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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 I. RENNERT B.A.. The U n i v e r s i t y o-F B r i t i s h Columbia. 1988 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER DF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (School of Audiology and Speech Sciences) We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September 1990 (£) K a r i n I. Rennert, 1990 •5 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Audiology and Speech Sciences The University of British Columbia Vancouver, Canada Date Sept. 19, 1990 . DE-6 (2/88) Abstract This study evaluated the a b i l i t y of nursing home s ta f f to implement communication s t ra teg i e s as a r e s u l t o-f in serv i ce education. Seventeen subjects , -from two occupational groups (patient care a ides , and r e h a b i l i t a t i o n sta-f-f), were observed twice each during rout ine i n t e r a c t i o n s with the nursing home res ident s . The measurement tool consisted o-f 11 communication behaviours, which were scored according to degree of use. There were two categories of s t ra teg i e s : those that could be used in a l l s i t u a t i o n s , and those that were appropriate only for some s i t u a t i o n s . Results were mixed: the experimental group (N=5), who attended the i n s e r v i c e , showed an increase in the use of l a t t e r category of communication s t r a t e g i e s , while the contro l group (N=12) decreased t h e i r use of the same s t r a t e g i e s . In the former category of s t r a t e g i e s , no d i f f erence was found between the experimental and control groups. The d i scuss ion focused on poss ib le sources of confound, and recommendations for further research. TABLE OF CONTENTS PAGE LIST OF TABLES i i i LIST OF FIGURES i v CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW 1 Purpose 9 2 METHODS 10 Su b j e c t s 10 Procedures 11 General Procedures 11 I n s e r v i c e Procedures . . . . 12 Measurement Procedures 13 S c o r i n g Procedures 14 R e l i a b i l i t y Procedures 15 Research Questions 11> 3 RESULTS IS I n s e r v i c e P a r t i c i p a t i o n 18 Gain S c a r e s 19 i i i Basel i ne Scores 20 Revised Gain Scores 21 Item Analys i s 21 Items 7 through 11 22 Summary of Results 24 4 DISCUSSION AND INTERPRETATION OF RESULTS . . 37 Confounding Factors 38 Null Hypothesis 46 Implicat ions for Future Research . . . . 48 Conclusions 50 BIBLIOGRAPHY . 5 2 APPENDICES A Subject Consent Form 54 B Screening Questionnaire 56 C Inservice Out l ine 57 D Communication Strategy Index 59 E R e l i a b i l i t y Data 61 i v L I S T O F T A B L E S T A B L E S P A G E I R A W S C O R E S A N D G A I N S C O R E S B Y I N D I V I D U A L S U B J E C T S F O R I T E M S 1 T H R O U G H 6 O F T H E C S I . . 26 I I C O M P A R I S O N O F M E A N G A I N S C O R E S B Y I N T E R V E N T I O N G R O U P A N D B Y O C C U P A T I O N G R O U P ( I T E M S 1 T H R O U G H 6 O F T H E C S I I N C L U S I V E ) . . . 27 I I I C O M P A R I S O N O F M E A N B A S E L I N E P E R F O R M A N C E ( O B S E R V A T I O N 1) B Y I N T E R V E N T I O N G R O U P A N D B Y O C C U P A T I O N A L G R O U P O N I T E M S 1 T H R O U G H 6 O F T H E C S I 28 I V C O M P A R I S O N O F M E A N R E V I S E D G A I N S C O R E S B Y I N T E R V E N T I O N G R O U P A N D B Y O C C U P A T I O N A L G R O U P O N I T E M S 2, 3, 5, A N D 6 O F T H E C S I 29 V C O M P A R I S O N O F G R O U P M E A N G A I N S C O R E S O N I N D I V I D U A L I T E M S , A N D T W O - W A Y A N O V A 30 v VI RAW SCORES BY INDIVIDUAL SUBJECT FOR ITEMS 7 THROUGH 11 OF THE CSI 31 VII TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR INDIVIDUAL ITEMS 7 THROUGH 11 OF THE CSI . 32 VIII TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR ITEMS 7 THROUGH 11 OF THE CSI . . . . . . 33 IX TOTAL OBSERVED USES OF STRATEGIES 7 THROUGH 11 DIVIDED BY TOTAL OPPORTUNITIES FOR USE, BY INTERVENTION GROUP AND OBSERVATION INTERVAL AND CHI—SQUARE DISTRIBUTION TEST . 3 4 v i L I S T OF FIGURES F I G U R E S PAGE 1 COMPARISON OF IMPROVEMENT IN GROUP MEAN PERFORMANCE ON ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX . . . . 35 2 FREQUENCY OF STRATEGY USE (ITEMS 7 THROUGH 11) NORMALIZED FOR EXPERIMENTAL AND CONTROL GROUPS 36 vi i CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW Communication e f f ect i veness i s the goal and purpose o-f a l l i n t e r v e n t i o n i n the area o-f communication d i s o r d e r s . The a u d i o l o g i s t s p e c i a l i z i n g i n a u r a l r e h a b i l i t a t i o n f o r the hard of he a r i n g c l i e n t has a number of i n t e r v e n t i o n s t r a t e g i e s a v a i l a b l e t o achieve t h i s g o a l , i n c l u d i n g h e a r i n g a i d e v a l u a t i o n and f i t t i n g , a s s i s t i v e l i s t e n i n g d e v i c e s , c o u n s e l l i n g , and communication t r a i n i n g . Most of these i n t e r v e n t i o n s t r a t e g i e s f o c u s on the communication d i s o r d e r as the c l i e n t ' s problem, and management of the communication d i s o r d e r as the c l i e n t ' s r e s p o n s i b i l i t y . However, communication by d e f i n i t i o n takes p l a c e when a message i s sent and r e c e i v e d ; thus t h e r e are a number of v a r i a b l e s which may i n f l u e n c e the e f f e c t i v e n e s s of a communication attempt. The usual mode of communication, speech, w i l l i n c l u d e at l e a s t the f o l l o w i n g f o u r v a r i a b l e s : speaker, message, environment, and l i s t e n e r (Sanders, 1982). Most r e h a b i l i t a t i v e e f f o r t s i n a u d i o l o g y are aimed at improving the hard of he a r i n g l i s t e n e r ' s e f f e c t i v e n e s s i n r e c e i v i n g / p e r c e i v i n g the message; t h i s goal i s accomplished by the use of a m p l i f i c a t i o n and a s s i s t i v e l i s t e n i n g d e v i c e s , 1 and by t r a i n i n g the hard o-f hearing l i s t e n e r to maximise communication s k i l l s , repa ir s t ra teg ie s , and assert iveness . The speaker's r o l e , which i s the o r i g i n o-f the spoken message, (and the one -factor in the above l i s t of var iab les which can exercise control over many aspects of the message) i s more often than not ignored in t h i s process, or at best considered in a passive manner. For example, the use of an FM system requires the hard of hearing l i s t e n e r to ask the speaker to wear the microphone/sender component while continuing to speak in t h e i r normal manner. The use of a personal hearing a id involves only the hard of hearing l i s t e n e r . On the other hand, communication t r a i n i n g in the form of aural r e h a b i l i t a t i o n c lasses or i n d i v i d u a l therapy sessions often includes the communication partner as a des i rab le and act ive p a r t i c i p a n t in the process. The importance of inc luding "s ign i f i cant others" in the aural r e h a b i l i t a t i o n process i s at least twofold: f i r s t l y , the family members and f r i ends of the c l i e n t learn about the nature of the communication disorder and have the opportunity to develop better understanding of the c l i e n t ' s f r u s t r a t i o n s in d i f f i c u l t s i t u a t i o n s , thereby easing the tension of misunderstanding and unreal expectations within these r e l a t i o n s h i p s . Secondly, some of the r e s p o n s i b i l i t y of communicating e f f e c t i v e l y may be appropr iate ly sh i f t ed from the hard of hearing c l i e n t to the communication partner , thereby reducing the burden -for the c l i e n t while at the same time opening more avenues -for achieving the goal , e f f ec t i ve communication. For the audio log i s t working with the i n s t i t u t i o n a l i z e d g e r i a t r i c populat ion, the p o s s i b i l i t y of invo lv ing and target ing communication partners may present a so lu t ion to a number of problems inherent to t h i s populat ion. That i s , the p r a c t i c a b i l i t y of the usual methods of hearing evaluat ion , hearing a id f i t t i n g s , etc , i s diminished when faced with the d i f f i c u l t i e s of mobi l i ty , access to the hearing c l i n i c , and l imi ted at tent ion span for sound booth evaluat ions . In f a c t , many hard of hearing nursing home res idents are not appropriate candidates, e i ther p h y s i c a l l y or emotionally, as f i r s t time users of prosthet ic devices such as hearing a ids (Shore, 1979; Oyer and Oyer, 1980). The high incidence of s i g n i f i c a n t hearing loss among the e l d e r l y population i s well documented. Nursing home res idents in p a r t i c u l a r have a high incidence of communication d i sorders ; approximately 82 "/. have a s i g n i f i c a n t hearing loss (Schow and Nerbonne, 1980). While r e h a b i l i t a t i o n of acquired hearing impairment i n the general population cons is ts -mainly of ampl i f i ca t ion and counse l l ing , these measures may be inappropriate and/or i n s u f f i c i e n t for the i n s t i t u t i o n a l i z e d e l d e r l y person. Communication e f fect iveness , however, must continue to be the c l i n i c i a n ' s goal -for t h i s p o p u l a t i o n . At a time i n l i f e when a c t i v e r o l e s i n the work f o r c e and o f t e n i n the f a m i l y are no longer p o s s i b l e , communication and s o c i a l i z a t i o n take on new importance as v e h i c l e s f o r l i f e f u l f i l l m e n t . However, the e l d e r l y o f t e n experience an impoverished communication environment w i t h i n the i n s t i t u t i o n a l s e t t i n g ; t a k i n g on the p a s s i v e r o l e of p a t i e n t , l i v i n g i n c l o s e q u a r t e r s with v i r t u a l s t r a n g e r s , depending on s t a f f who may seem u n f r i e n d l y , a re a l l f a c t o r s which c o n t r i b u t e t o a lack of t a l k i n g and s o c i a l i z a t i o n i n the n u r s i n g home ( L u b i n s k i , 1981). The hea r i n g impaired i n d i v i d u a l i n t h i s s i t u a t i o n must be p a r t i c u l a r l y i n danger of a u d i t o r y d e p r i v a t i o n . Oyer and Oyer (1980) l i s t no l e s s than 14 d e t r i m e n t a l s o c i a l consequences of a u d i t o r y d e p r i v a t i o n i n o l d e r people, i n c l u d i n g f a t i g u e , i n c r e a s e d endangerment t o b o d i l y s a f e t y , d e p r e s s i o n , and a c t i n g upon m i s i n f o r m a t i o n . In t h i s context, s h i f t i n g of some of the r e s p o n s i b i l i t y of e f f e c t i v e communication t o the p a r t n e r s or c a r e g i v e r s i s not onl y an a p p r o p r i a t e goal of i n t e r v e n t i o n , but p o s s i b l y a necessary one ( L u b i n s k i , 1988). In many extended care f a c i l i t i e s , the c a r e g i v e r s of the i n s t i t u t i o n a l i z e d e l d e r l y o f t e n i n c l u d e the n u r s i n g and r e h a b i l i t a t i o n s t a f f , who become important communication p a r t n e r s . The content of the communication between r e s i d e n t s and c a r e g i v e r s ( g i v i n g i n f o r m a t i o n and i n s t r u c t i o n s , and 4 asking q u e s t i o n s d u r i n g v a r i o u s personal care a c t i v i t i e s ) i s v i t a l t o the q u a l i t y of care provided t o n u r s i n g home r e s i dents. S a r v e l a et a l (1989), i n a study which compared the knowledge of extended care s t a f f by t h e i r o c c u p a t i o n , found that many c a r e g i v e r s are not aware of b a s i c i n f o r m a t i o n r e g a r d i n g the needs of p a t i e n t s who have communication d i s o r d e r s . While " t h e r a p i s t s " i n the study scored the hi g h e s t of the 11 o c c u p a t i o n a l groups examined, " a i d e s " ( i n c l u d i n g nurses' aides) scored the lowest. The authors of t h i s study suggested t h a t t r a i n i n g programs, such as i n s e r v i c e s , which f o c u s on communication d i s o r d e r s and s t r a t e g i e s t o overcome the problems faced when i n t e r a c t i n g with communication impaired r e s i d e n t s , are necessary t o ensure q u a l i t y c a r e — g i v i n g . S p e c i f i c s t r a t e g i e s t o be used by communication p a r t n e r s of hard of he a r i n g people t o f a c i l i t a t e e f f e c t i v e n e s s have been o u t l i n e d i n the a u r a l r e h a b i l i t a t i o n l i t e r a t u r e (e.g. Rezen and Hausman, 1985, p 58; Rupp, 1980, pp. 174 - 176; Schow et a l , 1978, p. 394; Shore, 1979, pp. 190 — 191). Many of these s t r a t e g i e s are based on common sense and c l i n i c a l e xperience; they i n c l u d e simple behaviours such as ensuring the hard of h e a r i n g l i s t e n e r can see the speaker's f a c e , a v o i d i n g d i s t r a c t i o n s such as smoking or chewing gum, minimizing d i s t a n c e between p a r t n e r s , u s i n g normal or s l i g h t l y louder than normal v o i c e , speaking c l e a r l y but without exaggeration, g e t t i n g the l i s t e n e r ' s a t t e n t i o n and e s t a b l i s h i n g a t o p i c be-fore c o n t i n u i n g the c o n v e r s a t i o n . These behaviours are a p p r o p r i a t e -for each and every i n t e r a c t i o n with a hard o-f hearing l i s t e n e r , and r e q u i r e o n l y that the speaker i s aware o-f the d i f f i c u l t y -faced by the hea r i n g impaired l i s t e n e r and i s w i l l i n g t o accept some o-f the r e s p o n s i b i l i t y f o r e f f e c t i v e communication. Other s t r a t e g i e s , which require? an a c t i o n o n l y i f they are a p p r o p r i a t e , i n c l u d e environmental f a c t o r s (e.g, ens u r i n g enough l i g h t i s on the speaker's f a c e , minimizing background noise) and r e p a i r s t r a t e g i e s (e.g.. checking l i s t e n e r understanding, r e p h r a s i n g key words). These communication s t r a t e g i e s , along with b a s i c i n f o r m a t i o n about communication d i s o r d e r s i n the e l d e r l y , seemed a p p r o p r i a t e f o r i n c l u s i o n i n c o n t i n u i n g education programs f o r extended care s t a f f . T h i s study was designed t o e v a l u a t e one such e d u c a t i o n a l program as an e f f e c t i v e means of t r a n s f e r i n g i n f o r m a t i o n and s k i l l s t o those s t a f f who need i t most ( i . e . , those who have l i t t l e knowledge about communication d i s o r d e r s , yet are faced with the task of communicating with e l d e r l y r e s i d e n t s d a i l y ) , and to ev a l u a t e s t a f f a b i l i t y t o implement the d e s i r e d s k i l l s i n t h e i r i n t e r a c t i o n with the r e s i d e n t s . 6 While the outcome o-f continuing education includes both -formal learning and actual performance of new behaviours, the goal of continuing education in health care i s to change behaviour (Cervero, 1985). Thus a program evaluat ion must consider 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 within t h e i r working environments, taking into account such var iab le s as the nature of the change and the receptiveness of the soc ia l system to change (Peden et a l . , 1990). One attempt to teach communication s tra teg ies to pat ient care aides used a videotape which out l ined the behaviours and i l l u s t r a t e d each as used by a communication partner and an e l d e r l y person (Purves and Brooks, 1987). This study evaluated the success of the video presentation by t e s t ing the patient care aides before and af ter viewing the video. The test consisted of a simulated i n t e r a c t i o n between the subject (patient care aide) and a volunteer hearing impaired res ident , in which the subject was required to read 10 sentences to the l i s t e n e r , and have the sentences repeated back, while an observer scored a c h e c k l i s t of the s t ra teg ie s that had been presented in the video. The r e s u l t s indicated that subjects were able to implement the targeted s t ra teg ie s in the simulated context. The Purves and Brooks study was an attempt at teaching and evaluat ing strategy use among s ta f f , however, i t was not 7 c lear whether the subjects were able to general ize the des irable behaviours to everyday natural s i t u a t i o n s , where caregiv ing a c t i v i t i e s were the intent o-f the i n t e r a c t i o n . Extended care sta-f-f are o-f ten pressed -for time, having many pat ients and r e s p o n s i b i l i t i e s to attend to? i t i s poss ib le that they encounter c o n f l i c t between achieving quality of care (such as ensuring e f f ec t i ve communication) or quantity of care, p a r t i c u l a r l y i f they perceive that using special communication s tra teg ies i s time-consuming or d i f f i c u l t to incorporate in to rout ine dut ies . The present study was an extension of the Purves and Brooks study, in that i t attempted to document the a b i l i t y of extended care s ta f f to general ize the use of communication s t ra teg ie s in t h e i r everyday r o l e s as pat ient care aides, and r e h a b i l i t a t i o n s t a f f . It d i f f ered from the previous study in that i t attempted to take in to account the var iab le s in f luenc ing performance (such as the d e s i r a b i l i t y and ease of the behaviour change, and motivation to implement change). While i t did not attempt to measure the actual fac tors in f luenc ing performance, i t did attempt to measure the outcome of a l l the fac tors by evaluating the p a r t i c i p a n t s in t h e i r work environment. 8 Purpose The purpose of t h i s study was t o e v a l u a t e an i n s e r v i c e program which was designed t o inform and educate n u r s i n g home s t a f f about the adverse e f f e c t s of hearing l o s s and use of communication s t r a t e g i e s t o overcome such e f f e c t s . The f o l l o w i n g r e s e a r c h question guided the study: Are n u r s i n g home c a r e g i v e r s a b l e t o become more e f f e c t i v e as communication p a r t n e r s of e l d e r l y r e s i d e n t s at r i s k f o r hea r i n g impairment, as a r e s u l t of p a r t i c i p a t i n g i n an e d u c a t i o n a l i n s e r v i c e ? 9 CHAPTER 2 METHODS Subjects The subjects in t h i s study were 17 nursing s ta f f and r e h a b i l i t a t i o n s ta f f at the extended care f a c i l i t y of the UBC Health Sciences Centre H o s p i t a l . These two departments (nursing and r e h a b i l i t a t i o n ) include reg i s tered nurses, pat ient care aides (PCAs), phys iotherapis t s , occupational therap i s t s , and r e h a b i l i t a t i o n aides . The inves t igator recru i t ed s ta f f members to p a r t i c i p a t e in the study during r e g u l a r l y scheduled s ta f f meetings. Nineteen s ta f f members, of which 12 were nursing s taf f and 7 were r e h a b i l i t a t i o n s t a f f , volunteered to p a r t i c i p a t e in the study. Each voluntary subject signed and received a copy of a consent form (see Appendix A) . The consent form indicated that the subjects would not be n o t i f i e d of the exact nature of the observations u n t i l after completion of data c o l l e c t i o n . P a r t i c i p a n t s were aware, however, of the general nature of the study ( i . e . , the study was about i n t e r a c t i o n between s ta f f and pa t i en t s ) , and that the student inves t igator was an audiology and speech sciences student. After the data c o l l e c t i o n was completed, a short 10 s c r e e n i n g q u e s t i o n n a i r e was administered t o each s u b j e c t (see Appendix B) . The purpose o-f t h i s s c r e e n i n g procedure was t o identi-fy those s u b j e c t s at r i s k -for h e a r i n g l o s s and to exclude any s u b j e c t s so i d e n t i f i e d from the study. None of the 17 s u b j e c t s who completed the study i n d i c a t e d any s i g n i f i c a n t r i s k f a c t o r s f o r h e a r i n g l o s s d u r i n g the p e r i o d covered by the study. The s u b j e c t s who completed the study c o n s i s t e d of s i x r e h a b i l i t a t i o n s t a f f ( i n c l u d i n g t h r e e o c c u p a t i o n a l t h e r a p i s t s , one p h y s i c a l t h e r a p i s t , and two r e h a b i l i t a t i o n aides) and i l n u r s i n g s t a f f , a l l of whom were c l a s s i f i e d as FCAs. E!?12£5dkl!iss General_orgcedures. T h i s study employed a repeated measurements desi g n . The dependent v a r i a b l e , use of s p e c i f i c communication s k i l l s , was measured twice f o r a l l s u b j e c t s . The f i r s t o b s e r v a t i o n , b e f o r e the i n s e r v i c e took p l a c e , c o n s t i t u t e d the b a s e l i n e measure; a second measurement was obtained a f t e r the i n s e r v i c e . One group of s u b j e c t s , the experimental group, was exposed t o i n s e r v i c e education, while the c o n t r o l group d i d not r e c e i v e any i n t e r v e n t i o n . S u b j e c t s were assig n e d t o the groups on the b a s i s of whether or not they attended the scheduled i n s e r v i c e . At the time of a l l measurements, the investigator—observer was b l i n d to the status o-f each subject; only af ter the invest igator had completed the data c o l l e c t i o n did she rece ive the inserv ice attendance record . Thus the inserv i ce and the evaluation of the inserv ice were conducted independently. It i s important to note that the subjects were not aware that the purpose of the observations was to evaluate the e f fect of the i nservi ce. Inseryi Lce_prgcedures. The audio log i s t on s ta f f at the extended care f a c i l i t y presented an inserv i ce on the topic of hearing loss among nursing home res idents , adverse e f fec t s of hearing loss , and s tra teg ies to use when conversing with a hard of hearing person (see Appendix C ) . The s ta f f audio log i s t determined the s t y l e and manner of information presented during the inserv ice with attent ion given to the audience in question; t h i s include playing an audiotape which simulated varying degrees of hearing loss , and an informal d iscuss ion of techniques that can be used in managing d i f f i c u l t communication s i t u a t i o n s . The main goal of t h i s i n s e r v i c e program was to r a i s e awareness of hearing loss and to encourage s ta f f to use a l l poss ib le means to overcome problems due to hearing loss . Thus, the emphasis was on d i s p e l l i n g myths about hearing loss ( e .g . , that hearing loss in e l d e r l y i s corre la ted with cogni t ive 12 d e - F i c i t ) . and on t e a c h i n g c o n s t r u c t i v e ways to communicate with hard o-f h e a r i n g p a t i e n t s . The a u d i o l o g i s t was aware o-f which communication behaviours were being evaluated, and ensured t h a t a l l o-f the d e s i r e d s t r a t e g i e s were presented d u r i n g the i n s e r v i c e . T h i s i n s e r v i c e was o f f e r e d t o a l l s t a f f members of the extended care f a c i l i t y . However, because some of the n u r s i n g s t a f f were r e q u i r e d t o remain on ward at a l l times, and because many n u r s i n g s t a f f work i r r e g u l a r hours, not a l l PCA s u b j e c t s had the o p p o r t u n i t y to attend the i n s e r v i c e . Measurement OLgcedures. The i n v e s t i g a t o r used a n a t u r a l i s t i c o b s e r v a t i o n t o o l t o measure b e h a v i o u r a l changes as a r e s u l t of the independent v a r i a b l e ( i . e . , the i n s e r v i c e e d u c a t i o n ) . T h i s procedure was chosen f o r the purpose of e v a l u a t i n g the a c t u a l performance a b i l i t i e s , r a t h e r than formal l e a r n i n g , of s u b j e c t s as a r e s u l t of i n s e r v i c e p a r t i c i pat i on. The o b s e r v a t i o n t o o l (see Appendix D) c o n s i s t e d of a l i s t of b e h a v i o u r a l c r i t e r i a which are c o n s i d e r e d by c l i n i c i a n s t o be h e l p f u l s t r a t e g i e s i n improving communication with hard of hearing p a r t n e r s (e.g. Rezen and Hausman, 1985; Rupp, 1930; Schow et a l , 1978; Shore, 1979). The t o o l was designed f o r s c o r i n g the behaviour of the normal—hearing c a r e g i v e r while i n t e r a c t i n g with a hard of h e a r i n g e l d e r l y r e s i d e n t d u r i n g n o r m a l work d u t i e s . The b e h a v i o u r a l o b s e r v a t i o n s were d i v i d e d i n t o two c a t e g o r i e s : - f i r s t , t h o s e s t r a t e g i e s w h i c h a r e a l w a y s a p p r o p r i a t e , and s e c o n d T t h o s e t h a t a r e o n l y a p p r o p r i a t e u n d e r some c i r c u m s t a n c e s ( s u c h a s r e d u c i n g b a c k g r o u n d n o i s e , w h i c h i s a p p r o p r i a t e o n l y when t h e r e i s n o i s e t o b e g i n w i t h ) . T h i s d i v i s i o n r e f l e c t s t h e - f a c t t h a t communication b e h a v i o u r s o c c u r w i t h i n a d y n a m i c environment, and t h a t c o m m u n i c a t i o n p a r t n e r s h a v e t o make c h o i c e s about using a p p r o p r i a t e s t r a t e g i e s t o ensure e-f-ficient communication. The d i v i s i o n a f f e c t s the s c o r i n g procedure and a n a l y s i s ; while a l l items i n the f i r s t c a t e g o r y were scored f o r each measurement, items i n the second category were scored o n l y as the o p p o r t u n i t y to use a given s t r a t e g y occured. The o b s e r v a t i o n t o o l , or Communication S t r a t e g y Index, evolved f r o m an e a r l y v e r s i o n to the f i n a l v e r s i o n r e p o r t e d here, by means of a p i l o t phase of data c o l l e c t i o n f o r the purpose of e s t a b l i s h i n g i n t e r - r a t e r r e l i a b i l i t y ( reported below). Scgring_Procedures The items i n P a r t A of the t o o l (see Appendix D) were scored on a t h r e e - p o i n t system t h a t r e f l e c t s the degree to which each behaviour was d i s p l a y e d . Each s t r a t e g y i n the f i r s t c ategory was scored as t o whether i t was used c o n s i s t e n t l y (2), used i n c o n s i s t e n t l y <1), o r n o t used at a l l (0). F o r a l l s i x items i n P a r t A, the s c o r e 14 range was -from a minimum of 0 to a maximum o-f 12 . The three—point system was designed -for speed and r e l i a h l i l i t y in scoring communication behaviour in natural s e t t ings . A l t e r n a t i v e s c a l i n g , that i s four points or more, would have allowed more s e n s i t i v i t y in scoring the degree of behaviour consistency by inc luding further r a t i n g s , such as "used most of the time". However, as a r e s u l t of experiencing some d i f f i c u l t y in achieving r e l i a b i l i t y during the p i l o t measurements, a three-point scale was the better a l t erna t i ve. Each item in the second category was scored as to whether or not the opportunity to use the strategy arose, and whether or not the strategy was in fact used (see Appendix D). The second category allowed the p o s s i b i l i t y for a score of 0 uses of a strategy out of 0 opportuni t ies to use that s trategy. The scores for t h i s part of the measurement were normalized by adding a l l observed uses of s t ra teg ie s (a l l occurrences of scores of 2) within an intervent ion group, and d i v i d i n g by a l l opportuni t ies for strategy use (a l l occurrences of scores of 1 or 2) within the same group, to allow s t a t i s t i c a l ana lys i s . R e l i a b i l i t y E'!I9c§?dures A p i l o t phase of data c o l l e c t i o n was carried out to prac t i ce the measurement procedures and to determine i n i t i a l r e l i a b i l i t y . Two observers (the researcher and a volunteer audio logis t ) watched and scored 8 in t erac t ions between caregivers and patients in a di-f-ferent extended care f a c i l i t y . Agreement between the two observers on the items in an ear ly version of the measurement tool ranged from 37.57. to 100% (see Appendix E> . It was c lear that items with poor r e l i a b i l i t y ( including bod1/ 1 anguage. and physical contact) e i ther could not be used or needed to be redefined and pract iced further to achieve better r e l i a b i l i t y . Appendix D presents the items that were used in the f i n a l measurement t o o l . During the f i n a l data c o l l e c t i o n phase, 6 of the 34 in terac t ions were observed and scored by both observers, in order to assess r e l i a b i l i t y of the revised measurement t o o l . The f i n a l r e l i a b i l i t y data are presented in Appendix E , note that the des i rab le i n t e r - r a t e r agreement (85%, as suggested by Chambers and Blum, 1988) was approximated for only 7 of the 11 items. Although some of the scoring di f ferences between observers was subjec t ive , there was a tendency for one observer to score more s t r i c t l y than the other ( i . e . , one observer required 1007. s trategy use for a score of 2, while the other observer accepted 90% strategy use for the same score) . This systematic d i f ference between the ra ters could have been el iminated with further p r a c t i c e , suggesting that the actual r e l i a b i l i t y for the f i n a l data was better than the f igures in Appendix E ind ica te . 16 R e 5 e a r c h _ g u e s t i g n s T h e g e n e r a l r e s e a r c h q u e s t i o n p o s e d a t t h e e n d o-f C h a p t e r 1 w a s : D o e s i n s e r v i c e p a r t i c i p a t i o n i n c r e a s e c a r e g i v e r s ' a b i l i t y t o u s e s p e c i - f i c c o m m u n i c a t i o n s t r a t e g i e s m o r e c o n s i s t e n t l y ? T h i s q u e s t i o n may now b e r e s t a t e d m o r e s p e c i f i c a l l y t o r e f l e c t t h e m e t h o d o l o g y u s e d i n t h i s s t u d y : i . A r e t h e r e s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e g a i n s c o r e s ( i t e m s 1 t h r o u g h 6) o f t h o s e s u b j e c t s who w e r e e x p o s e d t o t h e i n s e r v i c e ( e x p e r i m e n t a l g r o u p ) a n d t h o s e s u b j e c t s who w e r e n o t e x p o s e d t o t h e i n s e r v i c e ( c o n t r o l g r o u p ) ? i i . Do s i g n i f i c a n t d i f f e r e n c e s e x i s t b e t w e e n t h e g a i n s c o r e s ( i t e m s 1 t h r o u g h 6) o f P C A s a n d t h o s e o f t h e r e h a b i l i t a t i o n s t a f f ? i i i . A r e t h e r e s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s o n t h e p r e - a n d p o s t - i n t e r v e n t i o n f r e q u e n c y d i s t r i b u t i o n s c o r e s ( i t e m s 7 t h r o u g h I D ? 17 CHAPTER 3 RESULTS The purpose o-f t h i s study was to evaluate the e-f-f ec t i veness o-f an inserv i ce procedure in teaching extended care s ta f f the use o-f s p e c i f i c communication s t ra teg ie s to increase e f f ec t i ve communication with res idents . The data were s t a t i s t i c a l l y analysed to determine i f s i g n i f i c a n t d i f ferences existed in use of communication s t ra teg ie s between subjects who were exposed to the i n s e r v i c e and subjects who were not exposed to the i n s e r v i c e . In ferent ia l s t a t i s t i c a l procedures employed to answer the research questions were the t - t e s t for independent samples, ana lys i s of variance (ANOVA), and the Chi-Square d i s t r i b u t i o n t e s t . For a l l analyses, a 95% confidence leve l was selected to re j ec t the n u l l hypothesis (p < .05) . Items in Part I (#1 to #6, inc lus ive ) of the Communication Strategy Index were used to c a l c u l a t e gain scores which were analyzed s t a t i s t i c a l l y ; items in F'art II (#7 to #11) were considered separate ly . Ins§!iyice_DarticiDation Of the 11 PCAs who volunteered as subjects , only one (9 V.) a c t u a l l y attended the inserv ice ; 13 while 67 7. of the 6 rehabi 1 i at i on subjects attended the i n s e r v i c e . This di-f-ference introduced a con-found in the make—up o-f the control and experimental groups, s ince there were l i k e l y to be educational and vocational d i f ferences present between these groups p r i o r to the onset of t h i s study. The inserv ice attendence d i f ference also ra i sed the issue of larger patterns of continuing education among extended care f a c i l i t y s ta f f : while most rehabi1 ia t ion s taf f (who make up a small part of the t o t a l d i r e c t care s taf f ) seemed to be attending inserv i ce s , PCAs were attending s p o r a d i c a l l y at best, based on t h i s study. This was l i k e l y due in part to the fact that r e h a b i l i t a t i o n s ta f f have regular daytime schedules and are able to take time away from other dut ies as a group for the purpose of attending i n s e r v i c e s . Another factor which may have contributed to d i f ferences in inserv i ce attendance between the two occupational groups was the p o s s i b i l i t y of a higher l eve l of motivation or in teres t on the part of r e h a b i l i t a t i o n s ta f f as opposed to PCAs. G a i n S c g r e s Table 1 presents both the raw scores and the gain scores achieved by each subject . The raw scores re fer to the l eve l of use of each strategy during the course of an observat ion, thus, the minimum score (0) r e f l e c t s no observed use of the spec i f i ed s trategy, while the maximum 19 s c o r e (2) r e f l e c t s c o n s i s t e n t use of the s t r a t e g y throughout the p e r i o d of o b s e r v a t i o n . A s c o r e of 1 r e f e r s t o some, or i n c o n s i s t e n t , use of the s t r a t e g y . The gain s c o r e r e f l e c t s any change i n a s u b j e c t ' s performance between the b a s e l i n e (01) and the second o b s e r v a t i o n (02), f o r items one through s i x i n c l u s i v e on the measurement t o o l . The maximum sc o r e a s u b j e c t c o u l d a t t a i n f o r each o b s e r v a t i o n was 12; the minimum was zero. I n d i v i d u a l s c o r e s f o r a given o b s e r v a t i o n ranged from four ( s u b j e c t s N12 and N17 f o r 01) to 12 (subject Rl f o r 02). The average gain s c o r e f o r the experimental group was 1.2, while the average g a i n s c o r e f o r the c o n t r o l group was 1.25. A n a l y s i s of mean ga i n s c o r e s by i n t e r v e n t i o n group i n d i c a t e s the d i f f e r e n c e was not s i g n i f i c a n t (see Table 2). A comparison of mean gain s c o r e s by occupation of the s u b j e c t s ( r e h a b i l i t a t i o n vs. PCA) was a l s o n o n s i g n i f i c a n t . Basel^ne_Scores Table 3 compares the mean b a s e l i n e performance of the experimental group with t h a t of the c o n t r o l group, and the mean b a s e l i n e performance of the r e h a b i l i t a t i o n s u b j e c t s with t h a t of the PCA s u b j e c t s . N e i t h e r comparison reached s i g n i f i c a n c e u s i n g the t - t e s t f o r independent samples. However, the mean b a s e l i n e s c o r e of the experimental group i s c l o s e r t o the maximum a c h i e v a b l e score of 12 than t h a t of the c o n t r o l group, i n d i c a t i n g a c e i l i n g 20 ef fect -for the experimental group. While the overa l l improvement potent ia l o-f the experimental group was l imi ted to a maximum o-f 3 points , the control group performance could have improved by up to 4.S4 points be-fore reaching c e i l i n g . Thus, the d i f ference in basel ine performance, while not being s i g n i f i c a n t in i t s e l f , ind ica tes a greater c e i l i n g effect on the gain scores of the experimental group than of the control group. 0^yised_Gai_n_Scgres To minimize the c e i l i n g ef fect of the high basel ine performances, a revised gain score was es tab l i shed . The two items which showed highest basel ine scores (items 1 and 4) were removed for the c a l c u l a t i o n of the revised gain score. Basel ine performance on both items 1 and 4 indicated that fewer than 50% of a l l subjects had opportunity for improvement (see Table 1), and thus scores for these two items could have l i t t l e , i f not any, e f fect on increas ing the mean gain scores . Table 4 presents the mean revised gain scores by intervent ion group and by occupational group. No s i g n i f i c a n t d i f ferences were found on e i ther of the comparisons. Item Analys i s To explore the p o s s i b i l i t y that ind iv idua l items were more s ens i t i ve to change than the combined s e n s i t i v i t y of a l l items together, an item ana lys i s 21 was per-formed. Gain scores for the i n d i v i d u a l items (1 through 6) were ca lcu lated and averaged within the experimental and control groups (see Table 5) . The gain scores -for ind iv idua l items ranged -from a poss ib le maximum o-f 2 to a poss ib le minimum o-f -2; the actual mean gain scores -for ind iv idua l items by intervent ion group ranged •from a maximum of .4 (items 3 and 5 for the experimental group) to a minimum of - .08 (item 1 for the control group). Two—way ana lys i s of variance (item x group), with repeated measure on item, was c a r r i e d out to analyze poss ib le s e n s i t i v i t y to change of performance as a funct ion of item and group. No s i g n i f i c a n t main e f fec t s nor s i g n i f i c a n t i n t e r a c t i o n (item x group) were found (see Table 5) . Items_7_thrgugh_ii The raw scores for the items which were not used in c a l c u l a t i n g gain scores are presented in Table 6. The scoring of these items d i f f ered from the scoring of items 1 to 6: a r a t i n g of 0 indicated no opportunity to use that p a r t i c u l a r strategy during the observat ion; a r a t i n g of 1 indicated that the subject had an opportunity but did not d i sp lay the behaviour; a r a t i n g of 2 indicated that the subject used the strategy appropriate ly during the observat ion. Thus, the scoring r e f l e c t s the opportunity for using these s t ra teg ie s compared with the a c t u a l observed a p p r o p r i a t e use o-f the s t r a t e g i e s . In Table 7, the t o t a l number o-f s e s s i o n s i n which a s t r a t e g y was used a p p r o p r i a t e l y i s compared with the t o t a l number of s e s s i o n s i n which an o p p o r t u n i t y t o use a s t r a t e g y a p p r o p r i a t e l y o ccurred, f o r i n d i v i d u a l items. Note t h a t some items were more o f t e n a p p r o p r i a t e f o r use than o t h e r s : there were twice as many o p p o r t u n i t i e s f o r use f o r items 9 and 10 than any other items. In Table 8, the t o t a l number of s t r a t e g y o b s e r v a t i o n s i s compared with the t o t a l number of s t r a t e g y o p p o r t u n i t i e s f o r the two i n t e r v e n t i o n groups and the two o c c u p a t i o n a l groups. Note t h a t both o p p o r t u n i t y f o r use and a c t u a l o b s e r v a t i o n s are higher f o r the experimental group than the c o n t r o l group, d e s p i t e the d i f f e r e n c e i n group s i z e . T h i s d i f f e r e n c e i s even g r e a t e r between the o c c u p a t i o n a l groups, sugges t i n g t h a t the o p p o r t u n i t y t h a t a s u b j e c t has t o use such s t r a t e g i e s may be determined i n p a r t by t h e i r o c c u p a t i o n or job d u t i e s . In order t o perform s t a t i s t i c a l a n a l y s i s on these data, the raw s c o r e s were normalized f o r each i n t e r v e n t i o n group f o r each o b s e r v a t i o n by comparing the number of 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 with the number of observed 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 — t h a t i s , a l l occur r e n c e s of s c o r e s of 2 were added together and d i v i d e d by a l l occurrences of s c o r e s of 1 or 2 added together (see Table 9 ) . 23 Chi—square D i s t r i b u t i o n a n a l y s i s o-f the data was s i g n i f i c a n t (p < .05), i n d i c a t i n g unequal frequency d i s t r i b u t i o n of d e s i r e d s t r a t e g y usage as a f u n c t i o n of i n t e r v e n t i o n group x o b s e r v a t i o n i n t e r v a l . Summary o f . R e s u l t s Items 1 through 6 on the Communication S t r a t e g y Index d i d not r e v e a l any s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between i n t e r v e n t i o n groups as a r e s u l t of i n s e r v i c e exposure. F i g u r e 1 i l l u s t r a t e s the main f i n d i n g s f o r t h i s p a r t of the data: i . performance on the f i r s t 6 items i n c r e a s e d between the b a s e l i n e o b s e r v a t i o n and the second o b s e r v a t i o n by a comparable amount f o r the experimental group and the c o n t r o l group; and i i . the experimental group mean performance was higher than the c o n t r o l group mean performance at both i n t e r v a l s . Items 7 through 11 on the Communication S t r a t e g y Index i n d i c a t e d a s i g n i f i c a n t i n c r e a s e ( 45% ) i n the use of d e s i r a b l e behaviours by the experimental group as compared with the decrease ( - 147. ) i n use of s p e c i f i c behaviours by the c o n t r o l group. F i g u r e 2 i l l u s t r a t e s the change i n performance between the b a s e l i n e o b s e r v a t i o n and the second 24 o b s e r v a t i o n -For the two i n t e r v e n t i o n groups, based on r a t e o-f s t r a t e g y use given the o p p o r t u n i t y -for use. Table 1 RAW SCORES AND GAIN SCORES BY INDIVIDUAL SUBJECTS FOR ITEMS 1 THROUGH 6 OF THE COMMUNICATION STRATEGY INDEX fi^E^Ci m?Dt§I_GrguB (N = 5) Observation 1 Observation 2 Gain Score Item:l 2 3 4 5 6 t o t a l 1 2 3 4 5 6 t o t a l (02-01) Rl 1 1 1 •~y 1 2 8 2 2 2 12 4 R2 1 1 1 O 1 1 7 2 1 1 T> 1 9 2 R4 *-\ 1 1 *? 1 "7 9 1 1 1 '-v 1 2 8 -1 R6 2 1 1 10 2 2 2 2 1 11 1 N9 2 2 2 2 2 1 11 1 2 2 2 ^ _ 2 11 0 C o n t r o l _Grgup. <N = 12) Observation 1 Observation 2 Gain Score Item: 1 2 3 4 5 6 t o t a l 1 2 3 4 5 6 t o t a l (02-R3 1 1 2 1 2 9 2 2 1 2 •? 1 10 1 R5 *-» 1 2 1 1 9 2 1 1 2 <-> JL- 2 10 1 N7 1 1 1 0 7 2 2 r> 2 1 1 10 3 N8 1 1 1 2 1 0 6 2 1 1 0 1 1 6 0 N10 1 1 1 2 1 1 7 1 1 1 2 1 2 8 1 Nl 1 2 2 1 1 2 1 9 2 1 1 2 1 1 8 -1 N12 1 1 1 1 0 0 4 2 2 2 2 1 1 10 6 N13 2 1 1 1 1 1 7 1 1 1 2 o 0 7 0 N14 2 1 1 2 1 0 7 1 1 1 2 2 2 9 2 N15 2 1 1 2 2 1 9 1 1 1 2 1 0 6 -3 N16 2 1 1 2 1 1 8 2 2 2 2 1 2 11 N17 1 1 1 1 0 0 4 1 1 1 1 1 1 6 2 26 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 S. D. t-v a l Lie d. f , SIG? (p<0.05) Experimental 1.2 (N=5) 1. 72 -.05 NO (p = .96) Con t r o l (N=12) 1. 21 : . ^ 6 Rehab (N=6> PCA (N=l1) 1.63 . 15 15 NO (p=.88) 1. 18 2. 4 S.D. = standard d e v i a t i o n d.f. = degrees of freedom Rehab = R e h a b i l i t a t i o n s t a f f PCA = P a t i e n t c a r e a i d e s 27 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 Score ( 01 > >. D. ri-v a l ue d. +" SIG? (p<0.05) EM p e r i m e n t a l (N=5) 9. 0 3 8 2.09 NO (p=.07) C o n t r o l <N=12) 7. 16 1.8 Rehab 3.67 1.03 <N=6) PCA 7.18 2.08 (N=ll) 1.96 15 NO (p=.07) S.D. = standard d e v i a t i o n d . - f . = degrees o-f -freedom Rehab = r e h a b i l i t a t i o n sta-f-f PCA = p a t i e n t c a r e a i d e s 28 Table 4 COMPARISON OF MEAN REVISED GAIN SCORES BY INTERVENTION GROUP AND BY OCCUPATIONAL GROUP ON ITEMS 2, 3, 5 , AND 6 OF THE COMMUNICATION STRATEGY INDEX Mean Revi sec! Gain Score S.D. t -v a l ue d.-f. SIG? (p<0.05) Experimental <N=5) 1.2 1. 1 046 15 NO (p=.96) Co n t r o l (N=12) 1. 17 1.85 Rehab 1.17 0.98 <N=6) -.021 15 NO (p=.98) PCA 1.18 1.94 <N=11) S.D. = standard d e v i a t i o n d . f . = degrees of freedom Rehab = r e h a b i l i t a t i o n s t a f f PCA = p a t i e n t c a r e a i d e s Table 5 COMPARISON OF GROUP MEAN GAIN SCORES ON INDIVIDUAL ITEMS FOR ITEMS 1 THROUGH 6. AND TWO-WAY ANALYSIS OF VARIANCE WITH REPEATED MEASURES ON ITEM Ex per Mean i mental (S.D-) Co n t r o l Mean (S.D.) Mean Di -f -f erence Item 1 0 ( 1.0 ) -.08 ( .67 ) .08 Item *-* ( .45 ) .08 ( .67 ) . 12 I tern 3 .4 ( . 55 ) . 25 ( . 45 ) . 15 I tern 4 0 ( 0.0 ) . 17 ( .84 ) -. 17 I tern 5 . 4 ( . 55 ) . 33 ( .78 ) .07 I tern 6 . 2 ( . 45 ) .5 ( 1.0 ) . 3 Two—Way A n a l y s i s o-f V a r i a n c e Summary Table Source SS d-f MS I n t e r v e n t i on group E r r o r . 102 14.153 1 15 . 102 944 108 75 Item E r r o r 1.92 35.197 75 384 469 818 I n t e r v e n t i on group >: Item .783 E r r o r 35.197 157 469 334 89 S.D. = standard d e v i a t i o n d.-f. = degrees o-f -freedom 30 Table 6 RAW SCORES BY'INDIVIDUAL SUBJECT FOR ITEMS 7 THROUGH 11 OF THE COMMUNICATION STRATEGY INDEX Exper^menta^_Group (N=5) Observation 1 Observation 2 Item: ~7 8 9 10 11 7 8 9 10 11 Subj e c t : RI 0 1 0 1 0 0 2 2 1 R2 0 1 1 1 0 0 1 0 0 0 R4 0 0 0 0 0 ^ 0 0 0 R6 0 0 1 1 0 0 0 0 N9 0 0 2 0 0 0 0 0 2 0 Con t r o l _Grgup_ CN=12) Observation 1 Observation 2 Item: 7 8 9 10 11 7 B 9 10 1 1 Subje c t : R3 0 0 0 0 0 0 0 0 2 0 R5 0 0 2 2 0 0 0 2 0 0 N7 0 0 0 0 0 0 0 0 0 0 MB 0 0 0 0 0 0 0 0 0 0 N10 0 0 0 2 0 0 0 0 0 0 N i l 0 0 0 0 0 0 0 2 0 0 N12 0 0 0 0 0 0 0 0 0 0 N13 0 0 0 0 0 1 0 0 0 0 N14 1 0 0 0 0 0 0 1 1 0 N15 0 0 0 1 0 0 0 1 0 0 N16 0 0 0 2 0 0 0 0 0 0 N17 0 1 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 1 Observation 2 T o t a l Obs Opp Obs Opp 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 2 Obs = number o-f s e s s i o n s d u r i n g which a p p r o p r i a t e use o-f s t r a t e g y was observed at l e a s t once Opp = number o-f s e s s i o n s d u r i n g which o p p o r t u n i t y t o use s t r a t e g y a p p r o p r i a t e l y o c c u r r e d at l e a s t once 32 Table 8 TOTAL OPPORTUNITIES FOR USE AND OBSERVED USE FOR ITEMS 7 THROUGH 11 OF THE COMMUNICATION STRATEGY INDEX Observation 1 Observation 2 T o t a l Obs Opp Obs Opp Obs Opp E;-:per i mental group 3 10 6 8 9 18 Co n t r o l group 4 7 3 7 7 14 Al 1 subj e c t s 17 15 16 0 . 2 Rehabi1i t a t i on s u b j e c t s 4 11 PCA sub j ectf 3 11 5 i : Obs = number of s e s s i o n s d u r i n g which a p p r o p r i a t e use of s t r a t e g y was observed at l e a s t once Opp = number of s e s s i o n s d u r i n g which o p p o r t u n i t y t o use s t r a t e g y a p p r o p r i a t e l y o c c u r r e d at l e a s t once 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 2 E x p e r i mental group <N=5) 30 7. 75 7. Con t r o l group (N=12> 57 7. 43 7. Chi—Square D i s t r i b u t i o n Test 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 F i g u r e 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 INTERPRETATION OF RESULTS The r e s u l t s o-f the data a n a l y s i s suggest that the answers t o the qu e s t i o n s posed at the end o-f Chapter 2 are mixed. The a n a l y s i s o-f data from Part A of the Communication S t r a t e g y Index tends t o support the n u l l h y p o t h e s i s f o r the f i r s t q u e s t i o n : i n s e r v i c e t r a i n i n g does not cause s t a f f t o use some s p e c i f i c communication s t r a t e g i e s more c o n s i s t e n t l y , as compared with no exposure tD i n s e r v i c e t r a i n i n g . The answer t o the second q u e s t i o n i s a l s o n e g a t i v e : a n a l y s e s comparing the o c c u p a t i o n a l groups seem t o i n d i c a t e some d i f f e r e n c e s between the r e h a b i l i t a t i o n and PCA s t a f f i n use of communication behaviours, but not a t t r i b u t a b l e t o i n s e r v i c e t r a i n i n g . The t h i r d h y p o t h e s i s , t h a t i n s e r v i c e t r a i n i n g p r e d i c t s the frequency d i s t r i b u t i o n s c o r e s of the experimental and c o n t r o l groups a c r o s s o b s e r v a t i o n i n t e r v a l s , i s supported by the a n a l y s i s of items 7 through 11. However, l a c k of s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s can not be accepted as unequivocal support for. a n u l l h y p o t h e s i s ; nor can s t a t i s t i c a l l y s i g n i f i c a n t a n a l y s e s be co n s i d e r e d a b s o l u t e support f o r the h y p o t h e s i s . Many methodological or other confounding f a c t o r s may contaminate the data and produce such r e s u l t s . P o t e n t i a l l y confounding fac tors must be "teased out" one by one and discussed with s p e c i f i c reference to events that took place during the stages of research planning, data c o l l e c t i o n procedures, and analys i s procedures. There may be many i n d i v i d u a l fac tors whose sum ef fect i s greater than the combined e f fec ts of each i so la ted fac tor ; or there may be one or two s i g n i f i c a n t fac tors which may be shown a p o s t e r i o r i to be the primary cause of confound. A discuss ion which considers each and every poss ib le flaw in the study i s therefore appropriate , before considering the v a l i d i t y of the n u l l hypothesis . Confoundi^ng^factors One of the key elements of any research design invo lv ing human subjects i s the se l ec t ion of subjects and the assignment of subjects to control and experimental groups. In t h i s study, volunteers from two vocational groups had the opportunity to p a r t i c i p a t e : PCAs (nursing s t a f f ) , and r e h a b i l i t a t i o n s t a f f . The two vocat ional groups were d i f f erent on a number of var iab les which were not formal ly inves t igated , but some of which can be in ferred from the author's personal experience with the subjects during data c o l l e c t i o n . Differences between the PCA's and the r e h a b i l i t a t i o n s ta f f include: post-secondary education ( r e h a b i l i t a t i o n s ta f f included i n d i v i d u a l s with u n i v e r s i t y degrees or co l lege diplomas, while PCA's general ly have a 6 week t r a i n i n g program); job duties (main r o l e o-f PCA's i s to tend to hygiene and basic needs of res idents , while the r e h a b i l i t a t i o n r o l e i s to provide s o c i a l , mental and physical a c t i v i t y for res idents ) ; and Engl i sh language prof i c i ency (one r e h a b i l i t a t i o n subject was i d e n t i f i e d by author as ESL, while only one PCA was not ESL) . These d i f ferences between vocational groups become problematic when the d i s t r i b u t i o n of the subjects by vocation over control and experimental groups i s considered. The experimental group, those subjects who attended the in serv i ce , was made up of 4 r e h a b i l i t a t i o n s ta f f and 1 PCA; while the control group consisted of 10 PCA's and 2 r e h a b i l i t a t i o n s t a f f . It i s not s u r p r i s i n g that the mean scores of the control and experimental groups c lo se ly p a r a l l e l those of the corresponding vocational groups (see Table 2 and Table 3) . Any of the above mentioned v a r i a b l e s , not to mention others which were not observed by the author, could be a primary confounding factor to the aims of t h i s study. The education and job dut ies of these subjects , as with many hospi ta l employees, are probably r e l a t e d . R e h a b i l i t a t i o n s ta f f are educated to consider the soc ia l and psychological wel l -being of t h e i r pat ients as part of t h e i r profess ional r e s p o n s i b i l i t i e s , and therefore would be tra ined to value the soc ia l aspects of communication. On the other hand, the r o l e o-f the PCA emphasizes bodi ly care; a job in which communication l i k e l y takes the r o l e of a means of expressing basic needs. Thus, d i f ferences in occupation and job dut ies poss ib ly re su l t in a d i f f erent emphasis on the ro l e of communication with pat ients , which would af fect the communication behaviours of the subjects . S i m i l a r l y , the d i f ference between the two vocational groups in the i r Engl ish language prof i c i ency may have been a confounding f a c t o r . It i s p l a u s i b l e that ESL subjects , due to the ir ind iv idua l c u l t u r a l and l i n g u i s t i c backgrounds, have norms for communication behaviour which d i f f e r from each other and from those subjects whose native language i s Canadian E n g l i s h . Such di f ferences may surface in the form of pragmatic interference from the native language into the Engl i sh environment (Brosjean, 1982). It i s impossible to predic t how the ESL factor would af fect an i n d i v i d u a l ' s performance, but, s ince the control and experimental groups were not matched on t h i s v a r i a b l e , i t i s a lso impossible to r u l e t h i s out as a confounding f a c t o r . The f ind ing that the two vocational groups d i f f e r in t h e i r quant i ta t ive use of at least some communication behaviours (see Table S) i s consistent with the f indings of a previous study. Sarvela et a l . (1989), using a quest ionnaire to probe the knowledge of 208 hospi ta l employees, found that of 11 occupational groups, therap i s t s 40 were most knowledgable about communication d i s o r d e r s . while n u r s i n g a i d e s had the l e a s t awareness. The study concluded t h a t , while a l l new employees should r e c e i v e t r a i n i n g i n the area of communication d i s o r d e r s . the v a r i o u s o c c u p a t i o n a l groups r e q u i r e d i f f e r e n t f o c u s and amount of a t t e n t i o n . The r e s u l t s of the present study are c o n s i s t e n t with those of S a r v e l a et a l . , i n d i c a t i n g some d i f f e r e n c e s between o c c u p a t i o n a l groups i n terms of t h e i r communication behaviours, although i t i s not c l e a r whether t h i s d i f f e r e n c e can be a t t r i b u t e d d i r e c t l y to a d i f f e r e n c e i n l e v e l of knowledge. Table 3 i n the p r e v i o u s chapter i l l u s t r a t e s a p a r t i c u l a r problem c r e a t e d by the u n c o n t r o l l e d v o c a t i o n a l v a r i a b l e . The mean b a s e l i n e s c o r e f o r the experimental group not o n l y d i f f e r s from, but i s higher than the mean b a s e l i n e s c o r e f o r the c o n t r o l group. T h i s r a i s e s the p o s s i b i l i t y t h a t the overwhelming presence of r e h a b i l i t a t i o n s u b j e c t i n the experimental group a c t u a l l y drove the average b a s e l i n e s c o r e up, thereby l i m i t i n g the average gain s c o r e p o t e n t i a l f o r the experimental group. If the experimental group had been c l o s e r t o the c o n t r o l group i n i t s composition (and s t a r t e d out with lower b a s e l i n e s c o r e s ) , t h e r e may have been g r e a t e r p o t e n t i a l f o r improvement i n the experimental group, and t h e r e f o r e the p o s s i b i l i t y f o r a treatment e f f e c t t o be observed i n the gain s c o r e data (items 1 through 6). Thus 41 the combination of high b a s e l i n e s c o r e s and poor d i s t r i b u t i o n of s u b j e c t s over the two groups may have been enough to produce the r e s u l t s presented i n t h i s study. Another source of confound i s the measurement procedure used to e v a l u a t e the t r a i n i n g e f f e c t — the Communication S t r a t e g y Index. The t h r e e — p o i n t s c a r i n g procedure chosen (over the o p t i o n of a more s e n s i t i v e , f o r example f i v e - p o i n t , s c a l e ) f o r the sake of e f f i c i e n c y — time r e q u i r e d t o make a judgment d u r i n g an ongoing o b s e r v a t i o n — and r e l i a b i l i t y , r e s u l t e d i n a tendency t o lump the performance of the s u b j e c t s . While the behaviours which were being observed o c c u r r e d on a continuum from never t o always, the s c o r i n g procedure d i v i d e d t h i s continuum i n t o t h r e e unequal c a t e g o r i e s which p l a c e d the extreme ends i n t o two c a t e g o r i e s , and l e f t o n l y one c a t e g o r y f o r the wide range of behaviours between the two extremes. A f o u r t h s c o r i n g category, t o allow d i s t i n c t i o n w i t h i n the middle range of performance, would be an advantage i n f u t u r e r e s e a r c h . The c h o i c e of the communication behaviours to be e v a l u a t e d i n t h i s study p r e s e n t s another i s s u e : w h ile the a u r a l r e h a b i l i t a t i o n l i t e r a t u r e i n d i c a t e s t hat a l l of the s t r a t e g i e s e valuated i n t h i s study are d e s i r a b l e f o r p a r t n e r s of hard of h e a r i n g people, t h e r e i s no evidence t o suggest t h a t these behaviours are valid — t h a t i s , t h a t use c-f such behaviours ac tua l ly improves i n t e l l i g i b i l i t y — other than self—reports o-f hearing impaired i n d i v i d u a l s to t h i s e f f ec t . The items in the tool underwent a number of rev i s ions in order to improve interobserver r e l i a b i l i t y . The researcher and the second observer found i t d i f f i c u l t to define some items in operational terms during the p i l o t phase of t h i s study and thus replaced or e l iminated such behavioural c r i t e r i a as eye contact and topic maintenance in favour of focus attention, which included some of the former behaviours in i t s d e f i n i t i o n . However, the f i n a l vers ion of the measurement tool was by no means standardized, and beyond l imi ted r e l i a b i l i t y measures, could not be shown to have any v a l i d i t y in terms of a c t u a l l y measuring the concept of e f f e c t i v e communication. The outcome of the r e l i a b i l i t y measures (see Appendix E , and Chapter 3) ind ica tes that the scoring v a l i d i t y of items 2, 3, 5, and 10 are in fact questionable. Furthermore, while these s t ra teg ies are probably appropriate in many communication s i t u a t i o n s , not a l l may be appropriate goals for i n s t i t u t i o n a l s t a f f , where the communication environment i s quite d i f f eren t from that encountered by most people outs ide of i n s t i t u t i o n s . L i g h t i n g , for example, was general ly uniform throughout the rooms, and did not need to be adjusted; background noise , on the other hand, var ied from one session to another and quite 43 often could not be adjusted by the subject ( e .g . , when the source of the noise was another re s ident ) . The duties carr i ed out by the s ta f f tended to l i m i t the s t y l e of i n t e r a c t i o n between the subject and the res ident: PCA's were often in c lose physical proximity to t h e i r communication partner , while r e h a b i1 i t a t i o n s ta f f var ied great ly in the i r proximity depending on the a c t i v i t y . An i n t e r a c t i o n which focussed cn a physical a c t i v i t y such as breakfast allowed much opportunity for gesturing and physical contact , whereas a conversation about current a f f a i r s depended great ly on verbal communication and use of s t ra teg ie s such as rephras ing. Thus the natural s e t t ing for the measurements meant that there was m u c h t v a r i a b i1 i t y between subjects for appropriateness of s t ra teg ie s , in both parts I and II of the evaluation tool — a factor which i n t e r a c t s with the occupational confound in the intervent ion group composition. The use of an evaluation method which requires the observer to score behavioural c r i t e r i a in s i t u has advantages and disadvantages. While i t i s t ime—efficient, unobtrusive, and does not require any spec ia l equipment such as video cameras or audio recorders , i t a lso does not allow control over such elements as observer b ias , s ince there i s no opportunity to rescore a session for intra—observer r e l i a b i l i t y ^ In fac t , the r e s u l t s i l l u s t r a t e d in Figure 1 show a tendency for a l l of the subjects ' scores to increase 44 between the basel ine and second observat ion. This may be due to two d i f f eren t sources of b ias : f i r s t l y , the observer may have become more lax in scoring over time, r e s u l t i n g in higher scores awarded to s imi lar l eve l s of performance? secondly, the subjects may have become more relaxed with the presence of the observer and the procedure i t s e l f between the time of the basel ine and the second observation, r e s u l t i n g in a more natural and p o s i t i v e i n t e r a c t i o n with the res idents . The items (5, speech rate ; and 6, focus attention) which in p a r t i c u l a r show an unexpected increase between 01 and 02 for the control subjects r e f l e c t behaviours that may vary with the ta lkat iveness of the subject , i n d i c a t i n g that 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 problems are a source of confound, and are d i f f i c u l t to separate out. While a data c o l l e c t i o n procedure which permanently records the subject -partner in t erac t ions would help e l iminate observer b ias by al lowing double checking of the scor ing , the problem of p r a c t i c e e f fect i s d i f f i c u l t to control without e i ther e l iminat ing the second observation (and therefore requ ir ing a d i f f erent methodology), or r e q u i r i n g a lengthy t r a i n i n g period u n t i l the observer was able to score cons i s tent ly over a s p e c i f i c period of time. The f i n a l problem area which must be discussed i s the 45 effect iveness of the i n s e r v i c e procedure i t s e l f . As mentioned above, the s p e c i f i c s t ra teg ies that were chosen as goals for the educational program may not have been the ideal goals for e f f ec t i ve communication for the population in question. This problem i s one that addresses the theore t i ca l foundations of aural r e h a b i l i t a t i o n , and c l e a r l y exemplif ies the need for r igorous study to determine which s p e c i f i c communication behaviours and s t ra teg ie s are most bene f i c ia l to which populat ions. The contradic tory r e s u l t s for the two categories of s t ra teg ie s (those that are always appropriate , and those that are sometimes appropriate) suggest that inserv ice t r a i n i n g which focusses on those s p e c i f i c communication behaviours that are not being used opt imal ly may be appropriate for careg ivers . Assuming that the goals of the study were appropriate , there i s a f i n a l p o s s i b i l i t y which may have contributed to the present r e s u l t s . The inserv i ce presentat ion may have been i n e f f e c t i v e due to time cons tra ints — that i s , the 45 minutes a v a i l a b l e to present the information may have forced the s ta f f audio log i s t to rush through the material without s u f f i c i e n t d iscuss ion of i n d i v i d u a l po ints . It i s u n l i k e l y that c r u c i a l information was misrepresented or omitted from the inserv i ce presentat ion, s ince the s ta f f audio log i s t took every precaution to ensure that a l l of the s t ra teg ie s on the evaluat ion tool were covered. However, a longer time frame 46 with ac t ive p a r t i c i p a t i o n o-f the audience in role—playing to i l l u s t r a t e the des irable behaviours, or one-on—one t r a i n i n g i n the use o-f communication s t ra teg ie s , might have had quite d i f f erent r e s u l t s . Nul^ l^  hypotheses The f i n a l explanation of the nons igni f icant f indings i s the n u l l hypothesis i t s e l f : that extended care s ta f f are not able to increase t h e i r use of e f f ec t i ve communication behaviours as a r e s u l t of t r a i n i n g . Although a previous study suggests that s t a f f are able to implement s p e c i f i c communication behaviours in a s tructured se t t ing (Purves and Brooks, 1987), the present r e s u l t s do not unequivocal ly support t h e i r a b i l i t y to general ize these types of behaviours into t h e i r d a i l y rout ine a c t i v i t i e s . However, even t h i s statement must be made caut ious ly , for the base l ine data suggests that s ta f f are using at least some of the targeted s t ra teg ie s spontaneously at least some of the time, and the data from items 7 through 11 ind icate that s ta f f who are exposed to t r a i n i n g do use some s t ra teg i e s more often. It would be incorrec t to assume, from the lack of a p o s i t i v e f indings throughout the data, that extended care s ta f f are not able to communicate ef fect ively . : instead, o p t i m i s t i c a l l y , we may hope that the inconclus ive r e s u l t s are due to the fact that some e f f ec t i ve communication i s taking place , in at least t h i s p a r t i c u l a r 47 i n s t i t u t i o n -i < l ! E l i £ 2 t ^ g Q S _ f o r _ f u t ^ T h e n u m e r o u s - f a c t o r s w h i c h c o n t r i b u t e d t o t h e i n c o n c l u s i v e r e s u l t s o-f t h e p r e s e n t s t u d y u n d e r l i n e t h e n e e d - f o r f u r t h e r r e s e a r c h . T h e p r o b l e m s e n c o u n t e r e d i n t h i s s t u d y , w h e t h e r r e a l o r p o t e n t i a l , m a y b e u s e f u l f o r d e s i g n i n g f u t u r e s t u d i e s . T h e f o l l o w i n g g u i d e l i n e s f o r f u t u r e r e s e a r c h a d d r e s s t h e m a i n a r e a s o f c o n c e r n t h a t w e r e e n c o u n t e r e d i n t h i s s t u d y : i . S u b j e c t v a r i a b l e s . I n f o r m a t i o n a b o u t e d u c a t i o n , o c c u p a t i o n , a n d o t h e r p o t e n t i a l l y i n f l u e n t i a l v a r i a b l e s s h o u l d be i d e n t i f i e d a n d c o n t r o l l e d a c r o s s g r o u p s w h e r e p o s s i b l e , o r s u b j e c t s s h o u l d b e r a n d o m l y a s s i g n e d t o i n t e r v e n t i o n g r o u p s t o e n s u r e e q u a l d i s t r i b u t i o n o f n u m b e r s a n d o f u n c o n t r o l l e d v a r i a b l e s . i i . M e a s u r e m e n t t o o l . T h e m e t h o d o f e v a l u a t i o n m u s t b e r e l i a b l e a n d t h e s c o r i n g p r o c e d u r e m u s t b e p r a c t i c e d u n t i l t h e y a r e c o n s i s t e n t o v e r t i m e . A m e t h o d o f d a t a c o l l e c t i o n w h i c h a l l o w s a p e r m a n e n t r e c o r d o f t h e o b s e r v a t i o n s e s s i o n s i s p r e f e r a b l e . T h e t o o l s h o u l d b e d e s i g n e d t o e n s u r e o p t i m a l s e n s i t i v i t y t o c h a n g e — t h a t i s , a f i n e r s c a l e w h i c h a l l o w s m o r e g r a d a t i o n s o f p e r f o r m a n c e a n d t h e r e f o r e 48 m o r e o p p o r t u n i t y - f o r c h a n g e . i i i . I n s e r v i c e p r o c e d u r e s . T h e e d u c a t i o n a l p r o g r a m s h o u l d t a r g e t h e a p p r o p r i a t e g o a l s f o r t h e p o p u l a t i o n i n c o n s i d e r a t i o n . T h u s , c u r r e n t l e v e l s o f c o m m u n i c a t i o n s k i l l s , a s w e l l a s o c c u p a t i o n a l g r o u p s m o s t i n n e e d o f s p e c i f i c e d u c a t i o n , s h o u l d b e c o n s i d e r e d i n p l a n n i n g t h e i n s e r v i c e c u r r i c u l u m . 49 C o n e I u s i o n 5 T h e h y p o t h e s i s t h a t l e d t h i s s t u d y , t h a t e x t e n d e d c a r e s t a f f a r e a b l e t o i n c r e a s e t h e i r u s e o f s p e c i f i c c o m m u n i c a t i o n s t r a t e g i e s a s a r e s u l t o f i n s e r v i c e e d u c a t i o n , w a s s u p p o r t e d w i t h m i x e d f i n d i n g s . W h i l e s o m e c o m m u n i c a t i o n b e h a v i o u r s ( i t e m s 7 t h r o u g h 11) w e r e o b s e r v e d t o i n c r e a s e a f t e r p a r t i c i p a t i o n i n t h e i n s e r v i c e , o t h e r s t r a t e g i e s ( i t e m s 1 t h r o u g h 6) d i d n o t s h o w s i g n i f i c a n t d i f f e r e n c e i n g a i n b e t w e e n t h e e x p e r i m e n t a l a n d c o n t r o l . g r o u p . T h e r e l a t i v e l y h i g h b a s e l i n e p e r f o r m a n c e s o f a l l s u b j e c t s , o n t h e f i r s t 6 i t e m s , i n d i c a t e s t h a t s o m e c o m m u n i c a t i o n s t r a t e g i e s a r e b e i n g u s e d t o s o m e d e g r e e s p o n t a n e o u s l y ( i . e . , w i t h o u t i n t e r v e n t i o n ) . T h e s e f i n d i n g s s u g g e s t t h a t w h i l e i n s e r v i c e e d u c a t i o n a i m e d a t t e a c h i n g c o m m u n i c a t i o n e f f e c t i v e n e s s i s p a r t i a l l y s u c c e s s f u l , i t m a y b e h e l p f u l t o f o c u s o n t h o s e a r e a s o f c o m m u n i c a t i o n s t r a t e g i e s t h a t s t a f f m e m b e r s m a y b e l a c k i n g i n . T h e s e i n c l u d e s t r a t e g i e s t h a t a r e a p p r o p r i a t e o n l y o n c e r t a i n o c c a s i o n s , s u c h a s checking understanding, a n d rephrasing. T h e s u c c e s s o f i n s e r v i c e e d u c a t i o n m a y a l s o d e p e n d o n t h e l e v e l o f k n o w l e d g e t h a t t h e i n d i v i d u a l s t a f f m e m b e r s b r i n g w i t h t h e m , a s w e l l a s t h e d u t i e s p e r f o r m e d b y t h e v a r i o u s o c c u p a t i o n a l g r o u p s . I n c o n c l u s i o n , t h i s s t u d y 50 was designed to evaluate subjects ' Egr.£Qr.!D£QE.sv i n the natural work environment, as a re su l t o-f inserv ice in tervent ion , and did not attempt to evaluate the p a r t i c i p a n t s ' fgrmal_learning, or any other benef i ts that may have been derived -from the i n s e r v i c e . 51 BIBLIOGRAPHY Cervero. R.M., Continuing p r o f e s s i o n a l education and b e h a v i o u r a l change. Journal of Continuing Ed ucation in Nursing. 1935, 16, 35-83. Chambers, L.W. , and H.M. Blum. Measurement of a c t i o n s of c a r e -p r o v i d e r s i n long-term c a r e . Journal of CIinical Epidemiology1983, 41, 793-802. S r c s j e a n , F. Life Mith TMO Languages. Cambridge: Harvard U n i v e r s i t y Press, 1932. L u b i n s k i , R . , E.B. Morrison, and S. Rigrodsky. P e r c e p t i o n of spoken communication by e l d e r l y c h r o n i c a l l y i l l p a t i e n t s i n an i n s t i t u t i o n a l s e t t i n g . Journal of Speech and Hearing Disorders.. 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 : communication 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 (Ed.), Communication Behaviour and Qging. B a l t i m o r e : W i l l i a m s and W i l k i n s , 1938. Oyer H.J. and E.J., Oyer. S o c i a l consequences of hea r i n g l o s s f o r the e l d e r l y . Allied Health and Behavioural Sciences, 1979, 2, 123-138. Peden, A.R., H. Rose, and M. Smith. T r a n s f e r of c o n t i n u i n g education t o p r a c t i c e . Journal of Continuing Education in Nursing, 1990, 2, 68-72. Purves, B. and B. Brooks. 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 extended c a r e f a c i l i t y . Hunan Communication Canada, 1987, 13-16. R e z e n , S. and C . Hausman. Coping Mith Hearing Loss. New York: D e m b n e r Books, 1985. Rupp, R.R. Speech input p r o c e s s i n g , h e a r i n g l o s s , and au r a l r e h a b i l i t a t i o n with the e l d e r l y . In L.K. Obler and M.L. A l b e r t (Eds.), Language and Communication in the Elderly. Lexington, Massachusetts: Lexington Books, 1980. Sanders, D . Rural Rehabilitation (2nd Ed-). Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l , 1982. S a r v e l a , P.D., J.L. S a r v e l a , and J . Odulana. Knowledge of 52 communication d i s o r d e r s among n u r s i n g home employees. 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. Hutchinson, and M.A. Nerbonne. Communication Uisorders of the figed. B a l t i m o r e : Un i ver s i t y Par k Press, 1978. Schow, R. and M. Nerbonne. Hearing l e v e l s among e l d e r l y n u r s i n home r e s i d e n t s . Journal of Speech and hearing Disorders. 1980, 45, 124-132. Shore, H. Communication problems and communication needs i n a r e t i r e m e n t s e t t i n g . In M.A. Henoch (Ed.), ftural Rehahilitation for the Elderly. New York: 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 withdraw -from the study a any time; such withdrawal or 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 your 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 which 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 at any time. Only the i n v e s t i g a t o r s named above w i l l have access to the study data which w i l l be r e t a i n e d f o r f i v e years. S u b j e c t ' s Statement The study d e s c r i b e d above has 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 consent t o p a r t i c i p a t e . I have had the o p p o r t u n i t y t o ask q u e s t i o n s and understand t h a t f u t u r e q u e s t i o n s I may have about the r e s e a r c h or about the r i g h t s of s u b j e c t s w i l l b answered by the i n v e s t i g a t o r . I a l s o acknowledge r e c e i v i n g a copy of t h i s consent form. S i g n a t u r e s of I n v e s t i g a t o r s Date S i g n a t u r e of Subject Date S i g n a t u r e of Subject Date Appendix B: Screening Q u e s t i o n n a i r e The purpose of the -following q u e s t i o n s i s t o f i n d out whether or not you are at r i s k f o r he a r i n g l o s s . The answers to these q u e s t i o n s w i l l be used t o determine your personal r i s k f a c t o r s r e g a r d i n g h e a r i n g only. Subject Name: Date: DOB: 1. Do you now have, or have you ever had, a h e a r i n g problem" Yes No If yes, p l e a s e e x p l a i n : 2. Have you ever been m e d i c a l l y t r e a t e d f o r an ear problem? Yes No If yes, p l e a s e e x p l a i n : -3. Is t h e r e a h i s t o r y of he a r i n g l o s s i n your f a m i l y ? Yes No If yes, p l e a s e e x p l a i n (type of l o s s , r e l a t i o n s h i p , e t c ) : 4. Have you had a s i n u s or c o l d problem i n the past month? Yes No 5. Have you had a s e r i o u s i l l n e s s i n the past s i x months? Yes No If yes, p l e a s e e x p l a i n : 6. Are you now t a k i n g any medication? Yes No If yes, type and length of time: 7. Have you had any i l l n e s s or a c c i d e n t t h a t might a f f e c t y o u r n e u r o l o g i c a l f u n c t i o n ? Yes No If yes, p l e a s e e x p l a i n : 56 A p p e n d i x C: I n s e r v i c e H andout COMMUNICATING WITH THE HARD OF HEARING - MOST 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 loss - 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 h e a r i n g l o s s i s often mistaken -for cogni t ive d e f i c i t , d i s i n t e r e s t , lack of cooperation, 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. Sensorineural hearing loss i s the most common type. It i s character ised by a lack of c l a r i t y and some reduction in 1oudness. - sensorineural loss i s often c a l l e d "nerve deafness" - i t i s a common myth that nothing can be done to help sensorineural hearing loss - medical treatment i s not poss ib le , but hearing aids can d e f i n i t e l y help. Conductive hearing loss i s l ess common. It i s often medical ly t r e a t a b l e . It i s character ized by a reduct ion in loudness, but exce l lent c l a r i t y remains. People with conductive hearing loss are usua l ly very successful with hearing a ids . EVERYONE'S HEARING LOSS IS DIFFERENT. Some people have a more severe loss for high—pitched tones ( th is i s most common), and others have a more severe loss for low-pitched tones. There are very few people who cannot benefit from the use of a hearing a i d . b!9w_tg_make_communicat iLon_easie^ 1. i f the res ident h a s a hearing a i d , make sure he/she i s wearing i t . Be sure to check that i t i s turned on ("M" on the switch) and that the battery i s f re sh . — remember that the hearing aid w i l l help, but i t w i l l not provide normal hearing for the res ident . He s t i l l needs to be spoken to with extra care. 57 2- Lipreading i s very important -for someone with a hearing 1 O S S . - make sure the person i s fac ing you - do not cover your face, 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 lose to the res ident - speak in a normal volume of voice - i t i s not necessary to exaggerate your l i p movements 3. Bet the person's at tent ion 4. Speak f a i r l y s lowly, so he you are saying. 5. DO NOT speak into the important to l e t him see your before you s t a r t speaking. has a chance to process what person's ear. It i s much more face . 6. Reduce background noise . Noisy places make hearing even more d i f f i c u l t for hard of hearing people than for those with normal hearing. 7. Check to make sure the person i s understanding you. These suggestions may seem very simple — but i t i s s u r p r i s i n g how often we are unaware of our speaking habi t s . Please pay at tent ion to 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 l i k e , to remind yoursel f of what many of our res idents are up against . Hearing loss i s very s o c i a l l y d e b i l i t a t i n g , e s p e c i a l l y in 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 steps to improve communication, we w i l l make l i f e much more pleasant for both res idents and s t a f f . 58 Appendix D: COMMUNICATION STRATEGY INDEX Date Time Floor Subject Observer PARJ_I Scoring Procedure ( c i r c l e one): 2 = consistent use 1 = inconsis tent 0 = not used 1. distance 2 1 0 2. pos i t i on 2 1 0 3. -face v i s i b i l i t y 2 1 0 4. voice qua l i ty 2 1 0 5. speech qua l i ty 2 1 0 6. focus at tent ion 2 1 0 PART_II Scoring Procedure ( c i r c l e one): 2 = appropriate use as opportunity arose 1 = opportunity arose, but s trategy was not used 0 = No opportunity arose 7. l i g h t i n g 2 1 0 8. background noise 2 1 0 9. check understanding 2 1 0 10. rephrasing 2 1 0 NOTES: room res ident task es l NEXT OBSERVATION 59 Appendix D, continued Gu^delLines_£gr_scgrinQ_iL terns 1. Distance: one to two metres -from the l i s t e n e r . 2. P o s i t i o n : body -facing the l i s t e n e r 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 covering mouth) ; -face towards the I i stener. 4. Voice qua l i ty : use normal or s l i g h t l y louder than normal volume o-f vo ice . 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 using s l i g h t l y slower than conversational ra te . Overexaggeration o-f mouth movements i s inapppropriate . 6. Focus a t tent ion: i n i t i a t e at tent ion and -focus l i s t e n e r ' s a t tent ion 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 ta t ing t o p i c , using meaningful gestures ( e .g . , point ing out an objec t ) , physical contact . 7. L i g h t i n g : ensure enough l i g h t i s on speaker's face? do not stand with back to a br ight source such as a window. 8. Background noise: reduce volume of any source of noise such as t . v . or r a d i o , or move into quieter area. 9. Check understanding: any verbal attempt on speaker's part to get an a f f i rmat ive response; appropriate 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 provide extra cues (such as meal tray Dr medication). 10. Rephrasing: repeat content of message (one key word, phrase, or sentence, e tc . ) in d i f f eren t words. Appropriate when there 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 ee l s i t i s augmentative. 60 Appendix E". INTEROBSERVER RELIABILITY OF MEASUREMENT TOOL ITEM 7. AGREEMENT 7. AGREEMENT p i l o t data * -final data Part I (S observations) <6 observations) 1. distance 100 83 2. pos i t ion 100 67 3. -face v i s i b i l i t y 87.5 67 4. voice qua l i ty 75 100 5. speech qua l i ty 75 67 6. -focus at tent ion N/A * * 100 Part II 7. l i g h t i n g 87.5 100 8. background noise 100 100 9. check understanding 62.5 S3 10. rephrasing 75 67 11. check hearing a id N/A * * 100 * Note: two items, body 1anguage and physical contact, had such poor r e l i a b i l i t y (37.5%) during the p i l o t phase, that they were el iminated altogether -from the -final measurement t o o l . * * Two items, focus attention and check hearing aid, were added af ter the p i l o t phase and therefore have agreement f igures only for the f i n a l data phase. 61 

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