Using In-Vivo Modeling and Feedback to Teach Classroom Staff to Implement a Complex Behavior Intervention Plan

Behavior intervention plans (BIPs), implemented with high treatment integrity, are effective in decreasing challenging behaviors in individuals with autism spectrum disorder (ASD). High treatment integrity requires staff training such as Behavioral Skills Training (BST). Modeling and feedback alone, however, have been shown to be briefer and as effective as BST. Due to limited resources educational settings may prefer briefer training models to train staff to implement BIPs. This study used only two of the BST components, in-vivo modeling and feedback, to train three classroom staff members to implement a complex BIP. All three staff acquired the skills rapidly.     

An exploration of factors affecting the implementation of a randomized controlled trial of a transitional discharge model for people with a serious mental illness

Information about the contexts in which trials are carried out helps to identify confounding influences on the application of a trial. Furthermore, the ways in which context and implementation of trials influence participation are particularly important for trials which utilize people as part of the intervention. This is particularly likely in the mental health and psychosocial fields. The researchers used mixed methods to identify quality issues encountered during the conduct of a trial, aiming to explore process and contextual factors encountered during its implementation in a mental health setting. Staff and peer volunteers who contributed to the intervention provided information on implementation via diaries and group meetings. Findings in this paper relate to staff feedback. By providing an insider view, researchers were able to highlight the importance of obtaining feedback on implementation. Findings relate to the context of the study, particularly organizational, practitioner and trial preparation issues and illustrate the importance of building quality assurance mechanisms into research plans, such as monitoring and feedback processes. The issue of 'people involvement' in trial delivery requires sensitive management and flexibility in both preparation and delivery.     

Evaluation of an inservice education program regarding aggressive behavior on a psychiatric unit

A four-part inservice program on dealing with aggressive behavior on a psychiatric unit was developed, presented, and evaluated. The program was aimed at meeting staff members' cognitive, emotional, and psychomotor needs. Twenty-seven staff members participated. The program was successful in reducing extreme levels of burnout among staff members, and occurrences of patient aggressive behavior resulting in incidents declined after the program. Staff members reported that they felt more confident in dealing with aggression. Protocols and nursing care plans were developed, and ongoing support groups to examine staff members' feelings were established.     

Evaluation of an educational "toolbox" for improving nursing staff competence and psychosocial work environment in elderly care: results of a prospective, non-randomized controlled intervention

BACKGROUND: Lack of professional development opportunities among nursing staff is a major concern in elderly care and has been associated with work dissatisfaction and staff turnover. There is a lack of prospective, controlled studies evaluating the effects of educational interventions on nursing competence and work satisfaction. OBJECTIVES: The aim of this study was to evaluate the possible effects of an educational "toolbox" intervention on nursing staff ratings of their competence, psychosocial work environment and overall work satisfaction. DESIGN: The study was a prospective, non-randomized, controlled intervention. PARTICIPANTS AND SETTINGS: Nursing staff in two municipal elderly care organizations in western Sweden. METHODS: In an initial questionnaire survey, nursing staff in the intervention municipality described several areas in which they felt a need for competence development. Measurement instruments and educational materials for improving staff knowledge and work practices were then collated by researchers and managers in a "toolbox." Nursing staff ratings of their competence and work were measured pre and post-intervention by questionnaire. Staff ratings in the intervention municipality were compared to staff ratings in the reference municipality, where no toolbox was introduced. RESULTS: Nursing staff ratings of their competence and psychosocial work environment, including overall work satisfaction, improved significantly over time in the intervention municipality, compared to the reference group. Both competence and work environment ratings were largely unchanged among reference municipality staff. Multivariate analysis revealed a significant interaction effect between municipalities over time for nursing staff ratings of participation, leadership, performance feedback and skills' development. Staff ratings for these four scales improved significantly in the intervention municipality as compared to the reference municipality. CONCLUSIONS: Compared to a reference municipality, nursing staff ratings of their competence and the psychosocial work environment improved in the municipality where the toolbox was introduced.     

Improving the physical health of people with severe mental illness in a low secure forensic unit: An uncontrolled evaluation study of staff training and physical health care plans

The life expectancy of people with severe mental illnesses is substantially reduced, and monitoring and screening for physical health problems is a key part of addressing this health inequality. Inpatient admission presents a window of opportunity for this health‐care activity. The present study was conducted in a forensic mental health unit in England. A personal physical health plan incorporating clearly‐presented and easily‐understood values and targets for health status in different domains was developed. Alongside this, a brief physical education session was delivered to health‐care staff (n = 63). Printed learning materials and pedometers and paper tape measures were also provided. The impact was evaluated by a single‐group pretest post‐test design; follow‐up measures were 4 months’ post‐intervention. The feasibility and acceptability of personal health plans and associated resources were examined by free‐text questionnaire responses. Fifty‐seven staff provided measures of attitudes and knowledge before training and implementation of the physical health plans. Matched‐pairs analysis indicated a modest but statistically‐significant improvement in staff knowledge scores and attitudes to involvement in physical health care. Qualitative feedback indicated limited uptake of the care plans and perceived need for additional support for better adoption of this initiative. Inpatient admission is a key setting for assessing physical health and promoting improved management of health problems. Staff training and purpose‐designed personalized care plans hold potential to improve practice and outcomes in this area, but further support for such innovations appears necessary for their uptake in inpatient mental health settings.     

Training Staff to Manage Challenging Behaviour

Background A training package for staff working with clients presenting challenging behaviour was developed to (1) increase their knowledge regarding challenging behaviour, and (2) to improve the quality of physical intervention techniques. The latter aim was intended to reduce staff anxiety about dealing with incidents and limit physical risk of injury to both clients and themselves. Materials and Methods Sessions concerning theories of challenging behaviour were combined with physical intervention training. Effectiveness was assessed using knowledge questionnaires and observation of staff skills. Training effectiveness was tested in a pre–post‐test control group design. Results and Conclusions The training program proved to be effective. Staff knowledge of challenging behaviour and the quality of physical intervention techniques increased significantly. Scores remained above pre‐test levels at follow‐up. Staff members evaluated the training positively.     

Training Educational Staff in Functional Behavioral Assessment: A Systematic Review

Interventions for challenging behavior are more likely to be effective when based on the results of a functional behavioral assessment. Research to date suggests that staff members in educational settings may not have the requisite levels of expertise or support to implement behavioral assessment procedures and design corresponding behavior support plans. The current review sought to examine the nature and effectiveness of Functional Behavioral Assessment (FBA) training described in the literature. Twenty-five studies were examined in relation to type of FBA method used, training procedure, behavioral function and intervention outcome. Training was provided in indirect, observational and experimental functional assessment procedures. Video modeling, lectures, feedback and written protocols were some commonly used training procedures. Interventions derived from results of these assessments were used in twelve studies to treat problem behavior. Social validity and treatment integrity outcomes across all studies are reported. The implications of these findings for research and practice are discussed along with directions for future research.     

Resources,Staff Beliefs and Organizational Culture: Factors in the Use of Information and Communication Technology for Adults with Intellectual Disabilities

Background Access to, and the use of, information and communication technology (ICT) is increasingly becoming a vital component of mainstream life. First‐order (e.g. time and money) and second‐order factors (e.g. beliefs of staff members) affect the use of ICT in different contexts. It is timely to investigate what these factors may be in the context of service provision for adults with intellectual disabilities given the role ICT could play in facilitating communication and access to information and opportunities as suggested in Valuing People. Method Taking a qualitative approach, nine day service sites within one organization were visited over a period of 6 months to observe ICT‐related practice and seek the views of staff members working with adults with intellectual disabilities. All day services were equipped with modern ICT equipment including computers, digital cameras, Internet connections and related peripherals. Results Staff members reported time, training and budget as significant first‐order factors. Organizational culture and beliefs about the suitability of technology for older or less able service users were the striking second‐order factors mentioned. Despite similar levels of equipment, support and training, ICT use had developed in very different ways across sites. Conclusion The provision of ICT equipment and training is not sufficient to ensure their use; the beliefs of staff members and organizational culture of sites play a substantial role in how ICT is used with and by service users. Activity theory provides a useful framework for considering how first‐ and second‐order factors are related. Staff members need to be given clear information about the broader purpose of activities in day services, especially in relation to the lifelong learning agenda, in order to see the relevance and usefulness of ICT resources for all service users.     

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care

There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.     

Personalized Care Plans: Are They Effective in Decreasing ED Visits and Health Care Expenditure Among Adult Super-Utilizers?

ProblemSuper-utilizers comprise 4.5% to 8% of all ED patients, but account for 21% to 28% of all ED visits. Excessive use of the emergency department contributes to increased health care costs, recurrent and unnecessary ED workup, decreased emergency readiness, and reduced staff morale.MethodsThe impact of personalized care plan implementation was evaluated using a within-subjects pre-post design. The number of ED visits for each enrolled patient (N = 65) were analyzed before and after personalized care plan enrollment at 90, 180, and 365 days. A post-hoc analysis was completed for each ED visit that resulted in a disposition of discharge. Total and average charges from the ED visits were analyzed to determine the intervention’s effect on health care expenditure. Staff was anonymously surveyed to assess perceived efficacy and level of satisfaction with the intervention before completion of data collection.ResultsMedian ED visits had a statistically significant decrease over 90, 180, and 365 days. There was also a decrease in median, average, and total ED charges for all time points. ED staff perceived the personalized care plans to be an effective intervention and were satisfied with their implementation.DiscussionPersonalized care plans effectively decreased the number of ED visits, reduced health care expenditure, and were well-received by the staff.     

Readability and Reading Level of Behavior Treatment Plans in Intellectual Disabilities

Behavioral treatment plans are developed and implemented to enhance an individual’s skills or reduce maladaptive behavior. Often, they are written by doctoral-level psychologists and implemented by direct care staff. However, recent research on readability suggests that behavioral plans may not be implemented as designed because the direct care staff that implements them may not be able to fully understand or read the plans as they are written. The purposes of our study were to analyze the readability and reading level of 20 behavior treatment plans written by professional staff and to determine if the plans were understandable and written at an acceptable reading level. We used the RAIN to assess 20 randomly selected behavioral treatment plans for readability and the SMOG formula to assess reading level. Results showed that none of the treatment plans met all 12 criteria for readability examined by the RAIN. Further, reading levels of the plans measured by the SMOG ranged from 12 to 16 suggesting that an average reading level of 14 was required to read them. These results suggest that behavioral treatment plans are not being written in a manner that facilitates understanding by direct care staff and are written at six grade levels higher than the reading level of an average American. Our findings indicate an urgent need for psychologists to write behavioral treatment plans at least at the reading level of the staff who are entrusted to implement them.     

Role of technology in supporting quality control and treatment fidelity in a family caregiver clinical trial

This article describes how a family caregiver lifestyle physical activity clinical trial uses research technology to enhance quality control and treatment fidelity. This trial uses a range of Internet, Blaise(?) Windows-based software and Echo Server technologies to support quality control issues, such as data collection, data entry, and study management advocated by the clinical trials literature, and to ensure treatment fidelity concerning intervention implementation (i.e., design, training, delivery, receipt, and enactment) as proposed by the National Institutes of Health Behavior Change Consortium. All research staff are trained to use these technologies. Strengths of this technological approach to support quality control and treatment fidelity include the comprehensive plan, involvement of all staff, and ability to maintain accurate and timely data. Limitations include the upfront time and costs for developing and testing these technological methods, and having support staff readily available to address technological issues if they occur.     

Use of physician services under two prepaid plans.

Use of physician services under two prepaid plans offered to Stanford University staff is analyzed and compared. One is a Kaiser plan; under the other (Clinic plan), physician and outpatient ancillary services are provided by a predominantly fee-for-service group practice and hospital services are covered by a Blue Cross policy. The two plans provide much the same benefits but, in addition to the difference in their organization, they differ in their financial provisions. While the Kaiser plan has only a token copayment for office and home visits, the Clinic plan has a 25 per cent coinsurance provision applying to all physician and outpatient ancillary services. Despite these differences, the mean number of physician visits per year is the same for the two groups after account is taken of differences in age composition, socioeconomic status, health status, attitudes toward seeking care, length of plan membership, family size and satisfaction with the plan. However, when adjustment is also made for differences in physician affiliation, the Kaiser rate becomes half a visit higher than the Clinic rate. This is because under both plans, members who have a specific plan physician as regular source of care use more services than those without one, and because only 42 per cent of Kaiser members compared with 87 per cent of Clinic members stated that they had a specific plan physician.     

Consumer driven healthcare and the birth of health reimbursement arrangements

Consumers are quickly becoming more involved in the decisionmaking process as consumer-driven healthcare plans are surfacing across the country. When benefit programs are designed properly and when employees are properly informed, they can make wise decisions about healthcare that fits their needs and can help them save money. The process of engaging the plan member has come to be called consumer driven or consumer centric healthcare. The strategy of redefining responsibilities and costs between employer and plan member is generically referred to as a defined contribution strategy. Embedded in these efforts are choice, flexibility, and the belief that plan members can play an active part in managing costs when they are informed and empowered. Communication, education, and the use of Web-enabled technology are critical elements of this process.     

Staff perception of their roles during the transition of psychiatric care into the community

RED A S. (1995) Journal of Psychiatric and Mental Health Nursing 2 , 13–22: Staff perception of their roles during the transition of psychiatric care into the community. : The objective of this study was to investigate the staff's experiences involved in the processes of the transition of 20 non-demented long-stay psychiatric patients. Staff members expressed satisfaction from working outside the hospital. They believed that the patients' condition and their quality of life had improved and that they were likely to achieve successful resettlement after a lengthy process of rehabilitation. However, staff members considered that their roles were demanding and involved a lot of domestic activities. They recommended gradual and slow preparation for the patients, and an educational programme for the public as well as appropriate preparation and continuing professional support for staff.     

Intervention fidelity in Qigong randomized controlled trials: A method review

Intervention fidelity has important implications for the reliability and validity of a study. Despite the widely reported health benefits of Qigong exercise interventions, the quality of intervention fidelity is less clear. The purpose of this paper is to use a valid intervention fidelity assessment tool to evaluate how intervention fidelity has been addressed in five areas—design, training, delivery, receipt, and enactment—in Qigong randomized controlled studies. A total of 86 articles were drawn from CINAHL, PubMed, AMED, and Scopus, and 32 were selected for the review. The adherence to intervention fidelity strategies within the intervention design, training, delivery, receipt, and enactment was 0.66, 0.32, 0.22, 0.12, and 0.21, respectively. The findings suggest that intervention fidelity is inadequately implemented or reported in published Qigong studies. Developing a consistent intervention fidelity plan for Qigong interventions is needed. To this aim, we propose a treatment fidelity plan specific to Qigong research.     

Implementing the MOLST (medical orders for life-sustaining treatments): Challenges faced by nursing home staff

This study examined how the Medical Orders for Life-sustaining Treatment (MOLST) is implemented in two nursing homes in Massachusetts; one had primarily long-term care residents and high hospice utilization, the other had low hospice utilization and a high proportion of post-acute care residents. Qualitative in-person interviews with 21 staff members who had a role implementing the MOLST explored their experiences using the form in their daily work routines. Staff at both nursing homes described benefits of the MOLST such as providing guidance for staff and family. Yet, they also gave detailed accounts of challenges they face in implementing the form. They reported problems with the form itself such as confusing language and conflicting categories as well as a set of procedural challenges that undermined the timely completion of the form. The nursing home with more post-acute care residents faced more challenges with transferability of the MOLST to and from hospitals.     

Effect of Safewards on reducing conflict and containment and the experiences of staff and consumers: A mixed-methods systematic review

Safewards is an internationally adopted framework that provides interventions to reduce conflict and containment in healthcare settings. This systematic review evaluated the effect of Safewards on conflict and containment events in inpatient units and the perceptions of staff and consumers. Quantitative, qualitative, and mixed-methods studies were considered for inclusion. Following the Joanna Briggs Institute methodology, two reviewers independently screened, appraised, and extracted data. Qualitative data were synthesized using inductive-thematic analysis. Quantitative and qualitative data were integrated with a convergent-segregated approach and presented in tabular and narrative format. A search of 13 databases and grey literature yielded 14 studies of variable methodological quality. Four studies reported reduced rates of conflict and one study reported reductions that were not statistically significant. Six studies reported reductions in rates of containment, three studies found no statistical significance and one study reported statistically significant reductions at follow-up. Staff and consumers in four studies reported an improved experience of safety. Three themes were developed as follows: (i) therapeutic hold, cohesion, support and the environment, (ii) conflict, containment and the experience of safety, and (iii) the complexities of adapting and embedding change. This review found most staff and consumers reported Safewards improved therapeutic relationships, cohesion, and ward atmosphere. Staff and consumers reported improved ward atmosphere, leading to consumer-centred, recovery-oriented care. Safewards improved the experience of safety from the perspective of staff and consumers when combined with ongoing training, leadership and time for consolidation. While results are promising they should be used cautiously until more robust evidence is established.     

Veterans Health Administration Office of Nursing Services exploration of positive patient care synergies fueled by consumer demand: care coordination, advanced clinic access, and patient self-management

The consumers who utilize the Veterans Health Administration healthcare system are older, and most are learning to live with chronic diseases. Their desires and needs have driven changes within the Veterans Health Administration. Through patient satisfaction initiatives and other feedback sources, consumers have made it clear that they do not want to wait for their care, they want a say in what care is provided to them, and they want to remain as independent as possible. Two interdisciplinary processes/models of healthcare are being implemented on the national level to address these issues: advanced clinic access and care coordination. These programs have a synergistic relationship and are integrated with patient self-management initiatives. Positive outcomes of these programs also meet the needs of our staff. As these new processes and programs are implemented nationwide, skills of both patients and nursing staff who provide their care need to be enhanced to meet the challenges of providing nursing care now and into the 21st century. Veterans Health Administration Office of Nursing Services Strategic Planning Work Group is defining and implementing processes/programs to ensure nurses have the knowledge, information, and skills to meet these patient care demands at all levels within the organization.