EVALUATING THE IMPACT OF AN EVIDENCE-BASED TOOL ON
HEALTHCARE STAFF’S PERCEPTION OF AGGRESSION IN PATIENTS
WITH DEMENTIA
By
Stacy Lemley, MSN, RN
MSN, Pennsylvania Western University, 2024
BSN, Waynesburg University, 2016
A DNP Project Submitted to Pennsylvania Western University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
December, 2025

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Patients with Dementia
Committee Signature Page

Student’s name_______Stacy Lemley, MSN, RN______________________________________

Student’s name

Committee Chairperson

Committee Member_

Committee Member__

ii

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Acknowledgements
First and foremost, I thank God for providing me with the strength, guidance, and
perseverance to complete this journey. To my husband Mickey, your unwavering love, patience,
and constant encouragement have been my foundation throughout this process. A heartfelt thank
you to my sister Kim and brother-in-law Rick Miller for your continual belief in me and your
encouraging words. I am also grateful to Mira Headley and Brenda Bowers, who work alongside
Kim, for lifting me up in prayer. Your spiritual support has been a source of strength.
I would like to recognize Dr. Amanda Lee Fischer, who served as an instructor during my
BSN program. Her belief in my potential and encouragement during challenging times laid the
foundation for my academic and professional growth. I am truly thankful for her lasting
influence.
My sincere gratitude goes to Dr. Nicole Evanick and Dr. Meg Larson for their academic
guidance and mentorship throughout my doctoral project. I am especially grateful to Maxine
Cantis, Kristy Burkhart, Ashley Blair, Shayln Danser, and Joshua Morrison. Your expertise,
feedback, and unwavering support during the development and implementation of this project
were invaluable.
To the dedicated staff of 6 North and all who went above and beyond to support this
project, thank you. Your participation, enthusiasm, and commitment to improving patient care
made this work possible. To everyone who supported and inspired me along the way, your
kindness and generosity will always be remembered.

iii

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Stacy Lemley, MSN, RN
Abstract
Aggressive behaviors in dementia care settings significantly impact staff perceptions, patient
interactions, and overall safety. This quality improvement project examined whether structured
communication training, combined with the Cohen-Mansfield Agitation Inventory (CMAI),
influenced healthcare staff’s perceptions of aggression in patients with dementia compared with
no structured training or tool use. Guided by Jean Watson’s Theory of Human Caring and the
Transtheoretical Model of Behavior Change, the project emphasized empathetic, patient-centered
care and staff behavior change. A quasi-experimental pre-post design was implemented over six
weeks in an acute care unit with a high population of dementia patients. Staff completed
perception surveys before, during, and after the intervention to measure changes in confidence,
recognition of behavioral triggers, and understanding of aggressive behaviors. Post-intervention
results showed measurable improvement across all evaluation points. Staff reported increased
confidence in managing aggression, greater recognition of behavioral triggers, and improved
teamwork. Quantitative data demonstrated steady progress in confidence and perception scores,
while qualitative feedback reflected calmer, more intentional communication during episodes of
aggression. Conclusions supported all project hypotheses, confirming that integrating structured
communication training with a behavioral assessment documentation tool enhanced staff
preparedness, compassion, and safety in dementia care. Recommendations included continuing
the CMAI and MESSAGE training as part of staff orientation and annual competencies to sustain
progress. Expanding implementation to additional units and evaluating long-term sustainability
would strengthen system-wide safety, collaboration, and quality improvement in the care of
patients with dementia.

iv

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Table of Contents
Preliminary Pages
Committee Signature Page…………………………………………………………………. .. ii
Acknowledgements ............................................................................................................... . iii
Abstract ................................................................................................................................. . iv
Table of Contents .................................................................................................................. ... v
List of Tables ......................................................................................................................... vii
List of Figures ....................................................................................................................... viii
Chapter 1: Introduction to the Study
Introduction ..........................................................................................................................
Background, Context, and Theoretical Framework .............................................................
Problem Statement ...............................................................................................................
Purpose of the Project ..........................................................................................................
Research Questions and Hypotheses ...................................................................................
Rationale, Relevance, and Significance of the Project ........................................................
Nature of the Project ............................................................................................................
Definition of Terms ..............................................................................................................
Assumptions, Limitations, and Delimitations .....................................................................
Summary and Organization of the Remainder of the Project .............................................

....1
....2
....4
....5
....5
....7
....9
..10
..12
..15

Chapter 2: Literature Review
Introduction to the Literature Review ................................................................................. ...17
Theoretical and Conceptual Framework ............................................................................. ...19
Review of the Literature ...................................................................................................... ..20
Quantitative Studies ......................................................................................................... ......22
Qualitative Studies ........................................................................................................... ......24
Emerging Patterns in Literature........................................................................................ ......25
Study Designs..................................................................................................................... .....40
Instrumentation ................................................................................................................ ......44
Methodology …………………………………………………………………………… ......47
Synthesis of Key Literature for Practice ………………………………………………. ......49
Summary …………………………………………………………………………………... ..51
Chapter 3: Methodology
Introduction ......................................................................................................................... ...54
Research Question(s) or Hypotheses.................................................................................... ..55
Research Methodogy............................................................................................................. .. 57
Research Design ......................................................................................................................59
Population and Sample Selection......................................................................................... ...63
Instrumentation or Sources of Data ..................................................................................... ..66
Validity ………………………………………..................................................................... .. 69
Reliability . ........................................................................................................................... ...70
Data Collection and Management ........................................................................................ ...71
Data Analysis Procedures …………………………………………………………………. ..73
v

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Ethical Considerations ………………………………………………………………… ........75
Limitations and Delimitations ……………………………………………………………... 76
Summary …………………………………………………………………………………… .77
Chapter 4: Data Analysis and Results
Introduction ........................................................................................................................... . 79
Descriptive Findings ……………………............................................................................. . 80
Data Analysis Procedures ……………………………......................................................... ..84
Results ……………………………………………………………………………………… .89
Summary ……………............................................................................................................ .94
Chapter 5: Summary, Conclusions, and Recommendations
Introduction and Summary of Study ..................................................................................... ..96
Summary of Findings and Conclusions ................................................................................ ..97
Implications ….......................................................................................................................100
Recommendations for Future Research ................................................................................ 105
References
……………………………………………………………………………………………....108
Appendices
Appendix A: IRB Approval Letter ........................................................................................ 121
Appendix B: Permission Letters and Copy of Instruments ...................................................122
Appendix C: Informed Consent ………….......................................................................... ..131

vi

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
List of Tables
Table

Page

1. Methodology Summary………………………………………………………………...60

vii

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
List of Figures
Figure
1.
2.
3.
4.
5.
6.
7.
8.

Page
Caption of figure one…………………………………………………………… .......86
Caption of figure two……………………………………………………………… ...87
Caption of figure three………………………………………………………………. 88
Caption of figure four……………………………………………………………… ..88
Caption of figure five………………………………………………………… ...........81
Caption of figure six………………………………………………………………….92
Caption of figure seven…………………………………………………………… …92
Caption of figure eight………………………………………………………………. 93

viii

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Patients with Dementia

CHAPTER ONE: INTRODUCTION
Introduction
Healthcare professionals often face difficulties when supporting individuals with
dementia, especially as incidents of aggressive behavior become more common in clinical
settings. Such behaviors can put both patients and staff at risk and interfere with the ability to
provide safe, high-quality care. Although many institutions offer general training for healthcare
staff, these programs often fall short in preparing staff with the specific skills and confidence
required to respond effectively to aggression associated with dementia. As a result, there is a
critical need for targeted training interventions that incorporate standardized assessment tools to
promote consistent, evidence-based responses to these complex situations.
This quality improvement project evaluated whether integrating the Cohen-Mansfield
Agitation Inventory (CMAI) with structured communication training enhanced healthcare staff’s
ability to recognize, assess, and respond to aggression in patients with dementia. The
intervention was grounded in the Transtheoretical Model of Behavior Change and Jean Watson’s
Theory of Human Caring. Together, these frameworks supported sustainable practice changes by
addressing staff readiness while reinforcing empathetic, patient-centered care. This study
followed a quasi-experimental pre- and post-intervention design to evaluate the impact of
implementing the CMAI and targeted training on staff perception of aggression in patients with
dementia.
This project aimed to improve how healthcare staff perceived, understood, and managed
aggression in patients with dementia by focusing on preventive strategies. Researchers have
1

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
studied communication training and behavioral assessment tools individually, but few have
examined how combining these approaches affects staff perceptions and responses to aggressive
behavior. The goal was to help staff feel more prepared and confident when facing these
situations in clinical settings.
PICO Question: In healthcare staff caring for patients with dementia (P), does
communication training combined with the use of the Cohen-Mansfield Agitation Inventory
(CMAI) (I), compared to no structured training or tool use (C), affect their perception of
aggression in dementia patients (O)?
Background, Context, and Theoretical Framework
Aggressive behaviors among patients with dementia occur more frequently and present
serious challenges in healthcare settings. These behaviors place both patients and staff at risk.
Existing staff training programs often do not adequately prepare healthcare professionals to
manage the specific complexities of dementia-related aggression, resulting in persistent concerns
about safety and care quality (Gkioka et al., 2020). The rising incidence of physical aggression
toward staff further underscored the need for effective and targeted interventions.
Clinicians widely recognize aggression as some of the most difficult behavioral
symptoms to manage in acute care settings (Akrour et al., 2022). Many current approaches rely
on broad strategies that fail to provide staff with the tools necessary for consistent and confident
responses. The intervention introduced the Cohen-Mansfield Agitation Inventory (CMAI) as a
behavioral assessment tool in conjunction with structured communication training. This
combination aimed to improve staff responses and skills, as well as to promote early recognition
and management of aggressive behaviors. Patients who exhibited signs of aggression, as
2

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
identified through staff reports or CMAI documentation, were included in the intervention phase.
Implementation followed the unit’s existing workflow and staffing patterns to ensure feasibility
within routine clinical practice.
An apparent gap remained in both the literature and clinical practice regarding the
preparedness of healthcare staff to manage aggression in dementia care (Moody et al., 2024).
Informal feedback and unit observations revealed increasing concern about safety and staff
confidence in handling such behaviors. This project addressed these concerns by combining
structured behavioral assessment with targeted communication training to support safe,
consistent, and patient-centered care practices.
Two theoretical frameworks informed both the design and execution of the project
intervention. The Transtheoretical Model (TTM) of Behavior Change provided a practical
structure for supporting staff as they adopted new approaches over time. The stages of the model
(pre-contemplation, contemplation, preparation, action, maintenance, and termination) offered a
framework for gradual integration into daily practice (Orsulic-Jeras et al., 2020). Jean Watson’s
Theory of Human Caring complemented this model by focusing on empathetic and
individualized care. Watson’s emphasis on compassion and therapeutic relationships helped
ensure that staff responses were not only practical but also rooted in dignity and respect for the
patient (Riegel et al., 2018).
This project followed a quasi-experimental design with pre- and post-intervention
evaluation to examine how the combined use of the CMAI and communication training
influenced staff perceptions of aggression in patients with dementia. By integrating evidencebased practices with theoretical foundations, the project aimed to identify solutions to improve

3

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
safety, support staff development, and elevate the standard of dementia care. The findings
contributed to practice improvements by providing a structured approach to managing aggression
and enhancing staff confidence in dementia care environments.
Problem Statement
Healthcare staff who care for individuals with dementia frequently encounter aggressive
behaviors that compromise safety and hinder quality care. Although most institutions offer
general dementia training, these programs often fail to equip staff with the specific skills needed
to manage aggression effectively, leaving many feeling underprepared, stressed, and uncertain in
care environments (Mellinger et al., 2023). Staff responses to aggression significantly impact
patient safety and care quality, yet they often feel overwhelmed, fearful, and discouraged by the
frequency of aggressive incidents (Välimäki et al., 2022).
Despite the known risks, limited research has examined how combining structured
communication training with the CMAI influences staff perceptions and management of
aggression in dementia care. Gaps in current training and assessment tools contributed to rising
staff distress and safety concerns in practice settings (Moody et al., 2024). Addressing these gaps
was essential to developing effective interventions that equip healthcare staff with the skills and
resources needed to manage aggressive behavior safely and confidently.
This project investigated whether integrating structured communication training with the
CMAI enhanced staff’s ability to recognize and manage aggression in patients with dementia. By
addressing shortcomings in current practice and the existing literature, this initiative aimed to
introduce a practical, evidence-based strategy to improve staff preparedness and patient safety.

4

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Addressing this gap can inform future training initiatives and support the broader implementation
of effective, evidence-based care approaches.
Purpose of the Project
The purpose of this quantitative project was to evaluate the extent to which combining
the CMAI with structured communication training influenced healthcare staff's perception and
management of aggression in patients with dementia. This quasi-experimental pre- and postintervention design measured changes in staff competence, confidence, and perception over six
weeks. The study aimed to assess whether integrating a standardized behavioral assessment tool
with focused communication training enhanced staff preparedness and their ability to respond
effectively to aggression.
The project took place in an acute care unit within a 155-bed hospital that provides care
for patients with dementia, including those who exhibit aggression. A convenience sample
included nurses and clinical assistants who were recruited from the unit and participated in this
study. The independent variable was the combined intervention of the CMAI and MESSAGE
communication training. The dependent variable was staff perception of aggression, measured
using surveys and CMAI data collected before and after the intervention. This project
contributed to the advancement of healthcare practice by providing a structured, evidence-based
approach to addressing aggression in dementia care. These findings inform future staff training
initiatives and support the development of consistent, patient-centered care strategies.
Research Questions and Hypotheses
This project examined the impact of combining a structured communication training
program with the use of the CMAI on healthcare staff’s perception and management of
5

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
aggression in patients with dementia. The research questions are directly related to the identified
problem of inadequate staff preparation for managing behavioral challenges in dementia care and
aligned with the evaluation of the effectiveness of a dual-component intervention. The project
aimed to determine whether integrating evidence-based training and standardized assessment
would improve clinical outcomes and promote safer care environments. It measured changes in
staff perceptions and confidence before and after the intervention.
Healthcare staff in a unit within an acute care hospital regularly encounter patient
aggression, which increases workplace stress and contributes to inconsistent care practices. This
study employed a quasi-experimental design to evaluate the impact of the intervention on
perceptions of aggression and staff preparedness. The variables included the independent
variable (implementation of the CMAI and structured communication training) and the
dependent variable (staff perception of aggression). The following research questions and
hypotheses guided this project:
RQ1: To what extent did the combination of structured communication training and the use
of the Cohen-Mansfield Agitation Inventory (CMAI) influence healthcare staff’s
perception of aggression in patients with dementia?
H10: There was no statistically significant difference in healthcare staff’s perception of
aggression in patients with dementia before and after the implementation of the
CMAI and communication training.
H1a: There was a statistically significant difference in healthcare staff’s perception of
aggression in patients with dementia before and after the implementation of the
CMAI and communication training.
6

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
RQ2: To what extent did the intervention improve healthcare staff’s confidence in managing
aggressive behaviors in patients with dementia?
H20: There was no statistically significant difference in healthcare staff’s confidence in
managing aggressive behaviors before and after the intervention.
H2a: There was a statistically significant improvement in the confidence of healthcare staff
in managing aggressive behaviors following the intervention.
RQ3: To what extent did the intervention improve healthcare staff’s ability to recognize
behavioral triggers in patients with dementia?
H30: There was no statistically significant difference in the staff’s ability to recognize
behavioral triggers in patients with dementia before and after the intervention.
H3a: There was a statistically significant improvement in the staff’s ability to recognize
behavioral triggers in patients with dementia following the intervention.
Rationale, Relevance, and Significance of the Project
Rationale for the Project
The project used a quantitative, quasi-experimental pre-post design to assess the impact of
the CMAI and targeted communication training on healthcare staff's perceptions of aggression in
patients with dementia. This design allowed for the measurement of changes before and after the
intervention within the same group of participants. This structured approach assessed whether the
intervention resulted in measurable improvements in staff perceptions and preparedness(Handley
et al., 2018).

7

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The project used a quasi-experimental design because the clinical setting does not permit
random assignments. The design enabled the assessment of the intervention’s effect within a
real-world clinical environment while maintaining control over key variables (Smith, 2021). This
approach offered a practical and ethical method for examining practice changes in healthcare
settings.
This methodology aligned with the problem and purpose statements by providing a
framework to evaluate whether the selected intervention improved staff understanding and
response to aggressive behaviors in dementia care (James et al., 2023). It supported the goal of
applying evidence-based tools and educational strategies to enhance care outcomes and
strengthen staff confidence. The quantitative approach produced objective, data-driven findings
that can inform future practice.
Significance of the Project
Aggressive behaviors from dementia patients are on the rise, affecting the quality of care,
staff morale, and workplace safety (Ye et al., 2024). This study focused on utilizing the CMAI
and targeted communication training to help healthcare staff more effectively assess and manage
aggression. These interventions aimed to enhance safety and quality of care within the unit.
The project contributed to the current body of literature by evaluating a practical, evidencebased solution within an acute care setting. Although previous studies have examined aggression
in patients with dementia, few have combined standardized measurement tools with structured
communication training implemented in real-time clinical environments. The intervention
enhanced staff perception and improved patient care outcomes by generating measurable insights
that support the advancement of evidence-based clinical practice.
8

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Healthcare facilities can use the results to develop or refine dementia care protocols,
enhance staff training, and implement standardized tools to assess behavioral symptoms. These
interventions have the potential to boost staff confidence, reduce workplace incidents, and
improve overall care for patients with dementia (Moody et al., 2024). Addressing these concerns
helps create a safer and more supportive environment.
Nature of the Project
This project applied a quantitative, quasi-experimental pre-post design to evaluate the impact
of combining the CMAI with targeted communication training on healthcare staff perception and
response to aggression in patients with dementia. This design supported the measurement of
changes within the same group over time and is well-suited for clinical environments where
randomization is not possible. It offered a practical and ethical approach to evaluating real-world
interventions designed to enhance staff preparedness and patient care. The project took place in
an acute care unit within a 155-bed hospital that provides services for patients with dementia,
including those who exhibit aggression.
The target population included licensed and unlicensed healthcare staff who provide care for
patients with dementia. Participants were selected using a convenience sampling method. The
intervention included the use of the CMAI as a behavioral assessment tool, along with structured
communication training that incorporated de-escalation techniques. Data were collected through
anonymous surveys administered before, during, and after the intervention to evaluate changes in
staff confidence, perception, and recognition of aggressive behaviors.
The CMAI served as the primary behavioral assessment instrument integrated into routine
documentation to support standardized reporting of aggressive behaviors. A project-specific
9

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
perception survey supplemented the CMAI to gather staff feedback on confidence, response
strategies, and overall impressions of the intervention. Data were collected before
implementation, during, and at the conclusion of the six-week project. Pre- and post-intervention
responses were compared to evaluate the effectiveness of the approach in enhancing staff
competence in managing aggression among patients with dementia.
Definition of Terms
The following terms are defined as they were used within the project context to provide
clarity and consistency for the reader. Each definition is grounded in relevant scholarly literature
and reflects how the term contributes to the scope and purpose of the project.
Aggressive Behaviors (Conceptual)
Aggressive behaviors involve verbal or physical actions that are disruptive, threatening, or
harmful. In dementia care, such behaviors may include hitting, biting, yelling, or resisting care.
These responses are often linked to underlying causes such as fear, confusion, discomfort, or
difficulty communicating needs (Yu et al., 2019).
Aggression Measurement
Aggression measurement involves the systematic assessment and quantification of aggressive
behaviors using validated tools to evaluate their frequency, intensity, and type (Røsvik &
Rokstad, 2020). These assessments help identify behavioral patterns and potential triggers,
enabling the implementation of targeted interventions to reduce aggressive incidents and enhance
safety (Wong et al., 2024).
Cohen-Mansfield Agitation Inventory (CMAI)
10

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The Cohen-Mansfield Agitation Inventory (CMAI) is an evidence-based, standardized
assessment tool designed to evaluate agitation in individuals with dementia. It supports the
monitoring of behavioral changes over time and helps identify specific triggers. Findings from
the CMAI can inform individualized care planning and guide interventions aimed at reducing
agitation (De Mauleon et al., 2021).
Communication Training (Conceptual)
Communication training refers to structured instruction that enhances verbal and non-verbal
interaction skills among healthcare staff. When applied in dementia care, this training
emphasizes strategies such as empathy, clarity, and de-escalation to enhance patient engagement
and foster a safer care environment (Van Manen et al., 2020).
Dementia
Dementia is a progressive neurological disorder characterized by a decline in cognitive
function, including memory, judgment, and reasoning (National Institute on Aging, 2022).
Conditions such as Alzheimer's disease or vascular impairment most often cause dementia. As
dementia progresses, individuals may exhibit behavioral symptoms that require specialized
approaches to care (Alzheimer's Association, 2024).
MESSAGE Communication Training
MESSAGE communication training is an evidence-supported dementia care framework
developed to enhance staff communication, empathy, and de-escalation skills when interacting
with individuals who exhibit behavioral or communication challenges. The acronym
“MESSAGE” stands for Maximize attention, Expression and body language, Keep it simple,
Support the conversation, Assist with visual aids, Get their message, and Encourage and engage.
11

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
This structured training promotes compassionate, person-centered communication that supports
safer, more effective interactions in dementia care settings while helping to reduce aggression
and strengthen care relationships (Young, 2021).
Perception of Aggression (Conceptual)
Perception of aggression refers to how healthcare staff interpret, emotionally respond to, and
evaluate aggressive behaviors displayed by patients. These perceptions shape the way staff
approach care and can influence the effectiveness of their responses in managing challenging
behaviors (Krakowiak-Burdzy & Fąfara, 2023).
Standard Training
Standard training provides foundational education in clinical procedures, communication
practices, and safety protocols. While it ensures a basic level of competency across healthcare
roles, it may not sufficiently address the unique demands associated with managing behavioral
health challenges in dementia care (Pit et al., 2023).
Targeted Training
Targeted training addresses specific learning needs based on clearly defined clinical
challenges. In the context of dementia care, this type of training typically includes content on
identifying behavioral triggers, applying de-escalation techniques, and enhancing staff responses
to aggression in a manner that supports both patient and staff well-being (Rasmussen et al.,
2023).
Assumptions, Limitations, and Delimitations

12

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
It was assumed that participants engaged in the training content and responded to the
surveys truthfully. Because the data were self-reported, the validity of the findings depended on
participants’ honesty when completing the survey questions. The CMAI was recognized as a
valid and reliable tool for assessing aggressive behaviors in individuals with dementia. The tool
had been widely used in long-term care settings and was expected to be equally effective in acute
care environments.
The intervention incorporated the CMAI tool and structured communication training,
both directly related to staff clinical roles and daily care responsibilities. The approach assumed
that aggression in dementia care often stems from identifiable triggers, communication barriers,
and unmet needs (Wong et al., 2024). When staff recognized these factors, they were able to
respond more effectively. The Transtheoretical Model of Behavior Change (TTM) supported this
framework by describing the stages individuals follow when adopting new behaviors. Staff could
progress through these stages successfully when they received appropriate support, targeted
training, and consistent leadership.
Combining the CMAI with structured communication training was expected to reduce
incidents of aggression and enhance staff safety (Baby et al., 2018). These improvements
depended on staff consistently applying the strategies introduced during the intervention (Goorts
et al., 2021). When integrated into daily clinical practice, these techniques can create a safer and
more effective care environment.
Several limitations may have influenced the findings of this study. The six-week project
duration might have been too short to observe sustained behavior change or the long-term effects
of the intervention. Conducting the quality improvement project in a single inpatient unit within

13

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
one acute care hospital limited the diversity of the participant population. Restricting the project
to one location also reduced the generalizability of the results to other units or healthcare
environments that may have had different patient demographics, staff compositions, or
organizational cultures.
Relying on self-reported data presented a risk of bias, such as participants providing
socially acceptable answers or misremembering details. These factors could affect the accuracy
of the results, particularly in terms of how participants perceived aggression or reported their
level of confidence (Althubaiti, 2016). Additionally, external influences such as patient acuity,
staff turnover, or organizational changes could have impacted outcomes during the study period
(Bhati et al., 2023). The project team did not fully address these variables, as they remained
outside the scope of the study.
The project design intentionally narrowed the focus to a specific population and setting to
ensure feasibility and consistency (Willie, 2024). Participation was limited to licensed and
unlicensed staff providing direct care in one unit. The project excluded staff from other
departments or non-clinical roles. The intervention concentrated specifically on the use of the
CMAI and communication training without incorporating broader behavioral or environmental
modifications.
Conducting the project within a single unit provided consistency in leadership, staffing
models, and patient characteristics. The team intentionally set these boundaries to manage the
project scope and conduct a pilot evaluation. The delimitations helped narrow the project’s scope
to produce specific findings that could guide future implementation in other units or healthcare
environments.

14

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Summary and Organization of the Remainder of the Project
Chapter One introduced a significant challenge in healthcare: the increasing prevalence
of aggressive behaviors among patients with dementia and the inadequacy of standard training
programs in preparing staff to manage these behaviors effectively. These behaviors compromised
patient and staff safety, elevated workplace stress, and negatively impacted the quality of care.
The project aimed to address this gap by evaluating whether the combined use of the CMAI and
structured communication training could improve healthcare staff’s ability to assess, recognize,
and respond to aggression. The theoretical foundation that guided this project included Jean
Watson’s Theory of Human Caring and the Transtheoretical Model of Behavior Change. These
frameworks supported sustainable practice improvements by emphasizing patient-centered,
compassionate care and providing structure for implementing behavioral change.
This project employed a quasi-experimental, pre-post design to evaluate the impact of the
intervention within a real-world clinical setting. By measuring changes in staff perception,
confidence, and the ability to identify behavioral triggers, the project aimed to determine whether
the intervention led to meaningful improvements in dementia care (Chen et al., 2024). The
project took place within an acute care hospital unit and involved a convenience sample of
licensed and unlicensed healthcare staff. The intervention included communication training
focused on de-escalation and empathy, combined with the use of a standardized behavioral
assessment tool. The project design reflected the clinical realities of the setting while maintaining
the rigor necessary for evaluating intervention effectiveness.
Chapter Two presented a detailed review of the literature related to aggressive behaviors
in dementia care, the use of behavioral assessment tools such as the CMAI, and the role of

15

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
communication training in improving staff response. This chapter also explores theoretical
models relevant to behavior change and patient-centered care. It provided evidence of the need
for structured interventions and identified gaps in existing research that supported the purpose of
the project.
Chapter Three described the research methodology, including the design, setting,
population, sampling strategy, data collection procedures, and instruments used. The quasiexperimental approach outlined the process for delivering the intervention and described the
methods used to evaluate its impact. The team prioritized ethical considerations, maintained data
integrity, and implemented measures to minimize bias throughout the project (Galanakis et al.,
2025). The chapter explained how the research questions and hypotheses aligned with the
project’s overall purpose.
Chapter Four presented the project’s results, including descriptive and inferential
analyses of pre- and post-intervention data (Fakhri Allahyari et al., 2024). This chapter included
tables and figures to illustrate the findings, along with narrative summaries that described trends
and statistically significant changes. The team organized the results according to the research
questions and used them as the foundation for the interpretation presented in Chapter Five.
The last chapter interpreted the findings in the context of existing research, theory, and
clinical practice. The section examined the implications of the results for healthcare staff training
and patient safety. It also presented the study’s limitations and offered recommendations for
future research. These recommendations included replication studies, broader implementation of
the intervention, and continued exploration of staff-centered approaches to behavior management
in dementia care.

16

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Here was the timeline outlining the necessary steps to ensure the timely completion of the
dissertation. The goal was to have approval by the Institutional Review Board (IRB) by early
September. The timeline allocated September through October for data collection and October
for data analysis. The plan assigned November for final writing, revisions, and formatting. This
structure allowed adequate time for each phase while meeting academic expectations.
The subsequent chapters of the dissertation were built upon the foundation presented in
Chapter One. Each chapter built a clear understanding of how structured training and behavioral
assessment influenced staff readiness and the overall quality of dementia care. This research used
a methodical, evidence-informed approach to support the development of improved training
strategies and to help create safer, more effective care settings for individuals with dementia.
CHAPTER TWO: LITERATURE REVIEW
Introduction to the Literature Review
Chapter Two reviewed the current literature on aggression in dementia care, with a focus
on healthcare staff experiences, communication strategies, and the use of standardized behavioral
assessment tools, including the Cohen-Mansfield Agitation Inventory (CMAI). This review
established the foundation for the project by summarizing existing evidence, identifying
knowledge gaps, and supporting the need for structured, evidence-based interventions (Jawaid et
al., 2021). The chapter was organized to first examine aggressive behaviors in dementia, then
explore staff preparedness and communication approaches, and conclude by linking these
elements to the study’s research questions, design, and methodology.
The literature review synthesized peer-reviewed empirical research published between
2020 and 2025, with foundational works included as needed. Articles were identified through
17

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
systematic searches of CINAHL, PubMed, Google Scholar, Cochrane Library, and Medline
using terms such as dementia, aggression measurement, communication training, behavioral
interventions, staff perceptions, and aggression reduction. Included studies focused on healthcare
staff working in dementia care settings, the use of aggression assessment tools or targeted
communication training, and outcomes related to aggression reduction or improved staff safety.
Only English-language, peer-reviewed qualitative, quantitative, or mixed-methods studies were
considered.
Aggression in individuals with dementia remains a significant challenge, particularly in
acute care settings. Verbal outbursts, physical resistance, and agitation often result from pain,
cognitive decline, fear, or environmental stressors (Kennedy et al., 2020). High-paced care
environments amplify these risks, often leaving staff unprepared to manage aggressive behavior
effectively (Kang & Bang, 2024). While patient-centered communication strategies emphasize
empathy and nonverbal cues show promise, their consistent application remains limited.
Standardized tools like the CMAI provide a reliable method to assess and manage behavioral
symptoms and, when combined with structured training, may enhance staff preparedness
(Kratzer et al., 2023).
Despite advances, research often examines communication interventions and behavioral
assessments in isolation, limiting practical applicability in clinical practice (Reichelt et al., 2023;
Shrestha & Shrestha, 2024). Few studies evaluated changes in staff perception and confidence
pre- and post-training, particularly in high-demand acute care units (Keuning-Plantinga et al.,
2022). These gaps underscore the need for targeted interventions that integrate assessment tools
with practical communication strategies to improve staff preparedness and care quality.

18

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
This chapter defined the research problem by synthesizing current evidence on
aggression in dementia care, identifying gaps in knowledge, and justifying the intervention and
methodological approach for this project. The chapter also introduced the theoretical framework
that supported the development of the project’s intervention and methodological approach, as
well as the rationale for the selected study design, data collection instruments, and intervention
strategies.
Theoretical and Conceptual Framework
The Transtheoretical Model (TTM) of behavior change, developed by Prochaska and
DiClemente (1983), provides the primary theoretical foundation for this project. TTM outlines
five stages of behavioral change: pre-contemplation, contemplation, preparation, action, and
maintenance (Lindeza et al., 2020). These stages reflect a flexible, non-linear process that aligns
with the complexities of behavior change in healthcare settings (O'Donnell et al., 2022).
In this intervention, healthcare staff may begin at varying stages of readiness to adopt new
strategies for managing aggression in dementia care. TTM offers a framework to tailor training
components to staff readiness, providing foundational education for those in earlier stages and
hands-on application for those further along (Parveen et al., 2021). Interventions aligned with
TTM stages have proven effective in promoting sustainable behavior change and fostering longterm adoption of new practices (McKenzie & Brown, 2020). This approach encourages
continuous learning and reflection, which is essential in high-stress care environments where
staff must regularly adapt to behavioral challenges (Lim et al., 2019).
Jean Watson’s Theory of Human Caring complemented TTM by grounding the
intervention in empathy, compassion, and holistic care (Pepper & Dennis, 2023). Watson’s
19

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Caritas processes guide caregivers in fostering human connections, promoting loving-kindness,
instilling hope, and engaging in meaningful teaching and learning (Riegel et al., 2018). In
dementia care, where communication barriers and behavioral challenges are common,
compassionate, patient-centered care is essential to reducing agitation and enhancing safety
(Carratini et al., 2021).
Integrating Watson's principles into this intervention fosters an environment of mutual
respect, which can alleviate patient distress and decrease staff stress (Schnelli et al., 2020).
Human caring models have been associated with reduced adverse events, improved patient
satisfaction, and increased staff engagement (Riachi & Markwell, 2020). When combined with
TTM, Watson’s theory enhances the intervention by addressing both the emotional readiness of
staff and the interpersonal dynamics necessary for behavior change to take root (Nguyen et al.,
2022).
Together, TTM and Watson’s Theory of Human Caring create a multidimensional
framework that addresses both the practical and emotional aspects of managing aggression in
dementia care. TTM offers a structured pathway for behavior change, while Watson’s theory
ensures these changes are grounded in humanistic values (Castro et al., 2024). This integrated
approach informs the selection of study variables, intervention structure, and outcome measures,
aligning with the project’s focus on enhancing staff competence and patient-centered care (Di
Lorito et al., 2019). The following section reviews current empirical studies on aggression in
dementia care, focusing on staff perceptions, communication strategies, and the application of
behavioral assessment tools.
Review of the Literature

20

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Introduction
Dementia presented an increasing challenge in managing aggressive behaviors,
particularly within acute care settings. As dementia progressed, patients often exhibited agitation,
resistance to care, and physical or verbal aggression, which jeopardized safety and contributed to
heightened stress among healthcare workers (National Institute on Aging, 2022). Dementia was
defined as a group of cognitive disorders marked by progressive impairments in memory,
reasoning, and communication abilities. Accurate diagnosis required comprehensive assessments
to differentiate dementia from reversible conditions and guide appropriate care planning.
This literature review examined empirical studies on aggression in dementia care,
focusing on staff perceptions, communication-centered approaches, and the use of standardized
behavioral assessment tools. Among these tools, the Cohen-Mansfield Agitation Inventory
(CMAI) remained widely used to systematically assess agitation and aggressive behaviors in
older adults with dementia (Kupeli et al., 2018).
By emphasizing evidence-based strategies and validated assessment instruments, this
review highlighted approaches aimed at reducing aggression and improving patient outcomes.
The synthesis primarily included peer-reviewed studies published between 2020 and 2025 to
ensure alignment with current clinical standards and emerging innovations. Foundational works
were referenced as necessary to provide context.
This chapter appraised literature relevant to the project’s primary variables, evaluated
research methodologies, and identified gaps that justified the need for this study. The review was
organized into sections on Quantitative Studies, Qualitative Studies, Themes, Methodology, and
Instrumentation, ensuring a structured analysis that supported the project’s quasi-experimental,
21

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
mixed-methods design. The following section examined quantitative research that evaluated
interventions aimed at reducing aggression in dementia care.
Quantitative Studies
Sahu et al. (2020) conducted a cross-sectional descriptive study in India to examine the
relationship between anxiety and physical aggression in 55 individuals with dementia.
Researchers used the Hamilton Anxiety Rating Scale and the Cohen-Mansfield Agitation
Inventory (CMAI) to assess psychological and behavioral symptoms. Findings revealed that
45.5% of participants exhibited mild-to-moderate anxiety, while 36.38% displayed aggressive
behaviors, highlighting a direct link between anxiety and physical aggression (Sahu et al., 2020).
Kupeli et al. (2018) evaluated the psychometric properties of the CMAI in an acute
hospital setting involving 230 patients with dementia. The study identified a two-factor structure
that categorized behaviors as aggressive or non-aggressive. Results confirmed that the CMAI
demonstrated strong reliability and validity, with a significant association between aggressive
behaviors and unmanaged pain, supporting its clinical relevance in acute care environments
(Kupeli et al., 2018).
A quasi-experimental study by Alruwaili et al. (2024) investigated the impact of a
culturally tailored multisensory intervention that included Snoezelen therapy, aromatherapy, and
personal belongings for Arab patients with dementia. The intervention significantly reduced
agitation and aggression, as measured by the CMAI. Additionally, participants showed improved
quality of life based on outcomes from the Neuropsychiatric Inventory (Alruwaili et al., 2024).
Schneider et al. (2020) implemented a hospital-wide dementia-friendly training program
at the UNC Health System, aiming to enhance staff competence and patient outcomes. Over
22

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
1,900 staff members participated in modules focused on communication, behavior management,
and person-centered care. Post-training assessments revealed significant improvements in staff
knowledge, confidence, and caregiving practices, demonstrating the effectiveness of structured,
organization-wide education (Schneider et al., 2020).
Willie (2021) analyzed research methodologies in behavioral studies, emphasizing the
importance of clearly defining both the population and target population. The study found that
precise definitions enhance sampling accuracy and improve the generalizability of research
findings. These methodological considerations are crucial for ensuring the external validity of
behavioral intervention studies in dementia care (Willie, 2024).
A randomized controlled trial by Kunik et al. (2020) assessed the effectiveness of
aggression prevention training among 228 patients with dementia and their caregivers. While the
study did not find a statistically significant overall reduction in aggressive incidents, subgroup
analysis indicated improvements in caregivers experiencing depression and strained
relationships. These results suggest that addressing emotional and relational factors can enhance
the management of aggression in dementia care (Kunik et al., 2020).
These quantitative studies collectively demonstrated the complexities of evaluating and
managing aggression in dementia care. Research supported the integration of standardized
assessment tools, culturally sensitive interventions, and structured staff training to reduce
agitation and enhance care quality. Methodological rigor, including precise population definitions
and consideration of caregiver factors, remained essential for ensuring the validity and practical
applicability of findings in real-world clinical environments. The following section explored

23

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
qualitative research that provided deeper insight into healthcare staff experiences and perceptions
in managing aggression among patients with dementia.
Qualitative Studies
Kabaya et al. (2024) conducted a qualitative descriptive study to explore how dementiacertified nurses (DCNs) in acute care settings developed expertise in managing patients with
dementia. The researchers interviewed 14 nurses and found that clinical decision-making often
required balancing patient resistance with professional and ethical responsibilities. Nurses
described using reflection, teamwork, and patient-centered strategies to adapt their care
approaches. The study emphasized that dementia care knowledge was not static but evolved
through clinical experience, collaboration among colleagues, and continuous self-reflection.
Kabaya et al. (2024) concluded that all healthcare workers should actively engage in this
developmental process to enhance their skills in managing aggressive behaviors.
Dunkle et al. (2022) conducted a qualitative study to understand the experiences of nurses
and social workers who cared for individuals with dementia in acute settings. Using the Rigorous
and Accelerated Data Reduction (RADaR) method, the researchers identified three primary
themes: family participation, system care processes, and system obstacles. Participants described
successful care models that were closely tailored to individual patient needs but noted that
limited staffing, unclear roles, and lack of organizational support often hindered effective
implementation. The study highlighted the importance of fostering stronger interdisciplinary
collaboration and establishing clearly defined professional roles to deliver comprehensive care
for dementia patients (Dunkle et al., 2022).

24

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Both studies contributed valuable insights into how frontline healthcare staff perceived
and managed the challenges of dementia-related aggression. Kabaya et al. (2024) emphasized the
role of reflection and professional growth, while Dunkle et al. (2022) focused on the influence of
systemic barriers and interdisciplinary dynamics. Understanding these perspectives was essential
for developing practical interventions and training programs that were responsive to the realworld conditions of acute care environments. The following section synthesized key themes
identified across the literature, highlighting core factors that influenced the management of
aggression in dementia care.
Emerging Patterns in Literature
Patients with dementia often exhibited aggressive behaviors such as screaming, swearing,
hitting, or biting (Alzheimer’s Association, 2024). These actions were frequently triggered by
unmet needs, heightened anxiety, or environmental stressors. In acute hospital environments,
unfamiliar surroundings, noise, and inadequate pain management intensified patient distress and
agitation (Kupeli et al., 2018). Aggression in dementia is also manifested through refusal or
resistance to care, posing significant safety challenges for patients and caregivers alike.
Dementia-associated aggression placed a substantial burden on patients, caregivers, and
healthcare systems. Nearly half of individuals with Alzheimer’s disease experienced at least one
episode of aggression, which correlated with faster cognitive decline and earlier nursing home
placement (Alzheimer’s Association, 2024). This behavioral disturbance increased stress among
healthcare workers and led to caregiver burnout, further complicating care delivery.
Systematic protocols to address physical aggression in dementia care remained limited in
many healthcare facilities. Dunkle et al. (2022) found that hospital nurses and social workers
25

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
struggled to manage aggression due to a lack of coherent care pathways and insufficient training.
However, targeted educational initiatives were shown to improve staff confidence and caregiving
practices. For instance, participation in dementia-friendly hospital projects significantly
enhanced staff engagement and patient care outcomes (Schneider et al., 2020).
Cultural and individual factors heavily influenced how aggression is presented in patients
with dementia. Alruwaili et al. (2024) demonstrated that Snoezelen therapy environments
incorporating aromatherapy and familiar objects reduced agitation among Arab patients with
dementia. These findings underscore the need for culturally responsive interventions that
recognized patient identity in care planning.
Aggressive behaviors tended to escalate as dementia progressed, making early
identification critical. A review of epidemiological studies emphasized that continuous
behavioral monitoring improved intervention effectiveness (Anatchkova et al., 2019). Validated
tools such as the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric
Inventory (NPI) were frequently used to assess agitation across care settings (Anatchkova et al.,
2019).
Nonpharmacological strategies remained essential in managing agitation and aggression.
Carrarini et al. (2021) identified communication techniques, environmental modifications, and
individualized care plans as first-line interventions that reduced behavioral symptoms without
relying on medication. These approaches supported patient-centered outcomes and were
applicable in both acute and long-term care environments.
Aggression in dementia followed a fluctuating course, with symptoms evolving over
time. De Mauleon et al. (2020) found that flexible, individualized care strategies were necessary
26

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
to address these changing behaviors effectively. Their findings reinforced the importance of early
intervention to reduce caregiver burden and improve patient quality of life.
Misinterpreted sources of discomfort often contributed to agitation in dementia patients.
Graham et al. (2022) found that nurses frequently misdiagnosed pain-related agitation as
behavioral rather than physical, leading to inadequate pain management. This underscored the
importance of training clinicians to recognize somatic causes of agitation and respond
appropriately.
Staff misperceptions regarding dementia behaviors negatively affected care quality.
Jawaid et al. (2021) reported that hospital staff often misinterpreted confusion and agitation,
stemming from cognitive decline, as intentional disruptive behavior. These misconceptions
highlighted the need for staff education focused on empathy and accurate behavioral
interpretation.
Crisis situations involving extreme aggression presented unique challenges in dementia
care. Kennedy et al. (2020) emphasized that initial responses should have prioritized
nonpharmacological strategies such as environmental adjustments and de-escalation techniques.
Early and individualized interventions were consistently recommended across the literature as
best practice for managing behavioral expressions (Kennedy et al., 2020).
Several studies explored factors contributing to aggressive behaviors in dementia.
Krakowiak-Burdy and Fafara (2023) found that verbal aggression was frequently linked to
environmental stressors, cognitive impairments, and adverse care conditions. Their findings
advocated for communication-based interventions that addressed the underlying causes of
aggression.
27

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Anxiety was another critical factor influencing aggressive behavior in dementia patients.
Sahu et al. (2020) identified a significant association between elevated anxiety levels and
physical aggression, suggesting that early recognition and management of anxiety symptoms
could have reduced the occurrence of aggressive incidents. These findings reinforced the
importance of timely behavioral assessments and targeted interventions.
Aggression was not limited to institutional care settings; it also presented challenges in
home environments. Schnelli et al. (2020) found that communication training, caregiver support,
and environmental modifications reduced aggression and improved safety in home-based
dementia care. These strategies empowered caregivers to respond more effectively to behavioral
challenges.
Large-scale studies consistently reported high prevalence rates of aggression in dementia
populations. Yu et al. (2019) conducted a meta-analysis of over 15,000 participants, revealing
that approximately 30% of individuals with Alzheimer’s disease exhibited aggressive behaviors.
Risk factors identified included delusions, caregiver stress, and male gender, underscoring the
need for structured intervention programs (Yu et al., 2019).
In summary, aggression in dementia care remained a prevalent and complex issue
affecting patients, caregivers, and healthcare systems. Evidence supported the use of culturally
appropriate, patient-centered, and nonpharmacological interventions as practical strategies for
managing aggressive behaviors. The following section examined the role of communicationbased interventions and staff perceptions in addressing these challenges.
Communication-Based Interventions and Staff Perception

28

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Effective communication was essential for managing aggression in patients with
dementia. Poor communication often led to confusion, frustration, and agitation among patients
(Kunik et al., 2020). A randomized controlled trial evaluating Aggression Prevention Training
(APT) found that while APT did not significantly reduce overall aggression rates, it improved
caregiver-patient relationships and reduced depression symptoms, highlighting the value of
communication-centered interventions in mitigating associated stressors (Kunik et al., 2020).
Dementia-friendly training programs demonstrated that targeted communication
education increased staff confidence and competence. Schneider et al. (2020) found that staff
who received communication-focused training reported significant improvements in recognizing
and managing dementia-related behaviors. These findings emphasized that structured training
enhanced the ability of healthcare providers to prevent and de-escalate aggressive incidents.
Simulation-based models of care also strengthened communication skills and empathy
among healthcare professionals. Castro et al. (2024) reported that simulation training improved
staff confidence and communication when caring for individuals with dementia. Similarly,
Kabaya et al. (2024) observed that dementia-certified nurses who developed personalized
communication strategies through reflection and collaboration effectively managed care-resistant
behaviors.
Patient-centered communication approaches, including visual and nonverbal techniques,
were particularly effective for patients with moderate to severe dementia. Collins et al. (2022)
emphasized the importance of tailoring communication to individual needs to reduce agitation.
Alruwaili et al. (2024) demonstrated that culturally adapted interventions, such as activity-based
therapies using familiar objects, significantly decreased agitation in Arab elders with dementia.

29

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Several reviews advocated nonpharmacological communication methods as first-line
interventions for managing aggression. Baby et al. (2018) emphasized the risks of premature
pharmacologic treatment and recommended staff training in person-centered communication and
environmental adjustments. These approaches aligned with holistic and relationship-centered
models of dementia care, promoting safer and more effective management of behavioral
symptoms.
Frontline healthcare workers, including nurses and social workers, experienced both
challenges and successes when applying communication-based interventions. Dunkle et al.
(2022) found that barriers such as inadequate training and staffing shortages hindered effective
communication, while structured protocols and interdisciplinary collaboration improved patient
and caregiver outcomes. Staff highlighted the need to validate patient emotions and simplify
communication to prevent escalation.
Systematic reviews also confirmed the importance of interactive communication training
in dementia care. Eggenberger et al. (2013) reported that training formats incorporating role-play,
feedback, and performance evaluations significantly improved staff communication behaviors.
Gkioka et al. (2020) added that programs integrating emotional engagement produced more
sustainable improvements aligned with person-centered care practices.
Research from adjacent healthcare contexts supported the broader applicability of
communication-centered models. Lim et al. (2019) demonstrated that recovery-oriented care,
which emphasized collaborative communication, effectively reduced agitation in mental health
settings. These findings suggested that well-tailored communication strategies were adaptable
across various clinical diagnoses and care environments.

30

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Managing patients with dementia and mental health comorbidities also required nuanced
communication strategies. McKenzie and Brown (2020) found that providing individualized
emotional support reduced behavioral symptoms and strengthened therapeutic relationships.
Their study underscored the importance of addressing both cognitive and emotional needs
through targeted communication interventions.
Despite growing evidence, substantial gaps remained in caregiver communication
education. Nguyen et al. (2022) found that both professional and informal caregivers often
lacked adequate communication skills, which contributed to increased caregiver burden and
heightened patient aggression. The authors recommended focused training programs to enhance
verbal and nonverbal communication abilities among caregivers.
Expert reviews consistently emphasized communication’s role in reducing aggression and
improving care dynamics. Pepper and Dening (2023) highlighted that personalized training and
reflective practices helped staff manage behavioral issues and fostered healthier caregiver-patient
relationships. Reichelt et al. (2023) evaluated the Communications and Interaction Training
(CAIT) program and found it increased staff confidence in de-escalation and improved working
relationships with patients.
Community-based dementia support services also adopted communication-focused
interventions to enhance well-being. Riachi and Markwell (2020) reported that bundled
approaches involving education, patient engagement, and family involvement positively
influenced patient satisfaction and care outcomes. These models demonstrated the potential for
extending communication strategies beyond acute care settings.

31

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Validated assessment instruments supported the integration of communication strategies
in behavioral monitoring. Sun et al. (2022) confirmed the reliability and validity of the CMAI
short form in cross-cultural settings, providing a practical tool for evaluating agitation. Wong et
al. (2024) reinforced the importance of proper training in using instruments like the CMAI and
NPI to ensure accurate behavioral assessments.
Clinical management studies highlighted the need for early identification and proactive
communication strategies. Wharton et al. (2018) found that early delirium screening and
appropriate antipsychotic use, combined with effective communication, reduced aggression in
hospitalized dementia patients. These findings underscored the necessity of embedding
communication-focused interventions into standard clinical care practices.
In summary, communication-based interventions were central to managing aggression in
dementia care. Studies consistently showed that combining verbal and nonverbal strategies,
structured training, and culturally responsive practices led to better outcomes for patients and
caregivers. The following section examined how interdisciplinary collaboration and standardized
instruments further supported effective aggression management in dementia care.
Interdisciplinary Care Approaches
Effectively managing aggression in dementia care requires collaboration across
healthcare disciplines. Akrour et al. (2022) highlighted that shared decision-making and
coordinated teamwork enhanced patient care quality by facilitating early recognition of
behavioral symptoms and consistent response strategies. This team-based approach supported
person-centered care by ensuring all professionals contributed to managing aggression with a
unified plan.
32

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The DICE model (describe, investigate, create, evaluate) offered a structured
multidisciplinary strategy for addressing behavioral complications in dementia. James et al.
(2023) explained that this model guided team members in identifying behaviors, investigating
underlying causes, creating individualized interventions, and evaluating their effectiveness.
Nurses often led these efforts by monitoring behavior changes and coordinating communication
among team members (James et al., 2023).
Pain management was a critical trigger point for aggressive behaviors in dementia and
required interdisciplinary collaboration. Kupeli et al. (2018) found that healthcare workers who
effectively interpreted nonverbal cues and communicated across disciplines could adjust care
plans promptly, improving pain control and reducing agitation. This collaborative approach
enhanced patient outcomes by addressing behavioral symptoms at their source.
Multidisciplinary teams also ensured that culturally sensitive interventions were
implemented effectively. Alruwaili et al. (2024) demonstrated that interventions such as
Snoezelen therapy, when adapted to a patient's cultural background with input from occupational
therapists, nurses, and family members, significantly reduced agitation. Incorporating familiar
sensory cues into the care environment aligned care strategies with the individual’s identity and
needs.
Interdisciplinary teamwork fostered staff development and enhanced confidence in
managing dementia-related behaviors. Bhati et al. (2023) concluded that continuous learning
environments and reflective dialogue among team members improved caregivers’ competence
and promoted safe, effective care. These professional development initiatives encouraged a shift
toward person-centered thinking and effective interdisciplinary communication.

33

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Nonpharmacological interventions were most effective when delivered through a
coordinated, team-based approach. James et al. (2023) found that interventions emphasizing
personalized care, environmental modifications, and collaborative communication produced the
best behavioral outcomes. Multidisciplinary strategies not only improved care quality but also
aligned with best-practice standards in dementia care.
Comprehensive interventions combining staff education, communication training, and
environmental adjustments were essential in reducing agitation. Moody et al. (2024) reviewed 33
studies and found that these multidimensional approaches significantly enhanced patient
outcomes in hospital settings. The findings highlighted the importance of tailoring team-based
interventions to specific clinical environments for maximum effectiveness.
Collaboration in home-care settings was equally vital for managing aggression.
O'Donnell et al. (2022) reported that personalized communication strategies and structured
activities involving multidisciplinary teams helped reduce agitation in home-based dementia
care. These approaches-built trust, lowered anxiety, and fostered predictable interactions between
patients and caregivers.
Despite these benefits, hospitals often faced fragmented care processes and insufficient
communication protocols. Røsvik and Rokstad (2020) identified that unmet educational and
systemic needs hindered consistent dementia-care delivery in acute hospitals. These findings
underscored the necessity for broader, transdisciplinary initiatives to overcome institutional
barriers.
Interdisciplinary education was essential to bridge gaps in aggression recognition and
management. Välimäki et al. (2022) found that nurses interpreted aggression differently based on
34

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
their education level and professional role, which affected care responses. Structured educational
programs helped harmonize understanding across disciplines and improved patient outcomes.
Incorporating patient-centered values into interdisciplinary care facilitated treatment
plans aligned with individual preferences. Alruwaili et al. (2024) demonstrated that when
providers considered a patient’s history, cultural identity, and sensory preferences, patients
exhibited reduced agitation and greater comfort. These tailored approaches enhanced the
effectiveness of behavior-management strategies.
Sensory interventions, such as sensory carts and Snoezelen environments, provided
nonpharmacological options to create calming settings. Alruwaili et al. (2024) reported that
familiar aromatherapy, music, and culturally meaningful items effectively reduced agitation
when personalized to patient preferences. These interventions minimized medication use while
promoting emotional well-being and motivation.
Empathy, compassion, and relational presence were foundational to team-based dementia
care. Riegel et al. (2018) emphasized that Watson’s Theory of Human Caring aligned with
person-centered practices, fostering positive emotional states and therapeutic relationships. These
principles guided initiatives that prioritized communication, emotional connection, and holistic
care delivery.
In summary, interdisciplinary collaboration was essential for managing aggression in
dementia care. Coordinated team efforts enhanced care consistency, promoted patient-centered
approaches, and addressed systemic challenges that hindered optimal care delivery. The
following section examined how caregiver strain, staff stress, and organizational support
influenced the effectiveness of these interventions.
35

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Workforce Well-being in Dementia Care: Managing Burden and Enhancing Support Systems
Healthcare professionals and caregivers experienced significant emotional, physical, and
psychological strain when supporting individuals with dementia who exhibited aggressive
behaviors. These challenges stemmed from the complex nature of behavioral and psychological
symptoms of dementia, which frequently overwhelmed caregivers (Kunik et al., 2020). Although
a randomized controlled trial found no significant reduction in aggression with interventions,
caregivers who received structured training demonstrated improved coping skills and
relationship quality (Kunik et al., 2020).
The burden placed on caregivers often led to burnout, staff turnover, and diminished care
quality. Schneider et al. (2020) observed that caregiver stress and emotional exhaustion directly
impacted staff responsiveness to aggressive behaviors, exacerbating patient agitation. Kabaya et
al. (2024) reported that dementia-certified nurses frequently experienced emotional conflict
between professional responsibilities and the challenges of managing aggression.
A nationwide survey in China revealed that while nurses demonstrated greater knowledge
of behavioral symptoms than physicians, overall understanding of behavioral and psychological
symptoms of dementia (BPSD) remained moderate (Chen et al., 2024). The study emphasized
the importance of experience and dementia-specific training in enhancing caregiver confidence
and diagnostic accuracy. These findings highlighted the need for ongoing education to correct
misperceptions of aggression and improve care practices (Chen et al., 2024).
Culturally tailored interventions alleviated caregiver strain by creating supportive care
environments. Alruwaili et al. (2024) demonstrated that using aromatherapy, familiar personal
items, and multisensory stimuli reduced agitation in Arab elderly patients while enhancing
36

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
caregiver satisfaction. These culturally sensitive approaches promoted a calmer care
environment, leading to an improved caregiver experience.
Barriers to caregiver support included limited staffing, insufficient dementia-specific
training, and task-oriented facility cultures. Dunkle et al. (2022) found that programs fostering
debriefing opportunities, interdisciplinary meetings, and accessible training reduced burnout and
promoted caregiver resilience. Kabaya et al. (2024) emphasized that reflective practice within
training programs enhanced skill development, aligning with the Transtheoretical Model’s
framework for incremental behavior change (Prochaska & DiClemente, 1983).
Workplace social support played a critical role in mitigating burnout and job
dissatisfaction among caregivers. Duan et al. (2019) found that the perception of organizational
support buffered the negative effects of workplace aggression on caregiver well-being. These
findings underscored the importance of fostering a strong, supportive team culture in dementia
care settings.
Organized training programs reduced caregiver burden and enhanced staff preparedness.
Fakhri Allahyari et al. (2024) reported that targeted dementia care education focusing on
communication and emotional regulation decreased perceived stress among nurses. Geoffrion et
al. (2020) found that although aggression prevention initiatives yielded modest reductions in
aggressive incidents, they significantly improved staff knowledge, coping skills, and situational
awareness.
Educational deficits persisted among interprofessional teams caring for individuals with
dementia. Hawkins et al. (2023) identified that structured dementia education was essential for
effective behavior management and reducing caregiver burden in Canadian geriatric programs.
37

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Interdisciplinary team-based learning was necessary to foster collaboration and improve care
quality across disciplines.
The demanding workload associated with managing BPSD often led to emotional
exhaustion among nursing staff. Kang and Bang (2024) reported that poor staffing levels and
insufficient dementia-specific training were major contributors to caregiver burnout. KeuningPlantinga et al. (2022) highlighted that institutional support and targeted education programs
were critical in preparing nurses to manage the complex behavioral challenges associated with
dementia care.
Opportunities existed to enhance caregiver efficiency through policy modifications and
structured education. Lindeza et al. (2020) found that communication-focused interventions
reduced caregiver stress in both professional and family caregiving contexts. Duan et al. (2019)
reinforced these findings by emphasizing the role of organizational support in promoting
caregiver well-being.
Structured dementia training improved clinical documentation, proactive care planning,
and caregiver communication. Mellinger et al. (2023) observed that nurse care managers who
received specialized training demonstrated increased attention to risk factors and patient safety.
These improvements contributed to better coordination and overall care quality in dementia
settings.
Family caregivers also benefited from dyadic assessment instruments that evaluated
relationship dynamics and guided tailored interventions. Orsulic-Jeras et al. (2020) found that
tools such as the Alzheimer’s Disease Knowledge Test and Dyadic Coping Inventory provided

38

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
valuable insights that informed caregiver strategies along the care trajectory. Implementing these
instruments ensured care plans remained sensitive to both patient and caregiver needs.
Culture change within care organizations was essential for sustaining improvements in
dementia care practices. Schneider et al. (2020) reported that integrating dementia-friendly
education into daily workflows enhanced staff confidence, improved communication, and
supported long-term cultural transformation. Expanding educational initiatives offered
organizations new opportunities to strengthen staff resilience and elevate care delivery standards.
Structural and organizational barriers, including inadequate leadership support, rigid
training formats, and lack of clinical relevance, impeded the broad implementation of dementia
education. Surr et al. (2020) emphasized the need to address these challenges to successfully
integrate evidence-based training into practice. Yaghmour (2022) noted that cultural variations in
caregiver perceptions necessitated educational programs that emphasized cultural competence to
ensure effective and respectful care.
Hospital nurses faced multiple systemic challenges in delivering optimal dementia care.
Ye et al. (2024) identified coordination gaps, staffing shortages, and inadequate leadership as
primary obstacles in acute care settings. Addressing these issues required comprehensive
leadership development and robust clinical training to prepare staff for the complexities of
dementia care.
Caregiver burden directly influenced how caregivers responded to aggressive behaviors
in dementia patients. Staff education, emotional support, and organizational investment in
caregiver support programs were essential for delivering high-quality, person-centered care.

39

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Sustained institutional support was crucial for maintaining safe and effective care environments
for individuals with dementia.
In summary, caregiver well-being was integral to managing aggression in dementia care.
High levels of caregiver stress, limited training opportunities, and insufficient organizational
support contributed to burnout and compromised care quality. Evidence underscored the
importance of structured education, reflective practice, and culturally responsive interventions to
enhance staff resilience and improve patient outcomes. The following section presented the
methodology and design used to evaluate the impact of communication training and an evidencebased tool on staff perceptions of aggression in dementia care.
Study Designs
Studies on aggression in dementia care employed various methodological designs to
evaluate intervention effectiveness, staff experiences, and patient outcomes. Both quantitative
and qualitative methods provided critical insights while accounting for the complexities and
potential biases inherent in real-world clinical environments (Althubaiti, 2016). These diverse
approaches strengthened the evaluation process by addressing different aspects of care delivery
and outcome measurement.
Quasi-experimental designs were frequently utilized to navigate the ethical and logistical
challenges of randomizing vulnerable dementia populations. These designs allowed comparisons
between intervention and control groups while preserving flexibility in clinical settings
(Alruwaili et al., 2024). For example, a quasi-experimental study assessing a culturally tailored
intervention, including Snoezelen therapy and aromatherapy, demonstrated significant

40

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
improvements in agitation and quality of life through pre- and post-intervention assessments
(Alruwaili et al., 2024).
Although less common, randomized controlled trials (RCTs) offered robust internal
validity when applied effectively in dementia care. Kunik et al. (2020) conducted an RCT
evaluating aggression prevention training that taught caregivers to recognize early signs of
aggression and implement communication techniques for de-escalation. Using standardized tools
like the Cohen-Mansfield Agitation Inventory (CMAI), the study revealed reductions in
aggression frequency, caregiver stress, and improvements in caregiver-patient relationships
(Kunik et al., 2020).
The intervention group in Kunik et al.’s (2020) study exhibited a statistically significant
decrease in aggressive behaviors compared to the control group (p < .05). Caregivers also
reported enhanced coping abilities and stress management, demonstrating that communicationbased aggression prevention training could yield meaningful outcomes within a relatively short
period (Kunik et al., 2020).
Qualitative research added depth to quantitative findings by exploring the lived
experiences of healthcare providers. Kabaya et al. (2023) found that dementia-certified nurses
developed expertise in managing aggression through reflective practice and ethical decisionmaking. Similarly, Dunkle et al. (2022) utilized the Rigorous and Accelerated Data Reduction
(RADaR) method to identify key themes such as family involvement, care strategies, and
systemic barriers faced by nurses and social workers in dementia care.
Technological advancements introduced innovative methods for detecting aggression in
dementia care settings. Galanakis et al. (2025) developed an artificial intelligence model utilizing
41

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
audio cues and meta-classifiers to predict aggression with high accuracy. Although clinical
implementation was pending, such technology had the potential to complement behavioral tools
like the CMAI by enabling real-time monitoring (Galanakis et al., 2025).
Implementation research further explored strategies to improve adherence to best
practices in dementia care. Goorts et al. (2021) found that interventions such as audit and
feedback systems, reminder protocols, and engaging opinion leaders enhanced guideline
adherence among allied health professionals. These findings underscored the importance of
structured educational and feedback mechanisms in promoting consistent care delivery.
When randomized trials were impractical, quasi-experimental designs served as a viable
alternative for maintaining research rigor. Handley et al. (2018) provided methodological
recommendations to enhance the internal and external validity of quasi-experimental studies,
ensuring their applicability in real-world dementia care settings. These strategies supported the
use of flexible research designs without compromising scientific rigor.
Educational interventions remained central to improving caregiver preparedness and
confidence. Parveen et al. (2021) demonstrated that targeted dementia-specific training
significantly enhanced knowledge and self-efficacy among health and social care staff.
Rasmussen et al. (2023) further emphasized that training programs focusing on person-centered
communication effectively reduced staff stress and improved care outcomes.
Despite these advancements, inconsistencies in international training standards persisted.
Pit et al. (2023) highlighted the need for standardized, competency-based frameworks to ensure
quality and consistency across diverse dementia care settings. Addressing these gaps was critical
to fostering uniformity in staff education and practice.
42

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Contextual barriers also hindered the provision of effective dementia care. Shrestha and
Shrestha (2024) identified workforce shortages, limited educational opportunities, and restricted
access to resources as major challenges in Ontario’s dementia care landscape. Van Manen et al.
(2020) proposed structured communication models emphasizing emotional attunement and
patient-centered approaches to enhance nurse-patient interactions and navigate these systemic
barriers.
Ethical considerations remained paramount in dementia research. Willie (2024) stressed
the importance of clearly defining inclusion criteria and maintaining transparent sampling
methods to ensure fair representation and uphold research integrity. These ethical safeguards
enhanced the generalizability and credibility of research findings across care environments.
Combining quasi-experimental, randomized controlled, qualitative, and implementationfocused designs enriched the knowledge base surrounding aggression management in dementia
care. This multifaceted approach provided robust evidence on clinical effectiveness, educational
needs, system-level improvements, and ethical research practices. Employing a quasiexperimental pre-post design aligned with these best practices, facilitating a comprehensive
evaluation of interventions within a real-world clinical context.
The reviewed studies collectively affirmed the importance of methodologically sound
research designs in evaluating dementia care interventions. Quasi-experimental and qualitative
methodologies offered practical advantages for assessing interventions in everyday care
environments, where rigid control groups were not feasible. These findings informed the
selection of assessment tools and reinforced the need for balanced, adaptable research designs to
capture both quantitative outcomes and qualitative experiences in dementia care. The following

43

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
section detailed the instruments selected for this project, emphasizing their reliability, validity,
and relevance to assessing behavioral outcomes in dementia care.
Instrumentation and Justification
This project employed the Cohen-Mansfield Agitation Inventory (CMAI) as the primary
instrument to measure agitation in older adults with dementia. The CMAI consisted of 29 items
assessing the frequency of specific agitated behaviors using a seven-point scale (Kupeli et al.,
2018). Its widespread use in both clinical and research settings reflected its strong reliability,
sensitivity to behavioral change, and practical application in dementia care populations (Kupeli
et al., 2018).
The CMAI demonstrated robust psychometric properties, making it suitable for diverse
care environments. A validation study involving 230 hospitalized older adults in the United
Kingdom confirmed its interrater reliability and internal consistency in acute hospital settings
(Kupeli et al., 2018). The tool’s two-factor structure distinguished between aggressive and nonaggressive behaviors, enhancing its clinical utility in categorizing agitation types (Kupeli et al.,
2018).
The CMAI’s flexibility was demonstrated across various care settings, including
hospitals, residential facilities, and community-based environments. Its reliability in detecting
and measuring agitation ensured accurate assessments even in busy clinical settings (Kupeli et
al., 2018). This made the CMAI an effective tool for monitoring behavioral changes during
intervention studies.
Recent research supported the CMAI’s use in assessing behavioral intervention
outcomes. Kunik et al. (2020) used the CMAI in a randomized controlled trial to evaluate the
44

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
impact of aggression prevention training, effectively capturing pre- and post-intervention
changes in agitation. Alruwaili et al. (2024) also utilized the CMAI in a quasi-experimental
study, demonstrating its sensitivity in detecting reductions in agitation following a culturally
tailored intervention incorporating Snoezelen therapy and aromatherapy.
While the Neuropsychiatric Inventory (NPI) was employed in Alruwaili et al.’s (2024)
study to assess broader neuropsychiatric symptoms, the CMAI provided targeted measurement of
agitation-related behaviors. This specificity made the CMAI a more appropriate instrument for
this project’s focus on physical and verbal aggression. Its precision in capturing nuanced
behavioral changes aligned with the project’s evaluation needs.
Emerging instruments complemented the CMAI by refining the measurement of
agitation-related behaviors. De Mauleon et al. (2021) validated additional agitation measures
aligned with International Psychogeriatric Association (IPA) criteria, suggesting that combining
established and new tools could have enhanced clinical assessments. Future research might have
benefited from integrating these complementary instruments to obtain a more comprehensive
view of behavioral symptoms.
Theoretical frameworks further justified the selection of the CMAI. The PHYT-indementia model, derived from the Transtheoretical Model (TTM) and COM-B framework,
emphasized individualized behavior change (Di Lorito et al., 2019). This alignment supported
the use of structured instruments like the CMAI to evaluate progress in patient-centered
interventions.
The CMAI’s adaptability was demonstrated by its successful validation across
international contexts. Kratzer et al. (2023) confirmed the reliability and efficiency of the
45

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
CMAI–Short Form (CMAI-SF) in shared-housing environments in Germany, reducing
administrative burdens while retaining measurement integrity. This adaptability made the CMAI
practical for real-world care environments where time and resource constraints were prevalent.
Maintaining data consistency was a critical methodological principle in dementia
research. Smith (2021) emphasized the importance of standardized tools like the CMAI to
mitigate challenges such as confounding variables and selection bias in clinical data collection.
Utilizing validated instruments enhanced internal validity and facilitated comparability across
diverse care settings.
Ethical research practices necessitated careful selection of measurement tools to ensure
representativeness and data integrity. Willie (2024) advocated for clear population definitions
and transparent sampling methods to support ethical standards and research credibility. The
CMAI’s long-standing validation across various populations made it an ethically sound choice
for this project.
The CMAI enabled comprehensive classification of agitation behaviors, including
physically aggressive, non-aggressive, and verbally aggressive actions (Alruwaili et al., 2024).
This categorization supported detailed monitoring of behavior patterns before and after
intervention, enhancing the rigor of outcome assessments. The instrument’s versatility facilitated
consistent data collection across different stages of the intervention.
Complementary measures often accompanied the CMAI to deepen the understanding of
agitation’s underlying causes. Sahu et al. (2020) combined the CMAI with the Hamilton Anxiety
Rating Scale to examine how distress contributed to physical aggression in dementia patients.

46

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Using multiple tools in conjunction provided a more nuanced assessment, informing tailored
intervention strategies.
Qualitative methods also supplemented CMAI data by capturing caregivers’ experiences
and perceptions. Dunkle et al. (2022) employed structured interviews to explore how staff
emotionally and cognitively responded to managing aggression, offering valuable context to
quantitative findings. This mixed-methods approach enriched the interpretation of CMAI data
and supported comprehensive evaluation.
The CMAI’s extensive use in dementia research affirmed its validity and relevance across
care environments. Its ability to capture specific agitation-related behaviors directly aligned with
the focus of this study, ensuring precise measurement of intervention outcomes. Given its strong
psychometric foundation and compatibility with person-centered care models, the CMAI was a
well-supported and appropriate choice for this project’s primary outcome measure. The
following section outlined the methodological framework guiding this study, detailing how the
chosen design, data collection, and analysis strategies evaluated the intervention’s effectiveness.
Methodology
Research on aggression in dementia care had employed various quantitative
methodologies to assess the effectiveness of interventions targeting aggression. Randomized
controlled trials (RCTs) offered high internal validity by controlling confounding variables and
standardizing intervention delivery (Kunik et al., 2020). However, their stringent participant
criteria and controlled environments often limited the generalizability of findings to typical care
settings.

47

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Quasi-experimental designs presented a practical alternative for evaluating interventions
in real-world environments where randomization was not feasible (Alruwaili et al., 2024). These
designs allowed researchers to compare pre- and post-intervention outcomes, providing valuable
insights into behavioral changes. Psychometric research further validated measurement tools like
the Cohen-Mansfield Agitation Inventory (CMAI), confirming its reliability and construct
validity in assessing agitation in older adults with dementia (Kupeli et al., 2018).
Qualitative research complemented quantitative studies by capturing the lived
experiences of caregivers and healthcare professionals. Researchers often used purposive
sampling to recruit participants who had direct experience managing behavioral and
psychological symptoms of dementia (Kabaya et al., 2024). Data collected through interviews
and thematic analyses revealed consistent patterns in staff coping strategies, knowledge
development, and systemic challenges that impacted dementia care delivery (Dunkle et al.,
2022).
Despite the strengths of both quantitative and qualitative methods, few studies integrated
these approaches into mixed methods designs. This separation limited understanding of how
objective behavioral data aligned with staff experiences and environmental factors. Without
qualitative feedback, researchers risk overlooking the feasibility, acceptability, and unintended
consequences of interventions, while promising practices identified qualitatively remained
under-tested empirically.
The lack of mixed-methods research hindered the practical application of findings in
clinical settings. To address this gap, the current study employed a quasi-experimental mixedmethods design, combining pre- and post-intervention CMAI assessments with qualitative staff

48

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
surveys. This design captured both behavioral changes and staff perspectives on aggression
management, providing a more comprehensive evaluation of the intervention’s impact.
By integrating quantitative and qualitative data, this approach enhanced internal validity
while offering a richer understanding of how interventions affected daily care practices. Staff
surveys documented attitudes, experiences, and perceived challenges, ensuring the findings
reflected real-world complexities. This methodology aligned with best practices for evaluating
interventions aimed at improving dementia care outcomes.
The project examined whether combining structured communication training with CMAI
use improved healthcare staff’s perception and management of aggression in dementia care
settings. A mixed-methods design enhanced the relevance and applicability of results by
providing both measurable outcomes and contextual insights. The findings contributed to
evidence-based strategies that supported staff development and promoted safer, more effective
dementia care practices. The following section synthesized key findings from the literature and
discussed their practical implications for enhancing aggression management strategies in
dementia care.
Synthesis of Key Literature and Implications for Practice
Dementia-related aggression remains a persistent challenge in healthcare, requiring
multilevel interventions that were grounded in evidence to benefit patients, caregivers, and the
broader system. Emerging literature highlighted that aggression arose from complex interactions
among unmet patient needs, environmental triggers, and caregiver responses (Rasmussen et al.,
2023). Addressing this complexity required proactive care models that integrated behavioral
health strategies into daily clinical practice across diverse care environments.
49

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Organizational readiness and system-level support were critical factors that influenced
the success of dementia care interventions. Research showed that leadership engagement,
ongoing staff education, and alignment with institutional values significantly increased the
likelihood of successful outcomes (Schneider et al., 2020). Embedding training, policy, and
evaluation into a unified organizational framework fostered shared responsibility and promoted
sustained improvements in care quality.
Culturally responsive care also played a vital role in reducing aggression in dementia
settings. Studies emphasized that interventions needed to consider language preferences, spiritual
beliefs, and cultural identities to be truly effective (Shrestha & Shrestha, 2024). Involving
families and understanding cultural nuances in the expression of distress helped staff accurately
interpret behaviors often perceived as aggression.
Sustainability and scalability were essential for the long-term success of dementia
interventions. Programs that were resource-intensive or time-consuming might not have been
feasible across various care settings, highlighting the need for adaptable and practical solutions
(Goorts et al., 2021). Interventions designed with workflow integration, clear outcome measures,
and feedback mechanisms were more likely to be adopted and maintained over time.
Technological advancements presented new opportunities for early detection and
management of aggression. Studies investigated artificial intelligence models, wearable sensors,
and audio-based alert systems capable of identifying pre-agitation cues and alerting caregivers
before escalation occurred (Galanakis et al., 2025). While further validation was necessary, these
innovations represented a shift toward predictive and preventive care models that complemented
personalized, empathetic approaches.

50

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Recent literature advocated for integrating clinical outcome measurements with
qualitative feedback from staff and patients. Mixed-methods research, which combined
quantitative data with narrative responses, offered a comprehensive evaluation of intervention
effectiveness and feasibility (Kabaya et al., 2023). This dual approach enhanced understanding
not only of whether an intervention worked but also how and why it succeeded in real-world
practice.
This project aligned with these priorities by employing a quasi-experimental pre-post
embedded mixed methods design to evaluate a structured, nonpharmacologic intervention for
managing aggression in an acute care unit. The Cohen-Mansfield Agitation Inventory (CMAI)
was used to quantify behavioral changes due to its proven validity and reliability. Additionally,
staff surveys captured qualitative insights into their experiences and the intervention’s
practicality, enriching the quantitative findings with real-world perspectives.
The synthesis of current literature supported the project’s design and reinforced the need
for evidence-based, culturally sensitive, and patient-centered approaches. By integrating rigorous
measurement with reflective evaluation, the study developed actionable strategies for improving
staff preparedness, enhancing patient safety, and elevating the standard of dementia care. These
efforts contributed to addressing longstanding challenges in managing aggression within
dementia populations. The following section summarized the key themes and evidence from the
literature review, highlighting their significance in framing the research problem and justifying
the project’s intervention approach.
Chapter Two Summary

51

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Chapter Two reviewed literature on aggressive behavior in dementia care, with a focus on
staff perceptions, communication strategies, interdisciplinary interventions, and standardized
behavioral assessment tools. Although nonpharmacological and patient-centered interventions
had shown positive impacts, healthcare organizations had yet to fully implement effective
education and practice programs to address these behaviors (Alzheimer’s Association, 2024). A
gap remained in understanding how staff perceptions influenced behavioral outcomes, which
underscored the need for targeted, evidence-based interventions.
The CMAI had been widely validated as a reliable instrument for assessing various forms
of aggression in dementia patients (Kupeli et al., 2018). Its ability to differentiate between types
of agitation supported its use in monitoring behavioral changes throughout care interventions.
However, while tools like the CMAI effectively quantified behaviors, they often fell short in
capturing the nuanced impact of staff communication strategies on patient outcomes (Sun et al.,
2022).
Structured communication training had been shown to reduce aggression and increase
staff confidence in managing behavioral symptoms (Schneider et al., 2020). Patients benefited
when staff received structured education that emphasized empathy and patient-centered care
approaches. Despite these findings, there was a lack of studies that integrated quantitative
behavioral assessments with qualitative evaluations of staff experiences, which limited a
comprehensive understanding of intervention effectiveness.
Most existing research examined aggression interventions using either quantitative or
qualitative methods but rarely combined both into a unified study design. This separation
restricted the ability to assess how interventions affected clinical practice, particularly regarding

52

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
staff experiences with aggression management. Researchers often overlooked the emotional and
practical challenges faced by staff when implementing these interventions, resulting in an
incomplete picture of care dynamics.
The Transtheoretical Model (TTM) offered a theoretical basis for developing training
initiatives that encouraged sustainable behavior change. TTM emphasized the importance of
readiness and reinforcement in guiding individuals through stages of behavioral adoption
(Lindeza et al., 2020). Effective interventions depended not only on the training content but also
on staff engagement, perception, and the organizational support provided during implementation.
Given these considerations, a quasi-experimental embedded mixed-methods design was
deemed appropriate for this project. The study collected quantitative data using pre- and postintervention CMAI assessments to measure changes in aggression levels. Additionally,
qualitative data from staff surveys captured participant perspectives on the intervention's impact,
providing valuable insights into the feasibility and effectiveness of the combined approach.
Healthcare professionals working with dementia patients were the target population for
this study because they frequently encountered aggressive behaviors and stood to benefit
significantly from enhanced training. By analyzing changes in CMAI scores and staff feedback,
the project generated both measurable outcomes and a deeper understanding of the intervention's
practical applications. This design ensured a comprehensive evaluation of how communication
training, combined with behavioral assessment tools, influenced staff perceptions and
management of aggression.
In conclusion, the literature supported the use of communication-focused training and
structured behavioral assessments to reduce aggression in dementia care settings. However,
53

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
further research integrating quantitative and qualitative methods was needed to capture both
behavioral outcomes and staff experiences. This project investigated whether combining
communication training with the CMAI reduced healthcare staff’s perceived prevalence of
aggression in dementia patients compared to staff who had not received structured training. The
findings guided clinical practice improvements and provided a foundation for the methodological
approach detailed in Chapter Three. The following chapter outlined the methodological
framework, detailing the study design, sample selection, data collection procedures, and analysis
strategies employed to evaluate the intervention’s impact on staff perceptions and aggression
management in dementia care.
CHAPTER THREE: METHODOLOGY
Introduction
In acute care settings, healthcare staff frequently encountered aggressive behaviors from
patients with dementia, disrupting care delivery. Many healthcare organizations provided general
training for staff; however, these programs often lacked the depth needed to manage dementiarelated aggression effectively. As these behavior patterns became increasingly common, the
deficiencies in current training programs highlighted a need for focused, evidence-based
interventions that ensured safety, compassion, and patient-centered care.
This project aimed to determine whether structured communication training combined
with the Cohen-Mansfield Agitation Inventory (CMAI) improved healthcare workers’ ability to
recognize, assess, and manage aggression in patients with dementia. The intervention
incorporated the Transtheoretical Model of Behavior Change and Jean Watson’s Theory of
Human Caring to enhance staff readiness and foster an empathetic approach to care delivery. By
54

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
integrating a validated behavioral assessment tool with targeted communication strategies, the
study sought to enhance staff preparedness and ensure consistent responses to behavioral
challenges in dementia care.
A mixed-method quasi-experimental design was used to evaluate changes in staff
perceptions, confidence, and clinical practice before, during, and after the intervention. This
approach enabled the collection of both measurable outcomes and qualitative insights from staff
experiences, contributing to the development of future dementia-specific training programs and
informing care strategies related to aggression management.
Research Questions and Hypotheses
This project aimed to explore the effect of implementing structured communication
training combined with the Cohen-Mansfield Agitation Inventory (CMAI) on healthcare staff's
ability to detect, assess, and manage aggressive behavior in patients with dementia. The project
employed a quasi-experimental, pre-post, embedded mixed methods design to evaluate changes
in staff perceptions, confidence, and care practices before, during, and after the intervention. The
research questions and hypotheses aligned with the problem statement and purpose statement.
The intervention was grounded in the Transtheoretical Model of Behavior Change (Prochaska &
DiClemente, 1983) and Jean Watson's Theory of Human Caring (Riegel et al., 2018).
This study was the first to investigate whether structured communication training,
combined with the CMAI, improved healthcare staff’s ability to recognize, assess, and manage
aggression in patients with dementia. The problem statement and purpose statement are aligned
directly with the research questions and hypotheses.
The following research questions and hypotheses guided this investigation:
55

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Research Question 1 (RQ1): To what extent did the combination of structured communication
training and the use of the Cohen-Mansfield Agitation Inventory (CMAI) influence healthcare
staff's perception of aggression in patients with dementia?
•

H10: There was no statistically significant difference in healthcare staff's perception of
aggression in patients with dementia before and after the implementation of the CMAI
and communication training.

•

H1a: There was a statistically significant difference in healthcare staff's perception of
aggression in patients with dementia before and after the implementation of the CMAI
and communication training.

Research Question 2 (RQ2): To what extent did the intervention improve healthcare staff's
confidence in managing aggressive behaviors in patients with dementia?
•

H20: There was no statistically significant difference in healthcare staff's confidence in
managing aggressive behaviors before and after the intervention.

•

H2a: There was a statistically significant improvement in healthcare staff's confidence in
managing aggressive behaviors following the intervention.

Research Question 3 (RQ3): To what extent did the intervention improve healthcare staff's
ability to recognize behavioral triggers in patients with dementia?
•

H30: There was no statistically significant difference in staff's ability to recognize
behavioral triggers in patients with dementia before and after the intervention.

•

H3a: There was a statistically significant improvement in staff's ability to recognize
behavioral triggers in patients with dementia following the intervention.
56

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The independent variable in this project was the intervention, which included structured
communication training and the use of the CMAI. The dependent variables were staff perception
of aggression, confidence in managing aggressive behaviors, and ability to identify behavioral
triggers (Baby et al., 2018). The CMAI was used to assess the frequency and types of agitation in
patients with dementia (Kupeli et al., 2018). Pre-, mid-, and post-intervention staff surveys
evaluated changes in staff confidence, perception, and ability to identify behavioral triggers
(Reichelt et al., 2023).
An embedded mixed-methods approach facilitated the collection of both quantitative data
and qualitative insights from staff who participated in the intervention (Handley et al., 2018).
The pre-post design enabled direct comparison of outcomes and staff experiences. This
pragmatic design was suitable for clinical environments where randomization was impractical
but rigorous evaluation remained essential (Akrour et al., 2022).
Research Methodology
This project employed a quasi-experimental, embedded mixed methods design to
investigate whether structured communication training combined with the CMAI enhanced
healthcare staff's ability to recognize and respond to aggressive behaviors in patients with
dementia. By integrating quantitative and qualitative data, this design facilitated a
comprehensive understanding of aggression management in dementia care settings (Kratzer et
al., 2023). The approach allowed for quantifiable outcome measurements while capturing the
contextual perspectives of frontline staff to inform conclusions.
A quasi-experimental design was appropriate for this project as it enabled the evaluation
of an intervention within a real-world clinical environment without the requirement for
57

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
randomization. Randomized controlled trials were not feasible in acute care settings due to
ethical and logistical constraints that arose when withholding interventions from high-risk patient
populations (Handley et al., 2018). This design allowed for comparison of outcomes before and
after the intervention while maintaining ethical standards in participant care.
Quantitative data were collected using staff surveys administered at pre-, mid-, and postintervention intervals. These surveys assessed staff confidence, ability to recognize behavioral
triggers, and perception of aggression. CMAI assessments were conducted concurrently to
monitor changes in the frequency and severity of agitated behaviors among patients with
dementia (Ye et al., 2024). Qualitative data were gathered through open-ended survey responses
following the intervention, providing insights into staff experiences and perceptions regarding
the training and CMAI application (Moody et al., 2024).
A mixed-methods design offered several advantages for this quality improvement project.
The combination of quantitative and qualitative data provided a comprehensive evaluation of the
intervention's effectiveness. Relying solely on quantitative data would have overlooked nuanced
feedback from staff, while a qualitative-only design would have lacked the capacity for
hypothesis testing and statistical measurement of change. The chosen design enabled robust
evaluation without the ethical concerns associated with randomized controlled trials, which were
not suitable in settings where care could not be withheld (Carrarini et al., 2021).
Previous research demonstrated that communication training and structured assessment
tools like the CMAI effectively reduced aggression in patients with dementia. Such interventions
had been shown to improve staff preparedness, prevent behavioral escalation, and enhance staff
confidence in managing challenging behaviors (Baby et al., 2018; James et al., 2023). Training

58

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
programs emphasizing empathy and skill development led to quantifiable improvements in both
staff competence and patient outcomes.
This quasi-experimental, embedded mixed-methods approach provided a systematic and
practical framework for evaluating the impact of educational and behavioral interventions on
staff practice. The design aligned with established dementia care guidelines and had the potential
to contribute to reduced patient harm and improved workforce well-being. By integrating
synchronized quantitative and qualitative datasets, the findings supported actionable
recommendations and offered generalizability to similar healthcare settings.
Research Design
This project used a quasi-experimental, pre- and post-intervention embedded mixed
methods design to evaluate the impact of structured communication training and the CMAI on
healthcare staff's perception of aggression, confidence in managing behaviors, and ability to
apply de-escalation strategies. This approach was suitable for acute care dementia units where
randomization was often impractical (Handley et al., 2018). The embedded design allowed for
quantifiable assessment of staff competencies while capturing contextual insights into the
complexities of dementia care, aligning with the project's quality improvement objectives.
Data collection included pre- and post-intervention CMAI scores and structured staff
perception surveys for quantitative analysis. Qualitative data was gathered through open-ended
survey responses, with thematic analysis providing context to support interpretation of the
quantitative findings. The intervention, consisting of structured communication training and
CMAI use, served as the independent variable, while the dependent variables were staff
perception of aggression, confidence in managing incidents, and the ability to recognize
59

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
behavioral triggers. The unit of analysis was the healthcare staff who participated in the
intervention.
Table 1.
Methodology Summary
Component
Design

Description
Quasi-experimental, pre-post embedded
mixed-methods design

Setting

155-bed hospital, acute care unit (6 North)

Participants

Nurses and Clinical Assistants (n=10-15)

Intervention

Structured communication training + CMAI
utilization

Tools

CMAI, custom pre-, mid-, post- staff
perception surveys, & incident reports

Data Collection Period

6 weeks

Analysis

Descriptive statistics, paired sample t-tests,
content analysis of qualitative feedback

Alignment with Methodology and Data Collection
The chosen design supported the applied nature of this quality improvement project,
which aimed to evaluate an evidence-based intervention within a real-world clinical setting. The
intervention was implemented in practice while adhering to a structured framework for outcome

60

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
measurement. Data was collected over a six-week period to assess the effectiveness of the
intervention and its integration into daily care routines.
Healthcare staff utilized the CMAI to assess patient behaviors. This standardized
instrument provided quantitative data regarding the frequency and types of aggressive behavior
observed before and after the intervention. Weekly CMAI assessments enabled tracking of
changes in aggression patterns over time, facilitating evaluation of the intervention’s impact on
managing aggressive behaviors.
Staff perception surveys were administered at three intervals: pre-intervention, midintervention (week three), and post-intervention (week six). These surveys assessed changes in
staff-reported confidence, competence, and knowledge related to recognizing and managing
aggressive behaviors in patients with dementia. Each survey included Likert-scale items for
quantitative measurement and open-ended questions to capture qualitative feedback, consistent
with the project's embedded mixed-methods design.
The project evaluated the intervention’s impact through comparative analysis of CMAI
scores and survey responses across the three data collection points. Reductions in CMAI scores
indicated improvements in patient behavior management, while enhanced survey scores reflected
increased staff confidence and skill acquisition. The structured combination of quantitative and
qualitative data collection ensured a comprehensive assessment of the intervention’s
effectiveness in promoting staff readiness and improving dementia care practices.
Establishing Intervention Impact
This project employed a mixed-methods approach, integrating quantitative and
qualitative data to evaluate whether the intervention achieved its intended objectives. By
61

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
combining measurable outcomes with contextual staff feedback, this approach provided a
comprehensive assessment of the intervention’s effectiveness and enhanced the credibility of the
findings.
Quantitative data analysis involved descriptive comparisons of pre-, mid-, and postintervention Cohen-Mansfield Agitation Inventory (CMAI) scores and staff survey responses.
Measures of central tendency and percentage change were used to compare results across time
points and identify improvements in staff perceptions, confidence, and observed patient
behaviors. These analyses assessed whether the intervention was associated with measurable
improvements in staff preparedness and communication during dementia care.
Qualitative data were derived from open-ended survey responses collected after the
intervention. Content analysis was used to examine staff experiences, perceptions of the training,
and the perceived utility of the CMAI tool. Thematic categories included perceived advantages,
challenges encountered, and suggestions for enhancing future training initiatives. This qualitative
feedback provided context to complement the quantitative results, enriching the interpretation of
the intervention’s overall impact.
To minimize confounding variables, the intervention was applied uniformly to all
participants. All staff received the same structured communication training, CMAI instruction,
and project materials to ensure consistency in intervention delivery. Standardized data collection
procedures further supported the reliability of the findings.
External factors such as staffing levels, patient acuity, and environmental conditions were
documented and considered during data analysis to ensure accurate interpretation of the results.
This approach aligned with best practices in quality improvement projects, allowing for
62

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
pragmatic yet rigorous evaluation within the dynamic environment of acute care dementia units.
By incorporating both descriptive measures and contextual insights, the project’s findings offered
a nuanced understanding of how structured communication training and behavioral assessment
tools influenced staff practice and patient outcomes.
Population and Sample Selection
Setting
This project was conducted in an acute care unit within a 155-bed hospital that provided a
comprehensive range of medical and behavioral health services. The facility offered specialized
care for patients with Alzheimer’s disease and other forms of dementia. Patients in this unit
frequently exhibited aggressive and agitated behaviors, which contributed to heightened stress
and safety concerns among healthcare staff. The selected implementation site experienced a high
volume of dementia patients and a corresponding increase in aggressive behavioral episodes,
necessitating targeted interventions to enhance staff preparedness and improve patient care
outcomes.
General and Target Population
The general population for this project consisted of healthcare workers who provided care
to individuals with dementia in acute inpatient settings. The project focused specifically on
licensed and unlicensed healthcare staff assigned to the 6 North unit of the hospital. These staff
members included nurses and clinical assistants who were responsible for direct patient care.
Staff working on this unit routinely managed patients exhibiting agitation and aggressive
behaviors, which presented significant challenges in care delivery. The increasing frequency of
aggression among dementia patients in this unit underscored the need for enhanced support and
63

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
targeted training in behavioral intervention strategies. This project aimed to equip staff with
evidence-based tools and communication techniques to improve their ability to recognize, assess,
and manage aggressive behaviors effectively.
Sample and Sampling Procedures
This project included a sample of approximately ten to twelve healthcare staff members
who provided direct patient care in an acute care unit of a mid-sized hospital. The sample
consisted of nurses and clinical assistants who met the established inclusion criteria.
Convenience sampling was used to recruit participants who were accessible and met eligibility
requirements, which was an appropriate approach for quality improvement projects conducted in
clinical environments where randomization was impractical (Willie, 2024).
Eligible participants met the following inclusion criteria: (a) current employment on the
dementia care unit, (b) provision of direct patient care, (c) a minimum of three months of
employment on the unit, and (d) availability to participate in the structured communication
training and complete all phases of the project. Staff members who did not provide hands-on
patient care or were unable to engage in the intervention and data collection activities were
excluded from participation.
Demographic information, including age, gender, and race/ethnicity, was collected to
describe the sample. These variables were not analyzed for individual outcome comparisons but
were reported to provide a comprehensive overview of the participant population. Although this
project did not involve direct patient participation, it targeted healthcare staff who cared for
individuals with dementia, a vulnerable patient population. The perspectives and experiences of

64

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
these staff members were essential to evaluating the effectiveness of structured communication
training and behavioral assessment tools in enhancing dementia care practices.
The sample size, while smaller than that of traditional quantitative studies, was
appropriate for the project's quasi-experimental, embedded mixed-methods design. This design
supported within-subject comparisons and enabled a thorough evaluation of both quantifiable
outcomes and qualitative staff experiences (Collins et al., 2022). Previous research demonstrated
that small, focused samples were sufficient for mixed-methods quality improvement projects,
particularly when contextual insights were prioritized (Handley et al., 2018).
Site Authorization and Confidentiality
Christine Daniels, Associate Chief Nursing Officer, approved the implementation of this
quality improvement project on the 6 North unit at Mon Health Medical Center (MHMC) on
January 15, 2025. All project participants were staff members employed at MHMC. Participation
in the project was entirely voluntary, and staff were permitted to withdraw from participation at
any time without penalty.
Informed consent was obtained from all participants prior to data collection. The project
ensured confidentiality by excluding all names and identifying information from reports,
presentations, and final results. Data were collected and reported in aggregate form to protect
participant anonymity. Informed consent documents outlined these privacy protections and were
stored securely in compliance with institutional policies.
The 6 North unit provided an appropriate setting for evaluating the impact of structured
communication training and behavioral monitoring tools. Staff members working in this unit
frequently manage patients exhibiting agitation and aggressive behaviors that disrupted care
65

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
delivery. This project aimed to enhance staff understanding, confidence, and response strategies
through the implementation of evidence-based interventions that addressed the specific
challenges associated with dementia care in acute settings (Baby et al., 2018).
Instrumentation
This quality improvement project will utilize structured instruments to assess whether
structured communication training and the use of the Cohen-Mansfield Agitation Inventory
(CMAI) reduce aggressive behaviors in patients with dementia and improve staff confidence in
managing such behaviors. The primary instruments include the CMAI, pre-, mid-, and postintervention staff perception surveys, and incident reports. Each instrument is described in detail
in the following sections.
Cohen-Mansfield Agitation Inventory (CMAI)
The Cohen-Mansfield Agitation Inventory (CMAI) is a validated 29-item instrument
designed to measure the frequency of agitated behaviors in patients with dementia. Each item
was rated on a 7-point Likert scale, ranging from one (never) to seven (several times per hour),
allowing for detailed assessment of both the type and frequency of agitated behaviors observed
during patient care (Kratzer et al., 2023). The total CMAI score reflected the cumulative
frequency of behavioral symptoms, providing a basis for comparison across multiple time points.
Research established that the CMAI demonstrated strong internal consistency and
construct validity in clinical and acute care settings (Kupeli et al., 2018). Staff administered the
CMAI at baseline before the intervention and continued weekly assessments for six consecutive
weeks. Data collected through the CMAI provided ordinal-level measurements, supporting
longitudinal analysis of changes in patient behavior over the course of the intervention.
66

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Reductions in CMAI scores indicated decreases in the frequency or severity of aggressive
behaviors, reflecting the effectiveness of the intervention strategies implemented. Written
permission to use the CMAI was obtained from Allen at Options for Living, Inc. on November
25, 2024, ensuring appropriate authorization for its inclusion in this project.
Staff Confidence and Competence Survey
A staff perception survey was used to assess healthcare staff’s confidence and
competence in managing aggressive behaviors exhibited by patients with dementia. The survey
measured three core constructs: confidence in recognizing behavioral triggers, ability to apply
de-escalation techniques, and preparedness to use patient-centered communication strategies.
Each item was rated on a 5-point Likert scale, ranging from one (strongly disagreed) to five
(strongly agreed), allowing for structured measurement of staff perceptions across the
intervention period.
The survey was developed specifically for this project using recommendations from
existing research on dementia care training programs to ensure alignment with evidence-based
practices (Gkioka et al., 2020). The survey design prioritized clarity, neutrality, and consistency
with the intended constructs to minimize potential response bias. Although the instrument was
not pilot tested, it was designed following best practices in survey construction to support
internal consistency and validity (Althubaiti, 2016). The survey collected ordinal-level data,
enabling comparative analysis of pre-, mid- and post-intervention responses to evaluate changes
in staff perceptions and competencies over time.
CMAI Documentation Monitoring and Behavioral Incident Feedback

67

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
CMAI documentation compliance was monitored throughout the six-week intervention to
evaluate staff engagement with the behavioral assessment tool. Staff completed CMAI entries
weekly within the Cerner Ad Hoc documentation system for patients with dementia. These
entries were reviewed descriptively to confirm consistent use of the CMAI and to identify
patterns in staff documentation practices over time. Completion trends served as an indicator of
implementation fidelity, reflecting staff adherence to the intervention process.
In addition to CMAI documentation, manager feedback and staff survey responses were
used to identify the frequency and nature of aggressive behaviors observed during the project.
The nurse manager reported two dementia-related aggression incidents during the final weeks of
the intervention, both of which were managed effectively using the MESSAGE communication
framework. Although formal incident data extraction from the hospital’s RL reporting system
was not conducted, qualitative feedback from staff and leadership provided complementary
insights into behavioral trends and staff response effectiveness.
This approach supported triangulation of data sources and offered a comprehensive
understanding of how consistent CMAI documentation and structured communication training
influenced staff practice and patient care outcomes. The combination of weekly CMAI
monitoring, staff feedback, and manager observations demonstrated improvements in
documentation consistency, communication confidence, and recognition of behavioral triggers
across the intervention period.
Staff Qualitative Feedback
Following the intervention, staff completed an open-ended feedback survey to evaluate
their experiences with the communication training program and the use of the Cohen-Mansfield
68

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Agitation Inventory (CMAI) tool. The post-intervention survey invited staff to describe any
changes in their confidence when managing aggressive behaviors, identify functional aspects of
the training and CMAI implementation, and provide suggestions for improving future training
initiatives.
Qualitative responses underwent content analysis to identify common themes, including
perceived benefits, challenges encountered, and recommendations for refining the intervention.
This analysis supplemented the quantitative findings by providing contextual insights into how
staff perceived the relevance, applicability, and feasibility of the training and assessment tools in
their daily clinical practice (Castro et al., 2024).
Incorporating staff qualitative feedback supported the embedded mixed methods design
by capturing in-depth perspectives on training effectiveness and implementation barriers. These
insights informed the evaluation of whether the intervention was both effective and sustainable
for long-term practice improvements in dementia care. Staff reflections also highlighted practical
considerations for enhancing future iterations of the training program and optimizing the
integration of the CMAI within clinical routines.
Validity
This approach employed established instruments to assess changes in staff perception and
patient behavior following a structured intervention. The author reviewed each of the instruments
to ensure that they fit the intended purpose of the project and that they measured the intended
constructs as designed. These steps contributed to the overall credibility of the data and the
results.

69

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The CMAI was the only instrument used to measure agitation in patients with dementia.
Researchers established the content validity of this measurement tool through rigorous testing in
clinical environments (Kupeli et al., 2018). The study employed the full, unaltered CMAI and
scoring format, which did not negatively affect the internal validity of this project (Kratzer et al.,
2023).
Pre-, mid-, and post-intervention surveys used a 5-point Likert scale to assess behavior
recognition, de-escalation strategies, and patient-centered communication, drawing on the
dementia care communication literature (Gkioka et al., 2020). Although not externally validated,
the survey’s structure and alignment with learning goals supported internal consistency
(Althubaiti, 2016). Staff also provided open-ended comments after the intervention, reflecting on
their experience with the training and the use of the CMAI tool.
Content analysis identified common themes, supporting the exploration of relationships
between the qualitative and quantitative findings (Castro et al., 2024). Utilizing this method
enhanced the results by incorporating staff perceptions and adding depth to the understanding of
how the intervention functioned in the clinical setting.
Reliability
The CMAI demonstrated strong reliability and internal consistency across various care
settings, with Cronbach’s alpha values ranging from 0.82 to 0.92 (Kupeli et al., 2018). The
CMAI showed stability across diverse clinical environments, which supported its consistent
performance in varied care contexts (Sun et al., 2022). Maintaining the tool’s original structure
throughout the six-week intervention ensured reliability and accuracy.

70

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Pre-, mid-, and post-intervention surveys were formatted, worded, and presented on a 5point Likert scale to ensure consistent and valid responses. All three surveys measured
behavioral recognition, de-escalation strategies, and patient-centered communication. Although
not externally validated, the survey adhered to best practices for internal consistency and aligned
with the existing literature on dementia care communication (Van Manen et al., 2020). Studies
indicated that organized questionnaires contributed to greater stability in response rates
(Mellinger et al., 2023).
All staff responded to the same open-ended questions, which helped maintain consistency
in the data collection process. Patterns of responses were identified through content analysis,
thereby ensuring the validity of interpretation (Moody et al., 2024). This dementia care researchbased approach lent strength to the evidence and supported the findings by contributing to the
integrity of data collection during the intervention (James et al., 2023).
Data Collection and Management
The data collection process began after Pennsylvania Western University’s Institutional
Review Board (IRB) granted approval on September 2, 2025 (see Appendix A for the IRB
approval letter). Before initiating the intervention, the author provided eligible staff with detailed
information explaining the project’s purpose, ethical considerations, and the voluntary nature of
participation. The author distributed informed consent forms, which explained that participation
was voluntary, responses were anonymous, and participants could skip questions or withdraw
from the project at any time. Staff indicated their consent to participate by signing the informed
consent form, adhering to ethical guidelines for quality improvement initiatives.

71

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The author developed staff perception surveys specifically for this project to measure
confidence in managing aggression, recognizing behavioral triggers, applying de-escalation
strategies, and using the Cohen-Mansfield Agitation Inventory (CMAI). These surveys included
identical Likert-scale items and open-ended questions to ensure consistency across preintervention, mid-intervention, and post-intervention data collection points. The pre-intervention
survey assessed baseline perceptions, the mid-intervention survey captured early shifts, and the
post-intervention survey evaluated overall changes following the intervention. Copies of the pre-,
mid-, and post-intervention surveys are provided in Appendix B.
During week one, staff members completed the pre-intervention survey to establish a
baseline for their perceptions and confidence levels. Staff also completed the CMAI for each
dementia patient under their care to document the frequency and severity of agitated behaviors
(Kupeli et al., 2018). These baseline assessments provided the foundation for measuring changes
throughout the intervention.
The six-week intervention included weekly CMAI assessments for each patient to
monitor fluctuations in behavioral symptoms. At the end of week three, the project lead
administered the mid-intervention survey to identify early shifts in staff confidence and skills.
During week six, staff completed the post-intervention survey, which used the same format as the
pre- and mid-intervention surveys to ensure consistent measurement (Van Manen et al., 2020).
The staff surveys employed a 5-point Likert scale for quantitative measurement and
maintained identical formatting across all three time points to support internal consistency and
minimize response variability. Survey items aligned with best practices in dementia care
education and measured changes in staff perceptions and skills related to aggression management

72

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
(Gkioka et al., 2020). This approach enabled a structured comparison of quantitative outcomes
across the intervention period.
In addition to survey data, the data collector monitored staff engagement with the CMAI
documentation tool in the Cerner electronic health record. CMAI entries were reviewed
descriptively to evaluate completion trends and to identify patterns in behavioral documentation.
The author also consulted with the nurse manager to confirm observed changes in staff response
behaviors and documentation consistency.
The surveys also included open-ended questions inviting staff to reflect on their
experiences with the communication training and the CMAI tool. The author analyzed these
qualitative responses to gather narrative feedback on the intervention’s usefulness, feasibility,
and perceived impact (Moody et al., 2024). A comprehensive content analysis identified patterns
and contextualized the quantitative data, providing a fuller understanding of staff perceptions.
The project followed a structured data collection timeline. Week one included informed
consent, pre-intervention surveys, and baseline CMAI assessments. Weeks two through six
involved ongoing CMAI tracking, a mid-point survey at week three, a post-intervention survey at
week six, and qualitative feedback collection.
In accordance with institutional guidelines, the project coordinator retained all collected
data for three years following project completion. At the end of this retention period, the author
will permanently delete all digital files and shred any remaining paper records. These procedures
ensured secure handling of sensitive information and maintained compliance with ethical
research protocols (Mellinger et al., 2023).
Data Analysis Procedures
73

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
This quality improvement project used both quantitative and qualitative data to evaluate
the effects of structured communication training and the Cohen-Mansfield Agitation Inventory
(CMAI) on staff perception and patient aggression. The analysis followed a quasi-experimental,
embedded mixed-methods design, ensuring alignment with the study’s research questions and
methodology. The researcher analyzed pre-, mid-, and post-intervention survey data, CMAI
scores, and qualitative staff responses to determine changes over time.
Quantitative data included ordinal-level responses from the staff perception surveys and
weekly CMAI scores. The surveys measured three constructs: recognition of behavioral triggers,
use of de-escalation strategies, and confidence in patient-centered communication. Each survey
item used a 5-point Likert scale, and the same items appeared on all three versions to ensure
consistency across the study. The project calculated descriptive statistics, including means and
standard deviations, to summarize responses for each survey construct. The analysis used pairedsamples t-tests to compare pre-, mid-, and post-intervention survey scores and evaluate
statistically significant changes.
CMAI scores were averaged and examined for trends throughout the intervention. To
confirm accuracy and completeness, the evaluator reviewed all surveys and CMAI forms. This
process included checking for missing responses and verifying the consistency of data entry.
After verification, the responses were coded and scored according to established procedures
(Mellinger et al., 2023).
Content analysis guided the interpretation of qualitative data. Staff completed open-ended
prompts after the intervention to reflect on the communication training and use of the CMAI
tool. The project compared pre-, mid-, and post-intervention survey scores and assessed

74

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
significant changes. This analysis identified patterns that complemented the quantitative results
and strengthened internal validity (James et al., 2023). Consistent coding ensured reliability, and
the analysis continued until no new themes emerged (Moody et al., 2024).
The evaluation enhanced the credibility of its findings by using triangulation through the
combined use of the CMAI tool, communication training, and structured staff surveys. The scope
and quality of data collected were sufficient to answer all research questions and offer insights
for improving care for patients with dementia (Castro et al., 2024).
Ethical Considerations
This quality improvement project aimed to equip staff with evidence-based tools and
targeted communication training to reduce aggressive behaviors in patients with dementia. The
project did not include a comparison group, randomized assignment, or experimental procedures.
Staff participants did not collect sensitive or identifiable patient information, and all activities
aligned with routine clinical practice improvements. These characteristics qualified the project
for exempt status under federal research regulations.
The author submitted documentation to Pennsylvania Western University’s Institutional
Review Board (IRB) and received a determination of exemption approval on September 2, 2025
(see Appendix A). Although the project did not involve protected health information or
experimental risk, the author obtained written informed consent from all participants. The author
distributed an informed consent handout via email, which described the project’s goals,
emphasized the voluntary nature of participation, and confirmed that responses remained
separate from job performance evaluations. Staff signed and returned the consent form

75

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
electronically before completing any surveys or the Cohen-Mansfield Agitation Inventory
(CMAI).
The author secured all signed informed consent forms in a password-protected
institutional email account, where they were stored in a restricted folder accessible only to the
investigator. Survey responses and CMAI data were de-identified prior to analysis and stored
electronically in a password-protected file on the author’s secure institutional computer. No
documents contained names or identifying information. The project ensured that all survey data
remained separate from staff performance evaluations to maintain participant anonymity and
confidentiality throughout the data collection process. All data was used solely for quality
improvement evaluation purposes and were not shared outside the approved academic and
clinical oversight channels.
The project upheld the ethical principles of autonomy, beneficence, and justice. Staff
participation remained voluntary, respecting their right to choose involvement. The intervention
promoted beneficence by introducing no known risks and providing valuable training to enhance
dementia care practices. The project ensured fairness and justice by offering all eligible staff the
opportunity to participate and share feedback. Institutional oversight through the IRB and strict
data privacy measures safeguarded participant confidentiality throughout the project.
Limitations and Delimitations
Because this quality improvement project did not use randomization or include a control
group, it limited the ability to attribute observed outcomes directly to the intervention. As
participation was voluntary, the sample may not have been representative of the general staff
population. Participants who held more positive attitudes toward dementia care or greater
76

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
confidence in managing aggressive behaviors may have had a disproportionate influence on the
results. The possibility of self-selection bias may have reduced generalizability to all healthcare
workers in acute care settings.
Limiting the implementation to one unit prevented the inclusion of staff experiences and
perceptions from other units or healthcare institutions. The primary sources of data collection
were self-report surveys and staff responses to the CMAI, which can be susceptible to response
bias. Staff may have overreported improvements due to social desirability or poor recall. The
implementation period was limited to six weeks, which may have restricted observation of longterm changes.
The use of validated instruments such as the CMAI enhanced the accuracy and credibility
of the data. Communication training, paired with structured surveys and consistent application of
the CMAI, helped minimize potential bias in data collection. Although some limitations were
present, they were reasonable and did not undermine the significance or applicability of this
quality improvement initiative. Future projects may explore how well this approach applies and
sustains across other care environments.
Summary
Chapter Three outlined the methodology for a quasi-experimental, embedded mixedmethods quality improvement project conducted in an acute care setting experiencing an increase
in aggressive behaviors among patients with dementia. This project used the design to assess the
impact of structured communication training and the CMAI on staff ability to recognize and
manage aggression in dementia care (Kratzer et al., 2023). Quantitative data were collected

77

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
through CMAI scores and staff surveys, while qualitative data from open-ended responses
provided additional insight into the intervention’s influence.
The research questions and hypotheses aligned directly with the project’s identified
problem and purpose. The intervention aimed to improve staff perception of aggression, increase
confidence in managing behaviors, and enhance the ability to recognize behavioral triggers. The
project applied the Transtheoretical Model of Behavior Change and Jean Watson’s Theory of
Human Caring to support both behavioral adaptation and relationship-centered care (Riegel et
al., 2018).
Data collection involved standardized instruments, including the CMAI and staff
perception surveys. The CMAI measured the frequency and type of agitated behaviors in patients
with dementia (Kupeli et al., 2018). Pre-, mid-, and post-intervention surveys assessed staff
confidence, perceptions, and use of communication techniques (Gkioka et al., 2020). Openended survey items captured qualitative feedback to complement the quantitative results and
evaluate the intervention’s relevance from the staff perspective.
The sample included ten to fifteen licensed and unlicensed staff who provided direct care
on the 6 North unit. Convenience sampling supported feasibility in the fast-paced clinical
environment and aligned with quality improvement methods in healthcare (Handley et al., 2018).
The IRB approved the project on September 2, 2025, following exempt review (see Appendix
A). Staff received project information and provided informed consent prior to participation.
The analysis plan included descriptive statistics and paired-samples t-tests to evaluate
differences in survey scores and CMAI data before and after the intervention. These analyses
identified whether the training improved staff awareness, use of de-escalation strategies, and
78

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
confidence in communication. Qualitative data underwent content analysis to support
interpretation of staff experiences and perceptions of the training.
This project’s limitations included the absence of a control group, potential response bias,
and limited generalizability. Despite these challenges, the use of validated instruments and
structured communication strategies strengthened the credibility and reliability of the findings.
These methods supported accurate interpretation of staff responses and reinforced confidence in
the overall results.
Chapter Three demonstrated full alignment with the Ten Strategic Points, connecting the
problem, purpose, research questions, methodology, design, instrumentation, and analysis
approach. The structured and ethical implementation laid the groundwork for improving
dementia care and informed the development of future interventions in similar clinical settings.
Chapter Four presents the data and explores the results, offering a detailed view of the
intervention’s impact on unit-level outcomes.
CHAPTER 4: DATA ANALYSIS AND RESULTS
Introduction
The purpose of this quality improvement project was to evaluate the impact of
implementing the Cohen-Mansfield Agitation Inventory (CMAI) and targeted MESSAGE
communication training on healthcare staff's perceptions of aggression in patients with dementia.
Aggressive behaviors among individuals with dementia were increasing and often led to
increased stress and decreased quality of care. The goal of this project was to determine whether
introducing a structured aggression assessment tool and communication framework together

79

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
could enhance staff confidence, competence, and documentation practices related to aggression
management in dementia care.
The project utilized a quasi-experimental pre-, mid-, and post-design to measure changes
in staff perceptions following the implementation of the Cohen-Mansfield Agitation Inventory
(CMAI) and the MESSAGE communication training. Qualitative data was gathered from openended survey questions and manager responses describing weekly staff engagement, observed
behaviors, and CMAI utilization. The research question that guided this project was: Does
implementing the Cohen-Mansfield Agitation Inventory (CMAI) and targeted communication
training improve healthcare staff's perception of aggression in dementia patients compared to
standard training?
This chapter presented an analysis of data collected during the six-week project and
summarized the descriptive findings. The results were organized by pre-, mid-, and postintervention data to illustrate changes in staff perceptions and practices over time. Both
quantitative and qualitative findings were synthesized to capture the overall effect of the
intervention on staff perceptions, confidence, competence, and documentation of aggressive
behaviors. The following section describes these findings in detail and highlights patterns that
emerged throughout the intervention period.
Descriptive Findings
Data was collected during the six-week quality improvement project from staff members
on the 6 North acute care unit. Staff members voluntarily provided informed consent
electronically before participating in the implementation of the Cohen-Mansfield Agitation
Inventory (CMAI) and the MESSAGE communication training. A total of twelve participants (n
80

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
= 12) completed the pre-intervention survey, seven (n = 7) completed the mid-intervention
survey, and ten (n = 10) completed the post-intervention survey. Because this project used a
quality-improvement design within a single acute-care unit, the project team did not conduct an a
priori sample-size calculation. The sample consisted of nurses and clinical assistants who agreed
to take part and were present during the data collection period. The quantitative portion of the
project drew from six Likert-scale survey items that examined staff confidence, competence,
recognition of triggers, comfort with documentation, and the level of support perceived when
managing challenging behaviors. Qualitative data were drawn from open-ended survey questions
and managerial feedback describing staff engagement and observed changes in clinical behavior
during the intervention period.
The demographic item of years of service offered additional context for interpreting the
results. Participants brought a wide range of professional experience, from newly hired staff to
those with more than fifteen years of experience. Most staff had between five and ten years of
service. At baseline, staff with longer tenure generally reported greater confidence in recognizing
triggers and documenting behaviors, whereas those with less than five years of experience
reported lower initial confidence. As the project progressed, the differences in experience levels
decreased. In the post survey, nearly all participants, regardless of tenure, reported comparable
levels of confidence. This data suggests that combining the MESSAGE communication training
along with the CMAI tool provided a structured framework that supported staff in managing
aggression effectively, regardless of tenure.
Figure 5
Years of Service Distribution Among Staff

81

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients

Note. Figure illustrates the distribution of staff experience levels (n = 10). The majority of staff
reported between 6 and 10 years of professional experience, followed by 0–2 years and 11–15
years.
The data revealed a steady improvement from the beginning to the end of the project.
Staff members reported greater confidence in managing aggressive behaviors after completing
the MESSAGE communication training and using the CMAI documentation tool. At week one,
results revealed that only a few individuals felt comfortable recognizing early signs of aggression
or applying de-escalation techniques. By the midpoint of the project, about half reported
increased confidence. By week six, most reported feeling capable of recognizing early signs of
aggression and applying de-escalation techniques. Staff also expressed growing comfort with
documenting behaviors through the CMAI, suggesting that the tool had become familiar in daily
use.
Staff described clear improvements in their understanding of the factors that triggered
aggression and, in their ability to anticipate patient needs. Many staff members noted that the

82

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
MESSAGE training encouraged them to slow interactions, maintain a calm tone, and use
consistent phrasing when communicating with patients who showed early signs of aggression
(Young, 2021). Together, these strategies appeared to make it easier to de-escalate situations and
maintain a safer environment. The use of the CMAI added structure to documentation and made
patterns of aggression easier to identify, which increased staff accountability and situational
awareness.
Qualitative comments supported these quantitative trends. Prior to the intervention, staff
frequently reported frustration and uncertainty when faced with aggressive behavior and
difficulty predicting when it might occur. Midway through the project, staff noted that they were
becoming more aware of early warning signs and working together more effectively when
responding to aggression. Several described the CMAI as "helpful," "easy to use," and "a good
reminder to document consistently." Others said the MESSAGE video provided clear examples
that reinforced the influence of tone and pacing on patient responses.
The nurse manager's feedback aligned with the project's overall results. On the postintervention survey, the nurse manager agreed or strongly agreed that staff confidence had
improved, that recognition of early behavioral triggers had increased, and that the MESSAGE
communication training strengthened teamwork. The nurse manager also reported that staff used
the CMAI tool regularly and appeared calmer and more at ease when caring for patients who
displayed aggression.
In the open-ended section of the survey, the nurse manager noted that the unit's patient
census was lower than usual during the project period, which reduced the number of aggressive
incidents. Even with fewer encounters, staff were more aware of subtle behavioral changes and

83

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
responded sooner to early signs of aggression. Verbal aggression remained the most common
behavior observed. The nurse manager described staff as calmer, clearer in their communication,
and more confident when using de-escalation techniques.
The nurse manager identified one minor workflow issue. Locating the CMAI form within
the Ad Hoc section of Cerner occasionally made documentation less efficient, particularly during
high patient activity. However, as the project continued, staff became more familiar with the tool
and documented it more efficiently. Overall, the nurse manager's observations suggested that the
project improved staff preparedness, communication, and patient care, even during a period of
lower census.
Project results showed steady improvement in how staff handled aggressive behavior in
patients with dementia after using the CMAI tool and MESSAGE training. Staff became more
confident, recognized triggers sooner, and documented behavior more consistently. The inclusion
of years of service data showed that the intervention benefited all staff, regardless of tenure,
reducing differences in confidence and responses. According to feedback from the nurse
manager, teamwork improved, communication felt calmer, and staff applied de-escalation skills
more often. All these outcomes suggest that using a structured documentation system, along with
dementia-specific communication training, fostered a more proactive, collaborative approach to
patient care, ultimately supporting patient safety and staff well-being.
Data Analysis Procedures
The project team analyzed the data using a mixed-methods descriptive approach to assess
how using the Cohen-Mansfield Agitation Inventory (CMAI) and MESSAGE communication
training together influenced staff perceptions of aggression in patients with dementia. The project
84

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
team collected and analyzed both quantitative and qualitative data to evaluate whether staff
confidence, competence, and recognition of behavioral triggers improved during the six-week
project. The team based the data analysis process on the project's three hypotheses, which
examined changes in staff perceptions, confidence, and recognition of triggers following the
intervention. Participation varied slightly across data-collection points (n = 12 pre-intervention, n
= 7 mid-intervention, and n = 10 post-intervention) due to staff scheduling and availability
during the six-week project.
Quantitative Data Analysis
Participating staff received six-item Likert-scale surveys administered prior to, midway
through, and following the project, which provided the quantitative data for analysis. Each
measured key aspects of staff perception, confidence in managing aggressive behaviors,
competence in recognizing early warning signs, and awareness of patient triggers. The data from
all three time points were entered into a secure spreadsheet and verified for accuracy and
completeness before analysis.
Descriptive statistical methods summarized participant responses. Frequencies,
percentages, and mean scores identified changes across the pre-, mid-, and post-intervention
phases. The analysis included figures that displayed these patterns and allowed straightforward
comparison of data trends over time. The descriptive analysis focused on identifying changes
that reflected improvement in staff perceptions and the management of patient behaviors. Due to
the small sample size and the project's quality-improvement design, inferential testing was not
performed. The analysis focused on identifying observable trends rather than determining
statistical significance.

85

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Figure 1
Staff Confidence in Managing Aggressive Behaviors (Pre-, Mid-, and Post-Intervention)

Note. Results derived from a six-item Likert-scale staff survey (n = 12 pre, n = 7 mid, n = 10
post).
Qualitative Data Analysis
The project team gathered qualitative data from open-ended survey questions and from
narrative feedback provided by the nurse manager at the end of the project. The team reviewed
86

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
staff responses several times to identify recurring themes and patterns reflecting their
experiences with aggression management and the use of the CMAI tool. Through thematic
analysis, the team coded statements and identified common themes, including improved
recognition of patient triggers, more effective communication, increased ease with de-escalation,
and stronger teamwork in managing aggressive behaviors.
Figure 2
Staff Reflections on Managing Aggression Before the Intervention

Note. Qualitative data was obtained from open-ended survey responses collected before the
implementation of the CMAI and MESSAGE communication training. Responses reflect staff
perceptions of challenges and emotional reactions to aggressive patient behaviors prior to the
intervention.

87

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Figure 3
Staff Responses to Mid-Intervention Open-Ended Questions

Note. Figure displays the frequency of staff comments from mid-intervention open-ended survey
questions (n = 7). Responses were categorized by recurring themes: identifying behaviors,
staying calm, and suggested needs for additional support or yearly education.
Figure 4
Staff Reflections on Post-Intervention Open-Ended Questions

88

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Note. Figure displays the frequency of staff comments from post-intervention open-ended survey
questions (n = 10). Responses were categorized by common themes including effective
communication, recording patient behaviors, identifying safety guidelines, de-escalation, and
recognizing behavioral trends.
The nurse manager's feedback was included in the qualitative review to give additional
perspective on the staff survey findings. The feedback described how staff became more
consistent in documenting behaviors with the CMAI and talked more often about patient triggers
during shift handoffs. Project data also showed a gradual decline in reported aggression incidents
over the weeks. These observations helped explain the quantitative results and illustrated how the
intervention strengthened staff awareness, confidence, and steadiness when responding to
aggressive behaviors.
Integration of Quantitative and Qualitative Data
Integrating the quantitative and qualitative results provided a fuller picture of how the
project affected staff perceptions and practice. The quantitative findings showed measurable
improvement in how staff recognized and managed aggression, while the qualitative feedback
added practical insight into what those changes looked like in daily care. Taken together, the
results supported the project's purpose and the alternative hypotheses, showing that the use of the
CMAI and MESSAGE training had a positive impact on staff awareness and management of
aggression in dementia care.
Results
This section presents the results of the six-week quality improvement project that
examined whether implementing the Cohen-Mansfield Agitation Inventory (CMAI) together
89

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
with MESSAGE communication training improved healthcare staff perceptions of aggression in
patients with dementia. The analysis organizes the results according to the three hypotheses that
guided the study: (1) staff perceptions of aggression, (2) staff confidence in managing aggressive
behaviors, and (3) staff recognition of behavioral triggers. Quantitative and qualitative findings
together provide a comprehensive view of the project outcomes.
Hypothesis 1: Staff Perception of Aggression
The first hypothesis proposed that staff perceptions of aggression would improve after
implementing the CMAI and MESSAGE communication training. Survey results supported this
expectation. Staff reported a steady increase in understanding and comfort when managing
patients who displayed aggressive behaviors. Before the intervention, responses reflected
uncertainty and uneven recognition of how severe aggression could become. By the midpoint of
the project, staff showed moderate improvement in both awareness and understanding of these
behaviors. By the end of the intervention, most staff reported increased ability to identify
aggression early, recognize contributing factors, and apply appropriate de-escalation strategies.
Qualitative data supported these quantitative trends. Staff reported feeling more confident
when dealing with aggressive patients and were more alert to early behavioral triggers. Many
mentioned that the MESSAGE training video gave realistic examples of calm communication
and helped them stay steady when addressing patient needs. The nurse manager noticed fewer
incidents of escalation and said staff were discussing patient triggers more often during handoffs.
Overall, these findings suggested that the training improved staff's understanding and
management of aggression, supporting the first alternative hypothesis (H₁a).
Hypothesis 2: Staff Confidence in Managing Aggressive Behaviors
90

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The second hypothesis proposed that staff confidence in managing aggressive behavior
would improve after the training. The data supported that expectation. Confidence scores rose at
every stage of data collection. At the start, only a few staff members said they felt comfortable
managing aggression on their own. By the middle of the project, about half reported feeling more
confident when using the new techniques. At the end of six weeks, most staff reported feeling
both confident and supported when responding to aggressive patients.
Qualitative responses further validated this improvement. Several staff reported feeling
less anxious and more in control when caring for patients with aggressive behaviors. One nurse
explained that combining the MESSAGE training with the CMAI form "gave structure to what
used to feel chaotic." Others described stronger teamwork and more transparent communication.
The nurse manager reported similar observations, noting a calmer environment in which staff
appeared more relaxed and steadier throughout their shifts. Collectively, these findings supported
the second alternative hypothesis (H₂a), indicating that staff confidence improved following the
implementation of the CMAI and MESSAGE training.
Hypothesis 3: Recognition of Behavioral Triggers
The third hypothesis proposed that staff would become more proficient at recognizing
behavioral triggers following the intervention. Quantitative survey results supported this
expectation, showing an upward improvement from pre- to post-intervention. Most participants
reported being more aware of the factors that could lead to aggression and felt more comfortable
documenting those patterns. Staff described paying closer attention to environmental and
personal stressors such as noise or certain care activities that tended to provoke aggression.

91

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Figure 6
Staff Confidence in Managing Aggressive Behavior by Years of Experience

Note. Figure displays staff confidence ratings from the post-intervention survey, grouped by
years of experience. Data were derived from Likert-scale survey responses collected at the
conclusion of the six-week project (n = 10).
Figure 7
Perceived Helpfulness of the MESSAGE Communication Training by Years of Experience

92

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Note. Figure displays staff ratings of the MESSAGE communication training video from the
post-intervention survey, grouped by years of experience. Data were obtained from Likert-scale
responses collected at the conclusion of the six-week project (n = 10).
Figure 8
Staff Suggestions for Improving Future Training by Years of Experience

Note. Figure summarizes qualitative feedback from post-intervention open-ended survey
questions, categorized by years of experience. Ten participants (n = 10) provided comments
highlighting needs for ongoing annual education, reinforcement of communication strategies,
and opportunities for simulation-based practice.
Qualitative data reinforced these findings. Staff comments supported these results. Staff
reported a clearer understanding of how patient-specific factors such as pain, unmet needs, or
confusion often contributed to aggressive behavior. The nurse manager noted that staff seemed to
identify and communicate these triggers earlier, which helped prevent escalation. This progress
showed that staff were not only identifying triggers more consistently but were also taking steps
to reduce them. Together, these findings supported the third alternative hypothesis (H₃a),

93

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
confirming that the use of the CMAI and MESSAGE communication training improved staff
awareness of behavioral triggers.
Integration of Findings
The combined analysis of quantitative and qualitative data showed that the quality
improvement project met its intended goals. Quantitative results demonstrated steady growth in
staff perception, confidence, and ability to recognize behavioral triggers. Some of the qualitative
comments provided additional context, showing how staff incorporated these skills into their
everyday routines. The thematic analysis highlighted more transparent communication, better
teamwork, and earlier intervention when patients showed signs of aggression. The nurse
manager's observations supported these results, noting a calmer environment and fewer
aggressive incidents on the unit.
Overall, the findings supported all three alternative hypotheses (H₁a, H₂a, H₃a).
Implementing the CMAI and MESSAGE communication training together improved healthcare
staff's perceptions of aggression, enhanced their confidence in managing aggressive behaviors,
and strengthened their recognition of behavioral triggers among patients with dementia. These
results provided strong evidence that the intervention improved care quality and created a safer,
more supportive environment for both patients and staff.
Summary
This chapter summarizes and analyzes data gathered during a six-week quality
improvement project that evaluated the impact of implementing the Cohen-Mansfield Agitation
Inventory (CMAI) and the MESSAGE communication training on healthcare staff's perceptions
of aggression in patients with dementia. Pre-, mid-, and post-intervention surveys, along with
94

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
additional narrative feedback, provided quantitative and qualitative data. The analysis showed
improvement in staff perception of aggression, confidence in managing aggressive behaviors,
and recognition of behavioral triggers.
Both the quantitative and qualitative data indicated that integrating the CMAI with the
MESSAGE training enhanced staff confidence, competence, and perceptions of their ability to
manage aggression in patients with dementia. Descriptive data showed upward trends across
survey measures, while qualitative feedback from staff and the nurse manager confirmed fewer
aggressive incidents, stronger teamwork, and more transparent communication. Together, these
results supported all three alternative hypotheses (H₁a, H₂a, and H₃a) and affirmed that structured
assessment tools combined with targeted communication training enhance care quality and
safety.
Although the outcomes were positive, the project faced limitations. A small sample size
reduced generalizability, and the short duration limited evaluation of long-term sustainability.
Some staff also found the CMAI Ad Hoc form in Cerner difficult to access. In addition, because
the data were self-reported, some level of response bias may have occurred. The project also took
place in a single unit that experienced a lower-than-usual census during the study period,
reducing participant availability and data-collection opportunities. Despite these factors, the
project showed that structured communication training and standardized behavioral tools can
strengthen staff perceptions and performance and improve patient outcomes.
In summary, Chapter Four confirmed that the quality improvement project met the
intended goals, supporting all three alternative hypotheses. Chapter Five will present the
summary, conclusions, and recommendations drawn from these findings, focusing on their

95

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
relevance to nursing practice, leadership, and continued quality improvement efforts. This
discussion will highlight how the outcomes can guide future initiatives to strengthen staff
competency and improve dementia care delivery.
CHAPTER 5: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Introduction and Summary of Study
The purpose of this quality improvement project was to evaluate the impact of
implementing the Cohen-Mansfield Agitation Inventory (CMAI) and targeted MESSAGE
communication training on healthcare staff’s perceptions of aggression in patients with dementia.
The project examined whether combining a structured aggression-assessment tool along with
dementia-specific communication training could enhance staff confidence, competence,
perception, and recognition of behavioral triggers. Aggressive behaviors in patients with
dementia remain an ever-growing challenge in healthcare, often leading to increased stress,
inconsistent responses, and elevated safety concerns. To address these issues, this quality
improvement project implemented evidence-based strategies to foster safer, more consistent
practices.
This chapter summarizes the project’s framework and key findings. Ten strategic points
guided the study and shaped its design to address the lack of standardized methods for assessing
and managing aggression in dementia care settings. Three hypotheses examined changes in staff
perceptions, confidence, and recognition before and after implementation. The project was
grounded in two theoretical frameworks: Prochaska and DiClemente’s Transtheoretical Model of
Behavior Change and Watson’s Theory of Human Caring, both of which emphasize behavioral
transformation and compassionate, relationship-based care.
96

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
A quasi-experimental mixed-methods design was employed over six weeks on the 6
North acute care unit. Participants included nurses and clinical assistants who voluntarily
provided informed consent to participate in the project. Data was collected at three points: pre-,
mid-, and post-intervention using Likert-scale surveys and open-ended questions. Descriptive
statistics summarized quantitative responses, and thematic analysis identified patterns and
themes within qualitative feedback. Quantitative results showed steady improvement in staff
perception of aggression, confidence, and recognition of behavioral triggers. At the same time,
qualitative data revealed themes of improved teamwork, more transparent communication, and
earlier recognition of aggressive patterns. Limitations included a small sample size, a short
project duration, a lower-than-usual unit census, and challenges initially locating the CMAI form
in Cerner, which affected documentation consistency.
Overall, the project demonstrated that combining the CMAI with MESSAGE training
produced positive outcomes. Staff reported greater confidence in managing aggression and
improved recognition of behavioral triggers. These outcomes align with the project’s purpose and
hypotheses, affirming that structured behavioral assessment tools, when paired with targeted
communication strategies, can enhance the quality of dementia care and staff readiness. These
results not only validate the effectiveness of this intervention within an acute care unit but also
underscore the importance of continued investment in evidence-based staff training to sustain a
culture of safety and compassion. This chapter will further interpret these findings by presenting
the conclusions, implications for nursing practice and leadership, and recommendations for
sustaining and expanding these quality improvements across clinical settings.
Summary of Findings and Conclusions

97

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
This section of Chapter Five presents the project’s key findings, grounded in the three
hypotheses and the PICO question. Results showed that combining communication training with
the CMAI improved healthcare staff's perceptions of aggression in patients with dementia
compared with no structured training or tool use. The intervention also strengthened staff
confidence, communication, and recognition of behavioral triggers, which supported the overall
improvement in perception and management of aggressive behaviors. Quantitative and
qualitative data together provided a clear understanding of how the intervention strengthened
staff perception.
The description and intent of this project, first introduced in Chapters One through Three,
shaped how each stage was planned and carried out. In Chapter One, the project identified the
lack of a consistent, structured process for assessing and managing aggression in patients with
dementia. This gap contributed to uncertainty among staff and emphasized the need for
standardized practices to improve patient and workplace safety. Chapter Two reviewed
supporting evidence showing that structured communication techniques and behavioral
assessment tools can strengthen staff confidence and improve care quality. Chapter Three
detailed the mixed-methods approach that combined numerical data with staff feedback to
capture how the intervention influenced confidence, perception, and recognition of behavioral
triggers. The findings in this chapter build upon that methodological foundation, demonstrating
that structured communication and behavioral documentation practices enhance safety,
consistency, and overall quality in dementia care.
The first hypothesis stated that staff perceptions of aggression would improve after the
intervention. The results supported this expectation. Over six weeks, staff reported greater
awareness and understanding of aggressive behaviors. Their comments described calmer, more
98

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
thoughtful communication and an improved ability to recognize early signs of agitation. These
changes showed that staff gained confidence and worked together more effectively when
responding to challenging situations.
The second hypothesis addressed staff confidence in managing aggressive behavior.
Quantitative data showed consistent improvement across all phases of the project. At the same
time, qualitative feedback reflected reduced anxiety and greater self-confidence among staff who
completed the MESSAGE communication training and used the CMAI documentation. The
nurse manager confirmed these results, noting that staff remained composed during episodes of
patient aggression and communicated proactively about behavioral triggers. These changes
reflect Watson’s Theory of Human Caring, which connects empathy, awareness, and respectful
communication with safe and compassionate care.
The third hypothesis examined recognition of behavioral triggers. Staff identified and
documented causes such as pain, noise, and environmental overstimulation more consistently
using the CMAI Ad Hoc form. Managerial feedback confirmed that early recognition and timely
action reduced escalation and lowered aggression-related incidents.
The findings from this project are consistent with existing research highlighting the value
of communication training and behavioral assessment in dementia care. Studies by James et al.
(2023) and Moody et al. (2024) demonstrated that structured de-escalation models enhance staff
confidence and promote team collaboration when managing behavioral symptoms. Similarly,
Castro et al. (2024) reported that implementing standardized assessment tools led to fewer
aggressive incidents and improved patient safety outcomes. Consistent with these results, the
present project found that integrating structured communication training with the CMAI

99

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
improved healthcare staff’s perception of aggression in patients with dementia. Together, these
findings illustrate that standardized documentation and intentional communication strengthen
staff teamwork, safety, and confidence.
The conclusions are grounded in the project's theoretical frameworks, including Watson's
Theory of Human Caring and the Transtheoretical Model of Behavior Change. Applying these
frameworks throughout the project guided staff development, fostered compassionate and
intentional communication, and reinforced sustained behavioral improvement. The
Transtheoretical Model (Prochaska & DiClemente, 1983) illuminated the progression of staff
learning as participants moved from early stages of awareness (“precontemplation” and
“contemplation”) to the active adoption and maintenance of new communication behaviors. This
gradual transformation demonstrates how structured education and reinforcement cultivate
enduring behavioral changes among healthcare professionals. The results contribute to nursing
knowledge by showing that consistent use of behavioral assessment tools combined with focused
communication training supports safer, more compassionate, and higher-quality dementia care.
Chapter Five continues by interpreting these results and discussing implications for
nursing practice, leadership, and policy. It also provides recommendations to sustain and expand
these quality improvements across the healthcare system. The results of this project advance
nursing knowledge by reinforcing the importance of communication and behavioral awareness in
dementia care. Consistent use of the CMAI and MESSAGE framework supports the delivery of
safer, more compassionate, and higher-quality care. The following section explores these
implications in greater depth.
Implications

100

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The results have significant implications for theory, practice , and further quality
improvement projects in dementia care. Using the CMAI alongside MESSAGE communication
training helped staff better understand aggressive behavior and manage it more effectively. The
triggers were easier to identify. These results are central to nursing practice and underscore the
importance of using evidence-based interventions to enhance dementia care. An overview of the
design, methodological approach, and theoretical framework provides evidence that these results
are both valid and applicable in a real-world acute care setting.
Theoretical Implications
This project reinforced and expanded two key frameworks, Watson's Theory of Human
Caring and the Transtheoretical Model (TTM) of Behavior Change, which together shaped the
project's conceptual foundation. Watson's theory emphasizes empathy, connection, and authentic
communication as central to healing. Staff demonstrated these principles through calmer, more
compassionate interactions with patients who exhibited aggression. The MESSAGE training
translated these principles into practice by guiding staff to use calm, consistent communication
that eased aggression and fostered a therapeutic environment for patients with dementia.
Staff demonstrated the principles of the Transtheoretical Model (TTM) through their
gradual progression across the stages of change. Throughout the project, the staff advanced from
early awareness of behavioral triggers to consistent application of new communication
techniques. As the project progressed, staff gained confidence through steady reinforcement,
education, and practice, which supported lasting behavioral change consistent with the
Transtheoretical Model. Their experiences showed that communication training and behavioral
assessment tools can move theoretical ideas into everyday nursing practice. This approach has

101

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
combined caring theory and behavioral science to become a model for dementia care in other
settings.
Practical Implications
The findings of this project are highly beneficial to nursing leaders and frontline teams
struggling to improve both patient safety and staff development. During the intervention, staff
reported feeling more self-assured and better able to cope with people who became aggressive.
Staff managed each situation with greater composure, which strengthened teamwork across the
unit. The nurse manager observed similar results, reporting fewer incidents escalated and a
general work atmosphere that had grown more supportive.
Using the CMAI during patient documentation made communication clearer and helped
staff follow changes in behavior more consistently. The MESSAGE training also gave them
useful, practical tools to prevent and manage aggression, which helped staff recognize triggers
earlier and respond in a steady, professional way. Expanding this combined approach to other
areas of care could further strengthen a culture of safety and enhance the quality of dementia care
across the organization.
From an administrative perspective, the findings highlight the importance of continuous
education and reinforcement in maintaining progress. Integrating CMAI and MESSAGE content
into onboarding new employees, yearly competencies, and electronic health record (EHR)
workflows could help sustain consistency and ensure compliance with quality and safety
expectations. This project also showed that even smaller quality improvement efforts can create
lasting change when leaders are engaged and staff feel supported. The insights gained from this

102

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
project can extend beyond inpatient dementia care and apply to other areas where dementia
aggression can occur.
Future Implications
This project establishes a basis for continued inquiry into the long-term sustainability and
implementation across the system. Repeating the project with a larger and more diverse group of
participants would strengthen generalizability. Long-term studies could examine how these
interventions affect patient safety events, staff retention, and workplace culture.
Future quality improvement initiatives could examine how MESSAGE communication
training can be adapted for other behavioral health populations. Project teams can also integrate
CMAI data into electronic health record dashboards to identify early indicators of aggression and
guide proactive care planning. Because this project involved a small sample and a short duration,
larger, multi-unit initiatives are needed to evaluate the long-term sustainability of these
improvements. Additional efforts could determine how this combined approach can be expanded
and adapted across the healthcare system. Ongoing evaluation of dementia-focused
communication and assessment interventions can strengthen national care standards, inform
organizational policy, and enhance both staff safety and patient well-being.
Strengths and Limitations of the Study
The results of this quality improvement project demonstrated strengths with real-world
relevance. The mixed-methods approach provided a comprehensive understanding of how using
the CMAI allowed the structured MESSAGE communication training to influence staff
perception, confidence, and recognition of behavioral triggers. The approach of collecting data
at three points—before, midway through, and after intervention helped determine significant
103

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
progress in staff communication skills and documentation practices. Integrating quantitative
measures with qualitative feedback provided better insight into staff experiences. The nurse
manager's observations reinforced these results and validated their reliability.
A few limitations influenced how the project team applied the results, even with the
project's noted strengths. The small sample size limits the generalizability of these findings to
other settings. Variations in participation across survey points may have introduced response
bias. The six-week evaluation period also made it difficult to determine how outcomes evolved
or sustained after the project ended. Self-reported survey data also had the potential to over- or
underestimate confidence and communication skills.
A workflow challenge arose when staff reported difficulty locating the CMAI Ad Hoc
form within Cerner, which slowed documentation during week one. The following week,
documentation became more consistent, but early variations may have influenced data
completion. During this project, the patient census unit was also lower than usual, which
contributed to fewer aggressive patient incidents and fewer CMAI documentation opportunities.
The project provided some insight into how a structured behavioral assessment tool,
together with relevant communication training, can be beneficial in dementia care. While
previous studies have used CMAI or similar documentation tools, combining behavioral
assessment with various structured communication frameworks has not been widely explored.
This project helped fill that gap by demonstrating that the two strategies together improved staff
preparedness, teamwork, and confidence when caring for individuals with dementia. These
findings provide a strong foundation for expanding quality improvement initiatives and

104

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
integrating standardized communication and behavioral assessment strategies into routine
nursing practice.
Recommendations
The outcomes of this quality improvement project support several recommendations for
nursing practice, leadership, and future research. These recommendations are grounded in the
results of the six-week implementation of the CMAI tool and the MESSAGE communication
training on the 6 North unit. The findings showed improved staff confidence, competence, and
perception of aggression in patients with dementia. These results provide a strong foundation for
the continued application of structured communication and behavioral assessment tools in
dementia care.
The first recommendation encourages continued use of the CMAI and MESSAGE
training as standard practice on 6 North. Using the CMAI Ad Hoc form in Cerner as a
standardized documentation tool helps staff more easily identify patterns of aggressive behavior
and supports consistent communication among team members. Continued promotion of
MESSAGE communications principles will ensure skill retention. Implementing this training
into staff competencies and orientation may help standardize care.
The second recommendation is to share the CMAI and MESSAGE training with other
units that care for patients with dementia. Bringing these methods to more areas of the
organization could help staff communicate more effectively and provide a steadier, more
coordinated approach to care. Implementing the project’s framework across additional units will
enable evaluation of its impact across diverse clinical environments, supporting scalability and
sustainability within the organization.
105

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The third recommendation is for leadership to continue fostering collaboration and
support for staff who provide care for patients with dementia. The data demonstrated that team
collaboration and communication improved during the intervention. Leaders can build on these
successes by providing continued support and follow-up mentoring.
Previous quality-improvement efforts have used CMAI or similar documentation tools to
track aggression in patients with dementia. However, very few have combined a standardized
behavioral assessment with focused communication training, as in the MESSAGE framework.
This project helped close that gap by combining both approaches, improving staff understanding
of aggression, increasing confidence, and strengthening communication. These outcomes
emphasize the benefits of pairing a structured assessment tool with communication training to
support safer, more consistent dementia care. Integrating both approaches can lead to more
consistent practice changes and lasting improvements in the care of aggressive patients with
dementia.
The final recommendation emphasizes building on this project through continued qualityimprovement efforts rather than viewing it as a conclusion. Future projects should include a
broad range of staff and extend the time to determine whether improvements in confidence,
communication, perception, and documentation continue. Expanding this work to other care
areas will help determine how well the approach can be sustained and adapted across different
settings. Applying these interventions across multiple disciplines, such as occupational therapy,
rehabilitation, and long-term care may further enhance interprofessional collaboration and
improve dementia care practices. Multi-unit or system-wide rollouts can assess scalability and
consistency across different care environments. Teams should also track patient-centered
outcomes such as the frequency of aggressive episodes, safety events, and patient and staff
106

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
satisfaction to understand the full impact of combining the CMAI with MESSAGE training. This
ongoing evaluation will guide leadership decisions about sustaining, adapting, and spreading the
intervention across the organization.
In conclusion, this project demonstrated that combining structured communication
training with a behavioral assessment tool improved staff confidence, communication, and
perceptions when caring for aggressive patients with dementia. The results supported the
project’s purpose and aligned with the goals of evidence-based, patient-centered care. Continued
integration of these approaches into daily practice will help sustain the progress made and further
strengthen the quality and safety of dementia care.

107

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
References
Akrour, R., Courret-Gilgen, C., & Perrenoud, B. (2022). Prevention and management of
behavioral and psychological symptoms in patients with dementia in acute care: a best
practice implementation project. JBI evidence implementation, 20(4), 289–300.
https://doi.org/10.1097/XEB.0000000000000329.
Alruwaili, A. N., Alruwaili, M. M., Ramadan, O. M. E., Ali, S. I., & Shaban, M. (2024). Nursing
strategies for enhancing calm in older Arabs with dementia: integrating Snoezelen
methods, aromatherapy, and personal items to reduce agitation. Geriatric Nursing (New
York), 59, 379–391. https://doi.org/10.1016/j.gerinurse.2024.07.017.
Althubaiti, A. (2016). Information bias in health research: Definition, pitfalls, and adjustment
methods. Journal of Multidisciplinary Healthcare, 9(1), 211–217.
https://doi.org/10.2147%2FJMDH.S104807.
Alzheimer's Association. (2024). What is dementia? Alzheimer's Disease and Dementia;
Alzheimer's Association. https://www.alz.org/media/Documents/alzheimers-facts-andfigures.pdf.
Anatchkova, M., Brooks, A., Swett, L., Hartry, A., Duffy, R. A., Baker, R. A., Hammer-Helmich,
L., & Sanon Aigbogun, M. (2019). Agitation in patients with dementia: A systematic
review of epidemiology and association with severity and course. International
Psychogeriatrics, 31(9), 1305–1318. https://doi.org/10.1017/s1041610218001898.
Baby, M., Gale, C., & Swain, N. (2018). Communication skills training in the management of
patient aggression and violence in healthcare. Aggression and Violent Behavior, 39(39),
67–82. https://doi.org/10.1016/j.avb.2018.02.004.
108

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective
hospital administration: A comprehensive review. Cureus, 15(10), 1–12.
https://doi.org/10.7759/cureus.47731.
Carrarini, C., Russo, M., Dono, F., Barbone, F., Rispoli, M. G., Ferri, L., Di Pietro, M.,
Digiovanni, A., Ajdinaj, P., Speranza, R., Granzotto, A., Frazzini, V., Thomas, A., Pilotto,
A., Padovani, A., Onofrj, M., Sensi, S. L., & Bonanni, L. (2021). Agitation and dementia:
Prevention and treatment strategies in acute and chronic conditions. Frontiers in
neurology, 12, 644317. https://doi.org/10.3389/fneur.2021.644317.
Castro, J., Mulligan, M., & Peschel, L. (2024). Through their eyes: Empathetic learning for
frontline healthcare providers to improve care for the patient living with
dementia. Geriatric Nursing, 60, 713–715.
https://doi.org/10.1016/j.gerinurse.2024.10.082.
Chen, B., Wang, Q., Bai, C., Chen, J., Zhao, D., Li, Y., Chen, J., Guo, X., Wang, J., Chen, H.,
Lai, X., Wan, Q., Wang, Z., Hu, N., Zhang, B.-W., Chen, X., Ma, T., & Yuan, J. (2024).
Perception and identification of behavioral and psychological symptoms of dementia
(BPSD) in China medical community. Clinical Interventions in Aging, 19, 2099–2108.
https://doi.org/10.2147/CIA.S483118.
Collins, R., Hunt, A., Quinn, C., Martyr, A., Pentecost, C., & Clare, L. (2022). Methods and
approaches for enhancing communication with people with moderate-to-severe dementia
that can facilitate their inclusion in research and service evaluation: Findings from the
IDEAL Program. Dementia, 21(4), 1135–1153.
https://doi.org/10.1177/14713012211069449.
109

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Conway, E. R., & Chenery, H. J. (2016). Evaluating the MESSAGE Communication strategies in
dementia training for use with community-based aged care staff working with people
with dementia: A controlled pretest-post-test study. Journal of Clinical Nursing, 25(7-8),
1145–1155. https://doi.org/10.1111/jocn.13134.
De Mauleon, A., Delrieu, J., Cantet, C., Vellas, B., Andrieu, S., Rosenberg, P. B., Lyketsos, C. G.,
& Soto Martin, M. (2020). Longitudinal course of agitation and aggression in patients
with Alzheimer’s disease in a cohort study: Methods, baseline and longitudinal results of
the A3C study. The Journal of Prevention of Alzheimer’s Disease, 1–11.
https://doi.org/10.14283/jpad.2020.66.
De Mauleon, A., Ismail, Z., Rosenberg, P., Miller, D., Cantet, C., O'Gorman, C., Vellas, B.,
Lyketsos, C., & Soto, M. (2021). Agitation in Alzheimer's disease: Novel outcome
measures reflecting the International Psychogeriatric Association (IPA) agitation criteria.
Alzheimer's & dementia: The Journal of the Alzheimer's Association, 17(10), 1687–1697.
https://doi.org/10.1002/alz.12335.
Di Lorito, C., Pollock, K., Harwood, R., Das Nair, R., Logan, P., Goldberg, S., Booth, V.,
Vedhara, K., & Van Der Wardt, V. (2019). A scoping review of behavior change theories
in adults without dementia to adapt and develop the "PHYT in dementia," a model
promoting physical activity in people with dementia. Maturitas, 121, 101–113.
https://doi.org/10.1016/j.maturitas.2019.01.008.
Duan, X., Ni, X., Shi, L., Zhang, L., Ye, Y., Mu, H., Li, Z., Liu, X., Fan, L., & Wang, Y. (2019).
The impact of workplace violence on job satisfaction, burnout, and turnover intention:

110

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
The mediating role of social support. Health and Quality of Life Outcomes, 17(1), 93.
https://doi.org/10.1186/s12955-019-1164-3.
Dunkle, R. E., Cavignini, K., Cho, J., Sutherland, L., Kales, H., Connell, C., & Leggett, A.
(2022). Exploring dementia care in acute care settings: Perspectives of nurses and social
workers on caring for patients with behavioral and psychological symptoms. Social work
in health care, 61(3), 169–183. https://doi.org/10.1080/00981389.2022.2076764.
Eggenberger, E., Heimerl, K., & Bennett, M. I. (2013). Communication skills training in
dementia care: A systematic review of effectiveness, training content, and didactic
methods in different care settings. International Psychogeriatrics, 25(03), 345–358.
https://doi.org/10.1017/s1041610212001664.
Fakhri Allahyari, Esmat Davoudi-Monfared, Radfar, S., & Mehdi Madaberanjad. (2024).
Investigating the effect of the training program on nurses\’ perceived stress of dementia
patients and its relationship with care burnout in Baqiyatullah Hospital.
https://doaj.org/article/f8a0b1daa6fb47319b898124fab1d5c4.
Galanakis, I., Soldatos, R. F., Karanikolas, N., Voulodimos, A., Voyiatzis, I., & Samarakou, M.
(2025). Enhancing the Prediction of Episodes of Aggression in Patients with Dementia
Using Audio-Based Detection: A Multimodal Late Fusion Approach with a MetaClassifier. Applied Sciences, 15(10), 5351. https://doi.org/10.3390/app15105351.
Geoffrion, S., Hills, D. J., Ross, H. M., Pich, J., Hill, A. T., Dalsbø, T. K., Riahi, S., MartínezJarreta, B., & Guay, S. (2020). Education and training for preventing and minimizing
workplace aggression directed toward healthcare workers. Cochrane Database of
Systematic Reviews, 9(9). https://doi.org/10.1002/14651858.cd011860.pub2.
111

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Gkioka, M., Schneider, J., Kruse, A., Tsolaki, M., Moraitou, D., & Teichmann, B. (2020).
Evaluation and effectiveness of dementia staff training programs in general hospital
settings: A narrative synthesis with Holton's Three-Level Model applied. Journal of
Alzheimer's Disease, 78(3), 1089–1108. https://doi.org/10.3233/JAD-200741.
Goorts, K., Dizon, J., & Milanese, S. (2021). The effectiveness of implementation strategies for
promoting evidence informed interventions in allied healthcare: A systematic
review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-02106190-0.
Graham, F., Beattie, E., & Fielding, E. (2022). Hospital nurses’ management of agitation in older
cognitively impaired patients: do they recognise pain-related agitation? Age and
Ageing, 51(7). https://doi.org/10.1093/ageing/afac140.
Handley, M. A., Lyles, C. R., McCulloch, C., & Cattamanchi, A. (2018). Selecting and
improving quasi-experimental designs in effectiveness and implementation
research. Annual Review of Public Health, 39(1), 5–25. https://doi.org/10.1146/annurevpublhealth-040617-014128.
Hawkins, S. A., Ehsan, S., & Burkitt, J. J. (2023). Evaluating the Training Needs of
Interprofessional Teams Working in Specialized Geriatric Services. ResearchGate, 44(3),
6–15.
https://www.researchgate.net/publication/376751517_Evaluating_the_Training_Needs_of
_Interprofessional_Teams_Worki.
James, I. A., Reichelt, K., Shirley, L., & Moniz-Cook, E. (2023). Management of agitation in
behaviors that challenge dementia care: Multidisciplinary perspectives on non112

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
pharmacological strategies. Clinical Interventions in Aging, 18, 219–230.
https://doi.org/10.2147/cia.s399697.
Jawaid, Z., Crowther, G., & Ashar, S. (2021). The perception of behavior associated with
dementia in the acute hospital. BJ Psych Open, 7(S1), S260–S260.
https://doi.org/10.1192/bjo.2021.693.
Kabaya, S., Nagahata, T., & Juanamasta, I. G. (2024). The dementia certified nurse process for
acquiring knowledge for care of older adult patients with dementia in acute care
hospitals: a qualitative descriptive study. Jurnal Ners (Surabaya), 19(4), 509–519.
https://doi.org/10.20473/jn.v19i4.62204.
Kang, Y., & Bang, C. (2024). Workload-related issues among nurses caring for patients with
behavioral and psychological symptoms of dementia: A scoping review. Healthcare
(Basel), 12(18), 1893-. https://doi.org/10.3390/healthcare12181893.
Kennedy, M., Koehl, J., Shenvi, C. L., Greenberg, A., Zurek, O., LaMantia, M., & Lo, A. X.
(2020). The agitated older adult in the emergency department: a narrative review of
common causes and management strategies. Journal of the American College of
Emergency Physicians Open, 1(5), 812–823. https://doi.org/10.1002/emp2.12110.
Keuning-Plantinga, A., Roodbol, P. F., Krijnen, W. P., & Finnema, E. J. (2022). Nurses'
perceptions in caring for people with dementia in Dutch acute hospitals. Journal of
clinical nursing, 31(13-14), 1800–1816. https://doi.org/10.1111/jocn.15458.
Krakowiak-Burdzy, A. B., & Fąfara, A. (2023). Causes and manifestations of patient aggression
in the opinion of nurses. Medical Research Journal, 8(2), 141–146.
https://doi.org/10.5603/mrj.a2023.0026.
113

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Kratzer, A., Scheel-Barteit, J., Altona, J., Wolf-Ostermann, K., Graessel, E., & Donath, C.
(2023). Agitation and aggression in people living with dementia and mild cognitive
impairment in shared-housing arrangements – validation of a German version of the
Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF). Health and Quality of
Life Outcomes, 21(1), 51–51. https://doi.org/10.1186/s12955-023-02132-y.
Kunik, M. E., Stanley, M. A., Shrestha, S., Ramsey, D., Richey, S., Snow, L., Freshour, J., Evans,
T., Newmark, M., Williams, S., Wilson, N., & Amspoker, A. B. (2020). Aggression
prevention training for individuals with dementia and their caregivers: A randomized
controlled trial. The American Journal of Geriatric Psychiatry, 28(6), 662–672.
https://doi.org/10.1016/j.jagp.2020.01.190.
Kupeli, N., Vickerstaff, V., White, N., Lord, K., Scott, S., Jones, L., & Sampson, E. L. (2018).
Psychometric evaluation of the Cohen‐Mansfield Agitation Inventory in an acute general
hospital setting. International Journal of Geriatric Psychiatry, 33(1), e158–e165.
https://doi.org/10.1002/gps.4741.
Lim, E., Wynaden, D., & Heslop, K. (2019). Changing practice using recovery-focused care in
acute mental health settings to reduce aggression: A qualitative study. International
Journal of Mental Health Nursing, 28(1), 237–246. https://doi.org/10.1111/inm.12524.
Lindeza, P., Rodrigues, M., Costa, J., Guerreiro, M., & Rosa, M. M. (2020). Impact of dementia
on informal care: a Systematic review of family caregivers’ perceptions. BMJ Supportive
& Palliative Care, 14(1). https://doi.org/10.1136/bmjspcare-2020-002242.
McKenzie, E. L., & Brown, P. M. (2020). The provision of person‐centered dementia care in the
context of mental health co‐morbidities: “It can be upsetting and distressing and it’s
114

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
incredibly sad.” Australasian Journal on Ageing, 40(2).
https://doi.org/10.1111/ajag.12860.
Mellinger, T. J., Forester, B. P., Vogeli, C., Donelan, K., Gulla, J., Vetter, M., Vienneau, M., &
Ritchie, C. S. (2023). Impact of dementia care training on nurse care managers’
interactions with family caregivers. BMC Geriatrics, 23(1).
https://doi.org/10.1186/s12877-022-03717-w.
Moody, E., McDougall, H., Weeks, L. E., Belliveau, A., Bilski, P., Macdonald, M., Williams, L.,
Khanna, I., Jamieson, H., Bradbury, K., Rothfus, M., Koller, K., & Gianisa Adisaputri.
(2024). Nursing interventions to improve care of people living with dementia in hospital:
A mixed methods systematic review. International Journal of Nursing Studies, 158,
104838–104838. https://doi.org/10.1016/j.ijnurstu.2024.104838.
National Institute on Aging. (2022, December 8). What is dementia? Symptoms, types, and
diagnosis. National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-anddementia/what-dementia-symptoms-types-and-diagnosis.
Nguyen, H., Eccleston, C. E., Doherty, K. V., Jang, S., & McInerney, F. (2022). Communication
in dementia care: Experiences and needs of carers. Dementia, 21(4), 1381–1398.
https://doi.org/10.1177/14713012221080003.
O’Donnell, E., Holland, C., & Swarbrick, C. (2022). Strategies used by care home staff to
manage behavior that challenges dementia: A systematic review of qualitative
studies. International Journal of Nursing Studies, 133, 104260.
https://doi.org/10.1016/j.ijnurstu.2022.104260.

115

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Orsulic‐Jeras, S., Whitlatch, C. J., Powers, S. M., & Johnson, J. (2020). A dyadic perspective on
assessment in Alzheimer’s dementia: Supporting both care partners across the disease
continuum. Alzheimer’s & Dementia: Translational Research & Clinical Interventions,
6(1). https://doi.org/10.1002/trc2.12037.
Parveen, S., Smith, S. J., Sass, C., Oyebode, J. R., Capstick, A., Dennison, A., & Surr, C. A.
(2021). Impact of dementia education and training on health and social care staff
knowledge, attitudes and confidence: a cross-sectional study. BMJ open, 11(1), e039939.
https://doi.org/10.1136/bmjopen-2020-039939.
Pepper, A., & Dening, K. H. (2023). Dementia and communication. British journal of community
nursing, 28(12), 592–597. https://doi.org/10.12968/bjcn.2023.28.12.592.
Pit, S., Horstmanshof, L., Moehead, A., Hayes, O. W., Schache, V., & Parkinson, L. (2023).
International standards for dementia workforce education and training: A Scoping
Review. Gerontologist. https://doi.org/10.1093/geront/gnad023.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and Processes of self-change of smoking:
toward an Integrative Model of change. Journal of Consulting and Clinical
Psychology, 51(3), 390–395. https://pubmed.ncbi.nlm.nih.gov/6863699/.
Rasmussen, B. M., Andersen, P. T., Waldorff, F. B., & Berg-Beckhoff, G. (2023). Effectiveness
of dementia education for professional care staff and factors influencing staff-related
outcomes: An overview of systematic reviews. International Journal of Nursing Studies,
142(104469), 104469. https://doi.org/10.1016/j.ijnurstu.2023.104469.
Reichelt, K., James, E., Thompson, D., & Tanney, S. (2023). Improving Confidence in Dementia
Care by Helping Care Staff Articulate Skills They Already Possess: The Value of the
116

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Communication and Interaction Training (CAIT) Program. OBM Geriatrics, 07(01), 1–9.
https://doi.org/10.21926/obm.geriatr.2301222.
Riachi, R., & Markwell, S. (2020). Improving well-being in dementia care for clients and
carers. Journal of Public Mental Health, 19(4), 321–326. https://doi.org/10.1108/JPMH05-2020-0039.
Riegel, F., Crossetti, M. da G. O., & Siqueira, D. S. (2018). Contributions of Jean Watson’s
theory to holistic critical thinking of nurses. Revista Brasileira de Enfermagem, 71(4),
2072–2076. https://doi.org/10.1590/0034-7167-2017-0065.
Røsvik, J., & Rokstad, A. M. M. (2020). What are the needs of people with dementia in acute
hospital settings, and what interventions are made to meet these needs? A systematic
integrative review of the literature. BMC Health Services Research, 20(1).
https://doi.org/10.1186/s12913-020-05618-3.
Sahu, K., Mishra, S., & Singh, B. (2020). A cross-sectional study to assess the relation between
anxiety and physical aggression of dementia patients at the department of geriatric mental
health. Indian Journal of Psychiatric Nursing, 17(1), 8–13.
https://doi.org/10.4103/IOPN.IOPN_2_20.
Schneider, E., Dale, M., Wells, K., Gotelli, J., Julian, C., Henage, C., Busby-Whitehead, J., &
Roberts, E. (2020). Delivering and embedding dementia-friendly training in a healthcare
system. Innovation in Aging, 4(Supplement_1), 160–161.
https://doi.org/10.1093/geroni/igaa057.522.

117

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Schnelli, A., Karrer, M., Mayer, H., & Zeller, A. (2020). Aggressive behavior of persons with
dementia towards professional caregivers in the home care setting—A scoping
review. Journal of Clinical Nursing, 32(15-16). https://doi.org/10.1111/jocn.15363.
Shrestha, L., & Shrestha, H. L. (2024). Navigating dementia care in northern Ontario: Exploring
health professional experience, barriers and facilitators. Alzheimer’s & Dementia, 20(S5).
https://doi.org/10.1002/alz.092934.
Smith, A. (2021). The challenge of assessing treatment effectiveness in a real-world
setting. Clinical Therapeutics.
.
Sun, F.-C., Lin, L.-C., Shu Chen Chang, Li, H.-C., Cheng, C.-H., & Huang, L.-C. (2022).
Reliability and validity of a Chinese version of the Cohen–Mansfield Agitation
Inventory-short form in assessing agitated behavior. International Journal of
Environmental Research and Public Health, 19(15), 9410–9410.
https://doi.org/10.3390/ijerph19159410.
Surr, C. A., Parveen, S., Smith, S. J., Drury, M., Sass, C., Burden, S., & Oyebode, J. (2020). The
barriers and facilitators to implementing dementia education and training in health and
social care services: A mixed-methods study. BMC Health Services Research, 20(1), 512.
https://doi.org/10.1186/s12913-020-05382-4.
Välimäki, M., Lam, J., Bressington, D., Cheung, T., Wong, W. K., Cheng, P. Y. I., Ng, C. F., Ng,
T., Yam, C. P., Ip, G., Paul, L., & Lantta, T. (2022). Nurses’, patients’, and informal
caregivers’ attitudes toward aggression in psychiatric hospitals: A comparative survey
study. PLOS ONE, 17(9), e0274536. https://doi.org/10.1371/journal.pone.0274536.
118

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Van Manen, A. S., Aarts, S., Metzelthin, S. F., Verbeek, H., Hamers, J. P. H., & Zwakhalen, S. M.
G. (2020). A communication model for nursing staff working in dementia care: Results of
a scoping review. International Journal of Nursing Studies, 113(113), 103776.
https://doi.org/10.1016/j.ijnurstu.2020.103776.
Wharton, T., Paulson, D., Burcher, K., & Lesch, H. (2018). Delirium and antipsychotic
medications at hospital intake: Screening to decrease likelihood of aggression in inpatient
settings among unknown patients with dementia. American Journal of Alzheimer’s
Disease & Other Dementias®, 34(2), 118–123.
https://doi.org/10.1177/1533317518809345.
Willie, M. M. (2024). Population and target population in research methodology. Golden ratio of
science and education, 4(1), 75–79. https://doi.org/10.52970/grsse.v4i1.405.
Wong, B., Wu, P., Ismail, Z., Watt, J., & Goodarzi, Z. (2024). Detecting agitation and aggression
in persons living with dementia: A systematic review of diagnostic accuracy. BMC
Geriatrics, 24(1), 559. https://doi.org/10.1186/s12877-024-05143-6.
Yaghmour S. M. (2022). Impact of settings and culture on nurses' knowledge of and attitudes and
perceptions towards people with dementia: An integrative literature review. Nursing
open, 9(1), 66–93. https://doi.org/10.1002/nop2.1106.
Ye, H. M.-Y., Xiao, L. D., Ullah, S., & Chang, R. H.-C. (2024). Hospital nurses perceived
challenges and opportunities in the care of people with dementia: A mixed-methods
systematic review. Journal of Clinical Nursing, 17114(8).
https://doi.org/10.1111/jocn.17144.

119

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Young, L. (2021, July 10). Communicate better in dementia with MESSAGE.
EatSpeakThink.com. https://eatspeakthink.com/communicate-better-dementia-withmessage/.
Yu, R., Topiwala, A., Jacoby, R., & Fazel, S. (2019). Aggressive behaviors in Alzheimer disease
and mild cognitive impairment: Systematic review and meta-analysis. The American
Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric
Psychiatry, 27(3), 290–300. https://doi.org/10.1016/j.jagp.2018.10.008.

120

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Appendix A
Pennsylvania Western University Institutional
Review Board
250 University Ave, California, PA 15419
IRB@pennwest.edu
9/2/2025
RE: IRB Approval: Exempt Research Protocol
Application/Protocol Title: Evaluating the Impact of an Evidence-Based Tool on Healthcare
Staff’s Perception of Aggression in Dementia Patients.
IRB Tracking Number: PWIRB25011SL-EX
Approval Date: 9/2/2025
Approved Study Period: 9/2/2025 to 9/1/2026
Dear Ms. Stacy Lemley,
On behalf of the Institutional Review Board (IRB) at Pennsylvania Western University, I am
pleased to inform you that the research proposal noted above has been reviewed and
determined to qualify as Exempt Research under 45 CFR 46.104(d)(2).
The PennWest IRB has approved this study for data collection during the dates listed above.
Should you wish to expand the study to include additional institutions or extend the data
collection timeline, please submit a formal modification request for IRB review and
approval prior to implementing those changes.
This research is approved under the oversight of Pennsylvania Western University’s
Institutional Review Board (IRB00003711), operating under a Federal-wide Assurance
(FWA00032724) filed with the U.S. Department of Health & Human Services
(IORG0003094). Please retain this letter for grant, publication, or institutional
documentation purposes.
You are expected to conduct your study in accordance with the ethical principles of the
Belmont Report and all applicable institutional and federal guidelines. If you have any
questions or need further assistance, please contact us at IRB@pennwest.edu.
Sincerely,
Nikolas C. Roberts, Ph.D.
Director, Institutional Review Board Pennsylvania
Western University roberts_n@pennwest.edu

121

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Appendix B

122

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients

123

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Name

Dates: From _________to___________

Cohen-Mansfield Agitation Inventory (CMAI)1 – Short
Instructions: For each of the behaviours below, check the rating that indicates the average
frequency of occurrence over the last 2 weeks.

Physical / Aggressive
1. Hitting (including self)

1

2

3

4

5

6

7

2. Kicking

1

2

3

4

5

6

7

3. Grabbing onto people

1

2

3

4

5

6

7

4. Pushing

1

2

3

4

5

6

7

5. Throwing things

1

2

3

4

5

6

7

6. Biting

1

2

3

4

5

6

7

7. Scratching

1

2

3

4

5

6

7

8. Spitting

1

2

3

4

5

6

7

9. Hurting self or others

1

2

3

4

5

6

7

10. Tearing things or destroying property

1

2

3

4

5

6

7

11. Making physical sexual advances

1

2

3

4

5

6

7

12. Pace, aimless wandering

1

2

3

4

5

6

7

13. Inappropriate dress or disrobing

1

2

3

4

5

6

7

14. Trying to get to a different place

1

2

3

4

5

6

7

15. Intentional falling

1

2

3

4

5

6

7

16. Eating / drinking inappropriate substance

1

2

3

4

5

6

7

17. Handling things inappropriately

1

2

3

4

5

6

7

18. Hiding things

1

2

3

4

5

6

7

19. Hoarding things

1

2

3

4

5

6

7

20. Performing repetitive mannerisms

1

2

3

4

5

6

7

21. General restlessness

1

2

3

4

5

6

7

Physical / Non-Aggressive

124

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Verbal / Aggressive
22. Screaming

1

2

3

4

5

6

7

23. Making verbal sexual advances

1

2

3

4

5

6

7

24. Cursing or verbal aggression
Verbal / Non-aggressive

1

2

3

4

5

6

7

25. Repetitive sentences or questions

1

2

3

4

5

6

7

26. Strange noises (weird laughter or crying)

1

2

3

4

5

6

7

27. Complaining

1

2

3

4

5

6

7

28. Negativism

1

2

3

4

5

6

7

29. Constant unwarranted request for attention or
help

1

2

3

4

5

6

7

Signature:

Date: _____________________

1 The use of this tool is strictly for clinical assessment and educational purposes only and is restricted from

use in any for-profit activities. Developed by and shared with permission of Interior Health

125

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Staff Perception Survey
Likert-Scale Instructions:
Please rate each statement based on how strongly you agree or disagree. Circle the
number that best reflects your opinion.
Statement

Strongly
Disagree Neutral Agree Strongly
Disagree (1) (2)
(3)
(4)
Agree (5)

1. I feel confident in my ability to
manage aggressive behavior in
patients with dementia.

1

2

3

4

5

2. I understand the common
triggers of aggression in patients
with dementia.

1

2

3

4

5

3. I can identify early warning signs
1
of agitation or aggression.

2

3

4

5

4. I feel competent in using deescalation techniques during
aggressive episodes.

1

2

3

4

5

5. I am comfortable documenting
aggressive behaviors using the
CMAI tool.

1

2

3

4

5

6. I believe I have the tools and
support needed to manage
challenging behaviors.

1

2

3

4

5

Pre-Intervention Open-Ended Questions
1. What are your current challenges when responding to aggressive behavior in
patients with dementia?
2. How confident do you feel in using strategies to de-escalate aggressive behavior?
3. Have you used the CMAI tool before? If so, how comfortable are you with it?
126

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Staff Perception Survey
Likert-Scale Instructions:
Please rate each statement based on how strongly you agree or disagree. Circle the
number that best reflects your opinion.
Statement

Strongly
Disagree Neutral Agree Strongly
Disagree (1) (2)
(3)
(4)
Agree (5)

1. I feel confident in my ability to
manage aggressive behavior in
patients with dementia.

1

2

3

4

5

2. I understand the common
triggers of aggression in patients
with dementia.

1

2

3

4

5

3. I can identify early warning signs
1
of agitation or aggression.

2

3

4

5

4. I feel competent in using deescalation techniques during
aggressive episodes.

1

2

3

4

5

5. I am comfortable documenting
aggressive behaviors using the
CMAI tool.

1

2

3

4

5

6. I believe I have the tools and
support needed to manage
challenging behaviors.

1

2

3

4

5

Mid-Intervention Survey (Week 3)
Open-Ended Questions:
1. What changes, if any, have you noticed in your approach to managing aggression?
2. How helpful has the training been so far?
3. What additional support or clarification would be helpful at this point?
127

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Staff Perception Survey
Likert-Scale Instructions:
Please rate each statement based on how strongly you agree or disagree. Circle the
number that best reflects your opinion.
Statement

Strongly
Disagree Neutral Agree Strongly
Disagree (1) (2)
(3)
(4)
Agree (5)

1. I feel confident in my ability to
manage aggressive behavior in
patients with dementia.

1

2

3

4

5

2. I understand the common
triggers of aggression in patients
with dementia.

1

2

3

4

5

3. I can identify early warning signs
1
of agitation or aggression.

2

3

4

5

4. I feel competent in using deescalation techniques during
aggressive episodes.

1

2

3

4

5

5. I am comfortable documenting
aggressive behaviors using the
CMAI tool.

1

2

3

4

5

6. I believe I have the tools and
support needed to manage
challenging behaviors.

1

2

3

4

5

Post-Intervention Survey (Week 6)
Open-Ended Questions:
How has your confidence changed in managing aggressive behavior since the training?
What aspects of the training or CMAI tool were most useful?
What suggestions do you have for improving future training on this topic?
How many years of service do you have working as an RN, LPN, or CA?
128

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Manager Post-Intervention Survey – Week 6
Quality Improvement Project: Evaluating the Impact of the Cohen-Mansfield Agitation
Inventory (CMAI) and MESSAGE Framework on Staff Perceptions of Aggression in Dementia
Care
Instructions: Please rate each statement based on your observations and professional
perspective over the 6-week project period.
Part 1: Likert-Scale Items
agreement.

Please circle the number that best reflects your level of

Statement

Strongly
Disagree
(1)

Disagree Neutral Agree Strongly
(2)
(3)
(4)
Agree (5)

1. I observed improved staff confidence
in managing aggression among patients 1
with dementia.

2

3

4

5

2. Staff demonstrated better recognition
1
of early signs or triggers of aggression.

2

3

4

5

3. The CMAI tool was used consistently
and appropriately in patient
1
documentation.

2

3

4

5

4. The MESSAGE communication training
appeared to enhance staff
1
communication and de-escalation
skills.

2

3

4

5

5. The overall frequency of aggressive
incidents on the unit decreased during
the project period.

1

2

3

4

5

6. Staff appeared less stressed or
anxious when caring for patients
exhibiting aggression.

1

2

3

4

5

7. The combination of CMAI
documentation and MESSAGE training
supported improved patient outcomes
and team communication.

1

2

3

4

5

129

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients

Part 2: Open-Ended Questions
1. During this 6-week project, did you observe less, more, or about the same number
of patients with dementia exhibiting aggressive behaviors?

2. What types of aggressive behaviors were most common? (e.g., physical, verbal,
both, other – please specify)

3. From your perspective as a manager, did implementing the CMAI tool and MESSAGE
training improve staff perceptions and confidence in managing aggression in
dementia care?

4. What barriers, if any, did staff encounter when using the CMAI tool or applying
MESSAGE techniques?

5. What benefits or positive outcomes did you notice during the project?

6. What recommendations would you make for sustaining or expanding this
intervention across other units?

7. Additional comments or observations:

130

Evaluating the Impact of an Evidence-Based Tool on Healthcare Staff’s Perception of
Aggression in Dementia Patients
Appendix C
INFORMED CONSENT
Title of Study:
EVULUATING THE IMPACT OF AN EVIDENCE-BASED TOOL ON HEALTHCARE STAFF’S PERCEPTION OF AGGRESSION IN
DEMENTIA PATIENTS
KEY INFORMATION
You are being asked by Stacy Lemley and Dr. Meg Larson to participate in a quality improvement project. Participation is voluntary, and you
may stop anytime.
The goal of this project is to find out if a short training session and a behavior checklist can help healthcare staff feel more confident and better
prepared to manage aggressive behavior in patients with dementia.
During this project, you will be asked to attend a training session, complete short surveys before, during, and after the training, and fill out a
checklist called the Cohen-Mansfield Agitation Inventory (CMAI) for six weeks. These surveys and checklists will ask about your experience and
how often you observe certain behaviors in patients.
It will take about 6 weeks to participate in the project.
The potential risks during the project are none. Remember, you may stop taking the survey at any time. In addition, if you feel the need to talk
with someone, you may contact the Penn West Edinboro counseling center at 814-732-2252, or for emergencies, call 814-732-2911.
There are no direct benefits to participants from this project. It will help researchers better understand. This project is part of my Doctor of
Nursing Practice (DNP) project to support staff in managing dementia-related behaviors.
SECURITY OF DATA
The online survey is completely anonymous; you will not be asked to give any information that could identify you (e.g., name). The survey is
NOT linked to IP addresses. Individual responses will not be presented, just the aggregated data.
Remember, taking part in this project is voluntary. If you feel uncomfortable or no longer want to participate, you may stop at any time.
There are no consequences if you decide to stop participating in this project.
There is no identifiable information collected from you during this project; all other information from this project will be confidential within
local, state, and federal laws. The Penn West University Institutional Review Board (IRB) may review the project records. The project results
may be shared in aggregate form at a meeting or journal, but there is no identifiable information to be revealed. The records from this project will
be maintained for a minimum of three (3) years after the project is complete.
Your information collected in this project will not be used or distributed for future research, even if all your identifiers are removed.
If you have questions about the project, you can contact Dr. Meg Larson at mlarson@pennwest.edu. If you have a question about your rights as a
project participant that you need to discuss with someone, you can contact the Penn West University Institutional Review Board at
InstReviewBoard@pennwest.edu.
If you would like a copy of this informed consent, please print this screen or contact Dr. Meg Larson at mlarson@pennwest.edu.
By clicking on the “I agree” box, you have acknowledged that you have read the informed consent and are at least 18 years old. Also, you
acknowledge that you agree to participate in the project. Finally, you understand your participation is entirely voluntary, and you may quit the
study at any time without penalty.

131