Interprofessional Socialization And Valuing Scale Research Articles

Impact of a Grand Rounds Interprofessional Workshop: student perceptions of interprofessional socialization and cultural humility

ABSTRACT While uniprofessional education programs develop strong student identities, they may limit the development of behaviors needed for interprofessional socialization. Interprofessional education (IPE) creates an essential platform for student engagement in the development of interprofessional socialization and cultural humility, thus enabling improvement in collaborative communication. In this quasi-experimental observational study, health professional students attended one of three Grand Rounds Interprofessional Workshops (GRIW) and completed online pre- and post-workshop surveys including sociodemographic background, the Interprofessional Socialization and Valuing Scale (ISVS), and the Cultural Competence Self-Assessment Checklist (CCSAC). A total of 394 students from eight professions participated in the workshop with 287 (73%) of attendees completing both pre- and post-workshop surveys. No significant differences were observed in ISVS and CCSAC scores between students across workshops. Significant pre- to post-workshop differences were found in ISVS [t (284) = 13.5, p < .001, 95%], CCSAC [t (286) = 13.8, p < .001] and the cultural competence components of cultural awareness [t (285) = 12.9, p < .001, 95%], knowledge [t (285) = 9.5, p < .001, 95%], and skills [t (286) = 13.3, p < .001, 95%]. Interprofessional education learning opportunities that integrate socialization with health professional students and cultural humility education can improve educational awareness of cultural values and communication for collaborative professional practice.

Adaptation and validation of the Interprofessional Socialization and Valuing Scale (ISVS) in Spanish university health sciences students

ABSTRACT Many interprofessional education programs are being designed to help students improve their collaborative practice. Traditionally, the evaluation of these programs is focused on attitudes, knowledge and skills, but according to some authors, the evaluation of these activities should be expanded to include the evaluation of the development of an interprofessional identity. The Interprofessional Socialization and Valuing Scale (ISVS) is a self-report tool used to measure interprofessional socialization, but it has not been validated with Spanish students. In this study, the tool was translated into Spanish and administered to a sample of 645 undergraduate students. The data were analyzed to estimate structural validity, internal consistency and convergent validity. Regarding the structural validity, our data supported the unidimensional model found in the English version of the ISVS-21 (normed chi-square = 2.3, RMSEA = 0.045, SRMR = 0.087, CFI = 0.963 and TLI = 0.969). The internal consistency reliability of the scale was adequate, Cronbach α = 0.913 [95% CI 0.903, 0.923]. The Spanish version of the ISVS-21 shows adequate psychometric properties in terms of the construct validity (structural validity and convergent validity) and internal consistency of its scores. This study provides the Spanish-speaking population with an adaptation of the only instrument that has been specifically developed to assess interprofessional socialization.

Geriatric Interprofessional Simulation Education Results and Rapid Cycle Quality Improvement

Following a geriatric interprofessional education event, we measured learner progression in interprofessional collaborative competencies using the Interprofessional Socialization and Valuing Scale (ISVS). We also measured student satisfaction with an investigator generated assessment tool. Through Rapid Cycle Quality Improvement (RCQI) processes, we implemented a number of variations of both the in-person and the virtual events. Variations included differences in case studies, pre work requirements, geriatric didactic topics, poster topics and presentation format, facilitator training, standardized patient or patient presence, huddle format, and demonstration of how to effectively perform teamwork. Results showed gains in interprofessional collaborative competencies between pre- and post-education using this geriatric simulation model. Learner satisfaction was high for all simulation variations. Results of education variations and comparisons of the delivery methods will be presented.

Utilizing an interprofessional case conference series to teach care transitions in pharmacy and nursing curriculum

IntroductionSafe and effective care transitions require interprofessional collaboration, but there is limited literature on interprofessional strategies to teach care transitions. The objective was to evaluate student pharmacist and nurse readiness for change towards interprofessional collaborative practice during care transitions. MethodsInterprofessional teams were instructed to collaborate and provide care for their patient throughout multiple healthcare transitions. Students were asked to complete the Interprofessional Socialization and Valuing Scale (ISVS) 9A/9B, the nine-item set version, prior to implementation of the case conference series and after the activity debrief. ResultsThere was an increase across six items from the ISVS scale for pharmacy students and eight of nine for nursing students. There were significant changes in two of nine items for the pharmacy groups and three of nine in the nursing group. ConclusionsAn interprofessional case conference series demonstrated a significant increase in student pharmacist and student nurse awareness of the importance of working within a team during care transitions, as well as an appreciation towards their role within the interprofessional team.

Blending interprofessional education and simulation learning: A mixed-methods study of an interprofessional learning experience with nursing and occupational therapy students

ABSTRACT In aiming to train health professional students to collaborate in patient care settings, the purpose of this study was to evaluate the perception of registered nurse (RN) students and occupational therapy (OT) students jointly participating in an interprofessional education (IPE) patient simulation learning experience. Eighty-five RN and OT students engaged in a 3-hour IPE patient simulation in an acute care hospital setting. Each student participant completed a pre- and post-test data collection, assessing interprofessional socialization using the Interprofessional Socialization and Valuing Scale (ISVS) Version 9A and provided qualitative feedback about their experience. Findings indicated a significant change in interprofessional socialization for RN and OT students after engaging in the IPE patient simulation learning experience. Furthermore, qualitative findings described the perceived benefits of IPE and collaboration, simulation as a learning tool, and areas for enhancing IPE patient simulation education for the future. Study findings have implications for using simulated IPE experiences with health professional students to foster interprofessional collaboration and socialization with the goal of delivering person-centered quality healthcare.

Challenges to Interprofessional Education: will e-Learning be the Magical Stick?

PurposeIn Egypt, the main challenges to interprofessional education (IPE) implementation are complexity of the required curricular design, the attitudinal barriers between professions, and the needed resources. Action research work was planned and implemented to identify alternative solutions to overcome barriers to IPE in the local Egyptian context.Methods-An 8-week e-learning elective course was developed, implemented, and evaluated. A mixed group of 30 nursing and medical students was enrolled voluntarily in the course. Female to male ratio was 3:2. Four faculty members were assigned to manage the course. Based on the EMRO-WHO guidelines, ethics content was selected and organized. A closed Facebook group was created and utilized as the e-learning platform. Facilitated large-group and case-based discussions were the main instructional methods. Scoring of mixed small group assignments was the main assessment tool. Course evaluation was conducted using the Interprofessional Socialization and Valuing Scale (ISVS) and an Online-Course Evaluation Questionnaire (OCEQ).ResultsISVS results revealed that students’ perception of ability, comfort and value in working with others, were all positive. The OCEQ provided additional evidence regarding the satisfaction of students with the Facebook group as a learning platform. Assignment submission rate was 90%. Success rate of small group assignments (scores ≥ 60%) was 100%. Response rate to the open online discussions was 63%. Through peer evaluation as well as direct observation of online discussions, there was evidence of distinct contributions by females and by medical students compared to nursing students.ConclusionAs evidenced by the students’ perception and performance, our IPE distance learning experience was valuable. Motivation of medical students as well as females was evident. IPE is a challenging process. The elective approach and using DL can offer solutions. Conducting relevant practical sessions as well as sustainability of this IPE e-learning experience remain key challenges.

Perceptions of socialization in interprofessional practice among health science students and first-year practicing professionals

Abstract Background Interprofessional education (IPE) is integrated into health science programs with a goal to prepare practice ready graduates who are able to collaborate effectively. Purpose: The purpose of this study is to explore the perceptions of health science students and first-year practicing professionals from a variety of disciplines (medical imaging, nursing, occupational therapy, physical therapy, and speech-language pathology) on interprofessional socialization as it occurs in clinical environments in order to identify gaps that may exist between education and practice. Method A mixed-methods design was used to understand the perceptions of 98 health science students and first-year practicing professionals (medical imaging, nursing, occupational therapy, physical therapy, and speech-language pathology) using the Interprofessional Socialization and Valuing Scale (ISVS) along with four open-ended descriptive questions and demographic data. Descriptive statistics examined the ISVS survey responses and thematic analysis was used to explore the perceptions of the participants. Results Survey results indicated that students gained an appreciation for the benefit in interprofessional teamwork and the lowest scores relating to comfort being the leader in a team setting and comfort speaking out within a team. These findings are consistent with the qualitative themes of workplace culture, professional role identity, and worthiness of interprofessional education that emerged from the data. Conclusion This study adds a unique perspective on the experiences of health science students and first-year practicing professionals on interprofessional socialization in the clinical environment. The study suggests that although the value of collaborative practice is emphasized in academia, further strategies are necessary to help prepare students to navigate the transition from interprofessional education (IPE) to interprofessional practice (IPP).

Interprofessional learning during SARS-CoV-2 (COVID-19) pandemic conditions: the learning project I-reCovEr as a substitute for a rotation on an interprofessional training ward.

The COVID-19 pandemic has led to massive and aprupt changes in the training of health care professionals. Especially hands-on training can no longer take place in the usual form in everyday clinical practice. Rotations on the interprofessional training ward in Pediatrics (IPAPAED) at the University Medical Center Freiburg, had to be suspended starting March 2020. This report presents the interprofessional Covid-19 Replacement Program (I-reCovEr) as an alternative learning format for a rotation on the IPAPAED at the Center for Pediatric and Adolescent Medicine. I-reCovEr offers opportunities for pediatric nursing trainees (n=6) and medical students (n=9) to learn together, taking hygienic and distancing measures into account. Based on a case study, selected learning aspects regarding interprofessional cooperation and communication are targeted. The participants report increased knowledge about the work of the other professional group in the evaluation using the Interprofessional Socialization and Valuing Scale (ISVS) -9A. In comparison to participants of the IPAPAED, however, the self-evaluation did not reveal any self-perceived acquisition of other interprofessional skills or competences. I-reCovEr can therefore serve as an introduction to interprofessional training, but it cannot replace interprofessional learning and working on an interprofessional training ward.

Utilizing an Interprofessional Value Scale to Optimize Team Assessment

Wayne State University Interprofessional Team Visit (IPTV) is a program that introduces medical, nursing, occupational therapy, pharmacy, physical therapy, physician assistant, dental, and social work students to working in a collaborative team during an older adult home visit assessment. This 60-minute visit, students ask questions about the older adult’s daily activities, nutrition, medications, family health, and social supports. Interprofessional education is crucial for health care delivery, there is a need to evaluate the engagement of students in teams. The Interprofessional Socialization and Valuing Scale (ISVS), measures self-perceived experiences with collaborative teamwork, including the ability, value, and comfort in working with others. The ISVS tool was used to evaluate educational experiences of students. There are 18 questions pertaining to perceptions of what students have learned from other disciplines. Students respond to each statement using a 7-point scale with 1 = “Not at All” and 7 = “To a Very Great Extent.” The Pre and Post data discuss the differences between groups of students in feeling comfortable working in teams. The feedback ensure better care, value, and education of future healthcare practitioners.

Engaging the community through a longitudinal, interprofessional, interinstitutional experiential learning collaboration

Background Interprofessional education (IPE) and training in community settings is not commonly described in the literature. Studies primarily focus on clinical education of interprofessional teams in clinical practice and primary care. This is a description of a longitudinal, collaborative interinstitutional IPE project that engages community partners (CP) while delivering core IPE competencies.Interprofessional Education Activity: Twenty-seven students from five universities representing ten healthcare academic programs participated in the project. Participating CP were non-profit agencies developed to meet the needs of specific vulnerable, underserved populations. Students were divided into teams and then paired with CP. This was a six-month project, with students committing to 30 hours over two semesters. At the end of the project, students presented project deliverables to CP, faculty collaborative and other students. Interprofessional education collaborative (IPEC) domains were qualitatively assessed and students completed the Interprofessional Socialization and Valuing Scale (ISVS) at the beginning and conclusion of the project. Students provided written reflections at the conclusion of the project. Faculty completed the Team Observed Structured Clinical Encounter (TOSCE).Discussion” Twenty-seven students (100%) students completed the project and twenty-one students (77.8%) completed the evaluation tools. Students demonstrated a statistically significant difference between pre- and post-project ISVS total scores (5.81 +/− 0.64 vs. 6.51 +/− 0.37). Teamwork, communication skills, and increased comfort with those from other professions were common themes in the student reflections.Implications: Community-based IPE provides a venue for healthcare professionals to engage and partner with community organizations. This project demonstrates an effective inter-institutional, interprofessional method of delivering IPE.

Safe Place

Interprofessional collaborative practice (ICP) is an essential skill in today’s healthcare environment that can be cultivated through interprofessional education (IPE) in higher education, as students are in the process of developing their professional identities. Undergraduate social work field students and nursing students in clinical rotation explored their experiences together in clinical supervision groups co-led by instructors from both fields. Researchers used a mixed methods approach to measure changes in feelings and skills related to ICP among students who participated in clinical supervision groups. Eighteen nursing and social work students participated; those involved in the interprofessional clinical supervision groups performed better on the Inter-professional Socialization and Valuing Scale (ISVS) than the comparison group. Qualitative themes indicated that students enhanced their interprofessional knowledge; improved their interprofessional communication skills; and increased their comfort levels on an interprofessional team. Implications and suggestions for implementation are discussed.

Learning Outcomes of Diverse Oncology Professionals After the TEAM Cultural Competency Training

Racial, ethnic, sexual, and gender minorities are more likely to report challenges with oncology provider communication and quality of care. The Together-Equitable-Accessible-Meaningful (TEAM) training was developed to improve health equity across cancer care organizations by guiding teams of interprofessional learners through planning and implementation of quality improvements to advance equitable, accessible, and patient-centered cancer care. This study compared changes to self-reported cultural competence as measured by the Cultural Competency Assessment (CCA); Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS); and Interprofessional Socialization and Valuing Scale (ISVS). The primary aim of the study was to assess changes to self-reported cultural competence; the secondary aim was to examine changes to interprofessional valuation from baseline to post-intervention. Results indicated statistically significant improvements in self-reported Cultural Competency Behaviors (p = .055), a subscale of the CCA, and Attitudinal Awareness toward sexual and gender minorities (p = .046), a subscale of the LGBT-DOCSS, using p < .10 as statistically significant. These subscale results drove statistically significant improvements for their respective composite scales. No other statistically significant results were found. This study suggests that cultural competency training among interprofessional oncology health care professionals can be effective. Given the growing diversity within the USA, additional opportunities for cultural competency training are needed.

Impact of an interprofessional training ward on interprofessional competencies – a quantitative longitudinal study

ABSTRACT Complex learning strategies, like interprofessional training wards in which students work autonomously in interprofessional collaboration, can support the development of interprofessional competencies in terms of knowledge, abilities and attitudes. To assess the short-term and long-term effects of a three to five weeks placement on such an interprofessional training ward on nursing and medical undergraduates, a study with pre-post-follow-up design was conducted from April 2017 until February 2019. Outcome measures were the University of the West of England Interprofessional Questionnaire (UWE-IP), the Interprofessional Socialization and Valuing Scale (ISVS), and the Assessment of Interprofessional Team Collaboration Scale (AITCS) measuring interprofessional competencies, including teamwork, communication, interprofessional learning, collaboration, and socialization. 60 medical and 63 nursing undergraduates of the first 16 interprofessional student teams that were placed on the Heidelberg interprofessional training ward (HIPSTA) between April 2017 and November 2018 were included in the study. Data was analyzed using the linear mixed model analysis for longitudinal comparisons of scores before, directly after and three months after the placement on the interprofessional training ward. Statistically significant positive short-term effects in interprofessional competencies were found in all three questionnaires, with effect sizes up to d = 1.05. Statistically significant positive long-term effects with effect sizes up to d = 0.60 were found in the ISVS and the AITCS concerning socialization and collaboration. These results indicate that interprofessional education in a clinical setting positively influences the participants’ perception of interprofessional socialization and teamwork. This may possibly lead to improved interprofessional collaboration in their further career. Strategies to yield a sustainable improvement of attitudes toward interprofessional interaction are still needed.

Learning Together: Interprofessional Education at the University of New England.

Patient care delivered by well-functioning teams provides integrated and cohesive responses to the patients' needs and is considered more effective than care delivered by independent health professionals. The University of New England (UNE) College of Osteopathic Medicine integrates interprofessional education (IPE) curriculum into each year of its program. The UNE Center for Excellence in Collaborative Education coordinates strategically planned interprofessional learning opportunities. To assess the implementation of interprofessional competencies and learning outcomes using the Interprofessional Team Immersion (IPTI) at UNE. A team of students from various health profession programs worked on a simulated case with trained actors to learn about the roles and responsibilities of their professions in the optional IPTI. Pre- and postsurveys used the Interprofessional Core Competencies Assessment Scale (ICCAS) and the Interprofessional Socialization and Valuing Scale (ISVS) to evaluate student outcomes. Fifty-five students from various health profession programs at UNE participated in the IPTI activity in February/March 2018. Forty-four students (80%) responded to the surveys, and 43 (78%) completed both surveys. The mean (SD) total ICCAS score increased from presurvey (122 [27]) to postsurvey (127 [26]) (P=.018). The ISVS mean total scores increased from 48.3 presurvey to 57.9 postsurvey (P<.0001). The significant differences in the ICCAS and the ISVS scores indicate that the IPTI changed students' attitudes toward IPE and future collaborative practice. Interprofessional learning at UNE is a valuable experience for both students and faculty. UNE College of Osteopathic Medicine continues to develop IPE activities for all 4 years of its programming.

Preparing Master of Social Work Students for Interprofessional Practice

ABSTRACT Purpose This study aims to measure growth in interprofessional knowledge, skills, and values in MSW students from three universities who participated in a Behavioral Health Workforce Education and Training program focused on serving children, adolescents, and transition-age youth. Methods Students participated in an interprofessional field placement and specialized educational sessions that addressed interprofessional team-based care, engaging at-risk youth and families, and working with vulnerable populations. The Interprofessional Socialization and Valuing Scale (ISVS) was administered pre- and post-experience. Results Paired t-tests of the ISVS total score and each subscale showed statistically significant increases over time. Multiple regression models indicated only the pretest score was a significant predictor of the posttest score for the total or subscale of the ISVS. Conclusion Social work programs that create interprofessional education and training opportunities can achieve positive outcomes in student attitudes toward interprofessional practice.

Evaluating interprofessional socialization: Matched student self-assessments surrounding underserved clinic participation

IntroductionTo determine if an existing tool, the Interprofessional Socialization and Valuing Scale (ISVS), can be used to measure student perceptions of interprofessional (IP) socialization and teamwork in a cohort of pharmacy, medicine, physical therapy, and social work students volunteering in a student-run free clinic (SRFC). MethodsThe ISVS was distributed to these health professions students before and after participation at the SRFC. After a one-month pilot, the plan was to collect data for 12 months. A power analysis determined a minimum sample size was 15 students (power = 0.8). Student surveys were matched utilizing unique alphanumeric identifiers. Results of IP socialization were analyzed by total group and health profession. ResultsA mean value for each ISVS domain was compared before and after the IP SRFC experience over 11 months; the pilot was not included in the final data set. Significant improvement in interprofessional socialization was observed across all ISVS factors including Self-Perceived Ability to Work with Others (p < 0.001), Value in Working with Others (p = 0.002), and Comfort in Working with Others (p < 0.001). Pharmacy and social work disciplines met the threshold for statistical significance for at least one factor. ConclusionsUtilizing the ISVS in an IP SRFC setting can detect changes in professional development that is influenced by beliefs, behaviors, and attitudes as self-assessed in our student population. Engaging students in such a clinic demonstrates educational value and potentially leads to significant improvement in their interprofessional socialization and teamwork skills.

Recognizing Elder Abuse: An Interprofessional Simulation Experience With Prelicensure Health Care Students.

A common role within all health care professions includes the ability to recognize and report elder abuse. However, teaching the characteristics and assessment of abuse can be difficult. To allow students to engage in a realistic case-based scenario within a health care team, an immersive simulation was developed involving the care of an elderly woman with signs of abuse. The purpose of this quasiexperimental study was to explore the influence of the experience on the participants' perceptions of interprofessional care and their understanding of the assessment of abuse. This study utilized a mixed-methods research design. A sample of convenience of nursing and physical therapy students (n = 143) from 3 institutions in southwest Virginia was utilized for this study. Participants' perceptions were assessed using the Interprofessional Socialization and Valuing Scale (ISVS) and through focus group interviews. Students demonstrated a statistically significant improvement based on the Wilcoxon matched pairs test (P < .001) on all 21 questions of the ISVS. A phenomenological study design was employed for qualitative analysis of focus group interviews performed postsimulation to generate information about the students' perceptions of the experience. Two themes emerged from the interviews: (1) communication as a team to provide wholistic patient care and (2) recognition of abuse. The students reported an improved understanding of collaboration on a health care team and how to investigate potential abuse occurring in the home. This further supports research suggesting the importance of interactive learning techniques in teaching health care students to recognize symptoms of elder abuse.

INTERPROFESSIONAL SOCIALIZATION AND VALUING SCALE FOR HEALTH PROFESSIONAL STUDENTS WORKING WITH OLDER ADULTS

Interprofessional education allows students from two or more professions the opportunity to collaboratively practice patient centered care. Given the importance of interprofessional education in helping individuals become effective team members and understanding their value to a healthcare team, there is a need to evaluate the experiences. The Interprofessional Socialization and Valuing Scale (ISVS), aims to measure self-perceived experiences with interprofessional collaborative teamwork, including the ability, value, and comfort in working with others. The Wayne State University Interprofessional Team Visit (IPTV) program is an older adult home visit program that places pharmacy, social work, occupational therapy, nursing, and medical students in teams. Students form teams of 3 different disciplines and interview the older adult to assess various aspects of health and wellbeing. In order to evaluate the interprofessional educational experiences of the students, they are given a pre- and post- survey utilizing the ISVS tool. 18 questions pertaining to perceptions of what students have learned about working with professionals from other disciplines. Students respond to each statement using a 7-point scale with 1 = “Not at All” and 7 = “To a Very Great Extent.” Statistical analysis is conducted in order to compare pre- to post-surveys and also assess differences between groups. It is found that ISVS scores increase from pre- to post-survey, second year medical students and third year pharmacy students feel more comfortable working in teams, and teams consisting of these two have higher average scores.

Veteran and learner outcomes of interprofessional trainee-led group medical visits

Abstract Background Patient-centered primary care models encourage alternative methods of care delivery, including group medical visits (GMV). The Boise VA Medical Center conducted trainee-led GMV for patients with diabetes from 2013 to 2017. Purpose Patient-Aligned Care Teams in VA include implementation of GMV. Our aim was to address gaps in diabetes care while offering a novel clinical learning experience for interprofessional trainees. Methods Evaluation of patient and trainee participants in GMV from 2015 to 2017 was conducted. Patient data included HgA1c, systolic blood pressure, weight, and LDL cholesterol measurements. The Interprofessional Socialization and Valuing Scale (ISVS) assessed trainee attitudes about collaborative practice. Discussion Analysis of patient data showed improvements in HgA1c. Trainees demonstrated improved value, ability and comfort working with others. Conclusions GMV was associated with positive clinical outcomes in patients with diabetes. Participation in GMV during training may improve trainees’ collaborative attitudes and prepare them to plan, lead and execute GMVs in their future practice.

An Interprofessional Geriatric Experiential Learning Experience: Its Impact on Physical and Occupational Therapist Students

Introduction. Accreditation standards for physical therapist (PT) education require the inclusion of interprofessional education (IPE) in order to prepare health care professionals to work in collaborative environments. Additional guidelines document the need to educate PT students in the care of older adults; however, a gap in readiness for entry-level practice exists. Therefore, there were three purposes of this study that were to 1) examine the impact of an IPE experiential learning project on PT and occupational therapist (OT) students' knowledge and attitudes toward each other's professions, 2) examine students' comfort, value, and ability to work with another profession, and 3) assess the project's impact on PT and OT students' attitudes toward older adults. Methods. Physical therapist and OT student groups, under the supervision of faculty, evaluated a community dwelling older adult over 3 visits and developed a comprehensive wellness program, which was provided by the students on visit 4. Students completed 2 surveys: the Interprofessional Socialization and Valuing Scale (ISVS) and Kogan's Attitude Towards Old People Scale (KAOP), prior to and at the conclusion of the project. Results. The Wilcoxon’s signed rank test showed significant increases after the completion of the IPE project in the total ISVS (P &lt; .001) median scale scores for all students and on the subscales regarding the ability (P &lt; .001), value (P &lt; .001), and comfort (P &lt; .001) in working with others. Significant increases were observed for all students on the total KAOP scale scores (P &lt; .001) and the positive subscale scores (P &lt; .001); significant decreases were observed in the negative subscale scores (P &lt; .001). Discussion and Conclusion. This study demonstrates a successful IPE experiential learning project used to enhance PT and OT students' abilities, values, and comfort with collaborative practice and enhancement of PT and OT student groups' attitudes toward older adults.