            geront      Gerontologistgeront      The Gerontologist      The Gerontologist      0016-9013      1758-5341              Oxford University Press                    0020410.1093/geront/41.4.449                        RESEARCH ARTICLE                            Come Talk With Me        Improving Communication Between Nursing Assistants and Nursing Home Residents During Care Routines                                          Burgio            Louis D.                                a                                b                                                Allen-Burge            Rebecca                                a                                b                                                Roth            David L.                                c                                                Bourgeois            Michelle S.                                d                                                Dijkstra            Katinka                                d                                                Gerstle            John                                a                                                Jackson            Erik                                a                                                Bankester            Leanna                                a                          aApplied Gerontology Program, The University of Alabama, Tuscaloosa        bDepartment of Psychology, The University of Alabama, Tuscaloosa        cDepartment of Psychology, University of Alabama at Birmingham        dDepartment of Communication Disorders, Florida State University, Tallahassee                    Louis D. Burgio, The University of Alabama, Department of Psychology and The Applied Gerontology Program, Box 870315, Tuscaloosa, AL 35487-0315. E-mail: lburgio@sw.ua.edu.                    1        8        2001            41      4      449      460                        6          4          2001                          18          9          2000                            The Gerontological Society of America        2001                    Purpose: We examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNAs) on verbal interactions between CNAs (n = 64) and nursing home residents (n = 67) during care routines. Design and Methods: CNAs were taught to use communication skills and memory books during their interactions with residents with moderate cognitive impairments and intact communication abilities. A staff motivational system was used to encourage performance and maintenance of these skills. Formal measures of treatment implementation were included. Results:Results were compared with those for participants on no-treatment control units. Trained CNAs talked more, used positive statements more frequently, and tended to increase the number of specific instructions given to residents. Changes in staff behavior did not result in an increase in total time giving care to residents. Maintenance of CNA behavior change was found 2 months after research staff exited the facility. Although an increase was found in positive verbal interactions between CNAs and residents on intervention units, other changes in resident communication were absent. Implications: Nursing staff can be trained to improve and maintain communication skills during care without increasing the amount of time delivering care. The methodological advantages of including measures to assess treatment implementation are discussed.                    Long-term care        Staff training        Dementia                              hwp-legacy-fpage          449                          hwp-legacy-dochead          RESEARCH ARTICLE                            Decision Editor: Laurence G. Branch, PhD            The social milieu of the nursing home is a critical component of both quality of care and quality of life in this setting. In recent years, researchers have focused their efforts on understanding and improving various aspects of staff–resident and resident–resident social interactions. Direct behavioral observation of residents on a psychogeriatric ward revealed that 21% of residents' time was spent in physical care interactions (Hallberg, Norberg, and Eriksson 1990). Observation of certified nursing assistants' (CNAs') work behavior in nursing homes revealed that 53% of observation time was spent in a broader category of resident care, with 11.8% of observation time engaged in staff–resident verbal interaction (Burgio, Engel, Hawkins, McCormick, and Scheve 1990). Sadly, positive verbal interactions appear to be as rare as negative verbal interactions in nursing homes (Burgio et al. 1990), where neutral interactions appear to be the norm (Carstensen, Fisher, and Malloy 1995). These data suggest that intervention is necessary to structure staff–resident social interactions during care to positively affect resident quality of life.    Communication-based interventions in nursing homes have the potential to improve resident behavioral deficits such as excess disability, low-rate social engagement, and behavioral excesses such as disruptive vocalization (Allen-Burge, Stevens, and Burgio 1999; Burgio and Stevens 1999). Through these interventions, staff are taught therapeutic strategies for approaching residents and responding to both adaptive and maladaptive behaviors. Recent small-sample studies of communication-based staff-training interventions to reduce resident problem behaviors have suggested that training staff to communicate more effectively might reduce the incidence of physical aggression (Boehm, Whall, Cosgrove, Locke, and Schlenk 1995; Hoeffner, Radar, McKenzie, Lavelle, and Stewart 1997).    Many recent studies have used packaged staff interventions that include both communication skills training and the use of prosthetic memory aids, such as memory books, to compensate for residents' diminished cognitive capacity. Memory books contain images and brief, simple sentences that use the preserved automatic processing abilities of frail older adults to improve the structure and quality of communication with others, hopefully making interactions more pleasant for both older individuals and their partners in communication (Bourgeois 1990, Bourgeois 1992a, Bourgeois 1992b, Bourgeois 1993; Bourgeois and Mason 1996).    Memory books can serve two functions. First, they can provide meaningful stimulation to nursing home residents in an environment that can be both physically and socially barren. Second, they can be used as a tool by staff or other residents to facilitate communication with cognitively impaired residents. Through the use of memory books, community-residing dementia patients with a wide range of cognitive deficits have increased the informativeness and accuracy of their conversations and decreased their ambiguity and repetitiveness (Bourgeois 1990, Bourgeois 1992a, Bourgeois 1992b; Bourgeois and Mason 1996). Use of these aids has decreased disruptive verbal behaviors such as repetitive questioning (Bourgeois, Burgio, Schulz, Beach, and Palmer 1997). In nursing homes, content analysis of researcher-initiated, semistructured 5-min conversational interactions between demented residents and their primary CNAs, and social validity ratings of these interactions by unfamiliar judges, revealed modest improvements in resident and CNA conversational behaviors (Hoerster, Hickey, and Bourgeois in press).    Ripich, Wykle, and Niles 1995 developed and tested a didactic training program for improving communication between CNAs and residents. In addition to teaching specific verbal and nonverbal communication strategies, training modules included information on language difficulties associated with different stages of dementia, depression, and cultural–ethnic considerations. Results showed that training improved both CNA knowledge and attitudes toward residents with dementia.    McCallion, Toseland, Lacey, and Banks 1999 evaluated a Nursing Assistant Communication Skills Program on various staff and resident outcomes in nursing homes. In addition to teaching verbal and nonverbal communication skills, staff were taught to use memory aids. Memory aids included placing written and graphic signs in important locations and the use of memory charts placed on resident bedroom walls. Memory charts contained photographs, brief statements, and conversation topics that were meant to encourage communication with the residents. To facilitate maintenance of therapeutic effort, the trainer made informal monthly visits to the nursing homes to verify continued implementation of the Nursing Assistant Communiation Skills Program techniques. Results showed durable effects (6 months posttreatment) on resident depressive symptomatology. However, the effects on resident disruptive behaviors were mixed and generally transient.    McCallion, Toseland, and Freeman 1999 also developed a Family Visit Education Program, which focused on improving communication among residents, nursing staff, and visiting family members. Compared with a control group, the Family Visit Education Program showed benefits for residents and family members, but not for nursing staff. Specifically, family members demonstrated improved communication patterns with residents; residents showed improvements in depression, irritability, and verbal behavior. Staff also reported a reduction in agitation.    The success of communication-based interventions designed to improve nursing home care depends heavily on the receptiveness of nursing staff to learn new skills and on the establishment of staff motivational systems to ensure the maintenance of these skills (Burgio and Burgio 1990; Burgio and Scilley 1994; Burgio and Stevens 1999; Stevens et al. 1998). Staff motivational systems such as behavioral supervision (Burgio and Burgio 1990) and total quality management (Schnelle, Ouslander, Osterweil, and Blumenthal 1993) have been used successfully to motivate staff in the implementation of a variety of interventions in nursing homes. Behavioral supervision is designed to motivate management and direct care staff to observe and analyze skill performance in order to identify problems and to induce supervisory staff to provide direct and specific feedback suggesting practical ways of maximizing skills (Burgio and Stevens 1999; Daniels 1994). Using behavioral supervision, Stevens et al. 1998 showed that CNAs could be trained to increase and maintain the rate of task announcements and positive statements made to residents during care over a 46-week assessment period.    In a small intra-subject pilot study (N = 8), Allen-Burge, Burgio, Bourgeois, Sims, and Nunnikhoven 2001 examined the effects of communication skills training and the use of memory books. CNAs were taught to use communication skills and memory books during their interactions with residents with mild to moderate cognitive impairment but relatively intact communication abilities. An abbreviated system of behavioral supervision was attempted to encourage performance of these skills on the nursing units. Results showed that, regardless of sporadic implementation of the intervention by nursing staff, the intervention improved communication between staff and residents during care routines, increased the amount of time other residents and visitors spent talking with target residents, and increased the rate of positive statements made by the target residents and others in their immediate environment.    The purpose of the present study was to examine the efficacy of communication skills training and the use of individualized memory books in improving communication between CNAs and a larger group of residents (N = 67) during care. In contrast to the pilot study, we used a more comprehensive staff motivation system (behavioral supervision). In addition, formal measures of treatment implementation were included (Lichstein, Riedel, and Grieve 1994). We hypothesized that (a) through the use of behavioral supervision, CNAs' use of therapeutic procedures would increase, compared with their baseline performance, and would maintain at a 2-month follow-up assessment; (b) trained CNAs would increase their frequency of overall verbal interaction and positive verbal interactions compared with their own baseline performance and untrained CNAs; and (c) residents on trained nursing units would show increases in overall amount of coherent verbal interaction (i.e., understandable speech) compared with residents on untrained units.          Methods              Settings        This study was conducted in five nursing homes with an average census of 120 residents on three units. On average, 11% of the beds were Medicare, 50% were Medicaid, and the remainder were private pay. Four of the nursing homes were corporately owned facilities; one was privately owned with a religious affiliation. Special care units were not included in the study. Residents had an average length of stay of 3 years; 93% were female, 75% were white, and 25% were African American. Resident-to-CNA ratios were 9:1 during the day shift and 12:1 during the evening shift. Reported yearly rates of staff turnover were 8% among registered nurses (RNs), 18% among licensed practical nurses (LPNs), and 49% among CNAs. The American Health Care Association reported that the national turnover rate is 97% for CNAs (as cited in Harrington et al. 2000).                    Participants                  Residents          Residents were entered into the study on the basis of the following criteria: (a) age of at least 55 years; (b) Mini-Mental Status Examination (MMSE; Folstein, Folstein, and McHugh 1975) total score greater than 0 or Short Portable Mental Status Questionnaire (Pfeiffer 1975) with fewer than 10 errors (our purpose for using these criteria were to exclude nonresponsive residents); (c) retention of minimal ability in verbal communication involving spontaneous speech based on criteria established by Bourgeois 1993(criteria available by writing Louis D. Burgio or Rebecca Allen-Burge); (d) absence of major sensory impairment; (e) life expectancy greater than 6 months; and (f) residence within the facility for at least 1 month. Because of the importance in this study of observing staff–resident interactions during care routines, residents who completed activities of daily living (ADLs) independently during baseline were excluded. Residents were considered independent if the care tasks were completed with no nursing assistant present for at least 5 minutes across two observational occasions during baseline.          Two hundred sixty-three of 403 residents in the five nursing homes met entry criteria on the basis of nursing staff referral; 111 consented to participate, the majority through proxy. The consent rate was 42%. Nineteen were excluded during the baseline phase because the communication assessment and ADL observation indicated that they did not meet entry criteria; thus, 92 residents meeting entry criteria completed baseline. A decision was made to include in the data analyses only residents who had data available for all three assessment points (baseline, Postintervention Assessments I and II). Twenty-five residents were excluded due to incomplete data, leaving 67 residents for data analysis (33 control and 34 intervention residents). The reasons for exclusion were the following: eight residents died prior to the intervention phase, 9 moved to another nursing unit or different facility, 4 residents or sponsors withdrew consent for participation, and 4 residents refused to be observed during care. There were no significant differences between the surviving (n = 67) and the excluded (n = 25) residents on age, gender, race, dementia diagnosis, MMSE, or Functional Independence Measure (ADL) scores. Table 1  shows selected characteristics of surviving residents in the study sample at baseline. As can be seen, there were no significant differences between residents on the control and treatment units.                          Staff          Ninety-eight CNAs were working on either the intervention or control units during baseline assessment. Observational data were available during all three assessment points for 64 CNAs; thus, 34 CNAs were dropped from the analysis. There were no differences in gender, race, education, age, or length of service between the 98 CNAs available at baseline and the 64 surviving CNAs. Table 2  shows selected characteristics of surviving CNAs in the study sample at baseline; however, demographic data were available for only 37 CNAs in the intervention group. As can be seen, there were no significant differences between CNAs on the control units (n = 25) and treatment units (n = 39; 37 providing demographic data).                            Design and Procedures        We used a two-group comparison design with an intragroup comparison component embedded in each group. The two groups were (a) memory book intervention with a staff motivational system and (b) no-treatment control (NTC). The study was conducted sequentially across nursing homes. Upon entering a nursing home, two units were selected randomly and also randomly assigned to treatment and control conditions. Data were collected on treatment and control units concurrently. We spent the first 3 to 4 weeks in each facility, prior to baseline recording, gathering information on all consenting treatment and control residents and on regular day and evening shift nursing staff.        This was followed by a 4-week (Weeks 1 to 4) baseline phase (both units) designed to assess the social environment in the nursing homes before intervention. During this and all phases, direct observational and paper-and-pencil assessments were completed (see Measures section). On treatment units, communication–memory book skill inservice workshops were conducted during a 1-week period immediately following baseline (Week 5; see Intervention Conditions section). This was followed by hands-on training on the intervention units during the next 4 weeks (Weeks 6 to 9). During this phase, CNAs were instructed in the use of communication–memory book skills by research and indigenous nursing staff. Research staff also instructed supervisory nursing staff in the use of the staff motivational system during this time.        The next 8 weeks consisted of evaluation of the intervention's effectiveness using the same assessments as at baseline. This assessment period was divided into two phases: Postintervention Assessment I (PIA–I) represented staff and resident performance during the first 4 weeks (Weeks 10 to 13); Postintervention Assessment II (PIA–II) represented their performance during the second 4 weeks of this phase (Weeks 14 to 17). During the first segment of this latter phase, supervisory nursing staff continued to receive assistance from research staff on the use of the staff motivational system. By the end of the phase, indigenous staff controlled all aspects of the system and received no assistance from research staff.        To enhance maintenance of the staff motivational system, consultation visits by the project manager were conducted at 3 and 6 weeks after we had departed from the facility (i.e., after PIA–II). Two months after PIA–II, probe follow-up data were collected on staff and resident performance during a 1-week period in four of the five nursing homes. The fifth nursing home declined the follow-up assessment because of a high level of administrative and nursing staff turnover. Observational data were collected using a reduced sampling schedule.                    Intervention Conditions                  Communication–Memory Book Skills and Staff Motivational System          Participating residents received a personalized 12-page laminated memory book consisting of biographical, orientation, and daily schedule information. Each 5- × 5-in. page included a 6–10 word declarative sentence printed in 14- or 20-point Times New Roman type with a color or black-and-white photograph or line drawing illustrating the statement. Residents' books might contain pictures of their wedding and family, their CNA, other residents, their daily schedule, instructions on bathing, and pages targeting behavior problems such as wandering, aggression, or repetitive questioning. It was the CNA's responsibility to ensure that books were always present in the residents' living space. Residents were provided with individually tailored vests that attached the book to the resident's torso, wheelchair caddies that attached the book to the resident's wheelchair, or a stand to display the book prominently in the resident's room. Additional pages were added to the books every 4 weeks in order to maintain staff and resident interest in this aspect of the intervention. Memory books were replaced by research staff if lost. Replacements were provided for 38% of the residents.          All nursing staff on intervention units were trained in the use of memory books and general communication skills. The first component of staff training consisted of a 2-hr inservice session on communication–memory book skills conducted by the project manager (a licensed clinical psychologist). Members of the nursing staff were instructed to use memory books with residents (a) to increase general communication among residents and between nursing staff and residents, (b) to increase the independent functioning of residents during targeted care routines, and (c) as a distraction to decrease resident disruptive behaviors. Inservice materials are available from Louis D. Burgio or Rebecca Allen-Burge on request.          CNAs and supervisory staff then attended a 1-hr inservice to introduce the staff motivational system. An additional hour of training was provided to LPNs and RNs on the supervision of this system. The critical roles of the CNA and LPN were emphasized because these members of the nursing staff have the most direct contact with residents (Burgio et al. 1990). In addition to didactic training, active learning techniques including the use of role play, discussion of real-life examples from the nursing units, and discussion of written vignettes were used to engage staff. Notebooks were provided to each member of the nursing staff that included all information from the inservices. Staff were encouraged to refer to these notebooks while working with residents on the unit.          To increase the likelihood that staff would use the newly learned skills on the units, behavioral supervision (Burgio and Burgio 1990) was taught during the inservice, implemented by research staff during the 4-week hands-on training phase and trans-ferred to indigenous nursing home staff during the 8-week postintervention assessment period. Initially, the CNAs were trained by research staff in the use of memory books, communication skills, and components of the staff motivational system. CNAs on the day and evening shifts were observed by research staff once per day while providing care to residents. Researchers and LPNs used the Communication Skills Checklist (CSC) during the care routine to record whether CNAs displayed the skills taught in the inservice; feedback was provided to CNAs regarding their use of the memory books, use of specific versus general instructions, one-step instructions, positive statements, responses to behavioral disturbances, and general distraction techniques. CNAs were provided verbal performance feedback immediately following the care routine. The project manager also completed the Observation of the LPN's Supervisory Activities (OLSA) on the LPNs during this period. Only data collected by research staff were used in outcome analysis.          Thirty-nine CNAs on the intervention units were taught to monitor and record their own skill performance as a means of tracking their performance and as a daily reminder of the skills needed to be an effective communicator. CNAs were asked to use the self-monitoring form during shifts worked throughout the week. CNAs had the opportunity to use the form an average of four times (range 1–10) per week. To meet job performance goals, CNAs were asked to complete at least an average of 80% of their assigned self-monitoring forms. To reach performance criterion, they were also expected to obtain an average of 80% accuracy on the CSC completed by LPNs or research assistants.          Trained CNAs received public recognition for meeting job performance criteria (i.e., 80% completion of forms and 80% accuracy) by having their names posted weekly on a CNA Honor Roll. Those CNAs whose names appeared on the honor roll received an opportunity for a performance incentive. All honor-roll CNAs listed were entered into a performance-based lottery held once each week for day and evening shifts (Reid, Parsons, and Green 1989). For each shift, the individual winning the lottery was provided with his or her choice of incentives from a list of choices determined by each nursing home, including the following: (a) free lunch in the cafeteria every day for 1 week, (b) a "goodie bag" full of inexpensive snacks, beauty products, and knick-knacks, (c) permission to arrive at work 15 min later than scheduled every day for 1 week, (d) permission to leave work 15–30 min earlier than scheduled every day for 1 week, (e) permission to leave work 2.5 hr early on Friday, or (f) 2.5 hr of extra pay. Across nursing homes, the most frequently chosen incentives were the opportunity to leave work earlier than scheduled, extra pay, and goodie bags.          LPNs on the intervention unit also received public recognition for meeting job performance criteria (i.e., 80% completion of CNA monitoring and supervisory forms) by having their names posted weekly on an LPN Honor Roll. On average, LPNs were assigned 2–5 CNAs to monitor and supervise in their section on their shift.                          NTC          CNAs and LPNs on the NTC units did not participate in any intervention-related activity. Assessments were conducted on NTC units on the same schedule as on the intervention units. CNAs and LPNs on the intervention units were occasionally pulled to the NTC units. When this occurred, they were asked not to use any of the skills learned on the intervention units. After the 2-month follow-up assessment period, staff on the NTC units were offered instructions and materials on communication–memory book skills.                            Measurement                  CNA Communication Skills Checklist          The CSC is a direct observation behavioral frequency measure allowing the researcher to assess CNAs' use of specific versus general instructions, one-step instructions, positive statements, biographical statements not included in the memory book (generalization), responses to behavioral disturbances, and use of general distraction techniques (Allen-Burge et al. 2001). Research staff attempted to observe every CNA daily during hands-on training, twice during baseline and each of the two postintervention assessments, and once during follow-up. We were successful in completing this target number of observations for 83% of the CNAs. The CSC focused on communication skills demonstrated during a care interaction. To allow for an adequate sampling of CNAs' use of communication–memory book skills, at least three separate care activities (i.e., bathing, dressing, transfer) were included during the observation in order for the data to be retained.          A total of 76.37 hr of observation (range 2–60 min per CSC) were completed across all study phases (i.e., 22.60 hr during baseline, 18.94 hr during PIA–I, 16.20 hr during PIA–II, and 18.63 hr during follow-up). Data were expressed as total number of occurrences of each type of statement divided by the total number of seconds in the observation period.          Interobserver reliability was assessed independently among observers during 13% (80/603; 14.03 hr) of the observations across all sites and phases. Observer agreement for each behavioral category measured by the CSC was calculated by using a total occurrence agreement calculation. The average percentage of agreement for this measure across all categories was 84% (range 71%–99%).                          OLSA          The OLSA allows the researcher to measure LPNs' accuracy in observing and recording CNA skill performance during supervision, and LPNs' skill in providing CNAs with verbal performance feedback. As part of the staff motivational system, LPNs observed each of the CNAs under their supervision once per week using a form similar to the CSC during 15-min samples of care routines with residents. During these observations, LPNs recorded the occurrence of CNAs' use of memory books, specific versus general instructions, one-step instructions, positive statements, negative or unhelpful statements, biographical statements not included in the memory book, and CNAs' responses to behavioral disturbances.          LPNs' accuracy was checked against the project manager's recording of the same behaviors during the same observation. The project manager was present with LPNs observing CNAs using the CSC during the staff training period. The OLSA also allowed the project manager to rate the LPNs' use of verbal supervisory feedback. Verbal supervisory feedback is rated with regard to beginning and ending a session with a supportive statement to the CNA, the provision of accurate and specific positive and corrective feedback to the CNA, the provision of specific performance scores to the CNA with a statement indicating the CNA's training status, and the provision of an opportunity for the CNA to discuss any of the feedback given by the LPN.          CNAs received positive or negative written feedback letters at the end of the hands-on training period and at the end of PIA–I. To receive a positive feedback letter, CNAs had to attain an average performance score of 80% or better in their completion of self-monitoring forms and LPN evaluations for the previous 4-week period. These letters were placed in the CNAs' personnel files, and copies were given to CNAs and to administrative nursing staff.                          Computer-Assisted Behavioral Observation System (CABOS): Hardware and Software          As in Burgio, Scilley, Hardin, Hsu, and Yancey 1996 prior research, the Portable Computer Systems for Observational Research software programs from Communitech International (DeKalb, IL) were used for this project (Repp, Karsh, van Acker, Felce, and Harman 1989). The recording of behavior was synchronized with each computer's internal time clock and controlled through a software routine.          Real-time CABOS data were generated by sampling behaviors during care interaction between residents and their primary day- and/or evening-shift CNA. All participating residents were observed twice during baseline, PIA–I and PIA–II, and once during follow-up. Care routines had to be at least 5 min in length for the data to be retained.          Domains of behavior divided into mutually exclusive and exhaustive categories relevant to the hypothesized outcomes were identified, and detailed operational definitions were generated for all behavior codes within categories. One category coded the residents' activity, including the amount of ADL care. Four categories coded aspects of the residents' social environment: (a) nonverbal presence of staff or other residents, (b) verbal interaction, (c) verbal content, and (d) disruptive behaviors. Each behavioral category contained codes that allowed specification of type of behavior within the category and whether it was initiated by staff or resident (e.g., content had separate positive and negative statement codes).          A total of 70.29 hr of observation (range 5–51 min per care interaction) was completed across all study phases (i.e., 24.24 hr during baseline, 20.31 hr during PIA–I, 18.90 hr during PIA–II, 6.84 hr during follow-up). Interobserver agreement was calculated using Cohen's kappa (Cohen 1968; Hays 1994). Reliability was assessed independently among four observers during 14% (14.03 hr) of the total observation time across all phases. Average kappa reliability across all categories was .79 (range .68–.95). In behavioral research, recommended lower limits for acceptable kappas range from .60 to .75 (Hartmann 1982).                          Memory Book Checks          Research assistants recorded whether residents were in possession of memory books (i.e., memory books were prominently displayed and within arm's reach of the resident) during separate observational checks conducted twice daily, once during the morning and evening shifts. This yielded a total of 282 checks during PIA–I, PIA–II, and the 2-month follow-up assessment. Data were recorded dichotomously (yes/no) at both checks for each resident. Because NTC residents did not possess memory books, checks were conducted only on intervention units.                            Paper-and-Pencil Measures        Assessment instruments were administered either by a clinical psychologist or by research assistants trained and supervised by the clinical psychologist to administer these measures.                  MMSE (Folstein et al. 1975)          The MMSE, a measure of global cognitive ability, measures orientation, immediate and delayed recall for words, attention and concentration, language, and praxis (total score range 0–30). The test–retest and interevaluator reliabilities are .89 and .83, respectively.                          Functional Independence Measure (FIM)—REACH Version          Information for completing this instrument was provided by CNAs familiar with the daily care needs of the participating resident (Hamilton, Laughlin, Fiedler, and Granger 1994; Kidd et al. 1995). The version used in this study was developed for the National Institutes of Health–funded cooperative agreement Resources for Enhancing Alzheimer's Caregiver Health (REACH; Coon, Schulz, and Ory 1999). As in the REACH project, only the motor subscale consisting of self-care, sphincter control, transfer, and locomotion items was used in this study (total score range 13–91). Reliability data indicated an intraclass correlation coefficient of .96 for the motor domain, with unweighted kappas ranging from .53 to .66 (Hamilton et al. 1994).                            Method of Analysis        Analyses were conducted on the CSC and on CABOS data collected during care routines. CNAs were the unit of analysis for CSC data; data were expressed as mean rate of CNA statements per hour. CSC outcome data included (a) the rate of specific, one-step instructions, (b) the rate of CNA positive statements, (c) the rate of biographical statements, (d) the rate of multiple-step instructions, and (e) the total duration of care. CABOS data were expressed as mean total percentage of observation time spent in each activity or mean rate per hour of positive statements, and the unit of analysis was the resident. CABOS outcome data included (a) total percentage of time of resident coherent verbal interaction, (b) total percentage of time of staff speech directed to the resident, and (c) the rate per hour of positive statements made by either residents or CNAs. We did not discriminate between staff and resident positive statements on this variable. Positive statements are brief duration events and were expressed as the rate of statements per hour.        Our analytic questions centered on (a) assessment of treatment delivery and enactment (Lichstein et al. 1994), (b) establishing an initial change in behavior for both staff and residents after implementation of the intervention, and (c) assessing the maintenance of any staff or resident behavior change 2 months later. Descriptive statistics were used to address the first question. For the second analytical question, analyses were run by calculating 2 (group) × 3 (time) mixed-factor analysis of variance (ANOVA), where the between-subjects factor Group included intervention and control and the within-subjects factor Time included baseline, PIA–I, and PIA–II phases. The primary outcome of interest in these analyses were significant Group × Time interaction effects, showing that the intervention group improved in the targeted behavioral outcomes for CNAs and residents over and above any improvements seen in the control group as a result of the passage of time or observation. For these interaction effects, Greenhouse-Geisser p values are reported throughout in order to correct for potential violations to the sphericity assumption (Winer 1971).        Finally, a 2 (group) × 2 (time) mixed-factor ANOVA was run comparing PIA–II outcomes to follow-up. The primary outcome of interest in these analyses were significant main effects of Group, showing that intervention participants maintained any behavior change.                    Results              Treatment Receipt and Enactment                  Memory Book Availability          Observational data from research staff memory book checks indicated that residents were in possession of their memory books during 72% of the morning checks and 75% of the afternoon checks during the hands-on training phase. This figure remained steady or increased during the PIA–I (70% morning, 73% afternoon), PIA–II (78% morning, 81% afternoon), and 2-month follow-up phases (77% morning, 80% afternoon).                          CNA/LPN Training and Performance of the Staff Motivational System          Thirty-nine CNAs with data at all three assessment times (baseline, PIA–I, PIA–II) completed the hands-on training phase on the intervention units. Of these 39 CNAs, 92% (n = 36) passed a final evaluation with a performance score of 80% or above in the use of communication skills as measured by the CSC. The average final evaluation score for CNAs was 84.77% (range 53%–97%). The average number of training sessions on the unit per CNA was 6 (range 1–13).          CNAs completed an average of 64% of their self-monitoring forms during the training phase (SD = 28%; range 5%–100%). The percentage of self-monitoring forms completed increased somewhat during the postintervention phases (PIA–I M = 67%, SD = 33%, range 0%–100%; PIA–II M = 66%, SD = 36%, range 0%–100%). CNAs were not required to self-monitor during the follow-up phase.          Across the five nursing homes, a total of 55 written feedback letters regarding CNAs' skill performance were distributed. Fifty-eight percent of these letters were positive; 42% were negative. The number of supervisory training sessions conducted with 20 LPNs ranged between two and four. One hundred percent of LPNs reached a criterion of 80% correct performance in their accuracy of CSC recording and the provision of verbal feedback to CNAs regarding communication skill performance by the end of the hands-on training phase. On average, during the training phase LPNs conducted 62% (SD = 36%, range 0%–100%) of their assigned observations of CNAs. This number remained relatively stable after the hands-on training phase when LPNs conducted CNA observations independently (i.e., not accompanied by the project manager). During PIA–I, LPNs conducted 57% (SD = 44%, range 0%–100%) of their assigned independent observations, and during PIA–II LPNs conducted 61% (SD = 46%, range 0%–100%).                            CNA Use of Communication Skills        There were no baseline differences between intervention and control groups on the CSC-generated overall communication skills score, time spent giving care to residents, specific one-step instructions, multistep instructions, positive statements, or biographical statements.        Results of the 2 (group) × 3 (time) ANOVA analyses are shown in Fig. 1Fig. 2Fig. 3. The mixed-factor ANOVA for the overall total correct communication skill percentage score revealed significant main effects of group, F(1,62) = 16.87, p = .0001, and time, F(2,124) = 37.30, p = .0001, and a significant Group × Time interaction, F(2,124) = 17.20, p = .0001 (see Fig. 1). CNAs in the intervention group improved their use of general communication skills with residents during care in comparison with NTC group CNAs at both PIA–I and PIA–II.        More specifically, CNAs in the intervention group tended to increase their rate per hour use of specific, one-step instructions during care in comparison with control group CNAs at both PIA–I and PIA–II (see Fig. 2), as shown by a marginally significant Group × Time interaction, F(2,124) = 2.80, p = .06. Intervention CNAs significantly increased their rate of positive statements made to residents during care in comparison with control group CNAs at both PIA–I and PIA–II (see Fig. 3), as shown by a significant Group × Time interaction, F(2,124) = 6.16, p = .004. There was also a significant group effect with intervention CNAs using fewer multistep instructions, F(1,62) = 5.21, p = .03, but no Group × Time interaction. There were no differences between intervention and control group CNAs across time in use of biographical statements. Notably, there was also no difference between intervention and control group CNAs across time in the amount of time spent in daily care with residents.        Forty-three residents (21 control, 22 intervention) and 29 CNAs (13 control, 16 intervention) had data available from all assessment points from baseline assessment through the 2-month follow-up (i.e., maintenance sample). Analyses indicated that there were no significant differences in the characteristics of residents or CNAs who survived to follow-up and those who completed baseline. There were also no differences between CNAs on the control and intervention units at the 2-month follow-up assessment. The only significant difference between residents on the control and intervention units at the 2-month follow-up was that residents on intervention units were more independent in self-care as measured by the FIM, F(1,41) = 4.33, p = .04.        Results of the ANOVAs show significant main effects of group in overall communication skills score on the CSC, F(1,27) = 12.92, p = .001 (Fig. 1) and the use of positive statements, F(1,27) = 11.91, p = .002 (Fig. 3), indicating maintenance of change at the 2-month follow-up assessment point.                    CNA–Resident Interactions During Care        Results of the 2 (group) × 3 (time) mixed-factor ANOVA of the CABOS care interaction data are shown in Fig. 4 and Fig. 5. There were significant main effects of group, F(1,65) = 5.37, p = .02, and time, F(2,130) = 8.57, p = .0003, and a significant Group × Time interaction, F(2,130) = 4.11, p = .02, for the total amount of staff speech directed toward residents (see Fig. 4). CNAs in the intervention group increased their verbal interaction with residents during care in comparison with control group CNAs at PIA–II.        Regarding resident coherent verbal interaction, only the main effects of group, F(1,65) = 6.50, p = .01, and time, F(2,130) = 3.20, p = .05, were significant. However, the rate of positive verbal interactions between CNAs and residents during care routines increased in the intervention group across time, as shown in Fig. 5 by a significant Group × Time interaction, F(2,130) = 4.81, p = .01.        Analysis of maintenance data indicated that there were significant main effects of group for total amount of staff speech, F(1,41) = 5.20, p = .03 (Fig. 4), and positive statements by either staff or resident (i.e., positive verbal interactions), F(1,41) = 5.83, p = .02 (Fig. 5). Intervention group CNAs maintained a higher rate of speech with residents during care, and there were more positive statements made during care in CNA–resident dyads in the intervention group.        The occurrence of agitation during care among the 67 residents was extremely low during all phases of the study (e.g., on average less than 1% of observation time). Thus, changes in this behavior could not be assessed.                    Discussion      The results of this study suggest that, through the use of communication–memory book skills training and a staff motivational system, CNAs can improve aspects of their communication with nursing home residents. CSC data, derived from direct observation of care interactions, showed that CNAs' overall communication skills level increased significantly as compared with an NTC group. CNAs increased their use of positive statements and showed a marginal increase (p = .06) in single, one-step instructions, which can be less confusing than multiple nonspecific instructions when interacting with individuals with cognitive impairments. Moreover, CABOS data showed a significant increase in the amount of staff speech directed toward the resident during care routines. Finally, a behavioral code measuring the amount of positive statements during CNA–resident verbal interactions also showed a significant increase. Importantly, all of the changes in staff behavior were maintained at an assessment conducted 4 months after the initiation of treatment. Thus, the current data would appear to corroborate pilot data from Allen-Burge and colleagues 2001 and the findings of McCallion and colleagues 1999.      These changes in staff behavior were brought about without increasing the amount of time necessary to deliver daily care. It has been argued that even if CNAs can be taught to play a more therapeutic role in the nursing home, it would require a time commitment that might not be feasible in the current nursing home environment (Schnelle and Beck 1999). For example, Rogers and colleagues 1999 reported success in training research therapists to increase independent dressing in residents; however, their therapeutic procedure required more time for staff to complete. Our data suggest that using better communication skills and memory books during care routines does not require more staff time. It is important that researchers delineate which therapeutic routines do and do not require additional time commitments so that staffing adjustments can be made when planning therapeutic routines.      Contrary to our hypothesis, residents in the intervention group did not improve their rate of coherent verbal interactions with CNAs during care routines in comparison with control group residents. As discussed above, there was a significant increase in the rate of positive statements during CNA–resident interactions after training. However, due to our definition of this behavioral code, we did not examine how much residents contributed to this increase. Moreover, we were unable to assess any positive effects of the intervention on disruptive behavior due to its extremely low rate of occurrence in this sample. In this study, residents were required to show minimal ability in verbal communication involving spontaneous speech for entry. Consequently, residents were, on average, moderately cognitively impaired (MMSE M = 13.39), and prior research has indicated that moderately cognitively impaired residents are less likely to display serious disruptive behaviors (Burgio et al. 1994; Cohen-Mansfield, Werner, and Marx 1990).      A main feature of this study was the careful attention given to the assessment of treatment implementation (Lichstein et al. 1994). Although the assessment of treatment implementation has long been a standard in nongerontological psychosocial intervention research (Cook and Campbell 1979; Moncher and Prinz 1991; Sechrest, West, Phillips, Redner, and Yeaton 1979), it has seldom been used in gerontological intervention research (Burgio, Corcoran, et al. 2001). Aspects of treatment receipt (e.g., CNAs' understanding of and use of the treatment) and treatment enactment (e.g., use of the staff motivational system and memory books by CNAs and LPNs) were investigated. The methodological advantages of directly assessing the implementation of interventions in applied settings are numerous and include greater assurance in the internal and external validity of the study. Internal validity concerns whether observed changes in behavior in CNA and resident outcomes actually coincide with increased use of the communication–memory book skills by CNAs. Measurements of treatment implementation also provide guidelines for the assessment of external validity by indicating what level of enactment of therapeutic skills by indigenous nursing staff was necessary to produce the observed therapeutic gains.      Our results show that both CNAs and LPNs received (i.e., learned) the intervention as we intended. Ninety-two percent of CNAs demonstrated through direct observational evaluation that they could perform communication skills at the 80% criterion. One hundred percent of the LPNs reached a criterion of 80% accuracy of completing the CSC as compared with the project manager's completion of the CSC.      Demonstrating skill acquisition in no way guarantees that staff will use these skills in the clinical setting. However, our assessment of treatment enactment shows that memory books were available to staff and residents during an average of 76% of observations. Their availability remained constant after the intervention was transferred completely to indigenous staff.      CNAs completed an average of 66% of their self-monitoring forms. LPNs sent CNA performance feedback memos as instructed, and they completed an average of 60% of assigned observations of CNAs with the CSC form. This also remained relatively constant throughout all phases of the study. Although the completion of CNA self-monitoring forms and LPN CSC observations were only in the 60% range, considering the workload of these personnel we consider this to indicate successful, though less than ideal, treatment enactment.      There are several limitations of this study. First, the reported CNA turnover rate in the nursing homes was 49%, well below the national average of 97% (American Health Care Association, 1997, cited in Harrington et al. 2000). Large staff turnover rates present significant difficulties in implementing psychosocial interventions, and our results may not be replicable in more typical nursing homes with larger turnover rates. In this study, newly hired staff viewed videotapes of the inservice, and hands-on training was also provided. Still, it is possible that continuous training of incoming staff in nursing homes with turnover near 100% may present challenging logistical problems.      In all studies using direct observational measurement, participant reaction to observation is a potential problem. Specifically, the CNAs' performance of skills during observation may be influenced by social desirability factors and may not be representative of their actual day-to-day performance. There is no completely satisfactory answer to this problem, and we do not know to what degree social desirability influenced the CNA results. However, in this and our prior studies, we have developed specific procedures for observing staff unobtrusively; thus, and presumably, limiting reactivity (see Burgio 1996, and Burgio, Scilley, Hardin, and Hsu 2001, for a more detailed discussion of this issue).      Multiple outcome measures were collected to provide a comprehensive assessment of treatment effects. This was useful for broadly identifying effects on CNA behavior, resident responses, and CNA–resident interactions. However, the Type I error rate is undoubtedly inflated by the fact that no adjustments were made for each individual analysis. A Bonferroni correction might be considered, although this procedure markedly elevates the Type II error rate and decreases power. Given the relatively limited sample size available for this initial efficacy evaluation, we chose to not implement this more conservative approach. Exact probability levels are reported instead so that the reader can make any interpretive adjustments deemed necessary.      Another potential limitation was our choice to randomize nursing units within each nursing home into groups instead of randomizing entire nursing homes. Because CNAs were occasionally pulled to work on other nursing units, it is possible that trained CNAs applied communication skills on control units. This is a potential threat to the study's internal validity. However, we believe that this threat was minimized by including only nursing homes using fixed staffing and minimal pulling. The alternative of randomizing groups to nursing homes presents its own methodological problems, including the difficulty of finding nursing homes that are equivalent on all factors that might affect outcome. We have written about this dilemma in more depth elsewhere (Burgio and Stevens 1999).      Because this was an evaluation of a multicomponent treatment package, we do not know the separate contribution of communication training and memory book usage to the changes in staff behavior. Perhaps more important, we do not know whether the inclusion of a staff motivational system was necessary for producing and maintaining staff behavior change. Studies that have used similar training techniques, including hands-on training, have generally shown an immediate training effect but no maintenance of behavior change (e.g., Schnelle, Newman, and Fogarty 1990). In a study currently under review (Burgio, Stevens, et al. 2001) we compared a behavior management skills training package with and without a staff motivational system. As hypothesized, results showed an immediate training effect for both groups, but maintenance of CNAs' behavior change was demonstrated more frequently at a 6-month follow-up in the group that received a staff motivational system.      In conclusion, the results of this study suggest that CNAs can be trained to use improved communication skills and memory books with their residents during care interactions. With the use of a staff motivational system integrated into the training program, staff will perform these skills and will maintain this performance up to 4 months after the initiation of training. Although increases were observed in the overall amount of staff speech during interactions, use of positive statements, and positive statements during dyadic interactions between staff and residents, there is no direct evidence of changes in the resident communication behaviors targeted in this study. Future studies may want to examine other resident behaviors that may be influenced by improved CNA communication skills. One candidate for investigation is resident affect, which has been shown to be sensitive to change due to intervention in residents with dementia (Lawton, Van Haitsma, and Klapper 1996).      Finally, although management of the intervention program was transferred to indigenous staff midway through the intervention phase, this was predominantly an efficacy trial. To optimize the internal validity of the study, training was conducted by a PhD-level licensed clinical psychologist, both inservice and hands-on training were used, and, as discussed above, nursing homes with relatively low rates of CNA turnover were chosen. Although it is our belief that this intervention can be manualized and implemented by typical staff development personnel in most nursing homes, only an effectiveness trial can shed light on the true feasibility of this intervention program.      Practice Concepts      The Forum      Book Reviews                                                  Table 1.                                 Surviving Resident Characteristics by Group                                                              Variable                Intervention (n = 34)                No-Treatment Control (n = 33)                F /χ2 (df)                                            Agea                81.78 (8.88)                82.42 (7.10)                0.10 (1,65)                                            Mini-Mental Status Examinationa                13.50 (6.72)                12.94 (6.00)                0.13 (1,65)                                            Functional Independence Measurea                46.88 (22.26)                37.30 (18.79)                3.61 (1,65)                                            No. medicationsa                15.59 (9.79)                15.52 (8.49)                0.00 (1,65)                                            Gender (women)b                73.53                75.76                0.04 (1)                                            Race (White)b                76.47                90.91                2.54 (1)                                            Dementiab,c                 52.94                72.73                2.80 (1)                                                                        a              Characteristics reported as means (SD).                                      b              Characteristics reported as percentages (SD).                                      c              Dementia is listed as a diagnosis in the medical chart.                                                            Table 2.                                 Surviving Staff Characteristics by Group                                                              Variable                Intervention (n = 37)a                No-Treatment Control (n = 25)                F /χ2 (df)                                            Ageb                39.30 (11.46)                35.13 (7.05)                2.43 (1,56)                                            Years of educationb                13.57 (0.99)                14.00 (0.85)                3.01 (1,58)                                            Months at facilityb                46.79 (50.62)                40.41 (53.71)                0.21 (1,56)                                            Months as certified nursing assistantb                111.50 (81.26)                106.78 (64.94)                0.05 (1,57)                                            Gender (women)c                86.49                88.00                0.03 (1)                                            Race (Black)c                86.49                88.00                1.59 (1)                                                                        a              Demographic data were available for only 37 of the 39 CNAs in the intervention group.                                      b              Characteristics reported as means (SD).                                      c              Characteristics reported as percentages (SD).                                                                        Figure 1.                                 Mean total percentage correct on the certified nursing assistant Communication Skills Checklist across study phases for control (white bars) and intervention (black bars) groups. Asterisks denote significant differences between groups at p < .05. PIA–I = Postintervention Assessment I; PIA–II = Postintervention Assessment II.                                                          Figure 2.                                 Mean rate per hour of specific, one-step instructions by certified nursing assistants across study phases for control (white bars) and intervention (black bars) groups. Asterisks denote significant differences between groups at p < .05. PIA–I = Postintervention Assessment I; PIA–II = Postintervention Assessment II.                                                          Figure 3.                                 Mean rate per hour of positive statements by certified nursing assistants during care across study phases for control (white bars) and intervention (black bars) groups. Asterisks denote significant differences between groups at p < .05. PIA–I = Postintervention Assessment I; PIA–II = Postintervention Assessment II.                                                          Figure 4.                                 Mean percentage of total observation time across study phases during which certified nursing assistants were speaking to residents for control (white bars) and intervention (black bars) groups. Asterisks denote significant differences between groups at p < .05. PIA–I = Postintervention Assessment I; PIA–II = Postintervention Assessment II.                                                          Figure 5.                                 Mean rate per hour of positive statements made by certified nursing assistants or residents during care across study phases for control (white bars) and intervention (black bars) groups. Asterisks denote significant differences between groups at p < .05. PIA–I = Postintervention Assessment I; PIA–II = Postintervention Assessment II.                                                    Portions of this article were presented at the 52nd annual scientific meeting of the Gerontological Society of America, San Francisco, CA, November 1999. The research reported in this article was supported by funding from the National Institute on Aging (RO1AG13008) to M. Bourgeois and L. Burgio.      We thank the nurses, certified nursing assistants, and administrative staff of Civic Center Nursing Home, Pleasant Grove Health Care Center, St. Martin's in the Pines, Montclair East Nursing Home, and Shelby Ridge Nursing Home for their support and assistance. Special thanks are extended to Christy Fargason for assistance in data entry; to Shermetra DeLaine, Rachael Ragsdale, and Shane Thomas for assistance in data collection; and to Debbie Turpin, Jeff Phillips, and Karen Quarles for assistance in manuscript preparation.                      Allen-Burge R., Burgio L. D., Bourgeois M. S., Sims R., Nunnikhoven J., 2001. Increasing communication among nursing home residents. Journal of Clinical Geropsychology 7:213-230.                     Allen-Burge R., Stevens A. B., Burgio L. D., 1999. Effective behavioral interventions for decreasing dementia-related challenging behavior in nursing homes. International Journal of Geriatric Psychiatry 14:213-232.                     Boehm S., Whall A. L., Cosgrove K. L., Locke J. D., Schlenk E. A., 1995. Behavioral analysis and nursing interventions for reducing disruptive behaviors of patients with dementia. Applied Nursing Research 8: (3) 118-122.                     Bourgeois M., 1990. Enhancing conversation skills in Alzheimer's disease using a prosthetic memory aid. Journal of Applied Behavior Analysis 23:29-42.                     Bourgeois M., 1992. Conversing with memory impaired individuals using memory aids Northern Speech Services, Gaylord, MI.                     Bourgeois M., 1992. Evaluating memory wallets in conversations with patients with dementia. Journal of Speech and Hearing Research 35:1344-1357.                     Bourgeois M., 1993. Effects of memory aids on the dyadic conversations of individuals with dementia. Journal of Applied Behavior Analysis 26:77-87.                     Bourgeois M. S., Burgio L. D., Schulz R., Beach S., Palmer B., 1997. Modifying repetitive verbalizations of community-dwelling patients with AD. The Gerontologist 37:30-39.                     Bourgeois M. S., Mason L. A., 1996. Memory wallet intervention in an adult day-care setting. Behavioral Interventions 11: (1) 3-18.                     Burgio L. D., 1996. Direct observations of behavioral disturbances of dementia and their environmental context. International Psychogeri-atrics 8: (3) 343-349.                     Burgio L. D., Burgio K. L., 1990. Institutional staff training and management: A review of the literature and a model for geriatric long-term care facilities. International Journal of Aging and Human Development 30:287-302.                     Burgio L. D., Corcoran M., Lichstein K. L., Nichols L., Czaja S., Gallagher-Thompson D., Bourgeois M., Stevens A., Ory M., Schulz R., 2001. Judging outcomes in psychosocial interventions for dementia caregivers: The problem of treatment implementation. The Gerontologist 41:481-489.                     Burgio L. D., Engel B. T., Hawkins A. M., McCormick K., Scheve A. S., 1990. A descriptive analysis of nursing staff behaviors in a teaching nursing home: Differences among CNAs, LPNs, and RNs. The Gerontologist 30:107-112.                     Burgio L. D., Scilley K., 1994. Caregiver performance in the nursing home: The use of staff training and management procedures. Seminar in Speech and Language 15:313-322.                     Burgio L. D., Scilley K., Hardin J. M., Hsu C., 2001. Temporal patterns of disruptive vocalization in elderly nursing home residents. International Journal of Geriatric Psychiatry 16:378-386.                     Burgio L. D., Scilley K., Hardin J. M., Hsu C., Yancey J., 1996. Environmental "white noise": An intervention for verbally agitated nursing home residents. Journal of Gerontology: Psychological Sciences 51B:P354-P373.                     Burgio L. D., Scilley K., Hardin J. M., Janosky J., Bonino P., Slater S. C., Engberg R., 1994. Studying disruptive vocalization and contextual factors in the nursing home using computer-assisted real-time observation. Journal of Gerontology: Psychological Sciences 49:P230-P239.                     Burgio L. D., Stevens A. B., 1999. Behavioral interventions and motivational systems in the nursing home. Schulz R., Maddox G., Lawton M. P., , ed.Annual review of gerontology and geriatrics: Vol. 18. Focus on interventions research with older adults 284-320. Springer, New York.                     Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L., Paul, P., & Gerstle, J. (2001). Teaching and maintaining behavior management skills in the nursing home. Manuscript submitted for publication.                    Carstensen L. L., Fisher J. E., Malloy P. M., 1995. Cognitive and affective characteristics of socially withdrawn nursing home residents. Journal of Clinical Geropsychology 1: (3) 207-218.                     Cohen J., 1968. Weighted kappa: Nominal scale agreement with provision for scaled disagreement or partial credit. Psychological Bulletin 70:213-220.                     Cohen-Mansfield J., Werner P., Marx M., 1990. Screaming in nursing home residents. Journal of the American Geriatrics Society 38:785-792.                     Cook T. D., Campbell D. T., 1979. Quasi-experimentation: Design and analysis issues for field settings Rand-McNally, Chicago.                     Coon D. W., Schulz R., Ory M. G., 1999. Innovative intervention approaches for Alzheimer's disease caregivers. Beigel D., Blum A., , ed.Innovations in practice and service delivery across the lifespan 295-325. Oxford University Press, New York.                     Daniels A. C., 1994. Bringing out the best in people: How to apply the astonishing power of positive reinforcement McGraw-Hill, New York.                     Folstein M., Folstein S., McHugh P., 1975. "Mini-Mental State." A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatry Research 12:189-198.                     Hallberg I. R., Norberg A., Eriksson S., 1990. A comparison between the care of vocally disruptive patients and that of other residents at psychogeriatric wards. Journal of Advanced Nursing 15:410-416.                     Hamilton B. B., Laughlin J. A., Fiedler R. C., Granger C. V., 1994. Inter-rater reliability of the 7-level Functional Independence Measure (FIM). Scandinavian Journal of Rehabilitation Medicine 26:115-119.                     Harrington C., Kovner C., Mezey M., Kayser-Jones J., Burger S., Mohler M., Burke R., Zimmerman D., 2000. Experts recommend minimum staffing standards for nursing facilities in the United States. The Gerontologist 40:5-16.                     Hartmann D. P., , ed.New directions for methodology of social and behavioral science: Using observers to study behavior 1982Jossey-Bass, San Francisco.                     Hays W. L., 1994. Statistics 5th ed. Holt, Rinehart, & Winton, New York.                     Hoeffner B., Radar J., McKenzie D., Lavelle M., Stewart B., 1997. Reducing aggressive behavior during bathing cognitively impaired nursing home residents. Journal of Gerontological Nursing 23: (5) 16-23.                     Hoerster, L., Hickey, E., & Bourgeois, M. (in press). Effects of memory aids on conversations between nursing home residents with dementia and nursing assistants. Neuropsychological Rehabilitation.                    Kidd D., Stewart G., Baldry J., Johnson J., Rossiter D., Petruckevitch A., Thompson A. J., 1995. The Functional Independence Measure: A comparative validity and reliability study. Disability and Rehabilitation 17: (1) 10-14.                     Lawton M. P., Van Haitsma K., Klapper J., 1996. Observed affect in nursing home residents with Alzheimer's disease. Journal of Gerontology: Psychological Sciences 51B:P3-P14.                     Lichstein K. L., Riedel B. W., Grieve R., 1994. Fair tests to clinical trials: A treatment implementation model. Advances in Behavior Research and Therapy 16:1-29.                     McCallion P., Toseland R. W., Freeman K., 1999. An evaluation of a family visit education program. Journal of the American Geriatric Society 47: (2) 203-214.                     McCallion P., Toseland R. W., Lacey D., Banks S., 1999. Educating nursing assistants to communicate more effectively with nursing home residents with dementia. The Gerontologist 39:546-558.                     Moncher F. J., Prinz R. J., 1991. Treatment fidelity in outcome studies. Clinical Psychology Review 11:247-266.                     Pfeiffer E., 1975. A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 23:433-441.                     Reid D. H., Parsons M. B., Green C. W., 1989. Staff management in human services: Behavioral research and application Charles C Thomas, Springfield, IL.                     Repp A. C., Karsh K. G., van Acker R., Felce D., Harman M., 1989. A computer-based system for collecting and analyzing observational data. Journal of Special Education Technology 9:207-216.                     Ripich D. N., Wykle M., Niles S., 1995. Alzheimer's disease caregivers: The focused program. Geriatric Nursing 16: (1) 15-19.                     Rogers J. C., Holm M. B., Burgio L. D., Granieri E., Hsu C., Hardin J. M., McDowell B. J., 1999. Improving morning care routines of nursing home residents with dementia. Journal of the American Geriatrics Society 47: (9) 1049-1057.                     Schnelle J. F., Beck C., 1999. Costs of promoting independence. Journal of the American Geriatrics Society 47: (9) 1151-1153.                     Schnelle J. F., Newman D. R., Fogarty T., 1990. Management of patient continence in long-term care nursing facilities. The Gerontologist 30: (3) 373-376.                     Schnelle J. F., Ouslander J. G., Osterweil D., Blumenthal S., 1993. Total quality management: Administrative and clinical applications in nursing homes. Journal of the American Geriatrics Society 41:1259-1266.                     Sechrest L., West S. G., Phillips M. A., Redner R., Yeaton W., 1979. Some neglected problems in evaluation research: Strength and integrity of treatments. Sechrest L., West S. G., Phillips M. A., Redner R., Yeaton W., , ed.Evaluation studies review annual (Vol. 4) 15-35. Sage, Beverly Hills, CA.                     Stevens A., Burgio L. D., Bailey E., Burgio K. L., Paul P., Capilouto E., Nicovich P., Hale G., 1998. Teaching and maintaining behavior management skills with nursing assistants in a nursing home. The Gerontologist 38:379-384.                     Winer B. J., 1971. Statistical principles in experimental design 2nd ed. McGraw-Hill, New York.             