Cognitive Behavioral Therapy and Ageism
Condition: Ageism
Study type: Interventional

Summary: 
      Background: Healthcare settings must be a patient-friendly environment for the investigator's
      older adults who are in an imperative need for compassionate healthcare when approaching
      their later life. However, older adults until this moment are experiencing age discriminative
      acts by nurses who are supposed to act in favor of their patients. Ageism is not always a
      result of either negative attitudes or misconceptions toward older adults, but to the innate
      fear of death where nurses perceive older adults as a powerful reminder of death. Although
      cognitive-behavioral therapy (CBT) is well known for targeting psychological distresses, to
      date, no research has investigated its effectiveness in relieving nurses' death anxiety and
      ageism. This study examined the effectiveness of CBT to relieve nurses' death anxiety and
      ageism toward older adults.

      Methods: A randomized controlled trial was conducted during August 2019 in the university
      hospital. A total of 110 nurses selected through proportional stratified sampling and
      randomly assigned to the experimental and control groups. The intervention consisted of six
      two-hour training sessions delivered in five modules with the integration of different CBT
      exercises. The effect of CBT was assessed on measures of a series of validated questionnaires
      of study variables before and after the training sessions.
    

Detailed description: 
      Procedure After getting the IRB approval and completing the informed consent procedure, the
      researchers met with the administrator of the hospital to (1) discuss the inclusion criteria
      and obtain a list of eligible participants, (2) discuss the workflow of the study procedure,
      and (3) agree on the time/date of site visits to collect the data and run the CBT sessions
      based on the convenience of nurses and their work schedule. After having a list of all
      eligible nurses recorded in an excel sheet, the researcher randomly assigned the nurses into
      control and intervention groups using Excel's RAND function. After randomization was
      performed, the researchers distributed the pretest questionnaires to the nurses in both
      groups and asked them to drop the completed questionnaires in the designated box next to the
      front desk of their work department. Three days later the researchers collected the
      questionnaires.

      Intervention The CBT intervention was carried out through six two-hour sessions over a month.
      The intervention group was divided into three subgroups of 18 to 19 nurses each. It was
      required for each subgroup to attend two CBT sessions to complete the intervention. The main
      objective of the CBT was to improve nurses' senses of self-esteem, interpersonal
      relationship, and symbolic immortality. The CBT was guided by the five-factor model, which
      extensively used within the context of CBT (Bagby, Gralnick, Al-Dajani, & Uliaszek, 2016). A
      detailed description of the model was discussed in previous recent studies (Bagby et al.,
      2016; Hawley et al., 2017). The model explains the interactions between beliefs, attitudes,
      emotions, and behaviors. The intervention emphasized on how nurses can reinforce and enhance
      their anxiety buffering system by an improved understanding of how unconscious realization of
      eventual mortality affects explicit attitudes. Throughout the intervention, nurses were
      trained about the five-factor model and therapeutic beliefs, emotions, attitudes, and
      behaviors pertinent to death anxiety. The differences between therapeutic and nontherapeutic
      coping strategies of death anxiety were identified and discussed with nurses in the
      intervention group.

      The CB therapist followed the same structure in the delivery of each CBT session. The CBT
      session was delivered in five modules: generating objectives and outcomes, enhancing
      self-esteem and interpersonal relationships, changing beliefs regarding symbolic mortality,
      and changing attitudes regarding death anxiety. The CBT was tailored to meet the training
      needs of nurses based on the analysis of pretest questionnaire scores. The first session
      began with highlighting the objectives of the CBT. Then, a detailed presentation of the
      intervention modules was provided to the nurses with the integration of CBT exercises,
      including cognitive restructuring, graded exposure, mindfulness meditation, interpersonal
      skills training, and activity scheduling.

      . At the end of the first session, the nurses were assigned to solve some homework questions
      relevant to the CBT exercises. The second session began with a brainstorming of the CBT
      training assignments from the first session. Then thoughts and understandings of training
      assignments and reflection on life stories or real experiences of alternative therapeutic
      behaviors were discussed. The CBT therapist was an experienced certified psychologist with a
      Ph.D. degree in Applied Psychology.

      The nurses in the control group were divided into the same number of subgroups as the CBT
      nurses and trained by an experienced gerontological nurse who provided two consultations of
      120 minutes for each subgroup. The main objective of the consultations was to instruct the
      nurses on how to deal with or care for older adults with respect and dignity as well as
      eliminate any ageist attitudes that they might have. The control group did not receive active
      advice or referrals to a psychologist or CBT therapist. During the consultations, the nurses
      received written and verbal information about the atypical presentation of illnesses and the
      most common misconceptions related to aging. The nurses in the control group had the
      opportunity to discuss and reflect on their own experiences in caring for older adults and
      other geriatric care-related issues. The consultations were nurse-centered, goal-oriented,
      and guided by nurses' questions. On the last day of the training for each group (intervention
      and control), the nurses were asked to fill out the posttest questionnaires and return them
      to the researchers.

      Measures Outcome variables were measured twice; pre and posttest. The primary outcomes in the
      current were death anxiety and ageism, while the secondary outcomes self-esteem,
      interpersonal relationship, and symbolic immortality.

      Primary Outcome Measures Death anxiety. Death anxiety was measured using The revised
      Collett-Lester Fear of Death Scale (CL-FODS) (Lester & Abdel-Khalek, 2003). The CL-FODS is a
      28-item scale measure death anxiety about four main aspects of death and dying, including: "
      your own death,"; "your own dying"; " the death of others,"; and " the dying of other". Each
      subscale has seven items answered on a 3-point intensity scale (ranged from 1= "no" to 5=
      "very"). The CL-FODS had very satisfactory reliability scores ranged from .88 to .93, and
      good internal consistency scores ranged from .74 to .90 in the original study. In the current
      study, the internal consistency reliability was satisfactory (Cronbach's alpha= 0.79) Ageism.
      The Fraboni Scale of Ageism (FSA) (Fraboni et al., 1990) was used to measure nurses' ageist
      attitudes toward older adults. The FSA is a 29-item scale measuring the attitudinal and
      affective aspects of ageism. The FSA has three positive items (e.g., "Old people can be very
      creative"), which were reverse coded before calculating the total score. Each item of the FSA
      has four possible responses, including: "1= strongly disagree,"; "2= disagree,"; " 3=agree,";
      and " 4= strongly agree". The possible range of the total score of the FSA is from 29 to 116.
      Higher scores indicate greater levels of ageist attitudes. The internal consistency
      reliability of the FSA in this study was high (Cronbach's alpha = 0.89), which is very close
      to the original research (0.86) (Fraboni et al., 1990) Secondary Outcome Measures
      Self-esteem. Nurses' self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES)
      (Rosenberg, 2015). The RSES has five positive (e.g., "I take a positive attitude toward
      myself") and five negatives (e.g., "I feel I do not have much to be proud of") items. The
      nurses responded to these items using a 4-point Likert scale ranging from 1= "strongly
      disagree" to 4= "strongly agree." The total score of the RSES was calculated after reverse
      coding of the negative items yielding a range from 10 to 40, with higher scores indicating
      greater levels of self-esteem. The Cronbach's alpha reliability of the RSES in this study was
      high (0.91) Interpersonal relationship. Nurses' interpersonal relationships were measured
      using the Interpersonal Reactivity Index (IRI) (Davis, 1980). The IRS has four subscales
      consisting of five positive and two negative items each. The subscales include
      perspective-taking, fantasy, empathic concern, and personal distress. The nurses responded to
      the 28 items of IRS with five responses ranging from 0=" Does not describe me well" to 4=
      "describes me very well." The total score of the IRS was calculated after reverse coding the
      negative items, yielding a range from 0 to 112. The Cronbach's alpha reliability of the IRI
      in this study was very good (0.81) Symbolic immortality. Symbolic immortality was measured
      using the Sense of Symbolic Immortality Scale (SSIS) (Drolet, 2007). The SSIS contains 11
      negatives (e.g., nothing interesting happens in my life) and positive (e.g., I feel that I am
      doing what I want in life) items about areas of life showing the desire for symbolic
      immortality. The nurses responded to these items using a Likert scale of five choices ranging
      from 1 = "strongly disagree," to 5 = "strongly agree." The total score of the SSIS was
      calculated after reverse coding the negative items, yielding a range from 26 to130. Higher
      scores indicate a greater sense of symbolic immortality. The SSIS had good internal
      consistency in this study (Cronbach alpha = 0.86).

      Other Measures Demographic questionnaire. The demographic data of nurses such as age, gender,
      level of education, years of clinical experience, marital status, and the number of older
      adults living in their households were collected by asking the nurses to fill out the
      demographic questionnaire.

      Data Analysis IBM SPSS Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp) was used
      for the analysis of all statistical tests in this study. Descriptive statistics, including
      mean, standard deviation, and frequency were used to describe the nurses' levels of
      self-esteem, interpersonal relationship, sense of symbolic immortality, death anxiety, and
      ageism as well as sociodemographic and professional characteristics. Independent t-tests were
      used for comparisons between the intervention and control groups in the main variables of
      interest. For comparisons between the pre and posttest scores of nurses in both groups,
      paired t-tests were used. Hierarchical multiple regression was used to examine the
      significant predictors of nurses' ageism. The order of entry of the variables into the
      regression model was based on their order in the TMT. Death anxiety was entered in the final
      step into the regression model as it is the main independent variable of ageism.
    

Intervention name(s): Cognitive Behavioral Therapy
Intervention type(s): Behavioral
Intervention description(s): The CBT intervention was carried out through six two-hour sessions over a month. The intervention group was divided into three subgroups of 18 to 19 nurses each. It was required for each subgroup to attend two CBT sessions to complete the intervention.
The CB therapist followed the same structure in the delivery of each CBT session. The CBT session was delivered in five modules: generating objectives and outcomes, enhancing self-esteem and interpersonal relationships, changing beliefs regarding symbolic mortality, and changing attitudes regarding death anxiety. The first session began with highlighting the objectives of the CBT. Then, a detailed presentation of the intervention modules was provided to the nurses with integration of CBT exercises, including cognitive restructuring, graded exposure, mindfulness meditation, interpersonal skills training, and activity scheduling
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Treatment
Keywords: Cognitive Behavioral Therapy; Older Adults; Nurses; Death anxiety; Randomized Clinical Trials