Journal of Gerontological Nursing

VIOLENCE Against Caregivers in Nursing Homes: Expected, Tolerated, and Accepted

Donna M Gates, EdD, MSPH, MSN, RN; Evelyn Fitzwater, DSN, RN, CS; Ursula Meyer, MSN, RN

Abstract

Workplace violence is not a term traditionally associated with nursing home residents5 aggressive behaviors. Many nursing home residents experience dementia or other mindaltering disease processes that influence thinking and intent. Thus, when a resident experiencing dementia is aggressive toward staff, this behavior has not been considered violent because demented residents may not be considered responsible for the actions and do not intend to harm others. Yet, injuries caused by residents may be perceived as violence by staff who experience the assaults in the workplace regardless of resident diagnosis or intent. The purpose of this study was to explore the issue of caregivers' perceptions of violence in nursing homes as a workplace safety and health issue. The investigators used the Occupational Health and Safety Administration's (OSHA) definition of violence: "physical assault, threatening behavior, or verbal abuse occurring in the workplace" (OSHA, 1996a, p. 4).

Increasing violence against health care workers prompted OSHA to publish employer guidelines in 1996 (OSHA, 1996b). Health care employers must take actions to protect their employees from violence perpetrated by patients, families, visitors, and fellow employees. In studies describing the epidemiology of workplace violence, certified nursing assistants (CNAs) working in long-term care have been found to represent the occupation most at risk of workplace assault (Bureau of Labor Statistics [BLS], 1994, 1995).

The word caregiver invokes feelings of love, devotion, and compassion. However, currently many caregivers, as they attempt to care for patients in nursing homes, experience physical and emotional assaults on a regular basis. This study was initiated in response to informal discussions with nursing home personnel documenting a need for assistance in preventing violence in these settings. It was decided that before interventions could be planned and studied, it is important to increase the understanding of violence in this unique health care setting. The purposes of this study were to determine whether staff consider resident aggressiveness to be violence and to describe the nature and complex dynamics of the violence which occurs in nursing homes.

TABLE 1

CNA FOCUS GROUP QUESTIONS

TABLE 2

NURSING DIRECTOR FOCUS CROUP QUESTIONS

TABLE 3

DEMOGRAPHICS OF CNAs

TABLE 4

THEMES FROM THE CNA GROUPS

TABLE 5

THEMES FROM THE NURSING DIRECTOR CROUPS

TABLE 6

VARIABLES THAT CAUSE OR INCREASE THE RISK OF CAREGIVER VIOLENCE…

Workplace violence is not a term traditionally associated with nursing home residents5 aggressive behaviors. Many nursing home residents experience dementia or other mindaltering disease processes that influence thinking and intent. Thus, when a resident experiencing dementia is aggressive toward staff, this behavior has not been considered violent because demented residents may not be considered responsible for the actions and do not intend to harm others. Yet, injuries caused by residents may be perceived as violence by staff who experience the assaults in the workplace regardless of resident diagnosis or intent. The purpose of this study was to explore the issue of caregivers' perceptions of violence in nursing homes as a workplace safety and health issue. The investigators used the Occupational Health and Safety Administration's (OSHA) definition of violence: "physical assault, threatening behavior, or verbal abuse occurring in the workplace" (OSHA, 1996a, p. 4).

Increasing violence against health care workers prompted OSHA to publish employer guidelines in 1996 (OSHA, 1996b). Health care employers must take actions to protect their employees from violence perpetrated by patients, families, visitors, and fellow employees. In studies describing the epidemiology of workplace violence, certified nursing assistants (CNAs) working in long-term care have been found to represent the occupation most at risk of workplace assault (Bureau of Labor Statistics [BLS], 1994, 1995).

The word caregiver invokes feelings of love, devotion, and compassion. However, currently many caregivers, as they attempt to care for patients in nursing homes, experience physical and emotional assaults on a regular basis. This study was initiated in response to informal discussions with nursing home personnel documenting a need for assistance in preventing violence in these settings. It was decided that before interventions could be planned and studied, it is important to increase the understanding of violence in this unique health care setting. The purposes of this study were to determine whether staff consider resident aggressiveness to be violence and to describe the nature and complex dynamics of the violence which occurs in nursing homes.

BACKGROUND AND SIGNIFICANCE

Nursing Homes and Future Predictions

There are approximately 1,813,665 total nursing home beds in 16,995 nursing facilities in the United States (American Health Care Association, 1996). The number of nursing home beds is expected to increase dramatically in the near future as a result of the expected increase in people age 65 and older (Administration on Aging, 1997; Sekscenski, 1987). Certified nursing assistants, who represent 43% of the employees and 70% to 90% of the nursing personnel, are most likely to be in direct contact with residents in nursing homes (Hagan & Sayers, 1995; Strahan,1987; Wunderlich, Sloan, & Davis, 1996). As the number of nursing home residents increase, CNAs will continue to be the largest group of workers in nursing homes and primary providers of direct care. These health care workers currently have the least amount of education and training of health care workers in nursing homes. Yet, the patients in nursing homes often require some of the most difficult and challenging care because of the prevalence of mental disorders, Alzheimer's-type dementia, and physical limitations. Many of these patients exhibit aggressive behaviors as a result of mental disorders frequently not considered an admitting diagnosis.

Although CNAs provide the majority of physical care to residents in nursing homes, scant attention has been paid to the working environment of this occupational group (Wunderlich et al., 1996). The physical and emotional demands of working as a CNA in a nursing home makes the occupation difficult and challenging. Attention to the occupational safety and health of this occupational group is likely to have a positive impact on the future of the CNA job, as well as the care of nursing home residents.

Violence in Long-Term Care

Violence research, in particular violence prevention research, and nursing home violence is in its infancy stage. The following review exemplifies the need for increased efforts aimed at providing new information regarding violence prevention in this unique setting.

A focus group study describing CNAs and their experiences with violence in nursing homes found that these workers often experienced harassment, threats, and assaults from patients (Lusk, 1992). The study also found that the CNAs believed they did not receive much support from their supervisors related to the violence they were experiencing. These workers believed their employers should make more efforts to protect them from violence.

Studies have demonstrated that assaults against caregivers by elderly residents are common and occur primarily during basic care activities such as dressing, changing, bathing, feeding, and turning (Gage & Kingdom, 1995; Hagen & Sayers, 1995; Miller, 1997). Whall, Gillis, Yankou, Booth, and Beel-Bates (1992) also found that a large number of residents exhibit disruptive behaviors, including verbal and physical attacks on personnel. Strategies used to decrease disruptive behaviors often included the use of physical and chemical restraints, talking to and counseling patients, and touching patients.

Gage and Kingdom (1995) described a large, long-term care facility that undertook a training program for caregivers to help prevent violence. A needs assessment demonstrated that staff believed aggression occurred because of resident powerlessness, staff powerlessness, family conflict, time pressure, and lack of knowledge. Results of aggression toward the caregivers included passive coping, getting hurt physically and emotionally, and feeling unappreciated. The intervention consisted of a training program, team-building sessions, debriefing, space for staff to retreat, improved environment for residents, and more staff involvement in care planning. Those caregivers who participated in the intervention showed increased self-efficacy in handling aggressive residents. However, after the intervention there was no significant difference in the incidence of violence between the experimental group and the control group. The study, which was conducted in one large facility, did not evaluate changes in violence prevention skills.

Most of the published, violence intervention studies in nursing homes measured changes in the caregivers' knowledge, beliefs regarding safety, or self-efficacy to prevent violence (Cohen-Mansfield, Werner, Culpepper, & Barkley, 1997; Feldt & Ryden, 1992; Mentes & Ferrario, 1 989). Although knowledge and selfefficacy often precede behavioral changes, this is not always true. In addition, many of the intervention studies did not include a control group or randomize subjects. These studies do support the common belief that nursing home caregivers, usually CNAs, lack the knowledge and skills to manage the care of aggressive residents. There remains a paucity of intervention studies aimed at increasing and measuring caregivers' skills and decreasing incidents of violence in nursing homes. Intervention research, based on theory and rigorous design, is needed to provide useful information to caregivers working in nursing homes.

Table

TABLE 1CNA FOCUS GROUP QUESTIONS

TABLE 1

CNA FOCUS GROUP QUESTIONS

Table

TABLE 2NURSING DIRECTOR FOCUS CROUP QUESTIONS

TABLE 2

NURSING DIRECTOR FOCUS CROUP QUESTIONS

Effects of Violence

Workplace violence can seriously affect the employer and the employees (Gates, 1995, 1998). The effects can include varying financial costs for medical and psychological care, increased absenteeism, property damage, decreased productivity, increased security, litigation, increased workers' compensation, and personnel changes. Personnel changes are related to burnout and turnover. Studies have found that caregivers experiencing verbal or physical assaults had both shortterm and long-term emotional reactions including anger, sadness, frustration, anxiety, irritability, fear, apathy, self-blame, and helplessness (Gage & Kingdom, 1995; Hagen & Sayers, 1995; Lanza, 1992; Miller, 1997).

METHODS

The study consisted of focus group meetings with caregivers and nursing directors. The focus group method was used to capture the feelings and beliefs existing regarding violence in nursing homes. All focus group meetings were audiotaped and transcribed.

Violence is defined by OSHA and the National Institute of Occupational Health and Safety (NIOSH) as any "physical assault, threatening behavior, or verbal abuse occurring in the workplace" (OSHA, 1996a, p. 4). Both NIOSH and OSHA use the term violence for any work situation including incidents against taxicab drivers; post office employees; or health care workers in emergency departments, nursing homes, psychiatric hospitals, or long-term care facilities. One of the purposes of this study was to determine whether CNAs and nursing directors in long-term care would consider the residents' assaults against caregivers as "violence."

Table

TABLE 3DEMOGRAPHICS OF CNAs

TABLE 3

DEMOGRAPHICS OF CNAs

Instruments

Structured questions to guide the caregivers' and the nursing directors' focus groups were decided prior to data collection (Tables 1 and 2). Each caregiver group was asked the questions in the same order.

Procedure

A convenience sample of six nursing homes was selected to participate: three rural and three urban. Sizes of the nursing homes ranged from 75 to 208 beds. Employees providing direct, hands-on care were asked to speak with the researchers regarding their work in nursing homes. Refreshments and monetary incentives were provided for attending the lV6-hour caregiver discussion. Two researchers were present for each discussion, one to lead the discussion and the other to handle the audiotaping and make written notations.

The six nursing directors were asked to participate in a focus group discussion after the caregiver groups were completed. Because of scheduling conflicts, two discussions were held - one discussion with a group of five nursing directors and another for the sixth nursing director who was unable to attend the group discussion. Caregivers and nursing directors completed a brief demographic survey.

Subjects

Fifty-four caregivers and six nursing directors participated in the study. At one nursing home, 22 CNAs signed up to attend the meeting. Two groups were conducted to allow all caregivers the opportunity to express themselves and be heard. All caregivers who attended the meetings were CNAs, and all but one participant was female. See Table 3 for a description of demographics, employment, and previous violence prevenuon training.

The nursing directors ranged from age 32 to 56, including five women and one man. Nursing degrees held by the directors included two associate degrees, one diploma degree, two bachelor degrees, and one master's degree. The length of time in their present position included one director with less than 1 year, one with 1 year, two with approximately 4 years, and two with more than 6 years. Five of the directors reported they had received some training on how to handle hostile, mean, or aggressive residents. Three directors stated they had provided training during the past 12 months for their caregivers on handling such residents. One director reported that she did not know whether such training had occurred. When asked whether there was anyone in their facility skilled to provide violence prevention training to caregivers, two said yes, one said no, three said they did not know, and one left the item blank. Two nursing directors estimated the percentage of dementia residents as 30%, three as 45% to 50%, and one as 60%. Two directors estimated the percentage of residents with mental health problems as less than 5%, three as 10%, and one as 25%.

Table

TABLE 4THEMES FROM THE CNA GROUPS

TABLE 4

THEMES FROM THE CNA GROUPS

Table

TABLE 5THEMES FROM THE NURSING DIRECTOR CROUPS

TABLE 5

THEMES FROM THE NURSING DIRECTOR CROUPS

RESULTS

Focus Group Findings

The data was analyzed by identifying content themes that emerged from the caregiver and nursing director focus groups. The themes from the caregiver groups (Table 4) and nursing director groups (Table 5) were similar for five of the groups. However, there were some differences with one group which will be discussed later in this article. The following presentation of the findings is organized according to these content themes.

Caregivers

The caregivers unanimously described workplace violence as physical and verbal assaults, which they stated occurred on a daily basis. Although they included resident-toresident violence, family-to-resident violence, employee-to-employee violence, and family-to-employee violence, their most pressing concern was resident-to-caregiver violence. Physical violence included hitting with a hand or object, scratching, pinching, biting, grabbing, pulling hair, twisting wrists, poking, spitting, pinching, and throwing objects. Verbal assaults included threats of physical harm, cursing, racial slurs, demeaning remarks, screaming and yelling, excessive demands, and complaints. Every CNA in attendance stated they had experienced such events as a caregiver in a nursing home.

The caregivers also stated that violence often is unpredictable, sudden, and is most frequent when assisting residents with feeding, bathing, and changing. The caregivers stated that the violence occurs with demented and nondemented residents and seems to increase during the evening and night shifts. Some of the caregiver quotes describing such violent incidents included, the following: "confronted," "combative," "attacking," "beat up," "deserves combat pay," "do not know what you are walking into," and "it's like a war zone."

Words and phrases used by the caregivers to describe how they felt after a violent assault by a resident included: hurt, angry, frustrated, resentful, sad, unpredictable, lack of respect, violated, shocked, mad, fearful, bad, and ambivalent. Additional statements describing caregiver feelings included: "unappreciated," "wonder if it's worth it," and "robbed out of my rights."

All caregivers agreed that when a violent incident requires medical attention, an incident report is completed. If physical violence does not require medical attention, the type of reporting varies from doing nothing to verbally reporting the incident to the nurse, which may or may not result in a written report. All agreed most violent incidents do not get reported by the caregiver to the nurse. Reasons for not reporting an incident included the requirement of five nursing homes to perform drug testing for all incident reports, the lack of follow up to incidents, and the acceptance of violence as part of the job. One CNA commented that a nurse responded to her recent verbal report of violence by saying, "How dare you create more paperwork for me." The caregivers also discussed the fact that reporting could be job threatening and that often they are blamed for the violent incident. One CNA responded, "They think I am the bad guy," The caregivers also stated that the nurses and administrators "play up to the private pay people and do not want to cause problems."

The majority of caregivers said they receive no emotional support such as counseling, recognition of feelings, or opportunities to verbalize feelings or problem solve after reporting a violent incident. In addition, the caregivers expressed that they did not feel that nurses were concerned about their welfare. One CNA said, "The nurses could care less." The caregivers did report that they support each other.

Lack of communication was a major issue with the caregivers regarding violence. Five of the groups discussed the lack of information they receive and communicate regarding residents and families. Before caring for a resident they often have no information regarding the resident's condition, social history, violence history (short-term and long-term), or information regarding the family dynamics and family expectations. Caregivers also talked about the lack of ability to communicate their observations to others via verbal shift reports or daily logs or worksheets.

Caregivers overwhelmingly stated they lacked the formal education and training needed to care for violent and aggressive residents and families, stating that most of their training was provided "on the job." They also stated they would like to receive training on working in teams, understanding their rights, and handling stress.

Nursing Directors

The common themes that emerged from the questions asked of the nursing directors are shown in Table 5. The nursing directors defined workplace violence in their settings as employee to employee, employee to resident, resident to employee, and family to employee. One director stated that violence is "in the eyes of the beholder," and another stated, "violence is when there is a perceived threat." They agreed violence against caregivers includes physical and verbal abuse and occurs most often while bathing, changing, or doing anything the resident considers frightening or unusual. They all agreed that, although violence against caregivers occurs with nondementia residents, it is more common with demented residents. Five nursing directors stated violence occurs daily and it is sometimes predictable. Physical violence was described as hitting, biting, swinging objects, pinching, and grabbing. Although the directors discussed how violence with sexual overtones, such as grabbing the crotch or breast was the most disturbing type of violence for caregivers, the CNAs did not mention such feelings. Descriptions of verbal violence included cursing (i.e., swearing at caregivers), cussing (i.e., using vulgar language to intimidate caregivers), yelling, and lashing out. The directors stated they were concerned about the increasing violence brought into the nursing home from the outside, specifically domestic.

The nursing directors were in agreement for the most part with the CNAs regarding what typically occurs after a violent incident. Responses varied from a verbal report to the nurse to a written incident report. Those incidents requiring medical attention tended to be reported and recorded. The five nursing directors stated that many incidents probably do not get reported and there is little support for CNAs from the nurses or administration after an incident. Reasons suggested by the directors for the lack of violence reporting included: acceptance by CNAs that "violence is part of the job," resistance to perform drug testing, and fear that reporting violence may threaten their job.

Table

TABLE 6VARIABLES THAT CAUSE OR INCREASE THE RISK OF CAREGIVER VIOLENCE

TABLE 6

VARIABLES THAT CAUSE OR INCREASE THE RISK OF CAREGIVER VIOLENCE

The nursing directors recognized the focus in their facilities is on resident and family rights and state they have no policies, procedures, or discussions regarding employee rights. One nursing facility was just beginning to develop violence policies and procedures at the time of this study. There was a consensus that there was no violence plan and taking care of problems as they occurred was the norm. Although five directors of nursing verbalized that violence is a growing concern, there seemed to be other priorities in their workplaces. Violence was not viewed as a concern or priority for the administrators. However, the survey showed that four directors felt they would get support from their administrators for efforts to increase violence prevention training.

The nursing directors agreed there was no formal support system for caregivers after they experience a violent episode. One nursing director said, "I never really thought about it." Another said, "Something needs to be done to show the employees we value them." The directors discussed how difficult the CNAs' job was in the nursing home. One director said, "I would rather make hamburgers at a fast food restaurant than work as a resident assistant in a nursing home." Another said, "There is a lot of tension between the nurses and the nursing assistants." Another said CNAs are "on the front line."

The nursing directors agreed they provided minimal training on handling aggressive and violent residents and caregivers, with most of such training occurring during orientation for new staff. They stated that training is difficult to conduct because of the high CNA turnover rate.

The nursing directors were asked what they believed would help make an impact on nursing home violence. Their responses included education and training, preadmission screening, family education, decreased admission of mentally ill individuals, employee rights, improved staffing, and safety committee discussions about violence.

Variables Related to Violence

The caregivers and nursing directors were asked to name the causes or variables which increase the risk of violence against caregivers (Table 6). Similarities and differences are noted in their responses. The CNAs had difficulty separating the causes of violence from their general feelings about violence. The CNAs spoke often about the stress, providing examples of both internal and external stresses. Internal stresses included:

* Low self-esteem.

* Lack of self-respect.

* Feeling unappreciated.

* Fear of losing their jobs.

* Feeling guilty.

External stresses included:

* Low staffing.

* Demands from residents, families, coworkers, and administrators.

* Lack of rights for CNAs.

* A "you" (nurses) versus "us" environment.

* Lack of respect.

* Being told they can be replaced easily.

A Nursing Home With Differences

Participants at one nursing home responded somewhat differently to the focus group questions. The caregivers of this group felt more supported, respected, and cared for by the nurses, nursing director, and the administrator. The caregivers talked about frequent conversations with their administrator and used his first name when referring to him. These CNAs did not have any concerns with communication. They felt they received adequate histories on their residents and had opportunities to receive and share information regarding residents. The CNAs were present at shift reporting and were responsible for charting on daily logs, which became part of patients' records. Although the CNAs discussed frequent violence from residents, they did not discuss problems with physical violence from families. However, they did discuss receiving occasional pressure from families regarding the care of their loved ones. And although they did not appear threatened by reporting violence nor were they required to take a drug test, they did not report many of the incidents which did not require medical attention. The CNAs' biggest concerns regarding workplace violence were: not enough staff, lack of outside security, and quality and amount of training. The caregivers wanted training that provided opportunities to practice skills, using hands-on methods, stating that past training was "too high-level."

The nursing director of this particular nursing home described physical violence against caregivers as occurring approximately weekly and rarely requiring medical attention, reporting that the last episode to require medical attention occurred several years ago. The nursing director did believe most violent incidents were reported in the facility. The nursing director stated that violence is not a problem in their nursing home and felt the reasons for this included:

* Low staff turnover rate.

* Low resident turnover rate.

* An open-door policy between staff and administration.

* Presence of the administration on the units.

* Monthly inservices and patient-care conferences.

* A team approach.

For example, the director said, "because meals are so important, everyone passes food trays. This takes a team effort and includes housekeeping staff." The director continued saying, "The CNAs are valued here." For example, "The CNAs are told that they are vital to the nursing home, that if they were not here the place could not function." Another example was when a previously terminated CNA asked to be rehired, the administrator met with the caregivers to get their opinions on the matter. The nursing director also stated that residents have been transferred out of their facility when they have been consistently abusive to caregivers.

DISCUSSION

This preliminary study found CNAs and nursing directors unanimously defined workplace violence as verbal and nonverbal attacks against nursing home caregivers from demented and nondemented residents. Violence occurred frequently and was of serious concern to most of the caregivers. Caregivers who experience daily physical and verbal violence feel powerless to do anything about their situations. They need to work, yet they find themselves employed in a setting that expects, tolerates, and sometimes accepts violence against caregivers as part of the job. In time, many of them also begin to accept violence as part of their jobs. In addition, many caregivers were reluctant to express their thoughts and fears about such abuse to administration for fear of being reprimanded for their actions or even losing their jobs.

Some caregivers discussed their anger toward violent residents and how it affected their attitudes and care toward those people. For example, they said they were less eager to spend time with these residents and less willing to answer their call lights. Some caregivers discussed feeling guilty about their angry feelings after being abused by a resident. Many expressed that they sought this type of job to care and nurture others, yet often became angry, saddened, and frustrated by the overwhelming nature of their work. Such feelings and behaviors affect the quality of care for residents.

Because it is known that much of the violence against caregivers in nursing homes is not reported, the incidence of workplace assaults against CNAs in nursing homes is grossly underestimated in the published statistics. In addition, there are no statistics on the amount of verbal violence experienced by nursing home caregivers. Yet, caregivers were expected by the nurses and administration to accept the violence as "part of the job." There appears to be a lack of awareness that such daily violence may result in consequences to the employees' attitudes, mental health, and eventually resident care. For example, there were little efforts to provide support to the caregivers such as counseling, recognition of feelings, support groups, or incident problem solving. In addition, little or no formal training was provided for caregivers regarding handling aggressive and violent residents and families, despite directors' recognition that the caregivers are the ones who work daily on the "front line." Yet, of all the health care providers in nursing homes CNAs, who are the primary caregivers, have the least amount of formal education.

Residents and their families have rights in nursing homes, often written and communicated to all employees. This is important because residents in nursing homes often are fragile and dependent on their caregivers. Yet, CNAs appear to have little or no rights. The OSHA's General Duty clause, which requires all employers to provide a safe and healthy workplace for all employees, was applied when OSHA drafted violence prevention guidelines for health care and social service workers in 1996 (OSHA, 1996b). The OSHA states that:

failure to implement the guidelines is not in itself a violation of the General Duty clause of the OSHA act of 1970. However, employers can be cited under that clause if violence is a recognized hazard in their establishments, and they do nothing to prevent it (OSHA, 1996c, pp. 1-2).

Nursing homes are at risk for liability and negligence lawsuits when employees are not given adequate protection from violence. One of the nursing home directors discussed a lawsuit that a CNA recently had initiated against a resident as a result of violence.

Having rights also means being respected and valued. Many caregivers do not feel respected and valued working in nursing homes. In fact, many feel they have little or no job security because they often are told they can be replaced easily. Yet the nursing directors stated in the focus groups that staffing and CNA turnover is an ongoing problem at their facilities.

The caregiver and nursing director responses at one nursing home were different than the others. Although the CNAs reported frequent episodes of violence they felt respected, valued, and supported at their workplace. They did not fear reporting a violent incident. They felt they were part of the team, communicating through reporting, charting, and patient care conferences. They felt safe and comfortable voicing concerns to the nursing director and the administrator, including episodes of violence. The nursing director confirmed that the caregivers were vital to the institution, that they were comfortable with reporting violent episodes, and that staff turnover was not a problem. The question is whether a supportive working environment impacts the ability to prevent, recognize, and manage workplace violence in the nursing home setting.

IMPLICATIONS

Although this was a preliminary study, it did support the fact that caregivers consider assaults against them from demented and nondemented residents to be violence. The cause or intent of the violence may be very different but the effects can be equally as damaging to the caregivers. The results also suggest violence is a serious problem in nursing homes and efforts are needed to document the true incidence of physical and verbal abuse. The study also supports the fact that such violence is upsetting and demoralizing to many CNAs. Employers must take action to improve the working conditions for caregivers regarding workplace violence. The first step is the recognition that such violence is a common occurrence and that it has potential negative consequences to the employees' health and safety, as well as resident care.

Employers should develop policies and procedures which communicate to residents, families, and managers that caregivers have a right to a safe and healthy workplace. Recommendations from OSHA state that health care facilities should have a written violence plan including the following elements (Gates, 1998; OSHA, 1996b):

* Management commitment.

* Employee involvement.

* Worksite assessment.

* Prevention of hazards.

* Training and education.

* Prompt recognition, control, and monitoring.

* Reporting and record keeping.

Employees and managers need to know the specific procedures for preventing, managing, and evaluating violence in their workplaces.

Caregivers must be adequately trained in handling aggressive patients. Training needs to be comprehensive and allow participants the opportunity to practice newly learned skills through role playing or other simulated experiences. In addition, caregivers need to understand how state and federal regulations impact the care they are required to provide residents. For example, regulation changes in requirements for the frequency of weight assessments and food temperatures may not be accompanied by an improvement in staffing ratios. The CNAs and nurses need to communicate and problem solve ways to manage increased requirements in care with little or no increase in staff. The caregivers and the nursing directors stressed that staffing ratios affect the incidence of violence.

Caregivers should be involved in the communication process as part of the team. They should have the opportunity to obtain knowledge about residents, especially any shortterm or long-term history of violence, as well as any family dynamics which may affect them. Employers need to recognize that being assaulted can be traumatic and offer some formal mechanism for the employees to cope with their feelings and frustrations. After an assault, caregivers should be provided with opportunities to learn about their experience without feeling blamed.

Caregivers need to believe they are respected and valued by their employers and the nurses. They need to feel they are a vital part of the team and have employee rights. Some suggested policies that will communicate support to caregivers are:

* Caregivers are required to report all incidents of violence without fear of reprisal.

* Families and residents are notified that the caregivers have a right to work without being verbally and emotionally abused.

* Administration uses caution when accepting patients with a history of violence or mental illness. Employees also need to know residents will not be kept at the facility when it is believed the caregivers' safety is being compromised.

LIMITATIONS

The purposes of this focus group study were to determine whether CNAs and nursing directors consider assaults from residents to be violence and to provide necessary information for the development of an intervention aimed at decreasing the violence against caregivers in nursing homes. The ability to generalize the findings of this study to other populations is limited because of the use of a convenience sample of volunteers. No attempts were made to control for differences between the CNAs, such as difficulty of assignments and shifts worked. Selection bias could have occurred without randomization. It is possible those who volunteered were different in some way than those who did not participate.

SUMMARY

Violence against caregivers is not a new phenomenon. Caregivers have experienced verbal and physical assaults from nursing home residents for many years. However, because much of the violence has been associated with demented or mentally ill residents, the word aggression was used in lieu of violence. This study found that the caregivers and nursing directors considered the assaults to be violence. The study suggests that such violence occurs frequently and is of concern to caregivers and nursing directors. The study also suggests that nursing homes may not have policies or procedures in place for preventing, monitoring, and controlling violence in their workplaces. In 1996, OSHA published violence prevention guidelines for health are facilities These guidelines support OSHA's mandate that employees are entitled to a safe and healthy workplace (OSHA, 1996b). Although it is not possible to prevent all violence against caregivers in this unique setting, nursing home directors and administrators have a legal and moral responsibility to develop an action plan to minimize the violence and plan interventions for its effects. Violence against caregivers in nursing homes no longer can be thought of as expected, tolerated, and accepted. Quality of care and employee well-being depend on it.

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TABLE 1

CNA FOCUS GROUP QUESTIONS

TABLE 2

NURSING DIRECTOR FOCUS CROUP QUESTIONS

TABLE 3

DEMOGRAPHICS OF CNAs

TABLE 4

THEMES FROM THE CNA GROUPS

TABLE 5

THEMES FROM THE NURSING DIRECTOR CROUPS

TABLE 6

VARIABLES THAT CAUSE OR INCREASE THE RISK OF CAREGIVER VIOLENCE

10.3928/0098-9134-19990401-05

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