Aggression in nursing home residents is seen to be one of the most distressing manifestations of dementia affecting the quality of life of the resident and impacting on the care they are given (Edberg 2000). The impact of this behaviour on caregivers is also significant, contributing to absenteeism, occupational health and safety issues and a high attrition rate. Delivery of care is an important factor to consider in the quality of life of people living in residential care for several reasons. From the residents’ perspective, the way care is delivered can influence their response to a situation. People with dementia may easily misinterpret the actions of caregivers if they are approached incorrectly and respond defensively, creating difficulties in continuing with the task at hand. An overt response may lead to being treated differently, being given antipsychotic medication or being sedated. From the caregivers’ perspective there often arises a feeling of helplessness and dissatisfaction in their job.

The research carried out by Skovdahl et al. is therefore pertinent as residents naturally feel most vulnerable and threatened when being assisted with undressing and hygiene.

In an initial study the authors used a comparative design with a control situation. Caregivers were video taped while assisting an aggressive resident during the showering procedure. They then rated themselves on how well they had managed the situation. In this second study the reflections and thoughts of the first group of caregivers, who rated themselves highly, were compared with a second group who expressed difficulty in managing aggressive behaviour. The aim of this second study was to gain insight into the reasoning of the caregivers who had reported problems and then to discuss their reasoning in relation to the group that did not encounter as many problems.

The demographics of the participants and the units from which they came showed notable differences which may have had an impact on the outcomes of the research. For example, in unit one a registered nurse was the team leader and was factored in to staff ratios. Unit two, on the contrary, only had access to a registered nurse external to the unit for advice, resulting in less support for them. Other differences that were considered to have an impact on the care delivery were discussed during the analysis of the data, including the different levels of staffing per number of residents, education for one unit and not the other, mean age of and experience of staff members. Several studies have found that education is an important influencing factor on the way staff manage behavioural symptoms in nursing home residents (Cohen Mansfield et al. 1997, Haber et al. 1997, Silver et al. 1998, Middleton et al. 1999).

All of the above factors were considered during the analysis of the thematic material which gave added strength to the findings. However, there were other factors raised by the authors that were not discussed.

For example, in unit two caregivers worked in twos and threes when showering the resident so that they could enforce the procedure and provide added strength when the resident showed signs of aggression or resistiveness. This was reflective of Haber et al.'s (1997) work where he found that nurses with less education were more likely to use restraint as an intervention for managing aggressive behaviours. In unit one on the contrary, the procedure was more negotiable with only one nurse attending to the resident during the shower.

Other information given was that some of these staff members in unit two were males attending to the female resident and there were also, overall, six staff members involved for the care delivery of one resident compared with three in unit one. Best evidence shows that people with cognitive impairment respond more positively when given continuity in care with the people who are caring for them (Schafer 1985, Nay et al. 2003). These factors were not considered in the data analysis although it is possible that they had some impact on care and behavioural responses.

A further limitation of the study is the lack of psychometric tests carried out to establish level of cognitive impairment or the aetiology of the dementia in the residents being videotaped. For example the Mini Mental State Examination (MMSE) and Clinical Dementia Rating Scale (CDR) are both validated and reliable tools that can be used to assess cognitive status and any decline associated with dementia. Testing for frequency and severity of the behaviours of each resident may also have added more insight into the way caregivers managed aggression. For example the resident in unit one may have had less severe manifestations of the symptoms or displayed a different type compared with the resident in unit two, and therefore may require different management of the symptoms. The Neuropsychiatric Inventory/Nursing Home Version (NPI/NH) is an example of a useful tool that has been developed for the assessment of behavioural symptoms, and has been shown to have good construct reliability, high inter-rater reliability and high validity (Cummings 1996, Wood et al. 2000).

The authors stated that context was important in understanding a behaviour such as aggression, but with the exception of mentioning that one resident did not like to take her shoes off, did not explore it any further. Algase (1999) discussed behaviour in terms of the ‘Need Driven Dementia Compromised Behaviour Model’, linking the behaviour of concern to unmet needs or goals. To understand why the resident would not take her shoes off in the shower (which is the accepted norm) caregivers needed to delve further into her history and background to gain insight into why she was behaving in this way. No doubt the behaviour that was of concern to staff, had meaning and logic for the resident demonstrating it, but for staff to be able to respond in a meaningful way so that the behaviour was acknowledged as having a logical and legitimate purpose in that person's reality, the staff needed to investigate more fully.

Rigour of this study was well maintained. This was achieved by ensuring that the units selected were comparable in that they were both high level care, the procedures being videotaped were the same in each unit (showering a resident), and the participants selected met the same criteria (caregivers in residential care). The researchers gave detailed demographic information about the participants, the residents being studied and the units selected for the study. The actual procedure of having participants watch and comment on the video-tapes was a way of verifying that the data were true as was the detailed account of the data analysis which also contributed to the rigour evident in the study.

Findings from this study were interesting as they indicated that it was quite confrontational for caregivers to watch themselves on video tape. Even so, caregivers said that the tapes were a true reflection of the way they had felt and how they had behaved during the procedure. The researchers found that there was a variation in the ability of the caregivers to reflect upon their practices and evaluate them critically. The use of stimulated recall was found to be useful for caregivers in providing insight into carrying out their daily work. The caregivers who had experienced more problems were found to be more focused on completing the task at hand, no matter what the cost, while the other group of nurses were more concerned with resident well being during the procedure.

Conclusions reached from this study were that a power struggle existed between resident and staff in unit two where aggressive behaviour was more problematic. Had the behaviours been explored from the stance that they were need driven, staff may have reflected differently when viewing the videos. There existed for staff in unit two, the dilemma of whether to omit the shower and thus fall down in their duty of care, or to remain task focused and complete the shower no matter what the cost to the resident or to themselves, and at the same time compromising their duty of care to cause no harm. These same staff felt abandoned and inadequate in their skills and knowledge base.

In comparison, the staff from unit one appeared to be more compassionate and flexible in their care delivery with the result that the situation was less traumatic for all. It would have been interesting to explore further why this was the case. Was it their education program, leadership, skills mix, environment, or experience in the work situation?

The reflective nature of this research project was seen to be cathartic and educational in itself, although it appeared that some staff members were better at the reflective process than others. The study highlights the need for education about reflection and its relevance to care of residents with dementia for caregivers in residential living and the support network essential for delivery of high quality team care.


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  2. References
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