For several decades, researchers have identified reductionist tendencies in medicine that emphasize biological disease rather than the psychosocial complexity of individual patients as a major problem, not only in the clinical and institutional care of persons with dementia but also in geriatric education.1,2 In contrast, a more humanistic form of geriatric care would address neuropsychological symptoms and brain pathology while also bringing the individual into focus rather than the disease.1 Further, a more humanistic model of care for older adults would support the personhood of those affected by dementia, reduce the stigma associated with Alzheimer disease and related dementias (ADRD), and help preserve the meaningful interrelationships and valued social status of such patients.1
Previous investigators have found that clinical exposure to frail older adults during medical school can worsen student attitudes and engender negative regard for elderly persons that may carry over into future clinical practice.3,4 More recent research has shown that students report feeling not appropriately engaged in geriatrics, despairing of the effectiveness of care, and depressed by the decline and death of their patients.5 This research also indicates that students may consider communicating with older adults to be enjoyable but time-consuming and challenging, lacking intellectual stimulation and overwhelmingly complex.5 The attitudes students generate during medical school have an impact on the care they provide to older patients as health professionals6; therefore, education in medical schools has begun to invoke humanistic care of persons with dementia.7
A recent systematic review documented a variety of interventions that may improve medical students’ attitudes toward geriatric care by facilitating nonclinical interactions between students and elderly persons.6 Interventions included senior–junior student mentoring programs, experiential sessions with exposure to older patients, interactive activities involving simulated aging symptoms for students, game-based and community contact programs, and Web-based curricula.6 Physician-led home visit experiences have also generally improved medical students’ attitudes toward geriatric patients.8–10 These data suggest that geriatric experiences based outside of a hospital environment may positively affect students’ attitudes toward older patients—most likely because of their propensity to facilitate relationships that are not entirely oriented around biological illness. Thus, medical educators have argued that residential care settings and other such community-based venues should increasingly serve as “core teaching sites” for medical students and postgraduate medical trainees (residents).11
However, at present no known interventions use community-based venues to integrate creative arts—that is, activities including music, drama, graphic arts/cartooning, film, storytelling, and so forth—into geriatric education for medical students. Engagement with creative arts, either as an observer or as an active participant, can enhance moods, emotions, and other psychological states, as well as improve physiological parameters (blood pressure, heart rate variability, respiratory rates, etc.).12,13 Health psychologists have used a variety of creative modalities, such as music, reflective writing, photography, and photovoice (a method wherein a combination of photography and narrative allow participants to express perspectives in ways that educate the public and influence policies and programs), to heal psychological pain, to increase understanding and empathy, and to foster opportunities for self-reflection.14
The purpose of this study was to evaluate whether participation in a nonclinical, group-based creative storytelling program called TimeSlips at a local residential home would improve the attitudes of medical students toward patients with ADRD. In the 1990s Dr. Anne Basting,15 a theatre professor, developed TimeSlips, which is now practiced around the world. Unlike traditional reminiscence or recall therapies that evoke biographical details to capture a sense of who a person with ADRD was in the past, TimeSlips elicits an improvisational performance of self in the present moment. Traditionally, during TimeSlips sessions, groups of approximately a dozen individuals with ADRD join in a semicircle with caregivers. Each person with ADRD views a surreal, staged picture and is asked to use his or her imagination to make observations and tell stories about the people and objects in those pictures. Facilitators provide prompts (e.g., “What do you think is going on in the picture?” or “What should we name the characters?”), encouraging the participants to talk in the group. A scribe sequentially records all phrases spoken by the participants on a large pad of paper in order to build an unstructured narrative. Thus, at the end of each TimeSlips session, persons with ADRD (and those who have assisted them) have coauthored a collective free-form poem that is often whimsical and wide ranging, reflecting the personalities, experiences, and idiosyncrasies of individuals in the group. The activity is intended to help persons with ADRD exercise their imaginations—even in the face of memory loss and disorientation. In doing so, TimeSlips sessions underscore the inherent dignity of persons with ADRD by creating a valued social role for them and engendering playful yet substantive interaction.
A small evidence base has established that participation in TimeSlips can directly benefit the affect and communication skills of persons with ADRD.16 Further evidence indicates that participating in TimeSlips can nurture more positive views of individuals with ADRD among the staff who care for them and foster more frequent interactions and social engagement between staff and individuals with ADRD.17 More recently, the results of a pilot qualitative study suggested that participation in TimeSlips could improve medical students’ attitudes toward persons with dementia and highlighted a need for future quantitative research to substantiate these preliminary findings.18 Thus, in this study, we have tested the hypothesis that participating in TimeSlips would improve the attitudes of fourth-year medical students toward persons affected by dementia.
Study sites and population
We undertook this study as a partnership between Penn State College of Medicine (PSCOM) and Country Meadows (CM), a retirement community in south central Pennsylvania serving primarily older adults (hereafter, CM residents), that hosted the TimeSlips sessions. As part of an elective course entitled “Creativity and Narrative in Aging,” 22 fourth-year medical students participated in this study. Within their medical humanities curriculum, fourth-year medical students at PSCOM must take one 4-week humanities elective after they complete their medical school course work. PSCOM offered the elective in identical format in March/April 2010 and March/April 2011, which serve as the two study periods for this research.
Recruitment and ethical considerations
Twenty-two students (15 in 2010 and 7 in 2011) joined approximately 20 CM residents affected by ADRD who lived at CM. The course directors running the elective required all students in Creativity and Narrative in Aging to participate in TimeSlips as part of the class service–learning component; however, the students could choose whether or not to participate in the study. All students chose to participate and signed informed consent documents two weeks before the TimeSlips sessions began. The principal investigator (D.R.G.) reminded students at the beginning of the course that they could withdraw from the study at any point without penalty and that their grades would not be affected by participation or by their responses to the survey. Students were not formally evaluated on the quality of their participation in TimeSlips, but they were required to attend all sessions as part of the course.
Managers at CM used institutional review board (IRB)-approved inclusion criteria to identify CM residents eligible for the study: persons with ADRD who (1) would potentially benefit from a storytelling activity (i.e., persons who were verbal), (2) could provide personal consent and/or the consent of a caregiver for participation, and (3) lived on the memory support unit (i.e., the locked unit for persons with advanced dementia). We collected no demographic or personal data from the CM residents, though we did gain informed consent for their participation. We offered no incentives to CM residents for their participation. We obtained ethical approval from the IRB of both PSCOM and CM.
Using official training resources obtained at www.timeslips.org and modeling the storytelling process, the principal investigator (D.R.G.), a certified TimeSlips facilitator, conducted student training during two hours of classroom time. Students also attended an educational session at the retirement community to learn how to optimally interact with residents using the Validation Technique, which discourages reality-orientation and nurtures empathy toward persons with memory problems.19
At each of eight visits to the retirement community (four in 2010 and four in 2011), we separated the students into two groups of approximately equal numbers (seven and eight in 2010; three and four in 2011). Approximately 10 CM residents with ADRD were in each group. Student and CM resident groupings varied from visit to visit. During each session, students used approximately four images (either TimeSlips pictures downloaded from the Web site www.timeslips.org or original artwork created by Molly McInnis, a nurse at Penn State Hershey Medical Center, and donated for use during the Creativity and Narrative in Aging course).
Students took turns serving as facilitators, scribes, and storytellers with the residents. Students acting as facilitators prompted the residents with questions about the imagined events taking place in the pictures while students acting as storytellers sat next to the residents, repeating the facilitator’s questions and offering encouragement. One scribe in each group transcribed each verbalized response onto a pad of paper. At the end of each story, the scribe would read the narrative and query the CM residents about what they wished to title it. One story produced by CM residents and facilitated by PSCOM students, as well as the image that inspired it, is available as Supplemental Digital Appendix 1 (http://links.lww.com/ACADMED/A127).
Family caregivers and staff from the retirement community joined students on each visit to minimize potential risk to students and residents. The PI attended and oversaw each session, which lasted approximately 90 minutes including a postsession debriefing. The debriefings occurred in a lobby at CM, lasted 5 to 10 minutes, and entailed the students reflecting on the quality of the session and sharing their impressions about their own sense of comfort and command with TimeSlips.
Survey data collection
We administered the Dementia Attitudes Scale (DAS),20 a paper-and-pencil instrument that can be completed in fewer than five minutes, to all students both before and after their participation in the TimeSlips sessions. The DAS requires respondents to endorse their level of agreement with 20 statements on a seven-point Likert-like scale (where 1 = strongly disagree, 4 = neutral, and 7 = strongly agree). Higher scores indicate more positive attitudes toward people with ADRD, so negatively worded items are reverse-coded. Researchers have developed and validated the DAS for use with college students and direct care workers using structured interviews, qualitative concept mapping, exploratory factor analysis, convergent validity testing, and confirmatory factor analysis.20 Using concepts from previously existing self-report instruments for other disabilities, the creators of the DAS sought to meet a need in the global culture change movement for dementia care1 by developing an instrument to accurately assess attitudes toward persons with dementia and to observe the conditions under which attitudes become more positive.20 The instrument queries respondents about their perceptions of the competence and emotional well-being of people with ADRD, and about the reactions and feelings they think they might experience in the presence of an agitated person with ADRD. It contains an underlying two-factor coded structure for “knowledge” and “comfort” that serve as the scale’s subdomains. Four weeks passed between the pre- and post-session administration of the DAS. All 22 students took the DAS as a pretest on the first day of class and as a posttest on the final day of class.
We collected both the pre- and post-intervention DAS survey results from 2010 and 2011, pooling the results from these two study periods. We entered the data into a DAS-specific database and conducted our analysis using SPSS (Version 20; Chicago, Illinois). If one variable was normally distributed, then we used paired t tests to evaluate the mean change in the students’ self-reported attitudes toward individuals with ADRD at both pre- and post-session. If one variable was not normally distributed at either pre- or post-session, then we used the Wilcoxon signed-rank test to evaluate the mean change. We calculated all these statistical tests with α = 0.05. Although ideally a scale’s psychometric properties, which include at least a confirmatory factor analysis for factorial validity test, should be tested before being applied to a new sample,21 we did not determine the psychometric sample of the scale for this study because of the sample size.22 The original DAS was well developed and rigorously tested, including testing among a sample of medical students similar to our study population of 22 fourth-year medical students.20 This auspicious history made our use of the DAS reasonable.
We used Cronbach alpha23 to determine internal reliability; however, our analysis of internal reliability was preliminary because of our small sample size (especially since many believe that even a sample size of 300 is “small” for a reliable estimate of Cronbach alpha).24
All 22 students (100%) completed the study. Of these students, 12 were male and 10 were female. Sixteen students self-identified as Caucasian, 2 as black, and 4 as Asian/Pacific Islander. The average age of the students was 26.5 years.
Table 1 summarizes the results of comparisons pre and post intervention of the DAS scores on the individual items, on the two subdomains, and on the overall scale. The scores of all the individual items, except one (no. 6, “I feel uncomfortable being around people with ADRD”), showed an improvement, post participation in TimeSlips, in students’ attitudes toward people with ADRD. Of the 19 improved postintervention scores, 12 were statistically significant (P < .05). The relative improvement of these 19 items ranged from a 1.63% increase for item no. 18 (“I admire the coping skills of people with ADRD”) to a 50.56% increase for item no. 1 (“It is rewarding to work with people who have ADRD”). The absolute change of item no. 6 (the single item with a lower postintervention score) was only −0.09 (a 1.52% decrease); this item was reverse-coded because it contains the word “uncomfortable.” The two subdomains of the DAS also showed statistically significant improvement after the TimeSlips sessions: Scores improved 9.94% in the knowledge domain and 24.15% in the comfort domain. Further, the overall DAS scale score showed statistically significant improvement (16.02%).
The preliminary internal consistency reliabilities as estimated by the Cronbach alpha for the subdomains and the overall DAS are summarized in Table 2. The comfort domain had “acceptable” reliabilities (0.8 > α ≥ 0.7) at both of the pre- and post-sessions, the knowledge domain had “acceptable” reliability at presession and “good” reliability at postsession (0.9 > α ≥ 0.8), and the overall DAS had “good” reliability (0.9 > α ≥ 0.8) at both sessions.
Discussion and Conclusions
Previous research has suggested that participating in nonclinical geriatric experiences may improve students’ attitudes toward persons with ADRD, and the results of this study add preliminary statistical data to those findings. Our findings confirm that an arts-based, creative storytelling activity in a community-based venue can significantly improve medical students’ attitudes toward persons with ADRD. In the context of contemporary medical education, such findings are significant. During medical school, interactions between students and persons with ADRD are often confined to clinical encounters with patients whose challenging cognitive problems become the focal point of the interaction. Providing arts-based educational experiences for students may foster more positive attitudes toward this patient population by removing students from purely clinical interactions with aging persons and allowing less formal relationships to evolve around a playful, cocreative activity. Such improved attitudes could contribute to students taking a more humanistic and psychosocially oriented approach to the care of geriatric patients—not to mention persons affected by any medical condition—and perhaps motivate more students to pursue careers in geriatrics. As the incidence of ADRD rises precipitously in industrialized nations as well as in low- and middle-income countries,25 the demand for high-quality geriatric care will become more and more urgent in modern health care systems, including that of the United States.26,27
The findings from the comparison of pre- and post-session on the 20 individual DAS items, on the two subdomains, and on the overall scale are encouraging. Only one item (no. 6) showed a very slight decrease (−1.52%). Additionally, the statistically nonsignificant results on 8 of the 19 remaining items may be due to insufficient power given the small sample size in this study. Although the results of our internal consistency analysis are preliminary because of the small sample size, they add to the evidence supporting the reliability of the DAS, which had a Cronbach alpha of 0.83 as reported by the original author.20
This study has several limitations. The sample size is small and confined to one residential facility (for, among others, people with ADRD) and one group of medical students, and the intervention lacked a control. Because of curricular restrictions, introducing randomization in this medical education research project was not possible. Further, although our findings were positive, whether specific educational interventions in geriatrics have only an immediate or a long-lasting effect on the knowledge, skills, and attitudes of medical students toward older adults is unclear. In future research, investigators could apply an educational theory such as transformative learning28 to a longitudinal study of TimeSlips to see if, and how, the attitudes of medical students or other populations shift over time. Future research could also involve larger numbers of students and wider ranges of patients from different facilities and/or a control intervention that focuses on a conventional form of therapy. Given the increasing emphasis on interprofessionalism in academic medicine, studying the effects of TimeSlips on the attitudes, communication skills, and future career paths of interprofessional teams of students, particularly those in the earlier stages of their educations, might be fruitful. Researchers might also consider examining the pre and post attitudes of persons with ADRD to evaluate their perceptions of medical students as well as the overall effect on quality of life or other psychosocial modalities.
Acknowledgments: The authors wish to thank Joel Kroft and staff at Country Meadows for their collaboration on this research.
Other disclosures: D.R.G. has served on a volunteer advisory board for TimeSlips with no financial stakes in the project. The authors report no conflict of interest.
Ethical approval: Ethics approval was obtained from institutional review boards at both Penn State College of Medicine and Country Meadows.
1. Kitwood TM Dementia Reconsidered: The Person Comes First. 1997 Philadelphia, Pa Open University Press
2. Whitehouse PJ, George DR The Myth of Alzheimer’s: What You Aren’t Being Told About Today’s Most Dreaded Diagnosis. 2008 New York, NY St. Martin’s Press
3. Brooks TR. Attitudes of medical students and family practice residents toward geriatric patients. J Natl Med Assoc. 1993;85:61–64
4. Griffith CH 3rd, Wilson JF. The loss of student idealism in the 3rd-year clinical clerkships. Eval Health Prof. 2001;24:61–71
5. Bagri AS, Tiberius R. Medical student perspectives on geriatrics and geriatric education. J Am Geriatr Soc. 2010;58:1994–1999
6. Tullo ES, Spencer J, Allan L. Systematic review: Helping the young to understand the old. Teaching interventions in geriatrics to improve the knowledge, skills, and attitudes of undergraduate medical students. J Am Geriatr Soc. 2010;58:1987–1993
7. George DR. Humanities in a rapidly aging world: The TimeSlips Project at Penn State College of Medicine. Int J Healthc Humanit. 2011;6:9–17
8. LoFaso VM, Breckman R, Capello CF, Demopoulos B, Adelman RD. Combining the creative arts and the house call to teach medical students about chronic illness care. J Am Geriatr Soc. 2010;58:346–351
9. Yuen JK, Breckman R, Adelman RD, Capello CF, LoFaso V, Reid MC. Reflections of medical students on visiting chronically ill older patients in the home. J Am Geriatr Soc. 2006;54:1778–1783
10. Flaherty JH, Fabacher DA, Miller R, Fox A, Boal J. The determinants of attitudinal change among medical students participating in home care training: A multi-center study. Acad Med. 2002;77:336–343
11. Kanter SL. The nursing home as a core site for educating residents and medical students. Acad Med. 2012;87:547–548
12. Stuckey HL, Nobel J. The connection between art, healing, and public health: A review of current literature. Am J Public Health. 2010;100:254–263
13. Staricoff R, Loppert SKirklin D, Richardson R. Integrating the arts into health care: Can we affect clinical outcomes? In: The Healing Environment Without and Within. 2003 London, UK Royal College of Physicians:63–80
14. Camic PM. Playing in the mud: Health psychology, the arts and creative approaches to health care. J Health Psychol. 2008;13:287–298
15. Basting AD Forget Memory: Creating Better Lives for People With Dementia. 2009 Baltimore, Md Johns Hopkins University Press
16. Phillips LJ, Reid-Arndt SA, Pak Y. Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia. Nurs Res. 2010;59:417–425
17. Fritsch T, Kwak J, Grant S, Lang J, Montgomery RR, Basting AD. Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers. Gerontologist. 2009;49:117–127
18. George DR, Stuckey HL, Dillon CF, Whitehead MM. Impact of participation in TimeSlips, a creative group-based storytelling program, on medical student attitudes toward persons with dementia: A qualitative study. Gerontologist. 2011;51:699–703
19. Feil N The Validation Breakthrough: Simple Techniques for Communicating With People With “Alzheimer’s-Type Dementia. 1993 Baltimore, Md Health Professions Press
20. O’Connor ML, McFadden SH. Development and psychometric validation of the Dementia Attitudes Scale. Int J Alzheimers Dis. 2010;2010:Article ID 454218. doi:10.4061/2010/454218
21. Zumbo BDRao CR, Sinharay S. Validity: Foundational issues and statistical methodology. In: Handbook of Statistics 26: Psychometrics. 2007 Boston, Mass Elsevier:45–79
22. Kline RB. Introduction. In: Principles and Practice of Structural Equation Modeling. 20052nd ed New York, NY Gulford Press:3–19
23. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297–334
24. Segall DO. The reliability of linearly equated tests. Psychometrika. 1994;59:361–375
25. Ferri CP, Prince M, Brayne C, et al.Alzheimer’s Disease International. Global prevalence of dementia: A Delphi consensus study. Lancet. 2005;366:2112–2117
27. Bartels SJ, Naslund JA. The underside of the silver tsunami—Older adults and mental health care. N Engl J Med. 2013;368:493–496
28. Mezirow J. Transformative Dimensions of Adult Learning. 1991 San Francisco, Calif Jossey-Bass