A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: results from a cluster randomized trial

Exploring Overt Racial and Ethnic Conflict in Resident-to-Resident Aggression in Long-Term Care Facilities

Objectives

Resident-to-resident aggression (RRA) in long-term care facilities is gaining recognition as a serious problem. Racial/ethnic conflict may be a contributing factor to RRA incidents, but it remains insufficiently studied. Our goal was to explore overt racial/ethnic conflict in RRA.

Design

We used quantitative and qualitative secondary analyses of existing data from a large, rigorously conducted study of RRA to describe the involved residents and patterns of overt racial/ethnic conflicts.

Setting and Participants

The parent study included information of 2011 residents in 10 randomly selected New York State nursing homes with a wide range of racial/ethnic minority residents (4.2%-63.2%). A subset of 407 residents were involved in RRA.

Methods

We re-examined data from the parent study, which used an innovative approach to identify RRA incidents by reconstructing each incident based on residents' self-reports, staff interviews, field observations, and medical chart review. Resident and facility information was collected.

Results

A total of 35 residents (8.6% of those involved in RRA incidents) were identified as involved in overt racial/ethnic conflicts. These residents were more likely to have had less education than residents involved in other types of RRA but not in overt racial/ethnic conflicts. More than half (56.9%) of the 51 incidents of RRA involving overt racial/ethnic conflict between a specific pair of residents occurred repeatedly. Manifestation of racial/ethnic conflicts included physical violence, discrimination, racial/ethnic slurs, stereotypes, and microaggression. Acute precipitants of these incidents included various communal-living challenges and unmet needs at the facility, relational, and individual levels. Psychological and behavioral consequences were also described.

Conclusion and Implications

We found a broad range of manifestations, acute precipitants, circumstances surrounding, and consequences of overt racial/ethnic conflicts in RRA. Additional research is needed to improve understanding of this phenomenon and how staff may effectively intervene and prevent it.

Effectiveness of Nurses' Training in Identifying, Reporting and Handling Elderly Abuse: A Systematic Literature Review

The elderly population globally is estimated to grow by one-third of the world’s population by the year 2050. At the same time, elder abuse and neglect have been acknowledged as major growing concerns. With the growing elderly population and increasing concerns about elder abuse, understanding the ways to deal with elder abuse is important. The healthcare professionals, especially nurses, are among the first groups who come in contact with the elderly population and can identify and assess cases of elder abuse. There is evidence to suggest that nurses lack knowledge in the assessment, identification, management, and reporting of an elder abuse case. This study aims to explore the available literature in the effectiveness of training programs for nurses in elder abuse management. The search strategy included the electronic databases CINHAL, Medline, and Health Source. A total of 646 research articles published between 2010 and 2021 were screened against inclusion and exclusion criteria. After reviewing and removing duplicates and irrelevant studies, 14 articles were included in this review. The findings of this literature review revealed that providing education and training for nurses in elder abuse can enhance their knowledge and increase identification and reporting of elder abuse cases. It also indicated that mixed teaching methods, such as face-to-face lectures, simulation, or case scenarios and debriefings or feedback can strengthen the learning process of nurses. In conclusion, educational programs for nurses can significantly improve the identification, reporting, and handling skills of elder abuse incidents. This finding can help in developing accurate strategies for minimizing and preventing elder abuse cases. From the results of this systematic review, we propose the ECLiPSE pathway for the effective training of nurses and handling of elder abuse cases, eventually contributing to decreasing the incidents.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Factors associated with resident-to-resident elder mistreatment in nursing homes

BACKGROUND

Resident-to-resident elder mistreatment (RREM) in nursing homes has serious physical and psychological consequences, but factors related to RREM occurrence remain unclear. This study identifies individual and environmental characteristics associated with involvement in RREM episodes.

METHODS

The design was an observational study carried out in five urban and five suburban New York state nursing homes randomly selected on the basis of size and location. The sample consisted of 2011 residents in 10 facilities; 83% of facilities and 84% of eligible residents participated. RREM and potential correlates were identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports.

RESULTS

A multivariate analysis controlling for relevant covariates found that individuals involved in RREM incidents exhibit milder dementia, show behavioral symptoms, and are less functionally impaired. Although special care units (SCU) for dementia have benefits for residents, one potential hazard for SCU residents is elevated risk for RREM.

CONCLUSIONS

Interventions to prevent and intervene in RREM incidents are greatly needed. The correlates identified in this research point to the need for targeted interventions, specifically for residents with milder impairment and with behavioral symptoms and individuals in SCUs.

The Effectiveness of Educational Intervention in Improving Primary Health-Care Service Providers' Knowledge, Identification, and Management of Elder Abuse and Neglect: A Systematic Review

Elder abuse and neglect (EAN) occurrence is expected to increase in many countries due to rapidly aging populations, yet it is still unrecognized and underreported. Gaps were identified in the knowledge and skills to intervene EAN among health-care service providers. It is still unclear whether educating health-care service providers on EAN improve the identification and management of EAN cases. A systematic review was conducted on the effectiveness of educational intervention designed to improve primary health-care service providers' (PHSPs) knowledge, attitude, and practice in managing EAN cases. We performed a comprehensive and systematic search for original studies in the following major electronic databases (ScienceDirect, PubMed, EMBASE, and CINAHL) and specialist registers (Cochrane Central Controlled Trials Register) with a set of search terms. Studies included were randomized controlled trials (RCTs) and observational studies on EAN education intervention that aimed to improve knowledge, attitude, and management skills of the PHSPs. There were no publication period restrictions until June 2018 and written in English. Overall, three RCTs and 10 observational studies were selected. These studies were grouped based on the type of the study, methodological quality (six moderate risk of bias and seven serious risk of bias), and the type of educational intervention (seven face-to-face educational intervention, two educational videos, two simulation-based training, and two online educational training). The education programs in the selected studies range from brief didactic to experiential learning. EAN educational intervention among primary care service providers potentially result in increasing awareness and knowledge on EAN. However, there is a lack of evidence on the changes of attitude and practice.

Evaluation of an online course for prevention of unwanted sexual behaviour in residential aged care services-A pilot study

BACKGROUND

Residential aged care services (RACS) staff have substantial gaps in knowledge to prevent and manage unwanted sexual behaviour (USB) in RACS.

OBJECTIVES

This study aimed to explore the feasibility of a pilot online course (intervention) addressing USB in RACS.

METHOD

Development of a self-guided e-learning educational course was based on existing research, national and international approaches to human rights approaches to sexual assault and underwent internal and external peer review. An anonymous, online, cross-sectional survey was conducted post-intervention completion. RAC-Communiqué subscribers were recruited via an e-invitation. English speaking enrolled or registered nurses, employed in an Australian RACS, were eligible. From the 167 participants who expressed interest to enrol, 129 were eligible and 45 returned completed consent forms. Fifteen survey items regarding perceived competence and intervention satisfaction were analysed.

RESULTS

The intervention addressed content pertaining to staffs' legal and regulatory requirements, managing incidents and awareness of key services. Thirty-eight of 45 eligible participants responded (84.4%). Participants reported they would recommend the intervention to a colleague (n = 36, 97.3%). Participants self-reported (i) advanced learning post-completion; (ii) raised awareness (n = 29, 78.4%) (iii) prompted current practice reflection (n = 35, 94.6%) and (iv) prompted improving USB workplace management (n = 34, 91.9%). Results are subjected to social desirability bias.

CONCLUSIONS

The intervention was relevant, engaging and practical. The findings contribute to a more comprehensive understanding of the specific training topics relevant and useful to RACS staff.

IMPLICATION FOR PRACTICE

E-learning tools could be an effective teaching method for USB in RACS. The intervention may be a useful tool to encourage staff to reflect and change current practice.

Resident-to-resident elder mistreatment (R-REM) intervention for direct care staff in assisted living residences: study protocol for a cluster randomized controlled trial

Background

Resident-to-resident elder mistreatment (R-REM) is defined as negative and aggressive physical, sexual, or verbal interactions between (long-term care) residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical and/or psychological harm and distress. R-REM has been established as a serious problem that has a negative impact on the safety, physical well-being, and quality-of-life of residents living in nursing homes. Although there are no in-depth studies, there is evidence that it is prevalent in assisted living residences and associated with a variety of person, environmental, and facility characteristics. The authors conducted the first systematic, prospective study of resident-to-resident elder mistreatment in nursing homes and developed an intervention for direct care staff to enhance knowledge of R-REM and increase reporting and resident safety by reducing falls and associated injuries. The study aim was to examine the effects of this intervention in assisted living residences. The primary distal outcome is falls and injuries, and the key process outcomes are staff knowledge and reporting.

Methods

Twelve larger licensed assisted living residences with special care dementia units in two New York State regions will be enrolled on a rolling basis and randomized to intervention or usual care. Data derived from five sources, (1) resident interviews, (2) staff informants, (3) observational data, (4) chart, and (5) incident/accident report data, will be collected at baseline and 6 and 12 months with respect to 1050 residents (750 “downstate” and 300 “upstate”). The intervention is three training modules delivered on-site after baseline data collection for front line staff on all shifts in facilities randomized to the intervention. Modules relate to recognition, management, and reporting of resident-to-resident elder mistreatment.

Discussion

Given the movement toward alternative congregate living arrangements for older individuals with significant comorbidities, including cognitive impairment; it is critical to enhance resident safety measured by falls, accidents, and injuries and staff knowledge related to recognition, reporting, and treatment of resident-to-resident aggressive and related negative interactions in such settings. This project is important in developing approaches for ameliorating and preventing R-REM in assisted living residences and enhancing resident safety and quality of life.

Trial registration

ClinicalTrials.gov NCT03383289. Registered on 26 December 2017

Resident-to-resident aggression in Norwegian nursing homes: a cross-sectional exploratory study

Background

Resident-to-resident aggression in nursing homes is a public health problem of growing concern, impacting the safety, health and well-being of all residents involved. Despite this, little research has been conducted on its occurrence particularly in large-scale national studies. The aim of this study was to explore the extent and nature of resident-to-resident aggression in Norwegian nursing homes, as reported by nursing staff.

Methods

We conducted a cross-sectional exploratory study, where nursing staff in 100 randomly selected Norwegian nursing homes completed a pen and paper survey measuring how often they had observed incidents of resident-to-resident aggression during the past year. These rates were separated according to nursing home size, location and units of workplace.

Results

Of the 3693 nursing staff who participated (response rate 60.1%), 88.8% had observed one or more incidents of resident-to-resident aggression during the past year, with acts of verbal and physical aggression being the most commonly reported. Nursing staff working in dementia special care units, larger nursing homes and nursing homes located in suburban/urban municipalities, reported more incidents of resident-to-resident aggression than staff in short-term and long-term units, small institutions, and nursing homes located in rural municipalities.

Conclusions

This is the first national study of resident-to-resident aggression in Norwegian nursing homes and is one of the largest surveys worldwide exploring the extent and nature of resident-to-resident aggression in long-term care settings. Overall, we found a high occurrence of all types of aggression, suggesting a need for strategies to improve residents’ safety and quality of life in nursing homes.

Dental students' perceived and actual knowledge of elder abuse: An online training curriculum

AIMS

Elder abuse, defined as emotional, physical, or sexual abuse, financial exploitation, or neglect, is a growing problem. Dental professionals have the unique opportunity to identify elder abuse. However, elder abuse awareness training, targeting dental students, is insufficient and research is limited. This knowledge gap prompted the research team at the University of Tennessee Health Science Center (UTHSC) to develop, implement, and evaluate an online Elder Abuse Awareness Professional Education Training (EAAPET) program, designed to educate dental and other health professionals to recognize, respond to, and report elder abuse.

METHODS AND RESULTS

Ninety-six dental students, attending the UTHSC College of Dentistry during the fall semester of 2018, were enrolled. Pre- and post-assessments, designed to assess changes in students' perceived and actual knowledge, were conducted. Paired sample t-test results indicate that the EAAPET program significantly improved students' perception of their abilities to identify, respond to, and report elder abuse. Improvement was also demonstrated within students' actual knowledge of how to appropriately interact with suspected elder abuse victims. Qualitative assessment suggested the training was well received by the students.

CONCLUSIONS

Based on these findings, the authors recommend that dental schools integrate elder abuse awareness education into their curriculums.

Resident-to-Resident Aggression in Long-Term Care: Analysis of Structured and Unstructured Data From the National Violent Death Reporting System, 2003-2016

Aging adults are at risk for multiple types of abuse including emotional, sexual, or physical abuse. Adults in skilled nursing or assisted living facilities might be particularly vulnerable to injury, including fatal injury resulting from incidents of resident-to-resident aggression (RRA). The purpose of this research is to report findings from the multistate National Violent Death Reporting System (NVDRS) related to fatal RRA incidents between years 2003 and 2016. We analyzed structured categorical data and unstructured narrative data on 101 identified fatal RRA incidents among individuals aged 65+. Findings included that victims average 16 years older than exhibitors and dementia diagnoses are present in most cases. Qualitative analysis revealed that events are described as both unexpected and preventable. Training to improve long-term care staff recognition and reporting of RRA events may potentially improve prevention and provide more accurate trend data. NVDRS data provide a useful source to follow trends in fatal RRA going forward.

Aggressive Behaviors Among Nursing Home Residents: Association With Dementia and Behavioral Health Disorders

OBJECTIVES

We measured the prevalence and severity of aggressive behaviors (ABs) among nursing home (NH) residents and examined whether individuals with behavioral health disorders were more likely to exhibit aggressive behaviors than others.

SETTING AND PARTICIPANTS

The analytical sample included 3,270,713 first Minimum Data Set (MDS) assessments for residents in 15,706 NHs in 2015.

MEASURES

Individuals were identified as having (1) behavioral health disorders only (hierarchically categorized as schizophrenia/psychosis, bipolar disorder, personality disorder, substance abuse, depression/anxiety); (2) dementia only; (3) behavioral health disorders and dementia; or (4) neither. The Aggressive Behavior Scale (ABS) measured the degree of aggressive behaviors exhibited, based on 4 MDS items (verbal, physical, other behavioral symptoms, and rejection of care). The ABS scores ranged from 0 to 12 reflecting symptom severity as none (ABS score = 0), mild (ABS score = 1-2), moderate (ABS score = 3-5), and severe (ABS score = 6-12). Bivariate comparisons and multinomial logistic regressions were performed.

RESULTS

Residents with behavioral health disorders and dementia had the highest prevalence of ABs (23.1%), followed by dementia only (15.3%), behavioral health disorders only (9.3%), and neither (5.3%). After controlling for individual risk factors and facility covariates, the relative risk of exhibiting severe ABs was 2.47, 5.50, and 9.42 for residents with behavioral health disorders only, dementia only, and behavioral health disorders and dementia, respectively, with a similar pattern for moderate or mild ABs.

CONCLUSIONS

Residents with behavioral health disorders were less likely than residents with dementia to exhibit aggressive behaviors in nursing homes. Thus, anecdotally reported concerns that aggressive behaviors are primarily an issue for residents with behavioral health disorders, rather than those with dementia, were not empirically justified.

Resident-to-Resident Mistreatment: Evaluation of a Staff Training Program in the Reduction of Falls and Injuries

Resident-to-resident elder mistreatment (R-REM) occurs frequently in long-term services and support settings. The purpose of the current study was to evaluate the effect of a R-REM training program for nursing and other frontline staff on resident falls and injuries in a cluster randomized trial of units within four nursing homes. Interview and observational data from a sample of 1,201 residents (n = 600 and n = 601 in the usual care and intervention groups, respectively) and staff were collected at baseline and 6 and 12 months. A generalized linear model was used to model the falls/injuries outcome. The net reduction in falls and injuries was 5%, translating to 10 saved events per year in an averagesized facility. Although the result did not reach statistical significance due to low power, the findings of fall prevention associated with implementing the intervention in long-term care facilities is clinically important. [Journal of Gerontological Nursing, 44(6), 15-23.].

A systematic review protocol of educational programs for nursing staff on management of resident-to-resident elder mistreatment in residential aged care homes

AIM

To review evidence concerning educational programs for nursing staff on management of resident-to-resident elder mistreatment with the aim of preventing and reducing this abuse in residential aged care homes.

BACKGROUND

Although elder abuse has received considerable attention, very little is known regarding resident-to-resident elder mistreatment in residential aged care homes and about interventions/programs to prevent and reduce this harm. Nurses play an essential role in identifying and managing aggressive interactions. However, many nurses may not recognize these behaviours as forms of abuse. Thus, it is important to ascertain if educational programs for nursing staff have been developed and implemented.

DESIGN

Quantitative systematic review registered on PROSPERO (CRD42017080925).

METHODS

A systematic search of English published studies between 1980 - 2017 will be conducted in CINAHL, Embase, MEDLINE, ProQuest, PsychInfo and Scopus. Risk of bias and quality of the studies will be evaluated by using the Cochrane Collaboration's tool and the Methodological Index for Nonrandomized studies. A meta-analysis will be performed, if sufficient homogeneity exists; otherwise, data will be summarized by using a narrative description. This study was funded in January 2017.

DISCUSSION

Nursing staff should play a pivotal role in preventing and/or reducing resident-to-resident elder mistreatment. Therefore, it is important to identify available educational programs for nursing staff dealing with this abuse. Consequently, this review may provide evidence-based care for nursing staff to assist them in protecting older residents from experiencing abuse or being abused and in improving their well-being.

An assessment of interventions that target risk factors for elder abuse

Although there is increasing concern about both the prevalence of, and harms associated with the abuse of older adults, progress in the development of interventions to prevent its occurrence has been slow. This paper reports the findings of a systematic review of the published literature that identified studies in which the outcomes of preventative interventions are described. A total of eight different intervention trials, published since 2004, are described across the primary, secondary and tertiary levels of prevention and in terms of the types of risk factor that they target. The current evidence to support the effectiveness of these interventions is not only limited by the small number of outcome studies but also the poor quality of evaluation designs and the focus of many interventions on single risk factors. It is concluded that work is needed to strengthen the evidence base that supports the delivery of interventions to prevent elder abuse.

Determining the effectiveness of an Elder Abuse Nurse Examiner Curriculum: A pilot study

OBJECTIVES

To pilot and evaluate a novel Elder Abuse Nurse Examiner Curriculum and its associated training materials for their efficacy in improving Sexual Assault Nurse Examiner (SANE)s' knowledge of elder abuse and competence in delivering care to abused older adults.

METHODS

Pilot training was held with 18 SANEs from across Ontario, Canada. A 52-item pre- and post-training questionnaire was administered that assessed participants' self-reported knowledge and perceived skills-based competence related to elder abuse care. A curriculum training evaluation survey was also delivered following the training. Qualitative non-participant observational data were collected throughout the training.

RESULTS

There were statistically significant improvements in self-reported knowledge and perceived skills-based competence from pre-training to post-training for all content domains of the curriculum: older adults and abuse (p<0.0001), documentation, legislative, and legal issues (p<0.0001); interview with the older adult, caregiver, and other relevant contacts (p<0.0001); assessment (p=0.0018); medical and forensic examination (p<0.0001); case summary, discharge plan, and follow-up care (p<0.0001). The post-training evaluation survey demonstrated satisfaction among participants across all components of the curriculum and its delivery, particularly with reference to the comprehensiveness of the curriculum, and the clarity and appropriateness of the training materials.

CONCLUSIONS

The Elder Abuse Nurse Examiner Curriculum and associated training materials were efficacious in improving SANEs' self-reported knowledge of and perceived competence in delivering elder abuse care. Future steps will further evaluate these materials as a component of a pilot of a larger comprehensive Elder Abuse Intervention at multiple sites across Ontario.

Geriatric Trauma

Within the next 15 years, 1 in 5 Americans will be over age 65. $34 billion will be spent yearly on trauma care of this age group. This section covers situations in trauma unique to the geriatric population, who are often under-triaged and have significant injuries underestimated. Topics covered include age-related pathophysiological changes, underlying existing medical conditions and certain daily medications that increase the risk of serious injury in elderly trauma patients. Diagnostic evaluation of this group requires liberal testing, imaging, and a multidisciplinary team approach. Topics germane to geriatric trauma including hypothermia, elder abuse, and depression and suicide are also covered.

State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: Toward a conceptual framework for research

The goal of this review is to discuss the state of the science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/intimate partner violence. A conceptual measurement model for the study of elder abuse is presented and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Interventions for preventing abuse in the elderly

BACKGROUND

Maltreatment of older people (elder abuse) includes psychological, physical, sexual abuse, neglect and financial exploitation. Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality. Numerous interventions have been implemented to address the issue of elder maltreatment. It is, however, unclear which interventions best serve to prevent or reduce elder abuse.

OBJECTIVES

The objective of this review was to assess the effectiveness of primary, secondary and tertiary intervention programmes used to reduce or prevent abuse of the elderly in their own home, in organisational or institutional and community settings. The secondary objective was to investigate whether intervention effects are modified by types of abuse, types of participants, setting of intervention, or the cognitive status of older people.

SEARCH METHODS

We searched 19 databases (AgeLine, CINAHL, Psycinfo, MEDLINE, Embase, Proquest Central, Social Services Abstracts‎, ASSIA, Sociological Abstracts, ProQuest Dissertations & Theses Global, Web of Science, LILACS, EPPI, InfoBase, CENTRAL, HMIC, Opengrey and Zetoc) on 12 platforms, including multidisciplinary disciplines covering medical, health, social sciences, social services, legal, finance and education. We also browsed related organisational websites, contacted authors of relevant articles and checked reference lists. Searches of databases were conducted between 30 August 2015 and 16 March 2016 and were not restricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and quasi-RCTs, before-and-after studies, and interrupted time series. Only studies with at least 12 weeks of follow-up investigating the effect of interventions in preventing or reducing abuse of elderly people and those who interact with the elderly were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the studies' risk of bias. Studies were categorised as: 1) education on elder abuse, 2) programmes to reduce factors influencing elder abuse, 3) specific policies for elder abuse, 4) legislation on elder abuse, 5) programmes to increase detection rate on elder abuse, 6) programmes targeted to victims of elder abuse, and 7) rehabilitation programmes for perpetrators of elder abuse. All studies were assessed for study methodology, intervention type, setting, targeted audience, intervention components and intervention intensity.

MAIN RESULTS

The search and selection process produced seven eligible studies which included a total of 1924 elderly participants and 740 other people. Four of the above seven categories of interventions were evaluated by included studies that varied in study design. Eligible studies of rehabilitation programmes, specific policies for elder abuse and legislation on elder abuse were not found. All included studies contained a control group, with five of the seven studies describing the method of allocation as randomised. We used the Cochrane 'Risk of bias' tool and EPOC assessment criteria to assess risk of bias. The results suggest that risk of bias across the included body of research was high, with at least 40% of the included studies judged as being at high risk of bias. Only one study was judged as having no domains at high risk of bias, with two studies having two of 11 domains at high risk. One study was judged as being at high risk of bias across eight of 11 domains.All included studies were set in high-income countries, as determined by the World Bank economic classification (USA four, Taiwan one, UK two). None of the studies provided specific information or analysis on equity considerations, including by socio-economic disadvantage, although one study was described as being set in a housing project. One study performed some form of cost-effectiveness analysis on the implementation of their intervention programmes, although there were few details on the components and analysis of the costing.We are uncertain whether these interventions reduce the occurrence or recurrence of elder abuse due to variation in settings, measures and effects reported in the included studies, some of which were very small and at a high risk of bias (low- and very low-quality evidence).Two studies measured the occurrence of elder abuse. A high risk of bias study found a difference in the post-test scores (P value 0.048 and 0.18). In a low risk of bias study there was no difference found (adjusted odds ratio (OR) =0.48, 95% 0.18 to 1.27) (n = 214). For interventions measuring abuse recurrence, one small study (n = 16) reported no difference in post-test means, whilst another found higher levels of abuse reported for the intervention arms (Cox regression, combined intervention hazard ratio (HR) = 1.78, alpha level = 0.01).It is uncertain whether targeted educational interventions improve the relevant knowledge of health professionals and caregivers (very low-quality evidence), although they may improve detection of resident-to-resident abuse. The concept of measuring improvement in detection or reporting as opposed to measuring the occurrence or recurrence of abuse is complicated. An intervention of public education and support services aimed at victims may also improve rates of reporting, however it is unclear whether this was due to an increase in abuse recurrence or better reporting of abuse.The effectiveness of service planning interventions at improving the assessment and documentation of related domains is uncertain. Unintended outcomes were not reported in the studies.

AUTHORS' CONCLUSIONS

There is inadequate trustworthy evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse, although there is some evidence to suggest it may change the combined measure of anxiety and depression of caregivers. There is a need for high-quality trials, including from low- or middle-income countries, with adequate statistical power and appropriate study characteristics to determine whether specific intervention programmes, and which components of these programmes, are effective in preventing or reducing abuse episodes among the elderly. It is uncertain whether the use of educational interventions improves knowledge and attitude of caregivers, and whether such programmes also reduce occurrence of abuse, thus future research is warranted. In addition, all future research should include a component of cost-effectiveness analysis, implementation assessment and equity considerations of the specific interventions under review.

Best-Practice Guideline on the Prevention of Abuse and Neglect of Older Adults

A systematic review of the literature was conducted to identify effective approaches to preventing and addressing abuse and neglect of older adults within health care settings in Canada. The review was conducted using databases searched from January 2000-April-May 2013. Additionally, expert panel members submitted article citations from personal archives. Two research associates (NRA) screened each title and abstract for inclusion. After inter-rater reliability was determined between the NRAs (Kappa score of 0.76), the records were divided, appraised, and data extracted independently. The review resulted in 62 studies that focused on identifying, assessing, and responding to abuse and neglect of older adults; education, prevention, and health promotion strategies; and organizational and system-level supports to prevent and respond to abuse and neglect. Abuse and neglect of older adults remains under-explored in terms of evidence-based studies; consequently, further research in all of the areas described in the results is needed.

A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes

BACKGROUND

We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes.

METHODS

Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure.

RESULTS

Sixty-three unique studies were broadly grouped according to clinical domain-oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics).

CONCLUSION

Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review

BACKGROUND

resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes.

OBJECTIVE

the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes.

METHODS

in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions).

RESULTS

eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression.

CONCLUSIONS

we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

Resident-to-Resident Abuse: A Scoping Review

L'abus de résidents par d'autres résidents parmi de foyers de soins de longue durée (SLD) implique l'agressivité et la violence et peut avoir des conséquences graves pour tous les deux, agresseurs et victimes. Jusqu'à présent, il n'y a eu aucune tentative d'évaluer systématiquement la portée de ce problème au Canada. Pour combler cette lacune, nous avons entrepris une étude de délimitation de l'étendue pour améliorer la compréhension de l'abus chez les résidents des foyers de SLD. Nous présentons aussi un ensemble redigé de données canadiennes sur l'abus chez les résidents. On a cherché neuf bases de données bibliographiques électroniques; un total de 784 résumés a été trouvés, mais seulement 32 ont satisfait les critères d'inclusion. La majorité des documents (75 pour cent) étaient des études de cas rétro-perspectives, des études qualitatives et critiques/commentaires. Parmi eux, seuls 14 se consacrent exclusivement à l'abus parmi les résidents. L'ensemble redigé de données canadiennes suggère que l'abus des résidents par d'autres résidents représente environ un tiers des cas d'abus signalés. Afin de faire connaître cette phénomène et d'aider à diminuer son incidence, des recommandations pour la recherche future, la pratique clinique et la politique sont fournis.

Development of an instrument to measure staff-reported resident-to-resident elder mistreatment (R-REM) using item response theory and other latent variable models

OBJECTIVES

Although numerous studies have measured behaviors among individuals in congregate settings, few have focused on resident-to-resident elder mistreatment (R-REM). To our knowledge, there is no psychometrically developed measure of R-REM extant. The quantitative development of a measure of staff-reported R-REM is described.

METHODS

The design was a prevalent cohort study of residents of 5 long-term care facilities. The primary certified nursing assistant was interviewed about R-REM. Advanced measurement methods were used to develop a measure of R-REM.

RESULTS

The loadings on the general factor for the final 11-item scale were greater than those on the group factor except for the item "other physical behavior" (0.63 vs. 0.74), suggesting essential unidimensionality. Although the bifactor model fit was slightly better than that of the unidimensional model, the difference was trivial (bifactor comparative fit index [CFI] = 0.997, root mean square error of approximation [RMSEA] = 0.013, unidimensional CFI = 0.979, and RMSEA = 0.030). However, modest support was provided for use of verbal and physical subscales. The explained common variance statistics were 0.76 for the bifactor model compared with 0.63 for the unidimensional model.

DISCUSSION

The development of this R-REM measure will help to advance the measurement and ultimately evaluation of interventions associated with this important and under recognized problem facing residents in long-term care settings.

Managing resident-to-resident elder mistreatment in nursing homes: the SEARCH approach

This article describes an educational program to inform nursing and care staff of the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH (Support, Evaluate, Act, Report, Care plan, and Help to avoid) approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM because such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The goal of the SEARCH approach is to support staff in the identification and recognition of R-REM as well as to suggest recommendations for management. The educational program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how nurses and care staff can use the SEARCH approach to manage R-REM in nursing homes. Resident and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.

Elder abuse in residential long-term care: an update to the 2003 National Research Council report

A synthesis of the last decade of literature on elder abuse in residential long-term care (i.e., Nursing Homes and Assisted Living) is discussed. Presented are definitions of abuse, theoretical and conceptual models, prevalence rates of abuse, outcomes and costs, and sources of abuse. The synthesis represents an update to the literature in the influential 2003 National Research Council report. We identify many of the same issues and concerns exist that were surfaced in this prior report. Many theoretical and conceptual models need further elaboration. Conflicting definitions of abuse are pervasive. Rates of abuse are generally inaccurate, and probably under-reported. However, we also identify progress in many areas. An increase in empirical studies that exist in this area (although very few in Assisted Living). Other forms and types of abuse have also been identified as important, such as resident-to-resident abuse. These areas are discussed, along with potential suggestions for additional research.

Preserving personhood of individuals with advanced dementia: lessons from family caregivers

This article reports on a phenomenological study of 15 family caregivers who admitted their spouse or parent with probable Alzheimer's disease to long-term care. The caregivers were attuned to the needs, desires, moods and concerns of their family members with dementia; thus, they were attuned to personhood. Caregivers also reported observations of care by nurses and nursing staff. Observations were of individualized care and actions that promoted personhood and impoverished care delivered with minimal or no communication. These family caregivers' perspectives can inform the care of individuals with advanced dementia by nurses and nursing staff.