Comparing Short Stories Essay Example | Topics and Well Written Essays - 500 words

Comparing Short Stories - Essay Example Through the use of plot, tone, and irony, the authors were able to convey that during the realism era of France people were separated by the concepts of wealth and destitution, eventually succumbing to the fact that money never equated to happiness. Though the plots of both stories do differ from each other in the events that lead to their conclusions, they still share the same general idea: each male protagonist starts off with a comfortable life, perhaps not entirely rich, but with money enough to make them pleased with their lives. Due to circumstances, they each find themselves in a position that compromises this wealth and comfort. This is where the similarity ends. Monsieur Lantin sells off his late wife’s jewelry, making him incredibly rich. He dwells in this feeling, though eventually marries another woman who is angry and appalling. Rich he may be, but Lantin had lost his comfort of life. The banker, convinced that the young man would not see out his part of the bet, lives happily, spending money and losing it frivolously. When it becomes apparent that the banker will have to pay the young man, he realizes that he no longer has the money, and the only solution he can come upon is to kill the young man before the time is up. When he goes to perform this horrific deed, he comes upon a note from the young man stating that he despises what money does to people and says that he will not follow though with his part of the debt. The banker is relieved, though upset that he would even consider committing such a crime for money. These plot ideas show that, despite what these men were able to do with their money, they still ended up being morose. The tone of â€Å"The Jewels of M. Lantin†, at the beginning of the story, was cheerful and exuberant, as Monsieur Lantin proposed and lived happily married to one of the prettier girls of the the town. As the story went on, the tone changed to exasperation, then despair as his wife

How global warming affects animals Essay Example | Topics and Well Written Essays - 3000 words

How global warming affects animals - Essay Example The current literature blames the inability of policy makers and politicians to design measures that can help curb further destructions on climate. In fact, most nations lack political will to mitigate the impacts global warming poses on animals. The current literal works of researchers underscore on the need for the world to focus its activities towards protection of the environment but does not say about the future and uncertainty surrounding animals as global warming gets to its extreme. This paper takes the assumption that the situation of global warming is typical fight between cases of survival for the fittest against the selection of the fittest by Global Warming. This means that with time, every animal species in the globe will adapt to global warming in varying ways. For example some animals will undergo genetic regeneration whereas others will simply die. I plan to organize my paper by discussing the main points as earlier stated while giving a detailed analysis concerning the impact of global warming on animals on such matters as habitat displacement, breeding, hibernation and migration behaviours. in this regard, the points will be arranged chronologically. Melting ice in the polar region has caused flow of water disturbing natural habitats of polar bears in the arctic regions. In addition, the breeding environments for waterfowl in the prairie pothole region of north Iowa and central Alberta has been adversely affected due to rising temperatures in the springs. Animals often move into new habitats whenever their current habitats become elusive to their survival. However, the current human population limits this movement since land that would otherwise have been suitable in accommodation Global warming raises temperatures within the arctic regions of the world which is the main habitat of polar bears. In addition, raised temperatures in the springs destroy breeding conditions of waterfowl

Peer response Article Example | Topics and Well Written Essays - 250 words - 11

Peer response - Article Example re that manager or leaders of nursing homes have comprehensively evaluated techniques and strategies that would ensure continued existence of these nursing homes. Factors that are within management’s control are costs, which they deemed, should be kept at a minimum, to generate profits, as needed. Another comment is that team learning and shared mental models are internal factors that management could tap to increase job satisfaction and productivity (Bossche, Gijselaers, Segers, Woltjer, & Kirschner, 2011). But these alone, could not ensure increased profits, if and when not enough revenues are generated by nursing homes. I share the same contention, however, that ‘in times of economic scarcity, cutting back on teamwork is a mistake, as teamwork is needed then more than ever’. Actually, in diverse settings, regardless of economic condition, organizations should harness the power of teamwork as a means of improving performance and productivity. Teamwork should go beyond teams in respective departments of the organizations; but more so, the collaborative departments that comprise the entire organization. As such, shared decision models would be useful in soliciting responsible inputs from different departments to facilitate achievement of the organization’s

The Impact of Direct Digital Manufacturing on Supply Chains Essay

The Impact of Direct Digital Manufacturing on Supply Chains - Essay Example Eyebrows are getting raised over the potential of DDM in cutting the demand for logistics services, as products would be manufactured at the place of demand or use. Effect of DDM would be felt in all industry sectors for meeting urgent product needs, providing customized products and parts of products, which were earlier supplied in bulk through the logistics industry. The crucial question before the logistics businesses worldwide is whether DDM would affect the business of logistics industry for transporting goods from one location to another. Naturally future repercussions of the innovation in technology cannot be denied. When customized parts could be accessed from the local DDM in a cost-effective and faster way, who would like to order it through a logistics process? Possibility of getting parts supplied locally becomes more evident for implementing changes in the designs of products. Actually, the risk to logistics business is genuine because no company would like to pay airfre ight for getting a part from abroad when it can be produced locally but the business of DDM depends on innovation in concepts; only genius is not enough. If an idea is good enough, it will take time in proto-typing. 3D printing also requires time to process a concept into a product. It would start a war-like environment for safeguarding intellectual property. Imitators and innovators, both would make attempts to present their products fast to the market (â€Å"3D Printing† par. 27). For getting competitive edge from the given scenario, only those companies would get the leverage that would plan a long-term marketing strategy without considering the profit factor. Delivery of products would demand accuracy of timing in taking the products to the customer locations (â€Å"3D Printing† par. 30). A look at the business growth of DDM can help in evaluating the potential of new technology sweeping the stakes of supply chains. Seeing the latest market trends on manufacturing solid products by 3Dprinters, business in additive manufacturing reached $1.2 billion in 2008 and the possibility is that it could double in size by 2015. For understanding the impact of DDM business on logistics, some crucial data analysis is mandatory such as 75% of the sale of 3D printers has been registered for producing common sort of products while the balanced sale of the 3D printers has been made for producing industrial products. With the approaching time, there would be increase in the sale of cheap 3D printers, which can be to the tune of 90% market as price depreciates and functionality improves of 3D printers. Demand of the DDM machine is increasing not only for model-making and rapid prototyping, but for all types of machines for producing finished products as well (â€Å"A factory on your desk† par. 4). The only difference between the industrial revolution of the 1800s and the seeming-revolution of the future is that the manufacturing industry won’t be a ble to get the benefit of economies of scale that comes with bulk production. Another difference would be seen in the distribution of capital, employment, and intellectual property, thus, indirectly affecting the logistics business as any impact on various industries would get reflected in logistics, affecting its business potential (â€Å"Print me a Stradavarius† par. 9). Have a look at the success story of a U.S. company. Seeing the current status of rapid manufacturing (RM) in the business of making invisible dental braces, U.S. based Invisalign

Pre-writting Essay Example | Topics and Well Written Essays - 500 words

Pre-writting - Essay Example For instance, if you say that Joy is 90 years old, it automatically means that Joy is over 20 years even without mentioning that in the premise. This is because 20 is less than 90 and that it can validated by that, on the same not if Joy is 20 years, then you could not say that she is 90 years because it cannot be validated by the conclusion. The chapter then emphasizes on the arguments that are sound, effective, and cogent. The conclusion of a statement should be carved from the premise of the same sentence, this is what the book tries to put forth in terms of developing a research paper. The chapters have given a legion ways of ensuring that your writing is carefully argued with precaution of not falling into the trap of vagueness. For the authors to make the audience understand the points that they wants taken, they fondly use rhetorical strategies, this means that the author has to consider several factors before choosing on which rhetorical strategy to be used as it determines how the information will be consumed by the intended person. In the case of this book, the author has in forms those rhetorical analyses are important for communicating your purpose of writing and that one has to choose carefully which one to use when developing a research paper (Faigley and Selzer 244). The author has also informed that writing different research papers calls for different use of rhetorical analyses, for instance the way one would report a science paper based on a laboratory research is different with the way a paper that in forms on how something comes into existence or the working mechanism of a process. This book forms the basis of good writing especially for those who want to give a concise paper on their writings. Logical and sound writing is important for the conveyance of intended information, otherwise, the intended meaning of the whole process will no longer hold

Tap Dance in America Essay Example for Free

Tap Dance in America Essay According to Funk Wagnalls New World Encyclopedia, â€Å" tap dance [is a] style of American theatrical dance, distinguished by percussive footwork, [which] marks out precise rhythmic patterns on the floor.† Also, â€Å"Tap is an exciting form of dance in which dancers wear special shoes equipped with metal taps. Tap dancers use their feet like drums to create rhythmic patterns and timely beats,† Treva Bedinghaus, graduated from Holli Barrons School of Performing Arts and The Ballet Academy, writes in Tap for beginner, â€Å"The term tap dancing is derived from the tapping sound produced when the small metal plates on the dancers shoes touch a hard floor or surface. † In 125 Years of Tap, Jane Goldberg, a dancer-writer who is considered as one of the most prolific voices in the filed of tap dancing, writes: â€Å"What distinguishes tap [dancing] from most other dance forms is that it is two arts in one: music and dance. The dancers are ‘playing their feet’ and moving at the same time.† In another article The Art of Tap Dancing, Amy Brinkman-Sustache, artistic director of Dance-works on Tap (DOT), describes, â€Å"A step is a word. You put steps together to make a sentence. Questions are raised and answered through rhythm. It’s like listening to a conversation.† Literally, tap is America’s unique contribution to dance. â€Å"Tap history is mostly an oral tradition,† Kikelly, performer/scholars from Virginia Tech, says, â€Å"and a single definitive history has not yet been written.† Still, Kikelly and many other people like her are working hard to reveal the truth about how this art form developed. Tap is believed the double of diversity. â€Å"The history of tap has been a story of survival, revival, renaissance and innovation,† Jane Goldberg indicates in her 125 Years of Tap article, â€Å"the controversial roots of which arc still being debated, though the primary sources are usually considered to be Irish and African-American.† According to Constance Valis Hill, Ph.D. in Performance Studies from New York University, â€Å"tap dance is an indigenous American d ance genre that evolved over a period of some three hundred years. Initially a fusion of British and West African musical and step-dance traditions in America, tap emerged in the southern United States in the 1700s. The Irish jig (a musical and dance form) and West African gioube (sacred and secular stepping dances) mutated into the American jig and juba. These in turn became juxtaposed and fused into a form of dancing called â€Å"jigging† which, in the 1800s, was taken up by white and black minstrel-show dancers who developed tap into a popular nineteenth-century stage entertainment.† Furthermore, â€Å"early styles of tapping utilized hard-soled shoes, clogs, or hobnailed boots. It was not until the early decades of the twentieth century that metal plates (or taps) appeared on shoes of dancers on the Broadway musical stage,† Hill summarizes, â€Å"in the late twentieth century, tap dance evolved into a concertized performance on the musical and concert hall stage. Its absorption of Latin American and Afro- Caribbean rhythms in the forties has furthered its rhythmic complexity. In the eighties and nineties, tap’s absorption of hip-hop rhythms has attracted a fierce and multi-ethnic new breed of male and female dancers who continue to challenge and evolve the dance form, making tap the most cutting-edge dance expression in America today.† Yet, according to theatredance.com, â€Å"no one really knows when the phrase ‘tap dance’ was first used – perhaps as early as 1900 – but it didn’t appeared in print until around 1928.† â€Å"Unlike ballet with its codification of formal technique, tap dance developed from people listening to and watching each other dance in the street, dance hall, or social club where steps were shared, stolen and reinvented. ‘Technique’ is transmitted visually, aurally, and corporeally, in a rhythmic exchange between dancers and musicians. Mimicry is necessary for the mastery of form,† Hill points out. Moreover, she continues indicating, â€Å"The dynamic and synergistic process of copying the other to invent something new is most important to tap’s development and has perpetuated its key features, such as the tap challenge. [†¦] The oral and written histories of tap dance are replete with challenge dances, from jigging compe titions on the plantation that were staged by white masters for their slaves, and challenge dances in the walk-around finale of the minstrel show, to showdowns in the street, displays of one-upsmanship in the social club, and juried buck-and wing-contests on the vaudeville stage.† Indeed, Jane Goldberg also writes, â€Å"one documented fact is that many tap legends began performing any place they could — especially street corners — before the discipline Invaded vaudeville shows and, eventually, the silver screen. In a contest by the performers to outdo one another, tap kept evolving, transforming into an art form of self-expression as well as highly stylized production numbers.† For such a long time, tap was considered â€Å"a man’s game† or even â€Å"a largely black, male-dominated form.† People easily notice various famous male tap dancers in history like Bill Bojangles Robinson (1878-1949), John W. Bubbles (1902-1986), or Sammy Davis Jr. (1925-1990). Female dancers, in contrast, were not very honored in history books. Yet, Jane Golden presents, â€Å"a number of young white women got into the act starting in the mid-1970s. These women studied and often performed with their male mentors,† even though the fact Stacie Strong has noted in History, Herstory, OUR STORY article: â€Å"While male tap dancers acted as headliners, women tappers filled out the chorus lines. Though many of their names have been lost, these women were incredibly versatile and talented. Headliners often did the same act week after week (or even year after year), but the chorus had to learn a new routine every few weeks, often working with props and in outlandish costumes, performing as many as four shows a day.† Professor Constance Valis Hill’s inclusive history is the first to also highlight the outstanding female dancers, she wrote in Tap Dance in America: A Very Short History, â€Å"In 1986, La Mama presented Sole Sisters an all woman, multi-generational tap dance show directed by Constance Valis Hill that brought together high-heeled steppers and low-heeled hoofers, the veteran grande dames of tap and younger prima taperinas.† Next, she indicates, â€Å"Soul Sisters was not the only production to open the door for the recognition of female jazz tap dancers. On the West Coast Lynn Dally, who founded the Jazz Tap Ensemble in 1979, combined her extens ive experience in modern dance with jazz tap to organize a group of dancers that insisted on performing and interacting with a live jazz ensemble. On the East Coast, singer, jazz and tap dancer Brenda Bufalino, formerly a partner of Honi Coles, founded the American Tap Orchestra, and set about experimenting with how to layer and orchestrate rhythmic groups of dancers on the concert stage.† â€Å"Today the type of tap that mostly closely resembles the style current during Robinsons era is jazz or rhythm tap. These dancers concentrate on improvisation and choreography that incorporate the complicated rhythms of classic jazz music. Often they look crouched over, listening to their feet — and thats exactly what theyre doing. While some rhythm tappers have begun choreographing for their upper bodies, the emphasis is still on the dancers hearing themselves. The mentors of todays leading rhythm tappers have often been called ‘hoofers’,† writes Jane Goldberg. In addition, The Basic Characteristics of Tap Dancing shows, â€Å"Tap dancers make frequent use of syncopation. Choreography typically starts on the eighth or first beatcount. Another aspect of tap dancing is improvisation. This can either be done with music and follow the beats provided or without musical accompaniment, otherwise known as acappella dancing.† This article also points out another major variations on tap dance, besides rhythm tap: â€Å"Early tappers like Fred Astaire provided a more ballroom look to tap dancing, while Gene Kelly used his extensive ballet training to make tap dancing incorporate all the parts of the ballet. This style of tap led to what is today known as Broadway style, which is more mainstream in American culture.† Specially, the article give some examples of common tap steps and how professional tap dancers make their new steps: Common tap steps include the shuffle, shuffle ball change, flap, flap heel, cramp roll, buffalo, Maxi Ford, single and double pullbacks, wings, Cincinnati, the shim sham shimmy (also called the Lindy), Irish, Waltz Clog, the paddle and roll, the paradiddle, stomp, brushes, scuffs, and single and double toe punches, hot steps, heel clicks, single, double and triple time steps, riffs, over-the-tops, military time step, New Yorkers, and chugs. In advanced tap dancing, basic steps are often combined together to create new steps. Timesteps are widely used in tap and can vary in different areas. These consist of a rhythm that is changed to make new timesteps by adding or removing steps. The images of tap dancer and their shoes has also changed, especially for female dancers: â€Å"Boundaries have shifted dramatically since the 1970s, when high-heeled tap shoes were reserved for Broadway-style tap and flat oxford-style shoes were associated with rhythm tap,† according to Darrah Carr MFA from New York Universitys Tisch School of the Arts. Additionally, Carr notes that â€Å"Introductory high-heeled taps range from 1†³ to 1 ½Ã¢â‚¬ ³ high, while more advanced heels can be up to 3†³ high. [†¦] Dancing in heels also forces you to hold your body more upright, which can change your stage presence. [†¦] ‘Heels encourage you to incorporate your hips and your shoulders into your dancing and wearing heels makes you think about extending the line of your leg’. In contrast,  "many tap dancers find that nothing beats the comfort of flats,† Carr reveals, â€Å"Flat tap shoes are made in the same oxford style for women and men, and many dancers feel that the shoe looks best when paired with pants or jeans. And flats have larger metal taps than heels, so the sound produced is a deeper, heavier bass tone. (The smaller metal taps on high-heeled shoes create sounds that are higher in tone.)† Another ideas showed by Carr are: â€Å"A dancers body placement in flat tap shoes is centered between the toes and heels. [And] certain steps, such as side shuffles and toe stands, are easier to execute in flats because your weight is more evenly distributed.† Still, â€Å"Whether youre a heels lover or forever committed to flats, its important that you become comfortable with both shoe styles,† she advises. Indeed, according to Elena North-Kelly, â€Å"High heeled, low heeled, soft leather, hard leather, split soled, and full soledall tap shoes are not created equal. Different styles of tap shoes facilitate different styles of tap dancing. When shopping for a shoe, you need to consider comfort, flexibility, aesthetic, shape, and, of course, sound.† Also, North-Kelly quotes a statement from Lynn Schwab, who teaches tap at New York Citys Steps on Broadway, to help people with choosing tap shoes: While part of a tap dancers sound is a product of technique, it also relates to the material of the shoe. For rhythm tapping, the best sound comes from a harder shoe with a wider heel. Finally, North-Kelly says, â€Å"Dancers hoping for a career on Broadway, however, have a little more leeway, partly because most Broadway dancers use different tap shoes for performance, classes, and auditions.† Briefly, with a relatively brief but rich history, the tap tradition is growing bigger, better and broader every year. In fact, holding an enormous respect for the past, Jason Samuels Smith, the first tapper to win an Emmy award for choreography since Hermes Pan in 1958, used to say: â€Å"Tap culture is all about celebrating the past and accumulating its vocabulary over time. If we don’t maintain our history, we lose what’s valuable about tap.† He is not the only person who thinks that way, Donna-Marie Peters – professor at Temple University, also express her ideas in Passing On: The Old Head/Younger Dancer Mentoring Relationship in the Cultural Shpere of Rhythm Tap: Respect for the artistic tradition of tap is the value that humbles even the most seasoned performers. This value demands subservience to the art that is seen as bigger than the individual and takes a lifetime to master. By honoring the art over the individual, the tap dancers become servants to the art, working to the best of their ability to execute it well. The long-term survival of this struggling art form is dependent on a cot munity of individuals with a sense of purpose, dedicated to keeping the art form alive and moving forward. Works Cited TAP DANCE. (n.d.): Funk Wagnalls New World Encyclopedia. EBSCO. Web. 26 Oct. 2011. Bedinghaus, Treva. Tap for Beginners. About.com n. pag. Web. 26 Oct 2011. http://dance.about.com/bio/Treva-Bedinghaus-32821.htm Carr, Darrah. Heels vs. Flats. Dance Spirit 14.8 (2010): 98. MAS Ultra School Edition. EBSCO. Web. 26 Oct. 2011. Hill, Constance. â€Å"Tap Dance in America: A Very Short History.† (2002): n. pag. Web 26 Oct 2011. http://www.nypl.org/locations/tid/55/node/70581 Holmes, Vance. All ABout Tap Dance. TheatreDance.com n. pag. Web. 26 Oct 2011. http://www.theatredance.com/tap/. Goldberg, Jane. â€Å"125 Years of tap.† Dance Spirit 7.5 (2003): 34. Academic Search Premier. EBSCO. Web. 26 Oct. 2011. North-Kelly, Elena. Tap Shoes Meet These Dancing Feet. Dance Magazine 79.3 (2005): 68. MAS Ultra School Edition. EBSCO. Web. 26 Oct. 2011. Peters, Donna-Marie. â€Å"Passing On: The Old Head/Younger Dancer Mentoring Relationship in the Cultural Shpere of Rhythm Tap.† Western Journal of Black Studies 34.4 (2010): 438-436. Academic Search Premier. EBSCO. Web. 26.Oct.2011. Schneider, John. â€Å"The Art of Tap Dancing.† n. pag. Web. 26 Oct 2011. http://www.expressmilwaukee.com/article-11832-the-art-of-tap-dancing.html Strong, Stacie. â€Å"History, Herstory, OUR STORY,† Dance Spirit 11.10 (2007): 62. MAS Ultra – School Edition. EBSCO. Web. 26 Oct 2011. The basic characteristics of tap dancing. Ballet Shoes n. pag. Web. 26 Oct 2011. http://shoes-collection.net/2011/10/05/tap-shoes-capezio/.

Effects of Behavioral Interventions on Disruptive Behavior and Affect in Demented Nursing Home Residents Essay Example for Free

Effects of Behavioral Interventions on Disruptive Behavior and Affect in Demented Nursing Home Residents Essay Behavioral interventions might ameliorate them and have a positive effect on residents’ mood (affect). Objectives: This study tested two interventions—an activities of daily living and a psychosocial activity intervention—and a combination of the two to determine their efficacy in reducing disruptive behaviors and improving affect in nursing home residents with dementia. Methods: The study had three treatment groups (activities of daily living, psychosocial activity, and a combination) and two control groups (placebo and no intervention). Nursing assistants hired specifically for this study enacted the interventions under the direction of a master’s prepared gerontological clinical nurse specialist. Nursing assistants employed at the nursing homes recorded the occurrence of disruptive behaviors. Raters analyzed videotapes filmed during the study to determine the interventions’ influence on affect. Results: Findings indicated significantly more positive affect but not reduced disruptive behaviors in treatment groups compared to control groups. Conclusions: The treatments did not specifically address the factors that may have been triggering disruptive behaviors. Interventions much more precisely designed than those employed in this study require development to quell disruptive behaviors. Nontargeted interventions might increase positive affect. Treatments that produce even a brief improvement in affect indicate improved quality of mental health as mandated by federal law. Key Words: affect †¢ Alzheimer’s disease †¢ behavior therapy †¢ dementia †¢ nursing homes Nursing Research July/August 2002 Vol 51, No 4 proximately 1. 3 million older Americans live in nursing homes today (Magaziner et al. , 2000). By 2030, with the aging of the population, the estimated demand for long-term care is expected to more than double (Feder, Komisar, Niefeld, 2000). Thus, nursing home expenditures could grow from $69 billion in 2000 to $330 billion in 2030 (Shactman Altman, 2000). About half of new nursing home res idents have dementia (Magaziner et al. , 2000). The disease has an impact on four major categories of functioning in persons with dementia. These are disruptive behavior (DB), affect, functional status, and cognition (Cohen-Mansfield, 2000). This article will focus on the first two categories. Disruptive behavior has received much more attention than affect has (Lawton, 1997), perhaps for three reasons. First, more than half (53. 7%) of nursing home residents display DB with aggression (34. 3%) occurring the most often (Jackson, Spector, Rabins, 1997). Second, DB threatens the wellbeing of the resident and others in the environment. Consequences include: (a) stress experienced by other resiCornelia K. Beck, PhD, RN, is Professor, Colleges of Medicine and Nursing, University of Arkansas for Medical Sciences. Theresa S. Vogelpohl, MNSc, RN, is President, ElderCare Decisions. Joyce H. Rasin, PhD, RN, is Associate Professor, School of Nursing, University of North Carolina. Johannah Topps Uriri, PhD(c), RN, is Clinical Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences. Patricia O’Sullivan, EdD, is Associate Professor, Office of Educational Development, University of Arkansas for Medical Sciences. Robert Walls, PhD, is Professor Emeritus, University of Arkansas for Medical Sciences. Regina Phillips, PhD(c), RN, is Assistant Professor, Nursing Villa Julie College. Beverly Baldwin, PhD, RN, deceased, was Sonya Ziporkin Gershowitz Professor of Gerontological Nursing, University of Maryland. A Note to Readers: This article employs a number of acronyms. Refer to Table 1 to facilitate reading. 219 220 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 1. Acronyms Term Activities of daily living Analysis of variance Apparent affect rating scale Arkansas Combined Disruptive behavior(s) Disruptive behavior scale Licensed practical nurse(s) Maryland Mini mental status exam Negative visual analogue scale Nursing home nursing assistant(s) Observable displays of affect scale Positive visual analogue scale Project nursing assistant(s) Psychosocial activity Research assistant(s) Acronym ADL ANOVA AARS AR CB DB DBS LPN MD MMSE NVAS NHNA ODAS PVAS PNA PSA RA decreases in targeted behaviors (Gerdner, 2000; Matteson, Linton, Cleary, Barnes, Lichtenstein, 1997). However, others reported nonsignificant reductions (Teri et al. , 2000), no change (Churchill, Safaoui, McCabe, Baun, 1999), or increased behavioral symptoms (Mather, Nemecek, Oliver, 1997). These studies used nursing home staffs to collect data, had sample sizes below 100, and measured an array of DB with different assessments. Only in the last decade have researchers investigated affect. Compared to studies to reduce DB, far fewer studies have measured interventions using affect as an outcome measure. Studies reported positive outcomes on affect from such interventions as simulated presence therapy (Camberg et al. , 1999), Montessori-based activities (Orsulic-Jeras, Judge, Camp, 2000), advanced practice nursing (Ryden et al. , 2000), music (Ragneskog, Brane, Karlsson, Kihlgren, 1996), rocking chair therapy (Watson, Wells, Cox, 1998), and pet therapy (Churchill et al. , 1999). The studies on affect used global measures that relied on observer interpretation, which could have compromised objectivity. Theoretical Bases A number of conceptual frameworks have guided intervention research on persons with cognitive impairment (Garand et al. , 2000). The theoretical basis for this study was that individuals have basic psychosocial needs, which, when met, reduce DB (Algase et al. , 1996) (Table 2). The interventions, one focusing on activities of daily living (ADL) and the other focusing on psychosocial activity (PSA), and a combination (CB) of the two, were developed to meet most of the basic psychosocial needs that Boettcher (1983) identified. These included territoriality, privacy and freedom from unwanted physical intrusion; communication, opportunity to talk openly with others; self-esteem, respect from others and freedom from insult or shaming; safety and security, protection from harm; autonomy, control over one’s life; personal identity, access to personal items and identifying material, and cognitive understanding, awareness of surroundings and mental clarity. The section on study groups specifies which interventions were designed to meet which needs. Positive affect usually accompanies interventions that meet basic psychosocial needs (Lawton, Van Haitsma, Klapper, 1996). Several researchers and clinicians have suggested that displays of affect may offer a window for revealing demented residents’ needs, preferences, aversions (Lawton, 1994), and responses to daily events (Hurley, Volicer, Mahoney, Volicer, 1993). The study reported here dents and staff; (b) increased falls and injury; (c) economic costs, such as property damage and staff burn-out, absenteeism, and turnover; (d) emotional deprivation such as social isolation of the resident; and (e) use of physical or pharmacologic restraints (Beck, Heithoff, et al. 1997). Third, before the Nursing Home Reform Act (Omnibus Budget Reconciliation Act, 1987), nursing homes routinely applied physical and chemical restraints to control DB with only moderate results (Garand, Buckwalter, Hall, 2000). However, the Act mandated that residents have the right to be free from restraints imposed for discipline or convenience and not required to treat the residents’ medical symptoms. Thus, researcher s have tested a wide range of behavioral interventions to reduce DB and replace restraints. The Act (1987) also stipulated that all residents are entitled to an environment that improves or maintains the quality of mental health. Interventions that promote positive mood or affect fulfill this entitlement. Therefore, this article will report the effects of an intervention to increase functional status in activities of daily living (Beck, Heacock, et al. , 1997), a psychosocial intervention, and a combination of both on reducing DB and improving affect of nursing home residents with dementia. TABLE 2. Basic Psychosocial Needs Relevant Literature Literature suggests that behavioral interventions offer promise in managing DB. A wide range of modalities and approaches have been tested: (a) sensory stimulation (e. g. , music); (b) physical environment changes (e. g. , walled garden); (c) psychosocial measures (e. g. , pet therapy); and (d) multimodal strategies. Many studies found significant Territoriality Communication Self-esteem Safety and security Autonomy Personal identity Cognitive understanding Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 221 adopted the inference by Lawton et al. (1996) that frequent displays of positive affect when basic psychosocial needs are met might indicate improved emotional wellbeing. is leg continually and without apparent reason needs redirection. This intervention lasted 45–60 minutes a day during various ADL. PSA Intervention. A PNA also conducted the PSA intervention, which involved 25 standardized modules designed to meet the psychosocial needs for communication, selfesteem, safety and security, personal identity, and cogni tive understanding through engagement in meaningful activity while respecting the individual’s unique cognitive and physical abilities (Baldwin, Magsamen, Griggs, Kent, 1992). The intervention was chosen because it: (a) provided a systematic plan for the PNA to address some of the participant’s basic psychosocial needs; and (b) represented clinical interventions that many long-term care facilities routinely used, but had not been formalized into a research protocol or systematically tested. Each module contained five psychosocial areas of content (expression of feelings, expression of thoughts, memory/recall, recreation, and education) and stimulated five sensory modalities (verbal, visual, auditory, tactile, and gustatory/olfactory). For instance, Activity Module I involved life review, communicating ideas visually (identifying and making drawings), clapping to different rhythms, massaging one’s face, and eating a snack. Initially, many participants tolerated less than 15 minutes of the activity but eventually habituated and participated 30 minutes. CB Intervention. This treatment consisted of both the ADL and PSA interventions and lasted 90 minutes daily. Placebo Control. This involved a one-to-one interaction between the participant and PNA. It controlled for the effect of the personal attention that the PNA provided to the three treatment groups. The PNA asked the participant to choose the activity, such as holding a conversation or manicuring nails. It lasted 30 minutes a day. No Intervention Control. This condition consisted of routine care from a NHNA with no scheduled contact between participants and the PNA. Instruments: Disruptive Behavior Scale. The 45-item disruptive behavior scale (DBS), designed to construct scores based on the occurrence and severity of behaviors, assessed the effect of the interventions on DB (Beck, Heithoff et al. 1997). Gerontological experts (n 29) established content validity, and interrater reliability tests yielded an interclass correlation coefficient of . 80 (p . 001). Geropsychiatricnursing experts weighted the behaviors using a Q-sort to improve the scale’s capacity to predict perceived patient disruptiveness. Factor analysis identified four factors (Beck et al. , 1998). Two corresponded to two—physically aggressive and physically nonaggressive—of the three categories from the factor analysis of the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, Marx, Rosenthal, 1989). The third category of the Inventory was verbally agitated; in contrast, the factor analysis of the DBS produced a third and fourth category—vocally agitated and vocally aggressive. To obtain a score for the DBS, a trained individual completed a DBS form for every hour of a shift by check- Methods The primary aim was to conduct a randomized trial of the ADL and PSA interventions individually and in combination (CB) for their effect on DB and affect on a large sample of nursing home residents. The experimental design consisted of three treatment groups (ADL, PSA, and Combined) and two control groups (placebo and no intervention). Individual residents were assigned to one of the five groups at each of seven sites in Arkansas and Maryland, which controlled for site differences. To demonstrate the practicability of the interventions and assure adherence to the treatment protocols, certified nursing assistants were hired and trained as project nursing assistants (PNA). They implemented the interventions Monday–Friday for 12 weeks. Afterward, one-month and two-month follow-up periods occurred. Nursing assistants employed by the nursing homes (NHNA) recorded DB. To measure affect, raters were hired for the study to analyze videotapes filmed during intervention. Research Subjects: The sample initially consisted of 179 participants. The study design allowed for the detection of an improvement in DB scores on the Disruptive Behavior Scale (DBS) (Beck, Heithoff et al. , 1997) across time of at least 1. 6 units with a power of 80%. This power calculation assumed that the repeated measures would be correlated with one another at 0. 60. Inclusion criteria were age 65; a dementia diagnosis; a Mini Mental Status Exam (MMSE) (Folstein, Folstein, McHugh, 1975) score of 20; and a report of DB in the previous two weeks. To form a more homogeneous group for generalizing findings, exclusion criteria were a physical disability that severely limited ADL; a psychiatric diagnosis; and a progressive or recurring medical, metabolic, or neurological condition that might interfere with cognition or behavior. Study Groups: ADL Intervention. A PNA used the ADL intervention during bathing, grooming, dressing, and the noon meal based on successful protocols that improved functional status in dressing (Beck, Heacock et al. , 1997). It attempted to meet residents’ psychosocial needs for territoriality, communication, autonomy, and self-esteem to promote their sense of safety and security. The intervention also tried to respect participants’ cognitive and physical abilities by prescribing three types of strategies specific to the individual participant. First, strategies to complete an ADL address specific cognitive deficits. For example, the person with ideomotor apraxia needs touch or physical guidance to start movements. Second, standard strategies are behaviors and communication techniques that work for almost everyone with dementia. For example, the caregiver gives a series of one-step commands to guide the resident to put on her shoe. Third, problem-oriented strategies address particular disabilities such as fine motor impairment, physical limitations, or perseveration. For example, a subject who rubs his hand back and forth on 222 Effects of Behavioral Interventions ing the behaviors that occurred. The score for a behavior was the frequency (0–8) times the weight. The item scores were summed to obtain each of the four subscale scores. Mini Mental Status Exam. The Mini Mental Status Exam (MMSE) (Folstein et al. 1975) provided a global evaluation of participants’ cognitive statuses for screening subjects for the study. Test-retest reliability of the MMSE is . 82 or better (Folstein et al. ). Cognition is assessed in seven areas, and scores lower than 24 out of 30 indicate dementia. Nursing Research July/August 2002 Vol 51, No 4 Observable Displays of Affect Scale. The Observable Displays of Affect Scale (ODAS) (Vogelpohl Beck, 1997), designed to rate videotaped data, contains 41 behaviors categorized into six subscales of positive and negative facial displays, vocalizations, and body movement/posture. Raters indicate presence/absence of each behavior during five 2-minute intervals from a 10minute videotape. Scores range from 0–5 for each item. The range of scores for each scale is: facial positive (0–20), Aggression during bathing facial negative (0–20), vocal positive (0–45), vocal negative (0–50), body could stem from physical positive (0–30), and body negative discomfort or rough (0–40). Interrater reliabilities (Kappa handling coefficients) for the ODAS range from . 68–1. 00, and intrarater reliability is . 97–1. 00. Ten gerontological nursing experts established content validity (Vogelpohl Beck). Apparent Affect Rating Scale. The Apparent Affect Rating Scale (AARS) (Lawton et al. , 1996) is designed for direct observation of persons with dementia and contains six affective states: pleasure, anger, anxiety/fear, sadness, interest, and contentment. (In later work, Lawton, Van Haitsma, Perkinson, Ruckdeschel [1999] deleted contentment). Each item has a noninclusive list of behaviors that might signal the presence of the affect from which observers infer the affect. The observer assigns a score of 1 to 5 to measure the duration of the behavior. Visual Analogue Scales. The Positive Visual Analogue Scale (PVAS) and Negative Visual Analogue Scale (NVAS) (Lee Kieckhefer, 1989; Wewers Lowe, 1990) are two 10centimeter lines on separate pages for rating positive and negative affect. The PVAS has end anchors of â€Å"no positive affect† and â€Å"a great deal of positive affect. † The NVAS has end anchors of â€Å"no negative affect† and â€Å"a great deal of negative affect. † Scores range from 0 to 100. Procedure: The study consisted of six phases: (a) preliminary activities, (b) a three-week normalization/desensitization period, (c) a 12-week intervention period, (d) a onemonth follow-up period, (e) a two-month follow-up period, and f) a videotape analysis. Preliminary Activities. The institutional review boards at the University of Arkansas for Medical Sciences and the Univer- sity of Maryland approved the research. Each nursing home identified residents with dementia and sent letters informing persons responsible for the residents that researchers would be contacting them. Responsible persons could return a signed form if they did not want to participate. Willing responsible persons received a telephone call explaining the study followed by a mailed written description along with two consent forms. Those willing kept one consent form for their records and signed and mailed back the other. Screening involved a review of the residents’ charts, recording their diagnoses, and interviews with the staff to find evidence of DB during the previous two weeks. Each resident took the MMSE to meet inclusion criteria. Within each home, female residents who passed these screens were randomized to one of the five groups by a drawing, but males were assigned to the five groups to ensure even distribution of their small number. Simultaneously, research staff members were hired and trained. Normalization/Desensitization. For the next three weeks, each PNA accompanied a NHNA to learn the routines of the facility but did not help care for potential study participants. A videotape technician placed a camera that was not running in the dining and shower rooms to desensitize residents and staff to its presence. In addition, nursing home staffs participated in two-hour training sessions on the DBS. Throughout the study, a gerontological clinical nurse specialist trained any new NHNA and retrained if behaviors reported on the DBS differed from those she observed during randomized checks. Intervention. During the 12-week intervention period, the first three weeks were considered baseline and the last two weeks postintervention. The PNA administered the treatment/s or placebo five days a week. Every day, they asked participants to give their assent and espected any dissents. During weeks 11–12 (postintervention), the PNA prepared the participants for their departure by telling them that they were leaving soon. To facilitate data collection, a separate form of the DBS for each of the three eight-hour daily shifts was developed. Eight one-hour blocks accompanied each item of the scale. The NHNA placed a check mark in the block that corresponded to the hour when the NHNA observed the behavi or. The NHNA completed the DBS on all participants during or at the end of a shift. In addition, a technician videotaped participants in the treatment and placebo groups every other week during an interaction with the PNA and no intervention group monthly during an ADL. The technician monitored positioning and operation of the camera from outside the room or behind a curtain to respect the participants’ privacy. One-Month and Two-Month Follow-up. One month and two months after the research team left the nursing home, Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 223 esearch assistants (RA) retrained nursing home staffs on the DBS. The NHNA then collected DB data on their shifts Monday–Friday for one week. tervention, week 16 as one-month follow-up, and week 20 as two-month follow-up. Participants with fewer than six observations at any time period were omitted. For each period, a total DBS score represented an averVideotape Analysis. The videotapes ranged in length from age of the participant’s data for the t hree shifts of each day less than five minutes to 40 minutes, depending on the across the five days of the observation week. Therefore, activity and the participant’s willingness to cooperate with total DBS scores were obtained for baseline (M of weeks the treatment (baseline and control participants’ tapes 1–3), intervention (M of weeks 4–10), postintervention (M tended to be shorter). To standardize the opportunity for of weeks 11–12), first follow-up (M of week 16), and secbehaviors to occur, an editor took 10-minute segments ond follow-up (M of week 20). The same procedure from the middle of baseline and final treatment eek tapes yielded subscale scores for physically aggressive, physically and randomized them onto videotapes for rating. Because nonaggressive, vocally aggressive, and vocally agitated videotaping occurred to ensure appropriate implementabehaviors for each of the five time periods. tion of interventions, the treatment groups had more A repeated measures analysis of variance (ANOVA) usable videotapes than the control groups did. consisted of two between- subjects and one within-subjects A master’s prepared gerontological factors. The between-subjects factors nurse specialist intensively trained six were intervention group and state (AR raters on the Observer III Software or MD) to account for regional differSystem (Noldus Information Technolences in scoring DB, and the withinogy, 1993) for direct data entry and subjects factor represented DBS scores the affect rating scales. The raters for the five different time periods. Each reached . 80 agreement with the speanalysis allowed for testing by intervencialist on practice tapes before they tion group, time period, and state. The Screaming may started rating the study videotapes. nalysis of the interaction effect of She monitored reliability for each tape intervention group by time period express pain or monthly, retrained as needed, and rantested the hypothesis that the intervenself-stimulation domized the sequence of rating the tions would decrease DB across time in scales. The raters entered the ODAS treatment conditions as compared to and AARS data directly into a comcontrol conditions. The analysis was puter using the Observer. The system repeated five times, once for each suballowed raters to watch videos repeatscale of the DBS and once for the total edly in actual time and slow action to score. Level of significance was set at document behaviors objectively and 0. 05. The researchers believed that the precisely. The raters indicated their small group sizes justified the liberal perception of the participants’ positive and negative level of significance. For the videotape analysis, analyses of affect by placing a vertical mark at some point between covariance occurred for the 14 variables observed from the the two end anchors of the PVAS and NVAS. They videotapes during intervention. The baseline score served marked neutral affect as negative. s a covariate for the final score. While a multivariate analysis would have been desirable, it would have had Intervention Integrity: The PNA and video camera techniinsufficient power with this number of variables and subcian underwent two weeks of intensive training on general jects. The 14 univariate analyses do inflate the Type I error aging topics, stress management, information on dementia, rate. and confidentiality/privacy issues. Training also involved instruction on the study interventions, DBS, and research Results protocols. Of the 179 initial participants, 36 did not finish; the greatA gerontological clinical nurse specialist viewed treatest attrition occurred in the no intervention control group. ment and placebo videotapes biweekly in a private office to Attrition resulted from death (39%), withdrawal of fammonitor PNA compliance with research protocols, provide ily’s consent or at nursing home staff’s request (26%), discorrective feedback to PNA, and help PNA recognize and charge (18%), and change in health status/medications meet participants’ needs as they changed during treatment. hat did not meet inclusion criteria (17%). This left 143 The possibility for contamination appeared to be low participants: 29 in the ADL, 30 in PSA, 30 in CB, 30 in the because NHNA were unlikely to change their care practices placebo, and 24 in the no intervention, but 16 with incomand had little opportunity to observe PNA. Further, NHNA plete data were dropped. Table 3 gives the demographic were b linded to the hypothesis of the study, the nature of the statistics for the 127 participants with complete data. No interventions, and the participants’ group assignments, statistically significant demographic differences emerged although they probably could identify the no intervention among the five groups. In short, this sample primarily conparticipants. sisted of elderly, white females with severe cognitive impairment. Analysis: Reviewers checked for completeness of all data. For the videotape analysis, the final number was 84 The researchers designated intervention weeks 1–3 as baseparticipants with 168 videotape segments. Most were line, weeks 4–10 as intervention, weeks 11–12 as postin- 224 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 3. Description of the Sample by Intervention Group No Intervention 19 89. 5 78. 9 84. 2 86. 47 (6. 37) 11. 47 (6. 43) ADL Number in group Percent female Percent white Percent widowed Mean age (SD) M MMSE (SD) 28 78. 6 82. 1 64. 3 82. 29 (8. 40) 11. 44 (7. 69) PSA 29 82. 1 85. 7 66. 7 82. 18 (7. 64) 10. 65 (6. 76) CB 22 81. 8 77. 3 77. 3 82. 82 (9. 81) 7. 91 (5. 41) Placebo 29 75. 9 86. 2 75. 9 86. 45 (6. 92) 11. 11 (6. 39) Total 127 81. 0 82. 5 72. 8 83. 64 (7. 97) 10. 55 (6. 64) Note. ADL = activities of daily living; PSA = psychosocial activity; CB = combination. emale (79%) and widowed (69%) with a mean age of 83 (SD 7. 44). Participants had a mean score of 10 (SD 6. 34) on the MMSE, indicating moderate to severe cognitive impairment. Table 4 displays the means and standard deviations for the DBS overall and the four subscales across the five time periods for the five groups. No significant differences emerged for the interventi on-by-time interaction for any of the dependent variables. Thus, the results failed to support the hypothesis that the interventions would decrease DB across time in treatment groups as compared to control groups (statistical analysis tables on Website at: http://sonweb. nc. edu/nursing-research-editor). However, the main effect of state was significant in three analyses. Arkansas recorded significantly more behaviors than Maryland did for the dependent variables of physically nonaggressive (p . 001), vocally agitated (p . 001), and overall DBS (p . 002). Further, the main effect of time was significant for overall DBS (p . 002) and the four subscales of physically aggressive (p . 001), physically nonaggressive (p . 027), vocally aggressive (p . 021), and vocally agitated behaviors (p . 008). The significance resulted from increased DB after the PNA had left the home (generally from intervention or postintervention to first follow-up). For the videotape analysis, the hypothesis stated that treatment groups, compared with control groups, would display more indicators of positive affect and fewer indicators of negative affect following behavioral interventions. In general, neither the positive nor the negative affect scores were particularly high, indicating that this sample had relatively flat affect. Results from the analysis of covariance tests supported increased positive affect but not decreased negative affect. Compared to the control groups, the treatment groups had significantly more positive facial expressions (p . 001) and positive body posture/movements (p . 001), but not more positive verbal displays on the ODAS. The treatment groups displayed significantly more contentment (p . 037) and interest (p . 028) than the control groups did on the AARS. For the negative affects on the AARS, the treatment groups had a shorter duration of sad behaviors (p . 007) than the control groups did. Comparison of VAS scales likewise showed that the treatment groups displayed more positive affect (p . 012). Discussion In contrast to other studies (e. . , Hoeffer et al. , 1997; Kim Buschmann. , 1999; Whall et al. , 1997), this study found no treatment effect on DB. The interventions were a synthesis of approaches believed to globally address â€Å"triggers† of DB and meet psychosocial needs (Boettcher, 1983). They did not address the specific factors that might have been triggering the particular behavior (Algase et al. , 1996). Such triggers include under/over stimulation, unfamiliar or impersonal caregivers, and particular individual unmet psychosocial needs. For example, aggression during bathing could stem from physical discomfort or rough handling (Whall et al. 1997). Interventions much more individually designed require development. Increasing DB across all groups was reflected in the DBS scores at 1-month follow-up. Two factors may explain this increase. First, the PNA had warned participants that they would be leaving. Second, the ADL and CB participants no longer received care from the familiar PNA, and PSA, CB, and placebo participants no longer had a daily activity or visit. The increased stress and time constraints for NHNA as they resumed caregiving of the ADL and CB participants may explain the heightened DB in the control groups. Such changes may trigger increased behavioral symptoms in persons with dementia (Hall, Gerdner, Zwygart-Stauffacher, Buckwalter, 1995). Two measurement issues may have affected outcomes. First, observers view behaviors differently (Whall et al. , 1997) and come to expect particular behaviors from certain residents (Hillman, Skoloda, Zander, Stricker, 1999). If the NHNA were accustomed to a participant’s DB pattern, such as persistent screaming, they may have overlooked decreases in that behavior. Initial training and retraining of raters occurred as needed; however, some Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 225 TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and Time Period No Intervention (n = 19) Mean (SD) 408. 71 (427. 24) 303. 69 (408. 44) 281. 97 (410. 85) 418. 31 (630. 58) 292. 85 (405. 15) 114. 66 (202. 89) 90. 85 (182. 70) 77. 98 (173. 15) 130. 92 (257. 12) 128. 20 (195. 67) 191. 97 (157. 75) 117. 11 (112. 30) 118. 23 (137. 08) 154. 46 (225. 05) 100. 45 (153. 30) 55. 16 (74. 70) 42. 89 (54. 54) 33. 26 (47. 06) 64. 72 (77. 89) 28. 09 (37. 02) (continues) DB Category Time Period DBS total Baseline ADL (n = 28) Mean (SD) 172. 51 (191. 47) 182. 45 (181. 3) 164. 56 (154. 95) 207. 22 (205. 58) 190. 70 (291. 06) 20. 67 (30. 52) 32. 59 (51. 29) 15. 02 (26. 10) 44. 18 (100. 62) 21. 45 (36. 47) 95. 50 (105. 28) 87. 58 (87. 58) 85. 04 (89. 60) 88. 81 (85. 69) 148. 75 (187. 28) 22. 85 (32. 10) 28. 37 (32. 50) 21. 15 (26. 54) 30. 72 (48. 95) 18. 28 (24. 55) PSA (n = 29) Mean (SD) 348. 02 (467. 50) 306. 81 (393. 03) 303. 24 (367. 54) 373. 17 (533. 05) 300. 20 (366. 42) 85. 87 (199. 01) 83. 94 (167. 53) 82. 82 (166. 93) 113. 49 (235. 71) 81. 30 (151. 85) 162. 41 (206. 65) 130. 82 (142. 72) 133. 92 (145. 97) 141. 47 (188. 99) 164. 92 (223. 63) 49. 64 (93. 15) 43. 80 (64. 6) 37. 90 (53. 43) 54. 47 (90. 33) 40. 26 (45. 26) CB (n = 22) Mean (SD) 287. 66 (373. 73) 300. 84 (379. 33) 286. 21 (365. 78) 374. 10 (510. 10) 312. 83 (433. 18) 68. 84 (126. 18) 67. 14 (137. 79) 61. 04 (127. 78) 92. 68 (205. 52) 60. 40 (131. 54) 136. 67 (189. 03) 124. 64 (164. 49) 125. 99 (157. 78) 159. 97 (202. 75) 146. 53 (201. 83) 34. 49 (55. 91) 40. 73 (52. 60) 31. 18 (33. 85) 36. 95 (42. 70) 32. 82 (51. 32) Placebo (n = 29) Mean (SD) 325. 96 (337. 14) 337. 60 (328. 94) 336. 80 (366. 55) 389. 92 (434. 43) 319. 15 (384. 59) 49. 26 (90. 24) 62. 10 (112. 71) 59. 67 (106. 37) 76. 79 (165. 45) 48. 25 (101. 4) 167. 01 (177. 80) 164. 62 (161. 48) 175. 36 (189. 80) 201. 68 (212. 06) 87. 67 (127. 38) 47. 20 (79. 70) 39. 55 (57. 74) 32. 69 (55. 77) 29 . 30 (47. 60) 30. 18 (52. 85) Intervention Postintervention 1 month follow-up 2 month follow-up Physically aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Physically nonaggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Vocally aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up 226 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and Time Period (Continued) NoIntervention (n = 19) Mean (SD) 47. 65 (97. 22) 68. 32 (103. 13) 68. 01 (116. 62) 84. 50 (112. 48) 73. 07 (117. 12) DB Category Time Period Vocally agitated Baseline ADL (n = 28) Mean (SD) 33. 49 (84. 39) 33. 91 (62. 52) 43. 17 (72. 10) 43. 48 (64. 39) 50. 53 (117. 95) PSA (n = 29) Mean (SD) 46. 92 (98. 70) 52. 84 (96. 03) 52. 50 (90. 78) 68. 22 (98. 89) 48. 89 (92. 33) CB (n = 22) Mean (SD) 62. 49 (98. 97) 70. 43 (110. 85) 69. 08 (107. 29) 82. 14 (118. 97) 75. 80 (129. 67) Placebo (n = 29) Mean (SD) 50. 0 (92. 05) 48. 25 (81. 63) 48. 59 (72. 20) 63. 74 (95. 30) 54. 11 (80. 61) Intervention Postintervention 1 month follow-up 2 month follow-up Note. Scores were created by assigning each behavior with a severity weight prior to summing and then averaging across day and then week(s). DBS = disruptive behaviors; ADL = activities of daily living intervention; PSA = psychocial activity inte rvention; CB = combination of the two interventions. NHNA appeared to continue to consider participants’ behaviors, such as repetitive questioning, to be personality characteristics or attention-seeking efforts rather than DB. Thus, they may have under-reported behaviors. Further, staff may prefer withdrawn behaviors, such as isolating self and muteness (Camberg et al. , 1999), and view them as nonproblematic. Second, categorizing a behavior as disruptive without understanding its meaning to the person with dementia may be conceptually flawed. For example, screaming may express pain or self-stimulation. Two design features may explain differences between the findings of this study and others. First, this study had both placebo and no intervention control conditions. Just a few other studies randomized subjects to treatment or control groups or included two control groups (e. g. , Camberg et al. , 1999). In most studies, control conditions preceded or followed treatment conditions (e. g. , Clark, Lipe, Bilbrey, 1998). In both designs, subjects served as their own controls, which limits examination of simultaneous intra- and extra-personal events that might affect DB frequency. Second, many control groups came from separate units or different nursing homes (e. g. , Matteson et al. , 1997), which makes it difficult to control for differences in environment, staff relationships, and personalities. This study occurred at seven sites in two different geographical areas, but at each site, the randomization of female participants distributed the groups across all nursing units to control for environmental and staff characteristics. Acknowledged limitations include the following. First, in spite of the large overall sample, the group sizes were small (range 19–30) with the greatest loss in the no inter- vention group. Larger groups might have provided more definitive findings on the relationship between behavioral interventions and DB frequency as Rovner et al. (1996) did (treatment group 42; control group 39). Second, NHNA served as data collectors because using independent observers would have been cost-prohibitive. These results suggest that future intervention research should consider the individual characteristics of the person with dementia (Maslow, 1996) and the triggers of the behavior (Algase et al. , 1996). Studies that have individualized interventions have demonstrated decreased DB (Gerdner, 2000; Hoeffer et al. , 1997). Researchers need to continue to refine methods for identifying what works for whom (Forbes, 1998) to minimize the prevalent trial-anderror approach to DB management.