New knowledge gained over the last several years has altered the attitude toward residents who exhibit pacing/wandering behaviors and changed the way in which pacing/wandering is viewed, from predominantly a negative behavior to a possibly adaptive behavior (Cohen-Mansfield, Werner, Marx, & Freedman, 1991). In the past, the interventions used to treat pacing were geared mainly to prevent or limit the behavior. Physical and chemical restraints were widely used to forcefully limit the behavior (Burnside, 1980; Coons, 1988; Cornbleth, 1977; Heim, 1986; Rader, 1987; Rader, Doan, & Schwab, 1 985; Snyder, Rupprecht, Pyrek, Brekhus, & Moss, 1978). Although effective in eliminating the behavior, the use of physical restraints has been associated with serious injuries (King & Mallet, 1991) and increased agitation (Werner, Cohen-Mansfield, Braun, & Marx, 1989). Similarly, the use of chemical restraints is associated with severe side effects (King & Mallet, 1991).
Consequently, the legislated Omnibus Budget Reconciliation Act (OBRA, 1987) mandates that medication and physical restraints not be used to treat wandering and pacing in nursing home residents. As a result of this legislation, caregivers have to look for interventions aimed at accommodating the behavior rather than eliminating it. Although examples of such interventions are already described in the literature (a recent review of these interventions can be found in Cohen-Mansfield, Werner, Culpepper, Wolfson, &. Bickel, 1996), these changes may still not be reflected in the attitudes of nursing staff members. To change attitudes, new knowledge has to be incorporated into the mainstream education, training materials, and programs provided to caregivers in nursing homes. Therefore, the present study was designed to assess the effectiveness of an inservice training program to improve nursing staff members' knowledge of and perceptions/attitudes toward nursing home residents suffering from dementia and who pace/wander. Additionally, the impact of the inservice program on staff members' attitudes regarding their work and quality of care delivered was assessed.
The theoretical assumptions underlying this project rely on the understanding of pacing/wandering as an adaptive behavior, which provides physical stimulation and exercise for persons suffering from cognitive and communication deficits. As such, these behaviors should not be restricted but should be accommodated. To attain this goal, education should be provided to the caregivers to train them to deal effectively with these behavior problems.
The literature on the impact of training and education on nursing staff attitudes is controversial. Cohn, Horgas, and Marsiske (1990) found a substantial increase in knowledge gained after nurses' aides participated in an education program aimed at teaching behavioral management skills. Other researchers, however, found only a moderate and limited impact of education on staff attitudinal changes (Campbell, Knight, Benson, & Colling, 1991; Strumpf, Evans, Wagner, & Patterson, 1992; Werner, Cohen-Mansfield, Koroknay, & Braun, 1994). The aim of this project is, therefore, to expand the research in this area by exploring whether education has an effect on caregivers' attitudes and whether this change is translated to the care provided to the residents. Specifically, the questions addressed in this study were:
1) What changes in knowledge occurred following the inservice training?
2) Did the inservice training improve staff members* perceptions and attitudes regarding their work and the quality of care provided on their unit?
3) Did changes in staff members' knowledge and attitudes have a positive impact on the residents' behavior and the nature of residents' interactions with staff and other residents?
Twenty-one units in four nonprofit nursing homes in the Washington, DC, metropolitan area participated in this study. The nursing homes varied in size with two facilities with 100 beds, one with 230 beds, and one with 550 beds. All nursing homes had cognitívely impaired residents and residents who wandered or paced, and two had special care units for residents who were likely to wander. All nursing staff members from each unit were recruited. A total of 174 nursing staff members were initially enrolled into the study (i.e., participated at pretest), but only 103 completed the full protocol (i.e., all three assessments). Fifty-nine (57.3%) of these 103 participants worked in nursing homes 5 years or less, 41 (39.8%) worked over 5 years. No data were available for three participants.
Verbal consent was obtained from each nursing home's administrator and Director of Nursing. The intervention included an inservice educational session conducted by a nurse educator. It was preceded and followed by an evaluation of: 1) nursing staff members' knowledge concerning dementia and wandering; 2) staff members' satisfaction and perceptions of quality of care; and 3) observations of resident behavior on the units. An effort was made to schedule the inservice at the regular time for inservices for each participating facility. Additionally, we tried to involve staff members from all the shifts.
Assessments were performed at three time points: 1) pretest=! week prior to the inservice; 2) immediately after the inservice; and 3) followup=! month after the inservice.
Data were entered into SPSS/PC-f-4.1 and analyzed on a 48650 personal computer.
The following assessments were used in this study:
The Knowledge of Dementia and Pacing/Wandering Quiz was designed to assess nursing staff members' knowledge specifically related to dementia and pacing/wandering behavior, as well as management practices. The quiz consisted of 19 true/false items. Seventeen items were taken from standardized assessment instruments pertaining to caregivers* knowledge of dementia (Reindl, 1988; Spore, Smyer, & Cohn, 1991; Dieckmann, Zarit, Zarit, 8c Gatz, 1988). Two additional items (dealing specifically with issues concerning pacing/wandering behavior) were developed specifically for this study. Items were chosen by consensus of research team members to assure face validity. A measure of internal consistency was obtained through an item analysis. Correlation coefficients for the 103 participants were computed between individual binary items and the total number of correct scores. Significant positive correlations (p<-05) were found for 15 of the 19 items (only 1 would be significant by chance). Correlations ranged between r=.21 and .54. Reliability based on internal consistency was found to be moderate (standardized alpha=,45). However, as stated by Spore, Smyer, and Cohn (1991), this was expected because "...the items were constructed to measure separate but interrelated domains" (p. 311). The Knowledge of Dementia and Pacing/Wandering Quiz was self-administered a week prior to the inservice, immediately after the inservice, and 4 weeks after the inservice.
OUTLINE OF INSERVICE
The Staff Satisfaction Questionnaire (SSQ) was designed by the investigators to assess nursing staff members' feelings and perceptions of working with nursing home residents who suffer from dementia and who also pace/wander. Additionally, this questionnaire included items concerning the participants' impressions concerning the quality of care provided on their unit. The rationale for using the SSQ was the assumption that a better understanding of residents as a result of the inservice program would improve feelings about working with the residents and improve the quality of care provided. Each item was rated on a 5point scale where 1 indicated the most positive response (e.g., like very much; job is very easy), and 5 indicated the most negative response (e.g., dislike very much; job is very difficult). The SSQ was administered by research assistants 1 week prior to the inservice training and 4 weeks after it. To assure use of scales with sufficient psychometric properties, SSQ items were submitted to Pearson correlations, factor analysis, and reviewed by the authors. Two constructs evolved that tapped six questions. The constructs were: 1) work difficulty (WD) and 2) quality of care (QC). Cronbach's alpha was performed for these constructs to verify their reliability. Work difficulty included the following items: Is your job: "very easy" (1) to "very difficult" (5); "quickly done" (1) to "time consuming" (5); "satisfying" (1) to "frustrating" (5); "safe" (1) to "frightening" (5). These items yielded a Cronbach's alpha of .75. A composite score was derived by averaging the scores of the individual Ítems. Quality of care included the following items: How good is the QC on your unit? and How well do the staff treat residents? "very good/well" (1) to "very bad/poor" (5). These items yielded a Cronbach's alpha of :65 (Table).
Figure 2. Hook-and-loop fastener strip to prevent trespassing.
Figure 3. Keypad to secure nursing unit
Behavioral observations were performed on all the units participating in the inservice. The aim of these observations was to assess if there was any indirect effect of the inservice on the climate of the unit, and on the behavior of the nursing home residents at those units. Observations were performed using the Observer 2.0 software package in conjunction with the Psion LZ64 hand-held computer. This system allows the user to define a configuration file/program that maps the keyboard of the Psion to reflect different classes and types of behaviors and occurrences. Variables can be either frequency or duration, and behaviors within a class (or category) can be mutually exclusive (i.e., only one can occur at a time) or concurrent (i.e., two or more can occur simultaneously). The configuration for this study was developed by the investigators and consisted of: 1) the number of residents observed; 2) whether the residents were physically restrained or not; 3) the different agitated behaviors manifested by the observed resident; and 4) the variables reflecting the mood of the observed residents, such as anger, anxiety, pleasure, depression, contentment, and interest (Lawton, Van Haitsma, & Klapper, 1996). Each observation consisted of two passes through the units. The data were summed for each pass and averaged across the two passes to yield a single set of observational variables. For each assessment time (i.e., 1 week prior to the inservice, 1 week after the inservice, and 4 weeks after the inservice), observations were conducted on three consecutive days to provide a more representative sampling of problem behaviors on these units. Because of the large number of variables generated for the assessment of agitated behaviors (item 3 above) in the behavioral observations, syndrome scores were computed at each assessment time (TIME) by summing the counts of the individual behaviors for physically nonaggressive behaviors (PNAB) and verbally nonaggressive behaviors (VNAB) according to our previous work (Cohen-Mansfield, Marx, & Werner, 1992). The following variables comprised PNAB: general ambulation, aimless wandering, exit-seeking, trespassing, walk-sitstand inappropriately, pace like a "caged animal," purposeful pacing, strange movements, repetitious mannerisms, throw/handle things inappropriately. The following variables comprised VNAB: constant requests for attention, making strange noises, negative-complain, and refuse/uncooperative.
The inservice training was developed with the aid of a nurse educator (D.B.), based on recent findings from the clinical and research literature. The content of the inservice was designed to cover the following areas: 1) characteristics and causes of dementia; 2) problem behaviors commonly associated with dementia; 3) general guidelines for dealing with residents suffering from dementia; 4) different types of pacing/wandering behavior and their consequences/risks; and 5) management strategies for dealing with pacing/wandering behavior. The inservice is summarized in Figures 1-3.
The inservice was developed to instill in the staff members the notion that pacing/wandering behaviors are not all bad and that, in fact, most may be adaptive in that they provide exercise and physical stimulation to nursing home residents. Thus, it was emphasized at the inservice that these behaviors should be accommodated, rather than limited.
Nursing staff members attending the inservice were given a copy of a detailed outline of the training program to make notes on and keep for reference purposes. The instructor used a more detailed version of the outline printed on large poster board as a visual aid during instruction and encouraged open discussion and frequently asked attendees for specifics about what they do in a particular situation. The inservice lasted approximately 40 minutes to fit with the time generally allotted for inservice programs in the participating nursing homes. One inservice was provided on each unit at a time arranged to be convenient for staff members on that unit.
The inservice training was administered by the study nurse educator except at one nursing home that is comprised of two units. In this instance, the nurse educator of that nursing home administered the inservice after observing and receiving instruction for administering the inservice. The same visual aids were used by both persons.
Data analyses and results are presented below for: 1) changes in knowledge following the inservice training; 2) changes in nursing staff's perceptions of work difficulty, staff satisfaction, and quality of care; and 3) changes in the observed residents' behavior and quality of resident interactions with staff and other residents.
1) Changes in knowledge following the inservice training. These changes were assessed using the scores obtained in the Knowledge of Dementia and Pacing/Wandering Quiz. The majority of the participants answered all the questions in the Quiz: at pretest, 71% of the 103 participants answered all items, and an additional 20% answered 18 of the 19 items; immediately after the inservice, 81% answered all items, an additional 10% answered 18 items, and at follow-up, 83% answered all items, and an additional 1 2 % answered 1 8 items.
An overall score was computed for each staff member as the percentage of correctly answered items (QUIZ), i.e., [QUIZ=(# correct + # items completed)*100], and averaged 76% correct responses at pretest, 80% immediately after the inservice, and 79% at follow-up. These scores were submitted to a repeated measures MANOVA with the three quiz scores at the three time points as the repeated measures factor. There was a significant change in quiz scores following the inservice training [F(2 204|=7.5, /K.01], showing a significant increase after the inservice training, but some decrease at follow-up (Figure 4).
The items that showed significant learning after the inservice training concerned the topics of: the proper treatment of wandering/pacing (3 items: use of physical restraints, need to restrict the behavior, and need to develop a safe environment); the cause of Alzheimer's disease (1 item); the effectiveness and appropriateness of different options for treating persons with dementia (2 items: reminding persons of time and place and use of physical exercise).
2) Changes in nursing staff's perceptions of work difficulty, staff satisfaction, and quality of care. These were assessed using the Staff Satisfaction Questionnaire (SSQ). Although there was no significant change in the scores for the two constructs, work difficulty and quality of care, described above over the course of the study, both of them changed in the expected direction, i.e., staff members expressed more positive feelings of work satisfaction at follow-up than at pretest (2.89 vs. 2,93, respectivety) and rated the quality of care slightly higher at follow-up than at pretest (1.22 vs. 1.26, respectively).
The items which did not converge into the above-mentioned constructs were analyzed separately. Results from these analyses did not reveal statistically significant results, although the item: "To what extent are residents on your unit allowed to pace/wander?" was close to significance. This item was rated on a 5point scale where 1 indicated "residents allowed to pace/wander very much," and 5 indicated "residents were not allowed to pace/wander at all." The mean rating at pretest was 2.59 and at follow-up was 2.34, p=.08, indicating a perception that residents were allowed to pace more frequently after the inservice.
Behavioral Observations. To assess whether or not there was any change in residents' behavior, mood, or the nature of residents' interaction with staff and family, the variables from the behavioral observations were weighted by the number of residents observed and analyzed using repeated measures ANOVAs with TIME as the repeated factor. These analyses yielded one significant finding. The percentage of residents restrained increased from pretest to follow-up. No other significant findings were obtained for agitated behavior (aggregate or individual scores) or mood variables.
SUMMARY OF ANALYSES FOR THE CONSTRUCTS OF WORK DIFFICULTY, STAFF SATISFACTION, AND QUALITY OF CARE
Differences between nursing homes. Because of the imbalance in sample sizes between nursing homes (2 nursing homes had 2 units, 1 nursing home had 4 units, and 1 nursing home had 13 units), comparisons were performed between all four nursing homes. There was no difference between nursing homes regarding any of the dependent measures. The only significant difference between nursing homes for variables derived from behavioral observation was the percentage of residents restrained.
Nursing staff members' knowledge of dementia and pacing/wandering behavior improved following the inservice, although a slight decline was observed at the 1 -month followup, and staff reported a greater willingness to allow residents to pace/wander more after the inservice training (although the latter only approached statistical significance). The fact that knowledge (i.e., quiz scores) improved following the inservice indicates that nursing staff gained new information from the inservice; however, this new information was not fully retained at follow-up after the inservice presentation.
In a similar study, positive results were found by Cohn, Horgas, & Marsiske (1990) using five IVfc-hour sessions administered at 1 -month intervals. The program was designed to teach nurses' aides behavioral management skills for dealing with nursing home residents that adhered to a standard protocol augmented by written material, overheads, case studies, and interactive discussions. Significant gains in knowledge (i.e., test score) were obtained following the first training session and after the last training session with an overall increase in test score of 10.3%. Additionally, self-reported use of caregiving behaviors discussed in the training program significantly increased from "infrequent use" to "more than occasional or moderate use" by the end of the study period. After 3 months of training that encouraged nursing staff to communicate more with patients during morning care, giving patients more responsibility for their own care, Kihlgren and colleagues (1993) videotaped 10 patients and staff during "morningcare" activities: results showed that staff talked more to patients, gave patients more opportunities to participate, and elicited more cooperation from patients. The Brookdale Center on Aging of Hunter College trained 350 professional and paraprofessional nursing staff; results showed that training raised staff knowledge and, more important, improved staff performance. Linn, Linn, Stein, and Stein (1989) evaluated residents' perceptions of staff performance after staff at selected facilities had received inservice education geared to caring for dying patients; again, results showed the efficacy of inservice training.
The literature, however, on the impact of training to nursing staff members is not uniformly positive. Tellis-Nayak and Tellis-Nayak (1989) argued that inservices will not ensure improved job performance, given the exigencies of nursing assistants' home lives and the institutional strictures of nursing homes. Smyer, Brannon, and Cohn (1992) echo their conclusion, based on the Penn State Nursing Home Intervention Project. After a two-part intervention - one designed to improve nursing assistants' skills, the other designed to change their jobs, giving them more responsibility - the results showed a positive impact on staff knowledge, but not on staff performance. Campbell, Knight, Benson, and Colling (1991) tested the efficacy of inservice training geared to urinary tract infections. Again, the training raised knowledge but did not change practice. After 1 week of training in "integrity-promoting care of demented patients" and 3 months of on-the-job support to apply their knowledge, staff in a Swedish nursing home were evaluated as to the impact of the intervention. Compared to nursing home staff in a control facility, the staff that received the intervention expressed slightly higher job satisfaction; but the researchers note that most staff members on both the experimental and control wards enjoyed their jobs. Findings from this study corroborated these results; we found an increase in knowledge over time but no impact on quality of care.
Most important, the results underscore the limitations of inservice training. Even the acquisition of knowledge will not likely change behavior dramatically without an additional behavior program designed specifically to enhance the implementation of what was learned. The inservice training program in this study would probably have been enhanced by repeating the training over a several-month period as well as including supervisor monitoring/ratings/feedback and reinforcement concerning the actual implementation of skills and strategies presented in the inservice training program. Burgio and Burgio (1990) use the term "contingency management" for the various methods of systematic monitoring of staff performance and providing praise or remedial training as warranted. Providing feedback on one's performance throughout the training period and periodically thereafter would reinforce retention of the knowledge and skills.
Additionally, the modest effect of the in-training program on the quality of care constructs may reflect the fact that the facilities included in this study seemed to manifest high level of quality of care, as reflected in the fact that the nursing staff members participating in this program answered 76% of the questions correctly at pretest, demonstrating a basic knowledge of the topics discussed at the inservice.
Limitations of the study include its non-experimental design. Although a control group was not included in the study, the pretest-posttest design including a follow-up assessment allowed us to compare changes within groups. The attrition from 174 at pretest to 103 participants completing all data collection is mostly due to the fact that both the inservice and the data collection periods were designated to specific times which were coordinated with the unit coordinators in advance. Only staff members who were on the unit on these dates participated in these activities, so that staff members who were not scheduled to work on the unit on one of these days, or who were on sick leave, did not complete all assessments.
To summarize, the positive findings of improved knowledge immediately following the inservice show that the program per se was appropriate for its designated purpose, educating nursing staff as to the current knowledge and understanding of dementia and pacing/wandering behavior. Although the changes reflected in the knowledge scale were modest, this finding is similar to those found by other studies relying on a one-time inservice training (Werner, Cohen-Mansfield, Koroknay, & Braun, 1994). In terms of implications for nurse training, it is our conclusion that the materials presented in the inservice described above are useful as a basis for the development of effective training. However, this basis is not sufficient. Additional procedures are needed, such as restructuring the inservice so that it is repeated over a severalmonth period and nurse supervisors' monitoring staff performance and providing feedback and contingent reinforcement on the degree to which care follows the inservice recommendations. These combined methods would likely improve retention of the information and thus have a greater impact on the way for which residents are cared. Incorporation of such changes into a continuous training program is expected to impact actual nurse behaviors which would then be reflected in resident behavior, i.e., fewer behavioral problems and improved mood of the residents. Therefore, future development and research of training programs should adopt the strategy whereby the training program is focused (i.e., it deals with only one or two substantive areas/skills at a time); the training is repeated over a prescribed period of time to aid longterm retention; and nursing supervisors monitor and reinforce staff's implementation of the material covered and provide feedback regarding their performance. Additionally, the study underscores the importance of: 1) assessing staff and resident behaviors and not relying on staff knowledge or staff report of behaviors and 2) assessment of followup effects after termination of active training program.
- 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 ana Human Development, 30(4), 287-302.
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- Campbell, E.B., Knight, M., Benson, M-, St Colling, J. (1991). Effect of an incontinence training program on nursing home staff's knowledge, attitudes, and behavior. The Gerontologist, 31(6), 788-794.
- Cohen-Mansfield, J., Marx, M.S., & Werner, P. (1992). Agitation in elderly persons: An integrative report of findings in a nursing home. International Psychogeriatrics, 4(2), 221-240.
- Cohen-Mansfield, J., Werner, P., Culpepper, WJ., Wolfson, M., & Bickel, E. (1996). Wandering & aggression. In L.L. Carstensen, B.A. Edelstein, Si L. Dornbrand (Eds.), The practical handbook of clinical gerontology. Thousand Oaks, CA: Sage.
- Cohen-Mansfield, J., Werner, P., Marx, M.S., Sc Freedman, L. (1991). Two studies of pacing in the nursing home. Journal of Gerontology: Medical Sciences, 46(3), M77-M83.
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- Coons, D.H. (1988). Wandering. American Journal of Alzheimer's Care and Related Disorders & Research, 3(1), 31-36.
- Cornbleth, T. (1977). Effects of a protected hospital ward area on wandering and nonwandering geriatric patients. Journal of Gerontology, 32(5), 573-577.
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- King, T., & Mallet, L. (1991). Brachial plexus palsy with the use of haloperidol and a geriatric chair. DICP, The Annals of Pharmacotherapy, 25, 1072-1074.
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- Omnibus Budget Reconciliation Act (OBRA). (1987). P.L. 100-203, Subtitle C; Nursing Home Reform.
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- Snyder, L.H., Rupprecht, P., Pyrek, J., Brekhus, S., Se Moss, T. (1978). Wandering. The Gerontologist, 18(3), 272-280.
- Spore, D.L., Smyer, M.A., Sc Cohn, M.D. (1991). Assessing nursing assistants' knowledge of behavioral approaches to mental health problems. The Gerontologist, 31(3), 309-317.
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OUTLINE OF INSERVICE
SUMMARY OF ANALYSES FOR THE CONSTRUCTS OF WORK DIFFICULTY, STAFF SATISFACTION, AND QUALITY OF CARE