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STAR: A Dementia-Specific Training Program for Staff in Assisted Living Residences

Nancy Morrow-Howell, MSW, PhD, Editor

Correspondence: Address correspondence to Linda Teri, PhD, Psychosocial and Community Health, University of Washington, Box 358733, Seattle, WA 98195-8733. E-mail: lteri{at}u.washington.edu

	Abstract

TOP Abstract Methods Results Discussion and Implications References

 
Purpose: This article describes, and provides data on, an innovative, comprehensive, dementia-specific training program designed to teach direct care staff in assisted living residences to improve care and reduce problems in residents with dementia. Design and Methods: STAR—which stands for Staff Training in Assisted living Residences—provides two 4-hr workshops augmented by four individualized on-site consultations and three leadership sessions. Developed by means of an iterative process of implementation and revision, it was then evaluated in a small randomized controlled trial. A total of 114 staff and 120 residents in 15 residences participated. Results: STAR was exceptionally well received. Training details are provided with a discussion of unique challenges inherent in implementation. Following training, STAR residents evidenced significantly reduced levels of affective and behavioral distress compared with control residents. Furthermore, STAR residents improved whereas control residents worsened (p <.05). Staff with STAR staff training reported less adverse impact and reaction to residents' problems (p <.05) and more job satisfaction (p <.10) compared with control staff. Implications: STAR is an effective training program for direct care staff working with dementia residents in assisted living. The importance of continued development and investigation of STAR efficacy and effectiveness is underscored by the growing numbers of residents with dementia who are receiving care in these settings.

Key Words: Alzheimer's disease • Behavior problems • Depression • Anxiety

Older adults enter assisted living because they need help. The average assisted living resident is 84 years of age and requires assistance with one or more activities of daily living (McDougall, 2000). More than half are demented (Davis et al., 2000; Golant, 1998; Kopetz et al., 2000), and others often have significant enough cognitive impairment to require daily memory aides (McDougall). Many experience significant affective distress, including depressive disorders, prevalent and persistent depressive symptoms, anxiety, and agitation (Parmalee, Katz, & Lawton, 1989, 1992; Watson, Garrett, Sloane, Gruber-Baldini, & Zimmerman, 2003). This combination of cognitive, affective, and behavioral problems makes providing quality care for assisted living residents a significant challenge. Reduction of these disabilities may improve care and decrease associated care costs, including staff turnover. Indeed, evidence suggests that a major reason staff leave long-term care is the difficulty of working with dementia residents (Burgio, Jones, Butler, & Engel, 1988; Hoeffer, Rader, McKenzie, Lavelle, & Stewart, 1997).

Despite this, little to no mental health or dementia training is provided to assisted living staff. A recent review of studies that trained nursing assistants in long-term care found that all studies were conducted in nursing homes (Beck, Ortigara, Mercer, & Shue, 1999). We found only one study that addressed training of assisted living staff, and this was in conjunction with nursing home staff (Schonfeld et al., 1999). In this study, three conditions—train the trainer, university classroom instruction, and intensive staff training—were investigated in 26 facilities with 135 staff. Differences between nursing home and assisted living staff were not addressed, and resident outcomes were not reported. Significant improvements in staff knowledge were obtained in each training condition.

Assisted living residences are different from nursing homes in many ways. The basic tenet of assisted living is that care is resident centered and based on a social model of housing and service delivery rather than a medical model (Gorshe, 2000; Kane, 2001; Zimmerman, Sloane, & Eckert, 2001). The majority of residents live in private apartment-type settings; they are free to come and go as they wish, to accept or refuse care, and to socialize with others or stay alone in their rooms. Institutional programming, typical in nursing homes, is relatively absent in assisted living settings, where "care plans" are minimal and structured programs developed by professionals are rare. Assisted living staffing reflects this social model of care. The ratio of residents to staff is high and supervision is minimal. In many instances, supervisors have no clinical experience and lack the expertise to address the needs of individuals with mental health problems or dementia. Consequently, staff training programs developed for nursing homes are unlikely to translate easily to assisted living residences.

To address the uniqueness of the assisted living setting, the increasing demand for care of residents with dementia in these settings, and the lack of established training programs, we developed STAR (Staff Training in Assisted Living Residences). STAR is a comprehensive dementia-specific training program for direct care staff working with dementia residents in assisted living. In this article we present a description of the STAR program, along with data from a small randomized controlled trial designed to test its feasibility and potential efficacy in reducing resident affective and behavioral distress and in enhancing staff skill and job satisfaction.

	Methods

TOP Abstract Methods Results Discussion and Implications References

 
STAR
Theoretical or Conceptual Framework
STAR is based on an integrated model of person–environment fit and social learning theory. Person–environment fit argues for the need for synergy between the person and his or her environment; the person must accommodate and adapt to the changing demands of the environment, and the environment must be modified and changed to accommodate to the changing needs and preferences of the person (Lawton, 1990). Social learning theory posits that behaviors are initiated and maintained by a series of reinforcement contingencies that can be modified to alter the frequency and severity of behavior (Bandura, 1977). Thus, social learning theory provides a way to develop strategies to enhance person–environment fit in order to enable the person to modify her or his behavior to fit the environment or alter the environment to better suit the needs of the person.

Staff–resident interactions are an essential part of the assisted living residents' environment. Staff are responsible for organizing much of the residents' day and have frequent contact providing daily care and social opportunities. Consequently, improvements in staff–resident interactions form a critical link in improving resident–environment fit. STAR teaches direct care staff how to identify the factors within the environment and within their own interactions with residents that can be altered to enhance their care of residents and reduce resident affective and behavioral distress.

Essential Components or Features
STAR has three priorities: (a) reinforce values of dignity and respect for residents; (b) improve staff responsiveness to resident needs, and (c) build specific staff skills to enhance resident care and improve job skill and satisfaction. Training emphasizes teaching the staff the ABCs (activators, behaviors, and consequences) of behavioral distress in order to alter the sequence of events that initiate or maintain resident-care problems (Teri, 1990, 1994). It emphasizes the staff's interaction with the resident, their role in changing resident behavior, and the potential for them to intervene to decrease resident distress. STAR organizes training topics into a series of modules: (a) basic information about dementia and how it affects daily life; (b) verbal and nonverbal skills for communicating with dementia residents; (c) introducing and maintaining pleasant events for residents; (d) improving communication between staff and with families; and (e) using the ABC approach to identify and decrease resident distress (see Table 1).

Three separate meetings for residence leadership are held to provide leadership with an overview of STAR topics and opportunities to discuss site-specific issues that might hinder implementation or sustainability.

Procedures
A manual details all aspects of training, including specifics on how to present material; ideas for stimulating class discussion; case vignettes to illustrate training concepts; and copies of all overheads and handouts (this is available from the senior author). Currently, we use the Management of Behavioral Disturbance in Dementia: A Behavioral Approach videotape training program to allow staff to practice identifying ABCs and improved methods of care (Teri, 1990).

Uniqueness and Innovation
To date, and to our knowledge, no program has addressed the challenges of providing care to residents with dementia in assisted living. STAR is the first of its kind, and we specifically developed it to address the challenges of providing dementia care in assisted living by incorporating the assisted living philosophy of care, targeting the diverse needs of residents, and accommodating the varied learning abilities of assisted living staff. The assisted living philosophy is addressed by understanding that residents often have more say in their daily care than their counterparts in nursing homes. Consequently, staff must learn how to approach residents and actively solicit their involvement and support in accepting care. STAR addresses diversity among assisted living residents by tailoring treatment recommendations to optimize individual resident abilities, needs, and preferences. It addresses the diverse needs, backgrounds, and educational levels of assisted living staff by using everyday language, simple-to-read handouts, and overheads; allowing ample time for participant interaction; and making training directly relevant to the demands of assisted living. Finally, STAR incorporates training and assessments into ongoing work schedules to create minimal disruption.

Research Procedures
Overview
We investigated STAR in two phases. The first phase consisted of feasibility. We provided training in an open-ended manner, changing our approach as our experience grew and we received feedback from local advisory boards and staff. We also conducted assessments to determine if established measures could be used in this setting. The second phase consisted of a randomized trial. We investigated the final protocol by means of a small randomized controlled trial. We conducted both phases in compliance with the University of Washington Institutional Review Board. A total of 114 staff, 120 residents, and 15 residences participated in the two phases.

Feasibility
Sites
Because assisted living residences vary, we selected facilities that had (a) designated assisted living unit (or units) and (b) designated staff working on that unit(s). This ensured that staff understood ongoing resident needs. We also selected residences where administrators agreed to pay staff for time spent in training and arranged coverage for resident care. This was our attempt to gauge administrative support for training.

Residents
Because we wanted to focus on improving care of residents with dementia, we recruited residents who (a) were diagnosed with Alzheimer's disease or related dementia, (b) had problems with depression, anxiety, or agitation rated by staff as at least moderately distressing to the resident or requiring help, and (c) had a family member with power of attorney capable of providing consent. Thus, we included residents with dementia who were exhibiting problems that interfered with their care and ensured Institutional Review Board protection for participants with cognitive impairment.

Staff
We initially included all direct care staff. However, we later excluded night-shift staff (they did not see residents enough to engage in training tasks) and restricted involvement to direct care staff who worked at least one full shift, 2 days per week. Thus, we focused on staff who had ample opportunity to implement training strategies with residents during routine care and who could be accurate informants about resident behaviors.

Trainers
A clinical psychologist (L. Teri) and a graduate student in nursing (P. Huda), each with geriatric mental health experience, conducted most training sessions. As the training protocol was finalized, other trainers were involved, including graduate students in nursing and members of residence leadership.

Randomized Trial
Overview
For this phase, four assisted living residences were randomly assigned to (a) STAR or (b) usual on-site training (training routinely provided by residence staff on site that included general information on the needs of older adults and how to work with memory-impaired residents).

Assessment
Interviewers blind to treatment condition conducted pretraining and posttraining (8-week) assessments, which included resident affective and behavioral distress (behavior problems, depression, and anxiety), and staff skill and job satisfaction (perception of competence, reaction to resident problems, and job satisfaction). Specific measures included the following: (a) the Geriatric Depression Scale (GDS; Yesavage et al., 1983) assessed the presence or absence of 30 depressive symptoms; (b) the Clinical Anxiety Scale (CAS; Fischer & Corcoran, 1994) measured amount, degree, and severity of 25 clinical anxiety symptoms; (c) the Revised Memory and Behavior Problems Checklist (RMBPC; Teri et al., 1992), the Agitated Behaviors in Dementia (ABID; Logsdon et al., 1999), and the Neuropsychiatric Inventory (NPI; Cummings et al., 1994) provided staff report of the frequency of dementia-related behavioral problems as well as their reaction to these problems; (d) the Short Sense of Competence Questionnaire (SSCQ; Vernooij-Dassen et al., 1999) evaluated the staff's feelings of being capable of caring for a demented person; (e) job satisfaction measured staff satisfaction with patient care, supervision, and coworker relations; (f) demographic and clinical characteristics included resident age, gender, ethnicity, education, length of time in current residence; type, duration, and age at onset of dementia; score on the Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1975); and staff age, gender, ethnicity, education, duration of employment at current residence and of assisted living work experience.

Statistical Analysis
We analyzed data in Stata (StataCorp, 2001), and we evaluated baseline differences between groups with t tests or Fischer's exact test. We tested treatment effects on pretest–post-test change scores by using general linear models. Because the effect on participants within a residence could be correlated, we adjusted the error terms and the resulting p values by "clustering" on residence, using a modified Huber–White–Sandwich estimator (StataCorp).

	Results

TOP Abstract Methods Results Discussion and Implications References

 
Feasibility—Lessons Learned From Implementation
Results
114 staff and 120 residents in 15 residences participated. The majority of residents were female, widowed, and over 80 years old. Staff were ethnically diverse, with 56% speaking a language other than English at home (see Table 2). These findings are consistent with state and national data (Dollard & Hodlewsky, 2001; Zimmerman et al., 2001).

STAR evolved over time. We modified content, simplified handouts and overheads, developed new case vignettes specific to assisted living, and developed an ABC card. These revisions made training more relevant to staff and more suitable to their level of written and verbal skills.

Training logistics also changed over time. Most facilities had conference rooms and held in-house meetings, so scheduling workshops was relatively easy. Individualized sessions, however, were unusual. Staff were unaccustomed to having appointments during the workday. Coordinating schedules and ensuring attendance was difficult and required an inordinate amount of our time. We changed our approach and arranged to be on site and more available at times convenient to staff. This further allowed us to observe their interactions with residents and made our feedback more relevant.

Initially, we included supervisors and administrators in workshops. However, staff were very quiet and hesitant to speak out, and managers often monopolized the discussion. Consequently, we conducted separate training sessions to focus on their different needs. Direct care staff could then participate fully and share their experiences, and leadership could discuss how best to provide staff support.

We also modified assessments over time. Initially, we used both self-report and interviewer-administered measures for staff. We eventually conducted all measures in an interview to make assessments easier for staff with limited English reading skills.

Randomized Trial—Data Concerning Outcomes
Twenty-five staff and 31 residents in four assisted living residences participated in this phase. Residents and staff characteristics were again consistent with state and national data (see Table 2). There were no significant differences in demographic or baseline data between conditions.

At post-test, residents and staff who received STAR improved on all measures; those in the control condition stayed the same or worsened (see Table 3). For resident outcomes, intent-to-treat analyses yielded statistically significant differences on level of general behavioral disturbance (RMBPC, NPI, and ABID); depression (GDS and RMBPC—Depression Subscale); and anxiety (CAS). For staff outcomes, intent-to-treat analyses yielded statistically significant differences on the NPI-staff impact and RMBPC-reaction measures: staff receiving STAR reported less impact from resident problems at post-test whereas staff in the control condition reported more. Differences on staff level of job satisfaction and sense of competency were in the expected direction but not statistically significant.

	Discussion and Implications

TOP Abstract Methods Results Discussion and Implications References

Results of this initial investigation are quite promising. STAR was well received by assisted living administration, staff, residents, and families. Commitments made by assisted living leadership to support the program were upheld, and we were successful in developing a program that appealed to direct care staff with diverse levels of educational and cultural backgrounds. The STAR protocol evolved over time and is now available in a standardized manual that includes all trainer materials and staff handouts.

The randomized controlled trial yielded statistically and clinically significant changes in measures of resident behavior problems, depression, and anxiety. Residents in assisted living settings that received STAR improved; residents in control conditions did not. STAR also positively affected staff outcomes. Significant improvements were obtained on two measures of staff reaction to resident problems. No statistically significant differences were obtained on staff job satisfaction or sense of competence, although improvements were in the expected direction.

These positive findings in a study with such limited power are encouraging. STAR is a new intervention. Our goal was to investigate its feasibility and determine if training would improve resident and staff outcomes. STAR met its objective: Staff receiving STAR training were successful in reducing the level of resident affective and behavioral distress. These findings, however, must be interpreted cautiously. Our sample size was very limited and the facilities enrolled were eager to participate. Thus, they may represent unique settings in which to provide training. Plans are currently underway to replicate these findings in other assisted living residences to determine whether a "train-the-trainer" method of dissemination is effective and to evaluate the efficacy of STAR in other assisted living residences. In the interim, STAR provides the first feasible and potentially effective method to train staff to care for assisted living residents with dementia.

	Footnotes

 
This study was supported in part by a Pioneer Award from the Alzheimer's Association (PIO-1999-1800). Appreciation is extended to the staff of the STAR program for their hard work and diligence in conducting this trial: Judy Shannon, BSN, MLS, Judith Robar, MN, RNC, Linda Trippett, RNC, MSN, and Lissi Hanson, RN, PhD for their assistance in developing and conducting the STAR program; Rebecca Logsdon, PhD, Susan McCurry, PhD, Glenise McKenzie, RN, MN, and David LaFazia, MSW for providing feedback on earlier versions of this manuscript; Joanne Webb, Ray Houle, Nancy Blythe, and Adam Templeton for conducting the evaluations; Julie Cleveland for coordinating training logistics; Elizabeth "Buzzy" Mounce for her typing; Leslie Perlman for data management; and the assisted living residences in Seattle, Washington that participated in this study.

¹ Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle.

² Rural Health Research Development, OHSU School of Nursing, Ashland, OR.

Decision Editor: Nancy Morrow-Howell, PhD

Received for publication October 27, 2004. Accepted for publication March 15, 2005.

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