Journal of Gerontological Nursing

AGGRESSION TOWARD STAFF By Nursing Home Residents: FINDINGS FROM A GROUNDED THEORY STUDY

Mary M Conlin Shaw, PhD, RN

Abstract

ABSTRACT

Aggressive behaviors by nursing home residents are common and can result in injury to both staff and residents. In addition, such aggressive behavior may lead to resident abuse by staff. This article describes a grounded theory study of nursing home staff response to aggressive residents and explores the problem of aggressive behaviors by nursing home residents, the conditions and context of aggression, and strategies staff use to prevent and manage aggression. To effectively deal with resident aggression, staff must become proactive, which involves three dynamic and interactive processes: practicing vigilance, intuiting, and strategizing. This article details these processes as well as the strategies staff use to deal with aggressive behaviors and makes specific recommendations for handling aggression toward staff.

Abstract

ABSTRACT

Aggressive behaviors by nursing home residents are common and can result in injury to both staff and residents. In addition, such aggressive behavior may lead to resident abuse by staff. This article describes a grounded theory study of nursing home staff response to aggressive residents and explores the problem of aggressive behaviors by nursing home residents, the conditions and context of aggression, and strategies staff use to prevent and manage aggression. To effectively deal with resident aggression, staff must become proactive, which involves three dynamic and interactive processes: practicing vigilance, intuiting, and strategizing. This article details these processes as well as the strategies staff use to deal with aggressive behaviors and makes specific recommendations for handling aggression toward staff.

Providing direct care to nursing home residents is physically and emotionally demanding. Aggressive behaviors by residents, particularly those directed at staff, are a significant problem in nursing homes (Bowers & Becker, 1992; Diamond, 1992; Lusk, 1992; TellisNayak & Tellis-Nayak, 1989). Staff injury by residents is a hidden aspect of nursing home life (Savishinsky, 1991) and represents a form of workplace violence that can result in lost work time and emotional distress (Jones, 1985; Lanza, 1985; Lusk, 1992; Meddaugh, 1987; Shaw 1997).

Aggressive nursing home residents are at risk for accidental injury as well as for abuse by staff (Shaw, 1998). The US. General Accounting Office (2002) indicated more can be done to protect the 1.5 million vulnerable adults living in nursing homes from abuse. Abuse of residents is a widespread and serious problem (U.S. House of Representatives, 2001), with aggressive residents being four times more likely to be abused by staff than passive residents (Newbern, 1987). Pillemer and Bachman-Prehn (1991) suggested maltreatment of residents was related to stressful working conditions and staff burnout.

Given the deleterious effects of resident aggression on staff and residents, it is important for those in positions to make changes in nursing homes to take action to prevent and manage residents' aggressive behaviors. Prevention and management of resident aggression can reduce injuries to residents and staff, improve quality of care, and enhance the quality of life for residents and staff (Shaw, 1997).

TERMINOLOGY

Terms such as aggressive and abusive as well as other terms common to nursing home staff such as combative, agitated, and resistive are used interchangeably throughout this article to describe injurious behaviors (physical or verbal) directed at staff by nursing home residents. The etiology of behaviors varies depending on the context of occurrence and residents' interpretation of the situation. For example, a resident may interpret incontinent care as an attack by strangers and act aggressively with the intent of selfprotection.

PURPOSE

The purpose of this article is to present original data that illustrate a "real world" view from the perspective of direct care staff of the conditions and context of resident aggression and practical strategies staff use to prevent and manage aggression. These data represent focused findings from the author's original work of developing a grounded theory explaining the response of direct care nursing home staff to aggression by residents (Shaw, 1997). The Figure represents the author's original grounded theory (Shaw, 1997), with shaded components representing the specific focus of this article.

METHODOLOGY

The research design of this study was exploratory, descriptive, and based on classic grounded theory analysis methods (Glaser & Strauss, 1967). Symbolic interactionism provided the theoretical framework and refers to distinctive social interactions among individuals in which they interpret and define others' actions based on the meaning they attach to these actions (Blumer, 1969).

Prior to data collection, approval was obtained from the university's Institutional Review Board and informed consent was obtained from participants. The quantitative concepts of sample size and power do not apply to qualitative methods such as grounded theory. Rather, scientific integrity is based on grounded theory standards of credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Consistent with these standards, purposive and theoretical sampling techniques (Glaser & Strauss, 1967) were used. To maximize exposure to a wide variety of data and reveal as many relevant categories as possible (purposive sampling), the initial sample consisted of interviews with nursing home staff who cared for aggressive residents.

In grounded theory analysis, researchers systematically apply methods to generate concepts and conceptual relationships that explain and interpret variations in behavior, most often behavior relating to processing a problem for study participants (Glaser, 1992). Beginning with the first interview, the constant comparative method of simultaneously collecting, coding, and analyzing data was used (Glaser & Strauss, 1967).

Table

TABLE 1INJURIES INCURRED BY STAFF IN 138 RECORDED INCIDENTS OF RESIDENT AGGRESSION FOR A 12-YEAR PERIOD IN ONE NURSING HOME

TABLE 1

INJURIES INCURRED BY STAFF IN 138 RECORDED INCIDENTS OF RESIDENT AGGRESSION FOR A 12-YEAR PERIOD IN ONE NURSING HOME

To develop the emerging theory, theoretical sampling was used. Theoretical sampling represents a data collection process whereby the researcher jointly codes and analyzes data, and then decides what data to collect next and from what source (Glaser & Strauss, 1967). Once the core variables (i.e., basic social problem and process) were discovered, selective sampling along the lines of the central issues of the emerging theory was used (Glaser, 1978). As standard in grounded theory, sample size was not predetermined, but continued to the point of data saturation or redundancy, when no new information surfaced from newly sampled units (Lincoln & Guba, 1985).

Data included hundreds of pages of transcribed semi-structured interviews with 15 nursing home staff (9 nursing assistants, 3 registered nurses, and 3 nursing home administrative staff) from 6 facilities (3 federal government and 3 for-profit private facilities) with 90 to 168 beds in a 300mile area and 6 investigators from one district of the state Adult Protective Services (APS) agency. The response of nursing home staff was the focus of this research, not the nursing home facilities. Staff were selected from nursing homes in a large geographic area and in which the nursing home administrator allowed the researcher access. All of the nursing homes provided rehabilitation care, and most provided custodial and skilled care, with the exception of one private facility that did not provide custodial care and one government facility that did not provide skilled care.

All except two interviews were tape-recorded, transcribed, and coded line by line. One nursing assistant and one APS worker did not want to be tape-recorded, so research notes were taken during these two interviews. Additional data from one facility included incident reports, workers' compensation applications, and incident logs detailing 138 episodes of physical assaults against staff during a 12-year period.

All of the nursing assistant participants were certified. Eighty-nine percent were women, and 70% represented racial minorities (59% Black and 11% Hispanic). All had a high school education and 37% had some college education. The average length of time participants worked as a nursing assistant was 12.2 years (range, 2.5 to 20 years); the average length of time the nursing assistants were employed at their current facility was 7.5 months. The nursing assistants cared for an average of 10 residents per day (range, 6 to 15). All but one nursing assistant rotated shifts and 75% rotated units.

All data were initially coded line by line using open coding to fracture data into as many categories as possible until a core category emerged. When core categories emerged, theoretical coding was used (Glaser, 1992) to provide conceptual connectors to weave the fractured data together. This generated conceptual relationships between emerging categories and their properties. By comparing data as they were collected, increasingly abstract levels of theoretical connections were created, and theory was gradually and inductively built up from the progressive stages of data analysis (Glaser, 1978). The Figure illustrates the grounded theory developed from the original study data (Shaw, 1997) and provides the conceptual framework for discussing the following original research findings.

FINDINGS

Types and Consequences of Residents' Aggressive Behaviors Toward Staff

Almost daily, direct care staff experienced residents' aggressive behaviors that ranged from verbal threats and taunts to physical assaults. Some felt the aggressive behavior was almost continuous. One nurse commented:

There is probably a little bit of abuse going on all the time by these patients, whether it be verbal, manipulative behavior, sexual inappropriateness, or whatever.

Staff frequently reported and documented incidents of physical aggression and were surprised by its various manifestations. One nursing assistant said residents sometimes would do something that "you never would think they would do," such as throwing whatever was "the first thing in their hand...their urinal, feces."

Examples of physically aggressive behavior included direct assaults by punching, slapping, kicking, pinching, or throwing things. Staff sometimes incurred injuries severe enough to require medical attention or time off from work. Table 1 summarizes injuries incurred by staff for 138 recorded incidents of resident aggression for a 12-year period in one facility.

Threats often accompanied physical aggression. One nurse described an incident that occurred in a small bathroom while she was assisting a resident. At the time, she was 8 or 9 months pregnant, and the resident threatened to kick her in the stomach. The nurse was able to move out of the way, but she noted the incident "really scared me."

Verbal aggression, although frequent, was not routinely documented. Much of the verbal abuse consisted of "vile, insulting, and personal" remarks and racial slurs. Other verbal behaviors included swearing, constant yelling, threats to hurt staff, and false accusations of improper care or treatment.

The constant nature of verbal abuse troubled some staff more than physical abuse. One nurse described the constant verbal abuse as being the "worst problem" that "you just hear on and on...just constantly."

Context of Resident Aggression: Demanding Nursing Home Environment

The demanding nursing home environment provided the context for aggression toward staff. Residents, their families, and administration placed multiple and simultaneous demands on direct care staff. They expected staff to meet these demands despite residents' behavioral problems and staffing shortages. This created an atmosphere in which residents' care was often rushed and limited to the task at hand.

Staff, particularly nursing assistants, who did not rush or who delayed resident care sometimes faced complaints from families and administration. There were no easy solutions because both staff and residents faced injury if care was forced on agitated residents. One nursing assistant described the demands of her work:

You have one family.. ."Dad needs to go to the bath. "...[a] resident..."I need the nurse." It's like, I'm one person, hold on! When they ask you, they want you then. It's not enough bodies for the residents that are here. I don't see it, the staffing. If you don't have enough staffing, the family gets mad, the residents get mad. It's just not enough. So, somebody is going to be unhappy. They are just going to have to wait.

Staff related a sense of nonsupport from the administration who expected them to care for aggressive residents and deal with aggressive behaviors as "just part of the job." One nursing assistant said she was ordered to bathe a combative resident and was told "to go in and take it." She noted:

No matter how much they hit and scratch at you, you've got to give them a bath. They will be fighting, but we still have to do it.

Lack of administrative support and meeting demands to care for aggressive residents sometimes resulted in dire consequences. One nursing assistant described a nurse's demands to get a patient up and the consequences of doing so:

I've got to do it because if I don't, she's going to jump all over me... You end up trying to force them to dress or trying to force them into a shirt. They are real combatant and you end up dislocating a shoulder. That nurse will say, "Well, you know better. I didn't tell you to do that." They are not going to back you.

In some instances, administrators suggested staff pair up and not rush care with aggressive residents. However, direct care staff found it difficult to modify approaches because of heavy workloads and lack of sufficient staff. They struggled to complete their work and dealt with circumstances "the best" they could.

Conditions for Nursing Home Resident Aggression Toward Staff

Aggression toward staff occurred in a variety of situations. Some aggression toward staff was the result of personalities and prejudices (i.e., race, size, physical appearance). According to staff, not explaining care before providing it, looking at residents the wrong way, and withdrawing attention from residents sometimes provoked aggression. No particular diagnosis assured aggressive behavior, although staff identified residents with dementia, head injuries, and psychiatric disorders as being combative and difficult.

Staff indicated that when staff and residents knew each other and had a relationship, there were fewer problems with aggression. Staff knew which residents were potentially aggressive and noted residents responded differently to different staff and on different shifts. Some aggressive residents were simply offensive individuals acting in accord with their basic personality and life patterns. More often, however, aggression toward staff occurred when residents resisted care because they were fearful and overwhelmed, and staff invaded their personal space.

Residents' fear and being overwhelmed with care. Conditions for resident aggression included residents feeling afraid and being overwhelmed with care (Shaw, 1997). Residents' interpretation of their care was influenced by their cognitive, emotional, and sensory status (especially sight and hearing) and staff's approach to care. When residents interpreted care as dangerous or threatening, they became fearful and overwhelmed, and sometimes aggressively resisted care to protect themselves.

Staff described a maladaptive care strategy they called "bulldozing" in which two or more staff teamed up to care for combative residents. This show of force induced fear and panic in residents and caused them to become more combative. One nurse described bulldozing as:

Two at a time, sometimes four, making that person do what they want him to do. Turning and transferring them... shifting, moving, the person screaming the whole time.

Bulldozing places both staff and residents at risk for physical injuries. An administrator described such an incident when he, a nurse, and several nursing assistants went into a resident's room just after the resident hit a nursing assistant:

We tried to hold her to give her [an] intramuscular injection to calm her. I was holding her feet pretty tight...The foot let go. She kicked me in the chin.

Improper timing and pacing of care also contributed to resident aggression. Rushing care, approaching residents too quickly, and forcing care against residents' will increased the potential for aggressive behaviors. When staffing was insufficient, it became difficult or impossible for staff to properly time and pace activities and avoid rushing care. An administrator illustrated these key points when he described a resident assault that left one nursing assistant bruised and swollen, and in need of medical attention and time off from work:

She [the nursing assistant] knew she had accosted a resident too fast. The resident got very defensive. She knew that die resident could be physical. The resident's call light had been on. We were short on the floor, so she went at it fast. The resident was half asleep and dazed. I guess the nursing assistant startled the resident and [the] reaction of this resident was to hit her.

Close proximity and invasion of personal space. Another condition for resident aggression was close physical proximity, especially when providing personal care. Staff risked injury from residents when they worked in tight spaces or in close personal contact. One administrator described some of these various conditions contributing to aggressive behaviors:

Not knowing the resident and really approaching them too fast... because they have a lot of work duty. They want to do a good job but they have got to do it as fast as possible because maybe two other residents have the same needs. . . A lot [of residents] have a tendency to be defensive when their space is invaded. They slap out, bite, scratch, whatever. So, that's been the case, they've been just too fast up front and face to face.

Staff clearly risked injury when they invaded residents' body space during personal care activities such as dressing, showering, and providing incontinent care. These findings are consistent with others who found most aggressive episodes occurred on the day shift while dressing, changing, and bathing residents (Hagen & Sayers, 1995) or during intrusion into personal space (Bridges-Parlet, Knopman, & Thompson, 1994). Invading residents' body space during personal care created a panic response in some residents, and in resisting, nursing home residents may have been defending themselves against what they perceived as a personal assault (Wunderlich, Sloan, & Davis, 1996).

Becoming Proactive: A Process to Manage Nursing Home Resident Aggression

To prevent and manage resident aggression, staff must become proactive. Becoming proactive is defined as a process by which staff learn to anticipate and act in advance to deal with expected problems, rather than impulsively reacting when problems arise. The concept of becoming proactive, its definition, and three interactive and dynamic subphases - practicing vigilance, intuiting, and strategizing -emerged from an analysis of the original study data (Shaw, 1997).

Practicing vigilance. Staff practiced vigilance to protect themselves from resident aggression. Practicing vigilance involved being continually on guard and alert for verbal and nonverbal behaviors that indicated possible resident aggression (Shaw, 1997). One nursing assistant compared practicing vigilance to "universal precautions" in that you "expect the unexpected."

Staff learned to practice vigilance as they were socialized into the nursing home. Experience with aggressive residents taught staff to practice vigilance and act to avoid further incidents. One nursing assistant learned to practice vigilance after she was "knocked" on her head by a resident and "saw stars." From that incident, the nursing assistant said she learned a lesson and that when she noted a resident was agitated and bothered, she would not go close enough for the resident to hit her.

Because aggressive behaviors were not always predictable, staff needed to practice and maintain vigilance. One administrator said staff were surprised that residents had the strength and ability "to ball up their fist and to cold cock them," adding that the staff would say, "I knew better. I wasn't paying attention and they got me."

Staff who did not practice and maintain vigilance placed themselves and residents at risk of injury. Inexperienced staff did not know to watch for aggressive behaviors and failed to practice vigilance. Additionally, data indicated that distraction due to an excessive workload, family problems, financial difficulties, or other home and work pressures contributed to staff's lack of vigilance, which sometimes led to staff and resident injury.

Intuiting. As staff gained experience with aggressive residents and learned to practice vigilance, they developed an ability to intuitively know about residents' behaviors. Intuiting (Shaw, 1997) is knowing, sensing, gaining insights, and forming judgments about something not clearly evident. It is an internal "gut" sense of what is going on that does not come from logical reasoning. Staff's intuiting abilities focused on timing, people, and behaviors.

Some staff intuitively knew the best person and time to provide residents' care. By intuiting residents' behaviors, staff could avoid situations that placed residents or themselves at risk of injury. One nursing assistant illustrated intuiting behavior and timing when she spoke about a resident who sometimes hit staff. This nursing assistant cautioned new staff to "move out the way" and not to provide care if the resident cocked her arm. Intuiting helped staff prevent injuries by planning and providing care in ways that did not overwhelm and frighten residents.

Strategizing. Direct care staff developed and implemented care strategies using a dynamic process that flowed from intuiting and practicing vigilance. Two basic categories of strategies that emerged from the data (Shaw, 1997) were resident care and self-care strategies.

Resident care strategies used by staff included calming and fear-reducing, time and pace-altering, and distancing strategies (Table 2).

* Calming and fear-reducing strategies. Residents' perceptions and responses to care were partially determined by staff's approach to care. A calm and unhurried approach was an important general strategy. Knowing residents, respecting residents' need for control, and using spirituality were key components of calming and fear-reducing strategies. Staff used a variety of specific strategies to calm residents and were aware that a successful strategy might not work at a different time or on another shift with the same resident or another resident in a similar situation.

Staff emphasized the importance of developing relationships with residents so they got to know each other and connected as individuals. Staff indicated fewer problems with aggression and care in general when staff and residents were accustomed to each other and aware of each other's needs. Direct care staff understood that spending time with residents in leisure and social activities (i.e., talking, reminiscing, watching television) was important in building relationships and could help calm residents, thereby preventing aggression. One nursing assistant said patients needed "TLC [tender loving care]" and did "better if you can sit down and talk to each one of them gently," but noted that "you don't have time to do all of that because you have work to do."

Staff recognized anger, fear, and disruptive and aggressive behaviors sometimes resulted when residents, particularly those who were cognitively aware, felt a lack of control. In this situation, staff implemented strategies such as bargaining, bribing, negotiating, and letting the resident "win." Some staff respected the residents' right to refuse care, but only when they believed residents were capable of understanding the impact of their decision.

Staff also used spiritual interventions (e.g., prayer) combined with strategies such as singing to calm residents. One nursing assistant noted that she often prayed silendy for her patients and that when she had trouble calming residents down, she sometimes sang, which served to "calm down" the residents.

Table

TABLE 2RESIDENT CARE STRATEGIES USED BY NURSING HOME STAFF TO PREVENT AND MANAGE AGGRESSION

TABLE 2

RESIDENT CARE STRATEGIES USED BY NURSING HOME STAFF TO PREVENT AND MANAGE AGGRESSION

Staff seldom mentioned medicating residents as a calming strategy. Only administrative staff mentioned mechanical restraints.

* Time and pace-altering strategies. Improper timing and pacing of care contributed to residents feeling angry, fearful, and overwhelmed with care, and ultimately to resident aggression. Staff strategized to properly time and pace care delivery. Staff and nursing home administrators noted the importance of backing off from care and allowing residents to calm down. One nursing assistant noted backing off was the only technique that worked with "biters and spitters."

Table

TABLE 3SELF-CARE STRATEGIES USED BY NURSING HOME STAFF TO DEAL WITH AGGRESSION

TABLE 3

SELF-CARE STRATEGIES USED BY NURSING HOME STAFF TO DEAL WITH AGGRESSION

Staff sometimes used residents' memory loss to their advantage. One nursing assistant described a strategy she used for a resident who became angry during bathing and who "just didn't want to see me any more that day." The nursing assistant would bathe the resident at the end of her shift; by the next day, the resident had forgotten the episode and the nursing assistant could again provide care.

When staffing was inadequate, staff rushed care and did not have time to talk with and calm residents. Aggression sometimes resulted. Once aggression occurred, residents required even more time for care, leaving staff without enough time to complete their work. Staff continually felt pressured because they had "so much to do," yet they tried to keep residents from feeling "rushed."

* Distancing strategies. Staff frequently strategized to put physical distance between themselves and residents, thereby avoiding being close enough for residents to physically injure them. Staff knew that being physically close to aggressive residents, as in providing personal care, also put them at risk of injury.

One nurse described a strategy she developed to mmimize close contact time with a demented resident known to injure staff by biting, hitting, and kicking. She substituted sweatpants, stretch shirts, and hospital gowns for his button-down shirts, zip-up pants, and pajamas, thereby decreasing the amount of staff contact with the patient and lowering the risk of injury to staff. Another nurse noted that when caring for resistive and cognitively impaired residents, being ready was important. She learned how to perform care with one hand and use her other hand to either hold the resident's arm or protect her face.

Staff members distanced themselves from verbal abuse by ignoring or avoiding conversations with verbally abusive residents, drowning it out, or closing the door on it. One nurse said she would turn up the volume on the television or radio, noting that often "the patient cannot compete and sometimes they quiet or they just stop."

In addition to resident care strategies, staff used self-care strategies with aggressive residents. Major selfcare strategies that emerged from the data included switching, pairing up, taking time-out, and covering strategies (Table 3).

* Switching. Switching involved exchanging resident care assignments with other staff. Staff used switching when they felt that they could not care for a particular resident on a given day or that another staff person would get along better with the resident, thereby making it "easier on the patient and yourself."

* Pairing up. Nursing home staff worked in pairs to protect themselves from injury by aggressive residents as well as from false accusations of resident abuse or poor care. One nursing assistant noted it was "best to have a second person" when providing care so that "if the patient tried to say you did something to him, you would have a witness."

* Time-out. Staff sometimes felt angry and upset when caring for aggressive residents. Taking "timeout" by going to the break room or walking outside for a few minutes gave staff and residents time to calm down. In such instances, if staff are unable to calm down, they may react and abuse residents (Shaw, 1998). However, taking time-out was difficult or impossible when staffing was short or when supervisors did not allow it.

* Covering. Staff, particularly nursing assistants, invested considerable time and energy in "covering strategies" to protect themselves from accusations of injuring residents or not providing proper care. Covering strategies involved passing information to nurses, administrators, residents' families, and physicians. Some nursing assistants set up complex systems of checks and balances to assure the information they passed on was recorded properly, such as telling more than one person so they would be "covered" should someone "forget."

DISCUSSION AND RECOMMENDATIONS

Nursing home staff frequently encounter verbal and physical aggression from residents. Not uncommonly, these encounters result in emotional pain, physical injuries, need for medical attention, and lost work time.

Work in nursing homes is demanding. Administrators, nurses, and residents and their families place multiple demands on direct care staff. Insufficient numbers of available staff and the expectations of administrators and others that staff must tolerate abuse by aggressive residents as "part of their job" compound the stress for staff.

Aggression commonly occurs when residents become fearful and overwhelmed with care and when staff invade residents' personal space. Factors contributing to resident aggression include the types of and approaches to care by staff (including the timing and pacing of care) and residents' interpretation of their care.

Orientation, educational preparation, and ongoing support of direct care staff must be addressed by nursing home administration to assure staff are equipped to handle residents' care needs. Study participants made it clear that nursing assistant certification training was insufficient to equip nursing assistants with the ability to deal with nursing home demands, particularly aggressive and abusive residents.

Nursing assistants need experiential education, reaching beyond basic certification requirements, about aggressive and resistive behaviors. Working with experienced and expert peers is one way of providing education beyond the basics. Assigning nursing assistants as "peer educators" or "senior nursing assistant instructors" would provide new and less experienced staff with much needed peer orientation and mentoring, assist them in becoming socialized to the nursing home, and help them learn to become proactive. Additionally, it also provides a means to recognize senior staff for their knowledge and accomplishments.

Role play is cited in the literature as a successful means to reduce nursing home resident aggression and abuse of residents by staff (Hagen & Sayers, 1995; Pillemer & Hudson, 1993). Using explicit role play where staff act out verbal and physical aggression is more realistic than traditional methods, brings education from a verbal-conceptual to a physical-experiential level, and encourages open discussion about participants' feelings and coping strategies. In addition, stress and anger management strategies, relaxation techniques, and specific strategies to deal with aggressive residents should be part of ongoing staff education. This may help staff care for aggressive residents and avoid committing reactive acts of abuse against residents (Shaw, 1998).

Sufficient staffing may allow staff more opportunities to avoid key conditions for resident aggression. They could better time and pace care so as to avoid forcing, rushing, or neglecting care. Inadequate numbers of staff contributed to poor care, resident aggression toward staff, staff neglect of residents, and sometimes to resident abuse by staff (Shaw, 1997),

Developing relationships between residents and staff so that at a minimum they knew each other and what to expect from each other was key to preventing and managing aggressive behavior in nursing homes (Shaw, 1997). For the participants in this study, knowing residents clearly helped them provide care and develop strategies to prevent and manage behavioral problems.

Although administrators and nursing home corporations often acknowledge the importance of relationship-building and quality of life for nursing home residents, they do not support this with the necessary fiscal and human resources. In general, nursing home administrators determine and provide staffing based on the minimum requirements mandated by regulatory agencies for their case mix of residents. In reality, staffing levels in nursing homes are not always sufficient to guarantee that even basic care is well done, much less allow for relationship building (Foner, 1994; Kayser-Jones & Schell, 1997; Wunderlich et al., 1996).

The National Citizens' Coalition for Nursing Home Reform (2001) noted that in 2000, the Health Care Financing Administration issued a report showing less than half of the nation's 16,000 nursing homes have enough nursing assistants to avoid harm to residents. Additionally, adequate staffing based on expertdefined clinical dimensions of care may not capture the dimensions of care that constitute quality for nursing home residents (Bowers, Fibich, & Jacobson, 2001). For example, some residents viewed quality care in terms of the relationships they had with direct caregivers rather than on the technical aspects of care (Bowers et al., 2001).

As Diamond (1992) noted, most of the work in nursing homes goes unrecorded in charts, and building relationships and just being present does not fit with the industrial mode of productivity. The nursing home industry generally resists recommendations for increased staffing, citing fiscal concerns. Government, which funds a majority of nursing home care, holds these same concerns (Mass, Buckwalter, & Specht, 1996) and has been slow to require increased staffing despite recognizing the need for more nursing home staff.

FUTURE DIRECTIONS

The findings presented in this article and the theory developed from the original research (Shaw, 1997) present a basis for the development of further research, particularly quantitative studies, by those interested in the important issues related to aggression in nursing homes. Future researchers and others may want to consider the following moral and ethical questions that surfaced during data collection and analysis:

* Should nursing home residents ever be in a situation where they feel afraid and overwhelmed because their care was rushed, forced, or neglected as the result of short staffing?

* Should nursing home staff be expected to endure physical and verbal abuse and risk injury as "just part of the job?"

* How do the values healthcare institutions and society place on efficiency and profit affect the quality of life for nursing home residents and those who care for them?

More research is needed to develop approaches to prevent and manage aggression in nursing homes, to identify the best methods to educate and use nursing home staff, and to understand nursing home life from the residents' perspective. Any future research and workable interventions will be tempered by the deeper issue of how much we, as a society, value the lives and well-being of those who live and work in nursing homes.

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TABLE 1

INJURIES INCURRED BY STAFF IN 138 RECORDED INCIDENTS OF RESIDENT AGGRESSION FOR A 12-YEAR PERIOD IN ONE NURSING HOME

TABLE 2

RESIDENT CARE STRATEGIES USED BY NURSING HOME STAFF TO PREVENT AND MANAGE AGGRESSION

TABLE 3

SELF-CARE STRATEGIES USED BY NURSING HOME STAFF TO DEAL WITH AGGRESSION

10.3928/0098-9134-20041001-11

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