BEHAVIOR THERAPY (1972) 3, 444---446.

Reinforcing the Reinforcers: A Method of Supplying Feedback to Nursing Personnel 1

ROGER PATTERSON, 2 CHRISTINE COOKE, AND ROBERT PAUL LIBERMAN z

Clinical Research Unit, Center for the Study of Behavioral Disorders, Camarillo State Hospital

A novel method of supplying reinforcement to all three shifts of nursing personnel working in a hospital ward conducting behavior modification research is the weekly newsletter. The newsletter gives summary narratives on the patients with whom the nursing staff are making frequent behavioral observations and interventions.

The work behavior of hospital personnel applying behavior modifiea- t/on techniques is subject to the same principles of learning as are the behaviors of patients they are treating. The importance of reinforcing ward personnel has been recognized by behavior modifiers (Ayllon & Azrin, 1968 ). Reinforcing the reinforcers has been accomplished by means of trading stamps, video tape records and social acknowledgment, (Brie- ker, Morgan, & Grabowski, 1968). Panyan, Boozer, and Morris (1970) have demonstrated that feedback regarding the training sessions per- formed by staff in a behavior modification program for retardates is very effective reinforcement for nursing personnel's performance. In the be- havior modification program on the Clinical Research Unit (CRU) at Camarillo State Hospital we must maintain individual behavior modifica- tion programs for 12 patients brought in from other wards of the hospital in a consistent fashion by a nursing staff of 14 on three different shifts. Therefore, the question arose as to how to supply effective feedback to all of the staff on a regular basis.

The program developed at the CRU consists of weekly staff meetings with each shift, combined with a feedback "newsletter." This newsletter, known as the "CRU Crew News," (now titled, "Journal of the Behavior Mod Squad") contains weekly summaries of the progress of all 12

1 The opinions and conclusions contained in this article are solely those of the authors and do not reflect official policy of the California Department of Mental Hygiene.

"~ Roger Patterson is now Director, Day Treatment Center, Pensacola, Florida Com- munity Mental Health Center.

3 Requests for reprints should be sent to Robert Liberman, Center for the Study of Behavioral Disorders, Camarillo State Hospital, Box A, Camarillo, CA 93010.

444 © 1972 by Academic Press, Inc. All rights of reproduction in any form reserved.

BRIEF NOTES 445

patients, along with anticipated changes in their program. It includes follow:ups on previously treated patients, the results of patient-staff meetings, and comments about noteworthy achievements by staff members.

Some typical news items are the following: J. S. has shown no increase in delusional talk since her

medication was discontineud. This one fooled us all. Most of us didn't think the behavioral treatment alone (time-out) would be this effective, hut she has been rational on her observations and interviews 172 out of the 176 times that measurements have been made since the medication was stopped.

M. J. has greatly increased her output of office work. As a result she is earning more tokens. She has had another successful weekend at home with her mother. The mother paid her tokens for doing some tasks in the home, as was arranged by the therapist before the visit. It is encouraging that M. J. also helped with other tasks. A new facet this weekend was that the patient was also paid by her mother for going to the beauty parlor and to church as a form of social activity.

B. B. has continued to decline in the number of additional hal- lucinations reported. During baseline, there were more than 100 per day. Ileeent data taken after five weeks of the aversion-by- repetition program show a reduction to less than 20.

In addition to such factual information the paper also has a section devoted to good-natured humor about the staff members themselves. This serves to increase reader interest.

The paper is widely read, and serves to inform all staff members about each patient's progress. This is nmeh better than the more common operation in which only the day shift is well-informed. As a side benefit the newsletter is available for feedback to individuals outside the CtlU. Since the patients are referred by other wards for experimental behavior modification treatment, the "CtlU Crew News" is sent to the staff of these wards. This enables the referring staff to follow the patient's progress on the CRU, and learn about effective treatment programs which they will be asked to continue when the patient is returned to his "home ward." Copies of tile newsletter are also sent to administrative and clinical personnel in central positions of authority within the hospital and to staff members in the Ventura County Community Mental Health Department. Thus, the "CRU Crew News" serves a spreading function of education and coordination in behavior modification.

Extemperaneous comments by staff members on the CRU include the following: "It has opened the door for better communication between unit

446 BRIEF NOTES

staff members, and between the unit staff professionals. In many ways it is the reward for one's labor. But, most of all, it keeps you up to date on each patient's progress." "Being a new staff member the "CRU Crew News" has helped me to become familiar with the patients and the pro- grams that they have been on." "Nursing staff is aware of day to day changes in our procedures. But from the news we can see what's happen- ing on other shifts and also find out how our patients are doing with a weekly summary of the data we collect." Since the inception of the newsletter, staff morale has noticeably improved and the number of nursing personnel leaving the CRU because of dissatisfaction has declined.

REFERENCES

AYLLON, T., & AZaIN, N. H. The token economy: a motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts, 1968.

BRICKEn, W. A., MOnGAN, D., & GRABOWSKI, J. Token reinforcement of attendants who work with low-functioning children. Abstracts of Peabody Studies in Mental Retardation 1965-1968, 4, No. 2.

PANVAN, MARION, BOozEn, HOWAI~D, & Moemis, NANCY. Feedback to attendants as a reinforcer for applying operant techniques. Journal of Applied Behavior Analysis, 1970, 3, 1-4.