| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
a Applied Gerontology Program, University of Alabama, Tuscaloosa
b Center for Aging, University of Alabama at Birmingham
c Birmingham Veterans Administration Medical Center, AL
Correspondence: Louis D. Burgio, PhD, The University of Alabama, Applied Gerontology Program, Box 870315, Tuscaloosa, AL 35487-0315. E-mail: lburgio{at}sw.ua.edu.
Decision Editor: Laurence G. Branch, PhD
 |
Abstract |
|---|
 TOP Abstract MethodsResultsDiscussionReferences |
|---|
Key Words: Behavior management • Nursing homes • Staff training and motivation • Agitation
Among the most challenging problems faced by the staff of nursing homes are the behavioral disturbances of residents with dementia. Behaviors such as repetitive demands, verbal outbursts and physically aggressive acts, can create an uncomfortable and stressful work environment for nursing staff charged with caring for these residents. Behavioral disturbances can also affect the quality of life of other residents in the nursing home. In a review of published findings, Beck and colleagues (Beck, Rossby, and Baldwin 1991
) report a disruptive or problem behavior prevalence rate of 42.8%.
Traditionally, nursing home staff have managed behavioral disturbances with restrictive interventions such as psychoactive drugs and physical restraints. The use of these interventions has been criticized increasingly due to their questionable efficacy and adverse consequences, such as restraint-related injuries and the negative side-effect profiles of the medications (Class, Schneider, and Farlow 1997; Fleming and Evans 1995; Johansson and Skoog 1996; Ouslander and Schnelle 1995; Thapa, Meador, Gideon, Fought, and Ray 1994).
In 1987, the United States Congress passed the Omnibus Budget Reconciliation Act, which discouraged the use of pharmacological interventions for behavioral disturbances (Omnibus Budget Reconciliation Act). An alternative model of treatment was proposed in 1990 by the Health Care Financing Administration, which recommended that staff training and behavior management be considered first line treatment for behavioral disturbances in nursing homes (American Health Care Association 1990). This shift toward an emphasis on behavior management skills was facilitated by a growing understanding that the behavior of residents is influenced heavily by environmental factors. Nursing staff represent a major environmental factor in the daily life of the nursing home resident. In fact, 80% to 90% of a resident's contact with staff occurs with certified nursing assistants (CNAs). Thus, researchers recognized that the behavior of CNAs, including how they communicate with residents when providing care and how they respond to them when a behavior problem occurs, can influence the occurrence of behavioral disturbances.
There are initial data suggesting that behavior management skills training programs can increase CNA knowledge of behavioral skills and may result in a reduction in behavioral disturbances in nursing home residents (Burgio and Bourgeois 1992). Usually, behavior management skills are taught to the nursing staff through didactic workshops or in-service training. Whether the staff actually acquire the knowledge and skills to implement behavior management with residents has seldom been assessed in intervention trials (Burgio and Stevens 1999). Furthermore, few studies have used staff motivational systems to facilitate consistent and accurate application of therapeutic skills by CNAs (Burgio et al. 2001; Burgio and Scilley 1994; Schnelle, Newman, and Fogarty 1990).
Burgio and colleagues 2001 compared a staff communication training program that utilized a formal staff motivational system with a no-treatment control group. Results showed that the intervention successfully increased staff communication skills, which maintained up to 2 months after the research staff exited the facility. Unfortunately, any independent effects of the staff motivational system could not be assessed with this design.
The primary goal of the present study was to evaluate the efficacy of a comprehensive behavior management skills training program for improving CNA behavioral skill performance and to evaluate any resulting effects on residents' behaviors. In this study, two groups were compared. Each group received identical skills training. However, one group also received a formal staff motivational system so that the independent effects of this system could be evaluated.
|
Methods |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
), to assess overall severity of behavioral disturbances. Residents receiving a score of one (mildly troubling) or greater, on average, were considered eligible. We excluded residents if they were living on a rehabilitation unit with a limited length of stay. We requested proxy informed consent from the resident's sponsor as listed in the nursing home records. When appropriate, we obtained informed consent from the resident. We followed informed consent procedures of the University of Alabama's and University of Alabama at Birmingham's Institutional Review Boards for Human Use. From a pool of 480 residents, we deemed 236 residents eligible for participation. We obtained informed consent and resident assent for 146 residents, reflecting a 62% consent rate. Fourteen resident sponsors refused consent, and 76 sponsors failed to respond to multiple invitations from project staff. In addition, 58 residents were eligible but did not enter the study because of death, relocation to another nursing unit, or discharge from the nursing home. Therefore, 88 of the 146 consented residents were available for baseline data collection. Their average age was 80 years, and they were predominately White (67.0%) and female (77.3%).
According to a physician-established dementia diagnosis, 46% of these residents had possible Alzheimer's disease (AD), 22% a form of vascular disease, and 19% a mixed AD/vascular dementia. A dementia diagnosis could not be established for 13% of the residents.
Of the 88 residents who entered the baseline phase, 79 completed the baseline and post-intervention assessment periods (47 in formal staff management [FSM], 32 in conventional staff management [CSM]). We considered these residents the analysis sample. Randomization of nursing units that varied in size resulted in an unequal distribution of residents in the FSM and the CSM conditions. There was no differential attrition between groups. Nine residents did not complete the 12-week baseline through post-intervention period because of death, onset of severe medical condition, or discharge from the nursing home. There were no significant differences between the 79 surviving and the 9 discontinued residents, and no differences between the FSM and CSM groups on age, cognitive functioning (Mini-Mental State Examination [MMSE]; Folstein, Folstein, and McHugh 1975), frequency of behavior problems (Cohen-Mansfield Agitation Inventory [CMAI]; Cohen-Mansfield 1986), self-care ability (The Barthel Self-Care Rating Scale [Barthel]; Sherwood, Morris, Mor, and Gutkin 1977), dementia severity (Clinical Dementia Rating scale; Hughes, Berg, Danziger, Coben, and Martin 1982), ethnicity, or medication use. There were significantly more women on the FSM units. Table 1 shows selected characteristics of surviving residents on the FSM and CSM units.
|
One-hundred-six CNAs entered the study with 85 completing baseline and post-intervention assessment periods (46 in FSM, 39 in CSM). Twenty-five CNAs did not complete the baseline and post-intervention periods because of turnover or transfer to a nonparticipating unit. The discontinued CNAs did not differ significantly from the 85 surviving CNAs in age, length of time they worked as a CNA, length of time they worked in the facility, education level, gender, or ethnicity. Selected characteristics of the CNAs are presented in Table 2 . Thirteen LPNs participated as supervisors on the FSM units.
|
Procedures
Following baseline assessment, all CNAs and LPNs received 4 weeks of behavior management training with knowledge and performance-based assessments of skill acquisition. Upon training CNAs to established criteria of behavioral skill performance, we instructed supervisory nursing staff on FSM units to implement the FSM system, and we instructed those on CSM units to continue their normal supervisory routine. In order to examine CNA skill performance and any changes in resident behavior, we repeated assessments during a 4-week post-intervention phase immediately after staff training. We conducted follow-up assessments during week-long periods at 3 and 6 months after training to assess maintenance of change in staff and resident behaviors.
Behavior Management Skills Training
Nursing staff received behavior management skills training through in-service classes and hands-on training over the 4-week period intervention phase.
In-Service Classes
To convey knowledge of basic behavior management skills, a geropsychologist from the research staff taught in-service classes during the nursing staff's regular working hours. The geropsychologist presented instructional content during 5-hr of in-service training completed over 3 consecutive days during Week 1 of the intervention phase. We targeted the curriculum to an eighth grade reading level. We taught CNAs how to identify factors in the environment that could affect resident behavior, and two types of behavior management skills: communication skills and behavior management techniques. Specifically, we taught them to increase effective nonverbal and verbal communication skills (e.g., appropriate eye contact, announcing single activities, and delaying physical assistance following a verbal prompt) and decrease ineffective communication skills (e.g., announcing multiple activities and using multiple verbal prompts). Similarly, we taught staff to increase the use of effective antecedent and consequent behavioral techniques (e.g., distraction and diversion) and decrease ineffective responses (e.g., arguing with residents). In the class, we used videotaped depiction, examples of specific problem behaviors encountered on the unit, and discussion of written vignettes; we supplemented these with a workbook (available from the first author). Subsequently, we discussed specific behavior problems of residents on the unit and wrote an individualized behavioral program for the most problematic behavior, entered it into the resident's chart, and provided it to the care plan nurse. We gave CNAs a paper and pencil test before and after in-service training to assess their knowledge of behavior management skills.
Hands-On Training
Immediately following the in-service, we provided hands-on training in behavioral skills on the unit (Weeks 2–4 of the intervention phase). We observed CNAs on the day and evening shifts during one care interaction per day (Monday–Friday), and provided feedback (see Stevens et al. 1998 for details). On the CNAs' last scheduled work day during the intervention phase, two members of the research staff observed them independently to evaluate their skill performance. The criterion score was the CNAs' demonstration of behavioral skills during 80% of all opportunities to apply the skills in the evaluation session.
FSM
We asked supervisory nursing staff (LPNs and RNs) on FSM units to use the FSM system beginning during training in the intervention phase and continuing throughout all remaining phases of the study. Adapted from Burgio and Burgio 1990 Behavioral Supervision model, components of the FSM system included (a) a clear and specific description of behavioral skills, (b) CNA self-monitoring, (c) LPN monitoring of CNA skill performance, (d) verbal and written performance feedback to CNAs, and (e) CNA incentives for achieving established performance criteria. We provided training to CNAs, LPNs, and RNs to explain the philosphy and rationale for using a staff motivational system and the use of the system. Two LPNs left the facilities during the study. We replaced these individuals and provided one-on-one training. Supervisors received 2 hr of in-service training and an average of two hands-on training sessions approximately 15 min in length. The nursing home rarely assigned supervisory staff to another unit. This provided optimal consistency in supervision. We provided technical support to the nursing staff and supplied the FSM-related materials (See Stevens et al. 1998, for more detail).
CSM
After completing the hands-on training phase, CNAs on the CSM units received no additional training or feedback. We instructed supervisory nursing staff on units assigned to the CSM condition to continue their normal supervisory routine.
Screening Measures
We used the MMSE to assess global cognitive functioning (Folstein et al. 1975). We used The Barthel Self-Care Rating Scale to assess activities of daily living (ADLs; Sherwood et al. 1977). Nursing staff rated the resident's ability to eat, dress, toilet, ambulate, bathe, and care for hygiene needs on 4-point Likert scales. A study physician established a dementia diagnosis using the Clinical Dementia Rating scale (Hughes et al. 1982), medical records, information from a structured interview with the resident and a family caregiver, and the results of the Barthel and MMSE.
Outcome Measures
We measured several outcomes during the baseline phase, the post-intervention phase, and the 3- and 6-month follow-ups. The CMAI used nursing staff reports to assess 29 behavior problems of the residents (Cohen-Mansfield 1986). The CMAI yields three subscales: aggressive behavior, physically nonaggressive behavior, and verbally aggressive behavior. We measured behaviors of CNAs and residents using two behavior observational systems: the Behavior Management Skills Checklist (BMSC; Stevens et al. 1998) and two computer-assisted behavioral observation systems (CABOS; Burgio, Scilley, Hardin, et al. 1994).
BMSC
The BMSC is a checklist developed to measure CNA performance of behavior management techniques and communication skills during care interactions (Stevens et al. 1998). We developed separate methods to measure communication responses and the use of behavior management techniques used in response to agitation. During observational sessions, we recorded the number of occurrences of each of seven communication skills. We considered five of the responses therapeutic and increases were desirable: (a) announcing single activities, (b) prompting single activities, (c) providing positive statements, (d) delaying physical assistance following announcement, and (e) delaying physical assistance during a verbal prompt. We considered two of the communication responses counter-therapeutic and deemed decreases desirable: (a) announcing multiple activities and (b) prompting multiple activities. These variables were expressed in terms of rate of occurrence per hour.
We included on the checklist a list of eight effective and three ineffective behavior management techniques in response to agitation. During each session, we recorded the number of observed effective strategies (out of eight) and ineffective strategies (out of three). These data are expressed as the mean number of effective and ineffective strategies observed per session. Resident agitation was expressed as the percentage of sessions during which agitation occurred. The mean interobserver reliability coefficient across the four observation categories was 74%. We scheduled four checklist observations during baseline and again during the post-intervention phase. At each follow-up contact, we obtained an additional checklist observation for each resident.
CABOS
The CABOS was also used to record the occurrences of resident and staff behaviors (Burgio et al. 1994; Burgio et al. 2001). We developed two separate systems. The first system coded resident and staff behaviors during care interactions. The observation system provided data on the rates of positive statements and verbal prompts by the CNA, amount of physical assistance provided, and resident agitation (defined as disruptive vocalization, restlessness, or physical aggression). We observed four care interactions for each resident during baseline and again during the post-intervention phase. The interactions were separate and independent from those observed with the BMSC. At the 3- and 6-month follow-up assessments, we conducted two observations for each resident. Observation time per session ranged from 4.9 min to 20.4 min. We completed care observations on 72 of the 79 residents.
The second observation system used time-sampling to observe CNA and resident behaviors throughout the day on the nursing units. Residents were the main target of these observations. We scheduled residents to be observed and coded for two 30-min sessions during each hour between 8 a.m. and 8 p.m. Thus, we attempted 24 observations on each resident during the 4 weeks of baseline and repeated them during the 4-week post-intervention phase. At the 3- and 6-month follow-ups, each resident received a minimum of two 30-min observations. The time-sampling system recorded CNAs' verbal interactions with residents, positive statements made to the resident, and resident agitation. For both care interaction and time-sampling observations, two observers coded behavioral data simultaneously during approximately 11% of the sessions. Kappa values ranged from 0.69 to 0.88 for care interaction observations and from 0.71 to 0.82 for time-sampling.
Statistical Analysis
We analyzed significant training effects from baseline to post intervention by using two (FSM, CSM) by two (pre, post) analyses of variance. We used the main effects for time (i.e., pre vs. post) to determine whether the general effects for training across both FSM and CSM groups were significant. To assess whether the FSM and CSM groups showed differential change after training, we conducted analyses of covariance (ANCOVAs) on the change scores (e.g. post-intervention minus baseline), with baseline score serving as the covariate. We performed separate ANCOVAs at post-intervention, 3-month follow-up, and 6-month follow-up to accommodate the different patterns of missing data at the follow-up assessments. In all cases, we analyzed change from baseline as the dependent variable, with baseline score as the covariate.
|
Results |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
Treatment Receipt
We conducted knowledge tests of basic behavior management skills taught during the in-service classes before and immediately after the classes for 76 CNAs. Overall, knowledge test scores increased significantly (p < .001) from a mean of 80.74 (SD = 13.15) to a mean of 91.45 (SD = 9.58). There were no differences between FSM and CSM.
CNA Performance of Behavioral Skills on the Nursing Units
BMSC
The mean rates of effective and ineffective behavior management techniques and the seven communication skills are presented in Table 3 . We found significant decreases in the use of ineffective strategies across both groups. However, we found no general training effects for effective strategies. Regarding communication skills, we observed significant training effects in the hypothesized direction for five of the seven variables. Prompting multiple activities showed no change from baseline to post-intervention, and announcing multiple activities showed a small, but statistically significant, counter-therapeutic increase. From the ANCOVAs that tested differential change after training, we found that CNAs in the FSM condition showed significantly greater increases in the rate of delayed physical assistance following a verbal prompt than CNAs in the CSM condition, who demonstrated minimal change on this variable.
|
|
Maintenance of CNA Behavioral Skills at the 3- and 6-Month Follow-ups
We examined long-term maintenance of CNA behavioral skills on each dependent variable listed in Table 3 and Table 4 . In these analyses, we calculated changes from baseline by subtracting each variable's follow-up value from its baseline value, and we analyzed group differences on these change scores by using ANCOVA, with baseline score serving as the covariate. Covariate-adjusted difference scores are presented in figure format for all variables that showed significant group differences at either follow-up assessment point.
BMSC
Results indicated that the decreases in ineffective behavioral strategies shown for both groups at post-intervention were not maintained at the follow-up assessments. However, for all seven communication skills variables, rates were different across both groups at the 3- and 6-month assessments compared to baseline.
As hypothesized, Fig. 1 shows that the FSM and CSM groups differed in the rate of announcing single activities at the 6-month follow-up assessment, F(1, 56) = 6.22, p < .05, with the FSM group increasing their use of the skill and the CSM group decreasing their use of announcements. Similarly, the groups differed at the 6-month follow-up on the rate of delaying physical assistance following an announcement, F(1, 56) = 6.49, p < .05, with the FSM group continuing to increase the rate of this skill and the CSM group decreasing their use of the skill (Fig. 2). Although neither group nor time effects emerged at the pre–post evaluation for prompting multiple activities, Fig. 3 shows a significant group effect at the 3-month follow-up for rate of prompting multiple activities F(1, 64) = 4.74, p < .05, with the FSM group decreasing this counter-therapeutic behavior and the CSM group increasing the behavior. We observed a similar pattern of group differences at 6 months, but the effect only approached statistical significance (p = .09). A group difference trended toward significance for positive statements, F(1, 56) = 3.66, p = .06, with the FSM group continuing to increase their use of these statements and no increase over the initial change displayed by the CSM group (Fig. 4).
|
|
|
|
|
|
|
|
|
Discussion |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
; Burgio et al. 2001; McCallion, Toseland, Lacey, and Banks 1999). Direct observation of CNA performance during the 4 weeks immediately after training suggests a marked therapeutic change in five of the seven communication skills, especially the CNAs' use of positive statements. We detected these increases during care interactions and also throughout the day as measured by behavioral time-sampling. CNAs also showed significant improvements in their ability to inform the residents about impending tasks, increasing from 24.2 single announcements per hour in baseline to 57.5 after training. Unfortunately, this change was accompanied by an increase in multiple announcements, a staff behavior that can confuse residents with dementia.
CNAs showed a marked increase in their ability to delay providing physical assistance to residents after announcing a task or delivering a verbal prompt. The purpose of these skills was to allow the resident a greater opportunity to initiate the task independently. CNAs were more likely to deliver single verbal prompts after training, although there was no change in their use of counter-therapeutic multiple prompts.
We observed no changes in physical assistance provided by CNAs. This finding suggests that, although CNAs delayed providing physical assistance after announcing and prompting task activities, this did not increase resident independence. Two recent studies suggest that intensive interventions targeted at increasing resident independence during care routines can be used successfully (Beck et al. 1997; Rogers et al. 1999). However, it appears that delaying physical assistance alone is not sufficient for increasing resident independence during care routines.
Finally, although staff showed a significant decrease in their use of ineffective behavioral strategies (e.g., arguing with a resident) after training, they did not increase their use of effective strategies (e.g., diversion). Thus, although our training program was successful in improving therapeutic communication skills, it showed limited success in increasing CNAs' use of behavior management techniques in the nursing home.
Data from the BMSC indicate that both the CSM and FSM groups maintained the skills of announcing single activities and delaying physical assistance following an announcement at the 3-month follow-up assessment (Fig. 1 and Fig. 2). However, at the 6-month assessment, the FSM group showed superior maintenance, with the FSM group improving further and the CSM group decreasing performance of both skills. A similar pattern emerged for positive statements during care interactions, with the FSM group showing a significant increase in positive statements at the 6-month assessment (Fig. 4 and Fig. 5). However, Fig. 6 indicates a significant decrease in positive statements from post-intervention to 3-month follow-up for both groups. In contrast to results displayed in Fig. 1 and Fig. 2, CNAs on the CSM units generally maintained a higher level of positive statements; between-group differences emerged because performance on the FSM units increased significantly at the 6-month assessment.
The data on the CNAs' use of ineffective behavioral techniques suggest that the FSM system was not successful in maintaining initial reductions in the rates of these behaviors. However, the hypothesized superiority of the FSM system over conventional methods of supervision was generally supported for communication skills at the 6-month assessment. The maintenance of communication skills on the CSM units at the 3-month assessment is important. It is possible that these staff found the use of communication skills to be inherently reinforcing or that residents responded to pleasant statements with their own pleasant statements, producing a positive reciprocal interaction. However, although communication skills were maintained up to 3 months post-training, the results suggest that formal staff motivation produces superior performance and further improvements in skills over a longer time frame.
Regarding the impact on resident behavior, we did not detect reductions in agitation throughout the day. However, both groups demonstrated significant decreases in agitation during care routines, and these decreases maintained throughout all phases of the study (Fig. 8). The absence of group differences in agitation at the 6 month assessment is noteworthy. It is possible that, in spite of group differences in skill performance at 6 months, skills in the CSM group maintained above a threshold that produces change in resident agitation.
One weakness of this study is that we could only observe the application of effective and ineffective behavioral techniques if a behavioral disturbance occurred. Limited opportunities to observe these techniques produce low rates of occurrence, and change in low rate behaviors is difficult to detect using any measurement system.
The results of the current research support the inclusion of a formal staff motivational system in programs using CNAs as interventionists. Note that the intervention described in the current study occurred between 1994 and 1997. Since that time, reimbursement rates have been reduced in many states, resulting in leaner staff-to-resident ratios and less available time for staff training activities. Also, the staff turnover rates in our nursing homes were lower than the national average, and it is uncertain if nursing homes with more typical turnover rates would be able to adopt this program. To obtain the greatest degree of utilization and impact, the program should be feasible for use by existing staff development personnel with minimal input from consultant level staff.
|
Acknowledgments |
|---|
Received for publication October 18, 2001. Accepted for publication January 15, 2002.
|
References |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
4206, and 4715, codified at 42 U.S.C. 1395cc (a) (1) (q), 1395 mm (c) (8), 1395cc (f), 1396a (57), (58), 1396a (w).This article has been cited by other articles:
 |
|
 |
|
  L. D. Burgio, N. S. Park, J. M. Hardin, and F. Sun A Longitudinal Examination of Agitation and Resident Characteristics in the Nursing Home Gerontologist, October 1, 2007; 47(5): 642 - 649. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. L. Coogle, I. A. Parham, and K. A. Young Job Satisfaction and Career Commitment Among Nursing Assistants Providing Alzheimer's Care American Journal of Alzheimer's Disease and Other Dementias, September 1, 2007; 22(4): 251 - 260. [Abstract] [PDF]
|
|
|
|
 |
|
 L. Volicer and A. C. Hurley Review Article: Management of Behavioral Symptoms in Progressive Degenerative Dementias J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M837 - 845. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. E. Vance, L. D. Burgio, D. L. Roth, A. B. Stevens, J. K. Fairchild, and A. Yurick Predictors of Agitation in Nursing Home Residents J. Gerontol. B. Psychol. Sci. Soc. Sci., March 1, 2003; 58(2): P129 - 137. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Roth, A. B. Stevens, L. D. Burgio, and K. L. Burgio Timed-Event Sequential Analysis of Agitation in Nursing Home Residents During Personal Care Interactions With Nursing Assistants J. Gerontol. B. Psychol. Sci. Soc. Sci., September 1, 2002; 57(5): P461 - 468. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
