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Weekly UpdatesABSTRACT
The aim of this study was to evaluate the effectiveness of the daily interventions used by the nurses on disruptive vocalization (DV). DV includes all types of disturbing or unacceptable vocal expression: repetitive vocalization, verbal or nonverbal utterances, presented as inappropriate language, repeated and insistent demands, repeated calling out, shouting, complaining, or moaning that does not pertain to their circumstances or environment. A convenience sample of five nursing homes from the north of Italy, in the Friuli Venezia Giulia region, was included in the study. A randomized selection of 87 daily shifts was selected. Institutionalized patients with dementia, but with no associated psychiatric disorders, were eligible. Nurses involved in the study added patients progressively. Nurses involved were asked to keep diaries to record strategies and durations for each episode of DV encountered during the allotted shift. In the total amount of observation time (36,540 minutes), 23.6% (8,653 minutes) of nursing care time involved working with and managing DV patients. The nurses recorded an average of 6.5 (302/46) vocalizations on morning shifts and 7.3 (302/41) during afternoon shifts, with an average duration of about a quarter of an hour each. Managing DV with multistrategies reduces the duration of the DV episode and increases the perceived effectiveness of management.
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Disruptive vocalization (DV) is common in patients with dementia (White, Kaas, & Richie, 1996). The term disruptive vocalization includes all types of disturbing or unacceptable vocal expression: repetitive vocalization, verbal or nonverbal noises, presented as inappropriate language, repeated and insistent demands, repeated calling out, shouting, complaining, or moaning that does not pertain to their circumstances or environment (McMinn & Draper, 2005). Ryan, Tainsh, Kolodny, Lendrum, and Fisher (1998) and Algase, Beck, and Kolanowaski (1996) described DV as behavior comparable with other types of agitation typical of patients with dementia.
According to Lai (1999), there is still little known about the prevalence of DV, its manifestation, or its causes in between 11% and 36% of the patients with dementia. Hallberg, Luker, Norberg, Johnsson, and Eriksson (1990) and Hallberg, Norberg, and Eriksson (1990) conducted a study on 74 geriatric patients, 37 of whom demonstrated repetitive vocalization (the other 37 were a control group), adopting continuous semistructured observation from 7.00 a.m. to 10.00 p.m. For 71% of the total observation time (15 hours), the patients were left alone, and the rest of the time was dedicated to resting and nursing care such as personal hygiene and feeding. From their observation, the lack of stimulation that plays a major part in the daily lives of patients with dementia may be a cause of DV. McMinn and Draper (2005) also maintained that repetitive vocalization is associated with being left alone and to the lack of a social network and reduced participation in activities.
Matteau, Landreville, Lappante, and Laplante (2003) described vocalization as a way to communicate unfulfilled needs (physical, psychological, or social) and discomfort. Hunger, pain, insomnia, sadness, the difficulty of forming relationships with other patients, noise, and not being comfortable with the temperature of the environment are all factors that may be a cause of DV. These are also valid in the physical context, determining comfort or discomfort levels.
The effectiveness of management strategies of DV has also been given little attention in literature. Lindgren and Hallberg (1992) presented evidence that the number of vocalizations decreases following individual nursing intervention attempting to prevent social isolation, lack of sensory stimulus, disorientation, discomfort, and pain. More recently, Roth, Stevens, Burgio, and Burgio (2002) documented the effectiveness of strategies used to reduce DV in 66 elderly people in nursing homes. Data were collected before and after a course update on "comprehensive behavior" focused on helping nurses to understand patients' calls for help and for the patient to feel he or she has been understood. Cohen-Mansfield and Werner (1997), on the other hand, showed that managing pain or discomfort with medication reduces the amount of DV. Importantly, the same authors, in 1998, observed that talking to the patients about their past, hobbies, their family, and the weather reduced DV.
Despite the debate, there is little evidence to support the effectiveness of methods used to manage DV (Scottish Intercollegiate Guidelines Network, 2006) other than the associated impact on the patient or on the other patients (e.g., those sharing the same room), on the family, and on the nursing staff (Cohen-Mansfield, Werner, Watson, & Pasis, 1995). Whall, Gillis, Yankou, Booth, and Belel-Bates (1992) documented that, for 147 nurses working in facilities for older persons, DV was the hardest behavioral expression to manage, second only to physical aggression. DV causes emotional tensions, feelings of impotency and frustration, distancing from the patient (McMinn & Draper, 2005), burnout, and stress (Draper et al., 2000). The aim of this study was to evaluate the effectiveness of the daily interventions used by the nurses.
Aims
The aims of the study were as follows:
1. to describe the exposure by time of nurses working in nursing homes to dementia patients' DV and the types of DV during their daily shift work;
2. to describe the nurses' interventions used to manage DV in their daily practice;
3. to discover the effectiveness of these interventions during the DV episode and the nurses' perceptions of their effectiveness; and
4. to describe the determining factors for nurse intervention in DV.
Design
An observational multicentered study design was adopted. In the nursing homes included in the project, patients with dementia were recruited from the first time that DV was encountered for the entire length of the study (2 months). Nurses involved in the study kept a structured diary recording the strategies that they used for managing the observed DV and the duration of each episode.
Sampling
Context
A convenience sample of five nursing homes from the Friuli Venezia Giulia region (in the northeast of Italy) was included in the study (Table 1).
Nurses
Twenty-two nurses out of 39 of those working on the units were included in the study. The inclusion criteria were nurses who (a) gave their consent to be included in the study, (b) had done a specific course on the concepts of DV (first meeting) and on the methods for data collection (second meeting), and (c) had taken care of the same group of patients continuously for more than 80% of their shift. Exclusion criteria were, in particular, nurses involved in administrative or management roles or who were in charge of more than one ward or team and were therefore unable to give continuous care to the same group of patients.
Nurses included had graduated from a college of nursing or from the nursing science course at the university; three of them had a master's degree in geriatric nursing. They averaged 37.6 years old (range = 27-61 years, SD = 6.4 years), and they had worked in the nursing home for an average of 9.2 years (range = 0-33 years, SD = 7.7 years).
Shift Work
The study was done from July to October 2006. Daily shifts (mornings from 7:00 to 14:00 hours and afternoons from 14:00 to 21:00 hours) totaling 609 hours were observed. After having accepted the nurses and prepared them, the researchers selected their shifts to observe during the period considered for the study. A randomized selection of 87 daily shifts, from the 184 managed by the selected nurses during the period, was selected: 46 morning shifts and 41 afternoon shifts.
Patients
Institutionalized patients with dementia, but with no associated psychiatric disorders, were eligible. Nurses involved in the study added patients progressively. The inclusion criteria were patients with (a) a diagnosis of dementia, (b) one or more DV episodes during the randomized shift, and (c) care received by one of the nurses involved in the study. Patients were included progressively from the time they manifested DV behavior.
Thirty-nine patients (34 women and 5 men) were included in the study. They had an average age of 86.6 years (range = 71-97 years, SD = 6.1 years), and they had been institutionalized in the nursing home for an average of 3.3 years (range = 0-14 years, SD = 6.1 years). With reference to their medical records, these patients had an average score of 1.5 in the Mini Mental State Examination (MMSE; range = 0-14, SD = 3.4); 33 of them (89.1%) had an MMSE score of [less than or equal to] 2. Thirty (78%) patients had a Barthel's index score of [less than or equal to] 5.
Procedures Used for Data Collection First Phase
The preliminary phase involved the nurses doing a specific course with researchers to share the concept of DV of McMinn and Draper (2005) to standardize the recognition and documentation of DV. At the end of this course, organized in each nursing home where nurses involved in the study were working, researchers asked the nurses to keep a diary for 1 week to document the strategies they adopted for managing DV in their daily nursing practice. After this week, two researchers (A.P. and E.M.) collected the dairies and independently analyzed the strategies adopted by the nurses; according to the results of this analysis, researchers (A.P., E.M., R.P., and F.B.) decided to define three different DV interventions that nurses had used:
1. single strategy: when nurses used one or more of the following strategies to attend to the patient with DV:
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