Testing the Effectiveness of Cognitive Behavioral Therapy in Relieving Nurses' Ageism Toward Older Adults

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.