We appreciate that Pitcher and Koch have reviewed our paper (Skovdahl et al. 2004). The project consists of a total of three studies concerning caregivers’ interactions with persons with dementia showing aggressiveness. Firstly, the caregivers from the same two units, described in our papers, were interviewed regarding their feelings and experiences from interacting with these residents (Skovdahl et al. 2003a). These interviews seemed to capture some of the caregivers’ wishful thoughts and ideas of good quality care, which were evident when they, in the next step, were video recorded during interactions with a resident showing aggressive tendencies (Skovdahl et al. 2003b). These experiences are in line with Halimaa (2001) who considers that interviews are limited as the interviewees do not always say what they do but what they want to do. According to Robert et al. (1996) video recordings are limited by lack of context and the fact that the reader has no possibility to evaluate the interpretation of what has been observed. ‘Stimulated recall’, as described in Skovdahl et al. (2004), gave us a possibility of insight into how the caregivers reflected on their own actions and an opportunity to ask complementary questions to the caregivers regarding the situations displayed in the video recordings. Stimulated recall gave us the missing link so that we were able to gain significant insight into caregivers demanding and problematic situations, especially from an ethical and organisational perspective. Pitcher and Koch commented that the caregivers were working in rather different organisational situations despite their high staffing ratios. Our studies did not, however, aim to compare different units but compare caregivers’ varying views and feelings of interacting with persons showing aggressiveness since they had previously expressed dissimilar feelings when relating to persons with dementia showing aggressiveness. One unit had reported difficulties and had asked for support, clinical supervision and education but their needs had not been met (Skovdahl et al. 2003a). At the other unit the caregivers felt they were able to handle the aggressiveness and could see it as a challenge (Skovdahl et al. 2003a). Despite the fact that all 10 residents living at this unit had earlier shown high aggressive tendencies at other units, these caregivers felt they were able to interact with them in a positive way.

The criteria for selection of the units was based on the units’ own perception of being able to interact effectively with the persons showing aggressiveness or not. We focused on the morning care, but if other care situations had been studied from other times of the day, it might have been possible to capture different attitudes and gain a more balanced picture of the caregivers’ ways of handling the demanding situations. Findings in our study (Skovdahl et al. 2004) indicated, however, that the caregivers from the two different units had more fundamental differences in their ways of reflecting and reasoning. We agree with Pitcher and Koch who indicate that a further limitation in our study is that we did not reflect about the fact that some caregivers worked in twos or threes while others worked alone. We discussed this in the study when we described the video recordings (Skovdahl et al. 2003b). As the size of the paper was limited, we unfortunately had no possibility to discuss all findings as deeply as needed and agree with Pitcher and Koch that is a limitation in our study and we regret this lack of detail. Pitcher and Koch see the lack of psychometric tests for establishing a level of cognitive impairment or aetiology of the dementia in the residents being videotaped. The caregivers from the two units were asked to select a resident that they felt to be the most demanding to relate to because of the aggressiveness. As our studies aimed to study how people experience and reason regarding aggressiveness, a qualitative approach was used.

As the authors pointed out we unfortunately did not further explore the fact that one of the residents did not like to take her shoes off when she was showered. This may have brought better insight as to the complexity of the aggressive situation when the lady was being showered. An interesting aspect was when the caregivers viewed this video recording; they thought the resident's aggressive behaviour might be due to her fear of falling on the wet, slippery floor. After the stimulated recall interview we were told that one of the actual caregivers bought the resident special shoes she could wear when she was showering, which in the next step led to the fact that this problem was solved. This was a good example of how stimulated recall could lead to new insight and new ways of understanding demanding nursing care situations. The process of stimulated recall and this method's possibilities and limitations will, however, is reported in another paper.


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  2. References
  • Halimaa SL (2001) Video recording as a method of data collection in nursing research. Vård i Norden 21, 2126.
  • Robert BL, Srour MI & Winkelman C (1996) Videotaping: an important research strategy. Nursing Research 45, 334338.
  • Skovdahl K, Kihlgren AL & Kihlgren M (2003a) Different attitudes when handling aggressive behaviour in dementia – narratives from two caregiver groups. Aging & Mental Health 7, 277286.
  • Skovdahl K, Kihlgren AL & Kihlgren M (2003b) Dementia and aggressiveness; video recorded morning care from two different care units. Journal of Clinical Nursing 12, 888898.
  • Skovdahl K, Kihlgren AL & Kihlgren M (2004) Dementia and aggressiveness: stimulated recall interviews with caregivers after video-recorded interactions. Journal of Clinical Nursing 13, 515525.