A comparison between the care of vocally disruptive patients and that of other residents at psychogeriatric wards

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

Verbal interaction during the lunch-meal between caregivers and vocally disruptive demented patients

The purpose of this study was to investigate the establishment and maintenance of the relationship between vocally disruptive severely demented patients and their caregivers as well as what was communicated during a verbal interaction episode (lunchmeal). Two dimensions of verbal interaction were studied, the amount of interactions focused on the task versus the person and the process of verbal interaction. Tape-recordings that had been typed out were analyzed. They concerned 34 vocally disruptive demented patients at psychogeriatric wards and their caregivers. The caregivers'verbal interaction was extremely oriented towards the task performed. Very little interaction took place with more personal orientation. Clarity of cues was found in only one third of the episodes and turn-taking was established in about half of them. The findings show that there was little emphasis on making the feeding procedure a social experience in combination with the task performed. Seemingly, the therapeutic possibilities that caring entails was not taken advantage of

Vocally disruptive behaviors in people with cognitive impaitment: Current knowledge and future research directions

This paper is a literature review of vocally disruptive behaviors (VDB) in people with dementia. This area of interest has not caught the full attention of researchers and professionals alike. Thus, the knowledge base being developed is limited. This paper will discuss the prevalence and the severity of the problem. The profiles of persons displaying VDB will be portrayed, as will the context for which VDB frequently occurs. Then, postulations regarding the etiologies for VDB and corresponding interventions will be explicated. Unfortunately, systematic studies are few and the effectiveness of different kinds of intervention strategies has not been supported by empirical data. Finally, issues pertaining to the study of VDB will be examined and directions for future research will be recommended.

Preventing Excess Disability in an Elderly Person With Alzheimer's Disease

Staff of an adult day treatment facility reported that a client diagnosed with Alzheimer's disease was exhibiting physical and verbal aggression toward other clients. Direct observation of the client's interactions at the adult day treatment facility revealed that she was neither physically nor verbally abusive but was assertive and used a cane to access social attention. Treatment consisted of three in-service trainings during which staff received information about the symptomatology of dementia, environmental factors contributing to excess disability, and the importance of environmental support for maintaining adaptive behavior in persons with dementia. Results indicate that staff perceived verbal behavior less negatively, and allowed the client to interact with others at a significantly increased frequency.

Language-based communication strategies that support person-centered communication with persons with dementia

BACKGROUND

There are many recommended language-based strategies for effective communication with persons with dementia. What is unknown is whether effective language-based strategies are also person centered. Accordingly, the objective of this study was to examine whether language-based strategies for effective communication with persons with dementia overlapped with the following indicators of person-centered communication: recognition, negotiation, facilitation, and validation.

METHODS

Conversations (N = 46) between staff-resident dyads were audio-recorded during routine care tasks over 12 weeks. Staff utterances were coded twice, using language-based and person-centered categories. There were 21 language-based categories and 4 person-centered categories.

RESULTS

There were 5,800 utterances transcribed: 2,409 without indicators, 1,699 coded as language or person centered, and 1,692 overlapping utterances. For recognition, 26% of utterances were greetings, 21% were affirmations, 13% were questions (yes/no and open-ended), and 15% involved rephrasing. Questions (yes/no, choice, and open-ended) comprised 74% of utterances that were coded as negotiation. A similar pattern was observed for utterances coded as facilitation where 51% of utterances coded as facilitation were yes/no questions, open-ended questions, and choice questions. However, 21% of facilitative utterances were affirmations and 13% involved rephrasing. Finally, 89% of utterances coded as validation were affirmations.

CONCLUSIONS

The findings identify specific language-based strategies that support person-centered communication. However, between 1 and 4, out of a possible 21 language-based strategies, overlapped with at least 10% of utterances coded as each person-centered indicator. This finding suggests that staff need training to use more diverse language strategies that support personhood of residents with dementia.

Missed opportunities for person-centered communication: implications for staff-resident interactions in long-term care

BACKGROUND

Social interactions in long-term care settings between staff and residents with dementia have been characterized as task-oriented, patronizing, and/or overly directive. Long-term care settings can be contexts that emphasize dependency and threaten the personal identity of older residents. Yet, leaders in the long-term care sector have acknowledged recently that dementia care must move beyond the completion of caregiving tasks and adopt a person-centered approach. This approach involves caregivers incorporating a resident's life history and preferences during interactions. The objectives of this study were to examine the extent to which staff-resident communication is person-centered and the extent to which staff miss opportunities to communicate with residents in a person-centered manner.

METHODS

Conversations (N = 46) of 13 staff-resident dyads were audio-recorded during routine care tasks over 12 weeks. Staff utterances within these conversations were coded for person-centered communication and missed opportunities where person-centered communication could have been used.

RESULTS

Findings revealed a common communication sequence where utterances coded as person-centered were followed by utterances coded as missed opportunities. This sequence suggests that the positive impact of person-centered communication may be undermined when such communication is followed by missed opportunities. Data also revealed that missed opportunities highlight the need for staff training.

CONCLUSION

The findings underscore the importance of sustaining person-centered communication while completing routine care tasks.

Caring connections with older persons with dementia in an acute hospital setting - a hermeneutic interpretation of the staff nurse's experience

BACKGROUND

  The literature highlights the challenges inherent in caring for older persons with dementia in the acute care context. However despite concerns relating to the quality of care available to persons with dementia in this setting, there is a paucity of research with which to guide practice. Specifically the existing literature lacks in-depth knowledge on nurses' experiences.

AIM

  The aim of this paper is to report the findings of a study exploring nurses' experiences of caring for older persons with dementia in an acute hospital setting.

METHODS

  Using a hermeneutic approach, a purposive sample of seven nurses was interviewed regarding the research phenomenon. Interview texts were subjected to thematic content analysis. Multiple data sources were employed to expand the horizon of understanding including: the textual data, personal and professional understandings, reflective journal data and conceptual frameworks derived from theoretical and research literature. The data were collected in 2002.

RESULTS

  The findings reported here relate to the theme 'Meeting the patient as a person'. Meaningful care for the older person with dementia in the acute context required a respectful connection with the patient as person, which required establishing a bond with the person. The meaning of the caring experience was found to relate to the personhood of both the nurse and the patient, experienced within the context of relationship. To make this connection it was necessary to work with those who knew the patient best i.e. relatives/carers.

CONCLUSIONS

  Despite the contextual limitations of the acute setting, the importance of knowing and respecting the person with dementia and the centrality of relationship as the medium within which caring is experienced is demonstrated. However, nurses lack specific knowledge on which to base care. Further research is therefore recommended to identify how care which promotes the integrity of the person with dementia may be effectively operationalized across the acute care setting.

Perceptions of family and staff on the role of the environment in long-term care homes for people with dementia

BACKGROUND

Disruptive behaviors are frequent and often the first predictor of institutionalization. The goal of this multi-center study was to explore the perceptions of family and staff members on the potential contribution of environmental factors that influence disruptive behaviors and quality of life of residents with dementia living in long-term care homes.

METHODS

Data were collected using 15 nominal focus groups with 45 family and 59 staff members from eight care units. Groups discussed and created lists of factors that could either reduce disruptive behaviors and facilitate quality of life or encourage disruptive behaviors and impede the quality of life of residents. Then each participant individually selected the nine most important facilitators and obstacles. Themes were identified from the lists of data and operational categories and definitions were developed for independent coding by four researchers.

RESULTS

Participants from both family and staff nominal focus groups highlighted facility, staffing, and resident factors to consider when creating optimal environments. Human environments were perceived to be more important than physical environments and flexibility was judged to be essential. Noise was identified as one of the most important factors influencing behavior and quality of life of residents.

CONCLUSION

Specialized physical design features can be useful for maintaining quality of life and reducing disruptive behaviors, but they are not sufficient. Although they can ease some of the anxieties and set the stage for social interactions, individuals who make up the human environment are just as important in promoting well-being among residents.

The meanings of screams in older people living with dementia in a nursing home

BACKGROUND

Screaming is common among older persons living with dementia in nursing homes. Research on this population has not provided a useful basis for understanding such behavior that could help determine appropriate interventions. The purpose of this study was to explore the meanings of screams in older people living with dementia and their influencing factors.

METHODS

Critical ethnography was selected as the research design. Seven triads, each composed of an older person living with dementia who screamed, a primary family caregiver, and one or two formal caregivers, were recruited in a nursing home. Various data collection methods and Spradley's (1979) ethnographic analysis were used.

RESULTS

Screaming is related to vulnerability, suffering, and loss of meaning experienced by older persons. This singular behavior also expresses various final outcomes that can be differentiated through modulation criteria. The meanings of screams are influenced by stability and flexibility in the nursing care organization and reciprocal effects between older persons who scream and others in the nursing home environment. Each person's screams constitute a unique language that can be learned. Other influencing factors include respect for the older person's wishes, needs, and personality, shifts in power relations within the triad, and feelings of powerlessness and guilt in family and formal caregivers.

CONCLUSIONS

This study advances knowledge of the meanings of screams in older persons living with dementia. It has implications for and offers insight on culturally congruent care for older persons living with dementia and the people around them.

Étude préliminaire d'une intervention non-pharmacologique pour réduire l'agitation verbale chez les personnes atteintes de démence

Verbally agitated behaviours are among the behavioural symptoms of dementia most commonly encountered in long-term care facilities. These behaviours may be related to unmet needs that cannot be expressed adequately because of cognitive impairment. The objective of this preliminary study is to assess an intervention, based on the needs of social attention, sensory stimulation, and comfort, for managing verbally agitated behaviours in long-term care demented patients. A multiple baseline case study design was used, with two participants.

A different story: exploring patterns of communication in residential dementia care

This article reports findings from a three-year project on ‘Communication patterns and their consequences for effective care’ that explored communication in dementia-care settings. As the proportion of people with dementia living in British care-homes continues to grow, there is a need to understand better their care. Using a range of qualitative methods, the project set out to identify the constituent elements of dementia-care practice and the patterns that characterise day-to-day relations in care homes. The tightly prescribed and standardised nature of the interactions between staff and residents is described: it raises questions about the capacity for dementia care to be truly person-centred. The project found that people with dementia are both capable of communication, and invest much effort in seeking to engage those around them, but are excluded from the monitoring, planning and provision of care in ways that we argue are discriminatory. The case is made for promoting and supporting communication as key skills and competencies for care workers. The value of measuring the level and quality of communication as a means to evaluate care is demonstrated. The authors question the priorities that currently guide care practice and argue that we need to listen to people with dementia and rethink what lies at the heart of dementia care.

Screaming in elderly persons with dementia

This article presents a critical review of empirical data to guide knowledge development of screaming in elderly persons with dementia. Many reasons have been identified for why humans and animals scream. Studies on elderly populations have focused mostly on factors associated with screaming. Also, a vast selection of interventions for elderly persons with dementia who scream has been tested, but there is little evidence of their efficacy. Better knowledge of screaming in this population is needed. In particular, the meaning of this behaviour must be determined and stronger evidence of the efficacy of interventions must be acquired. In order to develop helpful clinical interventions, it is suggested that diverse research methods be used and that the perspective of all actors involved be considered, including that of the elderly persons, their families and their professional caregivers.

Verbal and physical non-aggressive agitated behaviors in elderly persons with dementia: robustness of syndromes

OBJECTIVE

More than a decade ago, different syndromes of agitation were identified in elderly nursing home residents, and it was found that these syndromes correlate with medical, cognitive, and psychosocial functioning. The present study was conducted to examine the robustness of two major syndromes, verbal agitation and physical non-aggressive agitation, as assessed via direct observations.

METHODS

Study participants were 175 elderly persons with dementia recruited from 11 nursing home facilities in Maryland. Observations of the participants' behavior were conducted using the agitated behaviors mapping instrument.

RESULTS

The profiles that emerged for physically agitated residents and for verbally agitated residents were remarkably similar to those originally reported. Specifically, verbally agitated behaviors correlated with female gender, with cognitive decline, poor performance of activities of daily living, impaired social functioning, and signs of depressed affect. Physically non-aggressive agitated behaviors correlated with cognitive impairment and with fewer concurrent medical diagnoses.

CONCLUSIONS

Examining correlates of different syndromes of agitated behaviors may provide researchers with valuable information that can be used for in-depth analysis of both the characterization and etiology of agitation, thus paving the way for the development of interventions that target particular types of problem behaviors.

Psychiatric nurses' attitudes towards identified inpatients as measured by the semantic differential technique

Nursing care can figuratively be described as a gift that is given by the nurse in the nurse-patient relationship where attitudes play an important role for the gift's appearance. Sometimes patients are unwilling to or incapable of accepting the gift and this can lead to situations in which nurses are not able to handle their situation in a professional manner. This research survey aimed to investigate nurses' attitudes and find a structure in nurses' attitudes towards their patients. Six psychiatric group dwellings and six acute psychiatric hospital wards participated in the study. In all, 2700 assessments of 163 patients were sent out to 160 respondents and 2436 answers were returned. The semantic differential technique was used. The scale has 57 bipolar pairs of adjective, which estimate an unknown number of dimensions of nurses' attitudes towards an identified patient. The respondents' answers were analysed through factor analysis rotated using the Varimax method and etropy-based measures of association combined with structural plots were also used. Both the factor analysis and the entropy revealed three factors, which were interpreted as being of evaluative type. Factor 1 was interpreted as describing nurses' answers mainly as a combination of an ethical and aesthetic evaluation of the patients. Factor 2 was interpreted as being of an empathetic type and factor 3 as nurses' experiences of the patients' cognitive capacity. The study indicates that the dominant aspect of nurses' attitudes in a psychiatric context is the ethical/aesthetic dimension, which is an important finding for the understanding of nurses' attitudes and actions towards their patients.

Staff's experience of and the management of violent incidents in elderly care

Violence towards staff has become an important issue, since it has been reported to be common in various health care settings. This study aimed to describe emotional reactions among staff being exposed to violence in residential community care for the elderly: to investigate consequences from violent incidents and to describe the management of violent incidents. Data were collected by telephone interviews with nursing staff reporting incidents of violence. During the period of investigation, 97 of 848 staff (11.4%) reported that they had been exposed to violence. More than one-third of them reported subsequent wound and bruises from the incident and two of the exposed staff consulted a doctor because of the violent incident. The most frequently reported reactions among the staff were aggression, astonishment, and antipathy against the perpetrating care recipient, as well as insufficiency, powerlessness, insult and fear. A majority of the incidents were judged as intentionally perpetuating from the care recipient. Most of the violent incidents were managed by informal discussions in the working team. A low number of the reported incidents of violence involved formal discussions with nurse managers.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

The meaning of caring as described by nurses caring for a person who acts provokingly: an interview study

Nurses working with people with learning disabilities are sometimes exposed to provoking behaviour such as unpredictable and violent actions, spitting and sexual harassment. Eight nurses at a group dwelling in Sweden were interviewed about their experiences when caring for a person who acts provokingly. Narrative interviews were conducted and interpreted using a method inspired by Ricoeur. Three themes were formulated which describe nurses' feelings of being tormented, disrupted and helpless. Nurses describe themselves as being deeply humiliated by physical violence, spittle, sexual invective and actions on the part of the patient. They respond more to being spat on and the sexual invective than to the patient's physical violence. The frequent humiliations could be seen as a symbolic language connected to defilement and 'evil' and therefore as having a deep symbolic meaning for the nurses. These results were interpreted and reflected on in the light of a theoretical framework from an affliction perspective in order to achieve a deeper understanding of the text. This paper shows that an affliction perspective is important when searching for the meaning of caring for a patient who acts provokingly. The study indicates that the goal in a provoking care situation must be to see the provoking patient, as he appears to the nurses in order to glimpse the goodness concealed behind the provoking facade.

Picking behaviour in cognitively impaired residents in geriatric settings: prevalence of the behaviour and characteristics of the residents

This paper presents the findings of a point prevalence study performed at all geriatric settings within a county in Northern Sweden. The aims of the study were twofold: to investigate the prevalence of picking behaviour in cognitively impaired residents in various kinds of geriatric care settings and describe the characteristics of the residents, and to investigate how the residents who exhibit picking behaviour are experienced by their care providers. The study comprises 1928 cognitively impaired residents. The prevalence of picking behaviour was found to be 17%. Multivariate analyses showed that behavioural and psychiatric symptoms such as 'often stands at the outer door and wants to go out', 'wanders alone or with other patients back and forth', 'aggressive threats to patients and staff' and being 'manic' and 'fearful' were associated with picking behaviour. Other factors associated with picking behaviour were 'taking part in daily tasks', 'can walk without assistance' and imposing a high psychological workload. Furthermore, residents who exhibited picking behaviour were experienced by care providers as more uncertain and unhappier than residents who did not behave in this way.

Nurses' attitudes towards older residents with long-term schizophrenia

BACKGROUND

In institutional care, a symptom-oriented approach is a frequently used but seldom-discussed method for treating people with severe mental illness.

AIM

To investigate whether nurses' approach could be explained with reference to a client's individual clinical picture or the fact that they had a diagnosis of schizophrenia.

METHODS

An exploratory study of the staff's view of a caring approach for a fictitious older long-term schizophrenic resident was conducted. All nurses working in the field of psychiatry at seven different units in one municipality in northern Sweden were an integral part of the study. The units were divided into two groups and classified as 'dwelling' or 'support'. The 'dwelling group' was characterized by nurses working at traditional group dwellings, and the 'support group' by nurses working in small teams and visiting people with long-term mental illness in their homes. Responses were received from 62 women and 23 men, of whom 14 were Registered Nurses and 69 were Enrolled Nurses. A questionnaire was used, developed from a case description of a 68-year-old woman with typical symptoms of severe cognitive decline, with problematic behaviour and a diagnosis of long-term schizophrenia.

FINDINGS

The main finding was that nurses with long experience became less sensitive in their relationship with the resident than less experienced nurses. There appeared to be a tendency for long work experience to have a negative effect on nurses' attitudes towards the resident.

CONCLUSIONS

The nurses could be interpreted as being caught in a moral dilemma between ends and means. This dilemma could be represented on the one hand as the 'conformist mode', with an acceptance of ends and means, and on the other hand as the 'innovation mode', with acceptance of ends but with few legitimate means to achieve them.

Incidence of violence towards staff caring for the elderly

A survey study concerning violence was conducted among staff (n=506) working with the elderly in residential settings and ordinary homes. The major aim of the study was to investigate the incidence of violence directed towards staff by elderly people living in residential settings. Furthermore, associations between the number of violent incidents and gender, age, year in service, year at present place of work, education of the staff, type of setting, the frequency and type of violence as well as the emotional reactions expressed by the staff should be examined. Forty percent of the staff was exposed to violence during the preceding year and 18% noted incidents of violence daily. A significantly larger proportion of staff working in nursing homes registered violence compared with those working in other types of settings. Physical violence was the most common (76%) type of violence. Powerlessness, sadness, anger and feelings of insufficiency were the most dominant feelings among staff facing by violent situations. Our results point to the necessity to further study caregivers' perception of patient violence and its impact on the quality of care.

The relationship between organizational climate and the content of daily life for people with dementia living in a group-dwelling

1. One factor influencing the outcome of care may be nursing staff's experience of the organizational work climate. The aim of the study was to investigate how people with dementia spend their time in group-dwelling units (GD) with either a creative or less creative organizational climate. 2. For the study, two GD units assessed as having a creative organizational climate and two units assessed as having a less creative climate were selected. Eighteen residents living in the units assessed as creative and 20 residents living in the units assessed as less creative participated in the study. 3. For measuring the organizational climate the Creative Climate Questionnaire was used. Observations of residents' activities were classified according to the Patient Activity Classification. For measuring residents' functional ability the Multi-Dimensional Dementia Assessment Scale was used. Their cognitive capacity was measured with the Mini Mental State Examination. 4. Residents living in the units assessed as having a creative organizational climate spent 45.2% of the time with nursing staff, while those in the less creative climate spent 25.6% (P < 0.001). Time spent with fellow residents in the creative climate was 13.9% and in the less creative climate 31.3% (P < 0.001). There was no significant difference between the units according time spent with relatives and time spent alone. 5. Since the purpose of GD is to offer care adapted to the abilities and psychosocial needs of people suffering from dementia, a less creative climate can be a threat to the aims of GD. In order to maintain these, it is important for managers to be aware of the work climate and its impact on care for people with dementia.

How patients with dementia spend their time in a psycho-geriatric unit

This paper presents the findings of a work sampling study conducted at an assessment unit for patients with dementia at a university hospital in Northern Sweden. The aim of the study was to describe the activity of the demented patients' day at a psycho-geriatric unit, and to investigate the correlation between the patients' characteristics and time provided by nursing staff, in order to increase our knowledge of institutionalized demented patients situation. The sample consisted of 24 patients with dementia. The activities of patients were monitored at 10-min interval between 7.00 a.m. and 9.10 p.m. In total, 2024 activities were recorded. The findings showed that being demented and placed in a psycho-geriatric unit is a life in solitude for most of the time. The variation in time patients spent in solitude could partly be explained by their communication abilities. For patients with dementia, communion is essential for their well-being. In order to develop their well-being, it seems important to enhance our knowledge about the reasons, that influence the nursing staffs' perceptions of patients with dementia, to decrease their time in solitude.

Interaction relating to privacy, identity, autonomy and security. An observational study focusing on a woman with dementia and "behavioural disturbances", and on her care providers

AIM

The study aims to illuminate how one woman with severe dementia and so-called behavioural disturbances acts in relation to her care providers and how the care providers act in relation to her.

METHODS

Fourteen participant observations, including one woman with dementia and six care providers, were performed. A reflective dialogue focusing on the interaction between the woman and her care providers followed each observation. The tape-recorded observational notes and reflective dialogues were fixed as a text, which was subjected to a thematic content analysis.

FINDINGS

The main findings are that the interaction between a woman with severe dementia and "behavioural disturbances" and her care providers relates to privacy, identity, autonomy and security. The phenomena are intertwined and also in conflict with each other. Interaction is a complex dialectic process in which those who are engaged meet problems that can be solved and are involved in dilemmas that cannot be solved, only related to.

Come talk with me: improving communication between nursing assistants and nursing home residents during care routines

PURPOSE

We examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNAs) on verbal interactions between CNAs (n = 64) and nursing home residents (n = 67) during care routines.

DESIGN AND METHODS

CNAs were taught to use communication skills and memory books during their interactions with residents with moderate cognitive impairments and intact communication abilities. A staff motivational system was used to encourage performance and maintenance of these skills. Formal measures of treatment implementation were included.

RESULTS

Results were compared with those for participants on no-treatment control units. Trained CNAs talked more, used positive statements more frequently, and tended to increase the number of specific instructions given to residents. Changes in staff behavior did not result in an increase in total time giving care to residents. Maintenance of CNA behavior change was found 2 months after research staff exited the facility. Although an increase was found in positive verbal interactions between CNAs and residents on intervention units, other changes in resident communication were absent.

IMPLICATIONS

Nursing staff can be trained to improve and maintain communication skills during care without increasing the amount of time delivering care. The methodological advantages of including measures to assess treatment implementation are discussed.

Nursing staff perceptions of the behaviour of older nursing home residents and decision making on restraint use: a qualitative and interpretative study

This study examined staff perceptions of the behaviour of older nursing home residents and how these perceptions govern their decision making on restraint use. Data were collected in unstructured interviews with 20 trained and untrained nursing staff from two Swiss nursing homes. Data analysis was based on Colaizzi's phenomenological method. Two main themes were extracted from the data: (i) situations in which behaviour is perceived in terms of a problem that needs to be controlled and consequently leads to restraint use; and (ii) situations in which behaviour is perceived in terms of something one has to learn to live with and consequently leads to avoidance of restraint. Staff members' choices to perceive resident's behaviour from the angle they did were clearly associated with the rights and responsibilities of both nursing staff and older people. It is concluded that the primary source of change towards the avoidance of restraint use does not necessarily lie in external factors, but in staff members themselves.

Unwillingness to be violated: carers' experiences of caring for a person acting in a disturbing manner. An interview study

Carers working in psychiatric care are sometimes exposed to insane, unpredictable and violent actions. In rare cases a patient appears to be resistant to all forms of pharmacological treatment. Fifteen carers (four registered nurses, 11 enrolled nurses) on a psychiatric ward in Sweden were interviewed about their experiences when caring for a person who acted in a disturbing manner. Narrative interviews were conducted and interpreted using a method inspired by Ricoeur. Four themes were formulated which describe the carers' uncertainty about the future, their inability to interpret the patient's disturbing behaviour and their own overall feeling of meaninglessness. The carers were of the opinion that the patient had the power and ruled the ward, which led to them feeling they were subjugated victims. The interviews also revealed the carers' recognition of forbidden feelings and actions and unknown negative sides. These results were interpreted and reflected on in the light of an ethical framework in order to achieve a deeper understanding of the text. This paper shows that an ethical perspective is important when searching for the meaning of caring for patients acting in a disturbing manner. The study raises the question: 'Is it possible to establish good when evil has dominion?'.

Longitudinal predictors of non-aggressive agitated behaviors in the elderly

Longitudinal predictors of physically and verbally non-aggressive inappropriate behaviors were examined in 200 community-dwelling elderly persons attending senior day care centers. Models based on ratings obtained from staff members and family caregivers were compared. Multiple factors contributed simultaneously to the prediction of non-aggressive behaviors. Similar to previous cross-sectional results, physically non-aggressive behaviors were predicted mainly by good health and cognitive impairment. In addition, depression emerged consistently as a predictor of physically non-aggressive behaviors in all models. Verbally non-aggressive behaviors were predicted by depressed affect and pain, confirming previous suggestions that these behaviors are related to discomfort. The relationship of these behaviors with cognitive functioning was relatively weak. Understanding the etiologies of non-aggressive problem behaviors can aid in developing appropriate care for this population.

Physical restraint: a descriptive study in Swiss nursing homes

This article focuses on the reasons for using physical restraints, their prevalence and nurses' experiences of their use. The data were collected by means of a questionnaire from nurses, trained nurse's aids and auxiliary staff (n = 173) in seven Swiss nursing homes. The results showed that physical restraints are used in nursing units, the mean number of restrained residents in each being 3.7 (SD 3.9). However, nursing staff did not necessarily understand and consider the term 'restraint' as a restrictive device in its negative sense. The most common reasons indicated for the use of restraint were related to the protection and safety of the residents themselves, the prevention of disturbance of other residents, and the residents' restlessness and aggressiveness. As for the reasons related to staffing, reference was made to understaffing, a lack of competence on the part of nurses, and the demands of residents, their next of kin and doctors. It was not common practice to inform the elderly residents that they would be restrained, and therefore they were not always aware of what was happening to them and why. Twenty-nine per cent of the respondents reported that the flexbility of their work was affected by the use of physical restraint.

The relationship of vocally disruptive behavior and previous personality in severely demented institutionalized patients

The aim of this study was to explore the previous personalities of patients, their behavior during the course of the disease, and the relationship between the previous personality and vocally disruptive behavior of severely demented patients. Twenty-one severely demented patients identified as vocally disruptive and 19 severely demented control subjects who were matched for gender and ward were studied. A family member or close relative who knew the patient very well described the patient's personal characteristics from what they judged to be the "best" period in the patient's life and responded, on behalf of the patient, to the 57 items in a modified version of the Eysenck Personality Inventory. The results of this study can be interpreted to indicate that a previous personality described as introverted, rigid, and with a tendency to control emotions, as remembered retrospectively by a close family member, may correlate to current disruptive behavior. Despite the limitations of this study, the findings indicated that a patient's previous personality characteristics need to be taken into consideration because they may partially explain vocal activity and are therefore important for the provision of nursing care. Further research has to be performed to highlight the impact of previous personality characteristics on various kinds of behavior during the course of the disease.

'Talk to me' Patient Communication in a Long-Term Care Facility

1. Staff are important facilitators for communication among elderly patients, who often are alone and bored for long periods. 2. Staff serve as an essential link between the patients and the outside world, and serve as a conduit for initiating contact between residents. 3. Environment--including the selection of roommates, the proximity of residents, and the volume of radios and televisions--may greatly alter residents' ability to communicate.

Evaluation of a clinical intervention for wanderers on a geriatric nursing unit

In this article, a clinical intervention designed to decrease unsafe wandering and reduce interpersonal tension on a dementia unit of a nursing home is described and evaluated. The intervention, a walking program for physically active persons with severe dementia, was designed to meet residents physical activity and social needs. Based on therapeutic milieu concepts, positive effects in the environment, were expected in addition to the individual benefits for participants. To measure the effect of the intervention on the nursing unit environment, the frequency of resident-to-resident and resident-to-staff aggression in the 24 hour period after the walking group was compared to time periods when the group did not meet. T-test analysis revealed a statistically significant reduction in the frequency of aggression in the 24 hour periods after the walkers group. An average reduction of aggressive events by 30% shown in this small study is important clinically. Further study of modifications in care on geriatric nursing units is warranted.

Effects of clinical supervision on nurse-patient cooperation quality: a controlled study in dementia care

An intervention consisting of individualized planned care for patients and regular clinical systematic supervision for nurses was carried out on a ward for dementia care (the experimental ward, EW). On a similar control ward (CW), no changes were made. Observations of nurse-patient cooperation during morning care were collected at both wards, before and during the intervention. The observations (N = 107) were analyzed blindly and sorted into already-developed categories. The distribution of the cooperation-style categories was then analyzed statistically. The patients who survived throughout the study period (N = 18) were also compared over time. Nurse-patient cooperation at the EW improved significantly during the intervention period, whereas, at the CW, it deteriorated (p = .02). Status of surviving patients followed the same pattern (p = .001). The findings indicate that such interventions can improve the quality of nurse-patient cooperation in dementia care.

Cooperation during morning care between nurses and severely demented institutionalized patients

Nurse-patient cooperation during morning care in two wards for the care of severely demented patients (107 observations) were analyzed by using a hermeneutic-phenomenological approach. Nurse-patient cooperation was found to be characterized by their acting in mutuality or unilaterality and in or out of pace with each other. When acting iri pace and mutuality, the nurse and patient turned to each other as persons as well as to the task. This theme related to confirming nurse actions and actions that provided opportunities for the patient to participate. When acting out of pace and unilaterality, cooperation was mainly task oriented and related to acts of resistance, the use of force, loss of attention or turning to others, or the patient wanted to escape. The findings were interpreted within the contexts of power, empowerment, and powerlessness and may serve as indicators of low- or high-quality nurse-patient cooperation during morning care provided for demented patients.

Initiating and terminating verbal interaction between nurses and severely demented patients regarded as vocally disruptive

The care of demented patients requires clear communication during care procedures. Earlier studies have shown that nurses were often vague in their verbal communication and unpublished observations indicated that in some cases demented patients continued to be verbally active after the nurses had left. This study aimed at exploring further the initiating and terminating phases of verbal interaction episodes between nurses and severely demented patients, to explore any relationship between nurses' communication style and vocally disruptive patients. Nine severely demented patients identified as vocally disruptive were tape-recorded between 07.00 h and 13.00 h. Any nurse-patient interaction episode lasting more than 30 s (n = 58) during care procedures was transcribed verbatim and its verbal communication activity was analysed for content and meta communication, and a communication index was calculated. The results showed strong task orientation and decreased verbal interaction during the course of the interaction. The data supported the assumption that the nurses' communication style increases or decreases patients' vocal activity. Vocal activity after the actual interaction episode seemed to coincide with the parties' communication on various levels, with a different focus of content, and with several nurses being involved in the same procedure. Nurses may become impatient and stressed by their patients' severe communication problems and therefore need to be relieved of this stress and supported so that they can remain close to the patient and be able to interpret his/her communication.