Although traditional communication techniques are frequently ineffective with cognitively impaired persons, little clinical research has been conducted to explore alternative methods. The results of this research demonstrate that validation techniques can be effective alter natives.
Over the past two decades, various types of therapies and approaches have been used with cognitively impaired nursing home residents. "Reality orientation" (RO) is a common nursing home technique used with persons exhibiting a lack of orientation to person, place, time, or situational context. Though well-intentioned, RO repeatedly attempts, but seldom succeeds, to correct the perceptions of the cognitively impaired person. Even experienced nurses frequently find these orientation efforts meet with withdrawal, vegetation or increasing hostility, however, RO continues to be suggested frequently as a therapeutic technique.
In 1963, Naomi Feil, a geriatric social worker, developed a new technique called Validation Therapy. Validation Therapy (VT) defines and focuses on four different stages of confusion using different communication techniques for each stage. Using appropriate VT techniques along with focused validation groups, Feil experientially found that the rate of cognitive regression was minimized and levels of agitation were decreased without corresponding increases in staff time or resources. Although Feil reported dramatic results implementing these new techniques, few clinical trials or scientific research investigations of these methods are known to exist. With increasing numbers of cognitively impaired older adults requiring care, any technique which can potentially reduce resource time, prevent deterioration, and minimize stress requires serious study.
More than 25 years have passed since the inception of Validation Therapy, however few relevant clinical studies exist. One study (Babins, 1988) examined the application of VT techniques appropriate to identified stages of confusion. Results indicated that improvements in participation and communication might be dependent on linking specific validation techniques to specific stages of confusion. A limited number of other articles (Bleathman & Morton, 1992; Scanland & Emershaw, 1993) were also intriguing but did little to establish a scientific database regarding the use of validation techniques. In response, a research shady was recently developed to study the clinical implications of linking spécifie validation approaches to identified stages of confusion in nursing home residents.
Partially funded by a grant from the Wisconsin Association of Homes and Services for the Aging, the purpose of this investigation was to study the effects of validation approaches on cognitively impaired nursing home residents and their caregivers. Research was conducted at Alexian Village of Milwaukee, a life-care retirement community in urban Milwaukee, Wisconsin. Although a successful no-restraint philosophy was in place, resident behaviors were becoming increasingly problematic to manage in a new 44-bed dementia unit. Clinical documentation was inconsistent regarding the effectiveness of current interventions and little information could be found concerning alternative options. Frustration with the limitation of existing data and the urgent need for more effective communication strategies was a compelling research catalyst. Although Feil's original work included validation groups, these researchers were specifically interested in studying the value of validation techniques for one-to-one staff /resident interactions independent of such groups. Analysis of the validation group, therefore, was not included.
A quasi-experimental, time series design was selected since separate control and experimental groups could not be created. Research was primarily conducted to determine the effects of validation techniques on resident behaviors. Statistical analyses (f-tests) were used whenever possible to support clinical observations.
The study sample of residents included any resident on the unit whose problem behavior required staff intervention. Individual staff responses to problem resident behaviors were compared before and after staff validation training. Problem behaviors were defined as wandering, repetitive actions or requests, rummaging, verbal noises or screaming, wanting to go home, and agitation with or without combativeness. The pre-training sample included 13 residents categorized in the four stages of confusion: malorientation (4), time confusion (6), repetitive motion (2), vegetation (1). The post-training sample included 22 residents categorized in the four stages of confusion: malorientation (7), time confusion (9), repetitive motion (6), vegetation (0).
Validation training sessions were conducted by a consultant from the Wisconsin Alzheimer's Information and Training Center. Staff members were taught how to identify the four stages of confusion and select appropriate communication techniques for residents exhibiting particular characteristics in each stage. Multiple training sessions were held over a 2week period with each employee receiving a minimum of 6 hours of validation training. Training sessions included employees from nursing, recreation therapy, rehabilitation, housekeeping, dietary, security, and maintenance departments. The specific research study, however, only targeted interactions between the nursing staff and residents of the dementia unit. Weekly follow-up staff sessions were conducted for approximately 3 months to reinforce the initial training. Visual reminders (posters and flash cards) were implemented to provide ready reference material. "Curbside consultations" occurred frequently, evaluating the utility of attempted communication techniques. Peer support was also significant.
To test treatment effects on resident behaviors, observations of interactions between staff and residents on the dementia unit were analyzed before and after training in the use of specified validation techniques. Staff members were asked to record any involvement with a resident that included the implementation of a communication strategy in response to a problem behavior. Prior to the training sessions, records included an identification of the problem behavior, a description of the approaches used, the length of time involved in the interaction, and an opinion as to the effectiveness of the approach. "Effectiveness" was determined by an absence of or decrease in the problem behavior. Following training, records were expanded to include categories identifying the stage of the resident's confusion and the specific validation approach attempted. Changes in psychotropic drug utilization were analyzed using computerized data logs provided by the facility's pharmacy. Changes in the frequency of accidents related to documented behavior problems were determined by Incident Report analysis.
Effect of Validation Training on Resident/Staff Interactions
Following validation training, the frequency, appropriateness and effectiveness of focused communication techniques increased dramatically. When comparing the frequency of approaches used by staff members, an average of 0.62 approaches per behavior were used for each recorded problem behavior before training; 4.3 approaches were used after training. More options were available for staff to use when they understood the principles of validation. Prior to the training program, staff members habitually used explanations or trial-and-error approaches to resolve resident needs. Following training, the option of choice became asking "who," "what," "where," and "when" questions to elicit additional communication from the resident. Other validation techniques, such as "eye contact," "touch," "repeating key words," "verbalizing emotions," and "reminiscence" were also used (Table 1).
Statistical analysis did not indicate a strong relationship between the approach chosen and its suitability to the resident's stage of confusion prior to validation training. Results did indicate, however, that approaches chosen after staff were trained were more appropriate for the behavior residents exhibited rather than just using the most familiar response. Prior to validation training, only 13% of the approaches selected were appropriate to the identified stage of confusion; following training 80% were at least partially appropriate (Table 2). Simply selecting an appropriate technique would have little clinical application if that technique were not effective. However, data indicate that communication technique effectiveness in ameliorating problem behavior greatly increased from 47% effective before validation training to 73% effective following training (Table 3).
There was no indication of a significant relationship between validation training and staff capabilities. However, staff were better able to work with worsening levels of confusion following their training. Prior to training, staff was most effective when working with maloriented residents (Stage 1) and those who were time-confused (Stage 2). While continuing to communicate effectively with time-confused residents following validation training, effectiveness with repetitive motion (Stage 3) residents improved dramatically. Lack of statistical significance may have been more influenced by variance in the numbers and types of residents observed before and after the training program.
By far the most encouraging research finding emphasizes the relationship between technique effectiveness and confusional stage. When selection of a particular communication technique is based on knowledgeable assessment of confusional stage, effectiveness should increase significantly. While data analysis prior to validation training showed no relationship between communication effectiveness and confusional stage, post-testing was statistically significant at the 0.05 level. When technique selection is appropriate for the identified stage of confusion, effectiveness in ameliorating problem behavior is greatly increased (Table 4).
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Effectiveness of Communication Ifecfinique
Relationship Between Technique Effectiveness and Appropriateness to Confusione! Stage
Changes in related indicators also yielded encouraging results. Prior to validation training, 7 out of 44 residents (16%) were receiving psychotropic medications. Five months later, following training and technique implementation, one additional resident was receiving psychotropic medication. Successful dose reductions had been accomplished, however, for 25% of the original sample. Documented incidents of behavior problems in the last full calendar prior to validation training accounted for 3% of 89 Incident Reports. In the first full calendar quarter following validation training, technique implementation and data collection, no documented Incident Reports related to resident behaviors were recorded.
Although results of this study are encouraging, the research itself had several limitations. Perhaps the most problematic was restricted funding that did not permit making independent, objective observations of resident/staff interactions. Both research investigators had other full-time responsibilities associated with the rapid pace of providing a full complement of nursing services to the older adults of this facility. As a result, time devoted to research was often fragmented and compromised by interruptions and unrelated responsibilities. When individuals record situations in which they are involved, objectivity can be compromised; it is likely that phenomena occurred during this research. Some strategies may not have been recorded as being effective simply because no one continued to observe the resident after the initial interaction had occurred. Nurses on busy units habitually initiate clinical strategies and then move on to other tasks; rarely do workloads permit the ability to continuously assess the results of a staff/resident communication over a period of hours.
Additionally, this particular staff was already skilled at working with cognitively impaired residents prior to their validation training. As a result, communication techniques taught in validation training sessions may have been unconsciously selected prior to training with no specific identification of the resident's stage of confusion. Skilled staff, already sensitized to working with dementia residents, may not have recorded all the behaviors that would lend themselves to validation interventions simply because such behaviors were seen as "routine." Also, the definition of "effective" was left to staff interpretation. Generally, an intervention was deemed effective if the resident's problem behavior stopped or diminished. This determination, however, was made by each staff member; what one person might think was improvement might not have been classified in the same way by someone else.
Observations were mostly recorded by day shift staff who worked 12-hour shifts which extended into the evening hours. Because of the length of time one staff member was on duty, multiple occurrences of the same problem behavior with the same resident during that tour of duty might not have been recorded. In a facility with more traditional day and evening shifts, individual staff members may have made additional recordings each thme a particular behavior occurred. The separation of dementia residents on a distinct unit may also have had a particular influence on this project. Validation techniques may have been more consistently used on this unit than would have been found on a more typical nursing home unit where residents at all levels of cognitive functioning reside together.
Regardless of issues that may have influenced the results, this research clearly has important clinical implications. Validation training affords staff more options to implement when attempting to defuse potentially catastrophic behaviors for confused residents. The selection of communication technique was made more deliberately and more appropriately following training. Research results clearly indicate that focused validation approaches may be more effective than the RO-type methods of communication so commonly used. Armed with more effective techniques, staff are able to defuse potential behavior problems even in residents with worsening levels of confusion. And, most significantly, the effectiveness of staff interventions can be greatly improved when the communication technique is chosen for its appropriateness to the resident's confusional stage.
On average, communication with a resident exhibiting problem behaviors took 4.5 minutes prior to validation training. Validation training did lengthen the intervention time to an average of 8 minutes since many more techniques were used per interaction. Since post-training interactions were more effective, however, this additional 3.5 minutes per interaction could actually save total time by eliminating the problem and preventing additional interventions from being required. As changing population demographics relentlessly increase the number of confused, older adults, resources required for their care will continue to be strained. Nursing home staff can ill-afford the time or frustration associated with repeating ineffective communication techniques. Worsening stages of confusion may not be as inevitable as previously believed. If not wholly preventable, the pace of progression through confusional stages may be slowed by consistent use of appropriate validation techniques which prevent the escalation of problem behaviors.
Clinicians working with confused older adults need effective communication strategies. Confused older adults need effective communication strategies as well. An efficient, effective technique such as validation needs further research to improve quality of life for both. This should be directed toward replication study with a fully-funded investigative team devoting its complete attention and objectivity to the research. Staff responsible for responding to resident needs should not be simultaneously involved in the recording of data relative to that response. In addition, future research should take a more focused approach, targeting the same select group of residents for observation before and after the staff's validation training. These two changes alone would eliminate many of the limitations associated with this study.
However encouraging, results of a single study can not be generalized to different populations at other facilities. If validation is to be more widely publicized and accepted as an effective communication technique, additional studies must be conducted in various types and sizes of nursing homes, with confused residents of varying ages, and with populations of differing acuities. Research should also be directed at studying this technique in acute care hospitals, community settings and with non-nursing implementers such as recreation therapists, social workers, and family members. Communication techniques focusing on validation must be included as part of the basic curriculum for all health care professionals. Increasingly strained health care resources create a compelling imperative to use validation techniques as outcome oriented, inexpensive, effective clinical approaches when caring for confused older adults.
- Babins, L. (1988). Conceptual analysis of validation therapy. Journal of Aging and Human Development, 26, 161-167.
- Bleathman, C., Morton, I. (1992). Validation therapy: Extracts from 20 groups with dementia sufferers. Journal of Advanced Nursing, 17, 658-666.
- Feil, N. (1989). VyF Validation* The Feil Method. Cleveland, OH: Edward Peil Productions.
- Feil, N. (1992). Validation,The Feil Method. Cleveland, OH: Edward Feil Productions.
- Scanland, S., Emershaw, L. (1993). Reality orientation and validation therapy: Dementia,depression,and functional status. Journal of Gerontdogical Nursing, 19, 7-11.
- van Amelsvoort Jones, G. (1985). Validation therapy: A companion to reality orientation. The Canadian Nurse, 20-23.
Appropriateness of Technique fe Stage ef Contusion
Effectiveness of Communication Ifecfinique
Relationship Between Technique Effectiveness and Appropriateness to Confusione! Stage