Increasing Communication Among Nursing Home ... - Springer Link

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Journal of Clinical Geropsychology [jcg]

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Style file version Nov. 19th, 1999

Journal of Clinical Geropsychology, Vol. 7, No. 3, 2001

Increasing Communication Among Nursing Home Residents Rebecca Allen-Burge,1,4 Louis D. Burgio,1,4 Michelle S. Bourgeois,2 Richard Sims,3 and Jennifer Nunnikhoven3

In this preliminary, intrasubject study (N = 8), we examined the effects of communication skills training and the use of memory books by Nursing Assistants (NAs) on the social ecology of a nursing home. Through inservice and on-the-job training, NAs were taught to use communication skills and memory books during their interactions with residents with mild to moderate cognitive impairment (Mini Mental Status Examination, M = 16.25), but relatively intact communication abilities. An abbreviated staff motivational system called Behavioral Supervision (Burgio and Burgio, 1990. Int. J. Aging Hum. Deve. 30: 287– 302.) was attempted to encourage performance of these skills on the nursing units. Results showed that, regardless of sporadic implementation of the intervention by nursing staff, the intervention improved communication between staff and residents during care routines, increased the amount of time other residents and visitors spent talking with target residents, and increased the rate of positive statements made by the target residents and others in their immediate environment. Results are discussed in terms of limitations of the staff motivational system and modifications made to the system in a larger ongoing intervention trial. KEY WORDS: nursing homes; communication; quality of life.

Despite federal mandates to transform the model of care in nursing homes from primarily custodial to therapeutic (OBRA, 1987), the diversity of residents and site-specific resources continue to make the achievement of quality therapeutic care an illusive goal. One important component of quality of life in the nursing home is the social milieu. The importance of social engagement as an aspect of resident quality of life was underscored by Mor and colleagues in their confirmatory factor analysis of the Minimum Data Set (MDS; Mor et al., 1995). MDS data were found to be well represented by the following four factors: social engagement, mood problems, conflicted relationships, and behavior problems. The authors suggested that resident functioning in these four areas could be interpreted as quality of life indicators. A life-span developmental perspective suggests that as healthy individuals age, they limit the breadth of their social networks but become more emotionally involved 1 Department

of Psychology, University of Alabama, Tuscaloosa, Alabama 35487-0348. of Communication Disorders, Florida State University, Tallahassee, Florida 32306-2007. 3 Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-2041. 4 Present address: Applied Gerontology Program, University of Alabama, Tuscaloosa, Alabama 35487-0315. 2 Department

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in specific relationships of their choosing (socioemotional selectivity theory; Carstensen, 1991). Thus, the impoverished social ecology of nursing homes undermines resident quality of life and the provision of adequate therapeutic care (Carstensen and Erickson, 1986). Measuring the rate of social interaction is one means of evaluating the social ecology of nursing home settings. One reason for the lack of social interaction in nursing homes is the functional impairments limiting the communication abilities of older residents. For example, Rovner and colleagues estimated that 72–74% of nursing home residents exhibit symptoms of dementia (Rovner et al., 1986). Additionally, the National Nursing Home Survey (NNHS; Dey, 1997) found that approximately one fourth of older residents had visual or hearing impairments severe enough to hamper communication. Because of their physical and cognitive limitations, nursing home residents are more vulnerable to environmental conditions. Lawton and others assert that each environment exerts a “press” on an individual’s resources, and each individual displays a certain level of capacity to deal with this press (Lawton, 1981, 1989). As the resident’s capacity to master environmental press decreases as a result of disease processes, the clinical sequelae for the resident will become more negative unless staff-directed environmental interventions can remediate these coping deficits. Nursing aides (NAs) are particularly important in this process because these individuals spend the most time with residents (Burgio et al., 1990; Tellis-Nayak and Tellis-Nayak, 1989). Interventions aimed at encouraging nursing home staff to engage in friendly interactions have shown positive outcomes for both residents and staff (Moss and Pfohl, 1988). Specifically, Moss and Pfohl (1988) reported that residents talked more and demonstrated increased self-esteem, and staff reported increased feelings of satisfaction. The success of therapeutic interventions designed to improve the social ecology of nursing homes depends heavily on the receptiveness of nursing staff to learn new skills and on the establishment of staff motivational systems to ensure the maintenance of these skills (Burgio and Burgio, 1990; Burgio and Scilley, 1994; Burgio and Stevens, 1999; Smyer, 1989; Stevens et al., 1998). Staff motivational systems such as Behavioral Supervision (Burgio, 1997; Burgio and Burgio, 1990; Stevens et al., 1998) and Total Quality Management (TQM; Schnelle et al., 1993) have been used successfully to motivate staff in the implementation of a variety of interventions in nursing homes. Only Behavioral Supervision, however, has shown NA maintenance of trained behavioral and communication skills for up to 1-year posttraining (Stevens et al., 1998). Behavioral Supervision is designed to motivate management and direct care staff to directly observe and analyze skill performance in order to identify problems and to provide direct feedback suggesting practical ways of maximizing skills (Burgio and Stevens, 1999; Daniels, 1994). Training staff to interact more and in a more positive manner with both cognitively impaired and intact residents, and to facilitate resident–resident interaction, is of critical importance in improving the social engagement of resident quality of life. A recent study employing direct observational procedures to examine social interaction in nursing homes showed that residents interact with other individuals during only 17% of observation time (Carstensen et al., 1995). Using computer-assisted real-time observational recording at regular 0.5-hr intervals throughout the day, Burgio and colleagues found that residents spent up to 87% of observation time engaged in “no activity” and 45% of observation time alone (Burgio et al., 1994b). Behavioral observations of nursing assistants’ work behavior


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reveal that 53% of observation time was spent in patient care, with 11.8% of observation time engaged in staff–resident verbal interaction (Burgio et al., 1990). The social environment of nursing homes continues to foster dependent behaviors among residents during care routines with staff (Baltes, 1988; Baltes and Reisenzein, 1986; Wahl, 1991). Sadly, positive interactions are as rare as blatantly negative interactions in nursing homes (Burgio et al., 1990), where neutral interactions are the norm (Carstensen et al., 1995). Notably, residents who are impaired in cognition, sensory functioning, and communication are at risk for spending little to no time with other residents (Retsinas and Garrity, 1985). Carstensen and Erickson (1986) investigated the quality of interaction (i.e., number of positive statements, negative statements, or ineffective communications) among residents during activities such as providing refreshments in common areas. Ineffective communications included verbalizations that did not elicit a response, and incoherent or unintelligible utterances. Direct observation of 30 residents indicated that the major portion of interactions consisted of ineffective communication, facts/opinions, and questions. While ineffective vocalizations increased during a treatment phase, positive statements, questions and facts/opinions declined. This paper presents findings from a preliminary study designed to improve the social ecology of nursing homes by increasing effective communication between residents and NAs and among residents. We designed our intervention to address communication deficits in nursing homes by teaching staff effective communication, including the use of external cues to compensate for residents’ diminished capacity. For residents with cognitive impairment, the introduction of prosthetic memory aids in the form of memory books can minimize the impact of residents physical and cognitive deficits. For residents without cognitive impairment, memory books can improve the socially barren environment of nursing homes by providing a concrete tool with which to engage more cognitively impaired peers. Memory books contain images and brief, simple sentences that use the preserved automatic processing abilities of frail older adults to improve the structure and quality of communication with others, hopefully making interactions more pleasant for both the older individual and their partner in communication (Bourgeois, 1990, 1992a,b, 1993; Bourgeois and Mason, 1996). Through the use of memory books, community-residing dementia patients with a wide range of cognitive deficits have increased the informativeness and accuracy and decreased the ambiguity and repetitiveness of their conversations; these treatment effects have been maintained over 30 months posttreatment (Bourgeois, 1990, 1992a,b; Bourgeois et al., 1997; Bourgeois and Mason, 1996). Use of these aids has decreased disruptive verbal behaviors such as repetitive questioning and verbal abuse (Bourgeois et al., 1997). This project employs a single-group, intrasubject pre–post design lasting 5 weeks with a 1-month postintervention follow-up assessment. We hypothesized that because of the implementation of the staff motivational system (Burgio and Burgio, 1990), the NA’s use of therapeutic techniques in communication would be maintained immediately after training and at the 1-month follow-up. In this project, we adapted Burgio and Burgio’s Behavioral Supervision model to increase the likelihood of staff’s consistent use of memory books as a means of social stimulation, distraction, orientation, and instruction during care (Burgio and Burgio, 1990). We predicted that residents with memory books would show increases in their overall amount of coherent verbal interaction with staff and with other residents when compared with the amount of interaction at baseline. Coherent verbal interaction presumes an attempt to communicate and thus excludes such vocalizations as humming,


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whistling, or low-volume moaning. After implementation of the intervention, we predicted that a higher frequency of positive verbal exchanges involving observed residents would be evident. Specifically, residents with memory books would be more likely to address positive statements to others (i.e., staff, other residents, and visitors) and to receive positive statements from others. As defined in this study, positive statements included statements of appreciation regarding the resident (e.g., “thank you for helping me so nicely”), statements of affection (e.g., “I like you” or the use of endearments), and statements of social convention (e.g., “good morning” or “you’re welcome”). METHOD Setting and Participants This study was conducted in a university-owned nursing home with 41 licensed beds and 2 nursing units. Average resident-to-NA ratios were 7:1 during the day shift and 10:1 during the evening shift. Average resident-to-licensed practical nurse (LPN) ratios were 19:1 during both day and evening shifts. Reported yearly rates of staff turnover were 15% among RNs, 15% among LPNs, and 25% among NAs. Residents had an average length of stay of 5 years; 66% were female; 41% white and 59% African American. Residents were entered into the study based on the following characteristics: (a) age at least 55 years, (b) Mini Mental Status Examination (MMSE; Folstein et al., 1975) total score greater than 0, (c) retention of minimal ability in verbal communication involving spontaneous speech, (d) absence of major sensory impairment, (e) life expectancy greater than 6 months, and (f) residence within the facility for at least 1 month. Fifteen of the 41 residents met entry criteria and were approached for consent; 10 consented to participate, the majority through proxy. Our resulting consent rate was 67%. Of the 10 consenting residents (eight women, two men), two white females were dropped from the study immediately following baseline and prior to intervention. One refused to continue participation and one died. Thus, eight residents (two white females, four African American females, two African American males) completed the study and their data are included in the analyses. Resident Characteristics The mean age of the eight residents completing the study was 76.87 (SD = 11.65, range = 65–94). This is a relatively young age group in comparison with the results of the 1995 NNHS (Dey, 1997), which reported an average age of 82 years. Three participants had an eighth grade education, three were high school graduates, and two had no documentation of formal education. One of these two individuals was illiterate, but responded well to pictures. Four residents were widowed, two were married, one was divorced, and one had never married. Primary diagnoses documented in the medical chart included Alzheimer’s disease, hypertension, stroke, quadriplegia, and congestive heart failure. Dementia diagnoses were established by an independent physician using the Senile Dementia of the Alzheimer’s Type questionnaire (SDAT; Fischbach, 1990; Fischbach et al., 1990; Robins and Fischbach, 1990), administered to both the resident and a sponsor. Based on the SDAT interviews, the physician diagnosed five residents with dementia


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(i.e., Washington University Clinical Dementia Rating severity scores: one mild, three moderate, one severe). The physician’s review of the SDAT data for the other three residents indicated cognitive decline of sufficient magnitude to make a diagnosis of questionable dementia. The average MMSE score for the eight residents in this study was 16.25 (SD = 5.39; range = 7–24). Scores below 24 on the MMSE are suggestive of cognitive impairment. Thus, our sample of eight residents was, on average, moderately cognitively impaired. For entry into the study, referred residents were required to pass a communication screen in order to demonstrate their potential to benefit from the memory book intervention. Thus, residents completed a 5-min semistructured conversation assessing their capacity for spontaneous speech (Bourgeois, 1990, 1992a, 1993; Bourgeois and Mason, 1996). A clinical psychologist with expertise in geriatric assessment and who had received additional training by a speech pathologist carried out these assessments. Residents needed to exhibit either use of multiword phrases in spontaneous speech or minimal responsiveness to linguistic or visual information. Additional information on the instrument and scoring criteria can be obtained by writing to the authors. Interrater reliability for the semistructured interview was based on scoring transcripts of taped interviews with five of the eight residents and revealed 100% interrater agreement for inclusion. All participating residents were capable of responding to the pictures and simple sentences used in their memory books. Staff Characteristics One male and 11 female NAs participated in this study. All NAs identified themselves as African American. Their average age was 39.80 (SD = 11.49, range = 24–59). Six of these individuals had a high school education or the equivalent, five had some college course work, and one had a college degree. Their average experience was 125.40 months (SD = 91.27, range = 6–276). Three LPNs also participated in the study. All LPNs were women who identified themselves as African American. Their average age was 48 (SD = 20.07, range = 25–62). One of these women had college course work in addition to her LPN training. The facility also employed six registered nurses (RNs) who served an administrative and supervisory function. Research Design and Procedures This preliminary project was conducted over a 5-week period and utilized a singlegroup, intrasubject pre–post design. The first week represented a baseline phase designed to assess the social environment in the nursing home prior to intervention. During this phase, direct observational and paper-and-pencil assessments were completed. Communication skills inservices were conducted during the second week. The inservices included information on communication skills and the staff motivational system (i.e., Behavioral Supervision). “Hands-on” communication skills training was conducted during the third and fourth week of the study. During this phase, memory books were introduced and selected components of the staff motivational system were put in place. The fifth week consisted of evaluation of the intervention’s effectiveness, using the same assessments used in baseline. One month after research staff exited the nursing facility, probe


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follow-up data were collected for 1 week to assess the maintenance of training effects. Computer-assisted observational data were collected using a reduced sampling schedule. The paper-and-pencil measures were administered as in the baseline and immediate postintervention phases. Observational Measures NA Communication Skills Checklist (CSC) The CSC (available from the authors) allows the researcher to measure NAs’ use of the memory books, specific versus general instructions, one-step instructions, positive statements, biographical statements not referenced to the memory book, responses to behavioral disturbances, and general distraction techniques in rate per hour. Research staff observed every NA daily during hands-on training and once per baseline and postintervention assessment. NAs’ use of communication skills was then rated and scored on the CSC. The CSC focused on communication skills demonstrated during a care interaction. Of the 12 NAs trained, data were available for only six at baseline and postintervention. These six NAs were compared to the 12 trained NAs on age, education, and months of job experience; no differences were found between the subset and the total sample in these characteristics. A total of 3.75 hr (range = 0.25–1.33) of observation was completed for these six continuing NAs across the two nontraining study phases (i.e., 2.02 hr of observation during baseline and 1.73 hr of observation during postintervention phases). Interobserver reliability was assessed independently among three observers during 27% of the observations across all phases. Observer agreement for each behavioral category measured by the CSC was calculated using a total occurrence agreement calculation (i.e., total number of agreements of occurrence divided by the total number of agreements plus disagreements). The average percent agreement for this measure across all categories was 81%. In behavioral research, the recommended lower limit for acceptable percent agreement is .80 (Hartmann, 1982). Observation of the LPN’s Supervisory Activities (OLSA) The OLSA (available from the authors) allows the researcher to measure LPN’s accuracy in observing/recording NA skill performance during “hands-on” supervision, and the LPN’s skill in providing NAs with verbal performance feedback. As part of the staff motivational system, LPNs observe each of the NAs under their supervision once per week using a form similar to the researcher’s CSC during 15-min samples of care routines with residents. During these observations, LPNs record the occurrence of NA’s use of memory books, specific versus general instructions, one-step instructions, positive statements, negative or unhelpful statements, biographical statements not referenced to the memory book, and NA’s responses to behavioral disturbances. LPN’s accuracy at recording these communication skills during direct observation is checked against the Project Manager’s recording of the same behaviors during the same direct observation. The Project Manager is present with LPNs observing NAs using the CSC during the staff training period. The OLSA also allows the Project Manager to rate the LPNs’ use of verbal supervisory feedback. Verbal supervisory feedback is rated with regard


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to their beginning and ending a session with a supportive statement to the NA, the provision of accurate and specific positive and corrective feedback to the NA, the provision of specific performance scores to the NA with a statement indicating the NA’s training status, and the provision of an opportunity for the NA to discuss any of the feedback given by the LPN. Every LPN received at least one training session with the Project Manager to learn how to use the CSC during the hands-on training period in which their behavioral observation skills and supervisory procedure was rated and scored. Computer-Assisted Data Collection System: Hardware and Software As employed in prior research (Burgio et al., 1996), the Portable Computer Systems for Observational Research software programs from Communitech International (DeKalb, IL) were used for this project (Repp et al., 1989). Four laptop computers with at least a 80286 microprocessor, a hard drive, and an internal or external 3/5 floppy disc drive were used to collect observational data. The recording of behavior was synchronized with each computer’s internal time clock and controlled via a software routine. Computer-assisted real-time observational data were generated by sampling behaviors during peak daily interaction time periods (i.e., time sampling). Time sampling sessions lasted 0.5 h and were collected on participating residents between the hours of 8 a.m. to 10 a.m. noon to 2 p.m. and 5 p.m. to 7 p.m. The computer-assisted data collection system sampled behavior throughout the day, but could include care interactions if they occurred during scheduled time sampling. Participating residents were each observed five times during the week. Thus, at the end of baseline week, each participating resident had a total of 2.5 hr of data generated by direct observation; 2.5 hr of observation was also available for the postintervention week. During the follow-up assessment period, the timesampling data collection schedule was reduced to three observations per resident per week, resulting in 1.5 hr of observational data for each resident. A total of 52 hr of computerassisted observational data were completed across participants and study phases (e.g., eight residents each with 2.5 hr of observation during baseline and postintervention phases and 1.5 hr of observation each during follow-up). Domains of behavior divided into mutually exclusive and exhaustive categories relevant to the hypothesized outcomes were identified and detailed operational definitions were generated for all behavior codes within categories. One set of keys was used to code the resident’s location. Two keys coded whether the resident was restrained. A third set of keys coded the residents’ activity (i.e., this category included use of memory book and ADL care). Finally, four sets of keys coded aspects of the residents’ social environment: (a) nonverbal presence, (b) verbal interaction, (c) verbal content (i.e., positive or negative statements), and (d) disruptive behaviors. All targeted behaviors were coded with the observed resident as the point of reference. Interobserver reliability was assessed independently among four observers during 17% (9.5 hr) of the total observation time across all phases. Comparison of records were completed on a second-by-second basis. Because of the small sample size and the exploratory nature of this preliminary study, only behaviors most relevant to the hypotheses were targeted for analyses. The codes included for analyses were the use of memory books by the observed resident, verbal interaction on the part of the observed resident with others, staff verbal interaction with the observed resident, verbal interaction between other residents or


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visitors and the observed resident, positive statements made by any actor, agitation, and the presence of staff or other residents in the observed residents’ environment without verbal interaction. Observer agreement was calculated using Cohen’s Kappa (Cohen, 1968; Hays, 1994). The Kappa coefficient is a conservative method of measuring interobserver reliability that corrects for chance agreement among observers. A computer program was written by the researchers to calculate Kappas through a second-by-second comparison of the observational files. Reliabilities for all but one of the targeted categories were above .65. The reliability coefficient for speech by other residents and visitors to the observed resident was .50, indicating discrepancies between observers, but also indicating that the agreement between observers was much better than chance. Average Kappa reliability across all categories was .74. In behavioral research, recommended lower limits for acceptable Kappas range from .60 to .75 (Hartmann, 1982). Memory Book Checks Research assistants recorded whether residents were in possession of their memory books (i.e., memory books were prominently displayed and within arm’s reach of the resident) during observational checks conducted two times daily at the nursing home, once during the morning shift and once during the evening shift. This yielded a total of 10 checks for each of eight residents (i.e., 80 checks) during both the immediate postintervention assessment and the 1-month delayed follow-up assessment. Data were recorded dichotomously (yes/no) at both checks for each resident.

Paper-and-Pencil Measures Assessment instruments were administered either by a clinical psychologist with expertise in geriatric assessment or by one of three research assistants trained and supervised by the clinical psychologist to administer these measures. Mini-Mental Status Examination (MMSE ) The MMSE, a measure of global cognitive ability, measures orientation, immediate and delayed recall for words, attention and concentration, language, and praxis (total score range = 0–30). This measure has been shown to identify individuals reliably with and without global cognitive decline. The test–retest and interevaluator reliabilities are .89 and .83, respectively. Functional Independence Measure (FIM)—REACH Version Information for completing this instrument was provided by NAs familiar with the daily care needs of the participating resident (Hamilton et al., 1994; Kidd et al., 1995). The version used in this study was developed for the National Institute of Health-Funded Cooperative Agreement (multisite): Resources for Enhancing Alzheimer’s Caregiver Health (REACH, Coon, Schultz, and Ory, 1999). As in the REACH project, only the motor subscale


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consisting of self-care, sphincter control, transfer, and locomotion items was used in this study. Reliability data indicate an intraclass correlation coefficient of .96 for the motor domain, with unweighted Kappas ranging from .53 to .66. The eight resident participants in this study had an average FIM total score of 45.5 (SD = 26.62; range = 13–91). On average, our residents required a moderate amount of physical assistance in performing daily care. Two residents, however, required near total care and two residents performed self-care tasks independently. Memory Book Intervention and Motivational System Memory Books Participating residents received a personalized 12-page laminated memory book consisting of biographical, orientation, and daily schedule information. Each 5 × 5 inch page included a 6–10 word declarative sentence printed in 14- or 20-point Times New Roman type with a color or black and white photograph or line drawing illustrating the statement. Resident’s books might contain pictures of their wedding and family, their NA, other residents, their daily schedule, instructions in bathing, and pages targeting behavior problems such as wandering, aggression, or repetitive questioning (e.g., a picture of the resident and their NA with a simple sentence, such as “Debbie helps me eat breakfast at 8 in the morning”). It was the responsibility of the NA to ensure that books were always present in the residents’ living space. Residents were provided with individually tailored sashes that attached the book to the resident’s torso, or a decorative paper bag that was hung on the residents’ wheelchair. Staff Training and Motivational System All nursing staff and the facility administrator were trained in the use of memory books and general communication skills. Because of the time constraints of this feasibility study, we were only able to implement an abbreviated form of the Behavioral Supervision system. During the second week of the study, two 2-hr inservice sessions were conducted by the Project Manager; all staff received 4 hr of inservice held twice to include all NAs. In addition to basic information regarding the research project and dementia, the following was emphasized: (a) identifying the ABCs of resident behavior problems, (b) the use of memory books, and (c) the use of general communication skills. Finally, the staff motivational system was described. The critical roles of the NA and LPN were emphasized because these members of the nursing staff have the most direct contact with residents. Members of the nursing staff were instructed to use memory books with residents: (a) to increase general communication among residents and between nursing staff and residents, (b) to increase the independent functioning of residents during targeted care routines, and (c) as a distraction to decrease resident disruptive behaviors. In addition to didactic training, active learning techniques including the use of videotapes, discussion of real-life examples from the nursing units, and discussion of written vignettes were used to engage staff during the inservice. Workbooks were provided to each member of the nursing staff that included all information from the inservices. Staff were encouraged to refer to these notebooks while working with residents on the unit.


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To increase the likelihood that staff would use the newly learned skills on the units, a formal staff motivational system termed Behavioral Supervision (Burgio and Burgio, 1990; Burgio and Stevens, 1999; Stevens et al., 1998) was described during the inservice and implemented during the 2-week “hands-on” training phase. During the 2-week hands-on training phase, we attempted to switch the responsibilities for implementing the staff motivational system from research staff to the LPNs. Initially, NAs were trained by research staff in the use of memory books, communication skills, and components of the staff motivational system. NAs on the day and evening shifts were observed by research staff once per day while providing care to residents. Researchers and LPNs used the CSC during the care routine to record whether the NA displayed the skills taught in the inservice; feedback was provided to the NA regarding their use of the memory books, use of specific versus general instructions, one-step instructions, positive statements, responses to behavioral disturbances, and general distraction techniques. NAs were provided verbal performance feedback immediately following the care routine. The Project Manager also completed the OLSA on the LPNs during this period. Only data collected by research staff were used in outcome analysis. NAs (n = 12) were also taught to monitor and record their own job performance as a means of tracking their performance and a daily reminder of the skills needed to be an effective communicator (behavioral self-monitoring). NAs were asked to use the selfmonitoring form during shifts worked Monday through Friday. Because of regular weekend scheduling, NAs had the opportunity to use the form an average of three times (range = 1–5) per week. To meet job performance goals, NAs were asked to complete at least 80% of their assigned self-monitoring forms. To reach performance criteria, they were also required to obtain a score of 80% accuracy on the CSC completed by the research assistants. NAs received public recognition for meeting job performance criteria (i.e., 80% completion of forms and accuracy) by having their name posted weekly on a “NA Honor Roll.” Those NAs whose names appeared on the Honor Roll received on opportunity to receive a performance incentive. All honor roll NAs listed were entered into a performance-based lottery held once each week for day shift and evening shifts (Reid et al., 1989). For each shift, the individual winning the lottery received his or her choice of one of the following incentives: (a) free lunch in the nursing home cafeteria every day for 1 week, (b) permission to arrive at work 15 min later than scheduled every day for 1 week, or (c) permission to leave work 15 min earlier than scheduled every day for 1 week. The most frequently chosen incentive was the opportunity to leave work 15 min earlier than scheduled. Method of Analyses Analysis was conducted on computer-assisted time-sampling observational data and on the CSC. Because of the small sample size, we used randomization t-tests of difference scores to assess the significance of any within-subjects changes on each of the outcomes of interest. Randomization tests compare the test statistic s for the observed data set to the sampling distribution of S generated by randomly reordering the data tens or hundreds of thousands of times (Manley, 1997). This bootstrapping method of analysis was chosen and preferred over the use of nonparametric techniques because the sampling distribution against which the test statistic is compared is itself generated from multiple subsets of the obtained data. This permutation test allows the researcher to use standard test statistics even


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when random sampling or other distribution assumptions have been violated (Edgington, 1987). Computer-assisted observational data were expressed as mean total percentage of observation time spent in each activity. Outcome data using this data collection technique included the following variables: (a) use of the memory book, (b) observed resident speech, (c) speech from staff, (d) speech from others, (e) rate per hour of positive statements made by any actor, and (f) presence of staff or other residents. Positive Statements were measured by the rate of statements made per hour and not the percentage of total time because these were typically brief duration events. Because our goal in this preliminary investigation is to report potentially interesting trends, our analytic questions center on (a) establishing an initial behavioral change for both staff and residents after implementation of the intervention and (b) assessing the maintenance of any staff or resident behavior change 1 month later. Thus, all randomization tests were run by calculating difference scores from baseline to immediate postintervention. In a second step, randomization tests were run on difference scores comparing postintervention to follow-up. Obtained significance levels are reported for all analyses. RESULTS NA Performance of Communication Skills Twelve NAs received training during the inservice and 2-week hands-on training phase. The average number of training sessions on the unit per NA was four (range = 3– 6). During the first week of hands-on training, NAs completed an average of 64% of their self-monitoring forms (n = 35 forms; range = 0 –100%). Completion dropped to 37.5% (n = 18 forms; range = 0–100%) during the second week. During the first week of hands on training, 50% of NAs received an accuracy score of 80% or above. By the end of the second week of hands-on training, 8 of the 12 trained NAs (67%) had achieved an accuracy score of 80% or above in the use of communication skills as measured by the CSC. During the first week of hands-on training, the three LPNs were attending mandatory continuing medical education classes and thus were unavailable for training. The number of training sessions conducted with LPNs during the second week of hands-on training ranged between one and three. Two of the three LPNs reached a criterion of 80% correct performance in their accuracy of CSC recording and the provision of verbal feedback to NAs regarding communication skill performance. The third LPN reached a criterion of 77% accuracy. Unfortunately, LPNs failed to conduct any independent observations of NAs after the hands-on training phase when not accompanied by the Project Manager. Because of the time-limited nature of this preliminary feasibility study, scheduling of NAs, and NA turnover, CSC data collected by research staff were available for only six NAs at both baseline and postintervention. Randomization t-test of the overall total correct communication skill percentage difference score revealed that NAs showed a significant increase in their use of effective communication skills on the CSC ( p < .01; see Fig. 1) from baseline (M = 67% correct, range = 60–83%) to postintervention (M = 87% correct, range = 77–90%). More specifically, NAs significantly increased the number of instructions per hour (M = 41, range = 18–84 baseline, M = 111, range = 38–258 postintervention, p < .03; see Fig. 2) and the number of positive statements per hour (M = 11,


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Fig. 1. Mean total percentage correct on the NA CSC.

range = 0–36 baseline, M = 69, range = 22–114 postintervention, p < .03; see Fig. 2) directed toward residents during care. Maintenance of this effect could not be assessed at follow-up because only four of the original NAs were scheduled to work during the observation week. Analysis of time-sampling data detected no pre–post-intervention changes in the amount of staff speech toward residents with memory books. Although inservice and hands-on training specifically targeted staff-resident interaction at times outside care

Fig. 2. Mean rate per hour of specific instructions (dark bars) and mean rate per hour of positive statements (light bars) by NAs during care interaction.


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routines, the rate of this interaction was not observed to change significantly from baseline to postintervention (M = 3.1%, range = 1.6 –7.2 and M = 5.1%, range = 1.6 –11.8, respectively). Resident Behaviors Observational data from research staff memory book checks indicated that residents were in possession of their memory books during 70% of the checks during the week immediately following the hands-on training phase. Memory book checks were taken once during the day and once during the evening shift (i.e., n = 80 observations). This figure dropped dramatically during the follow-up probe after research staff were no longer present in the facility on a daily basis. In this phase, residents were observed to be in possession of their memory books during only 25% of the day and evening checks by research staff. We found several trends suggesting that the intervention had positive effects on the social ecology of the nursing home. At baseline, these eight residents were observed to speak coherently on average 4.9% of observation time (range = 1.3–10.1). After implementation of the intervention, these residents spoke 8.4% of observation time (range = 3.2–15.8). Randomization t-tests indicate that this increase approaches statistical significance ( p = .07). Visual inspection of observational records reveals that resident speech occurred most frequently in the context of staff speech. However, during follow-up assessment when the memory books were no longer being used consistently resident speech returned to baseline levels (M = 4.1, range = 0.3–13.2). Second, nontarget residents and visitors were observed talking more with residents who had memory books after implementation of the intervention (M = 1.0%, range = 0–2.0 and M = 3.7%, range = 0.2–8.8, respectively). Randomization t-tests of difference scores revealed that this effect was significant ( p = .02). Speech by others toward residents with memory books continued at a reduced rate when the memory books were no longer being used consistently in the environment 1 month later. The rate of speech declined (M = 1.4%, range = 0–3.4), but this decline in verbal behavior was not significant. An important finding regarding the impact of our intervention was the striking increase in the rate of positive statements made by any actor in the environment. Figure 3 shows that the rate of positive statements made by any actor (including the observed resident) in the environment increased from one per hour (range = 0 –3.6) to six per hour (3.2–9.2) after implementation of the intervention ( p = .03). This effect maintained at follow-up assessment at a slightly reduced rate (M = 4 positive statements per hour, range = 0.7–12.6). The occurrence of agitation among our eight residents was extremely low (e.g., on average less than 1% of observation time during each phase). Thus, changes in this behavior could not be assessed. Finally, the results show a reduction in the amount of time staff and other residents were in the same room as, or within 5 feet, of residents who possessed memory books from baseline to postintervention (M = 69%, range = 44.6 –86.8 and M = 54%, range = 22.9–88.4 respectively; p = .01). The presence of staff and other residents in the observed resident’s immediate environment returned to baseline levels at follow-up 1 month later (M = 67%, range = 23.9–90.1, p = .01).


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Fig. 3. Mean rate per hour of positive statements by any actor in the environment during total time-sampling observations conducted between 8 a.m. and 10 a.m., noon and 2 p.m., and 5 p.m. and 7 p.m.

DISCUSSION These preliminary results suggest that, through inservice and hands-on training, NAs can improve their communication skills and can learn to use a memory book intervention with nursing home residents. Results also suggest that, in spite of uneven implementation of the intervention by nursing staff, the use of enhanced communication skills and memory books improved communication between staff and residents during care routines, increased the amount of time other residents and visitors spent talking with target residents, and increased the rate of positive statements made by target residents and others in the resident’s immediate environment. Using a precise and reliable computer-assisted observational system, we found that residents with memory books were marginally more likely to speak coherently with others, usually nursing staff, in comparison with their rate of interaction at baseline. However, it is important to note that the residents in this study displayed mild to moderate dementia (mean MMSE = 16.25), and that their ability to engage in effective communication was relatively intact. Results also show that individuals other than staff (e.g., other residents and visitors) significantly increased their amount of verbal interaction with residents who had memory books. Interestingly, the amount of speech from others directed to residents with memory books increased from baseline to postintervention in spite of a decrease in the presence of others in observed residents’ surroundings during the same period. Regarding the quality of verbal interactions, data from the CSC and computer-assisted observations revealed a higher frequency of positive verbal exchanges after implementation of the intervention. As defined in this study, positive verbal exchanges included


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statements of appreciation (e.g., “good job”), statements of affection (e.g., the use of endearments), and statements of social convention (e.g., “thank you”). Thus, the provision of information about the residents’ lives in the form of memory books coupled with training in effective communication techniques may have provided greater opportunities for more meaningful, positive interactions (Bourgeois, 1990, 1992b, 1993; Bourgeois et al., 1997). The opportunity for more positive conversational exchanges may act as a reinforcer for continued use of therapeutic communication skills by staff and for verbal interaction by residents. Results were mixed with regard to changes in the amount and quality of staff speech directed toward residents. Data from the CSC taken during care routines showed that NAs’ accurate performance of communication skills ( percent score) increased from baseline to postintervention assessment. NAs provided residents under their care with more specific instructions and positive statements immediately after training. Contrary to expectations, however, our intervention produced no changes in the amount of staff speech toward target residents during computer-assisted time-sampling observations conducted between 8 a.m. and 10 a.m., noon and 2 p.m., and 5 p.m. and 7 p.m. This finding may suggest that the intervention was not adequately powerful to produce changes in communication outside of a focused care interaction. However, it is possible that this pilot study was not sufficiently powered to detect generalized changes in behavior as measured through time-sampling methodology. A hypothesis of this study was that a modified, abbreviated staff motivational system would result in the maintenance over time of positive changes in the nursing staff’s performance of therapeutic communication skills (Burgio and Burgio, 1990). Implementation of the full Behavioral Supervision model has been shown effective in maintaining NA use of trained skills up to 46-week postintervention (Stevens et al., 1998). However, our data suggest that the modifications made to the motivational system used in this preliminary study limited the effectiveness of the intervention. The first modification to the system was a reduction in the duration of NA hands-on training from the 3 weeks reported in previous research (Stevens et al., 1998) to 2 weeks. In order to meet job performance criteria, NAs were expected to (a) ensure that memory books were in the immediate environment of observed residents, (b) complete 80% of the self-monitoring checklists assigned to them, and (c) score at least 80% on the LPN or researcher-administered CSC. Although CSC data indicated improvement in NAs’ use of communication skills (criterion C), data regarding the other two performance guidelines showed poor NA compliance with the staff motivational system. Observational checks of memory book availability indicated that memory books were present in the environment of target residents during only 70% of checks immediately postintervention and during 25% of checks 1 month after research staff left the facility. Additionally, NAs’ compliance with self-monitoring was unexpectedly low during handson training when research staff implemented most of the staff motivational procedures (i.e., 64% completion during the first week and 37.5% completion during the second). It would appear that NAs did not have the opportunity to complete checklists during the postintervention week because of a failure to transfer the staff motivational system to indigenous LPNs. A longer training period is probably necessary to induce LPNs to provide NAs with positive and enough corrective feedback on their use of memory books and selfmonitoring. Prior studies have found continued LPN-provided performance feedback to be


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necessary to ensure the consistent implementation of the intervention across time (Burgio et al., 1994b; Stevens et al., 1998). The second modification to the staff motivational system made was a reduction in the duration of LPN hands-on training from the 3 weeks reported in previous research (Stevens et al., 1998) to only 1 week. The Behavioral Supervision model stipulates that in order to meet job performance criteria, LPNs must observe and provide performance feedback to 80% of regularly scheduled NAs in their section each week. Although all three LPNs received training in Behavioral Supervision from the Project Manager and two of the three LPNs were trained to accurately code NA behavior and provide verbal feedback, the LPNs did not perform their supervisory function independently during the week postintervention. Because of the limited training period, the LPNs did not have the opportunity to practice these skills and to receive performance feedback from the Project Manager and/or administrative RN nursing staff. In the absence of a strong commitment by supervisory nursing staff to the implementation and maintenance of staff motivational systems, even intensive NA training is not sufficient to ensure the maintenance of gains in skill performance (Burgio and Burgio, 1990; Burgio and Stevens, 1999; Schnelle et al., 1993, 1997; Stevens et al., 1998). In the recently completed study funded by NIA (Burgio et al., in press) several modifications were made from the pilot experience and prior research regarding the implementation of the staff motivational system: (a) hands-on training of nursing staff took place over a 4-week period rather than a 2-week period; (b) when LPNs observed at least 80% of their NA supervisees each week, they were listed on a separate honor roll that was publicly posted; (c) RN unit managers, staff development, and the Director of Nursing received weekly written and graphic feedback on the performance of NAs and LPNs in their facility; and (d) the performance of Behavioral Supervision by indigenous nursing home staff after the exit of research staff from the facility was monitored during consultation visits by the Project Manager. During these consultation visits, feedback was given regarding the successful implementation of the motivational system and the memory book intervention. A major limitation of this preliminary study was the time-limited nature of the data collection period. This precluded the ability to follow all twelve trained NAs from baseline to postintervention and follow-up. During the 5 days of follow-up data collection, only four of the original NAs were scheduled for regular work activities including the provision of care. A further limitation is that in spite of the time-limited nature of the data collection period, there was significant change in NA staff from baseline to postintervention and follow-up. This limitation is reflected in the decrease in the number of NAs trained (n = 12) versus those observed working with residents during both baseline and postintervention (n = 6). Despite limitations, we believe that the findings from this preliminary study are promising. Most importantly, an increase in positive verbal exchanges between target residents and others was maintained 1 month after research staff exited the facility. In accordance with the hypotheses of socioemotional selectivity theory (Carstensen, 1991) and Lawton’s theories of environmental press (Lawton, 1981, 1989), the social environment of nursing home residents takes on greater importance as an indicator of quality of life. These preliminary results suggest that this intervention may have positive impact on the quality of social interaction in nursing homes, and, thus, can potentially have a positive effect on resident quality of life.


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ACKNOWLEDGMENTS The authors thank the nurses, nursing aides, and administrative staff of Mary Lewis Convalescent Center for their support and assistance. Special thanks are extended to Eric Bodner and Michael Demand for assistance in statistical analysis; to Shane Thomas, Carla Martin, and Tevis Denise for assistance in data collection; and to Rebecca Card for assistance in manuscript preparation. This paper was presented at the 50th annual scientific meeting of the Gerontological Society of America, Cincinnati, Ohio, November 17, 1997. The research reported in this paper was supported by funding from the National Institute on Aging (RO1AG13008) to M. Bourgeois and L. Burgio. REFERENCES Baltes, M. M. (1988). The etiology and maintenance of dependency in the elderly: Three phases of operant research. Behav. Ther. 19(3): 301–319. Baltes, M. M., and Reisenzein, R. (1986). The social world in long-term care institutions: Psychosocial control toward dependency. In Baltes, M. M., and Baltes, P. B. (eds.), The Psychology of Control and Aging, Erlbaum, Hillsdale, NJ, pp. 315–343. Bourgeois, M. (1990). Enhancing conversation skills in Alzheimer’s Disease using a prosthetic memory aid. J. Appl. Behav. Anal. 23: 29–42. Bourgeois, M. (1992a). Evaluating memory wallets in conversations with patients with dementia. J. Speech Hear. Res. 35: 1344–1357. Bourgeois, M. (1992b). Conversing With Memory Impaired Individuals Using Memory Aids, Northern Speech Services, Gaylord, MI. Bourgeois, M. (1993). Effects of memory aids on the dyadic conversations of individuals with dementia. J. Appl. Behav. Anal. 26: 77–87. Bourgeois, M. S., Burgio, L. D., Schulz, R., Beach, S., and Palmer, B. (1997). Modifying repetitive verbalizations of community-dwelling patients with AD. The Gerontologist 37: 30–39. Bourgeois, M. S., and Mason, L. A. (1996). Memory wallet intervention in an adult day-care setting. Behav. Intervent. 11(1): 3–18. Burgio, L. D. (1997). Behavioral assessment and treatment of disruptive vocalization. Semin. Clin. Neuropsychiatr. 2(2): 123–131. Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S., Dijkstra, K., Gerstle, J., Jackson, E., and Bankester, L. (in press). Come talk with me: Improving communication between nursing assistants and nursing home residents during care routines. The Gerontologist. Burgio, L. D., and Burgio, K. L. (1990). Institutional staff training and management: A review of the literature and a model for geriatric long-term care facilities. Int. J. Aging Hum. Deve. 30: 287–302. Burgio, L. D., Engel, B. T., Hawkins, A. M., McCormick, K., and Sheve, A. S. (1990). A descriptive analysis of nursing staff behaviors in a teaching nursing home: Differences among NAs, LPNs, and RNs. The Gerontologist 30: 107–112. Burgio, L. D., McCormick, K. A., Scheve, A. S., Engel, B. T., Hawkins, A., and Leahy, E. (1994a). The effects of changing prompted voiding schedules in the treatment of incontinence in nursing home residents. J. Am. Geriatr. Soc. 42: 315–320. Burgio, L. D., and Scilley, K. (1994). Caregiver performance in the nursing home: The use of staff training and management procedures. Semin. Speech Lang. 15: 313–322. Burgio, L. D., Scilley, K., Hardin, J. M., Hsu, C., and Yancey, J. (1996). Environmental “white noise”: An intervention for verbally agitated nursing home residents. J. Gerontol. Psychol. Sci. 51B: 354– 373. Burgio, L. D., Scilley, K., Hardin, J. M., Janosky, J., Bonino, P., Cadman, S., and Engberg, R. (1994b). Studying disruptive vocalization and contextual factors in the nursing home using computer-assisted-real-time observation. J. Gerontol. Psychol. Sci. 49(5): 230–239. Burgio, L. D., and Stevens, A. B. (1999). Behavioral interventions and motivational systems in the nursing home. In Schulz, R., Maddox, G., and Lawton, M. P. (eds.), Annual Review of Gerontology and Geriatrics, Vol. 18: Focus on Interventions Research With Older Adults, Springer, New York, pp. 284–320. Carstensen, L. L. (1991). Selectivity theory: Social activity in life-span context. In Schaie, K. W., and Lawton M. P., (eds.), Annual Review of Gerontology and Geriatrics, Springer, New York, pp. 195–215. Carstensen, L. L., and Erickson, R. J. (1986). Enhancing the social environments of elderly nursing home residents: Are high rates of interaction enough? J. Appl. Behav. Anal. 19: 349–355.


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