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A Cooperative Communication Intervention for Nursing Home Staff and Family Members of Residents

Correspondence: Address correspondence to Karl Pillemer, PhD, Director, Cornell Gerontology Research Institute, MVR G39, Cornell University, Ithaca, NY 14853. E-mail: kap6{at}cornell.edu

	Abstract

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Purpose: This article reports on a randomized, controlled study of Partners in Caregiving, an intervention designed to increase cooperation and effective communication between family members and nursing home staff. Design and Methods: Participants included 932 relatives and 655 staff members recruited from 20 nursing homes, randomly assigned to treatment and control conditions. Parallel training sessions on communication and conflict resolution techniques were conducted with the family and staff in the treatment group, followed by a joint meeting with facility administrators. Results: Positive outcomes were found for both family and staff members in the treatment group. Both groups showed improved attitudes toward each other, families of residents with dementia reported less conflict with staff, and staff reported a lower likelihood of quitting. Implications: Multiple studies report significant interpersonal stress between family members of nursing home residents and facility staff members. Partners in Caregiving appears to be an effective way to improve family–staff relationships in nursing homes.

Key Words: Long-term care • Family–staff relationships • Communication resolution

In recent years, increased attention has been devoted to the experiences of family caregivers to persons in long-term care facilities. Research has shown that many family members experience considerable stress in negotiating relationships with the nursing home (Bowers, 1988; Gaugler, Leitsch, Zarit, & Pearlin, 2000; Gladstone & Wexler, 2000; Grau, Teresi, & Chandler, 1993; Hertzberg & Ekman, 1996; McLeod & Schwartz, 1992; Tobin, 1995; Whitlach, Feinberg, & Stevens, 1999). Furthermore, it is clear that nursing home personnel also sometimes find their relationships with family members to be challenging (Cohen-Mansfield, 1995; Heiselman & Noelker, 1991; Pillemer, Hegeman, Albright, & Henderson, 1998).

Such problems result in part from structural barriers to cooperation between the two groups. In the most influential theoretical approach to this issue, Litwak (1985) noted fundamental differences between large-scale formal organizations and primary groups (such as families). Formal organizations are characterized by bureaucratic structure, formal rules for behavior, and impersonal ties, whereas families are based on ties of birth and love, concern for special characteristics of individuals, and a life-long period of contact. This theoretical framework suggests that problems emerge when there is a mismatch between the structure of the formal organization and the types of tasks it assumes from families. In nursing homes, the potential for such intergroup conflict is heightened because long-term care facilities represent the classic case of a formal institution seeking to take over primary group tasks (such as personal care) and to fit the performance of such tasks into a bureaucratic, routinized framework (Litwak, 1985; Litwak, Jessop, & Moulton, 1994).

Although research testing these theoretical ideas has been limited, several studies have revealed a set of obstacles to harmonious staff–family member relationships that are consistent with Litwak's argument. First, discrepancies between staff and family perceptions of appropriate tasks for each group have been found to be common (Nolan & Dellasega, 1999; Stephens, Ogrocki, & Kinney, 1991), often producing staff–family conflict (Duncan & Morgan, 1994).

The second pattern involves barriers to communication, including: (a) time pressure on the part of the staff (Pillemer, 1996), which can make interactions brief and cursory; (b) the tendency of relatives to be hesitant about offering suggestions and criticism because of fears that such comments might negatively affect the care provided to the resident (Hertzberg & Ekman, 1996); and (c) the fact that staff and residents frequently come from different ethnic groups and socioeconomic classes. As a result of these and related factors, staff and families report that there is often little sharing of detailed information about residents (Ekman & Norberg, 1988; Safford, 1989).

A third obstacle to cooperation is the negative stereotypes families and staff often have of one another. Family members may distrust staff (Krause, Grant, & Long, 1999; Tobin, 1995) and believe that staff need continual monitoring (Duncan & Morgan, 1994; Stull, Cosbey, Bowman, & McNutt, 1997). Concomitantly, staff members often believe that families hold unrealistic expectations for the care that can be provided in nursing homes (George & Maddox, 1989; Heiselman & Noelker, 1991). Studies have documented that families and staff members are sometimes annoyed and angry toward the other group (Foner, 1995; Vinton & Mazza, 1994).

The need for intervention programs to address these problem areas is highlighted by the negative effects of troubled relationships on family members of institutionalized persons. Poor relationships with the staff have been found to be predictive of family members' depression (Brody, Dempsey, & Pruchno, 1990), anxiety (Pruchno & Kleban, 1993), and emotional stress related to caregiving (Brody et al., 1990; Stephens et al., 1991). Troubled relationships with families are a likely source of distress for staff as well (Pillemer & Hudson, 1993; Wilner, 1994). These results are consistent with the general finding that few aspects of life are more distressing than interpersonal conflict (Sternberg & Dobson, 1987).

In the face of such compelling evidence, one might expect that interventions to address these problems would be widespread; however, this has not been the case. Most programs have focused only on the family, offering individual counseling or support groups for relatives of residents (Hansen, Patterson, & Wilson, 1988; Peak, 2000; Sancier, 1984; Tobin, 1995), or inviting family members to participate in their relatives' care or serve as volunteers in the facility (Anderson, Hobson, Steiner, & Rodel, 1992; Linsk, Miller, Pflaum, & Ortigara-Vicik, 1988). Such programs typically have not addressed staff perspectives and behaviors, although it is likely that training for both groups is needed to bring about change. Existing programs do not address facility procedures and policies that may generate family–staff problems. The intervention developed in this study (Partners in Caregiving [PIC]) was designed to address each of these issues.

	Conceptual Basis and Hypotheses

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Two major mechanisms were used by PIC to bring about changes in family and staff perceptions and behaviors. Most important is the development of improved communication skills on the part of both groups. Research has demonstrated that training health professionals in cooperative communication is effective. For example, several studies have shown that communication skills training leads to improved relationships between physicians and their patients (Greenberg, Doblin, Shapiro, Linn, & Wenger, 1993; Levinson & Roter, 1993; McCormick, Inui, & Roter, 1996). Communication training interventions have also been shown to improve nurse–patient relations (cf. Caris-Vehallen, Kerkstra, & Bensing, 1997). Evidence also exists that communication training can improve relations between families and community institutions, such as schools (Cochran & Dean, 1991; Henderson & Berla, 1994). Although not conducted specifically in the nursing home setting, this line of research suggests that enhancing communication skills may be a promising method for fostering partnerships and reducing conflict and hostility between families and nursing home staff.

The second component of the intervention focused on discussing (and recommending changes in) facility policies and procedures in a joint meeting of family and staff participants with facility administrators. These sessions were expected to increase the sense of involvement and control for participants and create solidarity between staff and families. They provided an opportunity for members of both groups to work toward consensus on changes in facility practices or policies.

Hypotheses
We hypothesized that family and staff involvement in PIC would lead to positive changes in three domains. First, we expected that participation would improve the quality of relations between staff and family members. Specifically, we hypothesized that treatment participants would report (a) improved experiences with and attitudes toward the other group; and (b) decreased problems in face-to-face interaction, including interpersonal conflict. Second, we hypothesized that participation in PIC would reduce staff and family members' distress. It was hypothesized that for family members, levels of caregiver burden would decrease in the intervention group in comparison with controls, whereas for both family and staff members there would be a decrease in depression. Third, we anticipated that staff would experience a decrease in job stress.

Subgroup Variations in Benefits
Although we hypothesized that all categories of participants would benefit from the intervention, we expected that the effects would be more pronounced in subgroups most likely to experience high levels of stress. The basis for this hypothesis lies in the finding that enhancing positive social interaction and reducing negative interaction have stronger effects on well-being in the face of higher levels of stress (cf. House, Umberson & Landis, 1988; Pillemer & Suitor, 1996). In the case of family members, this leads us to anticipate that the intervention will have greater effects when the relative has Alzheimer's disease or a related dementia—conditions under which relatives experience greater stress (Kammer, 1994; Levesque, Ducharme, & Lachance, 1999; Stephens et al., 1991). This stress is further compounded because the residents with dementia may not be able to provide information about care needed or received, making effective communication with staff all the more critical (Duncan & Morgan, 1994; Rowles, Concotelli, & High, 1996).

In the case of staff, we anticipated that those in a paraprofessional occupational position—certified nursing assistants (CNAs)—would experience higher levels of stress and therefore receive greater benefit from the intervention. Nurses are more likely to have received some prior training in communication skills than CNAs (McCallion, Toseland & Freeman, 1999), which would presumably decrease nurses' risk of high levels on conflict with family members. The greater occupational prestige accorded supervisory staff may reduce the frequency and intensity of their conflict with family members. Finally, because of their higher place in the occupational structure in the institution, nurses are likely to experience greater autonomy and therefore experience less day-to-day job stress than are CNAs (cf. Kelloway & Barling, 1991; Marshall & Barnett, 1993). On these bases, it was anticipated that CNAs would benefit more from the PIC intervention than would nursing personnel.

	Design and Methods

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Intervention Design
The PIC program consisted of two parallel workshop series, one for nursing staff (including registered nurses, licensed practical nurses, and nursing assistants) and one for family members of residents on the same unit. The content of each workshop required a total of approximately 7 hours. For staff, the training typically took place in a single day, whereas for family members training was delivered in two half-day sessions. Three trainers hired by the researchers, all of whom had extensive group leadership experience, conducted the program.

The components of the program (summarized in Table 1) are presented in an order that allows later program modules to build on earlier ones. Based on a review of the communications literature (cf. Burnard, 1992; Golen, 1990; Weaver, 1993), three specific skills were featured in the PIC program:

1. Active/empathic listening skills. This training component focuses on identifying "communication helpers" that encourage others to express their opinions and feelings. In addition, barriers to effective listening are also reviewed, which have been shown to reduce understanding and empathy.
   
2. Feedback. This training component focuses on providing verbal cues to a conversation partner that allow a person to know how a message is received, permitting the speaker to adjust the message as needed.
   
3. "I-messages." The I-message (or "owned" message) technique focuses on using the first-person singular to express a problem or complaint. The use of I-messages reduces blaming (thereby reducing defensiveness on the part of the other person) and encourages others to be more honest about their own feelings because it is nonthreatening.
   

The project ends with the joint session, in which the staff and family participants meet together to discuss issues of concern with the facility administrator. The joint session takes place as soon as possible after both groups complete the training. As in other components of PIC, the joint meeting was carefully structured and included opportunities for sharing of ideas, as well as for prioritization of recommendations for changes in policies and procedures.

Sampling Design
Treatment and control subjects in the study were drawn from staff members and relatives of residents in 20 nursing homes in the Central New York region. The sampling frame for facilities was the membership of the New York Association of Homes and Services for the Aging (NYASHA), the state association of not-for-profit nursing homes. All NYASHA facilities in a nine-county area (a total of 60) were categorized according to metropolitan/nonmetropolitan location and size (80–150 beds vs. 151 beds). Of these facilities, 52 agreed to participate in the study. Twenty facilities were selected for the study by stratified randomization methods, giving an even distribution over these two categories (five facilities in each of the four metropolitan/nonmetropolitan by size groups). Then, facilities in each of the strata were randomly assigned to treatment and control conditions.

A consideration is the exclusively not-for-profit status of sample facilities, which may reduce the generalizability of the findings. However, although differences may exist between for-profit and not-for-profit homes on some dimensions, there is no evidence that family–staff relations differ systematically according to ownership status. Practice experience suggests that all nursing homes, regardless of ownership, are subject to very similar family–staff pressures.

Selection of Treatment and Control Units Within Facilities
An important design question is the appropriate control group for the study. It should be noted that PIC is conceived of as a "unit-based" intervention. That is, although it was not necessary that all (or even necessarily the majority) of family and staff within a unit take part in the PIC training session for effects to occur, all individuals in a given unit must be exclusively treatment or exclusively control. Considerable diffusion was both expected and encouraged within a unit in the nursing home, with the assumption that participants in both staff and family groups would discuss the techniques learned with persons on the unit unable to attend.

For this reason, the comparison groups within the treatment facilities were staff members and families from a different, physically distinct unit in the same facility, rather than participants randomized on an individual basis into treatment and control groups. The treatment and control conditions were assigned randomly to two units, themselves sampled randomly from all available units in each facility, resulting in 10 treatment units and 10 control units within the treatment facilities. Subacute, rehabilitation, and other specialty care units were excluded for the purpose of comparability.

In addition, we wished to be able to account for potential contamination of the control unit. That is, it is possible that both families and staff members would discuss the intervention with their counterparts in the other unit. Staff members may rotate to a different unit during the course of the study, thus influencing that unit (although all facilities in this study had an official policy of "permanent assignment"). We did not expect that substantial contamination of this kind would occur, but it remained a possibility. For these reasons, we included 10 purely control facilities in the study. From each of these facilities, one control unit was sampled randomly from all units in the facility. In these facilities, staff and family members were recruited for a "survey of staff–family relationships," and no mention was made of PIC, thus providing a second type of control group, distinct from controls in treatment facilities.

Randomization and Recruitment of Study Subjects for the Intervention
All nursing staff members (RNs, LPNs, and CNAs) were recruited for the study from all shifts (day, evening, and night). Temporary staff (e.g., from staffing agencies) were not eligible. A facility liaison (usually the facility social worker) provided families and staff with information regarding the training program and carried out recruitment activities. The family member contacted was the individual identified as the "responsible relative" for each resident. In the treatment units, 41% of family members participated in the training workshops, and 82% of the staff (see Tables 2 and 3). The lower rate of family participation is in part owing to our inclusion of all eligible relatives, many of whom lived a considerable distance from the facility or who visited infrequently.

Interviews were attempted with 817 staff members, resulting in 655 respondents at Time 1, for a completion rate of 80%. The retention rate between Time 1 and Time 2 for staff was 81%, resulting in 527 Time 2 interviews. Time 2–Time 3 retention was 85%, resulting in 450 Time 3 interviews. Given high staff turnover rates in nursing homes, these retention rates exceeded prior expectations.

Baseline Equivalence of Treatment and Control Groups
Tables 4 and 5 provide descriptive data on the family members and staff at baseline. The treatment and control groups were very similar on most demographic variables at baseline. Despite random assignment, however, family members in the control group were somewhat more likely to be spousal caregivers, whereas members of the treatment group were more likely to be adult-child caregivers or other relatives. There were no interactions by caregiver relationship, nor any differences at baseline on any of the dependent variables (tables not shown). The one difference of substantive importance between staff members in the treatment and control groups was race—members of the control group were more likely to be White. This difference was taken into consideration throughout the analysis.

1. Pretest baseline assessment (T1) took place within 1–2 weeks after recruitment, before beginning the intervention, for treatment participants, and at the same time for control participants.
   
2. Posttest 1 (T2) took place 8 weeks after the intervention had ended, for both treatment and control participants.
   
3. Posttest 2 (T3) took place 6 months after the intervention for both treatment and control participants.
   

Two special conditions affected the pattern of interviews. Staff members who left employment in the nursing home after Time 1 received an abbreviated Time 2 interview and were not interviewed in Time 3. Family members whose relative died between Time 1 and Time 2 also received an abbreviated Time 2 interview and were not interviewed at Time 3.

Measures: Family Outcomes
Interpersonal Conflict
The Interpersonal Conflict Scale (Pillemer & Moore, 1989) asks how frequently the family member experiences arguments or conflicts with staff members over the following items: personal care, meals/food, administrative rules, laundry/clothing, residents' appearance, toileting, and attentiveness to residents' needs (never, once a month, a few times a month, a few times a week, or every day). The reliability coefficient (alpha) for the scale is.79.

Staff Behaviors Scale
The Staff Behaviors Scale was developed by the authors to measure family perceptions of how staff members behave toward them (Pillemer et al., 1998). The three items were how often staff provide them with news, encouragement, or suggestions. Response categories are never, rarely, sometimes, almost always (alpha =.82).

Staff Empathy Scale
The Staff Empathy Scale, also developed by the authors (Pillemer et al., 1998), asked families the degree to which they perceive staff as understanding, easy to talk to, or helpful, with response categories never, rarely, sometimes, almost always (alpha =.87).

Caregiver Burden
Caregiver burden was measured using a shortened version of the Zarit Burden Interview (Zarit, Todd, & Zarit, 1986). Six items from the scale were used that are particularly relevant to nursing home caregivers (alpha =.66).

Measures: Staff Outcomes
Two staff outcomes were measured using questions identical to those asked of family members: the conflict scale, with the word "family" substituted for "staff" (alpha =.86), and the Center for Epidemiologic Studies-Depression Scale (CES-D) depression scale (alpha =.80).

Additional measures for staff included the following:

Family Behaviors Scale
The Family Behaviors Scale measured staff perceptions of how family members behave toward them (Pillemer et al., 1998). Staff reported how frequently family members: treat you with respect, are rude with requests, smile and greet you, and ignore you or brush you aside. Response categories are never, rarely, sometimes, almost always (alpha =.69).

Family Empathy Scale
The Family Empathy Scale asked staff the degree to which family members: understand how much time it takes to do my job, are mostly concerned about their own needs, and are sensitive to my feelings (alpha =.548).

Burnout
Job burnout was measured by the Depersonalization Subscale of the Maslach Burnout Inventory (Maslach, 1982), modified by Pillemer and Moore (1989) for use with nursing home staff (alpha =.592).

Intention to Quit
Likelihood of leaving employment in the nursing home was measured by a single item that asked: "Thinking about the next 12 months, how likely do you think it is that you will decide to quit your job?" (very likely, likely, not too likely, not at all likely).

Statistical Models and Methods
Our interest is in evaluating effects of the intervention by looking at treatment group differences for the family and staff outcomes described previously, controlling for important influences on family and staff perspectives. All outcome variables were measured at baseline before the intervention and at follow-ups 2 and 6 months after the intervention. A 3x3 repeated-measures design (treatmentxtime) thus forms the core of the statistical models for evaluation. The key tests of whether the intervention has had an effect are the test of the timextreatment interaction and specific, preplanned contrasts partitioned from that interaction.

Analysis of the data found no significant differences in changes over time in key variables between the two types of control units (those in control facilities and those in treatment facilities). In the presentation of the results, we show only contrasts in which the two control groups are combined. The program was evaluated in terms of its effects at each of the two follow-up assessments and for effects averaged over those two assessments. Because the program is of short duration and moderate intensity, effects might be expected to be strongest at the first follow-up, nearest to the time of intervention. The examination of the second follow-up gives an indication of the extent to which effects are sustained over a longer period of time. It is also possible that certain effects may take a longer time after involvement with the program to be manifested and will be seen only at Time 3. The test of effects averaged over the two follow-up assessments provides the best evidence of beneficial consequences of the program that are sustained over time and is the most powerful test of those effects.

We also examined the effect of facilities. This was done under two different assumptions: facilities regarded as levels of a random factor (facilities regarded as sampled from a larger population of facilities); and facilities regarded as levels of a fixed factor. In both cases, facilities differed significantly, but the effect on the evaluation of the intervention was negligible. Facilities as levels of a classification factor were excluded from the final models reported here.

All analyses were carried out in general linear mixed models, with time included as levels of a fixed factor and individuals as levels of a random factor. By using mixed model methods rather than basic repeated measures, observations could be included for which data are missing at one or more time points.

An array of variables representing background characteristics of the patient and family members was examined in addition to treatment and time to carry out a thorough examination of potential confounding influences (race, age, gender, and socioeconomic status of the family member, the relationship of the family member to the patient; race, age, gender, and socioeconomic status of the staff member, whether the staff member has ever cared for a relative; and metropolitan vs. non-metropolitan location of the nursing home facility). Homogeneity of regressions was examined for all covariates, both to ensure correct interpretation of main effects and as part of the examination where intervention effects were strongest. None of these additional variables significantly altered the treatment effects, and the final models shown in the results included only treatment and time.

Our focus was not only on the detection of any overall effects of the intervention, but also on the examination of whether the effects of the intervention were stronger for groups under greater stress. For families, the variable examined was whether the resident has dementia; for staff, it was the effect of being a nurse versus being a CNA. This issue was examined through tests of the interaction of treatment and time with the third variable.

For each outcome variable in the results tables (Tables 6 and 7), the left-hand side shows the adjusted means for the treatmentxtime structure. The right-hand side shows the change in means for each treatment group over time and the probabilities associated with the test of these mean differences. The bottom row on the left gives the difference between groups for each time point. The bottom row on the right gives the probabilities for the tests of treatment effects for partitioned interaction contrasts from the overall treatmentxtime interaction (defined by the row and column headings).

	Results

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We analyzed an additional model for each outcome to determine whether the effects of the intervention were greater for families in which the relative had dementia. These analyses showed one interaction effect. As shown in the bottom two sets of rows in Table 6, for the nondementia group, staff–family conflict increased for both treatment and control groups, with a particularly marked increase between baseline and 2 months. For the dementia subgroup, however, conflict increased for controls, but remained unchanged for the treatment group, resulting in a treatment effect at 2 months and across both follow-up assessments.

Effect of Intervention on Staff Outcomes
Significant treatment effects were observed for two staff outcome variables. Perceptions about the supportiveness of family behaviors improved between baseline and 2 months for the intervention group and declined for the control group (Table 7). This effect also approached significance when tested jointly over the two follow-up assessments. For predicted likelihood of quitting the job in 12 months, a decline occurred in the treatment group between baseline and 2 months, whereas an increase occurred in the control group. In a finding that approached significance, job burnout increased in the control group between baseline and 2 months, but remained stable for the treatment group. The interaction analyses comparing CNAs versus nurses revealed no substantively important differences in effects between these groups on any dependent variable in the analysis.

In analyses including adjustment for race, nurse employment status, age, and sex of the staff member, none of the relationships presented previously was substantially changed, although in several instances the p value increased by an amount in the range of.01 points.

	Discussion

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The PIC intervention was designed to improve family–staff relationships in nursing homes. The intervention expanded on prior efforts in five ways. First, the intervention design was based on a clearly articulated conceptual framework derived from both theory and empirical research on interpersonal interactions in long-term care settings. Second, the study was conducted in a relatively large number of facilities, allowing us to examine effectiveness across a range of settings. Third, the training involved both family and staff members on particular units where they interact, rather than training only one of the two groups. Fourth, the program engaged participants in a dialogue with one another and with facility administrators regarding changes that would facilitate better family–staff relationships. Finally, the study focused on outcomes for both staff and family members.

Overall, the results of the treatment-control comparisons are encouraging for both staff and family members. The strongest effects were found for both groups' perceptions of one another: Family members perceived greater empathy on the part of staff, and staff viewed family behaviors toward them as more positive. Staff members in the treatment group improved in their feelings toward the job, as indicated by a reduction in likelihood of quitting. Finally, the fact that reports of conflict declined among family members whose relatives had dementia is of importance, given that such conflict is a strong predictor of well-being among caregivers, as well as the general population during periods of high stress (cf. Schuster, Kessler, & Aseltine, 1990).

It is worth noting that these findings are consistent with overwhelmingly positive subjective evaluations of the PIC intervention by participants. Ninety-eight percent of participants reported that they could relate the material covered to their own experiences in the nursing home, and 93% responded that they felt comfortable in the training program. Ninety-two percent of participants rated the program as excellent or good, and 96% reported that they would recommend the program to others in their situations. Such a response is highly encouraging because it suggests that similar interventions are likely to be both welcomed and effective across a range of long-term care settings.

The study had several limitations that require mention. Treatment effects were not found on all outcome variables, and in some cases the effect size was modest. Therefore, it is possible that a higher "dosage" may be necessary to bring about stronger effects. Potential modifications include increasing the length of the family and staff trainings or promoting additional joint meetings. Such increased intensity also might have moved the borderline findings to statistical significance. However, given the current difficulties in nursing home staffing, extending the training beyond the 8–10 hours offered in PIC may be problematic because of scheduling difficulties and additional expense. All of the intervention facilities were unanimous in their view that releasing staff for a longer period of initial training would be a hardship for the facility. Family members also noted that the time commitment was the maximum they could accomplish in the course of a week. Therefore, extending the workshop training time could be attempted, but seems unlikely to succeed given real-world constraints on participants.

It should also be noted that the strongest effects generally were found on the first posttest, with diminishing strength at the 6-month posttest. This suggests that the impact of PIC diminishes over time, perhaps because the skills require additional practice and reinforcement to be maintained. This pattern of findings suggests that providing additional "booster sessions" after the initial workshops would be beneficial. Because they would occur some weeks after the initial training, the time commitment might not be perceived as burdensome.

A further limitation of the study is its exclusive focus on staff and family outcome measures. Clearly, it is hoped that the PIC intervention had indirect benefits for residents, through improved care resulting from better communication between family and paid caregivers. Greater family comfort in the facility could also make daily interactions with residents more pleasant and fulfilling. Resident-level data collection was beyond the scope of the present study, but should certainly be a major priority for future researchers.

A final limitation relates to the component of PIC that encouraged discussion of policies and procedures that hinder family–staff communication. Although we have descriptive data on the content of the joint meeting, project resources did not permit tracking of the actual implementation of policy or procedural changes. We do know that PIC resulted in some kind of innovation in all of the 10 treatment facilities, ranging from the establishment of a family council to posting staff photographs on a bulletin board. Participants reported that they found the joint meeting useful and productive. However, future research should systematically track the role of PIC in structural changes in the facility and their impact in turn on treatment outcomes.

	Footnotes

 
This research was supported by an Edward R. Roybal Center grant from the National Institute on Aging (1 P50 AG11711-01). We are grateful to Benjamin Gottlieb, David Morgan, William Smith, and members of the Cornell Roybal Center Advisory Committee for valuable advice regarding the intervention and research design. Thanks are to Yasamin DiCiccio, Director, and the staff at the Cornell Computer-Assisted Survey Team who performed data collection activities. We would like to acknowledge project trainers Tammie Baker and Isabelle Jensen and research assistant Bonnie Pelenur. Christiann Dean generously shared portions of the Cooperative Communication between Home and School program for adaptation in the current project.

¹ Cornell Gerontology Research Institute and Department of Human Development, Cornell University, Ithaca, NY.

² Department of Sociology, Louisiana State University, Baton Rouge, LA.

³ Department of Human Development, Cornell University, Ithaca, NY.

⁴ Cornell Gerontology Research Institute, Cornell University, Ithaca, NY.

⁵ Braceland Center for Mental Health and Aging, Institute of Living, Hartford Hospital's Mental Health Network, Hartford, CT.

⁶ Foundation for Long Term Care, Albany, NY.

Decision Editor: Laurence G.Branch, PhD

Received for publication May 14, 2002. Accepted for publication August 8, 2002.

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