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An evaluation of intervention designed to teach communication strategies to care-givers of nursing home… Rennert, Karin I. 1990

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AN EVALUATION OF INTERVENTION DESIGNED TO TEACH COMMUNICATION STRATEGIES TO CARE—GIVERS OF NURSING  HOME RESIDENTS  By KARIN B.A..  I. RENNERT  The U n i v e r s i t y o-F B r i t i s h  A THESIS SUBMITTED  Columbia.  1988  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER DF SCIENCE in THE FACULTY OF GRADUATE STUDIES (School  of A u d i o l o g y  We a c c e p t  this  and S p e e c h  t h e s i s as  to the required  conforming  standard  THE UNIVERSITY OF B R I T I S H September (£) K a r i n  Sciences)  COLUMBIA  1990  I. R e n n e r t ,  1990  •5  In  presenting  degree freely  at  the  available  copying  of  department publication  this  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his thesis  and  study.  scholarly  or for  her  of I  I further  purposes  gain  shall  requirements  agree  that  agree  may  representatives.  financial  the  be  It not  that  is  of  Date  DE-6  (2/88)  Sept. 19, 1990 .  by  understood  be  Audiology and Speech Sciences  The University of British Columbia Vancouver, Canada  Library  an  allowed  advanced  shall  permission for  granted  permission.  Department  the  for  the that  without  make  it  extensive  head  of  copying my  my or  written  Abstract  T h i s study e v a l u a t e d the a b i l i t y of n u r s i n g implement communication s t r a t e g i e s education. (patient  Seventeen care  subjects,  aides,  and  routine  interactions  degree of use.  categories  of  those that c o u l d be used i n a l l s i t u a t i o n s ,  and  were a p p r o p r i a t e o n l y mixed:  the  inservice, of  two  for  experimental  some group  scored  experimental possible further  according  research.  of  strategies:  Results  were  (N=5),  attended  who  latter  w h i l e the c o n t r o l group In  the  and  the  category (N=12) former  no d i f f e r e n c e was found between  confound,  to  situations.  and c o n t r o l groups. The d i s c u s s i o n  sources  the  that  decreased t h e i r use of the same s t r a t e g i e s . c a t e g o r y of s t r a t e g i e s ,  with  those  showed an i n c r e a s e i n the use of  communication s t r a t e g i e s ,  were  c o n s i s t e d o-f 11  were  were  groups  sta-f-f),  The measurement t o o l  to  inservice  -from two o c c u p a t i o n a l  communication b e h a v i o u r s , which There  staff  as a r e s u l t o-f  rehabilitation  observed twice each d u r i n g n u r s i n g home r e s i d e n t s .  home  focused  recommendations  the on for  TABLE OF CONTENTS  PAGE  L I S T OF TABLES  i i i  L I S T OF FIGURES  iv  CHAPTER 1  INTRODUCTION AND LITERATURE REVIEW  1  Purpose  2  9  METHODS  10  Subjects  10  Procedures  11  General  Procedures  Inservice Procedures  . . . .  12  Measurement P r o c e d u r e s  13  Scoring  14  Procedures  Reliability Research  3  11  Procedures  Questions  15 11>  RESULTS  IS  Inservice Participation  18  Gain S c a r e s  19  iii  4  Basel i ne Scores  20  Revised Gain Scores  21  Item A n a l y s i s  21  Items 7 through 11  22  Summary of R e s u l t s  24  DISCUSSION AND INTERPRETATION OF RESULTS  .  . 37  Confounding F a c t o r s  38  Null  46  Hypothesis  I m p l i c a t i o n s f o r F u t u r e Research Conclusions  . . . .  48 50  BIBLIOGRAPHY  .52  APPENDICES A  Subject Consent Form  54  B  Screening Q u e s t i o n n a i r e  56  C  Inservice Outline  57  D  Communication S t r a t e g y  E  R e l i a b i l i t y Data  Index  59 61  iv  L I S T  OF  TABLES  TABLES I  PAGE RAW  SCORES  SUBJECTS  II  AND  FOR  COMPARISON  ITEMS  OF  INTERVENTION (ITEMS  III  1  COMPARISON  OF  OF  OCCUPATIONAL  OF  THE  INDIVIDUAL OF  6  SCORES BY  THE  CSI  ON  CSI  .  .  GROUP  INCLUSIVE)  .  .  .  ITEMS  2,  27  PERFORMANCE  ITEMS  GROUP 1  AND  THROUGH  6  28  CSI  COMPARISON  26  BY  INTERVENTION  GROUP  THE  OCCUPATION  BASELINE  BY  BY  ON  AND  6  BY  THROUGH  GAIN  MEAN 1)  OF  INTERVENTION  V  MEAN  THROUGH  SCORES 1  GROUP  (OBSERVATION  IV  GAIN  MEAN  REVISED  GROUP 3,  5,  COMPARISON  OF  INDIVIDUAL  ITEMS,  AND AND  GROUP  BY 6  MEAN  AND  GAIN  OCCUPATIONAL  OF  THE  GAIN  TWO-WAY  v  SCORES  CSI  SCORES ANOVA  BY GROUP 29  ON 30  VI  RAW  SCORES BY INDIVIDUAL SUBJECT FOR ITEMS  7 THROUGH 11 OF THE CSI  VII  TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR  VIII  INDIVIDUAL ITEMS 7 THROUGH 11 OF THE CSI . 32  TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR  IX  31  ITEMS 7 THROUGH 11 OF THE CSI  . . . . . .  33  TOTAL OBSERVED USES OF STRATEGIES 7 THROUGH 11 DIVIDED BY TOTAL OPPORTUNITIES FOR USE, BY INTERVENTION GROUP AND OBSERVATION AND CHI—SQUARE  DISTRIBUTION TEST  vi  INTERVAL .34  LIST  OF  FIGURES  PAGE  FIGURES  1  COMPARISON OF IMPROVEMENT IN GROUP MEAN PERFORMANCE ON ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX . . . .  2  35  FREQUENCY OF STRATEGY USE (ITEMS 7 THROUGH 11)  NORMALIZED FOR EXPERIMENTAL AND CONTROL  GROUPS  36  vi i  CHAPTER 1  INTRODUCTION AND  Communication all  intervention  audiologist hard  of  LITERATURE REVIEW  e f f ect i veness i s the goal  i n t h e a r e a o-f c o m m u n i c a t i o n  specializing  hearing  in  client  aural  has  a  evaluation  counselling, intervention as  and and  fitting,  number  assistive  communication  disorders.  of  listening  by d e f i n i t i o n  a message i s s e n t  and r e c e i v e d ;  variables  may  Most  speech,  will  speaker,  include  The  at l e a s t  the  usual  the hard  efforts  in  of h e a r i n g  receiving/perceiving  these  disorder  communication  are a  mode  of  listener's  t h e message; t h i s g o a l  by t h e u s e o f a m p l i f i c a t i o n and  1  assistive  of  a  variables:  (Sanders,  audiology  of  communication, four  listener  when  number  effectiveness  the following  message, e n v i r o n m e n t , and  Most r e h a b i l i t a t i v e improving  of  takes place  thus there  influence  attempt.  hearing  responsibility.  However, c o m m u n i c a t i o n  which  the  devices,  s t r a t e g i e s f o c u s on t h e c o m m u n i c a t i o n  as t h e c l i e n t ' s  communication  for  including  training.  The  intervention  t h e c l i e n t ' s p r o b l e m , and management o f t h e  disorder  p u r p o s e o-f  rehabilitation  s t r a t e g i e s a v a i l a b l e to achieve t h i s goal, aid  and  are  1982).  aimed  at  effectiveness  in  is  accomplished  listening  devices,  and by t r a i n i n g the hard o-f communication s k i l l s , The s p e a k e r ' s message,  role,  hearing  listener  repair strategies, which  is  the  to  and  origin  maximise  assertiveness. o-f  (and the one -factor i n the above l i s t  the of  spoken  variables  which can e x e r c i s e c o n t r o l over many a s p e c t s of the message) is  more often  considered  than not ignored i n t h i s p r o c e s s ,  in a p a s s i v e manner. For example,  to  wear  the  c o n t i n u i n g to speak  involves  the  r e h a b i l i t a t i o n c l a s s e s or  s e s s i o n s often  includes  d e s i r a b l e and a c t i v e  aural  the  The hard  including  rehabilitation  is  the while  use of  of  in  the  therapy as  at  others"  least  in  twofold: learn  about the nature of the communication d i s o r d e r and have  frustrations tension  b e t t e r understanding of the  in d i f f i c u l t  situations,  thereby  of misunderstanding and unreal  these r e l a t i o n s h i p s .  Secondly,  communicating e f f e c t i v e l y the hard of h e a r i n g c l i e n t  the  client's  easing  expectations  the  within  some of the r e s p o n s i b i l i t y  may be a p p r o p r i a t e l y s h i f t e d to  the  a  process.  the f a m i l y members and f r i e n d s of the c l i e n t  o p p o r t u n i t y t o develop  a  hearing  partner  "significant  process  an  ask  individual  communication  p a r t i c i p a n t i n the  The importance of  firstly,  of  On the other hand, communication t r a i n i n g  form of a u r a l  the  only  to  best  component  i n t h e i r normal manner.  personal h e a r i n g a i d listener.  microphone/sender  at  the use  FM system r e q u i r e s the hard of h e a r i n g l i s t e n e r speaker  or  communication  of  from  partner,  thereby r e d u c i n g the burden -for the c l i e n t  while at the same  time opening more avenues -for a c h i e v i n g the g o a l ,  effective  communication. For the a u d i o l o g i s t geriatric  population,  working with the  the  possibility  institutionalized of  involving  t a r g e t i n g communication p a r t n e r s may present  and  a s o l u t i o n to a  number of problems inherent t o t h i s p o p u l a t i o n . That i s , p r a c t i c a b i l i t y of the usual methods of hearing a i d f i t t i n g s , difficulties  hard  i s d i m i n i s h e d when faced with  of  span f o r sound booth e v a l u a t i o n s .  hearing  appropriate candidates, first  nursing  1979;  home  Oyer and Oyer,  the e l d e r l y p o p u l a t i o n in  communication significant  is  particular disorders;  hearing loss  residents  and  In f a c t , are  not  d e v i c e s such as h e a r i n g  well have  hearing  documented. a  high  approximately  aids  loss  among  Nursing  home  incidence 82  (Schow and Nerbonne,  "/.  have  1980).  r e h a b i l i t a t i o n of a c q u i r e d h e a r i n g impairment i n the population consists-mainly  as  1980).  The high i n c i d e n c e of s i g n i f i c a n t  residents  the  e i t h e r p h y s i c a l l y or e m o t i o n a l l y ,  time u s e r s of p r o s t h e t i c  (Shore,  evaluation,  of m o b i l i t y , a c c e s s t o the h e a r i n g c l i n i c ,  limited attention many  etc,  hearing  the  a  While general  of a m p l i f i c a t i o n and c o u n s e l l i n g ,  these measures may be i n a p p r o p r i a t e and/or i n s u f f i c i e n t the i n s t i t u t i o n a l i z e d  of  for  e l d e r l y person.  Communication e f f e c t i v e n e s s ,  however,  must continue  to  be t h e c l i n i c i a n ' s life  goal  -for t h i s  population.  when a c t i v e r o l e s i n t h e work f o r c e and  family  are  no  longer  possible,  t a k e on new i m p o r t a n c e a s  fulfillment.  However,  the  impoverished  communication  institutional  setting;  patient,  living  depending  taking  individual of  auditory  than  14  i n older  caregivers but  social people,  of e f f e c t i v e  i s not only  institutionalized  partners. and  staff,  The c o n t e n t  caregivers  (giving  elderly often who  become  4  factors  impaired in  danger  no  less  increased  and of  acting some  of  upon the  t o t h e p a r t n e r s or  goal  of  intervention,  1988). the  caregivers  include the nursing important  and  in  fatigue,  of t h e communication information  of  auditory  communication  facilities,  an  of  shifting  one ( L u b i n s k i ,  life  strangers,  hearing  depression,  an a p p r o p r i a t e  p o s s i b l y a necessary  rehabilitation  role  (1980) l i s t  including  and  the  socialization  consequences  In t h i s c o n t e x t ,  In many e x t e n d e d c a r e the  within  virtual  The  and Oyer  endangerment t o b o d i l y s a f e t y ,  responsibility  with  1981).  d e p r i v a t i o n . Oyer  misinformation.  experience  s i t u a t i o n must be p a r t i c u l a r l y  detrimental  deprivation  for  passive  o f t a l k i n g and  (Lubinski,  in this  the  in  i n the  who may seem u n f r i e n d l y , a r e a l l  which c o n t r i b u t e t o a l a c k home  vehicles  often  on  time  often  environment  i n close quarters  on s t a f f  nursing  elderly  a  communication  socialization  the  At  of and  communication  between  residents  instructions,  and  asking vital  questions during to the  quality  various personal  care a c t i v i t i e s ) i s  of  care  provided  e t a l (1989),  in a  study  to  nursing  home  r e s i dents. Sarvela  knowledge o f e x t e n d e d that  care s t a f f  many c a r e g i v e r s a r e  regarding  the  disorders. highest  While  of t h e  (including this  aides)  which  patients in  focus  impaired  the  communication  study  scored  examined,  t h e lowest.  the  "aides"  The a u t h o r s  programs,  communication  residents,  found  information  have  the  training  on  basic  groups  scored  that  of who  compared  occupation,  t o overcome t h e p r o b l e m s f a c e d  communication  ensure  aware  occupational  suggested  inservices, strategies  of  by t h e i r  "therapists"  11  nurses'  study  with  needs  not  which  such  disorders  when  as and  interacting  are  necessary  to  by  communication  quality care—giving. Specific  partners  of  strategies hard  of  to  be  hearing  used people  to  e f f e c t i v e n e s s h a v e been o u t l i n e d i n t h e a u r a l literature  ( e . g . Rezen and Hausman,  facilitate  rehabilitation  1985, p 58; Rupp,  1980,  pp.  174 - 176; Schow e t a l , 1978, p. 394; S h o r e ,  1979,  190  — 1 9 1 ) . Many o f t h e s e  on  sense  and  clinical  behaviours see  of  the  smoking  such  experience;  as ensuring  speaker's or  strategies  chewing  face, gum,  t h e hard avoiding  are they  based  include  of h e a r i n g  common simple  l i s t e n e r can  distractions  minimizing  pp.  distance  such  as  between  partners,  using  speaking  clearly  listener's  but  the  appropriate  willing  action  face,  to  i f they  interaction that  Other  strategies,  listener  topic  with  are  hard  i s aware  responsibility  is  for  w h i c h require?  the  repair  understanding,  an  environmental  on  and  o-f  l i s t e n e r and  include  noise)  the  be-fore  a  impaired  the  light  voice,  getting  the speaker  o-f  enough  normal  behaviours  some  background  checking  a  These  are appropriate,  (e.g, ensuring  minimizing  (e.g..  establishing  -faced by t h e h e a r i n g accept  than  exaggeration,  and r e q u i r e o n l y  communication.  only  factors  and  -for e a c h and e v e r y  listener,  effective  without  louder  conversation.  o-f t h e d i f f i c u l t y is  or s l i g h t l y  attention  continuing  hearing  normal  speaker's strategies  rephrasing  key  words). These information  communication  about communication  seemed a p p r o p r i a t e  for  programs f o r extended evaluate of  strategies,  staff.  one s u c h e d u c a t i o n a l  transfering information  need  i t most  (i.e.,  disorders  inclusion  care  those  who h a v e  disorders, yet are  communicating  with  staff  to  interaction  with  implement  in  with the  continuing  T h i s study  basic elderly,  education  was d e s i g n e d  p r o g r a m a s an e f f e c t i v e  communication  ability  in  and s k i l l s  elderly  along  to  those  little faced  with  residents daily), the  the residents.  6  desired  means  staff  knowledge the  to  who about  task  of  and t o e v a l u a t e  skills  in  their  While the outcome both  -formal  behaviours, is  learning  o-f  continuing  and  actual  education  includes  performance  of  the goal of c o n t i n u i n g education i n h e a l t h  to change  behaviour  (Cervero,  1985).  Thus  a  new care  program  e v a l u a t i o n must c o n s i d e r the education p a r t i c i p a n t s ' a b i l i t y to use the new behaviours w i t h i n t h e i r working environments, t a k i n g i n t o account such v a r i a b l e s change and the r e c e p t i v e n e s s (Peden et One  al.,  as  the  of the s o c i a l  nature  of  system t o  the  change  1990).  attempt  patient care aides  to  teach  used  a  communication videotape  which  behaviours and i l l u s t r a t e d each as used by p a r t n e r and an e l d e r l y person  (Purves  video  the p a t i e n t c a r e a i d e s before and  the v i d e o .  The t e s t c o n s i s t e d  between the s u b j e c t  (patient  h e a r i n g impaired r e s i d e n t ,  care  after  and  viewing  interaction a  volunteer  and have the sentences  repeated back, w h i l e an observer scored a c h e c k l i s t s t r a t e g i e s t h a t had been presented i n the v i d e o .  of  the  The r e s u l t s  were a b l e t o implement the  s t r a t e g i e s i n the s i m u l a t e d  1987).  i n which the s u b j e c t was r e q u i r e d  t o read 10 sentences t o the l i s t e n e r ,  indicated that subjects  the  presentation  simulated aide)  to  communication Brooks,  by t e s t i n g  a  outlined  a  and  T h i s study e v a l u a t e d the success of the  of  strategies  targeted  context.  The Purves and Brooks study was an attempt at and e v a l u a t i n g s t r a t e g y use among s t a f f ,  7  however,  teaching  i t was not  c l e a r whether the  subjects  were  able  to  d e s i r a b l e behaviours to everyday n a t u r a l c a r e g i v i n g a c t i v i t i e s were the i n t e n t  generalize  situations,  o-f  the  the where  interaction.  Extended c a r e sta-f-f are o-f ten pressed -for time, having p a t i e n t s and r e s p o n s i b i l i t i e s t o attend to? that they encounter c o n f l i c t between care  (such as e n s u r i n g e f f e c t i v e  it  is  achieving  that  using  communication s t r a t e g i e s i s time-consuming or  possible  quality  communication) or  of c a r e , p a r t i c u l a r l y i f they p e r c e i v e  many  of  quantity special  difficult  to  incorporate into routine duties. The present study was an e x t e n s i o n of the Brooks study,  in that i t  of  care  extended  attempted t o document  staff  to  Purves the  generalize  the  communication s t r a t e g i e s i n t h e i r everyday r o l e s as care aides,  and r e h a b i l i t a t i o n s t a f f .  p r e v i o u s study i n that i t  It d i f f e r e d  and  ease  of  the  implement change). actual  ability use  behaviour While i t  change,  and  from  measure the outcome of a l l the  factors  p a r t i c i p a n t s i n t h e i r work environment.  8  by  the the  desirability motivation  d i d not attempt t o  f a c t o r s i n f l u e n c i n g performance, i t  of  patient  attempted t o take i n t o account  v a r i a b l e s i n f l u e n c i n g performance (such as the  and  did  measure attempt  evaluating  to the to the  Purpose  The  purpose of t h i s  study  p r o g r a m w h i c h was d e s i g n e d home s t a f f of  about  communication  the adverse  research  Are  nursing  risk an  question  home  as communication  f o r hearing  educational  inform  effects  and  guided  of hearing  able  as a r e s u l t  9  l o s s and u s e  effects.  to  p a r t n e r s of e l d e r l y  inservice?  nursing  The  the study:  caregivers  impairment,  an i n s e r v i c e  educate  s t r a t e g i e s t o overcome s u c h  following  effective  to  was t o e v a l u a t e  become residents  more at  of p a r t i c i p a t i n g i n  CHAPTER 2  METHODS  Subjects The  subjects  i n t h i s study were 17 n u r s i n g  rehabilitation staff  at the extended care  UBC Health S c i e n c e s Centre H o s p i t a l . (nursing  and  rehabilitation)  patient care aides therapists,  and  recruited staff  (PCAs),  form (see  Appendix A ) .  The  after  student student.  study  volunteered to  exact nature of the o b s e r v a t i o n s u n t i l  P a r t i c i p a n t s were aware,  nature of the  interaction  investigator  between  during  members, of which 12 were n u r s i n g s t a f f  be  data c o l l e c t i o n .  nurses,  occupational  The  i n d i c a t e d t h a t the s u b j e c t s would not  general  departments  participate  Each v o l u n t a r y s u b j e c t signed and  copy of a consent  the  meetings.  7 were r e h a b i l i t a t i o n s t a f f , the study.  aides.  and  of  registered  members t o p a r t i c i p a t e i n the  Nineteen s t a f f  in  two  physiotherapists,  rehabilitation  r e g u l a r l y scheduled s t a f f  and  facility  These  include  staff  study staff  (i.e., and  A f t e r the data c o l l e c t i o n was  and  consent  notified  the  completion  study and speech  completed,  of  was that  a  form  of  however,  patients),  i n v e s t i g a t o r was an a u d i o l o g y  10  the  received  of the  about the  sciences a  short  screening  q u e s t i o n n a i r e was  (see Appendix was  B) . The  to identi-fy  to  exclude  of  the  any  covered  by  those  completed  to  each  subject  screening  procedure  -for h e a r i n g from the  the  study  loss  study.  and None  indicated  loss during  the  any  period  study.  rehabilitation  and  identified  factors for hearing  r i s k  s u b j e c t s who  therapists,  this  s u b j e c t s at r i s k  s u b j e c t s so  the  The  aides)  p u r p o s e o-f  17 s u b j e c t s who  significant  administered  completed  staff  one  the study  (including  physical therapist,  i l nursing  staff,  a l l of  c o n s i s t e d of  three and  s i x  occupational  two  rehabilitation  whom were c l a s s i f i e d  as  FCAs.  E!?12£5dk !iss l  General_orgcedures. measurements d e s i g n . communication The  first  or  not  the  was  variable,  the  use  group  exposed  to  t o t h e g r o u p s on  the scheduled  repeated  of  specific subjects.  took  place,  measurement  was  subjects,  the  of  inservice  receive  a  all  inservice  a second  One  group d i d not  attended  employed  measured t w i c e f o r  before  was  were a s s i g n e d  they  dependent  inservice.  group,  the control  Subjects  study  t h e b a s e l i n e measure;  after  experimental while  skills,  observation,  constituted obtained  The  This  any  education,  intervention.  the b a s i s of  inservice.  whether  At t h e t i m e  of  all  measurements,  the investigator—observer  s t a t u s o-f each s u b j e c t ;  only  after  the  was b l i n d to investigator  completed the data c o l l e c t i o n d i d she r e c e i v e the attendance r e c o r d .  to note that the  the s u b j e c t s  observations  had  inservice  Thus the i n s e r v i c e and the e v a l u a t i o n  the i n s e r v i c e were conducted independently.  was  the  It i s  of  important  were not aware that the purpose of  to  evaluate  the  effect  of  the  on s t a f f  at  the  i n s e r v i ce.  Inseryi ce_prgcedures. L  The a u d i o l o g i s t  extended care f a c i l i t y presented an i n s e r v i c e on of  hearing  effects  of  loss  among  hearing  nursing  loss,  home  and  The s t a f f  audiologist  residents,  strategies  c o n v e r s i n g with a hard of h e a r i n g person determined the  i n f o r m a t i o n presented during the  to  (see  style  this  include  C). of  attention playing  hearing  an  loss,  d i s c u s s i o n of techniques t h a t can be used i n The  main  i n s e r v i c e program was t o r a i s e awareness  l o s s and t o encourage s t a f f  to use  all  overcome problems due to h e a r i n g l o s s . was on d i s p e l l i n g  myths  hearing  elderly  loss  when  manner  with  managing d i f f i c u l t communication s i t u a t i o n s . of t h i s  adverse  Appendix  audiotape which simulated v a r y i n g degrees of and an informal  topic  use  and  inservice  given to the audience i n q u e s t i o n ;  the  in  about is  12  of  possible Thus,  hearing correlated  the  loss with  goal  hearing means  to  emphasis  (e.g.,  that  cognitive  de-Ficit).  and  with  o-f h e a r i n g  hard  on  teaching  which communication ensured during  that the  staff  p a t i e n t s . The behaviours  a l l o-f t h e  i n s e r v i c e was  care  aware  o-f  evaluated, were  offered to a l l staff  and  presented  s u b j e c t s had  the  staff  the  to attend  OLgcedures.  observation  tool  as a r e s u l t  of  education).  T h i s p r o c e d u r e was the  learning,  The  of  at  the  all hours,  the  times,  and  not  PCA  all  inservice.  investigator  variable (i.e., chosen  performance subjects  as  for  the  the  used  inservice  rather  result  a  changes  purpose  abilities, a  the  nursing  t o measure b e h a v i o u r a l  independent  actual  ward  work i r r e g u l a r  opportunity  Measurement naturalistic  members of  f a c i l i t y . However, b e c a u s e some of  b e c a u s e many n u r s i n g  formal  being  strategies  were r e q u i r e d t o r e m a i n on  evaluating  communicate  a u d i o l o g i s t was  were  desired  to  inservice.  This extended  c o n s t r u c t i v e ways  of  of than  inservice  p a r t i c i p a t i on.  list  The  observation  of  behavioural  clinicians  to  communication 1985;  The  was  tool  normal—hearing  be  with  Hausman,  tool  hard  Rupp,  designed  (see Appendix  D)  consisted  criteria  which  helpful  strategies  of  1930; for  hearing  are  considered  partners  caregiver while  the  interacting  in  Rezen  Shore,  behaviour with  a by  improving  (e.g.  Schow e t a l , 1978; scoring  of  a  and  1979). of  the  hard  of  hearing  elderly  The  resident  behavioural  categories:  -first,  appropriate,  and  during  observations those  those  under  some c i r c u m s t a n c e s  (such  which  i s appropriate This  behaviours  division occur  communication appropriate The  only  within  partners  affects  a l l items  a  to  the  as  t o use  the  opportunity  observation from  an  tool,  a pilot  establishing  reflects Each it not  to  begin  communication  choices  and  about  that using  procedure  and  category  a  given  final  were  strategy Strategy  collection  (reported  three-point  was  A  of  evolved  in Part  here,  by  purpose  of  the  tool  system  that  was  scored  The  below).  displayed.  as t o  inconsistently  F o r a l l s i x items  14  only  for the  on  used  scored  Index,  in Part  category  each  occured.  items a  for  version reported  reliability  The  analysis;  were s c o r e d  t h e d e g r e e t o which e a c h b e h a v i o u r  a t a l l (0).  noise  noise,  scoring  u s e d c o n s i s t e n t l y (2),  used  background  that  second category  first  appropriate  environment,  make  always  communication.  were s c o r e d  s t r a t e g y i n the  was  only  i s  -fact  are  two  e-f-ficient  p h a s e of d a t a  inter-rater  D)  the  or Communication  Scgring_Procedures (see Appendix  there  into  ensure  e a r l y v e r s i o n to the  m e a n s of  which  as reducing  to  i n the f i r s t i n the  divided  are  dynamic  have  measurement, i t e m s  that  when  reflects  strategies  division  while  second  were  strategies  T  with).  n o r m a l work d u t i e s .  A,  whether <1),  the  or score  range was -from a minimum of 0 t o a maximum o-f 1 2 . The three—point system reliahlility settings.  was  designed  -for  i n s c o r i n g communication behaviour  Alternative scaling,  that  speed in  by i n c l u d i n g f u r t h e r r a t i n g s ,  "used  time".  of  the  more,  i n s c o r i n g the degree of  behaviour c o n s i s t e n c y most  natural  i s four p o i n t s or  would have allowed more s e n s i t i v i t y  and  However,  as  a  such  as  result  of  e x p e r i e n c i n g some d i f f i c u l t y i n a c h i e v i n g r e l i a b i l i t y during the p i l o t measurements,  a t h r e e - p o i n t s c a l e was  the  better  a l t e r n a t i ve. Each item i n the second  category  whether or not the o p p o r t u n i t y t o use and  whether or not  the  strategy  was the  was  scored  as  strategy  in  fact  to  arose,  used  (see  Appendix D). The second category allowed the p o s s i b i l i t y f o r a s c o r e of 0 uses of a s t r a t e g y use  that  strategy.  The  out of  scores  for  0  opportunities  this  part  of  the  uses  of  within  an  measurement were normalized by adding a l l observed strategies  (all  occurrences  of  scores  i n t e r v e n t i o n group, and d i v i d i n g by s t r a t e g y use  (all  o c c u r r e n c e s of s c o r e s of  the same group, t o allow s t a t i s t i c a l  Reliability c o l l e c t i o n was procedures  and  all  E'!I9c§?dures  carried to  out  determine  A to  of  2)  opportunities 1  or  to  2)  for  within  analysis.  pilot practice  initial  phase the  of  data  measurement  reliability.  Two  observers  (the  researcher  watched and scored 8 patients  and  a  volunteer  interactions  i n a di-f-ferent extended  between care  audiologist)  caregivers  facility.  Agreement  between the two o b s e r v e r s on the items i n an  early  of  to  the measurement t o o l  ranged  from  37.57.  Appendix E > . It was c l e a r that items with ( i n c l u d i n g bod / 1 anguage. 1  and physical  version  100%  poor  that were used i n the f i n a l During the f i n a l  (see  reliability e i t h e r could  contact)  not be used or needed to be r e d e f i n e d and p r a c t i c e d to achieve b e t t e r r e l i a b i l i t y .  and  further  Appendix D p r e s e n t s the  items  measurement t o o l .  data c o l l e c t i o n phase,  6  of  the  34  i n t e r a c t i o n s were observed and scored by both o b s e r v e r s ,  in  order to a s s e s s r e l i a b i l i t y of the r e v i s e d measurement t o o l . The  final  r e l i a b i l i t y data are presented i n Appendix E , note  t h a t the d e s i r a b l e i n t e r - r a t e r agreement by  Chambers and Blum,  the 11 items.  1988)  Although  (85%, as  was approximated f o r o n l y  some  of  between o b s e r v e r s was s u b j e c t i v e ,  the  scoring  t h e r e was a  one observer t o s c o r e more s t r i c t l y than one observer r e q u i r e d  suggested  tendency  the  other  1007. s t r a t e g y use f o r a  score  T h i s s y s t e m a t i c d i f f e r e n c e between  c o u l d have been e l i m i n a t e d with f u r t h e r p r a c t i c e , that  the a c t u a l r e l i a b i l i t y f o r the f i n a l  than the f i g u r e s i n Appendix E i n d i c a t e .  16  data  of  differences  w h i l e the other observer accepted 90% s t r a t e g y use same s c o r e ) .  7  (i.e., of for  the  for  2, the  raters  suggesting was  better  R e 5 e a r c h _ g u e s t i g n s at  the  end  o-f  Does a b i l i t y  Chapter  1  inservice  to  use  The  general  research  question  posed  was: participation  speci-fic  increase  communication  caregivers'  strategies  more  consistently? This r e f l e c t  the  i . scores  question  there  (items to  subjects  now  methodology  Are  exposed  may  1  who  used  in  6)  inservice  were  restated  s i g n i f i c a n t  through  the  be  not  t h i s  more  s p e c i f i c a l l y  study:  d i f f e r e n c e s between of  those  subjects  (experimental  exposed  to  to  group)  the  the  gain  who  were  and  inservice  those (control  group)? i i . scores  Do  s i g n i f i c a n t  (items  r e h a b i l i t a t i o n i i i .  Are  experimental  1  through  6)  of  PCAs  between  and  those  the  gain  of  the  between  the  pre-  and  s t a f f ? there and  post-intervention through  d i f f e r e n c e s exist  s i g n i f i c a n t control  frequency  d i f f e r e n c e s  groups  on  d i s t r i b u t i o n  I D ?  17  the scores  (items  7  CHAPTER 3  RESULTS  The  purpose  o-f  this  study  was  to  evaluate  e-f-f e c t i veness o-f an i n s e r v i c e procedure i n t e a c h i n g care staff  the use o-f s p e c i f i c  increase e f f e c t i v e  communication with  were s t a t i s t i c a l l y differences  subjects  who  in  to  use  were  determine  of  the r e s e a r c h  statistical  questions  to  was s e l e c t e d Items  were  the  to r e j e c t  the n u l l  in  I  Communication S t r a t e g y  the  (#1  t-test and  Index were  were c o n s i d e r e d  o n l y one  and  answer  independent  the  Chi-Square  (p <  level  .05).  #6,  inclusive)  used  to  of  calculate  items i n  F'art  the gain II  separately.  I n s § ! i y i c e _ D a r t i c i D a t i o n Of the as s u b j e c t s ,  inservice  a 95% c o n f i d e n c e  s c o r e s which were analyzed s t a t i s t i c a l l y ; (#7 t o #11)  strategies  for  hypothesis to  data  significant  procedures employed t o  For a l l a n a l y s e s ,  Part  if  to  inservice.  a n a l y s i s of v a r i a n c e (ANOVA),  distribution test.  The  communication  exposed  extended  strategies  residents.  who were not exposed t o the  Inferential  samples,  analysed  existed  between s u b j e c t s  communication  the  11 PCAs who v o l u n t e e r e d  (9 V.) a c t u a l l y attended the  13  inservice;  w h i l e 67 7. of the inservice.  6  rehabi 1 i at i on  T h i s di-f-ference  subjects  introduced  a  attended  con-found  in  make—up o-f the c o n t r o l and experimental groups, s i n c e were l i k e l y to be  educational  and  present between these groups p r i o r study.  The i n s e r v i c e attendence  i s s u e of  larger  patterns  of  extended c a r e f a c i l i t y s t a f f :  vocational to  the  be  attending  s p o r a d i c a l l y at b e s t , due i n p a r t to  the  that  PCAs  and are a b l e  Another f a c t o r which inservice  this  raised  the among  care  were This  to  take  purpose  may  have  attending likely  staff  have  time  away  of  attending  contributed  differences  in  occupational  groups was the p o s s i b i l i t y of a h i g h e r l e v e l  m o t i v a t i o n or i n t e r e s t  attendance  staff)  was  rehabilitation  from other d u t i e s as a group f o r the inservices.  of  education  based on t h i s study.  r e g u l a r daytime schedules  onset  direct  inservices,  fact  there  w h i l e most r e h a b i 1 i a t i o n s t a f f  (who make up a small p a r t of the t o t a l seemed to  the  differences  difference also continuing  the  on the p a r t of  between  the  rehabilitation  to two of  staff  as opposed t o PCAs.  G a i n S c g r e s Table 1 p r e s e n t s both the raw the gain s c o r e s achieved by each r e f e r to the l e v e l of  subject.  The  scores raw  and  scores  of use of each s t r a t e g y d u r i n g the course  an o b s e r v a t i o n , t h u s ,  the minimum s c o r e  observed use of the s p e c i f i e d  strategy,  19  (0)  while  reflects the  no  maximum  score the  (2) r e f l e c t s  p e r i o d of o b s e r v a t i o n .  inconsistent, The  score r e f l e c t s  between  observation  A score  the  measurement t o o l .  Individual  scores  change  to  was  score 12;  f o r a given  in  (01)  one t h r o u g h  The maximum  observation  any  baseline  (02), f o r items  each  of 1 r e f e r s  throughout some,  or  u s e of t h e s t r a t e g y .  gain  performance  for  c o n s i s t e n t use of t h e s t r a t e g y  and  subject's  the  second  six inclusive  a subject  the  a  could  minimum  observation  on t h e attain  was  ranged  zero.  from  four  ( s u b j e c t s N12 and N17 f o r 01) t o 12 ( s u b j e c t R l f o r 0 2 ) . The average gain the  score  average gain  f o r the experimental  score  for  the  g r o u p was 1.2,  control  group  was  while 1.25.  A n a l y s i s o f mean g a i n  s c o r e s by i n t e r v e n t i o n g r o u p i n d i c a t e s  the  not  difference  comparison  was  o f mean g a i n  (rehabilitation  performance of t h e  Neither  12 t h a n  2). A  Table  of t h e s u b j e c t s  compares  mean  baseline  with  reached  group  that  of  the with  mean  baseline  that  of  the  performance  of  the  the  s i g n i f i c a n c e using  PCA  subjects.  the t-test f o r  s a m p l e s . However, t h e mean b a s e l i n e s c o r e  experimental of  3  experimental  subjects  comparison  independent  s c o r e s by o c c u p a t i o n  Table  g r o u p , and t h e  rehabilitation  (see  v s . P C A ) was a l s o n o n s i g n i f i c a n t .  Basel^ne_Scores  control  significant  group  i s c l o s e r t o t h e maximum  t h a t of t h e c o n t r o l group,  20  of t h e  achievable  indicating  a  score  ceiling  effect  -for  the  experimental  improvement p o t e n t i a l to a maximum o-f 3  group.  While  o-f the experimental  points,  the  control  4.S4  ceiling.  in baseline  the d i f f e r e n c e  not being s i g n i f i c a n t effect  in i t s e l f ,  overall  group was group  could have improved by up to Thus,  the  points  limited  performance  be-fore  reaching  performance,  i n d i c a t e s a greater  on the gain s c o r e s of the experimental  while  ceiling  group than  of  0^yised_Gai_n_Scgres To minimize the c e i l i n g e f f e c t  of  the c o n t r o l group.  the high b a s e l i n e established. scores  performances,  The two items  (items 1 and 4)  a  revised  which  showed  o p p o r t u n i t y f o r improvement  than (see  50%  of  i n c r e a s i n g the mean g a i n  the  mean  individual  were found on e i t h e r  Analysis  To  items were more  combined s e n s i t i v i t y  of  if  subjects  and  thus  had  scores  not any, e f f e c t  on  scores. revised  i n t e r v e n t i o n group and by o c c u p a t i o n a l  Item  baseline  calculation  all  Table 1),  f o r these two items c o u l d have l i t t l e ,  differences  was  B a s e l i n e performance on both items 1  and 4 i n d i c a t e d t h a t fewer  presents  score  highest  were removed f o r the  the r e v i s e d gain s c o r e .  Table 4  gain  of a l l  sensitive  by  comparisons.  the to  items t o g e t h e r ,  21  scores  group. No s i g n i f i c a n t  of the  explore  gain  possibility change an item  than  that the  analysis  was per-formed. Gain through  6)  were  experimental  scores  for  calculated  and c o n t r o l  the  individual  and  groups  averaged  (see  Table  s c o r e s -for i n d i v i d u a l items ranged -from a o-f 2 to a p o s s i b l e minimum  o-f  s c o r e s -for i n d i v i d u a l items •from a maximum of group)  .4  by  Two—way a n a l y s i s measure  on  of  within 5).  the  actual  5  for  the  item,  was  (item carried  x  item  and  significant  group.  No  interaction  significant  (item x group)  gain ranged  experimental group).  group),  out  main  maximum  group  to  p o s s i b l e s e n s i t i v i t y t o change of performance as a of  gain  mean  (item 1 f o r the c o n t r o l variance  (1 the  The  possible  intervention  (items 3 and  to a minimum of - . 0 8  repeated  -2;  items  with analyze  function  effects  were found  (see  nor Table  5) .  Items_7_thrgugh_ii  The raw s c o r e s f o r the items  were not used i n c a l c u l a t i n g Table 6.  The  s c o r i n g of  scoring  items  o p p o r t u n i t y to observation;  1 use  of to  these 6:  that  a r a t i n g of  gain s c o r e s  a  items rating  are  particular  presented  differed of  0  which  from  in the  indicated  strategy  during  no the  1 i n d i c a t e d t h a t the s u b j e c t had an  o p p o r t u n i t y but d i d not d i s p l a y the behaviour;  a r a t i n g of  indicated  appropriately  d u r i n g the  that the s u b j e c t used the observation.  Thus,  o p p o r t u n i t y f o r using these  the  strategy scoring  strategies  reflects  compared  with  2  the the  actual  observed In T a b l e  strategy number  an o p p o r t u n i t y  for individual  any o t h e r  observations control  8, t h e t o t a l the total  that  both  are higher  group,  number  strategies  may  be  or j o b d u t i e s .  a n a l y s i s on t h e s e  some  others:  there  the  10  data,  opportunities  a l l occurrences  occupational  use  and  actual  group than  group  determined In o r d e r  to  in  23  use their  statistical  normalized  observation  by  with  o f 1 o r 2 added  Table 9).  to by  perform  o f 2 were added t o g e t h e r  of s c o r e s  This  groups,  has  part  t h e raw s c o r e s were  the  size.  that a subject  o p p o r t u n i t i e s f o r s t r a t e g y use — of s c o r e s  observations  two  for  number o f a c t u a l s t r a t e g y o b s e r v a t i o n s observed  9 and  between t h e o c c u p a t i o n a l  i n t e r v e n t i o n group f o r each  occurrences by  and  despite the difference i n  that the opportunity  of  Note t h a t  of s t r a t e g y  f o r the experimental  suggesting  the  items.  opportunity  i s even g r e a t e r  each  total  t o use a s t r a t e g y  number o f s t r a t e g y  difference  occupation  a  items.  with  groups. Note  which  the  a s many o p p o r t u n i t i e s f o r u s e f o r i t e m s  t h e two i n t e r v e n t i o n g r o u p s  such  in  were more o f t e n a p p r o p r i a t e f o r u s e t h a n  compared  for  o-f s e s s i o n s  a p p r o p r i a t e l y i s compared w i t h  occurred,  In T a b l e is  number  o f s e s s i o n s i n which  were t w i c e than  7, t h e t o t a l  was u s e d  appropriately items  a p p r o p r i a t e u s e o-f t h e s t r a t e g i e s .  for  comparing the  that and  number  is,  all  divided  together  (see  Chi—square  Distribution <  .05),  significant  (p  distribution  of d e s i r e d  intervention  group  Summary  Items did  strategy  usage  x observation  the  data  unequal as  a  was  frequency function  of  interval.  1 t h r o u g h 6 on t h e Communication any  statistically  intervention  exposure. F i g u r e part  indicating  o-f  of.Results  not reveal  between  analysis  groups  as  1 illustrates  Strategy  significant a  result  t h e main  Index  differences  of  inservice  findings  for  this  of t h e d a t a : i.  performance  the baseline observation comparable  6 items increased  on t h e f i r s t and t h e  second  between  observation  amount f o r t h e e x p e r i m e n t a l g r o u p  by  a  and t h e c o n t r o l  group; and  ii.  t h e e x p e r i m e n t a l group  than t h e c o n t r o l  group  Items 7 t h r o u g h indicated  mean p e r f o r m a n c e  mean p e r f o r m a n c e  11  a significant  a t both  on t h e C o m m u n i c a t i o n increase  (  45%  )  the decrease  the control performance  ( -  group.  147.  in  ) i n use of s p e c i f i c  Figure  2  illustrates  between t h e b a s e l i n e o b s e r v a t i o n  24  higher  intervals.  Strategy  d e s i r a b l e b e h a v i o u r s by t h e e x p e r i m e n t a l g r o u p with  was  the as  Index  use  of  compared  b e h a v i o u r s by  the  change  and t h e  in  second  observation  -For t h e two  o-f s t r a t e g y  use g i v e n  i n t e r v e n t i o n groups,  the opportunity  based  -for u s e .  on  rate  Table 1  RAW SCORES AND GAIN SCORES BY INDIVIDUAL SUBJECTS FOR ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX  fi^E^Ci ?Dt§I_GrguB m  Observation  1  Observation  Item:l  2  3  4  5  6  total  Rl R2 R4 R6 N9  1 1 1 2 2  1 1 1 1 2  •~y  1 1 1  2 1  8 7 9 10 11  1 1  *-\  2  O *?  2  "7  1 1  2  (N = 5)  1 2  2 1 2 1  1 1 2 2  3  4  5  2 1 1 2 2  2  2  T> '-v  2 2  1 ^_  2 6  total  1 2 1 2  12 9 8 11 11  Gain Score (02-01) 4 2 -1 1 0  C o n t r o l _Grgup. <N = 12) Observation Item: 1 R3 R5 N7 N8 N10 Nl 1 N12 N13 N14 N15 N16 N17  Observation  2  2  3  4  5  6  total  1  2  3  4  5  6  total  1  1 1 1 1 1 1 1 1 1 1 1 1  2 2 1 2 2 1 1 1 2 2 2 1  1 1 1 1 1 2 0 1 1 2 1 0  2 1 0 0 1 1 0 1 0 1 1 0  9 9 7 6 7 9 4 7 7 9 8 4  2 2 2 2 1 2 2 1 1 1 2 1  2 1 2 1 1 1 2 1 1 1 2 1  1 1  2 2 2 0 2 2 2 2 2 2 2 1  •?  1 2 1 1 2 1 1 0 2 0 2 1  10 10 10 6 8 8 10 7 9 6 11 6  *-»  1 1 2 1 2 2 2 2 1  1  1 1 2 1 1 1 1 1 1  26  r>  1 1 1 2 1 1 1 2 1  <-> JL-  1 1 1 1 1  o  2 1 1 1  Gain Score (021 1 3 0 1 -1 6 0 2 -3 2  Table 2  COMPARISON OF MEAN GAIN SCORES BY INTERVENTION GROUP AND BY OCCUPATIONAL GROUP (ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX INCLUSIVE)  Mean Gain Score Experimental (N=5)  S. D.  1.2  tv a l Lie  d. f ,  1. 72 NO (p = .96)  -.05 1. 21  Control (N=12)  :.  Rehab (N=6>  ^ 6  1.63 . 15  PCA (N=l1)  = degrees  deviation o f freedom  Rehab = R e h a b i l i t a t i o n PCA = P a t i e n t  2. 4  1. 18  S.D. = s t a n d a r d d.f.  SIG? (p<0.05)  care  staff  aides  27  15  NO (p=.88)  Table 3  COMPARISON OF MEAN BASELINE PERFORMANCE iOBSERVATION 1) BY INTERVENTION GROUP AND BY OCCUPATIONAL GROUP ON ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX  Mean S c o r e ( 01 >  >. D.  EM p e r i m e n t a l (N=5)  9. 0  Control <N=12)  7. 16  1.8  Rehab <N=6)  3.67  1.03  riv a l ue  S.D. = s t a n d a r d d.-f.  2.09  7.18  2.08  deviation  = d e g r e e s o-f -freedom  Rehab = r e h a b i l i t a t i o n PCA = p a t i e n t c a r e  SIG? (p<0.05)  38  1.96 PCA (N=ll)  d. +"  sta-f-f  aides  28  NO (p=.07)  15  NO (p=.07)  Table  4  COMPARISON OF MEAN REVISED GAIN SCORES B Y INTERVENTION GROUP AND B Y OCCUPATIONAL GROUP ON ITEMS 2, 3 , 5 , AND 6 OF THE COMMUNICATION STRATEGY INDEX  Mean R e v i sec! Gain Score  Experimental <N=5)  S.D.  Control (N=12)  1. 17  1.85  Rehab <N=6)  1.17  0.98  1.18  1.94  S.D.  = standard  d.f.  = degrees of freedom  deviation  Rehab = r e h a b i l i t a t i o n PCA = p a t i e n t  care  d.-f.  SIG? (p<0.05)  1. 1  1.2  PCA <N=11)  tv a l ue  staff  aides  046  15  -.021  15  NO (p=.96)  NO (p=.98)  Table 5  COMPARISON OF GROUP MEAN GAIN SCORES ON INDIVIDUAL ITEMS FOR ITEMS 1 THROUGH 6. AND ANALYSIS OF VARIANCE WITH REPEATED MEASURES  Ex p e r i mental Mean Item  1  Item  *-*  0  TWO-WAY ON ITEM  Control Mean Di -f -f e r e n c e  (S.D-)  Mean  (S.D.)  ( 1.0 )  -.08  ( .67 )  .08  )  .08  ( .67 )  . 12 . 15  ( .45  I tern 3  .4  ( . 55 )  . 25  ( . 45 )  I tern 4  0  ( 0.0  )  . 17  (  .84 )  -. 17  I tern 5  .4  ( . 55 )  . 33  ( .78 )  .07  I tern 6  .2  ( . 45 )  .5  (  .3  Two—Way A n a l y s i s Source  SS  1.0 )  o-f V a r i a n c e Summary d-f  Table  MS  I n t e r v e n t i on group Error  . 102 14.153  1 15  . 102 944  108  Item Error  1.92 35.197  75  384 469  818  157 469  334  I n t e r v e n t i on g r o u p >: Item .783 Error 35.197  S.D. = s t a n d a r d d.-f.  deviation  = d e g r e e s o-f -freedom  30  75  89  Table  6  RAW SCORES BY'INDIVIDUAL SUBJECT FOR ITEMS 7 THROUGH 11 OF THE COMMUNICATION STRATEGY  Exper^menta^_Group Observation Item:  Subj e c t : RI R2 R4 R6 N9  ~7  0 0  0 0 0  8  9  1 1 0 0 0  0 1 0 1 2  1 1 0  C o n t r o l _Grgup_ Observation Item: Subject: R3 R5 N7 MB N10 Nil N12 N13 N14 N15 N16 N17  (N=5)  1  10  INDEX  Observation  2  11  7  8  9  10  11  1 0 0 0 0  0 0 0 0 0  0 1 ^ 0 0  2 0 0  2 0 0  0  2  1 0 0 0 0  CN=12)  1  Observation  2  7  8  9  10  11  7  B  9  10  11  0 0 0 0 0 0 0 0 1 0 0 0  0 0 0 0 0 0 0 0 0 0 0 1  0 2 0 0 0 0 0 0 0 0 0 0  0 2 0 0 2 0 0 0 0 1 2 0  0 0 0 0 0 0 0 0 0 0 0 0  0 0 0 0 0 0 0 1 0 0 0 0  0 0 0 0 0 0 0 0 0 0 0 0  0 2 0 0 0 2 0 0 1 1 0 0  2 0 0 0 0 0 0 0 1 0 0 0  0 0 0 0 0 0 0 0 0 0 0 0  Table 7  TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR INDIVIDUAL ITEMS 7 THROUGH 11 OF THE COMMUNICATION STRATEGY INDEX  Observation Obs Opp  1  Observation Obs Opp  2  Total Obs Opp  Item 7  0  1  0  1  0  2  Item 8  0  3  1  2  1  5  Item 9  2  4  4  6  6  10  Item  10  5  8  4  5  9  13  Item  1  1  0  1  0  1  0  Obs = number o-f s e s s i o n s d u r i n g w h i c h a p p r o p r i a t e s t r a t e g y was o b s e r v e d a t l e a s t o n c e Opp = number o-f s e s s i o n s d u r i n g w h i c h strategy appropriately occurred  32  u s e o-f  o p p o r t u n i t y t o use a t l e a s t once  2  Table 8  TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR ITEMS 7 THROUGH 11 OF THE COMMUNICATION STRATEGY INDEX  Observation Obs Opp  1  Observation 2 Obs Opp  Total Obs Opp  E;-:per i mental group  3  10  6  8  9  18  Control group  4  7  3  7  7  14  Al 1 subj e c t s  17  R e h a b i 1 i t a t i on subjects 4  11  PCA sub j e c t f  3  15  16  11 5  Obs = number o f s e s s i o n s d u r i n g w h i c h a p p r o p r i a t e u s e o f s t r a t e g y was o b s e r v e d a t l e a s t o n c e Opp = number o f s e s s i o n s d u r i n g w h i c h strategy appropriately occurred  0.2  o p p o r t u n i t y t o use a t l e a s t once  i:  Table 9  TOTAL OBSERVED USES OF STRATEGIES 7 THROUGH 11 DIVIDED BY TOTAL OPPORTUNITIES FOR USE, BY INTERVENTION GROUP x OBSERVATION INTERVAL, AND CHI—SQUARE DISTRIBUTION TEST OF ASSOCIATION  Observation  1  Observation  E x p e r i mental group  <N=5)  Control group (N=12>  Chi—Square D i s t r i b u t i o n Test  30 7.  75 7.  57 7.  43 7.  of A s s o c i a t i o n :  X* = 16.9 d.f.  = 1  p < .001  d.f.  = degrees of freedom  34  2  Figure 1  COMPARISON OF IMPROVEMENT IN SROUP MEAN PERFORMANCES ON ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX (BARS REPRESENT 1 STANDARD DEVIATION)  Figure 2  FREQUENCY OF STRATEGY USE (ITEMS 7 THROUGH 11) NORMALIZED FOR EXPERIMENTAL AND CONTROL GROUPS  experimental group (N=5) control group (N=12)  observation  interval  CHAPTER FOUR DISCUSSION AND  The  INTERPRETATION OF  r e s u l t s o-f t h e  data  answers t o t h e q u e s t i o n s posed mixed. The a n a l y s i s Strategy  t o support  first  question: inservice  use  some  specific  training. negative: indicate staff  some d i f f e r e n c e s use  attributable that  of  observation  However, l a c k be  staff  strategies  second  tD  to more  inservice  question  is  also  behaviours,  training.  The  third  the frequency  and  control  i s supported  but  not  hypothesis, distribution  groups  by t h e a n a l y s i s  across of  items  11.  7 through  not  the  between t h e r e h a b i l i t a t i o n and PCA  experimental  intervals,  are  t h e o c c u p a t i o n a l g r o u p s seem t o  training predicts  the  2  hypothesis f o r  exposure  communication  to inservice  inservice  scores  of  no  the  a n a l y s e s comparing  in  the null  with  to  the  P a r t A of t h e Communication  communication  answer  that  t r a i n i n g does not cause  a s compared  The  suggest  a t t h e end o-f C h a p t e r  o-f d a t a f r o m  Index t e n d s  consistently,  analysis  RESULTS  accepted  of s t a t i s t i c a l l y as  unequivocal  hypothesis;  nor can s t a t i s t i c a l l y  considered  absolute  methodological  support  or other  for  confounding  s i g n i f i c a n t r e s u l t s can support  for.  significant the factors  a  analyses  hypothesis. may  null be Many  contaminate  the data and produce such r e s u l t s . factors  Potentially  must be "teased out" one by one and  specific  reference  to events  that  took  discussed  place  stages of r e s e a r c h p l a n n i n g , data c o l l e c t i o n analysis  procedures.  whose sum e f f e c t each i s o l a t e d factors  is  There may be greater  factor;  many  than  the  every p o s s i b l e  flaw  which  i n the study i s  be  before c o n s i d e r i n g the v a l i d i t y of the n u l l  Confoundi^ng^factors One of the r e s e a r c h design s u b j e c t s and the experimental vocational (nursing vocational  key  assignment  groups.  In  of  primary each  and  appropriate,  hypothesis.  elements  this  subjects  study,  staff),  and  rehabilitation  groups were d i f f e r e n t  on a  s u b j e c t s d u r i n g data  collection.  of  degrees  or  staff college  control from  participate: staff.  number  of  The  any  experience  include:  included  two PCAs two  can  with  the  between  the  post-secondary  individuals  diplomas,  and  variables  but some of which  Differences  PCA's and the r e h a b i l i t a t i o n s t a f f (rehabilitation  to  volunteers  groups had the o p p o r t u n i t y to  be i n f e r r e d from the a u t h o r ' s personal  university  the  i n v o l v i n g human s u b j e c t s i s the s e l e c t i o n of  which were not f o r m a l l y i n v e s t i g a t e d ,  education  of  significant  considers  therefore  and  factors  effects  or t h e r e may be one or two  A discussion  the  procedures,  combined  to  with  during  individual  which may be shown a p o s t e r i o r i  cause of confound.  confounding  while  with PCA's  g e n e r a l l y have a 6 week t r a i n i n g program); job d u t i e s r o l e o-f PCA's i s t o tend residents, social,  while  the  to  hygiene  rehabilitation  mental and p h y s i c a l  activity  E n g l i s h language p r o f i c i e n c y  These d i f f e r e n c e s  problematic  when  the  between  inservice, while  control  rehabilitation staff. of  parallel  for  those  the  group  provide and  of  groups  the  who  and  by  considered. the  and 1 PCA;  PCA's that  experimental  become  attended  10  surprising  not  subjects  groups i s  of  was  PCA was  and  the  groups  those of the corresponding v o c a t i o n a l  Table 2 and Table 3 ) .  of  residents);  one  subjects  consisted  It i s not  control  needs to  was made up of 4 r e h a b i l i t a t i o n s t a f f  the  scores  is  vocational  distribution  group,  role  only  v o c a t i o n over c o n t r o l and experimental The experimental  basic  (one r e h a b i l i t a t i o n s u b j e c t  i d e n t i f i e d by author as ESL, while ESL).  and  (main  mean  closely  groups  Any of the above mentioned  2  (see  variables,  not t o mention o t h e r s which were not observed by the author, could be a primary confounding f a c t o r to the  aims  of  this  study. The e d u c a t i o n and job d u t i e s of these s u b j e c t s , many  hospital  employees,  Rehabilitation staff  are  probably  as with related.  are educated t o c o n s i d e r the s o c i a l  psychological  well-being  of t h e i r p a t i e n t s  professional  responsibilities,  t r a i n e d t o v a l u e the s o c i a l  and  as p a r t of  therefore  and  their  would  be  a s p e c t s of communication. On the  other hand, the r o l e o-f the PCA emphasizes  bodily  care;  job i n which communication l i k e l y takes the r o l e of a of e x p r e s s i n g  b a s i c needs.  Thus,  and job d u t i e s p o s s i b l y r e s u l t  differences  in a  different  the r o l e of communication with p a t i e n t s , the communication behaviours of the Similarly,  the d i f f e r e n c e  in  a  means  occupation emphasis  which would  on  affect  subjects.  between  the  two  vocational  groups i n t h e i r E n g l i s h language p r o f i c i e n c y may have been a confounding f a c t o r . to t h e i r  It i s p l a u s i b l e that ESL  individual  cultural  and  have norms f o r communication  subjects,  linguistic  behaviour  backgrounds,  which  differ  each other and from those s u b j e c t s whose n a t i v e Canadian E n g l i s h .  Such d i f f e r e n c e s  of pragmatic i n t e r f e r e n c e E n g l i s h environment p r e d i c t how the ESL performance,  but,  factor  would  r u l e t h i s out as a confounding The f i n d i n g that quantitative  behaviours a  (see  previous  employees,  to  is  affect  it  use  of  found t h a t of  form  into  impossible an  the to  individual's groups to  factor.  at  least  groups some  differ  et  the  al.  knowledge  of  (1989),  using  of  hospital  208  11 o c c u p a t i o n a l groups,  40  in  communication  i s c o n s i s t e n t with the f i n d i n g s  Sarvela probe  is  i s also impossible  the two v o c a t i o n a l  Table S)  study.  questionnaire  It  the  s i n c e the c o n t r o l and experimental  were not matched on t h i s v a r i a b l e ,  their  may s u r f a c e i n  1982).  from  language  from the n a t i v e language  (Brosjean,  due  a  therapists  were most nursing that,  knowledgable about communication  a i d e s had t h e l e a s t  disorders.  groups r e q u i r e d i f f e r e n t results  of t h e present  Sarvela  et  al . ,  occupational behaviours, can  a w a r e n e s s . The  w h i l e a l l new e m p l o y e e s s h o u l d  area of communication  although  be a t t r i b u t e d  study  concluded  receive training  the  various  while  i n the  occupational  f o c u s and amount of a t t e n t i o n .  study  are consistent  indicating  groups  disorders.  in  some  terms  directly  to  a  those  differences  of  i t i s not c l e a r  with  their  The of  between  communication  whether t h i s  difference  difference  in  level  of  knowledge. Table  3  particular variable. not  in  the  p r o b l e m c r e a t e d by  only d i f f e r s  s c o r e up, t h e r e b y  group.  This  limiting group.  out with  greater  potential  lower  t h e mean  raises  the  drove  t h e average If the group  the  experimental  in  group  baseline  possibility subject  average  gain score  a  vocational  than  of r e h a b i l i t a t i o n  group a c t u a l l y  t o the control  started  in  baseline potential group  i t s composition  had (and  b a s e l i n e s c o r e s ) , t h e r e may have been  f o r improvement  therefore the p o s s i b i l i t y  observed  illustrates  uncontrolled  from, but i s h i g h e r  the experimental  been c l o s e r  and  the  t h e overwhelming presence  the experimental  for  chapter  The mean b a s e l i n e s c o r e f o r t h e e x p e r i m e n t a l  score f o r the control that  previous  i n the experimental  f o r a treatment  i n the gain score data  41  (items  1  effect  through  group, to  6).  be  Thus  the  combination  distribution  of  Another  to  used  of  confound  evaluate  Strategy  chosen  t h e two  the  Index.  make  to  —  and  a  lump t h e p e r f o r m a n c e  to  always,  the scoring  t h r e e unequal two  range  —  scaring  in  an a  While  for  efficiency  during  ongoing  tendency  the  —  to  behaviours from  never  c a t e g o r i e s which p l a c e d t h e extreme ends  into  and  left  only  between  performance,  divided  the  sensitive,  o c c u r r e d on a c o n t i n u u m  category, to allow  of  measurement  into  of b e h a v i o u r s  scoring  been  effect  of  resulted  procedure  have  t h i s continuum  categories,  range  sake  of t h e s u b j e c t s .  w h i c h were b e i n g o b s e r v e d  poor  three—point  judgment  reliability,  and  study.  the  ( o v e r t h e o p t i o n o f a more  time  may  in this  is  The  scale) f o r the  observation  groups  training  example f i v e - p o i n t , required  scores  the r e s u l t s presented  source  Communication procedure  baseline  of s u b j e c t s o v e r  enough t o p r o d u c e  procedure  high  one the  category two  extremes.  distinction  would  be  an  for  within advantage  the  wide  A  fourth  the  middle  in  future  research. The evaluated aural  choice  of  in this  study p r e s e n t s another  rehabilitation  strategies  evaluated  p a r t n e r s of h a r d suggest  that  the  communication  literature in  this  behaviours issue:  i n d i c a t e s that study  of h e a r i n g people,  are  —  while all  be the  of  the  desirable  for  t h e r e i s no  t h e s e b e h a v i o u r s a r e valid  to  that  evidence  to  i s , that  use  c-f  such  behaviours  actually  other than self—reports this  effect.  revisions  improves  o-f h e a r i n g impaired  The items i n the t o o l  a  operational  phase of t h i s study and thus behavioural  criteria  focus  the measurement  as  it  terms  replaced  number  difficult  during or  and  the  topic  was  by  no  means  version  standardized,  c o u l d not be  e f f e c t i v e communication. The outcome of Appendix E , and Chapter 3)  s c o r i n g v a l i d i t y of  such  maintenance  shown  have any v a l i d i t y i n terms of a c t u a l l y measuring the  (see  to  pilot  eliminated  However, the f i n a l  beyond l i m i t e d r e l i a b i l i t y measures,  measures  of  in  which i n c l u d e d some of the former  definition.  tool  found  eye contact  attention,  behaviours i n i t s  of  to  i n order to improve i n t e r o b s e r v e r r e l i a b i l i t y . The  some items i n  favour of  —  individuals  underwent  r e s e a r c h e r and the second observer define  intelligibility  items 2,  3,  5,  the  10  and to  concept  reliability  indicates  and  of  are  that in  the fact  questionable. Furthermore,  while  these  strategies  a p p r o p r i a t e i n many communication s i t u a t i o n s , appropriate  goals  communication encountered Lighting,  for  institutional  environment by  most  f o r example,  is  people  quite outside  are  probably  not a l l may be  staff,  where  different  from  of  that  institutions.  was g e n e r a l l y uniform throughout  rooms, and d i d not need t o be a d j u s t e d ;  the  background n o i s e ,  the on  the other hand, v a r i e d from one s e s s i o n t o another and q u i t e  43  often  c o u l d not be adjusted by the s u b j e c t  source of  the  noise  c a r r i e d out by the  was  another  staff  tended  i n t e r a c t i o n between the s u b j e c t often  in close physical  partner,  (e.g.,  when  resident). to  limit  The  the  to  while r e h a b i 1 i t a t i o n s t a f f  their  duties  style  and the r e s i d e n t :  proximity  communication  p r o x i m i t y depending on the a c t i v i t y .  An  interaction  focussed  as  breakfast  verbal  communication  rephrasing.  and  affairs use  depended  of  for  the  meant t h a t t h e r e was m u c h v a r i a b i 1 i t y between t  a p p r o p r i a t e n e s s of s t r a t e g i e s , evaluation  tool  occupational  —  a  factor  score  which  method  behavioural  and d i s a d v a n t a g e s .  unobtrusive,  which  While  it  is  and does not r e q u i r e any s p e c i a l it  as  measurements subjects  for  with  the the  no o p p o r t u n i t y  to  rescore  In f a c t ,  a  session  the r e s u l t s  44  for  illustrated  show a tendency f o r a l l of the s u b j e c t s '  requires in  the  situ  has  time—efficient, equipment such  a l s o does not  over such elements as observer b i a s ,  reliability^  such  interacts  criteria  as v i d e o cameras or audio r e c o r d e r s , control  on  confound i n the i n t e r v e n t i o n group c o m p o s i t i o n .  to  advantages  whereas  i n both p a r t s I and II of  The use of an e v a l u a t i o n observer  which  greatly  strategies  Thus the n a t u r a l s e t t i n g  their  allowed  much o p p o r t u n i t y f o r g e s t u r i n g and p h y s i c a l c o n t a c t , a c o n v e r s a t i o n about c u r r e n t  of  PCA's were  varied greatly in  cn a p h y s i c a l a c t i v i t y such  the  allow  s i n c e there  is  intra—observer in  scores to  Figure  1  increase  between the b a s e l i n e to two d i f f e r e n t  and second o b s e r v a t i o n .  sources of b i a s :  have become more lax i n  firstly,  scoring  over  the observer  time,  resulting  secondly,  may have become more r e l a x e d with the  the  time  of  resulting  the  attention)  The items  (5,  the  positive speech  01  and  02  for vary  the with  between  observation,  interaction  rate;  and  with  6,  focus  unexpected  increase  subjects  reflect  control the  performance?  itself  second  which i n p a r t i c u l a r show an  b e h a v i o u r s that may subject,  procedure  and  i n a more n a t u r a l and  the r e s i d e n t s .  between  baseline  of  in  to  presence of the observer and the  levels  may  higher s c o r e s awarded the s u b j e c t s  similar  T h i s may be due  talkativeness  of  the  i n d i c a t i n g t h a t f a m i l i a r i t y with the procedure  and  the observer may have played a r o l e . Both of these methodological confound,  problems are a source  and are d i f f i c u l t to separate o u t .  collection  procedure  which  While  permanently  s u b j e c t - p a r t n e r i n t e r a c t i o n s would help  a  data  records  eliminate  of  the  observer  b i a s by a l l o w i n g double checking of the s c o r i n g , the problem of p r a c t i c e e f f e c t  i s d i f f i c u l t to  e l i m i n a t i n g the second o b s e r v a t i o n a different period u n t i l  methodology),  The f i n a l  p e r i o d of  able  without  (and t h e r e f o r e  or r e q u i r i n g  the observer was  over a s p e c i f i c  control  to  a  requiring  lengthy score  either  training  consistently  time.  problem area which must be d i s c u s s e d  45  is  the  effectiveness  of  mentioned above,  the  inservice  the s p e c i f i c  procedure  program  ideal  communication f o r  in  question.  This  problem  is  may  one  not  foundations of a u r a l  exemplifies  the need f o r r i g o r o u s study to  to which p o p u l a t i o n s .  f o r the two c a t e g o r i e s appropriate, suggest that specific  and  inservice  The  of s t r a t e g i e s  those  that training  the  the  population  addresses  are  determine  strategies  the  (those t h a t sometimes  which  which  are  contradictory  most  results  are  always  appropriate)  focusses  communication behaviours t h a t are  o p t i m a l l y may be a p p r o p r i a t e f o r  been  as  r e h a b i l i t a t i o n , and c l e a r l y  communication behaviours and  beneficial  have  that  theoretical  specific  As  s t r a t e g i e s that were chosen  g o a l s f o r the e d u c a t i o n a l goals for e f f e c t i v e  itself.  not  on  those  being  used  caregivers.  Assuming t h a t the g o a l s of the study were a p p r o p r i a t e , there i s a f i n a l  p o s s i b i l i t y which may have  the present r e s u l t s . been i n e f f e c t i v e  The  inservice  contributed  presentation  due to time c o n s t r a i n t s — that  may is,  to have  the  45  minutes a v a i l a b l e to present the i n f o r m a t i o n may have f o r c e d the s t a f f sufficient  audiologist  to rush through the  d i s c u s s i o n of i n d i v i d u a l  that c r u c i a l  points.  material It  is  without unlikely  i n f o r m a t i o n was misrepresented or omitted  the i n s e r v i c e p r e s e n t a t i o n ,  s i n c e the s t a f f  audiologist  from took  every p r e c a u t i o n t o ensure that a l l of the s t r a t e g i e s on the evaluation tool  were c o v e r e d . However, a longer  46  time  frame  with a c t i v e p a r t i c i p a t i o n o-f the audience i l l u s t r a t e the d e s i r a b l e b e h a v i o u r s ,  or one-on—one  i n the use o-f communication s t r a t e g i e s , different  training  might have had q u i t e  results.  Nul^l^  hypotheses  nonsignificant extended  i n role—playing to  The  findings  care s t a f f  final  i s the n u l l  explanation hypothesis  are not a b l e to i n c r e a s e  of  itself: their  e f f e c t i v e communication behaviours as a r e s u l t  of  Although a p r e v i o u s study suggests t h a t s t a f f  are  implement s p e c i f i c setting  use  able  their  daily  However, even t h i s statement must be  present  results  the b a s e l i n e  data suggests that s t a f f  some of the t a r g e t e d of  the time,  that  staff  routine made  using  s t r a t e g i e s spontaneously  who  are  exposed  to  training  at  at l e a s t  and the data from items 7 through  11 do  to  do  these  activities.  cautiously,  are  of  structured  not u n e q u i v o c a l l y support t h e i r a b i l i t y to g e n e r a l i z e types of behaviours i n t o  that  training.  communication behaviours i n a  (Purves and Brooks, 1987), the  the  for least some  indicate use  some  s t r a t e g i e s more o f t e n .  It would be i n c o r r e c t t o assume,  from  the lack of a p o s i t i v e  f i n d i n g s throughout  that  extended  care s t a f f  instead,  optimistically,  results  are  due  the  are not able to communicate  to  we may hope that the  fact  communication i s t a k i n g p l a c e ,  47  that  i n at l e a s t  the  data,  effectively.: inconclusive  some  effective  this  particular  i n s t i t u t i on -  i<l!Eli£2t^gQS_f o r_ f u t ^  numerous  The  -factors  i n c o n c l u s i v e  r e s u l t s  -for  r e s e a r c h .  f u r t h e r  s t u d y ,  whether  d e s i g n i n g f u t u r e  r e s e a r c h  i .  i n  o c c u p a t i o n , s h o u l d  be  p o s s i b l e ,  a d d r e s s  and  i i .  Measurement and  t h e y  c o n s i s t e n t  which i s  a l l o w s  p r e f e r a b l e .  o p t i m a l w h i c h  t h e  a  main  a r e a s  of  the  t h e  need  i n  t h i s  u s e f u l  f o r  g u i d e l i n e s  f o r  c o n c e r n  t h a t  e n s u r e  a c r o s s  be  e q u a l  about  were  e d u c a t i o n ,  i n f l u e n t i a l  c o n t r o l l e d s h o u l d  The  over  permanent The  more  be  f o l l o w i n g  p o t e n t i a l l y  s c o r i n g  s e n s i t i v i t y  a l l o w s  may  t o  v a r i a b l e s  g r o u p s  r a n d o m l y  where  a s s i g n e d  d i s t r i b u t i o n  of  t o  numbers  v a r i a b l e s .  t o o l .  r e l i a b l e  u n d e r l i n e  e n c o u n t e r e d  I n f o r m a t i o n  and  t o  u n c o n t r o l l e d  a r e  p r o b l e m s  The  t h e  o t h e r  g r o u p s  of  s t u d y  p o t e n t i a l ,  s u b j e c t s  and  c o n t r i b u t e d  s t u d y :  i d e n t i f i e d  i n t e r v e n t i o n  or  v a r i a b l e s .  o r  p r e s e n t  s t u d i e s .  t h i s  S u b j e c t  t h e The  r e a l  f u t u r e  e n c o u n t e r e d  o-f  which  t o o l t o  method  of  p r o c e d u r e t i m e .  A  r e c o r d  change  g r a d a t i o n s  — of  48  must  must  be  p r a c t i c e d  method  of  d a t a  of  s h o u l d  e v a l u a t i o n  o b s e r v a t i o n  be  d e s i g n e d i s ,  p e r f o r m a n c e  a  u n t i l  c o l l e c t i o n  t h e  t h a t  be  s e s s i o n s  t o  e n s u r e  f i n e r and  s c a l e  t h e r e f o r e  more  o p p o r t u n i t y  i i i .  I n s e r v i c e  t a r g e  t h e  as  s p e c i f i c i n s e r v i c e  change.  p r o c e d u r e s .  a p p r o p r i a t e  c o n s i d e r a t i o n . s k i l l s ,  -for  w e l l  T h u s , as  The  e d u c a t i o n a l  g o a l s  f o r  c u r r e n t  e d u c a t i o n ,  s h o u l d  be  c u r r i c u l u m .  49  t h e  l e v e l s  o c c u p a t i o n a l  p r o g r a m  g r o u p s  c o n s i d e r e d  s h o u l d  p o p u l a t i o n  of most i n  i n  c o m m u n i c a t i o n i n  need  p l a n n i n g  of the  C o n e I u s i  o n 5  The s t a f f  h y p o t h e s i s  a r e  a b l e  t h a t  t o  l e d t h i s  i n c r e a s e  s t r a t e g i e s  a s  was  w i t h  f i n d i n g s .  b e h a v i o u r s a f t e r  ( i t e m s  g a i n  t h r o u g h  1  between  r e l a t i v e l y f i r s t  ( i . e . ,  a r e  T h e s e aimed  a t  c o m m u n i c a t i o n T h e s e  c e r t a i n  members t h e  b r i n g  v a r i o u s  e d u c a t i o n ,  some  c o m m u n i c a t i o n t o  o t h e r  o f  i n c r e a s e s t r a t e g i e s  d i f f e r e n c e  c o n t r o l  t h a t  s t r a t e g i e s  t h a t  s t r a t e g i e s  l e v e l w i t h  t h a t  h e l p f u l  s u c h  T h e s u c c e s s t h e  a n d  some  c o m m u n i c a t i o n  o c c a s i o n s ,  o n  i n s e r v i c e  s i g n i f i c a n t  t o  s u g g e s t  may b e  i n c l u d e  rephrasing.  s p e c i f i c  o b s e r v e d  p e r f o r m a n c e s  u s e d  o f  i n s e r v i c e ,  show  c a r e  a l l  i n  . g r o u p .  T h e  s u b j e c t s ,  o n  some  c o m m u n i c a t i o n  d e g r e e  s p o n t a n e o u s l y  i n t e r v e n t i o n ) .  f i n d i n g s  i t  t h e  i n d i c a t e s  b e i n g  t e a c h i n g  s u c c e s s f u l ,  depend  b a s e l i n e  o f  were  e x t e n d e d  u s e  W h i l e  e x p e r i m e n t a l  i t e m s ,  6  w i t h o u t  i n  r e s u l t  11)  d i d n o t  6)  t h e  h i g h  s t r a t e g i e s  i n .  t h r o u g h  7  p a r t i c i p a t i o n  ( i t e m s  t h e  mixed  t h a t  t h e i r  c o m m u n i c a t i o n s u p p o r t e d  a  s t u d y ,  o f  o c c u p a t i o n a l  a s  f o c u s  s t a f f t h a t  o n  members a r e  i s t h o s e may  e d u c a t i o n t h e  a r e a s b e  o f  l a c k i n g o n l y  o n a n d  may  a l s o  i n d i v i d u a l  w e l l  a s  t h e  g r o u p s .  In  c o n c l u s i o n ,  50  p a r t i a l l y  understanding,  i n s e r v i c e t h a t  e d u c a t i o n  a p p r o p r i a t e  checking  knowledge  them,  i n s e r v i c e  e f f e c t i v e n e s s  t o  a s o f  w h i l e  d u t i e s  s t a f f  p e r f o r m e d t h i s  b y  s t u d y  was  designed  natural  work  intervention, participants' may  have  to  evaluate  environment, and  did  subjects' as  not  derived  or any -from  51  r  r  result  attempt  fgrmal_learning, been  a  Eg .£Q .!D£QE.s o-f  to other the  v  i  n  the  inservice  evaluate benefits  the that  inservice.  BIBLIOGRAPHY  Cervero.  R.M.,  behavioural  Nursing.  Continuing change.  professional education  Journal  of  Continuing  and  Ed ucation  in  1935, 16, 35-83.  Chambers, L.W. , and H.M. Blum. Measurement o f a c t i o n s o f c a r e p r o v i d e r s i n l o n g - t e r m c a r e . Journal of CIinical Epidemiology1983, 41, 793-802. S r c s j e a n , F. Life Mith TMO Languages. U n i v e r s i t y P r e s s , 1932.  Cambridge:  L u b i n s k i , R . , E.B. M o r r i s o n , and S. R i g r o d s k y . s p o k e n c o m m u n i c a t i o n by e l d e r l y c h r o n i c a l l y an  institutional setting.  Disorders..  Journal  of  Harvard  P e r c e p t i o n of i l l patients in  Speech  and  Hearing  1981, 46, 405-412.  L u b i n s k i , R. A model f o r i n t e r v e n t i o n : c o m m u n i c a t i o n s k i l l s , e f f e c t i v e n e s s , and o p p o r t u n i t y . In B. Shadden ( E d . ) , Communication  Wilkins,  Behaviour  and  Qging.  Oyer H.J. and E . J . , O y e r . S o c i a l for  the e l d e r l y .  1979,  2,  Williams  and  Allied  consequences of hearing  Health  and  Behavioural  loss  Sciences,  123-138.  Peden, A.R.,  H. Rose, and M. S m i t h .  education  Nursing,  Baltimore:  1938.  to practice.  Journal  Transfer  of  of c o n t i n u i n g  Continuing  Education  in  1990, 2, 68-72.  P u r v e s , B. and B. B r o o k s . Two s t r a t e g i e s f o r a u r a l r e h a b i l i t a t i o n i n an e x t e n d e d c a r e f a c i l i t y . Hunan Communication R e z e n ,  Canada,  1987,  S. and C . Hausman. Coping Books, 1985.  13-16. Mith  Hearing  New  Loss.  York:  D e m b n e r  Rupp, R.R. S p e e c h i n p u t p r o c e s s i n g , r e h a b i l i t a t i o n with the e l d e r l y . Albert  (Eds.),  Lexington,  Language  Massachusetts:  and  hearing loss, In L.K. O b l e r  Communication  Lexington  S a n d e r s , D . Rural Rehabilitation (2nd E d - ) . New J e r s e y : P r e n t i c e - H a l l , 1982. Sarvela,  P.D.,  in  Books,  and a u r a l and M.L.  the  Elderly.  1980.  Englewood  Cliffs,  J . L . S a r v e l a , and J . O d u l a n a . K n o w l e d g e o f 52  c o m m u n i c a t i o n d i s o r d e r s among n u r s i n g home e m p l o y e e s . Nursing Homes and Senior Citizen Care, 1989, 38, 21-24. Schow, R.L., J.M. C h r i s t e n s e n , J.M. H u t c h i n s o n , and M.A. Nerbonne. Communication Uisorders of the figed. Baltimore: Un i v e r s i t y P a r k P r e s s , 1978. Schow, R. and M. Nerbonne. home r e s i d e n t s . Journal 1980, 45, 124-132.  H e a r i n g l e v e l s among e l d e r l y n u r s i n of Speech and hearing Disorders.  S h o r e , H. C o m m u n i c a t i o n p r o b l e m s and c o m m u n i c a t i o n n e e d s i n a r e t i r e m e n t s e t t i n g . In M.A. Henoch ( E d . ) , ftural Rehahilitation for the Elderly. New Y o r k : Grune and S t r a t t o n , 1979.  You may re-fuse t o p a r t i c i p a t e or w i t h d r a w -from t h e s t u d y a any t i m e ; s u c h w i t h d r a w a l o r r e f u s a l t o p a r t i c i p a t e w i l l not j e o p a r d i z e y o u r employment s t a t u s . Your i d e n t i t y wi11 remain c o n f i d e n t i a l ; no i n f o r m a t i o n w h i c h i d e n t i f i e s you by name w i l l be r e l e a s e d a t any t i m e . O n l y t h e i n v e s t i g a t o r s named above w i l l have a c c e s s t o t h e s t u d y d a t a which w i l l be r e t a i n e d f o r f i v e years.  S i g n a t u r e s of I n v e s t i g a t o r s Subject's  Date  Statement  The s t u d y d e s c r i b e d above h a s been e x p l a i n e d t o me and I v o l u n t a r i l y c o n s e n t t o p a r t i c i p a t e . I have had t h e o p p o r t u n i t y t o ask q u e s t i o n s and u n d e r s t a n d t h a t f u t u r e q u e s t i o n s I may h a v e a b o u t t h e r e s e a r c h o r a b o u t t h e r i g h t s of s u b j e c t s w i l l b a n s w e r e d by t h e i n v e s t i g a t o r .  Signature  I a l s o acknowledge r e c e i v i n g  Signature  of  Subject  Date  a copy of t h i s consent  of  Subject  form.  Date  Appendix  B:  Screening  Questionnaire  The p u r p o s e o f t h e - f o l l o w i n g q u e s t i o n s i s t o f i n d o u t whether o r n o t y o u a r e a t r i s k f o r h e a r i n g l o s s . The a n s w e r s t o t h e s e q u e s t i o n s w i l l be u s e d t o d e t e r m i n e y o u r p e r s o n a l r i s k f a c t o r s regarding hearing only. Subject  1.  Name:  Do y o u now Yes  Date: DOB: have, o r h a v e y o u e v e r had, a h e a r i n g p r o b l e m " No If yes, p l e a s e e x p l a i n :  2. Have you e v e r been m e d i c a l l y t r e a t e d f o r an e a r p r o b l e m ? Yes No If yes, please e x p l a i n : -3. I s t h e r e a h i s t o r y o f h e a r i n g l o s s i n y o u r f a m i l y ? Yes No I f y e s , p l e a s e e x p l a i n (type of loss, relationship, e t c ) : 4. Have you had a s i n u s o r c o l d Yes No  problem  i n the past  month?  5. Have y o u had a s e r i o u s i l l n e s s i n t h e p a s t s i x months? Yes No If yes, p l e a s e e x p l a i n : 6. A r e you now t a k i n g any m e d i c a t i o n ? Yes No If yes, type 7. Have you had any i l l n e s s neurological function? If y e s , p l e a s e e x p l a i n :  and l e n g t h o f t i m e :  or a c c i d e n t t h a t might Yes No  56  affect  y o u r  Appendix  C: I n s e r v i c e  Handout  COMMUNICATING WITH THE HARD O F H E A R I N G  - M O S T r e s i d e n t s i n Purdy P a v i l i o n h a v e hearing l o s s - h a r d -for u s t o u n d e r s t a n d what i t ' s l i k e hearing loss i s often mistaken -for c o g n i t i v e d e f i c i t , d i s i n t e r e s t , lack of c o o p e r a t i o n , or h o s t i l i t y  What _i_s_hear i ng_igss_l_i_ke? It depends on the  type.  S e n s o r i n e u r a l h e a r i n g l o s s i s the most common t y p e . It is characterised by a lack of c l a r i t y and some r e d u c t i o n i n 1oudness. - s e n s o r i n e u r a l l o s s i s often c a l l e d "nerve deafness" - i t i s a common myth t h a t nothing can be done to help sensorineural hearing l o s s - medical treatment i s not p o s s i b l e , but h e a r i n g a i d s can d e f i n i t e l y help. Conductive hearing loss is less common. It i s often medically t r e a t a b l e . It i s c h a r a c t e r i z e d by a r e d u c t i o n in loudness, but excellent clarity remains. People with conductive hearing l o s s are u s u a l l y very s u c c e s s f u l with hearing a i d s . EVERYONE'S HEARING LOSS IS DIFFERENT. Some people have a more severe loss for high—pitched tones (this is most common), and o t h e r s have a more severe l o s s f o r l o w - p i t c h e d t o n e s . There are very few people who cannot b e n e f i t from the use of a h e a r i n g a i d . b!9 _tg_make_communicat i on_easie^ w  L  1. if the r e s i d e n t h a s a h e a r i n g a i d , make sure he/she i s wearing i t . Be sure to check t h a t i t i s turned on ("M" on the switch) and that the b a t t e r y i s f r e s h . — remember t h a t the hearing a i d w i l l h e l p , but it will not p r o v i d e normal h e a r i n g f o r the r e s i d e n t . He s t i l l needs to be spoken t o with e x t r a c a r e .  57  2- L i p r e a d i n g i s very important -for someone with a hearing 1OSS. - make sure the person i s f a c i n g you - do not cover your f a c e , chew gum, smoke, or do anything e l s e that may b e d i s t r a c t i n g - keep the l i g h t on your face (don't have your back to the wi ndow) - s i t or stand c l o s e to the r e s i d e n t - speak i n a normal volume of v o i c e - i t i s not necessary to exaggerate your l i p movements 3 . Bet the p e r s o n ' s  a t t e n t i o n before you s t a r t  4. Speak f a i r l y s l o w l y , you are s a y i n g .  so he has a chance to  5. DO NOT speak into the p e r s o n ' s e a r . important to l e t him see your f a c e .  speaking. process  It  what  i s much more  6. Reduce background n o i s e . Noisy p l a c e s make h e a r i n g even more difficult f o r hard of h e a r i n g people than f o r those with normal h e a r i n g . 7.  Check to make sure the person i s understanding you.  These s u g g e s t i o n s may seem very simple — but it is surprising how often we are unaware of our speaking h a b i t s . P l e a s e pay a t t e n t i o n t o your own, and with p r a c t i c e , most of these "helpers" become automatic. Remember what the hearing loss tape sounded like, to remind y o u r s e l f of what many of our r e s i d e n t s are up against. Hearing l o s s is very socially debilitating, especially i n a long—term care f a c i l i t y . . . but i f we are a l l aware of i t and take these simple s t e p s to improve communication, we w i l l make l i f e much more p l e a s a n t f o r both r e s i d e n t s and s t a f f .  58  Appendix D:  COMMUNICATION STRATEGY INDEX  Date  Time  Subject  Floor Observer  PARJ_I S c o r i n g Procedure ( c i r c l e one): 2 = c o n s i s t e n t use 1 = inconsistent  0 = not  used  1.  distance  2  1  0  2.  position  2  1  0  3.  -face v i s i b i l i t y  2  1  0  4.  voice quality  2  5.  speech q u a l i t y  2  1  0  6.  focus a t t e n t i o n  2  1  0  1  PART_II S c o r i n g Procedure ( c i r c l e one): 2 = a p p r o p r i a t e use as o p p o r t u n i t y arose 1 = o p p o r t u n i t y arose, but s t r a t e g y was not 0 = No o p p o r t u n i t y arose  0  used  7.  lighting  2  1  0  8.  background n o i s e  2  1  0  9.  check understanding  2  1  0  10.  rephrasing  2  1  NOTES: room resident task esl NEXT OBSERVATION  59  0  Appendix D, continued Gu^del ines_£gr_scgrinQ_i terns L  L  1. D i s t a n c e : one t o two metres -from the 2. P o s i t i o n : body -facing the  listener.  listener  3. Face v i s i b i l i t y : no d i s t r a c t i o n s around -face ( e . g . , smoking, chewing gum, hands c o v e r i n g mouth) ; -face towards the Ii stener. 4.  Voice q u a l i t y : use normal or s l i g h t l y louder than normal volume o-f v o i c e . So-fter than normal or too loud i s inappropriate.  5.  Speech q u a l i t y : speak c l e a r l y u s i n g s l i g h t l y slower than c o n v e r s a t i o n a l r a t e . Overexaggeration o-f mouth movements inapppropriate.  6.  Focus a t t e n t i o n : i n i t i a t e a t t e n t i o n and -focus l i s t e n e r ' s a t t e n t i o n during i n t e r a c t i o n , by c a l l i n g l i s t e n e r ' s name, s t a t i n g t o p i c , u s i n g meaningful g e s t u r e s ( e . g . , p o i n t i n g out an o b j e c t ) , p h y s i c a l c o n t a c t .  is  7. L i g h t i n g : ensure enough l i g h t i s on s p e a k e r ' s face? do not stand with back t o a b r i g h t source such as a window. 8.  Background n o i s e : as t . v . or r a d i o ,  reduce volume of any source of n o i s e such or move i n t o q u i e t e r a r e a .  9.  Check u n d e r s t a n d i n g : any v e r b a l attempt on s p e a k e r ' s p a r t to get an a f f i r m a t i v e response; a p p r o p r i a t e when l i s t e n e r does not respond spontaneously, or when s i t u a t i o n does not p r o v i d e e x t r a cues (such as meal t r a y Dr m e d i c a t i o n ) .  10. Rephrasing: repeat content of message (one key word, phrase, or sentence, e t c . ) i n d i f f e r e n t words. A p p r o p r i a t e when t h e r e i s an i n d i c a t i o n that l i s t e n e r has not understood, or when speaker f e e l s i t i s augmentative.  60  Appendix E". INTEROBSERVER RELIABILITY OF MEASUREMENT TOOL ITEM Part  7. AGREEMENT p i l o t data * (S o b s e r v a t i o n s )  I  7. AGREEMENT -final data <6 o b s e r v a t i o n s )  1.  distance  100  83  2.  position  100  67  3.  -face v i s i b i l i t y  87.5  4.  voice  75  100  5.  speech q u a l i t y  75  67  6.  -focus a t t e n t i o n  N/A * *  100  87.5  100  Part  quality  II  7. l i g h t i n g 8.  background n o i s e  9.  check understanding  10.  67  100  rephrasing  100  62.5  S3  75  67  11. check h e a r i n g a i d  N/A * *  *  and physical  Note: two  items,  body 1anguage  100 contact,  such poor r e l i a b i l i t y (37.5%) d u r i n g the p i l o t phase, were e l i m i n a t e d a l t o g e t h e r -from the -final measurement **  Two i t e m s ,  focus  attention  and check  hearing  added a f t e r the p i l o t phase and t h e r e f o r e f i g u r e s o n l y f o r the f i n a l data phase.  61  have  aid,  had  that they tool. were  agreement  

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