Journal of Gerontological Nursing

ASSESSING DISRUPTIVE BEHAVIORS OF NURSING HOME RESIDENTS: Use of Microcomputer Technology to Promote Objectivity in Planning Nursing Interventions

Ann Yurick, PHD, RNC; Louis Burgio, PHD; Stephanie M Paton, MS

Abstract

Nursing, as a science and an art, is affected significantly by technological advances. Ellis and Hartley (1992) summarize definitions of nursing developed by major theorists. Abdellah (1960) and Rogers (1984) are among those nurses who specifically address the "art and science" of nursing. While the "art" of providing nursing care continues to be valued highly by nurses and consumers of nursing care, the demand increases to qualify and quantify the process and outcomes of care. Thus, the science of nursing affects the "art" of providing care.

OBSERVATION AS PART OF ASSESSMENT

Observation is an example of a nursing skill that is a basic part of the art of nursing. The art of observation of an experienced nurse often amazes the neophyte nursing student. Major portions of assessment data are obtained through these astute observational skills. These vital assessment data provide the base on which individualized interventions are planned arid implemented.

Indirect observation involves the person's report of behaviors; a direct observation is witness to the actual demonstration of a behavior. Nurses must be aware of measurement errors in both direct and indirect observation.

Inadequate sampling of the target behavior is a major source of error in direct measurement (Pender, 1987). Error in measurement can occur if a client demonstrates a specific behavior in an artificial setting or if a distorted picture of the actual behavior is presented through the indirect observation. Because observation is such an integral part of nursing, reducing subjectivity and promoting objectivity in observation advances nursing science. The use of computerassisted, real-time observations is a tool that promotes the science of observation.

Computer-assisted, real-time observations provide a useful method to study, with greater precision, disruptive behaviors among cognitively impaired elderly residents in a nursing home setting. Prior to this technology, the usual method of studying behavioral disturbances was through retrospective reporting of these behaviors (Burgio, Butler, & Engel, 1988). The potential for negative emotional responses by the staff to disruptive behaviors of a resident could introduce subjectivity in recording and reporting these behaviors. This subjectivity can impede individualized nursing interventions directed toward decreasing the disruptive behavior. Moreover, this subjectivity has a strong potential to spawn the overuse of psychotropic medications and restraints.

STUDY OF DISRUPTIVE BEHAVIOR

There is a need for an objective body of information and tested techniques for the management of persons with dementia. This is in response to the crisis created by an increase in the population of people with dementia. This population represents as much as 10% of the nation's annual total health care expenditure (Duffy, Hepbum, Christensen, & Burgge-Wiger, 1989). The agenda for the care of patients with AIzheimer's disease, a leading cause of dementia, includes research in health systems on the "how tos" with these individuals. The systems and environments that have been established for this care are rooted in clinical folklore and are more a matter of art than science (Duffy et al, 1989). There is a need to develop care strategies and guidelines by which to measure the quality of existing strategies. Again, the need for an objective scientific approach dearly is recognized.

COMPUTER-ASSISTED OBSERVATION

Numerous factors can be studied through the technology of computer-assisted observation. The purpose of this research was to use computer-assisted data systems to investigate the contextual variables affecting behaviors of disruptive nursing home residents. Data from this recently completed study are being analyzed. The purpose of this article is to inform nurses of this promising method for obtaining objective observation information.

The behaviors and contextual variables that were examined in five nursing homes in the Pittsburgh area included the location of the resident within…

Nursing, as a science and an art, is affected significantly by technological advances. Ellis and Hartley (1992) summarize definitions of nursing developed by major theorists. Abdellah (1960) and Rogers (1984) are among those nurses who specifically address the "art and science" of nursing. While the "art" of providing nursing care continues to be valued highly by nurses and consumers of nursing care, the demand increases to qualify and quantify the process and outcomes of care. Thus, the science of nursing affects the "art" of providing care.

OBSERVATION AS PART OF ASSESSMENT

Observation is an example of a nursing skill that is a basic part of the art of nursing. The art of observation of an experienced nurse often amazes the neophyte nursing student. Major portions of assessment data are obtained through these astute observational skills. These vital assessment data provide the base on which individualized interventions are planned arid implemented.

Indirect observation involves the person's report of behaviors; a direct observation is witness to the actual demonstration of a behavior. Nurses must be aware of measurement errors in both direct and indirect observation.

Inadequate sampling of the target behavior is a major source of error in direct measurement (Pender, 1987). Error in measurement can occur if a client demonstrates a specific behavior in an artificial setting or if a distorted picture of the actual behavior is presented through the indirect observation. Because observation is such an integral part of nursing, reducing subjectivity and promoting objectivity in observation advances nursing science. The use of computerassisted, real-time observations is a tool that promotes the science of observation.

Computer-assisted, real-time observations provide a useful method to study, with greater precision, disruptive behaviors among cognitively impaired elderly residents in a nursing home setting. Prior to this technology, the usual method of studying behavioral disturbances was through retrospective reporting of these behaviors (Burgio, Butler, & Engel, 1988). The potential for negative emotional responses by the staff to disruptive behaviors of a resident could introduce subjectivity in recording and reporting these behaviors. This subjectivity can impede individualized nursing interventions directed toward decreasing the disruptive behavior. Moreover, this subjectivity has a strong potential to spawn the overuse of psychotropic medications and restraints.

STUDY OF DISRUPTIVE BEHAVIOR

There is a need for an objective body of information and tested techniques for the management of persons with dementia. This is in response to the crisis created by an increase in the population of people with dementia. This population represents as much as 10% of the nation's annual total health care expenditure (Duffy, Hepbum, Christensen, & Burgge-Wiger, 1989). The agenda for the care of patients with AIzheimer's disease, a leading cause of dementia, includes research in health systems on the "how tos" with these individuals. The systems and environments that have been established for this care are rooted in clinical folklore and are more a matter of art than science (Duffy et al, 1989). There is a need to develop care strategies and guidelines by which to measure the quality of existing strategies. Again, the need for an objective scientific approach dearly is recognized.

COMPUTER-ASSISTED OBSERVATION

Numerous factors can be studied through the technology of computer-assisted observation. The purpose of this research was to use computer-assisted data systems to investigate the contextual variables affecting behaviors of disruptive nursing home residents. Data from this recently completed study are being analyzed. The purpose of this article is to inform nurses of this promising method for obtaining objective observation information.

The behaviors and contextual variables that were examined in five nursing homes in the Pittsburgh area included the location of the resident within ihe nursing home; frequency and duration of the disruptive behaviors (verbal disruption, restlessness, or physical aggression); activity in which the resident was engaged (bathing, eating); environmental sound, such as that from the radio or television; and the presence or absence of restraints.

Subjects for this study were residents with dementia in one of five nursing homes. These residents were identified by the staff as displaying specific disruptive behaviors. Written consent was secured from the next of kin of each referred resident. Orientation sessions were conducted at each home to explain the study's purpose and procedures to the staff. In the initial observation wave, 123 residents were observed. Of these residents/ 97 participated in two observation waves; 78 in three observation waves; and 55 in four observation waves.

During 12 randomly selected halfhour observation sessions for each data collection wave (8 a.m. to 8 p.m.) the residents' physical and social environment and their disruptive behavior were coded directly into a lap top computer. With each observation, the observer coded the following information into the computer: the resident's location and activity, the presence or absence of sounds, with whom the resident was interacting, whether the resident was restrained, and when disruptive behaviors were displayed. The type of behavior and duration of the behavior also were entered into the computer

A log book was kept for file names created and for relevant comments during the observation sessions. Backup data disks were maintained. Through the use of lag sequential analysis, the temporal relationship between environmental factors and behavioral disturbances can be investigated. This is a powerful observational and analytical technique for studying environment-behavior relationships (Repp, Karsh, van Acker, Felce, & Karman, 1989; Sackett, 1979). Simultaneous recording of multiple behaviors, as well as their antecedents and consequences is made possible with the use of microcomputers.

Figure. Real-rime observerions were coded directly into a lap-top computer.

Figure. Real-rime observerions were coded directly into a lap-top computer.

Multiple codes were developed to describe the location within the nursing home (bedroom, dining room); the presence of environmental noises, such as those from a television; the activity of the resident (bathing, dressing, eating), any use of restraints, and the resident's behavior (Figure).

FOCUS ON THE RESIDENT

Although the impact of multiple environmental factors on behavior was studied, the focus was on the resident. Focused data include the resident's cognitive status, functional status, prescribed medications, and health status. To determine whether a resident met the entry criteria of diagnosed dementia of the Alzheimer's type, we used the Senile Dementia of the Alzheimer's Type (SDAT) Screener. This is a structured, standardized instrument developed for administration by a nonphysician interviewer. The SDAT Screener contains the Mini-Mental State Evaluation (MMSE) and a modified Blessed Test.

This screening provides a presumptive diagnosis of the presence or absence of dementia, a differential diagnosis of the type of dementing disorder, a staging of disease severity, and selected information about functional dependence (Davis, White, McKeIl, & Robins, 1991).

The Severe Impairment Battery (SIB) also was used. It was developed to detect changes in cognitive status in patients who were unable to complete existing standard neuropsychological assessment scales (Saxton, McGonigle-Gibson, Swihart, Miller, & Boiler, 1990). To determine the patient's ability to provide self-care activities, the Barthel Self-Care Rating Scale was used (Sherwood, Morris, Mor, & Gutkin, 1977). A health/life-event tracking form addressed changes in the resident's dayto-day environment, as well as health factors that could potentially result in a behavioral change (Yurick, Spier, Robb, & Ebert, 1989). Finally, a structured format was used for recording residents' medications. The relationship between medications and behavioral changes was investigated.

Analysis included the relationship of the resident status with the observed behaviors. A study of these responses over time using microcomputer technology provided data concerning relationships with changes in behavior; changes in cognition and functional status; and the medications prescribed as the resident's dementia progressed.

The time of day for specific behavior occurrence was another factor being studied. Each resident in the study was observed for 30 minutes once a day from 8 a.m. to 8 p.m., Monday through Friday. Twelve samples of observed time for each resident were collected. During each observation of the resident, the computer was coded for the resident's location and activity, the sound present, with whom the resident was interacting, any restraints being used, and any disruptive behavior displayed by the resident. The same observational and assessment data were collected on the resident within 6 months of the first observation times.

SCIEhKE OF OBSERVATION

To operationalize the naturalistic observation using microcomputer technology requires strict adherence to observational procedures. In this study, each resident was observed at a randomly selected time and day. With half-hour observation samples during each of the 12 hourly intervals between 8 a.m. and 8 p.m., each resident was observed for 6 hours. If the nursing home resident was hospitalized, make-up days were scheduled in order to obtain the 12 representative sample times.

The skilled observer needed to be in a position to see and to hear the resident clearly while being as unobtrusive as possible. A standard position for observing was behind and to the right of the resident. While the focus remained on the resident's behaviors, the observer needed to be alert to all environmental changes occurring.

During 10% of the observations, two observers coded the same session independently in order to ensure reliability. The two computer files were compared second by second. The Kappa Statistic was used to evaluate the degree of agreement of the two simultaneous observations Cohen, 1968). To ensure that the observations were recorded in the computer, files were checked immediately following the observation session. Immediately after the observation, a back-up of the data file was created. Stable quantitative measures were extracted from the database and observed behaviors were related statistically to the environmental factors studied. For the precise skill needed by the observer, an intensive training period was held.

NURSING HOME ENVIRONMENT

The unique characteristics of a nursing home environment must be considered in the observational study of resident behaviors (Ouslander & Schnelle, 1993). The culture of each individual nursing home needed to be appreciated by the research team. This included respect for policies, routines of the home, and interpersonal dynamics.

The cooperation of the nursing staff was vital. In this study, the preparation of the nursing staff prior to beginning observations was a crucial part of promoting this cooperation. Of equal importance was preventing staff concerns that their activities were being evaluated by the study observers.

Contact with key nursing administrators was an initial step in paving the way with other members of the nursing staff. To explain the purpose of the research and the research protocol, an orientation meeting with the nursing home staff was needed prior to any data collection. Opportunity was provided for staff expression of personal concerns and protection of resident rights. Orientation of new staff occurred throughout the study.

Evaluation of nursing staff response to this method of naturalistic observation with microcomputers was planned at regular intervals. Nursing staff adaptation was promoted through support of the research team by nurse managers, by the nonthreatening approach of the research team, through respect for the rights and needs of the residents and family members, and by consistent, open communication between the research team and the nursing staff.

To demonstrate appreciation to the staff and to maintain cooperation, research progress reports were given as determined appropriate. Presentation of the research findings is necessary to encourage continued research in the setting. When research results are available, family members should be included in a reporting session. The precise observations through the use of microcomputer technology are dependent upon the resident, family, staff, and nursing home administrators.

NURSING IMPLICATIONS

The technology of computerassisted observations can provide significant data about the impact of environmental factors on resident behaviors. The National Institute of Nursing Research (NINR) provided support for this study of direct observation of behavioral disturbances in residents of nursing homes with dementia of the Alzheimer's type (DAT). This study fits within the nursing research agenda calling for development of measures for clinical assessment of patient symptoms (NINR, 1988). Moreover, this research supports a priority established by the American Nurses Association (ANA) Cabinet on Nursing Research (1985) to minimize or prevent behaviorally and environmentally induced health problems that compromise quality of life and reduce productivity. Behavioral disturbances affect care needs of nursing home residents (Beck & Heacock, 1988; Beck, Modlin, Heithoff, & Shue, 1992; Buckwalter, Abraham, & Neundorfer, 1988; Marx, Cohen-Mansfield, & Werner, 1990).

This scientific method of observation provides an important base for development of nursing interventions and makes nursing practice even more effective. As simplified bedside tools are developed, computer-assisted observations hold much promise for greater accuracy in documenting disruptive behaviors. These observations can promote individualized nursing interventions. Improvements in nursing practice occur through thoughtful analyses of carefully and systematically recorded observations of human beings in clinical situations (Schlotfeldt, 1990).

The regulations of the Omnibus Reconciliation Act, effective in 1990, affect nursing home reform. This law, designed to help residents of nursing homes attain the highest level of physical, mental, psychological, and social well-being, mandates comprehensive assessment. Major categories in the Minimum Data Set include cognitive patterns, communication patterns, psychosocial well-being, mood, and behavior patterns (Burggraf, 1991). Computer-assisted technology provides a method of tracking the resident's behavior patterns, as well as the effects of psychotropic and other medications.

In the search for a better understanding of the symptoms of Alzheimer's disease, interventions for undesirable behaviors too often have focused on chemical and physical restraints. With a more precise assessment base through naturalistic observation of disruptive behaviors, nursing management of these behaviors can affect, more postively, the quality of life of the nursing home resident.

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