FINAL REPORT. CMS Project # FL AHCA Agreement/Project #GFA063. Submitted by:

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1 FINAL REPORT Developing One Hour Version nd Spnish Versions of Two Evidence Bsed Trining Progrms to Improve Person Centered Cre nd Outcomes in Nursing Homes: Bthing Without Bttle nd Mouth Cre Without Bttle CMS Project # FL 0812 AHCA Agreement/Project #GFA03 Submitted by: Sheryl Zimmermn, PhD, Principl Investigtor nd Director Genertivity, LLC Philip Slone, MD, MPH, Co Principl Investigtor nd Director Genertivity, LLC November 20, 2018

2 BACKGROUND Two res in which there hs been notble concern regrding the qulity of nursing home cre include bthing nd mouth cre. Bthing hs long been recognized s the cre tsk tht most frequently results in resident gittion nd ggression, nd then reltedly, in stff distress, frustrtion, disstisfction, nd turnover. 1 Mouth cre hs come to be seen s the cre tsk lest often provided by nursing home stff, responsible for the fct tht only 1% of residents cross the country hve very good or better orl hygiene; 2 besides ffecting qulity of life, there is evidence tht improved orl cre cn reduce the incidence of pneumoni. 3 Providing cre for nursing home residents who hve cognitive or physicl impirment requires both generl nd specific knowledge nd skills generl in the context of cre prctices tht pply regrdless the tsk being conducted (such s sking permission before providing cre, nd focusing on the person rther thn the tsk), nd specific in reltion to, for exmple, knowing techniques to provide towel bth nd how to brush teeth using the giggle sweep pproch, nd being fmilir with products such s no rinse sop nd chlorhexidine to reduce gum inflmmtion. Bthing Without Bttle nd Mouth Cre Without Bttle both promote better generl nd specific knowledge nd skills, nd result in improved resident outcomes. Stff who used Bthing Without Bttle were significntly more gentle nd supportive when providing cre, nd found cre provision to be esier; 4 resident ggression declined 3 0% (depending on the type of bth provided), nd discomfort declined 14 27%; in ddition, ntipsychotic use declined 30%. Stff who used Mouth Cre Without Bttle reported being significntly more ble to overcome residents resistnce to mouth cre nd to provide cre to residents who hit or scremed; 7 they were significntly more likely to clen the inside of the teeth nd between the teeth (e.g., before trining no stff clened between the teeth, wheres 90% did so fter), nd the extent of dentl plque nd gum inflmmtion significntly decresed. 8 Before the current project, both Bthing Without Bttle nd Mouth Cre Without Bttle were vilble only in English, mening tht stff who do not primrily spek English were not ble to benefit; consequently, the qulity of the cre they provided suffers, s did the well being of the residents for whom they provide cre. Also, Mouth Cre ws vilble only s three hour trining progrm, mking it infesible for some homes to benefit from the full progrm due to hving insufficient time to trin their stff. This project creted one hour version (English nd Spnish) of Mouth Cre Without Bttle, nd Spnish version of Bthing Without Bttle, nd evluted stff self efficcy nd the overll qulity of the progrms. PROGRAM DESCRIPTION: AIMS, METHODS, RESULTS nd EVALUATION The three components of this project included development of the one hour version of Mouth Cre Without Bttle; development of the Spnish versions of the one hour Mouth Cre nd Bthing Without Bttle progrms; nd evlution of the trining progrms. 1 Hoeffer et l. (1997). Reducing Aggressive Behvior During Bthing Cognitively Impired Nursing Home Residents. Journl of Gerontologicl Nursing 23(), Gift et l. (1997). Orl Helth Sttus nd Relted Behviors of U.S. Nursing Home Residents, 199. Gerodontology, 14, Yoneym et l. (2002). Orl Cre Reduces Pneumoni in Older Ptients in Nursing Homes. Journl of the Americn Geritrics Society 0(3), Hoeffer et l. (200). Assisting Cognitively Impired Nursing Home Residents with Bthing: Effects of Two Bthing Interventions on Cregiving. The Gerontologist 4 (4), Slone et l. (2013). Effect of Person Centered Mouth Cre Intervention on Cre Processes nd Outcomes in Three Nursing Homes. Journl of the Americn Geritrics Society 1, Gozlo et l. (2014). Effect of the Bthing Without Bttle Trining Intervention on Bthing Associted Physicl nd Verbl Outcomes in Nursing Home Residents with Dementi: A Rndomized Crossover Diffusion Study. Journl of the Americn Geritrics Society 2, Zimmermn et l. (2014). Chnging the Culture of Mouth Cre: Mouth Cre Without Bttle. The Gerontologist 4, S2 S34. 8 Slone et l. (2013). Effect of Person Centered Mouth Cre Intervention on Cre Processes nd Outcomes in Three Nursing Homes. Journl of the Americn Geritrics Society 1,

3 Aim 1. Develop the One Hour Version of Mouth Cre Without Bttle. An orl cre ide, supervisory nurse, nd dministrtor from ech of seven nursing homes were invited to prticipte in dy long meeting to discuss the most importnt mteril to retin in the one hour version of Mouth Cre Without Bttle, nd to provide recommendtions regrding dditionl content to include. Meeting prticipnts lso included two reserch bsed triners nd the dentl hygienist involved in the development of Mouth Cre Without Bttle, s well s the reserchers submitting this proposl nd the project coordintor (lso expert in the subject mtter), who took notes nd udiotped the meeting. In preprtion for the meeting, the reserch tem prepred synopsis of the trining components (e.g., informtion regrding the reltionship between mouth cre nd pneumoni; proper positioning of the toothbrush nd the relted brushing technique; product options nd when to use them; denture storge; overcoming resident resistnce; wht to do when resident bites down on the toothbrush). Attendees rted the importnce of ech component on 1 4 scle s either criticl to know, importnt to know, helpful to know, or cn be omitted. Those components considered criticl nd importnt (nd some considered helpful to know) were discussed in detil nd the relted trining segment ws viewed nd critiqued. Results: The resulting recommendtions were incorported into the script for the one hour version of Mouth Cre Without Bttle, nd beneficil new informtion ws identified. The tem worked with Horizon Productions to shoot new video nd crete the one hour version of Mouth Cre Without Bttle. No chllenges were encountered in this effort. Aim 2. Develop the Spnish Versions of Mouth Cre Without Bttle nd Bthing Without Bttle. Using best prctices for trnsltion nd culturl dpttion 9 tem of bilingul individuls were recruited to conduct trnsltion nd bck trnsltion. They red the entire one hour version of the progrms nd wrote out the trnsltion, ided by the project coordintor. Discrepncies mong the tem were resolved, nd finl script ws greed upon. Results: The reserch tem worked with Horizon Productions to identify nd engge Spnish speking nrrtor, nd develop the Spnish versions of Mouth Cre Without Bttle nd Bthing Without Bttle. No chllenges were encountered in this effort. Aim 3. Evlution of the Implementtion nd Outcomes of Both Progrms. All four trining progrms the one hour nd Spnish versions of both Mouth Cre Without Bttle nd Bthing Without Bttle were miled to ll nursing homes in Florid in Jnury Bthing Without A Bttle Evlution Nurses (, ) nd certified nursing ssistnts (s) could receive 1.0 hours of continuing eduction credit for wtching the DVD nd completing short evlution. Nurses nd s were sked to evlute their selfefficcy to provide bthing, evlute new techniques they hd lerned, nd rte the overll content of the trining progrm. As of October 2018, 30 nurses nd s submitted evlution forms to receive continuing eduction credit for viewing the trining progrm. 9 Wild et l. (200). Principles of Good Prctice for the Trnsltion nd Culturl Adpttion Process for Ptient Reported Outcomes (PRO) Mesures: report of the ISPOR Tsk Force for Trnsltion nd Culturl Adpttion. Vlue Helth 8(2),

4 Self efficcy. The self efficcy section of the evlution consisted of six items. It incorported retrospective pre test methods, such tht stff were sked to consider their bseline self efficcy fter being trined essentilly, sking to report wht they did not know erlier fter cquiring new knowledge. All items were rted on scle of 1 to 4, where 1 ws strongly disgree nd 4 ws strongly gree. After being trined in Bthing Without Bttle, nurses nd s reported sttisticlly significnt increse in ll res queried. As shown in Tble 1, they hd sufficiently more knowledge to do the job (men [M]=3., chnge from before trining p < ), were fmilir with the prcticl procedures of the job (M=3., chnge p < ), nd felt more confident to bthe residents with dementi (M=3., chnge p < ). The nurses nd s lso reported they were now ble to bthe resistive resident without forcing them (M=3., chnge p < ), were more fmilir with methods to successfully bthe residents who might hit or screm (M=3., chnge p=0.0004), nd were ble to get residents to cooperte with bthing (M=3.4, chnge p=0.003). Tble 1. Bthing Without Bttle self efficcy evlution Rnge 1 4, where 1 = strongly disgree nd p vlue 4=strongly gree (Overll, Overll now (N=30) (N=1) (N=8) (N=) nd before) Now, I hve sufficient knowledge to do this job. 3. (0.) 3.7 (0.) 3. (0.) 3. (0.) <.0001 Before, I hd sufficient knowledge to do this job. Now, I m fmilir with the prcticl procedures to do this job. Before, I ws fmilir with the prcticl procedures to do this job. Now, bthing residents with dementi is tsk I feel confident to crry out. Before, bthing residents with dementi ws tsk I felt confident to crry out. Now, when resident does not wnt to hve shower, I cn usully figure out wy to get the job done without forcing them. Before, when resident did not wnt to hve shower, I could usully figure out wy to get the job done without forcing them. Now, I know wys to successfully bthe residents who might hit or screm. Before, I knew wys to successfully bthe residents who might hit or scremed. Now, I cn usully get my residents to cooperte with bthing. Before, I could usully get my residents to cooperte with bthing. Sttistics shown re men nd (stndrd devition). 3.1 (0.4) 3.1 (0.4) 3.1 (0.4) 2.8 (0.4) 3. (0.) 3.8 (0.4) 3. (0.) 3.3 (0.) < (0.) 3.3 (0.7) 3.1 (0.4) 2. (0.) 3. (0.7) 3. (0.8) 3. (0.) 3. (0.) < (0.7) 3.3 (0.7) 3.0 (0.) 2. (0.) 3. (0.) 3. (0.) 3. (0.) 3.3 (0.) < (0.) 3.1 (0.4) 3.3 (0.) 2.3 (0.) 3. (0.) 3.8 (0.4) 3. (0.) 3.3 (0.) (0.) 3.3 (0.) 3.1 (0.4) 2. (0.) 3.4 (0.) 3. (0.) 3. (0.) 3.2 (0.8) (0.) 3.2 (0.7) 3.1 (0.4) 2. (0.) New techniques lerned. Nurses nd s rted improvement in bthing techniques fter completing Bthing Without Bttle. All items were rted on scle of 1 to 4, where 1 is strongly disgree nd 4 is strongly gree. Respondents reported tht fter wtching Bthing Without Bttle they knew how to get 3

5 residents clen who hve dementi (M=3., stndrd devition [SD]=0.), knew bout no rinse sop nd understood how to use it (M=3., SD=0.), knew how to encourge residents to llow bthing (M=3., SD=0.), nd knew how to do individulized bthing (M=3., SD=0.). See Tble 2. Tble 2. Bthing Without Bttle new techniques evlution After wtching Bthing Without Bttle Rnge 1 4, where 1 = strongly disgree nd 4=strongly gree Overll (N=30) (N=1) (N=8) (N=) I know how to get residents clen who hve dementi. 3. (0.) 3.8 (0.4) 3.4 (0.) 3.3 (0.) I know wht no rinse sop is nd how to use it. 3. (0.) 3.7 (0.) 3. (0.) 3.3 (0.) I know how to encourge residents to llow me to bthe them. 3. (0.) 3. (0.) 3. (0.) 3.3 (0.) I know how to do individulized bthing. 3. (0.) 3.7 (0.) 3. (0.) 3. (0.) Sttistics shown re men nd (stndrd devition). Overll content of the trining progrm. Nurses nd s were lso sked to rte their overll impression of the Bthing Without Bttle progrm. Items were rted on scle of 1 to, where 1 is poor nd is excellent. Nurse nd s gve high rtings for ll items relted to content, overll progrm content (M=4.3, SD=0.8), overll progrm ppernce (M=4.2, SD=0.8), ppropriteness of the progrm to experience level (M=4.3, SD=0.8), how well the progrm met trinee s needs (M=4.2, 0.8), nd overll stisfction (M=4.3, SD=0.8). See Tble 3. Tble 3. Bthing Without Bttle overll evlution Rnge 1, where 1 = poor nd = excellent Overll (N=30) (N=1) (N=8) (N=) Overll progrm content 4.3 (0.8) 4. (0.7) 4.1 (0.8) 3.8 (0.8) Overll progrm ppernce 4.2 (0.8) 4. (0.8) 4.0 (0.9) 3.8 (0.8) Appropriteness of the progrm to your experience level 4.2 (0.8) 4. (0.7) 3.9 (0.9) 3.8 (0.8) How well the progrm met your needs 4.2 (0.8) 4. (0.) 3.9 (1.0) 3.8 (0.8) Overll stisfction 4.3 (0.8) 4.7 (0.) 4.0 (0.9) 3.8 (0.8) Sttistics shown re men nd (stndrd devition). In ddition, 87% of respondents reported lerning new techniques for bthing people with dementi, nd of those, ll reported tht these new techniques will chnge how they provide bthing to residents with dementi. Similrly, 83% reported lerning techniques for providing cre to people who my be resistive, ll of whom reported they would use these techniques on residents who my be resistive to bthing. And, 87% reported tht they would recommend Bthing Without Bttle to someone else in their position. See Tble 4. Tble 4. Bthing Without Bttle content evlution Did you lern new techniques for bthing persons with dementi? If yes, will wht you lerned in the progrm chnge how you do bthing in your work? Did you lern techniques for bthing persons who my be resistive to cre? If yes, will you use these techniques in your work? Would you recommend this progrm to someone else in your position? Sttistics shown re number nd (percent). Overll (N=30) 2 (87%) 2 2 (83%) 2 2 (87%) (N=1) 13 (81%) (81%) 12 (92%) 13 (81%) (N=8) 7 (88%) 7 (7%) 7 (88%) (N=) 4

6 Qulittive evlution. Nurses nd s were sked to provide nrrtive responses regrding wht ws the most vluble component of the trining progrm (Tble ), the lest vluble component (Tble ), nd how the progrm cn be improved (Tble 7). Not ll individuls proved nrrtive responses, nd overll, responses were highly positive. Tble. Most vluble prt of Bthing Without Bttle, by respondent Person centered cre How to help the most resistnt ptients Towel bth ws new to me It ws good progrm for people tht re just lerning how to tke cre of ptients tht hve dementi All Reestblish good grooming hbits nd re evl needs bthe vrious residents Very good The most vluble prt is to lern how to pproch resident especilly with dementi on giving shower Towel bth; no rinse sop New technique to bthe with dementi Ptience nd tlking to the resident so they don't relize they re getting bth Seeing the resident point of view scred, embrrssed Being ble to ssist my 's Better help my 's Cre nd concern of the individul Bthing techniques Review nd eduction to support the stff Video Mking bthing chir more comfortble Tble. Lest vluble prt of Bthing Without Bttle, by respondent Everything ws OK The progrm ws good None The lest is to hndle this without proper trining How to give resident with dementi comfortble bthing Didn't like the towel technique in the plstic bgs fter while, the towel turns cold Time frme fforded for shower/bth Testimonils Not sure, ll ws good Nothing Tble 7. How Bthing Cre Without Bttle cn be improved, by respondent No improvement required It ws good progrm Very good To lern the right wy on giving the residents shower Use proper technique nd be ptient nd give more time for the residents. And lwys check with residents before you do things with them. None. It is n wesome video. Nothing

7 Mouth Cre Without A Bttle Evlution Nurses (, ) nd certified nursing ssistnts (s) could receive 1. hours of continuing eduction credit for wtching the DVD nd completing short evlution. Nurses nd s were sked to evlute their selfefficcy to provide mouth cre, evlute new techniques they hd lerned, nd rte the overll content of the trining progrm. As of October 2018, 28 nurses nd s hd submitted evlution forms to receive continuing eduction credit for viewing the trining progrm. Self efficcy. The self efficcy section of the evlution consisted of eight items. It incorported retrospective pre test methods, such tht stff were sked to consider their bseline self efficcy fter being trined essentilly, sking to report wht they did not know erlier fter cquiring new knowledge.. All items were rted on scle of 1 to 4, where 1 is strongly disgree nd 4 is strongly gree. After being trined in Mouth Cre Without Bttle, nurses nd s reported sttisticlly significnt increse in their knowledge to complete mouth cre (M=3.7, chnge from before trining p < ), were fmilir with the prcticl procedures of the job (M=3.8, chnge p < ), nd felt more confident to clen residents teeth (M=3.7, chnge p < ). The nurses nd s lso reported they were now ble to figure out wys to perform mouth cre without forcing resident (M=3.3, chnge p=0.02), were more fmilir with methods to provide mouth cre to residents who hit or screm (M=3., chnge p < ), were ble to get residents to cooperte (M=3.4, chnge p=0.0002), nd were less frid of being bitten by resident while performing mouth cre (M=2.3, chnge p=0.008). Nurses nd s did not report significnt improvement in their bility to provide mouth cre to residents with dementi fter prticipting (M=2.1, p=0.99), perhps becuse they did not rte their initil bility s low. See Tble 8. Tble 8. Mouth Cre Without Bttle self efficcy evlution Rnge 1 4, where 1 = strongly disgree nd 4=strongly gree Overll (N=28) (N=17) (N=) (N=) Now, I hve sufficient knowledge to do this job. 3.7 (0.) 3.7 (0.4) 3. (0.) 3. (0.) Before, I hd sufficient knowledge to do this job. 3.0 (0.) 3.0 (0.2) 3. (0.) 2. (0.) Now, I m fmilir with the prcticl procedures to do this job. Before, I ws fmilir with the prcticl procedures to do this job. Now, clening residents nturl teeth is tsk I feel confident to crry out. Before, clening residents nturl teeth ws tsk I felt confident to crry out. Now, I m not very good t providing mouth cre to residents with dementi. Before, I ws not very good t providing mouth cre to residents with dementi. Now, when resident does not wnt me to brush his/her teeth, I cn usully figure out wy to get the job done without forcing them. Before, when resident did not wnt me to brush his/her teeth, I could usully figure out wy to get the job done without forcing them. 3.8 (0.4) 3.8 (0.4) 3.8 (0.4) 3. (0.) 3.2 (0.7) 3.3 (0.) 3.4 (0.9) 2.7 (0.) 3.7 (0.) 3.8 (0.) 3.8 (0.4) 3. (0.) 3.1 (0.7) 3.1 (0.) 3. (0.) 2.7 (0.8) 2.1 (0.9) 2.1 (0.9) 2.0 (0.8) 2.3 (0.8) 2.2 (0.7) 2.0 (0.) 2.4 (1.1) 2. (0.) 3.3 (0.8) 3.4 (0.8) 3. (0.) 2.7 (0.8) 2.9 (0.7) 3.0 (0.) 3.4 (0.9) 2.3 (0.8) p vlue (Overll, now nd before) <.0001 <.0001 <

8 Now, I know wys to successfully provide mouth cre to residents who hit or screm. Before, I knew wys to successfully provide mouth cre to residents who hit or scremed. Now, I cn usully get my residents to cooperte with mouth clening. Before, I could usully get my residents to cooperte with mouth clening. Now, I m frid tht I will be bitten by resident if I try to clen his or her mouth. Before, I ws frid tht I would be bitten by resident if I tried to clen his or her mouth. Sttistics shown re men nd (stndrd devition). 3. (0.) 3. (0.) 3.8 (0.4) 3.2 (0.4) 2.8 (0.7) 2. (0.) 3.4 (0.9) 2.8 (0.4) 3.4 (0.) 3.4 (0.) 3. (0.) 3.0 (0.0) 2.9 (0.) 2.8 (0.) 3.4 (0.9) 2.7 (1.0) 2.3 (0.9) 1.9 (0.7) 3. (0.) 2.3 (0.8) 2. (1.0) 2.4 (0.9) 3. (0.) 2.7 (1.0) < New techniques lerned. Nurses nd s rted improvement in mouth cre techniques fter completing Mouth Cre Without Bttle. All items were rted on scle of 1 to 4, where 1 is strongly disgree nd 4 is strongly gree. As shown in Tble 9, respondents reported tht fter wtching Mouth Cre Without Bttle they knew how to use the jiggle sweep pproch to clen teeth (M=3., SD=0.), knew how to clen gums nd dentures (M=3.7, SD=0.), knew different products to clen teeth, gums, nd dentures (M=3.8, SD=0.4), knew how to encourge residents to llow tooth brushing (M=3., SD=0.), nd knew tht good mouth cre my prevent pneumoni nd improve other helth conditions nd qulity of life (M=3.8, SD=0.4). s, s, nd s reported similr rtings for ech item, lthough s reported somewht lower scores thn others. Tble 9. Mouth Cre Without Bttle new techniques evlution After wtching Mouth Cre Without Bttle Rnge 1 4, where 1 = strongly disgree nd 4 = strongly gree Overll (N=28) (N=17) (N=) (N=) I know how to use the jiggle sweep pproch to clen teeth. 3. (0.) 3. (0.) 3.8 (0.4) 3. (0.) I know how to clen gums nd dentures. 3.7 (0.) 3.7 (0.) 3.8 (0.4) 3. (0.) I know different products to clen teeth, gums, nd dentures. 3.8 (0.4) 3.9 (0.3) 3.8 (0.4) 3. (0.) I know how to encourge residents to llow me to brush their teeth. 3. (0.) 3. (0.) 3.8 (0.4) 3.3 (0.) I know tht good mouth cre my prevent pneumoni nd improve other helth conditions nd qulity of life. 3.8 (0.4) 3.9 (0.4) 4.0 (0.0) 3. (0.) Sttistics shown re men nd (stndrd devition). Overll content of the trining progrm. Nurses nd s were lso sked to rte their overll impression with the progrm, where 1 is poor nd is excellent. As shown in Tble 10, they gve high rtings for ll items: progrm content (M=4., SD=0.7), progrm ppernce (M=4.4, SD=0.8), ppropriteness to experience level (M=4.3, SD=0.9), how well the progrm met their needs (M=4.4, 0.9), nd overll stisfction (M=4., SD=0.8). Respondents reported similr rtings, lthough gin, s reported somewht lower scores thn others. Tble 10. Mouth Cre Without Bttle overll evlution Rnge 1, where 1 = poor nd = excellent Overll (N=28) (N=17) (N=) (N=) Overll progrm content 4. (0.7) 4. (0.7) 4. (0.) 4.2 (0.8) Overll progrm ppernce 4.4 (0.8) 4. (0.7) 4.4 (0.9) 4.0 (0.9) Appropriteness of the progrm to your experience level 4.3 (0.9) 4.4 (0.9) 4.8 (0.4) 3.7 (0.) How well the progrm met your needs 4.4 (0.9) 4.4 (0.9) 4. (0.) 4.0 (0.9) Overll stisfction 4. (0.8) 4. (0.8) 4.8 (0.4) 3.8 (0.8) Sttistics shown re men nd (stndrd devition). 7

9 In ddition, 9% of respondents reported lerning new techniques for providing mouth cre, nd ll of those reported tht these new techniques will chnge how they provide dily mouth cre. Ninety three percent reported lerning techniques for providing cre to people who my be resistive, ll of who reported they would use these techniques on residents who my be resistive to mouth cre. Similrly, 9% reported tht they would recommend Mouth Cre Without Bttle to someone else in their position. Overll, s nd s rted the progrm the sme, with s rting the progrm somewht lower, perhps due to the different scope of prctice nd trining mong the groups. See Tble 11. Tble 11. Mouth Cre Without Bttle content evlution Did you lern new techniques for providing dily mouth cre? If yes, will wht you lerned in the progrm chnge how you provide dily mouth cre? Did you lern techniques for providing mouth cre to people who my be resistive to cre? If yes, will you use these techniques to provide mouth cre to people who my be resistive? Would you recommend this progrm to someone else in your position? Sttistics shown re number nd (percent). Overll (N=28) 27 (9%) 27 2 (93%) 2 27 (9%) (N=17) (N=) (N=) (83%) 4 (7%) 4 (83%) Qulittive evlution. Nurses nd s were sked to provide nrrtive responses regrding wht ws the most vluble component of the trining progrm (Tble 12), the lest vluble component (Tble 13), nd how the progrm cn be improved (Tble 14). Not ll individuls proved nrrtive responses, nd overll, responses were highly positive. Tble 12. Most vluble prt of Mouth Cre Without Bttle, by respondent How to wrp finger with guze to provide mouth cre Denture prt The time nd techniques tht [were] used in the video Techniques in performing tsks All of it very informtive Lern the jiggle nd sweep The most vluble prt of the trining is to lern proper technique in doing mouth cre Jiggle nd sweeping technique Brush, sweep, jiggle, jiggle, sweep, gum line Wht ws nice is tht they used "rel" ptients Helping people with dementi brush their teeth Lern proper technique of providing mouth cre ppropritely Lern new techniques Techniques tught to open orl cvity Jiggle sweep pproch Very good informtion All of it Reminder of the need for excellent cre of mouth/teeth relted to totl helth cre needs Knowing how to clen resident's teeth properly Techniques to use with difficult residents New techniques 8

10 Tble 13. Lest vluble prt of Mouth Cre Without Bttle, by respondent It ws very helpful, it ws good progrm. Nothing ws lest. It ws well put together. Very informtive, excellent To do the wrong wy in doing cre All vluble informtion given Approprite pproch nd techniques to do mouth cre especilly for demented people Denture cre Being very ptient Denture cre It ws ll vluble informtion Tble 14. How Mouth Cre Without Bttle cn be improved, by respondent If the viewers keep [illegible] the progrm Free dentl cre for the veterns Prctice nd pply dily Very well presented to get informtion This ws very good It s fine how it is Prctice nd pply everydy None Shorter in length, one sitting lose concentrtion for lerning Progrm is very thorough using the techniques nd ssisting clients with dementi. Thnks for more ides to id my clients. Shorten length of module Nothing Provide models for demonstrtion CONCLUSION This project successfully creted nd disseminted new trining progrms to ll nursing homes in the stte of Florid. Although smll number of stff prticipted in the evlution of the project, the results overwhelmingly demonstrte the benefit of the trining progrm in terms of stff self efficcy, the bility to provide informtion bout new techniques, nd the overll fit of the progrm with lerners needs. 9