The Great Plains Sociologist - South Dakota State University

The Great Plains Sociologist

The Official Journal of the Great Plains Sociological Association Volume 23, 2013

Great Plains Sociologist Editors Daphne E. Pedersen, University of North Dakota Laura Colmenero-Chilberg, Black Hills State University The Great Plains Sociological Association publishes the Great Plains Sociologist (GPS) as a general sociological journal. We endeavor to publish articles of general interest to sociologists in the region and beyond. The organization primarily seeks to serve sociologists from the Great Plains; however, that does not limit material published in the journal by author or subject. The following guidelines are offered to authors who wish to submit work to the GPS for publication. 1. Topics should be of interest to a wide audience of sociologists. This should not be read as implying that a majority must agree with the findings or discussions. Popularity of findings plays absolutely no role in the decision to publish. The decision to publish is based on quality of work. 2. Manuscripts should be in the range of 15 to 25 journal pages, including tables, charts, etc. 3. GPS will consider many types of manuscripts for publication. We publish traditional research articles that empirically test hypotheses derived from social theory, thought pieces explicating ideas or investigating specific topics, and articles that focus on teaching techniques or experiences to mention but a few. 4. Articles submitted for review should be saved as Word documents and emailed to the editor. Upon acceptance, full contact information for each contributing author, including a brief biographical sketch, must be submitted. Contact information for submission of articles: Daphne E. Pedersen [email protected] (701) 777-4247 5. Manuscripts submitted for publication are emailed to the journal editor and then sent to at least two reviewers for comment and recommendation. The journal editor also reads submissions and has responsibility for the final decision to publish or not. The editor and reviewers may request that a manuscript be rejected, or rewritten and resubmitted. 6. To preserve anonymity, please attach a cover page to the manuscript that contains authorship, address, and institutional affiliation. The next page should contain the title of the article only. The authorship page will be removed and retained by the editor to assure anonymity. Please omit author citations in the reference page and text. 7. Manuscript format should follow American Sociological Review (ASA) standards, including intext and bibliographic references.

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About the Authors Roxanne Gerbrandt,

PhD, is an assistant professor of sociology at Austin Peay State University. Her wide range of teaching and research interests include social inequalities, sexualities, political economy, critical pedagogy, and sociology of education.

Preston Gilmore

is a recent graduate with a B.S. in Sociology from Austin Peay State University. He is an anti-war and education rights activist studying political economy and pedagogy. He plans on pursuing his PhD in Sociology next fall.

Gina Aalgaard Kelly,

PhD, is an Assistant Professor of Sociology in the Department of Sociology and Anthropology at North Dakota State University. Dr. Aalgaard Kelly’s research and teaching interests are medical and aging sociology, and quantitative research methods.

Carolyn Townsend,

RN, DNP is an Associate Professor of Nursing at Bemidji State University, Minnesota. Dr. Townsend’s teaching and research interests include psychiatric nursing and mental health.

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Index of Articles Page Number

Title

Author(s)

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Hearing Social Structure: A Musical Exercise in Teaching Introduction to Sociology

Roxanne Gerbrandt Preston Gilmore

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Quality of Life in Nursing Homes: A Theoretical and Empirical Review

Gina Aalgaard Kelly

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A Comparative Approach to Promotional Methods for Seasonal Influenza Immunizations to Dorm Dwelling College Freshmen

Gina Aalgaard Kelly Carolyn Townsend

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Hearing Social Structure: A Musical Exercise in Teaching Introduction to Sociology Roxanne Gerbrandt ∗

Abstract

Preston Gilmore

This article details employing music as a pedagogical tool to enable introductory students to relate personal experiences to larger social structures such as class, race, and gender through a creative yet rigorous exercise. The authors review earlier uses of music in the classroom, and expand on that framework, adding a number of crucial elements. The exercise includes the selection of a song by students, then a review of the sociological frameworks influencing the song, culminating in a formal research paper to enhance critical thinking and a presentation where students educate their classmates. The exercise enables the popularity of music to act as biographical proxy for students, allowing them to broach sociological topics that might be personally relevant through the medium of the song. The authors utilize two different assessment measures of student learning and their employment in relation to the objectives. The article further discusses the assignment’s limitations and concludes by assessing the effectiveness of this exercise.

INTRODUCTION As many instructors who have taught an Introduction to Sociology course can attest, persuading students to abandon individual explanations for complex social phenomena so that they might better understand the complicated relations between social structures and lived experiences can be an arduous task. The individualistic interpretations offered by many introductory students veil structural constraints. It often does not occur to them that forces and

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Roxanne Gerbrandt, Department of Sociology, Austin Peay State University, P.O. Box 4566, Clarksville, TN 37044; e-mail: [email protected]

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social relations beyond their immediate control are influencing the content of their experiences and consciousness in ways that may not be readily apparent. In order to overcome this common problem, we introduce a lively but rigorous classroom exercise entitled Hearing Social Structure. We present our findings on students’ increased awareness of social structure from this term-long exercise used in two Introduction to Sociology courses. The assignment begins with students choosing a song that they feel speaks to them, then researching the social structures that might have impacted the views expressed in the song. Students are prompted to develop critical thinking skills through the writing of a formal research paper, and share their analysis with their peers in the form of a multimedia presentation. The intent of this exercise is to leverage the popularity of music by incorporating it in a learning environment, and employ that music to expand student’s personal understanding to a larger social structural context, particularly the basic sociological concepts of race, class and gender. In detailing this exercise we argue that the sociological imagination can be stimulated through a cooperative pedagogy (here defined as the inclusion of students sharing in the teaching role and exemplified by the peer-oriented presentations). This exercise encourages students to deconstruct individualized explanations of their everyday experiences, allowing them to discover relationships between biographies and social structures. These relationships are also placed within historical context through the use of music from differing eras, focused research, and taking on the role of teacher to elucidate sociological concepts for their peers. To evaluate the success of the exercise, we utilize two different measures of analysis. First, we employ a questionnaire to capture student responses at the end of the exercise. The questionnaire consists of two parts: a fixed-response section, designed to provide a 1 to 5 rating response on specific themes relevant to our goals, and an open-ended question section, enabling the authors to capture emergent themes and concepts that might otherwise be

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missed. Secondly, we evaluate students’ test scores as another measure of the exercise’s efficacy, and further judge the ability of this exercise to reach our stated purposes. USING MUSIC AS A LEARNING TOOL The merits of using music as a tool to teach sociology have been demonstrated by numerous researchers for decades. In one of the earliest published examples, Elterman (1983) chose six songs from the time period ranging from 1930 to the early 1960s to teach the topic of social class. After the publication of Elterman's article, other documented examples of music used as an instructional device to facilitate student learning in the sociology classroom appear. Walczak and Reuter (1994) commissioned popular music “song lyric packets” and had classes listen to musical selections from a discography. Homework assignments asked questions regarding song lyrics to be turned in at the next class meeting. The authors noted retrospectively that this technique could be improved by allowing students to choose the music (Walczak and Reuter 1994). Martinez (1994, 1995, and 1998) prescribed music as a pedagogical tool for teaching a variety of courses and demonstrated its success in enhancing class discussion and illustrating concepts and theories. Ahlkvist (1999) had students in introductory courses perform cultural analyses of heavy metal music from the late 1960s through the 1990s, including associated album images and artwork. Ahlkvist (2001) also used similar techniques to teach classical sociological theory in introductory courses with music from the 1970s including Yes, Pink Floyd, and Emerson Lake and Palmer (ELP). While this technique was successful, Ahlkvist (2001:481) commented that, “A more ambitious extension of the technique might include the use of popular music that emerged in the aftermath of progressive rock.” Albers and Bach (2003) utilized more contemporary rock music; however, their application involved playing relevant songs prior to the beginning of class as a way to humanize the instructors and to encourage critical thinking and participation.

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Muschert (2006) extended the use of music in the classroom by offering the opportunity for students to pick and analyze music that was more familiar to them. The effectiveness of this approach in advancing course goals was substantiated with student responses indicating that the technique was overwhelmingly well received and greatly enhanced rapport among students. Muschert (2006) applied the technique of using music to teach sociology in a senior level course on juvenile delinquency and thus was able to have each student present a song of their choosing at the start of each class throughout the semester. They were also asked to turn in a brief account that simply explained their musical selection (Muschert 2006). GOALS, DEVELOPMENT, AND DETAILS OF EXERCISE We started working on this project together, a professor and a senior sociology student, at a mid-sized university in the southern region of the United States. Class size for our Introduction to Sociology classes is normally 33 to 36 students. Our intent in developing this assignment was to construct an exercise for use in Introduction to Sociology classes that would unite the themes of the course throughout the semester and supplement traditional instruction, while allowing the students to exercise their creativity and maintain a high level of engagement in the class. As stated earlier, our main objective was focused on the area of improving student’s understanding of social structure and the basic social issues of race, class and gender. In particular, we were looking for an exercise that would enable students to bridge the gap between their own experiences and a more sociological approach to understanding the world. In short, our goal was to develop an exercise that would do more than entertain: our primary purpose was to create and implement an exercise that would cultivate the comprehension of social structure; the challenging core of developing the sociological imagination (Mills 1959).

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Another important objective of the assignment was to prompt students to increase the quality of communication between themselves and the instructor and with their peers. The instructor has made one-on-one time with students a pedagogical goal for more than a decade. However, mandating additional interaction between the instructor and students does not guarantee that the communication will improve. Likewise, requiring group interaction does not necessarily improve the quality of student-to-student communication. In searching for a solution to this goal, the authors have noticed that quality of communication seems to be closely tied to the elements of creativity and personal expression. In other words, we hypothesized that by allowing the students some say in the choices made for the exercise (such as choosing which song and sociological issues to explore), it would enhance the communication process as well. Increasing the quality of communication between students is also of particular importance in a university such as ours where our student body is racially diverse and enrolls a large number of non-traditional students. Discussions about inequalities, particularly race inequality, have occasionally triggered defensive posturing among some students, resulting in a nonproductive atmosphere. Rather than skirting these issues, we spent time deliberating how to help students from various backgrounds connect to different perspectives while minimizing reactive elements. In noticing that many students’ musical tastes seemed to cross racial barriers that were not ordinarily breached, and knowing that the sharing of music has the ability to nurture symbolic rapport (Ridgeway 1976), we developed the idea of using music as a biographical proxy, where students could share something of themselves with the rest of the class in a nonthreatening way. Student’s musical selections effectively stood-in for their personal experiences. This proxy effect became an important element of the exercise because as students shared a song that was meaningful but not necessarily directly experienced by the student, the risk of direct personal disclosure could be diffused.

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The third objective of this assignment was to develop and enhance the students’ critical thinking skills. As the level of input from media and other sources seems to expand exponentially, it becomes more important that, as instructors, we highlight and encourage critical thinking skills in our interactions with students. To this end, Mayer (1986:251) states that, “The key to developing critical thinking lies in creating conditions for participation rather than passivity, and in providing opportunities for emotional engagement with the materials.” Having music as a vehicle for that emotional engagement, and requiring students to “teach” their choice of song through a presentation and discussing how that song is linked to a larger social structural issue provided both elements necessary to further a critical thinking environment. 1

Instructional Elements The first step of the exercise required students to choose a song that symbolized a challenge, problem, or concern of everyday life. They were given both written and verbal instructions on how to find and analyze a song in which the song lyrics also held personal meaning. Students were encouraged to follow up on core lecture and reading material by considering songs that addressed a primary social issue such as race, class, and gender inequality. Students were allowed to use any song that they wished, providing that the song meant something to them on a personal level, so that they could if desired inject some of their own personal biographies. The instructor explained that the song choice made would ultimately lead to an in-class presentation intended to strengthen the comprehension of sociological issues

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For actual examples of the exercise instructions and associated analysis tools, refer to

Appendices A – C, where the assignment handout, post-assignment survey and grading rubric are reproduced in full.

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for the entire class. Students could work alone on this exercise but also had the option to work in pairs. The analysis of the song began the research process of the exercise. After choosing their song, students were directed to meet with the professor during the first five weeks of the term, presenting their song choice and explaining the social issue it represented to them. After brief instruction on how to conduct journal searches, they were encouraged to use academic sources, including their textbook, to research their focus topic. This is the point where personalized attention in the form of a scheduled face to face meeting was crucial. During the meeting more specific guidance could be provided, therefore increasing the likelihood that each student recognized their main topic before the research process began. Writing up their findings was another important element of the assignment. We included a requirement of a four to five page research paper, complete with citations and other hallmarks of formal research. For this paper, each student needed to summarize their topic and explain the links between their musical selection and the social structure or issue they were focused on. We believed that a formal written assignment would also aid in the development of the critical thinking that is necessary for the successful completion of this exercise. As Grauerholz (1999:310) notes, “Writing is one of the most important and useful pedagogical tools available to instructors to help students achieve a variety of goals central to sociological instruction, including critical thinking and the development of students' sociological imaginations.” Earlier incarnations of the assignment did not include the written research component and subsequently lacked the rigor that a fully developed research paper added. By including the research paper, the individual elements of the exercise complemented one another, producing a more complete learning experience for the students. Finally, it was essential that once the paper was completed, students were required to deliver the paper for

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final approval either via email or an additional face to face meeting before they were allowed to lead the class presentation. This gave the professor one more opportunity to offer guidance and encouragement, and verify that each presentation would be as factually accurate and instructive as possible. Students then reserved a 15 minute instructional period during the last three weeks of the term to play their song and teach their results to the rest of the class. On their reserved date, each student or pair of students played a selected song (and accompanying music video if applicable), presented the lyrics to the song on a separate printed sheet or on screen, and gave a presentation to the class on the concepts and issues explored in the paper. The presentations, using audio, video, and other presentation aides, were limited to approximately ten minutes each. Students were asked to prepare for an additional five minutes allocated for discussion and response to questions from the class. This schedule usually allowed at least three student presentations per 55 minute class period, which accommodated a 36 student class within a three week window when about half of the students’ research, writing, and presentations were done in pairs. The use of currently available presentation aides such as audio, the song’s video (typically available online), overhead slide presentations, and other aides enhanced the presentation process, allowing students to become quite sophisticated in their presentations. In summary, our intent was to design an assignment consisting of a live “teaching” presentation as well as a paper, with the objectives of challenging students to link their personal connection or biography to the larger social structures or issues, improve communication about those issues in the classroom between each other and the instructor, and enhance their critical thinking skills along the way.

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EVALUATING THE APPROACH In any learning exercise it is important to be able to gauge the efficacy of the outcomes, to ascertain whether the exercise is having the desired effect. We concur with Appling, Naumann, & Berk (2001) that the use of multiple sources in judging effectiveness (in this case the efficacy of a particular assignment within a class) is generally more accurate than a model using only a single source. By employing diverse measures of effectiveness, our goal was to minimize those biases inherent within each measure, while enhancing the accuracy of overall effectiveness measurement (Berk 2005). We employed two tools in assessing this exercise. The first measure was a student survey, used to gain insight into the students’ perspectives on the exercise and how it may have added to their understanding, comprehension and development of critical thinking. The second tool employed was an outcome measure of learning using examination scores, and the measurement of change that was evidenced by comparing student test results of comprehension-oriented questions both before and after the assignment was completed. The university’s Institutional Review Board granted us permission to solicit feedback from two sections of Introduction to Sociology at the end of the term during which this teaching exercise was implemented. The surveys were anonymous and voluntary and neither of the authors was present while the surveys were being administered. Student feedback was solicited through a two part evaluation, which included both a fixed response section and an open-ended questionnaire (see Appendix B for complete derivation). Students were asked to respond to questions regarding the effectiveness of the music project. In the first section, 34 students were registered and 24 responded to the survey. The second section had 36 students registered and 27 responded to the survey. The overall response rate for both sections was 72.9 percent.

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In choosing the assessment measures, student surveys can be one of most useful tools of measuring the effectiveness of a classroom exercise. There are benefits to measuring the effectiveness of an exercise versus measuring the instructor’s effectiveness. Evidence suggests that gender and race influences student evaluations of an instructor (Laube, Massoni, Sprague, and Ferber 2007). However, when evaluating a classroom assignment, that bias may be minimized by having the students evaluate the exercise using multiple measures (Clare and Aschbacher 2001). We were careful to craft the questions to provide some real measure of effectiveness of the assignment itself, rather than rating questions focused on teacher effectiveness. In designing our survey, our decision in combining a more quantitative student rating output with the more qualitatively focused open-ended questionnaire is a methodological approach to leverage the strengths of both types of student response. Biggs (1996) noted that these kinds of assessments evince a deeper student understanding, and also demonstrate student’s abilities to apply that understanding in a contextual way; precisely the kind of measure that would help us accurately assess our main objectives, particularly the advancement of critical thinking skills. Using a combination of fixed response scale-rating questions in conjunction with open-ended responses enabled a more detailed understanding of students’ responses and also helped to measure the assignment’s effectiveness in reaching our main objectives. The fixed response data was summarized by simply assigning an average score to each question, while the open ended questions required additional analysis. Taking the open-ended question results as a whole narrative, we utilized a simplified grounded theory technique (Gerbrandt 2007) where we coded for emergent themes within the students’ responses. Unlike the formal inductive methodology introduced by Glaser and Strauss (1967) we utilized only the

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mapping techniques to categorize the open-ended answers into themes. We detail the results of these surveys, followed by examination scores and teacher observations in the Findings and Reflections from Students section. Comparing the test scores between the mid-term and the final was the other measurement of student learning outcomes. While test scores are not a complete measure of student learning, they do provide a separate independent evaluation that adds an important dimension to the survey results. Theall and Franklin (2001) found high correlations between the ratings that students provide (similar to the ratings from the fixed-response portion of our student survey) and their test scores, making student testing outcomes a good assessment match to the previously discussed student survey. This measure was focused to assess two of our three main objectives: improvement in comprehension of social structures and issues, and development of student’s critical thinking skills. In order to develop this measure as an effective indicator of those objectives, the instructor crafted both mid-term and final examinations as a combination of knowledge-based questions and comprehension focused queries. The completion of the research papers and the music presentations given by the students occurred in between the timing of the two exams. The mid-term was scheduled about seven to eight weeks into the term. After the mid-term, the student presentations began, and continued until approximately one week prior to the final, at the end of the term. This timing of mid-term and final exams offered an opportunity to gauge the impact these presentations and their preparation had on student learning, since the presentations occurred in between the two assessments. The final exam was designed similarly to the mid-term exam, but assessed the latter half of the text and lectures. Each exam had a series of multiple choice, true/false, fill in the blank, and short answer essay questions. Each exam was created to reflect the same measure of cognitive challenge (Clare and Aschbacher 2001). In particular, test scores were

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examined not only for overall achievement, but also by separate assessment comparison of knowledge-based questions from the book and lectures; those questions that measured comprehension, and the ability of students to apply their critical thinking. To analyze this data, the instructor coded all the questions in both exams as either knowledge-based or structurally-oriented comprehension questions. Ten questions were part of the comprehension question group in each exam, with at least three fill in the blank or short answer essay questions included in that group. These questions were graded according to a rubric designed to focus on comprehension of the concepts, and ability of students to apply their understanding of social structures (see Appendix C). FINDINGS AND REFLECTIONS FROM STUDENTS

Ratings and Themes from the Survey As previously elucidated, one of the components of the survey included a series of fixedresponse questions. When asked to rate the effectiveness of the student teaching presentations at clarifying sociological concepts on a one to five scale (where one is least effective and five is most effective), a full 80 percent of students responded with very effective or most effective (fours and fives). Although students felt that the research paper portion of the exercise was not as effective as the presentation at clarifying sociological concepts, 69 percent still reported that this aspect of the project was very effective or most effective. Nevertheless, having a majority of students come to the realization that writing a paper was an effective means of enhancing their own education was significant. As one student recalled, “When writing the paper I learned how to relate sociological problems with how I feel but also based on fact instead of uneducated opinion.” Students were also asked to rate their conscious awareness of social structure before and after taking Introduction to Sociology on a similar one to five fixed response scale (where

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one is no awareness and five is highly aware). Altogether, 57 percent of students responded that they had no awareness or very little awareness of social structure before taking Introduction to Sociology. Conversely, fully 96 percent (49 of 51 respondents) indicated that they were very aware or highly aware of social structure after engaging in this exercise. Using the modified-grounded theory technique mentioned previously, we examined student responses to the open-ended questions from the second half of the survey, looking for emergent themes. The first theme was quite evident because of the number of students who mentioned it. Of the students sampled, 62 percent wrote that this exercise aided their comprehension of sociology. One student summarized the theme of many comments by saying, “It [the music presentation] was helpful because it allowed me to associate sociological issues with songs. This will make it easier to retain the knowledge beyond this course.” This was affirmed by another student who said, “The presentations of the other students greatly reinforced many concepts that we learned in class. The presentations linked sociological concepts with actual lives - which helps me to remember.” Many students reported that they became conscious of the social problems presented by their peers. In response to the survey question “Explain the impact (if any) the teaching presentations from the other students had on you,” one student replied that “This made me more aware of my peers concerns.” Another student responding to the same question remarked that, “It allowed me, for five to ten minutes, to walk in the shoes of my classmates, to know what issues are of concern to them.” In fact, several students mentioned that the project enabled them to relate course material beyond just their own lives to the lives and experiences of their classmates and thereby reevaluate previously held beliefs about themselves and others. As Browne and Freeman (2000:307) said, “Understanding the importance of multiple perspectives and of context is obligatory for critical thinking because it prevents premature

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commitment.” This effect was especially apparent and viable when detailing painful issues surrounding social inequalities. In a region such as ours, where discourse around racial inequality has been tacitly silenced, the following comment as a response to the survey question, “Is there anything else you would like to add,” was noteworthy: I believe after taking this class I am much more aware of racism. I didn’t believe I was racist but now it is clear to me that I am. It showed me I was raised to be racist, expected to be racist, and frowned upon by my closest piers [sic] if I wasn’t racist. Very good class! Presentations discussed important issues. Some comments clearly point towards the presentations having a personal proxy effect, enabling students to share and discuss deeply felt issues by allowing the artist and song choice to speak for them. This was especially evident in issues of race. As one student said, “You can’t talk about race around here without it getting personal, but in my song [presentation] it wasn’t me, it was this cool old school rapper.” As student presenters began the discussion and fielded questions immediately following the song, many seemed to feel more able to express their own personal experiences as they related to the social structure under discussion. Although there is typically reluctance among students in divulging any personal, deeply felt convictions about social issues, the students presenting exhibited very little of this reluctance when they allowed the song to initially ‘speak’ for them. The authors believe that the vehicle of music aides this personal proxy effect, and alleviates some of the normal reticence experienced by students. This proxy effect also appeared in issues of gender and class as well. For example, a pair of students presented the song, “If I Were a Boy,” by Beyoncé, which deals directly with gendered double standards. In response to the survey question, “Is there anything else you would like to add,” one of the students remarked, “I tried talking to guys about gender stuff I learned in this class, but it was always turned back to me, like there was something wrong with me. But when Beyoncé said it, well, they listened; what guy doesn’t pay attention to Beyoncé!”

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Overall, student responses affirmed that the exercise aided students in the process of demystifying the dominant social relations, a process that, as Gramsci (1971) pointed out, is crucial to an inclusive pedagogy. By allowing the students to use music as a biographical proxy, the presenters created a learning environment that allowed other students to more easily connect the personal to social structure, thereby using individual empathy as a bridge for students to reach a deeper, more direct connection with the issues being addressed.

Testing Student learning outcomes were also evidenced by the improvement in scores from midterm to final exam among the students.

As a measure of comparison, we calculated the

percentage of correct scores for both knowledge-based questions and structurally-oriented comprehension focused questions from raw test scores, but particular attention was given to the answers that required awareness of social structures before and after the music exercise. After analysis, we found that the results of the knowledge based questions actually decreased slightly (-1.1 percent) from the mid-term to the final exam. However, the assessment showed a marked increase of 10.13 percent on the results of the comprehension question responses. A comparison of their mid-term and final exam scores also showed an improvement in their ability to illustrate a clear and accurate understanding of social structure. For example, one of the midterm structurally-oriented questions asked students to “Compare and contrast social differentiation and social stratification.” The students (in aggregate, N= 64) scored 54.2 percent on the question, using the rubric previously mentioned. Conversely, one of the similar final exam questions was “Provide an example of past-in present discrimination,” where students scored an improved 68.8 percent on this question. On the final exam, the students were more able to provide concrete answers drawn from their own research papers and particularly from the other students’ presentations. The fact that many students used concrete examples from

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other students’ presentations in their final exam suggests not only an improvement in comprehension, but also a recognized advancement in their critical thinking skills. While we are not permitted to expose any individual student’s answer, the student’s use of sociologically focused language in answering this and other final exam questions pertaining to comprehension of social structures points toward an improvement in their understanding, as well as an improvement in the student’s critical thinking skills. While this increase does not identify the source of improvement, the student responses, particularly on the short essay answers on the final exam, demonstrate a heightened awareness of sociological structure, which is a primary focus of the music presentations.

Improved Communication The authors observed a noticeable change in communication between the instructor and students, as well as the improved communication between students, upon completion of this exercise. Before this assignment was implemented, the instructor witnessed very little voluntary discussion about race, class, or gender before, during, or after class. In contrast, after this assignment was implemented the willingness to breach these sometimes difficult topics and issues was noticeably improved. In essence, this assignment helped to pave a way for the students to discuss more structural and sensitive topics in ways that were both constructive and instructive. While not used as a measure of assessment, these observations further describe the improvement in interactions between students and between student and teacher after this exercise was completed. APPLICABILITY AND LIMITATIONS This was an ideal exercise for relatively small Introduction to Sociology classes. Even so, the time commitment required for the teaching presentations prevents this exercise from being directly executed in large classrooms. In order to reproduce this exercise, the feasible class size

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is recommended at forty students or less. However, modifications to this exercise in order to accommodate larger classes may be tenable. Large classrooms of students could, for example, be grouped into smaller heterogeneous sections. The research paper is another element that requires additional focus. We found that at least one face to face meeting between instructor and student to discuss song choice and the social issues involved, together with the review of the student research paper before presentation, required considerable time resources from the instructor. While guiding students through research is labor intensive, one possible way to alleviate some of the time investment for both students and the instructor would be to take the students to the library early in the semester and have a librarian explain how to use academic search engines. In earlier incarnations of this exercise, students were given the opportunity to present their findings without approving their research paper beforehand. This resulted in some students presenting personal favorites, and expounding on the song, rather than doing sociological analysis. We are convinced that the research portion of the project was vital for its overall success. As one student commented, “Just hearing it in lecture is one thing, but to have to go out and actually find the truth in the material for yourself really brings it into perspective.” Even with these safeguards in effect, however, we still had three students among the two classes cited who used the opportunity of an audience to espouse their ideological opinions. Instead of stopping the student in mid-presentation, this instructor waited until after the presentation to deconstruct the difference between ideology and science. We have to admit that these were scary moments, but these are the risks an instructor takes whenever an inclusive pedagogy is initiated. These moments however did become teaching opportunities because many students admitted during those discussions that they had not really thought about the difference before learning sociology.

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Additionally, there is a potential for problems at the end of the student presentations. If left unguided, we found that students would occasionally discuss their subject endlessly, and sometimes veer off topic. It is important that the professor maintain engagement during the class discussion to keep the class on topic and on schedule. While it was heartwarming to witness high levels of interactions between students, a call must be made at some point in the question and answer period to end the presentation. Finally, there is the occasional problem of paralyzing stage fright for some students. In each class, the instructor experienced at least one student who was virtually petrified at the thought of getting up in front of the class. Although these situations were rare, and certainly not encouraged, there are some students who would ultimately elect to fail the class, rather than present in front of their peers. These students were allowed to give their presentations directly to the instructor as a stepping stone to presentations with a wider audience. This possibility, as well as the others mentioned need to be anticipated, so that the instructor has a plan before they occur. CONCLUSION Our goal was to create an assignment that would inspire students to grasp a greater level of understanding of social structure, to increase both the level and quality of communication between the students and the instructor, and to advance and develop their critical thinking skills, particularly in relation to sensitive social issues. At the outset, we intuitively understood through our own lived experiences that music had the potential to inspire empathy and breach boundaries. This was also the case for students. Music is emotionally compelling in ways that no textbook or lecture from an instructor can approximate. The medium can be just as important as the message. When applied in the classroom in a way that

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incorporates scholarly texts with the knowledge and expertise of the instructor, the result is a dynamic introduction to sociology that substantively links everyday life to academic discourse. We were very satisfied with the overall outcomes of the project. Using music as a biographical proxy in an exercise such as Hearing Social Structure encourages students to momentarily suspend and reconsider their possible distrust and apprehension towards a sociological approach by allowing students to learn from not only the instructor, but one another as well. This effectuates an environment where students become producers of knowledge and, by design, legitimizes their experiences and researched ideas as sociologically valuable. This proxy effect of music allows students to self-disclose as much or as little as they feel comfortable. Regardless of how much biographical content each student chose to disclose, each became an active participant in the learning process. The assignment highlights the historical and structural context of their lives through music thus making it easier for them to make the pivotal connections between lived experiences and social structures that is the crux of a sociological imagination.

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REFERENCES Ahlkvist, Jarl A. 1999. “Music and Cultural Analysis in the Classroom: Introducing Sociology through Heavy Metal.” Teaching Sociology 27(2):126-144. Ahlkvist, Jarl A. 2001. “Sound and Vision: Using Progressive Rock to Teach Social Theory.”

Teaching Sociology 29(4):471-482. Albers, Benjamin D. and Rebecca Bach. 2003. “Rockin’ Soc: Using Popular Music to Introduce Sociological Concepts.” Teaching Sociology 31(2):237-245. Appling, S.E., P.L. Naumann, and Ronald A. Berk. 2001. “Using a Faculty Evaluation Triad to Achieve Evidence-Based Teaching.” Nursing and Health Care Perspectives 22:247-251. Berk, Ronald A. 2005. “Survey of 12 Strategies to Measure Teaching Effectiveness.”

International Journal of Teaching and Learning in Higher Education 17(1):48-62. Biggs, J. 1996. “Assessing Learning Quality: Reconciling Institutional, Staff, and Educational Demands.” Assessment and Evaluation in Higher Education 21:5-15. Browne, M. Neil and Kari Freeman. 2000. “Distinguishing Features of Critical Thinking Classrooms.” Teaching in Higher Education 5(3):301-309. Clare, Lindsay and Pamela R. Aschbacher. 2001. “Exploring the Technical Quality of Using Assignments and Student Work as Indicators of Classroom Practice.” Education

Assessment 7(1):39-59. Elterman, Howard. 1983. “Using Popular Music to Teach Sociology.” Teaching Sociology 11(4):529-538. Gerbrandt, Roxanne. 2007. “Exposing the Unmentionable Class Barriers in Graduate Education.” PhD dissertation, Department of Sociology, University of Oregon, Eugene, OR. Glaser, Barney G. and Anselm L. Strauss. 1967. The Discovery of Grounded Theory: Strategies

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for Qualitative Research. Chicago, IL: Aldine. Gramsci, Antonio. 1971. Selections from the Prison Notebooks. (Q. Hoare & G. Nowell Smith, Eds. and Trans.) New York: International. Grauerholz, Liz. 1999. “Creating and Teaching Writing-Intensive Courses.” Teaching Sociology 27(4): 310-323. Knowles, Beyoncé. 2008. “If I Were a Boy.” I Am… Sasha Fierce, Columbia Records. Laube, Heather, Kelley Massoni, Joey Sprague and Abby L. Ferber. 2007. “The Impact of Gender on the Evaluation of Teaching: What We Know and What We Can Do.” NWSA

Journal 19(3):87-104. Martinez, Theresa A. 1994. “Popular Music in the Classroom: Teaching Race, Class, and Gender with Popular Culture.” Teaching Sociology 22(3):260-265. Martinez, Theresa A. 1995. “Where Popular Culture Meets Deviant Behavior: Classroom Experiences with Music.” Teaching Sociology 23(4):413-418. Martinez, Theresa A. 1998. “Race and Popular Culture: Teaching African American Leadership Styles Through Popular Music.” Teaching Sociology 26(3):207-214. Mayer, Jan. 1986. “Teaching Critical Awareness in an Introductory Course.” Teaching Sociology 14(4):249-256. Mills, C. Wright. 1959. The Sociological Imagination. Oxford, UK: Oxford University Press. Muschert, Glenn W. 2006. “Pop Music in the Social Problems Classroom: Its Use to Illustrate Claims-making in a Juvenile Delinquency Course.” Sociological Imagination 42(1):7-16. Ridgeway, Cecilia L. 1976. “Affective Interaction as a Determinant of Musical Involvement.” The

Sociological Quarterly 17(3):414-428. Theall, M. and J.L. Franklin. 2001. “Looking for Bias in All the Wrong Places: A Search for Truth

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or a Witch Hunt in Student Ratings of Instruction?” Pp. 45-65 in Student Ratings of

Instruction: Issues for Improving Practice, edited by M. Theall and J.L. Franklin. (New Directions for Institutional Research 109). San Francisco: Jossey-Bass. Walczak, David and Monika Reuter. 1994. “Using Popular Music to Teach Sociology: An Evaluation by Students.” Teaching Sociology 22(3):266-269.

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APPENDIX A

Initial Written Instructions for Exercise

Hearing Social Structure: An Exercise of the Sociological Imagination Pick a song that you feel describes or encompasses a challenge, problem, or concern of your everyday life. The song does not need to be analyzed on a literal basis. The song you choose could be a metaphor for your topic. You have creative license to interpret the song. Analyze the song with your sociological imagination: that is, link the personal issue/topic to larger social structures within society.

Meeting: Meet with me during office hours, or we can set another time during the first five weeks of the term. Bring your song choice, song lyrics, and ideas about the direction you like to take your research.

Presentation: You will have ten minutes as the teacher for this subject. An additional five minutes will be allowed after your presentation for questions and answers with the class. A maximum of five minutes should be used to play the song. Use your time wisely, (I will be keeping time for you) and use the sociological data from your book alone or in combination with outside sources to explain your topic, and how your music relates that topic. As an option, you may want to present the lyrics of the music, either as an overhead (Smart Board) or in hard copy for the class. Note: Outside sources must be from reliable articles or books. Government statistics are also acceptable. Please see me first if you have any doubt about the merits of outside readings.

Paper: You will also be required to complete a 4-5 page essay where you will discuss and analyze these issues. Include a copy of the lyrics in your paper, but do not count the lyric page(s), cover sheet, or reference page(s) in your 4-5 pages. Some possible topics to consider might include (but are certainly not limited to) your experiences with day care, police

27

harassment, crime, racism, sexism, classism, unemployment, low wages, experiences of education, or safety. Your biggest challenge in this paper will be distinguishing between sociological fact and uneducated opinion (hint: the majority of the grade you will earn for this assignment hinges on your ability to do this effectively). Your paper MUST be turned in to me to review for accuracy before your presentation time. The sooner you can complete and turn in your paper, the more time you will have to make any changes. A final version of your paper MUST be turned in to me at the time of your presentation. Be sure to keep track of the date you are teaching with your presentation. Due to time constraints, it will not be possible to forget and then present at another time. It is also acceptable, in fact interesting, if the same song is chosen by more than one person. A different angle and data on the same topic can be very useful to us as we are learning about the issues of interest to you. The purpose here is not simply to describe your subjective experience but to ultimately link this experience to structural factors. However, this is your opportunity to allow your classmates to feel, through the music, the way you feel.

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APPENDIX B

Student Survey

1) What is your level of college education? Freshman Sophomore Junior Senior Other (describe)__________________ 2) On a scale from 1 to 5 below, where 1 is least effective and 5 is most effective, rate how effective you feel that the teaching presentation exercise was at clarifying sociological concepts for you. 3) On the scale of I to 5 below, where I is least effective and 5 is most effective, rate how effective you feel the research paper was at clarifying sociological concepts for you. 4) On a scale of 1 to 5 below, where 1 is no awareness and 5 is highly aware, how would you rate your conscious awareness of social structure before taking Introduction to Sociology? 5) On a scale of 1 to 5 below, where 1 is no awareness and 5 is highly aware, how would you rate your conscious awareness of social structure after taking Introduction to Sociology?

One half of a page was given for students to answer the following questions:

6) Did the teaching presentation, writing the paper, and listening to the other student’s presentations help you understand the sociological imagination? 7) Compare your conscious knowledge and awareness of social structure before taking Introduction to Sociology with your knowledge and awareness of social structure now.

29

8) Explain the impact (if any) the teaching presentations from the other students had on you. 9) What do you feel would make the exercises used in this class more effective at clarifying social structure and sparking a sociological imagination in future students? 10) Is there anything else you would like to add?

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APPENDIX C

Grading Rubric

Goal: To demonstrate an understanding of the link between biography, history and social structures. 4-Accomplished •

Knowledge of the subject is accurate throughout.

•

Demonstrates comprehension of the Sociological Imagination and illustrates with examples.

•

Demonstrates a deep understanding of theoretical frameworks in order to explain contemporary social phenomena.

•

Accurately describes social structures in depth and uses more than one strong example as a framework for analysis.

•

Integrates and applies basic sociological concepts.

3- Competent •

Shows clear comprehension of basic sociological concepts.

•

Knowledge of the subject is accurate throughout except in minor details.

•

Demonstrates comprehension of the Sociological Imagination, but uses weak examples.

•

Uses theoretical frameworks to explain contemporary social phenomena, but understanding of theory is weak.

•

Accurately describes social structure and using one strong example as a framework for analysis.

•

Applies basic sociological concepts.

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2-Developing •

Able to state basic sociological concepts.

•

Knowledge of the subject is generally accurate, though flawed.

•

Demonstrates understanding of the Sociological Imagination, but provides unrelated examples.

•

Uses theoretical frameworks to explain contemporary social phenomena, but makes weak connections.

•

Accurately describes social structure, but examples are weak.

•

Does not apply basic sociological concepts.

1-Beginning •

Lacks understanding of basic scientific concepts and principles.

•

Knowledge of the subject is generally inaccurate.

•

Does not demonstrate an understanding of the Sociological Imagination and provides no examples.

•

Does not use theoretical frameworks to explain contemporary social phenomena.

•

Uses uninformed opinions or uses irrelevant facts to explain a social phenomenon.

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Quality of Life in Nursing Homes: A Theoretical and Empirical Review Gina Aalgaard Kelly ∗

Abstract

Quality of life is a complex and multi-dimensional notion which individuals and their families try to attain. This paper provides an overview of quality of life literature guided by Lawton’s (1983: 351) “Four Sectors of the Good Life”.” This model of organization demonstrates a multidimensional conceptual view of quality of life in which theoretical and empirical domains were recognized in the literature. Parameters used to understand quality of life and how it is studied provide the framework of the review, specifically in the nursing home setting. Quality of life is of growing importance because people are living longer and population projections suggest an increase in elderly over the next few decades will steadily increase.

QUALITY OF LIFE: A MULTIDIMENSIONAL VIEW Quality of life is important to many individuals, families, professionals and health care researchers because of increased longevity and more Americans aging due to the baby boom generation and immigration. In the Midwest the aging population is increasing and projected to continue (NDcompass.org 2013) and nursing home utilization is higher than in many other areas of the United States (Markeson 2003).

Therefore, understanding aspects of nursing

homes, such as quality of life is of particular importance to this region of the country. Research suggests the analysis of nursing homes is an important issue because of the interplay between multiple family members before and after nursing home placement (Caron 1997; Janzen 2001; Nandan 2006).

This concept is supported by the enmeshed nature of family systems,

∗

Gina Aalgaard Kelly, MS, Ph.D., Assistant Professor, Department of Sociology-Anthropology, North Dakota State University, Dept. 2350, PO Box 6050, Fargo, North Dakota 58108-6050; e-mail: [email protected]

33

specifically with roles, relationships, involvement, interaction, and caregiving which continue after a change in environment, such as moving to a nursing home (Friedemann et al. 1997; Gaugler 2005; Janzen 2001; McKee, Houston and Barnes 2002; Nandan 2006).

Individual

family members (i.e., the older adult family member or other family members) are consumers of long-term care, and have expectations for that care and services from the facility. With the changing demographics in the United States, specifically the growing number of elders living to older ages, there is an increased need for nursing homes and simultaneously a need to thoroughly understand family caregiving issues including quality of life. Therefore, this critical review examines quality of life within the context of nursing homes. This review of literature on quality of life is organized and guided by Lawton’s (1983: 351) “Four Sectors of the Good Life.” This model of organization allows for a multidimensional view of quality of life, both the theoretical and empirical domains found in the literature. The literature was selected on overarching parameters utilizing Lawton’s definition of quality of life which states, “Quality of life is the multidimensional evaluation, by both intrapersonal and social-normative criteria, of the person-environment system of an individual in past, current, and anticipated” (1983: 6). The multidimensional view allows for a critical review of the quality of life literature through multiple domains which postulate what and how quality of life has been examined (See Figure 1).

Quality of Life Literature Emerged from Quality of Care Quality of life has traditionally been examined through medical and health sciences lenses. Nearly all early research on quality of life during the mid 1980’s was reported in medical journals and began to appear in psychological journals by the late 1980’s. Research was health related and medically focused due in part to the fact that the data were collected from ill

34

Figure 1.

A Multidimensional View of Quality of Life for Old Adults in Nursing Homes Four Sectors: Model for Conceptual Structure and Literature Content (Lawton’s Model).

Psychological W ell-Being Dom ains: Psychological Well-being/Mental Health, Satisfaction with Life, and Nursing Home Satisfaction.

Perceived Quality of Life Dom ains: Autonomy/Control/Internal Self, Communication/Relationships/Family Connectedness, Spiritual Well-being/ Dignity, Decision Making, Emotional Reactions, Reflecting, Self-Esteem, and Sexual Satisfaction.

Psychological Well-Being

Perceived Quality of Life

Behavioral Competence

Behavioral Com petence Dom ains: Functional Competence – Physical, Functional Competence – Cognitive, Physical Comfort/Health, Caring for Self and Helping Others.

Objective Environment

Objective Environm ent Dom ains: Safety/Security/ Privacy, Meaningful Activity/ Enjoyment, Growth, Learning, Technical and Preservative Care, and Environment/Therapeutic, Physical and Social Environment.

35

patients primarily in health care settings (Lawton 1991), with illnesses and diseases such as cancer, (Habu, Saito, Sato, Takeshita, Sunagawa and Endo 1988), hypertension (Wenger 1988), and stroke (Niemi, Laaksonen, Kotila and Waltimo 1988). Therefore, much of the quality of life literature was directly linked to quality of care (Bowers 1988; Challiner et al. 1995; Glass 1988; Grau et al.1995; Janzen 2001; Kane 2001; Lawton 1991; Peak 2002). Quality of life literature from a medical perspective examines the relationship of quality of life and quality of care (Bowers 1994; Cohn and Sugar 1991; East and Binney 1989; Glass 1988; Kane 2001; Lawton 1991). Kane (2001:297) suggested “a good quality of life (QOL) should be elevated to a priority goal for [long term care] rather than a pious afterthought to quality of care.” Similarly, East and Binney (1989) supported the notion that it was appropriate to link quality of care and quality of life, noting that the two concepts are both somewhat similar and also somewhat different issues with older adults. It may be appropriate to examine them both separately and in combination to learn from one another (East and Binney 1989; Glass 1988). Researchers studying quality of care from a medical model have found that good quality of care was a predictor of good or high quality of life. Glass (1988:426) stated, “for nursing home residents, quality of life is largely determined by the quality of care they receive.” Several researchers challenged this notion due to the complex nature of the quality of life concept that cannot be adequately examined through medical outcomes alone (Challiner et al. 1995; Farber et al. 1991; Janzen 2001; Kane 2003). Challiner et al. (1995), while studying quality of life, quality of care, and the relationship between the two, examined the combination of several perspectives (models) of quality of life and quality of care, specifically, the medical, social, and psychological perspectives. Also, policy regulations in health care, specifically with long-term care, suggest objective measures to access quality of care in long term care (LTC) settings (Bowers 1988; Challiner et al. 1995). As

36

research moved into social sciences and other fields, more emphasis on all facets of quality of life emerged (Lawton 1991). A result of the quality of life and quality of care debate was the complexity of concepts and multiple perspectives which have gained ground in the research literature (Challiner et al. 1995; Cohn and Sugar 1991; Farber et al. 1991; Kane 2003). Therefore, the use of Lawton’s multidimensional view of quality of life was identified by the author as a useful framework to build the review structure and organization around because of the multiplicity of lenses.

Lawton’s Multidimensional View of Quality of Life Lawton’s (1983) four sectors of quality of life provide a framework for understanding the complexity of the multidimensional domains which include: 1) Behavioral Competence; 2) Perceived Quality of Life; 3) Objective Environment; and 4) Psychological Well-being. Each of these sectors will be described. The four sectors of quality of life can overlap and have been found to be inter-related in the research literature. Lawton (1993) suggested overlap in the multidimensional view of quality of life is present as a result of the nature of sectors and domains which include both objective and subjective perspectives.

After each sector is

discussed, the multiple domains found in the literature within one of the four sectors of quality of life will be discussed conceptually as well as operationally.

Four Quality of Life Sectors Much of the quality of life literature captures concepts into “domains” of quality of life (Kane 2001; Kane et al. 2000; Lawton 1991; Stewart and King 1994).

Included in these

domains is a wide range of subjective aspects of quality of life as well as physical and cognitive aspects, such as cognitive functioning (Stewart and King 1994).

Different language (i.e.,

terminology) is used to examine and measure quality of life concepts within the research literature. However, the domains remain relatively similar (Cohn and Sugar 1991). The content

37

area of each domain impacts how each concept or domain is defined conceptually and empirically measured.

The variation of definition encourages investigator adaptation when

studying quality of life (Stewart and King 1994). The first sector, Behavioral Competence, is defined as aspects of one’s quality of life that “…accommodate any external observable facet of a person” (Lawton 1991:8). For example, this could include one’s roles, biological health, functional health, cognition, time use, and social behavior. Relevant domains found in the literature and be explained in the upcoming section of this review include functional competence – physical; functional competence – cognitive; physical comfort/ health, caring for oneself and helping others. The second sector is Perceived Quality of Life. This sector includes the “internal structure that parallels directly the sector of behavioral competence” (Lawton 1991:9). Lawton (1991:9) further discussed “…by definition, Perceived QOL is subjective.” Examples of perceived quality of life can include pain, cognitive self-efficacy, quality of spare time, and relationships with one’s children and spouse. Subjective domains found in the literature include autonomy, control, internal self, communication, relationships, family connectedness, spiritual well-being, dignity, decision making, emotional reactions, reflecting, self-esteem, and sexual satisfaction. Objective Environment is a third sector and is often associated with “…some forms of behavioral competence and not others and to constitute a subset of important conditions of the dimensions of perceived QOL” (Lawton 1991:10). Lawton (1991:10) stated the “…environment has a more diffuse relationship to dimensions within these sectors.”

Examples of objective

environment could include water and air quality, physical access to the dwelling as well as physical structural aspects within a home, neighborhood, social networks, objective physical entities which enact self-care, intellectual stimulation, and social behavior. Specific domains

38

include: safety, security, privacy, meaningful activity, enjoyment, growth, learning, technical and preservative care and environment/ therapeutic, physical and social environment. The fourth sector of Lawton’s is Psychological Well-being and is more than the “sum of competences and satisfactions” (Lawton 1991:11). The self is made up of a complex model which includes all past, present, and future experiences. Several examples of the psychological well-being sector include mental health, cognitive judgments, life satisfaction, and emotions. The domains reviewed in the literature, to be discussed, include psychological well-being/ mental health, and satisfaction with life, and nursing home satisfaction. SECTOR 1: BEHAVIORAL COMPETENCE

Functional Competence - Physical Functional competence or physical functioning is one aspect of quality of life of great importance for older adults in the nursing home (Stewart and King 1994).

Functional

competence is usually an objective measure ranging from activities of daily living and upper and lower body movement, such as walking or climbing stairs.

Functional competence might

include an older adult’s ability to go places inside and outside of the nursing home facility (Gaugler et al. 2004). Functional competence is conceptually discussed in the literature as possessing medical limitations (Mosher-Ashley and Lemay 2001). One reason older adults live in a long-term care facility is due in part to several physical limitations. Physical limitations have been found to lead to lower life satisfaction as well as less control over one’s life. Conversely, physical limitations have been found to be unrelated to one’s level of life satisfaction. (Mosher-Ashley and Lemay 2001). It is important to note differences in how an individual perceives their own functional competence which, in turn, greatly impacts how they perceive other aspects of their quality of life.

39

Kane et al. (2000:10) discussed functional competence of nursing home residents as defined in the following way: “Within the limits of their physical and cognitive abilities, residents are as independent as they wish to be.” This definition of functional competence allows the resident to be the point of reference rather than just a subjective or objective measure of the researcher. Functional competence as a domain of quality of life in regard to the research of Kane and colleagues (2000), allows the resident to determine of their status allowing for the individual perception. The concept of functional competence is similar to but not the same as one’s functional abilities (Kane et al. 2000). Challiner and colleagues (1995) examined dependence as a functional competence concept of quality of life. This research used a life history approach beginning with interviews and followed up with structured questionnaires to examine functional competence, specifically dependence (Challiner et al. 1995).

Using this mixed-method approach of biographic data

collection to gather the life history of residents and using structured questionnaires, Challinger and authors (1995) may have facilitated a more critical response from the participants. Specifically, dependence and independence of residents was measured using the Barthel index score to assess dependence on activities of daily living (Mahoney and Barthel 1965). was measured using Lawton’s (1972) dimensions of morale index.

Morale

The findings suggested

quality of life is good if a resident has high morale and high independence with their activities of daily living (ADLs) (Challiner et al. 1995).

Functional Competence - Cognitive Functional competence regarding cognitive status or one’s abilities is often conceptually defined as cognition (Lawton 1993). Cognition or a person’s ability to think and reason on many levels is often measured by the Mini-Mental State Examination (Folsgtein, Folstein, and McHugh 1975). About one-half of the nursing home population has a dementia related illness

40

(Markeson 2003). Therefore, it is important to include these residents and their families in research because they make up a large proportion of nursing home residents. However, much of the research literature does not have residents included in the study with cognitive limitations (Aller et al. 1995; Iwasiw, Goldenber, Bol, and MacMaste 2003; Peak 2000).

Many issues

prohibit cognitively impaired residents and their families to be included in research studies. A possibility for why people with dementia are not included is vulnerability issues.

Getting

adequate informed consent forms to satisfy Institutional Review Boards (IRB) might be difficult with persons who have difficulty fully understanding the research and consent process. Even with these reasons discussed, there are a few research studies that have included people with dementia in their samples (Kane et al. 2000; Ready, Ott, Grace, and Fernandez 2002).

Researchers often use proxies (i.e., a substitute or representative) with elderly

populations, specifically in nursing homes due to cognitive impairment. A proxy for elders living in nursing homes is often close family or staff member(s) of the nursing home facility (Totten 2004). Kane (2001) included persons with dementia in the study of quality of life from the original data set with the presented study.

Data was collected from residents even if an

impairment of cognitive functioning occurred during the interview process. Response categories for identified dementia-related residents were dichotomous rather than the Likert scales were used with the rest of the sample.

Physical Comfort and Health Stewart and King (1994) and Kane (2001) discussed physical comfort as a domain of quality of life. These researchers conceptually define the domain “pain in general” or to have “specific pain”.

Physical comfort, therefore, can range depending on the severity of the

discomfort. Specific pain could include back pain or chronic leg pain, for example. The severity or intensity can vary and the extent, duration, and frequency of the pain may or may not

41

interfere with one’s daily activities potentially resulting in a change of one’s quality of life within this domain. Health is a related but different domain of quality of life from physical comfort (Stewart and King 1994).

Health or perceived health can include current health, future health, past

health, or one’s resistance to illness. This domain has been assessed by asking an older adult (i.e., individual perception) if they are satisfied with their level of health or more objectively their health may be observably rated or with the use of medical records (Stewart and King 1994). Therefore, the concept of health has been measured both objectively and subjectively.

Caring for Self and Helping Others Two domains of quality of life which have inductively emerged from qualitative study includes caring for oneself and helping others (Aller and Coeling 1995). Orem’s Theory of Selfcare was relevant to Aller and Coeling’s (1995) research findings concerning “self help,” which is a concept they used to define the meaning of quality of life from the resident’s perspective. Aller and Coeling (1995) discussed how Orem’s theory of self-care explained “self-help” as being an important aspect of resident quality of life. However, Aller and Coeling did not go beyond mentioning the theory. By doing so, the reader cannot interpret conclusive connections with how the researchers felt Orem’s theory was applicable to their findings or to quality of life of the resident in a nursing home. SECTOR 2: PERCEIVED QUALITY OF LIFE

Role of Individual Perceptions Debate surfaces as to whether quality of life is the same for one person as it is for another (Bubolz and Sontag 1993; Cohn and Sugar 1991; Lawton 1991).

Within a family,

members can have differing perceptions based on individual experiences and one’s point-ofview (Bubolz and Songtag 1993; Cohn and Sugar 1991).

42

The individual’s perception is

important and influential through social interaction within a family and society. Therefore, a discussion of how an individual or the “self” perceives aging and quality of life is important before moving forward with multiple perceptions. George Herbert Mead (1934) discussed the social self as being influenced by others around oneself and within oneself. He stated, “self is constituted not only by an organization of these particular individual attitudes of others, but also by an organization of the social attitudes of the generalized other or the social group as a whole to which he belongs” (Mead 1934:158). When understanding family level perceptions, an examination of the individual, a person who is part of the family “organization” is also necessary to consider.

Families are constructed of

individuals bringing more than one perception to a phenomenon, incorporating two, three, or more family members depending on how many are a part of the family unit. Approaches to examining perceptions vary and several researchers utilized qualitative methods when, for example, examining domains of autonomy, control, and the internal self as aspects of quality of life (Aller and Coeling 1995; Bowers 1988; Friedemann et al. 1997; Iwasiw et al. 2003; Peak 2000).

This is a consistent mode of inquiry for the interpretive science

perspective (Brown and Paolucci 1979). opportunity

to

build

rapport

with

Qualitative research provides for the researcher(s) participants,

whereas

with

quantitative

research

methodologies building rapport is more difficult and usually does not occur due to the structure or nature of the data collection methods. Qualitative approaches often involve small samples of participants who are interviewed, observed, or “visited” in their own environment (Copeland and White 1991) as is often done with residents of a nursing home.

The engagement of

researcher and participant can build trust, unfolding a wealth of personal information about the phenomenon, and reveal personal meanings regarding one’s quality of life which may have not been understood otherwise.

43

Minimal empirical research has examined how an older adult resident living in a nursing home perceived their own quality of life (Cohn and Sugar 1991). However, many studies have identified factors of self-perceptions impacting outcomes on health in old age (Deeg and Kriegsman 2003; Ginac, Cott and Badley 2000; Hong, Zarit and Malberg 2004; Levy, Slade and Kasl 2002). Levy et al. (2002) longitudinally examined six waves of data collection to understand how 433 participants viewed their own health.

Specifically, the research found

positive self-perception of one’s aging benefits their functional health in old age (Levey et al. 2002). This suggested an individual’s own perceptions of self can be both positive and negative as they age. This adds complexity for understanding multiple perspectives because individuals in a family system may likely perceive aging and aspects of aging quite differently than those of their family members.

Autonomy, Control, and Internal Self Conceptually, autonomy has been defined in many ways including authenticity, independence, informed consent, and self-rule (Kane 1991).

The concept of autonomy is

heavily embedded in philosophy and means decision making is made at the direction of one’s self (Kane 1991)

However, as Collopy (1988:316) pointed out, self-rule can be further

elaborated or paraphrased into “a whole family of value-laden ideas, including individual liberty, privacy, free choice, self-governance, self-regulation, and moral independence.” Autonomy is an important aspect of quality of life due to the fact that throughout their lives, people want to have the capacity to make decisions or have a sense of control over what they are doing and the decisions they make (Boyle 2004; Cohn and Sugar 1991; Stewart and King 1994). Maintaining a sense of personal responsibility and having personal choices and values is important during our life span and is important during later life as well (Boyle 2004). The need for personal control with older adults is associated with many losses, such as

44

independence (as opposed to an increase in dependence) or loss of the mind (Lachman, Ziff and Spiro 1994). Several researchers have examined autonomy as an aspect of quality of life (Boyle 2004; Kane 2001; Kane 1991; Kane et al. 2000; Guse et al. 1999; Stewart and King 1994). The measure of autonomy (i.e., personal choice) and individuality was used in Kane (2001), Guse et al., (1999), and Cohn and Sugar (1991). In Kane’s (2001) discussion of her research, as well as in the work of many other researchers (Hofland 1988, 1990; Seligman, 1976), autonomy is important to an elder’s quality of life. Kane (1991, 2001), Guse and colleagues (1999) and Cohn and Sugar (1991) suggest encouraging residents to utilize personal choices in their daily lives and maintaining individuality as a resident in a nursing home setting are important to an elder’s quality of life. Specifically, Kane (2001:298) stated there are important contributions of “…this property of autonomy to the well-being, mental health, and even physical health of cognitively intact older people.” Maintaining identity or a sense of personhood is another concept within the domain of autonomy (Iwasiw et al. 2003). Iwasiw and colleagues found listening to residents and their family members helped the staff (e.g., nurses) identify information to improve resident quality of life by promoting individualism. The findings of this research (Iswasiw et al. 2003), and other research (Cohn and Sugar 1991; Duncan-Myers and Heubner 2000; Ratz et al. 1999) support that residents need to be treated with respect and this can be achieved by getting to know the resident as a person.

Iwasiw et al. (2003) further discussed enhancement or

improvement of quality of life in nursing homes can be achieved by providing individualized care, acknowledging personal histories, values, and preferences of the resident.

Therefore,

quality of life in the nursing home is about identifying personhood within each resident.

45

Autonomy was examined in a study by independence and dependence of 286 older adults examining their ability to adapt to chronic illness (Gignac et al. 2000).

Gignac and

colleagues defined autonomy by a common definition used in research which is the ability to make decisions for oneself, to have personal choices and values (Boyle 2004). Older adults’ perceptions of autonomy including independence, dependence, helplessness, emotional reactivity and coping efficacy were measured and outcomes found varied.

The loss of

independence and feelings of the development of dependence were highly correlated with one another. These findings suggest the amount of independence or feelings of dependence one perceives affects an elder’s perceptions of coping efficacy and feelings of helplessness. Cohn and Sugar (1991) examined patterns of perceptions between family and residents in accordance with quality of life. Five out of eleven decision-making items used in this study used to measure autonomy, identified similarities between residents and family.

Residents

reported issues of autonomy important to their quality of life included access to a telephone, a place to be alone, transportation availability, choice of roommates, and having keepsakes nearby. Family members agreed with residents on four of five issues, (though not in the same rank order) with the exception of choice in food replaced transportation as being important to quality of life in regard to making autonomous decisions. These findings suggested dimensions of autonomy were operationally measured in the study but differed by population (Cohn and Sugar 1991).

Communication, Relationships, Family Connectedness Communication, relationships, and social networks were identified and related quality of life domains. Each domain has been found to be significantly related due to the interactions between an older adult and family members within the conceptual definitions and dimensions.

46

Communication can be conceptually defined as the verbal and nonverbal interactions between two or more people (Cohn and Sugar 1991).

Communication has also been defined

conceptually as the ability to communicate with others (Aller and Coeling 1995). Relationships with various people, including family and friends, was found in the literature as an important domain of quality of life. Kane et al. (2000:10) conceptually defined relationships with nursing home residents as, “residents engag[ing] in meaningful person-to-person social interchange with other residents, staff, and/or family and friends outside the facility.” Family connectedness was another distinct concept of relationships and was defined as those families who maintained an emotional bond with the resident, as well as provided regular updates concerning family events (Friedemann et al. 1997).

A number of studies (Aller and

Coeling 1995; Cohn and Sugar 1991; Friedemann et al. 1997) examined comparable domains of quality of life because the concepts have similar definitions. Residents and family members had similar perceptions in regards to the importance of quality of life within the social-emotional environment, specifically to the role of relationships with relatives (Cohn and Sugar 1991).

Respondents were asked to rate the importance of

relationships with relatives, friends outside the facility, friends inside the facility, and facility staff. Both groups of respondents, family members and residents, reported relationships with relatives to be a critical aspect to their quality of life. More than 50 percent of the resident respondents felt their relationships with all relatives, friends inside and outside of the facility, and staff were all important to quality of life (Cohn and Sugar 1991).

Less Frequently Discussed Quality of Life Domains Much less research has examined and explored additional quality of life domains including: 1) Spiritual well-being; 2) Dignity; 3) Decision-making; 4) Emotional reactions; 5) Reflecting; 6) Self-esteem; and 7) Sexual satisfaction.

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Spiritual Well-Being and Dignity Spiritual well-being and dignity as domains of quality of life have had very little attention given to them. However, both of these domains have been found to be important domains of quality of life to nursing home residents (Kane 2000, 2001, 2003). Conceptually, spiritual wellbeing is defined as whether or not the “resident’s needs and concerns for religion, prayer, mediation, spirituality, and moral values are met” (Kane 2000:10).

Dignity is conceptually

defined as the level to which “residents perceive their dignity is intact and respected, and they do not feel belittled, de-valued, or humiliated” (Kane 2000:10).

Decision-Making, Emotional Reactions, and Reflecting Similar to the domains of spiritual well-being and dignity, decision-making, reactions, and personal reflections have had very little research and attention given to them (Iwasiw et al. 2003). Through an exploratory and inductive study, decision-making in regards to moving into the nursing home, emotional reactions to the nursing home, and personal reflection emerged from the data (Iwasiw et al 2003). However, these three domains of quality of life have yet to be empirically measured.

Self-Esteem and Sexuality Two more domains of quality of life found in the literature have limited research are self-esteem and sexuality (Stewart and King 2003).

Self-esteem is conceptually defined as

one’s general esteem, physical esteem (e.g., appearance and competence), social self-esteem, and one’s intellectual self-esteem. Dimensions of this domain can include satisfaction with self or the agreement of statements about one’s self. The sexuality domain of quality of life is conceptually defined as both sexual functioning and intimacy (Stewart and King 2003). Both self-esteem and sexual satisfaction do not have validated empirical measures.

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SECTOR 3: OBJECTIVE ENVIRONMENT

Meaningful Activity and Enjoyment Meaningful activity is an important aspect of quality of life (Kane 2000; McKee et al. 2002). Meaningful activity can be found in the literature with varying conceptual definitions, such as pleasant events (McKee et al. 2002), involvement in activities, (Tornatore and Grant 2004), or the actual language of meaningful activity (Kane 2000).

Conceptually defined,

meaningful activity is the perception that life is complete with meaning and interesting things which one sees or experiences (Kane 2000). When an older adult moves to the nursing home, meaningful activities do not necessarily cease (Kivnik 1993; McKee et al. 2002; Ryan and Scullion 2000). The nature of an elder’s activity level and roles before the move to a nursing home will affect their activity level after the move as well. For example, a resident who actively engages in activities around them might continue to do so, or if they are more of a spectator, they may choose to maintain that role in their day-to-day activities (Kane 2000). According to Kane (2000:297), “still others, such as Kivnik (1993) has demonstrated, can make meaningful contributions to their families, the nursing homes, or the community at large despite their physical dependency on care.” Meaningful activity is measured in various ways.

McKee et al. (2002) assessed

meaningful activity based on a 53-item inventory called the Pleasant Events Schedule – Alzheimer Disease (PES-AD). This scale, designed by Teri and Logsdon (1991), was designed to help family caregivers identify activities appropriate and enjoyable for those older persons with Alzheimer’s disease. McKee et al. (2002) altered the inventory and streamlined it to 39items which were then rated four times. The ratings included: “whether or not the ‘opportunity’ for the activity to take place occurred; secondly, the ‘frequency’ with which it occurred during the last month (none/few/often); and thirdly, whether or not the activity had been ‘enjoyed in

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the past’ by the cared person; fourthly, whether or not the activity was ‘enjoyed now’ by the cared persons” (p. 741). The researchers found use of the PES-AD was a reliable measure for examining quality of life within the domain of meaningful activity.

Safety, Security, and Privacy Safety, security, and privacy are three domains found in the quality of life literature with little attention, but are domains of quality of life important to nursing home residents (Kane et al. 2000; Kane 2001; Lawton 1991).

Kane et al. (2000) defines safety and security in the

following way: “Residents feel secure and confident about their personal safety, ability to move about freely, the security of their possessions and the good intentions of staff. They know and understand the rules, expectations, and routines of the facility” (p. 10). Privacy is conceptually defined as: “Residents have bodily privacy, can keep personal information confidential, can be alone as desired, and can be with others in private” (p. 10).

Technical and Preservative Care Bowers (1994) suggests the caregiving typology of technical and preservative care is a way to understand quality of life because of the connection to quality of care from the resident’s family perceptions and from staff. Conceptually, the caregiving typology of care was used to study quality of life. An attribute to this domain is a constructed concept and measure. However, it has yet to be validated for its present use.

The study focused on family

perceptions, consequently finding family members consider most tasks the nursing home’s responsibility. Also suggested, is that family members do feel responsible to act as a manager by monitoring and evaluating their family member’s quality of care. Family members feel it is their duty to teach individualized resident care to staff in order to obtain high quality of care and promote the resident’s “self”. Using a measure, such as the caregiving typology, assumes

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quality of care is an adequate measure of quality of life. This approach combines two different concepts, quality of life and quality of care for nursing home residents (Bowers 1994).

Growth and Learning Growth and learning are two domains which emerged from Friedmann, Montgomery, Maiberger and Smith’s (1997) inductive research on quality of life. These domains suggest that if residents can continue to learn and grow while living in the facility, their quality of life is maintained (Friedmann, et al. 1997). Both of these domains have yet to be empirically studied and there are no validated measures found.

Environment: Therapeutic, Physical and Social Guse and Masesar (1999) found that being able to enjoy nature, being outside, and the ability to help others (Guse and Masesar 1999:536) contributed to having higher quality of life from the resident’s point of view. Cohn and Sugars’ (1991) research also focused on individual perspectives of residents and their family members’ views on quality of life specifically within the nursing home environment.

Differences in perceptions of the physical and social

environment were found between the residents and the family members.

A possible

explanation for these may stem from variation between a resident’s role in the nursing home environment and the role of family member(s) living in another environment outside of the nursing home.

Resident and family perceptions were quite positive and similar for overall

perceptions of quality of life. However, greater variations were found in specific content areas of quality of life.

Participants were asked the question, “Do residents feel they have good

quality of life?” The majority of respondents (73 %), including the resident, agreed their life in the institution was “contented, comfortable, and meaningful” (Cohn and Sugar, 1991: 36). In response with the content domain of care, residents focused primarily on activities contributing to their quality of life, followed by basic needs, and then professional care next. Researchers

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found the majority of residents felt physical problems were “not at all” an important part of their quality of life. Family members, however, held the perception that physical problems are an important aspect of quality of life for residents in a nursing home (Cohn and Sugar 1991). SECTOR 4: PSYCHOLOGICAL WELL-BEING

Psychological Well-Being Psychological well-being is the remaining quality of life outcome to be understood. Psychological well-being is typically another subjective measure of well-being of one’s life within the research (Hickey and Bourgeois 2000). Included in this concept can be depression, anxiety, anger or irritability, loneliness, and stress (Gaugler et al. 2004; Hickey and Bourgeois 2000; Sterwart and King 1994). Psychological well-being can also include an older adult’s interest in life or an assessment of their overall outlook on life (Stewart and King 1994).

Psychological

well-being can encompass aspects of mental health and social well-being and is sometimes discussed as simply “well-being” in the literature (Gaugler et al. 2004). Researchers have found psychological well-being of nursing home residents significant and an important domain of quality of life in nursing homes (Gaugler et al. 2004). Several researchers have discussed the importance of understanding depression or psychological wellbeing and its relationship to quality of life. Gaugler and colleagues (2004:773) stated, “social relationships and interactions also appear to be integral to the well-being of residents; results indicate higher levels of social cohesiveness in the long-term care environment, participation in activities, and close relationships and interactions with staff and family are strongly correlated with positive mood and lower levels of depression.” These findings illustrate the conceptual overlap with many domains of quality of life in one of the four sectors as they were discussed in the literature.

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Farber et al. (1991) examined depression and emotional well-being as an important measure and aspect of quality of life. Good quality of life in this research was measured by the quality of relationships between the nursing home resident and family member(s).

This

research specifically found significant correlation between the quality of relationship between the nursing home resident and family member impacting the resident’s emotional well-being. Suggesting the quality of relationship rather than the frequency of interaction between a family member and resident is related to higher levels of emotional well-being.

Therefore, Farber et

al. (1991) suggested by examining (or measuring) the quality of family interactions rather than frequency of interactions are more important to improving resident well-being and decreasing depression.

Nursing Home and Life Satisfaction Life satisfaction is another important aspect of psychological well-being as it relates to quality of life in the nursing home setting. (Moser-Ashley and Lemay 2001; Tornatore and Grant 2004). The concept of satisfaction can include current, past, or present life in the nursing home setting (Hickey and Bourgeois 2000; Snowdon 1986; Stewart and King 1994). Farber et al. (1991) and Mosher-Ashley and Lemay (2001) examined nursing home life satisfaction and operationally measured for depression, hopelessness, and life satisfaction to assess quality of life. Social support from family and friends (e.g., help with tasks or help with finances) was examined and was found to be associated with increased life satisfaction. Another finding of this research was that life satisfaction is closely associated with an older adult’s physical health. Many of the residents had age-related medical problems but did not have low life satisfaction; this suggests that life satisfaction closely related to mental/emotional health and not just physical health. The researchers (Farber et al. 1991; Mosher-Ashley and Lemay 2001) measured quality of life by assessing emotional and physical well-being with social

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support thereby bridging quality of life measures through physical health (i.e., a medical model), emotional health (i.e., a psychological model), and social support (i.e., a social model). Nursing home satisfaction has historically been measured through the examination (or through the surveying of) of a family member rather than the resident.

The Ohio Nursing

Home Resident Satisfaction Survey and the Ohio Nursing Home Family Survey are among the few large scale surveys allow the resident voice to speak to their satisfaction of the nursing home (Straker, Ehrichs, Ejaz and Fox 2002; Straker and Ejaz 2001). Other long-term care and acute care settings (i.e., home healthcare) have been more progressive with asking the resident or patient about life satisfaction. However, little is known about nursing home life satisfaction from the resident and family members combined as an aspect of quality of life.

Quality of Life Sectors and Domains are Inter-related. Aspects of quality of life can overlap and be related (Lawton 1993).

The

multidimensional view of quality of life examines the domains within the four sectors to allow for interrelationships or overlap to occur. As introduced earlier, this can be a result of including the subjective nature of quality of life meanings to objectively examining the phenomenon (Lawton 1993).

Lawton (1993:12) suggested, “[a] …reason for giving objective measures of

person and environment a major position in quality of life is that such measures provide an anchoring point from which individual perceptions may deviate.”

It is this deviation in

perceptions provides a range of meanings and overlap of these meanings to the literature. As a result, multiple domains and concepts have been examined for this literature review. Mosher-Ashley and Lemay (2001) discussed how moving into a long-term care facility can be challenging to an older person’s sense of autonomy, independence, and sense of control. Adjusting to staff or family members completing daily tasks for the resident can be difficult. These researchers found residents who viewed living in the facility as a “benefit” had

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high life satisfaction. Residents who felt they were forced or had to live in the long-term care facility were less satisfied with their lives (Mosher-Ashley and Lemay 2001). Good quality of life in this research was defined as the quality of relationship between the nursing home resident and a family member (Farber et al. 1991). Significant correlations between the quality of relationship with the nursing home resident and family member with nursing home life satisfaction were found. These findings suggest improving quality of family interactions and the type of interaction, rather than frequency of interactions alone, is more influential to improving quality of life, specifically the measure of life satisfaction as an outcome of one’s quality of life. Quality of life as a more complex whole, rather than single domain inquiry was discussed in the literature with several indexes being discussed (Arling et al. 2005; Challiner et al. 1991; Farber et al. 1991; Guse, et al. 1999).

Several measures were found that were used to

examine quality of life in nursing homes (Challenger et al. 1991; Farber et al. 1991; Guse, et al. 1999). Guse et al. (1999) used two scales. These scales include the Rated Latitude of Choice Scale and the Quality of Institutional Life Scale. The latter of the two seems an appropriate scale for measuring quality of life for institutional elders.

However, the scale is yet to be

validated. Farber et al., (1991) uses quantitative relational measures, specifically the Quality of Relationships Scale. The Cornwell-Brown Scale for Quality of Life (2002), a validated quality of life measure, has been used to assess community dwelling of older adults with dementia. The scale includes ratings negative and positive affectivity, physical complaints, and satisfaction (Ready et al. 2002). Future research could adapt this scale to nursing home setting and include residents with dementia.

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The measures or scales researchers have utilized to examine quality of life have had limited or no validation. Quality indicators (QIs), such as those collected through the Minimum Data Set (MDS), have paved the way for a systematic source of quantifying quality in nursing homes (Arling et al. 2005).

The QIs identified and collected in the MDS are important for

quality assessment of nursing home residents. However, the focus remains primarily on quality of care (QOC) factors rather than QOL. DISCUSSION To date, conceptual and theoretical literature dominated the quality of life literature. However, quality of life research needs to move in a direction linking theory and empirical research (Lawton 1991). Literature gaps could be eliminated by building a conceptual model from system theories and through empirical testing the quality of life model. Two suggested frameworks, family systems theory and human ecological theory, have surfaced from the review. Much of the quality of life literature either was at a conceptual level or empirical level, with even less research explicitly bridging the two together (Caron 1997; Copeland and White 1991; Nandon 2006). Methodologically, using multiple family members versus a single family member or one older adult to provide a perspective of quality of life could be used.

With the addition of

dementia as a factor in nursing homes residents, multiple perspectives could move research from an individual voice or one person representing another family member, as with a single “proxy,” to future research including multiple informants. approaches to studying families are suggested.

Further in-depth empirical

Family gerontological research in nursing

homes settings with multiple family member voices was missing in the literature. Implications include future research from multiple family perspectives by developing sound operational measures for dyadic and triadic family levels. More thorough and complex empirical research

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approaches to understand the “whole” family unit, congruence, and quality of life should be completed. According to Bubolz and Sontag (1993:419), “human ecology theory is unique in its focus on humans as both biological organisms and social beings in interaction with their environment.” Bubolz and Sontag (1993:437) stated, “quality of life of humans is defined in terms of the extent to which basic needs are met and values realized.” Different systems that might interact with one another could suggest families, nursing home residents, and the nursing home environment are interconnected systems in the nursing home environment. Only a few researchers have moved beyond a two person family perspective, adding depth to include three perspectives (Pruchno et al. 1997). Assessing aspects of resident quality of life requires a multiple perspective view because many facets contribute to one’s quality of life (Abeles et al. 1994; Lawton 1997). Therefore, an expanded conceptualization of quality of life in nursing homes is needed to fully understand the nursing home experience of residents today and in the future when even more elder adults rely on this form of long term care.

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A Comparative Approach to Promotional Methods for Seasonal Influenza Immunizations to Dorm Dwelling College Freshmen Gina Aalgaard Kelly ∗

Abstract

Carolyn Townsend

Introduction: Comparing tailored e-mail messaging to mailed postcards promoting seasonal influenza immunizations for dorm dwelling college freshmen is important for early health prevention and promotion. Dorm dwelling college students are particularly at risk of viral diseases due to the close proximity of their living conditions. Understanding influences with health care decisions and practices is therefore also important with the college dorm dwelling population. Method: A convenience sample was used to collect data from influenza clinic participants on a Midwest college campus over three seasonal flu periods. A Health-E card was sent in 2010 via university issued student e-mail accounts informing students how to prevent influenza through immunization. Postcards were sent in 2008 and 2009 solely to dorm dwellers and parents of college freshmen. Short questionnaires gathered demographic data from participants at flu clinics for comparison. Results: In 2008 and 2009, 8% and 14% of dorm dwelling college freshmen participated in flu clinic following printed media sent to them and their parents. In 2010, only 3% of the same population participated in campus flu clinics following tailored e-mail messages sent via campus listserv. Discussion: Efficiency of social media e-mail messaging was established, however effectiveness of tailored e-mail to college freshmen was not supported. Family was most influential for the seasonal influenza in the third year of the study. Further study is needed to determine efficacy of social media intervention for college students and parental or family influence.

∗

Gina Aalgaard Kelly, MS, Ph.D., Assistant Professor, Department of Sociology-Anthropology, North Dakota State University, Dept. 2350, PO Box 6050, Fargo, North Dakota 58108-6050; e-mail: [email protected]

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INTRODUCTION In this research note, we describe the evolution and assessment of a tailored intervention devised to increase influenza immunization among college freshmen. In the recent past, dramatic shifts have occurred in national recommendations from the Centers for Disease Control and Prevention (CDC) regarding seasonal influenza immunizations for college students. In 2008, for the first time the CDC recommended that all 5-18 year olds receive annual seasonal influenza immunizations, which included most college freshmen. During the influenza season of 2009-2010, the H1N1 influenza pandemic disproportionately affected college-aged students.

This created heightened awareness of the risk for influenza in the previously

untargeted population of students over the age of 18 (CDC 2010). In 2010, the CDC issued a new recommendation that everyone over the age of six months should be annually immunized for seasonal influenza. The new criteria included the entire college student population for the first time (CDC 2010). For a number of reasons, college students have an increased risk of developing influenza. Any population living in confined settings, such as dormitories, has a heightened risk of contracting droplet-based diseases because of shared living space and close proximity. Of all college dorm-dwellers, freshmen are at greatest risk for contracting influenza (Butler 2006). Some universities require first-year students to live on campus so a greater percentage of dorm-dwellers belong to the freshmen class. Other characteristics of freshmen students, such as loneliness and decreased social network size, decrease immune response even if the influenza vaccination has been obtained (Pressman et al. 2005). In response to the CDC guidelines, we conducted an intervention and clinical research study from 2008 – 2010 on our Midwestern campus.

The shape of this intervention, which

sought to increase influenza immunizations among freshmen, evolved as the recommendations

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from the CDC changed.

In 2008, we targeted 18 year old dorm-dwellers because of their

inclusion in the new CDC recommendation, as well as their status of being at greatest risk for developing influenza (CDC 2008). Through the use of a mailed postcard, we informed all dormdwelling students and their parents about the CDC guidelines and provided information about an upcoming clinic on campus. In 2009, the same approach was used. At this time, awareness of seasonal influenza was likely heightened following declaration of the H1N1 influenza pandemic. The seasonal influenza immunization was a separate injection and offered early in the flu season before the H1N1 vaccine became available (CDC 2010). By 2010, new information regarding the health information seeking preferences of college students became available.

The American College Health Association (ACHA) identified

that college students preferred the internet as a health information source more than information from their parents. During the 2009 H1N1 influenza pandemic, the CDC developed a number of social media resources. An electronic Health E-card encouraging an individual to receive influenza immunizations was selected from the CDC resources shared with ACHA member colleges (ACHA 2009a-c, CDC 2010).

Specifically, the e-card contained a message

identifying four methods of protection from seasonal influenza, including washing hands, covering a cough, staying home if ill, and getting an influenza immunization (CDC 2010). The change in the 2010 CDC seasonal influenza recommendations to include the entire campus population encouraged us to seek a new cost-effective approach to intervention. We decided to use an E-Card, sent to all students via the campus listserv. Social media interventions sent via the internet have been found to be cost effective in comparison to traditionally mailed interventions, especially when the target population is a large audience. Colleges have student e-mail accounts for the entire student body and messages can be sent via an already created student listserv quickly and efficiently. Furthermore, past use of web-based, tailored health

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interventions has shown promise in reducing alcohol-related risk with first-year college students and increasing awareness of smoking cessation (Bingham et al. 2010; Staten and Ridner 2006). A personalized message from the student health center used the Health Promotion Model (HPM) to tailor the message to the student population (Pender, Murdaugh, and Parsons 2006; Staten and Ridner 2006). Three of the social behavioral cognition issues identified in the HPM affecting the target population of college students were addressed.

The first issue

promoting the perceived benefit to students was staying healthy may aid in academic success for the college student (Nichol, D’Heilly, and Ehlinger 2008).

The second issue addressed

perceived barriers which include busyness, lack of time, inconvenience, class/work schedule, and location of the clinic being too far out of the way (Martinelli 1999; Mayo and Cobler 2004; Taylor et al. 2009; Von Ah et al. 2004). The third issue addressed self-efficacy or the ability to make and follow through with a decision (Jackson, Tucker, and Herman 2007).

The three

issues were woven into the message, tailoring the message to address common student concerns. The informational intervention in the form of a Health E-card was sent to the entire student body via student listserv e-mail two weeks prior to the campus walk-in flu shot clinic from the student health center. Date, time, location, and cost of the influenza immunization was included in the message to students. See Appendix A for the E-card and Appendix B for a copy of the Postcard that was printed and mailed. In the next section of this note, we describe the outcomes for each of the three years of our intervention program. ASSESSMENT Approval was obtained from the participating university’s Institutional Review Board (IRB) as well as the university where the researcher was enrolled in graduate study. Data was collected through a short questionnaire at the time of the on-campus immunization with each

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participant.

Cost comparison between printed and mailed postcards to electronically sent

influenza immunization reminders found significant cost savings (Table 1). Informing college students of health information via Health E-cards was both efficient and cost effective.

Table 1

Cost Comparison of Mailed Reminders versus E-mailed Reminders 2008, 2009

2010

Postcard Printing

Health E-card

$405

$0

Postage

E-mail Use

$324

$0

Total

Total

$729*

$ 0**

*Cost for freshman class only **Cost for entire college Students presenting for immunization at the on-campus flu clinics were given a clipboard that included a personal disclosure and data collection form.

The disclosure explained that

return of the data collection form implied consent. The students were assured that the information was completely anonymous with no personal identifiers. A convenience sample of demographic information with 100% participation was collected that included year of study, age, gender, place of residence (i.e., on or off campus), if this was the student’s first influenza vaccination, and reason why they decided to get immunized. RESULTS The percentage of dorm dwelling freshmen receiving an influenza immunization in 2010 following a tailored social media intervention in the form of a Health E-card was compared to

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the percentage of dorm dwelling freshmen in the years 2008 and 2009 receiving an influenza immunization after receiving a printed media tailored intervention. Official college data was used for accuracy in determining the percentages of dorm dwelling freshmen receiving the influenza immunization (Minnesota State University [MSUM] 2009). The participation rate of dorm dwelling freshmen in 2008 following postcards in dorm mailboxes and mailed to parents of freshmen was 82 (8%) of the 1039 dorm dwelling freshmen.

Following the same messaging interventions, the 2009 participation rate was 133

(14%) of the 983 dorm dwelling freshmen. The 2010 rates following an e-mail message to the campus using the student listserv was 34 (3%) of the 1094 dorm dwelling freshmen, the lowest of the three years. The highest participation rate of the three years occurred in 2009, with the confounding factor of the H1N1 pandemic.

Efficacy was not established for electronically

delivered health information for freshmen college students. The data are shown in Table 2.

Table 2

Percentage of Dorm Dwelling Freshmen of Total Receiving Influenza Immunizations

Year

Promotional

Freshmen

Freshmen Attended Clinic

Method

Enrolled/Dorm

N / (%)

Dwelling Freshmen Fall 2008

Postcard

1938 / 1030

82 / (8)

Fall 2009

Postcard

1686 / 983

133 / (14)

Fall 2010

E-card

1683 / 1094

34 / (3)

In addition, a comparison was made identifying what influenced the participant’s decision to get the immunization. The majority of participants (57.1% and 57.8%) were influenced more by

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campus advertising with post card delivery during the years 2008 and 2009 compared to the tailored social media messages electronically sent to students (14.3%) in 2010. Also, in 2010 family influence was the highest reason (46.2%) for getting immunized and not campus advertising like it had in the previous two years. This data suggests again that tailored social media messages in the form of listserv e-mails promoting seasonal influenza immunization were not effective with this population of students. See Table 3.

Table 3

Comparison of Reasons for Getting Immunized 2008-2010

Decision-Making

2008

2009

2010

Influence Campus Advertising

57.1 %

57.8 %

14.3 %

Family Influence

32.7 %

26.5 %

46.2 %

IMPLICATIONS College is the ideal setting for establishing lifelong health habits (Martinelli 1999; Von Ah, Ebert, Ngamvitroj, Park, and Kang 2009). As the largest group of healthcare providers in student health centers, nurses are ideally positioned to shape student health patterns (Nicoteri and Arnold 2005).

Students are developmentally formulating their health belief system while

separating from their parents (Pender, Murdaugh, and Parsons 2006). Results of this study suggest family influence is the most effective source of immunization decisions for disease prevention rather than social media for freshmen. Healthcare providers have a high level of believability when students are seeking health information (Kwan et al. 2010). The student health center professionals responsible for most of health education are seen as credible sources of health information by the student body (ACHA

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2008, 2009a-c). When targeting the college student population, the approach must be relevant to their lifestyle, health and wellness (Staten and Ridner 2006).

Messaging must be

appropriately geared to the college age group and tailored to their social cognition and affect (Mayo and Cobler 2004). Cost and convenience have always been major factors in college students’ budgets and decisions. The method of dissemination must be appealing to the student (Hanauer, Dibble, Fortin, and Col 2010; Baxter, Egbert and Ho 2008). Student health centers have a unique opportunity while students are pursuing their education to assist them to develop health prevention habits that will benefit them throughout life (Von Ah et al. 2004; Martinelli 1999). The importance of discovering effective methods of distributing information to students as well as supporting their decisions as they develop and solidify their health beliefs, will have tremendous impact on students’ future health prevention habits. Limitations of this study were that the sample groups for comparison were restricted solely to dorm dwelling college freshmen, an H1N1 influenza pandemic occurred during the three years of data collection, and a single Midwestern university campus setting was used for study. Because dorm dwelling freshmen were the target population from the previous media intervention of mailed postcards to all dorm dwellers and parents of all freshmen, that same group was used for comparison to the intervention of a Health E-card sent out via the student listserv with no notification to parents. The heightened national awareness surrounding the 2009 H1N1 pandemic influenza may have influenced the higher participation rates in that year. Despite the current evidence suggesting students prefer web-based social media for health information, this was not supported in the study findings for dorm dwelling college freshmen, but the limitations prevent generalization of findings to other situations. Future projects could be conducted regardless of place of residence, include all years of undergraduate and graduate students to determine efficacy for the entire campus community.

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Several issues unique to the freshman age group may have impacted their assessed response to seasonal influenza immunization on campus.

Freshmen have been living away

from home for two months or less when influenza immunizations are traditionally offered. Freshmen may not have been familiar with the student health services offered on campus and sought health services at their home of origin. Freshmen covered under their parents insurance may have returned to their healthcare provider at home to receive influenza immunizations. Any freshmen receiving an influenza immunization elsewhere would not have been included in the measurement of the percent of freshmen receiving influenza immunizations on campus. This action may have caused lower reported rates than they were in actuality. Secondly, freshmen are transitioning from home and they may view themselves as independent, they may need advice from their parents for health care decisions (Nicoteri and Arnold 2005).

Autonomous health care behaviors are accomplished over time as students

separate from family and transition from adolescence to adulthood. Social and cognitive skills forming during this developmental stage assist them to develop health habits and sense of self efficacy (Pender, Murdaugh, and Parsons 2006; Jackson, Tucker, and Herman 2007). Without parental involvement, freshmen students may not have the ability to make decisions for influenza immunizations. With the efficiency and cost effectiveness of e-mail, a message could be sent more than once. Future projects could send a message initially two weeks in advance of the on-campus influenza immunization clinic, followed by follow up reminders sent two days prior and repeated on the day of the clinic. Other formats of social media that may be preferred by college students such as texting, Facebook or My Space, Tweeting and Twittering should be explored. Future influenza clinics could benefit from a broader literature review regarding factors contributing to college student population decision making for immunizations. At the systems

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level, exploring feasibility of including parents in the e-mail messaging is another factor that bears investigation. Social media has become a standard of societal communication and has limitless potential for distributing health prevention communication to the college student population. Further research and projects are needed to provide evidence of best practice for effective health prevention messaging tailored to this developmental stage in life when life-long health prevention habits are being formed.

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REFERENCES American College Health Association [ACHA]. 2009a. “The American College Health Association National College Health Assessment (ACHA-NCHA) Spring 2008 Reference Group Data Report (abridged).” Journal of American College Health 57:477-488. American College Health Association [ACHA]. 2009b. “The American College Health Association National College Health Assessment (ACHA-NCHA II) Fall 2008 Reference Group Executive Summary.” American College Health Association [ACHA]. 2009c. “The American College Health Association National College Health Assessment (ACHA-NCHA II) Spring 2009 Reference Group Executive Summary.” American

College

Health

Association

[ACHA].

2008.

“The

American

College

Health

Association National College Health Assessment (ACHA-NCHA) Spring 2007 Reference Group Data Report (abridged).” Journal of American College Health 56:469-479. Baxter, Leslie, Nichole Egbert, and Evelyn Ho. 2008.

“Everyday Health Communication

Experiences of College Students.” Journal of American College Health 56:427-435. Bingham, C. Raymond, Andrea Ippel Barretto, Maureen Walton, Christopher Bryant, Jean Shope, and Trivellore Raghunathan. 2010. “Efficacy of a Web-Based, Tailored, Alcohol Prevention/Intervention Program for College Students:

Initial Findings.” Journal of

American College Health 58:349-356. Butler, Karen. 2006. “Meningococcal Meningitis Prevention Programs for College Students: A Review of the Literature.” Worldviews on Evidence-Based Nursing 3:185-193. Centers for Disease Control and Prevention [CDC]. 2008. Vaccines and Immunizations for

Groups of People: College Students and Young Adults. Retrieved from http://www.cdc.gov/vaccines/spec-grps/college.htm

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Centers for Disease Control and Prevention [CDC]. 2010. “Prevention & Control of Influenza with Vaccines - Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2010.” Morbidity and Mortality World Report 59:1-62. Centers for Disease Control and Prevention [CDC]. 2010. The 2009 H1N1 Pandemic: Summary

Highlights,

April

2009-April

2010.

Retrieved

from

www2c.cdc.gov/podcasts/download.asp?f=2011242+af=h&t=1 Centers for Disease Control and Prevention [Producer]. 2010. What You Can Do to Prevent the

Flu [Health E-card]. Available from http://transparency.cit.nih.gov/flu_ecard/message.cfm?CFID=503074&CFTOKEN=69403 278&jsessionid=4a30504b53cdfbc2c358514f52191032412a Flynn, Brian, John Worden, Janice Bunn, Laura Solomon, Takamaru Ashikaga, Scott Connolly, and Amelie Ramirez. 2010.

“Mass Media Intervention to Reduce Youth Smoking

Prevalence.” American Journal of Preventive Medicine 39:53-62. Hanauer, David, Emily Dibble, Jennifer Fortin, and Nananda Col. 2010. “Internet Use Among Community College Students:

Implication in Designing Healthcare Interventions.”

Journal of American College Health 52:197-202. Jackson, Erin, Carolyn Tucker, and Keith Herman. 2007. “Health Value, Perceived social work Support, and Health Self-Efficacy as Factors in a Health-Promoting Lifestyle.” Journal of

American College Health 56:69-74. Kwan, Matthew, Kelly Arbour-Nicitopoulos, David Lowe, Sara Taman, and Guy Faulkner. 2010. “Student Reception, Sources, and Believability of Health-Related Information.” Journal of

American College Health 5:555-562.

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Martinelli, Angela. 1999. “An Explanatory Model of Variables Influencing Health Promotion Behaviors in Smoking and Nonsmoking College Students.” Public Health Nursing 16:263269. Mayo, Ann and Steffanie Cobler. 2004. “Flu Vaccines and Patient Decision Making: What We Need to Know.” Journal of the American Academy of Nurse Practitioner 16:402-410. Minnesota State University Moorhead (MSUM). 2009. Institutional Research. Retrieved from http://www.mnstate.edu/publications/facts.html Nichol, Kristin, Sarah D’Heilly, and Edward Ehlinger. 2008. “Influenza Vaccination Among College and University Students: Impact on Influenza Like Illness, Healthcare Use and Impaired School Performance.” Archive of Pediatrics & Adolescent Medicine 162:1131118. Nicoteri, Julie and Emma Arnold. 2005. “The Development of Health Care-Seeking Behaviors in Traditional-Age Undergraduate College Students.” Journal of the American Academy

of Nurse Practitioners 17:411-415. Pender, Nola, Carolyn Murdaugh, and Mary Ann Parsons. 2006. Health Promotion in Nursing

Practice. (5th Ed). Upper Saddle River, NJ: Pearson Education Inc. Pressman, Sarah, Sheldon Cohen, Gregory Miller, Anita Barkin, Bruce Rabin, and John Treanor. 2005. “Loneliness, Social Network Size, and Immune Response to Influenza Vaccination in College Freshmen.” Health Psychology 24:297-306. Staten, Ruth and S. Lee Ridner. 2006. “College Students’ Perspectives on Smoking Cessation: “If the Message Doesn’t Speak to Me, I Don’t Hear It”.” Issues in Mental Health Nursing 28:101-115. Taylor, Melanie, Beverly Raphael, Margo Barr, Kingsley Agho, Gary Stevens, and Louisa Jorm.

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2009. “Public Health Measures During and Anticipated Influenza Pandemic:Factors Influencing Willingness to Comply.” Risk Management and Health Care Policy 2:9-20. Von Ah, Diane, Sheryl Ebert, Anchalee Ngamvitroj, Najin Park and Duck-Hee Kang. 2004. “Issues and Innovations in Practice: Predictors of Health Behaviors in College Students.”

Journal of Advanced Nursing 48:463-474.

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APPENDIX A

E-card

E- Mail Subject line: Your friends at Hendrix Health Center have sent you an urgent message Text accompanying the Health E-card

NO FLU 4 U

Your friend's personal message:

Did you know? Healthy students perform better academically. In a national survey conducted on college campuses in 2009, students indicated the #1 issue interfering with their academic performance was cold/flu/ sore throat. Don’t let the flu slow down your academic performance. Choose to protect yourself. Please open the Health E-greeting card for 4 tips on how to do that. One of them is to get your flu shot which the Center for Disease Control and Prevention (CDC) recommends for all students even if you are healthy. Annual flu shots are the most effective method for preventing influenza infection and its complications according to the CDC. NO FLU 4 U walk in flu shot clinic in room XXX of the Comstock Memorial Union on Wednesday, October XX from 10:00-5:00. Cost: $20. No appointment necessary. Less than 15 minutes waiting time.

DISCLAIMER: Comments and views expressed in the personal message feature are those of the individual sending the personal message and do not necessarily reflect those of the HealthReform.gov, the Department of Health and Human Services (DHHS) or the Federal government. DHHS does not control or guarantee the accuracy or relevance of the information sent in a personal message, nor does DHHS endorse any content or links provided therein.

78

Back

Send Flu.gov eCards

http://transparency.cit.nih.gov/flu_ecard/message.cfm?CFID=503074&CFTOKEN=69403278&js essionid=4a30504b53cdfbc2c358514f52191032412a Flu eCard

79

Right click to open the Hyperlink to the

APPENDIX B

Postcard

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FLU SHOTS FOR STUDENTS washing your hands

$0

covering your cough

$0

health center flu shot

$20

not being sick with the flu

priceless

you can’t predict but you can prepare get vaccinated!!

The CDC recommends that your college student get vaccinated. Wednesday Nov 12 CMU Room 227 11AM - 5PM