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Graduate Student Journal of Psychology                                                                             Copyright 2010 by the Department of Counseling & Clinical Psychology  
2010, Vol. 12                                                                                                                        Teachers College, Columbia University                          
  

 

  Impact of an Elderspeak In-Service Training on Resident Well-Being, Self-
Esteem, and Communication Satisfaction 

 
Lonnie S. Bradford and Christian M. End 

Xavier University 
 

reinforce negative stereotypes of aging, deprive older adults of meaningful interactions, and erode 
their well-being.  A brief communication in-service training based on Williams, Kemper, and 
Hummert (2003) was presented to nursing home staff to replace elderspeak with more helpful 
communication behaviors.  Resident - staff interactions were coded, and impact of the training on 

-esteem, and well-being was assessed across three 
time periods.  A separate unit of untrained staff and residents served as a comparison group.  
Significant reductions in the proportion of interactions containing features of elderspeak were 
observed for the trained staff, along with significant increases in resident satisfaction, well-being, 
and self-esteem. 

 
 

(1994), is an undesirable yet common speech modification 
directed at older adults.  Also known as patronizing speech 
(Ryan, Giles, Bartolucci, & Henwood, 1986), or secondary 
baby talk (Caporael, 1981), elderspeak consists of several 
characteristic psycholinguistic features, including the use of 
childish terms (e.g., good girl), over inclusive pronoun 

our bath), the use of terms 
of endearment in place of formal names (e.g., sweetie), a 
higher pitch and slow singsong tone of voice, as well as 
several other speech adjustments (for a review, see Ryan, 
Hummert, & Boich, 1995).  The primary goal of the present 
study was to examine if nursing home staff can successfully 
reduce their use of elderspeak following a brief in-service 
training, and if so, explore if this reduction will help 

 
According to the Communication Predicament Model 

of Aging (Ryan et al., 1986), elderspeak is problematic 
because it reinforces stereotypes of aging and reduces 
opportunities for older adults to engage in more meaningful 
communication, undermining their well-being and self-
concept (Ryan et al., 1995).  Additionally, many 
components of elderspeak such as reducing sentence length, 
slowing speech rate, or speaking using a higher pitched 
voice do not confer communication benefits to older adults, 
and may actually undermine their confidence in their ability 
to communicate (Kemper & Harden, 1999).  Speech 
modifications such as increasing pitch and prosody may 
also be counterproductive, given that the most common 
form of hearing loss affecting older adults actually reduces 

                                                                                                  
Correspondence concerning this article should be addressed to 

Lonnie Bradford, Xavier University, Department of Psychology 
3800 Victory Parkway Cincinnati, Ohio 45207, Email: 
bradfordl@xavier.edu. 

sensitivity to higher-frequency tones (Van-Rooij & Plomp, 
1990).   

While there is considerable complexity in how older 
adults actually regard elderspeak (Nelson, 2005) compared 

irritating and patronizing (Giles, Fox, & Smith, 1993).  
Further, older adults may rate those who use elderspeak less 
favorably (Gould & Dixon, 1997; LaTourette & Meeks, 
2001).  Though it is not clear how these unfavorable 
perceptions might relate to caregiver outcomes such as job 
related stress, a case study by Cunningham and Williams 
(2007) provides preliminary support for the hypothesis that 

behaviors to care.   
When considering the negative consequence elderspeak 

may hold for older adults, seeking to reduce the use of this 
speech behavior has considerable merit.  An intervention to 
reduce elderspeak has previously been evaluated in nursing 
home settings.  In two separate studies, Williams et al. 
(2003, 2005) conducted an in-service program to review 
communication barriers for older adults while sensitizing 
staff members to the key features of elderspeak.  The results 
of these studies are very encouraging; following the in-
service training, significant reductions were observed in 

 inappropriate 
collective pronouns, and shortened sentence length.  In 
addition, in both studies, the experimenters rated the 
immediate post-training conversations between the staff and 
the residents as less controlling, and more respectful than 
the pre-training recordings.  Further, Williams et al. (2005) 
found that 
maintained at two-month follow-up.  While both of these 
studies demonstrated that a brief in-service could 

neither study addressed the impact their intervention had on 
the nursing home residents.  Considering the complexity of 



ELDERSPEAK IN-SERVICE TRAINING 
 

   15 

resident outcomes following such training would provide a 
greater understanding of the success and significance of the 
intervention.   

Consistent with previous research by Williams et al. 
(2003, 2005), the current study sought to evaluate whether a 
brief communication training can reduce staff member use 
of elderspeak.  Specifically, the present study sought to 
develop a training program that demanded less staff time, 
was effective in increasing awareness of elderspeak, and 
prompted nursing home staff to reduce their use of 
elderspeak.  The other objective of the current study was to 
evaluate whether the training program conferred any 
benefits to nursing home residents, specifically in terms of 
improved communication satisfaction, self-esteem, and 
well-being.   
 
Staff Outcomes 

Knowledge gain, attitude, and the intention to change 
behavior are variables that have previously been identified 
as important mediators of behavior change following 
communication trainings (Francke, Garssen, & Huijer Abu-
Saad, 1995).  Knowledge gain, in particular, is commonly 
assessed in intervention research and is thought to be an 

behavioral changes in 
continuing education (Kiener & Hentschel, 1989; Warmuth, 
1987).  According to reasoned action theory, the intention 
to demonstrate a particular behavior is closely related to 
actual behavior (Fishbein & Ajzen, 1975).  That is, the 
greater the intent, the more likely it is that a person will 
actually change their communication behaviors.  Thus, we 
tested the following hypotheses:  1)  nursing home staff will 
show a significant increase in knowledge and ability to 
identify elderspeak at the end of the in-service training 
indicated by positive change between pre and post-test 
ratings on the Communication Evaluation Tool (Williams, 
2001); 2) trained staff will show an increase in behavioral 
commitment and positive attitude towards training when 
comparing the sample mean to the midpoint score as 
measured by the Affective Learning Scale (ALS; Andersen, 
1979); nursing home staff in a unit that has undergone 
training will: 3) reduce their use of elderspeak at both post-
training assessments (within group hypothesis), and 4) 
when compared to staff not receiving the training (between 
groups hypothesis).   

 
Resident Outcomes 

To evaluate the merits of an elderspeak intervention 
more fully, it is important to understand what impact such 
training has on the experiences of the nursing home 
residents.  As elderspeak may reduce opportunities for 
meaningful communication and lead older adults to 
experience decreased self-esteem and well-being (Ryan et 
al., 1995), measures were selected to assess these variables.   

Thus we tested the following additional hypotheses: 5)  
Residents will show an increase in older adult well-being as 

measured by the Mental Health Inventory-5 (MHI-5; Veit 
& Ware, 1983), self-esteem as measured by the Rosenberg 
Self-Esteem Scale (Rosenberg, 1989), and communication 
satisfaction as measured by the Feelings of 
Understanding/Misunderstanding Scale (FUM; Cahn & 
Shulman, 1984) at both post-intervention assessment 
points; 6) Residents residing in the unit that receives 
elderspeak training will report significantly higher well-
being, communication satisfaction, and self-esteem at both 
post intervention assessments than the unit that does not 
receive the training. 

 
M ethod 

 
Participants 

Nursing home staff.  The study was conducted at a 
large retirement community in rural Ohio.  Twenty-five 
staff members participated in the in-service training on a 
voluntary basis and were compensated with a $20 dollar 
gift certificate.  Eighty-three percent of staff in the selected 
unit completed the training.  Staff members serving as the 
control condition (n = 31) were taken from a separate unit 
within the same retirement community.  Due to facility 
concerns over the privacy of the staff, specific demographic 
data were not collected.  In general, the majority of staff 
that completed the training was certified nursing assistants 
(81% CNAs), predominantly young adult to middle aged 
(staff age data not collected), Caucasian (92%), and female 
(92%). 

Residents.  All nursing home residents in the selected 
treatment and control units of the facility were eligible to 
participate.  Of the total number of residents in the selected 
units, 83 (51%) agreed to participate.  The resident attrition 
rate during the five months of the study was 18.75% for the 
treatment unit and 17.14% for the control unit, leaving data 
from 39 residents in the treatment unit, and 29 residents in 
the control unit in the final analyses (N = 68).  The two 
nursing home units were chosen on the basis of similarities 
in size, level of care, and resident demographics.  No 
significant differences were found between baseline age, 
gender composition, or mental status (see Table 1).  After 
an in-person briefing on informed consent, each resident 
was given a short quiz to ensure he or she understood the 
costs and benefits of participation and that withdrawal 
could occur at anytime without penalty.  For their 
participation, residents received $2 each time they 
completed the questionnaires. 
 
E lderspeak Intervention 

The elderspeak in-service training created for this study 
had a firm basis in the empirically supported Theory of 
Reasoned Action (TRA; Fishbein & Ajzen, 1975).  The 

components of behavioral change: 1) intent, with a goal of 

2) attitude, with a goal of fostering a positive attitude 



BRADFORD & END 
  

   16  

toward the topic and recommendations provided by the 
training; and 3) subjective norms, that is, creating an 
atmosphere in the unit that recognized elderspeak as an 
undesirable speech accommodation.  Since knowledge gain 
has also previously been identified as a salient factor 
contributing to the actual behavior change of nursing home 
staff (Francke et al., 1995; Kiener & Hentschel, 1989), it 
was also assessed. 

The intervention was conducted by the primary author 
(graduate student) during a single 90-minute classroom 
session, offered at either the end of the day shift or prior to 
the start of the afternoon shift.  The objective of the 
intervention was to assist the nursing home staff in 
becoming aware of elderspeak, identify the characteristic 
features of elderspeak, and foster an understanding of how 
patronizing communication can impair communication and 
negatively affect the well-being of older adults.  In-class 
exercises included outlining the characteristics of 
elderspeak, distinguishing elderspeak from neutral speech, 
and viewing and critiquing written and video vignettes 
individually and as a group.  Short video segments allowed 
staff participants the opportunity to identify features of 
elderspeak and affirming communication in videotaped 
vignettes.   

 
Program Evaluation  

Applied knowledge.  Knowledge gained from the 
intervention was measured using the procedure outlined by 
Williams (2001).  At the start of the program, staff 
participants observed a short videotaped nursing home 
interaction and then rated the video using the 
Communication Evaluation Tool (Williams, 2001).  The 
original tool was modified to consist of two items asking 
staff to describe the effectiveness and appropriateness of the 
interaction on a five-point scale, and eight items asking 
them to identify the presence or absence of specific 

same form to rate the videotaped interaction again.  Pre-test 
and post-test ratings for each item were compared to assess 

the effectiveness of the intervention in increasing staff 
knowledge of elderspeak. 

Attitude and intention to change behavior .  The 
Affective Learning Scale (ALS; Andersen, 1979).  The 
ALS is a 20-item measure asking staff participants to rate 
their attitudes towards the intervention content and subject 
matter.  This scale attempts to capture both the attitude 
towards the training, and the attitude towards the behavioral 

-point 
Likert-scale along a bipolar continuum with endpoints such 
as Valuable or Worthless.  Scores on the ALS range from 
20 to 140, where a higher number indicates greater 
behavioral commitment and positive attitude toward the 
training.  Internal consistency reliability for the current 
study was high (alpha = .94).  

Behavioral changes.  Concealed naturalistic 
observation was used to evaluate if staff members reduced 
their use of elderspeak.  Two trained research assistants 
(RA), who were blind to both the treatment and control 
conditions, completed the observations.  Prior to the in-
service program, each RA observed 15 unique interactions 
between staff and residents occurring in the common areas 
of the nursing home units.  A total of 30 observations were 
coded for each group of staff (treatment and control).  An 
interaction was operationally defined as the complete 
verbalizations of the staff member from the beginning to 
end of the exchange with the resident.  All observations 
took place in the shared public spaces of each unit where 
any visiting public could potentially overhear the 
interaction.  With IRB and facility approval, staff members 
were unaware their interactions were observed and coded 
until completion of the study.   

The same procedure was followed for three-week post-
training observations, and three-month follow-up.  Each 
observed interaction was rated on a seven-item checklist.  
Research assistants indicated whether they observed 
specific communication behaviors in the interactions 
including baby talk, high pitch voice, shortened sentences, 
diminutives, over inclusive pronouns, and tag questions. 

Table 1 
 
Description of residents (N = 68) 
Resident 
Demographics 

Trained Unit (n = 39) Control Unit (n = 29) p-value 

Age M(SD) 84.87(8.44) 84.21(6.58) .73 
Sex    

Male 9 10 .30 
Female 30 19  

Ethnicity    
Caucasian 37 29 .21 
Other 2 0  

Mental Status M(SD) 4.01(1.77) 4.48(1.45) .35 
 



ELDERSPEAK IN-SERVICE TRAINING 
 

   17 

If any of the six psycholinguistic features were observed in 
the interaction, the entire interaction was counted as a 

-rater reliability 
estimates were obtained on a sample of 15 staff - resident 
interactions for each of the coded psycholinguistic features 

interpretation for categorical data developed by Landis and 
Koch (1977) was used to interpret the coefficients.  The 
inter-rater reliability for global elderspeak was found to be 
high, Kappa = 1.00 (p < 0.001), with 100% agreement.  
Inter-rater reliability estimates for each of the individual 
psycholinguistic features ranged from Kappa = 0.29 to 1.00 

agreement for shortened sentences.  
 
Resident M easures 

Communication satisfaction.  Feelings of 
Understanding /Misunderstanding Scale.  (FUM; Cahn & 
Shulman, 1984).  The FUM is a 16-item measure on a 5-
point Likert-scale ranging from Never to Always 
representing the degree to which each adjective reflects 
how a person felt after attempting to communicate with a 
specific target.  The FUM includes eight adjectives to 
measure the perception of being understood and eight 
adjectives to measure feelings of being misunderstood.  A 

levance to the current 
study.  A composite score was calculated with a range from 
-32 to +32, where higher scores indicate a greater degree of 
perceived understanding.  A high degree of internal 
consistency reliability was found in the current study (alpha 
= .89).   

Self-esteem.  The Rosenberg Self-Esteem Scale  State 
Version (Rosenberg, 1989).  This 10-item measure asks 
participants to indicate their degree of agreement on a 4-
point scale where higher scores indicate higher self-esteem.  
This instrument has been used widely in the literature and 
has a high reliability, and correlates with a number of self-

esteem related constructs.  Internal consistency reliability 
for the current study was good (alpha = .81). 

W ell-being.  Mental Health Inventory  5 (MHI-5; 
Veit & Ware, 1983).  The MHI-5 is a 5-item measure of 
psychological well-being that requires participants to 
respond to questions regarding the frequency of their 

the time were you a happy per -point scale.  To 
increase clarity and ease of use for the residents and for the 
measure to correspond with the other dependent measures, 
item scoring was reversed so that it ranged from 1 (None of 
the time) to 6 (All of the time).  Higher scores indicate the 
experience of psychological well-being and the absence of 
psychological distress.  This scale has well-established 
reliability and validity (Berwick et al., 1991).  Internal 
consistency reliability for the current study was good (alpha 
= .84) with a test-retest reliability over a three-month period 
in the control group of 0.73. 

Baseline mental status.  Six-Item Screener (SIS, 
Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002).  The 
SIS, a brief six-item screener, was used to compare the 
mental status of the resident groups.  It is composed of three 
orientation items (year, month, and day) and a three-item 
word recall task. Scores range from zero to six where lower 
scores are suggestive of greater cognitive impairment.  
 
Procedure 

Pre- training stage. After receiving a brief explanation 
of the study and providing consent, residents in both the 
intervention and control units completed a demographics 
sheet, a short mental status exam (SIS), along with baseline 
outcome measures of communication satisfaction (FUM), 
self-esteem (Rosenberg Self-Esteem Scale), and well-being 
(MHI-5).  All questionnaires were read to the participating 

interested in studying communication between residents 
and staff in long-
unit staff would be completing any type of communication 
training.  Trained research assistants, also blind to the study 

  
Table  2  
  
Proportion  of  Staff  Identifying  Elderspeak  Characteristics  in  a  Scripted  Video  Interaction  

Elderspeak  Features   Pre-­training  proportion   Post-­training  proportion   p-­value  

Baby  Talk   75%   100%   .008*  

Shortened  Sentences     46%   79%   .039*  

Overinclusive  Pronouns   54%   83%   .022*  

Terms  of  Endearment   96%   100%   .50  
Use  of  high  pitch  voice   100%   100%   1.00  
Note.  To  assess  knowledge  gain,  staff  members  were  asked  to  identify  listed  features  while  viewing  a  scripted  eldespeak  video.  
*McNemar  Binomial  test  indicates  significant  difference  in  pre-­  and  post-­training  proportion  at  p  <  .05.  
  



BRADFORD & END 
  

   18  

hypotheses, conducted the pre-training field observations a 
week prior to the start of the in-service training. 

Post- training stage.  After staff members completed 
the in-service training, the residents completed the 
measures of self-esteem, well-being and communication 
satisfaction within three weeks of the conclusion of the 
training, and again at a three month follow up to assess for 
change over time.  Research assistants began the first post-
training field observation three weeks following the 
training, and performed field observations again at a three 
month follow-up.   

 
Results 

 
Staff K nowledge Gain and Ability to Identify 
E lderspeak in V ideos (Hypothesis One) 

In order to examine if the training significantly 
increased the staff members ability to identify elderspeak in 
videos, a paired sample t-test was used to compare the staff 

- and post-interval data on two items from the 

training (M = 4.17, SD = 1.77) was significantly reduced 
post-training (M = 3.20, SD = 1.70), t(24) = 2.83, p < 0.01.  
Further, the pre-
of elderspeak (M = 2.33, SD = 1.89) was also significantly 
reduced post-training (M = 1.75, SD = 1.36), t(24) = 2.07, p 
< 0.05.   

To assess knowledge gain, McNemar proportions tests 
were conducted on each of the dichotomous pre-test and 
post-test responses of the Communication Evaluation Tool 
(Williams, 2003).  Results indicated that post training, staff 

members significantly improved in their ability to identify 
several key features of elderspeak in videos including baby 
talk, overinclusive pronouns, and shortened sentences (see 
Table 2).  

 
Staff A ttitude Toward T raining (Hypothesis Two)  

To determine whether nursing home staff trained in the 
intervention had a positive commitment and attitude toward 
the training, a one-sample t-test was used to compare the 
sample mean to the midpoint score (80) on the Affective 
Learning Scale.  The one-sample t test indicated that the 
training group had a positive attitude toward the training (M 
= 130.25, SD = 12.91), t(23) = 19.06, p < .001. 
 
Staff Reduction of E lderspeak  

To compare the proportion of elderspeak observed in 
staff-resident interactions after completion of the training 
with the proportion of elderspeak observed in staff-resident 
interactions before the training (hypothesis three), two-
sample chi-square tests were performed on the 
observational data.  The proportion of elderspeak features 
observed out of 30 interactions for the trained staff group is 
reported in Table 3.  Results of the analysis indicated that 
the proportion of observed interactions containing 

significantly reduced between the baseline and the Time 1 
post-training observations, 2 (1, N = 60) = 4.34, p < .05 
and baseline and Time 2 post-training observations, 2 (1, N 
= 60) = 4.34, p < .05.   

Two-sample chi-square tests were also used to evaluate 
whether there were differences between the trained group 
and control group in the proportion of elderspeak over time 
(hypothesis four).  While the proportions of many of the 

Table 3 
 
Percentage of interactions containing elderspeak characteristics for trained and untrained staff. 

 Trained Staff Untrained Staff 
Features Baseline Time 1 Time 2 Baseline Time 1 Time 2 
Elderspeak 
(Global)a 

57% (17)a 30% (9)b 30% (6) b 53% (16) 47% (14) 46% (13) 

Shortened 
Sentences 

13% (4) a 0% (0) b 0% (0) b 13% (4) 13% (4) 6% (2) 

Baby Talk 7% (2) 3% (1) 0% (0) 10% (3) 17% (5) 13% (4) 
Terms of 
Endearment 

20% (6) a 13% (4) a 0% (0) b 7% (2) 10% (3) 10% (3) 

Overinclusive 
Pronouns 

17% (5) a 3% (1) a b 0% (0) b 20% (6) a 13% (4) a b 3% (1) b 

Tag Questions 13% (4) 3% (1) 6% (2) 0% (0) 7% (2) 3% (1) 
High Pitch Voice 33% (10) a 10% (3) b 13% (4) a b 33% (10) 23% (7) 27% (8) 

Note. Values indicate the percentage of times the elderspeak marker was observed across 30 interactions. Values in parentheses are the actual 
number of times the elderspeak characteristic was observed. Percentages in the same row and under the same group heading (Trained or 
Untrained) that do not share the same subscript are statistically different at p <.05. a Elderspeak (Global) was coded when staff used any of 
the target features of elderspeak in an interaction in addition to the specific feature.  

 



ELDERSPEAK IN-SERVICE TRAINING 
 

   19 

 
control condition at Time 1 and Time 2, results indicated 
these differences were not significant. 

 
Resident Outcome Variables 

To determine whether there was an impact of the 
elderspeak training on resident outcomes (hypotheses five 
and six), specifically, well-being, self-esteem, and 
communication satisfaction, a 2x3 repeated measures 

 
(baseline, post-training Time 1, or post-training Time 2),, 
while the dependent variables were the total scores of the 
self-esteem, communication satisfaction, and well-being 
scales.  The mean and standard deviation of each outcome 
variable for each group are presented in Table 4.  Results of 
the MANOVA indicted a significant within-subjects main 

F(6, 61) = 3.50, p < .001, 
multivariate 2 = .26; a significant between-subjects main 

F(3, 64) = 2.77, p < .05, 
multivariate 2 = .12; and a significant Time X Group 

F(6, 61) = 5.82, p < .05, 
multivariate 2 = .36. 

The Time X Group interaction effect was analyzed 
using two-way (2x3) mixed ANOVA for each dependent 
variable.  All follow-ups were adjusted using the 
Bonferroni correction.  Inferential statistics were only 
reported for tests yielding significant results.  For 
communication satisfaction, a significant interaction was 
observed between Group and Time (F(2, 132) = 11.62, p < 
.001, partial 2 = .08), along with significant main effects 
for both Group (F(1, 66) = 8.93, p < .01, partial 2 = .11) 
and Time (F(2, 132) = 5.89, p < .01, partial 2 = .08).  The 
simple main effect for group indicated that the treatment 

significantly differed at post-training Time 1 (F(1, 66) = 
17.41, p < .001, partial 2 = .21) and post-training Time 2 
(F(1, 66) = 13.44, p < .001, partial 2 = .17), and did not 
differ significantly at baseline.  The simple main effect of 
time was significant for only the treatment group (F(2, 65) 
= 17.41, p < .001, partial 2 = .21).  Simple comparisons 

satisfaction over time indicated a significant increase in 
communication satisfaction from baseline to Time 1 (p < 
.001) and baseline to Time 2 (p < .001). 

Following the same procedure for self-esteem, there 
was a significant interaction between Group and Time (F(2, 
132) = 7.97, p 2 = .11), and a significant 
main effect for Time (F(2, 132) = 4.32, p 2 = 
.06).  The main effect for Group was not significant.  
Simple main effects analysis of the interaction indicated 
that while there were no significant differences between the 
two groups on self-esteem at baseline or post-training Time 
1, the treatment group reported significantly higher self-
esteem than the control group at post-training Time 2 (F(1, 
66) = 8.98, p 2 = .12).  The simple main 
effect of Time was significant for only the treatment group 
(F(2, 65) = 9.88, p 2 = .23).  Simple 
comparisons examining the treatment group over time 
indicated a significant increase in self-esteem from baseline 
to Time 1 (p < .005) and baseline to Time 2 (p < .001). 

Follow-up analysis for well-being also revealed a 
significant Group x Time interaction effect, F(2, 132) = 
4.60, p 2 = .07.  The main effects for Group 
and Time were not significant.  Simple main effects 
analysis of the interaction demonstrated no significant 
differences between the groups at baseline or post-training 
Time 2; however, the treatment group showed significantly 
higher well-being than the control group at post-training 
Time 1 (F(1, 66) = 8.98, p 2 = .12).  The 
simple main effect of Time was significant only for the 
treatment group (F(2, 65) = 3.65, p 2 = .10) 
with simple comparisons indicating significant increase in 
well-being from baseline to Time 1 (p <.05).  

 
Discussion 

 
Staff Improvements 

Consistent with previous research (Williams et al., 
2003, 2005), the present study indicates that a brief 
educational intervention can reduce nursing home staff use 
of elderspeak.  Following the in-service training, there were 
significant reductions found in the proportion of 
interactions coded for the global presence of elderspeak 

 
Table 4 
 
Mean and standard devia tion for the PUI, RSE , MHI-5 for intervention and control .  

 Intervention Group Residents  Control Group Residents 
DV Baseline Time 1 Time 2 Baseline Time 1 Time 2 
Communication 
Satisfaction 

14.44 (12.01) a 21.90 (9.56) b 20.46 (10.37) b 13.14 (11.3) 12.31 (9.10) 11.41 (9.65) 

Self-esteem 29.31 (4.26) a 31.18 (3.69) b 31.90 (3.61) b 29.69 (5.03) 29.93 (4.82) 29.01 (4.09) 
Well-being 22.41 (5.58) a 24.33 (4.60) b 23.77 (4.65) a 22.83 (21.51) 21.41 (19.15) 22.03 (13.67) 
Note. Values in dicate means and (standard deviations). Means in the same row and under the same group heading (Intervention or 
Control) that do not share the same subscript are statistically different at p < .05.  
 
 



BRADFORD & END 
  

   20  

with trends toward reductions on many of the specific 
psycholinguistic features.  Specifically, significant 
reductions in the component psycholinguistic features of 
elderspeak were observed in both the short term (i.e., 
shortened sentences and high-pitched voice), and long term 
follow up assessments (i.e., shortened sentences, terms of 
endearment, and overinclusive pronouns).  Moreover, the 
reductions in elderspeak observed immediately in the three 
weeks following the training program were maintained over 

of elderspeak did not change significantly over time with 
only a single psycholinguistic feature indicating a 
significant reduction (overinclusive pronouns) over the 
three months of the study.  The success of the program in 
prompting staff members to make behavioral changes is 
notable, considering the relatively short length of the in-
service training (90-minutes) and the limited success of 
similar communication programs (Kruijver et al., 2000).  
Several factors likely contributed to the overall success of 
the present program.  The shorter, focused, single session 
trainings provided flexibility in which training session staff 

of time typically dedicated to staff trainings and meetings.   
Additionally, the current training program was 

anchored in the TRA (Fishbein & Ajzen, 1975), a specific 
theoretical framework of behavior change.  Following the 
training, staff members significantly improved their 
knowledge and ability to identify characteristics of 
elderspeak, harbored generally favorable attitudes toward 
the in-service recommendations, and reported intentions to 
change their behavior.  While the subjective norms 
component of the TRA model was not formally assessed, a 

gaining strong support from the facility administrators, 
department directors, and other professionals in leadership 
positions who attended the trainings alongside the CNAs,  
and ultimately having the training written into the treatment 

e a buzz 
word around the trained unit). While results are 
resoundingly positive, the study had several limitations.  As 
both the trained and the untrained staff members worked 
within the same facility, this opens the possibility of a 
contamination effect wherein staff in the control group 
could have adopted some of the in-service training practices 
through communication with their coworkers.  However, 
while there was a significant reduction in overinclusive 
pronouns observed in the untrained staff at Time 2, several 
factors make this constraint less likely:  1) each unit was 
geographically separate within the facility with its own 
common areas, dedicated staff, and director of nursing; 2) 
untrained staff showed no significant difference in their 
global use of elderspeak over the three months of the study; 
3) three of the psycholinguistic features observed in the 
untrained staff group actually trended toward increased use 
while all six features in the trained group trended 
downward; and 4) any speech adjustments the untrained 

staff might have made did not seem to be reflected on 
resident outcome measures.  

While staff members in the trained condition reduced 
their use of elderspeak across time, the difference in 
proportions between the trained staff and comparison group 
did not differ to a statistically significant degree.  Given the 
improvements of the residents on the outcome measures 
following the training though, these findings may have been 
related to limitations inherent in the method used to code 
elderspeak.  As the trained coders were blind to the 
conditions (trained unit vs. untrained unit) they were also 
blind to which individual staff members had participated in 
the training.  While the vast majority, 83% of the treatment 
unit staff, completed the training, almost a fifth of the 
treatment staff did not (17%).  The inclusion of interactions 
between residents and staff members that worked regularly 
in the treatment unit but never attended the in-service 
training may have masked a larger reduction in elderspeak.  
An additional limitation is simply coding for the global 

of the six target psycholinguistic features were observed in 
the interaction.  Coding in this manner left the potential to 
ignore decreases in the use of multiple characteristics of 
elderspeak during a single interaction.  A final limitation of 
the observation coding method was the relative infrequency 
of some of the psycholinguistic features such as 

subjective nature of others (e.g., high pitch tone).  As terms 

occurred with relatively low frequency at baseline, it was 
difficult to demonstrate that there was a significant 
reduction across only 30 sampled interactions even though 
the trained staff no longer used any of these characteristics 
at Time 2.  While recordings were not used in the current 
study due to facility request, video and audio recordings of 
interactions could have addressed many of the 
aforementioned limitations; however, one advantage of 
using the covert naturalistic observations is a reduction in 
staff member reactivity.  
 
Resident Outcome and Improvements 

Previous elderspeak intervention studies have not 

goal was to address the impact of the intervention on 
nursing home resident outcomes, specifically 
communication satisfaction, self-esteem, and well-being.  
Residents of the unit which received the training showed a 
significant increase in their communication satisfaction as 
well as small but significant increases in their self-esteem 
and psychological well-being.  These changes corresponded 
with staff reductions in elderspeak, and were observed three 
weeks after conclusion of the training, and for 
communication satisfaction and self-esteem, were 
maintained at the three-month post assessment.  While there 
were no baseline differences between the resident treatment 



ELDERSPEAK IN-SERVICE TRAINING 
 

   21 

and comparison groups on the dependent variables, the 
resident communication satisfaction observed in the 
treatment group was significantly higher than the 
comparison group at both post-training assessments.  
Additionally, the treatment group reported significantly 
higher well-being three weeks after the training, and 
significantly higher self-esteem than the comparison group 
three months later.  

The Communication Enhancement Model (CEM; 
Ryan, Meredith, Mclean, & Orange, 1995) posits that better 
communication in the form of an individualized approach to 

empowerment, well-being, and satisfaction with care 
providers.  According to the CEM, the well-being of older 
adults is enhanced when their ability to express themselves 
is maximized.  Findings from the present study are 

elderspeak.  While there were no significant changes in the 

correspondi
on outcome measures, a significant reduction in staff 
member use of elderspeak in the trained condition was 
associated with increases in self-esteem, communication 
satisfaction, and at least shortly following the training (i.e., 
3 weeks), well-being.  In short, as the communication 
environment improved in the trained unit, so too did the 

 
It seems plausible that residents improved on these 

variables because of a reduction in communication that 
older adults typically find aversive (elderspeak).  Educating 
staff members about elderspeak may have disrupted the 
cycle of the Communication Predicament Model of Aging, 
allowing residents to achieve more neutral or satisfying 
types of interactions.  Additionally, prompting staff 
members to reduce their use of elderspeak may have 
necessitated that staff rely on alternative methods of 
communication that actually enhanced communication with 
the residents.   

As previously noted, while significant increases were 
observed in resident communication satisfaction and self-
esteem at both the three-week and three-month post-
training assessments, interestingly, significant changes were 
observed for well-being only in the short term (three weeks 
later).  This may reflect limitations in the mental health 
inventory  five (Veit & Ware, 1983) which is relatively 
brief, and not an encompassing measure of well-being.  
Additionally, it may reflect the observations of Williams et 
al. (2005) that while the staff in their study continued to use 
fewer of the concrete features of elderspeak at the two 
month mark, their interactions were rated as more 
controlling, less respectful, and less caring than 
immediately following the training.  This suggests that 
changing specific speech behaviors may be only one part of 
the equation in teaching nursing staff to interact 
consistently in a way that will convey respect and foster 
well-being for older adults. 

 

M ethodological L imitations 
While the present study replicated and extended 

existing elderspeak research, it is important to acknowledge 
the limitations of the findings.  It should be noted that the 
resident participants of the study resided in a single large 
long term care facility, and therefore the nursing home 
environment and the residents themselves may not be 
representative of the larger population.  The present study 
also employed a quasi-experimental design, as random 
assignment was not possible.  While the use of both a 
pretest and a comparison group makes it easier to avoid 
certain threats to internal validity, because the two groups 
were not randomly assigned, selection bias may have been 
present.  In addition, while it is notable that there were no 
significant differences between the two conditions in age, 
gender, and mental status, data on a number of other 
potentially important resident characteristics were not 
collected for comparison.  Further, while the study 
outcomes varied statistically with the intervention the 
observed changes in resident satisfaction and self-concept 
may be the result of alternative explanations.  One 
alternative is that simply offering training to one group of 
staff and not to the other could have led to changes in the 

satisfaction benefits in the residents (Mayo, 1933).   
Another limitation of the study was the relatively small 

sample size, with only 51% of eligible residents agreeing to 
participate, and the high attrition rate (18%) of residents 
who participated in the study.  This opens the possibility of 
selection or attrition bias.  Further, the turnover rate for the 
trained staff was not available, which may be an important 
factor with regard to the long-term benefits of the training, 
especially when considering the national annual turnover 
rate for CNAs has been previously reported at 71% 
(AAHSA, 2008).  As a result of turnover, efforts to create a 
better communication environment for residents may have 
start at the level of initial care provider training, such as 
including discussions of elderspeak in CNA training 
programs, and be revisited through facility in-services post-
training.  
 
Directions for Future Research 

Replication of these results is necessary to increase 
y 

of the CPA model.  Future studies may consider including 
additional resident outcome measures that correspond to the 
predictions of the Communication Enhancement Model 

self-efficacy, and feelings related to the quality of 
interactions and competence of the staff.  Qualitative 
interviews may also provide insight into how explicitly 
aware residents are of staff behavioral changes.  As 
research indicates that staff elderspeak use is associated 
with increases in residents disruptive behaviors 
(Cunningham & Williams, 2007), future elderspeak 



BRADFORD & END 
  

   22  

benefits of their effectiveness and work related stress 
following the training.  Additionally, while MANOVA 
analysis makes it possible to observe a variety of main 
effects and interactions, it does not allow for as strong 
assertions of causality as a regression model which controls 
for confounding variables.  Future research may benefit 
from using a more complex model with regression analysis. 

Overall, the training program described in this study 
indicated that nursing home staff can improve their style of 
communication to promote resident quality of life.  It is 
hoped that future research will validate these findings and 
continue to underscore the potentially negative effects of 
elderspeak have for nursing home residents.  

 
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