Abstract
Nursing home communication is frequently limited and task-focused and fails to affirm resident personhood. We tested the feasibility and effects of automated digital displays of resident photographs to remind staff (N = 11) of resident (n = 6) personhood. Historical photographs were displayed in digital photo frames mounted in each resident’s room. To evaluate the intervention’s effects, staff–resident conversations were audio-recorded prior to displaying the frames and repeated 2 weeks and 3 months later. Conversations were transcribed and statements were topic coded (task-focused vs. interpersonal). Staff person-centered talk increased from 11% to 32% (z = 2.37, p = .02) after the intervention and task-talk decreased from 64% to 40%. Resident interpersonal topics increased from 20% to 37%. Staff statements increased from 29 at baseline, to 37 postintervention, and 41 at 3-month follow-up and resident engagement and reminiscence also increased. Effects were reduced after 3 months. Automated photo displays are an easily implemented, low-cost intervention to promote person-centered communication.
Keywords
Culture change in today’s nursing homes aims to refocus care to be more person- or relationship-centered and less institutional. Despite changes in nursing home (NH) culture, staff–resident communication is usually limited and primarily task-focused in contrast to person-centered communication that is valued by and affirms the personhood of older adult residents (Levy-Storms, 2008; Lubinski, 1995). This study tested the feasibility and effects of using automated bedside digital displays of resident photographs to remind staff of resident personhood with a goal of increasing interpersonal communication. This low-cost, automated intervention has potential to improve person-centered care without resource-intensive staff training and increasing demands on busy NH staff.
Problem Statement
Nursing home (NH) residents’ opportunities for communication rest primarily on busy nursing staff and NH communication has been characterized as superficial, patronizing, and task-focused (Levy-Storms, 2008, Lubinski, 1995). In contrast, person-centered communication that recognizes and affirms the unique individuality or personhood of older adults is lacking. NH staff communication often fails to support a sense of personhood essential to quality of life for elders (Buron, 2008) and has been linked to negative care outcomes (Burgio et al., 2000; Talicero, Evans, & Strumpf, 2002). Our research found that residents with dementia were more than twice as likely to resist care when staff used elderspeak, a patronizing communication style that sounds like baby talk (Williams, Herman, Gajewski, & Wilson, 2009).
Conceptual Framework
Personhood is defined as value, respect, and honor for the individual, regardless of his or her disease or disability, and the provision of person-centered care is defined as incorporating personhood, person-knowledge, autonomy and choice, comfort care, interpersonal relationships, and supportive environment (White, Newton-Curtis, & Lyons, 2008). Staff with person-knowledge incorporate the resident’s unique life story, cultural experiences, personality, patterns of daily life, values, needs, and preferences to enrich care. Autonomy is reflected in choices such as meal and bathing schedules that are necessary to maintain control in self-care and the environment. Interpersonal relationships, promoted by consistent staff assignments and staff-resident activities, are important to reduce social isolation and maintain social connections. Comfort care (such as optimal pain control and alternatives to restraints) attends to both physical and emotional needs of individuals. Supportive environments include both physical and organizational designs tailored to support the individual needs of residents. The intervention tested in this study was designed to increase staff’s person-knowledge of residents and to provide reminders of individual personhood to enhance communication during care.
Enhancing NH staff–resident communication by increasing person-centered communication and reducing task-oriented communication increases resident satisfaction and quality of life, improves staff job satisfaction, and reduces anxiety and problem behaviors of the growing population of residents with dementia (Acton, Yauk, Hopkins, & Mayhew, 2007). However, training NH staff to communicate effectively requires extensive resources (Beeber, Zimmerman, Fletcher, Mitchell, & Gould, 2010; Kuske et al., 2006; Levy-Storms, 2008). Reinforcement of training and supervision of skill use in clinical practice (over multiple weeks of observation and feedback) and supervisory and administrative involvement is essential to support ongoing implementation (Burgio et al., 2002). Extensive retraining is needed due to annual staff turnover rates that reach and exceed 100% (Cohen-Mansfield, 1995). Despite extensive efforts, staff workloads limit consistent application of learned skills in practice, resulting in marginal improvements in clinical outcomes (Beeber et al., 2010; Kuske et al., 2006; Levy-Storms, 2008).
Purpose
The purpose of this study was to test the feasibility and effects of using automated photo displays to improve staff–resident communication and related outcomes. The aims included evaluating the intervention effects on staff and resident communication immediately (2 weeks) and 3 months after the intervention was implemented. We hypothesized that the intervention would increase the amount of person-centered communication between residents and staff immediately and 3 months postintervention. We also hypothesized that residents would participate more in conversations with nursing staff and would engage more in reminiscence.
Research Design
A pre- and postintervention comparison design was used to determine the effects of the intervention on resident and staff communication. Following approval by the University Institutional Review Board for the Protection of Human Subjects, the skilled nursing facility of a continuous care retirement community was invited and volunteered to participate.
Sample and Setting
The NH facility that served as the research site was affiliated with a corporate chain of for-profit facilities and included a total of 140 beds on four units, one exclusively devoted to dementia care. The facility offered residents choices in times for meals and bathing, a menu for meal choices, and permitted pets in private rooms if the resident could manage animal care. One 30-bed unit that served a general skilled nursing population that included some residents with dementia was chosen by the NH administration to participate based on staff stability and unit managerial and staff interest in the study.
Six resident subjects and their surrogate decision makers were recruited from eligible residents, identified and initially contacted by the social worker. Criteria for inclusion were adequate vision and hearing to allow communication with staff and visualization of the photo frame display and the availability of photographs of historical significance to the resident. All invited residents agreed to participate. Residents and their surrogate decision makers gave signed informed consent prior to participation in the study.
Ten nursing staff who had permanent unit assignments and were assigned to care for the resident participants were also recruited as conversational partners in staff–resident dyads. Additional staff inclusion criteria were English fluency and at least 18 years of age as required to provide signed informed consent. All staff who were invited to join the study as communication partners for the residents in recordings agreed to participate. Several unit staff were excluded due to not working on the days that data recordings were collected.
Method
The research team contacted each resident and surrogate decision maker to recruit them and to obtain informed consent. The researcher recruited nursing staff volunteers from assigned staff on data collection days. Staff participants received a US$10.00 money order as an incentive for participation on each day of recording. Residents were not paid but were given the digital photo frames after the study was completed. To control for variations in communication between different staff and participating residents, we limited analysis to the data including only the staff–resident dyads recorded at two or more time points, including baseline and postintervention. These dyads were again recorded after 3 months.
Each resident participant and surrogate decision maker was contacted and asked to provide at least three dozen photos of significance to and likely to prompt positive reminiscence for the resident. The research team used a portable scanner and laptop computer to scan photos and load them onto 15-inch digital photo frames at the facility. The photo frame was set to continuously rotate and display the photos. Residents, family, and staff were taught how to turn on and off the display frames as desired. Facility support staff mounted each photo frame in the room of each participating resident, in direct view of the resident and staff.
Prior to installing the photo frames in each resident’s room, 2 days of baseline audio recordings were collected during morning care. Mini digital recorders were placed in each participating resident’s room when staff entered the room at the start of the day shift. Recorders were placed in plain view in a safe location such as the bedside table of each resident and set to continuously record. Assent to participate was reaffirmed for each staff and resident, and a sign was posted on the resident’s door indicating that recording was taking place. Residents, staff, and family members were given the option to have recording stopped or erased at any time. If residents left the room during the 2-hr recording session, they were given the recorder to take with them (to the dining hall).
Postintervention recordings were collected again 2 weeks after the photo frames were placed in the residents’ rooms, allowing time for residents and staff to adjust to the initial novelty of the photo frames. A third set of recordings was collected 3 months after the frames were placed to determine whether intervention effects were maintained over time.
Study Measures
Descriptive information about residents including age, gender, marital status, occupational history, diagnoses, medication. were extracted from each resident’s medical record. Functional status was assessed using the Minimum Data Set Activities of Daily Living scale. Staff participants provided information about their age, gender, primary language, education, and staff role as well as length of experience in staff role and within this facility.
Analyses
One recording lasting at least 1 min (to allow ample time to engage in communication of an interpersonal nature) was randomly selected from each 2-hr recording session for each staff–resident dyad and computer archived for analysis. Each recording was reviewed to assure that only consented participants were included. Archived sound recordings were identified by code numbers so that research assistants who transcribed and coded them were unaware of participant identity and were not biased by knowledge of when the recordings were collected.
Each of the selected recordings (N = 76) was transcribed verbatim using standard communication research protocols (Kemper, 1994) using the Transcript Builder Program Version 1.9.1 (Thinking Publications, Greenville, South Carolina). This software uses a computer to play audio and video files while using word processing to transcribe communication in the media files. The Systematic Analysis of Language Transcripts (SALT) computer program (LLC, Muscoda, Wisconsin), designed to tabulate language samples in specially formatted transcripts was used to count staff and resident utterances (statements) and turns (reciprocal exchanges of turn-taking) in the transcribed conversations.
Topic Coding
The qualitative content analysis system used in prior NH communication research was adapted for this study (Williams, Ilten, & Bower, 2005). Each staff statement was topic coded as (a) instrumental (task-focused pertaining to activities of daily living, assessment of resident condition, or technical care tasks such as administering medication), (b) interpersonal (person-centered reflecting resident individuality, self-disclosure), or (c) superficial. Superficial communication included greetings and chitchat not specifically targeted to an individual. Intercoder agreement using this system was 80% or greater in our earlier NH communication research (Williams, Ilten, & Bower, 2005).
Resident utterances were coded as (a) instrumental (task-focused), (b) interpersonal (reminiscence, self-disclosure, staff topics), or (c) superficial. Reminiscence, an outcome of interest for residents, was defined as historical talk about the resident’s own life, experiences, or family. Self-disclosure included talk about current resident experiences as well as talk about staff interpersonal matters.
Four student coders were trained in the operational coding definitions. The team jointly coded practice transcripts and proceeded to independently code practice materials. The team reconvened and compared coding, discussing utterance coding disagreements and revising operational definitions. After coder agreement exceeded 85% on practice materials, the student coders each coded 10% of the actual study transcripts. Coding agreement exceeded 90%.
Each of the trained coders completed a portion of the remaining transcripts. One group of students coded resident communication and a second group coded staff communication. Mean scores for staff and resident communication measures were compared for each dyad at baseline, postintervention, and 3-month follow-up. A sample coded transcript appears below.
Ready [Instrumental]?
Open your mouth please [Instrumental].
Thank you [Instrumental].
Here’s some more water [Instrumental].
Ahhh. That sure helps to swallow it [Instrumental].
Got them swallowed alright [Instrumental]?
Yup [Instrumental].
Is Betty coming in today to see you [Interpersonal]?
Yes, she is coming after church [Self-Disclosure].
Mmmhmm [Superficial].
Isn’t she bringing those new pictures [Interpersonal]?
Yes, she found my pictures from our wonderful trip to Paris in 1962 [Reminscense].
Statistical Analysis
Due to the small sample size and nonnormal distribution of data, we used the Wilcoxon signed ranks test, a nonparametric statistical analyses to compare mean scores between baseline and 2 weeks following photo frame implementation and between baseline and 3 month follow-up. The Wilcoxon test is appropriate for nonparametric analysis for related samples and repeated measures over time.
Findings
Seventy-six conversations of 7 dyads in our sample were analyzed. The five resident participants were White and ranged in age from 70 to 90 years. One participant was hospitalized and was not included in the analysis due to missing postintervention data. Resident participants varied in cognitive and physical disabilities and required nursing care. The 10 staff (1 licensed practical nurse and 9 certified nursing assistants) were all native English speakers and ranged in age from 22 to 58 years. Experience in their health care role ranged from less than 1 year to more than 15 years. Four had less than 1 year of experience in the facility, but all had worked on this unit for more than 6 months. Two were male. Staff–resident dyads including the same staff and resident were recorded over the repeated time points.
Mean scores for communication measures for each dyad at the three time intervals are reported in Table 1 (for staff) and Table 2 (for residents). The aggregate distributions of communication topics comparing baseline, postintervention, and follow-up are shown in Figure 1 for staff communication and Figure 2 for resident communication.
Wilcoxon Signed Ranks Z scores for Staff Communication Topic Changes Over Time
Based on positive ranks.
Based on negative ranks.
Significant at the p = .05 level.
Wilcoxon Signed Ranks Z scores for Resident Communication Topic Changes Over Time
Based on positive ranks.
Based on negative ranks.
The sum of the negative ranks equals the sum of the positive ranks.
Staff communication topic changes over time
Resident communication topic changes over time
Proportions of staff interpersonal talk rose from 11% at baseline to 32% (z = 2.37, p = .02) after the frames were placed with corresponding reductions in task-talk, which decreased from 64% to 40% (z = 1.35, p = .17). After 3 months, 23% of staff talk was interpersonal and instrumental talk had increased to 45% but was still 19% below baseline (z = 0.67, p = .5). The mean number of staff statements (utterances) increased from 29 at baseline, to 37 postintervention (z = 0.25, p = .80), and 41 at 3-month follow-up (z = .11, p = .27). See Table 1.
Resident engagement, the amount and proportion of resident participation in conversations, and topics of resident communication were also affected. The mean number of resident statements increased from 21 to 24 after the intervention (z = 0.25, p = .79) but decreased to 12 after 3 months (z = -1.1, p = .27). Resident interpersonal communication increased from 19% to 34% (z = 1.36, p = .17) and reminiscence increased from 5% to 15% 2 weeks after the intervention was implemented (z = 1.83, p = .07). See Table 2.
Staff, residents, and family members provided positive evaluations of the photo frame intervention. Surveys completed by residents and family members rated the intervention as helpful in improving communication with staff. The NH administrative staff reported that the digital photo frames were also very useful when orienting new staff to the residents on the unit.
Discussion
This study established the feasibility of using automated photo displays in this busy NH setting. The frames were created on-site by scanning photographs provided by each resident and surrogate decision maker. Some family members required coaching in selection of photographs for the display. Setup and periodic updating of the photo frames might be completed by volunteers or activities staff and may extend effects on interpersonal communication.
Hypothesized increases in person-centered staff-resident communication occurred 2 weeks after the photo frames were implemented. Although not statistically significant, clinically meaningful increases in resident engagement, person-centered communication, and reminiscence also occurred. At the 3-month follow-up, many of the communication measures returned to baseline or near baseline levels. We hypothesize that photo novelty was reduced over repeated viewing and failed to present opportunities for new topics of person-centered conversation. At the follow-up, 2 residents reported that they seldom turned the photo frame on during the day. Periodic updating of photos may be needed to sustain and reinforce person-centered communication effects. Identifying staff, family, or volunteers to create and update the displays will be critical for widespread use of photo frames in practice. Internet transfer of photos to digital photo frames is now possible and may provide a means to keep frames interesting and dynamic.
This pilot study has a number of limitations that should be considered in interpreting the findings. Because staff and residents were aware of audio recording and the study focused on communication, natural conversations could have been altered. To limit this possible effect, staff were told that the study focused on resident communication. The small convenience sample was not randomly selected and may be biased limiting the ability to generalize findings to other NH settings. The small sample also limited statistical power and required nonparametric statistical analyses. Other confounding variables may have affected responses to this intervention including changes in resident physical condition, staff assignments, and changes in the NH environment such as staffing levels and administrative and regulatory changes that were not controlled or measured in this pilot study.
Staff communication with residents who had more physical disability (as reflected in their nursing care plans) included more instrumental communication that continued after the intervention. Task-focused (instrumental) communication is essential for staff working with residents to prompt them in participating in their own care and is not a negative finding. Additional research is needed to establish the optional balance of instrumental and person-centered communication in NH care. For most dyads, the proportion of interpersonal talk was highest immediately after the intervention. Increased instrumental talk at the 3-month follow-up may indicate a need to periodically update photos for each resident.
This study provides preliminary evidence supporting the value of a digital photo frame intervention to increased person-centered staff-resident communication in NH care. This intervention limits reliance on busy NH staff for interventions, instead providing an automated bedside intervention to remind them of the personal characteristics during care. This is an important consideration in translation of interventions into practice in long-term care settings (Beeber et al., 2010). This digital photo frame intervention adds to staff person-knowledge about residents (White et al., 2008), recognized as a critical component of person-centered care. This intervention is similar to other interventions such as memory boxes (Bourgeois, Dijkstra, Burgio, & Allen-Burge, 2001) and video biographies (Coleman & Medvene, 2011) were also found to support person-centered communication. The photo frame intervention may improve care and also increase satisfaction with living and working in a nursing home for residents, families, and staff by increasing person-centered communication (Berglund, 2007).
Application
Future research is needed to test the photo frame intervention on a larger, randomly selected sample that will permit evaluation of communication effects as well as more diverse intervention outcomes including benefits to residents (such as improved mood, reorientation, and therapeutic reminiscence), staff (including job satisfaction and turnover rates), and families and significant others (such as increased visiting). Resident and staff characteristics that might predict variable responses to the intervention should also be explored. Assessment of factors related to the likelihood of translation to practice is needed as well as cost-effectiveness analysis. Furthermore, research is indicated to determine whether the photo frame intervention has additive effects when used in conjunction with staff communication-skill training.
Future trials comparing photo frame effects in special populations including persons with dementia, those with aphasia and other neuromuscular conditions that limit communication and terminally ill residents are indicated. For example, because maintaining personhood is a critical challenge for persons with dementia, testing of this intervention in dementia care settings is warranted and may show outcomes such as increased affect and reduced problem behaviors (Buron, 2008; Kitwood & Bredin, 1992).
We conclude that photo displays are a feasible means to increase person-centered NH care. Pending confirmation of these findings in ongoing research, photo displays can be effective in prompting reminiscence and improving communication and quality of care for NH residents in a variety of elder care settings (Bourgeois, 2003). Automated interventions are practical and likely to be used in practice because they are easy to implement and do not require training or additional work for busy nursing staff. Adding an automated visual reminder of resident personhood has potential to increase and enhance person-centered care.
Footnotes
Acknowledgements
The authors thank Ruth Herman and Sally Barhydt for assistance in article preparation.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the University of Kansas School of Nursing, Office of Grants and Research Spring 2009 Faculty Research Award to Kristine Williams, RN, PhD.