encounters might raise the awareness that working with individuals with ID requires similar professional skills as those used with other populations (Russo-Gleicher, 2008). Besides implementing interventions at the student level, the results of our study stress
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the need to implement attitude change programs for the students’ significant others via effective educational approaches and positive contact opportunities (Seccombe, 2007). 4.2. Study limitations The results of the current study need to be interpreted in light of several limitations. First, the data employed were crosssectional. Consequently, conclusions regarding causality are tentative and should be treated with caution. Additionally, relationships with behavior were not examined. Future longitudinal studies should examine the relationships between intentions and actual behavior. Finally, the study sample consisted of a convenience sample, which may affect the generalizability of the findings. Despite these limitations, the current research suggests that the decision-making process of students in various professional groups to work with individuals with ID is influenced by a range of personal (attitudes, knowledge) and social (subjective norms) forces. Thus, future efforts targeted toward increasing the number of professionals willing to work with this population may benefit by adopting a TPB-based perspective that will guide the development of interventions focused on changing attitudes and increasing knowledge at both the university and societal levels.
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