ARTICLE

Distress experienced by nurses in response to the challenging

behaviour of residents – evidence from German nursing homes
Sascha G Schmidt, Martin N Dichter, Rebecca Palm and Hans Martin Hasselhorn

Aims and objectives. The aim of this research is to investigate the degree of distress experienced by nurses in response to the
challenging behaviour of nursing home residents (residents’ challenging behaviour) and their impact on nurses individual
resources (general health, burnout and work ability).
Background. Because of the increasing and ageing population of nursing home residents, professional nursing care faces sev-
eral challenges. One highly prevalent issue among nursing home residents is the so-called ‘challenging behaviour’. However,
to date, ‘challenging behaviour’ has not yet been recognised as an occupational stressor, and the extent of the impact of
‘challenging behaviour’ on nurses’ well-being and functioning is not well understood.
Design. Cross-sectional study.
Method. Self-report questionnaire data collected from 731 registered nurses and nursing aides in 56 German nursing homes
were used in a secondary data analysis. The level of residents’ challenging behaviour-related distress that nurses experienced was
assessed using a scale consisting of nine questions. Validated instruments were used for the assessment of individual resources.
Results. The mean score for residents’ challenging behaviour-related distress was 41
3 (SD 21
2). Twenty-seven per cent of
all nurses reported over 50 residents’ challenging behaviour. Residents’ challenging behaviour had a significant impact on all
three measures of individual resources. Specifically, nurses exposed to frequent residents’ challenging behaviour reported a
significantly lower quality of general health, reduced workability and high burnout levels.
Conclusion. Our findings indicate that residents’ challenging behaviour-related distress is a significant work place stressor
for nurses in nursing homes with a clear impact on general health, the risk of burnout and work ability.
Relevance to clinical practice. Our findings suggest that residents’ challenging behaviour is a stressor for nurses in nursing
homes. Further scientific and practical attention is necessary from the point of view of working conditions for nurses. The
development of preventive concepts for nursing staff and residents is recommended.

Key words: burnout, challenging behaviour, general health, nurses, nursing homes, work ability

Accepted for publication: 8 September 2012

increasingly challenging not only for the nurses themselves

Introduction
but also for the healthcare systems. There are several chal-
Working in nursing homes (NH) is a job that is both fulfill- lenges that nurses and NHs have to confront every day,
ing and demanding. In developed countries, this work is including the ageing population, the increasing number and

Authors: Sascha G Schmidt, MScN, RN, Research Assistant,
Nursing Research Section, Institute for Safety Technology, Uni-
versity of Wuppertal, Wuppertal; Martin N Dichter, MScN, RN,
Research Assistant, German Center for Neurodegenerative Dis-
eases, Witten; Rebecca Palm, MSc, RN, Research Assistant, Ger-
man Center for Neurodegenerative Diseases, Witten; Hans
Martin Hasselhorn, PhD, Professor, Department of Work and
Health, Federal Institute of Occupational Health, BAuA, Berlin,
Germany
Correspondence: Sascha G Schmidt, Research Assistant, Nursing
Research Section, Institute of Safety Technology, University of Wup-
pertal, Gaussstrasse 20, 42097 Wuppertal, Germany. Telephone:
+49 202 439 3321.
E-mail: saschmi@uni-wuppertal.de

© 2012 Blackwell Publishing Ltd

3134 Journal of Clinical Nursing, 21, 3134–3142, doi: 10.1111/jocn.12066
Article
multimorbidity of residents and the high rates of residents
with dementia today (Jakob et al. 2002, Matthews &
Dening 2002, Advisory Council on the Assessment of
Developments in the Health Care System 2009, Beske
2011). The extent of these challenges is only expected to
increase in the future (Wancata et al. 2003, Ferri et al.
2005).
Since 1999, the number of nursing home residents in
Germany has increased by about 27% to approximately
717,000 residents in almost 12,000 nursing homes in 2009
(German Federal Statistical Office 2011). Dementia and its
course of development presents several risks for nursing
home admission such as the severity of cognitive impair-
ment, a high dependence on others in the basic activities of
daily living, behavioural symptoms and depression (Gaugler
et al. 2009, Rothgang et al. 2011). Behavioural symptoms
are highly prevalent and involve a range of challenging
behaviour such as aggressive behaviour (Kolanowski 1995),
verbally disruptive behaviour (Bourbonnais & Ducharme
2008), wandering (Everitt et al. 1991) and passive, apa-
thetic behaviour (Colling & Buettner 2002). Challenging
behaviour is frequently perceived as unpleasant, disturbing
or frightening (Cohen-Mansfield 2003). Studies examining
the prevalence of challenging behaviour in German nursing
homes have found that up to 90% of the residents with
dementia show symptoms of challenging behaviour (Schäuf-
ele et al. 2009), whereas 30% of residents without a diag-
nosis of dementia also show a few of the described
behavioural symptoms (Schäufele et al. 2009, Hardenacke
et al. 2011). The most prevalent challenging behavioural
symptoms exhibited by nursing home residents in Germany
included depressive symptoms (exhibited by all residents),
followed by aggression in residents with dementia and irri-
tability in residents without dementia (Schneekloth & Wahl
2007).
Institutions have been forced to respond by changing
their residential structure. In particular, many nursing
homes in Germany have established dementia-specific care
units and implemented dementia-specific care concepts
(Weyerer et al. 2006, 2010). Special guidelines for handling
the challenging behaviour of residents with dementia in
nursing homes have been published (Bartholomeyczik et al.
2007).
However, there is one area that has not received enough
attention to date. All of the behavioural symptoms listed
above are assumed to be stressful and challenging, not
only for the residents themselves, but also for the staff.
For example, staff who are frequently confronted with
challenging behaviour tend to be more anxious and less
satisfied (Jenkins et al. 1997). Challenging behaviour has
© 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 3134–3142
Nurses distress due to the challenging behaviour
been found to be a work stressor that adversely affects the
well-being of nurses (Rodney 2000, Franz et al. 2010).
The increasingly high prevalence of residents’ challenging
behaviour (RCB) and the adverse impact it may have on
the nursing workforce emphasise the need for more scien-
tific evidence concerning the consequences of RCB on the
individual resources (including general health, burnout and
work ability) of nurses. A better understanding of these
consequences may help to promote the individual
resources of the nursing staff and the well-being of the
residents. Therefore, the aim of this research is to investi-
gate the intensity of distress due to the challenging behav-
iour of residents (i.e. RCB-related distress) experienced by
nursing staff in German nursing homes and the effect on
individual resources. Three main research questions were
examined:
1 How frequently does the nursing staff in German nursing
homes experience distress related to the RCB?
2 What are the socio-demographic and occupational char-
acteristics associated with RCB-related distress?
3 What is the impact of RCB-related distress on nurses’
individual resources, such as general health, burnout and
work ability?
Methods
Research design and sample
For this secondary data analysis, we used cross-sectional
data from the German 3Q-Study, a self-administered paper
and pencil survey among nurses and nursing aides. The
3Q-Study, which was launched in 2007, is a research pro-
ject aiming to investigate the interconnectedness among
working conditions, nursing outcomes and economic indi-
cators in German nursing homes. This investigation was
based on data from a 2009 staff survey of 56 nursing
homes throughout Germany. The 56 nursing homes were
institutions belonging to a welfare organisation with resi-
dents numbering between 23–143 (Median = 80 residents).
Instruments
Residents’ challenging behaviour–related distress index
The RCB-related distress index was developed by the
researchers who conducted the 3Q-Study. It consists of nine
questions concerning the degree of perceived distress in
response to specific caring scenarios characterised by RCB.
Eight questions were developed on the basis of ten behavio-
ural areas defined in the Neuropsychiatric Inventory Nurs-
ing Home Version, NPI-NH (Wood et al. 2000, Advisory
3135
SG Schmidt et al.

Table 1 Factor matrix of distress in response to residents’ challenging behaviour and the distribution of responses

Factor Cronbach’s alpha, Does not stress Stresses me Stresses me a

loadings when item deleted n me at all (%) somewhat (%) lot (%) Mean SD

Hallucination in residents 0
779 0
841 723 29
3 56
3 13
8 1
85 0
64
Contact with labile residents 0
768 0
843 731 23
3 64
0 12
7 1
89 0
59
Contact with anxious residents 0
767 0
844 729 35
5 55
1 9
7 1
75 0
62
Dealing with depressed and 0
710 0
849 731 22
2 62
9 14
9 1
93 0
61
apathetic residents
Contact with euphoric residents 0
699 0
851 725 52
6 44
8 2
6 1
50 0
55
The limited communication ability 0
684 0
852 728 25
5 60
2 14
3 1
89 0
62
of residents
Contact with uninhibited residents 0
670 0
854 726 28
1 58
7 13
2 1
85 0
62
The aggressiveness of residents 0
592 0
861 727 19
2 59
1 21
6 2
02 0
64
Contact with residents with abnormal 0
582 0
862 724 36
0 53
2 10
8 1
75 0
64
motoric behaviour
Eigenvalues 4
386
Total variance 48
74%
Cronbach’s a 0
87

Council on the Assessment of Developments in the Health

Care System 2009). As shown in Table 1, the items cover the
degree of perceived distress caused by different behavioural
characteristics (aggression, depression/apathy, hallucinations/
delusions, anxiety, euphoria, disinhibition, irritability/lability,
aberrant motor behaviour), for example, ‘The contact with
labile residents distresses me’ or ‘The contact with anxious
residents distresses me’. Based on Everitt et al.(1991), the
response categories were as follows: 1 = does not stress me at
all; 2 = stresses me somewhat; and 3 = stresses me a lot. We
included one additional item that probed the level of distress
due to limited possibilities of communicating with the residents.
A principal component analysis showed that all nine
items loaded significantly on the first principal component.
The Kaiser–Meyer–Olkin measure verified the sampling
adequacy for the analysis (KMO = 0
93), and the relations
between the items were sufficient (v2(36) = 2566
29;
p < 0
001) (Field 2009). A one-component solution was
identified with eigenvalues over Kaiser’s criterion of 1 with
item loadings ranging from 0
58–0
78. The one factor
explained 48
7% of the total variance (Table 1). High inter-
nal consistency (Cronbach’s a = 0
87) confirmed the homo-
geneity of this newly developed scale (Streiner & Norman
2003). All item scores were summed to the RCB-related
distress Index. The transformed index ranged from 0 (not
distressed) to 100 (highly distressed). For further analysis,
the participants were categorised into three RCB-related
distress groups: ‘no or low’ distress (0–25), ‘moderate’
distress (>25–50) and ‘high’ distress (>50). The RCB-related
distress index was used as the dependent variable. In addi-
tional analyses, the trichotomised index was used as the
independent variable.
General health
General health was assessed with a single item based on the
EQ-5D (The EuroQol Group 1990) that assesses current
subjective general health, as proposed in the German
COPSOQ validation study (Nübling et al. 2005). Partici-
pants rated their current health status using a 10-point Lik-
ert-type scale ranging from 0 (worst imaginable health
status) to 10 (best imaginable health status). The scale was
later transformed to range from 0–100.
Burnout
Burnout was assessed with the four-item personal burnout
scale from the Copenhagen Psychosocial Questionnaire
(COPSOQ), second version (Pejtersen et al. 2010). The
items represent the short version of the personal burnout
scale from the Copenhagen Burnout Inventory (CBI) devel-
oped by Kristensen et al. (2005). Participants had to indi-
cate on a five-point scale the frequency at which they ‘felt
worn out’, ‘been emotionally exhausted’, ‘been physically
exhausted’ or ‘felt tired’. The response categories ranged
from ‘(almost) never’ to ‘(almost) every day’. As was done
with general health, the burnout scale was transformed to
range from 0–100. Higher scores represented more severe
burnout. Data for this scale yielded a Cronbach’s a of 0
92,
which is higher than the value reported in the validation
study of the CBI (a = 0
83) (Pejtersen et al. 2010).
Work ability
Work ability as a personal resource is an important compo-
nent of the broader concept of employability. The Work
Ability Index (WAI), which was developed by the Finnish

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3136 Journal of Clinical Nursing, 21, 3134–3142
Article
Institute of Occupational Health (FIOH) as an instrument
mainly for the occupational health settings (Tuomi et al.
1991), was used in the 3Q-Study. The WAI is a validated
seven-dimension instrument for assessing the compatibility
between workers and their present jobs, with the scores
ranging from 7–49 (Hasselhorn & Freude 2007). Work
ability is considered poor with a score of 7–27, moderate
with a score of 28–36, good with a score of 37–43 and
excellent with a score above 43 (max. 49). Cronbach’s
alpha for the WAI was 0
81 [compared with Cronbach’s
a = 0
83 in the validation study (Tuomi et al. 2001)].
Background data
The socio-demographic data used in this analysis included
gender, age and family status. The occupational characteris-
tics focused on qualification, occupational position and
professional seniority (years worked in nursing). All socio-
demographic and occupational characteristics were assessed
with single items.
Procedure
The data in the 3Q-Study were collected from all nursing
home employees: nursing, social services, kitchen, adminis-
trative and technical/cleaning staff (n = 2933). The ques-
tionnaires were distributed to nursing home staff with a
page of information about the 3Q-Study and a prepaid
envelope for returning the completed questionnaires to the
research team. The participation in the survey was anony-
mous and voluntary. Confidentiality of all data was
assured. The overall response rate was 43%. This analysis
was based on the responses to the RCB-related distress
index from 731 registered nurses and nursing aides who
worked in a ward with residents with dementia.
Ethical considerations
The 3Q-Study received approval from the ethical committee
of the University of Wuppertal. In addition, written consent
from the employee representative committee at each of the
nursing homes was obtained.
Data analysis
Descriptive statistics were analysed in relation to socio-
demographic and occupational characteristics, RCB-related
distress and individual resources’ outcomes. Additional inde-
pendent t-tests and one-way ANOVAs were also performed.
A multivariate regression model was constructed to evaluate
the explanatory relationships between the socio-demographic
© 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 3134–3142
Nurses distress due to the challenging behaviour
and occupational characteristics as independent variables
and the RCB-related distress as the dependent variable. Anal-
yses of covariance (ANCOVA) were conducted for the three
individual resources (general health, burnout and WAI), with
each one as a dependent variable and the three distress-based
groups of participants (‘no or low’ distress, ‘moderate’
distress and ‘high’ distress) as independent variable and using
the significant socio-demographic and occupational charac-
teristics variables from the regression model as covariates.
All analyses were performed using the program SPSS 19.0
(SPSS Inc., Chicago, IL, USA). p-values of <0
05 were con-
sidered statistically significant.
Results
Characteristics of the sample and the residents’
challenging behaviour-related distress Index
Qualified nurses with at least three years of training composed
the largest part of the sample (64
8 vs. 35
2%). The partici-
pants had worked for an average of almost 14 years in the
nursing sector (including nursing training). The mean age of
the sample was 41
9 years (SD 10
7) with a range of
18–68 years. The group of qualified nurses was younger than
the group of nursing aides (mean = 41
3 years SD 10
6 vs.
mean = 43
0 years SD 10
8; t(729) = 6
39, p = <0
001) and
had worked for a longer length of time in the nursing care
setting (mean = 14
7 years SD 8
8) vs. mean = 11
2 years SD
8
7; t(713) = 5
12, p = <0
001). The majority of the partici-
pants were women (86
9%) who lived with a partner or with
a partner and child/children (75
6%).
The mean score on the newly developed RCB-related
distress index was 41
3 (SD 21
2) and ranging from 0–100.
Twenty-five per cent of all nurses had scores  25 points (no
RCB-related distress), almost half of the sample (48%) had
scores between 25 and  50 (moderate RCB-related distress)
and 27% of all nursing staff had an RCB-related distress index
exceeding 50 (high RCB-related distress). The single item
associated with the highest reported RCB-related distress was
aggressiveness (mean = 2
02 SD 0
64), followed by depressive
behaviour (mean = 1
93 SD 0
61). The item associated with
the least distress was contact with euphoric residents, with
almost 53% of the responding nurses stating that this type of
exposure did not stress them at all (Table 1).
Characteristics associated with residents’ challenging
behaviour-related distress
To explore the strength of the association between the socio-
demographic and occupational characteristic variables on
3137
SG Schmidt et al.

RCB-related distress and to select variables for inclusion in
further analyses as covariates, a multiple regression model
was tested. The included characteristic variables explained
only 1% of the variability on the RCB-related distress index.
Only the age of the nurses was significantly associated with
RCB distress (b = 0
12; p < 0
001) (Table 2).
Residents’ challenging behaviour-related distress and
individual resources
terms of general health, burnout and the Work Ability Index
were calculated. RCB-related distress had an effect on all three
variables, even after adjusting for age. The nursing staff in the
‘high’ RCB-related distress group reported significantly higher
burnout values (age-adjusted mean = 56
5), the lowest general
health scores (age-adjusted mean = 59
0) and lowest work
ability scores (age-adjusted mean = 35
6). Post hoc tests indi-
cated significance for all differences between the three distress
groups with respect to all three types of individual resources.

Table 3 shows results corresponding to the impact of RCB-

Discussion
related distress on the three types of individual resources.
Based on the RCB-related distress Index, participants were The aim of these analyses was to investigate the distress
divided into three groups (‘no or low’ distress, ‘moderate’ dis- experienced by nurses due to the challenging behaviour of
tress and ‘high’ distress), and the mean group differences in residents (RCB-related distress) in nursing homes and the
association of this distress with socio-demographic and
Table 2 Relations between socio-demographic and occupational occupational characteristics as well as indicators of individ-
characteristics and distress in response to residents’ challenging ual resources. The data were gathered via a cross-sectional
behaviour (RCB) among 731 nurses in German nursing homes and
survey of 731 nurses in 56 German nursing homes. To
multiple regression estimates for BCB-related distress
assess the level of distress experienced by nursing staff in
Multiple relation to RCB, we developed and evaluated the RCB-
RCB-related distress
Variables regression related distress Index. The results showed that the psycho-
(independent) n Mean SD t/F b
metric properties of this index were satisfactory, supporting
†
Age 3
51*** 0
12** the use of this index in future studies.
Under 45 393 38
7 21
0
45 and higher 298 44
3 21
2
Gender 1
75 0
04 Residents’ challenging behaviour as a stressor among
Female 628 41
8 21
1 nursing staff
Male 95 37
7 22
1
Family status 0
77 0
01 Descriptive statistics showed that nurses experienced a
Living alone 104 42
4 20
6 moderate level of RCB-related distress. In line with the
Single with kids 71 37
9 22
6 findings of Wood et al. (1999), the challenging behaviours
With partner 261 40
9 20
9
of residents perceived as most distressing were aggression
no kids
With partner 281 41
7 21
4 and depression/apathy.
and kids
Qualification 0
58 0
01
Nursing aid 257 41
9 22
0 Socio-demographic and occupational characteristics and
Registered nurse 474 40
9 20
8 their association with RCB-related distress
Occupational position 0
70 0
01
Management role 137 41
3 21
0
Our results indicate that occupational characteristics such
No management 583 41
4 21
3 as position and seniority had no influence on the RCB-
role related distress among nursing staff. In particular, we had
Years working in 2
26 0
03 expected the level of qualification to have an influence on
nursing distress and expected higher education or training to result
Up to 4 years 89 40
9 21
5
in stronger resilience. However, neither the level of qualifi-
5–8 years 146 37
3 20
1
9–14 years 212 42
1 21
4 cation nor the occupational position showed differences in
15 or more years 281 42
8 21
5 RCB-related distress. These results are inconsistent with
that reported in previous studies (Wood et al. 1999, Bro-
Multiple regression model: adj R2 = 0
006.
**p < 0
01.
daty et al. 2003), which identified higher qualification as a
***p < 0
001. buffer for distress by fostering the acquisition of better cop-
†
In the multiple regression model, age was included as a continued ing skills. This buffer effect was not found in our sample;
variable. thus, it may be that nursing education in Germany does not

© 2012 Blackwell Publishing Ltd

3138 Journal of Clinical Nursing, 21, 3134–3142
Article
Table 3 Residents’ challenging behaviour (RCB)-related distress index (three groups) and individual resources adjusted for age
Burnout
Mean
RCB-related distress index Low 34
2
Medium 42
5
High 56
5
F 34
9***
Adj R2 0
09***
***p < 0
001.
take this topic sufficiently into account. Furthermore, no
differences in working hours were identified.
Of the personal characteristics assessed, only age was asso-
ciated with RCB-related distress, although only to small
degree. Nurses above the age of 45 years reported higher dis-
tress than did younger nurses. Similar results were reported in
a study conducted by Brodaty et al. (2003). In this cross-
sectional study from Australia, strain related to dementia was
investigated in 253 nurses working in nursing homes, with the
results revealing that strain was positively associated with age.
Residents’ challenging behaviour-related distress and
nurses’ individual resources
Aspects of individual resources were assessed, with burnout
and general health being perceived as important aspects of the
nurses’ individual resources and well-being. The mean score on
the general health scale was good, approaching 68 points, but
was somewhat lower than in the value found in the German
COPSOQ validation study (mean = 71
8 SD 18
1) (Nübling
et al. 2005). The mean score on the burnout scale was higher
than that found in the validation study (mean = 43
9 SD 27
0
vs. mean = 34
1 SD 18
2) (Pejtersen et al. 2010).
In contrast, the Work Ability Index was higher than in the
value found in the German nursing home cohort that partici-
pated in the European NEXT-Study (36
2) (Simon et al. 2005).
The analysis showed a significant impact of RCB-related
distress on the individual resources of nurses. This finding is
in line with other results from the healthcare sector regard-
ing staff working with people with intellectual disabilities
(Mills & Rose 2011). Nurses with higher RCB-related
distress tended to show a higher rate of burnout and a lower
quality of general health. Burnout is associated with the like-
lihood for nurses to respond to their residents with negative
emotional reactions, a reduced willingness to help (Todd &
Watts 2005) and a higher tendency to leave the nursing pro-
fession (Leiter & Maslach 2009, Simon et al. 2010).
The group of nurses with the highest RCB-related distress
had the lowest work ability. Work ability is a measure for the
© 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 3134–3142
Nurses distress due to the challenging behaviour
General health WAI
95% CI Mean 95% CI Mean 95% CI
30
3–38
0 75
8 72
6–79
0 41
0 40
0–42
0
39
7–45
3 66
7 64
4–69
0 38
9 38
2–39
6
52
8–60
2 59
1 56
0–62
2 35
7 34
8–36
7
27
2*** 28
9***
0
08*** 0
11***
effectiveness with which a nurse meets his or her work
demands. It has a clear impact on the nurses’ quality of life
and, again, their tendency to leave the nursing profession
(Hasselhorn et al. 2005, Milosevic et al. 2011, Derycke et al.
2012). Our findings address one of the components that con-
stitute work ability and, therefore, highlight one area to target
in attempts to sustain the work ability of nurses.
Study limitations
The limitations of this study are as follows. First, there are sev-
eral aspects that we did not know concerning the management
of challenging behaviour in the nursing homes. It is unknown
whether strategies for handling challenging behaviour were
implemented or whether there were any supportive or relief
measures in place for the nurses. We assume that there were
differences between institutions in these respects. Another
aspect associated with the management of challenging behav-
iour on the part of the institution is the prevalence of such
behaviour. As we did not measure the frequency of challeng-
ing behaviour, we do not know whether this frequency had an
influence on the distress. However, a study conducted by Bro-
daty et al. (2003) showed significant differences between
nursing homes in terms of the levels of strain that were unre-
lated to levels of behavioural disturbances. At the same time,
the current findings could be constrained by the fact that we
sampled nursing staff from only one welfare organisation.
Conclusion
In spite of the limitations, the results imply that RCB-
related distress may be a workplace stressor for nursing
staff with corresponding impact on the risk of burning out,
general health and work ability. Older nurses are identified
as a group that is especially at risk.
Taken together with the increasing proportion of residents
with dementia and the simultaneously increasing proportion
of older nurses, our findings suggest that more scientific and
practical attention should be given to RCB. Another impor-
3139
SG Schmidt et al.

tant implication is the high turnover rate among nurses who
experience burnout, which is a serious problem in times of
nursing staff shortage.
It is necessary to conduct further assessments and
develop preventive interventions while considering the vari-
ous settings and features of nursing homes. Supervision,
case conferences and staff education are potential ways to
empower nurses in their management of RCB. At the
same time, further longitudinal research is needed to inves-
tigate ways of supporting nurses in their interaction with
residents with challenging behaviour (Farrell et al. 2010).
Interventions may focus on the needs of both the residents
and the nurses, thus enhancing the well-being and the
work ability of nurses and, in turn, ensure that they con-
tinue working in their chosen profession. Finally, nurses’
individual resources should be taken into consideration in
any future evaluations of interventions that target the
management of challenging behaviour.
Relevance to clinical practice
Residents’ challenging behaviour-related distress has serious
consequences for clinical practice. On the one hand,
perceived work-related stress in nurses can have negative
implications on the quality of care (Edvardsson et al.
2008). On the other hand, challenging behaviour affects
the residents themselves. Therefore, interventions aiming to
reduce challenging behaviour should focus on both the
nurses and the residents. A study conducted by Verkaik
et al. (2011a,b) involved the introduction of nursing guide-
lines concerning depression in dementia and reported posi-
tive effects on the perceived professional autonomy of
certified nursing assistants and a reduction in the severity
of depression among residents with dementia. The idea of
publishing nursing guidelines is promising, inviting future
development and scientific evaluations that take into
account both nurses and residents.
Based on our results, we recommend that nursing education
for advanced nurses includes a focus on managing challenging
behaviour and the subsequent distress that may be experi-
enced. Our findings on the association between RCB and dif-
ferent aspects of the nurses’ individual resources suggest an
increased need to focus on workplace health promotion and
organisational interventions for nurses in the context of their
work with people (residents). The development and imple-
mentation of those concepts is recommended and deserves
specific attention from the nursing home management to fos-
ter the development of attractive and healthy working condi-
tions for nursing staff.
Acknowledgements
The 3Q-Study was funded by the ‘New Quality of Work
Initiative’ (INQA) of the German Federal Institute for
Occupational Safety and Health (BAuA) and the Knights of
St. John Home for Elderly GmbH.
Contributions
Study design: HMH, SGS, MND; data collection and analy-
sis: SGS, MND and manuscript preparation: SGS, MD, RP,
HMH.
Conflict of interest
The authors declare that they have no conflict of interest.

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