Document Type



Doctor of Philosophy



Date of Defense


Graduate Advisor

Jean Bachman PhD


Wilma Calvert, PhD

Judith Maserang, PhD

Justin Springer, PhD


. Disruptive behaviors are often related to care giving situations in which the patient wants something that is not possible, refuses to participate in what is required, demands instant gratification, or demands immediate emotional support. In response to the patients’ demands and actions, health care providers use limit setting, activity demand, and denial of request. This study sought to answer the following questions: (a) Are code greens associated with symptoms of a medical and/or psychiatric diagnosis, denial of request, limit setting, and activity demand? (b) Are activity demand, denial of request, and limit setting more likely to be associated with code green events than are symptoms of a psychiatric or medical diagnosis, and are denial of request, activity demand, and limit setting associated with verbal de-escalation, chemical restraint, and physical restraint? (c) Are there relationships between incidents of disruptive behavior, time of day, and practice environment? The study involved examining 432 code green incidents that occurred from 2007 to 2010. The results of the statistical analysis indicate a significant relationship exists between time of day and patients’ disruptive behavior involving potential self-harm occurred most often from 4:00 p.m. to midnight, X2(2, N = 43) = 6.96, p = 0.03. Patients were more likely to be given medication or restrained, p = 0.009, when disruptive behavior was associated with refusal of request and/or activity demand. The study results that indicate caritas literacy, the concept of using caring techniques to prevent and manage disruptive behavior, was present during 46.76% of the code greens as nursing staff endeavored to de-escalate the disruptive behavior by engaging in caring actions and using verbal de-escalation. When verbal de-escalation was not effective, nursing staff used chemical restraint (the mildest form of restraint) 32.64% of the time and manual holds 14.58% of the time to keep the disruptive patients from hurting themselves and others. Mechanical restraint, seclusion, and turnover to the police (techniques that lack caritas literacy) were used less than 5% of the time, a clear indication that the nursing staff at the study site used forceful measures only as a last resort.

OCLC Number


Included in

Nursing Commons