University of Missouri - Saint Louis

The Graduate School


An oral examination in defense of the dissertation for the degree

Doctor of Philosophy in Nursing

Marylois Lacey
M.S. in Nursing, May, 1988, Psychiatric Mental Health Clinical Nurse Specialist, University of Central Arkansas, Conway
B.S. in Nursing, May, 1977, University of Arkansas Medical Sciences, Little Rock

Factors Mediating Disruptive Behaviors in a Veteran Affairs Medical Center



The healthcare industry leads all other service oriented industries in nonfatal assaults against workers with 45% resulting in lost work days in the U.S. with nurse aides, orderlies, and attendants suffering the most non-fatal assaults resulting in injury (Janocha & Smith, 2010). Although the Veteran Health Administration implemented a directive requiring all Veteran Affairs Medical Centers to implement a standardized curriculum for the prevention and management of disruptive behavior, the program has not prevented patient on healthcare worker assaults. Disruptive behaviors are often related to care giving situations in which the patient wants something that is not possible, refuses to participate in what is required, demands instant gratification, demands immediate emotional support which results in limit setting, activity demand, and denial of request by a health care provider which serve as antecedents to disruptive behavior (Wellman & Taylor, 2003; Quanbeck et al, 2007; Newbill et al, 2010). This study sought to answer the following questions when disruptive behavior occurs: (a) Is there an association among code greens and symptoms of a medical and or psychiatric diagnosis, denial of a request, limit setting, and or activity demand? (b) Are code green events more likely to be associated with denial of request, limit setting and or activity demand likely to result in verbal de-escalation, chemical restraint, or physical restraint? and (c) Is there a relationship between incidents of disruptive behavior, time of day, and nursing staff man hours? Study findings demonstrated a significant relationship between denial of request and time of day (p = 0.0308) which was coded as leaving against medical advice. Veterans were more likely to be given medication or restrained (p = 0.009) when disruptive behavior was associated with refusal of treatment and or activity demand.

Over a three year period, there were a total of 432 code green incidents. In this investigation, clearly caritas literacy, the premise of the caring prevention and management of disruptive behavior model, was present in that the nursing staff engaged caring actions and used verbal de-escalation 46.76% of the time. When verbal de-escalation was not as effective, chemical restraint the mildest from of restraint was used 32.64% of the time and manual hold was used 14.58% only to keep the disruptive veteran from hurting themselves. Mechanical restraint, seclusion, and turn over to the police (absence of caritas literacy) were used less than five percent of the time a clear indication that the nursing staff at the Veterans Affairs Medical Center used forceful measures only as a last resort.


Date: November 22, 2013

Time: 10:00 a.m. – 12:00 p.m.

Place: Conference Room 2 Nursing Administration Building


Defense of Dissertation Committee


Jean Bachman, Ph.D., Advisor

Wilma Calvert, Ph.D.


Judy Maserang, Ph.D.

Justin Springer, Ph.D.