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Effects of a Feeding Skills Training Program On EFFECTS OF A FEEDING SKILLS TRAINING PROGRAM ON KNOWLEDGE, ATTITUDE, PERCEIVED BEHAVIOR CONTROL, INTENTION, AND BEHAVIOR OF FORMAL CAREGIVERS TOWARD FEEDING DEMENTIA PATIENTS IN TAIWAN NURSING HOMES by CHIA-CHI CHANG Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Adviser: Dr. May L Wykle Frances Payne Bolton School of Nursing Case Western Reserve University January, 2005 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the dissertation of ______________________________________________________ candidate for the Ph.D. degree *. (signed)_______________________________________________ (chair of the committee) ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ (date) _______________________ *We also certify that written approval has been obtained for any proprietary material contained therein. 1 TABLE OF CONTENTS CHAPTER 1: INTRODUCTION Problem Statement and Background ----------------------------------------------------------8 Significance for Nursing ----------------------------------------------------------------------11 Purpose of the Study ------------------------------------------------------------------14 Research Questions and Hypotheses-------------------------------------------------------- 15 Conceptual Framework----------------------------------------------------------------------- 17 Theoretical Framework------------------------------------------------------------------------22 Definitions of the Terms-----------------------------------------------------------------------24 CHAPTER 2: REVIEW OF LITERATURE Overview of Dementia Disease---------------------------------------------------------------27 Normal Feeding Behavior---------------------------------------------------------------------33 Characteristics of Feeding Difficulties in Persons with Dementia-----------------------36 Measurement of Feeding Difficulties in Persons with Dementia------------------42 Factors Related to Feeding Difficulty in Persons with Dementia------------------------47 Interventions for Feeding Difficulty in Persons with Dementia ------------------------53 Educational Training Program for Nursing Assistants-------------------------------------58 CHAPTER 3: METHOD Design--------------------------------------------------------------------------------------------62 Sample-------------------------------------------------------------------------------------------65 Sample Size Determination-------------------------------------------------------------------66 Sampling Procedure----------------------------------------------------------------------------68 Setting--------------------------------------------------------------------------------------------69 Treatment----------------------------------------------------------------------------------------69 Data Collection Procedure---------------------------------------------------------------------71 Measurements-----------------------------------------------------------------------------------73 Data Management------------------------------------------------------------------------------79 Data Analysis------------------------------------------------------------------------------------79 Protection for Human Subjects---------------------------------------------------------------81 2 CHAPTER 4: RESULTS AND DISCUSSION Results--------------------------------------------------------------------------------------------83 Review of Research Questions------------------------------ ---------------------------------83 Characteristics of Sample----------------------------------------------------------------------84 Demographic characteristics of nursing assistants----------------------------------84 Demographic characteristics of observed nursing assistants and dementia patients------------------------------------------------------------------------------------85 Feeding difficulties among dementia patients---------------------------------------87 Preliminary Analysis---------------------------------------------------------------------------92 Description and test differences on dependent and control variables------------92 Testing the statistical assumptions----------------------------------------------------97 Hypothesis Testing----------------------------------------------------------------------------99 Discussion--------------------------------------------------------------------------------------106 Comparison of to the Theory of Planned Behavior and the study findings----------- 106 Effects of a Feeding Skills Training Program---------------------------------------------107 CHAPTER 5: SUMMARY, LIMITATIONS, AND IMPLICATIONS Summary of the Study------------------------------------------------------------------------113 Method---------------------------------------------------------------------------------114 Qualitative Data------------------------------------- ---------------------------------118 Procedure------------------------------------------------------------------------------118 Data Analysis------------------------------------------------------------------------ 119 Pertinent Findings--------------------------------------------------------------------119 Study limitations------------------------------------------------------------------------------120 Implications for Nursing Practice-----------------------------------------------------------122 Recommendations for Future Study--------------------------------------------------------124 Appendix---------------------------------------------------------------------------------------126 Bibliography-----------------------------------------------------------------------------------214 3 LIST OF TABLES Table I Summary of Studies Using a Training Program Intervention-----------------64 Table II Data Collection Points for the Nursing Assistants-----------------------------72 Table III Demographic Characteristics of Nursing Assistants--------------------------85 Table IV Demographic Characteristics of Observed Nursing Assistants-------------86 Table V Demographic Characteristics of Observed Dementia Patients---------------87 Table VI Feeding Difficulties among Dementia Patients as Measured by EdFED Scale------------------------------------------------------------------------------ --89 Table VII Knowledge, Attitude, Perceived Behavior Control, Intention, and Control Variables Scores of Nursing Assistants and Student’s t-test-----------------94 Table VIII Knowledge, Attitude, Perceived Behavior Control, Intention, Behaviors and Control Variables Scores and Student’s t-test for the Observed Sample---------------------------------------------------------------------------96 Table IX Model Summary for Hierarchical Regression- Nursing Assistants Feeding Behaviors------------------------------------------------------------------------102 Table X Hierarchical Regression for Analysis Behavior Change of Nursing Assistants------------------------------------------------------------103 Table XI Slope Scores for Knowledge, Attitude, Perceived Behavior Control, and Intention of Nursing Assistants------------------------------------------------105 4 LIST OF FIGURES Figure I Theoretical Model of the Theory of Planned Behavior----------------------20 Figure II Theoretical Model of the Study------------------------------------------------22 Figure III Substruction of the Study------------------------------------------------------23 5 ACKNOWLEDGEMENTS First, I would like to thank the nursing assistants, dementia patients, and their family members who participated in this study. This study would not have been a success without their participation and all the guidance and support from my advisor, Dean Wykle, and committee members, Dr. Whitehouse, Dr. Roberts, and Dr. Madigan. Many thanks go to Dr. Wykle for her guidance throughout my study, Dr. Whitehouse for his strong support during the study, Dr. Roberts for coaching in methods, and Dr. Madigan for her statistical guidance. My greatest thanks go to my parents and family members for their moral and social support throughout my three years of studying abroad. Special thanks go to Dr. Li-Chan Lin, my mentor in Taiwan for reviewing the Chinese versions of the training program and questionnaires. Many thanks go to Dr. Chin-Hong Chan and Chien-Ning Tseng for their expert reviews and Chao-Hau Houng and Man-Hua Yang for back-translating the instruments. I want to thank Dr. Ping-Cheng Wang for checking the equivalence of instruments. I also acknowledge Laura Bobrowski for her timeless editing of my dissertation. I appreciate all my colleagues, faculty and staff at the School of Nursing for their academic and social support. I also thank all the friends that I have met in U.S.A; they assisted me to adjust to living and studying here. I would like to extend my gratitude to a specially friend, Ping-Wu, and his family for their help and support. I also want to thank my best friend, Li-Ning, for data entry and mental support and the research assistant, Wan-Ting, for collecting the data. I extend my most heartfelt appreciation to a person who is my friend and also as my mentor, Dr. Fong-Tung Wu for his encouragement and inspiration. Last, I want to thank Sigma Theta Tau International- Alpha Mu Chapter and the Alumni Association of FPB School of Nursing
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