Elsevier

Geriatric Nursing

Volume 34, Issue 3, May–June 2013, Pages 194-198
Geriatric Nursing

Feature Article
The CARES® Observational Tool: A valid and reliable instrument to assess person-centered dementia care

https://doi.org/10.1016/j.gerinurse.2013.01.002Get rights and content

Abstract

The goal of the current study was to develop a valid and reliable tool to measure whether person-centered care is delivered by direct care workers to persons with dementia. Face validity was initially established through multiple revisions of the CARES® Observational Tool (COT™) by members of the study team. Afterward, content validity of the COT was established by piloting the tool on 31 observations across 7 nursing homes and review by an interdisciplinary panel of nine scientific experts. The final 16-item version of the COT was then tested for inter-rater reliability by 5 reviewers across 5 standardized dementia care videos. An intra-class coefficient of all possible Kappa coefficients resulted in an ICC of .77. The brief and easy-to-use COT has potential to assess person-centered care interactions between direct care workers and persons with dementia.

Introduction

The principal objective of this study was to develop and test an observational assessment tool (the CARES® Observational Tool, or COT) to ascertain whether person-centered care was present in the day-to-day care interactions between direct care workers and persons with dementia. The concept of person-centered care (“supporting the rights, values, and beliefs of the individual; involving them and providing unconditional positive regard; entering their world and assuming that there is meaning in all behavior, even if it is difficult to interpret; maximizing each person's potential; and sharing decision making”)1 has been hailed as a transformative approach in dementia care. However, there remain few valid measures to ascertain whether person-centered elements are present in residential dementia care.

As recent and prior qualitative investigations in nursing homes have emphasized, the personal relationships direct care workers forge with individual residents appear central to quality of care or quality of life outcomes on the part of residents.2, 3 As most analyses of the staff-resident dynamic focus on ratios rather than relationships, assessing the presence of person-centered dementia care in nursing homes or other residential care settings may help to advance clinical understanding of essential quality of care. Bowers, Esmond, and Jacobson (2000) found that direct care providers considered personal relationships with residents integral to providing individualized care.3 Therefore, the current study aimed to develop and test an observational measure of direct care worker-person with dementia interactions to determine if elements of person-centered care are present.

A review of Alzheimer's disease rating scales found that although 68 measures of Alzheimer's disease exist, most consider major dysfunction in specific domains and are not easy-to-use tools that can assess individuals' responses to specific therapies.4 While routine staff reporting of the behavior exhibited by persons with Alzheimer's disease or related dementias (sometimes referred to as “problem behavior” or “inappropriate behavior”) is easier to administer and less time-consuming than observational rating protocols, concordance between staff ratings of resident behavior and direct observational measures is moderate at best.5 Several observational protocols assess quality of dementia care in residential or other settings.6, 7 In a review of 34 studies of Dementia Care Mapping (where an observer tracks 5 people with dementia continuously over a period of time and codes whether certain behavior occurs as well as direct care worker interactions with persons with dementia), it was concluded that such approaches effectively measure quality of dementia care and demonstrate concurrent validity with other established measures of quality of life.8 A behavioral observational protocol, the Communication Skills Checklist, can help investigators determine whether trained communication skills are applied for persons with dementia.9 Other strategies have also been utilized, including a computer-assisted observational tool to examine activity, behavior, and emotional affect of residents every 10 minutes over a 12-hour period (which summarily found that residents were not engaged with their environment).10

An effective and easy-to-administer instrument to assess person-centered care in dementia remains a gap in the clinical and scientific literature.1 The goal of the current study was to develop a valid and reliable tool to easily determine the presence of person-centered care elements in direct care worker-person with dementia interactions. While direct care workers' perceptions of their relationships with residents appear key to ensuring person-centered care in nursing homes,2, 3 direct care worker-reports are not as reliable as behavioral observations. Although various observational protocols exist, these tools are time-intensive to administer and do not necessarily track the direct care worker-resident interaction domains that reflect person-centered care. The present study summarizes the development, testing of face and content validity, and inter-rater reliability analysis of the COT, an observational protocol that is designed to measure the presence of person-centered care elements for individuals with dementia.

Section snippets

Sample

Thirty-one interactions between nursing home residents and direct care workers were included to establish content validity of the COT. These residents were identified from 7 nursing homes in the Minneapolis/St. Paul region. One nursing home was randomly selected from the Center of Medicare and Medicaid Services list of nursing homes in Minnesota; a convenience sample approach was used to select the other 6 facility sites based on the recommendations of the research assistant and a doctor of

Face validity

The COT was revised to include the following: a) a narrative description of the direct care worker-person with dementia interaction event; b) 7 items assessing whether the direct care worker connected with the person with dementia; c) 2 items to ascertain whether the direct care worker assessed the behavior of the person with dementia; d) 4 items to determine whether the direct care worker responded appropriately to the person with dementia's behavior; e) 2 items to assess whether the direct

Discussion

The findings pertaining to the development, establishment of face and content validity, and inter-rater reliability of the COT suggests its utility in assessing important direct care worker-person with dementia interactions in long-term care. Based on several other rigorous tools,6, 11 the COT pinpoints critical domains of person-centered dementia care interactions including evidence of interpersonal connection between the direct care worker and the person with dementia, ongoing assessment of

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This research was supported by a grant from the National Institute on Aging (AG023451; John V. Hobday, Principal Investigator). Mr. Hobday, creator of the CARES© Observational Tool, is the Chief Executive Officer of HealthCare Interactive Incorporated, the company that has developed and is selling the CARES® online training programs. Ms. Savik is a Co-Investigator and biostatistician of the National Institute on Aging grant that supported the results presented in this paper. Dr. Gaugler is a scientific consultant with HealthCare Interactive, Incorporated. The authors would like to thank Merrie Kaas, Georgia Lane, Deborah Richman, Ashley Brooks-Danso (dearly departed), Lou Burgio, Deborah Lindgren-Clendenen, Mary Mittelman, Lynne Morishita, Lisa Nelson, Mark Sager, and Stan Smith for their assistance in the measurement development process.

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