Table 2 Quotes for themes and subthemes

Theme 1 Self-preparation: subthemes and quotes

Self-awareness

The resident has the SS, which may also be induced in me! (B339–340).

Often, residents may become confused. When I hear that an older woman is searching a scarf, I think: “Oh no, here she comes again, and know that today is going to be a bad day.” (B342–343).

Control my emotions and do not get angry! Do not be affected by older residents. I cannot let myself be disturbed by their emotions, even when they create disturbance. (B273–274).

Familiarity with residents and establishing trust

When an older resident shows emotions or the SS occurs, only staff with whom he/she is familiar can make him/her feel safe and at ease. (A196–197).

Identification of prodromal symptoms

If an older resident acts strange, we should not ignore or pretend to not him/her, as it is difficult to pacify him/her when his/her emotions appear. This will cause a chain reaction and result in difficulty in subsequent management. (B289–292).

When you can predict the appearance of the SS in a resident, arrange for him/her to rest or partake in an activity beforehand. (A173–175).

Exploration of possible causes

(Restless behavior) I think of what he/she wants to express. Is it due to a physical condition, like wanting to go to the toilet, hunger, dry mouth, or other problems that cause restless behavior? I will first satisfy his/her physiological needs. (C017–020).

Theme 2 Pacification: subthemes and quotes

Listening

When encountering an anxious or restless resident, I first hold his/her hand, ask him/her to sit down together, and ask what happened. How was he or she? (C022–031).

When an older resident shows emotions, or he/she is anxious or crying, I act with consideration and affection to pacify him/her! I listen to ascertain what he/she wants. (B156–159).

Empathy

(Resident who asks for her son every afternoon) Every time, she talks to me as I pacify her. I say, “Your son has found someone to take care of him and you need not worry. Please sit here and I will take you to find him later.” She says, “Later you must take me to him else I will cry.” I say, “You cannot cry. You have to sit here and wait.” She then sits down and forgets about it. Others say, “Your son is not a child but adult so do not worry about him.” However, in her memory, the son is at a stage where he requires her care… (A140–146).

Little white lies

When an older resident requests to go home, I say, “Please wait for a while because the unit is on a mountain. We do not have a vehicle to transport you home. Later I will call your son and ask him to come fetch you.” The resident says, “Really? Are you going to call him?” I reply, “You have to give me some time. I must go to the office to make a call. I will call him and ask him to come fetch you.” This pacifies the resident who forget the conversation after a while. (A017–025).

(Looking for family members) I say: “Oh no! The vehicle just left. Why are you looking for your family members? Why didn’t you say so earlier? You would have to sleep here tonight. There will be free transport tomorrow morning and the first bus can send you home.” This was used to pacify residents. (B078–081).

Role play

(Looking for exit, requesting to go home) We pretended to be her family members and called her to tell him that we were on the way to the institution. We used this method to make her think that her family members had called her, and she would accept any reason given by her fake family members, such as a car breakdown. (B093–100).

An older resident used to rush to the elevator saying that his daughter had called. So, we asked a female staff from another department to call him. After talking to the impersonator, he forgot about rushing to the elevator. (D045–046).

An older resident with persecutory delusions kept thinking that we were stealing his money and chased us. We would first hide in a room, with masks on, and then remove the masks and come out. He would think we were other people, and this pacified him. (D059–062).

Theme 3 Diversion: subthemes and quotes

Arranging individual activities

When the resident becomes restless, he/she will find things to do. These activities include asking older people to sort beans. A few older residents may need people to accompany them, sing, watch television, or want to perform certain activities quickly (B440–443).

Pandering to their interests

One method of diverting attention from older residents is to identify things that they like (B060–061).

Ascertain their preferences and give it to them. Assuming that they enjoy music, we first allow them to listen to music. In case they like to watch television or eat, we pander to their likes (D042–044).

In case they keep searching for an exit, wanting to go home, and wandering around anxiously, we first identify things they like, such as food or chatting, to distract their attention (C010–011). There are certain older residents who like cash; we ask their family members to bring stacks of fake currency notes for them to count (E313).

Changing the scene

I take the resident away from the scene (public space) and to his/her room. There, I spend 5–10 min to distract him/her by folding clothes or writing. After his actions become stable, I leave the room, periodically returning to see what he/she is doing (C100–104).

(Management of visual and auditory hallucinations) First, we guide him to another place, away from that environment, and then help him/her manage the emotion. This helps him/her forget about the hallucinations (D052–055).

Accompaniment by dedicated staff

At night, we have time to accompany the resident. For example, in case he/she wants to pack clothes, I help him/her pack. The accompaniment process can divert his/her attention; I ask him/her when did he/she buy these clothes? Which clothes does he/she like? This can divert his/her thoughts of returning home (B183–191).

Using technology

(When a resident is restless and wants to find his/her son) I tell him/her that the son is currently busy. I also show him/her a video of the son, which may not be effective, but it diverts his/her attention, resulting in slight calmness. I ask family members to record videos for the resident (E302–303).

After the resident sees his/her son on the mobile phone, who does not talk to him, his/her attention is slightly diverted (E306–307).

Heading off a disaster using reverse psychology

(Collective restless behavior) When a group of older residents quarrel, pacification does not suffice. Therefore, we say: “Why not directly fight? Why quarrel.” The residents feel embarrassed. At this point, we ask them to sing, partake in activities, or exercise. This transition is sometimes better than pacification (B293–299).

I say, “Wait! Wait! You can only quarrel after I say ‘Start’! The competition has not started yet, and winners can go overseas for a competition. It is a waste of your breath if you all quarrel now. After I say ‘Start,’ please quarrel all the way.” Then they laugh or even forget, or ask to sing or watch videos. Ke-liang Chu’s videos distract them, and they forget the entire incident (B300–305).

Theme 4 Non-suppression: subthemes and quotes

A safe environment

When residents disassemble curtains or things and move them around, we first observe them without interrupting them as it makes them angry. Therefore, we first pacify other roommates, and “let the resident move around a little.” When the resident is exhausted, he/she sits quietly. We then show concern for him/her and switch on his/her favorite television channel (A353–360).

For residents who keep wandering around, we allow them to do so. When they become tired, they sit down, point at the air and scold, and then resume walking. We follow behind the resident to prevent him/her from falling or knocking onto objects, or hitting other older residents. We just need to ensure their safety. This is how we handle them (C194–98).

Going with the flow

(Clamoring to go home) We open the door for them; telling them that it is not possible agitates them further (E104–106).

I fix a time with the resident, telling him/her that I would take him/her home at that time (E107).

(Rushing for lifts) There is an elevator in the unit whose doors do not open. We tell the resident that the elevator doors will open later, and bring him/her a chair to wait in the elevator lobby. The resident sits there quietly, awaiting the elevator doors to open (B107–113). (Using onsite facilities and equipment to go with the flow)

Cold treatment

Sometimes, we are unable to pacify an agitated resident. We just let him/her walk around. Additionally, we have other tasks to complete; therefore, we just let him/her be! Once we are free, we attempt to pacify him/her again. After a while, his/her agitation subsides, and he/she forgets what had just happened (A160–164).

(Agitated behavior in two or more people) We separate them and take them away from the scene to avoid affecting others. Sometimes, we take them for a walk, which leads to a slight improvement (B140–144).

(When aggressive behavior occurs) I take the resident to an open space and ask him/her to calm down. This is because he/she may shout if left at the scene, and hit us if we approach him/her. We are also afraid that he/she will fall; therefore, we first take him to an open space (D074–D076).

Theme 5 Collaboration: subthemes and quotes

Between colleagues

When an older resident becomes agitated and my methods prove ineffective, I seek help from my colleagues. They switch with me and accompany the resident on a walk to soothe his/her emotions (D035–037).

Support from residents

When several residents simultaneously become agitated, first we take the leader away. Often, other older residents without SS around the scene can play a role in the pacification. Usually, we arrange for them to chat and perform activities together, such as watching television. This helps pacify residents with SS (B248–252).

Support from non-clinical coworkers

A recently admitted, highly aggressive older resident was unmanageable for even 4–5 people. We sought assistance from security guards and administrative staff (D108–111).

In our entire institution, other external administrative staff could help. One day after dusk, an older resident kept wanting to go out and I had no choice but to take him on a big round around the park. However, he knew the location of the doors; therefore, we asked the security guard to lock the main door (D112–122).

Theme 6 Continuity of meeting: subthemes and quotes

Medication adjustment

Excluding sporadic cases, when family members called or the resident was brought out of the institution, if the frequency of problematic behavior increases even though there is no major change to his/her daily life, we verify the records, discuss, and may recommend the physician to administer drugs (C088–095).

For residents with more severe symptoms, we observe for a period of time to ascertain whether the dose be increased. If this was an occasional incident, we would not increase the dose as these mood-regulating drugs tend to cause them to fall (D093–095).

Enhancing safety precautions

Most of our efforts aim to prevent falls. These days, we rarely encounter emotional agitation. Unless the resident becomes agitated or is a hazard, the probability of using restraints is negligible (B447–449).

A while ago, an older resident wanted to climb the door; I restrained the resident with the help of two males. We knew about the resident’s condition; therefore, we temporarily restrained him for safety (A414–419).