Nursing staff stress from challenging behavior of residents with dementia: concept analysis

T.J.G.M. Hazelhof1,2 RN, MSc, L. Schoonhoven3,4RN, PHD, B.G.I. van Gaal3 RN, PHD, R.T.C.M. Koopmans5,6 MD, PHD & D.L. Gerritsen7 PHD

1 Senior Health Psychologist, Vitalis WoonZorggroep Eindhoven, Eindhoven, 2 Junior Researcher, 5 Professor, 7 Senior Researcher, Department of Primary and Community Care, Radboud University Medical Center, Radboud University, 3 Senior Researcher, Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), 6 Elderly Care Physician, Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, the Netherlands, 4 Professor, Faculty of Health Sciences, University of Southampton, Southampton, UK

Correspondence address: Theo J.G.M. Hazelhof, Vitalis WoonZorggroep Eindhoven, Herman Gorterlaan 4, 5644 SX, Eindhoven, the Netherlands; Tel: 0031-40-2933331;E-mail: theo.hazelhof@radboudumc.nl.

FundingThis study was funded by Vitalis WoonZorgGroep Eindhoven.

Conflict of interestNo conflict of interest has been declared by the authors.

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Abstract

Aim. Provide insight into the concept of stress in the context of challenging behavior of nursing home

residents with dementia and its causes and consequences.

Background. Challenging behavior is frequent in residents with dementia, but consequences for

nursing staff are unclear.

Introduction. Challenging behavior of residents can be enervating for nurses and may lead to stress.

Although stress in general is associated with negative outcomes, an overview of stress in this context

would be a welcome addition to the field.

Method. Concept analysis according to Walker and Avant.

Results. Identified antecedents of stress: physical and verbal aggression, conflicts, excessive demands

and being unresponsive (residents), age, experience, tenure, nursing level and training (nursing staff).

Defining attributes: disturbed homeostasis and the personal appraisal of the situation. Identified

consequences regard health, psychological aspects and behavior.

Discussion. Intervening in the identified factors may contribute to prevention of stress in nursing

staff.

Limitations. Given a lack of strong empirical studies, our analysis is not based on a high level of

evidence and needs to be tested. Papers from before 1990 might have been missed.

Conclusion. The concept analysis revealed that nursing staff stress in the context of challenging

behavior may result from resident and nursing staff factors. Besides health- and psychological

consequences, behavioral consequences can enormously impact the well-being of residents.

Implications. Application in daily care to support teams in influencing resident and nursing staff

factors could prevent stress, for instance using behavioral management training or recruiting higher

educated nursing staff. Given the increasing complexity of care, creating specialized units with

specifically trained staff for different groups of people with dementia may be desirable.

Key words: Challenging behavior, concept analysis, dementia, nursing staff, prevention, residents,

stress.

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Introduction

Nursing staff members often experience stress. This may result from patient factors and

environmental factors pertaining to staff, unit and institutional characteristics (Cohen-Mansfield

1995). Although many nursing home residents with dementia show challenging behavior -which may

contribute to stress in nursing staff (Zwijsen et al. 2014)-, the mechanism behind it remains unclear,

as are other factors involved. A concept analysis about nursing staff stress related to such behavior

may thus be useful. A concept analysis disentangles the concept into its basic elements in order to

clarify its internal structure. This way, an operational definition may be formulated, thereby

increasing the validity of the construct (Walker et al. 2011). More insight into stress from challenging

behavior of residents with dementia may provide managers and policy officers with tools to prevent

and decrease stress in the process of managing challenging behavior and, through this, improve the

health of their workforce. Furthermore, clarification of the concept of stress and identification of

niches in the knowledge can support nursing researchers’ investigations into this area.

Background

Although nurses are considered to be of high importance in empowering informal caregivers in

managing challenging behaviors (Smith et al. 2004), working with residents with dementia can be

enervating for nursing staff themselves. Up to 97% of nursing home residents with dementia exhibit

challenging behavior during the course of their disease (Wetzels et al. 2010). Since the number of

people with dementia rises, but the number of long-term care beds does not, only people with

complex health problems will be admitted to nursing homes (Selbaek et al. 2013). Furthermore,

when people with dementia remain at home longer, the dementia will be more progressed at nursing

home admission. This also implies more agitation and aggression of residents, since these are

associated with more severe deterioration (Zuidema et al. 2010). Additionally, because challenging

behavior is a predictor of nursing home admission, an even greater number of nursing home

residents with dementia will exhibit challenging behavior (Gaugler et al. 2009).

Various studies into nursing stress show that it may result from interactions with and

characteristics of the patients they care for (Cohen-Mansfield 1995, McVicar 2003, VonDras et al.

2009), and of the setting in which they provide care, more specifically working conditions such as the

workplace in total, leadership/management style, workload, staffing shortage, clarity of job

expectations, interactions with co-workers, and the nature of tasks (Schaefer et al. 1996). A

systematic review of Pitfield et al. (2011) showed that stress in staff caring for people with dementia

living in 24-hour care settings may not be very high, although others found that working with people

with dementia was associated with stress, and thus with adverse outcomes, in nursing staff (e.g.

Brodaty et al. 2003, Chrzescijanski et al. 2007).

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Since stress is subject to multiple explanations (Mulhall 1996), concept analyses have focused on

stress in general (Goodnite 2014), role stress among nurses (Riahi 2011) and post-traumatic stress

disorder in the nursing population (Nayback 2009). A concept analysis of stress in nursing staff in the

context of challenging behavior of residents with dementia has, to our knowledge, not been

published yet.

Aim of the study

To provide insight into the concept of stress in the context of challenging behavior of residents with

dementia by exploring its core elements, causes, and consequences.

Methods

Design

The Walker and Avant method for concept analyses was chosen (Walker et al., 2011). In this

approach, the use of the concept in current approaches is described and the antecedents, defining

attributes, consequences, model- borderline and contrary cases, and empirical referents of the

concept’s attributes are identified.

Data sources

This analysis was based on existing research about nursing staff stress in the context of challenging

behavior as included in the databases of PUBMED, Web of Science and CINAHL. Additionally,

definitions were sought using the term “stress” in dictionaries, such as the Free Dictionary, and

Merriam Webster’s Dictionary and medical sites such as medilexicon.com and medscape.com.

Search strategy

A filter was applied for year of publication (January 1, 1990 – January 1, 2015) and language (English).

The first search term “stress” generated 562,114 articles. To limit the search to nursing staff and

dementia, the terms ”nurse,” “nursing staff”, “nurse aides”, and “dementia” (MESH, PUBMED) were

added, resulting in 681 articles. To further restrict the search, the search terms “behavior” or

“behaviour” were added. This brought 645 articles. Finally, the search was narrowed to residents in

nursing homes or long-term care institutions by adding the terms ”nursing home” or “long-term care

institution”, leaving 340 papers.

Papers were manually selected if they empirically studied the relationship between behavior

of residents and nursing outcomes in nursing homes. Empirical papers that compared the effects of

resident behavior on nursing staff in various settings, including nursing homes, were also selected.

Further, theoretical papers describing the concept of stress were selected.

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Data extraction

The included empirical research papers were summarized in three tables for antecedents

(Supplementary file 1), defining attributes (Supplementary file 2) and consequences (Supplementary

file 3) respectively, reporting the first author, year of publication, design of the study with sample

size and questionnaires used, and findings of each study.

Results

In total 19 papers were selected. From the reference lists of these, 11 additional papers were

included. We identified eight definitions of stress in the papers and dictionaries (Table 1).

Use of the concept

The American Psychological Association defines stress as ‘the pattern of specific and nonspecific

responses an organism makes to stimulus events that disturb its equilibrium and tax or exceed its

ability to cope’. The Free Dictionary describes stimulus as ‘any change that evokes a response from

an organism.’ Medilexicon.com offers homeostasis as a synonym for equilibrium. Lazarus (2007)

describes stress as a process of appraisal of the situation by the person under stress and defines it as

a dynamic process that occurs when an individual appraises situational demands as exceeding

available resources (Lazarus 2007). The current analysis builds on, but also diverges from the concept

analysis of stress by Goodnite (2014), who describes its defining attributes as: ‘the application of

tension, force or pressure (a stimulus) to an organism, the appraisal of the stimulus as overwhelming

and a measurable response by the organism to the stimulus’ (Goodnite 2014, p.72). In Goodnite’s

(2014) approach, a marked change in the equilibrium of the organism is the consequence of stress .

In the current concept analysis, the stimuli that precede stress are considered antecedents; disturbed

homeostasis and the appraisal of the stimulus by the organism are considered defining attributes;

and the measurable responses are the consequences of stress (Figure 1).

INSERT TABLE 1.

INSERT FIGURE 1.

Antecedents

Antecedents ‘may shed considerable light on the social context in which the concept is generally

used…. and are events that must occur or be in place prior to the occurrence of the concept’ (Walker

et al. 2011, p. 167). In this concept analysis, the antecedents resulting from the literature review

could be divided into antecedents concerning the resident and antecedents concerning nursing staff

(Supplementary File 1).

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Antecedents: Residents

Antecedents concerning residents are separated into two groups: their behavior and their (physical)

condition. Behavioral antecedents include both physical and verbal aggression, which have been

found to result in nursing staff distress and lower job satisfaction (Goodridge et al. 1997, Rodney

2000, Miyamoto et al. 2010, Everitt et al. 1991). Caring for residents with severe aggression has been

found to be significantly more stressful than caring for residents with low aggression (Rodney 2000).

Other behavioral antecedents associated with nursing staff stress include conflicts about eating,

toileting, dressing and/or wanting to go home and verbal abuse, excessive demands or being

unresponsive and screaming (Benjamin et al. 1990, Goodridge et al. 1997, Miyamoto et al. 2010,

Rodney 2000). Antecedents related to the (physical) condition of residents include communication

problems (Benjamin et al. 1990), which were found to be stressful for nursing staff, and low Activities

of Daily Living (ADL)- and cognitive functioning, which appeared to be related to burden in Special

Care Units (SCUs) (Miyamoto et al. 2010, Pekkarinen et al. 2006).

Antecedents: Nursing staff

The identified antecedents regarding nursing staff are age, experience, nursing level and training

(Astrom et al. 1991, Evers et al. 2002, Morgan et al. 2005, Schmidt et al. 2012). More stress from

challenging behavior correlated with younger age: older formal caregivers experienced less job strain

from challenging behavior (Edvardsson et al. 2009). Furthermore, the longer nursing assistants

worked in SCUs the more ‘assaults’ they experienced, although they experienced less distress. On the

other hand, it appeared that less work experience was related to more stress resulting from

challenging behavior (Evers et al. 2002, Morgan et al. 2005, Edvardsson et al. 2009). Nursing level is

an antecedent as well: nursing assistants experienced more stress than registered nurses when they

were confronted with, for instance, physical abuse, agitation or behavior that was uncooperative,

inappropriate or unpredictable (Park 2010). However, Schmidt (2012) did not find an influence of the

qualification level, occupational position or seniority on stress resulting from residents’ challenging

behavior. Training is also an antecedent: after learning strategies for managing challenging behavior,

nursing staff became more confident and less stressed (Morgan et al. 2002).

Defining attributes

Defining attributes are ‘attributes that are the most frequently associated with the concept and that

allow the analyst the broadest insight into the concept’ (Walker et al. 2011, p.162). Two defining

attributes are derived from the definitions as shown in Table 1: disturbed homeostasis and appraisal.

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Disturbed homeostasis

Cohen-Mansfield (1995) describes occupational stress as: ‘the condition in which some factor or

combination of factors at the workplace interacts with the worker to disrupt his or her psychological

or physiological homeostasis’ (Cohen-Mansfield 1995, p. 445). Challenging behavior of residents with

dementia can be regarded as one such factor. We divided disturbed homeostasis into two categories:

changes in physical state and changes in emotional state. With regard to physical changes, we use

the term: ‘the alarm phase’ (Selye et al. 1950), which is characterized by physiological change in the

body in response to a stressor (e.g., increased heart rate, blood pressure, adrenaline level, breathing

rate) (Cohen-Mansfield 1995). Changes in emotional state as attributes of stress include anxiety (e.g.,

psychological tension, apprehension, trepidation, affliction) and pressure (e.g., psychological strain,

tension) (Mulhall 1996).

Appraisal

Appraisal is a cognitive component of the defining attributes (Folkman et al. 1986, Goodnite 2014,

Rodney 2000) (Supplementary File 2). Lazarus et al. (1984) point out that stress occurs when a person

appraises situational demands as exceeding his or her available resources. Accordingly, primary

appraisal is the person’s notion that something is a threat. The perception of threat triggers

secondary appraisal; the ‘process of determining what coping options or behaviors are available to

deal with a threat and how effective they might be’ (Rice 2012, p.9) (Table 1).

Consequences

‘Consequences are those events or incidents that occur as a result of the occurrence of the concept…

the outcomes of the concept’ (Walker et al. 2011, p. 167). As with antecedents, consequences shed

considerable light on the social context in which the concept is generally used. In the current concept

analysis, three groups of consequences of stress are identified in the reviewed literature: health-,

psychological-, and behavioral consequences (Supplementary File 3).

Psychological consequences

The terms stress, burden, strain and burnout are often used interchangeably (Morgan et al. 2002;

Astrom et al. 1991; Gates et al. 1999, Maslach 1978). However, in our view, given the evidence—

albeit limited— from research that combines stress and burnout explicitly, burnout is best

considered a consequence of stress. Kennedy (2005) found that stress was significantly correlated

with burnout in nursing staff working with geriatric residents in long-term care. Maslach et al. (1981)

stated that, for professionals who help people, chronic stress can be emotionally draining and has a

risk of becoming burnout. With regard to the relationship between challenging behavior and

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burnout, it has been found that physical and psychological aggression in residents have an effect on

emotional exhaustion and on depersonalization, two domains of burnout (Evers et al. 2001). Another

psychological consequence is job (dis)satisfaction. Physically and/or verbally aggressive behavior and

general disruptive behavior from residents were found to be correlated to lower job satisfaction

(Dougherty et al. 1992). VonDras (2009) found that stress was related to lower job satisfaction.

Health consequences

Stress in the context of challenging behavior may have health consequences (Chappell et al. 1994) .

Agitation from residents has been found to be associated with subjective health complaints in

nursing staff (Testad et al. 2010). Uncooperativeness, restlessness and constant crying of residents

were related to nursing assistants missing work shifts due to physical health stress (Chappell et al.

1994). Stress was significantly associated with sick days (Kennedy 2005).

Behavioral consequences

Several behavioral consequences of nursing staff stress in the context of challenging behavior have

been found: shortcuts in providing care (VonDras et al. 2009), increased absenteeism (Chappell et al.

1994) turnover (Maslach et al. 1981), shouting back at residents (Macpherson et al. 1994), reacting

negatively towards residents, or even abusing residents (Goodridge et al. 1997). Lower levels of

stress are correlated with more staff-resident interactions (Jenkins et al. 1998, Pillemer et al. 1991)

(Supplementary File 3).

Three illustrative fictitious cases

Model case

Jenny, a 22-year-old nurse in a nursing home for older people with dementia, is on sick leave.

After passing her exam as a licensed nurse, she immediately started working there and

considered this a positive challenge. She had worked there for a few weeks as a trainee and

liked it very much. However, lately she has been feeling tense and out of balance. Some

residents are not able to verbally communicate and behave extremely resistive when being

cared for. Other residents are always arguing with each other and Jenny has to make

considerable efforts to stop or prevent them from doing so, but is not always successful. One

of the residents whom she liked very much in the beginning is increasingly agitated and can

become violent at erratic times. Now Jenny thinks she is no longer able to communicate

properly with a resident with aggression. Two weeks ago, when she heard that she had to

wait months before following a course on managing challenging behavior she lost her

courage. When she observed her colleagues refrain from intervening as a resident yelled

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fiercely at his neighbor she cried and subsequently called in sick. Now she has terrible

headaches and asks herself whether she is good enough to do this job and if she has ever

done the job properly.

This is a model case because it includes antecedents like challenging behavior, attributes concerning

appraisal and consequences like crying and feelings of inadequacy.

Contrary case

Erica, a 56-year-old nurse, works in an SCU for people with dementia. She cares for Mr.

Wright, a newly admitted resident who has delusions: he thinks he is in World War II and that

he is going to be tortured again. As a result of this delusion, he demolishes his room and

attempts to escape. When someone tries to calm him down, he points his finger and yells

that they are not going to get him this time. When Mr. Wright is in a rage, Erica enters the

room without speaking and presents him with a cup of hot chocolate. He calms down and

accepts the chocolate.

This case is a contrary case because it does not describe any attribute of stress: Erica does not

appraise the situation as a threat. Further, she does not experience negative consequences from Mr.

Wright’s behavior.

Related case

Jessica, a 21-year-old nurse, has been working on an SCU for residents with dementia for the

past three months. She very much enjoys her work, especially because she can sing well and

the residents really like her singing. Mr. Smith, a resident who was admitted a few weeks

ago, sometimes frightens her. At times he can be very aggressive. Despite using medication

to calm him down, he acts fiercely when any of the other residents make a noise or speak to

him. When he is tense he speaks Indonesian, a language Jessica doesn’t understand, looks

very threatening, and does not want to be touched. Jessica reacts in a strained manner when

he behaves that way; she becomes frightened. Now that the psychologist has recommended

that two members of staff care for Mr. Smith to ensure they are able to react appropriately if

he becomes angry and has instructed staff to speak to Mr. Smith in a very friendly manner,

Jessica feels relieved and better able to cope with his behavior.

This is a related case because Jessica feels tension from the resident’s behavior but this tension

lessens and she feels able to cope.

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Empirical referents

Concepts are measured by empirical referents. ‘Empirical referents are classes or categories of actual

phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself.’

(Walker et al. 2011, p. 168). Empirical referents thus regard the defining attributes, in this case

disturbed homeostasis and appraisal.

Empirical referents that measure disturbed homeostasis

Disturbed homeostasis consists of the following two elements: changes in physical state and

emotional changes. The first element, changes in physical state such as increased heart rate, blood

pressure, adrenaline level and breathing rate, are measured by physicians, doctor’s assistants and

nurses. Levels of adrenaline and cortisone in the blood can be measured by analyzing blood samples.

There are several options for measuring the second element, emotional changes. However, only one

questionnaire was found for measuring emotional changes at work, the Questionnaire on the

Experience and Evaluation of Work (Van Veldhoven et al. 2009).

Empirical referents that measure appraisal

Several questionnaires are available for measuring appraisal, such as the Resident Challenging

Behavior Distress Index (Schmidt et al. 2012). Appraisal of aggressive behavior is measured using the

Experienced Aggressive Behavior Scale (EABS) (Evers et al. 2001, Evers et al. 2002). The Modified

Strain in Nursing Care Assessment Scale (M-NCAS), measures burden associated with care for

institutionalized individuals with dementia (Kleinman et al. 2004). The Neuro Psychiatric Inventory

distress scale measures stress experienced by nursing staff resulting from challenging behavior

(Cummings 1997). The Caregiver Stress Inventory (CSI) is described by Park (2010).

Discussion

In this concept analysis of nursing staff stress in the context of challenging behavior of residents with

dementia, antecedents, defining attributes, consequences and the cohesion between these elements

are described. Most research into nursing staff stress includes forms of (verbal) aggression as

determinants. After an extensive literature search, these antecedents were supplemented by other

antecedents regarding the behavior and (physical) condition of residents that precede and contribute

to stress in nursing staff. However, characteristics of nursing staff such as age, experience, nursing

level and training also appeared to be related.

This concept analysis was performed methodologically and transparently by applying a

comprehensive literature search, formulating inclusion and exclusion criteria, describing the data

extraction process and reporting the resulting studies in tables. This is in accordance with Draper

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(2014), who described the necessity of these criteria in his critique of concept analysis, which was

endorsed by Morse (2014). In this analysis, a specific and clear description of the elements of stress is

presented, regarding antecedents and defining attributes differently than the concept analysis of

Goodnite (2014), who included not only the stimulus application in the defining attributes, but also

the appraisal of the stimulus as well as a measurable response by the organism. Based on the

literature found, we consider the stimuli that are applied as antecedents, stemming from residents or

nursing staff. Furthermore, defining attributes regard internal processes resulting from stimuli:

disturbed homeostasis and appraisal, which may in turn have psychological -, health- and behavioral

consequences. In contrast, Goodnite (2014) describes consequences more generally as a marked

change in the organism’s state, which is difficult to distinguish from the ‘measurable response by the

organism’ that she identified as a defining attribute.

Some limitations have to be mentioned. Firstly, as the scope of this article was on stress in

the context of challenging behavior, antecedents of nursing staff stress that have not (yet) been

studied in this context were not included. Secondly, we may have missed papers published before

1990, the start date of our search strategy. However, as we included relevant papers from the

reference lists of selected papers –also papers from before 1990-, we expect that this chance is small.

Thirdly, it was not possible to base our analysis on empirical research with high levels of evidence.

The relationships in the framework are supported by empirical studies, but these mostly have a

cross-sectional design and do not always use validated measurement instruments. We also did not

select studies based on their methodological quality. This implies that in future –longitudinal-

research, our framework has to be tested. Given that our literature search revealed mostly intra- and

interpersonal factors, future research could focus particularly on non-personal unit- and institutional

factors using more specified search terms. Moreover, possible additional relationships between the

components of the framework call for further study, for instance between staff factors and resident

behavior (see Figure 1). Furthermore, especially behavioral consequences of nursing staff such as

shouting back at residents, reacting negatively, and abusing residents might result in decreased well-

being of residents and/or challenging behavior, which may in turn increase stress levels in nursing

staff again, possibly resulting in a downward spiral. This would imply there is a loop in the

framework.

Implications for Nursing & Health Policy

More insight into the causes and consequences of stress provides opportunities to develop

interventions that prevent and address stress in nursing staff effectively. The management of nursing

homes may use the current findings to influence antecedents of nursing staff and residents. It is

expected that teams composed of nursing staff that is higher educated, better trained, older and

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more experienced are more able to cope with stress related to challenging behavior. In units with

high levels of health-, psychological- and/or behavioral consequences, nursing staff with the

mentioned characteristics may be brought in. Nevertheless, it is probably even more important for

nursing schools to specifically prepare their students for challenging behavior of patients and

empower them in behavioral management strategies. Additionally, resident antecedents could be

used for composing the resident group in a unit, since residents with communication problems, low

ADL functioning and/or severe cognitive problems more often have challenging behavior. It may be

advisable to create specialized units for specific groups of residents (e.g. residents with extreme

problem behavior, with psychiatric morbidity or with early onset dementia), and provide the

pertaining nursing staff with specific tools for managing the behavior of these specific groups.

In terms of international nursing policy this systematic concept analysis contributes to the

health of the nursing workforce, by providing insight into the factors that contribute to work-related

stress. It further supports research about nursing stress. It does so by giving investigators in nursing

research a basic understanding of the antecedents and consequences of nursing stress from

challenging behavior, which helps to clearly define the concept and gives researchers the possibility

to investigate hypotheses that reflect the relationships between concepts. Research in this area is of

particular importance because the studies reported here are cross-sectional.

Conclusion

In this paper, we have presented a conceptual framework for stress of nursing staff in the context of

challenging behavior of residents with dementia. It appeared that this stress is not only the result of

characteristics of the resident but is also influenced by characteristics of the nursing staff.

Consequences are not limited to health and psychological aspects but include behavioral

consequences as well. These behavioral consequences may have an especially large impact on the

well-being of residents. Having provided these insights and, at the same time, having revealed lacks

of knowledge, the proposed framework can substantially contribute to improving nursing policy and

practice and, through this, to enhancing quality of care for residents with challenging behavior.

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Morgan, D. G., Semchuk, K. M., Stewart, N. J. & D'arcy, C. (2002) Job strain among staff of rural nursing homes - A comparison of nurses, aides, and activity workers. Journal of Nursing Administration, 32, 152-161.

Morgan, D. G., et al. (2005) Work stress and physical assault of nursing aides in rural nursing homes with and without dementia special care units. J Psychiatr Ment Health Nurs, 12, 347-358.

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in nursing homes. Mar 1991. Research on Aging, 13, 74-95.Pitfield, C., Shahriyarmolki, K. & Livingston, G. (2011) A systematic review of stress in staff caring for

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Zwijsen, S. A., et al. (2014) Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes. International Journal of Geriatric Psychiatry, 29, 384-391.

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Table 1: Definitions of stress

Source Definition American Psychological Associationi

Medilexiconii

‘The pattern of specific and nonspecific responses an organism makes to stimulus events that disturb its equilibrium and tax or exceed its ability to cope’

Reactions of the body to forces of a deleterious nature, infections, and various abnormal states that tend to disturb its normal physiologic equilibrium (homeostasis).

Merriam-Websteriii A state resulting from a stress: especially: one of bodily or mental tension resulting from factors that tend to alter an existing equilibrium.

(Selye 1976) Stress is the nonspecific response of the body to any demand. A stressor is an agent that produces stress at any time. The general adaptation syndrome (GAS) represents the chronologic development of the response to stressors when their action is prolonged. It consists of three phases: the alarm reaction, the stage of resistance and the stage of exhaustion.

(Goodnite 2014) 1. The application of tension, force or pressure (a stimulus) to an organism . 2. The appraisal of the stimulus as overwhelming. That is, the organism perceives an inability to meet the challenge.3. A measurable response by the organism to the stimulus.

Free Dictionaryiv A mentally or emotionally disruptive or upsetting condition occurring in response to adverse external influences and capable of affecting physical health, usually characterized by increased hearth rate, a rise in blood pressure, muscular tension, irritability and depression.

(Cohen-Mansfield 1995)

Occupational stress is the condition in which some factor or combination of factors at the workplace interacts with the worker to disrupt the psychological or physiological homeostasis (Margolis & Kroes, 1974).Inadequate fit between the person and the environment.

(Lazarus 2007, Lazarus et al. 1984)

Stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or hers resources and endangering his or her well-being.Primary appraisal evaluates the question: Am I in trouble? Is what is happening relevant to one’s values, goals, commitment, beliefs about self and world and situational intentions. Secondary appraisal evaluates the question: That what might and can be done. It refers to a cognitive evaluative process that is focused on what can be done about a stressful person-environment relationship.

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(Rice 2012) Primary appraisal is a judgment about what the person perceives a situation holds in store for him or her. Specifically, a person assesses the possible effects of demands and resources on well-being. Secondary appraisal, is the process of determining what coping options or behaviors are available to deal with a threat and how effective they might be.

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Figure 1: Conceptual framework of stress of nursing staff in the context of challenging behavior of residents with dementia

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Psychological consequencesBurnoutJob (dis)satisfactionHealth consequencesSubjective health complaintsPhysical health stress/complaintsMissing days at work/sick daysBehavioral consequencesTaking shortcuts in careShouting back at residentsReacting negatively towards residentsAbusing residentsMore or less interactions with residents

Defining attributesAntecedents Consequences

Staff factorsLow ageExperienceLevel of nursing staffLevel of training

StressDisturbed homeostasisChanges in physical stateChanges in emotional stateAppraisalPrimary: Perceiving threat (self or client) Secondary: Determining coping options

Resident behaviorAggressionArguing Excessive demandsBeing unresponsiveScreaming

(Physical) condition residentsHaving communication problemsLow ADL functioningLow cognitive functioning

Supplementary File 1: Antecedents of nursing staff stress in the context of challenging behavior of residents with dementia: staff and resident antecedents

Resident factors

     

First author

Design Results Antecedent

(Benjamin et al. 1990)

Cross-sectional design, questionnaire studySample: 27 nurses at a short-stay ward in a general hospital, a long-stay ward in a psychiatric hospital, or social services bungalows for demented patients.The Clifton Assessment Procedure for the Elderly (CAPE) and the Crichton Royal Behavioural Rating Scale (CRBRS) were administered

Residents having communication problems was stressful for approx. 67% of the carers. Resident that has made excessive demands on the nurses was stressful for 71% and a resident being unresponsive was stressful for 71%.

Communication problems, excessive demands and being unresponsive

(Everitt et al. 1991)

Cross-sectional design, interview and questionnaire study.Sample: nurses in 12 nursing homes assessed each resident. In total: 346 residents. Nurse assessments: the Physical Self-Maintenance Scale of activities of daily living,” and the assessment of behavior. The resident-assessment: a Folstein Mini-Mental Status Examination

Physical abuse caused the most distress; at least mild to moderate distress was caused by 92% of the physically abusive residents, and in 32% of cases the staff was severely distressed. In addition, 90% of verbally abusive patients caused distress.

Physical and verbal abuse

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(Goodridge et al. 1997)

Pre-post-test design, questionnaire study Sample: 126 nursing staff, of a long term care facility. The Staff Burn-Out Scale for Health Professionals and an instrument that examines the frequency and nature of staff-client conflicts as reported by staff and aggression toward nursing assistants by residents.

Open ended questioning: physical and verbal abuse, being unappreciated were stressors.

 

Physical and verbal abuse

(Miyamoto et al. 2010)

Cross-sectional design, questionnaire study. Sample: 445 respondents in hospitals, nursing homes and geriatric care facilities.Zarit caregiver burden Interview, Personals self- maintenance Scale, MMSE, Troublesome behavior scale. 

Aggression and screaming were significantly correlated with higher formal caregiver burden. Low ADL levels was significantly correlated with higher caregiver burden from nurses: ZBI,PSMS, r = -.22; p <.001.Lower cognitive levels of clients were significantly related with higher caregiver burden. Types of BPSD explained 25% of the variance in the burden of the formal caregiver: ZBI,MMSE, r= -.15; p = .002.

Aggression and screaming ADL functioning/cognition

(Park 2010)

Cross-sectional design, questionnaire study.Sample: 267 nursing staff members in 10 long-term care facilities.Caregiver Stress Inventory and Attitudes About Family Checklist

Nursing assistants scored higher on stress than nurses in aggressive behavior (Mean 4.84 vs. Mean is 4.32 t = -2.28, p = 0.04). Nurses’ assistants were most stressed from uncooperative behavior, (Mean = 5.41 vs. 4.65 fighting (mean =5.25 vs. 5.02), agitation (mean = 4.0 vs. 3.81).

Aggression

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(Pekkarinen et al. 2006)

Cross-sectional design, survey study.Sample: 390 staff in SCU’s and 587 staff in non-SCU’s in Finland.Resident Assessment system (RAI) (Minimum Data Set) Work stressors measured by a staff survey questionnaire.

Resident’s dependency in activities of daily living (ADL) was related to increased work stressors in SCU’s.

ADL functioning

Rodney (2000)

Cross-sectional design, questionnaire study.Sample: 102 nurses in 15 nursing homes and hostels.Personal Views Survey II measures of hardiness, primary appraisal, secondary appraisal and coping in relation to the most aggressive resident. Adapted version of 58 coping methods by Dewe (1987). Rating Scale for Aggressive Behavior in the Elderly,

Resident aggression significantly related to nurse stress. Stress associated with caring for the highly aggressive resident was significantly higher than the stress associated with caring for the resident displaying low aggression.The hierarchical regression accounted for 35% of the explainable variance of nurse stress in response to aggressive behaviour by dementia sufferers. Of this 35%, 1% was contributed by the hardy personality construct; 32% by both primary threat and challenge appraisal, less than 0% by secondary appraisal; and 2% by action and palliative coping strategies. 

Aggression

Staff factors

     

First author

Design Results Antecedent

(Astrom et al. 1991)

Cross-sectional design, questionnaire study.Sample: 60 nursing staff in a nursing home, a psycho geriatric clinic and a somatic long-term care clinic.Pines burnout measure, La Monica empathy scale, Astrom’s attitude scale

Time spent at present place of work was the most important determinants of the experience of burnout.

Tenure on the unit

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(Edvardsson et al. 2009)

Cross-sectional design, questionnaire study.Sample: 344 nursing staff in residential dementia care settings.Self-report demand and control questionnaire and a questionnaire measuring caring climate and own knowledge.

Staff education level had a statistically significant relationship with job strain. The group of staff reporting higher job strain consisted of a significantly greater proportion of less educated nursing staff (p < 0.001). Younger carer’s levels of job strain: r = -.13; p < 0.05. Lower education was associated with higher job strain: r = .12; p < 0.05..

Education level, age

(Evers et al. 2002)

Cross-sectional design, questionnaire study.Sample: 551 nursing staff in homes for the elderly.Maslach Burnout Inventory, Brouwers and Tomic questionnaire for Self-efficacy, a self-developed aggression scale

When growing older caregivers experience aggressive behavior less burdensome. The more working hours the more physical aggression is experienced.

Age

(Morgan et al. 2002)

Cross-sectional design, interview and questionnaire study.Sample: 7 focus groups of 10 to 12 persons in nursing homes.Job Content Questionnaire.

Learning specific strategies for managing difficult behavioral problems leads to less stressed staff become less stressed. Being adequately prepared is negatively correlated with job strain.

Training in management strategies

(Morgan et al. 2005)

cross-sectional survey design, questionnaire studySample: 355 nurses in nursing homes.Comparing nursing aides in rural nursing homes on exposure to and distress from disruptive behaviors exhibited by residents.

Feeling being inadequately prepared increases risk of being assaulted.Nurses’ assistants being longer at work in the SCU's reported more assault but less distress, lower psychological job demands and lower job strain.

Training level Work experience

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(Park 2010)

Cross-sectional design, questionnaire study..Sample: 267 nurses in 10 long term care facilities.Caregiver Stress Index and Attitudes about Family Checklist .

Nursing assistants scored higher on stress than nurses in aggressive behavior (Mean 4.84 vs. Mean is 4.32 t = -2.28, p = 0.04). Nursing assistants reported higher stress levels from caring for residents with aggressive behaviors.

Nursing level, education

(Schmidt et al. 2012)

Cross-sectional design, questionnaire studySample: 731 registered nurses and nurses’ aides in nursing homes.Self-report questionnaire: Residents’ challenging behaviour–related distress index was used. General health was assessed with a single item based on the EQ-5D. Burnout was assessed with the four-item personal burnout scale from the Copenhagen Psychosocial Questionnaire and the Work Ability Index was used.

Age was associated with resident challenging behavior distress. Neither the level of education, nor occupational position and seniority were.

Age

ReferencesAstrom, S., et al. (1991) Staff burnout in dementia care--relations to empathy and attitudes. Int J

Nurs Stud, 28, 65-75. Benjamin, L. C. & Spector, J. (1990) The relationship of staff, resident and environmental

characteristics to stress experienced by staff caring for the dementing. International Journal of Geriatric Psychiatry, 5, 25-32.

Edvardsson, D., Sandman, P. O., Nay, R. & Karlsson, S. (2009) Predictors of job strain in residential dementia care nursing staff. J Nurs Manag, 17, 59-65.

Everitt, D. E., Fields, D. R., Soumerai, S. S. & Avorn, J. (1991) Resident behavior and staff distress in the nursing home. J Am Geriatr Soc, 39, 792-800.

Evers, W., Tomic, W. & Brouwers, A. (2002). Aggressive behaviour and burnout among staff of homes for the elderly. International Journal of Mental Health Nursing, 11, 2-9.

Goodridge, D., Johnston, P. & Thomson, M. (1997) Impact of a nursing assistant training program on job performance, attitudes, and relationships with residents. Jan-Feb 1997. Educational Gerontology, 23, 37-51.

Miyamoto, Y., Tachimori, H. & Ito, H. (2010) Formal caregiver burden in dementia: impact of behavioral and psychological symptoms of dementia and activities of daily living. Geriatr Nurs, 31, 246-253.

Morgan, D. G., Semchuk, K. M., Stewart, N. J. & D'arcy, C. (2002) Job strain among staff of rural nursing homes - A comparison of nurses, aides, and activity workers. Journal of Nursing Administration, 32, 152-161.

Morgan, D. G., et al. (2005) Work stress and physical assault of nursing aides in rural nursing homes with and without dementia special care units. J Psychiatr Ment Health Nurs, 12, 347-358.

23

Park, M. (2010) Nursing staff stress from caregiving and attitudes toward family members of nursing home residents with dementia in Korea. Asian Nurs Res (Korean Soc Nurs Sci), 4, 130-141.

Pekkarinen, L., et al. (2006) Resident care needs and work stressors in special care units versus non-specialized long-term care units. Res Nurs Health, 29, 465-476.

Schmidt, S. G., Dichter, M. N., Palm, R. & Hasselhorn, H. M. (2012) Distress experienced by nurses in response to the challenging behaviour of residents - evidence from German nursing homes. J Clin Nurs, 21, 3134-3142.

24

Supplementary File 2: Defining attributes of nursing staff stress in the context of challenging behavior of residents with dementia

First author

Design Results Attributes

(Rodney 2000)

Cross-sectional design, questionnaire study.Sample: 102 nurses in 15 nursing homes and hostels.Rating Scale for Aggressive Behaviour in the Elderly, Personal Views Survey II (hardiness), four items for primary appraisal, three questions for secondary appraisal. Adapted version of 58 coping methods by Dewe (1987).

Appraisal of residents behavior as negative or threatening is associated with stress.Primary appraisal had a significant positive relationship with stress (r .50; p< 0.01). Increased threat appraisal was associated with higher stress outcome (r 0.5; p< 0.05). Perceiving the possibility of aggressive behavior by the resident as a threat was related directly to high stress level. No relationship between secondary appraisal and stress.

Primary appraisal of residents behavior.Secondary appraisal.

ReferencesRodney, V. (2000) Nurse stress associated with aggression in people with dementia: its relationship

to hardiness, cognitive appraisal and coping. J Adv Nurs, 31, 172-181.

25

Supplementary File 3: Consequences of nursing staff stress in the context of challenging behavior of residents with dementia

Psychological

     

First author Design Results Consequences (Astrom et al. 2002)

Cross-sectional design interview study.Sample: 506 nurses in residential settings and ordinary homes.

Consequences of aggression were powerlessness (56%), unhappiness (51%), anger (49%), shame (11%) and guilt (15%). 

Powerlessness, unhappiness,Anger, shame, guilt

(Dougherty et al. 1992)

Cross-sectional design, interview study.Sample: 28 (16 mental health workers, 7 licensed Practical Nurses, 5 Registered Nurses from a long term care hospital.A self constructed Likert-type scale for exposure to aggression, a semi structured interview to describe characteristics of aggressive clients, methods that could have prevented or changed the aggressive action and their coping methods

Job satisfaction correlated negatively with: overall aggressive behavior(r=-.777; p < .0001), physical aggressive behavior (r=-.622; p < .0005), verbal aggressive behavior (r=-.766; p <.0001).

Job satisfaction

26

(Evers et al. 2001)

Cross-sectional design, questionnaire study.Sample: 551 nurses in 22 homes for the elderly.MBI, PSE from Brouwers and Tomic A self-composed questionnaire on aggression.(Kennedy 2005)

Experiencing physical aggression is related to an increase of emotional exhaustion (r = .25; p < .01) and depersonalization (r = .15; p < .01). Physical aggression is associated with lower self-efficacy. The results for psychological aggression were the same. Psychological aggression was stronger associated with emotional exhaustion (r = .33; p < .01). Depersonalization was only related to psychological aggression (r = .36; p< .01). Emotional exhaustion was related to depersonalization (r= .46 ; p= < .01). Emotional exhaustion and depersonalization were negatively related (r = -.12 ; p= < .01). Emotional exhaustion was negatively related to personal accomplishment (r = -.10; p= < .05). 

Exhaustion, depersonalization, self-efficacy, burnout

(Kennedy 2005)

Cross-sectional design, questionnaire study.Sample: 72 nurses in nursing home.Nursing Stress Scale , Maslach and Jackson Burnout Inventory (MBI).

Stress was significantly correlated with burnout (F = 6.36; p= .003).

Stress/burnout

27

(VonDras et al. 2009)

Cross-sectional design, questionnaire study.Sample: 44 nurses: 33 Certified Nursing Assistants, 4 License Practical Nurses and 7 Registered Nurses in nursing homes.Brief self-report questionnaire with two questions that provided a global assessment of job satisfaction, modeled after items found in the Generic Job Satisfaction Scale. Workplace stress using, a global measure of stress, modeled after the Perceived Stress Scale. Perceptions of nursing practice was assessed using brief self-report ratings modelled about provision of care.

Stress was negatively associated with job satisfaction (r = - .36; p = < 01).

Job satisfaction

Health      First author

Design Results Consequences

(Chappell et al. 1994)

Cross-sectional design, interview study.Sample: 245 nurses in long-term care facilities.Interview: the proportion of cognitively impaired patients, minutes of physical care and disturbing patient behaviors Memory an Behavior Problems List.

Those caring for constantly restless clients and caring for more patients with mental disturbances miss more days at work. Those caring for residents who were uncooperative and cry constantly report more health problems. Number of residents with gross mental impairment and the frequency of some difficult behaviors were found to have small but significant effects on health outcomes. Gross mental impairment was related to health stress.

Missing days at work, health problems, health stress

(Kennedy 2005)

Cross-sectional design, questionnaire study.Sample: 72 nursing staff in a nursing home in southeastern United States.Nursing Stress Scale (NSS) Maslach and Jackson Burnout Inventory (MBI).

Stress and burnout were significantly correlated with number of sick days (r = .30;p =.01).

Sick days

28

(Testad et al. 2010)

Cross-sectional design, questionnaire study.Sample: 197 care staff at 13 dementia wards in 4 nursing homes.Perceived Stress Scale (PSS) Hopkins Symptom Checklist (HSC), Cohen-Mansfield Agitation Index (CMAI) General Nordic Questionnaire for Psychosocial and Social Factors at work (QPSNordic).

Agitation was associated with subjective health complaints. (2.8% of the explained variance).

Subjective health complaints

29

Behavioral

     

First author

Design Results Consequences

(Jenkins et al. 1998)

Cross-sectional design, questionnaire study.Sample: 18 nurses in residential care homes for the elderly.GHQ, Maslach Burnout Inventory (MBI), The Perceived Involvement Personal. Questionnaire (PIPQ), Quality of Interactions Schedule (QUIS).

Personal accomplishment (i.e. lower levels of burnout) was positively correlated with the quantity of staff-resident interactions (but not the quality). Staff distress, emotional exhaustion and depersonalization were not significantly related to quantity or quality of interactions. 

Quantity and quality of interactions

(Macpherson et al. 1994)

Cross-sectional design, questionnaire study.Sample: 188 workers, in 4 homes for the elderly with mental handicaps, 4 elderly persons’ homes, 4 long-stay wards and 4 private nursing homes.General health Questionnaire with CGHQ scoring system, additional questions about aggression.

More stress of staff was correlated with “shouting back” at residents.

Shouting back

(Pillemer et al. 1991)

Cross-sectional design, questionnaire study.Sample: 577 nurses and nurses’ aides working in long-term care facilities.Questions based on the Conflict Tactics Scale.

The probability of psychological abuse was released by four factors; staff burnout (coefficient .065; p = .002), patients aggression (coefficient =.097; p= .000), negative attitude toward clients (coefficient = .166; p = .079) and staff age (-/_). The chance of physical abuse rose when staff burnout, patient aggression and conflict between staff and patient were present.

Abuse

30

(VonDras et al. 2009)

Cross-sectional design, questionnaire study.Sample: 44 nurses: 33 Certified Nursing Assistants, 4 License Practical Nurses and 7 Registered Nurses in nursing homes.Brief self-report questionnaire with two questions that provided a global assessment of job satisfaction, modeled after items found in the Generic Job Satisfaction Scale. Workplace stress using, a global measure of stress, modeled after the Perceived Stress Scale. Perceptions of nursing practice was assessed using brief self-report ratings modelled about provision of care.

Correlation between stress and taking shortcuts in providing care (r = .36; p= < .001).

Taking shortcuts in care

ReferencesAstrom, S., et al. (2002) Incidence of violence towards staff caring for the elderly. Scand J Caring

Sci, 16, 66-72. Chappell, N. L. & Novak, M. (1994) Caring for Institutionalized Elders - Stress among Nursing

Assistants. Journal of Applied Gerontology, 13, 299-315. Dougherty, L. M., et al. (1992) Effects of exposure to aggressive behavior on job satisfaction of

health care staff. J Appl Gerontol, 11, 160-72. Evers, W., Tomic, W. & Brouwers, A. (2001) Effects of aggressive behavior and perceived self-

efficacy on burnout among staff of homes for the elderly. Issues Ment Health Nurs, 22, 439-454.

Jenkins, H., Jenkins, H. & Allen, C. (1998) The relationship between staff burnout/distress and interactions with residents in two residential homes for older people. International Journal of Geriatric Psychiatry, 13, 466-472.

Kennedy, B. R. (2005). Stress and burnout of nursing staff working with geriatric clients in long-term care. J Nurs Scholarsh, 37, 381-382.

Macpherson, R., Eastley, R. J., Richards, H. & Mian, I. H. (1994) Psychological distress among workers caring for the elderly. May 1994. International Journal of Geriatric Psychiatry, 9, 381-386.

Pillemer, K. & Bachman-Prehn, R. (1991) Helping and hurting: Predictors of maltreatment of patients in nursing homes. Mar 1991. Research on Aging, 13, 74-95.

Testad, I., Mikkelsen, A., Ballard, C. & Aarsland, D. (2010) Health and well-being in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes. International Journal of Geriatric Psychiatry, 25, 789-797.

Vondras, D. D., Flittner, D., Malcore, S. A. & Pouliot, G. (2009) Workplace stress and ethical challenges experienced by nursing staff in a nursing home. Educational Gerontology, 35, 323–341.

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i American Psychological Association. "Glossary." Retrieved March 2016, from http://www.apa.org/research/action/glossary.aspx?tab=18.ii Medilexicon. Medilexicon Dictionary. Retrieved March 2016, from http://www.medilexicon.com/medicaldictionary.php?t=85479iii Merriam-Webster. 1828-2015. Merriam-Webster Dictionary. Retrieved March 2016, from http://www.merriam webster.com/dictionary/stress (Accessed 10 March 2016.iv Free Dictionary. Retrieved March 2016, from http://www.thefreedictionary.com/stimulus.