Research in Gerontological Nursing

State of the Science Supplemental Data

Interventions to Enhance Empathy and Person-Centered Care for Individuals With Dementia: A Systematic Review

Ellen L. Brown, EdD, MS, RN, FAAN; Marc E. Agronin, MD; Jennifer R. Stein, BS

Abstract

Empathy, or the ability to imagine what someone else may be feeling or thinking, is a crucial component of meaningful care provision, including person-centered care (PCC), and has been shown to enhance care provider and patient well-being. The purpose of the current review was to examine the impact of interventions focused on improving the ability of health care providers or students to experience and/or communicate with empathy. Of 1,427 publications reviewed, 18 articles met inclusion criteria. All studies incorporated empathy or empathic communication competencies in their training or intended variables of change. PCC concepts were used in guiding the development of most interventions. Some interventions significantly improved participant empathy, attitudes toward patients with dementia, and certain verbal and nonverbal communication skills. Current study reports on improved positive interpersonal communication skills by nursing assistants are promising. Future study to improve therapeutic communication and delivery of dementia care with empathy using enhanced study design and measurement are needed. [Research in Gerontological Nursing, 13(3), 158–168.]

Abstract

Empathy, or the ability to imagine what someone else may be feeling or thinking, is a crucial component of meaningful care provision, including person-centered care (PCC), and has been shown to enhance care provider and patient well-being. The purpose of the current review was to examine the impact of interventions focused on improving the ability of health care providers or students to experience and/or communicate with empathy. Of 1,427 publications reviewed, 18 articles met inclusion criteria. All studies incorporated empathy or empathic communication competencies in their training or intended variables of change. PCC concepts were used in guiding the development of most interventions. Some interventions significantly improved participant empathy, attitudes toward patients with dementia, and certain verbal and nonverbal communication skills. Current study reports on improved positive interpersonal communication skills by nursing assistants are promising. Future study to improve therapeutic communication and delivery of dementia care with empathy using enhanced study design and measurement are needed. [Research in Gerontological Nursing, 13(3), 158–168.]

The tremendous growth and development of long-term care (LTC) settings over the past half-century have spurred philosophical movements to create ideal care models and regulatory agencies to hold them accountable. Both entities have given particular attention to LTC residents with Alzheimer's disease and other forms of dementia, as they pose unique challenges in terms of providing skilled care that meets their needs while also preserving dignity and their sense of personhood (Kitwood, 1997; Post, 2000). These interests have converged in the development of person-centered care (PCC) but there is “no standardized, agreed upon parameters for delivering such care” (American Geriatrics Society Expert Panel on Person-Centered Care, 2016, p. 1). The Alzheimer's Association defines PCC as a “philosophy of care built around the needs of the individual and contingent upon knowing the person through an interpersonal relationship” (Fazio, Pace, Flinner, & Kallmyer, 2018, p. S10). To date, attempts to identify an underlying methodology to PCC have focused on interventions to help frontline professional caregivers understand and communicate effectively with LTC residents with dementia. In many studies, empathy is frequently cited as a key interpersonal tool.

A major component of PCC is empathy (Fazio et al., 2018), although this quality has been identified as difficult to conceptualize, teach, and measure (Lam, Kolomitro, & Alamparambil, 2011). With a large body of literature emphasizing the demand for improvements in dementia care, and a significant number of subsequent interventions attempting to make these improvements, the current authors sought to identify those interventions that in some way incorporated the delivery of care with empathy or emphasized empathic communication by care providers of persons with dementia in the LTC setting.

In the LTC setting, PCC models vary but there is recognition that PCC is dependent on “staff's belief and acceptance of person-centered philosophy, their knowledge to develop a therapeutic relationship, their skill in interacting with residents, and personal qualities such as empathy, kindness and patience” (Li & Porock, 2014, p. 1413). Consistent with this tenet, federal training programs (Centers for Medicare & Medicaid Services, 2012) and recent evidence-based practice recommendations (Fazio et al., 2018) have identified empathic communication or competencies focused on the development of a caring relationship with nursing home residents and specifically with persons with dementia as needed to support and complement PCC.

Overall, there has been increasing interest in promoting empathy and evaluating the impact of empathy in the delivery of health care (Decety & Fotopoulou, 2015). There is varying interest in health care provider empathy and empathic communication including the role of empathy in PCC (Fazio et al., 2018), the association of provider empathy and patient outcomes (Dambha-Miller, Feldman, Kinmonth, & Griffin, 2019), and the use of empathy inventories to determine medical education admissions (Hojat et al., 2019). Why this interest in empathy? Multiple benefits of clinical empathy have been documented, including improved patient satisfaction, adherence to treatment recommendations, more accurate diagnoses (Decety & Fotopoulou, 2015; Riess, 2015), and a reduction in lawsuits (Decety & Fotopoulou, 2015). Moreover, empathy in medical care delivery may impact patient “expectations, perceptions of being understood and care(d) for, feeling safe, satisfaction and compliance with treatment, trust, social connectedness, and homeostasis” (Decety & Fotopoulou, 2015, p. 4).

At the outset, the current authors acknowledge there is lack of agreement on how the concept or process(es) of empathic communication and empathy are understood and defined, which complicates scientific investigation and measurement. With empathy, the empathizer is trying to feel, think, or “imagine” what someone else is experiencing. However, imagining “the world from the perspective of the individual living with dementia” (Fazio et al., 2018, p. S18) presents unique challenges as “there are as many manifestations of dementia as there are persons with dementia.” Furthermore, “imagining” requires knowledge about the person receiving one's empathy, mental flexibility, and appreciation that it is more difficult to empathize with someone whom one is different than (Coplan & Goldie, 2011). The focus of the current study is to understand how to develop care providers' empathic understanding and “special resourcefulness” (Kitwood, 1997, p. 119), including the ability to communicate with empathy (Fazio et al., 2018).

In 2018, the Alzheimer's Association recommendations for individuals with dementia identified empathic communication and experiencing empathy as essential for delivery of PCC (Fazio et al., 2018). Consistent with this recommendation, the current study systematically explored how previous investigators approached this goal. The purpose was to examine the impact of interventions focused on improving the ability of health care providers or students to experience and/or communicate with empathy.

Method

The protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al., 2009).

Selection Criteria

All studies that fulfilled the following inclusion criteria were selected: (a) primary research study published in English in a peer-reviewed journal; (b) study setting was LTC environments (e.g., nursing homes, assisted living facilities, home care); (c) intervention studies focused on training current or future health care providers (i.e., professional or paraprofessional) to develop a greater understanding or knowledge of the lived experience (i.e., the act of imagining what someone else may be feeling or thinking) (Kitwood, 1997) of dementia or interventions targeting a therapeutic communication technique (verbal or nonverbal) that may contribute to the delivery of health care with empathy; (d) interventions with a component of empathy or outcome measures; and (e) all intervention studies considered either experimental or quasi-experimental, which included quantitative analysis and statistical inference, for the primary outcomes.

Articles were therefore excluded if: (a) Alzheimer's disease or other dementia was not the primary diagnosis of the target population or patients; (b) research was conducted in a hospital; (c) family or informal care providers were the only/primary participants or were not separated from formal care providers in the analysis; and (d) the focus was on palliative or end-of-life care, as this indicates finality of care rather than implementation in the LTC setting.

Information Sources

The systematic review was conducted using a university online library, which provided access to research databases. The following databases were searched: AgeLine, CINAHL, MEDLINE, and PsycINFO. The authors collaborated with a library scientist to conduct the search and refine the search strategy. The search was restricted to peer-reviewed journal articles and publications prior to January 31, 2018.

Search

To summarize, the search comprised terms relating to (a) general health personnel or health administration, (b) communication skills or empathy training, and (c) Alzheimer's disease or dementia. The general search included the following terms, which were adapted for use in each database: (‘health personnel’ OR ‘health services’ OR ‘health services administration’ OR ‘health administration’ OR ‘geriatric psychiatry’ OR ‘professional-patient relations’ OR ‘nurse-patient relations’ OR ‘nurs*’ OR ‘care*’ OR ‘psychiatr*’ OR ‘psycholog*’) AND (‘empath*’ OR ‘communication skills training’ OR ‘communication skills’ OR ‘communication training’) AND (‘Alzheimer* OR ‘dement*’). Table A (available in the online version of this article) shows the complete search strategy.

Data Base Searches

Table A:

Data Base Searches

Study Selection

Following the initial search, duplicates were removed from the final group of articles. The remaining articles were reviewed by title and abstract (by two independent reviewers [E.L.B., J.R.S.]) and in the case of a discrepancy a full-text review occurred. Titles and abstracts not meeting inclusion criteria or deemed irrelevant were excluded. The resulting articles were obtained for full-text review and reviewed by two independent reviewers. Any differences in the review determination were discussed and resolved as needed with the third author (M.E.A.). This process resulted in the final group of articles in this systematic review (Figure 1).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Data Collection Process and Data Items

A data abstraction form developed for the study included author, year of publication, journal name, geographic locale, health care setting, study participant characteristics, sample size, study duration, intervention components, design, and study outcomes relevant to the research question. Descriptive information about each intervention is provided including the number of intervention sessions, training approach, an overview of the content, conceptual underpinning based on Kitwood's (1997) work described below, and intensity of the intervention: low investment (<15 minutes to implement); moderate investment (15 to 60 minutes to implement); and high investment (>60 minutes to implement) (Scales, Zimmerman, & Miller, 2018).

The outcomes of interest for the current systematic review were focused on the care provider or student ability to experience and/or communicate with empathy in interactions with persons with dementia. Specifically, extracted study outcomes included empathy measures, and implicit measures of empathy through measures of PCC beliefs (Table 1). As there is no agreed on definition of “communication with empathy” or “empathic communication,” for the current study, communication with empathy is defined by specific therapeutic communication techniques (e.g., use of positive statements, not using elderspeak, spending time speaking with the resident) and the “positive interaction(s)” identified by Kitwood (1997, p. 89) as needed for provision of PCC for dementia. Studies were assessed for components of (a) recognition, the availability of a person to another by being interested, demonstrated by looking or observing, direct eye contact, appropriate greeting and facial expression, and listening; and (b) negotiating, putting assumptions aside, demonstrated by asking and listening to learn about preferences, desires, and needs of persons with dementia (Kitwood, 1997, p. 90).

Standardized Self-Report Measures to Assess Empathy and Personhood in the Systematic Review

Table 1:

Standardized Self-Report Measures to Assess Empathy and Personhood in the Systematic Review

Quality Appraisal

All three authors were involved with appraising the studies methodological quality, and each study was assessed by at least two authors. The team graded the quality of the studies, using the Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines (Newhouse, Dearholt, Poe, Pugh, & White, 2007), where studies were categorized as randomized controlled trials (RCTs) or quasi-experimental studies. To assess the quality of studies, the research team evaluated the characteristics of each study, such as properties of measures used, if a measure used to evaluate the intervention was developed specifically for the study, types of control conditions (e.g., wait list control, no treatment control, or an alternative), and power analysis and effect sizes when provided (Table 1).

To assess methodological study quality, the 18 study reports were assessed by two independent reviewers with the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project [EPHPP], 1998). Reviewers assessed each study independently, and discrepancies were resolved through discussion until consensus was reached (Table B, available in the online version of this article). The tool was used to appraise six domains: selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts. Each domain is assessed and rated as strong, moderate, weak, or non-applicable. Global ratings are assigned as follows: strong (no weak ratings), moderate (one weak rating), and weak (two or more weak ratings).

Results of the 18 Studies Reviewed: Using the Effective Public Health Practice Project (1998) Quality Assessment Tool for Quantitative Studies

Table B:

Results of the 18 Studies Reviewed: Using the Effective Public Health Practice Project (1998) Quality Assessment Tool for Quantitative Studies

Narrative Synthesis

A narrative synthesis was undertaken that provides a “structured summary and discussion of the studies' characteristics and findings” (Higgins & Green, 2011, para. 1). An intervention's effect on primary outcome(s) of interest, the effect consistency across studies, and the overall strength of evidence are provided.

Results

Study Selection

The initial literature search generated a total of 1,427 citations. Upon importing the search into Covidence (access https://www.covidence.org/home), 430 duplicate articles were removed (412 from Covidence, 18 from second review). Two independent authors reviewed the remaining 997 article titles and abstracts for eligibility using the previously described inclusion and exclusion criteria. In addition, citations referenced within these articles were reviewed to obtain relevant studies not found in the initial database search. An additional 56 citations from external sources were identified and reviewed for eligibility. From the initial screening of 1,053 total studies from the databases and reference sections, 64 articles remained. The full-text articles were obtained and reviewed by the authors for inclusion. The final review produced 18 eligible studies published between 1995 and 2017 (Figure 1) (Table C, available in the online version of this article).

Assessment of Included StudiesAssessment of Included StudiesAssessment of Included StudiesAssessment of Included StudiesAssessment of Included StudiesAssessment of Included StudiesAssessment of Included Studies

Table C:

Assessment of Included Studies

Study Characteristics

Study characteristics, research methods, and interventions varied among the 18 studies. In this section, study characteristics, including locale, setting and sample, intervention structure and approach, conceptual underpinning, measures, study designs, and study global quality ratings, are summarized and synthesized.

Locale. Of the 18 studies, 11 studies took place in the United States (Beer, Hutchinson, & Skala-Cordes, 2012; Burgio et al., 2001; de Abreu, Hinojosa-Lindsey, & Asghar-Ali, 2017; Fritsch et al., 2009; George, Stuckey, & Whitehead, 2014; Levy-Storms, Harris, & Chen, 2016; McCallion, Toseland, Lacey, & Banks, 1999; Passalacqua & Harwood, 2012; Ripich, Wykle, & Niles, 1995; Teri, Huda, Gibbons, Young, & Leynseele, 2005; Williams, Perkhounkova, Herman, & Bossen, 2017). Seven studies took place in other countries, including the United Kingdom (Adefila, Graham, Clouder, Bluteau, & Ball, 2016; Cockbain, Thompson, Salisbury, Mitter, & Martos, 2015), The Netherlands (Sprangers, Dijkstra, & Romijn-Luijten, 2015), Australia (Broughton et al., 2011; Conway & Chenery, 2016), and Canada (Eritz et al., 2016). Hattink et al. (2015) included participants from the United Kingdom and The Netherlands.

Setting and Sample. Ten studies took place in or recruited staff from LTC facilities (Broughton et al., 2011; Burgio et al., 2001; Eritz et al., 2016; Fritsch et al., 2009; Levy-Storms et al., 2016; McCallion et al., 1999; Passalacqua & Harwood, 2012; Ripich et al., 1995; Sprangers et al., 2015; Williams et al., 2017). Two studies involved home-based care or community-dwelling individuals (Conway & Chenery, 2016; Hattink et al., 2015) and only one involved assisted living residents (Teri et al., 2005). Five studies enrolled students at academic settings or universities (Adefila et al., 2016; Beer et al., 2012; Cockbain et al., 2015; de Abreu et al., 2017; George et al., 2014). Two studies assessed the same intervention but in different health care contexts— nursing homes and community aged care centers, respectively (Broughton et al., 2011; Conway & Chenery, 2016).

Care provider sample sizes ranged from 16 (Levy-Storms et al., 2016) to 192 (Fritsch et al., 2009) at post-intervention analysis. Sample size was often even smaller at follow-up assessments. Seven studies specify the inclusion of nursing assistants (NAs) or certified nursing assistants (CNAs) in their study population (Burgio et al., 2001; Fritsch et al., 2009; Levy-Storms et al., 2012; McCallion et al., 1999; Ripich et al., 1995; Sprangers et al., 2015; Williams et al., 2017). Details of the study samples are shown in Table C.

Five studies used student participants, specifically those preparing to enter fields that included dementia care (Adefila et al., 2016; Beer et al., 2012; Cockbain et al., 2015; de Abreu et al., 2017; George et al., 2014). Two studies included students in medical school (de Abreu et al., 2017; George et al., 2014), one included students studying medicine in undergraduate school (Cockbain et al., 2015), one included students receiving higher degrees in a variety of medical fields (Adefila et al., 2016), and one included students in a NA training program (Beer et al., 2012).

Nine studies included actual patients or residents (range = 16 to 105) residing in a LTC facility or assisted living facilities with moderate to severe levels of cognitive impairment. Burgio et al. (2001) included 67 patients with a mean Mini-Mental State Examination (MMSE) score of 13.39; McCallion et al. (1999) included 105 patients with a mean MMSE score of 4.9 in the control group and 6.3 in the treatment group; Sprangers et al. (2015) included 26 residents with a mean MMSE score of 11.17; and Teri et al. (2005) included 25 residents with a mean MMSE score of 16 and problems with depression, anxiety, or agitation. The remaining three studies used a variety of approaches to assess cognitive function, but all three included a mix of residents with moderate and severe levels of cognitive impairment (Eritz et al., 2016; Levy-Storms et al., 2016; Williams et al., 2017). Two studies did not provide details regarding the number of patient participants included or cognitive function status (Fritsch et al., 2019; George et al., 2014).

Intervention Structure and Approach.Table C provides details about the study intervention components including the number of intervention sessions, training approach, and an overview of the content. To summarize, 15 of 18 interventions included multiple sessions, and 13 of 18 studies included an intervention with high investment of time to implement (i.e., >60 minutes). Six studies focused on communication skills training. Some studies taught skills in a lecture format, whereas others used multimedia components, such as DVDs, or interactive components, such as role-play, scripted vignettes, and facilitated group discussions. Hattink et al. (2015) provided training entirely on the internet in a self-directed program in which care providers watched videos, completed interactive exercises, interacted with a learning path advisor (i.e., learning facilitator), and participated in an online social community. Other studies used a variety of approaches, including a simulation of what it is like to live with dementia (Adefila et al., 2016; de Abreu et al., 2017).

The simulation intervention used by de Abreu et al. (2017) attempted to enhance attitudes among U.S.–based psychiatry residents and medical students, specifically their person-centeredness. Adefila et al. (2016) studied virtual reality experiential learning on empathy, defined as compassion, in U.K. health professional students. It is significant that both studies used simulation to promote empathic understanding or imagining of the cognitive and sensory impairments persons with dementia struggle with on a daily basis. In addition, these studies included learning about the person by attempting to see the world from his/her perspective, which is a key component of empathy (Adefila et al., 2016; de Abreau et al., 2017).

Two studies evaluated the impact of a group story-telling program (Fritsch et al., 2009; George et al., 2014). George et al. (2014) also incorporated an educational classroom component to teach the training and a care method known as validation therapy. Finally, Eritz et al. (2016) assessed the use of patient life histories in care provision, in which care providers were given information and participated in interactive discussion with other staff members.

Studies Conceptual Underpinning. Kitwood's (1997) person-centered approach for dementia care was implicitly or explicitly acknowledged in several studies. Kitwood (1997, p. 89) identified 12 “positive person work(s)” to guide care providers involved in dementia care to enhance personhood, with each one enhancing personhood in a different way. Interventions were assessed for inclusion of two of these positive interactions (i.e., recognition and negotiation) (Kitwood, 1997). Eleven of 18 interventions included a component of staff-initiated recognition by specifically making and/or maintaining eye contact (Beer et al., 2012; Broughton et al., 2011; Cockbain et al., 2015; Fritsch et al., 2009; Levy-Storms et al., 2016; Ripich et al., 1995; Teri et al., 2005; Williams et al., 2017), consideration of the care provider's facial expression (Conway & Chenery, 2016; Teri et al., 2005), and showing interest through listening or body mechanics (Beer et al., 2012; Conway et al., 2015; Fritsch et al., 2009; George et al., 2014; Levy-Storms et al., 2016; Passalacqua & Harwood, 2012; Teri et al., 2005). Ten interventions included a component of staff-initiated negotiating (i.e., putting assumptions aside, demonstrated by asking and listening to the care recipient, and learning about preferences, desires, and needs of the person with dementia). Of the 10 studies, two used simulation to learn about the experiences and challenges of a person with cognitive and sensory impairments (Adefila et al., 2016; de Abreu et al., 2017). Eight studies included learning about the background of the resident, including the use of photographs and memorabilia to promote conversations and improve care (Beer et al., 2012; Broughton et al., 2011; Burgio et al., 2001; Conway et al., 2015; Eritz et al., 2016; McCallion et al., 1999; Sprangers et al., 2015; Teri et al., 2005). An examination of the intervention programs focused on Kitwood's (1997) positive interactions revealed that recognition (i.e., gaining and/or maintaining eye contact and other nonverbal communication) and/or negotiating (i.e., asking or learning about preferences, desires, and needs) were techniques used in most studies.

Measures. There were a number of measures used to assess the effectiveness of the intervention studies reviewed. Table 1 provides descriptions and properties of the established measures used to assess empathy and person-centeredness. Of the 18 total studies, only five measured empathy explicitly or personhood using either validated measures or modifications of an existing measure for the study. Two scales, the Jefferson Scale of Physician Empathy/ Health Professions (JSPE-HP; Fields et al., 2011; Hojat et al., 2001) and the Interpersonal Reactivity Index (IRI; Davis, 1980, 1983) have been used frequently in medical education research, but have been used less in examining empathy and caring for patients with dementia. The JSPE-HP scale is significantly correlated with conceptually relevant measures such as compassion (Hojat, Mangione, Kane, & Gonella, 2005). The IRI is not specific to health care and comprises four subscales, including (a) perspective taking, defined as the “tendency to spontaneously adopt the psychological point of view of others”; (b) fantasy, defined as “tendencies to transpose themselves imaginatively into the feelings and actions of fictitious characters”; (3) empathic concern, defined as “other-oriented feelings of sympathy and concern for unfortunate others”; and (4) personal distress, defined as “self-oriented feelings of personal anxiety and unease in tense interpersonal settings” (Davis, 1983, pp. 113–114). Passalacqua and Harwood (2012) measured empathy using a modified version of the IRI, only evaluating five items from the empathic concern and perspective taking subscales.

Other studies evaluated more implicit measures of empathy through person-centered beliefs or behaviors (Table 1). Four studies used the Approaches to Dementia Questionnaire (ADQ) to assess attitudes in staff working with persons with dementia. The ADQ includes an 11-item person-centered subscale. The ADQ does not explicitly measure empathy, but the “recognition of personhood” subscale measures the person-centeredness of care providers and includes items such as, “It is important to respond to people with dementia with empathy and understanding.” The Personhood in Dementia Questionnaire (PDQ) is a measure of person-centered attitudes toward persons with dementia in care providers working with this population (Hunter et al., 2013). This questionnaire addresses the personhood of persons with dementia, including their sense of purpose, ability or right to make choices, and feelings and emotions. In this way, it is an indirect measure of care providers' empathy.

Of the studies that measured communication skill competency, two used video recordings of patient–care provider interactions (Levy-Storms et al., 2016; Williams et al., 2017), whereas others collected data through direct observation (Burgio et al., 2001; Fritsch et al., 2016; Sprangers et al., 2015) or self-report (Passalacqua & Harwood, 2012). Another method of assessing the effectiveness of the intervention was through patient outcomes. Five studies measured resident emotions, such as depression or agitation (Eritz et al., 2016; Fritsch et al., 2016; McCallion et al., 1999; Sprangers et al., 2015; Teri et al., 2005). Five studies assessed the effect of the intervention on participant knowledge using mostly measures developed for the individual study (Table C).

Research Design and Study Quality. Eight studies used a pre-post design that analyzed before and after intervention effects (Adefila et al., 2016; Broughton et al., 2011; Cockbain et al., 2015; de Abreu et al., 2017; George et al., 2014; Levy-Storms et al., 2016; Passalacqua & Harwood, 2012; Ripich et al., 1995). Seven studies were RCTs with either the care provider (Beer et al., 2012; Hattink et al., 2015), nursing home resident (Eritz et al., 2016), or facility (Conway & Chenery, 2016; Fritsch et al., 2009; Sprangers et al., 2015; Teri et al., 2005; Williams et al., 2017) as the unit of analysis. Two studies used cluster randomization, in which groups of individuals were randomized by unit within facilities (Burgio et al., 2001; McCallion et al., 1999). Broughton et al. (2011) originally performed a cluster randomization by unit within the nursing homes but switched one of the control units to receive the intervention due to low recruitment at that facility. Control groups in five studies received no training (Broughton et al., 2011; Burgio et al., 2001; Conway & Chenery, 2016; Fritsch et al., 2009; Sprangers et al., 2015). Eritz et al. (2016) exposed control participants to resident medical histories rather than life histories; Teri et al. (2005) provided usual on-site training focused on the needs of older adults; and Beer et al. (2012) provided training on an unrelated topic (i.e., emergency medical services). Finally, three studies included a crossover design in which the control group received the intervention following completion by the experimental group (Hattink et al., 2015; McCallion et al., 1999; Williams et al., 2017).

Results of Individual Studies and Intervention Effect on Outcomes of Interest

Empathy. Of five studies that explicitly analyzed empathy or other qualities related to person-centeredness, three found significant improvements. Hattink et al. (2015) found formal dementia care providers significantly increased their empathic concern and perspective of others, and felt less personal distress (using subscales of the IRI) following an e-learning training, although no significant changes were seen in their attitudes toward persons with dementia (measured using the ADQ person-centered subscale). The simulation intervention evaluated by de Abreu et al. (2017) significantly enhanced students' attitudes, including the person-centeredness subscale in the ADQ (d = 0.48). Adefila et al. (2016) also found student empathy, operationalized as compassion, increased significantly after simulation (p < 0.001).

Three studies found no significant results, including one study assessing the global concept of empathy (using five items from the IRI) (Passalacqua & Harwood, 2012); a second study assessing attitudes toward persons with dementia, including recognition of personhood (Conway et al., 2015); and a third study using the JSPE-HPS (Eritz et al., 2016). However, Passalacqua and Harwood (2012) reported significant results following a communication training program using the ADQ (i.e., hope subscale, three items), although the “variable (hope) had reliability substantially below standard levels” (Passalacqua & Harwood, 2012, p. 442).

Communication With Empathy. Six studies focused on improvement of care provider communication with empathy or therapeutic communication skills for persons with dementia (Burgio et al., 2001; Fritsch et al., 2009; Levy-Storms et al., 2016; Passalacqua & Harwood, 2012; Sprangers et al., 2015; Williams et al., 2017) and all six reported positive outcomes. Four studies were experimental (Burgio et al., 2001; Fritsch et al., 2009; Sprangers et al., 20015; Williams et al., 2017) and a moderate global study quality rating was assigned in five of the six studies (Burgio et al., 2001; Levy-Storms et al., 2016; Passalacqua & Harwood, 2012; Sprangers et al. 2015; Williams et al., 2017).

The interventions varied and included a/an: communication skills training (Burgio et al., 2001; Passalacqua & Harwood, 2012); therapeutic communication program during mealtime (Levy-Storms et al., 2016) and morning care (Spranger et al., 2015); intervention to alert staff to elder-speak (Williams et al., 2017); and group story-telling program (Fritsch et al., 2009). The outcome measures varied across studies (Table C). Video recordings revealed CNAs' therapeutic communication behavior increased significantly post-intervention by a range of 27% to 48% (p < 0.05) (Levy-Storms et al., 2016), and Williams et al. (2017) found the Changing Talk (CHAT) intervention significantly improved the quality of communication in CNA–resident dyads. Specifically, elderspeak communication (i.e., use of terms of endearment, exaggerated voice intonation, looking away) declined significantly at 3-month follow up (34.6% vs. 12.2%; p = 0.016) (Williams et al., 2017).

Resident Outcomes. Only two of five studies that measured the effect of an intervention on resident symptoms including depression and agitation (McCallion et al., 1999; Teri et al., 2005) following a staff skills training program reported positive findings. In the McCallion et al. (1999) study, which evaluated the Nursing Assistant Communication Skills Program, depression symptoms and agitated behaviors were assessed. There was a significant decrease in all subscales of the Cornell Scale for Depression in Dementia in the treatment condition at 3 and 6 months, and a significant decrease was also noted in depression symptoms observed in the wait list control cross-over group. In addition, a significant decrease of physically nonaggressive behavior and aggressive behavior (using the Cohen-Mansfield Agitation Inventory [CMAI]) was demonstrated but for only 3 months following the intervention; the CMAI effects were not sustained at 6 months for two of the three subscales (McCallion et al., 1999). Teri et al. (2005) reported a significant decrease in assisted living residents' depression, problem behaviors, and anxiety symptoms 8 weeks after the Staff Training in Assisted Living Residences training program. This program addresses challenges of dementia care and tailors recommendations to the individual.

Other studies, however, did not report positive patient outcomes. Sprangers et al.'s (2015) evaluation of a communication skills training in a nursing home found no impact on the Dutch version of the CMAI. An intervention designed to familiarize nursing staff with residents' life histories found no impact on agitated behavior assessed with the CMAI (Eritz et al., 2016). A creative expression program resulted in an unanticipated increase in resident fear, anxiety, and sadness (Fritsch et al., 2009).

Discussion

The current systematic review focused on interventions to enhance empathy and empathic communication competencies in dementia care providers. These findings contribute to the growing literature focused on PCC and empathy in care delivery. The intervention studies varied significantly in regard to participants, country of origin, communication skills training programs, intervention intensity, organizational support initiatives to foster behavior change, and evaluation. Although the concept of empathy may be universal, the studies reviewed do not provide conclusive evidence to support a specific way of training care providers to promote personhood or enhance empathy. In addition, the reviewed studies used multiple approaches to assess the impact of interventions on staff and student empathy and attitudes toward personhood.

Studies that focused on improving communication skills reported an increase in positive therapeutic communication—a foundation of empathic understanding and PCC (Kitwood, 1997)—by NAs or paraprofessionals (Burgio et al., 2001; Fritsch et al., 2009; Levy-Storms et al., 2016; Passalacqua & Harwood, 2012; Sprangers et al., 2015; Williams et al., 2017). The positive results across multiple studies with varying designs, scientific rigor (all but one of these studies had a moderate global rating for study quality), and approaches to improving communication skills is promising and should be considered in developing training programs. It is logical that recognizing an individual (i.e., showing interest verbally and nonverbally) and providing persons with dementia the opportunity to express themselves, explore their environment, make choices, and be actively involved with their care would impact emotional health and well-being. Support for this view comes from a study examining nursing home resident choice that found inquiring and acting on nursing home residents' choice is associated with feelings of satisfaction with their care (Bangerter, Heid, Abbott, & Van Haitsma, 2017).

The measures used in the studies reviewed included multiple surveys, questionnaires, and other measures. A number of investigators modified existing measures to make administration feasible and several others developed measures specifically for a study, making it difficult to draw conclusions. A validated scale to assess NA empathy is needed; a scale such as the JSPE-HP should be considered for modification and validation (M. Hojat, e-mail correspondence, May 1, 2019). The challenge to reliably documenting resident–staff interactions was approached differently in the studies reviewed; approaches included video recordings, time sampling design, various observational checklists, use of trained research assistants and clinicians, and a combination of multiple approaches.

Several interventions included multiple components including staff motivation strategies and reminders (e.g., posters, lanyards) or boosters. Incorporation of reminders, staff motivation strategies, leadership training, and boosters have been associated with a change in health care provider behavior. In addition, providing “incentives or at least not disincentives within the working environment for the proposed change” (Cervero, 1985, p. 87) has been identified as essential for implementing change in continuing nursing education programs. Incentives for practice change used in the trials reviewed included a nurse's aide public recognition program (Burgio et al., 2001) and provision of a certificate of completion (McCallion et al., 1999); methods to provide staff with recognition upon completing educational programs appear to be beneficial and well-received.

Five studies (Adefila et al., 2016; Beer et al., 2012; Cockbain et al., 2015; de Abreu et al., 2017; George et al., 2014) focused on student participants who were being prepared to enter the workforce. These interventions used multiple approaches to prepare students, including providing a simulated experience of living with dementia and a focus on perceived communication skill confidence. Student participants (i.e., NAs, medical students, and a mix of health professionals) and the goals of these studies (i.e., experiencing empathy and enhancing interpersonal skills) were not different from the studies that focused on dementia care staff. Furthermore, the competencies needed to develop empathy and an empathic caring relationship through communication with a person with dementia do not differ (Kitwood, 1997). However, it is recognized that staff may be at greater risk for decline in empathy as they could be “emotionally overloaded, overwhelmed, exploited, or burned out” (Riess, 2017, p. 76).

Five studies evaluated the indirect impact of communication competencies on patient outcomes (e.g., depression, agitation, anxiety). Only the McCallion et al. (1999) intervention, which encouraged more effective communication with nursing home residents, and the Teri et al. (2005) study resulted in improved patient outcomes. Both RCTs included multiple sessions and individualized training sessions between the trainer and trainee and a focus on positive interactions to enhance personhood. The authors of these studies recommended further investigation to determine the effectiveness of these interventions with larger and more diverse groups of nursing homes (McCallion et al., 1999) and representative samples (Teri et al., 2005).

Limitations

Some limitations of the studies reviewed include problems with recruitment, study participant attrition, and intervention fidelity. Other limitations to consider include lack of standardized definitions (i.e., for empathy and therapeutic communication), few RCTs, use of multiple intervention approaches, and modification of existing measures to accommodate study participants or development of measures for the individual study. Lastly, results should be interpreted with caution and are limited by studies that included a variety of participants. The studies also took place in multiple countries in which training and licensure requirements may vary. Consistent with a narrative review evaluating PCC interventions in LTC (Li & Porock, 2014), the current review found that the use of subjective measures, small sample sizes, and lack of reported effect sizes limits the ability to draw conclusions.

Implications for Dementia Care

As noted by the 2018 recommendations of the Alzheimer's Association report “The Fundamentals of Person-Centered Care for Individuals with Dementia” (Fazio et al., 2018), more research is needed to further assess the outcomes of PCC approaches and models. Yet, a 2016 literature review found that “empathy within care interactions” and “recognition of personhood” were among the least identified principles and values central to PCC dementia care (Kogan, Wilber, & Mosqueda, 2016). Clinical competencies for delivering empathic PCC and a feasible approach to evaluate mastery of these competencies is required. Kitwood's (1997) PCC approach for dementia was implicitly or explicitly identified in most studies reviewed and in a previous literature review (Li & Porock, 2014), providing a road map for future research.

There is a need for future research dedicated to developing and evaluating the delivery and impact of PCC models, including facilitating an empathic caring approach. Further investigation is required in developing empathic caregivers and assessing whether increased empathy and empathic caring have significant impacts on patient outcomes.

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Standardized Self-Report Measures to Assess Empathy and Personhood in the Systematic Review

MeasureMeasure DescriptionReliabilityStudies that Used the Measure
Jefferson Scale of Physician Empathy/Health Professions (JSPE-HP)Assesses health care provider empathy in patient care situations, originally validated with physicians, medical residents, and, medical school students (Hojat et al., 2001) and then adapted for other health professionals and students (Fields et al., 2011). 20 itemsAlpha reliability estimated in 0.80 range; reliability coefficient (test–retest) = 0.65 (Hojat et al., 2005)Eritz et al. (2016) modified the JSPE-HP for use in the study (i.e., word changes)
Interpersonal Reactivity Index (IRI)Assesses four aspects of global concept of empathy, validated with college students. No health care–related items. 28 itemsStandardized alpha coefficients = 0.70 to 0.78; reliability coefficient (test–retest) = 0.61 to 0.81 across four subscales (Davis, 1980, 1983)Hattink et al. (2015); Passalacqua & Harwood (2012) modified the IRI for use in the study by selecting five items
Approaches to Dementia Questionnaire (ADQ)Assesses attitudes of dementia care providers toward persons with dementia, with subscales measuring hope and recognition of personhood, validated with home care staff in the United Kingdom. 19 itemsCronbach's alpha = 0.83; reliability coefficient (test–retest) = 0.76 (Lintern, 2001)Conway & Chenery (2016); De Abreu et al. (2017); Hattink et al. (2015); Passalacqua & Harwood (2012) modified the ADQ for use in the study by selecting two subscales
Personhood in Dementia Questionnaire (PDQ)Assesses beliefs of dementia care providers about personhood of long-term care residents with dementia, validated with nurses and continuing care assistants. Kitwood's (1997) definition of personhood used to develop questionnaire items. 20 itemsCronbach's alpha = 0.92 (as reported by Eritz et al. [2016]; Hunter et al. [2013]; P. Hunter, personal communication, September 9, 2014)Eritz et al. (2016) modified the PDQ for use in the study by selecting 10 items from 64 measure items

Data Base Searches

AgeLine:(DE “Health Personnel” OR DE “Health Services” OR “Health Personnel” OR “Health Services” OR “Nursing Care” OR “Geriatric Psychiatry” OR “Professional-Patient Relations” OR “Health Services Administration” OR “Health Care” OR “Health Care Delivery” OR “Nursing” OR “Health Care Services” OR “Nursing Care” OR “Long Term Care” OR “Patient Care” OR “Nurse-patient relations” OR “Health administration” OR nurs* OR physician* OR psychiatr* OR psycholog* OR care* OR healthcare* OR doctor*) AND (DE “Empathy” OR “Empathy” OR “Communication Skills Training” OR Empath* OR “Communication Skills” OR “Communication Training”) AND (DE “Dementia” OR DE “Alzheimers Disease” OR “Alzheimers Disease” OR “Alzheimer's Disease” OR Dement* OR Alzheimer*)
CINAHL:((MH “Nursing Care+”) OR (MH “Health Personnel+”) OR (MH “Geriatric Psychiatry”) OR (MH “Professional-Patient Relations+”) OR (MH “Health Services Administration+”) OR “Health Personnel” OR “Health Services” OR “Nursing Care” OR “Geriatric Psychiatry” OR “Professional-Patient Relations” OR “Health Services Administration” OR “Health Care” OR “Health Care Delivery” OR “Nursing” OR “Health Care Services” OR “Nursing Care” OR “Long Term Care” OR “Patient Care” OR “Nurse-patient relations” OR “Health administration” OR nurs* OR physician* OR psychiatr* OR psycholog* OR care* OR healthcare* OR doctor*)) AND ((MH “Empathy”) OR “Empathy” OR “Communication Skills Training” OR Empath* OR “Communication Skills” OR “Communication Training”) AND ((MH “Dementia+”) OR “Alzheimers Disease” OR “Alzheimer's Disease” OR Dement* OR Alzheimer*)
MEDLINE:(MESH.EXACT.EXPLODE(“Health Care”) OR MESH.EXACT.EXPLODE(“Health Personnel”) OR “Health Personnel” OR “Health Services” OR “Nursing Care” OR “Geriatric Psychiatry” OR “Professional-Patient Relations” OR “Health Services Administration” OR “Health Care” OR “Health Care Delivery” OR “Nursing” OR “Health Care Services” OR “Nursing Care” OR “Long Term Care” OR “Patient Care” OR “Nurse-patient relations” OR “Health administration” OR nurs* OR physician* OR psychiatr* OR psycholog* OR care* OR healthcare* OR doctor*) AND (MESH.EXACT(“Empathy”) OR “Empathy” OR “Communication Skills Training” OR Empath* OR “Communication Skills” OR “Communication Training”) AND (MESH.EXACT.EXPLODE(“Dementia”) OR “Alzheimers Disease” OR “Alzheimer's Disease” OR Dement* OR Alzheimer*)
PsycINFO:(MAINSUBJECT.EXACT.EXPLODE(“Health Personnel”) OR MAINSUBJECT.EXACT.EXPLODE(“Health Care Delivery”) OR MAINSUBJECT.EXACT(“Nursing”) OR MAINSUBJECT.EXACT.EXPLODE(“Health Care Services”) OR “Health Personnel” OR “Health Services” OR “Nursing Care” OR “Geriatric Psychiatry” OR “Professional-Patient Relations” OR “Health Services Administration” OR “Health Care” OR “Health Care Delivery” OR “Nursing” OR “Health Care Services” OR “Nursing Care” OR “Long Term Care” OR “Patient Care” OR “Nurse-patient relations” OR “Health administration” OR nurs* OR physician* OR psychiatr* OR psycholog* OR care* OR healthcare* OR doctor*) AND (MAINSUBJECT.EXACT.EXPLODE(“Empathy”) OR MAINSUBJECT.EXACT(“Communication Skills Training”) OR “Empathy” OR “Communication Skills Training” OR Empath* OR “Communication Skills” OR “Communication Training”) AND (MAINSUBJECT.EXACT.EXPLODE(“Dementia”) OR MAINSUBJECT.EXACT(“Alzheimer's Disease”) OR “Alzheimers Disease” OR “Alzheimer's Disease” OR Dement* OR Alzheimer*)

Results of the 18 Studies Reviewed: Using the Effective Public Health Practice Project (1998) Quality Assessment Tool for Quantitative Studies

ArticlesSelection BiasStudy DesignConfoundersBlindingData Collection MethodsWithdraw/Drop-outsGlobal Rating
Adefila et al. (2016)WeakModerateN/AModerateWeakN/AWeak
Beer et al. (2012)ModerateModerateWeakModerateModerateStrongModerate
Broughton et al. (2011)ModerateStrongStrongStrongWeakModerateModerate
Burgio et al. (2001)StrongStrongStrongWeakStrongModerateModerate
Cockbain et al. (2015)ModerateModerateN/AWeakWeakN/AWeak
Conway & Chenery (2016)ModerateStrongStrongStrongModerateWeakModerate
De Abreu et al. (2017)WeakModerateN/AWeakStrongN/AWeak
Eritz et al. (2016)WeakStrongStrongModerateStrongStrongModerate
Fritsch et al. (2009)WeakStrongWeakModerateStrongWeakWeak
George et al. (2014)ModerateModerateN/AWeakStrongStrongModerate
Hattink et al. (2015)ModerateStrongModerateStrongStrongWeakModerate
Levy-Storms et al. (2016)WeakModerateN/AModerateStrongStrongModerate
McCallion et al. (1999)ModerateStrongModerateModerateStrongStrongStrong
Passalacqua & Hardwood (2012)WeakModerateN/AModerateModerateModerateModerate
Ripich et al. (1995)WeakModerateN/AWeakWeakWeakWeak
Sprangers et al. (2015)ModerateStrongStrongModerateStrongWeakModerate
Teri et al. (2015)WeakStrongStrongStrongStrongModerateModerate
Williams et al. (2017)ModerateStrongModerateStrongStrongWeakModerate

Assessment of Included Studies

Author/Yr. Locale/SettingDesign & ParticipantsDependent Variables of Interest and MeasuresIntervention IOutcomesa(with effect sizes when available)bLimitationsc
Adefila et al. (2016) UK EducationPre-Post Pilot 55 students from a mix of health professionals & FU following IEmpathySelf Assessed “compassion” or “affective empathy”d15 min. virtual reality (VR) simulation of the lived dementia experience↑ Empathy score (d = 0.51).Students self-selected, unable to determine if participants are likely to representative. Data collection methods not known to be reliable or valid.
Beer et al. (2012) U.S.A. Nurse Aide Training Program, Community CollegeRandomized Trial (no pre-intervention data) & FU following I47 NAs (I 26/C21) Control group: 45 minute training on emergency medical servicesKnowledgePerceived Communication Skills/Dementia Knowledge d45-min. training module (education on dementia, residual memory, how to work with PWD). Lecture, video-audio excerpts, group reflection, and handouts↑ Understanding of advanced dementia (d = 1.5).Unknown if there were differences between groups prior to the intervention.
Broughton et al. (2011) Australia 4 NHsPre-Post (controlled trial), FU following I (for the training group) & 3 months later 52 (I37/C15) NAs (63.5%) and others (RN, ENs, recreational/activity officers) NTCKnowledge and Positive Aspects of CaregivingCommunication and Memory Support in Dementia Knowledge Test (CMSDK) dPositive Aspects of Caregiving (PAC) Power set at 0.80, a = 0.0590-minute DVD based communication skills I: verbal/nonverbal techniques and use of photos and memorabilia Expert commentary, booklets and reminders (posters and lanyards).↑ Knowledge from baseline to the 3 month FU for I group (n2p = 0.13) I and C groups no difference inknowledge atbaseline or 3-month FU ↑Only RNs and ENs satisfaction with caregiving (PAC) at 3 month FU (n2p = 0.17)Not all data collection methods known to be reliable or valid.
Burgio et al. (2001) USA 5 NHsRCT (nursing units randomly selected and randomized) & 4 month FU 64 CNAs (I39/C25) 67 Residents NTCCommunication SkillsCSC (direct observation of CNA behaviors), OSLA (measure of LPN accuracy CNA supervision), CABOS (observation research software).3 hours (2 sessions) hands-on communication skills I with PWD Memory book, staff motivation system, role-play, vignettes, and discussion.↑Rate of positive statements and time speaking to residents increased and maintained at FUOutcome assessor is aware of intervention status of participant.
Cockbain et al. (2015) UK EducationPre-Post & FU following I104 Medical studentsPerceived ConfidenceCommunicating with PWD d4, two-hour I sessions focused on the process of communication with PWD. Feedback on basic skill, discussion, practice with trained actors.↑ Increased confidence in communicating with PWD post-intervention (median = 2.75) compared to pre-intervention (median = 1.50), with a significantly large effect size (Z= −8.47).Data collection methods not known to be reliable or valid. Limited pre intervention data.
Conway & Chenery (2016) Australia 12 Community aged care centersCluster randomized (center unit of randomization) pre-post test trial & F/U 38 (I22/C16) RNs, ENs, home care and respite care workers. NTCEmpathy/Personhood, KnowledgeADQ, Communication and Memory Support in Dementia Knowledge Test (CMSDK-modified) d, Self-efficacy for communication situations (SEQ)d, Preparedness to Provide care (PPC) dPower set at 0.80, a = 0.0560 min. multimedia skills training communication IFollowing training individual feedback sessions with instructor included 5-mininute conversations with PWD during routine care.No impact on ADQ ↑ Knowledge (CMSDK) maintained at F/U. ↑ self-efficacy (SEQ) ↑preparedness to provide care(PPC) n2p = 0.210Follow-up rate is less than 60%. Not all data collection methods known to be reliable or valid.
De Abreu et al. (2017) U.S.A. Medical EducationPre-Post& FU following I48 students (medical students, physician assistant students, pharmacy interns, and psychiatry residents)Empathy/PersonhoodADQ10-min. physical and cognitive simulation devices used while completing daily tasks↑ ADQ mean scores for Hope subscale (1.46 points, d=.45), Recognition of Personhood subscale (1.75 points, d = .48), and Total Score (3.22 points, d=.61).51% of individuals agreed to participate with varying backgrounds. Participants aware of research questions.
Eritz et al. (2016) Canada 6 LTC facilitiesRandomized Controlled Design [residents randomized to Life History Intervention (LH) Treatment or Medical History Control Group (MH)] & FU (average of 46 days). 99 Special Care Aides (70.7%) and other staff. 73 ResidentsEmpathy/PersonhoodJSPE HP-version and PDQ Resident Outcomes: ABS and CMAI Power set at 0.80, a = 0.05Time intensity not provided. Residents' life histories made available, retrieved from families (past accomplishments, preferences, and photos).No effects seen on the JSPE empathy scale. Intervention improved staff perception of resident personhood. No significant change in resident outcomes.Suitability of staff participants determined by Director of Care. English proficiency may have affected the psychometric properties of the JSPE HP.
Fritsch et al. (2009) U.S.A. 20 NHs with dementia SCUs.RCT (NHs matched and randomized within pairs, post only study design) to intervention or NTC & 2 week F/U 10 Intervention NHs 10 NTC NHs 192 CNAs and activity staff members Unknown number of residentsCommunication SkillsTime Sampling Observation of Resident-Staff Interactions: QUIS (modified). Staff Attitudes Towards PWDs.dResident Outcomes: Philadelphia Geriatric Center Rating Scale, Resident Engagementd10-weeks (1 hr per week) Timeslip (TS) a group storytelling program that encourages creative expression among PWD and those that care for them, with groups of 10–12 residents. TS based on “PCC' philosophy, focus on resident capabilities.↑ Staff interactions with residents compared to than Non-TS, specifically demonstrated greater social eye contact, touch, and verbal communication. TS group residents exhibited unexpected negative reaction.“Nearly” 60% of staff participated in I facilities and 54% in control facilities. Outcome variableswere only assessed after the intervention.
George et al. (2014) U.S.A. Locked dementia unit of a retirement communityPre-Post & 6 week FU 22 fourth-year medical students Unknown number of residentsDementia AttitudesDementia Attitudes Scale (DAS)2-hour classroom session, 4 sessions, with students split into 2 groups of 10 residents Timeslip creative expression intervention.↑DASPsychometric properties of the DAS were not established for the sample.
Hattink et al. (2015) Netherland s and UK Online EducationRCT & & 2 to 4 month FU Professional caregivers for PWD (living in the community) randomized to online intervention or wait list control (WC) 24 (10I/14C) Non professional caregivers participated as well, not included hereEmpathy/Personhood and KnowledgeIRI, ADQ (modified) Alzheimer's Disease Knowledge Scale (ADKS)8 module multilingual online platform (accessible for 4 months): knowledge about dementia care, empathic communication, and care of self. “Learning advisor”and online national communities.IRI subscales: ↓ Personal distress (n2 =0.46), ↑ Empathic concern (n2 = 0.49), and ↑ Perspective taking (n2 = 0.24), found significant differences between I and C. No impact on ADQ or ADKS52% of professional caregivers completed the study. No information provided about the educational background of professional caregivers.
Levy-Storms et al. (2016) U.S.A. 1 Skilled nursing home, specializing in care for AD and PWD.Pre-Post & FU following I16 CNAs 15 ResidentsCommunication SkillsVideoed interactions during mealtimes. Resident: Mealtime Refusals4, one-hour I program focused on therapeutic communication during mealtime including a DVD demonstrating mealtime assistance to residents. Focus on Kohler's Therapeutic Communication Behaviors: 1. Sit infront of the person; 2. Make and keep eye contact; 3. Direct and redirect the person to the task at hand; 4. Give adequate time to respond.↑ CNA therapeutic behavior at meal time: Sitting in front of the person, direct/redirect theperson to the task at hand. Both negatively associated with count of resident refusals.39% of selected individuals agreed to participate
McCallion et al. (1999) U.S.A. 2 NHsRCT [nursing units randomized to Nursing Assistant Communication Skills Program (NACSP) or usual treatment] & 3, 6 month FU 88 NAs (I39/C49) 105 ResidentsKnowledgeKnowledge of AD Test (KAT) Knowledge to manage problem behaviors/agitated behavior, Penn State Mental Health Questionnaire (MHQ) Primary Resident Outcomes: CSDD, CMAI, Resident behaviors, Physical restraint and psychotropic medication use (MDS+ items).5, forty-five minute I sessions (NACSP): 1.Normal age-related communication & impact of dementia; 2. Communication techniques; 3. Use of memory aides; 4. Communication-approaches to problem behaviors; 5. Practice and feedback. Trainer visited with each NA three times once a month to verify continued use.No impact on Knowledge of AD (KAT) ↑ Knowledge to manage problem behaviors/agitat ed behavior (MHQ) (not sustained at 6 months) ↓ Depression (CSDD) symptoms at 3 and 6 month FU, ↓Physically non-aggressive behavior subscale of CMAI from baseline to 3-month FU and for verbally aggressive behavior subscale from baseline to 3 and 6 month FU. No effects on restraint or psychotropic medication useImbalance between control and intervention group (depression, marital status).
Passalacqua & Harwood, (2012) U.S.A 1 Long term facility specializing in memory issuesPre-post & 6 week FU 26 paraprofessionalsEmpathy/PersonhoodIRI, ADQ Communication Strategies-self reportd4, one hr.VIPS communication skills workshops:1. Valuing people, 2. Individualized Care, 3. Personal Perspectives “seeing the world from the perspective of PWD” and; 4.Social Environment included techniques to encourage independence↑ ADQ Hope Subscale (ADQ) (d=1.89). IRI no significant impact ↑ Use of gestures (d=1.13), asking yes/no questions (d=.86), and giving choices between 2 options (d=.85).52% of selected individuals agreed to participate. “Variable (hope) had reliability substantially below standard levels” (Passalacqua & Harwood, 2012, pg. 442).
Ripich et al. (1995) U.S.A 1 Long-Term Care FacilityPre-post & & 6 month FU 17 Nurses AidesKnowledge & Staff AttitudesKnowledge of AD, d and Communication Satisfaction Attitudes. d6 weekly 2-hour group sessions using 7-step communication skills (FOCUSED) program: Face-to-face, Orientation to topic, Continuity of topic, Unstick any communication blocks, Structure with yes/no and choice questions, Exchange and encourage interaction, Direct short simple sentences.↑ Knowledge across all areas, attitudes towards AD patients, & communication satisfaction with AD patients.Data collection methods not known to be reliable or valid.
Sprangers et al.(2015) Netherlands 1 NH“Pretest/Posttest design and intervention group/control group comparison” (2 wards randomly assigned to intervention or control group) & 8 week FU Total Participants: 24 Nurses Aides 26 ResidentsCommunication SkillsOFGC d(positive/negative statements) and CSC (instructions: short, general, multiple) Resident Outcomes: CMAI (Dutch version), NPI-Q (Dutch Version)Number of training sessions for each NA based on the mean score of the CSC at baseline. I focus on effective positive skills during morning care and not using ineffective skills: multiple instructions, negative speech.↑ Number of NA positive statements (n2p = .29) and short instructions (n2p = .19). No interactions between time and groups or main effects for resident outcomes (CMAI, NPI-Q)Outcome assessor is aware of intervention status of participant and participants were aware of the research question. Unintended intervention may have occurred.
Teri et al. (2005) U.S.A. 4 Assisted Living ResidencesRCT [4 assisted living residences randomized to STAR-Staff Training in Assisted Living Residences I or usual onsite training] & 8 week FU Total Participants: 25 direct care staff 31 residents (had dementia diagnosis and problems with depression, anxiety, or agitation) Feasibility study conducted as well not reported here.Staff reactions to dementia related behavioral problems and satisfactionNPI-staff impact, RMBPC-reaction measures, and job satisfaction and sense of competency. Resident Outcomes: GDS, CAS, RMBPC, ABID, NPI.Two half-day workshop sessions, four individualized on-site consultations, over 2 months. STAR I - addressed the challenges of dementia care and tailors recommendations to the individual.↓ NPI-staff impact & total score ↓ RMBPC-staff reaction & total score ↓ GDS, CAS, ABID No impact on job satisfaction or sense of competency.Assisted living residences may represent unique facilities.
Williams et al. (2017) U.S.A. 13 NHsRCT [cluster randomization by NH to either Changing Talk (CHAT) I or Control group]. Control Group NHs crossed over and received I. 3 month FU. 42 dyads: 29 staff (27 CNAs, 2 RNs) 27 residentsCommunication SkillsAssessed with video recordings of staff-resident interactions. (elderspeak, silence) and resident behaviors (cooperative or resistiveness to care [RTC]). d3, one hour I sessions given over 3 weeks. CHAT intervention alerts staff to elderspeak communication and its negative message.↓ Staff elderspeak and resident resistiveness to care declined.Less than 50% of dyads completed the study.
Authors

Dr. Brown is Wallace Gilroy Endowed Faculty Scholar, Associate Professor, Graduate Nursing Department, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami; Dr. Agronin is Senior Vice President for Behavioral Health and Chief Medical Officer, MIND Institute, Miami Jewish Health, and Affiliate Associate Professor of Psychiatry and Neurology, University of Miami Miller School of Medicine, Miami; and Ms. Stein is Medical Student, University of Florida College of Medicine, Gainesville, Florida.

Dr. Brown receives support from Miami Jewish Health as part of a grant from the Wolfson Foundation. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ellen L. Brown, EdD, MS, RN, FAAN, Wallace Gilroy Endowed Faculty Scholar, Associate Professor, Graduate Nursing Department, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, 11200 SW 8th Street, AHC-3, Office 226, Miami, FL 33199; e-mail: ebrown@fiu.edu.

Received: May 04, 2019
Accepted: September 06, 2019
Posted Online: November 11, 2019

10.3928/19404921-20191028-01

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