Disruptive behavior is an annoying and potentially dangerous problem in most nursing homes. In order to initiate changes that will reduce the frequency of such behavior or mitigate its harmful effects, nurses must have a better understanding of how environmental factors influence the evolution of disruptive episodes. This qualitative study was developed in an effort to describe the nature of person-environment interactions in disruptive behavior incidents in an extended care facility.
THEORETICAL FRAMEWORK AND REVIEW OF THE LITERATURE
Environmental factors have been addressed in several theories on the etiology of disruptive behavior. Hall's conceptual model of a Progressively Lowered Stress Threshold (HaU & Buckwalter, 1987) explains that dysfunctional behavior in cogrdtively-impaired individuals is the result of the increasing anxiety associated with environmental stimuli that exceeds the impaired person's level of tolerance. Provision of a lowstimulus environment is a primary focus of care based on the PLST model (Hall & Buckwalter, 1990, 1991; Hall, Kirschling, & Todd, 1986; Swanson, Maas, & Buckwalter, 1993).
Reactance theory (Brehm & Brehm, 1981) emphasizes the importance of personal freedom and control, and the reactions that occur when individual choice is threatened or curtailed in a restrictive environment. Gerontologie application of reactance theory (Meddaugh, 1990) emphasizes the need to maximize freedom of choice for persons residing in extended care facilities. The Boettcher basic need model (Boettcher, 1983; Rossby, Beck, & Heacock, 1992) describes "violent'' behavior as a response to altered biopsychosocial needs, and the nursing role as that of diagnosing and formulating plans for human need fulfillment.
Numerous studies have identified specific correlates of disruptive behavior in extended care settings. Variables identified as significant include cognitive impairment, falling tendency, previous life Stressors, sleep disturbances, age, dependence on care- givers, inability to ambulate, length of stay in the facility, impaired communication, incontinence, time of day, and the use of restraints (CohenMansfield, 1986, 1988; Cohen-Mansfield & Marx, 1989, 1990; CohenMansfield, Marx, & Rosenthal, 1989, 1990; Donat, 1986; Ryden, Bossenmaier, & McLachlan, 1991; Jackson, Drugovich, Fretwell, Spector, Sternberg, & Rosenstein, 1989; Meddaugh, 1986; Werner, Cohen-Mansfield, Braun, & Marx, 1989; Winger & Schirm, 1989; Winger, Schirm & Stewart, 1987). Beck, Rossby, and Baldwin (1991) provide a succinct summary of these correlational studies.
For the purposes of this study disruptive behavior was defined as any behavior resulting in negative consequences for the disrupting individual, other persons, or the physical environment (modification of Beck, Rossby, and Baldwin's 1991 definition). Environment was defined as all physical and interpersonal variables that surround an individual and interact with that individual in a given situation; incident was defined as a single event or series of events that occur in continuity.
METHODOLOGY OF STUDY
Data collection for this study was done by observation in a skilled nursing care facility, on a 59-bed unit whose residents were elderly persons with varying degrees of impaired cognition. The primary criterion for admission to this particular unit was the need for placement on a "secure floor." The researcher completed 172 hours of observation during variable times of the day and evening over a five-month period. Because the agreement of consent was with the facility and not with individuals, ethical constraints limited the observation to the public domain, which was defined as communal areas of the unit including the dayroom, halls, and solariums.
The researcher usually sat in a corner of the dayroom, observing the environmental milieu and writing field notes in a notebook. Brief tours of the halls were made at regular intervals, or whenever there was indication of disruptive activity. Although staff members and residents were informed of the reason for the researcher's presence, residents tended to forget this and generally treated the researcher - an older, middle-aged female - as a fellow resident. On one occasion a visitor expressed concern to the Head Nurse about "the resident who sits in the corner writing all the time." Although this impression was unintentional, it was helpful in that it placed the researcher into a participantobserver role.
Following each day of observation information from the recorded field notes was entered into a matrix (Table). Ongoing matrix analysis provided a systematic method for documentation and analysis of findings.
During the observation period, 185 disruptive incidents were documented with the time frames of disruptions varying from brief outbursts to episodes lasting more than eight hours. The intermittent repetition of similar behavior by an individual over time was considered to be a single incident. During the time of the study, 41 residents were involved in at least one disruptive episode, with more than half of these participating in multiple episodes.
Screaming was by far the most common disruptive behavior, noted in all recorded incidents. Other verbally disruptive behaviors included use of profane language, name-calling, and threats of bodily harm to another person. Many screaming incidents involved verbalizations of altered basic needs: hunger, thirst, elimination needs, unpleasant room temperatures, requests for personal items, and concerns about absence of significant others. A low tolerance for mild deprivation often was apparent in screaming residents. For example. an individual would continue to scream for food even after staff members had provided snacks and information about the next meal time.
Physical actions against other persons included attempted and actual hitting, hair-pulling, pushing, pinching, kicking, and eating another person's food. Disruptive behavior affecting the physical environment included moving, pounding, or knocking over furniture; pulling on draperies; and attempting to pull a large mirror down from the wall. Additional disruptive actions were hitting self and undressing self in public.
A few disruptive incidents involved aborted exit attempts, and/ or attempts at extrication from a gerichair or wheelchair with a rollbar. Although small in number, these episodes accounted for some hostile resident reactions. In the context of reactance theory (Brehm & Brehm, 1981), efforts to escape from a locked unit or from a restraining device may represent individual attempts to regain freedom and control in a situation where behavioral freedom has been threatened.
Environmental factors present during the onset and escalation of disruptive behavior incidents were examined to detect elements that might be perceived as Stressors by cognitively-impaired persons. In almost all of the incidents, loud noises were noted to be present concurrently. Loud noises resulted from sources, such as television at high volume, loud talking and shouting of residents and staff members, ringing of alarm bells when emergency exit doors were opened, group singing and clapping during music sessions, announcements on the public address system, and pill-pounding - a sound resembling the hammering of nails produced when nurses crush tablets while dispensing medications from carts in the dayroom or hall.
Matrix tor Day I of Observation
Environmental factors specifically noted during disruptive episodes in the dayroom included the presence of more than 20 people in the room; movement of people and /or equipment through the area; disruptive behavior of other residents; meals being served in the room; frightening visual images, such as horror movies on the television; stimulating entertainment, such as live music and dancing; competitive games, such as shuffleboard; individuals wearing seasonal costumes and/or masks; and the presence of a dog brought in by a visitor.
Disruptive incidents in the hallways often accompanied minor collisions of two residents in wheelchairs, or episodes in which one resident temporarily blocked the path of another. Low tolerance for stress was evident in these situations, in that minor "traffic jams" led to outburst of screaming, swearing, and /or hitting. Similar behavior, also suggesting low stress tolerance, was noted in the dayroom when screaming and swearing erupted as an ambulatory resident briefly obscured another resident's view of the television.
Termination of disruptive behaviors
Environmental elements associated with the termination of disruptive behavior incidents were examined to detect possible mitigating factors. It was noted that many such episodes ended when the disrupting person was removed to a more secluded area.
Other changes associated with termination of disruptive behaviors included fulfillment of basic physical needs, as by provision of food, beverages, toileting, or rest; fulfillment of needs for interpersonal support, as by conversation with a staff member or contact with a significant other; a simple request to the disruptive person that the behavior be discontinued; provision for increased freedom by releasing the person from a gerichair or wheelchair with rollbar; separation of residents involved in disputes, and resolution of disputes over belongings.
SUMMARY AND RECOMMENDED NURSING INTERVENTIONS
The Figure summarizes the personenvironment interface observed in multiple disruptive episodes during the course of this study. It synthesizes elements of the Progressively Lowered Stress Threshold (PLST) model, reactance theory, and basic need theory. The observed antecedents to disruptive behavior - bombardment of external environmental stimuli, perceived threats to personal freedom, and individual expressions of unmet basic needs - are all Stressors that may overwhelm the person whose stress threshold has been lowered by cognitive impairment.
Specific nursing interventions may be planned to reduce the antecedents of disruptive behavior observed in this study. A variety of measures may help to decrease the bombardment of disturbing environmental stimuli. Noise levels can be reduced by turning down the volume of the television, turning down or eliminating the public address system, restricting shouting and loud talking by staff members, restricting unnecessary traffic, and performing any necessary, but noisy activities in more remote areas. Disturbing visual images, such as horror movies on the television, can be eliminated by the careful monitoring of programs.
HaU, Kirschling, & Todd (1986) recommend that on low-stimulus units the television sets be removed from communal areas and placed in small rooms where residents may watch favorite programs upon request. They also suggest that pictures and mirrors be removed from the walls and replaced by carpet remnant pieces with soft colors and textures. Relaxing music has been found to have beneficial effects on confused and agitated elderly persons (Gerdner & Swanson, 1993; Goddaer & Abraham, 1994). Some residents may be less disruptive at meals if they eat in small groups rather than in a large dining room. In addition, planned activities, such as small reminiscence groups may be better for some than competitive games and other large group functions.
To minimize hostile behavior associated with psychological reactance, the use of restraining devices should be limited to those situations in which safety considerations mandate such intervention. Chaperoned walks may be helpful for residents who are restless and seeking to leave the unit. Improved staffing is needed so that the supervision of cognitivelyimpaired residents will be optimal and prompt attention may be given to meeting their basic needs. Staff education also is needed so that caregivers will understand the rationale for a low-stimulus environment.
The method of systematic observation employed in mis study was helpful in the identification of possible environmental Stressors on a nursing home unit for cognitivelyimpaired residents. This observational method could be utilized in any setting in which environmental restructuring is desired to improve the quality of life.
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Matrix tor Day I of Observation