La respuesta general al estrés (“stringent response”): regulación de la

There has been a tendency for research evaluating nursing home environments to use a multiplicity of assessments in a scattergun approach to see what will emerge. This is partly due to the fledgling state and complexity of nursing home research. A scattergun approach means that

the research lacks a clear focus. In addition, a highly complicated analysis may not produce outcomes that are meaningful and of practical value. In short, a scattered research approach can be superficial and lacking in depth. In the case below (Zeisel, et al., 2003), the research was undertaken using a scattergun approach. Furthermore, the physical assessment was undertaken

in one single walk through visit.

A multivariate analysis of 427 residents with dementia in 15 SCU’s (Zeisel et al., 2003) reported a correlation between design features and behaviour. The researchers identified

different features of the SCU physical environments (privacy, personalization in bedrooms, residential character, and an environment that residents can understand) and equated these with an increase or decrease in problem behaviours. Their Environment-Behavior Factors Model check list (E-B checklist) was developed, using the Delphi technique, by experts in the field

hypothesizing on the environmental factors which were most important in dementia care. These were then amended until agreement was reached by the expert panel.

The definitions of an SCU were not very distinctive. To qualify as an SCU the units had to:

 function as a self-contained unit

 be a physically distinct part of a nursing home complex

 have staff dedicated to work on the unit

 be secure

 include only those residents who have a dementia.

There were two investigators who evaluated the same 30 premises independently. Pictures were taken in case of discrepancy between the two raters in order to assist resolution. If opinions of the environment still varied a third professional was engaged to help reach a common resolution. And, finally, the five point rating was collapsed into a less challenging three point

rating scale: excellent, moderate, poor. The research outcomes were not conclusive, so the researchers used only the 15 most variable SCU’s in their analyses in order to increase any potential differences in outcomes. Below are some of the ranges of physical environment components covered by their E-B checklist:

 camouflaged doors and exits

 immediately locking doors, long sight lines and straight corridors

 orienting devices along the corridors

 single person bedrooms and toilets

 doors to outdoor space

 appropriate security fencing to prevent exiting

 7-15 residents

 homelike character, which includes non-uniformed staff and domestic style furniture and fittings

 ease of staff surveillance

 prosthetic supports such as grab rails for toilet and shower, banister rails in hallways

 moderate levels of background noise

 sensory input that is meaningful, including kitchen smells and sounds of activities.

In the Zeisel et al. (2003) study, problem behaviours were assessed from the medical records and the professional judgement of a nurse who was familiar with each resident. No actual

observations were made by the investigators. The three established scales used were:

1. the Cohen-Mansfield Agitation Inventory (CMAI)(Cohen-Mansfield, Marx, & Rosentha,

1989), which rates aggressive, physically agitated and verbally agitated behaviour such as hitting out, wandering, restlessness, complaining or noncompliance, making repetitive vocalizing sounds retrospectively over the previous fortnight

2. the Multidimensional Observation Scale for Elderly Subjects (MOSES)(Helmes, Csapo,

& Short, 1987) which is a nurse respondent’s opinion of the resident’s affect or verbal communication that would indicate sadness, being in good spirits, being socially withdrawn, or being self-occupied

3. BEHAVE-AD Psychotic Symptom List (Reisberg, et al., 1987) which is the nurse respondent’s opinion of the frequency of paranoid delusions, such as being stolen from or being harmed and their opinion of the resident’s frequency of

misidentification syndromes (e.g. seeing someone else in the mirror, rather than one’s own face)

Aspects of this study (Zeisel et al., 2003) exemplify architectural determinism (Keen, 1989). The authors sought to correlate the physical environment, as surveyed on a single walk-through

visit, with the agitation, aggression and mood of residents, as identified retrospectively by nursing staff.

A once off survey gives very limited information. As an example, having a door to the outdoors was scored as a positive feature in the E-B Checklist. However, a once off walk-through

visit cannot indicate if and how often residents have access to the garden, if it is used for calming residents, or, if it is ever used for outdoor activities to create a more stimulating day. Such pragmatic real-life operational policies cannot be observed in a one-off walk through visit.

Architectural determinism leaves little room for rival explanations for the outcome measures. In contrast, Cohen-Mansfield and colleagues (2010a) were able to verify, through direct observation, that different types of stimulation (music, social stimuli, and individualized stimuli)

directly (proximally) affects agitation. They hypothesized that physical agitation is the result of boredom, which is relieved by stimulation, whilst verbal agitation arises from loneliness and pain (Cohen-Mansfield et al., 2010a). In other words, it is not the physical environment itself, but the boredom, low levels of physical activity and psychic distress in nursing home environments which create aggression and agitation for residents with dementia (Scherder, Bogen, Eggermont,

Hamers, & Swaab, 2010), so agitation is only distally related to any specific physical environment component.

The Zeisel et al. (2003) study obtained some noteworthy findings. Contrary to their expectations, they found that social withdrawal was more prevalent in the smaller units. The

study also found that higher staffing levels were associated with lower verbal aggression scores. Reduced aggressiveness, reduced agitation and fewer psychological problems were correlated with (a) privacy and personalization in the bedrooms, (b) having a residential character, and, (c) having an environment which was easier for residents to understand. This research has the same problems as identified earlier, that of outcome measures which are only distally related to the environmental changes, allowing only a tenuous associative link. It did not take into account

other intervening variables, such as boredom and absence of activity, which may be influencing any results recorded. In addition, direct observations were not performed, but the researchers relied on the memory of the experiences of nursing staff about each resident, which is a potential source of subjective error.

Trying to understand residential environments has been challenging because of the

complexity of defining environmental variables. The Zeisel et al. (2003) study helps to move the research debate forward in that the authors recommend the need for establishing greater rigour, with greater specificity of interventions and outcome measures. They recognize the contribution of both behavioural and environmental approaches to improve quality of life. However their results give only a scattered and superficial understanding of the environmental factors as they influence residents with dementia, because the research tries to marry environmental variables

with distal global behavioural outcome measures, which may, or may not, be directly influenced by the environmental interventions they are seeking to investigate.