Transcript A Comparison of Three Training Methods on the Acquisition

PSY 4600 U7: Gerontology and
Staff Management
Schedule
Lecture: Today and Tuesday
Exam: Thursday, 4/03
But before U7, a word or two about U8….
(these are two rapidly growing areas, and while the topics don’t seem to be related, they are. Studies have been done
in long term care facilities – nursing homes and facilities for those with dementia; but right now most staff mgt
is being done in group homes/residential homes for developmentally disabled adults, schools/programs for autistic children)
Unit 8: Very Different Assignment!
• Topics covered:
– Certification and licensing in behavior analysis
– Research and professional ethics
• Unit Assignment: 2 parts
– 20 pt exam over study objectives in course pack
– 15 pts for completion of an on-line training
program about research ethics (Behavioral and
social sciences modules)
• Research and professional ethics have the same
overarching principles, and thus there are a lot of
similarities between them
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Unit 8: Online Training Program
• You must hand in a computer print out that you have
completed the on-line training on the day of U8 exam,
which is Tuesday, 4/15 (no electronic copies via email)
• For the computer print out – MODULES COMPLETED,
which lists the score you got on the quiz for each module
• Completion Criteria:
– Complete all modules in the behavioral and social sciences
category
– 80% average on quizzes across modules
• Quizzes at the end of the modules can be retaken before you move on to
the next module; once you move on, then the quizzes cannot be retaken
• If you have already completed this training, you only need to print off a copy
of the page that indicates that you have completed it. You don’t need to do it
again.
– You do not have do to this all in one sitting – in fact I recommend
that you not try to do that!
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Unit 8: Online Training Program
• If you do not hand this in on the day of the exam - no
credit. I will not accept late assignments.
• See Study objectives for grading criteria
• See Study objectives for instructions on logging onto the
training program (tend to update these on a regular
basis)
• Some of you have already completed this
– Required to complete it if you were/are an RA
• Some students like to hand this in early - that’s fine with
me!
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Behavioral Gerontology
Linda LeBlanc, Ph.D.
Allison Jay, MA
Alyce Dickinson, Ph.D.
Based on:
LeBlanc, L. A., Raetz, P. B., & Feliciano, L. (2011)
SO1: Aging of America
• The proportion of the population over
age 65 in the U.S. increased from 4% to
13% in the 20th Century
• It is predicted to be 20% of the
population by 2030
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SO2: Aging of America, Contributing Factors
• Medical advances increased life
expectancy about 30 years between
1900 & 2000
• 1900: 47 years
• 1950: 67 years
• 2000: 76 years
• Aging of Baby Boomers
• Born during the post-World War II baby boom
• Years between 1946 and about 1953
(longer life expectancy has increased about 30 years between 1900 & 2000 - fine for exam)
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SO3: Effects of Aging
Living longer means a substantial
portion of elders live with chronic illness
and disability
– Higher total cost of care
– Greater care needs
– Potentially lower quality
of life
(more doctor’s visits, more medication, more MRIs,, more protthestics - hearing aids, walkers, etc.)
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Behavioral Gerontology
• Application of behavioral principles to aging
issues
– Clinical/Rehabilitation Issues
– OBM/Staff Training Issues
• Small sub-field of behavior analysis that needs
new interested students
– Check out the Behavioral Gerontology SIG at ABAI
• Different approach to aging from typical
medical model of inevitable biological decline
(Just because you lost it, doesn’t mean you can’t get it back; provide behavioral/environmental supports; teach
people how to self-prompt)
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SO4: Behavioral Gerontology
• From a behavioral perspective, when a
person ages (examples of each follow)
– Fewer discriminative stimuli control
behavior
– Different motivating operations are likely
– Contingencies of reinforcement tend to
support the wrong behaviors
(Go back and look at examples of each)
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SO4: SDs become less effective
• Get lost when driving to someplace you go to frequently (i.e.,
the grocery store) and don’t know how to get home
• Faces may no longer evoke correct names - even of loved
ones
• Trouble with ordinary conversations; words don’t evoke typical
responses, particularly with a quick change of topics
• Can’t write a check anymore, and certainly cannot master web
banking (how do you pay bills?)
• TV/DVD/TIVO remotes: two or more remotes, each one is
different (stimulus control combined with punishment), can’t
figure out how to do things
• Changing technology – phones used to be easy; using
menus and navi keys are 2nd nature to you – not to
seniors; too many buttons, too many options!
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Stimulus Control & Punishment
(buttons are all in different places, symbols v. words, not one but two navi pads, jitterbugs)
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SO4: Different MOs
• Deprivation of social contacts makes elders
susceptible to telephone solicitors and scams by
strangers (someone comes to the door - they let
them in)
• Foot pain, hip replacement, arthritic pain make a
decrease in pain reinforcing and evoke behaviors
that lead to decreased pain – and, inactivity,
watching TV, win out over activities such as
gardening, walking in the woods, needlepoint (also
punishes those behaviors if engaged in)
• Sleep deprivation is often present so evokes more
irritable behaviors (when cut off when driving, or a
relative is late for a visit, or a grandchild begins to
cry/scream)
Fact that not only quantity but quality of sleep changes with age
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SO4: Reinforcement for dependent
behaviors and punishment for active
behavior
• When do you go see Grandma? When she is not
feeling well. (reinforcement for complaining and
behaviors related to not feeling well)
• Punishment for verbal behavior when can’t “find the
right word” or “follow the conversation”
• “Does it hurt to do that? Why don’t you rest and let
me do it?” (reinforcement for dependent behaviors)
• “Let me go to the grocery store for you”
(same issue as with Fordyce, chronic pain)
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Behavioral Gerontology
• Use of behavioral procedures to solve
problems related to SDs, MOs, and wrong
reinforcement/punishment contingencies
– No different than the approach we take in other
areas of specialization
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Enjoy Old Age, 1983
(click, animation)
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SO5: Why behavioral gerontology is needed
• Behavior problems, not health declines or
medical problems are
– Major cause of caregiver stress
– The most common cause of
institutionalization
• I “can’t take it anymore” on the part of the
caregiver
– aggression, arguing, losing things, wandering,
incontinence
• 65% of individuals in nursing homes have
significant behavior problems
• Can lead to high staff turnover
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NFE: Obstacles to widespread
behavioral services
• Practitioners are reluctant to serve elders – no
training
– Because of that it is hard to locate behavioral
services
• Older people and caregivers perceive stigma
for accessing mental health services
– Older adult: means “I’m crazy”
– Caregiver: “a good son/daughter/wife/husband”
could handle it without help
(Cont. on next slide)
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Obstacles, cont.
• Medical Model Myths
– Psychotropic medications are the only thing that will
work - most common intervention
– Once a skill is lost it cannot be regained
• Cost and effort constraints
– Simple and/or cheap will always be selected
Which is simpler and less effortful?
Medication or behavioral interventions?
Elders are taking an average of 5 different meds
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SO6: NFE: Anxiety and Depression
• Anxiety and depression are not common in
seniors, contrary to popular belief
• Anxiety:
– Only about 6% of healthy elders have clinical anxiety
– Higher rates in elders with medical conditions
• Depression
– Only occurs in 2 - 10% of older adults
– 2x more in women (as in younger population)
– 40-50% of people in nursing/retirement homes
• Which comes first, the chicken or the egg?
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Behaviorally . . why depression/anxiety?
– Loss of reinforcers due to changes in the environment
• Including deaths of siblings, friends, and perhaps life mate
– Loss of reinforcers due to physical deterioration of
receptors
• can’t hear or see as well
• aren’t as strong
• have trouble opening containers
– Increased dependence but don’t want to be a burden
• can’t drive anymore (can’t go shopping when you want to)
– But remember, healthy seniors are not depressed or
anxious
• Economically stable (hopefully)
• Tend to become more “forgiving” and “kinder”
• Not as concerned about what other people think
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Behavioral Gerontology Services
• Typical Nursing Home
– No active engagement, even in leisure
activities
– No social interaction or conversations
– Memory problems
– High rates of problem behavior
Behavioral gerontologists have tackled
each of these problems successfully
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SO7: Aggression
• 85% of seniors with dementia physically aggress their
care providers
– This is one of the most common behavioral problems that
leads to placement in long-term care facilities, physical
constraints, and/or medication
•
75% of the aggressive behaviors have been shown to
be escape behaviors from antecedent task demands
(MOs) related to daily living activities
– Dressing, taking the senior to the bathroom,
showering/bathing, brushing teeth, shaving, etc. (moderate to
severe)
– Antecedent MOs include verbal prompts, physical prompts,
task demands: it’s time to get up, you need a bath/shower, put
on your out-door clothes, why don’t you take a walk, you
shouldn’t be drinking that glass of wine (mild to moderate)
• NAG, NAG, NAG all day long!
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SO7: Aggression
• Common behavioral interventions:
– Care provider moves away and stops the demands
• Often done to prevent the senior from “being too upset”
• Care provider doesn’t want to be hurt
– Time out (a punishment procedure)
What’s wrong with these interventions??
(answer, next slide)
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SO7: Aggression
What’s wrong with these interventions??

MO:
R
Task demands, prompts
Aggression
SrNo task demands
In words:
These interventions terminate the task demands,
which negatively reinforces the aggression
(This is why functional assessment, determining the cause of the behavior is so important before designing
an intervention )
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SO7: NFE, What to do instead?
• Noncontingent escape
– Determine interresponse time of aggression
• Seconds before onset, seconds in-between
– Provide escape (terminate the activity or prompt)
before aggression occurs
• Form of differential reinforcement
Example:
Elder in a nursing home aggressed against care givers during toileting.
Found it was escape-maintained. It started ~30 s after toileting began, and
thereafter every 25 s. Care givers prompted toileting, but stopped after 20
s, paused for 10 s, then began prompts again. Repeated this until end of
toileting. Aggression decreased to near 0 levels.
(extinction next)
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SO7: NFE What to do instead?
• Extinction is also possible if the senior will not
hurt himself/herself or the care giver
– There is, of course, concern about an extinction burst
• Seems “cruel” but
– Literature suggests that alternatives have been
punishment or high doses of medication
• Physical restraints
• Strong verbal reprimands
Food for thought: Think of respondent conditioning, what happens if
strong verbal reprimands and other stimuli that elicit unpleasant
emotional responses are consistently paired with the care provider?
(How would you extinguish? Are these kinder? Drugs do decrease aggression, but are systemic and decrease the entire activity
level of the elder. Do you want a doped up Grandpa?)
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SO8: Bourgeois (1993), Memory Wallets
• Effects of memory aids (wallet) on conversations
of individuals with dementia
• People with dementia appear incoherent in
conversation because they (mainly intraverbals)
– Substitute vague words for specifics
– Don’t follow the content or topic
– Cannot spontaneously generate topics
• Interventions like memory wallets do result in
better conversations
(really like this, simple intervention; if you ask them what they did that morning, they may start complaining
about the food at dinner or staff , or talk about an event that was a very long time ago)
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My Nieces:
Caroline, Courtney, Jessica
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My favorite color is blue.
My cat is Mr. Snuffles and he is a Siamese.
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I live at 427 Bloomfield Ave
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Bourgeois (1993) Memory Wallets
• Participants: 6 individuals at adult day care
centers
• Two individuals talk to each other
• Memory wallet for one of the two was used
– Interviewed family members to develop list of facts
and topics
– Took corresponding pictures to include in wallet
• 5 minute conversations 3 times per week
• Measured
– Statements related to the memory aid
– On-topic statements
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SO8: Bourgeois (1993) Memory Wallets
• Research design
– Reversal: BAB
• Results (exception one P, most demented)
– Quite a few statements directly related to the aids
– More on-topic statements about the aids, but also
about other areas (generalized to other topics)
– More on-topic statements by the partner - it wasn’t
their aid!
• Social Validity
– 13 Speech Staff listened to tapes and rated quality
– Aided conversations rated higher on staying on topic,
being less ambiguous, and in general, just being more
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comfortable to listen to,
No Aid
Memory Aid
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SO9 Intro (NFE): The Intersection of
Gerontology and OBM/Staff Mgt
• It’s important for behavior analysts to develop
and experimentally evaluate interventions to
deal with problem behaviors
• However, if we want to alter/improve the
behaviors of consumers permanently, we need
care givers and staff to implement those
interventions
• This is where OBM/Staff Mgt comes in
(OBM in business and industry, but typically staff mgt in human services)
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Gerontology and OBM/Staff Mgt
• Direct care staff in nursing homes
– Are CNAs (Certified Nursing Assistants)
– Often receive low pay and work long hours
– Have many potentially unpleasant aspects to their
job
– Are often kind people who sincerely want to help
– Often have no idea that their actions are directly
contributing to an environment that
• Suppresses independence and activity
• Reinforces problem behavior
(note medical model, nursing, rather than hiring direct care staff with behavioral background – different than in group homes and
residential facilities for DD and autistic children supervisors have a psychology/behavioral background)
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Gerontology and Staff Mgt
• Staff training and performance monitoring are
a critical part of providing good care in
nursing home settings
• Staff will often acquire knowledge of
procedures in in-service then fail to use the
procedures when they interact with clients
– No system in place to make it worthwhile
or feasible to maintain new procedures
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SO9: Engelman, Altus & Mathews (1999),
Increasing Leisure Activities
• Designed to increase engagement in leisure activities
• Engagement in leisure activities is believed to:
– Increase the quality of life of individuals by bringing
them into contact with reinforcers they enjoy
– Decrease inappropriate behaviors
• Often, however, elders with dementia don’t initiate
activities without assistance
• While staff are encouraged to facilitate this, they are not
trained to help them choose or maintain leisure activities
• Furthermore, staff have a lot to do and may have many
competing job responsibilities
(Basically, just make them happier; True of other at-risk populations as well, DD)
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SO9: Engelman, Altus & Mathews (1999)
• 5 residents in a nursing home with dementia
• Intervention:
– CNAs were trained to
• Check-in with each of their assigned residents every 15 min
• If engaged, praise activity
• If not engaged, offer activity choices and assist if necessary
– CNAs were observed and given written performance
feedback
• Measured appropriate engagement, inappropriate
engagement, no engagement of residents
• Research Design = MB across morning/afternoon
(really cool design)
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40
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Engelman, Altus & Mathews (1999)
• Results
– All participants experienced increased
appropriate engagement
• over 80% of intervals in morning
• over 70% of intervals in afternoon
– MB design clearly shows the increase was
due to the check-in procedure
– Greater diversity of activities
• 7 in baseline, over 20 in intervention
(Piano player; sometimes the problem is they just can’t get started by themselves)
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SO10: Engelman et al. (2003),
Increasing independence
• Well meaning staff may increase resident
dependence by doing everything for them
• System of “Least to Most” Prompts ensures
opportunity to perform independently
– Verbal (least help/prompt, fosters most independence)
– Gestural (next level of help/prompt, independence)
– Physical (most help/prompt, fosters least independence)
• Intervention
– Interactive 30 min training on System of Least to Most
Prompts (model, rehearse, feedback)
– Feedback: Daily monitoring of consumer performance
by CNA
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SO10: Engelman et al. (2003),
Increasing Independence
• Participants: 2 CNAs; 3 elders with dementia
• Measured
– CNA use of Least to Most Prompts
– Time it took to dress elders
• Research Design = MB across elders
• Results
– Prompts increased for all CNAs across elders
– No increase in time it took to dress elder (6.7 vs. 6.5
min)
• Why is the above result very important?
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(during baseline, no prompts at all, they were dressing the elders)
Conclusions:
Behavioral Gerontology
• Increasing need for
professionals with
experience and
expertise in aging
• Opportunity to create
new models for service
delivery that allow
individuals to retain
independence as long
as possible
• Allows you to blend
clinical and OBM
interests
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Interested in this area?
• Southern Illinois University, Rehabilitation Institute
– Dr. Jonathan Baker: [email protected]
• University of Colorado, Colorado Springs, Clinical
Psychology
– Dr. Leilani Feliciano: [email protected]
• WMU’s Center for Gerontology
– wmich.edu/hhs/centers/gerontology
– minor in gerontology (relatively new)
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Staff Management
• Staff management, while similar to OBM interventions in business
and industry, offers some unique challenges
• One is that few professionals in human services are trained in staff
management; rather they are trained to develop effective training
and behavior management programs for their consumers
• There has been increasing recognition over the past 10 years that
staff management skills are essential for professionals in human
services
• Most individuals who obtain graduate degrees to work in human
services, end up as supervisors or managers – they do not
implement the programs with the consumers themselves, rather
they supervise those that do
(most of sm studies have been conducted in group homes or residential facilities for DD; however, the results of that research
are clear: there is a need for individuals with expertise in staff mgt in all areas of human services. schools and programs that serve
children with autism, to name a few)
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SO11: Staff Management
• Furthermore, many professionals manage several different units
or programs within human service agencies and some have
started their own human service organizations, but again they
have no or little training in staff management or organizational
systems analysis
• Yet, it is quite clear that no matter how well designed a training
or behavior management program is, unless it is
implemented correctly by staff, the consumers will not
benefit (answer to SO11)
– Functional daily living and job skill training
– Management of disruptive and inappropriate behavior
– Verbal behavior training
• In business and industry, it’s a given that employees need to
acquire new skills and supervisors/managers need to know how
to supervise their employees
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Staff Management
• Most business organizations hire experts in training,
performance management, and organizational
systems analysis, usually in the human resources
dept.
• Human service agencies have not done that
• Human service professionals, therefore, have little or
no training in staff training, performance management,
and organizational systems analysis
• And, there aren’t experts in the organization to help
them
(At WMU, over the years, no idea how many of our graduates in human services have told me that
they wished they had taken all of our OBM courses while in graduate school here)
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Why haven’t students been trained in
staff mgt or OBM?
• Failure to recognize the importance of staff mgt
• Lack of availability of courses in staff mgt/OBM at the
undergraduate and graduate level
– Very few graduate training programs in OBM
• OBM courses that are offered typically focus on business
and industry and are marketed that way, thus students
pursuing a career in human services don’t recognize the
relevance of these courses
– How many of you who are interested in human services (working
with autistic children, developmentally disabled, brain injured)
have considered taking PSY 3440, Organizational Psychology?
(WMU has historically been the exception; since 80s; our graduates in academic positions are primarily
the ones who are infusing staff mgt into training of human service professionals, so this is changing)
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What three OBM courses should
human services personnel take?
• Performance management
– PSY 3440, Organizational psychology, undergrad
– PSY 6450, Psychology of Work
• Personnel Training
– PSY 6440, Training
• Organizational systems analysis
– PSY 6510, Behavioral Systems Analysis
(WMU has historically been the exception; since 80s; our graduates in academic positions are primarily
the ones who are infusing staff mgt into training of human service professionals, so this is changing;
Personnel selection might also be good, but not as necessary; business course in accounting/finance)
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Challenges for the direct care staff
• Pay is typically low
• Sometimes staff get “kicked, bitten, and scratched”
• They often have little or no professional training before
being hired
– High school degrees
• Job responsibilities are often not well defined after hire
– Often are excellent at daily care of consumers and scheduled
activities (meal preparation, outings, etc.)
– Often not given much guidance about what to do when there is
“free time” for consumers
DCS need job training and support that management
is often not trained to give them.
(similar to the factors I talked about earlier with respect to DCS in gerontology; don’t blame the staff, but
you can’t blame mgt either!)
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SO23A: The Results of Lack of
Supervisor Skills in Staff Mgt
Research has consistently shown:
• Developmentally disabled individuals who live in
residential facilities or group homes spend ~65% of their
time off-task
– That is, not doing any meaningful activities or leisure activities
• Direct care staff who work in such facilities spend ~45%
of their time off-task
– That is, not doing any work-related activities
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(I just want to mention the data on this before moving on…this is SO23A, I haven’t made a mistake on the slide)
SOs 13-22: Reid et al. Article
in Course Pack, Summary
• Supervisors in human service settings use the least
effective training and management procedures
– Verbal training methods (lectures and written material) rather than
performance-based training methods (modeling and practice)
– Antecedent interventions (training alone, memos, instructions)
rather than feedback (the most common performance mgt
procedure in the research; money, etc., is too expensive for
human service agencies)
– Punishment instead of feedback
(Reid et al. make all of the points I have made about the lack of training for supervisors in their article –
it is a terrific article. SOs are straightforward and on your own.
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SOs 13-22: Reid et al. Article
in Course Pack, Summary, cont.
• Why do supervisors use the least effective staff training
and management procedures?
– Lack of training
– Time and effort required by the effective procedures
(two reasons, always the same)
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Green, Reid, Perkins, & Gardner (1991):
Increasing Staff On-task Performance
• Participants
– 8 direct care staff
– 14 consumers who were profoundly mentally retarded,
non-ambulatory, and had multiple physical disabilities
• Setting: State residential facility
• Goal: Increase staff on-task performance
– Interactions with consumers
– Training with consumers
Example of a multifaceted program to increase staff on-task performance)
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SO24: Green et al. (1991):
Increasing Staff On-task Performance
• First step: Determination of when DCS had free time to
implement interactions and training
– Did not want to schedule a time for interactions and
training that would interfere with basic care of
consumers
• Observed the DCS throughout the day
– Lowest level of basic care and highest levels of
nonwork: 10:30-11:00 AM and 2:00-2:30 PM
• Scheduled interactions and training with consumers
during those times
Example of a multifaceted program to increase staff on-task performance)
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NFE: Green et al. (1991):
Multifaceted Staff Mgt. Program
• Assigned each DCS to a specific consumer to increase
accountability
• Individualized performance training for DCS based on
their assigned consumers
• Daily observations and vocal feedback to DCS re their
interactions/training with consumers
• Weekly written feedback summarizing daily feedback
(6 basic components, cont. on next slide, NFE, but I wanted to give you an example)
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NFE: Green et al. (1991):
Multifaceted Staff Mgt. Program
• Self-recording: DCS initialed a chart posted in the living
area when they completed assigned interactions/training
• Monthly reward drawing for DCS who completed at least
80% of their interaction/training sessions, 1 winner
– Free lunch
– 30 extra minutes for lunch
– Leave 30 minutes early one shift
– Reserved, private parking place
– Written commendation letter placed in personnel file
(choose a prize, similar to the ones listed, results next; illustrates how much effort and time
is required by supervisors for this type of program.)
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SO25: Green et al. (1991):
Results
• Nonwork
– Baseline: ~30%-95%
– Intervention: 2%-8%
– Decrease: 28 and 87 percentage points (30&85 OK FE)
• Interactions/Training
– Baseline: 7%-0%
– Intervention: 86%-91%
– Increase: 79 and 91 percentage points
(first number, 10:30, second number, 2:00; % = percentage of observation intervals, last slide)
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Instructional Assistance Hours
• Wednesday, 4/02
• 6:00-7:30 PM, Wood Hall First-Floor
Lounge
• Derek will be there!
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