Journal of Gerontological Nursing

EDITORIAL 

Bring Violence Out of the Closet

Geri Richards Hall, PhD(C), ARNP, CS

Abstract

As the aging population increases, nurses and health care providers - including gerontological nurses - are being increasingly subjected to violence on the job. America is a violent place. One cannot read the newspaper in a major city, watch television, or view a movie without daily exposure to people who use violence as a coping mechanism. Anecdotal reports and research demonstrate that this propensity toward violent alternatives has not bypassed the aged.

At a recent meeting, adult day care providers complained about the increasing frequency of aggression and physical confrontation in the participants they serve. A rural nursing home consultant reviewed corporate workman's compensation claims and reported she was surprised to learn that injuries from assaults far outnumbered other causes, including back injuries. A state survey of nursing homes indicated there are 250 or more nursing home residents who are so violent they can not be managed using medications or other interventions. At a continuing education course, nursing assistants complained that their requests for help with aggressive behavior during cares were being ignored.

In too many cases we hear that the person who was assaulted contributed to or caused the attack either by approaching the patient in the wrong way or being in the wrong place at the wrong time. A director of nursing at a care facility reported to me that two of her nursing assistants were assaulted by a resident with a lifelong history of violence. When reported during the multidisciplinary staffing, a team member replied, "Perhaps they (the staff) deserved it!" If we blame the victims, we can dismiss the act without looking at prevention. Moreover, we have become fearful of using pharmacological interventions because of their classification as chemical restraints. In our zeal to provide for resident rights, are we placing staff and other residents in jeopardy?

There is a growing body of meaningful research demonstrating that aggression in nursing homes increases with length of stay, cognitive decline, advanced age, and a loss of sense of control (Winger, Schirm, & Stewart, 1987). Functional decline did not contribute to aggression. A study conducted on a long-term care unit at a Veterans Affairs Hospital noted 38 residents with high potential for violence. Of those 38, 29 (76.3%) of patients demonstrated aggressive behavior severe enough to report (Beck, Robinson, & Baldwin, 1992). Two studies associated violent behavior with environmental factors, especially large areas such as the day room and during room (Beck, Robinson, & Baldwin, 1992). Yet staff are often reticent to report violence as they view it as a failure of their performance, as "just part of the job," or avoid filling out reports because of time involved (Negley & Manley, 1990).

We must begin to take violence toward health care professionals seriously, first by acknowledging the problem. We must assess every patient for the potential for violence. We must stop blaming care providers for causing aggressive incidents, instead examine all episodes for antecedents, develop, and test interventions. All staff must be trained in non-confrontational approaches and violence management. Psychiatric consultation should become routine for violence in all long-term care settings. Environments must be assessed as triggers for aggression and appropriate modifications made.

Violence should be monitored monthly as part of quality programming thereby letting administrators know when problems arise or increase. We must pursue clinical research aggressively with the goals of providing comfortable meaningful care to the aged and a safe workplace for all employees. We must all work together to work to stop the violence.…

As the aging population increases, nurses and health care providers - including gerontological nurses - are being increasingly subjected to violence on the job. America is a violent place. One cannot read the newspaper in a major city, watch television, or view a movie without daily exposure to people who use violence as a coping mechanism. Anecdotal reports and research demonstrate that this propensity toward violent alternatives has not bypassed the aged.

At a recent meeting, adult day care providers complained about the increasing frequency of aggression and physical confrontation in the participants they serve. A rural nursing home consultant reviewed corporate workman's compensation claims and reported she was surprised to learn that injuries from assaults far outnumbered other causes, including back injuries. A state survey of nursing homes indicated there are 250 or more nursing home residents who are so violent they can not be managed using medications or other interventions. At a continuing education course, nursing assistants complained that their requests for help with aggressive behavior during cares were being ignored.

In too many cases we hear that the person who was assaulted contributed to or caused the attack either by approaching the patient in the wrong way or being in the wrong place at the wrong time. A director of nursing at a care facility reported to me that two of her nursing assistants were assaulted by a resident with a lifelong history of violence. When reported during the multidisciplinary staffing, a team member replied, "Perhaps they (the staff) deserved it!" If we blame the victims, we can dismiss the act without looking at prevention. Moreover, we have become fearful of using pharmacological interventions because of their classification as chemical restraints. In our zeal to provide for resident rights, are we placing staff and other residents in jeopardy?

There is a growing body of meaningful research demonstrating that aggression in nursing homes increases with length of stay, cognitive decline, advanced age, and a loss of sense of control (Winger, Schirm, & Stewart, 1987). Functional decline did not contribute to aggression. A study conducted on a long-term care unit at a Veterans Affairs Hospital noted 38 residents with high potential for violence. Of those 38, 29 (76.3%) of patients demonstrated aggressive behavior severe enough to report (Beck, Robinson, & Baldwin, 1992). Two studies associated violent behavior with environmental factors, especially large areas such as the day room and during room (Beck, Robinson, & Baldwin, 1992). Yet staff are often reticent to report violence as they view it as a failure of their performance, as "just part of the job," or avoid filling out reports because of time involved (Negley & Manley, 1990).

We must begin to take violence toward health care professionals seriously, first by acknowledging the problem. We must assess every patient for the potential for violence. We must stop blaming care providers for causing aggressive incidents, instead examine all episodes for antecedents, develop, and test interventions. All staff must be trained in non-confrontational approaches and violence management. Psychiatric consultation should become routine for violence in all long-term care settings. Environments must be assessed as triggers for aggression and appropriate modifications made.

Violence should be monitored monthly as part of quality programming thereby letting administrators know when problems arise or increase. We must pursue clinical research aggressively with the goals of providing comfortable meaningful care to the aged and a safe workplace for all employees. We must all work together to work to stop the violence.

REFERENCES

  • Beck, C, Robinson, C, & Baldwin, B. (1992). Improving documentation of aggressive behavior in nursing home residents. Journal of Gerontological Nursing, 18(2), 21-24.
  • Negley, E., & Manley, J. (1990). Environmental interventions in assaultive behavior. Journal of Gerontological Nursing, 16(3), 29-33.
  • Winger, J., Schirm, V., & Stewart, D. (1987). Aggressive behavior in long-term care. Journal of Psychosocial Nursing and Mental Health Services, 25(4), 28-33.

10.3928/0098-9134-19960801-06

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