Journal of Nursing Education

Research Briefs Open Access

Undergraduate Placements in Geriatric Care Facilities: Students Gaining Experience With Challenging/Responsive Behaviors

Beverly O'Connell, PhD, RN; Lorna Guse, PhD, RN; Loreley Greenslade, MSc; Angela Osterreicher, MLS; Fiona Jensen, MN, RN

  • Journal of Nursing Education. 2017;56(10):623-627
  • https://doi.org/10.3928/01484834-20170918-08
  • Posted October 4, 2017

Abstract

Background:

Undergraduate nursing students may experience challenging behaviors in residents during their clinical placement in geriatric long-term care (GLTC) facilities.

Method:

Bachelor of Nursing students participated in an anonymous online questionnaire (n = 116).

Results:

The students witnessed a wide range of challenging behaviors, also referred to as responsive behaviors, in GLTC residents. The most frequent behaviors included agitation/restlessness, repetitive talk, and wandering. Although behaviors such as physical aggression and disinhibited sexual behavior were experienced less frequently, students found these behaviors the most distressing. Students felt ill-prepared to manage these behaviors, which was associated with higher levels of distress.

Conclusion:

The students demonstrated good theoretical knowledge about responsive behaviors, but the lack of personal experience in managing such behaviors left the students feeling ill-prepared and distressed. Incorporating the opportunity to experience behaviors in a supported environment, such as in simulation, could reduce student distress and increase their sense of competency. [J Nurs Educ. 2017;56(10):623–627.]

Abstract

Background:

Undergraduate nursing students may experience challenging behaviors in residents during their clinical placement in geriatric long-term care (GLTC) facilities.

Method:

Bachelor of Nursing students participated in an anonymous online questionnaire (n = 116).

Results:

The students witnessed a wide range of challenging behaviors, also referred to as responsive behaviors, in GLTC residents. The most frequent behaviors included agitation/restlessness, repetitive talk, and wandering. Although behaviors such as physical aggression and disinhibited sexual behavior were experienced less frequently, students found these behaviors the most distressing. Students felt ill-prepared to manage these behaviors, which was associated with higher levels of distress.

Conclusion:

The students demonstrated good theoretical knowledge about responsive behaviors, but the lack of personal experience in managing such behaviors left the students feeling ill-prepared and distressed. Incorporating the opportunity to experience behaviors in a supported environment, such as in simulation, could reduce student distress and increase their sense of competency. [J Nurs Educ. 2017;56(10):623–627.]

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.

Objective

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.

Method

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?”

Results

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).

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

Table:

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.

Discussion

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).

Conclusion

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.

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Level of Distress Felt by Students Who Encountered Responsive Behaviors in Residents of Geriatric Long-Term Care Facilities

Responsive BehaviornNot at All Distressed (%)A Little Distressed (%)Distressed/Very Distressed (%)
Hoarding7463.535.11.4
Shadowing5464.831.53.7
Wandering10372.821.45.8
Vocalizing with repetitive talk11160.432.47.2
Appearing apathetic9038.951.110
Sleep/wake disturbances9345.241.912.9
Agitation/restlessness11119.861.318.9
Swearing7821.852.625.6
Shouting or screaming10115.850.533.7
Resistance to care9011.147.841.1
Disinhibited sexual behavior4710.642.646.8
Physical aggression773.941.654.5
Authors

Dr. O'Connell is Dean, Dr. Guse is Associate Professor, Ms. Greenslade is Research Associate, Ms. Jensen is Instructor, College of Nursing, Rady Faculty of Health Sciences, and Ms. Osterreicher is Section Head, J.W. Crane Memorial Library, Health Sciences Libraries, University of Manitoba, Winnipeg, Manitoba, Canada.

© 2017 O'Connell, Guse, Greenslade, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the Manitoba Centre for Nursing and Health Research, University of Manitoba, for their technical assistance with this project, and their financial support through the Faculty Endowment Fund.

Address correspondence to Loreley Greenslade, MSc, Research Associate, College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg, MB, Canada R3T 2N2; e-mail: Loreley. greenslade@umanitoba.ca.

Received: December 12, 2016
Accepted: May 30, 2017

10.3928/01484834-20170918-08

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