Increasingly, investigators are addressing treatment fidelity when reporting research from behavior change-related interventions (
). In behavior change research, an intervention can be said to satisfy treatment fidelity requirements if the treatment provided is consistently given to all participants randomized to treatment, there is no evidence of non-treatment-related effects, and the intervention is true to the theory and goals underlying the research (
Treatment fidelity helps optimize the findings from any intervention study through better understanding of what was tested during the study and by decreasing unintended interventions that can influence findings. Given the challenges associated with research among older adults in nursing home settings (e.g., recruitment, attrition), it is especially critical to evaluate and monitor treatment fidelity so true testing of the intervention occurs. Typically, interventions in these sites involve changing behavior among the caregivers, as well as enacting a change in behavior among the residents. Consequently, treatment fidelity must consider both groups.
When treatment fidelity was considered in nursing home behavior change interventions, it generally focused on delivery aspects of the intervention (Lichstein, Riedel, & Grieve, 1994). Alternatively, some research teams have considered adherence to the interventions implemented (Beck et al., 1997; Beck, Heacock, Rapp, & Mercer, 1993; Beck, Ortigara, Mercer, & Shue, 1999; Engelman, Altus, Mosier, & Mathews, 2003; Field, 2004; Jex, Bliese, Buzzell, & Primeau, 2001; Lim & Taylor, 2005; Sandman, Norberg, Adolfsson, Axelsson, & Hedly, 1986) but have not considered treatment fidelity throughout the course of the research. When this is neglected, it is difficult to know if the lack of long-term adherence is because the intervention was ineffective or if it simply was not initially delivered optimally, understood by the participants, and/or enacted on a regular basis.
The most comprehensive way to evaluate treatment fidelity involves using the model of treatment fidelity established by the Behavior Change Consortium Treatment Fidelity Workgroup (Bellg et al., 2004). The components of this model include treatment fidelity related to:
- Research design, which focuses on whether the study is consistent with the underlying theory.
- Training, which addresses skill acquisition and maintenance in those providing the intervention.
- Delivery, which is the assessment of the interventionist’s ability to present the intervention as intended.
- Receipt, which focuses on whether the participants received and understood the intervention as intended.
- Enactment, which establishes whether the participants are able to carry out the activities taught in their own environment.
The purpose of this article, therefore, is to describe how treatment fidelity was comprehensively evaluated in a two-tiered motivational intervention, the Res-Care Intervention Study, focused on restorative care interventions in nursing home settings.
Treatment Fidelity in the Res-Care Intervention Study
Prior to implementation of the Res-Care Intervention Study, we established a comprehensive treatment fidelity plan (Table 1). The Res-Care Intervention Study was a randomized controlled trial that involved 12 nursing homes in which 6 were exposed to the Res-Care Intervention and 6 received a placebo control intervention. The Res-Care Intervention focused on teaching the nursing assistants (NAs) how to motivate residents to engage in restorative care activities and how to incorporate those activities into routine care with residents. The intervention was based on Bandura’s (1997) theory of self-efficacy, which states that the stronger an individual believes in his or her ability to engage in a specific activity and in the outcomes associated with the activity, the more likely it is that he or she will initiate and adhere to the behavior.
Table 1: Treatment Fidelity Plan
It was hypothesized that residents who were exposed to the Res-Care Intervention would maintain and/or improve function and muscle strength, and compared with those exposed to the control intervention, would have fewer contractures and better quality of life, as well as stronger self-efficacy and outcome expectations related to function, less pain, and less fear of falling. The control intervention included a one-time inservice educational program for the NAs, focused on behavioral management.
The Res-Care Intervention
The components of the Res-Care Intervention have been described in detail elsewhere (Resnick, 2004; Resnick, Gruber-Baldini, et al., in press; Resnick, Simpson, et al., 2006). Briefly, the Res-Care Intervention was initiated by a Restorative Care Nurse (RCN) trained and supported by the investigative team. The RCN worked with the NAs in each of the treatment facilities for 20 hours per week during the 12-month intervention period. At the beginning of the 12-month period, the NAs in each site participated in a 6-week educational program (Table 2). The sessions addressed the philosophy of restorative care, taught ways to integrate restorative care into daily functional tasks with residents (e.g., bathing, dressing), taught the NAs how to motivate residents to engage in restorative care activities, and defined for the NAs a restorative care interaction and taught them how to document restorative care activities on a daily basis.
Table 2: Res-Care Intervention: Educational Component (6-Week Educational Series)
The 6-week educational program was implemented on a weekly basis, and each class lasted 20 to 30 minutes. In addition, the NAs were exposed to ongoing interventions provided by the RCN that were focused on motivating them to engage in restorative care in all care interactions with residents. The motivational techniques included verbal encouragement, role-modeling, cueing, and helping the NAs overcome the challenges and barriers associated with restorative care in their sites. The RCN also worked with the NAs to evaluate the residents and establish their restorative care goals. The goals were posted in the residents’ rooms and updated monthly by the RCN with input from the NAs.
Details of recruitment have been previously published (Resnick et al., 2008). NAs and residents were recruited from 12 nursing homes in the greater Baltimore area. NAs were eligible to participate in the study if they could read and write English, had worked in the facility for at least 6 months, and worked at least 16 hours per week on day or evening shifts. Residents were eligible to participate if they were age 65 or older, had a Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) score of 11 or greater, had a life expectancy greater than 6 months, and were not receiving skilled rehabilitation services. A total of 486 residents and 523 NAs were eligible and consented to participate in the study.
Overall, the mean age of the NA participants was 38.1 (SD = 12 years), and the majority were women (n = 486, 93%), African American (n = 466, 89%), and had an average of 12.5 (SD = 1.5) years of education and 11.5 (SD = 8.6) years of experience as NAs. The mean age of the residents was 83.8 (SD = 8.2), and they had a mean MMSE score of 20.4 (SD = 5.3). The majority were women (n = 389, 80%), and more than half were White (n = 325, 67%). Eighty-five individuals (17%) were married, 284 (58%) were widowed, and the remaining were single (n = 52, 11%) or divorced/separated (n = 65, 13%).
Study aims and results with regard to the primary study outcomes have been reported elsewhere (Resnick, Gruber-Baldini, et al., in press; Resnick et al., 2008). With regard to the residents, significant treatment by time interactions (p < 0.05) were found for the Tinetti Mobility Score, and its subscores for gait and balance, walking, bathing, and stair climbing. No significant difference was found over time in residents between groups with regard to contractures, grip strength, quality of life, self-efficacy or outcome expectations, pain, or fear of falling. Among the NAs, there was a statistically significant increase in outcome expectations related to restorative care activities (p = 0.04) and performance of restorative care (p = 0.001) at 4 months, and an increase in knowledge of restorative care (p = 0.001) and job satisfaction (p = 0.011) at 12 months among those randomized to treatment. There was no difference between the groups with regard to the NAs’ self-efficacy expectations for providing restorative care. Overall, our hypotheses were partially supported.
Treatment Fidelity Results
Treatment Fidelity Related to Design
To stay true to the underlying theoretical design of the study, it was essential the NAs and residents in the treatment and control groups received only the intervention they were randomized to receive. Separate interventionists were used to implement the educational components of the intervention to avoid any possible contamination between treatment and control sites. We met monthly with the RCNs throughout the course of the 5-year study to discuss intervention strategies and to maintain adherence to the sources of self-efficacy information known to strengthen self-efficacy and outcome expectations. At the meetings, the RCNs described their interactions with the NAs and implementation of the intervention, raised questions about restorative care goal development for residents, and discussed challenges noted in work with the NAs (e.g., incomplete documentation).
Treatment Fidelity Related to Training
As indicated in Table 1, an extensive training manual was developed for the interventionists, and training was performed with each of the 5 RCNs involved in the study. The training involved a one-on-one review of the intervention with the principal investigator (PI) and shadowing an RCN in the field for several weeks. Following initial training, the RCN had to demonstrate the ability to complete a baseline evaluation of a resident and establish restorative care goals. Training continued throughout the course of the study during the monthly RCN meetings. Moreover, the RCNs were encouraged to ask questions of the project manager and PI during monthly meetings and as questions arose during the course of the study.
Treatment Fidelity Related to Delivery
To optimize delivery of the educational component of the intervention, the research team met with the Director of Nursing or designee to arrange the classes. The classes were planned at times that would be convenient to the staff and generally were offered at two to four different time slots on 1 or 2 days during the week. This was done to ensure attendance by different shifts.
All staff were invited and encouraged to attend the inservice sessions, regardless of whether they had consented to participate in the study. The days and times for classes varied by facility but remained consistent in each facility. Refreshments were served at each of the sessions. For consented NAs who missed 50% or more of the classes, the RCN provided one-on-one or small group make-up sessions. In addition, hard copies of the class materials were placed on the units in all treatment sites. There was no incentive provided for the NAs to attend the individual classes. However, the NAs were informed that they would be invited to a certificate party and receive a certificate indicating completion of the Restorative Care training if they completed the 6 weeks of classes and successfully passed the Restorative Care Training test (e.g., our test of knowledge related to restorative care). This celebration was very well received and appreciated by the NAs.
The control site intervention was implemented in a similar manner in that the interventionist met with the Director of Nursing and established a time and date for the educational session. As with the 6-week program in the treatment sites, multiple sessions were held on a single day to facilitate attendance, and refreshments were provided. There was no direct incentive provided to the control group NAs for attending the class. All consented NAs did receive a $10 gift certificate at the end of the 12-month study, but this was following the completion of their survey data and was in no way related to class attendance.
Table 3 describes the delivery of the classes. A total of 87 (33%) of the 265 consented NAs in the treatment sites attended all six classes, 177 (67%) treatment group participants missed 50% or more of the group classes, and 53% of those who did not attend at least half of the classes received a one-on-one review of the class content. Overall, 228 (86%) of the consented NAs were exposed to the material in the 6-week educational program. In the control sites, 48 (18%) of the consented NAs attended the inservice training. No make-up sessions were delivered in the control sites.
Table 3: Delivery Outcomes for NA Inservice Sessions
Delivery of the components of the Res-Care Intervention relevant to the residents was demonstrated based on evidence that all residents had a restorative care motivational poster placed in their rooms and goal forms completed and updated monthly by the RCN with input from the NAs. In addition, on the basis of the restorative care documentation flow sheets, the residents were exposed to 70.5 (SD = 56.2) minutes daily of restorative care from the NAs. The NAs provided restorative care during 60% (SD = 29%) of all care interactions at 4 months and 65% (SD = 25%) of care interactions at 12 months.
Treatment Fidelity Related to Receipt
In an attempt to determine whether the NAs had actually received (i.e., learned) the material from the 6-week restorative care inservice program, a paper-and-pencil test of restorative care knowledge was given at baseline and then at the completion of exposure to the six inservice sessions. Pretesting and posttesting was completed on 222 (87%) of 256 consented NAs in the treatment sites. Missing data were due to NAs leaving the facility, being on family or sick leave, or being unreachable (i.e., not coming in to work, not responding to multiple attempts to schedule a make-up test). On the basis of a paired t test using a significance of p < 0.05, there was a statistically significant (t = −16, p < 0.01) increase in scores from a pretest mean score of 54% (SD = 16%) to a posttest mean score of 76% (SD = 17%).
Treatment Fidelity Related to Enactment
Enactment in treatment sites was based on data from the Restorative Care documentation flow sheets, completion of which was part of the study intervention. This documentation included the amount of time the NA spent providing restorative care with each resident. The daily documentation was a motivational strategy for the NAs, as it was a cue to engage in restorative care and provided some self-modeling and role-modeling (i.e., NAs were reminded of their prior restorative care activities, as well as the restorative care activities of their peers). Overall, the NAs completed the Restorative Care documentation flow sheets for 9.2 months (SD = 2.6) of a total of 10 expected months of documentation (i.e., documentation was not initiated until after the 6-week training). There were only 2,284 missing shifts of 354,780 shifts (1%) in which documentation was supposed to be completed for each of the consented residents. As noted above, the NAs delivered or enacted 70.5 (SD = 56.2) minutes daily of restorative care to the consented residents.
Interpretation of Treatment Fidelity Findings
The treatment fidelity findings provide some support that we were able to implement the Res-Care Intervention as intended. The level of treatment fidelity achieved was sufficient to support some of the hypotheses, particularly those related to resident function. The Res-Care Intervention did not have an impact on contractures, grip strength, quality of life, pain, or fear of falling. This may be because the primary focus of the restorative care goals for residents was on functional tasks such as bathing, dressing, and walking, rather than implementation of a more intensive exercise intervention focused on increasing strength. It is further anticipated that the Res-Care Intervention did not impact quality of life due to measurement issues. The Dementia Quality of Life measure (Brod, Stewart, Sands, & Walton, 1999) used in this study is not reflective of the things that are important to the quality of life of nursing home residents (e.g., interactions with staff, having space to themselves, having a sense of security) (Hjaltadóttir & Gústafsdóttir, 2007; Robichaud, Durand, Bédard, & Ouellet, 2006).
Alternatively, it is possible that the Res-Care Intervention did not fully support our hypotheses because enactment was insufficient in this study. Although the NAs completed documentation on 99% of all shifts as was intended, they provided restorative care to residents in only approximately 60% of all care interactions and for only 70 minutes daily. Restorative care, however, is a philosophy of care that optimally is provided in all interactions with residents. It is possible that increased enactment of the intervention in the residents’ daily lives would have improved outcomes focused on contractures, strength, quality of life, pain, and fear of falling.
We noted other areas in which treatment fidelity could be improved. Delivery of the intervention to the NAs in the treatment sites was only done for 86% of the participants. Although this is consistent with attendance at inservice education programs in nursing home settings (Cohn, Horgas, & Marsiske, 1990; Hagen & Sayers, 1995; Smyer, Brannon, & Cohn, 1992), it is possible that 100% attendance with regard to education may have had a greater impact on outcomes. Numerous recommendations have been made regarding how to motivate and engage NAs in inservice education sessions. These include (Blair & Glaister, 2005; Kemeny, Boettcher, Deshon, & Stevens, 2004):
- Ensuring the education material is relevant to clinical experience.
- Allowing time for hands-on demonstrations and feedback.
- Designing programs that meet the needs of adult learners.
- Providing easy access to information (e.g., handouts).
- Allocating time within the clinical day and providing financial support for participation.
Generally these recommendations were used in our inservice educational program. In our experience, the sites with the highest class participation were those that scheduled the NAs to attend the classes. In future work, we would specifically ask the administrative staff to allocate time for the NAs to attend classes and would consider providing financial incentives for class participation. Research is needed, however, to determine whether financial incentives can improve participation in inservice trainings among nurses as they have with regard to completion of surveys or participation in focus groups (Resnick, Keilman, et al., 2006; Ulrich et al., 2005).
In addition to using these supported approaches to inservice education, alternative methods of delivery, such as the use of technology (e.g., Web) (Irvine, Bourgeois, Billow, & Seeley, 2007; Upstairs Solutions, 2007) should be considered. For example, there is evidence to support the use of podcasting to increase education delivered to informal caregivers (Abreu, Tamura, Sipp, Keamy, & Eavey, 2008) and physicians (Corl, Johnson, Rowell, & Fishman, 2008) and for interactive computer-based learning for nurses (Durkin, 2008; Magnan & Maklebust, 2008; Sanders et al., 2008).
Treatment fidelity related to delivery of the intervention to the residents was supported at some level by evidence that the residents in the treatment group received restorative care during 60% to 65% of all care interactions and for approximately 70 minutes daily. Unfortunately, there is no evidence to determine how much time spent in restorative care activities is needed to establish optimal outcomes. Under the current Medicare reimbursement system, nursing homes are able to capture costs related to the provision of restorative care for their residents if they document and demonstrate two or more nursing rehabilitation activities for 15 or more minutes per day for 6 or more of the past 7 days, and nursing interventions that assist or promote the resident’s ability to attain his or her maximum functional potential, promote the resident’s ability to adapt and adjust to living as independently and safely as possible, and focus on optimal physical, mental, and psychosocial functioning. While we can assume that the 70 minutes of restorative provided to residents in the treatment sites would be considered sufficient from a Medicare perspective, we believe that delivery of restorative care is needed in all care interactions to achieve the best possible benefit for residents.
The treatment fidelity data supported evidence of receipt of the intervention for NAs on the basis of increased knowledge of restorative care, as demonstrated on a paper-and-pencil test. However, restorative care knowledge must be applied to real-world clinical settings. Therefore, future work might consider using more of a case-based approach to testing via technology. Alternatively, the RCN could present the NAs with several case scenarios and evaluate their response to the cases (Table 4).
Table 4: Examples of Scenarios for Demonstration of Receipt of Restorative Care Knowledge Among Nas
Treatment fidelity related to receipt of the intervention for residents was not comprehensively addressed. Future work in this area should consider observing the residents’ response to restorative care during objective measurements of NA-resident interactions. This could be done, for example, when completing the Restorative Care Behavior Checklist (Resnick, Rogers, Galik, & Gruber-Baldini, 2007). Alternatively, a Goal Attainment Scale (Gordon, Powell, & Rockwood, 1999; Kiresuk, Smith, & Cardillo, 1994) could provide evidence that the resident understood what he or she was to do and engaged in the behavior at a level sufficient to achieve his or her identified goals. While this scale has been used with individuals with some evidence of mild to moderate dementia (Resnick, Galik, Gruber-Baldini, & Zimmerman, in press), it would not be appropriate for those with more significant impairment.
Traditionally, enactment is the most challenging component of treatment fidelity to evaluate. The Restorative Care flow sheets were used to show that the NAs were providing restorative care to residents during routine care activities. Information from the Restorative Care flow sheets was similarly used to consider whether the NAs documented daily (i.e., looked at and used the documentation flow sheets) and if they performed restorative care with residents on a daily basis. To optimize our data collection, an entire inservice class focused on documentation, and the RCN worked one-on-one with the NAs throughout the course of the study on their documentation. We recognize, however, that there are challenges associated with self-report, and it is possible that responses were influenced by social desirability (Tan & Grace, 2008) or that there may have been instances in which restorative care was provided but not documented. Testing the validity of the data entered on the Restorative Care flow sheets by comparing this information with direct observation or videotaping of NA behavior is needed.
Benefits of Evaluating Treatment Fidelity
The rigorous focus on treatment fidelity in this study optimized our adherence to implementing the intervention protocol as intended. Moreover, our treatment fidelity plan allowed us to identify and address implementation challenges when they occurred. For example, meeting with our interventionists for ongoing training resulted in keeping the RCNs focused on motivating the NAs to provide restorative care to residents. This is in contrast to the RCN simply providing restorative care to residents as is done in designated restorative care programs (Remsburg, Armacost, Radu, & Bennet, 1999). In addition, during these monthly meetings, we discussed with our interventionists changes in our protocol that might improve the implementation of restorative care in nursing home settings. These ideas were then saved for future studies.
Where We Are and Where We Need to Go Regarding Treatment Fidelity
Increasingly, treatment fidelity is recognized as an important aspect of research focused on behavior change. In 1980, only 5.6% of intervention research reported evaluating treatment fidelity, with the focus of these reports being on delivery of the intervention (Billingsley, White, & Munson, 1980). In 1991, there was evidence that 45% of intervention studies evaluated treatment fidelity (Moncher & Prinz, 1991). A little more than a decade later, a similar review noted that 63% to 94% of published intervention studies reported treatment fidelity results related to design, 16% to 25% reported on training of the interventions, 6% to 46% reported on delivery of the intervention, 40% to 53% reported on receipt of the intervention, and 46% to 69% reported on enactment of the intervention in real-world settings (Borrelli et al., 2005).
Although there is growing evidence that researchers are considering treatment fidelity, rigorous methods to evaluate treatment fidelity have not yet been established. In addition, we continue to establish treatment fidelity plans that are only relevant to the study being implemented (Bellg et al., 2004; Borrelli et al., 2005; Kearney & Simonelli, 2006; Kolanowski et al., 2006; Resnick, Bellg, et al., 2005; Resnick, Inguito, et al., 2005; Spillane et al., 2007). For example, treatment fidelity plans were established for the Exercise Plus Program, a home-based exercise program post hip fracture (Resnick, Inguito, et al., 2005), an activity intervention designed for older adults with dementia (Kolanowski et al., 2006), and a pilot study testing a nurse-delivered intervention to prevent or reduce long-term obesity following childbirth (Kearney & Simonelli, 2006). While each intervention requires the establishment of a plan that will inform the proposed study, the ultimate goal with regard to treatment fidelity is to establish a treatment fidelity plan for successful interventions that can be used across multiple studies (Bond & Salyers, 2004).
Critical to the evaluation and interpretation of treatment fidelity is the evidence that a treatment is effective and that the treatment outcomes were related to specific intervention ingredients. Likewise, it is important to understand how robust the treatment is and if small deviations from treatment fidelity will result in poor outcomes. It is possible, for example, to have situations in which treatment fidelity may be intact, but the treatment does not result in expected outcomes. The treatment fidelity findings in such a case would guide the researcher to conclude that the treatment was truly ineffective and revise as appropriate.
The Res-Care Intervention has been implemented in multiple clinical settings and with a variety of patient populations (Galik et al., 2008; Pretzer-Aboff, Galik, & Resnick, in press; Resnick, Galik, et al., in press). The treatment fidelity plan described in this article has been used consistently in these other studies to assure adherence to the intervention and to guide revisions. Cumulative work in this area will allow us to establish a standard method of evaluating and interpreting treatment fidelity related to restorative care.
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Treatment Fidelity Plan
|Treatment Fidelity Focus
||Description of Treatment Fidelity Indicators
||The intervention was developed based on social cognitive theory and the theory of self-efficacy. This was reviewed with experts in cognitive theories and behavior change. Evaluators were kept blinded from treatment intervention and randomization of sites. Different interventions provided the training for the treatment versus the control sites.
||RCN training: (a) training of the RCN was based on a training manual, (b) RCNs met monthly with the PI to discuss intervention process and activities to prevent intervention drift.
|NA training: (a) each NA attended the six classes or was provided with written material and one-on-one sessions to review the class content.
||NA class attendance was recorded, as were one-on-one sessions to assure delivery of the intervention. Daily logs completed by NAs were reviewed on a monthly basis to assure delivery of restorative care activities.
||Each NA completed the NA theoretical testing of restorative care activities before and after the 6-week training period.
||Monthly logs recording the NA restorative care activities were reviewed in the treatment sites to determine daily enactment of restorative care. Direct observation of restorative care using the Restorative Care Behavior Checklist was done at 4 and 12 months postintervention as evidence that restorative care activities were completed.
Res-Care Intervention: Educational Component (6-Week Educational Series)
|Week 1: Introduction to Restorative Care—Nursing with a strong focus on the new philosophy of care.
||NAs are taught techniques to motivate residents to perform restorative care activities:
|Week 2: Restorative Care Interventions—Transfers, ambulation, and exercise training activities; range of motion exercises; and splint/brace training.
||• Verbal encouragement through education, goal setting, and positive reinforcement.
|Week 3: Restorative Care Interventions—Bathing, dressing, feeding, communication, and bowel/bladder training.
||• Cueing through use of reminders (visual and other).
|Week 4: Documentation of restorative care activities and review of interventions.
||• Elimination of unpleasant sensations, such as treating pain with medication.
|Week 5: Restorative Care Interventions—How to motivate the resident to participate in functional activities.
|Week 6: Incorporating restorative care activities into regular daily care.
Delivery Outcomes for NA Inservice Sessions
|Teaching Provided at Treatment Sites
|Percentage of consented NAs present at all 6 inservice classes
|Percentage of NAs enrolled in the study who received one-on-one education
|Percentage of NAs not enrolled in the study who were present at inservice classes (all 6 classes)
|Percentage of NAs not enrolled in the study who received one-on-one education
|Teaching Provided at Control Sites
|Percentage of consented NAs present at inservice classes (all 6 classes)
|Percentage of NAs enrolled in the study who received one-on-one educationa
|Percentage of NAs not enrolled in the study who were present at inservice classes (all 6 classes)
|Percentage of NAs not enrolled in the study who received one-on-one educationa
Examples of Scenarios for Demonstration of Receipt of Restorative Care Knowledge Among Nas
|Scenario 1: The activity aide is pushing a resident in a wheelchair. You, as the NA, stop the activity aide and ask, “Why are you pushing Harold in a wheelchair? He can walk to the dining room.” The activity aide answers, “Because we’re short of help. Molly called in sick today, and I have to get these residents to the morning activity—current events. I don’t have time to walk them, so I’m just going to push them all down to the dining room in their wheelchairs.” Ask the NA how he or she would respond.
|Scenario 2: A resident and a family member are talking with a social worker. The resident says, “My wife died 2 years ago. They sold my home and put me here. My children and grandchildren don’t visit me very often, so why should I do anything for myself? They would all be better off if I just died.” The resident’s family member adds, “Mother used to take care of father. She did everything for him. Since mother died, there’s no one available to take care of him. He was alone at home and fell and broke his hip. That’s why we put him here. But he says that the staff makes him do things for himself. They won’t do what mother did for him, and we’re paying a lot of money for you to take care of him.” The social worker looks to you for help. How would you as the NA respond?