Journal of Gerontological Nursing

REDUCING AGGRESSIVE BEHAVIOR: During Bathing Cognitively Nursing Home Residents

Beverly Hoeffer, DNSc, RN, FAAN; Joanne Rader, MN, RN FAAN; Darlene McKenzie, PHD, RN; Mary Lavelle, MSN, RN; Barbara Stewart, PHD

Abstract

Among the most troublesome problems for nursing home staff are behavioral symptoms of Alzheimer's Disease and related dementias that occur when assisting residents with personal care (Aronson, Post, & Guastadisegni, 1993; Beck, Baldwin, Modlin, & Lewis, 1990; Burgener, Jirovec, Murrell, & Barton, 1992). Descriptive studies indicate that these behaviors often occur during bathing and are especially common among moderately and severely cognitively impaired residents (Aronson, Post, & Guastadisegni, 1993; Burgener, Jirovec, Murrell, & Barton, 1992; Rossby, Beck, & Heacock, 1992). Aggressive behavior is one of the most difficult behavioral symptoms for staff to manage. Physically and verbally aggressive behavior toward staff has been linked to staff's experience of jobrelated distress (Everitt, Fields, Soumerai, & Avorn, 1991), frustration with caregiving (Mentes & Ferrario, 1989), job dissatisfaction and burn-out (Colenda & Hamer, 1991), and turnover (Burgio, Jones, Butler, & Engel, 1988) as well as staff's avoidance of residents (Meddaugh, 1990) and the use of chemical and physical restraints (Ryden, Bossenmaier, & McLachlan, 1991).

Documented antecedents of aggressive behavior toward staff during assistance with personal care include touch or invasion of personal space (Marx, Werner, & CohenMansfield, 1989; Rossby, Beck & Heacock, 1992; Ryden, Bossenmaier, & McLachlan, 1991), frustration experienced because of declining functional abilities or anticipation of pain (Cohen-Mansfield, Marx, & Rosenthal, 1990), perceived loss of personal control or choice (Meddaugh, 1990; Winger, Schirm, & Stewart, 1987), and lack of attention to personal needs or preferences (Chrisman, Tabar, Whall, & Booth, 1991). An observational study of cognitively impaired residents conducted in two nursing homes suggested that physically aggressive behavior during caregiving was a defensive response to a perceived threat that occurred because cognitive and perceptual deficits impaired the ability to recognize the staff's assistance as helpful, not as an intention to harm (Bridges-Parlet, Knopman, & Thompson, 1994).

In the early 1990s, Ryden and colleagues (Feldt & Ryden, 1992; Ryden, Bossenmaier, & McLachlan, 1991) identified a need to develop and test interventions aimed at preventing or reducing aggressive behavior of cognitively impaired elderly nursing home residents, particularly during hands-on care given by nursing assistants. Based on the promising results of their pilot educational program for 17 nursing assistants, which included developing individualized management plans for aggressive residents (Feldt & Ryden, 1992), the investigators called for further evaluation of the effectiveness of teaching and rolemodeling direct care to residents known to be aggressive during personal care.

The pilot study reported in this article was designed to help nursing assistants reduce the aggressive behavior of cognitively impaired residents during bathing and to determine if this improved nursing assistants' perceptions of residents and experience of caregiving during this personal care activity. We selected bathing because the majority of nursing home residents require assistance with this activity, which occurs routinely in most facilities for residents once or twice a week (Rader, 1994; Sloane et al., 1995). Moreover, bathing provides an interpersonal context in which aggressive behavior may readily occur (e.g., touch, invasion of personal space, personal control and choice issues) as well as an opportunity for staff to be responsive to the individual needs of residents.

Prior to piloting the intervention, a preliminary study designed to describe the frequency and nature of aggressive behavior of residents . who required assistance with bathing was conducted in a 130-bed non-profit religiously affiliated intermediate and skilled care nursing facility (Hoeffer, Rader, McKenzie, Lavelle, & Stewart, 1996). The facility, known for the quality of care provided to residents, was located in a small town in a rural area. At the time of the preliminary study, 102 residents in the facility were long stay residents and 93 of these required assistance with…

Among the most troublesome problems for nursing home staff are behavioral symptoms of Alzheimer's Disease and related dementias that occur when assisting residents with personal care (Aronson, Post, & Guastadisegni, 1993; Beck, Baldwin, Modlin, & Lewis, 1990; Burgener, Jirovec, Murrell, & Barton, 1992). Descriptive studies indicate that these behaviors often occur during bathing and are especially common among moderately and severely cognitively impaired residents (Aronson, Post, & Guastadisegni, 1993; Burgener, Jirovec, Murrell, & Barton, 1992; Rossby, Beck, & Heacock, 1992). Aggressive behavior is one of the most difficult behavioral symptoms for staff to manage. Physically and verbally aggressive behavior toward staff has been linked to staff's experience of jobrelated distress (Everitt, Fields, Soumerai, & Avorn, 1991), frustration with caregiving (Mentes & Ferrario, 1989), job dissatisfaction and burn-out (Colenda & Hamer, 1991), and turnover (Burgio, Jones, Butler, & Engel, 1988) as well as staff's avoidance of residents (Meddaugh, 1990) and the use of chemical and physical restraints (Ryden, Bossenmaier, & McLachlan, 1991).

Documented antecedents of aggressive behavior toward staff during assistance with personal care include touch or invasion of personal space (Marx, Werner, & CohenMansfield, 1989; Rossby, Beck & Heacock, 1992; Ryden, Bossenmaier, & McLachlan, 1991), frustration experienced because of declining functional abilities or anticipation of pain (Cohen-Mansfield, Marx, & Rosenthal, 1990), perceived loss of personal control or choice (Meddaugh, 1990; Winger, Schirm, & Stewart, 1987), and lack of attention to personal needs or preferences (Chrisman, Tabar, Whall, & Booth, 1991). An observational study of cognitively impaired residents conducted in two nursing homes suggested that physically aggressive behavior during caregiving was a defensive response to a perceived threat that occurred because cognitive and perceptual deficits impaired the ability to recognize the staff's assistance as helpful, not as an intention to harm (Bridges-Parlet, Knopman, & Thompson, 1994).

In the early 1990s, Ryden and colleagues (Feldt & Ryden, 1992; Ryden, Bossenmaier, & McLachlan, 1991) identified a need to develop and test interventions aimed at preventing or reducing aggressive behavior of cognitively impaired elderly nursing home residents, particularly during hands-on care given by nursing assistants. Based on the promising results of their pilot educational program for 17 nursing assistants, which included developing individualized management plans for aggressive residents (Feldt & Ryden, 1992), the investigators called for further evaluation of the effectiveness of teaching and rolemodeling direct care to residents known to be aggressive during personal care.

The pilot study reported in this article was designed to help nursing assistants reduce the aggressive behavior of cognitively impaired residents during bathing and to determine if this improved nursing assistants' perceptions of residents and experience of caregiving during this personal care activity. We selected bathing because the majority of nursing home residents require assistance with this activity, which occurs routinely in most facilities for residents once or twice a week (Rader, 1994; Sloane et al., 1995). Moreover, bathing provides an interpersonal context in which aggressive behavior may readily occur (e.g., touch, invasion of personal space, personal control and choice issues) as well as an opportunity for staff to be responsive to the individual needs of residents.

Prior to piloting the intervention, a preliminary study designed to describe the frequency and nature of aggressive behavior of residents . who required assistance with bathing was conducted in a 130-bed non-profit religiously affiliated intermediate and skilled care nursing facility (Hoeffer, Rader, McKenzie, Lavelle, & Stewart, 1996). The facility, known for the quality of care provided to residents, was located in a small town in a rural area. At the time of the preliminary study, 102 residents in the facility were long stay residents and 93 of these required assistance with bathing. Eighty-six of these residents who remained in the facility were included.

The Ryden Aggression Scale (RAS), Form II (Ryden, Bossenmaier, & McLachlan, 1991) was used to count the number of aggressive behaviors observed during bathing and describe their characteristics. The RAS is a paper-and-pencil checklist of physically, verbally, and sexually aggressive behaviors, suitable for use by nursing assistants. Convergent validity of the RAS had been established, and interrater agreement was .88 in a previous study (Ryden, 1989). A standardized definition for each behavior (Heithoff, Beck, Baldwin, Cuffel, & O'Sullivan, 1993) was added to the back of the checklist. Also added were checklists for the kind of bath given (shower, tub, bedbath) and when the behavior was observed (dressing/undressing, going to /from the bath, during the bath procedure). A videotape of a simulated bathing situation was used to train the nursing assistants on how to complete the RAS. Nursing assistants completed the RAS after each bath with which they assisted residents. The first four baths for each resident were analyzed since less than 10% of the data for these baths were missing. Few sexually aggressive behaviors were observed; hence the analysis examined the occurrence of physically and verbally aggressive behaviors only.

Of the 86 residents observed during the four baths, 41% (n=35) were aggressive during at least one of these baths, or approximately once a month (most residents were bathed weekly). Sixteen percent were aggressive during at least three of four baths, that is, during the majority of times that nursing assistants helped them with bathing. Sixty percent of the residents who were aggressive during at least one bath had a diagnosis of Alzheimer's Disease (AD) or other dementia; 72% of residents who were aggressive during three of the four baths had a diagnosis of AD or other dementia.

Nearly two-thirds (n=22) of the aggressive residents were both physically and verbally aggressive during bathing. By far the most frequent types of physically aggressive behavior reported by nursing assistants were being hit, punched or slapped by residents, followed by being pinched/squeezed and pushed/ shoved. Verbally aggressive behavior reported was fairly evenly distributed among the use of hostile language, name calling and cursing/obscene language. Aggressive behavior occurred most frequently during the bath itself but occurred often during assistance with dressing/undressing and during transportation to and from the bath or shower. The frequency and severity of aggressive behaviors observed during bathing were consistent with other reports and provided further support for piloting a different approach to this personal care activity.

At the time we began our project, no intervention studies on reducing aggressive behavior specifically during bathing cognitively impaired nursing home residents had been reported in the literature except for research conducted by Ryden. Several articles have been published more recently (Hagen & Sayers, 1995; Maxfield, Lewis & Cannon, 1996; Miller, 1994).

METHODS

Design

A pretest-posttest design in which subjects served as their own controls was used to test the effectiveness of the intervention in reducing the number of aggressive behaviors during bathing and improving both residents' and nursing assistants' experience with the bath. Three nursing assistants, who were designated bath aides in the facility and consented to participate in the study, were assigned by the Director of Nursing Service to bathe subjects during the study. The intervention was introduced by the second author, a geropsychiatric clinical nurse specialist (CNS), who accompanied each nursing assistant when bathing study subjects. Data were collected pre- and post-intervention on subjects' behavior and on nursing assistants' experiences.

Setting and Sample

The intervention was piloted in a 76-bed proprietary intermediate care facility located in a residential neighborhood in an urban area. Eleven of the 61 residents in the facility who required assistance with bathing met sample selection criteria for aggressive behavior (verbally or physically aggressive behavior during two of four baths). Informed consent for participation in the study was obtained for these residents from a family member. A score of 21 or less on the Mini Mental State Exam (Folstein, Folstein & McHugh, 1975) was used to confirm that all subjects met sample selection criteria for cognitive impairment. Data were analyzed for only 10 subjects because a change in assignments resulted in the loss of one subject during the post-intervention period. Most of the 10 subjects were female (80%) and all were white. Their mean age was 89.5 years; the age range was 86 to 98. The mean MMSE score was 5.7 (i.e., severely impaired); scores ranged from 0 to 16. The average length of stay in the facility was 40 months; all subjects had been in the facility for a rninimum of 5 months.

Description of the Intervention

A brief description of the intervention follows as the intervention has been described elsewhere also (Rader, 1994; Rader, Lavelle, Hoeffer & McKenzie, 1996; Sloane et al., 1995). The intervention had two major components: a bedside consultation model and individualized bathing care plan. Essentially, the intervention was aimed at changing the psychosocial environment in which bathing care occurred although the physical environment was also altered (e.g., temperature of water, means of washing hair). The emphasis was on shifting the nursing assistant's perspective from task-focused (i.e., getting the assigned bath done) to person-focused (i.e., attending to the perspective and preferences of the resident and individualizing the bathing care). To achieve this, the CNS used what we labeled as the three Fs of bathing: function, frequency, and form. The CNS observed the nursing assistant and the subject during the first bath and then worked alongside the assistant for three to eight baths problem solving and trying out alternative approaches. The first step was to help the nursing assistant identify the specific function the bath served for a particular resident (e.g., maintain skin integrity by removing urine residue, reduce odor from armpit area), and then identify the frequency with which a bath would need to be given and in what form to achieve that function. Thus, the option of flexibility was introduced instead of following a routine bath schedule for each resident. The CNS consultant and the nursing assistant experimented with varying the length of time between baths and varying the bath method, and tried the use of in-bed procedures such as the towel bath. The CNS modeled skillful verbal and non-verbal approaches during bathing the resident and provided feedback to the nursing assistant on "reading the resident" and adjusting the approach based on behavioral cues. She debriefed the nursing assistant after each bath to clarify what had transpired and to identify strategies that had worked. She also kept field notes on each bath with each resident, including the debriefing, and used these notes along with additional information gathered from family and staff to develop the individualized bathing care plan with the nursing assistant.

The individualized bathing care plan was written from the perspective of the resident (Smith & Gamroth, 1995) and contained the goals for the bath, the outcomes to be achieved, and information and background about the resident that would be helpful to anyone assisting with bathing care (Figure). Introduction of the intervention lasted from 2 to 4 weeks for each resident and involved from 3 to 8 baths per subject. This variability occurred because of the differing lengths of time required for the CNS and the nursing assistant to problem solve and try out alternative strategies and methods during bedside consultation and to develop the written, individualized bathing care plan. The intervention was considered as implemented when the individualized plan was finalized and placed in the flowsheet book at the nurses' station.

The implementation of the intervention was staggered to accommodate the number of subjects included. The CNS worked first with four subjects and the nursing assistants assigned to bathe them (early intervention group) and then with the additional six subjects and the nursing assistants assigned to bath them (later intervention group). Because of the timing involved in this pattern, aggressive behavior was recorded during three pre-intervention baths for subjects in the early intervention group and during six pre-intervention baths for subjects in the later intervention group. Aggressive behavior also was recorded for all subjects during five baths after the intervention was implemented, three approximately 1 month after the intervention phase and two at the end of the 6-month study.

FIGURESuggested Bathing Caro Plan for Mrs. W 6/25/96

FIGURE

Suggested Bathing Caro Plan for Mrs. W 6/25/96

Table

TABLE 1Behavioral Items on the Revised Ryden Aggression Scale, Form II

TABLE 1

Behavioral Items on the Revised Ryden Aggression Scale, Form II

Instruments and Data Collection Procedures

A revised version of the Ryden Aggression Scale (RAS) was used to collect data on the number and types of aggressive behavior. Since sexually aggressive behaviors very rarely occurred during the preliminary study, they were eliminated. Other similar physically and verbally aggressive behaviors were combined so that the revised RAS consisted 10 physically and 3 verbally aggressive behaviors. Internal consistency reliability across three baths ranged from alpha=.78 to .90 for the physical aggression items and from alpha=.83 to 1.00 for the verbal aggression items. Two non-aggressive behaviors indicative of distress (crying and screaming) that nursing assistants reported as disruptive during bathing and an overall "upset" rating, ranging from 0 at all upset) to 3 (very upset) were added to the RAS. Behavioral items on the revised RAS are listed in Table 1. A videotape of a simulated bathing situation was used to train the nursing assistants on the use of the revised RAS. The nursing assistants completed the RAS for all preand post-intervention baths for each subject. Interrater agreement during 42 baths for the revised RAS was .92.

A new instrument, titled the Assessment of Bathing Experience and incorporating items from the Experience of Caring semantic differential scale (Feldt & Ryden, 1992), was used to measure nursing assistants' perceptions of the resident's behavior and experience of caregiving during bathing. To make the Experience of Caring scale easier to use, the six items were converted to a Likert-type scale ranging from 0 (not at all ) to 3 (very) for each item. Additionally, a 4-item and a 2-item Likert-type scale were added to measure assistants' perceptions of the resident's behavior and their sense of relatedness to each resident. Scores on these scales ranged from 0 (not at all) to 3 (very) for each item also. The items from the latter two scales were derived in part from interviews with the nursing assis-, tants who participated in the preliminary study. Internal consistency reliabilities for the three scales postintervention were alpha=.78 (experience of caring), .94 (perception of behavior), and .72 (relatedness), respectively. The nursing assistants completed the Assessment of Bathing Experience instrument containing the three scales pre- and post-intervention for each subject that they bathed.

Results

Aggressive Behavior During Bathing. Scores were averaged across the pre-intervention and across the post-intervention baths for all 10 subjects. As shown in Table 2, significant differences were found between the pre- and post-intervention mean scores for the number of physically and verbally aggressive behaviors observed and for how upset the subjects appeared.

Because changing the form of bathing by using a towel bath appeared to be an effective in-bed method for reducing aggressive behavior, this approach was used systematically with one subject who was aggressive during showering. Although not all distressful behavior (e.g., crying) diminished, physically aggressive behavior did decrease during the times that the towel bath was given and it increased again once the towel bath was withdrawn. The results of this single subject study for seven baths (S=shower, TB=towel bath) are shown in Table 3.

Assessment of Bathing Experience. Significant differences were found between pre- and postintervention scores on the perceptions of subject's behavior (t=2.93, p=.02). The nursing assistants rated subjects as less upset and aggressive and more calm and relaxed during bathing after the intervention. Significant differences also were found between pre- and postintervention scores on the experience of caring for aggressive residents during bathing (t=2.47, p=. 03). Post-intervention, the nursing assistants rated their experience as less frustrating and frightening and as more quickly done, hence, more positive. However, there was no significant difference in how they described their relationship with residents who were aggressive during bathing (t=1.73, p=.07). Thus, the intervention may have been effective in changing the nursing assistants' perceptions of residents' behavior and their own experience of caregiving during bathing residents, but less effective in changing how they felt toward residents who could be aggressive. Results for individual scale items are found in Table 4.

DISCUSSION

This pilot study demonstrated that a model of care that emphasizes an individualized personfocused rather than a task-focused approach can reduce aggressive behavior during bathing and make it a more positive caregiving experience for nursing assistants and a less upsetting experience for residents. A critical element in the intervention was getting the nursing assistant to question the function of bathing for each resident (i.e.. Was there a compelling health, social or comfort reason for the bath from the perspective of the resident?). Interviews with nursing assistants provided several clues to why the intervention was successful. They indicated that the bedside consultation process used to develop individualized bathing care plans was effective in changing their approach for several reasons. They felt validated (i.e., it helped to have someone else observe the difficult bathing situations they encountered with aggressive residents) and supported (i.e., given permission to try something different such as altering the frequency or form of bathing), and they had an opportunity to observe alternative strategies modeled in actual bathing situations. Thus, although the focus of the intervention was on changing the psychosocial environment during bathing, the study also suggests that altering the organizational environment is essential for success (Rader, Lavelle, Hoeffer, & McKenzie, 1996). Nursing assistants are concerned that if they alter standard routines they will be perceived by supervisors and co-workers as not doing their job, so validation and support from co-workers and supervisors are critical to their willingness to try new approaches.

Table

TABLE 2Paired T-test Results for Aggressive Behavior and Being Upset Before and After the Intervention

TABLE 2

Paired T-test Results for Aggressive Behavior and Being Upset Before and After the Intervention

Table

TABLE 3Number of Aggressive and Other Distressful Behaviors During Shower and Towel Bath Conditions Over Time for Single Subject

TABLE 3

Number of Aggressive and Other Distressful Behaviors During Shower and Towel Bath Conditions Over Time for Single Subject

Table

TABLE 4Paired T-test Results tor Assessment of Bathing Scale Items Before and After the Intervention

TABLE 4

Paired T-test Results tor Assessment of Bathing Scale Items Before and After the Intervention

We think the towel bath approach (i.e., changing the form of the bath procedure) is especially promising for several reasons. The findings from the one subject suggest that it can be effective in reducing physically aggressive behavior. Lack of effectiveness with verbally aggressive and other distressful behaviors was probably a function of the infrequent occurrence of these behaviors for this subject. Moreover, as found in the preliminary study, aggressive behaviors also occurred during bathing-related activities such as undressing and transporting the resident to the bath area. Since the towel bath is given in bed, this eliminates potentially distressful activities that may escalate aggressive behavior before the bath even begins. The procedure itself is soothing and comforting and provides maximum privacy for the resident (Rader, Lavelle, Hoeffer, & McKenzie, 1996). Nursing assistants can readily identify the towel bath as a strategy that works because it is a concrete "thing" that they can do. Overall, it takes less time and provides less opportunity for resistive behavior to develop and escalate into aggressive behavior.

CONCLUSION

We realize that we must use caution in generalizing the findings from this pilot study because of the small sample of residents and nursing assistants who participated. Nonetheless, we believe that changing the psychosocial, physical and organizational environment in which bathing occurs and emphasizing an individualized, personfocused approach that takes into account the function, frequency and form of bathing will reduce aggressive behavior. As a result, bathing will be a less distressful and more pleasant experience for residents and their caregivers.

REFERENCES

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TABLE 1

Behavioral Items on the Revised Ryden Aggression Scale, Form II

TABLE 2

Paired T-test Results for Aggressive Behavior and Being Upset Before and After the Intervention

TABLE 3

Number of Aggressive and Other Distressful Behaviors During Shower and Towel Bath Conditions Over Time for Single Subject

TABLE 4

Paired T-test Results tor Assessment of Bathing Scale Items Before and After the Intervention

10.3928/0098-9134-19970501-07

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