CRITICALLY APPRAISED PAPER (CAP) Passalacqua, S. A., & Harwood, J. (2012). VIPS communication skills training for paraprofessional dementia caregivers: An intervention to increase person-centered dementia care. Clinical Gerontologist, 35, 425 445. http://dx.doi.org/10.1080/07317115.2012.702655 CLINICAL BOTTOM LINE The authors studied the effect of a communication skills intervention designed around the principles of Brooker s (2004, 2005, 2007) four elements of person-centered dementia care valuing people, individualized care, personal perspectives, and social environment (VIPS). After conducting a series of workshops based on VIPS, the authors determined that education of paraprofessional caregivers may result in improved care for residents of long-term care facilities by affecting the way care is provided. In particular, the results suggest that the communication skills intervention resulted in a decrease in depersonalization of residents and an increase in hope for people with Alzheimer s disease. In addition, the intervention improved participants communication and interaction strategies (e.g., using more gestures, asking yes no questions, giving a choice between two options) and increased the time they spent engaging with patients in leisure activities. Occupational therapists possess the knowledge and skills necessary to provide similar training. Additionally, by reinforcing and supporting the use of skills learned by paraprofessional caregivers through such training, occupational therapy professionals can promote improved opportunities for engagement in meaningful occupation among individuals with dementia. However, the results of this study may not be generalized, given its small sample size and design. In particular, outcome measures were modified (i.e., shortened) secondary to literacy issues, and results relied on self-reported data. Even so, the results suggest that further investigation of this topic is warranted, with more robust study design and methodology. RESEARCH OBJECTIVES List study objectives. Examine the feasibility of a communication skills intervention for caregivers based on Brooker s four elements of person-centered dementia care: valuing people (V), individualized care (I), personal perspectives (P), and social environment (S) Determine whether the intervention fostered more person-centered attitudes, beliefs, and communication behaviors 1
DESIGN TYPE AND LEVEL OF EVIDENCE Level III: Nonrandomized before after or pretest posttest design SAMPLE SELECTION How were participants recruited and selected to participate? Please describe. The authors used a convenience sample: All participants were employed as paraprofessional dementia caregivers in a single for-profit long-term care facility in the southwest United States that specialized in memory issues. No specific information was provided regarding how the participants were recruited. Inclusion Criteria Be employed at the facility as a paraprofessional caregiver Be available to attend training outside of regular work hours Attend at least 2 of the 4 sessions provided Exclusion Criteria Be employed at the facility as an administrator or professional caregiver Serve as a nonprofessional caregiver (e.g., family member, friend) SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 26 #/% Male 3/11% #/% Female 23/89% Ethnicity Data regarding ethnicity for the sample were not gathered; however, approximately 35% of caregivers at the facility were South or East Asian, 35% were Hispanic, 15% were White, and 15% were Black. Disease/disability diagnosis N/A INTERVENTION AND CONTROL GROUPS Add groups if necessary Group 1: VIPS intervention Brief description of the intervention Researchers used a variety of tools, including videotaped vignettes, Power Point slides, discussion, group and dyadic activities, roleplaying, and guided visualization exercises, to implement a foursession workshop based on principles of patient-centered dementia care. Each session focused on one of the four elements of personcentered dementia care and featured an explanation of the week s concept, with emphasis on communication skills shown to be effective in the literature. Session 1 focused on valuing people (V) and explored attitudes about aging and respectful versus disrespectful communication. Session 2 centered on individualized 2
How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? care (I), particularly the importance of recognizing and honoring residents unique identity. Session 3 addressed personal perspectives (P), with discussion of the mental and emotional experience of dementia. Finally, Session 4 concentrated on social environment (S), with presentation of techniques to encourage independence, improve health and happiness, promote opportunities for quality time, and reduce caregiver burden. 26 A for-profit long-term care facility in the southwestern United States specializing in memory issues Two university faculty members with research expertise in both gerontology and provider patient communication 4 1-hr sessions were offered over a period of 4 weeks, with each session offered 3 times. 4 weeks Intervention Biases Check yes, no, or NR and explain, if needed. Contamination: NO Comment: There were no alternative interventions and no control group. Cointervention: Timing: NO Site: Comment: The authors did not indicate whether the participants were receiving any other training (e.g., new employee training) or were exposed to additional factors encouraging or discouraging the use of skills learned during sessions (e.g., employment as a paraprofessional caregiver in a second long-term care setting) during this time period. Comment: Four 1-hr sessions were sufficient to convey basic information. Comment: Participants might have been employed at more than one site and therefore might have received training or encouragement that did or did not support the training provided in this study. Because the authors did not indicate additional employment as an inclusion or exclusion criterion, it is unclear whether this might have been a source of bias. 3
Use of different therapists to provide intervention: NO Comment: The same individuals provided all sessions. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy. Measure 1 Interpersonal Reactivity Index (IRI) Five items from the Empathetic Concern and Perspective Taking subscales of the IRI were used to measure empathy. The index uses a 5- point scale ranging from does not describe me to describes me very well. The IRI items were administered 4 weeks prior to intervention and 6 weeks after intervention. Measure 2 Measure 3 Short Depression Happiness Scale (SDHS) Two items from the SDHS were used to measure happiness. The scale rates the frequency with which caregivers felt happy during the previous 7 days of work, on a 4-point scale ranging from never to often. The SDHS item was administered 4 weeks prior to intervention and 6 weeks after intervention. Burnout Inventory (BI) The Emotional Exhaustion and Depersonalization subscales of the BI were used to measure burnout. The inventory uses a 7-point scale ranging from never to every day. The BI items were administered 4 weeks prior to intervention and 6 weeks after intervention. 4
Measure 4 Measure 5 Measure 6 Measure 7 Attitude to the Aging Process Scale (AAPS) Two items for the AAPS were used to measure attitudes about aging. The AAPS items were administered 4 weeks prior to intervention and 6 weeks after intervention. Approaches to Dementia Questionnaire (DQ) The Hope and Person-Centeredness subscales from the DQ were used to assess attitudes toward dementia. (the Hope scale has low reliability) The DQ items were administered 4 weeks prior to intervention and 6 weeks after intervention. Quality Communication Measure (QCM) The authors designed the QCM to measure use of communication strategies described in the intervention sessions. It is composed of 14 selfreported items and uses a 5-point scale ranging from never to very often. The QCM was administered 4weeks prior to intervention and 6 weeks after intervention. Time in Activity Engagement (TAE) The authors designed the TAE to measure the amount of time at work spent engaged in one of seven types of activities, including chores, personal care of residents, and leisure time with residents. Respondents indicated the percentage of time spent in the past week in each activity, using a 10-point scale ranging from 1 (0 to 10%) to 10 (90 to 100%). 5
Measure 8 What outcome was The TAE was administered 4 weeks prior to intervention and 6 weeks after intervention. Participant Feedback Questionnaire (PFQ) The authors designed the PFQ to gather feedback regarding what participants liked and disliked and what they found useful and not useful about the workshops, through a series of open-ended questions. Additionally, a 5-point scale ranging from not at all useful to very useful was used to identify participants perception of the usefulness of the workshops. The PFQ was administered at the end of Session 4. Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. NR Comment: Was there recall or memory bias? Check yes, no, or NR, and if yes, explain. Comment: All measures relied on self-report, which resulted in the potential for significant recall or memory bias. Others (list and explain): After initial administration, the authors determined that the English literacy skills and reading abilities of some staff represented a challenge to completion of outcome measures. As a result, they reported truncating the measures used. It is unclear whether the list of measures provided in the article is the truncated list and, if not, which measures were modified during follow-up administration. RESULTS List key findings based on study objectives. Include statistical significance where appropriate (p 6
<.05). Include effect size if reported. Intervention Outcome Measures The authors compared all pretest and posttest scores using paired t tests, with the exception of time spent engaged in activity. After training, caregivers reported a decrease in depersonalization of residents (p <.05) and an increase in hope for those with Alzheimer s disease (p <.01). Additionally, caregivers reported using more gestures (p <.05), asking yes no questions (p <.05), and giving the choice between two options (p <.05). The authors did not provide details of the remaining effects, reporting them to be nonsignificant. With regard to time spent engaged in specific activities, estimated time spent on the majority of activities increased as the study progressed. Therefore, to control for overall change and identify which activities changed the most, the authors used repeatedmeasures analysis of covariance to analyze this outcome. After they controlled for the change in reported time spent on all activities, increased time spent engaging in leisure activities with residents after the workshops was the only statistically significant change (p =.02). Participant Evaluations Participant feedback was generally positive, with the measure of usefulness of the workshops generating a mean of 4.05 on a 5-point scale (SD = 0.99). Participants further reported finding the workshops informative and the communication tips and techniques particularly useful. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. NR Comment: Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. Comment: The authors used appropriate methods for testing parametric data and adequately addressed the need for inclusion of a control variable. However, given the small sample size, nonparametric statistical analysis would have been more appropriate. Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. NO Comment: The authors used a table to illustrate the comparison of psychosocial and communication measures; however, no such visualization was provided for the results of time spent in activities. Inclusion of such a visual might have been useful to some readers. Was the percentage or number of participants who dropped out of the study reported? 7
Limitations What are the overall study limitations? Study design did not include a control group. The study used a small sample size. Some measurement tools were designed specifically for the study. Some or all measurement tools were adapted to the needs of participants, which affects reliability and validity. All measures relied on self-report. CONCLUSIONS State the authors conclusions related to the research objectives. The authors successfully implemented a communication skills intervention for paraprofessional caregivers in a long-term care facility, on the basis of Brooker s elements of person-centered dementia care valuing people, individualized care, personal perspectives, and social environment. A decrease in caregiver depersonalization of residents is valuable because depersonalization is associated with suboptimal care practices. It is also linked to caregiver burnout and feelings such as decreased self-worth, increased irritability, and unhappiness. Increased caregiver hope regarding dementia is equally important because it reflects a valuing of people with dementia and results in positive approaches to care. By improving their communication strategies, caregivers can help residents function within their level of competence and explore shared understanding. Finally, spending more time engaged in leisure activities with residents is reflective of individualized care and creates a positive social environment. The preliminary results suggest that the VIPS communication skills intervention may be useful in improving the quality of care provided by paraprofessionals in long-term care facilities. However, given the limited reporting of the results of outcome measures, the small sample size, and the study design, further research is required to conclude that the intervention had a significant impact on outcomes such as caregiver burnout, improved communication strategies, and quality of care provided. References Brooker, D. (2007). Person-centered dementia care: Making services better. London, United Kingdom: Jessica Kingsley. Brooker, D. (2004). What is person-centered care in dementia? Reviews in Clinical Gerontology, 13, 215 222. Brooker, D. (2005). Dementia care mapping: A review of the research literature. The GerontologLst, 45, 11 18. This work is based on the evidence-based literature review completed by Susan E. Connor, OTR/L, University Correctional Health Care, Trenton, NJ, & Catherine Verrier Piersol, PhD, OTR/L, FAOTA, Faculty Advisor, Thomas Jefferson University. CAP Worksheet adapted from Critical Review Form--Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8
9