Controlled trial of dementia training with a peer support group for aged care staff

OBJECTIVE: This study evaluated the impact of an eight-session training program for aged care staff in managing dementia-related challenging behaviours. Participation in the training program with an additional five-session peer support group was compared with both participation in training only and a wait-list control condition. METHODS: Outcomes were evaluated for 90 participating staff members and 113 residents with challenging behaviours from six aged care facilities. Measures of staff attitudes and the behaviours of staff and residents were collected pre- and post-intervention, and at six month follow-up. RESULTS: Staff members in both dementia training groups reported improved attitudes regarding their knowledge and skills in managing residents with challenging behaviours, immediately after the training and six months later. Facility supervisors rated the nursing performance of trained staff more positively, particularly those who participated in a peer support group. The dementia training programs, whether with or without the inclusion of peer support, did not impact on levels of staff burnout or substantially reduce the level of challenging behaviours among aged care residents. CONCLUSIONS: While training programs may impact positively on staff performance, organisational characteristics of aged care facilities, including low levels of management support for staff training initiatives, limit the potential outcomes. Methodological limitations are discussed.     

An observational study to evaluate the impact of a specialist outreach team on the quality of care in nursing and residential homes

Observations of the quality of interaction between staff and residents were made to assess the impact of training and support provided to care staff in nursing and residential homes. Assessments were made before, during and at the end of the training intervention using an adaptation of the Quality of Interactions Schedule (QUIS: Dean et al ., 1993a) modified to avoid the ceiling effect of the original version. A significant increase in the proportion of time staff spent in positive interactions with residents was observed, both in terms of direct care (plessthan 0.002) and social contact (plessthan0.05) at the end of the training schedule. Levels of resident activity were also found to increase immediately after completion of training (plessthan0.001). The results suggest that changes in the quality of interaction between staff and residents can be obtained by providing regular training and support to care workers. These findings suggest that the training schedule used in the present study may have a positive impact on the quality of care provided in nursing and residential homes for the elderly.     

Palliative care for advanced dementia: a pilot project in 2 nursing homes

This article describes a pilot project involving training, case consultations, and administrative coaching over a period of 1 year aimed at introducing palliative care in 2 nursing homes among 31 residents with advanced dementia. Resident outcomes that examined numerous clinical measures were assessed at 3 points in time. Changes in the knowledge and attitudes of 80 staff members and 33 family members who participated in the multimodal intervention were also assessed at 3 points in time. Limited improvements were demonstrated on measures for residents, staff members, and family members at the first nursing home (site 1) and significant improvements were demonstrated at the other nursing home (site 2). Top leadership turned over 3 times at site 1 which limited the integration of palliative care, whereas leadership of site 2 remained stable. Implications for implementing a program of palliative care in nursing homes are discussed.     

Feasibility of a staff training and support programme to improve pain assessment and management in people with dementia living in care homes

Objectives

The objective of this study was to establish the feasibility and initial effectiveness of training and support intervention for care staff to improve pain management in people with dementia living in care homes (PAIN‐Dem).

Methods

PAIN‐Dem training was delivered to care staff from three care homes in South London, followed by intervention support and resources to encourage improved pain management by staff over 4 weeks. Feasibility was assessed through fidelity to intervention materials and qualitative approaches. Focus group discussions with staff explored the use of the PAIN‐Dem intervention, and interviews were held with six residents and family carers. Pain was assessed in all residents at baseline, 3 and 4 weeks, and goal attainment scaling was assessed at 4 weeks.

Results

Delivery of training was a key driver for success and feasibility of the PAIN‐Dem intervention. Improvements in pain management behaviour and staff confidence were seen in homes where training was delivered in a care home setting across the care team with good manager buy‐in. Family involvement in pain management was highlighted as an area for improvement. Goal attainment in residents was significantly improved across the cohort, although no significant change in pain was seen.

Conclusions

This study shows good initial feasibility of the PAIN‐Dem intervention and provides valuable insight into training and support paradigms that deliver successful learning and behaviour change. There is a need for a larger trial of PAIN‐Dem to establish its impact on resident pain and quantifiable staff behaviour measures. Copyright © 2017 John Wiley & Sons, Ltd.     

Training basic teaching skills to community and institutional support staff for people with severe disabilities: A one-day program

Shortcomings in the technology for training support staff in methods of teaching people with severe disabilities recently have resulted in calls to improve the technology. We evaluated a program for training basic teaching skills within one day. The program entailed classroom-based verbal and video instruction, practice, and feedback followed by on-the-job feedback. In Study 1, four undergraduate interns participated in the program, and all four met the mastery criterion for teaching skills. Three teacher aides participated in Study 2, with results indicating that when the staff applied their newly acquired teaching skills, students with profound disabilities made progress in skill acquisition. Clinical replications occurred in Study 3, involving 17 staff in school classrooms, group homes, and an institution. Results of Studies 2 and 3 also indicated staff were accepting of the program and improved their verbal skills. Results are discussed regarding advantages of training staff in one day. Future research suggestions are offered, focusing on identifying means of rapidly training other teaching skills in order to develop the most effective, acceptable, and efficient technology for staff training.     

The TAPS project 38: level of training and its availability to carers within group homes in a London district

This study investigates the professional characteristics of care staff working in group homes for the mentally ill in a north London region. Opportunities for training and staff attitudes with respect to training and career prospects are examined. The majority of care staff are unqualified and in many cases the training needs of staff are not being met. Staff viewed their career prospects as limited. Training that is on offer to staff in principle is often not accessed, possibly owing to budget restrictions. The need for more stringent guidelines on staff training to maintain standards across agencies is highlighted.     

An evaluation of strategies for training staff to implement the picture exchange communication system

The picture exchange communication system (PECS) is a functional communication system frequently used with individuals diagnosed with autism spectrum disorders who experience severe language delays (Frost & Bondy, 2002). Few empirical investigations have evaluated strategies for training direct care staff how to effectively implement PECS with clients. Using a multiple probe design, the current investigation evaluated staff training procedures for teaching three direct care staff to implement phases 1–3 of PECS for 3 adults with autism. Training with verbal instructions and an instructional video resulted in little improvement from pretest scores, underscoring the limited utility of workshops and instructional videos alone in teaching paraprofessional staff important clinical skills.     

Fostering futures: a preventive intervention program for school-age children in foster care

Children in foster care have social and emotional problems at rates three to ten times higher than those found in the general population. During the elementary school years (i.e. 5-12 years), research indicates that disruptive behavior in children in care can negatively impact social, emotional and academic development, as well as placement stability. Evidenced-based interventions to improve children's behavior and reduce parenting stress are necessary. This pilot study augmented an existing evidenced-based intervention (i.e. the Incredible Years) developed for birth families for use with foster caregivers. Results from 18 families indicate that foster caregiver-reported conduct symptoms were significantly lower for children whose families participated in the treatment group. A similar trend was found for the overall externalizing behavior. No significant changes were identified in parenting attitudes and stress. Participants reported high levels of satisfaction and acceptability with the program and outcomes. These findings indicate that foster caregiver training should be examined in larger, randomized control trials.     

Practice style in the nursing home: dimensions for assessment and quality improvement

OBJECTIVE: Based on research staff observations during several studies in nursing homes and the findings of other studies, we propose a nomenclature of components of care for the elderly in nursing homes. The paper seeks thereby to operationalize those aspects of the nursing home practice style that can be improved. METHODS: This operationalization examines two main components (staff and institutional components) of practice style of care in nursing homes. Four domains characterize staff conduct (knowledge, practice style proficiency, flexibility and individualization of care and communication) and three domains define institutional conduct (staff support, resources and flexibility/rigidity of policies). RESULTS: The paper addresses critical aspects of staff conduct, and by extension, key features that require training, monitoring, and systemic change. Examples for each domain of practice style are provided. CONCLUSIONS: After systematically reviewing the observations and findings it was concluded that enhancing practice styles in the nursing home requires knowledge, communication, flexibility, understanding, and genuine concern on the part of nursing home staff and administrators at all levels. We acknowledge and understand, of course, that changing practice styles in nursing homes is a difficult and time-consuming process.     

Educating staff working in long-term care about delirium: the Trojan horse for improving quality of care?

OBJECTIVE: This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice. METHODS: The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes. Our intervention incorporated the following features: targeting risk factors for delirium, a 'delirium practitioner' functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback. The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation. RESULTS: We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems. CONCLUSION: We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.     

The relationship between general and specific attribution of blame for a "serious" act and the role of personality

Methods for regular monitoring of care and services are needed for psychiatrists to act on, to refine practice. We developed a computer-based instrument to be used by staff working with schizophrenic patients. The instrument was tested in a group of patients randomly assigned to an integrated-care program. Data on time, place, direct/indirect contacts, and the main elements of the content of care were regularly recorded on a pocket computer and later transferred to a desktop computer for analysis. One-year data on 24 subjects are presented on three levels: individual, case load, and total patient population. Of the encounters 66% were individual patient contacts. Staff spent 59% of the time at patients' homes. A computer-aided system with built-in information on care delivery, program fidelity, and outcome can be the basis of decision-making on different health-management levels.     

Group homes in North Carolina for children and adults with autism

Autistic people not living with their families live in 11 group homes throughout North Carolina. These homes, funded by both state and federal sources, are affiliated with TEACCH, the state agency for the identification and treatment of autism. This article looks at several aspects of group homes including cost effectiveness, staff selection and training, level of structure and programming, composition of the client group, adherence to a central philosophy, and the role of administration. Evidence suggests that group homes are a viable and cost-effective residential option for autistic people. While more group homes are needed, development of other residential options is encouraged.     

Residential Staff: How They View Their Training and Professional Support

The needs and views of 86 community residential staff, supporting people with a learning disability, were investigated. Questionnaire items were developed from the agency's induction program and NVQs for residential, domiciliary and health care services. They were divided into four categories: direct support skills, background knowledge, values and philosophy of service provision, organisational/operational knowledge. Items were rated along three dimensions: importance, preparation and usefulness. Staff also reported on opportunities for professional development, appraisal processes and support structures, their expected tenure, the operation of the agency and the needs of clients. The findings highlight the priorities that staff attach to various aspects of their training and the degree to which they believe they have been prepared to undertake their work. Suggestions are made for the planning of induction and in-service training and the development of staff support structures.     

Investigating the relationship between stress and worker behaviour

Direct care staff working in six residential group homes for people with intellectual disability were asked to complete a questionnaire which asked for information on levels of stress (anxiety and depression), the types of demand experienced by the staff, the support they received and the constraints they faced at work. Staff were also observed at work using a schedule which detailed who they interacted with, the content and type of interaction, and what activities staff were involved in. Measurement of workers' anxiety and depression levels confirmed management assessments of staff stress levels in the homes: two residential group homes were classified as 'low stress' and four as 'high stress'. A number of differences emerged between the two groups. Staff in the high stress homes reported greater demands and less support than those in the low stress homes. Higher levels of interaction were found between staff and residents in low stress houses, where more of the interaction was given as assistance and positive interactions. However, activities in higher-stress group homes appeared to be more community oriented, with staff spending a much greater amount of time out of the house. The importance of these results for both staff and residents is discussed, and suggestions for further work are made.     

Transfer of staff training from workshops to group homes: a failure to generalize across settings.

Two experiments were conducted to assess acquisition and generalization of skills acquired in a workshop by trainees who were primary caregivers on the staffs of group homes for developmentally disabled clients. In Study 1, 31 staff trainees received an intensive, 1-week workshop in behavioral theory and treatment techniques. When assessed at the workshop site, these staff trainees showed increased treatment skills, relative to 18 staff trainees who did not participate in the workshop. In Study 2, pre- and postworkshop observations were taken on 53 developmentally disabled clients in group homes where the staff trainees worked. These observations provided no evidence that the workshop had any effect on group home client functioning. Future training programs for caregivers may be more successful if they occur in the group home, involve clients in the home, and enlist the support of supervisory staff, rather than focusing only on primary caregivers.     

Health and long-term care for people with Alzheimer's disease and related dementias: policy research issues

Policy research into the service needs of persons with dementia had its origin looking at challenges confronting caregivers--extended hours of instrumental task assistance, social isolation, fatigue, depression--and how public policy might support informal care-giving while saving public expenditures from nursing home care. This paper, drawing on the experience of the Medicare Alzheimer's Disease Demonstration and other work, provides suggestions for extending care and financing considerations to include health care use and the medical management of chronic health conditions. Basic research is needed to document current use and risk factors, as is experimentation with clinical and other interventions designed to achieve desired quality of care and cost outcomes. This section of the paper will be of direct interest to both US and international readers. The second half of the paper reviews the US state role in regulating and financing nursing homes, home and community-based care, and residential care. All these sectors have high rates of staff turnover, staff shortages, and concerns with quality of care. The international community and US states provide naturally occurring opportunities for delivery system experimentation and innovation. Research taking advantage of these opportunities could greatly inform public policy.     

Event recording in psychiatric care: development of an instrument and 1-year results

Methods for regular monitoring of care and services are needed for psychiatrists to act on, to refine practice. We developed a computer-based instrument to be used by staff working with schizophrenic patients. The instrument was tested in a group of patients randomly assigned to an integrated-care program. Data on time, place, direct/indirect contacts, and the main elements of the content of care were regularly recorded on a pocket computer and later transferred to a desktop computer for analysis. One-year data on 24 subjects are presented on three levels: individual, case load, and total patient population. Of the encounters 66% were individual patient contacts. Staff spent 59% of the time at patients' homes. A computer-aided system with built-in information on care delivery, program fidelity, and outcome can be the basis of decision-making on different health-management levels.     

Mindful staff increase learning and reduce aggression in adults with developmental disabilities

Aggression by individuals with developmental disabilities may threaten their community placement. In a multiple baseline design across group homes, we provided group home staff with behavioral training and later with mindfulness training to assess the impact on aggressive behaviors and the number of learning objectives mastered by individuals in their care. We also assessed other outcomes including activities engaged in by the individuals, use of restraint by staff, and measures of satisfaction. The effect of varying staff-resident ratios was evaluated on all measures. When compared to baseline, the number of staff interventions for aggression showed some reduction following behavioral training, but decreased substantially only following mindfulness training. There was also some increase in the number of learning objectives mastered by the individuals following behavioral training, but greater and more consistent increases were obtained only after mindfulness training. Improvements also occurred on the other measures assessed after behavioral training, but these were always greater and more consistent following mindfulness training. In addition, consistent gains followed behavioral training only with a high staff-resident ratio whereas the larger gains after mindfulness training occurred with both medium and low staff-resident ratios. Our results suggest that the addition of mindfulness training considerably enhanced the ability of the group home staff to effectively manage the aggressive behavior and learning of the individuals.     

Training direct care staff to increase positive interactions with individuals with developmental disabilities

This study tested the effects of direct training on direct care staff's initiation of positive interactions with individuals with developmental disabilities who resided in an intermediate care facility. Participants included four direct care staff and their residents. Direct training included real-time prompts delivered via a one-way radio, and data were collected for immediate and sustained increases in rates of direct care staff's positive interactions. Additionally, this study evaluated the link between increased rates of positive interactions and concomitant decreases in residents’ challenging behaviors. A multiple baseline design across participants was used and results indicated that all direct care staff increased their rates of positive interactions during direct training. Moreover, all but one participant continued to engage residents in positive interactions at levels above the criterion during the maintenance phase and follow-up phases. The direct care staff member who did not initially meet the criterion improved to adequate levels following one brief performance feedback session. With regard to residents’ challenging behaviors, across phases, residents engaged in low levels of challenging behaviors making those results difficult to evaluate. However, improvements in residents’ rate of positive interactions were noted.     

Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: two-year outcomes

OBJECTIVE: There has been growing interest in the dissemination of supported employment, but few studies have used a control group to examine the benefits of multisite dissemination efforts for clients or have addressed the needs of homeless persons with psychiatric disorders, addiction disorders, or both. This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1). METHODS: Special funds and sustained training, which was based primarily on teleconferencing, were used to support implementation of the IPS model of supported employment at nine VA programs for homeless veterans. A comparison cohort (phase 1) (N=308) was recruited from the nine sites before IPS was implemented. A postimplementation cohort (phase 2) (N=321) was recruited at the same sites and offered IPS. Mixed models were used to compare quarterly employment outcomes over two years in phase 1 and phase 2, adjusting for significant baseline differences (N=629). RESULTS: Measures of both client-level service delivery and site-level fidelity to IPS suggest that implementation was successful at most, but not all, sites. Overall, compared with veterans in the phase 1 group, those in the phase 2 group had a better long-term work history at the time of program entry. When the analyses controlled for baseline differences, the mean number of competitive employment days per month over the two-year follow-up period was 15% higher for veterans in phase 2 (8.4 days compared with 7.3 days; p<.001) and the mean number of days housed during follow-up was also higher in phase 2 (34.1 days compared with 29.8 days; p=.04), but there were no differences for other outcome measures. CONCLUSIONS: A sustained training program can be used to implement IPS in systems that have had little past experience with this approach. This effort was associated with improved employment outcomes and more rapid housing placement.