How an elderly person with mental illness effect the quaility of care they receive - Essay Example

? Lynette Harvey Research Proposal Introduction There are an enormous number of elderly people with mental illness that have difficulty receiving good care while living in a nursing home. Many elderly people have physical disabilities associated with aging but one of the most debilitating conditions is mental illness. Mental illness is one of the most alarming problems in institutions as well as in communities today. An elderly person with a mental illness poses challenges to caregivers making it difficult to provide them good care, including interfering with the caregiver’s ability to assist with grooming, meal preparation, and proper medical care. These caregivers are nurses and certified nursing assistants (CNA) who providing primary caregiving roles in nursing homes. Many feminist theorists view the work of nursing and certified nursing assistance as care work and low wage and low skill jobs, with very little value due to male dominance institute structured base on gender and minorities. Elderly people with a diagnosis of mental illness such as bi polar, schizophrenia, and anxiety often have behaviors that are stressful and a burden to caregivers. Many of the behaviors associated with mental illness are physical and verbal aggression that included hitting, biting, yelling, and screaming. These behaviors pose stress on caregivers many times putting the elderly at risk for abuse. The stress of caring for an elderly person with mental illness can be overwhelming for caregivers in nursing homes , agree that caring for a mentally ill person with behaviors can be challenging, “gerontological nurses find that physical or verbal attacks by an elderly person they are giving nursing care for is one of the most difficult, emotionally distressing, and potentially dangerous aspect of their work, often resulting in feelings of powerlessness, sadness, anger, and ineffectiveness.” Caregivers that face daily challenges with behaviors tend to be physically and mentally stressed. The day to day effort to meet the demands of the elderly person becomes so emotionally stressful that often caregivers may resort to using physical force, neglect or become verbally aggressive towards the care receiver. The primary objective of this study is to identify the behaviors associated with an elderly person who has a mental illness and how these affect the quality of care they receive. The second objective is to examine how the same behaviors interfere with caregiver’s ability to assist with daily living activities (ADL’s), which is related to stress leaving the elder person poorly groomed, malnourished, and many times without proper medical care. Originating Questions There are many studies that focus on the burdens and stress of being a caregiver for an elderly person who is physically and cognitively impaired. Mental illness is often associated with difficult behaviors and has an impact on the type of care an elderly person may receive. Many studies have found that these burdens contribute to the way in which a caregiver perceives the role of caring for a physical and cognitive impaired person. However, this is an area that still needs further research. Another contributing factor is that those who provide care to the mentally ill elderly person are low skilled workers that lack support from higher up management. This can significantly increase the risk of stress for caregivers. The amount of time and physical assistance that is needed to care for an elderly person is a predictor of stress, the greater the need the greater the stress. These factors mean that there are a number of different potential causes for stress for caregivers of elderly patients, and that these stress factors increase when the patient is suffering from a mental illness. There are many studies which examine mental illness in elderly patients, and the general consensus is that the behaviors attributed to mental illness in the patient are a major factor contributing to burdens and stress of caregivers. The literature does not focus on the mechanism by which this occurs. The research question for this study is how does an elderly person with mental illness impact their quality of care they receive? This question is based on studies that have been reviewed on mental illnesses such as bi polar, schizophrenia and anxiety, as well as the impact this has on nursing home caregivers. One area that is not addressed in current literature is the quality of care that some elderly do not receive as a consequence of these behaviors. The research problem of interest is mental illness which a serious problem in the elderly population and many elderly people go without proper care due to the behaviors associated with their mental illness. Rationale Mental illness is a serious problem that affects the elderly and their caregivers. An elderly person with mental illness may exhibit signs and symptoms of hallucination or delusion which can cause behaviors of combativeness or verbal aggression during care. The purpose of this study is to examine the relationship between elderly people with mental illness and the impact associated behaviors have on the quality of care they receive. Researching this problem can help with education and intervention programs to improve the relationship between caregivers and the mentally ill elderly with behaviors that live in long term care institutes. This study gives opportunity to theoretically view the problem of mental illness in the elderly, and the difficult work that is involved in caring for them, which is often unnoticed and unappreciated. This study will be a great contribution to community organizations such as Citizens for Better Care that work with the aging population. Such organizations will be able to benefit from the study's findings and potentially use these to raise public awareness. Nursing home institutions can benefit from the study’s findings to educate employees, address stress levels in the work force and to cope with the behaviors will alleviate some of the stress and their approach to giving care. Finally, the study will help with elderly abuse prevention and interventions. Literature Review Caregiver’s stress and Burdens Caring for an elderly person can be so overwhelming putting stress on a caregiver’s health and mental state. Nursing home caregiver's are often paid low wages and have low job satisfaction , and yet these are the individuals that care for the most vulnerable. The responsibility of caring for the family has historically been designated to women, and despite feminist and woman’s rights movements, women still dominate in caring professions in nursing homes. This comes as a consequence of the maternal nature and the tendency to help and care that is present in females and is generally absent in males . Under Marxist feminist theory nursing home work is categorized as reproductive labor “maintaining people both on a daily basis and intergenerationally”, and is stressful for the carer . Marxism considers that families are a structure that is subject to change much like any other type of structure, and as a consequence, the role of women does not need to remain static, but rather can grow and change with the times .This is true whether the role is at the home or at the workplace.This theory suggests that, “reproductive labor is the center of women's oppression”, particularly due to the uneven way that this type of labor is structured across the genders. Women should not be forced into the lowest, most demeaning forms of work because there is no one else that wants to do them. The theory considers historical issues of care work and the institutional structure that has radically contributed to those working as nurses and nursing aids. Glenn refers to these professions as “dirty work” and points out that “care work and dirty work” is racially and gender driven division of labor in nursing home institutions. “Women of color are disproportionately assigned to do the dirty work, as nurse's aides in hospitals, kitchen workers in restaurants and cafeterias, maids in hotels, and cleaners in office buildings” . Another feminist perspective approach to care work or caring labor is the hypothesizing of “wage penalty”. According to the authors those occupations such as nurse's aides that are stressful because they are dealing with what is considered the “dirty work”, providing care to a elderly person with a mental illness and problematic behaviors has always paid less because it is associated with care being symbolically associated with women and mothering. The responsibility of caring for an elderly family member with mental illness will need future research because it brings such stress, causing the care receiver’s family member to place them back into institutions, . Yet this is the same stress nursing home workers are faced with daily. There are many studies that show caregiver’s stress is a problem and will remain a problem in the future. According to many gerontology studies, as the population ages and the baby boomers have reached aging numbers the need of formal care from nursing homes will be in great need. In the study of Mittelman, , the New York University Intervention conducted several studies which showed more than sixty percent of older persons living in the community and in need of long term care depend on caregivers. The authors estimate that more than five million people provide care for an elderly person in the United States. The percentage of elderly persons living in the community will continue to increase as the population ages. Reinhard et al. , examined and captured the attitudes of stress of caregivers to those with mental illness through two studies which were conducted using the Burden Assessment Scale to assess families. “These were families who family members were discharged from an institution and return to live with their families”. The study was of two groups the “Club” an aftercare program and the other group of participants in a new initiative, the New Jersey’s Division of Mental Health and Hospitals (DMH&N). The Club collected data by interviewing participants and the DMH&H collected data by providing a self-administered survey to participants (p.261). The Burden Assessment Scale (BAS) developed by Reinhard and Horwitz, measured objective and subjective consequences of proving care to the severely mentally ill. Objective meaning actual concrete problems associate with stress and, subjective meaning feelings that are associated with stress were measured by a series of experience of the caregiver. The result of the studies gave clear evidence that factors that measured stress and burden of those who provide care to a mentally ill elderly person the findings in the studies were consistent. The stress of those who were caring for those relatives with the diagnoses of having schizophrenia was 54% of the DMH&H group and 73% of the Club group. When comparing to stress factors associated with behaviors the findings were the DMH&H group outcomes were that 40% of the participants showed disrupted activities, for the Club group 37.2% showed disruption in activities. The DMH&H showed 8.1% of participants showing personal distresses, embarrassed by disruptive behaviors and feeling trapped and resentful, while The Club found 9.7 % for the same factors. According to Bartels, Mueser and Miles 12 percent of elderly people living in the community are diagnosed with one or more psychiatric disorder, such as schizoaffective disorder, bi-polar disorder, and major depression. The authors conducted a study that examining elderly people with mental illness functional impairments such as social skills, behavior problems, self-care, and community living skills. The study focused on the psychosocial treatment that the mentally ill received and the functional impairment associated with mental illness. The authors gathered their data from four sources of studies; longitudinal, cross-section descriptive, late vs. early onset Schizophrenia studies. The study suggests that the elderly people receiving mental health treatment in the study continue to experience ongoing symptoms, blunted affect, poverty of speech, are socially withdrawn and suffer from cognitive impairment. The late vs. early onset Schizophrenia studies have found that those who were diagnosed with late onset schizophrenia appeared to have the same symptoms of early onset, which were delusion and paranoid. In addition patients with late onset schizophrenia have formal thought disorder, negative symptoms, or inappropriate effect. The study used an assessment instrument used by primary clinician, the Brief Psychiatric Rating Scale, which measured the patient’s “ affect(depression, anxiety, suicidal, guilt, hostility), anergia (emotional withdrawal, blunted affect), through disorder (unusual thought content, hallucinations, suspiciousness, grandiosity), activation ( motor hyperactivity, tension, excitement), and disorganization ( distractibility, conceptual disorganization)” . Another measuring instrument used in the study was the Specific Level of Function Scale (SLOF). This scale was used to measure living skill and behaviors problems the survey was a five point Likert type scale consisting of 43 items to rate functional and behavioral areas. The behavioral problems were verbal or physically aggressive behaviors, self-injury, property destruction, repetitive behaviors and self-care deficits were personal hygiene. According to the results of the assessments in the study it showed that persons with schizophrenia had more severe anergia, thought disorder, server disorganization, and severe cognitive impairment then the other groups. Those with the diagnosis of schizophrenia show problems with behavior to be rated more severe on verbal abusiveness, and repetitive behaviors than any other group. The author states in his conclusion that, “despite of treatment persons with mental illness will remain disable in their late years. Future studies will be needed to provide the community with appropriate support and intervention for the caregivers” . Behaviors and Care Behaviors associated with mental illness are associated with the increase of stress level for caregivers. In 2001a study by Nagatomo et al., examined the relationship between behavioral factors, including: abnormal behaviors, depression, impairments in cognition, activities of daily living (ADL) and the stress level of 28 employees at a special nursing home. The study included 99 elderly people. The Cornell scale for depression in dementia patients, the dementia behavior disturbance scale and rating of performance of ADL were used to assess behavior and psychiatric symptoms in elderly patients. The stress level of caregivers is measured using the burnout scale.. The results showed abnormal behaviors such as aggressiveness is associated with cognitive impairment and there is a relationship between abnormal behaviors and efforts to provide assistance with ADL. The burnout scale showed that the higher the scores the less satisfactions and greater stress on the job and nursing home staff scores show to be higher than home helpers. Like many other studies that have been done on caregiver’s stress “abnormal behavior among the elderly and demented patients, such as aggressiveness, combativeness and wandering, interferes with provision of care, and lowers the morale of the care staff and relative caregivers” have stated that abnormal behaviors including aggressiveness are associated with mental illness . Other studies have also shown that behaviors that are associated with mental illness are a factor for stress in nursing homes and community caregivers inability to provide quality care. Nikolova et al. used a risk behavioral tool to assess patients that had behaviors relating to their care and mental state. The psychogeriatric and risk behavior assessment scale (PARBAS) is a scale used by practitioner to get information to assist with interventions planning. The PARBAS included 34 items organized in ten sections of risk behaviors. The model was used to measured the frequency of behaviors on a five point scale, meaning behaviors not present to behaviors always present, and the consequences of the behaviors were also ranged from 0 (no consequence) to 2 (severe consequences). As a result the study was more interested on aggressive behaviors that pose harm to the elderly person with mental illness and the harm to others. These behaviors are also described as the main reason that nursing home and caregivers are unable to provide care due to the aggression towards them being a stressful factors contributing to their work. Zeller et al. , conducted a study using relevant publications of quantitative and qualitative studies taking from the search from Medline, CINAHL, PsychINFO. These publications provided evidence stating that aggressive behaviors are both verbal and physical and occur most frequently during personal care. Aggressive behaviors are more than likely to occur among older people with cognitive impairment than among those with no cognitive impairment. The study also revealed that nurses and caregivers find physical and verbal attacks by an elderly person they are giving nursing care to the most difficult, emotionally distressing and potentially dangerous aspect of their work, often resulting in feelings of powerlessness, sadness, anger, and ineffectiveness. An elderly person with behaviors associated with mental illness often has a negative relationship with the caregiver which impacts the quality of care they receive. The 1988 study conducted by Sheehan and Nuttall, suggests that there are certain types of behavior of elderly people with mental illness have that are more stressful than others. Behaviors that are disruptive and impair social functioning are difficult for caregivers because they are not seen as the direct link to the illness of the older person . As the study examined the feelings and conflict of providing care to a mentally impaired older adult, it used a self administered questionnaire that measured levels of functional impairment (ADL) and memory and behavior problems. The ADL were bathing, dressing, toileting, grooming, shopping, laundry etc. The measure of memory and behaviors were the frequency forgetting, wandering, hiding things, waking up at night, and inability to communicate thoughts and feelings. The findings suggest that the caregiver’s feelings of the role as a caregiver were emotions of frustration, impatience, depression, helplessness, resentfulness, isolation, emotional exhaustion, nervousness, anger and feelings of incompetence. According to the study these feelings were greater when the functional impairment was greater also when the behaviors were greater. Another study done by Dilwork-Anderson, Williams, and Cooper also have provided data that measure the caregivers inability to provide care and ongoing behaviors during the care giving process, the scale asked questions like, “I am uncertain about what to do with (CARE RECIPIENT).” The results show that behaviors were greatly associated and impact the quality of care that caregivers were able to provide, behaviors and care received is significantly associated. The task becomes greater for caregivers if the behaviors are ongoing or become increasingly aggressive. Caregivers find themselves at a point that caring for an elderly person with impaired functional abilities as well as behavioral problems disrupts the entire home as they attempt to give care. A study conducted by Pinkston, Linsk and Young interviewed caregivers who were caring for an psychologically and physically impaired elderly person. During the study participants felt that their loved one had poor personal care, aggressive behavior, and social withdrawal. The study suggested that there is a great need for implementing interventions to caregivers who are stressed and burdened with the role of caring for their physically and mentally impaired elderly family member. The study provided positive reinforcement interventions that would help families cope and handle the behaviors of their love ones in a different manner. The findings suggest that behaviors often occur during care when the care receivers become aggressive and refuses to be cared for. The purpose of the study is to help families to rethink and react different towards the behaviors, the outcomes suggest that behaviors of the impaired did change and the perceptions of the caregiver was different but it still remains that more research and studies are needed to address this problem. Aggressive behaviors are a challenge for caregivers of both residential and institutions such as nursing homes facilities. Beck, Rossby and Baldwin examined studies that explain disruptive behaviors to be correlated with cognitive status, and functional ability. The authors agree with previous studies that there is a relationship with mental illness and the impact it has on the quality of care received. The author’s review of studies have linked disruptive behaviors with cognitive impairment such as dementia, Alzheimer’s and mental illness and functional dependency, which is ADL care that is provided by nursing home staff daily. In the studies it was found that, “what is consider to be serious disruptive behavior problems included aggressiveness, is correlated to physical resistance to care, These types of behavior endangered others or self, which is disturbing others and a great concern to caregivers.” Conclusion Elderly people with a diagnosis of mental illness and exhibits behaviors that are associated with mental illness are stressful and put a burden on caregivers in the community and in the institutions such as nursing homes. According to Beck, Rossby and Baldwin and many other studies behaviors categorized as disruptive, aggressive or agitating is often compounded by coexisting cognitive impairment. These behaviors exist as caregivers attempt to provide care. It is difficult for caregivers to assist with activities of daily living such as bathing, showering, personal care, meal preparation and medical attention when the elderly person’s behaviors are challenging. This is a problem that needs future research and development of interventions to implement in the nursing home and community. “Management of residents exhibiting aggressive and disruptive behaviors is an escalating problem as the elderly population continues to grow” . The studies in the literature review have stated evidence that support the theory elderly people with mental illness impact the quality of care they receive. It is clear in the studies that caregivers are burdened and stressed during care which is due to the aggressive behaviors associated with mental illness. The studies have suggested that future studies should be conducted to continue to help professional as well as other community programs continue with interventions and preventions of possible stress that can lead to negative consequence. Hypothesis The first hypothesis is caregivers caring for a mentally ill elderly person will have greater stress and difficulty providing good care to them. Caregivers have a challenge providing care to an elderly person with mental illness because of the behaviors that are associated with mental illness. Mental illness alters the perceptions, moods and behaviors of an elderly person. Their behaviors may be aggressive, delusional and thoughts that may bring harm or other threatening acts towards themselves or the caregiver. The second hypothesis is an elderly person with a diagnosis of mental illness will more than likely have aggressive behaviors towards caregivers during care. Often the behaviors that are associated with mental illnesses such as bi polar, schizophrenia, personality disorder and anxiety are kicking, hitting, yelling out, and refusing care. The aggressive behaviors impact the caregiver’s ability to provide good care and increase the stress to the role of being a caregiver. Research Plan The research study will focus on a skilled nursing home that provides skilled nursing and rehabilitation services. The participants selected for the study will come from two sampling groups, the family members who are the primary caregiver to an elderly person with the diagnosis of mental illness and have received therapy in the nursing home and discharged home back into the community. The other participants will come from the direct working staff, the nurse's aides in the nursing who provided residents who have exhibited behaviors of physical and verbal aggression towards staff while in the nursing home. The data collection technique will be a survey. The participants will be interviewed by phone. The survey will address each of the hypotheses with questions that are constructed based on the independent variable mental illness and behaviors and dependent variable quality of care. The survey will consist of a questionnaire of thirty questions that are likert scale and the thurstone scale. The questionnaire will measure the attitudes and beliefs of caregivers and the stress dealing with behaviors that impact the quality of care. Measurement Conceptualization In this study the independent variable mental illness. Mental illness is defined as “a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, it is characterized by a disintegration of the process of thinking and of emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusional thinking, this includes the diagnoses of bi-polar, Schizophrenia, personality disorder and, anxiety.” (Diagnostic and Statistical Manual of Mental disorders (DSM) 1994). The variables are discrete because they "have a relatively fixed set of separate values or variable attributes." (Neuman p.199.). The dependent variable is quality of care. Quality of care is defined as the standards in which services is provided to a person receiving assistance with showers or bathing, personal care, proper nutrition, medication and medical assistance, these are activities of daily living (ADL). The variable dimensions are quality of care, the indicators are frequency or completion of assisting with showers, bathing, personal care such as brushing teeth, comb or cutting hair, shaving, meal preparation and, being complaint with medications and medical appointments. The independent and dependent variables level of measurement is a nominal level. Measurement: Operationalization: Sampling The sampling frame will come from a list of residents who were in a nursing home facility and receive therapy and have documented diagnoses of mental illness. The list of residents will be those who discharged home from the skilled nursing and rehabilitation facilities within one year. The caregivers of the residents will be selected to participate in the study. The caregiver will be interviewed by phone. Systematic sampling technique will be used to choose the participants. A hundred names will be selected out of two hundred names that have discharge within the time frame of one year. Every second name of the two hundred names will be the sample used in the study. The sampling ratio will be 2; 22.2 percent would be represented in the sampling frame. The limitation and problems using the systematic sampling technique may be during the interval selecting there is no guarantee that the 100 names selected will be an equal representation of any certain mental illness described in the study or an equal representation of gender in the study. Survey A survey was constructed to capture the attitudes of caregivers who are caring for an elderly person with mental illness. It was also designed to examine the relationship between elderly people with mental illness and the care they receive. The survey consists of questions that were form from operationalizing the independent and dependent variables in the study. The independent variable is mental illness; the indicators are the diagnoses of bi polar, schizophrenia, personality disorder and anxiety. Theses diagnoses are associated with aggressive behaviors such as hitting, kicking, biting and yelling out. The dependent variables are quality of care with the indicators of frequency of showers/bathing, personal care, proper nutrition, and compliance to medication and medical service. The survey will consist of thirty questions that are likert scale and thurstone scale to measure the attitudes and beliefs of the caregiver. The survey will addressed each of the hypotheses with questions that are constructed based on the independent and dependent indicators. The first hypotheses, caregivers caring for a mentally ill elderly person will have greater stress and difficulties providing good care. The questions 1 through 7 are written to measure the attitudes of the caregiver's stress and difficulties caring for an elderly person with mental illness. The second hypotheses, elderly people with a diagnosis of mental illness will more than likely have aggressive behaviors towards caregivers during care. The questions 8 through 19 measures the aggressive behaviors associated with mental illness and the effect it has on receiving care. Questions 20 through 30 measures the behaviors of mental illness and how it is related to poor health care. The questionnaire was constructed to answer the research question; it was constructed to capture the attitudes, belief and behaviors of the caregiver as they are challenged to care for someone who has cognitive impairment. Reliability and validity The study’s equivalence reliability; the survey questions will be dependable and consistent. The survey’s equivalence reliability "measures reliability across indicators, a measure that yields consistent results using different specific indicators, assuming that all measure the same construct."(Neuman, p.190.). The questions on the questionnaire can be divided into two parts using different indicators that will measure the same results. The indicators for mental illness and quality of care each can be divided into two sets and both sets of indicators will measure the same results. The survey will increase reliability by clearly conceptualize the concept's indicators to only one meaning. In the survey the level of measure is precise the variables are nominal level. The chance of increasing reliability is by having multiple indicators for each variable which will allow the survey to be able to measure the content of the conceptual definition at a broader range. The survey’s validity is measured by what is known as "content validity which is the measurement of validity that requires that a measure represent all the aspects of the conceptual definition of a construct."(Neuman p.193). The survey will clearly specifies the constructs definitions for the independent and depended variables, the working definition's ideas and concepts are represented in the questions on the questionnaire. The indicators of both the independent and dependent variable will be represented in the conceptual definition. The survey will increase validity by having question that measures all aspects of the concepts definitions and ideas. Limitations There could be two problems or limitations conducting the study or using this instrument. One of the problems could be getting participants to complete the survey due to the nature of the content. Questioning caregivers regarding mental illness or not being able to provide adequate or good care to a love one is a delicate subject that may cause them to reframe from truthfully answering or participating in the study. The other problem is often caregivers who take their love ones home to care for them often put the elderly person with mental illness in a nursing home for long term stay. The person is no longer in the community and will not fit the sampling frame. An attempt to limit the problems can be to reinforce to the participants that, the information being collected will not disclosed personal identity, and only the responses may be used in the study as well as other future studies. There is the possibility of having to resample from the sampling frame to get samples that will best fit the study. Survey Hello, my name is Lynette I am conducting a survey to examine the relationship between caregivers who are caring for a loved one who has a mental illness. The information you give me will be used for a study, your answers will be used to help others understand caregiving for someone with a mental illness. Your identity will be kept confidential, no one will know who you are. Your responses may be shared with other scholars or researchers, but not any identifying information. You may withdraw from the interview at any time, before answering the questions I must have your consent. If you should have any questions or concerns regarding the survey you may contact me at (734) 425-4200. I __________________________ agree to participate in the study by answering questions relating to me as a caregiver and the person I am caring for. Please carefully read the questions 1 through 5 and answer. 1. What is the age of the elderly person you are caring for? ________ 2. Gender: Male/Female 3. Race ____________________________________ 4. Does the person you are caring for have a mental illness? Yes or No 5. If you answered yes for question 4 please circle the answer(s) that best describe the diagnoses that apply to the person you are caring for and continue to the next section. a) Bi polar b) Schizophrenia c) Personality Disorder d) Anxiety Please read the following questions and circle the answers that best describe your feelings. 1. I am frustrated when I am assisting with showers/bathing, personal care, and meal preparation a) All the time b) Most of the time c) Sometimes d) Rarely 2. I find myself angry with the person I am caring for during or after care a) All the time b) Most of the time c) Sometimes d) Rarely 3. I find to be a burden caring for a person with a mental illness a) All the time b) Most of the time c) Sometimes d) Rarely 4. I find myself feeling angry after being hit, bitten, kicked or yelled at while providing care a) All the time b) Most of the time c) Sometimes d) Rarely 5. I find myself not giving showers/bathing or personal care to avoid being hit, bitten, kicked or yelled at a) All the time b) Most of the time c) Sometimes d) Rarely 6. I find it difficult to complete the task of assisting with showers/bathing, personal care or meal preparation a) All the time b) Most of the time c) Sometimes d) Rarely 7. Please read the six statements. After each statement please choose a number from 1 to 10 on the scale to express how you feel. 1 – Impossible, 5 – Neutral, 10 – Possible 1. I am able to dress the person I care for in adequate clothing daily 2. I am satisfied with the way the person I care for looks after I have given them personal care 3. I think the person I care for eats a balanced meal daily 4. I am able to assist the person I care for with brushing teeth 5. I am able to assist the person I care for with medications and medical appointments 6. I feel the person I am providing care for is overwhelming Please read each question and circle that answer that best describes the behaviors of the person that you are caring for during care 8. The person I am giving care to yells out or screams at me during care a) Always b) Most of the time c) Sometimes d) Seldom e) Never 9. When I am showering/bathing, doing personal care or preparing meals, the person I am caring for kicks, hits, bites or yells during care a) All the time b) Most of the time c) Sometimes d) Rarely e) Never 10. I am able to bathe/shower, do personal care, give medications without being hit, bitten, kicked or yelled at a) All the time b) Most of the time c) Sometimes d) Rarely e) Never 11. During care, the person I am caring for appears to have delusional ideas or thoughts and will hit, kick, bite or yell at me a) All the time b) Most of the time c) Sometimes d) Rarely e) Never 12. When I am providing care the person I am caring for appears to have hallucinations and will hit, bite, kick or yell at me a) All the time b) Most of the time c) Sometimes d) Rarely e) Never 13. The person I am caring for is seeing things or talking to people who are not present during care and has hit, bit, kicked or yelled at me during care a) Strongly agree b) Agree c) Disagree d) Strongly disagree 14. The person I am providing care for often yells or screams without cause a) Strongly agree b) Agree c) Disagree d) Strongly disagree 15. The person I care for is always suspicious during care a) Strongly agree b) Agree c) Disagree d) Strongly disagree 16. The person I care for accuses me of things I have not done and becomes physically aggressive towards me a) Strongly agree b) Agree c) Disagree d) Strongly disagree 17. The person I am caring for cries without cause during care a) Always b) Most of the time c) Sometimes d) Seldom e) Never 18. The person I am caring for has unkempt hair and facial hair due to refusal of care a) Always b) Most of the time c) Sometimes d) Seldom e) Never 19. The person I am caring for has bad eating habits because they refuse to eat what I prepare for meals a) Always b) Most of the time c) Sometimes d) Seldom e) Never Please read and circle the answer that best describes the person you are caring for when you are providing assistance with medications and medical appointments 20. I am able to give medication timely to the person I am caring for a) Strongly agree b) Agree c) Disagree d) Strongly disagree 21. I often find mediations that I have given hidden or thrown away a) Strongly agree b) Agree c) Disagree d) Strongly disagree 22. The person I am caring for refuses to take medication because they think it will harm them a) Strongly agree b) Agree c) Disagree d) Strongly disagree 23. The person I am caring for refuses to take medication as prescribed a) Strongly agree b) Agree c) Disagree d) Strongly disagree 24. The person I am caring for refuses to take medication because they think I am trying to harm them 25. It is difficult assisting the person I am caring for to a doctor’s appointment because of behaviors that are aggressive a) Strongly agree b) Agree c) Disagree d) Strongly disagree 26. I find it difficult to follow up with medical appointments with the person I am caring for due to refusal a) Strongly agree b) Agree c) Disagree d) Strongly disagree 27. I find it difficult to let healthcare professionals visit the home to provide services for the person I am caring for due to their mental illness a) Strongly agree b) Agree c) Disagree d) Strongly disagree 28. Healthcare professionals often visit to provide healthcare services a) Strongly agree b) Agree c) Disagree d) Strongly disagree 29. 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Abnormal behavior of residents in a long-term care facility and the associated stress of care staff members. Archives of Gerontology and Geriatrics, 33, 203-210. Nikolova, R., Carignan, M., Moscovitz, N., & Demers, L. (2004). The psychogeriatric and risk behavior assessment scale (PARBAS): a new measure for use with older adults living in the community. Archives of Gerontology and Geriatrics, 39, 187-200. Nye, A. (1989). Feminist theory and the philosophies of man: Psychology Press, 40-45. Pinkston, E. M., Linsk, N. L., & Young, R. N. (1988). Home-based behavioral family treatment of the impaired elderly*. Behavior Therapy, 19, 331-344. Reinhard, S. C., Gubman, G. D., Horwitz, A. V., & Minsky, S. (1994). Burden assessment scale for families of the seriously mentally ill. Evaluation and Program Planning, 17, 261-269. Sheehan, N. W., & Nuttall, P. (1988). Conflict, emotion, and personal strain among family caregivers. Family Relations, 92-98. Snow, M., & White, G. (2007). What Do CNAs Want? A Survey. Nursing Homes, 56, 81. Zeller, A., Hahn, S., Needham, I., Kok, G., Dassen, T., & Halfens, R. J. G. (2009). Aggressive behavior of nursing home residents toward caregivers: a systematic literature review. Geriatric Nursing, 30, 174-187.  Read More