Journal of Gerontological Nursing


Maura Farrell Miller, PHD, ARNP, CS


Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Ad (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was defined as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.


Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Ad (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was defined as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

The purpose of this qualitative study was to explore nursing staff responses to physically aggressive patient behavior, and the effect that physically aggressive behavior had on them personally and on their nursing practice from the perspective of the nursing staff. The specific research objectives focused on the following areas of inquiry:

1. What were the physically aggressive resident behaviors the nursing staff reported as disturbing?

2. What effects did physically aggressive resident behavior have on the nursing staff personally?

3. What effects did physically aggressive resident behavior have on nursing practice?

Cognitively impaired residents require assistance with activities of daily living (ADLs), which includes the provision of intimate physical contact by nursing personnel for the purposes of hygiene, feeding, dresstoileting and mobility. Disruptive behaviors such as physical aggression are often manifested by cognitively impaired nursing home residents during the provision of a bath. In a comprehensive review of the literature of correlates of disruptive behavior in elderly nursing home residents, Beck, Rossby and Baldwin (1991) found that most disruptive behaviors seemed to occur during the day, during assistance with ADLs (Cohen-Mansfield, Marx, & Rosenthal, 1989; Nilsson, Palmstierna, & Wistedt, 1988; Ryden, Bossenmaier & McLachlan, 1991), in response to touch (Marx, Werner, & Cohen-Mansfield, 1989; Ryden, Bossenmaier, & McLachlan, 1991), invasion of personal space (Ryden, Bossenmaier, & McLachlan, 1991), the presence of other residents, and unoccupied time, and in the presence of family members (Beck, Rossby, & Baldwin, 1991). These findings have important implications for research on the concerns of nursing staff who participate in nursing care rituals such as a patient bath.

Displays of physical aggression toward nursing home staff are not uncommon. Kikuta (1991) found that physical aggression can be detrimental to the work life of nurses and may result in staff conflict and team dysfunction. The deterioration of the nursing team can detract from the overall quality of care delivered to the cognitively impaired resident (Kikuta, 1991). In addition to presenting a difficult challenge for caregivers, aggressive behavior can negatively affect the quality of life for residents by alienating family and staff (Ryden & Feldt, 1992). The problems attributed to aggressive behaviors in cognitively impaired nursing home residents include: lowered staff morale (Rovner, Kafonek, Filipp, Lucas, & Folstein, 1986), stress experienced by both staff (Koggan, Caftan, Duffy, Simunek, & Northrup, 1991; Mobily, Maas, Buckwalter, & Kelley, 1992) and residents and decreased quality of patient care (Meddaugh, 1987, 1990, 1992; Mentes & Ferrarlo, 1989). Roberts (1986) suggested that involvement in aggressive incidents caused staff to feel upset, to question their ability to do the job, to feel insecure and that they have failed. Other studies indicate there are economic consequences of aggressive behavior (Drummond, Sparr, & Gordon, 1989; Heine, 1986; Martin & Kirkpatrick, 1987; Ryden, 1987, 1988). The economic consequences of aggressive behavior in nursing home settings include increased staffing needs, burnout, absenteeism, and turnover of caregivers due to high work-related stress (Koggan, Caftan, Duffy, Simunek, & Northrup, 1991). In addition to these consequences, some studies report emotional costs in the form of social isolation of the aggressive resident (ArmstrongEsther, 1986; Drummond, Sparr, & Gordon, 1989; Martin & Kirkpatrick, 1987; Meddaugh, 1987, 1990, 1992; Ryden, 1987, 1988; Winger, Schirm, & Stewart, 1987). Social isolation of the aggressive elderly patient may lead to unmet needs for social interaction, love and belonging, as well as to diminished quality and quantity of care (Ryden & Feldt, 1992).

Both licensed and unlicensed assistive nursing personnel in longterm care settings are often unprepared to manage the complex physical, psychosocial, emotional, and spiritual needs of the aged adult, let alone have the skills to care for the behavioral manifestations of the cognitively impaired. In addition, many nursing home staff are poorly trained to cope with the emotional and behavioral problems of cognitively impaired elderly (Stolley, Buckwalter, & Shannon, 1991) and are therefore, repeatedly frustrated by their inability to manage these recurrent problems (Mobily, Maas, Buckwalter, & Kelley, 1992). Although all staff need a better understanding of the nature and treatment of behavioral problems, nursing is the discipline which bears the brunt of violent patient outbursts (Burgio, Butler, & Engel, 1988).

Nursing has a responsibility to determine strategies for care that are grounded in knowledge gained from the systematic study of phenomena that compromise the experience of cognitively impaired patients and their caregivers over the course of the disease process. Despite the severity of the problem, there has been no qualitative inquiry to elucidate nursing staff caregiving experiences with physical aggression in cognitively impaired institutionalized elderly. Such research is necessary because there is a dearth of nursing research studies investigating the care of physically aggressive patients based on the views of the caregivers themselves. The need for qualitative data was the impetus for this study.


TABLE 1Demographit Data at Respondents


Demographit Data at Respondents



The purposive sample consisted of 30 nursing staff employed on a secured DSCU. The sample included Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants. The setting, chosen for convenience, was a not-forprofit, long-term care institution. Nurse staffing was unchanged during the duration of this study. Nursing home aclministration granted approval for the study and for the interviews to be conducted during regular working hours. Nursing staff were informed of the purposes of the study and that participation was voluntary. Participants who volunteered to be interviewed signed an informed consent form that explained procedures, risks, and assurances.


The investigator met with nursing staff on the unit to request cooperation. The investigator explained that she was investigating nursing care of physically aggressive cognitively impaired residents to learn how nursing staff provided care to the demented elderly on a secured DSCU. All three shifts of nursing staff were to be interviewed a minimum of two times. However, one LPN was interviewed four times and one CNA was interviewed three times as a result of patient care demands, staff demands, time constraints of each interview, and the need for the researcher to seek further information and clarity from these expert informants. One LPN and two CNAs declined to be interviewed a second time. The data were collected over a 12-week period during the months of June, July, August and September 1993. A total of 54 interviews from 27 nursing staff employed on a secured DSCU were generated as a result of this study. Three Certified Nursing Assistants (CNA) declined to be interviewed. The final sample included 2 Registered Nurses, 8 Licensed Practical Nurses, and 17 CNAs. Demographic data obtained on the nursing staff included the number of years employed in long-term care, education, age, and ethnicity. Sample demographic data can be found in Table 1.

During these interviews, nursing staff's verbal responses were obtained and recorded by hand and were qualitatively analyzed using techniques described by Miles and Huberman (1994). The methodology was a complex interplay of qualitative descriptive methods including in-depth interviewing and methods described by Miles and Huberman (Denzin & Lincoln, 1994). Data analysis included noting relationships between the variables, making contrasts and comparisons, clustering [content analysis], building a logical chain of evidence for supporting a coherent understanding of the data, building a logical chain of evidence to support conclusions, use of the self as a research instrument, use of the Ethnograph (Seidel, Kjolseth, & Clark, 1985) computer program, and collaboration with an auditor.


The conclusions generated as a result of this dissertation research study far exceed the scope of this article. Therefore, the findings presented here are the conclusions which are limited to nursing staff responses during hygienic care of physically aggressive cognitively impaired institutionalized elderly.

Research Objective Number One

The first objective of this study was "What were the physically aggressive patient behaviors the nursing staff reported as disturbing?" The physically aggressive behaviors reported as disturbing to the nursing staff included being hit with fists or objects, such as a cane or walker; being pinched, punched, spat at, kicked, scratched, bit, being chased down the hall, and having hair pulled. Physical resistance to care was found to be disturbing to the staff and was also reported as aggressive behavior. Physical resistance to care included spitting out medication, refusing to eat or drink, and pushing nursing staff away during attempts at bathing, dressing, and toileting.

Physically threatening gestures were reported as disturbing to the staff and were also reported as physically aggressive behaviors. These gestures were described as a clenched fist moving toward them in the air, or use of a potential weapon, such as a cane, walker, or other object. In the verbally intact residents, the physically threatening gestures often came in combination with a verbal threat, such as, 'Tm going to get you," whereas, the nonverbal residents were only capable of making physically threatening gestures.

Residents who consistently refused or resisted attempts at activities of daily living (ADLs) were reported by the CNAs to be the most challenging. Staff reported that most of the behaviors occurred during their attempts at providing physical care and that the aggressive behavior was often unexpected and unprovoked. Providing hygienic care in the form of showering a resident was the ADL reported by all CNAs as the most difficult task to accomplish and as most likely to elicit physically aggressive behavior from the residents. Consistent with previous studies, the nursing staff reported that they were exposed to physically aggressive resident behaviors in response to touch (Marx, Werner, & Cohen-Mansfield, 1989; Ryden, Bossenmaier, & McLachlan, 1991) invasion of personal space (Ryden, Bossenmaier, & McLachlan, 1991), the presence of other residents, unoccupied time, and spontaneously without provocation (Swanson, Maas, & Buckwalter, 1993). Another finding was the incidence of physically aggressive behavior demonstrated in front of relatives which was previously reported by Beck, Baldwin, Modlin, and Lewis (1990).

Research Objective Number Two

The second research objective of this study was "What are the effects of physically aggressive behavior on the nursing staff personally?" Nursing staff who care for aggressive cognitively impaired elderly may develop a decline in their physical and mental health status as a result of their experiences with patient aggression. Declines in physical health include wounds inflicted by the patients (scratches, bites, kicks, and hair pulling), physical pain, and physical exhaustion. Declines in mental health status include being hypervigilant while at work, worrying about safety, resentment about being expected to work in pain, fear of being perceived a poor worker by their peers, fear of retribution by peers and /or administration, fear of another injury, mental exhaustion, frustration, anger, sadness, depression and anxiety.

Research Objective Number Three

The third research objective of this study was "What effects did physically aggressive behaviors have on nursing practice?" Nursing staff who care for physically aggressive cognitively impaired elderly may develop changes in their nursing practice as a result of their daily experiences with patient aggression. These changes were perceived by the nursing staff as follows: a) a decline in the perceived amount and quality of nursing care, b) an increased potential for staff-to-patient abuse and neglect, and c) a nursing staff member's desire to eventually leave the profession, the nursing home, or the unit.


TABLE 2Working Through Aggression to the Person


Working Through Aggression to the Person

Thematic Descriptions

The realities of nursing staff who work the frontlines in nursing homes for the cognitively impaired emerged from the qualitative interview data. Their nursing responses to physically aggressive behavior were driven by the opposing forces of professional responsibility and aversion to injury of the self. The nursing staff interviews described accounts of how the staff nursed physically aggressive patients, their responses and the subsequent changes they noted in themselves and their nursing practice. As a consequence of these interviews, the overarching theme, Caregivers in Conflict, was identified. Caregivers in Conflict describes the conflicts the nursing staff faced between fulfillment of their professional duties and responsibilities and prevention of injury. Nursing care was focused on prevention of physically aggressive behavior, but prevention of aggression was limited by the knowledge, skill, and experiences of the nursing staff. Since the CNAs were the primary providers of hands-on care, and were the majority of staff interviewed (n=17) their views dominated this research.

Five themes emerged from this study: "Working Through Aggression to the Person," "Demands Exceed the Abilities of Staff," "Dealing With It," "Personal Safety Becomes the Priority" and "Losing It." These five themes describe the nursing staff conflicts and reveal how the responses of nursing staff were aimed toward preventing, reducing or eliminating aggressive behavior during the provision of nursing care while at the same time attempting to maintain safety.

The focus of this article is specifically on the first theme, "Working Through Aggression to the Person". Specific nursing approaches which can be utilized by staff for improving the nursing care of institutionalized persons with cognitive impairments are included within this theme. These nursing approaches include: a) knowing the patient, b) adjusting care to the patient, c) waiting until the patient invites you, d) empathizing with the patient, e) watching for warning signs, f) speaking to the person behind the dementia, g) helping them understand, h) going into their world, i) preserving patient dignity, and j) protecting the patient. A summary of specific nursing approaches identified in "Working Through Aggression to the Person" can be found in Table 2.

Knowing the Patient

Understanding the patients and their behavior was crucial for the nursing staff to be able to provide safe nursing care to physically aggressive patients. Knowing the Patient included nursing approaches used to gain an understanding of the patients and their behavior so that the nursing staff member could prevent aggression and maintain safety. The nursing staff reported that once they understood a patient's behavior, and if, when, and how a patient was aggressive, they could better prepare their approaches so that nursing care could be individualized to that patient and safety could be maintained. For the purposes of this study. Knowing the Patient is described as a dynamic process between the resident and the nursing staff member whereby the resident's behavior is understood relative to the resident's needs within the context of each caregiving situation. Although the registered nurses comprised only two of the nursing staff interviewed in this study, Knowing the Patient has relevance for the provision of nursing care by both licensed and unlicensed assistive nursing personnel in nursing home settings.


TABLE 2Working Through Aggression to the Person


Working Through Aggression to the Person

Knowing the Patient has always been a valued and important aspect of humanistic nursing practice (Jenny & Logan, 1992, 1994). Knowing the Patient has been defined by Benner & Wrubel (1989) as the process of acquiring and using a form of particularistic clinical knowledge. The interpretation and synthesis of the meaning of "Knowing the Patient" illustrates an important aspect of clinical reasoning in a specific nursing context and contributes to the development of skilled clinical knowledge (Benner & Wrubel, 1989). Knowing the Patient has been associated with the concept of individualized care which in the literature has been described as a patient's right, a hallmark of professional nursing practice, and an ingrethent of quality care. Evans (1996) further describes knowing the patient as "both knowing the patient's typical responses and knowing the patient as a person." Knowing the patient is essential to patients feeling cared for and cared about. It makes the difference between care that is personalized, not just routine. Knowing the patient is central to skilled clinical judgment necessary to determine what is of priority importance, to judge how the person is now in comparison to usual behavior, and to particularize prescriptions (Jenny & Logan, 1992).

The nursing staff further noted that identifying the nursing activities during which aggression was known to occur and not to occur with each patient could help them better prepare for those activities. The nursing staff reported knowing the patient's behavior patterns and knowing which patients had a history of resisting care and causing injuries to staff, helped them prepare for caregiving (bathing a patient in bed instead of the shower; having a favorite CNA give a shower), prevent aggression and subsequent resident-to-staff injuries.

Another nurse stated: "Most of the CNAs and nurses know all the patients well, so we can almost predict how the patients will react and can alleviate problems before they come up."

Adjusting Care Io the Patient

Adjusting Care to the Patient included nursing approaches which reflected the nursing staff members' attempts to individualize care and included responses "putting patient needs before your own" and "adjust yourself to the patient." These nursing responses were used to personalize the nursing care and adapt care to the ever-changing moods and behaviors of the cognitively impaired residents. These adjustments in care maximized the quantity and quality of nursing care given to the resident and rninimized the incidence of resident-to-staff aggression.

CNAs reported that they, not the patients, were the ones that needed to adjust their behavior during the provision of activities of daily living to aggressive cognitively impaired residents, i.e., bathing, dressing, toileting, feeding, etc. The possibilities that the demented can adapt or change in response to their environment are limited. It has to be adjusted to them (Miller, 1977; Hanley, 1984; Jeffery & Saxby, 1984). Nursing activities need to be performed in a manner that is adjusted to the difficulties the patient has in perception, memory, and orientation, as well as the need for activity and social interaction (Beck & Heacock, 1988) and in a way that supports the patient experience of wholeness and meaning (Kihlgren, Hallgren, Norberg, Brane, & Karlsson, 1990). The nursing activities provided have to be integrated into the demand for interaction with the patient as a whole person, and they must not be concerned only with the task performed in an impersonal manner (Hallberg, 1990).

A nurse describes how she assists the CNA with ADLs and interacts in ways that adapt to the patient's mood and preference:

If the CNA can't get them to cooperate, I step in with caution. I always try talking first. I explain why it is important to take a shower for example. And if they start to raise their fist... I explain "how would you like it if I did that to your daughter or wife?" and sometimes they understand, sometimes not. Sometimes I say "I'll come back in an hour when you're in a better mood" and you wouldn't believe it was the same person. If the person insists "leave me alone" I back off cause I know it's dangerous for me to keep trying. Then that's it, they won't cooperate.

A CNA shares her view of bathing a cognitively impaired resident:

I have a patient for 2 weeks, well, I try everyday but sometimes they [cooperate] and sometimes not. But after 2 weeks I have to force them to be clean. I say "I have to give you a shower" and they scream a lot and fight. I need help so I don't get hurt. A patient like that, you have to have someone with y ou... I know them, so if they are really in a bad mood, I just walk away and give them time and space until they are ready. I tell them I'll be back in a while to bathe them or whatever. Then I move on to the next person, and when I come back they usually have forgotten about it. If not, then I try to give them more time if they need it.

Another CNA described her strategies for showering physically aggressive residents:

One lady, I tried to give her the shower, but she kept being violent so I had to take her back out, dress her, and try again later. But I never was able to that day. I had to wait until the next day. Another patient, Roberta, she lets me wash everything, as long as its not in the shower, and thats ok with me. Rachel doesn't like the shower, so I can wash her in the bed and she is very cooperative. You can't force anybody to take a shower. So she lets me wash everything. Also, as long as it's not in the shower, and thaf s ok with me. Dorothy really fusses when you say "shower" so sometimes you have to compromise and sponge her in her room and change her clothes...well it helps the smell.

Another CNA suggested changing the time of the bath to a time that the resident's preference was one approach to decrease episodes of aggression:

You've got to let them be the boss, in their time frame, when they want it done. You've got to put your schedule around theirs more or less. I've been a CNA a long time and that mentality is 'Tve got to get them bathed and dressed and in the day room by 11 o'clock". But I know now as a nurse you just have to change your nursing approach because of the task orientation. A lot of these residents aren't morning people so they don't want to eat or get dressed, then a lot of CNAs don't want to do it twice [bathing/dressing] even though that may be exactly what the patients need. On the evening shift the aides want to bathe the patients at 5 PM then feed them at 5:30 PM and put them to bed even though they'd sleep better if they showered before they go to bed.

Still another CNA describes how she organizes care around her patients:

I get the patients up, shower them, and dress them for breakfast. Sometimes they don't want to brush their teeth. This other lady puts her makeup on first before she bathes. You have to tell her you'll put it back on after the shower, then she'll take a shower for you. These people really don't have much freedom. We have to tell them what to do, how to do it and everything. The ones who are alert, you tell them what you will be doing or give them options..."do you want this or that... do you want your shower now?" and the confused ones, like Bernie, I say, "Let's try later." I say "Let's take a shower, you're wet and you have to be changed now." But he refused and was uncomfortable and wanted to feel better, but he didn't connect the shower with feeling better.

Waiting Until the Patient Invites You

Waiting Until The Patient Invites You describes how the nursing staff understood each individual patient's behavior patterns, what was considered a safe nurse-patient distance in regard to invasion of personal space of each resident, and identified patient behaviors indicating readiness or willingness for care. The "invitations" for caregiving, which indicated resident readiness or willingness to interact nonaggressively with staff, included such behaviors as calling for the nurse, requesting help with ADLs, verbally requesting or gesturing for a CNA to stay with them. The act of physically touching a person, with the intent of providing intimate hygienic care, for example, may be misinterpreted by someone with dementia and as a result the resident may react aggressively.

One nurse described how she approached her residents when offering to give physical care:

In the morning for the shower, you have to wait until they are ready, calm. They will not fight you...but once in a while you get a patient that likes a shower. Ifs an individual thing. I talk nicely. .then they say "yes." But when it's time, they say no... so I wait 30 minutes more and sometimes an hour and I try again. I tell them I'll be back at 10 AM and then they're ready. (Some of them do not always understand.] I say it whether they understand or not. We can't force them too much; they have rights...then we give them bed baths if they don't want the shower...

Empathizing with the Patient

Empathizing with the Patient included how the nursing staff put themselves in the resident's place so they could experience what the patient might be going through. Statements of nursing staff who used empathy included "imagining how it is for them," "thinking of how you would want to be treated," and "feeling for them." The staff reported that when they empathized with the patient they had more tolerance and respect for what the resident could be going through, were better able to wait until the patient was cooperative, and reduced the incidence of aggression. Empathizing with the patient included the staff reflecting on what was happening to the resident, refocusing on what the resident could be experiencing by putting themselves in his or her place, and going on. One CNA shared her experience:

You have to think how you would want to be treated...with respect and compassion. Sometimes that is hard. But you know, they could be your mother, or your father... [long pause] and it makes you wonder if you might end up like that someday... so I try to keep that in mind when I go about my business here.

A CNA stated:

One of my patients said to me "I can't believe you are doing that to me, after all I've done for the Jews and Blacks, you're strapping me in this [shower chairj!" Part of me wanted to let him go, so I said I'm sorry but you have to.

AnRN stated:

Like us, we have our days, but for them, it's magnified. Their moods and emotions are in less control plus they are frightened and confused and disoriented.. .lost. At least we know what is going on, so I feel for these people. Sometimes I lose empathy, but I stop and think how sick they are. But as a nurse, it is so heartbreaking every day.

A CNA describes how she empathizes with her patient:

If I had another Grace* [patient known to bite and kick] you have to have another CNA [help you]. She spits and kicks, she doesn't like to take a shower or change her clothes. I never will get accustomed to that. I try to think how I'd be if I was the patient... You are helping them and they are screaming f - you at me...I feel so bad. I try to deal with it by not working over time. I really need the money but I need the day off more. If it comes to the point I will not be able to handle the patients in a nice way, I'll quit.

Watching for Warning Signs

Watching for Warning Signs included the activities the nurses performed as they were observing for behaviors that were antecedents to patient aggression. The nursing staff stated that they were "on the alert all the time." The nursing staff became hypervigilant, always observing for subtle changes in nonverbal behaviors (increased wandering, pacing, purposeless movement), mood, and facial expression. The non-verbal behaviors included "getting an evil look in their eyes," "seeing their face change," "watching their mood /behavior change" and "raising their fists." The nursing staff reported that they "kept their distance," "kept an eye out," and "watched their backs" as ways to prevent self-injury when patients demonstrated these non-verbal behaviors. Unprovoked physical attacks occurred, however, even to the most skilled nursing staff members. A CNA shared her learning experience with unprovoked physical aggression:

But this one lady she grabbed my breast, right on the nipple. really hurt me bad, but you know, she was smiling the very next minute and I didn't even have time to get angry...when I was there, the supervisor was with me and she helped me remove the residents hand from my breast. The resident said to me, "Get outta here, you moron." The supervisor helped, but no permanent damage was done. I've learned to watch, when you see them coming, you pull away.

Another CNA explained how understanding patient non-verbal behaviors was an important part of learning patient warning signs which helped the nursing staff reduce aggressive episodes and maintain safety:

Sometimes they tell you what they need, but sometimes you have to watch them. Florence kept banging on the table and I didn't answer her but I realized she really had to go to the bathroom. So I figured it out after a while. I knew she wanted to get away from the table and walk away, but after I moved the table, she got up and ran to the bathroom.

Speaking to the Person Behind the Dementia

Speaking to the Person Behind the Dementia was reported by the staff as understanding something about the person to whom they were providing care, and using that information when communicating with the patient during attempts at caregiving. Speaking to the person behind the dementia was demonstrated when the staff interacted with the residents using words and language that were most familiar [to the residents] and using information which reflected knowledge (religious orientation, hierarchical family role. business role, position in the community, uniforms) of what was important to the patient in their past and present life. Even though the words may not have been understood due to the advanced stage of dementia, the familiarity of words, sounds, and symbolic clothing may have provided comfort to the cognitively impaired patient, thus reducing the incidence of aggressive behavior.

The nursing staff reported that they often used aspects of a patients religious orientation to comfort the resident and reduce the incidence of aggression. Judaism was the predominant faith of the residents on this dementia unit. Reaching back into the long-term memories of their faith may have provided a sense of familiarity and security for the residents. One CNA described how he used familiar words in everyday conversation with his Jewish residents:

Smiling, I make people like me.. .even the families like me. I call everyone "Darling" [I say] "How are you my love?" "Good shabbos, everybody." I also say "Shabbat Shalom."

The CNA used Hebrew words gleaned from his clinical experience at this geriatric center, as he found that he was able to care for the Jewish residents with fewer episodes of resident resistance and aggression during ADLs. Another nurse described how learning about the residents' backgrounds, and what was important to them, helped her get the residents to calm down when they were getting physically aggressive. By reaching back into familiar memories, she was able to connect with the residents at some level, thus reducing the incidence of aggressive behavior. She explained:

Jack, a retired attorney, used to say "if you get me out of bed now, I'll sue you" and I say, "well Perry Mason is my attorney" and he laughs and calms down. He twisted my arm once and I screamed. I said to him, "are you gonna hit a pregnant woman? and if you hit a pregnant woman, your chances are not good in court" and he calmed down. Another patient, Michael, a retired policeman, likes to play "good guy, bad guy" then he calms down. I say "don't talk to me that way," and he starts to cuss, so if he tries to leave, we call the security guard and he comes up and the police, they know to play along. Michael will say [to the security guard] "I want you to make out a report" and the security guard plays along. The uniform gives Michael a sense of security knowing everything is under control and he calms down.

Helping Them Understand

Helping Them Understand included various nursing responses used by the staff to help the residents understand what they were attempting to do for them, elicit patient cooperation, and reduce the incidence of aggressive behavior. These nursing responses included: reminding, redirecting, making eye contact, using comforting words /touch, and making deals/negotiating with them. The CNAs believed these responses maximized resident cooperation and reduced incidents of aggression when attempting to provide nursing care. However, the CNAs, in particular, thought that if they could in some way communicate to the residents that they were really trying to help them, then the residents would cooperate with fewer episodes of aggression. All responses did not necessarily work for all residents at all limes but knowing which responses worked with which residents was helpful for the CNAs. Repeated attempts and trial and error were the norm. A CNA describes her attempts to communicate to the patient that she is trying to help:

Ho, she is a tough one. She wears a lot of makeup and she really fights. She really talks more and really wants a shower, but she says "do I stink?" She gets excited but once you talk nice to her she calms down and lets you bathe her. After that, change of clothes is hard. She screams, "they're trying to kill me." She likes soft colors on her clothes, and she wants you to change them until you get it right. So she tries to put on her dirty clothes again. She says "I'm too old for these clothes" so she refused this one time. I tried to change her and she didn't want to wear clean clothes. She was in the shower chair [at the time] and tried to grab her dirty clothes and almost fell out of the chair. I said "let me help you" and she screamed "I don't need your help" and I grabbed her arm to prevent her from falling [out of the shower chair.] She started screaming telling everyone I hurt her. And I felt really bad about it...I didn't want her to fall... but she said I hurt her... In school they taught us to go outside and get some air...but I had a witness and [the other CNA] said I tried to help the patient but the patient reported me. I felt so bad...The nurses knew I would never do that. I went outside and cried. I felt it is a weakness to cry...I let it all out. I went home and told my mother I felt like giving up. Maybe I should get some other kind of job? But she encouraged me to go back and do the best I can. There is always that fear that the patient will report you. I think she's comfortable in her dirty clothes. I just keep reminding her. I tell her "leave your dirty clothes for Maggie [her daughter]" but I think she feels comfortable in them.

A nurse attempts to communicate to the patient when the CNA is unsuccessful:

If the CNA can't get them to cooperate, I step in with caution. I always try talking first. I explain why it is important to take a shower for example. And if they start to raise their fist...I explain, "how would you like it if I did that to your daughter or wife?" and sometimes they understand, sometimes not. Sometimes I'll say, "I'll be back in an hour when you're in a better mood. And an hour later I'll come back and you wouldn't believe it was the same person. If the person insists "leave me alone" back off, cause I know it's dangerous for me to keep trying. Then that's it, they won't cooperate. If they see the same face, they will cooperate, if if s a new face, they think...well I can get away with they refuse, just like a child. Sometimes they think they can get away with not taking a shower with this new person, but after a while you know the patients and they won't give you a hard time because you know them.

Negotiating with residents was another approach used by CNA staff to help the patient understand they wanted to help them.

One CNA stated:

Everybody here, you have to take on a different personality. Take Edythe, for example, you have to dance around and be happy. She knows that if she's having a good day, I'll take her out for a smoke. I approached her and told her I'd take her out for a smoke if she'd let us [wash] her hair. Lately, she will wave her arm back and forth [with the wanderguard bracelet] and set off the alarm. Now she refuses to go into the elevator. Each day is so different.

Hasselkus (1992) stated that "the helping behavior of nursing staff is a way to prevent harm and to enhance the quality of life and well-being of a client with dementia." Fisher, Nadler, and Whitcher-Alagna (1983) state that a relational model of therapeutic helping depends on a care recipient who, like the caregiver, is actively attempting to make sense of the helping interaction. The sense that the person with dementia makes of a situation is not apt to be in synchrony with the sense made by the caregiver. Since the care recipient (resident) and the caregiver (the nursing staff member) cannot develop the desirable relationship of interdependence and partnership, caring for a person with dementia is more reflexive rather than reflective (Hasselkus, 1992). Athlin and Norberg (1987) speak to the special need in dementia care for clarity of non-verbal and verbal cues, sensitive interpretation of cues, responsiveness of the caregivers and the synchrony of interaction. As the competencies of the cognitively impaired person decreases, the main responsibility for upholding an interaction falls on the [nursing staff member]. Thus the asynchrony in a nursing staff-resident care relationship becomes more pronounced when the resident has dementia (Athlin & Norberg, 1987).

Going Into Their World

Techniques such as reality orientation and redirection have historically been recommended as psychiatric nursing interventions for communicating with residents with memory loss. As the nursing staff gained insight into what nursing responses were most appropriate to use for the individual resident and situation they substituted "going into their world" as an attempt to elicit patient cooperation and minimize aggression. "Going into their world" included responses such as "being part of their fantasy," and "going along with them" when providing care to disoriented elderly residents. The staff reported that by "Going Into Their World" they did not attempt to bring the patient into the reality of the nursing home, rather, they allowed the patienfs fantasy to continue, and entered into it with the patient. As a result, the patients were more cooperative and did not resist care. Feil (1982) advocates the use of nursing approaches which validate the patienfs experience rather than attempting to bring the patient into the reality of the nursing staff member. Validation therapy is based on the assumption that the disoriented older person can be "helped" by "validating" his or her feelings and personal views of the world, even if those feelings and views appear to conflict with accepted reality. It is accomplished by the validation worker's ability to demonstrate a degree of empathy for the disoriented older person, to "tune into feelings, pick up rhythms, listen to verbal cues, observe nonverbal cues" (Feil, 1982). One CNA described her attempts at going along with the patient:

We're supposed to redirect them and reorient them back to reality. But for some patients we just have to go along with them. If you don't, it will frustrate and upset them. You have to go into their world. Otherwise you'll have problems. You can't force them as long as you're safe and they're safe, you just gotta do it.

A night nurse stated:

You never know what is going to happen. If I told them, "look, you are living at the Geriatric Center" they'll never get it. They are in their own world. They want to get to a train and meet their husband or whatever, so going along is the way to go...I wish we could go into their minds for one day, just to see where they are.

Another CNA stated:

You have to act the part so they believe in you. I think it's easier for them to understand the fantasy than reality. So going along is easier on them and on us. It really depends on the resident and how you handle it.

Preserving Patient Dignity

The nursing staff reported that attempts at Preserving Patient Dignity while providing care reduced the incidence of physically aggressive behavior. Honoring preferences, saving face, and giving choices were responses included within Preserving Patient Dignity. The functional dependency of the patients resulted in most of the dayto-day decisions being made by the professional caregivers. Giving a resident choices about which clothing to wear, meal selection, or types of snacks gave the resident an opportunity to make decisions about small aspects of life, and helped preserve some of the remaining aspects of a resident's humanity. One CNA shared how he attempted to preserve patient dignity by honoring preferences:

Some ladies, first thing I do is close the door. Some ladies like me to give them their shower. I say to them "you wash the front and I'll wash the back." One lady told her husband "He has a lot of respect for me." Some ladies still don't want me [to shower them] so I will trade with another CNA. Thaf s only fair to the patient. We have to keep them all happy here. I feel embarrassed to work with females. It is easier for me to work with men, so I asked my supervisor to let me work with the men on [another floor]. At that time the other CNAs liked it because they liked to work with the women. I do everything for the patients here, bathe, feed, dress them. I do everything. Some of the patients are very agitated and get physically abusive. This one lady, she likes me, but doesn't like me to give her a shower. So I trade with another CNA and then she takes a shower OK. She lets me do anything I want except a shower. She doesn't like to take her clothes off in front of me because I am a man. I can understand that. I like to try and be patient with them even if they are short with me. Sometimes I wash them in the bed and thaf s ok with me, too. Some of the ladies don't like it because they are modest. They don't like men washing and touching them. Most of the Alzheimer's patients react this way...screaming and fighting. They don't understand what you are going to do to them. They pull away because they are afraid they will be hurt.

A registered nurse agrees that the gender of CNAs may be a cause of aggression:

Sometimes the women residents don't like the male CNAs [to wash them]. So we switch the [CNA] or I would go in and wash them up.

Saving Face was another nursing response identified within Preserving Patient Dignity. The CNAs reported that some staff, as well as some of the more cognitively intact residents, teased the more severely impaired residents about their mistakes; mistakes like incontinence were especially embarrassing to the residents. The CNAs found that Saving Face was one way that they could minimize a resident's embarrassment and prevent the resident from getting upset, agitated, and physically aggressive. Saving Face was an attempt by the staff to keep directions simple and straightforward to maximize the patienfs cooperation while at the same time preventing patient embarrassment related to cognitive loss. Some of the CNAs were acutely aware of the [cognitive] losses the residents were experiencing, and made an extra effort to prevent the resident from being embarrassed as a result of actions which occurred secondary to those losses. A CNA described how she prevented a resident's embarrassment by saving face:

For example, you could say "lef s go change your clothes, your dress is wet in the back" and they will start to scream, "are you looking at me?" So you have to know the trick, and speak softly to them and say 'look, you have tomato sauce on your sleeve, lefs go." Some people try to get them to change, but they say, "lefs go, you haven't changed your clothes in two days," and then they fight tooth and nail. So you have to work around them. They are afraid of stinking, so I try to keep them from being embarrassed. So I whisper really nice..."let's go change your clothes." I think if you say it really loud in front of everyone they do get embarrassed and the other patients do make fun.

Reducing the number of words or steps used by staff when interacting with a cognitively impaired elder can reduce the amount of stimuli a patient is required to process at any given moment, and potentially reduce the incidence of overstimulation, escalating disorientation, and subsequent aggressive behavior. One CNA described how she used a simple approach and saved face during her provision of nursing care:

With Daniel you gotta keep it simple. If you make it too complicated, he gets confused, then he gets more agitated. For example, Daniel will put on layers of shirts, so I say "Daniel, you're too warm" and he'll realize, then he'll take them off. I tried to do it another way, I'd say, "Daniel, you have too many shirts on" and he'd get agitated and look at me like I was the crazy one. He'd say "what are you talking about?" So simple is the way to go.

Nursing staff attempts at Preserving Patient Dignity were often compromised by the task orientation of the CNA group, the knowledge and skills of the staff, and the staff perception of being overwhelmed by the endless emotional and physical demands of the aggressive residents. Some less experienced CNAs verbalized difficulties in preserving the dignity of the resident versus getting the job done.

A CNA describes her view of the bath as a task to be accomplished:

I think the women are easier to handle than the men. When the men say "I don't want anything" I let them go. They can dump you on the floor. I prefer the women. Murray, for example, I say "lets get ready for day care" I say "you don't want the ladies to have you smelling bad. They want to hug you smelling nice." So I say "let's take a shave and a shower" Sometimes he tries to help himself, but he's slow, so I help him along. He says "I can do it myself," but I tell him he's slow, so I'll help you. Get him out of the way, then you won't have to worry about him anymore. Bathing is a difficult chore. Everyday we have to bathe somebody. Today I have 2 showers minimum and if someone else is dirty, we have to clean them, too. Teeth, peri care, everything. If they are difficult, I say we're going to get clean, lets go get pretty. If they scream, well, I let them go for a while then come back, but I'm always talking to them to keep them busy to try and make them feel better and want to take a shower and tell them maybe they'll enjoy it better. They always say "No, I don't need a shower, I have a cold or I have a clean body" whatever, [they] just don't want to take a shower, but eventually everybody gets a shower. Mostly, screaming and cussing and trying to hit you during the shower. That is the hardest part of it all.

One CNA described the reality of available choices there are to offer the residents:

I told you about choices. Mostly we try to give them as much choice as we can. But the bottom line is, they have to eat, they have to bathe, they have to get out of bed. They have to do what we want them to do, because otherwise it would look like we are not giving them good care. So really, what choice do they have? If they don't want to get dressed, well, we can't leave them naked, can we? So we have to dress them and keep them warm, even when they don't want that. So when it comes down to what they need versus what they want, and if push comes to shove, we are going to have to make decisions for them even if they don't like it. And thats when the aggressive behavior comes in. In their mind, its Like "who are you to tell me I need a bath?" So if you can't convince them, you have to take away that choice, because really, you can't leave an incontinent patient like that. So after you take away all their choices, there is nothing left.

Protecting the Patient

In addition to their attempts to reduce the incidence of patient-tostaff aggression during the provision of nursing care, the nursing staff was also expected to maintain the safety of the patients by preventing patient-to-patient altercations. Ongoing supervision of patient safety, while mamtaining patient independence in a least restrictive environment, was a daily challenge to the nursing staff. Staff injuries and lost work time resulted as a consequence of breaking up resident-toresident physically aggressive confrontations. Resident falls, residents wandering into each other's space, residents attempting to take food, clothes or other possessions from one another, residents taking the favorite chair or resting places of another, and resident-to-resident verbal confrontations precipitated resident-to-resident aggressive incidents.

A Licensed Practical Nurse shared her experience in protecting her patients:

I can't afford to be injured. If they are fighting, I always get another person to help me and wait until they calm down. You've got to think quickly; you make mistakes but you've got to think "residents' needs first" then your own needs, especially if he's combative. But then you've got to put your own safety on par with them.

One CNA described the use of teamwork as one way to maintain the safety of the resident as well as the staff:

I've been scratched and kicked. This one lady, I strapped her down and held her hands and we needed extra people to hold them so they don't hurt themselves. We protect them, protect ourselves, then get them clean. Selma doesn't like to take a shower. So...two or three of us get together and shower her. She will thank us afterward. But if she is really upset, we'll give her really good peri care and that is enough. But she will still cuss you out.

Another CNA described her team approach to complete her daily shower assignments:

Showers are the worst time. Edythe takes three CNAs to do her. She'll try to talk you out of it; she'll bite and scratch and kick. She'll say, "I don't need a shower, I haven't slept with a man." Another one, Bobbie, we strap her in the shower chair and tell her "we're gonna take you for ice cream" and we take her to the shower and she gets so angry, she forgets about the ice cream.

Fear of patient injury was a constant concern of the nursing staff due to the fear of administrative retributions, concerns about personal injury, as well as a concern for a patienfs well-being and comfort. One CNA describes his concerns about safety issues when showering an aggressive resident:

Sometimes they are scary. Showers are a big part...they kick and hit you and act like crazy people...they are so uncoordinated. Not that they would hurt me but they might hurt themselves sometimes. They hit me but I am stronger than them. I am scared a lot that they will hurt themselves...I am also scared when they scream so loud, especially in the beginning, when I was new. I was afraid that [the administration] will think I was hurting them or something. I wish [administration] had a camera so they could see the shower room. I really think they could understand all the screaming then...


The focus of this study was aimed toward describing how the nursing staff of one DSCU responded to the physically aggressive behaviors demonstrated by the residents in their care. The purpose of this study was descriptive rather than theoretical. The perspectives of caring for the cognitively impaired residents of this DSCU was predominantly that of the CNA since they were the majority of the subjects interviewed in this study. For the purposes of this article, the conclusions will be limited to those which have pertinence to the nursing staff actions of providing hygienic care to cognitively impaired institutionalized elderly.

Hygienic care of persons with cognitive impairments in this study was found to cause patient distress and precipitate physically aggressive behaviors toward staff. The nursing staff who were interviewed identified that showering a patient was the most difficult of all ADLs. The practice of bathing patients was often prompted by the nursing staff's need for control of incontinence odor and the maintenance of skin integrity, the task orientation of CNAs and the nursing ritual and/or daily assignment of bathing the residents.

It has been estimated that between 80% and 100% of direct care provided to nursing home residents is provided by nurses' aides (Halbur, 1982; Institute of Medicine, 1986; Reagan, 1986), and the average amount of skilled nursing time allocated to each nursing home resident is about 12 minutes per day (Institute of Medicine, 1986). Given this short amount of time allocated for each resident in a nursing home, professional nurses can only imagine the perspective of the CNA when they view the bath as one of the many tasks to be accomplished in their daily patient care assignment.

Burgener and colleagues (1992) found a number of significant relationships between caregiver and elder behaviors during bathing. Allowing the resident to perform self-care tasks and the caregiver smiling and exhibiting a relaxed affect were positively associated with a calm, functional, and attentive resident response. Unfortunately, the CNAs who are rushed for time, and their perception of feeling pressured to accomplish all assigned tasks within an 8-hour shift, offers little choice for the resident or the nursing staff member. Nursing practice rituals such as bathing need to be re-thought in terms of who really benefits from this activity. The need to put the resident's needs first and adjust nursing care to them via individualized approaches cannot be overemphasized.

The nursing interventions identified within the theme "Working Through Aggression to the Person" can assist nursing home personnel in the provision of individualized, hygienic care to the resident, making the process as pleasant as possible, maintaining safety of both the staff and the resident, and reducing the incidence of physically aggressive behavior. These preventive approaches that have been identified by the caregivers in one secured Dementia Special Care Unit are supportive of the OBRA '87 regulations which focus on maintaining resident dignity and the provision of individualized care. AU caregivers must continue to focus on the need for individualized resident care, specifically hygiene care. This qualitative research study provided data for the development of new nursing interventions and revealed geropsychiatric nursing approaches used by caregivers for the management of physically aggressive elderly in Dementia Special Care Units. It is a source of data that has validated the roles of CNAs as frontline caregivers, and raises further attention to the needs of persons with advanced cognitive decline.


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