and lack of personal accomplishment; (2) depression, which is the degree of negative affect experienced by nursing personnel; (3) job satisfaction, which is the affective orientation of nursing personnel toward the work situation; and (4) work involvement, defined as the degree to which nursing personnel identify with the job (Weiler et al., 1990).

It has been suggested that nursing personnel who work with patients with Alzheimer's disease are especially vulnerable to the effects of stress and burnout. Alzheimer's disease patients present many difficult care and management problems because of their progressive cognitive, functional, and psychosocial deterioration, which can result in bizarre and combative behaviors, emotional outbursts, and wandering. Moreover, nursing home staff are often poorly trained to cope with the disruptive behaviors of residents, and they are therefore repeatedly frustrated by their inability to manage recurrent problems (Stolley et al., 1991). Many nursing homes are also not equipped with environmental structures or the support and service systems required to care appropriately for the person with Alzheimer's disease (Peppard, 1984). A recent study, using a quasi-experimental design with repeated measures, examined whether staff who cared for Alzheimer's disease patients on a special care unit were less stressed and less burned out than staff who cared for such patients on traditional (integrated) units. Findings revealed that the principal area of stress reduction for nursing personnel working on the SCU occurred with respect to staff knowledge, abilities, and resources. Subscale analysis indicated significantly less stress for staff who worked in the SCU with respect to residents' verbal and physical behavior. The SCU was designed specifically to provide the special environmental structures and support and service systems for the care of Alzheimer's disease patients that would enhance functioning and decrease associated behavioral problems. These may be important factors in reducing stress and burnout for staff caring for residents with Alzheimer's disease (Mobily et al., 1992). The investigators also recommended that whenever possible, staff who work with residents who have Alzheimer's should be carefully screened and selected for their ability to be sensitive to the needs of these residents, their flexibility, and their imagination, as well as ability to respond to persons with impaired communication and ever-changing moods (Coons, 1991). Specialized training in the care of residents with Alzheimer's disease is also a critical factor (see next section, "Education and Training").

In an effort to manage stress among nursing personnel in long-term-care facilities, it seems logical to examine those antecedent conditions in the model depicted above that are amenable to change. Research by Hare and Pratt (1988) has shown that higher levels of nursing burnout in both acute and long-term-care settings may be related to the nature of the physically and emotionally strenuous work tasks, low status in comparison to other positions in the health care system, limited training, low wages and benefits and, of interest to this report, poor staffing-to-patient ratios. Further, problems with support in the work environ-



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