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Using observational methods to measure treatment integrity in
psychosocial intervention researchKimberly S. Van Haitsma, Ph.D.
Director, Polisher Research InstituteMadlyn & Leonard Abramson Center for Jewish Life
(formerly Philadelphia Geriatric Center)1425 Horsham Road
North Wales, PA 19454-1320215 371 1895 [email protected]
Presented at the Gerontological Society of America64th Annual Scientific MeetingPre-Conference Workshop
Current and Future Challenges in Designing Behavioral Interventions: From Randomized Trials to Community ImplementationNovember 18th 2011 12:30 to 4;30
K2A: Knowledge to Action Framework for Public Health
EVALUATION
Translation Supporting StructuresResearch
Supporting Structures
Institution-alization
Supporting Structures
DISCOVERYSTUDIES
EFFICACYSTUDIES
EFFECTIVENESSAND
IMPLEMENTATIONSTUDIES
TRANSLATION PHASERESEARCH PHASEINSTITUTION-
ALIZATION PHASE
KNOWLEDGE INTO
PRODUCTSDISSEMINATION PRACTICE
INSTITUTION-ALIZATION
DECISION TO
TRANSLATE
ENGAGEMENT
DECISION TO
ADOPT
DIFFUSION
Practice-basedDiscovery
Practice-basedEvidence
Wilson, K., Brady, T. &Lesesne, C. (2011). An organizing framework for Translation in public health: The knowledge to action framework. Preventing chronic disease Public health research, practice and policy, 8(2),1-7. www.cdc.gov/pcd/issues/2011/mar/10_0012.htm
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Overview of presentation
• Illustration of how real-time observations can be used to enhance fidelity in psychosocial intervention studies– What behavior observation measures
are available?– What aspects of fidelity measurement
can be optimized by real time observational techniques?
An illustrative example: The Individualized Positive Psychosocial Intervention Study
Funded by
• To examine the impact of an individualized recreational intervention on quality of life outcomes for persons with dementia residing in nursing homes.
– Focus on CNA as the interventionist of choice (with the assistance of RT)
– Intervention focus was on enhancing CNA communication skills and individualizing content of intervention
– Outcomes focused on enhancing resident positive emotion and behavior and diminishing negative emotion and behavior.
– Methodology focused on real-time observation of dyadic interactions.
Intervention Study Design
• Randomized Controlled TrialResidents randomly assigned to one of two intervention conditions (IPPI or Attention Control) or Usual CareCNAs were assigned to provide intervention based on their existing permanent assignment to a given resident and were blind to intervention condition
• Residents (n=180) • CNAs (n=84)• Number of real-time observations (n=2,638
occasions)
Resident Group AssignmentsIndividualized Positive Psychosocial Intervention
(IPPI) (n=44 residents)• Content of activity selected based on resident preferences Attention Control Intervention (N= 43 residents)• Standardized 1-1 interaction (e.g. reading a magazine aloud)
Both Interventions– CNA intervention delivery facilitated by coaching from
Recreational Therapist– 10 minute sessions, 3x/week, for 3 weeks– Half of CNAs received additional Communication training; half did
not.
Usual Care (n=93 residents)• No prescribed interactions. Captured normative behaviors.
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Intervention delivery focused on Communication Skills of CNAs
Definitions of Observed CNA Behavior VariablesVan Haitsma, K., Lawton, M.P., Kleban, M., Klapper, J.A. & Corn, J.A. (1997). Methodological aspects of the study of streams of behavior in
dementing illness. Alzheimer Disease and Associated Disorder, 11(4), 228-238. PMID: 9437440
Prescribed Positive Communication Behaviors
Greeting Saying hello, goodbye, handshake
Explanation Explains what activity is or will be occurring
Courtesy Saying excuse me, please, thank you, you’re welcome
Offers choice Offers choice by explicitly identifying 2 alternatives
Asks preference Solicits resident preferences for past, present, or future activities
Praise/compliment Expresses praise, compliment or approval
Reassurance Provides reassurance or validates feelings
Positive touch Gently touching resident, stroking arm or back, holding hands, hugging, kissing
Positive/neutral prompt Verbal prompt to initiate an activity without negative tone
Nonverbal prompt Points, shows something to orient toward object
Task engagement Verbal interaction related to the task at hand; Physical manipulation of objects related to task at hand, assisting resident in manipulation of objects
Proscribed Negative Communication Behaviors
Ignores resident Does not look at resident or respond to resident verbal or nonverbal behavior
Talks to other Talks to third party while interacting with resident
Rebuke/disapprove Reprimand, admonish, express disapprovalNegative touch Handles resident roughly; grabs resident; moves resident without warning
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Intervention Outcomes Focused on Enhancing Resident Affective and Behavioral Outcomes
related to Quality of Life
Definitions of Observed Resident Behavior VariablesPositive Behavior
Task Engagement engages in conversation, manually manipulates or gestures toward an object
Positive Verbal coherent conversation, responding to questionVery Positive Verbal complimenting, joking, singing
Positive Touch physically receptive to another person, gently touching, stroking, hugging, kissing
Negative behaviorAggression hitting, kicking, throwing things, grabbing, spittingUncooperative pulling away, saying “no”, turning head or body awayVery Negative Verbal swearing, screaming, mocking, making strange noisesNegative Verbal incoherent, repetitious statements, mutteringGeneral Restlessness pacing, fidgeting, disrobing, repetitive movementEyes Closed Sits with eyes closed
Van Haitsma, K., Lawton, M.P., Kleban, M., Klapper, J.A. & Corn, J.A. (1997). Methodological aspects of the study of streams of behavior in dementing illness. Alzheimer Disease and Associated Disorder, 11(4), 228-238. PMID: 9437440
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Resident Affective Responses
Lawton, M. P., Van Haitsma, K., Perkinson, M., & Ruckdeschel, K. (1999). Observed affect and quality of life in dementia: Further affirmations and problems. Journal of Mental Health and Aging, 5, 69-81.
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Detailed information about measurement properties of observational measures of outcomes
•Curyto, K., Van Haitsma, K., Vriesman, D. (2008). Direct Observation of Individual Behavior: A Review of Current Methods and Measures for Use with Older Adults with Dementia. Research in Gerontological Nursing 1(1), 52-76.
•Updates pertinant to this review since 2008:Burgio, L. D., Park, N. S., Hardin, J. M., & Sun, F. (2007). A longitudinal examination of agitation and
resident characteristics in the nursing home. The Gerontologist, 47(5), 642-649. Cohen-Mansfield, J., Thein, K., Dakheel-Ali, M., & Marx, M. S. (2010). Engaging nursing home residents
with dementia in activities: The effects of modeling, presentation order, time of day, and setting characteristics. Aging & Mental Health, 14(4), 471-480. doi:10.1080/13607860903586102 .
Ersek, M., Polissar, N., & Neradilek, M. B. (2011). Development of a composite pain measure for persons with advanced dementia: Exploratory analyses in self-reporting nursing home residents. Journal of Pain and Symptom Management, 41(3), 566-579. doi:10.1016/j.jpainsymman.2010.06.009.
Horgas, A. L., Elliott, A. F., & Marsiske, M. (2009). Pain assessment in persons with dementia: Relationship between self-report and behavioral observation. Journal of the American Geriatrics Society, 57(1), 126-132. doi:10.1111/j.1532-5415.2008.02071.x
Husebo, B. S., Strand, L. I., Moe-Nilssen, R., Husebo, S. B., & Ljunggren, A. E. (2009). Pain behaviour and pain intensity in older persons with severe dementia: Reliability of the MOBID pain scale by video uptake. Scandinavian Journal of Caring Sciences, 23(1), 180-189. doi:10.1111/j.1471-6712.2008.00606.
Pulsford, D., Duxbury, J. A., & Hadi, M. (2011). A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings. J Psychiatr Ment Health Nurs, 18(2), 97-104. doi:10.1111/j.1365-2850.2010.01646.x.
Razani, J., Bayan, S., Funes, C., Mahmoud, N., Torrence, N., Wong, J., Josephson, K. (2011). Patterns of deficits in daily functioning and cognitive performance of patients with Alzheimer disease. Journal of Geriatric Psychiatry and Neurology, 24(1), 23-32. doi:10.1177/0891988710390812
www.noldus.com
Observational Method used in the IPPI study: “The Observer”
Measuring Behavior with The Observer
Customized
coding schemePrecisely
detail behaviors & affect
Time-stamped event log
Annotate behavior via simple key pressCoding can be done live or via videorecording
Record who does what, where, when and how/to whomBehaviors can be coded with modifiers, e.g., intensity
Maintain time-stamped event log Synchronize with multimodal data
Pocket Observer: be free to move
Code on a handheld device
Mobile observations, outdoor use
Add behaviors/modifiers on the handheld
Supports Smart phones, rugged handhelds,
PDAs (Windows Mobile 6.x)
Gather & score behavior data live usingPocket Observer
Data collection: Continuous Coding via Video
The ObserverXT: Analyzing the data
Descriptive statistics
Frequency: How many times did the resident strike out?
Duration: How long did the resident express pleasure?
Latency, rate per minute, percent observation, inter-rater reliability, etc.
Bellg, A, Borrelli, B., Resnick, B. et al., (2005). Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations form the NIH Behavior Change Consortium, Health Psychology, 23, 443-451.
What is fidelity in psychosocial intervention research?Focus Purpose
Design Study
Ensure that a study can adequately test its hypotheses in relation to the underlying theory and clinical processes.
Training Interventionist
Ensure that interventionists have been satisfactorily trained to deliver the intervention to participants.
Delivery InterventionistEnsure that the intervention is delivered as intended.
Receipt RecipientAssures that the treatment has been received and understood by the individual
Enactment Recipient
Monitors that the individual performs treatment-related behavioral skills and cognitive strategies in relevant real life settings as intended.
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What aspects of fidelity are optimally measured by real- time observational
methods?
Focus Purpose
Design Study
Ensure that a study can adequately test its hypotheses in relation to the underlying theory and clinical processes.
Training Interventionist
Ensure that interventionists have been satisfactorily trained to deliver the intervention to participants.
Delivery InterventionistEnsure that the intervention is delivered as intended.
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Fidelity of Treatment Delivery
Do CNA’s adhere to communication skills (prescribed and proscribed) in intervention protocols while delivering a one to one intervention to persons with dementia?
Protocol fidelity for adherence to proscribed communication skills for CNAs (N=84) trained to deliver
psychosocial interventions to nursing home residents with dementia: Percent who used communication behaviors
CNA Communication Behaviors Total N=84 (%)
Positive
Greeting 86 Explanation 89 Courtesy 79 Offers choice 80 Asks preference 98 Praise/compliment 79 Reassure 60
Positive announcement 89
Positive touch 96 Positive verbal prompt 92 Non-verbal prompt 89
Task engagement 71
Negative
Negative announcement 1
Ignores resident 6 Talks to another 87 Rebuke/disapprove 13 Negative touch 0
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Benefits of real- time observation in measuring treatment delivery integrity
•Interventionist self reports of adherence are heavily influenced by demand characteristics or need for social approval1 •Differences between observed and interventionist reported adherence can be substantial (e.g., 100% for self report, 44% for observed)2
•Precision in measuring adherence can prevent premature abandonment of potentially effective interventions that are simply not delivered effectively.
1. Perepletchikova, F. & Kazdin, A. (2005). Treatment integrity and therapeutic change: Issues and research recommendations. ClinicPal Psychology: Science and Practice, 12(4), 365-383.2. Hardeman, W., Michie, S., Fanshawe, T., et al. (2008). Fidelity of delivery of a physical activity intervention: Predictors and consequences. Psychology and Health, 23 (1), 11-24.
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Fidelity and Study Design: How Observational Methods Can Help
•Can enhance study power by reducing random or unintended variability resulting in a more modest “n” in future studies2
•Facilitate identification of crucial, active ingredients and their relationship to immediate (during intervention sessions) and longer term outcomes1
Observational methods can enhance the ability to empirically validate which intervention ingredients are most or least crucial to outcomes
Observed intervention components should be theory-based and tied to outcomes of choice
1. National Advisory Mental Health Council Workgroup Report (2010). From discovery to cure: Accelerating the development of new and personalized interventions for mental illnesses. http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/fromdiscoverytocure.pdf2. Horner, S., Rew, L., & Torres, R (2006). Enhancing intervention fidelity: A means of strengthening study impact. JSPN, 11(2), 80-89
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. The psychology of adult development and aging, 619-674.
Theoretical basis for focusing on verbal and nonverbal communication behaviors of CNAs in the context of intervention delivery to persons with dementia
Pearson Correlations (N=2638 real-time observation occasions) Resident Negative Behavior Resident Positive Behavior
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative CNA
communication
behavio
rs
Negative prompt .
Negative announcement
Ignores resident
Talks to another
Rebuke/disapprove
Negative touch
Positive CNA
communication behavio
rs
Greeting
Explanation
Courtesy
Offers choices
Asks preference
Praise/compliment
Reassurance
Positive verbal prompt
Positive announcement
Positive touch
Non-verbal prompt
General conversation
Verbally engaged in task
Physically engaged in task
**. Correlation is significant at the 0.001 level (2-tailed).
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt .12
Negative announcement
Ignores resident
Talks to another .08 .12 .09
Rebuke/disapprove .06 .12
Negative touch
Greeting .35 .16 .38 .20
Explanation .46 .20 .51 .24
Courtesy .47 .27 .46 .32
Offers choices .34 .21 .42 .13
Asks preference .41 .19 .52 .16
Praise/compliment .38 .35 .54 .20
Reassurance .16 .22 .10
Positive verbal prompt .29 .08 .48 .11
Positive announcement .34 .12 .37 .14
Positive touch .22 .14 .40 .23
Non-verbal prompt .43 .26 .42 .16
General conversation .66 .09 .19
Verbally engaged in task .39 .43 .90 .21
Physically engaged in task .07 .12 .22 .20
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt
Negative announcement .11
Ignores resident
Talks to another .26 .10 .28 .08
Rebuke/disapprove .10
Negative touch
Greeting .15 .11 -.09 .08
Explanation .15 .15 -.12 .20 .12
Courtesy -.14
Offers choices .11 .12 -.12
Asks preference .17 .14 -.14 .10 .11
Praise/compliment .07 -.13
Reassurance .20 .12
Positive verbal prompt .13 .17 -.12 .13 .10
Positive announcement .08 .11 -.10 .12
Positive touch .09 .12 -.08
Non-verbal prompt .09 -.07 -.15 .07 .09
General conversation .11 .09 -.08 -.18 .09 .09
Verbally engaged in task .10 -.12
Physically engaged in task . .15
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt .12
Negative announcement .11
Ignores resident
Talks to another .08 .12 .09 .26 .10 .28 .08
Rebuke/disapprove .06 .12 .10
Negative touch
Greeting .15 .11 -.09 .08 .35 .16 .38 .20
Explanation .15 .15 -.12 .20 .12 .46 .20 .51 .24
Courtesy -.14 .47 .27 .46 .32
Offers choices .11 .12 -.12 .34 .21 .42 .13
Asks preference .17 .14 -.14 .10 .11 .41 .19 .52 .16
Praise/compliment .07 -.13 .38 .35 .54 .20
Reassurance .20 .12 .16 .22 .10
Positive verbal prompt .13 .17 -.12 .13 .10 .29 .08 .48 .11
Positive announcement .08 .11 -.10 .12 .34 .12 .37 .14
Positive touch .09 .12 -.08 .22 .14 .40 .23
Non-verbal prompt .09 -.07 -.15 .07 .09 .43 .26 .42 .16
General conversation .11 .09 -.08 -.18 .09 .09 .66 .09 .19
Verbally engaged in task .10 -.12 .39 .43 .90 .21
Physically engaged in task . .15 .07 .12 .22 .20
Pearson Correlations (N=2638 real-time observation occasions) Resident Negative Behavior Resident Positive Behavior
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative CNA
communication
behavio
rs
Negative prompt .
Negative announcement
Ignores resident
Talks to another
Rebuke/disapprove
Negative touch
Positive CNA
communication behavio
rs
Greeting
Explanation
Courtesy
Offers choices
Asks preference
Praise/compliment
Reassurance
Positive verbal prompt
Positive announcement
Positive touch
Non-verbal prompt
General conversation
Verbally engaged in task
Physically engaged in task
**. Correlation is significant at the 0.001 level (2-tailed).
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt .12
Negative announcement
Ignores resident
Talks to another .08 .12 .09
Rebuke/disapprove .06 .12
Negative touch
Greeting .35 .16 .38 .20
Explanation .46 .20 .51 .24
Courtesy .47 .27 .46 .32
Offers choices .34 .21 .42 .13
Asks preference .41 .19 .52 .16
Praise/compliment .38 .35 .54 .20
Reassurance .16 .22 .10
Positive verbal prompt .29 .08 .48 .11
Positive announcement .34 .12 .37 .14
Positive touch .22 .14 .40 .23
Non-verbal prompt .43 .26 .42 .16
General conversation .66 .09 .19
Verbally engaged in task .39 .43 .90 .21
Physically engaged in task .07 .12 .22 .20
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt
Negative announcement .11
Ignores resident
Talks to another .26 .10 .28 .08
Rebuke/disapprove .10
Negative touch
Greeting .15 .11 -.09 .08
Explanation .15 .15 -.12 .20 .12
Courtesy -.14
Offers choices .11 .12 -.12
Asks preference .17 .14 -.14 .10 .11
Praise/compliment .07 -.13
Reassurance .20 .12
Positive verbal prompt .13 .17 -.12 .13 .10
Positive announcement .08 .11 -.10 .12
Positive touch .09 .12 -.08
Non-verbal prompt .09 -.07 -.15 .07 .09
General conversation .11 .09 -.08 -.18 .09 .09
Verbally engaged in task .10 -.12
Physically engaged in task . .15
Very neg verbal
Neg verbal
Gen restless
Eyes closed
Uncoop- erative
Aggres- sion
Pos verbal
Very pos verbal
Task en-gagement Pos touch
Negative prompt
Negative announcement
Ignores resident
Talks to another
Rebuke/disapprove
Negative touch
Greeting .35 .38 Explanation .46 .51 Courtesy .47 .46 Offers choices .42 Asks preference .41 .52 Praise/compliment .38 .35 .54 Reassurance
Positive verbal prompt .48 Positive announcement .37 Positive touch .40 Non-verbal prompt .43 .42 General conversation .66
Engaged in task .39 .43 .90 Physically engaged in task
Why focus on positive emotion as an outcome of choice?
1. Fredrickson, B. (2004). The broaden-and-build theory of positive emotions. Phil Trans R Soc Lond B Biol Sci. September 29; 359(1449): 1367–1378. doi: 10.1098/rstb.2004.15122. Fredrickson, B.L., & Losada, M.F. (2005). Positive affect and complex dynamics of human flourishing. American Psychologist, 60, 678-686. doi:10.1037/0003-066X.60.7.6783. Meeks, S., VanHaitsma, K., Kostiwa, I. & Murrell, S. (in press). Positivity and Well-Being among Community-Residing Elders and Nursing Home Residents: What is the Optimal Affect Balance? Journals of Gerontology: Psychological Sciences.
Broaden-and-Build Theory of Positive Emotion (Fredrickson, 2004)1
•Positive emotions are a primary means to improve psychological and physical well-being over time.•Positive emotions broaden people’s momentary thought-action repertoires (enhance attention, flexibility, openness to new experiences) and build their enduring personal resources (social attachments, resiliency, creativity, enhanced cardiovascular recovery). •Positive emotions serve to “undo” or “correct” the after effects of negative emotional experiences.•In order for an individual to flourish, the ratio of positive to negative emotional experiences needs to be at least 3 to 1 .2,3
Pearson Correlations (N=2638 real-time observation occasions)
Resident Positive Affect Resident Negative Affect
Pleasure Interest Anger Anxiety Sadness
Positive CNA communication
behaviors
Greeting
Explanation
Courtesy
Offers choice
Asks preference
Praise/ compliment
Reassure
Positive announcement
Positive touch
Positive verbal prompt
Non-verbal prompt
Verbal task engagement
.
Physical task engagement
Negative CNA communication
behaviors
Negative announcement
Ignores resident
Talks to another
Rebuke/ disapprove
Negative touch
**. Correlation is significant at the 0.001 level (2-tailed).
Pleasure Interest Anger Anxiety Sadness
Greeting .24 .11
Explanation .30 .12
Courtesy .38 .14
Offers choice .25 .11
Asks preference .34 .14
Praise/ compliment .42 .12
Reassure .12
Positive announcement .26 .09
Positive touch .25 .12
Positive verbal prompt .27 .12
Non-verbal prompt .37 .20
Verbal task engagement .51 .10
Physical task engagement .14 .07
Negative announcement
Ignores resident
Talks to another .09 .07
Rebuke/ disapprove .07
Negative touch
Pleasure Interest Anger Anxiety Sadness
Greeting .15
Explanation .17 .20 .08
Courtesy
Offers choice .12
Asks preference .10 .16
Praise/ compliment
Reassure .11 .08 .13
Positive announcement .09 .09
Positive touch .13
Positive verbal prompt .14
Non-verbal prompt
Verbal task engagement .07
Physical task engagement .17
Negative announcement
Ignores resident
Talks to another .17 .09
Rebuke/ disapprove
Negative touch
Pleasure Interest Anger Anxiety Sadness
Greeting .24 .11 .15
Explanation .30 .12 .17 .20 .08
Courtesy .38 .14
Offers choice .25 .11 .12
Asks preference .34 .14 .10 .16
Praise/ compliment .42 .12
Reassure .12 .11 .08 .13
Positive announcement .26 .09 .09 .09
Positive touch .25 .12 .13
Positive verbal prompt .27 .12 .14
Non-verbal prompt .37 .20
Verbal task engagement .51 .10 .07
Physical task engagement .14 .07 .17
Negative announcement
Ignores resident
Talks to another .17 .09 .09 .07
Rebuke/ disapprove .07
Negative touch
Pearson Correlations (N=2638 real-time observation occasions)
Resident Positive Affect Resident Negative Affect
Pleasure Interest Anger Anxiety Sadness
Positive CNA communication
behaviors
Greeting
Explanation
Courtesy
Offers choice
Asks preference
Praise/ compliment
Reassure
Positive announcement
Positive touch
Positive verbal prompt
Non-verbal prompt
Verbal task engagement
.
Physical task engagement
Negative CNA communication
behaviors
Negative announcement
Ignores resident
Talks to another
Rebuke/ disapprove
Negative touch
**. Correlation is significant at the 0.001 level (2-tailed).
Pleasure Interest Anger Anxiety Sadness
Greeting .24 .11
Explanation .30 .12
Courtesy .38 .14
Offers choice .25 .11
Asks preference .34 .14
Praise/ compliment .42 .12
Reassure .12
Positive announcement .26 .09
Positive touch .25 .12
Positive verbal prompt .27 .12
Non-verbal prompt .37 .20
Verbal task engagement .51 .10
Physical task engagement .14 .07
Negative announcement
Ignores resident
Talks to another .09 .07
Rebuke/ disapprove .07
Negative touch
Pleasure Interest Anger Anxiety Sadness
Greeting .15
Explanation .17 .20 .08
Courtesy
Offers choice .12
Asks preference .10 .16
Praise/ compliment
Reassure .11 .08 .13
Positive announcement .09 .09
Positive touch .13
Positive verbal prompt .14
Non-verbal prompt
Verbal task engagement .07
Physical task engagement .17
Negative announcement
Ignores resident
Talks to another .17 .09
Rebuke/ disapprove
Negative touch
Pleasure Interest Anger Anxiety Sadness
Greeting
Explanation
Courtesy .38 Offers choice
Asks preference
Praise/ compliment .42
Reassure
Positive announcement
Positive touch
Positive verbal prompt
Non-verbal prompt .37
Verbal task engagement .51
Physical task engagement
Negative announcement
Ignores resident
Talks to another
Rebuke/ disapprove
Negative touch
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Summary: Pros and Cons afforded by real time observation of treatment fidelity
compared to other methodsCons:
•Expensive and time intensive to train researchers.•Is not efficient for use in “real world” of clinical practice
Pros: •Provide a more accurate and objective account of treatment delivery•Enhanced understanding what treatment ingredients give you the biggest “bang for your buck” in outcomes•Knowledge of potent treatment ingredients can lead to
1) refinements of treatment protocols2) more targeted treatment training materials3) refined platform for building fidelity measures used for
quality improvement purposes in clinical settings .
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Thank you!
