Evid Based Nurs 16:124-125 doi:10.1136/eb-2012-101203
  • Care of older people
  • Cross-sectional design

Exposure to challenging behaviour from nursing home residents is associated with reduced general health and work ability, and increased burnout reported by nurses

  1. Ulf Isaksson
  1. Department of Nursing, Umeå University, Umeå, Sweden
  1. Correspondence to : Ulf Isaksson
    Department of Nursing, Umeå University, The Caring Sciences Building, Umeå SE-90187, Sweden; ulf.isaksson{at}

Commentary on: [CrossRef][Medline] Search Google Scholar

Implications for practice and research

  • The study highlights the impact of challenging behaviour on nursing staff.

  • It is important that the problems associated with challenging behaviour are attended to and that staff are supported in their work.

  • Future studies should examine if other aspects, such as coping resources, could be a protective factor for nursing distress.


An increasing proportion of people with dementia has and will continue to be admitted to nursing homes or similar accommodations such as special care units. One of the reasons for being admitted to such institutions is challenging, behavioural or psychological symptoms in dementia. Several studies have shown that challenging behaviour is highly prevalent1–3 and perceived by staff and stakeholders as unpleasant, disturbing or frightening, and causing severe distress.4 The purpose of the present study was to investigate nurse distress in relation to challenging behaviour among residents in German nursing homes.


The study used a cross-sectional design and was based on data from 731 nursing staff working in 56 nursing homes throughout Germany. Data consisted of background data and four instruments. One instrument (Residents’ Challenging Behaviour-related Distress Index) was designed for the present study, based on an earlier, well-used and validated instrument (the Neuropsychiatric Inventory (NPI)). The other instruments that were used assessed general health, burnout and work ability among nursing staff.


The study found that 75% of the sample assessed distress stemming from residents’ challenging behaviour as moderate to high. The behaviours causing most distress were aggressiveness and depressive behaviours. The behaviour causing least distress was contact with euphoric residents, which did not stress 53% of staff at all.

An interesting result was that only 1% of the variability of the Residents’ Challenging Behaviour-related Distress Index was explained by sociodemographic and occupational characteristics; although, older nurses were identified as a group that is especially at risk.

Staff that assessed highest on behaviour-related distress were also found to report highest on burnout, lowest on general health, and, finally, scored lowest on work ability.


This is an interesting study that examines the effect of challenging behaviour among residents on the nursing staff. A majority of staff are, in one way or another, affected by these behaviours and this have an effect on their ability to work. This study, as well as others,5 ,6 has found that staff who have to manage challenging behaviour, such as violence, rate high on burnout. It is important that this is recognised by the management and supervisors so that staff receive proper support in their work with people with challenging behaviour. This may help to reduce staff sick-leave and turn-over.

The low association between sociodemographic or occupational characteristics in the staff and distress is in contrast with other studies7—these found that age and education alleviate distress among nursing staff. However, this points to the fact that further studies in the area are needed.

The study design raises a question: Why did Schmidt and colleagues develop this new instrument since it is, to this commentator's knowledge, identical to the NPI, with the exception of one item: limited communication ability of residents? This should not be considered to be a challenging behaviour. This item also provoked stress in the staff. It may be the case that the distress the staff experience is actually their own incapacity to communicate with the resident—the distress is not owing to resident factors, but caregiver factors. This makes the new instrument somewhat questionable.

More evidence in this area is needed. Can different coping resources or personality traits among the staff protect them from distress? What interventions could alleviate challenging behaviour among persons living in nursing homes?


  • Competing interests None.


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