Journal of General Internal Medicine

, Volume 28, Issue 5, pp 660–667

Verbal and Physical Aggression Directed at Nursing Home Staff by Residents

  • Mark S. Lachs
  • Tony Rosen
  • Jeanne A. Teresi
  • Joseph P. Eimicke
  • Mildred Ramirez
  • Stephanie Silver
  • Karl Pillemer
Original Research

Abstract

Context

Little research has been conducted on aggression directed at staff by nursing home residents.

Objective

To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.

Design

Prevalent cohort study.

Setting

Large urban nursing homes.

Participants

Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.

Main Outcome Measures

Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.

Results

The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).

Conclusion

Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.

KEY WORDS

nursing home dementia-related behaviors elder abuse staff mistreatment 

References

  1. 1.
    Hawes C. Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed? Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. In: Bonnie RJ, Wallace RB, eds. The National Academies Press; 2003.Google Scholar
  2. 2.
    Kusserow RP. Resident abuse in nursing homes: understanding and preventing abuse. Office of the Inspector General; 1990 Apr. 62p. Report No.: OEI-06-88-00360. https://oig.hhs.gov/oei/reports/oei-06-88-00360.pdf
  3. 3.
    McCarthy M. Report finds abuse in US nursing homes goes unreported and unpunished. Lancet. 2002;359:860.PubMedCrossRefGoogle Scholar
  4. 4.
    Harrington VL. Nursing home abuse: the tragedy continues. Nurs Forum. 1984;21:102–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Hirst SP. Resident abuse: an insider’s perspective. Geriatr Nurs. 2000;21:38–42.PubMedCrossRefGoogle Scholar
  6. 6.
    Hirst SP. Defining resident abuse within the culture of long-term care institutions. Clin Nurs Res. 2002;11:267–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Pillemer K, Moore DW. Abuse of patients in nursing homes: findings from a survey of staff. Gerontologist. 1989;29:314–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Schiamberg LB, Oehmke J, Zhang Z, et al. Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. J Elder Abuse Negl. 2012;24:65–83.PubMedCrossRefGoogle Scholar
  9. 9.
    Shinan-Altman S, Cohen M. Nursing aides’ attitudes to elder abuse in nursing homes: the effect of work stressors and burnout. Gerontologist. 2009;49:674–84.PubMedCrossRefGoogle Scholar
  10. 10.
    Wang JJ. Psychological abuse behavior exhibited by caregivers in the care of the elderly and correlated factors in long-term care facilities in Taiwan. J Nurs Res. 2005;13:271–80.PubMedCrossRefGoogle Scholar
  11. 11.
    Wierucka D, Goodridge D. Vulnerable in a safe place: institutional elder abuse. Can J Nurs Adm. 1996;9:82–104.PubMedGoogle Scholar
  12. 12.
    Payne B, Cikovic R. An empirical examination of the characteristics, consequences, and causes of elder abuse in nursing homes. J Elder Abus Negl. 1995;7:61–74.CrossRefGoogle Scholar
  13. 13.
    Hawes C, Mor V, Phillips CD, et al. The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality. J Am Geriatr Soc. 1997;45:977–85.PubMedGoogle Scholar
  14. 14.
    Humane and compassionate elder care as a human right. Lancet. 2007;370:629. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61311-7/fulltext
  15. 15.
    Huber R, Borders K, Netting FE, Nelson HW. Data from long-term care ombudsman programs in six states: the implications of collecting resident demographics. Gerontologist. 2001;41:61–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Huber R, Netting FEK, Kautz JR 3rd. Differences in types of complaints and how they were resolved by local long-term care ombudsmen operating in/not in area agencies on aging. J Applied Geront. 1996;15:87–101.CrossRefGoogle Scholar
  17. 17.
    Litwin H, Monk A. Do nursing home patient ombudsmen make a difference? J Gerontol Soc Work. 1987;11:95–104.CrossRefGoogle Scholar
  18. 18.
    Bharucha AJ, London AJ, Barnard D, Wactlar H, Dew MA, Reynolds CF 3rd. Ethical considerations in the conduct of electronic surveillance research. J Law Med Ethics. 2006;34:611–9. 482.PubMedCrossRefGoogle Scholar
  19. 19.
    Carlson EM. Videotaping to protect nursing facility residents: a legal analysis. J Am Med Dir Assoc. 2001;2:41–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Galloro V. Watching out for nursing home residents. Cameras could help curb abuse but others argue they invade patient privacy. Mod Healthc. 2001;31:24–6.Google Scholar
  21. 21.
    Vickery K. Long-term care wrestles with ‘granny cams’. Provider. 2002;28:20–1.PubMedGoogle Scholar
  22. 22.
    Brown T. Feeling strain when violent patients need care. The New York Times [Internet] 2012 January 30. 18 paragraphs. http://well.blogs.nytimes.com/2012/01/30/feeling-strain-when-violent-patients-need-care/
  23. 23.
    2011 ANA health & safety survey: hazards of the RN work environment. [Internet] American Nurses Association; 2011. [Cited October 17, 2012], at http://nursingworld.org/2011HealthSurveyResults.aspx.
  24. 24.
    Gates DM, Fitzwater E, Meyer U. Violence against caregivers in nursing homes. Expected, tolerated, and accepted. J Gerontol Nurs. 1999;25:12–22.PubMedGoogle Scholar
  25. 25.
    Zeller A, Hahn S, Needham I, Kok G, Dassen T, Halfens RJ. Aggressive behavior of nursing home residents toward caregivers: a systematic literature review. Geriatr Nurs. 2009;30:174–87.PubMedCrossRefGoogle Scholar
  26. 26.
    Astrom S, Karlsson S, Sandvide A, et al. Staff’s experience of and the management of violent incidents in elderly care. Scand J Caring Sci. 2004;18:410–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Pulsford D, Duxbury J. Aggressive behaviour by people with dementia in residential care settings: a review. J Psychiatr Ment Health Nurs. 2006;13:611–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Isaksson U, Graneheim UH, Astrom S. Female caregivers’ experiences of exposure to violence in nursing homes. J Psychiatr Ment Health Nurs. 2009;16:46–53.PubMedCrossRefGoogle Scholar
  29. 29.
    Kristiansen L, Hellzen O, Asplund K. Swedish assistant nurses’ experiences of job satisfaction when caring for persons suffering from dementia and behavioral disturbances. An interview study. Int J Qual Stud Health Well-Being. 2006;1:245–56.CrossRefGoogle Scholar
  30. 30.
    Gates D, Fitzwater E, Succop P. Relationships of stressors, strain, and anger to caregiver assaults. Issues Ment Health Nurs. 2003;24:775–93.PubMedGoogle Scholar
  31. 31.
    Sandvide A, Astrom S, Norberg A, Saveman BI. Violence in institutional care for elderly people from the perspective of involved care providers. Scand J Caring Sci. 2004;18:351–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Rosen T, Lachs MS, Bharucha AJ, et al. Resident-to-resident aggression in long-term care facilities: insights from focus groups of nursing home residents and staff. J Am Geriatr Soc. 2008;56:1398–408.PubMedCrossRefGoogle Scholar
  33. 33.
    Teresi J, Holmes D, Benenson E, et al. A primary care nursing model in long-term care facilities: evaluation of impact on affect, behavior, and socialization. Gerontologist. 1993;33:667–74.PubMedCrossRefGoogle Scholar
  34. 34.
    Helmes E, Csapo KG, Short JA. Standardization and validation of the Multidimensional Observation Scale for Elderly Subjects (MOSES). J Gerontol. 1987;42:395–405.PubMedCrossRefGoogle Scholar
  35. 35.
    Toner J, Teresi J, Gurland BJ, Tirumalasetti F. The Feeling Tone Questionnaire: reliability and validity of a direct patient assessment screening instrument for detection of depressive symptoms in cases of dementia. J Clin Geropsychiatry. 1999;5:63–78.CrossRefGoogle Scholar
  36. 36.
    Kuriansky J, Gurland B. The performance test of activities of daily living. Int J Aging Human Dev. 1976;7:343–52.CrossRefGoogle Scholar
  37. 37.
    Petkova E, Teresi J. Some statistical issues in the analyses of data from longitudinal, intervention studies of elderly chronic care populations. J Psychosom Res. 2002;64:531–47.Google Scholar
  38. 38.
    Gurland BJ, Wilder D, Cross P, Teresi J, Barrett VW. Screening scales for dementia: toward reconciliation of cross-cultural findings. Int J Geriatr Psychiatry. 1992;7:105–13.CrossRefGoogle Scholar
  39. 39.
    Teresi JA, Kleinman M, Ocepek-Welikson K, et al. Applications of item response theory to the examination of the psychometric properties and differential item functioning of the CARE Dementia Diagnostic Scale among samples of Latino, African-American and White non-Latino Elderly. Res Aging. 2000;22:738–73.CrossRefGoogle Scholar
  40. 40.
    Ramirez M, Teresi JA, Holmes D, Gurland B, Lantigua R. Differential item functioning (DIF) and the Mini-Mental State Examination (MMSE). Overview, sample, and issues of translation. Med Care. 2006;44:S95–S106.PubMedCrossRefGoogle Scholar
  41. 41.
    Teresi JA. Mini-Mental State Examination (MMSE): scaling the MMSE using item response theory (IRT). J Clin Epidemiol. 2007;60:256–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Almvik R, Rasmussen K, Woods P. Challenging behaviour in the elderly-monitoring violent incidents. Int J Geriatr Psychiatry. 2006;21:368–74.PubMedCrossRefGoogle Scholar
  43. 43.
    Bowie CR, Moriarty PJ, Harvey PD, Parrella M, White L, Davis KL. Aggression in elderly schizophrenia patients: a comparison of nursing home and state hospital residents. J Neuropsychiatry Clin Neurosci. 2001;13:357–66.PubMedCrossRefGoogle Scholar
  44. 44.
    Gruber-Baldini AL, Boustani M, Sloane PD, Zimmerman S. Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management. J Am Geriatr Soc. 2004;52:1610–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Leger JM, Moulias R, Robert P, et al. Agitation and aggressiveness among the elderly population living in nursing or retirement homes in France. Int Psychogeriatr. 2002;14:405–16.PubMedCrossRefGoogle Scholar
  46. 46.
    Morgan DG, Stewart NJ, D’Arcy C, Forbes D, Lawson J. Work stress and physical assault of nursing aides in rural nursing homes with and without dementia special care units. J Psychiatr Ment Health Nurs. 2005;12:347–58.PubMedCrossRefGoogle Scholar
  47. 47.
    Schreiner AS. Aggressive behaviors among demented nursing home residents in Japan. Int J Geriatr Psychiatry. 2001;16:209–15.PubMedCrossRefGoogle Scholar
  48. 48.
    Somboontanont W, Sloane PD, Floyd FJ, Holditch-Davis D, Hogue CC, Mitchell CM. Assaultive behavior in Alzheimer’s disease: identifying immediate antecedents during bathing. J Gerontol Nurs. 2004;30:22–9. quiz 55–6.PubMedGoogle Scholar
  49. 49.
    Voyer P, Verreault R, Azizah GM, Desrosiers J, Champoux N, Bedard A. Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities. BMC Geriatr. 2005;5:13.PubMedCrossRefGoogle Scholar
  50. 50.
    Farrell Miller M. Physical aggressive resident behavior during hygienic care. J Gerontol Nurs. 1997;23:24–39.PubMedGoogle Scholar
  51. 51.
    Shaw MM. Aggression toward staff by nursing home residents: findings from a grounded theory study. J Gerontol Nurs. 2004;30:43–54.PubMedGoogle Scholar
  52. 52.
    Ramirez M, Teresi J, Holmes D, Fairchild S. Ethnic and racial conflict in relation to staff burnout, demoralization, and job satisfaction in SCUs and non-SCUs. J Ment Health Aging. 1998;4:443–458.Google Scholar
  53. 53.
    Ramírez M, Teresi J, Holmes D. Demoralization and attitudes toward residents among certified nurse assistants in relation to job stressors and work resources: cultural diversity in long term care. J Cult Divers. 2006;13:119–25.PubMedGoogle Scholar
  54. 54.
    Zeller A, Dassen T, Kok G, Needham I, Halfens RJ. Factors associated with resident aggression toward caregivers in nursing homes. J Nurs Scholarsh. 2012;44:249–57.PubMedCrossRefGoogle Scholar
  55. 55.
    Holmes D, Teresi J. Personnel costs in special dementia care units compared with costs on traditional care units. Res Practice Alz Dis. 2000;4:199–215.CrossRefGoogle Scholar
  56. 56.
    Castle NG, Ferguson-Rome JC, Teresi JA. Elder abuse in residential long-term care. J Applied Geront. In press.Google Scholar
  57. 57.
    Dettmore D, Kolanowski A, Boustani M, Henry P. Aggression in persons with dementia: use of nursing theory to guide clinical practice. Geriatr Nurs. 2009;30:8–17.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Mark S. Lachs
    • 1
  • Tony Rosen
    • 2
  • Jeanne A. Teresi
    • 1
    • 3
    • 4
  • Joseph P. Eimicke
    • 1
    • 3
  • Mildred Ramirez
    • 1
    • 3
  • Stephanie Silver
    • 1
    • 3
  • Karl Pillemer
    • 5
  1. 1.Division of Geriatrics and GerontologyWeill Cornell Medical College, Cornell UniversityNew YorkUSA
  2. 2.Emergency Medicine ResidencyNew York Presbyterian HospitalNew YorkUSA
  3. 3.Research DivisionHebrew Home at RiverdaleRiverdaleUSA
  4. 4.Columbia University Stroud Center and New York State Psychiatric InstituteNew YorkUSA
  5. 5.Department of Human Development and Cornell Institute for Translational Research on AgingCornell UniversityIthacaUSA

Personalised recommendations