As part of a Bachelor of Nursing program, undergraduate nursing students are required to undertake clinical education placements in a variety of clinical settings. Geriatric long-term care (GLTC) facilities are increasingly being used as clinical placement settings for students to gain valuable experiences interacting and caring for older residents (Chen, Brown, Groves, & Spezia, 2007). These types of settings provide the students with a stable group of older residents who they can care for and interact with over a period of time throughout their multi-week clinical placement, thus providing students with a good environment to consolidate their learning.
The care for older residents living in GLTC can be complex. An emphasis on prolonging community care has meant that residents entering GLTC come with greater physical and cognitive issues and therefore greater care needs (Chen et al., 2007; Dumpe, Herman, & Young, 1998; Gaugler, Yu, Krichbaum, & Wyman, 2009). Some residents exhibit behavioral symptoms as a result of their dementia, although such behaviors can also be found in residents without a diagnosis of dementia. These challenging behavioral symptoms can be referred to as responsive behaviors because the behaviors occur in response to social, environmental, and physical triggers. Responsive behaviors include agitation and restlessness, physical or verbal aggression, vocalization, wandering, shadowing, and disinhibited sexual behaviors (Snowdon, Miller, & Vaughan, 1996). The literature indicates that between 66% and 92% of GLTC residents living with dementia displayed responsive behaviors (Boustani et al., 2005; Edvardsson, Sandman, Nay, & Karlsson, 2008).
These responsive behaviors are often difficult to manage, and caring for these residents is often challenging (Abbey et al., 2006). Inexperienced staff, including undergraduate nursing students, are particularly vulnerable to experiencing negative and potentially dangerous situations, such as verbal abuse (Wondrak & Dolan, 1992) and physical assault (Astrom, Bucht, Eisemann, Norberg, & Saveman, 2002; Hegney, Plank, & Parker, 2003; Tak, Sweeney, Alterman, Baron, & Calvert, 2010). Nursing staff often find behavioral symptoms distressing, and repeated exposure causes a greater psychological workload (Isaksson, Astrom, Sandman, & Karlsson, 2008) that results in poorer general health (Chappell & Novak, 1994), higher stress and burn-out, and poorer work ability (Schmidt, Dichter, Palm, & Hasselhorn, 2012).
Undergraduate nursing students may find themselves in situations where they have to handle residents' complex care issues, coupled with behaviors they may find distressing (Abbey et al., 2006). More important, GLTC staff struggle to support students who find residents' behavior disturbing (Robinson & Cubit, 2007). Studies have shown that the students' experiences during their clinical placement have an influence on their future career decisions to stay in GLTC and gerontology care (Abbey et al., 2006; Chenoweth, Jeon, Merlyn, & Brodaty, 2010; King, Roberts, & Bowers, 2013; Williams, Nowak, & Scobee, 2006). Students typically view GLTC placement as undesirable (Berntsen & Bjork, 2010; Happell, 2002; King et al., 2013; Skaalvik, Normann, & Henriksen, 2010). However, with a positive, supported experience, students look more favorably on the possibility of working with older adults in GLTC (Banning, Hill, & Rawlings, 2006; Duggan, Mitchell, & Moore, 2013; Lea, Robinson, Mason, & Eccleston, 2016).
Although some research has been published on the effects of experiencing and managing residents' behaviors on nursing staff (i.e., nurses and aides) (Banerjee et al., 2008), minimal research has been published on students' experiences with responsive behaviors. More specifically, it is important to understand what the students experience, what they find distressing, and how prepared they feel to try to make the experience as positive as possible because it will influence the future aged care workforce.
A pilot study was undertaken to explore undergraduate nursing students' experience with responsive behaviors in long-term care residents during the students' clinical placement, the emotional effects of these behaviors on the students, and the students' involvement in and preparedness to manage these behaviors. This was an anonymous online questionnaire. This project commenced after all ethics approvals were granted by the site university.
Setting and Design
Second-year bachelor of nursing students in a Canadian university were recruited for this study in the 2013 to 2014 academic year. They were required to complete a theory course that focused on the health needs of older adults, with a clinical placement in a GLTC facility. The clinical course ran concurrently with the theory course, and students began their clinical placements in a GLTC facility in week two of the 13-week course. A theory session that focused on interventions and communication strategies to manage responsive behaviors was conducted in week five. Students spent two 8-hour shifts at their placement site each week, under the supervision of a clinical education facilitator (CEF). The CEF held a short debriefing session with the students after each shift to discuss situations that arose during the shift.
Information about the research project was shared with the students during one of the class periods, and afterwards, an e-mail was sent to all students that contained more information about the project and a link to a Fluid Survey™ questionnaire.
Questionnaire and Data Analysis
The questionnaire was developed by the authors to assess the frequency with which students encounter responsive behaviors in residents, the extent to which these behaviors were distressing to the students, and the nature of the students' involvement in managing the behaviors. The responsive behaviors listed in the questionnaire were taken from the Tri-Focal Model of Care: Management of Behaviours of Concern Module (O'Connell et al., 2011), which was developed based on literature review of evidence-based practices. Academics who are experts in the area of gerontology established the face validity of the questionnaire.
Students were provided with a list of 12 behaviors, and they were instructed to rate the frequency with which they experienced each of the behaviors during their clinical placement in GLTC facilities using a 4-point Likert scale, which was dichotomized into 1 = not at all, 2 = rarely, 3 = sometimes, 4 = often. For the behaviors the students had experienced, the distress they felt when they witnessed these behaviors was rated using a 4-point Likert scale. Crosstabulations were conducted to measure relationships between the variables at a confidence level of 95%. Overall level of distress was computed as the uncollapsed mean across all behaviors experienced, and ranged from 1 = not at all distressed to 4 = very distressed (alpha = .78). Students were also asked the extent to which they were involved in managing the behaviors and who assisted them. The degree to which the students felt prepared to manage the responsive behaviors in GLTC residents was assessed on a 4-point scale from 1 = not at all prepared to 4 = very prepared.
An open-ended question asked the students why they thought some residents displayed responsive behaviors. Responses were coded into 14 categories. Up to five responses for each student were coded. Frequencies for the coded responses were analyzed using multiple response. Another open-ended question elicited general comments, stating: “Are there any comments that you would like to make about your experiences in the personal care home units related to experiencing responsive behaviors?”
Of the 231 eligible students, 116 questionnaire responses were submitted, for a response rate of 50.2%. The completion rate of the questionnaire was excellent, with 99.9% of all valid items in the questionnaire containing responses.
Experience With Responsive Behaviors
Almost all of the students had encountered responsive behaviors in the residents of the GLTC facility. Twenty-five of the students (21.6%) had encountered all of the behaviors listed. Of the list of 12 behaviors, the students encountered an average of 2.2 behaviors regularly (indicated as sometimes or often) (range = 0 to 7; SD = 1.9). The majority of students had encountered residents who displayed agitation or restlessness (85.3%), vocalization with repetitive talk (83.6%), and wandering without a planned destination (82.8%) (Figure).
Percentage of students who had encountered each of the responsive behaviors regularly (sometimes or often).
Some students noted that students were protected or isolated from residents who exhibited responsive behaviors during their placement. Students noted that they were usually assigned to residents who were less likely to display responsive behaviors, but they still witnessed these behaviors while on their shifts. Encountering this behavior affected the students emotionally, and they felt disturbed when they were told not to interact with some residents.
Feelings of Distress About Residents' Responsive Behaviors
The behaviors that the students found the least distressing were hoarding, shadowing, wandering, and repetitive talk. In contrast, almost all of the students felt at least some distress when faced with residents who exhibited shouting or screaming, resistance to care, disinhibited sexual behavior, or physical aggression (Table). For physical aggression, there was a significant correlation between experience and distress; students' feelings of distress increased with the frequency with which they experienced physical aggression in the GLTC residents (r = .261; p < .05, n = 77). This relationship was not found with any of the other behaviors.
Level of Distress Felt by Students Who Encountered Responsive Behaviors in Residents of Geriatric Long-Term Care Facilities
Involvement in Managing Responsive Behaviors
For eight of the 12 listed behaviors, fewer than half of the students indicated that they were directly involved in managing the residents' behavior. The four behaviors that the students were most likely to directly manage were agitation or restlessness (66.7%), vocalization with repetitive talk (60.7%), wandering (66.7%), and resistance to care (67.7%). Students were most likely to manage wandering and repetitive talk with another student, whereas they most often managed agitation/restlessness and resistance together with staff.
Some of the students commented about the quantity and quality of support that they received during their clinical placement, from both their clinical education facilitator and GLTC staff. Although there were instances in which staff failed to provide assistance when the students would have wanted it, most of the comments suggested that the support they received was positive.
Feelings of Preparedness
Three fifths of the students (60.0%) reported that they had felt only a little prepared to manage the responsive behaviors in the residents, and 11.3% did not feel prepared at all. A minority of students felt well-prepared (24.3%) or very well-prepared (4.3%). Some students suggested changes to the structure of the theory and clinical courses that may have better prepared them for what they faced in their clinical placement. Several students noted that the theory course content and the Non-Violent Crisis Intervention® training that they received were helpful in providing basic skills and knowledge, but the timing of this training was not in sync with the clinical placement and often came too late. Suggestions included completing the theory classes before beginning the clinical placement and having longer placements to provide better continuum of care.
The extent to which the students felt prepared to manage the responsive behaviors of residents was associated with their overall level of distress. Students who felt that they were well-prepared or very prepared to manage the behaviors were significantly less distressed about the behaviors they had experienced (M = 1.76, SD = .31) than the students who felt that they were not at all prepared (M = 2.08, SD = .53) (t = 2.58, df = 43, p = .013). Although disinhibited sexual behavior was only encountered by about one fifth of the students, 63.3% of the students who did not feel well-prepared to manage behaviors were distressed by this behavior, whereas only 12.5% of the students who felt well prepared were distressed (χ2 [1, 46] = 10.69, p = .001).
Reasons for Responsive Behaviors
Students listed a wide range of perceived underlying causes of responsive behaviors. These included underlying conditions, such as dementia or chronic illnesses; physical factors, such as poor pain management, medication interaction, and unmet needs; social factors, such as loneliness, boredom, and rushed or inattentive staff; and psychological factors, such as frustration, depression, and mental illness.
To ensure confidentiality, this study is limited by the absence of demographic data, student background, and experience that may have affected their responses on the questionnaire. No generalizability is being claimed.
The aim of this pilot study was to explore undergraduate nursing students' experiences caring for residents who display responsive behaviors during the students' clinical placement in GLTC facilities. During their clinical placements, students witnessed a wide range of responsive behaviors, with the most frequent being agitation/restlessness, vocalizing with repetitive talk, and wandering. This compares closely with behaviors reported by staff working in GLTC, who found restlessness, wandering or pacing, repetitive sentences or actions, and verbal aggression to occur regularly (Cubit, Farrell, Robinson, & Myhill, 2007; Testad, Aasland, & Aarsland, 2007; Wood et al., 1999).
Students reported being distressed witnessing behaviors that were physically and emotionally threatening or aggressive. This finding resembles the findings of Cubit et al. (2007), who found that physical aggression was among the behaviors that caused the most personal distress to staff. Interestingly, no studies reported disinhibited sexual behavior as being distressing for staff; it may be that staff are educated on how to manage this behavior and may find it less distressing.
Students also reported being distressed after about residents who resisted care. As these students were in their first clinical placement and new to their role as care provider, it is not surprising that encountering residents who were uncooperative with their efforts would be upsetting. Similarly, staff experienced distress when faced with residents' depression-related behavior, such as resistance to care and apathy (McKenzie, Teri, Pike, LaFazia, & van Leynseele, 2012).
Students reported being inadequately prepared to manage the responsive behaviors. This finding supports the findings of Scerri and Scerri (2013), who also reported that most undergraduate nursing students had not received adequate dementia training prior to clinical placement. Students who were better prepared to manage these situations prior to their clinical placement reported less distress over these behaviors.
Students exhibited a diverse and well-grounded understanding of the underlying factors that may cause residents to display responsive behaviors. Robinson and Cubit (2007) reasoned that although students in their study had some theoretical understanding of dementia, the students' lack of experience in putting their knowledge into action added to feelings of distress. Therefore, it is important for nurse educators to review their curriculum and determine whether sufficient content exists to adequately prepare students to manage these responsive behaviors, especially those that are not seen frequently but cause student distress. It may be useful to prepare students in in-house simulation training environments so they can learn to manage these conditions in a controlled environment, and where they can be supported and have the opportunity to debrief.
Nolan, Brown, Davies, Nolan, and Keady (2006) recommended that the needs of all stakeholders be addressed to enhance the quality of care of older people. This extends to the education of students and staff and to the ongoing support that these individuals receive while providing care. To meet the educational needs of both students and staff, it may be useful for GLTC facilities to consider using models of care that address the educational needs of all stakeholders, such as the one described in the Tri-Focal Model of Care (O'Connell, Ostaszkiewicz, Sukkar, & Plymat, 2008). This model emphasizes that the perspectives of all stakeholders (i.e., staff, students, residents and family members) must be recognized and accommodated so the well-being of all individuals is enhanced. In the module related to managing responsive behaviors (O'Connell et al., 2011), evidence-based practices for the training and education of staff and students include the opportunity to discuss behaviors to increase understanding and tolerance, understanding the importance of verbal and nonverbal communication, and limiting the use of antipsychotic medications.
The students reported that they often received support in managing responsive behaviors from other students or from GLTC staff rather than from their CEF. Because the CEF is responsible for supervising a number of students (sometimes in different units), it would have been difficult for the CEF to be present for all of the interactions between student and resident. This highlights the importance of CEFs organizing supportive debriefing sessions at the end of the shift. The importance of conducting these sessions is supported in the literature where students whose GLTC placement was well-supported had a more positive experience and better learning outcomes than students who did not have this support (Lea et al., 2014).
Undergraduate nursing students witnessed and managed residents with various responsive behaviors. It is important that students are well-supported in these types of placements in a positive way that attracts the students to work in those settings. Similar to teaching hospitals, a need exists for further development of teaching GLTC facilities, so adequate infrastructure exists to support the learning needs of both students and staff. Given the complexity of the physical and psychosocial health care needs of older adults, the authors of the current study recommend that gerontology placements occur later in the bachelor of nursing program, so the students are better equipped to manage the care of the frail and elderly.
- Abbey, J., Abbey, B., Bridges, P., Elder, R., Lemcke, P., Liddle, J. & Thornton, R. (2006). Clinical placements in residential aged care facilities: The impact on nursing students' perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23, 14–19.
- Astrom, S., Bucht, G., Eisemann, M., Norberg, A. & Saveman, B. (2002). Incidence of violence towards staff caring for the elderly. Scandinavian Journal of Caring Sciences, 16, 66–72. doi:10.1046/j.1471-6712.2002.00052.x [CrossRef]
- Banerjee, A., Daly, T., Armstrong, H., Armstrong, P., Lafrance, S. & Szebehely, M. (2008). ‘Out of control’: Violence against personal support workers in long-term care. Retrieved from https://www.researchgate.net/publication/237562810_Out_of_Control_Violence_against_Personal_Support_Workers_in_Long-Term_Care
- Banning, M., Hill, Y. & Rawlings, S. (2006). Student learning in care homes. Nursing Older People, 17(10), 22–24. doi:10.7748/nop2006.01.17.10.22.c2403 [CrossRef]
- Berntsen, K. & Bjork, I.T. (2010). Nursing students' perceptions of the clinical learning environment in nursing homes. Journal of Nursing Education, 49, 17–22. doi:10.3928/01484834-20090828-06 [CrossRef]
- Boustani, M., Zimmerman, S., Williams, C.S., Gruber-Baldini, A.L., Watson, L., Reed, P.S. & Sloane, P.D. (2005). Characteristics associated with behavioral symptoms related to dementia in long-term care residents. The Gerontologist, 45(Special Issue 1), 56–61. doi:10.1093/geront/45.suppl_1.56 [CrossRef]
- Chappell, N.L. & Novak, M. (1994). Caring for Institutionalized elders: Stress among nursing assistants. Journal of Applied Gerontology, 13, 299–315. doi:10.1177/073346489401300306 [CrossRef]
- Chen, S.L., Brown, J.W., Groves, M.L. & Spezia, A.M. (2007). Baccalaureate education and American nursing homes: A survey of nursing schools. Nurse Education Today, 27, 909–914. doi:10.1016/j.nedt.2007.01.004 [CrossRef]
- Chenoweth, L., Jeon, Y., Merlyn, T. & Brodaty, H. (2010). A systematic review of what factors attract and retain nurses in aged and dementia care. Journal of Clinical Nursing, 19, 156–167. doi:10.1111/j.1365-2702.2009.02955.x [CrossRef]
- Cubit, K., Farrell, G., Robinson, A. & Myhill, M. (2007). A survey of the frequency and impact of behaviours of concern in dementia on residential aged care staff. Australasian Journal on Ageing, 26, 64–70. doi:10.1111/j.1741-6612.2007.00217.x [CrossRef]
- Duggan, S., Mitchell, E.A. & Moore, K.D. (2013). ‘With a bit of tweaking…we could be great’. An exploratory study of the perceptions of students on working with older people in a preregistration BSc (Hons) Nursing course. International Journal of Older People Nursing, 8, 207–215. doi:10.1111/j.1748-3743.2012.00317.x [CrossRef]
- Dumpe, M.L., Herman, J. & Young, S.W. (1998). Forecasting the nursing workforce in a dynamic health care market. Nursing Economic$, 16, 170–188.
- Edvardsson, D., Sandman, P.O., Nay, R. & Karlsson, S. (2008). Associations between the working characteristics of nursing staff and the prevalence of behavioral symptoms in people with dementia in residential care. International Psychogeriatrics, 20, 764–776. doi:10.1017/S1041610208006716 [CrossRef]
- Gaugler, J.E., Yu, F., Krichbaum, K. & Wyman, J.F. (2009). Predictors of nursing home admission for persons with dementia. Medical Care, 47, 191–198. doi:10.1097/MLR.0b013e31818457ce [CrossRef]
- Happell, B. (2002). Nursing home employment for nursing students: Valuable experience or a harsh deterrent?Journal of Advanced Nursing, 39, 529–536. doi:10.1046/j.1365-2648.2002.02321.x [CrossRef]
- Hegney, D., Plank, A. & Parker, V. (2003). Workplace violence in nursing in Queensland, Australia: A self-reported study. International Journal of Nursing Practice, 9, 261–268. doi:10.1046/j.1440-172X.2003.00431.x [CrossRef]
- Isaksson, U., Astrom, S., Sandman, P. & Karlsson, S. (2008). Factors associated with the prevalence of violent behaviour among residents living in nursing homes. Journal of Clinical Nursing, 18, 972–980. doi:10.1111/j.1365-2702.2008.02440.x [CrossRef]
- King, B.J., Roberts, T.J. & Bowers, B.J. (2013). Nursing student attitudes toward and preferences for working with older adults. Gerontology and Geriatrics Education, 34, 272–291. doi:10.1080/02701960.2012.718012 [CrossRef]
- Lea, E., Marlow, A., Bramble, M., Andrews, S., Crisp, E., Eccleston, C. & Robinson, A. (2014). Learning opportunities in a residential aged care facility: The role of supported placements for first-year nursing students. Journal of Nursing Education, 53, 410–414. doi:10.3928/01484834-20140620-02 [CrossRef]
- Lea, E., Robinson, A., Mason, R. & Eccleston, C. (2016). Aspects of nursing student placements associated with perceived likelihood of working in residential aged care. Journal of Clinical Nursing, 25, 715–724. doi:10.1111/jocn.13018 [CrossRef]
- McKenzie, G., Teri, L., Pike, K., LaFazia, D. & van Leynseele, J. (2012). Reactions of assisted living staff to behavioral and psychological symptoms of dementia. Geriatric Nursing, 33, 96–104. doi:10.1016/j.gerinurse.2011.12.004 [CrossRef]
- Nolan, M., Brown, J., Davies, S., Nolan, J. & Keady, J. (2006). The senses framework: Improving care for older people through a relationship-centred approach. Getting Research into Practice (GRiP) Report No 2. Sheffield, UK: Sheffield.
- O'Connell, B., Crowe, J., Gilbee, A., Johnson, S., Ockerby, C., Ostaszkiewicz, J. & Tran, C. (2011). The tri-focal model of care: Management of behaviours of concern. In Tri-focal model of care education program for residential aged care. Deakin University, Geelong, Victoria, Australia.
- O'Connell, B., Ostaszkiewicz, J., Sukkar, K. & Plymat, K. (2008). The Tri-focal model of care: Advancing the teaching-nursing home concept. International Journal of Nursing Practice, 14, 411–417. doi:10.1111/j.1440-172X.2008.00714.x [CrossRef]
- Robinson, A. & Cubit, K. (2007). Caring for older people with dementia in residential care: nursing students' experiences. Journal of Advanced Nursing, 59, 255–263. doi:10.1111/j.1365-2648.2007.4304.x [CrossRef]
- Scerri, A. & Scerri, C. (2013). Nursing students' knowledge and attitudes towards dementia—A questionnaire survey. Nurse Education Today, 33, 962–968. doi:10.1016/j.nedt.2012.11.001 [CrossRef]
- Schmidt, S.G., Dichter, M.N., Palm, R. & Hasselhorn, H.M. (2012). Distress experienced by nurses in response to the challenging behavior of residents—Evidence from German nursing homes. Journal of Clinical Nursing, 21, 3134–3142. doi:10.1111/jocn.12066 [CrossRef]
- Skaalvik, M.W., Normann, H.K. & Henriksen, N. (2010). Student experiences in learning person-centred care of patients with Alzheimer's disease as perceived by nursing students and supervising nurses. Journal of Clinical Nursing, 19, 2639–2648. doi:10.1111/j.1365-2702.2010.03190.x [CrossRef]
- Snowdon, J., Miller, R. & Vaughan, R. (1996). Behavioural problems in Sydney nursing homes. International Journal of Geriatric Psychiatry, 11, 535–541. doi:10.1002/(SICI)1099-1166(199606)11:6<535::AID-GPS345>3.0.CO;2-1 [CrossRef]
- Tak, S., Sweeney, M.H., Alterman, T., Baron, S. & Calvert, G.M. (2010). Workplace assaults on nursing assistants in US nursing homes: A multilevel analysis. American Journal of Public Health, 100, 1938–1945, doi:10.2105/AJPH.2009.185421 [CrossRef]
- Testad, I., Aasland, A.M. & Aarsland, D. (2007). Prevalence and correlates of disruptive behavior in patients in Norwegian nursing homes. International Journal of Geriatric Psychiatry, 22, 916–921. doi:10.1002/gps.1766 [CrossRef]
- Williams, K.N., Nowak, J. & Scobee, R.L. (2006). Fostering student interest in geriatric nursing: Impact of senior long-term care experiences. Nursing Education Perspectives, 27, 190–193.
- Wondrak, R.F. & Dolan, B.M. (1992). Dealing with verbal abuse: evaluation of the efficacy of a workshop for student nurses. Nurse Education Today, 12, 108–115. doi:10.1016/0260-6917(92)90036-N [CrossRef]
- Wood, S.A., Cummings, J.L., Barclay, T., Hsu, M.-A., Allahyar, M. & Schnelle, J.F. (1999). Assessing the impact of neuropsychiatric symptoms on distress in professional caregivers. Aging and Mental Health, 3, 241–245. doi:10.1080/13607869956208 [CrossRef]
Level of Distress Felt by Students Who Encountered Responsive Behaviors in Residents of Geriatric Long-Term Care Facilities
|Responsive Behavior||n||Not at All Distressed (%)||A Little Distressed (%)||Distressed/Very Distressed (%)|
|Vocalizing with repetitive talk||111||60.4||32.4||7.2|
|Shouting or screaming||101||15.8||50.5||33.7|
|Resistance to care||90||11.1||47.8||41.1|
|Disinhibited sexual behavior||47||10.6||42.6||46.8|