The frustration in the nursing assistant is evident as she reaches to assist Mrs G, an 83-year-old woman with profound senile dementia, from her bed to a chair. She anticipates Mrs G's next move, straining unsuccessfully to keep her head away from the frail resident. Mrs G grasps the nursing assistant's hair in her hand and pulls with all her strength. Minutes later, when the transfer is completed, the nursing assistant peels the tightly clasped fingers away from her hair and looks up with a sense of weariness and despair. "I've asked the nurses what I should do and they just say, 'Do the best you can/ I guess nothing can be done."
The care of nursing home residents with behavior problems is viewed by many staff as one of the most unrewarding aspects of long-term care (Glasspoole, 1990). Yet this is a pervasive problem among the residents with cognitive impairment or neuropsychiatrie disturbances, who comprise between 63% and 94% of the nursing home population (Chandler, 1988; Newman, 1989; Selker, 1988). Estimates indicate that nursing assistants (NAs) provide 80% to 90% of the care to residents in nursing homes (Harrington, 1987), although few have received training in approaches for preventing or reducing behavioral problems in the persons for whom they care.
In many nursing homes, Licensed staff have been diverted away from hands-on care for residents to spend the majority of time providing documentation required by state and federal regulations (Wiener, 1989). With licensed staff focused on "desk" activities, NAs rarely see professional nurses role modeling appropriate ways to deal with difficult behavior. In a recent survey of NAs, fewer than 28% reported that they had received training on how to handle hostile, threatening, or abusive behavior, and fewer than 22% reported that they had received training on how to handle delusions, hallucinations, agitation, or wandering (Cohn, 1987).
To address the problem of inadequate training of nonprofessional staff, the Omnibus Budget Reconciliation Act (OBRA) of 1987 strengthened educational requirements for NAs with the aim of improving the quality of care in nursing homes. Hours of mandatory NA education were increased from 30 to 75. A draft of the regulations describes framing for mental health and social service needs of the resident to include the following goals:
The nurse aide will demonstrate basic skills by: modifying his/her own behavior in response to resident's behavior; identifying the developmental tasks associated with the aging process, and using task analysis and segmenting of those tasks to increase independence; providing training in, and the opportunity for self-care according to residents' capabilities; demonstrating principles of behavior modification by reinforcing appropriate behavior and causing inappropriate behavior to be reduced or eliminated; demonstrating skills supporting age-appropriate behavior by allowing the resident to make personal choices; providing and reinforcing other behavior consistent with resident's dignity; and, utilizing residents' families as a source of emotional support" (Health Care Financing Administration, 1988).
A recent study of nursing staff in nursing homes indicated that 88% of nursing homes across the country do not meet the direct caregiver proposed standard to meet the requirements and intent of OBRA '87 and that this understaf fing contributes to the high staff turnover rate (Mohler, 1990). Wagnild (1988) reported that 80% of the 119 NAs in her study had no special framing other than on-thejob training for the care of nursing home residents. At most nursing homes, inservice training for NAs is focused on orientation to the institution, specific care responsibilities, and basic skills such as turning residents in bed and monitoring vital signs (Brown, 1988). The lack of education regarding behavioral issues of cognitively impaired residents severely limits the ability of NAs to provide appropriate approaches to the majority of residents for whom they care.
Does framing NAs alter the prevalence or severity of behavioral problems in nursing home residents? A few studies have examined framing programs designed to reduce aggressive episodes in nursing home residents. Mentes and Ferrano (1989) used a Calming Aggressive Reactions in the Elderly program to train NAs in the nature of aggression in nursing home residents, identification of risk factors, preventive approaches, calming techniques, and using protective intervention as a last resort. Their study showed a slight decline in documented incidents of physical abuse of staff by residents.
Hoffman, Piatt, and Barry (1987) concluded that what most staff are doing in frying to manage their difficult and demented patients "doesn't seem to be working," and that the lack of training leads to bewilderment, upset, and stress in staff. They indicate that training nursing home staff in better nonverbal communication changes staff attitudes toward difficult residents, but their study lacked quantitative evidence that changes had occurred as a result of the educational program. In summarizing a study of caregivers' perceptions of aggressive behavior in nursing home residents, Beck, Baldwin, Modlin, and Lewis (1990) conclude that studies on the efficacy of educational programs for nonprofessional caregivers are sorely needed.
The focus of this article is to describe an educational program for NAs that was part of a small-scale study testing the feasibility of an intervention to prevent or reduce aggressive behavior in a sample of cognitively impaired residents (Ryden, 1991a). Resident outcomes will be reported elsewhere. A 147-bed skilled nursing facility in a Midwestern city was the setting for the intervention, which consisted of an educational program for NAs followed by a phase of caregiving for aggressive resident subjects that included role modeling and problem solving by a gerontological clinical nurse specialist (CNS).
Prior to the initiation of the educational program, the CNS had completed a comprehensive assessment of the resident subjects and developed an individualized aggression management careplan for each resident. Seventeen nursing assistants who were among the primary caregivers of the 13 aggressive resident subjects participated. This report focuses on both aspects of the intervention: the educational sessions and the CNS-assisted caregiving. The report will include an outline of critical content areas on cognitive impairment and understanding aggression in nursing residents that was presented in the educational sessions; teaching strategies for preventing or reducing aggression; goal setting and care planning techniques; and activities of the CNS in the caregiving phase.
The NAs had been interviewed prior to the educational program to determine the approaches and resources they used to deal with aggressive behavior. Many expressed frustration with aggressive residents and reported that when they did seek advice on what to do, it was not always useful. One NA stated, "I will seek out the RN's suggestions, but no one seems to have ideas." Another stated, "We've tried everything; nothing works." Nurses are taught to write care plans to guide their own practice, but the transfer of these directions for care to NAs is problematic in long-term care settings. More than half of the NAs interviewed stated they did not get help from the nursing care plan, and several stated that they were not allowed to look at the chart. In these initial interviews, the researchers perceived a sense of hopelessness in regard to the behaviors that cognitively impaired aggressive residents were demonstrating. It became apparent that the fluctuating nature of cognitive losses was confusing and frustrating to NAs in their efforts to provide care.
Content Areas and Objectives for Educational Program
The educational program was based on a review of the gerontological and psychiatric literature and on the prior experience and research of the authors. We incorporated content and strategies from the work of Hall (1988); Gwyther (1985); Mace and Rabins (1981); Robinson, Spencer, and Waite (1989); and South Carolina Educational Television and South Carolina Commission on Aging (1989). The program involved eight content areas, which are listed with objectives in Table 1.
A pretest on knowledge of dementia care was given prior to the education sessions. NAs also completed two additional brief instruments for each of the resident subjects for whom they were the primary care provider. Characteristics of Residents is a six-item semantic differential scale that elicited their view of each of the residents (Table 2). Experience of Caregiving (Table 3) is a six-item semantic differential scale that elicited their perspective of what it was like to care for each of the residents. On each scale, NAs were asked to check the place between each set of words that best described the specific resident and the experience of caring for that resident.
Nursing Assistants' Characterization of Residents
Understanding Cognitive Impairment
Basic to understanding disruptive behaviors in cognitively impaired older adults is an appreciation of the losses associated with dementia and the functional and behavior changes that accompany these losses. Cognitive impairment has been shown to be associated with aggression and agitation in nursing home residents (Cohen-Mansfield, 1986; Jackson, 1989; Ry den, 1988). The first content area was structured to provide foundational information on which all other sessions would build. This content area was devoted to an overview of dementing illnesses, such as Alzheimer's disease and multiinfarct dementia. Descriptions of the stages of cognitive decline were linked to losses that may affect feelings and behavior, and illustrated by examples of behaviors of residents who were familiar to the NAs. This allowed the NAs to associate levels of cognitive loss with specific residents for whom they cared and to begin to see why difficult behaviors might occur.
Understanding Precipitants/Etiology of Aggressive Behavior
This content area focused on specific precipitants of aggressive behavior, including factors both internal and external to the resident. Internal factors included a sense of threat or fear; loss of control or loss of previous structure; frustration with tasks that exceeded ability; misinterpretation of behavior of staff or other residents; fatigue; impaired perception; pain; and medication effects. The external factors included the physical environment; interpersonal approaches of staff or other persons; nature and degree of environmental stimulation; and use of restraints. A previous study had shown that an antecedent event could be identified for 98% of aggressive behavior in residents (Ryden, 1991b). Identifying precipitating factors in situations with residents they knew allowed the NAs to begin thinking of the underlying basis for behavior instead of reacting personally.
Basic communication techniques, both verbal and nonverbal, are essential keys to preventing aggressive responses. The third focus area of the educational sessions dealt with these communication techniques. A brief review of losses of communication skills in cognitively impaired elders was provided. To learn about nonverbal communications, NAs practiced strategies such as gesturing for various commands, approaching residents from the front, and use of touch when communicating requests or concerns. They also practiced verbal strategies, such as introducing themselves and their tasks, using short simple sentences, providing one-step commands, and using a nonthreatening tone of voice. Practice included changing complex questions such as, "What would you like to eat today?" to simple choices such as, "Would you like a sandwich or soup?" Although communication techniques are basic to professional nursing education programs, the NAs indicated that this had not been part of their previous training.
Identifying Basic Goals for Aggressive Residents
To provide quality care for residents, NAs need to have a clear sense of what goals are to be achieved for each resident and appropriate interventions for each goal. Ideally, this information is found in the nursing care plan. However, in initial interviews with the NAs we identified that, in this nursing home, fewer than half of the NAs received help for dealing with aggressive behaviors from the nursing care plan, and some believed that the care plans were written by the nurses simply to comply with state regulations.
Although we had developed individualized care plans for each resident in response to target behaviors, we believed that a complex plan of care might be difficult for the NAs to remember and apply. Therefore, we presented the NAs with five basic goals designed to prevent or reduce aggressive behavior. The goals were stated in terms of resident outcomes: the resident will feel safe; the resident will feel in control; the resident will feel comfortable; the resident will experience optimal stress; the resident will experience pleasure and satisfaction. These goals and the specific interventions to achieve them are described elsewhere (Ryden, 1992). The framework of these simply stated goals helped the NAs to focus on residents' needs and perceptions and not only on completion of the task at hand. A complex care plan with a "laundry list" of goals is likely to remain in the resident's medical record for surveyors to see, but is not likely to be operationalized by nonprofessional staff. However, five items can readily be remembered by most persons (Simon, 1979).
Nursing Assistants' Perceptions of the Experience of Caring for the Residents
Strategies for Preventing Aggressive Behavior
The final content areas focused on very pragmatic, how-to approaches. The fifth area linked the etiologic factors to the goals, with examples of actions to achieve each goal. Many of the communication techniques were re-emphasized and examples were given that applied to specific situations. For example, when the precipitating factor "sense of threat" and the goal "safety" were discussed, strategies included: offer reassurance during a task that seems threatening; specifically tell the residents that they are safe and that no one is going to harm them; acknowledge a resident's fear ("This bath seems to be a little frightening for you"); approach the residents from the front and make them aware of your presence with a nonthreatening use of touch as you speak to them; explain each step of the task so the resident has a sense of what to expect; and be alert to what arouses fear in the resident and anticipate ways to prevent that fear arousal.
Strategies for Preventing Aggression During Bathing
Active learning was especially important for reinforcing these strategies. For example, one NA played the role of a resident who had a certain agenda (eg, wanting to get into bed), but was unable to communicate that to the NA caring for him. This provided a forum for discussing loss of control and the perceptions and feelings of the resident. These empathy-building exercises reinforced the need to attend to the resident's verbal and nonverbal signals and reinforced the value of using good communication skills.
We also focused on specific activities of daily living when aggression was likely to occur, such as bathing, grooming, toileting, or dressing. Previous research had identified that 72.3% of aggression occurred in response to touch or invasion of personal space (Ryden, 1991b). Strategies for each activity were shared among the nursing assistants and discussion was encouraged. A list of strategies for each activity was developed. As an example, the list for preventing aggression during bathing can be found in Table 4.
Preventing Escalation of Aggressive Behaviors
Preventing all aggressive behaviors in a group of cognitively impatred residents was not a realistic goal; some aggression may be an integral part of the disease process. However, our target was the reducible portion of aggression that represents excess disability (Reifler, 1989). We wanted to acknowledge that some aggressive behaviors will occur and to provide strategies to avoid the escalation of aggression. Therefore, we discussed what to do when an aggressive response has already begun. Concepts of resident and NA safety; removal of the stimplus for aggression; use of diversion, distraction, or time out; and momentarily leaving the situation were presented. NAs were taught not to shout, confront, reason or argue, with, or touch an already aggressive resident.
Managing Personal reelings
This content area focused on the personal feelings and issues of to them. Because none of supervisors or licensed staff parin the educational sessions, he NAs had a nonthreatening envionment in which to discuss anger frustrations regarding their work caring for these difficult residents. questions posed to the group ncluded: What kinds of emotions you bring to work with you from iome? How do you usually handle inger or frustration? Have you ever ost your temper at work? What are ome healthy ways to deal with inger and frustration?
We developed a STOP strategy or handling feelings (Table 5). This imple strategy encourages NAs to low down when tensions build, hink carefully about what is hapening, use problem-solving techto consider optional approaches, and plan for their own needs.
Individualizing the Plan of Care
Prior to the conclusion of the educational program, the CNS had completed a comprehensive assessment of the resident subjects and developed individualized aggression management plans for each resident using the five basic goals. These care plans included a brief social history, a list of target behaviors, probable enologie factors, and suggested approaches to each goal. We found that the NAs knew little about the person the resident had been. Limited access to the medical record and exclusion from care planning conferences involving professional staff had left them outside an important information loop. Providing them with a brief social history for each resident gave them important information about past patterns of behavior, interests, and values of the residents that enabled greater individualization of approaches. For example, knowing that one woman had taught music and sung opera provided cues as to possible interventions that might bring her pleasure and inmimize stress.
The approaches in the individualized care plans drew not only on the social history, but also on the assessment of the CNS and interviews with the family. Approaches were designed to eliminate or alter etiological factors when feasible. For example, for one resident who had always been a "loner" according to her family, transition to the nursing home and living in proximity to many people was an etiological factor. Therefore, one approach for the goal of experiencing optimal stress was to limit her exposure to large groups of residents and to make certain other residents did not violate her personal space. The NAs proved creative in contributing additional approaches for achieving specific resident goals.
CLINICAL NURSE SPECIALIST ROLE
Licensed nurses in long-term care settings are more likely to have a background in medical/surgical nursing than to have worked in a psychiatric setting. Many are practical nurses prepared in a 1-year educational program. The registered nurses working in nursing homes are predominantly graduates of associate degree or diploma programs who may be assigned supervisory positions with little direct patient care, particularly assistance in activities of daily living. Few staff in nursing homes have exposure to expert clinicians who might teach and model comprehensive assessment and therapeutic ways of dealing with aggressive residents.
It was our belief that the classroom framing might be better integrated into practice if the NAs could see the techniques in action and receive ongoing help in using interventions appropriate to the five basic goals. Following the educational program, the CNS spent several hours each week over a 6-week period working with the NAs in the daily care of the residents. This enabled her to demonstrate ways of dealing with problematic behaviors and then discuss alternatives and ideas with the NAs as they worked. This also provided an opportunity for the CNS to role model therapeutic communication and teach the NAs not to take the statements and the behaviors of the cognitively impaired residents personally.
Advanced practice nurses have the potential to provide a bridge between the developing knowledge base in gerontology and the everyday practice world of long-term care. The value of gerontological nurse practitioners in the role of primary care provider has already been substantiated. We need research to document the effectiveness of the CNS as a resource for staff in providing direct care to residents with complex and challenging care problems.
IMPACT OF THE PROGRAM
The impact of the program was measured by comparing the NAs' pre- and post-test scores on three measures. On the Knowledge of Dementia Care measure, no significant change in pre- to post-test scores was found. Problems in adniinistering the post-test may have contributed to the lack of demonstrable learning. The post-test was not given immediately following the education sessions; it was given following the 6-week caregiving phase. At that time, pressure to return to the station to care for residents meant that some NAs had inadequate time for completion.
On the measure Characteristics of Residents (Table 2), a nonsignificant trend toward perceiving the residents more positively was noted. For two items related to the Experience of Caregiving measure (Table 3), there was a significant difference between the pretest mean score and the post-test mean. NAs viewed the task of caregiving as significantly more rewarding and significantly less frustrating.
Follow-up interviews validated these positive outcomes. NAs reported that the knowledge they had gained had changed their way of providing care. Many stated that the changes they noted in the residents were "because I have changed." All of the NAs reported a change in the way they communicated and reported that they had begun to think of alternative ways of approaching residents. One NA said that not only had she changed the way she communicated with residents, but she also had changed the way she communicated with her daughter. Some participants indicated surprise at how much one's tone of voice can influence the responses of others. Many mentioned that they used these techniques with other residents who were not participants in the study.
The educational sessions had incorporated several types of active learning and participant interaction that facilitated the exchange of ideas and strategies. NAs showed they could observe the actions of others and infer why certain responses might occur. Most seemed hungry for knowledge that was relevant to their work. The response from the NAs to the five basic goals was very encouraging. As each goal was discussed, comments were heard such as, "How could I help Esther feel in control?" NAs identified many apparent precipitants of fear in residents and were animated in brainstorming ways to prevent or decrease fear. With respect to the goal of comfort, they were surprised to discover that, for residents for whom pain was a concern, they could ask nurses to adrninister an as-needed analgesic before carrying out a painful maneuver. Ninety-four percent of the NAs reported that they were more likely to ask for pain medications for the residents for whom they cared.
A welcome outcome of this education program was the fostering of a teamwork approach for the NAs. Prior to the study, fewer than 45% of the NAs sought help from each other in dealing with aggressive behaviors of residents. Following the educational sessions and CNS-assisted care, 94% of the NAs reported that they communicate more with other staff members about approaches that work with individual residents. They also reported that the CNS was helpful in guiding approaches to behaviors. At the conclusion of the study, one of the registered nurses on a unit involved in the education program commented, "You have made our NAs more professional."
NAs provide most of the direct care to aggressive, cognitively impaired residents and are the targets of verbal, physical, and occasional sexual aggression. The NAs in this study were responsive to opportunities to enhance their knowledge and skill about dementia care and were eager to participate actively in trying out intervention strategies once they had a clear sense of the goals that might prevent or reduce residents' aggressive behavior. The use of an advanced practice nurse to teach and to assist in role-modeling direct care of residents provided a conduit for current knowledge to be applied to the nursing care of these challenging residents. Further research is needed to differentiate between the effects of the education program alone and effects of a CNSassisted intervention.
To provide high-quality care, long-term care settings must address the issue of staff education and develop means to improve their skill in working with aggressive cognitively impaired residents. An educational program that provides a groundwork of understanding and promotes problem solving among staff can empower NAs. The value of this educational program was best described by an NA in a final interview: "We just come in here off the street and don't know a thing about how to handle these people. If there was one thing you should do differently it would be, train all the aides! Train all the nurses!"
- Beck, C, Baldwin, B., Modlin, T., Lewis, S. Caregivers' perception of aggressive behavior in cognitively impaired nursing home residents. J Neurosci Nurs 1990; 22:169172.
- Brown, M. Nursing assistants' behavior toward the institutionalized elderly. QRB 1988; 14(1):15-17.
- Chandler, J., Chandler, J. The prevalence of neuropsychiatrie disorders in a nursing home population. J Geriatr Psychiatry Neurol 1988; 1:71-76.
- Cohen-Mansfield, J. Agitated behaviors in the elderly: II. Preliminary results in the cognitively deteriorated. J Am Geriatr Soc 1986; 34:722-727.
- Conn, M., Smyer, M., Garfein, A., Droogas, A., MaloneBeach, E. Perceptions of mental health training in nursing homes: Congruence among administrators and nurse's aides. Journal of Long-Term Care Administration 1987; 15:(Summer) 20-25.
- Glasspoole, L., Aman, M. Knowledge, attitudes, and happiness of nurses working with gerontological patients. Journal of Gerontological Nursing 1990; 16(2):11-14.
- Gwyther, L. Care of Alzheimer's patients: A manual for nursing home staff. Chicago: Alzheimer's Association and American Health Care Association, 1985.
- Hall, G. Alterations in thought process. Journal of Gerontological Nursing 1988; 14(3):3037.
- Harrington, C. Nursing home reform: Addressing critical staffing issues. Nurs Outlook 1987; 35:208-209.
- Health Care Financing Administration. Nurse aide training and competency evaluation programs: Draft document circulated for commentary. Baltimore: Health Care Financing Administration, 1988. Unpublished manuscript.
- Hoffman, S., Piatt, C, Barry, K. Managing the difficult dementia patient: The impact on untrained nursing home staff. American purnal of Alzheimer's Care and Related Disorders and Research 1987; 2(4)26-31.
- Jackson, M., Drugovich, M., Fretwell, M., Spector, W., Sternberg, ]., Rosenstein, R. Prevalence and correlates of disruptive behavior in the nursing home. Journal of Aging and Health 1989; 1:349-369.
- Mace, N., Rabins, P. The 36 Hour Day. Baltimore: Johns Hopkins University Press, 1981.
- Mentes, J., Ferrario, J. Calming aggressive reactions: A preventive program. Journal of Gerontological Nursing 1989; 15(2):22-27.
- Mohler, M., Lessard, W. Nursing staff in nursing homes: Additional staff needed and cost to meet requirements and intent of OBRA '87. Gerontologist 1990; 30:27A.
- Newman, E, Griffin, B., Black, R., Page, S. Linking level of care to level of need: Assessing the need for mental health care for nursing home residents. Am Psychol 1989; 44:1315-1324.
- Reifler, B., Larson, E. Excess disability in dementia of the Alzheimer's type. In E. Light, B.D. Lebowitz (Eds.). Alzheimer's disease treatment and family stress: Directions for research. Rockville, MD: National Institute of Mental Health, 1989.
- Robinson, A., Spencer, B., Waite, L. Understanding difficult behaviors. Ypsilanti, MI: Eastern Michigan University, 1989.
- Ryden, M., Feldt, K. Nursing intervention to prevent/ reduce aggressive behavior in cognitive])' impaired nursing home residents. Final Progress Report to Alzheimer's Association, 1991a. Unpublished manuscript.
- Ryden, M.B. Aggressive behavior in persons with dementia who live in the community. Journal of Alzheimer's Disease and Related Disorders. 1988; 2:342-355.
- Ryden, M.B. Alternatives to restraints and psychotropics in the care of aggressive, cognitively impaired elderly persons. In K.C. Buckwalter (Ed.). Geriatric mental health nursing: Current and future challenges. Thorofare, NJ: Slack, Ine, 1992, pp. 84-93.
- Ryden, M.B., Bossenmaier, M., McLachlan, C. Aggressive behavior in cognitively impaired nursing home residents. Res Nurs Health 1991b; 14:87-95.
- Selker, L. The politics, economics, and demographics of health care and aging. In National League for Nursing. Associate degree nursing and the nursing home. New York: National League for Nursing, 1988. NLN Publication No. 15-2241.
- Simon, H. Information processing models of cognition. Ann Rev Psychol 1979; 30:363396.
- South Carolina Educational Television and South Carolina Commission on Aging. Alzheimer's 101: The basics of caregiving. Trainer's manual. Columbia, SC: South Carolina Educational Television, 1989.
- Wagnild, G. A descriptive study of nurse's aide turnover in long-term care facilities. Journal of Long-Term Care Administration. 1988; 16(Spring):19-23.
- Wiener, C, Kayser-Jones, J. Defensive work in nursing homes: Accountability gone amok. Soc Sci Med. 1989; 28:37-44.
Content Areas and Objectives for Educational Program
Nursing Assistants' Characterization of Residents
Nursing Assistants' Perceptions of the Experience of Caring for the Residents
Strategies for Preventing Aggression During Bathing