Minnesota State University, Mankato
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State University, Mankato
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All Graduate Theses, Dissertations, and Other
Capstone Projects
Graduate Theses, Dissertations, and Other
Capstone Projects
2020
Understanding Communication Dynamics in Group Home Setting
Understanding Communication Dynamics in Group Home Setting
Jacinta O. Anyanwu
Minnesota State University, Mankato
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Anyanwu, J. (2020). Understanding communication dynamics in group home setting [Master’s thesis,
Minnesota State University, Mankato]. Cornerstone: A Collection of Scholarly and Creative Works for
Minnesota State University, Mankato. https://cornerstone.lib.mnsu.edu/etds/1065/
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Understanding Communication Dynamics in Group Home Setting
By
Jacinta O. Anyanwu
A Thesis Submitted in partial Fulfillment of the
Requirements for the Degree of
Master of Arts
In
Clinical Psychology
Minnesota State University, Mankato
Mankato, Minnesota
(May 2020)
(07/16/2020)
Understanding Communication Dynamics in Group Home Setting
Jacinta O. Anyanwu
This thesis has been examined and approved by the following members of the student’s
committee.
Advisor
Committee Member
Committee Member
Table of Contents
Table of Contents
………………………………………………………………………………………….. 3
INTRODUCTION ………………………………………………………………………………………. – 1 –
NEED FOR EFFECTIVE COMMUNICATION PATTERN
…………………………………. – 2 –
COMMAND TYPES …………………………………………………………………………………… – 4 –
CURRENT STUDY ……………………………………………………………………………………. – 8 –
METHODS
……………………………………………………………………………………………… – 10 –
Interview Development ………………………………………………………………………….. – 10 –
Participant Demographics ……………………………………………………………………… – 11 –
Procedure
……………………………………………………………………………………………. – 12 –
CODES AND FREQUENCY OF OCCURENCE
……………………………………………. – 15 –
RESULTS ………………………………………………………………………………………………. – 19 –
Data Analysis ………………………………………………………………………………………. – 19 –
Response to Interview Questions ……………………………………………………………. – 19 –
Code Relations/Communication Interrelations
…………………………………………… – 26 –
DISCUSSION …………………………………………………………………………………………. – 27 –
LIMITATIONS …………………………………………………………………………………………. – 31 –
IMPLICATIONS AND FUTURE DIRECTIONS ……………………………………………… – 32 –
CONCLUSION
………………………………………………………………………………………… – 35 –
References …………………………………………………………………………………………….. – 37 –
Appendix I
………………………………………………………………………………………………. – 41 –
Understanding Communication Dynamics in Group Home Setting
Jacinta O. Anyanwu
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF
Master of Art in Clinical Psychology
MINNESOTA STATE UNIVERSITY, MANKATO
MANKATO, MINNESOTA
May 2020
ABSTRACT
Purpose: Limited research has examined the communicative interaction patterns
within group home settings between adults with developmental disabilities and
their non-disabled direct care staff. There is evidence from studies that improving
the communication pattern of caregivers will eventually lead to better interaction
with residents. An approach that might clarify this issue is to have direct care staff
who currently work in group homes describe their interaction with their residents.
This study evaluated the communication pattern of direct care staff and their
residents in group home settings by looking at the types of instructions that direct
care staff use on a daily basis to get their residents to accomplish tasks and
comply. Design and Methods: An online survey with open-ended questions was
provided online to direct care staff (N = 14) who were working in group homes
regarding to their daily tasks oriented interaction with residents, the type of
command they used and the response they get from residents. Data was coded and
analyzed in MAXQDA 2020 and compared to features of command and
compliance. Results: Data indicated that direct care staff used more vague and
ambiguous instructions (i.e., beta instructions), than clear and specific instructions
(i.e., alpha instructions). Direct care staff reported that residents either refused or
responded passively to instructions. In addition, instructions given during intimate
or personal care activities were the mostly refused. Assistance with intimate care
was also the most occurring tasks daily. Implications: Training direct care staff
in effective instruction method when seeking compliance from resident such as
the usage of more alpha command type as well as appropriate attitude will
improve interactions between direct care staff and residents in group homes. The
implication of study outcomes is reviewed.
Key Words: communication, group home, direct care staff, command, compliance
– 1 –
INTRODUCTION
An estimated 56.7 million people in the United States have some forms of disability (one
in every five people), and it is approximated that between 4.6 to 7.7 million Americans
live with intellectual and developmental disabilities (United State Census, Newsroom
Archive, 2012). The supportive needs of these individuals are contingent upon the
severity of the disability. Persons with severe to profound intellectual disability are likely
to require extensive and pervasive supports for all forms of interactions such as skills to
perform activities of daily living, skills for integration into community living,
socialization, and communication skills (American Association on Mental Retardation,
2002). In order to facilitate services for individuals in the group home settings, there is
the need for efficient communicative interactions between the residents and their direct
care staff. The residents should be able to understand directives from direct care staff.
Direct care staff on their part would need to be able to understand the nuances of the
individuals they support.
Direct care staff are often charged with giving instructions that requires residents to obey.
These instructions could be in the form of helping them with activities of daily living,
learning appropriate social skills to enable them to integrate well into the community or
keeping the rules and regulations of the group homes. As noted by Blunden (1988),
individuals who require a high degree of assistance often benefit from a functional
communication pattern. This is the ability of the direct care staff to understand the
comprehension level of their residents in order to give them instructions that they can
– 2 –
understand and be able to follow. In fact, for direct care staff to form and maintain
relationship with residents, there is the need for communicative competence.
Previous studies have established that communication difficulties are prevalent in
individuals with varied forms of disabilities. For instance, Bott, Farmer and Rhode
(1997), noted communication challenges in people with intellectual disabilities. Kuder
and Bryen (1991) assessed the communicative performance of institutionalized
individuals with developmental disabilities. Their findings indicated that staff and clients
used conversational discouragers, for instance, direct orders twice as often as they made
use of conversational encouragers such as social exchange. These forms of
communication have been associated with frustration on the parts of the residents as well
as their caregivers. In as much as this current study is not focusing specifically on
individuals with intellectual or developmental disabilities, in a broader sense, there is the
possibility of finding such individuals in group home settings. Group homes are settings
in which many people with severe disabilities are likely to reside (DeSimone & Cascella,
2005). The current study focused on understanding the impact of different
communication styles used by direct care on the compliance of residents in the group
home setting.
NEED FOR EFFECTIVE COMMUNICATION PATTERN
Communication between direct care staff and their residents has been linked with
challenging behaviors in some residents. McConkey, Morris, and Purcell (1999)
investigated communications between staff and adults with intellectual disabilities in
– 3 –
natural occurring settings. Their participants consisted of 43 staff-client dyads in small
scale residential and day service settings. They utilized frequency count method to collect
data on communicative acts between care givers and their clients. Each care giver was
asked to choose a client as a partner to work with. The care staff and clients were
instructed to interact as normally as possible. Their interactions were video-taped. The
settings recorded included social chat, making tea, doing household chores, swimming,
art and craft activity et cetera. Two experienced language therapists rated the
communicative interaction in terms of appropriateness. Data was analyzed by counting
the communicative acts performed by care giver and client. Care givers’ communicative
behaviors were rated as appropriate or inappropriate given the context of the interaction
and the communicative competencies of the client. Their findings evidenced that clients
were not presented with enough opportunities to engage as equal partners in the
conversational interaction. Care givers relied exceedingly on verbal acts even amongst
non-verbal clients. Some of the explanations the authors offered with regards to care
givers’ communication patterns were that care givers might had misjudged the
communicative competencies of their clients, care givers might have overestimated the
their client’s comprehension levels in terms of understanding language, they also might
have failed to identify non-verbal behavior of their clients as a way of communication.
A similar result was found by Bradshaw (2001). In investigating the complexity of staff
communication and reported level of understanding skills in adults with intellectual
disability, the author reported that on an average of 45%, staff appeared unable to adapt
their communication to the skills of the service users. And staff communicative acts were
– 4 –
outside the reported understanding skills of the residents. As informative as these studies
might be, there is still the need to explore more on the communicative interactions
between direct care staff and their residents.
COMMAND TYPES
Command use by direct care staff in group home settings to get compliance from
residents is another area that has not given adequate attention in research. A crucial
question would be what types of commands are issued by direct care staff that avails
them the optimal response or the prospect of getting optimal compliance from residents
in group homes. Types of command were first identified by Peed, Roberts, and Forehand
(1977) as used in preschool settings between teachers and pupils. Two types of command
differentiated by Peed et al (1977) are alpha command and beta commands. Alpha
command was defined as “an order, rule, suggestion, or question to which a motoric
response is appropriate and feasible.” Beta command was defined as “commands in
which the child is not given opportunity to demonstrate compliance (within a
predetermined time), either due to vagueness or ambiguity, interruption, indirectness, or
parental inferences such as carrying out the task for the child” (Christenson et al., 2011).
The outcome of the investigation by Peed et al. (1977), indicated that several cases of
noncompliance resulted from the usage of incorrect instructions. They also found that
without training, parents tend to use more beta command as opposed alpha commands.
A further investigation into command and compliance in communicative interaction by
Bertsch, Houlihan, Lenz, & Patten, (2009) resulted in a further categorization of
– 5 –
commands based on form and specifity. This categorization clarified the looming
confusion from previous command studies because of different forms of commands that
were found. Bertsch et al. (2009), identified eight command types (e.g., questions,
regular, indirect et cetera), which could be further classified according to specifity by the
alpha/beta commands. They recommended that not just the alpha/beta command affects
compliance, but the command forms do as well. So, they recommend considering both
when investigating command and compliance.
Negative consequences that have been reported by studies on command and compliance
with emphasis on cognitive impaired persons in long term care facilities. Such negative
effects of using ineffective instructions include physical aggression and verbal agitations.
Buchanan et al. (2018), examined the relationship between instruction specifity and
resistiveness to care during activities of daily living in persons with dementia. The
authors hypothesized that resistiveness to care (RTC) would likely occur more following
the use of beta instructions by the certified nursing assistants (CNAs) when compared to
alpha instructions. They also hypothesized that CNAs use of beta instruction in response
to resistiveness to care would be correlated to increase with resistiveness to care in
comparison to when alpha instruction is used. The participants in the study included
11individuals diagnosed with dementia who live in a long-term care facility. The second
group of participants were made of 11 CNAs. Data was collected in 3 different large
settings that housed persons with dementia. Video recordings were utilized to record
interactions between CNAs and their residents with dementia. Their result showed that
– 6 –
the use of beta command was preceded by physical aggression and verbal agitation when
beta command is used. Beta instructions also occurred more frequently following
physical aggression. They received mixed result for their second hypothesis. Beta
instructions did precede verbal agitation in comparison to alpha instruction as they had
anticipated. However, they found that physical aggression was followed by more frequent
usage of beta instructions. They suggested the need for a communication training
program for caregivers working with persons with dementia.
A similar result was found by Schwarzkopf, Houlihan, Kolb, Lewinsky, Buchanan, and
Christenson (2008) who investigated the command types used in police encounters. They
reported that police officers used more beta command during stressful situations for
instance, when suspects exhibit aggressive behavior.
Another study by Christenson et al. (2011) on command use and compliance in staff
communication with elderly residents of long-term care facilities, implicated command
type and clarity in eliciting an appropriate response from residents. They further added
that direct and clear command that is stated repeatedly in the exact form produce better
compliance. Although it is tempting to generalize the findings of command and
compliance in gerontology literature to group home settings population, there is
insufficient evidence to support an assertion that there will be similar dynamics in all
aspects to the direct care staff-resident model typically found in group home settings.
Despite the attractions of enhancing communication through optimizing caregiver
interactions, relatively little information is available on the relationship between the types
– 7 –
of instructions used and compliance in the context of interactions between direct care
staff and group home population.
Group homes, also known as adult residential services, are licensed residential facilities
that are located in community settings where adults with intellectual disabilities,
developmental disabilities, and severe and persistent mental disabilities live. They came
into existence between 1960s and 1970s in response to the deinstitutionalization
movement. Group homes are less restrictive facilities that provide assistance with
community integration, destigmatization, and help with the improvement of the quality of
life of individuals with disabilities (American Association on Mental Retardation, 2002).
Group homes provide residential services for individuals across the continuum of
intellectual disability, developmental disability, severe and persistent mental health
disorders (DeSimone & Cascella, 2005). Services provided by group homes to persons
with disabilities include supervision, lodging, meal preparations, habilitative or
rehabilitative services (Regulation of Health and Human Services Residential Facilities,
2018).
Direct care staff work on daily basis to assist individuals in group homes with learning
daily living skills, self-care skills, assist them with transportation needs, and to keep them
safe and healthy. They are responsible for everyday house-hold operations, takes lead
role in program implementations, and typically spend more time with residents than any
other paid personnel in group homes (Regulation of Health and Human Services
Residential Facilities, 2018). Their interaction with residents’ hinges on communicative
– 8 –
interaction. Communication opportunities in these environments may happen on many
different levels (e.g., social communication during community outings, communication
about basic needs getting met). Because of the noted increased difficulty in
communicating with individuals with intellectual disability more than non-disabled
individuals (Bott et al., 1997; McConkey et al., 1999), examining the command and
compliance between direct care staff and their residents becomes a necessity.
CURRENT STUDY
The overarching goal of this study is to better understand the types of command used and
compliance in the context of interaction between direct care staff and their residents in
group home settings. Fewer studies of this nature have been conducted with individuals
in group homes and their direct care staff. Moreover, despite the attractions of enhancing
communication through optimizing caregiver interactions, relatively very little
information is available on the communication pattern between direct care staff and their
residents with a variety of disabilities who live in group home settings. An approach that
might meet these criteria is to have direct care staff who currently work in group homes
describe their interaction dynamics with residents. Direct care staff spend the most one-
to-one time with residents than any other group home staff. Descriptive information
about the common characteristics of direct care staff communication pattern would help
inform the content of training courses for group home staff. Direct care staff reports are
useful because they are time efficient, ecologically valid, and useful for the descriptions
of peculiar communication dynamics often seen in this population (McLean et al., 1996).
Due to limited research in this area, the current study will be focused on:
– 9 –
1. Understanding the daily activities of direct care staff in group homes
2. Understanding situations that call for issuing of command/instructions, and
residents’ compliance and,
3. Understanding strategies utilized by direct care staff to increase the compliance
and response they get from residents.
– 10 –
METHODS
The present study formed the first phase of a project aimed at devising training materials
for use with direct care staff who provide services for individuals with varied disabilities
who live in group homes.
Interview Development
The interview questions were developed by two clinical psychology professors with
doctorates in psychology and the author. The aim of the interview was to obtain
information regarding the daily tasks of direct care staff in group home settings.
Specifically, the questions explored command from staff and compliance from residents.
Direct care staff were asked open-ended questions about the tasks that require them to
give instructions to residents, how they framed the questions and the response received
from residents. Five group home supervisors were recruited as subject matter experts
(SMEs) who read and rated each interview question on clarity, understandability, and
relevance toward understanding the jobs of direct care staff in group homes. All the
questions were rated by the SMEs as necessary. The data was obtained either through in-
person meeting or by phone. After feedback was received from the SMEs, the interview
questions were revised. The format for the interview questions were open-ended
questions. There were opportunities for the direct care staff to provide strategies used,
and examples of exact tasks that required compliance during interactions with their
residents. The questions asked include “describe the most common task you complete on
a daily basis as part of your job,” “ Name and describe the three most common situations
– 11 –
in your day-to-day work that require you to give instructions to residents or where you
must request residents to complete a task?” (See Appendix 1).
Participant Demographics
Participants were undergraduate students (N= 14) who were currently working as direct
care staff in group home settings. Participants were currently enrolled in classes at a large
Midwestern university who were age 18 or older. The participants were predominantly
female and Caucasian. Eight participants indicated that they work for their current agency
between 0-1 year (57.1%), three participants reported working for 3 years in their present
job, and three participants reported 3 or more years in their current job. Of the fourteen
participants, four identified as Direct Support Professionals (DSP), 3 as Certified Nursing
Assistants (CNA), two as Personal Care Staff (PCA), and the remaining participants as
youth care professional, general caretaker, group home staff, activities coordinator, or
resident assistant. Eleven participants were female (78.6%) and three were male (21.4%).
Their ages ranged between 18 and 23 with an average age of 20.5. All participants
consented to the study before participation, and the Minnesota State university
Institutional Review Board approved all procedures.
– 12 –
As a means of determining the sample size in this study, the principle of informational
power was applied. Informational power suggests that the more information the sample
holds that is relevant to the actual study, the lower the number of participants needed
(Malterud, Siersma, & Guassora, 2015). The aim of the study is narrow, the interview
questions were open-ended, clear, concise, and have high relevance to the research
question. The participants working as direct care staff in group homes fit with the specific
characteristics required for the study.
Procedure
The respondents signed up online through SONA systems to participate in the study.
After signing up through the SONA System, the participants were directed to Qualtrics
through a link provided for the study. There is an age restriction of 18 years or older and
a screening question that asked if the individual was currently working in a group home
setting. Any participant that did not meet the criterion of working in a group home was
directed to the end of the questionnaire. The interview questions consisted of six
questions with probes to ensure detailed responses. The survey was online, which
allowed individuals to participate at a time and place that was convenient for them using
a computer, cell phone, or tablet. and lasted approximately 30 minutes. At the completion
– 13 –
of the study, participants were thanked for their participation and were awarded partial
credit.
CODING
The coding process involved a review of the data collected by the author trained in
qualitative data methods. The codes were developed in MAXQDA 2020 using a mix of
concept-driven and data-driven method (Schreier, 2012). The responses were coded into
main codes and subcodes. The main codes were adapted to the research questions and are
as follows: daily tasks, challenging situations, instructions given, response to instructions,
best strategies for giving instruction, best strategies for compliance, training, and training
background, respectively.
Daily tasks were defined as the tasks that direct care staff endorsed that they do on a daily
basis as part of their job description. Challenging situations are the circumstances or
events that direct care staff reported as the least likely for them to get residents to
comply. Instruction given is defined as the command types that direct care staff uses
when trying to get compliance from client (e.g., alpha command, beta command,
elderspeak, directive-questions etc.). Response to instructions are examples provided by
direct care staff as how a client responded to their instruction or command. Best
– 14 –
strategies for giving instruction are the strategies that direct care staff endorsed that they
use most when giving instructions that requires residents to obey or comply. Best
strategies for compliance are defined as the best strategies endorsed by direct care staff as
most likely for clients to comply with instructions or commands. While training and
training focus are reports from the participants, whether they have been trained in
managing stressful interactions with residents and the skills that were most emphasized
during their training.
– 15 –
CODES AND FREQUENCY OF OCCURENCE
CODES
SUBCODES
NUMBER OF
OCCURENCE
DAILY TASKS
Intimate Care
13
House Chores
11
Meal Preparation/Eating
10
Medication Management
6
Transportation
4
Paperwork
3
Recreational Activities
3
CHALLENGING SITUATIONS
Intimate Care
5
House Chores
4
Recreational Activities
2
Meal Preparation/Eating
1
Medication Management
1
INSTRUCTIONS/COMMAND TYPES
Alpha
4
Beta
5
– 16 –
CODES
SUBCODES
NUMBER OF
OCCURENCE
Unknown
4
RESPONSE
Complied
10*
Refused
5
Passive
6
Verbal Agitation
2
MOST USEFUL STRATEGIES TO REQUEST
COMPLIANCE
Calm Approach
8
Incentive
7
Education/Explanation
7
Persistent
4
Listen to Residents
3
MOST USEFUL STRATEGIES TO REQUST
COMPLAINCE CONTD.
Compromise
3
Redirection
2
– 17 –
CODES
SUBCODES
NUMBER OF
OCCURENCE
Friendly Reminder
1
“white lies”
1
MOST USEFUL STRATEGIES FOR
OBTAINING COMPLIANCE
Calm Approach
8
Listening to Residents
5
Compromise
4
Giving extra time
3
Incentives
3
Persistent
2
Threatening
2
TRAINING BACKGROUND
Calm Approach
9
Restraining/Self
Protection
3
Redirection
2
Assertive
1
– 18 –
CODES
SUBCODES
NUMBER OF
OCCURENCE
TRAINING BACKGROUND CONTD.
Seek help from other staff 1
Table 1. This table illustrates the codes, subcodes and their frequency of occurrence
*. Depicts requests that were resolved after some form of intervention either through
calling a second staff, threat or persistent from direct care staff.
– 19 –
RESULTS
The results are presented in two sections. The first section highlights the frequency of
response to each interview question. The general information on the most endorsed
response from participants are given. The second section is comprised of a detailed
analysis of the interrelationship between the codes; the interrelations between the
questions being asked and the responses. For example, the relationship between the type
of command used and the type of response received from the residents as reported by
participants.
Data Analysis
All data analysis was carried out using MAXQDA 2020. The “compare cases and group”
function was used to generate the frequency and percentage of each coded item. To
determine the relationship between code, the “code relations browser” was utilized. The
code relations browser was used to determine the intercept of two or more codes.
Response to Interview Questions
Daily tasks. A variety of tasks were reported by participants as to what they do on a daily
basis per their job descriptions. The most commonly reported daily task is intimate care
