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Ageing and Aged Care
Ongoing challenges responding to behavioural and psychological symptoms of dementia J. Ostaszkiewicz1 RN, MN, PhD, P. Lakhan2 PhD, MN, BN, BA, GradCert Ed, B. O’Connell3 PhD, FACN & M. Hawkins4 PhD, BA 1 Post-Doctoral Fellow, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 4 Senior Research Fellow, School of Nursing and Midwifery, Deakin University, Melbourne, Vic., 2 Adjunct Research Fellow, Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, QLD, Australia, 3 Dean, Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
OSTASZKIEWICZ J., LAKHAN P., O’CONNELL B. & HAWKINS M. (2015) Ongoing challenges responding to behavioural and psychological symptoms of dementia. International Nursing Review 62, 506–516 Background: Mid- to late-stage dementia is often characterized by behavioural and psychological symptoms, including, but not limited to physical and verbal aggression. Introduction: Although there is a considerable research about the prevalence, aetiology, and management of behavioural and psychological symptoms of dementia, there is limited research about the experience of caring for people with such symptoms in long-term aged care facilities. Aim: The aims of the study were to describe: (i) nurses’ experiences of caring for people with behavioural and psychological symptoms of dementia in long-term aged care facilities, and (ii) strategies nurses used to deal with these symptoms. Methods: A qualitative exploratory and descriptive design, involving focus group interviews with 30 nurses from three long-term aged care units in Australia. The transcripts were analysed using inductive content analysis. Results: The findings revealed five interrelated themes: (i) working under difficult conditions, (ii) behavioural and psychological symptoms of dementia: an everyday encounter, (iii) making sense of behavioural and psychological symptoms of dementia, (iv) attempting to manage behavioural and psychological symptoms of dementia, and (v) feeling undervalued. Conclusion: This study highlighted the difficult conditions under which nurses worked and the complexity of caring for individuals who have behavioural and psychological symptoms of dementia. Implications for nursing and health policy: Organizational efforts to enhance the quality of care for individuals with behavioural and psychological symptoms of dementia in long-term aged care facilities should extend beyond staff education to heed nurses’ concerns about organizational barriers to interpersonal care. Keywords: Aggression Management, Dementia, Focus Groups, Gerontology, Older People Nursing, Psycho-Geriatrics Nursing, Qualitative Methods, Restraint, Violence in the Workplace, Workforce Issues
Correspondence address: Dr Joan Ostaszkiewicz, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, 221, Burwood Hwy, Burwood, Vic. 3125, Australia; Tel: +61-3-92445099; Fax: +61-3-95946094; E-mail: [email protected].
Conflict of interest statement: The authors have no conflict of interest to declare.
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Introduction
Background
Agitation, physical aggression, disruptive vocalization, resistance to care, wandering, shadowing and inappropriate sexual behaviours are common behavioural symptoms of mid- to late-stage dementia. Similarly, anxiety, depression, delusions and hallucinations are common psychological symptoms (Alzheimer’s Disease International 2009). Medically, these behavioural and psychological symptoms of dementia (BPSD) are explained by the damage to the structures of the brain and associated progressive, global deterioration in intellect (i.e. memory, learning, orientation, language, comprehension and judgement) (Alzheimer’s Disease International 2009). The literature offers three complementary theoretical models to explain BPSD: (i) the unmet needs model, (ii) a behavioural/ learning model, and (iii) an environmental vulnerability/ reduced stress-threshold model (Cohen-Mansfield 2004). Specifically, Cohen-Mansfield (2004) hypothesized that BPSD could relate to the possibility that persons with dementia have physical and/or emotional needs, which are not being fully realized. For example, in the absence of the ability to communicate the desire for food or fluid, the presence of hunger or thirst could trigger agitation. The behavioural/learning model posits that BPSD are a manifestation of a negative relationship between the antecedents of such behaviours, the behaviours themselves, and their consequences. The third explanatory model; that is the environmental vulnerability/ reduced stress-threshold model, theorizes that having dementia may reduce the cognitively impaired person’s coping skills, making them more sensitive to environmental stressors. Therefore, some care activities, such as assisting a person with dementia to shower or bathe could constitute stressors that trigger BPSD (Cohen-Mansfield & Parpura-Gill 2007). Arguably, caring for people with BPSD involves learning to interpret their behavioural responses as legitimate human emotions within the context of the disease process (Chrzeschijanski et al. 2007). In the absence of this knowledge, carers, that is informal or formal, are likely to adopt negative responses or approaches to care, particularly if they observe other people using these approaches. Negative responses could include emotionally distancing oneself from the person with BPDS and labelling them as aggressive, lazy or resistant, rather than understanding and addressing the behaviour (Landes et al. 2001). Similarly, if carers are not aware that individuals with dementia often experience visual-perceptual-cognitive deficits that affect how they interpret their environment, they may inadvertently label them as ‘resistant’. When carers persist with care the person resists, the behaviour is likely to escalate, and in some cases, become combative (Mahoney et al. 1999).
Forty-four million people worldwide currently live with dementia (Alzheimer’s Disease International 2013a). One-third to one-half of people with dementia from high income countries, and approximately 6% of those from low and middle income countries are cared for in a long-term aged care facility (LTC) (Alzheimer’s Disease International 2013b). The main reason for admission to LTC is that the person’s care needs escalate beyond what family and paid carers can manage (Alzheimer’s Disease International 2013b). Individuals who display BPSD such as physical and verbal aggression pose a considerable risk to carers. In the workplace setting, exposure to aggression has implications for healthcare workers’ physical and mental health (Hills et al. 2012). Arguably, all carers, including nurses and other staff working in LTC have the right to work in a safe environment. Indeed, in many countries, workers’ rights to work in a safe environment are enshrined in legislation. However, very few individuals with mid- to late-stage dementia have the cognitive capacity to understand the nature of their BPSD or recognize the impact of their behaviours on carers and other people. Negative impacts of nurses’ exposure to workplace aggression include decreased job satisfaction and job performance (Hesketh et al. 2003; Merecz et al. 2009; Schat & Frone 2011), absenteeism, a fear of returning to work (ED Management 2007; Gates et al. 2006; Kansagra et al. 2008), changed attitudes towards patients, psychological withdrawal and burnout (Merecz et al. 2009). Some nurses exposed to aggression in the workplace experience anxiety, depression and post-traumatic stress disorder symptoms (Needham et al. 2005; Richter & Berger 2006). As three-quarters of people living in LTC have dementia (Alzheimer’s Society 2014), it is important to investigate nurses’ experiences of caring for people with BPSD. This information could be used to develop targeted interventions to support the nursing workforce provide optimal care for these individuals.
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Aim The aims of this study were to describe (i) nurses’ experiences of caring for people with BPSD in LTC, and (ii) strategies nurses used to deal with these symptoms.
Methods Study design
A qualitative exploratory and descriptive design was used to elicit information about nurses’ experiences of caring for people with BPSD in LTC. This approach was chosen because it
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does not impose an existing framework on the data (Patton 2002). Sample and setting
All nurses experienced in caring for residents with BPSD and employed in three LTC units in Melbourne, in the state of Victoria, in Australia, were invited to participate in the study. Each unit cared for frail older adults (hereafter termed ‘residents’) who were highly dependent. Two units (i.e. one 48-bed unit and one 35-bed unit) were designated as aged care mental health units, where residents had a diagnosis of dementia and/or a mental health disorder. The third unit, which had 60 beds, provided care for frail older adults with cognitive and/or functional impairments. The units contained a number of common areas and gardens with courtyard areas that residents could access. Two of the three units were newly built and there were a small number of double rooms for couples or others who wished to share. The older facility had single rooms. All resident rooms had a garden outlook. The units were mainly staffed by permanent staff, and in the event of staff leave or sickness, agency or bank staff were employed. Nursing care was mainly provided by enrolled nurses (ENs), whose role and level of education is similar to that of licensed practice nurses in the USA. In Australia, the minimum educational requirement for an EN is a 1-year diploma in nursing from a vocational education and training provider, or equivalent from a recognized hospital-based programme. Registered nurses (RNs) were also employed, albeit in managerial or supervisory roles. In Australia, entry to practice education for RNs is at a degree level offered by a recognized university. The RN undertakes initial and ongoing assessment of nursing care needs, supervises and delegates aspects of care to the EN. All nursing staff attended regular in-service education on gerontological issues, including education about the care of older people with dementia and other mental health disorders and BPSD. Although each unit had multiple resources about policies, procedures and guidelines, there were no specific resources about person-centred approaches to the care of residents with BPSD. The units employed 1 nurse to 7 residents on a morning shift, 1 to 8 in the afternoon, and 1 to 15 overnight as required under state legislation (Fair Work Act 2009). Data collection
The unit managers were informed about the study, and invited to provide organizational consent. Information sessions about the study were convened for all nursing staff and plain language and consent forms were distributed. Nurses wishing to participate were invited to contact the researcher to arrange a
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time to attend an audio-recorded focus group (FG) interview. All FG interviews were conducted by the same researcher at the units, and were held at the end of one shift, and beginning of next. A total of eight focus groups were conducted over 3 months in 2011. Each FG was conducted for 1 h and was attended by a small number of participants. The composition of each FG was designed so that differences in roles, responsibilities and educational background would have minimal impact on the nurses’ willingness to share their experiences. Hence, focus groups were held for different levels of nursing staff that is focus groups for ENs, and focus groups for RNs. Prior to the FG interview, nurses completed a demographic data collection form indicating their age, gender, years of experience working in the LTC sector and years of experience caring for residents with BPSD. During the FG interview, they were invited to share their experiences of caring for residents with BPSD, including the types of challenges they faced, and the methods or strategies they used to manage such symptoms. Nurses’ participation was voluntary and the information they shared was de-identified. The study was approved by the healthcare services and Deakin University Human Research and Ethics Committees.
Data analysis
The recorded interviews were transcribed verbatim. Data from all sources were analysed using inductive content and thematic strategies. Two researchers independently read short segments of the transcribed interview text data to closely examine, interpret, code and categorize the text. A coding matrix was developed in which the researchers independently assigned one or more codes or labels to the text to describe what the data indicated. The codes and their content were repeatedly read, regrouped and recoded in order to delimit the overall number of codes to ensure consistency and fit. This process led to the emergence of reoccurring themes. Thereafter, independently coded data were compared and agreement reached about the themes.
Rigor
Consistent with guidelines for enhancing the rigor of qualitative studies (Guba 1981), while conducting focus groups the researcher adopted an open, reflexive and empathic stance. The questions were open ended. While interpreting the data, the researchers searched for disconfirming cases, re-examined the data to look for other ways to organize it. They also shared findings with clinical colleagues and other researchers from the university who were not involved in the study. They also searched
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for alternative interpretations. The findings were them compared with those reported in the literature.
Results Thirty nurses (21 women, and nine men; 3 RNs and 27 ENs), aged between 21 and 64 years [mean 41.8 years; standard deviation (SD) ± 12.8], participated in the study. Twenty of the ENs were qualified to administer medications. The number of years of being employed as a nurse varied with a mean of 12 years (SD ±10.7; range 2 months to 41 years). The number of years employed in the LTC sector ranged between 1 and 30 years (mean 9 years; ± SD 8.0). The number of years of experience caring for residents with BPSD ranged between 7 months and 41 years (mean 10 years; SD ± 9.6). Four participants indicated they had been caring for residents with BPSD longer than they had worked in the aged care sector, and in some cases, prior to their registration as a nurse. The findings revealed five main interrelated themes: 1 working under difficult conditions, 2 BPSD: an everyday encounter, 3 making sense of BPSD, 4 attempting to manage BPSD, and 5 feeling undervalued. These themes and the specific context, conditions and consequences that led to them are described later and are illustrated in Fig. 1. Working under difficult conditions
The findings revealed the nurses’ main concerns centred on a number of organizational factors they felt hindered them from delivering the type of care residents required and from providing optimal care. These factors included: • unpredictable work environment with multiple and competing demands, • a lack of staff to provide the necessary levels of supervision and care, exacerbated by frequent staff sick leave and the use of agency staff, • heavy workloads and pressure to rush care, • documentation responsibilities that took nurses away from direct care, • cuts to services that limited residents’ access to support from lifestyle and allied health staff, and • a physical environment that did not accommodate residents’ behaviours and needs – including a lack of: ‘quiet rooms’ safe and secure outdoor areas, and areas from which staff could observe residents with challenging behaviours. BPSD: an everyday encounter
Nurses described a day-to-day work environment in which they were continually at risk of being hit, bitten, kicked, scratched,
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spat at, head butted, grabbed, pulled, choked, having their hair pulled, and/or verbally abused. The verbal abuse allegedly included racial slurs. For example, one nurse described being called a ‘black bitch’. Nurses also described being exposed to residents’ persistent vocalizations, screaming, moaning, and loud persistent banging or tapping on surfaces. Sometimes we get banging, bang, bang. Like I’ll be on the computer and someone [a resident] will be banging. It just makes me want to throw something (FG site 2). They indicated the most common BPSD was physical resistance from residents, which occurred when nurses assisted residents to shower, dress and when residents with incontinence needed help. Rushing to complete these tasks exacerbated the potential for residents’ resistance. Nurses reported sustaining bruises, scratches and strained shoulders when residents’ physically resisted their attempts to be moved. For example, one nurse said: They’re [residents are] resistive and rigid. They are not mobile so we have to do everything for them. So when you want to put them forward to put a sling in the bed for them to go on the [lifting] machine . . . they go backwards and you try to pull them forward and you really put strain on your shoulder (FG site 1). Nurses indicated another challenge was they could not consistently rely on residents’ cognitive and behavioural status being stable. As one nurse said ‘some are like . . . most of the time they are very settled, then you cannot predict him or her . . . just suddenly [they] become agitated or aggressive’. Moreover, what was acceptable to a resident 1 day, might not be acceptable the next. The unpredictable nature of residents’ responses and behaviours meant nurses had to remain vigilant to the constant possibility of an adverse event. Making sense of BPSD
Although nurses accepted that dealing with residents’ BPSD was an inevitable part of their day-to-day work, they also downplayed its significance and impact. This response seemed to be linked to their desire to be regarded by other people, particularly their peers and managers, as competent and able to deal and cope with the difficult working conditions. One nurse who felt her training in mental health had equipped her to deal with residents’ BPSD said: You try to work out strategies of how and why [to manage residents with BPSD]. I’ve learnt over the years. It takes a lot to get me. I don’t know if anybody’s ever seen me ever really frustrated. I don’t think you’ve ever seen me with a patient ever lost
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Working under difficult conditions
BPSD: an everyday encounter
• An unpredictable work environment • Not enough staff to provide care • Heavy workloads • Excess documentation requirements • Cuts to services • Unsuitable physical environments
Feeling undervalued • Senior management being unsupportive • Relatives’ expectations difficult to achieve • Being blamed • Staff feeling ‘not heard’ • Underreporting to minimize being blamed
Residents display: • Limited insight into BPSD • Frequent physical and verbal abuse toward staff • Often resisted care • Not always predictable
Managing residents’ behavioural and psychological symptoms of dementia (BPSD)
Making sense of BPSD • Accepted BPSD was part of the job • Wanted to be considered competent to manage BSPD • Tried not take BPSD personally • Empathized with residents with BPSD • Interpreted BPSD as an attempt to communicate • Were aware of possible triggers • Were sometimes emotionally affected
Attempting to manage BPSD Nurses used a range of strategies: • Drew on knowledge of each individual resident • Read residents’ individual BPSD cues • Managed the environment to avoid or minimize BPSD • Used sedation and restraint as last resort options • Tried to manage own emotions
Fig. 1 Themes and their specific context, conditions and consequences.
it or anything. I mean I’ll take a punch, a whack and everything, I’ll just say ‘no’ . . . I’ll just turn around. I know when to give eye contact, when not – that’s because I’ve done a bit of psych [mental health nursing]. That’s where you really [learn the skills] (FG site 2). Nurses indicated they tried not to take residents’ aggression towards them personally. After all, they understood that, most residents with challenging behaviours were cognitively impaired and lacked insight into their actions. One nurse said:
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It’s a natural illness, a disease in their mind their brain. You can’t take anything that they do personally. It’s not personal (FG site 2). Most nurses were aware that residents’ behaviours were a way of them trying to communicate to others, as conveyed in the following comment: They [residents] are aware that something [is] wrong in their life. There’s different people and just everything that is gone away from them, but the only way they can express themselves is
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Table 1 Strategies nurses’ described to manage residents’ behavioural and psychological symptoms of dementia (BPSD) Drew on knowledge of each individual resident Read residents’ individual BPSD cues and problem solved
Managed the environment to avoid or minimize BPSD
Used sedation and restraint as last resort options Tried to manage own emotions
Attempted to get to know each resident and their personal preferences and used this knowledge to plan and implement individualized care Recognized BPSD as an attempt to communicate Deferred tasks that were likely to trigger BPSD Assisted and attended to care needs, such as provided pain relief Tried not to rush tasks, but also tried to complete tasks that could distress residents in as short as time as possible Ensured another staff member was available to assist perform tasks that were likely to trigger BPSD Tried to keep the environment calm Removed environmental factors that could trigger BPSD or removed residents from environmental triggers Engaged residents in activities they enjoyed Altered their tone of voice to speak slowly and quietly to convey a sense of calm Used touch in a therapeutic manner (i.e. hand massage) to responsive residents Distracted residents Danced with residents Read the newspaper with residents Took residents for a walk Encouraged residents to go on outings Sat with residents with BPSD Used a Snoezelen or Quiet Room Ensured residents received their medication in a timely manner Used restraints to keep residents, themselves and others safe Took time out to ‘cool down’ Tried to maintain a consistent approach to care delivery Tried to maintain a positive attitude
by attention seeking, by displaying different behaviour. Their environment’s completely different. So that’s when they start the behaviour getting up. That’s the only way of expression (FG site 2). Indeed, nurses identified a number of triggers for residents’ BPSD, such as their exposure to a new and unfamiliar environment, their dependence on staff for assistance with highly personal matters, language barriers, and certain times of day (sundown and sunset). Because nurses believed residents were not responsible for their actions, they indicated nurses had little choice but to simply ‘take’ or accept whatever behaviour residents displayed. One nurse said: We do understand that this individual doesn’t really know what they’re doing and everything so they don’t really mean it. So we have to take – but for me because I came here and I decided myself that . . . and I know these are the kinds of patients . . . so you deal with it [BPSD] (FG site 1). Although nurses rationalized residents’ BPSD and tried not to take things personally, they nevertheless described feeling worn down, stressed, frustrated and hurt.
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Even though we know that they are like mentally not stable or not aware of what they are doing or saying but if they verbally abuse you, you feel that – hurt (FG site 2). Attempting to manage BPSD
Nurses described a range of strategies they used in an attempt to manage residents’ BPSD. These strategies included: (i) drawing on knowledge of each individual resident, (ii) reading residents’ individual BPSD cues, and problem solving, (iii) managing the environment to avoid or minimize BPSD, (iv) using sedation or restraint as last resort options, and (v) trying to manage own emotions (Table 1, Fig. 1). Knowing each individual resident and their personal ‘like’s and dislikes’ helped nurses predict, and therefore, better manage residents’ BPSD. When nurses ‘knew’ residents well, they felt they were better positioned to structure their work in ways that were responsive to that resident’s triggers and individual needs, and to try to minimize resident’s adverse behaviours. One nurse said: It’s [providing care] easier when you get used to the residents . . . [when] you can tell what’s going to happen the next
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minute . . . the approach is the most important thing . . . how you can approach the residents (FG site 1). Nurses described knowing the cues for some residents’ behaviours and then managing the situation to ensure optimal safety for all concerned, as described by one nurse who said: We will just do whatever we can and try to avoid everything. If you can see that their behaviour is escalating you try to minimise it so everyone they will be safe, the patient will be safe and for yourself also (FG site 2). When residents developed BPSD, nurses indicated they attempted to distract them, and engaged in skilled communication with them. For example, they described purposefully lowering the tone of voice and speaking quietly to residents, or engaging them in activities. However, residents did not always respond to the interpersonal approaches nurses used. In such cases, nurses attempted to manage residents’ BPSD with sedation or restraint. Insufficient or inappropriate sedation, or a delay in receiving sedation could trigger BPSD. Therefore, nurses indicated they had to remain vigilant to identify or preempt residents’ need for more sedation. As one nurse said: Well [we give residents] medication. So if we can see that their behaviour is really escalating, starting to escalate, we will tell it to the in-charge . . . we need . . . this patient. Because we were observing them and we know already the movement that they were doing. So if we get in a little bit earlier before it escalates it will be effective most of the time. But if it’s going to be too late it [the medication] doesn’t [help] (FG site 1). Because nurses expected residents’ behaviour was manageable when residents took their sedation, residents’ inability or refusal to swallow tablets constituted a dilemma. Nurses described a range of strategies, including the use of deception, to optimize the possibility that residents would take their sedation. A nurse said: There’s a trick for each individual person, generally. So one person might have it [their sedation] in tea and we’ll crush it and melt it to the point – extra sugar in it, so it doesn’t taste bad. Another person might want it in chocolate, so we’ve got chocolate. Another person might have it in yoghurt . . . or [we] might follow it with lollies, we need to follow it up with lollies, because that particular resident still has the mind of a child. Or [we] put it [the sedation] in their meals or in their dessert . . . you know, some people you have to crush it . . . it’s crucial that they get their meds, otherwise the aggression . . . it [their challenging behaviours] just blows up (FG site 2).
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Another response to residents’ BPSD involved physically restraining certain residents. Nurses indicated physical restraint could only be used after certain conditions were met: For example, a nurse stated: You have to have tried all the other interventions first. You have to have tried a PRN [medication that has been prescribed to be given ‘as needed’] before you get to the restraint. Then the [Division one Registered Nurse] has to sign off on it. Then you’ve got to check them every 15 min (Site 1). Nurses described having to seek medical authorization to use physically restraint. Theoretically, nurses supported using interpersonal strategies to respond to resident BPSD, and stated restraint was only used as a last resort option, such as when resident behaviours were so extreme that they could not manage the resident in any other way. Another rationale for using restraint was that the staff-to-resident ratios did not enable the nurses to provide the one-on-one support that they felt residents with BPSD required. Moreover, nurses felt some residents were at risk of falling unless they were restrained. Nurses were aware they had a duty of care to avoid or minimize the use of restraint, but also perceived they were caught in a difficult situation of having no other option. The following transcript from a nurse illustrates the dilemma from her perspective: We’ve got one man who will just – he will just fall and get up and fall and his wife doesn’t like the restraint, but she doesn’t like the falls either. Sometimes it’s [restraint] necessary . . . I mean, unless you’re going to give us a special [a person allocated to oversee care of the one resident] – which they don’t like to give them because it’s going to cost money – you’re not going to stop – you’re going to have an increase in either falls, so – and it is a last resort . . . We’re very good at managing behaviours without having to get to that point. But because of the nature of our residents usually you need two people to deal with them. So if two people are in a shower, who’s looking after everyone else? Usually it’s no-one while you’re in that environment. If you’re in a bedroom, nobody’s looking after the rest. Then you’ve got a problem if you’ve got someone who’s aggressive, sexually inappropriate or is a high falls risk (FG site 1). Nurses’ attempts to manage residents BPSD were also characterized by attempts to manage their own feelings of frustration, and emotional ‘hurt’. For example, one nurse described having to take time out to ‘cool down’. Others described having to consciously work to maintain a positive manner, especially as their manner affected residents’ behaviours.
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Feeling undervalued
Another key theme was nurses’ concern about being undervalued for the work they performed, and particularly, for the way in which they dealt with residents’ BPSD. Nurses described having their opinions about the need to restrain or sedate residents discounted, and senior managers giving greater weight to residents’ family members’ opinions. In such cases, nurses described feeling undermined. One nurse summed up this situation as follows: Management support family members’ views over nurses’ views. Sometimes they take the family’s suggestions instead of the nursing staff that’s on the floor. That’s a big problem. Then you watch the management backing the family. So it makes us look like idiots, that we’re not doing our job properly. We are doing our job properly (FG site 1). Nurses indicated they also felt undervalued by some residents’ family members who did not treat them with the respect they deserved. They also felt family members did not always understand residents’ behaviours in the way staff did, especially if family members did not spend time with the resident. Nurses perceived they were the singular target for complaints about care, as conveyed in the following transcript: But where we’ve got a difficulty is it’s sometimes hard to manage a relative. More than the patients. They [residents’ family members] give us a lot of flak. They don’t appreciate . . . You know. We get complaints and stuff like that. It’s a bit demoralising sometimes you know (FG Site 2). Nurses believed some family members underestimated the severity of residents’ BPSD and therefore, had unrealistic expectations about the challenges associated with delivering care. They [family members] are in denial and also they don’t accept the change. They [family members] want the perfect care, but we can’t [provide perfect care] if their [behaviour is] like that. It’s very hard. (FG Site 2). Nurses also described a situation in which they felt undervalued by managers who they believed did not always understand the challenges associated with work, the difficulty of getting through their workloads, and did not always believe their versions of events surrounding residents with BPSD. Indeed, some nurses vented considerable frustration about some managers. They just walk in . . . ‘oh good morning everybody’ . . . they just come in and then they say ‘oh so-and-so do this and do that’. You begin to wonder what’s wrong with these people, they just come in for two minutes and they’re telling you what to do. Come and be here for eight hours and realise what we’re going through, you know (FG site 1).
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Nurses also described situations in which some managers made them feel responsible for having caused resident’s BPSD that led to staff injuries. One nurse described a manager’s response to her having reported an injury associated with a resident’s BPSD as follows: What did you do wrong? You should have . . . Yeah, – it wasn’t the resident’s fault. It’s all, how did you mishandle the resident? It’s not about the resident, it’s more about what we did wrong (FG site 1). Given this situation, nurses indicated there was a tendency to underreport BPSD or any consequential staff injury. One nurse stated: Half the time I don’t even report getting injured. Yeah. If I get – coming home with bruises, and I just don’t report them now. Because otherwise you do too many reports and it looks like you’re not a person who’s handling the job very well, so you’ll be brought into the office. You’ve got a lot of incident forms of people hitting you. You’re obviously not very good at your job. It’s not that you’re been good at reporting, exposing what this patient’s like. It’s more that you’re not good at your job. So I just don’t report most [BPSD or injury] . . . unless it’s been observed by someone else, then I kind of have to (FG site 1).
Discussion and recommendations The aim of the study was to describe nurses’ experiences of caring for people with BPSD in LTC and the strategies they used to deal with these behaviours. Nurses described being continually exposed to BPSD as part of their everyday work. They also described a range of strategies to care for residents’ with BPSD, and many of these strategies resembled good models of care. For example, they spoke about the importance of ‘knowing’ each individual residents’ life history and personal preferences. They also described trying to problem-solve the cause of BPSD, and using a range of techniques to prevent symptoms from escalating. The main challenge for them was not the management of BPSD per se, but rather work constraints that hindered their efforts to implement interpersonal approaches to care for residents with BPSD, and they felt their efforts and expertise were poorly recognized, especially when they were blamed for triggering residents’ BPSD. Hence, while the models of care described in the literature represent best practice, they may also represent an ideal that is difficult to implement in the context of organizational constraints. The concerns described by nurses in this study about the constraints of working in LTC are not new. The Institute of Medicine (1986) reported similar problems in its seminal report about US nursing homes as long ago as 1986. Research
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continues to reveal stress associated with understaffing in LTC, having an excessive workload, being unable to perform ones’ role, and being poorly paid (Bostick et al. 2006; Lapane & Hughes 2007; Schmidt & Diestel 2013; Schmidt et al. 2014). Consistent with findings from other research (Morgan et al. 2002), nurses feel ‘rushed’ and anxious about their ability to keep up with the work demands, and they link this situation to not having enough staff to perform the work. Current evidence-based clinical practice guidelines for the LTC sector and interdisciplinary collaborations such as the project titled Re-imagining Long-term Residential Care (2011–2014), and models of care such as The Eden Alternative® (Thomas 1996), and The Tri-Focal Model of Care (O’Connell et al. 2008) promote partnership-centred, evidence-based, team-based and non-pharmaceutical approaches to the care of people with BPSD. However, if the current findings hold true for other LTC facilities, further work is required to address workforce constraints that hinder nurses from the uptake and sustained use of best practice recommendations about such care. The combined findings from the study and extant research highlight the importance of attending to the multifactorial constraints associated with care delivery in LTC, and to avoid quick fixes that focus solely on nurses’ education. Nurses’ responses indicated they were well informed about interpersonal approaches to manage residents with BPSD and they conveyed support for a restraint-free environment. However, nurses indicated they often had no choice but to use medical and physical restraint, particularly when staff-to-resident ratios did not enable them to supervise residents with BPSD on a one-onone basis, and when nurses felt unsafe. It is important to note that understaffing, working with insufficient resources, working with a style of management based on intimidation, and functioning in a culture of tolerance or acceptance of violence are important risk factors for violence in the healthcare workplace (International Labour Organization et al. 2002). It is incumbent on managers to heed nurses’ concerns about the structural factors that hinder them from consistently implementing interpersonal approaches to prevent BPSD or circumvent an escalation in symptoms. It is important that managers in LTC recognize the difficult circumstances under which LTC staff are providing care and provide staff with more encouragement and support. The fact that some nurses described being cast as the cause of residents’ adverse behaviours should also elicit concern. This finding resembles Morgan et al. (2008) and Scott et al. (2011) who reported that nurses often felt frustrated as they were blamed for triggering BPSD. In the current study, nurses indicated they underreported the injuries they experienced, which masked the true extent of the problem. The situation was com-
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pounded by residents’ family members who expressed dissatisfaction to managers about the level of care nurses provided. In these circumstances nurses felt unfairly judged as family members did not fully appreciate the difficulties managing residents with BPSD. This issue warrants further attention and a more complex strategy of caring that promotes a collegial and partnership centred approach to residents’ care. Limitations
This study was conducted in three LTC units in Australia. The findings are context-based and representative of LTC units that care for older adults with mid- to late-stage dementia and high care needs. Moreover, they were limited to nurses’ perspectives and experiences, and were not representative of other care providers in LTC, such as allied health staff. The nurses shared their opinions with a nurse researcher in the context of small group forums. It is probable that the information the nurses shared was influenced by the presence of other nurses in the FG interviews, the number of participants in each group, as well as the role of the researcher. As the study was not designed to compare nurses’ subjective reports with their actual practice, it is not possible to comment on the degree to which care was personcentred. Moreover, generalizability is not being claimed, and it is acknowledged that transferability of the findings is limited. Implications for nursing and health policy
Organizational efforts to enhance the quality of care for individuals with BPSD in LTC should extend beyond staff education. They need to address nurses’ concerns about the contextual factors in LTC that hinder them from consistently using interpersonal approaches to care for residents with BPSD. Managers in LTC need to acknowledge the difficult and pressured conditions care staff are working under and provide them with positive feedback and support. Given the financial constraints experienced in these settings, there is need for further research in LTC that explore everyday strategies that are able to be easily implemented in a sustainable way. It is also important to educate the public about BPSD and its prevalence in today’s elderly population and to lobby governments for increased allocation of research and healthcare funds.
Conclusion This study found that nurses encountered many challenges while caring for residents with BPSD. Given the global trend in increased life expectancy, ageing population and increased prevalence of dementia, the findings have major implications for the global nursing workforce, and should be of concern to policymakers, researchers and leaders in aged care. As the
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population ages and the demand for nursing knowledge and skills to care for people with dementia increases, there is a commensurate need to support the workforce deliver high-quality care that involves creating a culture in which staff and residents alike feel safe and valued.
Acknowledgement This project was funded by a grant from the Quality and Patient Safety Research (QPS) Strategic Research Centre, Deakin University.
Author contributions PL, BO and MH were involved in the study conception/design; JO conducted the data collection. JO and PL conducted the analysis. MH provided statistical support. JO drafted the paper and all authors provided critical revisions for important intellectual content.
References Alzheimer’s Disease International (2009) World Alzheimer Report 2009. The Global Prevalence of Dementia. Available at: http://www.alz.co.uk/ research/world-report-2009 (accessed 2 February 2015). Alzheimer’s Disease International (2013a) Alzheimer’s Disease International Policy Brief for Heads of Government. The Global Impact of Dementia 2013–2050. Available at: http://www.alz.co.uk/research/G8-policy-brief (accessed 28 April 2014). Alzheimer’s Disease International (2013b) World Alzheimer Report 2013: An Analysis of Long-Term Care for Dementia. Available at: http:// www.alz.co.uk/research/world-report-2013 (accessed 28 April 2014). Alzheimer’s Society (2014). Dementia UK. (2nd ed). (accessed 2nd February 2015). Available at: http://www.alzheimers.org.uk/dementiauk Bostick, J.E., Rantz, M.J., Flesner, M.K. & Riggs, C.J. (2006) Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7, 366–376. Chrzeschijanski, D., Moyle, W. & Creedy, D. (2007) Reducing dementiarelated aggression through a staff education intervention. Dementia (Basel, Switzerland), 6, 271–286. Cohen-Mansfield, J. (2004) Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary and critique. Focus (San Francisco, Calif.), 2 (2), 288–308. Cohen-Mansfield, J. & Parpura-Gill, A. (2007) Bathing: a framework for intervention focusing on psychosocial, architectural and human factors considerations. Archives of Gerontology and Geriatrics, 45, 121–135. ED Management (2007) Survey: most ED staff victimized by violence never report incident. ED Management: The Monthly Update on Emergency Department Management, 19 (10), 109–111. Fair Work Act (2009) Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012–2016. S.185 – Enterprise agreement Victorian hospitals’ industrial association (ag2012/ 9133). Available at: https://www.fwc.gov.au/awards-and-agreements (accessed 2 December 2014).
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Gates, D.M., Ross, C.S. & McQueen, L. (2006) Violence against emergency department workers. The Journal of Emergency Medicine, 31 (3), 331– 337. Guba, E.G. (1981) Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal, 29 (2), 75–92. Hesketh, K.L., et al. (2003) Workplace violence in Alberta and British Columbia hospitals. Health Policy, 63, 311–321. Hills, D.J., Joyce, C.M. & Humphreys, J.S. (2012) A national study of workplace aggression in Australian clinical medical practice. The Medical Journal of Australia, 197 (6), 336–340. Institute of Medicine (1986) Improving the Quality of Care in Nursing Homes. The National Academies Press, Washington, DC. International Labour Organization, International Council of Nurses, World Health Organization & Public Services International (2002) Workplace Violence in the Health Sector. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva, International Labour Office. Kansagra, S.M., et al. (2008) A survey of workplace violence across 65 US emergency departments. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 15 (12), 1268–1274. Landes, A.M., Sperry, S.D., Strauss, M.E. & Geldmacher, D.S. (2001) Apathy in Alzheimer’s disease. Journal of the American Geriatrics Society, 49 (12), 1700–1707. Lapane, K.L. & Hughes, C.M. (2007) Considering the employee point of view: perceptions of job satisfaction and stress among nursing staff in nursing homes. Journal of the American Medical Directors Association, 8, 8–13. Mahoney, E.K., et al. (1999) Development and testing of the Resistiveness to Care Scale. Research in Nursing and Health, 22 (1), 27–38. Merecz, D., Drabek, M. & Moscicka, A. (2009) Aggression at the workplace-psychological consequences of abusive encounter with co-workers and clients. International Journal of Occupational Medicine and Environmental Health, 22 (3), 243–260. Morgan, D.G., Semchuk, K.M., Stewart, N.J. & D’Arcy, C. (2002) Job strain among staff of rural nursing homes: a comparison of nurses, aides, and activity workers. The Journal of Nursing Administration, 32 (3), 152–161. Morgan, D.G., et al. (2008) Taking the hit: focusing on caregiver ‘Error’ masks organisational-level risk factors for nursing aide assault. Qualitative Health Research, 18 (3), 334–346. Needham, I., et al. (2005) Non-somatic effects of patient aggression on nurses: a systematic review. Journal of Advanced Nursing, 49 (3), 283– 296. O’Connell, B., Ostaszkiewicz, J., Sukkar, K. & Plymat, K. (2008) The trifocal model of care: advancing the teaching-nursing home concept. International Journal of Nursing Practice, 14 (6), 411–417. Patton, M.Q. (2002). Qualitative research and evaluation methods (3rd ed). Thousand Oaks, CA: Sage. Re-imagining Long-Term Residential Care. (2011–2014). York University. Available at http://reltc.apps01.yorku.ca/our-project (accessed 2 December 2014). Richter, D. & Berger, K. (2006) Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study. BMC Psychiatry, 6, 15.
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Schat, A. & Frone, M. (2011) Exposure to psychological aggression at work and job performance: the mediating role of job attitudes and personal health. Work and Stress, 25 (1), 23–40. Schmidt, K.H. & Diestel, S. (2013) Job demands and personal resources in their relations to indicators of job strain among nurses for older people. Journal of Advanced Nursing, 69 (10), 2185–2195. Schmidt, S.G., Dichter, M.N., Bartholomeyczik, S. & Hasselhorn, H.M. (2014) The satisfaction with the quality of dementia care and the health,
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burnout and work ability of nurses: a longitudinal analysis of 50 German nursing homes. Geriatric Nursing, 35, 42–46. Scott, A., Ryan, A., James, I. & Mitchell, E.A. (2011) Perceptions and implications of violence from care home residents with dementia: a review and commentary. International Journal of Older People Nursing, 6, 110– 122. Thomas, W. (1996) Life Worth Living. Vander Wyk and Burnham, Massachusetts.
Ageing and Aged Care
Ongoing challenges responding to behavioural and psychological symptoms of dementia J. Ostaszkiewicz1 RN, MN, PhD, P. Lakhan2 PhD, MN, BN, BA, GradCert Ed, B. O’Connell3 PhD, FACN & M. Hawkins4 PhD, BA 1 Post-Doctoral Fellow, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 4 Senior Research Fellow, School of Nursing and Midwifery, Deakin University, Melbourne, Vic., 2 Adjunct Research Fellow, Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, QLD, Australia, 3 Dean, Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
OSTASZKIEWICZ J., LAKHAN P., O’CONNELL B. & HAWKINS M. (2015) Ongoing challenges responding to behavioural and psychological symptoms of dementia. International Nursing Review 62, 506–516 Background: Mid- to late-stage dementia is often characterized by behavioural and psychological symptoms, including, but not limited to physical and verbal aggression. Introduction: Although there is a considerable research about the prevalence, aetiology, and management of behavioural and psychological symptoms of dementia, there is limited research about the experience of caring for people with such symptoms in long-term aged care facilities. Aim: The aims of the study were to describe: (i) nurses’ experiences of caring for people with behavioural and psychological symptoms of dementia in long-term aged care facilities, and (ii) strategies nurses used to deal with these symptoms. Methods: A qualitative exploratory and descriptive design, involving focus group interviews with 30 nurses from three long-term aged care units in Australia. The transcripts were analysed using inductive content analysis. Results: The findings revealed five interrelated themes: (i) working under difficult conditions, (ii) behavioural and psychological symptoms of dementia: an everyday encounter, (iii) making sense of behavioural and psychological symptoms of dementia, (iv) attempting to manage behavioural and psychological symptoms of dementia, and (v) feeling undervalued. Conclusion: This study highlighted the difficult conditions under which nurses worked and the complexity of caring for individuals who have behavioural and psychological symptoms of dementia. Implications for nursing and health policy: Organizational efforts to enhance the quality of care for individuals with behavioural and psychological symptoms of dementia in long-term aged care facilities should extend beyond staff education to heed nurses’ concerns about organizational barriers to interpersonal care. Keywords: Aggression Management, Dementia, Focus Groups, Gerontology, Older People Nursing, Psycho-Geriatrics Nursing, Qualitative Methods, Restraint, Violence in the Workplace, Workforce Issues
Correspondence address: Dr Joan Ostaszkiewicz, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, 221, Burwood Hwy, Burwood, Vic. 3125, Australia; Tel: +61-3-92445099; Fax: +61-3-95946094; E-mail: [email protected].
Conflict of interest statement: The authors have no conflict of interest to declare.
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Introduction
Background
Agitation, physical aggression, disruptive vocalization, resistance to care, wandering, shadowing and inappropriate sexual behaviours are common behavioural symptoms of mid- to late-stage dementia. Similarly, anxiety, depression, delusions and hallucinations are common psychological symptoms (Alzheimer’s Disease International 2009). Medically, these behavioural and psychological symptoms of dementia (BPSD) are explained by the damage to the structures of the brain and associated progressive, global deterioration in intellect (i.e. memory, learning, orientation, language, comprehension and judgement) (Alzheimer’s Disease International 2009). The literature offers three complementary theoretical models to explain BPSD: (i) the unmet needs model, (ii) a behavioural/ learning model, and (iii) an environmental vulnerability/ reduced stress-threshold model (Cohen-Mansfield 2004). Specifically, Cohen-Mansfield (2004) hypothesized that BPSD could relate to the possibility that persons with dementia have physical and/or emotional needs, which are not being fully realized. For example, in the absence of the ability to communicate the desire for food or fluid, the presence of hunger or thirst could trigger agitation. The behavioural/learning model posits that BPSD are a manifestation of a negative relationship between the antecedents of such behaviours, the behaviours themselves, and their consequences. The third explanatory model; that is the environmental vulnerability/ reduced stress-threshold model, theorizes that having dementia may reduce the cognitively impaired person’s coping skills, making them more sensitive to environmental stressors. Therefore, some care activities, such as assisting a person with dementia to shower or bathe could constitute stressors that trigger BPSD (Cohen-Mansfield & Parpura-Gill 2007). Arguably, caring for people with BPSD involves learning to interpret their behavioural responses as legitimate human emotions within the context of the disease process (Chrzeschijanski et al. 2007). In the absence of this knowledge, carers, that is informal or formal, are likely to adopt negative responses or approaches to care, particularly if they observe other people using these approaches. Negative responses could include emotionally distancing oneself from the person with BPDS and labelling them as aggressive, lazy or resistant, rather than understanding and addressing the behaviour (Landes et al. 2001). Similarly, if carers are not aware that individuals with dementia often experience visual-perceptual-cognitive deficits that affect how they interpret their environment, they may inadvertently label them as ‘resistant’. When carers persist with care the person resists, the behaviour is likely to escalate, and in some cases, become combative (Mahoney et al. 1999).
Forty-four million people worldwide currently live with dementia (Alzheimer’s Disease International 2013a). One-third to one-half of people with dementia from high income countries, and approximately 6% of those from low and middle income countries are cared for in a long-term aged care facility (LTC) (Alzheimer’s Disease International 2013b). The main reason for admission to LTC is that the person’s care needs escalate beyond what family and paid carers can manage (Alzheimer’s Disease International 2013b). Individuals who display BPSD such as physical and verbal aggression pose a considerable risk to carers. In the workplace setting, exposure to aggression has implications for healthcare workers’ physical and mental health (Hills et al. 2012). Arguably, all carers, including nurses and other staff working in LTC have the right to work in a safe environment. Indeed, in many countries, workers’ rights to work in a safe environment are enshrined in legislation. However, very few individuals with mid- to late-stage dementia have the cognitive capacity to understand the nature of their BPSD or recognize the impact of their behaviours on carers and other people. Negative impacts of nurses’ exposure to workplace aggression include decreased job satisfaction and job performance (Hesketh et al. 2003; Merecz et al. 2009; Schat & Frone 2011), absenteeism, a fear of returning to work (ED Management 2007; Gates et al. 2006; Kansagra et al. 2008), changed attitudes towards patients, psychological withdrawal and burnout (Merecz et al. 2009). Some nurses exposed to aggression in the workplace experience anxiety, depression and post-traumatic stress disorder symptoms (Needham et al. 2005; Richter & Berger 2006). As three-quarters of people living in LTC have dementia (Alzheimer’s Society 2014), it is important to investigate nurses’ experiences of caring for people with BPSD. This information could be used to develop targeted interventions to support the nursing workforce provide optimal care for these individuals.
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Aim The aims of this study were to describe (i) nurses’ experiences of caring for people with BPSD in LTC, and (ii) strategies nurses used to deal with these symptoms.
Methods Study design
A qualitative exploratory and descriptive design was used to elicit information about nurses’ experiences of caring for people with BPSD in LTC. This approach was chosen because it
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does not impose an existing framework on the data (Patton 2002). Sample and setting
All nurses experienced in caring for residents with BPSD and employed in three LTC units in Melbourne, in the state of Victoria, in Australia, were invited to participate in the study. Each unit cared for frail older adults (hereafter termed ‘residents’) who were highly dependent. Two units (i.e. one 48-bed unit and one 35-bed unit) were designated as aged care mental health units, where residents had a diagnosis of dementia and/or a mental health disorder. The third unit, which had 60 beds, provided care for frail older adults with cognitive and/or functional impairments. The units contained a number of common areas and gardens with courtyard areas that residents could access. Two of the three units were newly built and there were a small number of double rooms for couples or others who wished to share. The older facility had single rooms. All resident rooms had a garden outlook. The units were mainly staffed by permanent staff, and in the event of staff leave or sickness, agency or bank staff were employed. Nursing care was mainly provided by enrolled nurses (ENs), whose role and level of education is similar to that of licensed practice nurses in the USA. In Australia, the minimum educational requirement for an EN is a 1-year diploma in nursing from a vocational education and training provider, or equivalent from a recognized hospital-based programme. Registered nurses (RNs) were also employed, albeit in managerial or supervisory roles. In Australia, entry to practice education for RNs is at a degree level offered by a recognized university. The RN undertakes initial and ongoing assessment of nursing care needs, supervises and delegates aspects of care to the EN. All nursing staff attended regular in-service education on gerontological issues, including education about the care of older people with dementia and other mental health disorders and BPSD. Although each unit had multiple resources about policies, procedures and guidelines, there were no specific resources about person-centred approaches to the care of residents with BPSD. The units employed 1 nurse to 7 residents on a morning shift, 1 to 8 in the afternoon, and 1 to 15 overnight as required under state legislation (Fair Work Act 2009). Data collection
The unit managers were informed about the study, and invited to provide organizational consent. Information sessions about the study were convened for all nursing staff and plain language and consent forms were distributed. Nurses wishing to participate were invited to contact the researcher to arrange a
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time to attend an audio-recorded focus group (FG) interview. All FG interviews were conducted by the same researcher at the units, and were held at the end of one shift, and beginning of next. A total of eight focus groups were conducted over 3 months in 2011. Each FG was conducted for 1 h and was attended by a small number of participants. The composition of each FG was designed so that differences in roles, responsibilities and educational background would have minimal impact on the nurses’ willingness to share their experiences. Hence, focus groups were held for different levels of nursing staff that is focus groups for ENs, and focus groups for RNs. Prior to the FG interview, nurses completed a demographic data collection form indicating their age, gender, years of experience working in the LTC sector and years of experience caring for residents with BPSD. During the FG interview, they were invited to share their experiences of caring for residents with BPSD, including the types of challenges they faced, and the methods or strategies they used to manage such symptoms. Nurses’ participation was voluntary and the information they shared was de-identified. The study was approved by the healthcare services and Deakin University Human Research and Ethics Committees.
Data analysis
The recorded interviews were transcribed verbatim. Data from all sources were analysed using inductive content and thematic strategies. Two researchers independently read short segments of the transcribed interview text data to closely examine, interpret, code and categorize the text. A coding matrix was developed in which the researchers independently assigned one or more codes or labels to the text to describe what the data indicated. The codes and their content were repeatedly read, regrouped and recoded in order to delimit the overall number of codes to ensure consistency and fit. This process led to the emergence of reoccurring themes. Thereafter, independently coded data were compared and agreement reached about the themes.
Rigor
Consistent with guidelines for enhancing the rigor of qualitative studies (Guba 1981), while conducting focus groups the researcher adopted an open, reflexive and empathic stance. The questions were open ended. While interpreting the data, the researchers searched for disconfirming cases, re-examined the data to look for other ways to organize it. They also shared findings with clinical colleagues and other researchers from the university who were not involved in the study. They also searched
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for alternative interpretations. The findings were them compared with those reported in the literature.
Results Thirty nurses (21 women, and nine men; 3 RNs and 27 ENs), aged between 21 and 64 years [mean 41.8 years; standard deviation (SD) ± 12.8], participated in the study. Twenty of the ENs were qualified to administer medications. The number of years of being employed as a nurse varied with a mean of 12 years (SD ±10.7; range 2 months to 41 years). The number of years employed in the LTC sector ranged between 1 and 30 years (mean 9 years; ± SD 8.0). The number of years of experience caring for residents with BPSD ranged between 7 months and 41 years (mean 10 years; SD ± 9.6). Four participants indicated they had been caring for residents with BPSD longer than they had worked in the aged care sector, and in some cases, prior to their registration as a nurse. The findings revealed five main interrelated themes: 1 working under difficult conditions, 2 BPSD: an everyday encounter, 3 making sense of BPSD, 4 attempting to manage BPSD, and 5 feeling undervalued. These themes and the specific context, conditions and consequences that led to them are described later and are illustrated in Fig. 1. Working under difficult conditions
The findings revealed the nurses’ main concerns centred on a number of organizational factors they felt hindered them from delivering the type of care residents required and from providing optimal care. These factors included: • unpredictable work environment with multiple and competing demands, • a lack of staff to provide the necessary levels of supervision and care, exacerbated by frequent staff sick leave and the use of agency staff, • heavy workloads and pressure to rush care, • documentation responsibilities that took nurses away from direct care, • cuts to services that limited residents’ access to support from lifestyle and allied health staff, and • a physical environment that did not accommodate residents’ behaviours and needs – including a lack of: ‘quiet rooms’ safe and secure outdoor areas, and areas from which staff could observe residents with challenging behaviours. BPSD: an everyday encounter
Nurses described a day-to-day work environment in which they were continually at risk of being hit, bitten, kicked, scratched,
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spat at, head butted, grabbed, pulled, choked, having their hair pulled, and/or verbally abused. The verbal abuse allegedly included racial slurs. For example, one nurse described being called a ‘black bitch’. Nurses also described being exposed to residents’ persistent vocalizations, screaming, moaning, and loud persistent banging or tapping on surfaces. Sometimes we get banging, bang, bang. Like I’ll be on the computer and someone [a resident] will be banging. It just makes me want to throw something (FG site 2). They indicated the most common BPSD was physical resistance from residents, which occurred when nurses assisted residents to shower, dress and when residents with incontinence needed help. Rushing to complete these tasks exacerbated the potential for residents’ resistance. Nurses reported sustaining bruises, scratches and strained shoulders when residents’ physically resisted their attempts to be moved. For example, one nurse said: They’re [residents are] resistive and rigid. They are not mobile so we have to do everything for them. So when you want to put them forward to put a sling in the bed for them to go on the [lifting] machine . . . they go backwards and you try to pull them forward and you really put strain on your shoulder (FG site 1). Nurses indicated another challenge was they could not consistently rely on residents’ cognitive and behavioural status being stable. As one nurse said ‘some are like . . . most of the time they are very settled, then you cannot predict him or her . . . just suddenly [they] become agitated or aggressive’. Moreover, what was acceptable to a resident 1 day, might not be acceptable the next. The unpredictable nature of residents’ responses and behaviours meant nurses had to remain vigilant to the constant possibility of an adverse event. Making sense of BPSD
Although nurses accepted that dealing with residents’ BPSD was an inevitable part of their day-to-day work, they also downplayed its significance and impact. This response seemed to be linked to their desire to be regarded by other people, particularly their peers and managers, as competent and able to deal and cope with the difficult working conditions. One nurse who felt her training in mental health had equipped her to deal with residents’ BPSD said: You try to work out strategies of how and why [to manage residents with BPSD]. I’ve learnt over the years. It takes a lot to get me. I don’t know if anybody’s ever seen me ever really frustrated. I don’t think you’ve ever seen me with a patient ever lost
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Working under difficult conditions
BPSD: an everyday encounter
• An unpredictable work environment • Not enough staff to provide care • Heavy workloads • Excess documentation requirements • Cuts to services • Unsuitable physical environments
Feeling undervalued • Senior management being unsupportive • Relatives’ expectations difficult to achieve • Being blamed • Staff feeling ‘not heard’ • Underreporting to minimize being blamed
Residents display: • Limited insight into BPSD • Frequent physical and verbal abuse toward staff • Often resisted care • Not always predictable
Managing residents’ behavioural and psychological symptoms of dementia (BPSD)
Making sense of BPSD • Accepted BPSD was part of the job • Wanted to be considered competent to manage BSPD • Tried not take BPSD personally • Empathized with residents with BPSD • Interpreted BPSD as an attempt to communicate • Were aware of possible triggers • Were sometimes emotionally affected
Attempting to manage BPSD Nurses used a range of strategies: • Drew on knowledge of each individual resident • Read residents’ individual BPSD cues • Managed the environment to avoid or minimize BPSD • Used sedation and restraint as last resort options • Tried to manage own emotions
Fig. 1 Themes and their specific context, conditions and consequences.
it or anything. I mean I’ll take a punch, a whack and everything, I’ll just say ‘no’ . . . I’ll just turn around. I know when to give eye contact, when not – that’s because I’ve done a bit of psych [mental health nursing]. That’s where you really [learn the skills] (FG site 2). Nurses indicated they tried not to take residents’ aggression towards them personally. After all, they understood that, most residents with challenging behaviours were cognitively impaired and lacked insight into their actions. One nurse said:
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It’s a natural illness, a disease in their mind their brain. You can’t take anything that they do personally. It’s not personal (FG site 2). Most nurses were aware that residents’ behaviours were a way of them trying to communicate to others, as conveyed in the following comment: They [residents] are aware that something [is] wrong in their life. There’s different people and just everything that is gone away from them, but the only way they can express themselves is
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Table 1 Strategies nurses’ described to manage residents’ behavioural and psychological symptoms of dementia (BPSD) Drew on knowledge of each individual resident Read residents’ individual BPSD cues and problem solved
Managed the environment to avoid or minimize BPSD
Used sedation and restraint as last resort options Tried to manage own emotions
Attempted to get to know each resident and their personal preferences and used this knowledge to plan and implement individualized care Recognized BPSD as an attempt to communicate Deferred tasks that were likely to trigger BPSD Assisted and attended to care needs, such as provided pain relief Tried not to rush tasks, but also tried to complete tasks that could distress residents in as short as time as possible Ensured another staff member was available to assist perform tasks that were likely to trigger BPSD Tried to keep the environment calm Removed environmental factors that could trigger BPSD or removed residents from environmental triggers Engaged residents in activities they enjoyed Altered their tone of voice to speak slowly and quietly to convey a sense of calm Used touch in a therapeutic manner (i.e. hand massage) to responsive residents Distracted residents Danced with residents Read the newspaper with residents Took residents for a walk Encouraged residents to go on outings Sat with residents with BPSD Used a Snoezelen or Quiet Room Ensured residents received their medication in a timely manner Used restraints to keep residents, themselves and others safe Took time out to ‘cool down’ Tried to maintain a consistent approach to care delivery Tried to maintain a positive attitude
by attention seeking, by displaying different behaviour. Their environment’s completely different. So that’s when they start the behaviour getting up. That’s the only way of expression (FG site 2). Indeed, nurses identified a number of triggers for residents’ BPSD, such as their exposure to a new and unfamiliar environment, their dependence on staff for assistance with highly personal matters, language barriers, and certain times of day (sundown and sunset). Because nurses believed residents were not responsible for their actions, they indicated nurses had little choice but to simply ‘take’ or accept whatever behaviour residents displayed. One nurse said: We do understand that this individual doesn’t really know what they’re doing and everything so they don’t really mean it. So we have to take – but for me because I came here and I decided myself that . . . and I know these are the kinds of patients . . . so you deal with it [BPSD] (FG site 1). Although nurses rationalized residents’ BPSD and tried not to take things personally, they nevertheless described feeling worn down, stressed, frustrated and hurt.
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Even though we know that they are like mentally not stable or not aware of what they are doing or saying but if they verbally abuse you, you feel that – hurt (FG site 2). Attempting to manage BPSD
Nurses described a range of strategies they used in an attempt to manage residents’ BPSD. These strategies included: (i) drawing on knowledge of each individual resident, (ii) reading residents’ individual BPSD cues, and problem solving, (iii) managing the environment to avoid or minimize BPSD, (iv) using sedation or restraint as last resort options, and (v) trying to manage own emotions (Table 1, Fig. 1). Knowing each individual resident and their personal ‘like’s and dislikes’ helped nurses predict, and therefore, better manage residents’ BPSD. When nurses ‘knew’ residents well, they felt they were better positioned to structure their work in ways that were responsive to that resident’s triggers and individual needs, and to try to minimize resident’s adverse behaviours. One nurse said: It’s [providing care] easier when you get used to the residents . . . [when] you can tell what’s going to happen the next
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minute . . . the approach is the most important thing . . . how you can approach the residents (FG site 1). Nurses described knowing the cues for some residents’ behaviours and then managing the situation to ensure optimal safety for all concerned, as described by one nurse who said: We will just do whatever we can and try to avoid everything. If you can see that their behaviour is escalating you try to minimise it so everyone they will be safe, the patient will be safe and for yourself also (FG site 2). When residents developed BPSD, nurses indicated they attempted to distract them, and engaged in skilled communication with them. For example, they described purposefully lowering the tone of voice and speaking quietly to residents, or engaging them in activities. However, residents did not always respond to the interpersonal approaches nurses used. In such cases, nurses attempted to manage residents’ BPSD with sedation or restraint. Insufficient or inappropriate sedation, or a delay in receiving sedation could trigger BPSD. Therefore, nurses indicated they had to remain vigilant to identify or preempt residents’ need for more sedation. As one nurse said: Well [we give residents] medication. So if we can see that their behaviour is really escalating, starting to escalate, we will tell it to the in-charge . . . we need . . . this patient. Because we were observing them and we know already the movement that they were doing. So if we get in a little bit earlier before it escalates it will be effective most of the time. But if it’s going to be too late it [the medication] doesn’t [help] (FG site 1). Because nurses expected residents’ behaviour was manageable when residents took their sedation, residents’ inability or refusal to swallow tablets constituted a dilemma. Nurses described a range of strategies, including the use of deception, to optimize the possibility that residents would take their sedation. A nurse said: There’s a trick for each individual person, generally. So one person might have it [their sedation] in tea and we’ll crush it and melt it to the point – extra sugar in it, so it doesn’t taste bad. Another person might want it in chocolate, so we’ve got chocolate. Another person might have it in yoghurt . . . or [we] might follow it with lollies, we need to follow it up with lollies, because that particular resident still has the mind of a child. Or [we] put it [the sedation] in their meals or in their dessert . . . you know, some people you have to crush it . . . it’s crucial that they get their meds, otherwise the aggression . . . it [their challenging behaviours] just blows up (FG site 2).
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Another response to residents’ BPSD involved physically restraining certain residents. Nurses indicated physical restraint could only be used after certain conditions were met: For example, a nurse stated: You have to have tried all the other interventions first. You have to have tried a PRN [medication that has been prescribed to be given ‘as needed’] before you get to the restraint. Then the [Division one Registered Nurse] has to sign off on it. Then you’ve got to check them every 15 min (Site 1). Nurses described having to seek medical authorization to use physically restraint. Theoretically, nurses supported using interpersonal strategies to respond to resident BPSD, and stated restraint was only used as a last resort option, such as when resident behaviours were so extreme that they could not manage the resident in any other way. Another rationale for using restraint was that the staff-to-resident ratios did not enable the nurses to provide the one-on-one support that they felt residents with BPSD required. Moreover, nurses felt some residents were at risk of falling unless they were restrained. Nurses were aware they had a duty of care to avoid or minimize the use of restraint, but also perceived they were caught in a difficult situation of having no other option. The following transcript from a nurse illustrates the dilemma from her perspective: We’ve got one man who will just – he will just fall and get up and fall and his wife doesn’t like the restraint, but she doesn’t like the falls either. Sometimes it’s [restraint] necessary . . . I mean, unless you’re going to give us a special [a person allocated to oversee care of the one resident] – which they don’t like to give them because it’s going to cost money – you’re not going to stop – you’re going to have an increase in either falls, so – and it is a last resort . . . We’re very good at managing behaviours without having to get to that point. But because of the nature of our residents usually you need two people to deal with them. So if two people are in a shower, who’s looking after everyone else? Usually it’s no-one while you’re in that environment. If you’re in a bedroom, nobody’s looking after the rest. Then you’ve got a problem if you’ve got someone who’s aggressive, sexually inappropriate or is a high falls risk (FG site 1). Nurses’ attempts to manage residents BPSD were also characterized by attempts to manage their own feelings of frustration, and emotional ‘hurt’. For example, one nurse described having to take time out to ‘cool down’. Others described having to consciously work to maintain a positive manner, especially as their manner affected residents’ behaviours.
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Feeling undervalued
Another key theme was nurses’ concern about being undervalued for the work they performed, and particularly, for the way in which they dealt with residents’ BPSD. Nurses described having their opinions about the need to restrain or sedate residents discounted, and senior managers giving greater weight to residents’ family members’ opinions. In such cases, nurses described feeling undermined. One nurse summed up this situation as follows: Management support family members’ views over nurses’ views. Sometimes they take the family’s suggestions instead of the nursing staff that’s on the floor. That’s a big problem. Then you watch the management backing the family. So it makes us look like idiots, that we’re not doing our job properly. We are doing our job properly (FG site 1). Nurses indicated they also felt undervalued by some residents’ family members who did not treat them with the respect they deserved. They also felt family members did not always understand residents’ behaviours in the way staff did, especially if family members did not spend time with the resident. Nurses perceived they were the singular target for complaints about care, as conveyed in the following transcript: But where we’ve got a difficulty is it’s sometimes hard to manage a relative. More than the patients. They [residents’ family members] give us a lot of flak. They don’t appreciate . . . You know. We get complaints and stuff like that. It’s a bit demoralising sometimes you know (FG Site 2). Nurses believed some family members underestimated the severity of residents’ BPSD and therefore, had unrealistic expectations about the challenges associated with delivering care. They [family members] are in denial and also they don’t accept the change. They [family members] want the perfect care, but we can’t [provide perfect care] if their [behaviour is] like that. It’s very hard. (FG Site 2). Nurses also described a situation in which they felt undervalued by managers who they believed did not always understand the challenges associated with work, the difficulty of getting through their workloads, and did not always believe their versions of events surrounding residents with BPSD. Indeed, some nurses vented considerable frustration about some managers. They just walk in . . . ‘oh good morning everybody’ . . . they just come in and then they say ‘oh so-and-so do this and do that’. You begin to wonder what’s wrong with these people, they just come in for two minutes and they’re telling you what to do. Come and be here for eight hours and realise what we’re going through, you know (FG site 1).
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Nurses also described situations in which some managers made them feel responsible for having caused resident’s BPSD that led to staff injuries. One nurse described a manager’s response to her having reported an injury associated with a resident’s BPSD as follows: What did you do wrong? You should have . . . Yeah, – it wasn’t the resident’s fault. It’s all, how did you mishandle the resident? It’s not about the resident, it’s more about what we did wrong (FG site 1). Given this situation, nurses indicated there was a tendency to underreport BPSD or any consequential staff injury. One nurse stated: Half the time I don’t even report getting injured. Yeah. If I get – coming home with bruises, and I just don’t report them now. Because otherwise you do too many reports and it looks like you’re not a person who’s handling the job very well, so you’ll be brought into the office. You’ve got a lot of incident forms of people hitting you. You’re obviously not very good at your job. It’s not that you’re been good at reporting, exposing what this patient’s like. It’s more that you’re not good at your job. So I just don’t report most [BPSD or injury] . . . unless it’s been observed by someone else, then I kind of have to (FG site 1).
Discussion and recommendations The aim of the study was to describe nurses’ experiences of caring for people with BPSD in LTC and the strategies they used to deal with these behaviours. Nurses described being continually exposed to BPSD as part of their everyday work. They also described a range of strategies to care for residents’ with BPSD, and many of these strategies resembled good models of care. For example, they spoke about the importance of ‘knowing’ each individual residents’ life history and personal preferences. They also described trying to problem-solve the cause of BPSD, and using a range of techniques to prevent symptoms from escalating. The main challenge for them was not the management of BPSD per se, but rather work constraints that hindered their efforts to implement interpersonal approaches to care for residents with BPSD, and they felt their efforts and expertise were poorly recognized, especially when they were blamed for triggering residents’ BPSD. Hence, while the models of care described in the literature represent best practice, they may also represent an ideal that is difficult to implement in the context of organizational constraints. The concerns described by nurses in this study about the constraints of working in LTC are not new. The Institute of Medicine (1986) reported similar problems in its seminal report about US nursing homes as long ago as 1986. Research
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continues to reveal stress associated with understaffing in LTC, having an excessive workload, being unable to perform ones’ role, and being poorly paid (Bostick et al. 2006; Lapane & Hughes 2007; Schmidt & Diestel 2013; Schmidt et al. 2014). Consistent with findings from other research (Morgan et al. 2002), nurses feel ‘rushed’ and anxious about their ability to keep up with the work demands, and they link this situation to not having enough staff to perform the work. Current evidence-based clinical practice guidelines for the LTC sector and interdisciplinary collaborations such as the project titled Re-imagining Long-term Residential Care (2011–2014), and models of care such as The Eden Alternative® (Thomas 1996), and The Tri-Focal Model of Care (O’Connell et al. 2008) promote partnership-centred, evidence-based, team-based and non-pharmaceutical approaches to the care of people with BPSD. However, if the current findings hold true for other LTC facilities, further work is required to address workforce constraints that hinder nurses from the uptake and sustained use of best practice recommendations about such care. The combined findings from the study and extant research highlight the importance of attending to the multifactorial constraints associated with care delivery in LTC, and to avoid quick fixes that focus solely on nurses’ education. Nurses’ responses indicated they were well informed about interpersonal approaches to manage residents with BPSD and they conveyed support for a restraint-free environment. However, nurses indicated they often had no choice but to use medical and physical restraint, particularly when staff-to-resident ratios did not enable them to supervise residents with BPSD on a one-onone basis, and when nurses felt unsafe. It is important to note that understaffing, working with insufficient resources, working with a style of management based on intimidation, and functioning in a culture of tolerance or acceptance of violence are important risk factors for violence in the healthcare workplace (International Labour Organization et al. 2002). It is incumbent on managers to heed nurses’ concerns about the structural factors that hinder them from consistently implementing interpersonal approaches to prevent BPSD or circumvent an escalation in symptoms. It is important that managers in LTC recognize the difficult circumstances under which LTC staff are providing care and provide staff with more encouragement and support. The fact that some nurses described being cast as the cause of residents’ adverse behaviours should also elicit concern. This finding resembles Morgan et al. (2008) and Scott et al. (2011) who reported that nurses often felt frustrated as they were blamed for triggering BPSD. In the current study, nurses indicated they underreported the injuries they experienced, which masked the true extent of the problem. The situation was com-
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pounded by residents’ family members who expressed dissatisfaction to managers about the level of care nurses provided. In these circumstances nurses felt unfairly judged as family members did not fully appreciate the difficulties managing residents with BPSD. This issue warrants further attention and a more complex strategy of caring that promotes a collegial and partnership centred approach to residents’ care. Limitations
This study was conducted in three LTC units in Australia. The findings are context-based and representative of LTC units that care for older adults with mid- to late-stage dementia and high care needs. Moreover, they were limited to nurses’ perspectives and experiences, and were not representative of other care providers in LTC, such as allied health staff. The nurses shared their opinions with a nurse researcher in the context of small group forums. It is probable that the information the nurses shared was influenced by the presence of other nurses in the FG interviews, the number of participants in each group, as well as the role of the researcher. As the study was not designed to compare nurses’ subjective reports with their actual practice, it is not possible to comment on the degree to which care was personcentred. Moreover, generalizability is not being claimed, and it is acknowledged that transferability of the findings is limited. Implications for nursing and health policy
Organizational efforts to enhance the quality of care for individuals with BPSD in LTC should extend beyond staff education. They need to address nurses’ concerns about the contextual factors in LTC that hinder them from consistently using interpersonal approaches to care for residents with BPSD. Managers in LTC need to acknowledge the difficult and pressured conditions care staff are working under and provide them with positive feedback and support. Given the financial constraints experienced in these settings, there is need for further research in LTC that explore everyday strategies that are able to be easily implemented in a sustainable way. It is also important to educate the public about BPSD and its prevalence in today’s elderly population and to lobby governments for increased allocation of research and healthcare funds.
Conclusion This study found that nurses encountered many challenges while caring for residents with BPSD. Given the global trend in increased life expectancy, ageing population and increased prevalence of dementia, the findings have major implications for the global nursing workforce, and should be of concern to policymakers, researchers and leaders in aged care. As the
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population ages and the demand for nursing knowledge and skills to care for people with dementia increases, there is a commensurate need to support the workforce deliver high-quality care that involves creating a culture in which staff and residents alike feel safe and valued.
Acknowledgement This project was funded by a grant from the Quality and Patient Safety Research (QPS) Strategic Research Centre, Deakin University.
Author contributions PL, BO and MH were involved in the study conception/design; JO conducted the data collection. JO and PL conducted the analysis. MH provided statistical support. JO drafted the paper and all authors provided critical revisions for important intellectual content.
References Alzheimer’s Disease International (2009) World Alzheimer Report 2009. The Global Prevalence of Dementia. Available at: http://www.alz.co.uk/ research/world-report-2009 (accessed 2 February 2015). Alzheimer’s Disease International (2013a) Alzheimer’s Disease International Policy Brief for Heads of Government. The Global Impact of Dementia 2013–2050. Available at: http://www.alz.co.uk/research/G8-policy-brief (accessed 28 April 2014). Alzheimer’s Disease International (2013b) World Alzheimer Report 2013: An Analysis of Long-Term Care for Dementia. Available at: http:// www.alz.co.uk/research/world-report-2013 (accessed 28 April 2014). Alzheimer’s Society (2014). Dementia UK. (2nd ed). (accessed 2nd February 2015). Available at: http://www.alzheimers.org.uk/dementiauk Bostick, J.E., Rantz, M.J., Flesner, M.K. & Riggs, C.J. (2006) Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7, 366–376. Chrzeschijanski, D., Moyle, W. & Creedy, D. (2007) Reducing dementiarelated aggression through a staff education intervention. Dementia (Basel, Switzerland), 6, 271–286. Cohen-Mansfield, J. (2004) Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary and critique. Focus (San Francisco, Calif.), 2 (2), 288–308. Cohen-Mansfield, J. & Parpura-Gill, A. (2007) Bathing: a framework for intervention focusing on psychosocial, architectural and human factors considerations. Archives of Gerontology and Geriatrics, 45, 121–135. ED Management (2007) Survey: most ED staff victimized by violence never report incident. ED Management: The Monthly Update on Emergency Department Management, 19 (10), 109–111. Fair Work Act (2009) Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012–2016. S.185 – Enterprise agreement Victorian hospitals’ industrial association (ag2012/ 9133). Available at: https://www.fwc.gov.au/awards-and-agreements (accessed 2 December 2014).
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Gates, D.M., Ross, C.S. & McQueen, L. (2006) Violence against emergency department workers. The Journal of Emergency Medicine, 31 (3), 331– 337. Guba, E.G. (1981) Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal, 29 (2), 75–92. Hesketh, K.L., et al. (2003) Workplace violence in Alberta and British Columbia hospitals. Health Policy, 63, 311–321. Hills, D.J., Joyce, C.M. & Humphreys, J.S. (2012) A national study of workplace aggression in Australian clinical medical practice. The Medical Journal of Australia, 197 (6), 336–340. Institute of Medicine (1986) Improving the Quality of Care in Nursing Homes. The National Academies Press, Washington, DC. International Labour Organization, International Council of Nurses, World Health Organization & Public Services International (2002) Workplace Violence in the Health Sector. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva, International Labour Office. Kansagra, S.M., et al. (2008) A survey of workplace violence across 65 US emergency departments. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 15 (12), 1268–1274. Landes, A.M., Sperry, S.D., Strauss, M.E. & Geldmacher, D.S. (2001) Apathy in Alzheimer’s disease. Journal of the American Geriatrics Society, 49 (12), 1700–1707. Lapane, K.L. & Hughes, C.M. (2007) Considering the employee point of view: perceptions of job satisfaction and stress among nursing staff in nursing homes. Journal of the American Medical Directors Association, 8, 8–13. Mahoney, E.K., et al. (1999) Development and testing of the Resistiveness to Care Scale. Research in Nursing and Health, 22 (1), 27–38. Merecz, D., Drabek, M. & Moscicka, A. (2009) Aggression at the workplace-psychological consequences of abusive encounter with co-workers and clients. International Journal of Occupational Medicine and Environmental Health, 22 (3), 243–260. Morgan, D.G., Semchuk, K.M., Stewart, N.J. & D’Arcy, C. (2002) Job strain among staff of rural nursing homes: a comparison of nurses, aides, and activity workers. The Journal of Nursing Administration, 32 (3), 152–161. Morgan, D.G., et al. (2008) Taking the hit: focusing on caregiver ‘Error’ masks organisational-level risk factors for nursing aide assault. Qualitative Health Research, 18 (3), 334–346. Needham, I., et al. (2005) Non-somatic effects of patient aggression on nurses: a systematic review. Journal of Advanced Nursing, 49 (3), 283– 296. O’Connell, B., Ostaszkiewicz, J., Sukkar, K. & Plymat, K. (2008) The trifocal model of care: advancing the teaching-nursing home concept. International Journal of Nursing Practice, 14 (6), 411–417. Patton, M.Q. (2002). Qualitative research and evaluation methods (3rd ed). Thousand Oaks, CA: Sage. Re-imagining Long-Term Residential Care. (2011–2014). York University. Available at http://reltc.apps01.yorku.ca/our-project (accessed 2 December 2014). Richter, D. & Berger, K. (2006) Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study. BMC Psychiatry, 6, 15.
516
J. Ostaszkiewicz et al.
Schat, A. & Frone, M. (2011) Exposure to psychological aggression at work and job performance: the mediating role of job attitudes and personal health. Work and Stress, 25 (1), 23–40. Schmidt, K.H. & Diestel, S. (2013) Job demands and personal resources in their relations to indicators of job strain among nurses for older people. Journal of Advanced Nursing, 69 (10), 2185–2195. Schmidt, S.G., Dichter, M.N., Bartholomeyczik, S. & Hasselhorn, H.M. (2014) The satisfaction with the quality of dementia care and the health,
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burnout and work ability of nurses: a longitudinal analysis of 50 German nursing homes. Geriatric Nursing, 35, 42–46. Scott, A., Ryan, A., James, I. & Mitchell, E.A. (2011) Perceptions and implications of violence from care home residents with dementia: a review and commentary. International Journal of Older People Nursing, 6, 110– 122. Thomas, W. (1996) Life Worth Living. Vander Wyk and Burnham, Massachusetts.
