Dr. Robinson is Professor and Executive Director, Volunteer Caregivers Program, University of Louisville School of Nursing, Louisville, Kentucky; and Dr. Tappen is Christine E. Lynn Eminent Scholar and Professor, Florida Atlantic University, Christine E. Lynn College of Nursing, Boca Raton, Florida.
This paper was approved by the members of the American Academy of Nursing Expert Panel on Aging.
Address correspondence to Karen M. Robinson, DNS, APRN, BC, FAAN, Professor and Executive Director, Volunteer Caregivers Program, University of Louisville School of Nursing, HSC K Building, Room 3057, Louisville, KY 40292; e-mail: Kmrobi01@louisville.edu.
The problem of resident-to-resident and resident-to-staff violence in long-term care (LTC) facilities remains unaddressed by policy makers and administrators. Yet it is a source of constant anxiety and potential injury for staff and residents alike. Violence is the use of physical force with the potential of harming or actual harm to other individuals (World Health Organization, 2002). Violent behaviors may be defined as physical violence without bodily contact (e.g., threatening gestures) or physical violence with bodily contact (e.g., hitting, punching, kicking) (Lanza, Demaio, & Benedict, 2005). It is a category within the constellation of agitated behaviors, one of the behavioral and psychological symptoms evidenced in dementia and in other chronic mental health illnesses in LTC residents (Shah, Dalvi, & Thompson, 2005; Snowden, Sato, & Roy-Byrne, 2003). This article emphasizes the importance of understanding underlying causes of this behavior and the use of strategies to prevent aggressive behavior.
In an intervention study of 138 certified nursing assistants (CNAs), Gates, Fitzwater, and Succop (2005) reported that 71% had experienced a total of 624 assaults (defined as aggressive physical incidents with bodily contact) in a baseline period of 80 hours. The mean number of assaults for all CNAs was 4.52; the mean for those who were assaulted at least once was 6.64. The number of assaults per CNA during the baseline period ranged from 0 to 64, and the assaults resulted in 31 injuries among the total sample. The most common primary diagnosis for residents who had assaulted staff was dementia (87%). Cahill and Shapiro (1993) reported that 89% of CNAs had experienced some kind of aggression from residents, and 26% had encountered serious violence. The most common kinds of assault were hitting and punching (51%).
In a study of resident-to-resident violence in nursing homes, injured residents were more likely to exhibit symptoms of wandering, verbally or physically abusive behavior, socially inappropriate or disruptive behavior, and resistance to care. Some of the injured residents may have accidentally provoked an attack by entering another resident’s personal space (Shinoda-Tagawa et al., 2004). A study of 5,776 Medicare recipients with dementia suggested that combativeness occurs in 24% of Caucasian patients, 30% of African American patients, and 37% of Hispanic patients (Sink, Cournsky, Newcomer, & Yaffe, 2004). Caregivers reported the presence of unreasonable anger in 45% of Caucasian patients, 50% of African American patients, and 48% of Hispanic patients. The overall prevalence of disruptive agitated behaviors in this population was 92%, with a mean Mini-Mental State Examination score of 14 ± 8.8 (Sink et al., 2004).
Conditions for Resident Aggression Toward Staff
Each year, more than 12 million Americans receive formal long-term care in nursing homes. In 2001, nursing homes provided care for an average of 1.4 million residents each day (U.S. Department of Health and Human Services & U.S. Department of Labor, 2003). More than 54% of employees in nursing homes are RNs, licensed practical nurses (LPNs), and CNAs; this nurse workforce now exceeds 1.9 million individuals. The current shortage of nursing personnel in LTC is projected to increase by 45% between 2002 and 2012 (U.S. Department of Health and Human Services & U.S. Department of Labor, 2003). Complicating the nursing workforce shortage is a high rate of turnover in LTC. The nationwide average annual turnover rate is 49% for RNs and 71% for CNAs (National Commission on Nursing Workforce for Long-Term Care, 2005).
Demanding LTC environments provide the context for resident aggression. Residents, their families, and administration place multiple and simultaneous demands on direct care staff. In a study predicting risk of violence, working in a nursing home resulted in the greatest increased risk of physical violence among RNs and LPNs (Gerberich et al., 2004). Behavior management, including prevention and control of aggression, absorbs 5% of nurses’ work time and 3% of CNAs’ work time. However, the emotional effects of having sustained an injury or fearing the next outburst are far greater (Cardona, Tappen, Terrill, Acosta, & Eusebe, 1997). CNAs have the highest incidence of work-place assault among all workers (U.S. Department of Labor, Bureau of Labor Statistics, 2002) due to their intimate involvement with residents, frequent use of restraint strategies, lack of training, limited understanding of dementia or mental illness, and misperceptions about residents’ intent (Miller, 1996).
Several studies have described CNAs’ experiences with violence in nursing homes. CNAs often experience harassment, threats, and assaults from residents (Gates et al., 2005). However, the number of such assaults is probably seriously underestimated; studies indicate that 60% to 80% of aggressive incidents in nursing homes are unreported (Gates et al., 2005). A vicious cycle can occur when, in retaliation, such aggressive behavior results in staff-to-resident abuse. Aggressive residents are four times more likely to be abused by staff than are passive residents (Newbern, 1987). Because of the frequency of assaults on CNAs, staff often empathize with CNAs who retaliate, and formal incident reports are not filed (Dyer, Pavlik, Murphy, & Hyman, 2000). Empathy was stronger for CNA perpetrators in cases when other CNAs had also experienced abuse from a confused resident (Garner & Evans, 2000).
Gates et al. (2005) reported a significant relationship between CNA state and trait anger and resident assaults. State anger is an immediate, current reaction, and trait anger is experienced over time. Frustrated and fearful, CNAs’ voices might be louder and their movements rougher, causing residents to respond in an aggressive manner. A need exists for continued investigation into the influence of anger on repeat assaults following an initial assault.
Research on prevention of aggression in LTC suggests that behavioral treatment may reduce the severity of the behavioral disturbance, but not completely eliminate the behavior (Lichtenberg, Kemp-Havican, MacNeill, & Johnson, 2005; Sloane et al., 2004). Nonpharmacological interventions include sensory stimulation, physical activity, psychotherapy, behavior modification, and environmental enhancements. Although fewer in number, pharmacological studies also indicate some improvement in certain symptoms, but controversy persists about the use of drugs in preventing aggression (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003). More research is needed to compare pharmacological and nonpharmacological treatments and the potential synergistic effects of combining the two (Snowden et al., 2003). Results of nurse aide training studies have produced negative or mixed results. Snowden et al. (2003) suggest that aide training may be necessary, but insufficient, in preventing resident aggression.
Factors Contributing to Violence in LTC Settings
Both organic and psychosocial factors need to be considered in the identification of contributors to resident aggression (Kolanowski & Whall, 2000). Diseases of the brain affect certain regions and spare others, resulting in different patterns of behavior for different kinds of dementia. Frontotemporal dementia, for example, is pathologically distinct from other dementias and is clinically characterized by striking behavioral changes. Although some individuals appear apathetic, many others become hyperactive and disinhibited (Tallis & Fillit, 2002). Those with Lewy body dementia are similarly more likely to experience hallucinations, resulting in resistance to care that can escalate into combativeness (Volicer & Hurley, 2003). Physical distress such as fatigue, hunger, thirst, or pain may also precipitate aggressive behaviors (Kolanowski & Whall, 2000).
Psychosocial factors include both intrapersonal and interpersonal contributing causes as well as environmental triggers of aggression. Aggression may reflect a decreased ability to cope with frustration or ambiguity (Algase et al., 1996). People with dementia can become so anxious, upset, or threatened that they strike out to protect themselves. Ability to control their environment decreases as dependence increases, setting the stage for aggressive outbursts unless care is taken to reduce these triggers. In addition, psychotic symptoms (e.g., seeing nonexistent people, believing threatening events have occurred) are common mental health concerns that often go unrecognized in LTC settings.
The triggers of these behaviors also vary depending on context and residents’ interpretation of the situation (Shaw, 2004; Volicer & Hurley, 2003). For example, a resident may interpret receiving bath care as an attack by strangers and act aggressively for self-protection or to decrease embarrassment. Aggression tends to persist and become more severe over time. Most LTC facilities are not prepared to handle these serious mental health problems, which escalate if untreated. CNAs are not prepared to care for aggressive residents with dementia. How can this be changed? What policy options should be pursued?
Recruitment efforts can increase the supply of all levels of nurses and other mental health professionals who have geriatric training in LTC. Partnerships in LTC could help maintain ongoing recruitment initiatives to increase RNs in LTC settings. An example of such a partnership might be between a nursing school that provides continuing education, higher degrees, and credentialing and a LTC facility that provides incentives for staff to participate in the school’s programs.
Training and Support
Basic nursing assistant certification alone is not sufficient to equip CNAs to cope with aggressive residents. CNAs need experiential education about aggressive behaviors. Using role-play, with staff acting out verbal and physical aggression, is more realistic than traditional lecturing and encourages open discussion about feelings and the appropriateness of various management strategies. Management must prove commitment to training by rewarding employees’ involvement in training. Team leaders need to learn how to improve delegation and supervision. Effective training sessions need to include ancillary staff, supervisors, and managers.
Those who have experienced an assault also need support (Skovdahl, Kihlgren, & Kihlgren, 2003). Debriefing sessions are essential after an assault occurs. Small, long-term support groups may help staff cope with the experience and better prepare them for working with aggressive residents in the future (Lanza et al., 2005).
Current reimbursement levels for LTC, particularly for mental health services, are inadequate. Without sufficient reimbursement, facilities are unable to provide adequate staffing. Sufficient staffing is a strategy for decreasing the incidence of abuse by decreasing stress on CNAs. CNAs are more apt to deliver care in a rushed, rough, and hurried manner when assigned a large number of residents. A hurried approach is likely to cause residents to become more aggressive, thus increasing the risk of assault. When aggression occurs, even more time is required for care (Shaw, 2004). Application of new skills to prevent aggressive behavior (e.g., distraction, time-out, validation) requires a slower pace, and these skills are likely to be seen as impossible to carry out when CNAs have large assignments (Gates et al., 2005). The presence of more colleagues can also diffuse a situation because staff members feel less threatened. Implementation of these policies may help LTC facilities save money over time as the number of violent incidents decreases.
Develop ongoing funding from state and local credentialing and workforce boards to support LTC workforce recruitment and retention. Activities that increase retention include CNA training, development of career ladders, and expansion of continuing education for LTC employees. States might be encouraged to dedicate LTC civil money penalty funds to the support of programs to improve the LTC workforce. Orientation, educational preparation, and ongoing support of direct care staff must be addressed by nursing home administration to ensure staff are equipped to handle residents’ care needs.
Care providers need evidence-based guidelines with assessment recommendations that use validated measures (beyond the Minimum Data Set). Guidelines must include assessment for identification of contributing factors and effectiveness of behavioral and pharmacological interventions. In addition, resident-centered care that addresses the holistic needs of care recipients and strengthens the relationships between caregivers and residents must be facilitated. Individual nursing homes and other providers should transform nurse supervision in the workplace from the traditional punitive approach to a coaching and mentoring approach.
More research is needed to develop strategies to prevent and manage aggression in LTC settings, identify best practice methods, and educate LTC staff about aggression. Further study on the effects of physical aggression on LTC staff and on the effectiveness of strategies to better prepare them to handle aggression should be conducted. A focus on physical aggression as a distinct type of behavioral and psychological symptoms evidenced in dementia within a constellation of behavioral symptoms is also needed (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003). Investigation of both physiological and psychosocial contributing factors and their interaction, more accurate identification of triggers of aggression, and both pharmacological and behavioral interventions should be conducted to better inform care providers about the most effective and appropriate measures to undertake.
Using the above potential solutions as a guideline, the following steps are recommended to prevent violence in LTC facilities:
- Increase staff-to-resident ratios to decrease strain on LTC staff.
- Increase the supply of health care professionals in LTC with specialty training in mental health and dementia care.
- Require specific training about the causes, assessment, and management of resident violence for all direct care staff.
- Increase reimbursement levels for care of residents who display aggressive behavior.
- Develop evidence-based guidelines for assessment and management of aggressive behavior.
- Require facilities to have specific policies and procedures to be followed when an episode of violence occurs in LTC facilities.
- Conduct more research on the sources and effects of aggressive behavior in LTC settings and identify the most effective behavioral and pharmacological strategies to manage aggression.
Implications for Clinical Practice
Although it may take time to fully implement strategies to prevent violence in LTC settings, the first step, assessing both physiological and psychosocial factors contributing to resident aggression, can begin immediately. Because aggression tends to persist and become more severe over time, a greater number of risk factors suggests greater risk for violent behaviors. Nurses’ expertise in health promotion and illness prevention is a valuable part of the health team effort to prevent violence. Knowledge of the incidence of violence, conditions and factors contributing to violence, and potential solutions and recommendations on the prevention of violence can assist nurses in achieving better resident outcomes.
A culture change must begin by redesigning individual LTC facilities to be more resident and staff friendly (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003). A smaller, more homelike and caring environment is needed. Treatment of the care recipients’ underlying conditions must occur, whether for an organic dementing disease, psychosis, or anxiety. Leadership, resources, and infrastructure are required to implement major workplace culture and organizational change. It is imperative that the links between violence in LTC facilities and adverse outcomes, such as occupational strain, low job satisfaction, high staff turnover, anger, injury, and abuse, be adequately addressed. Policy makers need to understand that caring for LTC staff will result in better resident outcomes.
- Algase, DL, Beck, C, Kolanowski, A, Whall, A, Berent, S & Richards, K et al. . 1996. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer’s Disease and Other Dementias, 1111, 10–19. doi:10.1177/153331759601100603 [CrossRef]
- American Geriatrics Society, & American Association for Geriatric Psychiatry. 2003. Consensus statement on improving the quality of mental health care in U.S. nursing homes: Management of depression and behavioral symptoms associated with dementia. Journal of the American Geriatrics Society, 51, 1287–1298.
- Cahill, S & Shapiro, M. 1993. “I think he might have hit me once”: Aggression towards caregivers in dementia care”. Australian Journal of Aging, 124, 10–15.
- Cardona, P, Tappen, RM, Terrill, M, Acosta, M & Eusebe, MI. 1997. Nursing staff time allocation in long-term care. Journal of Nursing Administration, 272, 28–36. doi:10.1097/00005110-199702000-00007 [CrossRef]
- Dyer, CB, Pavlik, VN, Murphy, KP & Hyman, DJ. 2000. The high prevalence of depression and dementia in elder abuse and neglect. Journal of the American Geriatrics Society, 48, 205–208.
- Garner, J & Evans, S. 2000, June. Institutional abuse of older adults: Council report CR84. London, United Kingdom: Royal College of Psychiatrists.
- Gates, D, Fitzwater, E & Succop, P. 2005. Reducing assaults against nursing home caregivers. Nursing Research, 54, 119–127. doi:10.1097/00006199-200503000-00006 [CrossRef]
- Gerberich, SG, Church, TR, McGovern, PM, Hansen, HE, Nachreiner, NM & Geisser, MS et al. . 2004. An epidemiological study of the magnitude and consequences of work-related violence: The Minnesota Nurses’ Study. Occupational and Environmental Medicine, 61, 495–503. doi:10.1136/oem.2003.007294 [CrossRef]
- Kolanowski, A & Whall, AL. 2000. Toward holistic theory-based intervention for dementia behavior. Holistic Nursing Practice, 14, 67–76.
- Lanza, ML, Demaio, J & Benedict, MA. 2005. Patient assault support group: Achieving educational objectives. Issues in Mental Health Nursing, 26, 643–660. doi:10.1080/01612840590959524 [CrossRef]
- Lichtenberg, PA, Kemp-Havican, J, Mac-Neill, SE & Johnson, AS. 2005. Pilot study of behavioral treatment in dementia care units. The Gerontologist, 45, 405–410.
- Miller, M. 1996. Nursing staff responses to physically aggressive behavior in cognitively impaired institutionalized elderly: A qualitative study. Unpublished doctoral dissertation, University of Miami.
- National Commission on Nursing Work-force for Long-Term Care. 2005, April. Act now for your tomorrow: Final report. Retrieved October 27, 2005, from http://www.ahca.org/research/workforce_rpt_050519.pdf
- Newbern, VB. 1987. Caregiver perceptions of human abuse in health care settings. Holistic Nursing Practice, 1, 64–74.
- Shah, A, Dalvi, M & Thompson, T. 2005. Behavioural and psychological signs and symptoms of dementia across cultures: Current status and the future. International Journal of Geriatric Psychiatry, 20, 1187–1195. doi:10.1002/gps.1417 [CrossRef]
- Shaw, MM. 2004. Aggression toward staff by nursing home residents: Findings from a grounded theory. Journal of Gerontological Nursing, 3010, 43–54.
- Shinoda-Tagawa, T, Leonard, R, Pontikas, J, McDonough, JE, Allen, D & Dreyer, PI. 2004. Resident-to-resident violent incidents in nursing homes. Journal of the American Medical Association, 291, 591–598. doi:10.1001/jama.291.5.591 [CrossRef]
- Sink, KM, Cournsky, KE, Newcomer, R & Yaffe, K. 2004. Ethnic differences in the prevalence and pattern of dementia-related behaviors. Journal of the American Geriatrics Society, 52, 1277–1283. doi:10.1111/j.1532-5415.2004.52356.x [CrossRef]
- Skovdahl, K, Kihlgren, AL & Kihlgren, M. 2003. Different attitudes when handling aggressive behavior in dementia: Narratives from two caregiver groups. Aging & Mental Health, 7, 277–286. doi:10.1080/1360786031000120679 [CrossRef]
- Sloane, PD, Hoeffer, B, Mitchell, CM, McKenzie, DA, Barrick, AL & Rader, J et al. . 2004. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation and discomfort in nursing home residents with dementia: A randomized, controlled trial. Journal of the American Geriatrics Society, 52, 1795–1804. doi:10.1111/j.1532-5415.2004.52501.x [CrossRef]
- Snowden, M, Sato, K & Roy-Byrne, P. 2003. Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: A review of the literature. Journal of the American Geriatrics Society, 51, 1305–1317. doi:10.1046/j.1532-5415.2003.51417.x [CrossRef]
- Tallis, RC & Fillit, HM. (Eds.). 2002. Brocklehurst’s textbook of geriatric medicine and gerontology. Edinburgh, Scotland: Churchill Livingstone.
- U.S. Department of Health and Human Services, & U.S. Department of Labor. 2003, May. The future supply of long-term care workers in relation to the aging baby boom generation: Report to Congress. Washington, DC: Office of Disability, Aging and Long-Term Care Policy. Retrieved December 27, 2007, from http://aspe.hhs.gov/daltcp/reports/ltcwork.pdf
- US Department of Labor, Bureau of Labor Statistics. 2002. National census of fatal occupational injuries in 2001. Retrieved January 30, 2008, from http://bls.gov/iif/oshcfoi1.htm#19922992
- Volicer, L & Hurley, AC. 2003. Management of behavioral symptoms in progressive degenerative dementias. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 58A, 837–845.
- World Health Organization. 2002. World report on violence and health. Retrieved November 13, 2006, from http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf