Joumal of Advanced Nursing, 1996,24,439-447
Effects of an environmental manipulation
emphasizing client-centred care on agitation and
sleep in dementia sufferers in a nursing home
Ernest A Matthews RMHN RGN BA BHSC MNurs
staff Development/Research Nurse, Selby-Lemnos Hospital, Perth
Gerald A Farrell RMN RGN DipN ArtEd MSc
Lecturer, Tasmanian School of Nursing, University of Tasmania, Launceston, Tasmania
and AM BlackmorePhD
Lecturer, Department of Academic Programmes, Edith Cowan University, Perth, Australia
Accepted for publication 6 October 1995
MATTHEWS E A , FARRELL G A & BLAGKMORE A M (1996) Joumal of Advanced
Nursing 24, 439-447
Effects of an environmental manipulation emphasizing client-centred care on
agitation and sleep m dementia sufferers in a nursing home
This study was designed to determine whether a change from a task-oriented
care approach to a client-oriented care approach affects (a) the level of agitation
and (b) 24-hour sleep in residents suffering from dementia in a nursing home
The levels of dementia and sleep of 33 nursing home residents were measured
four times over 12 weeks (twice hefore and twice after the change m care
approach) using the Cohen-Mansfield agitation inventory and the dementia
mood assessment scale Verhal agitation levels significantly decreased 6 to 8
weeks following the change, whereas more infrequent agitated hehaviours,
which were classified as 'other', significantly increased Daytime sleep
increased initially after the change but then returned to hasehne levels after 6
weeks While the main focus of the study was on residents' behaviour following
an environmental manipulation, anecdotal observations of staff members
interactions with residents indicated that they felt less rushed and were more
tolerant of residents' behaviour following the intervention
dementia sufferers into institutional care (Fraser 1987) It
can compromise the comfort and safety not only of the
One consequence of our rapidly ageing population is that agitated client hut also of fellow residents and staff
the incidence ofdementia IS increasing (Jorm& Henderson Agitation may also lead to sleep disturhance (Hall &
1990) Dementia sufferers exhihit hehaviours that are com- Buckwalter 1987) At least some dementia sufferers are
monly descnhed hy nurses as agitated, disruptive, proh- more agitated towards sunset (Evans 1987, Cohenlematic and challengmg The term agitation is also widely Mansfield, Marx & Rosenthal 1989), therefore any nursmg
used to denote similar hehaviours Agitation is least toler- strategy that reduces clients' agitation might he expected
ated hy care-givers of dementia sufferers (Stnihle & eilso to reduce their sleep disturbance
Sivertsen 1987), and is a major reason for admission of
Much of the existing literature on management of c i tation and sleep disturbance is speculative and anecdotal
Con^pondence Ernest A Matthews, 33 Delage Way Balcatta Westem
Any claim of SUCCess m cani^ for demenUa SuffererS may
Austiaha 6021, Australia
he due more to the 'enthusiasm and dedication' of specific
© 1996 Blackwell Science Ltd
439
EA
Matthewseial
nurses, than to the effectiveness of the mtervention (Ford
et al 1986} The meffectiveness of strategies to manage
agitation has a negative effect on ntirses (Tafl 1989, FopmaLoy 1989) and contnbutes to staff burnout (Maas 1988,
Fopma-Loy 1989) One strategy for dealmg with agitation
and sleep disturbance that has recently been suggested
mvolves allowing patients freedom of choice m deciding
when, where and how they conduct behavioural activities,
instead of compellmg them to submit to the routimzed
care that is usual m mstitutional settmgs (Hayter 1983,
Andreason 1985, Ryden 1986) In an attempt to determme
the value of such advice, this study empincally tests the
effect of the provision of client-onented care (involving
freedom of choice) m place of task-onented care (mvolvmg
mandatory institutional routines) m the management of
agitation and sleep disturbance m patients suffenng from
dementia
Moms 1987) Traditional practice has been to promote a
structured sleep schedule and to discourage da}^me napping to mmmuze sleep disturbance (Muncy 1986, Hoch
etal 1988, Wemer ef ai 1991) However, daytimenappmg
IS common among the elderly population (Regestem &
Moms 1987) and therefore it may be mappropnate to
impose such rigid sleep schedules on elderly people who
suffer from dementia
Environmental manipulation
An altemative to structured routines for the management
of dementia is the suggestion by some authors (Ha5rter
1983, Andreason 1985, Ryden 1986) of an environmental
manipulation that allows patients freedom of choice This
environmental manipulation is based on the theory that
the environment affects the individual and the individual
affects the environment (Kahana 1974, 1975, Moos 1976,
Lawton 1983) The behaviours and subsequent well-bemg
LITERATURE REVIEW
of individuals depend on how well they are able to control
the environment to make it fit or be congruent with their
Agitation
needs (Kahana 1975) Low self-esteem (Fawcett et al 1980,
Recent research, while still unclear as to the precise aeti- ^ Maccoby 1980), reduced satisfaction with life (Thomas
ology of agitation, has identified a numher of its possible 1988), depression (Hunter et al 1981), poor health status
predisposing and precipitatmg factors, one of which is and greater use of medication (Wood & Strong 1987) have
confusion (Cohen-Mansfield, Werner & Marx 1989) To been associated with individuals who perceive loss of conminimize confusion, a structured routine is advised when trol over their environment One aspect of control over the
organizing activities of daily living for dementia sufferers environment is the ability to make choices
(Peppard 1984, Andreason 1985) The literature also advoThreats to this ability to make choices can trigger reaccates the provision of a home-like environment, mvolving tions ranging from uneasiness to an attempt to regain consuch factors as personal belongmgs, appropriate room trol Institutionalization involves rules and regulations
decor and familiar lifestyle (Hayter 1983, Ryden 1986) that often impinge on an mdividual's freedom of choice,
However, a structured routine may not be compatible with which may result ui attempts to regam control by disa home-like environment a home-like environment sug- pla5nng agitated behaviours, such as frequent demands
gests freedom of choice as to when, where and how activi- or non-compliance with instructions (Bumside 1980,
ties of daily living are conducted Loss of freedom of choice Wolamn & Philhps 1981) Hamel et al (1990) found that
has been found, among other things, to generate agitation, being told to do something was the most common situation
fiiistration and aggression (Meddaugh 1990) Nurses there- that elicited aggressive behaviours in patients Meddaugh
fore need to have clear guidelmes to address the problem (1990) investigated verbal and physical aggressive behavof formulating structured routines and facilitating choice iours m 27 cognitively impaired elderly residents of three
for dementia sufferers m such a way as to minimize their nursing facilities Findings indicated that those who had
agitation
previously led a more active hfe were more likely to be
aggressive m institutional care It was suggested that,
because these individuals expenenced greater loss of freeSleep
dom of choice, they tendbd to demonstrate a stronger reacAnother clinically important aspect of nursing care of tion m terms of agitation Paradoxically, as a consequence
dementia sufferers is the management of their disrupted of their agitation, staff were less disposed to offer them
sleep Elderly people wake up more often at mght and choices In contrast, non-aggressive residents were likely
remain awake for longer than young adults (Pnnz 1977, to he offered more choices
Re3molds et al 1985), and dementia sufferers expenence
Hall & Buckwalter (1987) h5fpothesize that as the day
even greater difficulty in achieving and mamtaining sleep progresses dementia sufferers are rendered less able to
than other elderly people (Kahn & Fisher 1969, Femberg cope with stressors ansmg from extemal stimuli, that is,
1974) Information on promoting sleep m healthy elderly their threshold of tolerance of stress is progressively lowmdividuals is scarce, and there is even less regardmg man- ered (sundownmg syndrome) Anecdotal evidence mdiaging sleep disturbance m demenba sufferers (Regestem & cates that allowmg patients to rest dunng the day has
440
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 439-447
Agitation and sleep m dementia sufferers
resulted m a reduction m agitated behaviour among
dementia sufferers In addition, the effects of sundownmg
syndrome have been minimized and even the quality and
quantity of sleep have improved as the result of reduced
mght awakemngs (Hall & Buckwalter 1987)
Although widely advocated, envuonmental mampulation has not been the subject of empmcal testing
Therefore the purpose of the present study is to mvestigate
the effect of an environmental mampulation on the agitation and sleep disturbance of dementia sufferers, thus
providing an empmcal basis on which both patient management and further research into this issue can be
planned
THE STUDY
Research questions
This study is designed to answer the following questions
1 Does the change from a task-onented care approach to
a client-oriented care approach affect the level of agitation in dementia sufferers'
2 Does the change from a task-onented care approach to
a chent-oriented care approach affect 24-hour sleep in
dementia sufferers'
Definitions of terms
Agitation An mappropnate verbal, vocal, or motor
activity that is not explained by needs or confusion per se
(Cohen-Mansfield & Billig 1986) In this study, agitation
IS divided into aggressive behaviours, non-aggressive
physical agitation, verbal agitation, and other agitated
behaviours
24-hour sleep Sleep across the three nursing shifts (early,
late and mght) estimated from difficulty m falling asleep,
frequency and duration of wake penods at mght, length
of uninterrupted sleep, early mommg awakenings,
drowsiness during the day, and day-time nappmg
Environmental manipulation A move away from taskonented care to client-centred care whereby patients are
allowed to decide, as far as possible, for themselves
METHOD
Design
The study used a longitudinal time design consistmg of
four phases, each covering a penod of 4 weeks Data were
collected at the end of each phase The four data collection
points will be referred to below as times 1 to 4 At times
1 and 2, baselme data on residents' levels of agitation and
sleep were collected, immediately after time 2, the
environmental mampulation commenced, and at times 3
and 4. data on residents' levels of agitation and sleep were
again collected
Setting
The study was conducted m a 44-bed dementia ward in a
120-bed metropolitan nursmg home m Perth, Westem
Australia Space m the ward was limited most residents
shared sleepmg accommodation and one multi-purpose
living area served as lounge, dimng-room and activities
area Nursing staff mcluded registered nurses, enrolled
nurses, nursmg assistants and, dunng times of staff shortage, tramed and untramed staff from nursing employment
agencies The ward was divided into two sections for
staffing purposes, with at least one registered nurse on
duty at all times On an early shift (07 00 to 15 30), four
nurses worked m each area On a late shift (13 00 to 21 30),
three nurses were assigned to cover both areas, with two
additional part-time nurses working from 17 00 to 21 00
Night shift (21 00 to 07 30) involved only two nurses to
cover the whole ward
Participants
Participants were included m the study only if they were
dementia sufferers and 65 years or over Of the 42 residents
in the ward, two were excluded because they did not meet
the age cntenon, one was discharged dunng the course of
the study and six died, leavmg 33 participants m the study
The sample consisted of 12 males and 21 females, whose
ages ranged from 67 to 98 years (mean=84 2, SD = 7 8
years) Their cogmtive status, as measured hy the hnef
cognitive rating scale (descnbed below) ranged from 3 5
to 6 8 (mean=6 1, SD = O 8) Four piuticipants took sleep
medication reguleirly and two took it occasionally
Instruments
Level of agitation was measured usmg the CohenMansfield agitation mventory (CMAI) (Cohen-Mansfield &
Billig 1986) This instrument lists 29 behaviours reported
by the literature and by nurses to be associated with agitation Each behaviour was rated on a 7-point scale (where
1 indicates that the behaviour is never observed and 7
mdicates that it is observed a few times an hour) Interrater rehability coefficients calculated by Cohen-Mansfield,
Marx & Rosenthal (1989) range from 0 88 to 0 92
Sleep was measured using a part of the dementia mood
assessment scale (DMAS) which was developed by
Sunderland et al (1988) specifically for dementia
sufferers The sleep scale of the DMAS consists of two
components day-time and mght-time sleep, each with a
7-pomt ratmg scale On the night-time scale, 0 mdicates
no disturbance of mght time sleep and 6 mdicates almost
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 439—447
441
EA Mitt/ieivsetal
mghtly disturbance On the day-time scale, 0 indicates
absence of daytime nappmg and 6 mdicates contmuous
drowsiness
Cognitive functioning was measured using a modified
version of the bnef cognitive rating scale (BCRS) (Reisberg
et al 1983), which consisted of four axes of cognitive functionmg concentration, recent memory, past memory and
onentation Each axis has a 7-point scale in which 1 indicates cognitive mtactness and 7 indicates severe cognitive
decline Cognitive status is the mean of the scores obtained
on the four axes Correlations between the BCRS axes and
other tools measuring cognitive status have been found to
range from 0 51 to 0 84 (Reisberg et al 1985) and lnterrater reliability coefficients have been found to range from
0 76 to 0 82 (Cohen-Mansfield et al 1990)
Environmental manipulation
Pnor to the commencement of the study and dunng its
first 8 weeks, nurses adopted a task-onented care
approach, m which they were expected to ensure that the
institution's schedules for meal times, toileting times,
ward activities and bed tunes were followed Accordingly,
whether reluctant or not, patients were required to be out
of bed by a certain time m the mormng, to be in bed by a
certain time at night, to take their meals at certain hours,
and to participate m ward activities programmes
Immediately after time 2, and for the remainder of the
study, nurses adopted a client-oriented care approach, m
which they were expected to ensure that residents' wishes,
whether expressed verbally or non-verbally (e g resistive
behaviour), were respected Accordingly, residents were
given the freedom of choice to rise from bed, go to bed,
and take their meals when they wished, and mvolvement
m ward activities was optional Meals were still served at
scheduled times, but set aside for those who were absent
In the case of severely demented residents, nurses helped
them out of bed if they were awake and co-operative, but
if they showed resistance, nurses let them settle and
returned later
Staff were mformed of the proposed change m approach
to client care 2 months before its introduction Meetings
of the director of nursing and staff were held to discuss
the changes, their possible outcomes and to encourage staff
to express their views about whether they wanted the
changes The director of nursmg reported that most staff
were enthusiastic about the changes, and those who were
not in favour of them were given the opportunity to transfer to other wards Several staff from other wards who
wished to work m the dementia ward took their place
To facilitate the change, joumal arbcles and books on
dementia were made available to nurses m the nursing
station A one-day workshop on dementia care mvolvmg
several speakers addressed issues such as use of appropnate communication techniques with dementia sufferers
442
and management of agitation and sleep disturbance Bnef
educational sessions on other aspects of dementia care
were also provided to all staff (lncludmg caterers and domestics) m the weeks precedmg the implementation of the
intervention
Data coUecbon
Ethical approval to conduct the study weis granted by the
Ethical Review Committee of Edith Cowan University and
by the director of nursing of the nursing home Signed
consent was also obtamed from the next of km of each
resident m the ward
Demographic information was collected from the case
history notes of residents by a registered nurse and verified
by the ward charge nurse The BCRS was administered to
all residents by a senior nurse familiar with the residents
on an early shift
The CMAI and DMAS were completed four times (at
times 1 to 4) Four nurses who were familiar with the residents (two from the early shift, one from the evening shift
and one from the late shift) completed these forms, giving
one score for early shift, one score for late shift and one
score for night shift for each patient at each time The
scores referred to the 2 weeks immediately precedmg the
completion of the forms (Two nurses, instead of one, were
required from the early shift because no one nurse from
this shift had contact with all the residents) The first
author explained the use of the instruments pnor to the
study and was aveulable for quenes dunng the course of
the study
RESULTS
Effects on agitation
Table 1 shows the percentages of residents exhibiting agitated behaviours at a frequency of at least once a week
(rating a score of 3 or more on the CMAI) at each Ume
Eleven agitated behaviours were exhibited by at least 20%
of all residents at all stages in the study In order of frequency, these were general restlessness, grabbing, constant requests for attention, negativism, cursing or verbal
aggression, repetitious sentences or questions, performing
repetitious mannensms, hitting, pushing, mappropnate
robing or disrobing, and making strange noises None of
the other agitated behaviours was common, and a few were
not observed at all at some times
Table 2 shows the mean scores for each scale on the
CMAI for each tune at each shift The scores at each time
were compared using one-way repeated measures analyses
of vanance Because of the large number of tests being
conducted on these data (12 ANOVAs), a conservative
alpha level of 0 01 was set
Table 2 shows that although neither aggressive behav-
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 439—447
Agitation and sleep m dementia sujforers
Table 1 Percentage of snhjonts
exhibiting agitated behaviours
at least once a week
Behaviour
Aggressive behaviours
Grabbing
Cursing or verbal aggression
Hitting
Pushing
Scratching
Spitting
Hurting self and others
Kicking
Biting
Tearing things
Non-aggressive physical agitation
General restlessness
Repetitious sentences/questions
Repetitious mannerisms
Inappropriate robing/disrobmg
Pacing
Trying to get to a different place
Handling things inappropriately
Verbal agitation
Constant requests for attention
Negativism
Making strange noises
Complaining
Screaming
Other agitated behaviours
Hiding things
Hoarding things
Throwing things
Physical sexual advances
Verbal sexual advances
Intentional falling
Eating inappropriate substances
Timel
Time 2
Time 3
Time 4
48 5
36 4
33 3
30 3
24 2
27 3
18 2
15 2
48 5
42 4
39-4
33 3
15 2
30 3
6 06
9 09
30 3
39 4
27 3
21 2
18 2
9 09
6 06
12 1
45 5
36 4
30 3
42 4
12 1
12 1
3 03
30
00
30
30
30
00
60
30
60 6
36 4
33 3
18 2
18 2
15 2
51 5
54 5
27 3
21 2
21 2
12 1
61
51 5
27 3
33 3
21 2
24 2
21 2
63 6
36 4
42 4
30 3
24 2
24 2
30
91
33 3
36 4
21 2
15 2
21 2
45 5
42 4
24 2
36 4
15 2
51 5
39 4
21 2
27 3
18 2
39 4
39 4
24 2
12 1
61
61
91
61
00
12 1
15 2
212
61
30
00
61
00
91
91
91
30
30
30
61
91
30
00
212
606
9 09
91
30
61
30
00
lours nor non-aggressive physical agitation altered signifi- therefore was not associated with the envuonmental
cantly dunng the course of the study, verbal agitation m manipulation
The significant difference m other agitated behaviours
the early and late shifts and other agitated behaviours m
the early shift did Post-hoc comparisons showed that, in m the early shift resulted from an increase between times
the early shift, there was significantly less verbal agitation 3 and 4 (F (1,32) = 7 96, P<0 01), although there was no
at tune 4 than at time 3 (F (1,32) = 11 03, P<0 01), although sigmficant difference between times 2 and 3 (F (1,32) =
there was no difference between time 2 and time 3 (F 124, P>0 01) The data m Table 1 suggest that this
(1,32) = 1 96, P> 0 01) In other words, although there was mcrease may have been due to a slight mcrease m hidmg,
not significantly less verbal agitation ui the early shift 2 to hoardmg and throwing things
4 weeks after the environmental mampulation than there
had been immediately before it, there was sigmficantly less
Effects on 24-hour sleep
verbal agitation 6 to 8 weeks after it The data m Table 1
suggest that the reduction m verbal agitation may have Table 3 shows the mean scores for day-time and mghtbeen due to less requests for attention, and less com- time sleep on the DMAS instrument Day-tune sleep
plaimng and screaming
covered early and late shifts and mght-time sleep covered
The significant difference m verbal agitabon m the late the night shift (21 00 to 07 30) The scores at each time
shift resulted from a difference between the two baselme were agam compared to determine whether there was a
measures, time 1 and time 2 (F (1,32) = 3 41, P<0 01) and significant difference between the foiu times using one© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 439-447
443
EA Matthews^d
TM/e 2 Comparison of levels of mean agitation levels on the
subscales at each tune in each shift
Timel
Time 2
Aggressive behaviours
Early shift
185
190
151
Late shift
1 30
Night shift
1 33
1 26
Non-aggressive physical agitation
Early shift
204
2 14
2 17
Late shift
2 21
1 55
Night shift
145
Verbal agitation
Early shift
2 02
2 40
Late shift
1 76
2 25
Night shift
1 41
1 29
Other agitated behaviours
107
Early shift
1 22
Late shift
1 12
1 17
Night shift
1 13
106
Time 3
Time 4
il3,96)
158
152
1 70
1 70
1 32
2 99
3 82
1 02
1 97
2 50
149
0 75
2 48
0 47
1 73
2 32
1 23
7 82*
5 10*
3 41
1 24
2 03
206
155
2 18
2 19
148
1 11
1 10
108
124
5 03*
1 26
1 08
304
160
*i'<0 01
Table 3 Comparison of day-time and mght-time sleep at each
time m each shift
Timel
Day-time sleep
2 91
Night-time sleep 1 45
Time 2
Time 3
Time 4
ft3,96)
2 97
121
3 82
1 70
2 97
1 39
4 75*
1 90
*P<0 01
way repeated measures analyses of vanance, witb an
alpha level of 0 01
As shown in Table 3, night-time sleep did not change
significantly, whereas day-time sleep increased significantly between times 2 and 3 (F(l,32) = 8 62,P<0 01), but
decreased significantly between times 3 and 4 (F (1,32) =
10 52, P < 0 01) to return to the baselme level by time 4
DISCUSSION
Agitation
The study supports the findmgs of earlier researchers that
agitation is common among dementia sufferers (CohenMansfield 1986,1988, Cohen-Mansfield, Marx & Rosenthal
1989, 1990, Ryden 1986, Jackson et al 1989, Deutsch &
Rovner 1991) There were 11 agitated behaviours common
to at least 20% of participants throughout all stages of the
study penod Restlessness was the most common agitated
behaviour ohserved
The results suggest that following the environmental
manipulation, residents' verbal agitation was significantly
decreased on the early shift, where it had previously been
444
highest, but mcreased sigmficantly on the late shift after
the first 4 weeks of data collection, and this mcrease
remamed high at the end of data collection Other agitated
behaviours mcreased significantly on the early shift following the introduction of the envuonmental mampulation No other significant effects were found in any of
the other categones of agitated behaviours at any of the
shifts
Nurses on the early shift reported that allowmg choice
fostered co-operation from theu patients, minimized confrontational situations, and made them more relaxed and
tolerant of agitated behaviours, all of which may have contnbuted to a reduction in patients' verbal agitation
However, the same effects were not achieved on the evemng shift Evemng staff reported that the lower staff patient ratio did not permit them to implement fully the
intervention They complained that because patients were
allowed to sleep m (pnor to the intervention all patients
were out of bed before 08 00 every morning), some of the
activities of daily living formerly conducted on the early
shift were deferred to the late shift, thus resultmg in
increased interpersonal interaction and m consequence a
nse in agitation level In addition, sleeping m may have
contributed to patients being more alert and active on the
late shift
The first author observed that staff on the late shift were
less fiexible than those on the early shift — patients continued to be given their evening meals at set times, and
almost all were in bed by the commencement of the night
shift at 21 00 Also, the late shift suffered from a lack of
contmuity of staff Agency nurses were more frequently
employed on this shift, and these nurses were not always
familiar with the intervention — thus these staff maintained a broadly similar routine as prior to the
intervention
These observations highlight the importance of monitoring the implementation of such an envuonmental manipulation It IS essential for the success of such an mtervention
that all staff, including casual staff, understand the pnnciples involved and are willing to co-operate Moreover,
problems that anse in the implementation of such an mtervention — such as an increase in workload without a conconutant increase m staff patient ratio — need to be
addressed
Although other agitated behaviours were significantly
worse followmg the mtervention, less than 10% of residents mamfested these behaviours It may have been that
greater tolerance on the part of staff may have encouraged
these behaviours Possibly the intervention could be
adjusted, for the few residents who mcrease such behaviours, hy the introduction of behavioural modification
strategies
The lack of any significant change for the other two
categones of agitation (aggression and physically nonaggressive behaviours) may suggest either that the
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 439-447
Agitation and sleep m dementia sufferers
evaluation penod may have been too short or that these
behaviours are not amenable to change when residents are
severely demented It is notable that among the agitated
behaviours, only verbal agitation was reduced It might be
expected either that all agitated behaviours would have
been reduced (if the mtervention made residents more
relaxed) or that none would have been affected (if the intervention did not) One possible explanation for verbal agitation along bemg affected may be that the reasons for
verbal agitation may be easier to identify than the reasons
for non-verbal agitation Therefore, if nurses were
attemptmg to accommodate residents' wishes more after
the mtervention commenced, then they may have been
more successful in domg so when residents expressed
such wishes verhally However, m those cases where residents expressed non-verbal agitabon, it may have been
more difficult for nurses to identify the cause of the
agitation and thus satisfy the residents' needs
One of the challenges to nurses implementing a more
client-centred approach with sufferers of severe dementia
IS, of course, the difficulty m ascertammg theu wishes
The success of such an approach will naturally be dependent upon the extent to which nurses are able to read accurately residents' wishes, whether they are expressed
verbally or non-verbally This ability may develop with
practice, and therefore a lengthier study of this kind may
reveal further changes in agitation levels of patients
Sleep
Residents' day-tune sleep increased sigmficantly m the 4
weeks followmg the intervention and returned to premtervention levels by the end of the study (8 weeks later)
Residents' night-time sleep was not significantly affected
The change in residents' day-time sleep is not surprising, considenng that, pnor to the mtervention, nurses routinely got the patients out of bed m tune for breakfast at
08 00 Furthermore, as a rule, day-time nappmg was discouraged Following the intervention, patients were
allowed to set theu own schedule, that is, wake spontaneously in the mommgs, perhaps have a day-time nap,
and retue to hed when sleepy The return to preintervention day-time sleep levels suggests several possible explanations Fust, it might be that as time went on,
the patients were given less choice over theu sleep routines Observations suggest that, at least on the early shift,
staff did not revert to pre-mtervention routines, whereas
on the late shift the intervention was less m evidence
Secondly, it is possible that the mtervention was not strong
enough to alter patients' sleep routmes Exeunination of
sleep results over a 24-hour penod mdicates that the
amount that participants slept mcreased following the
mtervention and then reverted back to pre-mtervention
levels Alternatively, the change m sleep patterns may
merely reflect a penod of adjustment, which disappeared
once residents had become more accustomed to their new
routmes
CONCLUSION
Task-centred care places considerable demands on residents to adapt to their environment and, m particular, the
institutional routine The present study was designed to
determme whether residents' well-being could be promoted by facilitating person-environment fit with a more
client-centred approach to care Following the change from
a task-onented to a client-centred care module, subjects
showed significantly less verbal agitation on the early shift
Although a sigmficant mcrease occurred among behaviours descnbed as other agitated behaviours, only a small
percentage of participants m this study and in previous
studies (Cohen-Mansfield, Marx & Rosenthal 1989) exhibited these behaviours Finally, from a management perspective, allowing flexibility with institutional time
schedules may be of benefit to staff, and therefore
mduectly to residents, because nurses were less stressed
and were able to provide improved care to theu residents
However, to maximize these benefits, management need
to mamtam a good staff client ratio, particularly on the
late shift
The findings of the study need to be treated cautiously
because of several limitations, mcludmg the relatively
short observation penod, the limited sample size and the
lack of a control group As discussed earlier, the intervention on the late shift was not as complete as would
have been ideal due to inadequate staffing, and this may
have moderated the effect of the intervention
Furthermore, it is possible that the changed nursing
mtervention did not constitute a major impact on residents' agitation and sleep behaviours because the situation
m which It was introduced outweighed its potentisd therapeutic effects The cramped livmg environment of the
nursing home meant that the residents' recreational area
served as both dining room and lounge This, combined
with the wide age range and cogmtive abilities of residents,
meant that attempts at fostenng a therapeutic milieu were
handicapped For mstance, it was not always possible to
ensure residents could have a day-time nap due to interference from other residents Therefore, future studies
should ensure that the living environment affords
residents the maximum opportunity to enable them to
capitalize on any options offered by staff
Further research
Verbal s t a t i o n was the mam aspect of agitation that
showed any improvement m this study even though it
tends to be more pronounced m early dementia (CohenMansfield et al 1990) than m severe dementia, such as
that from which the participants in the present study
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursmg, 24, 439-447
445
EA Matthewse^ai
suffered Therefore, an environmental manipulation, such
as the one m this study, may be more successful with
cogmtively more intact dementia sufferers
Furthermore, the present study focused on the effects of
this environmental mampulation on residents, however,
anecdotal observations of staff suggested that the removal
of a ngid timetable made them feel less rushed and more
tolerant of residents' behaviours A further study systematically examining the effects of this type of manipulation
not only on residents hut also on staff may determme
whether such changes occur reliahly
Fmally, it was not possible in the present study to use
a control group Residents acted as theu own controls over
time m a time senes design It would be difficult, both
from a practical and an ethical point of view, to conduct
a study of this kind with an adequate control group, even
though such a study would provide a firmer basis for conclusions regardmg the effects of client-centred care on
agitation behaviours
Acknowledgements
The authors would like to thank Dr Patricia Percival, Edith
Cowan Umversity, for her guidance and support m the
preparation of the thesis upon which the paper is based,
the duector of nursing and nursing staff of the nursmg
home where the study was conducted for theu enthusiasm
and co-operation, and staff of Selby/Lemnos Hospital for
theu feedback and encouragement
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