Teaching and Maintaining Behavior Management Skills in the Nursing Home

Transcription

1 The Gerontologist Vol. 42, No. 4, Copyright 2002 by The Gerontological Society of America Teaching and Maintaining Behavior Management Skills in the Nursing Home Louis D. Burgio, PhD, 1 Alan Stevens, PhD, 2 Kathryn L. Burgio, PhD, 2,3 David L. Roth, PhD, 2 Penelope Paul, RN, DSN, 2 and John Gerstle, MS 1 Purpose: To examine the efficacy of a comprehensive behavior management skills training program for improving certified nursing assistants (CNA) skill performance in the nursing home, to assess the effectiveness of a staff motivational system for maintaining newly acquired behavior management skills for a 6-month period, and to evaluate any resulting effects on resident agitation. Design and Methods: This study used a randomized clinical trial of 88 residents with behavior disturbances and 106 CNAs who cared for them in two urban nursing homes. After CNAs received 4 weeks of behavior management training, supervisory nursing staff implemented formal staff management (FSM), designed to maintain training effects over time. The supervisory staff used conventional staff management (CSM, usual supervisory routine) on control units. We completed behavioral observations and paper-and-pen assessments at baseline and repeated them during a 4-week post-intervention phase and at 3- and 6-month follow-ups. Results: During the immediate post-training phase, both the FSM and CSM groups improved five out of seven communication skills and the ability to delay physical assistance during care routines. Although CNAs showed a reduction in the use of ineffective behavior management strategies, they did not increase their use of effective behavioral strategies. Follow-up assessments suggested that the FSM system was more effective than CSM for maintaining and even improving communication skills over time. Resident agitation was reduced during care interactions and maintained at follow-up. Implications: The behavior management skills training program improved This research was funded by Grant RO1NR03497 from the National Institute of Nursing Research to Dr. Louis D. Burgio. We thank the residents and the nursing and administrative staffs of Jefferson County Nursing Home and Oak Knoll Nursing Home for their commitment to this project. This project would not have been possible without their enthusiastic support. Special thanks are extended to Elaine Bailey, Debra Tanner, Donna Norris, Sarah Ware, and Edie Cole for data collection. Thanks are due to Debbie Turpin and Rachel Rodriguez for manuscript preparation and to Jeff Phillips for data management. Address correspondence to Lou Burgio, PhD, The University of Alabama, Applied Gerontology Program, Box , Tuscaloosa, AL lburgio@sw.ua.edu 1Applied Gerontology Program, University of Alabama, Tuscaloosa. 2Center for Aging, University of Alabama at Birmingham. 3Birmingham Veterans Administration Medical Center, AL. CNAs ability to interact with behaviorally disturbed nursing home residents and produced sustained reductions in agitation. The FSM system was more effective for maintaining communication skills 6 months after training. 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, & 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, & Farlow, 1997; Fleming & Evans, 1995; Johansson & Skoog, 1996; Ouslander & Schnelle, 1995; Thapa, Meador, Gideon, Fought, & 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 Vol. 42, No. 4,

2 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 & 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 & 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 & Scilley, 1994; Schnelle, Newman, & 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 Participants Residents. Participants in this study were nursing home residents who displayed behavioral disturbances. Research staff screened all residents in two nursing homes for possible participation. The staff completed screening and consent procedures on all residents upon entering into the nursing home. CNAs assigned to day and evening shifts on a resident s unit completed a single question, the global rating item on Reisberg s BEHAVE-AD (Reisberg et al., 1987), 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, & 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, & Gutkin, 1977), dementia severity (Clinical Dementia Rating scale; Hughes, Berg, Danziger, Coben, & 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. Nursing Staff. All nursing staff (registered nurses [RNs], licensed practical nurses [LPNs], and CNAs) working on the nine targeted nursing units were required by their respective nursing home to participate in training activities as a normal part of their duties. We also asked CNAs to complete questionnaires about themselves and the residents under their care, and we obtained verbal consent for completion of the questionnaires. 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 488 The Gerontologist

3 Table 1. Selected Characteristics of Nursing Home Residents Variable FSM (n 47) CSM (n 32) F Value/ 2 Age, M (SD) (10.10) (11.73) 3.67 MMSE, M (SD) 6.69 (9.17) 6.59 (7.59) 0.00 CMAI, M (SD) (18.57) (13.56) 1.91 Barthel, M (SD) 3.10 (0.72) 3.00 (0.78) 0.60 CDR, M (SD) 2.55 (0.79) 2.52 (0.69) 0.02 Female, % * African American,% Medication Category, % Cardiovascular Analgesic Anticonvulsant Antidepressant Tranquilizing Anxiolytic Note: FSM formal staff management; CSM conventional staff management; MMSE Mini-Mental State Examination; CMAI Cohen-Mansfield Agitation Inventory; Barthel Barthel Self-Care Rating Scale; CDR Clinical Dementia Rating scale. *p.05. 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. Design We conducted the study sequentially in the two nursing homes over a period of 4 years. Each nursing home divided its population into distinct, physically separate nursing units. Research staff entered residents into the study in groups by random assignment of nursing units to one of two conditions, FSM or CSM, with CNAs in both conditions receiving equivalent skills training. Five nursing units were assigned to the FSM condition and four to the CSM condition. Both conditions were represented in each of the two nursing homes. Within each unit, the study progressed through several phases: baseline assessment, intervention (behavior management skills training either with or without a staff motivational system), post-intervention assessment, and two follow-up assessments. 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 Table 2. Selected Characteristics of CNAs Variable FSM (n 46) CSM (n 39) F Value/ 2 Age, M (SD) (9.73) (10.27) 0.11 Number of months working in facility, M (SD) (79.12) (77.94) 0.16 Number of months working as CNA, M (SD) (90.72) (99.77) 0.02 Education level, M (SD) (1.26) (1.33) 0.02 Female, % African American, % Note: CNA certified nursing assistant; FSM formal staff management; CSM conventional staff management. Vol. 42, No. 4,

4 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 inservice, 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 s (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 490 The Gerontologist

5 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; 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 AN- COVAs 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 Comparability of Nursing Homes One-way analyses of variance showed no statistically significant differences between nursing homes on residents age, global cognitive functioning (MMSE), or self-care ability (Barthel). Thus, we combined the data in all analyses. 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 (SD 13.15) to a mean of (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. CABOS. Data on CNA behaviors coded by the CABOS are displayed in Table 4. The analysis strategy was the same as that for the BMSC, but the degrees of freedom differed across specific analyses for Vol. 42, No. 4,

6 Table 3. Use of Behavior Management Skills at Baseline and Post-Intervention as Recorded on the BMSC Post- F Baseline Intervention Variable M (SD) M (SD) Time a on Change b ANCOVA Behavior Management Techniques (occurrence per session) Effective strategies FSM 0.61 (0.41) 0.69 (0.48) CSM 0.65 (0.54) 0.74 (0.58) Ineffective strategies FSM 0.20 (0.42) (0.195) 4.77* 0.03 CSM 0.14 (0.26) (0.152) Communication Skills (rate per hour) Announcing single activities FSM (16.30) (23.15) *** 0.06 CSM (17.96) (34.17) Announcing multiple activities FSM (10.57) (9.25) 5.40* 1.05 CSM 6.47 (6.11) (8.90) Delayed physical assistance following announcement FSM 3.24 (4.27) (13.38) 58.03*** 0.01 CSM 3.37 (5.08) (15.19) Prompting single activities FSM (31.78) (25.60) 6.71* 2.89 CSM (20.48) (24.03) Prompting multiple activities FSM (22.07) 9.27 (14.01) CSM (14.78) (17.70) Delayed physical assistance following a verbal prompt FSM 0.91 (2.69) 4.57 (7.87) 6.62* 8.11** CSM 0.80 (1.70) 0.84 (2.04) Positive statements FSM 8.50 (11.49) (43.27) CSM 7.64 (9.69) (36.21) 82.59*** 0.48 Note: BMSC Behavior Management Skills Checklist; ANCOVA analysis of covariance; FSM formal staff management; CSM conventional staff management. a df 1, 82. b df 1, 81. *p.05. **p.01. ***p.001. two reasons. First, as with the BMSC, the CNA served as the unit of analysis for the care interaction variables that reflected CNA behaviors, but the resident was considered to be the unit of analysis for resident agitation during care interactions and for all time-sampling behaviors. Second, the time-sampling analysis included 13 residents who were not observed during care interactions because they did not require assistance during care. Analysis of general training effects indicated that CNAs in both groups increased positive statements to the residents both during care interactions and at other times of day. ANCOVA comparisons of the FSM and CSM conditions indicated that the two groups did not differ at post-intervention in terms of the amount of change observed on any other CABOS 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 Tables 3 and 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 followup 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, Figure 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 492 The Gerontologist

7 Table 4. CNA and Resident Behaviors Coded by CABOS Baseline Post- Intervention Variable M (SD) M (SD) Time (df) F ANCOVA on Change (df) Care Interaction Positive statements by CNAs (per hour) FSM 7.53 (11.93) (30.30) 62.17*** 1.37 CSM 9.32 (16.65) (34.96) (1, 62) (1, 61) Verbal prompts by CNAs (per hour) FSM (66.61) (53.26) CSM (62.10) (41.00) (1, 62) (1, 61) Physical assistance to resident (% of time) FSM (13.28) (14.73) CSM (14.84) (14.03) (1, 62) (1, 61) Resident agitation (% of time) FSM (18.88) (18.70) 5.12* 1.68 CSM (22.54) 9.37 (20.15) (1, 64) (1, 63) Time-Sampling Positive statements by CNAs (per hour) FSM 0.65 (0.73) 1.67 (1.85) 19.52*** 2.82 CSM 0.49 (0.41) 0.94 (0.93) (1, 77) (1, 76) Verbal interaction with resident (% of time) FSM 4.09 (2.69) 4.76 (2.92) CSM 4.30 (2.72) 4.74 (2.64) (1, 77) (1, 76) Resident agitation (% of time) FSM 5.84 (8.53) 6.01 (7.85) CSM 8.00 (14.33) 7.57 (14.20) (1, 77) (1, 76) Note: CNA certified nursing assistant; CABOS computer-assisted behavioral observation systems; ANCOVA analysis of covariance; FSM formal staff management; CSM conventional staff management. *p.05; ***p.001. 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 (Figure 2). Although neither group nor time effects emerged at the pre post evaluation for prompting multiple activities, Figure 3 shows a significant group effect at the 3-month followup 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 Figure 1. Change in rate per hour of certified nursing assistant s announcements of single activities on the Behavior Management Skills Checklist. FSM formal staff management; CSM conventional staff management. Figure 2. Change in rate per hour of certified nursing assistant s delaying physical assistance following announcements on the Behavior Management Skills Checklist. FSM formal staff management; CSM conventional staff management. Vol. 42, No. 4,

8 Figure 3. Change in rate per hour of certified nursing assistant s verbal prompting of multiple activities on the Behavior Management Skills Checklist. FSM formal staff management; CSM conventional staff management. Figure 5. Change in rate per hour of certified nursing assistant s positive statements during care interactions on the computer-assisted behavior observation system. FSM formal staff management; CSM conventional staff management. and no increase over the initial change displayed by the CSM group (Figure 4). CABOS. We used similar ANCOVAs to test group differences at follow-up on the CABOS systems. Figure 5 indicates that the pre post increases in the rate of positive statements during care interactions were maintained at the 3-month follow-up and that group differences emerged at the 6 month follow-up assessment, F(1, 33) 5.33, p.05. Positive statements in the FSM group continued to increase, whereas the rate remained stable in the CSM group. Figure 6 indicates that the initial increase in positive statements observed throughout the day with the time-sampling system reverted to baseline levels for both groups during the 3- month follow-up assessment, F(1, 70) 7.32, p.01. Although there were no group or time effects for the percentage of CNA verbal interactions directed toward residents in the pre post analysis, Figure 7 shows that a group effect emerged at the 6-month follow-up, with the FSM group interacting less frequently with residents than the CSM group, F(1, 45) 5.72, p.05. Resident Agitation Agitation during care interaction is represented in Table 4 and Figure 8. Analyses showed a significant decrease in agitation between the baseline and postintervention time points, F(1, 77) 5.12, p.05, in both the FSM and CSM groups. Figure 8 shows that the decreases were maintained during the 3- and 6- month follow-up assessments. Inspection of Figure 8 suggests a further decline in agitation during the two follow-up assessments; however, these decreases did not reach statistical significance. We observed no Figure 4. Change in rate per hour of certified nursing assistant s positive statements on the Behavior Management Skills Checklist. FSM formal staff management; CSM conventional staff management. Figure 6. Change in rate per hour of certified nursing assistant s positive statements time-sampled throughout the day on the computer-assisted behavior observation system. FSM formal staff management; CSM conventional staff management. 494 The Gerontologist

9 Figure 7. Change in percentage of total observation of certified nursing assistant s verbal interactions with residents time-sampled throughout the day on the computer-assisted behavior observation system. FSM formal staff management; CSM conventional staff management. changes in agitation through the time-sampling system, the BMSC, or the CMAI. Discussion We addressed three experimental questions in this study. First, would a comprehensive behavioral skills training program increase CNAs knowledge and performance of these skills on the nursing units? Second, would a staff motivational system result in the maintenance of skill performance over time? Finally, would the CNAs performance of behavioral skills result in reductions in resident agitation that would maintain over time? Our results corroborate the findings of recent studies showing that CNAs can be taught therapeutic skills and that these skills have an impact on resident outcomes (Beck et al., 1997; Burgio et al., 2001; McCallion, Toseland, Lacey, & Figure 8. Change in percentage of total observation of resident agitation during care interactions on the computer-assisted behavior observation system. FSM formal staff management; CSM conventional staff management. 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 (Figures 1 and 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 (Figures 4 and 5). However, Figure 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 Figures 1 and 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. Vol. 42, No. 4,

10 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 (Figure 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 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. References American Health Care Association. (1990). The Long Term Care Survey: Regulations, forms, procedures, guidelines (Cat. No. 4697/UBP/2.5K/ 7/90). Washington, DC: U.S. Government Printing Office. Beck, C., Heacock, P., Mercer, S. O., Walls, R. C., Rapp, C. G., & Vogelpohl, T. S. (1997). Improving dressing behavior in cognitively impaired nursing home residents. Nursing Research, 46, Beck, C., Rossby, L., & Baldwin, B. (1991). Correlates of disruptive behavior in cognitively impaired elderly nursing home residents. Archives of Psychiatric Nursing, 5(5), Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S., Dijkstra, K., Gerstle, J., et al. (2001). Come talk with me: Improving communication between nursing assistants and nursing home residents during care routines. The Gerontologist, 41, Burgio, L. D., & Bourgeois, M. (1992). Treating severe behavioral disorders in geriatric residential settings. Behavioral Residential Treatment, 7, Burgio, L. D., & Burgio, K. L. (1990). Institutional staff training and management: A review of the literature and a model for geriatric long-term care facilities. International Journal of Aging and Human Development, 30, Burgio, L. D., & Scilley, K. (1994). Caregiver performance in the nursing home: The use of staff training and management procedures. Seminars in Speech and Language, 15, Burgio, L. D., Scilley, K., Hardin, J. M., Janosky, J., Bonino, P., Slater, S. C., et al. (1994). Studying disruptive vocalization and contextual factors in the nursing home using computer-assisted real-time observation. Journal of Gerontology: Psychological Sciences, 49, P230 P239. Burgio, L. D., & Stevens, A. B. (1999). Behavioral interventions and motivational systems in the nursing home. In R. Schultz, G. Maddox, & P. Lawton (Eds.), Annual review of gerontology and geriatrics (Vol. 18; pp ). New York: Springer. Class, C. A., Schneider, L., & Farlow, M. R. (1997). Optimal management of behavioural disorders associated with dementia. Drugs and Aging, 10, Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly: II. Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34, Fleming, K. C., & Evans, J. M. (1995). Pharmacologic therapies in dementia. Mayo Clinical Procedures, 70, Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State : A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Hughes, C. P., Berg, L., Danziger, W. L., Coben, L. A., & Martin, R. L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140, Johansson, C., & Skoog, I. (1996). A population-based study on the association between dementia and hip fractures in 85-year olds. Aging, 8, McCallion, P., Toseland, R. W., Lacey, D., & Banks, S. (1999). Educating nursing assistants to communicate more effectively with nursing home residents with dementia. The Gerontologist, 39, Omnibus Budget Reconciliation Act of 1990, P. L , 4206, and 4715, codified at 42 U.S.C. 1395cc (a) (1) (q), 1395 mm (c) (8), 1395cc (f), 1396a (57), (58), 1396a (w). Ouslander, J. G., & Schnelle, J. F. (1995). Incontinence in the nursing home. Annals of Internal Medicine, 122, Reisberg, B., Borenstein, J., Salob, S. P., Ferris, S. H., Franssen, E., & Georgotas, A. S. (1987). Behavioral symptoms in Alzheimer s disease: Phenomenology and treatment. Journal of Clinical Psychiatry, 48 (Suppl.), Rogers, J. C., Holm, M. B., Burgio, L. D., Granieri, E., Hsu, C., Hardin, J. M., et al. (1999). Improving morning care routines of nursing home residents with dementia. Journal of the American Geriatrics Society, 47, Schnelle, J. F., Newman, D. R., & Fogarty, T. (1990). Management of patient continence in long-term care nursing facilities. The Gerontologist, 30, Sherwood, S. J., Morris, J., Mor, V., & Gutkin, C. (1977). Compendium of measures for describing and assessing long-term care populations [Mimeographed]. Boston: Hebrew Rehabilitation Center for Aged. Stevens, A. B., Burgio, L. D., Bailey, E., Burgio, K. L., Paul, P., Capilouto, E., et al. (1998). Teaching and maintaining behavior management skills with nursing assistants in a nursing home. The Gerontologist, 38, Thapa, P. B., Meador, K. G., Gideon, P., Fought, R. L., & Ray, W. A. (1994). Effects of antipsychotic withdrawal in elderly nursing home residents. Journal of the American Geriatrics Society, 42, Received October 18, 2001 Accepted January 15, 2002 Decision Editor: Laurence G. Branch, PhD 496 The Gerontologist