Journal of Gerontological Nursing


Joan I Middleton, RN, BSCN, MN; Norma J Stewart, RN, PhD; J Steven Richardson, PhD


Related to Disruptive Behaviors on Special Care Units Versus Traditional Long-Term Care Units


Related to Disruptive Behaviors on Special Care Units Versus Traditional Long-Term Care Units

The nature of the relationship that exists between formal caregivers and residents of long-term care facilities influences the quality of life for both caregivers and residents. While considerable research has been conducted on assessing and improving the situation of cognitively impaired residents and informal (i.e., family) caregivers, relatively little work has emphasized the perceptions and feelings of professional caregivers (Chappell & Novak, 1992). The shift in the delivery model for dementia care toward separate units designed to meet the special needs of cognitively impaired individuals has not adequately addressed the reactions of staff in these settings.

The purpose of this study was to compare the perceptions of formal caregivers (staff) on special care units (SCUs) versus traditional units (TUs) regarding their relationships with residents on these long-term care units, their reports of exposure to disruptive behaviors from residents, and their reports of distress related to disruptive behaviors in general and physical aggression in particular. Disruptive behaviors included aggressive and aversive behaviors (Jackson et al., 1989). Aggressive behavior was defined as verbal and physical behaviors that could inflict physical or psychological pain on another but with no necessary assumption of intent to hurt another person (Patterson, 1982). Aversive behavior, such as calling out, was annoying but not hurtful.


During the past 15 years, SCUs designed to provide quality care for older adults with dementia have developed throughout Canada, the United States, and Europe (Mace, 1993). Although these units vary widely in design and treatment approaches, their intent is usually to care for individuals who exhibit some form of disruptive behavior, such as aggression or wandering. These units segregate individuals who place themselves and others at risk when they reside in TUs where other residents have severe physical disabilities (Sloane & Mathew, 1991). Secure exits on SCUs mean that individuals can wander safely on the unit without risk of elopement. On the other hand, the provision of care for groups of individuals with disruptive tendencies on closed units is a challenge for the maintenance of therapeutic caregiver-resident relationships.





The aim of SCUs is to provide a therapeutic milieu (Coons, 1991). Evaluation research regarding the effectiveness of these units to improve quality of care recently has been conducted (Coons, 1991; Gold, Sloane, Mathew, Bledsoe, & Konanc, 1991; Sloane & Mathew, 1991). During the same time period, relatively little research has focused on the effect that SCUs, as workplaces, have on staff (Mobily, Maas, Buckwalter, & Skemp Kelley, 1992). However, there is a large body of literature on the effects of caring for cognitively impaired older adults by informal caregivers in home settings (Gatz, Bengtson, & Blum, 1990).

As behavioral problems worsen in individuals with dementia, these individuals often are institutionalized (Cohen-Mansfield & Billig, 1986). Individuals who exhibit the most severe behavioral problems are usually placed on SCUs. Research completed in this area suggests it is stressful for staff to work with cognitively impaired individuals because of the heavy physical work, the agitation and aggression exhibited by these individuals, and the difficulty of forming meaningful caregiver-resident relationships as dementia advances (Mace, 1990). Initial studies also suggest that the level of distress experienced by individual staff when exposed to disturbed behaviors varies widely (Everitt, Fields, Soumerai, & Avorn, 1991) and is related to individual differences in empathy, attitudes (Astrom, Nilsson, Norberg, Sandman, & Winblad, 1991), and cognitive appraisal of behaviors (Novak & Chappell, 1994).

Formal caregivers spend a great deal of time with the individuals for whom they care; yet, research is lacking on whether there are differences in distress levels for staff who care for mentally alert but frail older adults compared to relatively physically well but severely mentally impaired older adults. Studies of perceived burnout in formal caregivers of cognitively impaired individuals (Heine, 1986; Mobily et al., 1992; Novak & Chappell, 1994) have identified characteristics of the job, the individual caregiver, and the workplace environment that lead to stress.

Staff stress has been linked to exposure to verbal and physical aggression (abuse) in a variety of nursing care settings (Graydon, Kasta, & Khan, 1992). Nurses exposed to high rates of aggression experience detrimental effects on their well-being (Burrows, 1984; Ryan & Poster, 1991). In some cases, individuals exposed to aggression tend to blame themselves for eliciting this response. Others, such as coworkers and families of the individuals for whom they care, tend to blame them as well (Lanza, 1987). This process increases the stress on these individuals and does not allow them to resolve the feelings they have as a result of the abuse (Morrison, 1987).

Most of the long-term care research on disruptive behaviors (Jackson et al., 1989) and agitation (Cohen-Mansfield & Billig, 1986; Cohen-Mansfield & Marx, 1989) in cognitively impaired individuals examines the patterns and correlates of behavior rather than the impact on formal caregivers. Research has linked caregiver touch to resident aggression (Marx, Werner, & CohenMansfield, 1989), particularly when the touch is associated with physical care (Ryder, Bossenmaier, & McLachlan, 1991). On the other hand, touch has been considered a positive, comforting intervention with cognitively impaired individuals, and evidence suggests benefits to residents' attention (Langland & Panicucci, 1982) and nutritional intake (Eaton, Mitchell-Bonair, & Friedmann, 1986) when formal caregivers touch residents with dementia during care.

Marzinski (1991) found that pain may be a factor which contributes to aggression in cognitively impaired residents who have a concurrent diagnosis of a painful condition such as degenerative joint disease or osteoarthritis. In these cases, caregiver assistance with activities of daily living may cause pain for residents. Consequently, when the residents are severely impaired and do not understand what staff are trying to do, residents may fight back in a protective gesture that staff experience as abuse.

The formal caregivers in longterm care settings are actively involved in all aspects of the daily lives of residents and, over a long period of time, gain extensive and intimate knowledge of the residents placed in their charge. In some cases, these caregivers spend almost as much interactive time with the residents as with their own families. During the course of years, it is possible relationships between formal caregivers and residents may evolve into relationships more like those found in families. Family dyads can be functional and, therefore, beneficial to both individuals involved; however, sometimes they are dysfunctional with distressing and hurtful interactions leading to a decrease in self-esteem and enjoyment of life for both individuals.


Peplau (1952) was one of the first nurse theorists to write about the nurse-client relationship. Her interpersonal theory was related to the work of the psychiatrist Sullivan (1953) and became the basis for many of the nursing theories to follow (Butcher & McFarland, 1991). Peplau (1952, 1989) suggested that through an understanding of their own behavior, nurses are more able to assist clients in the management of interpersonal anxiety expressed in behavior patterns. Through communication skills, nurses can help clients clarify perceptions and improve interactions with others. The role of nurses in therapeutic relationships focuses on the needs of clients and, therefore, is very different from relationships that meet mutual needs, such as those developed with friends or family. Peplau (1952) also referred to the interpersonal environment which includes interactions between the individuals and their caregivers (e.g., families, staff). Because formal caregivers provide "around-the-clock nursing care" of residents in institutions, their contribution to the environment likely will have high impact as either a therapeutic milieu or "illness maintenance" (Peplau, 1989, p. 273).

In applying this theory to the interactions between staff and residents in long-term care, some unique characteristics regarding these relationships can be noted. Most staff in long-term care are not educated on what is required to develop therapeutic relationships with residents. Many staff are individuals who have been trained on the job. Also, few staff have been assisted in self-explorations to better enable them to understand their own feelings or motivations when interacting with residents. Thus, the relationships they develop are more similar to those with friends or families, particularly because of the long-term nature of these relationships. The concept of interpersonal anxiety, which is a key concept analyzed by Peplau (1952, 1989), also is central to the problems of agitation and aggression that compose the class of disruptive behaviors as defined in this study.

The research reported in this article explored the formal caregiver perceptions of relationships with residents in two types of long-term care settings. Because selection of residents for SCUs usually is based on history of aggression or other disruptive behaviors, it could be assumed that SCU staff would encounter more disruptive behaviors and experience more distress related to these behaviors than their counterparts on TUs. However, empirical data are lacking on this assumption.

Hypotheses tested were that:

1) Formal caregivers working on SCUs wouid repon greater exposure to disruptive behaviors (i.e., aggressive, aversive) from residents than caregivers on TUs.

2) SCU formal caregivers would report more distress related to the disruptive behaviors of residents than caregivers on TUs.

The hypotheses were developed from clinical experience. Peplau's theory (1952, 1989) provided context for the problem rather than specific predictions regarding staff perceptions. Further exploratory analyses were performed to compare perceptions of formal caregivers across type of unit to determine whether aspects of caregiver relationships and reactions to physical aggression discriminated between staff who worked in SCU versus TU settings.


Participants in Pilot Study

Prior to the comparison between formal caregivers on SCUs and TUs1 a pilot study was conducted to develop and refine the questionnaire instrument used in this study. A convenience sample of 70 formal caregivers (e.g., nurses, attendants, therapists) from two long-term care facilities with SCUs and TUs was used in the process of instrument development and reliability testing. The sample for the present study was recruited from three facilities. Two of the pilot facilities were the same as in the present comparison study, but a different SCU and TU were selected from these facilities for the pilot phase.

Participants in Comparison Study

An additional convenience sample of 77 full-time formal caregivers at three long-term care facilities was selected to provide the comparison between SCU staff (n = 39) and TU staff (n = 38). Ethics approval was received from the participating facilities. Recruitment into the study was on a voluntary basis, and all eligible staff agreed to be participants.

Units were selected on the basis of the structure of exits, criteria for admission of residents to the units, and staffing ratios. The two SCUs in this study had secure exits and admitted cognitively impaired residents who were likely to exhibit disruptive behaviors (e.g., aggression or agitation with elopement risk ), such as those demonstrated in ambulatory individuals with advanced dementia. The three TUs had open exits, and admission was based on a variety of diagnoses that either restricted physical mobility or did not pose elopement risk and a range of cognitive function including no impairment. The staff-to-resident ratio was the same for both the SCUs and TUs selected for this study. On average, each member of the nursing staff was responsible for the care of approximately eight residents per day. All residents needed more than 2 hours of nursing care in a 24-hour period.

Selected demographic characteristics of the caregiving staff in relation to type of unit are presented in Table 1 . Caregiving staff were assigned to either a TU or SCU by nursing administration at the time of employment based on where a position was available. Therefore, there was no advance reason to suggest there was selection bias between groups of formal caregivers. Over time, there may have been options to move from one unit to another based on seniority. This variable was not tracked because of the fact that 49% of the total sample (n = 38) had been employed in their particular facility for more than 10 years, and consistent records were not available.

Instrument Development

A questionnaire was developed in the pilot study to provide survey data from formal caregivers. Items came from an observational phase of study, clinical experience, and a review of the literature related to existing instruments. The survey instrument was administered to caregivers recruited for the pilot study. Items were refined where necessary, and internal consistency reliability testing was conducted on components of the questionnaire structured as Liken scales. The selfreport instrument was divided into sections in the following order: demographics, job characteristics, staff-resident relationships, and resident behaviors. A final section of questions was directed at the subset of participants who had experienced a physically aggressive incident in the workplace within the prior year.

Reliability results from the pilot study for the Likert scales used in the present comparison study were:

1) Staff Perceptions of Caregiving Relationships (23 items), alpha = .86, n = 70.

2) Disruptive Behaviors (20 items)

* Exposure, alpha = .93, n = 30.

* Distress, alpha = .95, n = 34.

3) Job Characteristics (16 items)

* Importance, alpha = .84, n = 33

* Satisfaction, alpha = .90, n = 32.

A list of 20 disruptive behaviors (No. 2) was used to obtain data regarding exposure to and distress from objectionable behaviors. Disruptive behaviors included physical aggression (e.g., kicking), verbal aggression (e.g., swearing), and aversive behaviors (e.g., repeatedly calling out for attention). Similarly, a list of 16 job characteristics (No. 3) were used to elicit two types of responses from participants: importance of particular characteristics of a job and satisfaction with present employment. The items on Job Characteristics were grouped into five categories for statistical analysis:

* Financial and benefit issues (alphas on importance and satisfaction = .85 and .73).

* Work environment (alphas = .94 and .97).

* Perceived value as a worker (alphas = .93 and .93).

* Control issues (alphas = .94 and .98).

* Relationships (alphas = .94 and .96).

The rationale for examining perceptions of job characteristics was to provide empirical evidence on the potential confounding effect of other distressing issues in the workplace.


Formal caregivers were recruited with the aim of balancing the sample accrual across SCUs and TUs within each facility. One facility in the pilot study did not have a SCU. For both the pilot and hypothesis tenting phases of study, data were collected on one occasion for each caregiver. A teaching room was used for group administration of the questionnaire. Each formal caregiver provided consent and completed the questionnaire in approximately 20 minutes without discussion with the other caregivers.









Because random assignment to groups was not feasible, the potential for selection bias was examined by comparing occupational attitudes of staff according to type of unit. The two scales on Importance and Satisfaction with Job Characteristics were used for this purpose. Using two-tailed t tests, there were no significant differences on any of the five categories of Importance relative to the five categories of Job Characteristics, and only one difference (t = 2.Iy p < .05) on Satisfaction of the Work Environment. Formal caregivers on SCUs were less satisfied with the work environment (mean = 9.61, SD = 3.13) than those on TUs (mean = 11.01, SD = 2.68). This variable included three questions on environmental design, opportunities for learning, and opportunities for professional advancement. The maximum score was 15, which represented "very satisfied." Both groups of formal caregivers had mean scores on the positive side of the continuum, and because there were no other differences, the authors concluded that selection bias related to Job Characteristics and demographics (Table 1) was not a confound for the subsequent hypothesis testing.






In support of Hypothesis 1, there was more exposure to disruptive behaviors on SCUs than TUs (f[72] = 2.80, p < .005). As indicated in Table 2, formal caregivers on SCUs reported they had experienced the 19 aversive and aggressive behaviors more often (mean = 79.87, SD = 23.57) than their counterparts on TUs (mean = 62.89, SD = 28.07). Table 2 includes only 73 of the original 77 subjects because of missing data. However, the groups remained balanced (n = 37 on SCUs versus 36 on TUs).

Contrary to Hypothesis 2, the distress ratings related to disruptive behaviors reported by formal caregivers was less on SCUs than TUs (t[72] = 2.18, p < .05. Table 2 shows that mean distress scores were 46.30 on SCUs and 54.03 on TUs.

An exploratory stepwise discriminant function analysis was conducted using each of 23 items that examined staff perceptions of caregiving relationships on SCUs versus TUs (Table 3). One discriminant function was calculated; chi square (16, N = 77) = 77.92, p < .0001. Although this function included 16 of the 23 items, only the first four steps are reported in this article because the structure matrix indicated that the remaining 12 items did not meet the criterion of a meaningful correlation between the discriminating variable and the canonical function (Tabachnick & Fidell, 1989). Examination of means by unit (Table 3) reveals that SCU formal caregivers, as opposed to TU formal caregivers, report that more residents do not want the physical care they require (Step 1), less resistance to care was perceived to be related to pain (Step 2), more aggres sion was attributed to caregiver responsibility (Step 3), and less appreciation was experienced from residents (Step 4).

In a series of true and false questions, staff were questioned about the most distressing physically aggressive incident they had experienced while working at this facility within the past year. They were directed to complete these questions only if they considered they had been involved in such an incident. As shown in Table 4, 32 of 39 staff in SCUs (82%) had experienced such an incident, compared to 15 of 38 staff on TUs (40%). During these incidents, 44% of SCU staff feared they would be severely injured, compared to 20% of TU staff. In addition, 19% of SCU staff versus 13% of TU staff feared for their lives (Table 4). None of the TU staff thought being hit was part of their job, whereas, 47% of SCU staff agreed with this statement. Chisquare analysis was not conducted because of the small cell sizes (including a zero score) in the TU group.

Staff were asked to identify the interaction context when the aggressive incident occurred. The context could involve interaction with caregivers and others in the social environment (e.g., personal care, treatments, medications, exercises, social or recreational activity) or nonsocial situations (e.g. exiting behaviors, no care being given). Both units reported that the most aggressive incidents occurred during personal care. Comments from staff indicated that formal caregivers on SCUs realized the aggressive behaviors were part of the disease process (e.g., Alzheimer's disease) for the individuals for whom they cared, and they did not feel these behaviors were directed toward them personally. Staff on TUs reported that many of the aggressive behaviors to which they were exposed were performed with intent by cognitively aware individuals and were meant to be very hurtful. Staff on TUs stated that because these residents knew the staff so well they seemed to know their vulnerabilities and the most destructive things to do and say to them. Therefore, even infrequent aggression was very distressing.


While Hypothesis 1 was supported in this study, indicating that staff on SCUs were exposed to higher rates of disruptive behaviors than staff on TUs, Hypothesis 2 was not supported. Contrary to expectation, staff on SCUs were less distressed by these behaviors than staff on TUs. Staff on SCUs had more frequent exposure to residents calling out, swearing, yelling, making verbal threats, scratching, slapping, and kicking; yet, they reported less distress from these behaviors than staff from TUs. One possible explanation for this discrepancy is that staff from SCUs who had experienced physical aggression in the past year were more likely to have the attitude that "being hit is part of the job." This attitude was related to the fact that SCU staff who worked with individuals with dementia attributed the behaviors to a disease process, and therefore, there was no perception of intent to harm. By contrast, staff from TUs were more likely to think the intent to harm was central to an aggressive act and was a personal attack by the resident on a particular staff member. While TU staff reported significantly less exposure to disruptive behaviors than SCU staff, the mean difference between groups (means = 62.89 versus 79.87) was not as great as expected given that disruptiveness was an admission criterion to SCUs, and therefore, less disruptive behaviors would be expected on TUs in the same facility. Another possible explanation for the distress of TU staff was that these units were not designed for management of disruptive behaviors, while the SCUs had "special" architectural features and programs related to enhancement of positive behaviors. These findings are similar to those of Mobily et al. (1992).

This was a preliminary study with a small sample size so the results must be interpreted with caution. The exploratory discriminant function analysis did not have a validation sample, and the ratio of predictors to participants was less than 1 to 4. However, the difference in perception of pain as a reason for resistance to care was a finding that merits further study. Although no control was made for painful diagnosis, there were cases of arthritis distributed across both types of units as would be expected in an elderly cohort. The SCU staff were less likely to perceive pain as the cause of resistance to care than the TU staff, but both groups of staff had mean scores near the "never" anchor of the scale (Table 3), suggesting that both groups may have underestimated pain as a contributor to resistance (Marzinski, 1991). Improved pain assessment is important for both groups of staff caregivers.

This study supported other research (Astrom et al, 1991; Novak & Chappell, 1994) that suggested there is a wide variance in the ability of individual caregivers to tolerate aggression. Although staff initially did not choose the unit on which they worked, it is possible that over time there was some movement of staff into positions with better personal fit, including the ability to tolerate high amounts of aggressive behaviors. The apparent tolerance of aggression by SCU staff existed despite their perceptions, relative to TU staff, that residents do not appreciate the efforts of their caregivers. The SCU staff were more likely than TU staff to feel responsible for causing aggressive behaviors during care, although both groups scored near the negative extreme of the scale indicating low tendencies of both groups to attribute the cause of aggressive behaviors of residents to their own behaviors during caregiving.

Peplau's theory (1952, 1989) suggests caregivers' behaviors always have an impact on the individuals who are receiving care. This interpersonal theory provided the context for the research problem examined in this article. The theory also has applicability in relation to the clinical implications of this study. Educators could work with staff on both SCUs and TUs to enhance the therapeutic milieu from Peplau's (1952, 1989) theoretical perspective. For example, the formal caregivers could use self -exploration and analysis of disruptive situations to determine whether they could develop new strategies for managing interpersonal situations to reduce anxiety and prevent aggressive incidents. Caregivers could examine whether their roles are enabling, as opposed to dysfunctional, to promote high quality of life for both residents and caregivers.


This study found that distress related to disruptive behaviors was less for SCU staff than TU staff, although SCU staff reported greater exposure to disruptive behaviors in general and physical aggression in particular. The attitude of SCU staff that "being hit is part of the job," even when these staff fear they may be severely injured or fear for their lives, is one that merits further examination. It is recommended that education and support for staff on both types of units be enhanced to focus on therapeutic staff-resident relationships and environmental methods to reduce disruptive behaviors. Staff perceptions affect the interpretation of resident behaviors and the quality of life in the workplace.


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