Running head: DISRUPTIVE BEHAVIOR CRITIQUE

Whall Disruptive Behavior Model Critique

Jody French
Joe Johnson
Lisa A Morrill
Monica Woolman
Ferris State University

DISRUPTIVE BEHAVIOR CRITIQUE

Abstract
The disruptive behavior theory was developed by Ann Whall. The theory was based from the
Need-driven Dementia-comprised Behavior Model (NDB). The NDB model is a Western
middle range theory that follows the principles of Florence Nightingales descriptions of the
metaparadigm concepts of nursing. This paper includes a critique of the Disruptive Behavior
Theory. In this paper the theory was evaluated by defining the origin, focus, clarity, simplicity,
and generality. Also included is the examination of the future of the theory, testability, usability,
and importance

DISRUPTIVE BEHAVIOR CRITIQUE

Whall Disruptive Behavior Model Critique
Examination
During the research of our assigned theory on disruptive behavior we determined that
Ann part of the theory development on The Need-driven Dementia-compromised Behavior
Model (NDB). This theory is based on a Western middle range theory that follows principles of
Florence Nightingales theory as well as many others focusing on the nursing concept
surrounding the metaparadigm of environment. We can summarize further by saying that the
NDB model has suggested that patients with dementia and/or disruptive behavior are reacting
from needs that are not met in their environment. Four million Americans suffer from some
form of dementia (Kolanowski & Whall, 2000). By the year 2030, one in every three people
on earth will be age 60 or over and at risk for dementia (Whall & Kolanowski 2004). Dementia
does not have a cure at this time, and long term care is frequently necessary to provide for the
safest healthcare attention. Some dementia can be mild and minimal; other forms of dementia
can cause disruptive behavior that can frequently be unsafe for the patient as well as caregivers,
and be very concerning to those within the local environment.
Over time the use of physical and chemical restraints for disruptive/aggressive behavior
has become more and more discouraged in our standards of care written by governing bodies in
healthcare. These regulations as well as the fact that restraints have shown only modest effects
toward disruptive behavior lead researchers toward identifying other options and answering
further questions on how best to care for the disruptive patient (Whall & Kolanowski 2004).
Focus
While developing the NBD it was felt that disruptive behavior was a result of
personal needs not being identified and met and that by using corresponding interventions to

DISRUPTIVE BEHAVIOR CRITIQUE

address these needs, we can increase the quality of life and the comfort level for these patients.
In the model, the interaction of two classes of variables produces what are now referred to as
need-driven behavior: background factors (historical/developmental) and proximal factors
(current environmental/situational) (Whall & Kolanowski 2004). The model has divided the
behaviors into three categories, wondering, vocalizing and physical aggression. Seen this way,
these behaviors become meaningful and therefore, potentially useful in directing nursing care
(Algase et al. 1996). The disruptive behaviors can be used to test specific interventions for
evaluation of their effectiveness of meeting the goals set forth after identifying the type of need
not being met. With further theory development and research based testing these interventions
can be tested for their effectiveness and subsequently be used to guide practice for those caring
for the patients expressing signs of disruptive behavior that is outlined in the model. Using the
need-driven dementia-compromised behavior model caregivers can help identify aggressive
behavior, the needs behind the behavior and implement interventions to lessen the burden of
caring for this type of patient.
The need-driven dementia-compromised behavior (NDB) model is a middle range
nursing theory which seeks to improve health in dementia using an environmental focus (Whall,
Shin, & Colling, 1999). The theory focus is on that of controlling the environmental factors in
order to decrease the aggressive behaviors exhibited by dementia patients. This is important to
look at as by the year 2030, one in every three people on earth will be age 60 or over and at risk
for dementia (Whall & Kolanowski, 2004). Algase et al. (1996) contends that NDB arise in
pursuit of a goal or as an expression of a need. According to the theory, the NBD may be
affected by background factors or proximal factors. Although disruptive, dysfunctional, or
ineffective from an objective stance, NDBs constitute the most integrated and meaningful

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response possible, given limitations imposed by a dementing condition, strengths preserved from
the person's basic abilities and personality, and constraints, challenges, or supports offered by the
immediate environment (Algase, 1996). Background factors such as neurological, cognitive,
general health status, and psychosocial history are more enduring (Whall & Kolanowski, 2004).
Proximal factors are more fluid or fluctuating aspects of the immediate physical and social
environment and are likely to precipitate NDBs (Algase et al, 1996). Whall et al. (2008)
observed that one proximal factor that significantly predicted aggressive behavior was the total
amount of nighttime sleep. There was also a significant correlation of negative caregiver
behaviors and negative participant affect. Beck et al. (2011) noted a prediction of increased
likelihood of aggressive behavior in patients with poorer general health, and a decreased
incidence in patients with increased age. Additional theory development could come about if
nursing were to analyze the effect of amount of nighttime sleep and negative caregiver behaviors
to other patients that are cognitively impaired and exhibit aggressive or NDB. There are many
constructs available for nursing to apply a general part of this theory and many others and I do
believe that further theory generation is possible with further research.
The generality and scope of the NDB model could be considered broad yet narrow. Broad
in the manner that it looking at disruptive behaviors to become meaningful and potentially useful
in directing nursing care (Algase et al. 1996) Narrow in the fact that they are looking at specific
factors and how they affect patients with a diagnosis of dementia. This narrow population is
inclusive of those with a diagnosis of dementia displaying disruptive behaviors that are thought
to be and expression of need. Research has been done looking at background factors and
proximal factors, as descried previously, with variation as to specific outcomes and actions such
as wandering, vocalization and physical aggression (Algase et al. (1996). The ability to

DISRUPTIVE BEHAVIOR CRITIQUE

minimally change background factors also limits the potential scope. The scope is quite specific
as to the inclusion population but this could be adapted to be used with any cognitively impaired
patients. Algase et al. (1996) stated that damage to certain regions of the central nervous system
(CNS) may contribute to NDB.
The purpose of the theory is to develop targeted interventions for the need driven
behaviors to decrease the incidence. Interventions that have been identified to decrease
disruptive behaviors include increased social interaction, interact in a relaxed and warm manner,
use gestures over verbal communication, decrease wake time during the night and minimize
noise and activity levels in confined spaces ( Algase et al.1996)
Whalls theory of distruptive behavior is based on a Western middle range theory that
combines a Nightingale based model (Whall, Shin, & Colling, 1999). Whall, Shin, & Colling
(1999) discuss the Western middle range theory and how this theory was used to develop the
Need-drive Dementia compromised Behavior Model (NDB Model). The NDB Model reflects
how the caregiver can function to promote the optimal health of the impaired person (Algase et
al., 1996). Algase et al. (1996) have used the NDB model to breakdown the factors that affect/
cause disruptive behavior. The NDB model consists of background factors and proximal factors
that lead to three specific disruptive behaviors. The key behaviors that are described in the NDB
model are wandering, vocalizing and physical aggression.
This theory is very clear. Algase et al. (1996) define disruptive behavior as a reflection
of the caregivers view of the impaired person. The theory and the NDB model are aimed at
changing the views of disruptive behaviors. If the caregivers respond appropriately the quality
of life for the impaired [person will be enhanced (Kolanowski & Whall, 2000). With the concept

DISRUPTIVE BEHAVIOR CRITIQUE

of improving the quality of life all of the metaparadigm concepts have been identified in this
theory.
Whall, Shin, & Colling (1999) described many of the metaparadigm concepts as relating
to Nightingales model. The person in this theory is the patient with the disruptive behavior.
The person has some type of cognitive compromise or dementia. The persons compromised
cognitive ability has impaired their ability to display their personal needs. Enhanced health is the
goal for the cognitively impaired individual. This is the persons most optimal state given their
compromise and co-morbidities. To reach this optimal health the nursing care is going to be
based on sick nursing or health nursing. Nursing is defined as what care is needed to get the
patient to their best condition. Nursing care has the ability to alter the existing situations.
Finally, the metaparadigm concept of environment is the largest concept in this theory.
The environment directly affects the influence on the health of the individual. It is the
interactions and changes practices in the environment that directly impact the disruptive
behaviors (Whall, Shin, & Colling, (1999). For most of the persons with dementia where
disruptive behavior is address is in the nursing home.
One study by Beck et al. (2011) evaluated the impact of the environment in patients with
disruptive behavior. It was found that the background variables including demographics,
cognitive ability, general health and history of aggressive behavior directly affect the behaviors
of the person. It is the background factors that also play into the proximal factors which are the
person and environment that leads to the disruptive behavior. The environment can affect the
persons physiological needs including sleep, thirst, hunger, pain and elimination.
With that said I do feel that the theory is clear as it defines all of the metaparadigm
concepts to a very specific group of people and a very specific environment. Also, the theory is

DISRUPTIVE BEHAVIOR CRITIQUE

simple as it relates to one major population and set of cognitive impairments. The theory is
valued because it is the understanding of why patient have these disruptive behaviors and how
the nurse is taught to understand the patient and their needs that will lead to the patients optimum
health.
The empirical use of the NDB model with regard to testability is well established. In a
literature search for articles using the NDB model multiple instances were found of its use in
research. According to Fawcett (2005), It is unlikely that any one test of a theory will provide
the definitive evidence needed to establish it empirical adequacy (p. 133). As such, it should be
fair to say that the NDB model has been tested extensively, given the numbers of articles
identified that use it as a basis for research. Unfortunately, it is a daunting task to evaluate all the
studies that included the NDB model. However, the sample of studies that were evaluated in a
literature search, were all at least somewhat positive in reference to the model. According to
Beck et al. (2011) in reference to the use of the NDB model with respect to further research
related to dementia care, it provides a useful framework for examining these factors in future
studies (p. 403). The models clarity and understandable framework make it straightforward to
apply testing methods. The NDB model has been proven to be very testable as evidenced by the
number of research articles found that utilize its framework.
The usability of the NDB model within the framework of dementia is also frequently
identified in the literature. According to Alligood and Tomey (2010), Empirical precision is
linked to testability and ultimate use of a theory (p. 13). The numerous number of articles
available, negate an exhaustive search of all articles on the use of the NDB model in practice.
However, the several articles that were examined had positive experiences regarding the use of
the NDB model. For example, Whall et al. (2008) were able to identify that three of four

DISRUPTIVE BEHAVIOR CRITIQUE

background factors used from the NDB model were predictive of aggressive behavior. Whall
(2008) also noted that Negative caregiver behavior and negative participant affect.were also
significantly correlated although because of insufficient data the relationship remains unclear
(p. 728). This information can be transferred to dementia care in the respect that this knowledge
can be used by caregivers to transition care based on this knowledge to decrease the aggressive
behaviors in these patients. By using the information garnered by the many studies using the
NDB model caregivers can positively affect the care of dementia patients.
The derivable consequences of the NDB theory are easily provable. If research, theory
and practice are to be related meaningfully, then nursing research should lend itself to research
testing, and research testing should lead to knowledge that guides practice (Alligood & Tomey,
2010, p. 13). According to this statement the NDB model should be considered an important
theory. As explained above, the model lends itself to effective use for research and has been
used for many studies that can be transferred to practice to help decrease disruptive behavior in
patients with dementia. The knowledge gained through using the framework of this study can
help identify patients at greater risk for disruptive behaviors. Further, the framework of the
study can help care-providers positively change some of the proximal factors (Algase et al.,
1996, p. 13) identified to help minimize the potential for disruptive behaviors. The scope of
practice may be somewhat narrow because of the focus on use for dementia. However, for
patients with dementia, as well as the families and caregivers, the positive results that can be
attributable to this theory can have a positive impact on their lives.

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DISRUPTIVE BEHAVIOR CRITIQUE

References
Algase, D. L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K., & Beattie, E.
(1996). Need-driven dementia-compromised behavior: an alternative view of disruptive
behavior. American Journal of Alzeihmers Disease, Nov/Dec pp. 10-19.
Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work. Maryland Heights,
MO : Mosby.
Beck, C., Richards, K., Lambert, C., Doan, R., Landes, R. D., Whall, A., Algase, D.,
Kolanowski, A., & Feldman, Z. (2011). Factors associated with problematic vocalizations
in nursing home residents with dementia. The Gerontologist, 51, 389-405.
doi:10.1093/geront/gnq129
Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 12, 131-135.
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Kolanowski, A. M., & Whall, A. L. (2000). Toward holistic theory-based intervention for
dementia behavior, Holistic Nursing Practice, 14(2) 67-76.
Whall, A.L., Colling, K., B., Kolanowski, A., Kim, H., Hong, G.S., DeCicco, B., Beck, C.
(2008). Factors associated with aggressive behavior among nursing home residents with
dementia. The Gerontologist, 48(6), 721731.
Whall, A., Kolanowski, A. (2004). Editorial-the need-driven dementia-compromised behavior
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Whall, A.L., Shin, Y., & Colling, K.B. (1999). A Nightingale-based model for dementia care
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