Estimates indicate that over 1.2 million Americans live in nursing homes and that more than half of these residents suffer from a psychiatric disorder. Of those estimated to manifest symptoms of a psychiatric disorder, only approximately 8% are chronic mental patients who were previous residents of long-term psychiatric facilities. A study by Rovner and Rabins1 suggests that 70% to 80% of nursing home residents suffer from one of the cognitive disorders common to aging including: Alzheimer's disease, multiinfarct dementia, Parkinson 's disease, and drug-induced toxicity. These disorders are often manifested by changes in mood and behavior. It is not unusual to observe such symptoms as delusions, wandering, restlessness, agitation, and problems related to eating and sleeping.1
With the steady increase in numbers of nursing home residents who exhibit cognitive disorders, the authors were interested in identifying behaviors perceived to be the most disruptive by both residents of a long-term care facility and nursing staff in the facility. If, in fact, such behaviors could be identified as disruptive to the living and working milieu, those persons exhibiting such behaviors could be identified and nursing care plans could be formulated that would offer a more supportive milieu for these residents.
The "milieu" concept developed from a humanitarian framework that looked at the need to counteract the negative and regressive factors of institutionalization such as the loss of independence of thinking and acting, and the loss of contact with and commitment to the outside world. Strategies suggested to counteract these factors included a distribution of power, open communication, structured interactions, work-related activities, involvement of the community and family in the treatment process, and adaptation of the environment to meet developmental needs.2 Often due to staffing and fiscal constraints, as well as the demands for intermediate and skilled nursing care, these strategies are not necessarily present in existing long-term care facilities. -All residents of long-term care facilities may not respond to this type of milieu, however. Identification of residents who would benefit from some form of special care unit would be one way in which to begin a more therapeutic milieu.
A therapeutic milieu involves a planned use of the environment allowing all participants to have a voice in decisionmaking. Communication of information is of major importance since decision-making relies on accurate communication. Staff and client interactions must be meaningful and consistent in this type of milieu.3 The notion of an adaptation of the therapeutic milieu model for aging individuals with alterations in their health status could become a reality, if residents and nursing staff had a mechanism by which to communicate their concerns with regard to their daily living and working environment. Although the degree of alteration in health status will vary from person to person, thus affecting the resident's ability to participate in the milieu, there is still a continuing need for self-determination, privacy, and personal dignity. The living environment should be structured to enhance in every way possible the individual's self-care where these needs are concerned.
Since residents of a long-term care facility are not necessarily being prepared to return to the community, the most important issues to be addressed would be: 1) self esteem; and 2) satisfaction with the needs of solitude and social interaction. Based on this, perceived control over the impinging environment would be one of the important factors in maintaining the physical and psychological status of the elderly individual. This control could be achieved through an orientation focusing on resident involvement, responsibility, and freedom of choice.
The behavioral approach to establishing a therapeutic milieu is probably best for a long-term care faculty. Specific problem behaviors are identified by the individuals within the facility and planned environmental interventions are then established, thus allowing for specific behaviors to be targeted for change.
This study set out to describe specific disruptive behaviors of residents of a 180-bed, long-term care facility in a large metropolitan area. The facility provides intermediate and skilled nursing care. Its residents come from the surrounding community which includes a large mental hospital. Medicaid is its primary reimbursement source.
At the time of the survey, the resident population was approximately 83% black, 71% female, with a mean age of 79 years. Eight percent had been discharged from a mental institution. The nursing staff consisted of 125 licensed and unlicensed personnel, most of whom lived in the vicinity of the facility.
Resident subjects were assessed by the three tools administered routinely by the institution to determine resident status: 1) Mental Status - The Short Portable Mental Status Questionnaire (SPMSQ)4; 2) Functional StatusKatz's Index of Activities of Daily Living (ADL)5; and 3) Well being- Philadelphia Geriatric Center (PGC) Morale Scale.6 Residents' perceptions of behaviors that most disrupt their living environment were assessed using the Working/Living Environment Survey developed for this study. Demographic data of age and admission date were obtained from the residents' medical records.
The Short Portable Mental Status Questionnaire has been found to be valid and reliable in assessing mental deficits. The ??-point scale ranges from 0-2 (no mental deficit) to 8-10 (severe mental deficit). It is standardized for race and level of education. Functional status, as assessed using the Katz Index of Activities of Daily Living, is considered to be reliable in evaluating rehabilitation progress. It starts with the most complex activity, bathing, and goes through the sixth and least complex activity of daily living, feeding oneself. The individual's level of independence/ dependence in each of the six activities and as a whole were rated 1 (independent) to 7 (dependent). Well-being, as measured by the Philadelphia Geriatric Center Morale Scale, is a 17-item tool for measuring older persons' perceived congruence with their environment. The overall scale has a range of 17 (high morale) to O (low morale). It is further divided into three reliable and valid subscales: 1) agitation; 2) attitude toward own aging; and 3) lonely dissatisfaction.7
The Working/Living Environment Survey was developed in order to identify resident behavior which nursing staff and residents perceived as disrupting then- working/living environment. Twenty-two behaviors were identified from a review of the literature dealing with problem behaviors of residents of nursing homes.8
A 4-point Likert type scale was used: 1) is not noticeable; 2) is noticeable but not disruptive to my working/ living environment; 3) is disruptive to my working/living environment; and 4) is very disruptive to my working/living environment. Face validity was obtained by testing the tool on several nursing staff and residents. Reliability has not been established.
In addition to the Working/Living Environment Survey, staff were also assessed for job satisfaction using Brayfield and Rome's9 "An Index of Job Satisfaction." This tool is widely used in studies of job satisfaction. It consists of 19 positive and negative statements about the job which can be answered using a 5-point Likert scale. Scores can range from -4 (least satisfied) to +35 (most satisfied) with a median score as -6 (neutral). Demographic data obtained from the nursing staff were .age, sex, race, length of employment in long-term care, and !icensure status.
Resident subjects were chosen based upon appropriate responses to the SPMSQ, the routine assessment tool used by the facility. Of the 168 residents present during the time of the study, 41 were unavailable for assessment (hospitalized, in therapies, not located after repeated attempts); 32 were unable to respond (communication disorders, comatose); 26 responded inappropriately (confused); and 25 refused to sign the consent form to participate. Fortyfour subjects consented and completed the survey.
Sixty-six nursing staff participated in the study. The remainder of the staff were either not present at one of the three mandatory inservice education programs, covering all three of the facilities' work shifts where the survey and job satisfaction questionnaires were administered, or they chose not to participate.
RESULTS OF WORKING/LIVING ENVIRONMENT STRESSES
Staff who agreed to participate were administered the questionnaires at the conclusion of the inservice education programs during one week in April 1985. Participants were told that the purpose of the survey was to identify resident behaviors which disrupt their work day. If they agreed to participate, they signed a consent form which included an assurance of anonymity. Each item on the demographic data sheet, the Working/Living Environment Survey, and the Index of Job Satisfaction was read to the group by the graduate students in gerontologie nursing serving as research assistants for this study. Participants responded in writing on answer forms provided for each tool.
Residents were interviewed by the research assistants individually. Data collection took place during April and May of 1985. Frequency, mean, mode, median, and standard deviation data were obtained on all demographic items as well as on scores for the tools administered. Items on the Working/Living Environment Survey were compared between the nursing staff results and the residents' results. Staff and resident demographic data were correlated (using the Pearson Product Moment Correlation) with all items on the Working/Living Survey that had a mean rating of 2.5 or greater on the 4-point Likert scale.
Results of this study indicated that there are certain behaviors identified by both residents and nursing staff of this facility as disruptive to their working/ living environment (greater than 2.0 on the Working/Living Scale) (see Table 1). Residents identified only one behavior of the 22 surveyed as disruptive to their living environment: entering the wrong room (M= 2. 8). This behavior correlated (p=.05) with nine other behaviors but was not one of the 15 behaviors identified by the nursing staff as disruptive. "Wrong room" had a negative correlation with length of time in residence and mental deficit.
Nursing staff identified 15 behaviors with M =2. 5 or greater on the 4-point scale. Five behaviors were greater than 3.0: troublemakers (M=3.9) perceived as being lucid and purposely irritating; verbal assault (M = 3.3); physical assault (M=3.4); behavior exhibiting destruction of other's property (M=3.3); and threatening behavior (M=3.3) where there was a perception of the possibility of physical harm. The fact that there did not appear to be a commonality of items between residents and nursing staff suggests the need to look at differences in perceptions of situations and understanding of terminology.
Residents identified "wrong room" as the most disruptive behavior for them. In her study of locus of control in the institutionalized elderly, Chang10 states that an elderly person may define self control of the immediate environment through the way in which personal daily activities are managed, ie, ambulating, dressing, eating, grooming, socializing, and toileting.
An individual's style of management may be influenced by perceptions of how much control there is over basic resources, such as time, space, and assistance. Residents apparently identified loss of control over their own basic needs, especially space, through consistent identification of this single item.
Certain other items identified by the residents as disruptive correlated with some of the demographic data about them. For example, residents scoring high on the PGC Morale Scale found the occurrence of physical assault, destructive behavior, and general crankiness on the part of other residents to be less bothersome to them. Chang10 postulated that one might ''conceptualize morale as a function of congruence between generalized expectancies and perceptions of immediate situations."
Those persons who had successfully adapted to the environment would have higher morale and, therefore, a minimum conflict between expectations and perceptions of the immediate situation as appeared to be the case with these respondents.
Residents included in the study who had lived longer at the facility had greater mental deficits, greater agitation, greater dependence for self-care, and tended to be more tolerant of aberrant behavior. Residents with a positive attitude toward aging found verbal noise to be less disruptive suggesting a correlation between acceptance and tolerance.
On the Working/Living Scale, the staff identified "troublemaking" as the most disruptive behavior. This was highly correlated with the unlicensed nursing staff. As the questions were posed, it is not possible to discern whether or not staff saw the item "wrong room" as a type of troublemaking. Four other behaviors were identified by nursing as between disruptive and very disruptive: 1) verbal assault; 2) physical assault; 3) destructive behavior; and 4) threatening behavior. Staff were generally unlicensed (68.2%), young (under age 30), working the day shift, and had been employed at the facility for one to three years. This might suggest that staff with this profile needs more assistance in learning to cope in threatening situations.
Staff identified an overall satisfaction with their work while indicating that conditions could be improved. Staff on the whole found their working environment more disrupted by resident behaviors than did the residents themselves.
Age and experience of the staff may have been factors, as well as the fact that where residents must at some point recognize that they are in a permanent environment, the staff is only there for eight hours a day. Awareness on the residents' part might increase their tolerance for their living environment.
The study was limited by the size of the sample and the inability of the investigators to use random sampling. Its intent was to identify specific behaviors disruptive to the working/living environment in a specific long-term care facility. It would appear that the Working/Living Environment Survey could benefit from further refinement, especially where there may be ambiguity of meaning for certain behaviors. This type of study cannot be generalized to a larger population of longterm care facilities without bearing in mind that the population studied was not necessarily representative of the general population of all long-term care facilities.
The authors have attempted to look at some overall implications for nursing's role in such areas as formulating institutional policies for the creation of specialized care units, and establishing nursing protocols for planned care and staff education. Nursing strategies in long-term care facilities need to focus on protection of the resident's personal space whenever possible. At the same time, staff indicated a feeling of concern for their personal safety. Strategies which include education programs for staff on how to manage the working environment and ensure optimal safety would be indicated. There would also appear to be a place for the consultation services of a nurse specialist in psychogerontology to assist in identification of nursing problems, and goal setting as a means of alleviating anxiety in both nursing staff and residents.
In considering possible implications for the planning of nursing care, several issues come to mind based on the selfcare model: 1) maintenance of a balance between solitude and social interaction; and 2) safety and security and the prevention of hazards to human life, human functioning, and human wellbeing.
Orcm" suggests the following questions for investigation in order to formulate a plan of care that will meet the patient's self-care ability in these areas: A Balance Between Solitude and Social Interaction
1. What constitutes a balance between solitude and social interaction in the long-term care setting?
2. What would be considered a hazard to solitude and social interaction in the existing setting?
3. What degree of solitude and social interaction are available to the individual in this setting which would both enhance the quality of life and be feasible?
A Balance Between Safety and Security
(The prevention of hazards and the promotion of normal human functioning and development)
1 . What are the hazards to life, functioning, and development in the environment?
2. What are the consequences of uncontrolled hazards?
3. What action should the individual take in order to prevent or control hazards?
The nursing plan of care must address these questions and include ways of ensuring optimum safety of the patient. This can be accomplished through addressing such issues as monitoring the activities on the unit to ensure that only persons who are supposed to be in a patient area, are in fact there. Possibly, the consideration of specialized units for selected patients was based on identified behaviors rather than diagnoses. An in-depth initial orientation for new employees, which includes a discussion of resident and staff concerns, is still another way of addressing the issues of this study. Finally, ongoing educational and informal groups to discuss identified concerns are a must if the self-care needs of the patient and agency of the caretaker are to be addressed.
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