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

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

Importance

Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown.

Objective

To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities.

Design, Setting, and Participants

This study used cross-sectional, observational data from a clinical trial, in which residents of assisted living facilities were monitored for events over a 1-month period. All residents of 14 large facilities randomly selected from 2 geographic locations (N = 1067), except those receiving hospice care (n = 11), were invited to participate; 93 died or moved prior to enrollment. There were 33 family and resident refusals; 930 residents were enrolled. Data were collected between May 30, 2018, and August 11, 2022.

Main Outcomes and Measures

The data are from a clinical trial testing the effectiveness of an intervention to reduce resident-to-resident aggression. In addition, the study was designed to assess prevalence using the Time 1 (baseline) data, using a probability sample of facilities to allow for this analysis. Resident-to-resident aggression was identified using a mixed-method, case-finding strategy involving 6 sources: (1) cognitively capable resident reports regarding 22 possible events, (2) direct care staff report, (3) staff member reports collected from event-reporting forms, (4) research assistant observation of events in real time, (5) facility accident or incident reports, and (6) resident records.

Results

The prevalence of resident-to-resident aggression among the 930 participants (mean [SD] age, 88.0 [7.2] years; 738 women [79.4%]) during the past month was estimated to be 15.2% (141 of 930 residents; 95% CI, 12.1%-18.8%). The most common forms of aggression included verbal (11.2% [104 of 930 residents; 95% CI, 8.8%-14.2%]), physical (41 of 930 residents; 4.4% [95% CI, 3.1%-6.3%]), sexual (0.8% [7 of 930 residents; 95% CI, 0.4%-1.6%]), and other (70 of 930 residents; 7.5% [95% CI, 5.5%-10.2%]). These categories are not mutually exclusive as residents could be involved with more than 1 type of aggressive behavior.

Conclusions and Relevance

In this cross-sectional, observational prevalence study, resident-to-resident aggression in assisted living facilities was highly prevalent. Verbal aggression was the most common form, and physical aggression also occurred frequently. The effects of resident-to-resident aggression can be both morbid and mortal; therefore, intervention research is needed to prevent it and to treat it when it occurs.

Adverse impacts in residential aged care facilities: The resident perspective

OBJECTIVES

Inclusion of consumer perspectives is a key component to person-centred health-care approaches. While current residential aged care systems focus on recording adverse events to meet the requirements of regulatory reporting, little is known about the views of residents. The aim of this research was to explore residents' responses on the types of incidents that have an adverse impact on them and how they are affected by these incidents.

METHODS

The study used a qualitative, inductive approach to derive themes from interviews with 20 permanent residents of aged care facilities in New South Wales and the Australian Capital Territory.

RESULTS

Four main themes surrounding adverse incidents emerged: (i) social relationships and the adverse impacts of lack of meaningful interactions, (ii) adjustment to life in the residential aged care facility and the loss of residents' former life and self-determination, (iii) the impact of COVID-19 lockdowns which meant that residents were not able to go out or interact with others and (iv) acceptance, resignation and resilience in coping with adverse incidents.

CONCLUSIONS

This research highlights the difference between health-care definition, used for incident management reporting and quality indicators, and the way residents respond when asked to describe an incident that has affected them. Resident responses discuss situations having an adverse effect on them in contrast to the way adverse events and incidents are reported and monitored. The findings suggest that within adverse event and incident management systems and resident governance systems, there is scope for incorporating periods of transitions and well-being measures that capture elements that matter to older people.

Trauma-informed care within residential aged care settings: A systematic scoping review

OBJECTIVES

The importance of trauma-informed care (TIC) within residential aged care (RAC) settings has been increasingly recognised. TIC would ensure that older people who have experienced trauma over their lifetime have their needs better understood and accommodated. This scoping review examined the extent to which TIC has been applied within RAC settings.

METHODS

A scoping review was conducted according to Cochrane recommendations and the PRISMA-ScR checklist. A systematic search of six databases (Embase, Emcare, CENTRAL, CINAHL, PsychInfo and Medline) was performed in July 2022 and March 2023 and peer-reviewed primary research, in English and involved RAC staff or residents (aged 65 years and over) providing or receiving TIC were eligible for inclusion. Studies focused on trauma intervention, assessment, screening, or treatment were excluded. Thematic synthesis was performed to extract themes relating to trauma-informed practice, barriers and enablers to TIC, and outcomes from the application of TIC approaches.

RESULTS

Five articles were included. There was little evidence of the implementation of TIC interventions in RAC settings. Only one study examined the application of a TIC framework in a RAC setting. However, there was some evidence that approaches that consider resident's experience of trauma have emerged from practice experience and been used in RAC as an extension of person-centred care.

CONCLUSIONS

Whilst trauma-informed approaches to resident care are emerging through practice experience, and despite policy recommendations to do so, there is little evidence that formal TIC interventions or frameworks have been applied to RAC internationally. This study highlights a gap in research and practice and makes several recommendations for further research and implementation of TIC in RAC.

Staff Experiences in Managing Incidents in Nursing Homes: A Descriptive Qualitative Study

Introduction

Adverse incidents in nursing home (NH) may occur as the result of inadequate monitoring for signs of unobservable initial complications, medical errors, improper nursing interventions, lack of communication, and inadequate reporting.

Purpose

This study explores incident types, causes, handling, and documentation in Indonesian NHs through a qualitative approach.

Patients and Methods

In-depth interviews were conducted with 23 NH staff members, including managers, nurses, and support staff.

Results

Five themes and 17 sub-themes emerged, with falls and resident-to-resident abuse as common adverse incidents. Causes included older adults' conditions, environment, and misunderstanding. Follow-up action included first aid, hospital referrals, and assertive communication. Adverse incidents were actively reported through verbal and written reports or WhatsApp groups. Reports and documentation remain unstructured, however, as there were no standard operating procedures regarding incident reporting, documentation, and the types of adverse incidents that staff should report.

Conclusion

Improvements in management, documentation, and reporting adverse incidents are highlighted in this research. Practitioners, nurses, and social workers should develop guidelines for handling, reporting, and documenting adverse incidents in NHs.

Practices countering resident-to-resident aggression and promoting wellness care for older adults in congregate residential facilities: results from a systematic review

Resident-to-resident aggression (RRA) is an important issue in congregate residential facilities (CRFs) for older adults and has devastating effects. This study aimed to provide an inventory and content analysis of the practices used to counter RRA and promote wellness care for older adults in CRFs. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, original, peer-reviewed research and systematic reviews published in 14 electronic databases and two gray literature sources were examined. Of the 6196 articles identified, 28 met the inclusion criteria. Practices aimed to prevent, track or intervene in RRA, mostly in long-term care centers, but few were evidence-based and ready for widespread implementation. It emerges that continuous training of staff is necessary and that it should prioritize a person-centered approach. CRFs' managers must promote a culture of wellness care and policymakers should consider the prevention practices to improve the quality of life of older adults in CRFs.

An Analysis of Long-Term Care Home Inspection Reports and Responsive Behaviours

Concern about residential long-term care quality and safety is a critical issue in developed countries internationally, often fueled by media scandals exposing riveting accounts of resident-to-resident aggression/responsive behaviours. These scandals raise questions about standards of care set through long-term care regulation. Using a participatory action research approach and document analysis method, we analyzed incidents related to responsive behaviours documented in three types of public version inspection reports posted for 535 Ontario, Canada long-term care homes from 2016 through 2018. Creation of an Individual Home Data Collection and Analysis Tool facilitated data collation and descriptive statistical analysis of seven long-term care service areas in the province of Ontario. Results highlight several combined service areas differences between for-profit and not-for-profit home documentation related to responsive behaviours in (a) resident quality inspection means; (b) total complaint and critical incident proportions and means; (c) total enforcement actions proportions; and (d) enforcement penalties. We discovered that documented evidence of incidents related to responsive behaviours was instead represented by other sections of the legislation. The highest proportion of enforcement actions related to responsive behaviours involved no follow-up by inspectors and only four enforcement penalties over three years. Recommendations include revision of the inspection report judgement matrix tool to produce separate enforcement actions specific to responsive behaviours. We submit that attending to this will contribute to protecting long-term care residents from harm and improving their quality of care through more effective connection of long-term care regulation to responsive behaviour care management.

Losing hope or keep searching for a golden solution: an in-depth exploration of experiences with extreme challenging behavior in nursing home residents with dementia

Background

Situations of extreme challenging behavior such as very frequent and/or severe agitation or physical aggression in nursing home residents with dementia can be experienced as an impasse by nursing home staff and relatives. In this distinct part of our WAALBED (WAAL-Behavior-in-Dementia)-III study, we aimed to explore these situations by obtaining the experiences and perspectives of nursing home staff and relatives involved. This can provide a direction in providing tools for handling extreme challenging behavior of nursing home residents with dementia and may improve their quality of life.

Methods

Qualitative multiple case study with individual interviews and focus group discussions. Interviewees were elderly care physicians, psychologists, care staff members, unit managers and relatives (n = 42). They were involved with nursing home residents with dementia and extreme challenging behavior living on dementia special care units in the Netherlands. For these residents, external consultation by the Centre for Consultation and Expertise was requested. Audio-recordings of the interviews were transcribed verbatim and analyzed with thematic analysis, including conventional content analysis.

Results

Seven cases were included. Forty-one individual interviews and seven focus group discussions were held. For six stakeholder groups (resident, relative, care staff, treatment staff, nursing home staff, and the organization), three main factors could be identified that contributed to experiencing a situation of extreme challenging behavior as an impasse: 1) characteristics and attitudes of a stakeholder group, 2) interaction issues within a stakeholder group and 3) interaction issues among (groups of) stakeholders. The experienced difficulties with the resident’s characteristics, as well as suboptimal interdisciplinary collaboration and communication among the nursing home staff are remarkable. Nursing home staff kept searching for a golden solution or lost hope.

Conclusions

This study offers important insights into situations of extreme challenging behavior in nursing home residents with dementia and offers caregivers targets for improving care, treatment and interdisciplinary collaboration, such as working uniformly and methodically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03438-0.

Bullying in Old Age: A Qualitative Study on Older Adults' Perceptions About Being Bullied

Significant demographic changes and a growing aging population increasingly emphasize the importance of assessing phenomena of violence against older adults, who constitute a vulnerable population. Therefore, bullying in old age is a poorly studied phenomena, but of growing importance. This study aims to analyze the perspectives of bullying in old age, using qualitative research at a cross-national level. We interviewed 173 older participants aged 65-91 years. Participants were Portuguese and English and lived in the community. Participants were subjected to semi-structured interviews. All the interviews went through a process of content analysis. Sample recruitment occurred through initial telephone contact, followed by a request to participate. Outcomes of content analysis produced seven themes, all of them associated with bullying experiences such as compromised learning capacity, loss of sense of agency and decision-making, asexuality, less attractive appearance, less social skills, gender discrimination, and less financial resources. Portuguese older adults felt mostly bullied for their loss of sense of agency and decision-making, less attractive appearance, less social skills, and less financial resources, while English participants mostly felt bullied for their compromised learning capacity, gender discrimination, and asexuality. The themes identified as being the most prominent in bullying are valuable guidelines for social policies and interventions toward bullying among older adults. Considering the scarcity of studies on bullying in older adults, this study is relevant for understanding the experience of older adults in relation to being bullied and for implementing psychosocial intervention programs including bullying situations that affect community-dwelling older adults.

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.

A Novel Intervention for Management of Behavioral and Psychological Symptoms of Dementia in Nursing Home Communal Areas: Results of a Small-Scale Pilot Trial

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) exhibited by persons with dementia (PwD) in nursing home communal areas are generally managed by segregation and/or pharmacological interventions.

OBJECTIVE

This study trialed MindfulGarden (MG), a novel digital calming device, in a Canadian nursing home.

METHODS

Participants were 15 PwD (mean age = 87.67; 5m,10f; mean MMSE = 11.64±7.85). Each was observed by a research assistant (RA) for an average of 8-10 hours on two separate days. The RA followed them during time spent in communal areas of the nursing home including their unit's dining space, lounges, and corridors and spaces shared with other units (e.g., gym and gift shop) and documented any BPSD exhibited. Day-1 provided baseline data; on Day-2, residents were exposed to MG if nursing staff considered their BPSD were sufficiently intense or sustained to warrant intervention. Staff rated the impact as positive, neutral, or negative.

RESULTS

On Day-1, 9 participants exhibited both aggressive and non-aggressive behaviors, 4 non-aggressive behaviors only, and 2 no BPSD. On Day-2, 7 exhibiting aggressive behaviors were exposed to MG. Staff reported MG as having distracting/calming effects and gave positive impact ratings to 6/13 exposures; there were no negative ratings. The most common aggressive BPSD on days of observation were pushing/shoving and screaming.

CONCLUSION

MG may have value as a "psychiatric crash cart" in de-escalating agitation and aggression in care home settings.

Aged care nurses' perception of unwanted sexual behaviour in Australian residential aged care services

OBJECTIVES

To explore aged care nurses' awareness and experience of unwanted sexual behaviour (USB) in residential aged care services (RACS).

METHODS

An anonymous online questionnaire was administered to an opportunistic sample of RACS nurses enrolled to complete an e-learning course in Australia. From the 167 participants who expressed interest to enrol, 129 were eligible and 53 returned completed consent forms.

RESULTS

46/53 responded of which most were females (41/45, 91.1%). Few respondents reported resident-resident USB (<35%) or staff-resident USB (<22%) happened once a year. Most respondents had not been informed by a resident of USB (>75%) or had personally reported USB within their internal reporting system (>77%). Respondents were also unaware if their facility had lodged an incident report to the regulator or law enforcement authorities within the past 12 months (34/46, 73.9%). Finally, most considered there to be no barriers to reporting USB (35/46, 77.8%).

CONCLUSIONS

Respondents' awareness and estimates of USB directed at residents were much lower than known national prevalence rates. This lack of awareness could be a substantive barrier to recognition and optimal management of this form of abuse.

Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol

Background

Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings.

Methods

Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained ‘champions’ on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy.

Discussion

Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes

OBJECTIVES

Workplace disruptive behavior incidents can be costly for organizations, employees, and customers. Persons with dementia living in long-term care settings have a high risk of exhibiting distressed behaviors. We examined whether a resident-centered, behavioral intervention for residents with dementia led to a reduction in reported workplace disruptive behaviors and staff injury rate due to assault. Impactful interventions are important for quality of care.

DESIGN

We examined whether a team-based behavioral program in community living centers (CLCs), where a nurse champion and behavioral coordinator were trained to work with the clinical team to understand and manage distressed behaviors commonly associated with dementia, was associated with reductions in behavior incidents.

SETTING AND PARTICIPANTS

The setting was Veterans Health Administration CLCs. The sample consisted of 120 aggregated CLCs operating between 2012 and 2017 with 62 completing training. CLCs were distributed across the United States.

METHODS

Outcomes included CLC-level rates of staff injury and number of workplace disruptive behavior incidents. Outcomes were regressed on measures of intervention completion, time since intervention, and several CLC characteristics.

RESULTS

The intervention was significantly associated with lower incidence of assault with staff injury rates overall, particularly following the first year of training, but not with other reported workplace disruptive behavior incident rates.

CONCLUSIONS AND IMPLICATIONS

A team-based behavioral intervention was associated with reduction of employee assaults, a critical repercussion of distressed behavior in dementia. Given rapid growth in patients with dementia in nursing homes, effective treatment practices, such as interdisciplinary behavioral management approaches may be impactful and valuable to implement.

Very frequent physical aggression and vocalizations in nursing home residents with dementia

OBJECTIVES

We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia.

METHOD/DESIGN

This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses.

RESULTS

We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31).

CONCLUSION

Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

Ambient Intelligence Based on IoT for Assisting People with Alzheimer’s Disease Through Context Histories

New Internet of Things (IoT) applications are enabling the development of projects that help with monitoring people with different diseases in their daily lives. Alzheimer’s is a disease that affects neurological functions and needs support to maintain maximum independence and security of patients during this stage of life, as the cure and reversal of symptoms have not yet been discovered. The IoT-based monitoring system provides the caregivers’ support in monitoring people with Alzheimer’s disease (AD). This paper presents an ontology-based computational model that receives physiological data from external IoT applications, allowing identification of potentially dangerous behaviors for patients with AD. The main scientific contribution of this work is the specification of a model focusing on Alzheimer’s disease using the analysis of context histories and context prediction, which, considering the state of the art, is the only one that uses analysis of context histories to perform predictions. In this research, we also propose a simulator to generate activities of the daily life of patients, allowing the creation of data sets. These data sets were used to evaluate the contributions of the model and were generated according to the standardization of the ontology. The simulator generated 1026 scenarios applied to guide the predictions, which achieved average accurary of 97.44%. The experiments also allowed the learning of 20 relevant lessons on technological, medical, and methodological aspects that are recorded in this article.

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.

Nursing home residents' perspectives on their social relationships

AIMS AND OBJECTIVES

To explore nursing home residents' perspectives on their relationships with other residents, family members and staff.

BACKGROUND

The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility.

DESIGN

Qualitative secondary analysis.

METHODS

We analysed individual and group interviews obtained during "stakeholder engagement sessions" with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed.

RESULTS

Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents' relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents' psychosocial well-being.

CONCLUSION

Recognising the diverse roles of different actors from residents' social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents' psychosocial well-being.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the need for nursing home staff to understand how residents' social relationships influence residents' psychosocial outcomes. Staff training programmes are needed to support residents' rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

Prevalence and nature of resident-to-resident abuse incidents in Australian residential aged care

OBJECTIVES

To determine the prevalence of resident-to-resident abuse (RRA) in aged care facilities and to explore the nature, contributing factors and outcomes of abuse incidents.

METHODS

Retrospective cohort study of residents in 13 aged care facilities between 1 January and 31 December 2017, using data extracted from organisational incident reports.

RESULTS

A total of 169 RRA incidents were recorded, representing 0.56 incidents per 1000 bed days. 7.6% of residents were targets, and 6.9% exhibited aggression, in one or more RRA incidents over one year. In the majority of incidents (152, 89.9%), the aggressor had a cognitive impairment. Impacts on targets were mostly minor. The most common aggressor intervention was behaviour management (142; 84.0%).

CONCLUSIONS

Resident-to-resident abuse was found to be lower than in other reports. Typically, it involves residents with cognitive impairment and does not result in serious harm. Managing behavioural symptoms associated with cognitive impairment is critical in preventing and managing RRA.

Preventing The Abuse Of Residents With Dementia Or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review

Purpose

The main objective of this study was to investigate abuse of residents with either dementia or Alzheimer’s disease in long-term care settings, to identify facilitators and barriers surrounding implementation of systems to prevent such occurrences, and to draw conclusions on combating the issue of abuse.

Patients and methods

A systematic review was conducted using the Medline, CINAHL, and Academic Search Ultimate databases. With the use of key terms via Boolean search, 30 articles were obtained which were determined to be germane to research objectives. The review was conducted and structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Residents with dementia or Alzheimer’s disease are at greater risk of abuse. The growing population could increase this problem exponentially. The most common facilitators were the introduction of policies/programs in the facility, education, and working conditions. The most cited barriers were poor training, lack of research, and working conditions in the long-term care setting.

Conclusion

The examples given would be useful in minimizing the potential for abuse in the long-term care setting. Leadership can take an active role in the prevention of abuse of the elderly through their actions, education of employees, and changes in the work environment.

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.

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.

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.

Stakeholder perceptions on resident-to-resident aggression: implications for prevention

Objective Resident-to-resident aggression (RRA) in nursing homes is a matter of serious and profound concern, yet action to eliminate or mitigate RRA is hampered by a paucity of research. The aim of this study was to explore key stakeholders’ knowledge and perceptions of RRA in Australian nursing homes. Methods A qualitative cross-sectional study design was used, and semistructured telephone interviews were conducted. Participants were purposively and conveniently sampled with replacement from a range of aged care, healthcare and legal professional bodies, as well as advocacy organisations. The interview contained 12 closed-ended questions and six open-ended questions about participants’ knowledge, experiences, perceptions and attitudes to RRA. Participant characteristics and responses to closed-ended questions were aggregated and proportions calculated, and thematic analysis was conducted by two independent researchers using a directed content approach. Results Fifteen participants (11 females; 73.3%) in senior management positions were interviewed. All were familiar with the concept of RRA and just over half (n=8; 53.3%) had witnessed an incident. Major themes included the nature and causes of RRA and attitudes and responses to RRA. Potential causes of RRA included maladaptation to nursing home life, transfer of pre-existing issues into the nursing home environment, physical environment and staffing-related issues. RRA was commonly viewed by participants as dangerous and unpredictable or, conversely, as expected behaviour in a nursing home setting. A person-centred care approach was considered most effective for managing and responding to RRA. Conclusion The research demonstrates that understanding perceptions of RRA among key stakeholders is critical to identifying the nature and scope of the problem and to developing and implementing appropriate prevention strategies. What is known about the topic? RRA is common in nursing homes, with potentially fatal consequences for residents involved, and has serious implications for nursing home staff, managers, providers, and regulators. Despite this, the prevalence, impact, and prevention of RRA remains under-recognised and under-researched in Australia. What does this paper add? This is the first Australian study to produce qualitative findings on the knowledge and perceptions of RRA in nursing homes among key stakeholders. This paper reports on the knowledge and perceptions of individuals in senior management and policy roles in aged care and related fields in relation to four themes: nature; causes; attitudes; and responses to RRA. Our findings highlight the complex and multifactorial nature of RRA. What are the implications for practitioners? A movement towards person-centred care that promotes understanding of individual care needs is favoured as an approach to reducing RRA. Increased reporting of both minor and major incidents of RRA will help to identify patterns and inform appropriate responses. However, a cultural shift is first required to recognise RRA as a manageable and preventable health care and adult safeguarding issue.

Elderly peoples' experiences of nursing homes in Bam city: A qualitative study

Background

With the increasing number of elderly, especially in recent decades, transfer to nursing homes and the number of centers has also increased but experiences and problems of elders in these centers is less considered. So, the goal of this study is to explore the Elderly peoples’ experiences of nursing homes.

Methods

The current research was performed using a phenomenological approach in 2016. Participation in the study is comprised of the elderly residents in a nursing home in Bam city who were selected based on an objective-oriented approach. The sampling was done until data saturation. Data collection methods were observation and an unstructured and in-depth interview. Data were analyzed using seven-stage Colaizzi process.

Results

In total, fifteen 68 – 82 years old people participated in our study and 52 primary and conceptual codes that were eventually categorized in five main themes (sense of rejection, sense of daily routine, impaired of communications, sense of hardship and mental obsession) and ten sub-themes emerged.

Conclusion

Overall, most of the elders were not satisfied with the conditions. It seems that helpful, community and family education to acculturate respect for the elderly in the community, teach proper coping strategies, use the elderly’s experiences, and consultation with them could be a way to maintain a sense of usefulness, independence and to prevent them from sensing monotonous and routine rhythm of life.

Aggressive Behaviour Risk Assessment Tool for newly admitted residents of long-term care homes

AIM

The aim of this study was to revise the 10-item Aggressive Behaviour Risk Assessment Tool for predicting aggressive events among residents newly admitted to long-term care homes.

BACKGROUND

The original tool had acceptable sensitivity and specificity for identifying potentially aggressive patients in acute care medical-surgical units, but its usefulness in long-term care homes is unknown.

DESIGN

A retrospective cohort study design was used.

METHODS

All residents admitted to 25 long-term care homes in western Canada were assessed for the risk of aggression using the original tool within 24 hours of admission from January 2014 - December 2014 (n = 724). Incident reports of aggressive events occurring within 30 days of admission were collected. Multiple logistic regression and receiver operating characteristics analyses were performed.

RESULTS

Fifty-three residents of 724 exhibited aggressive behaviours. The demographic variable of age less than 85 years was found to be a positive predictor of aggressive events in multivariate logistic regression model and was added to the tool. The revised six-item Aggressive Behaviour Risk Assessment Tool for Long-Term Care consists of one new item, age less than 85 years and five items from the original tool: History of physical aggression, physically aggressive/threatening, anxiety, confusion/cognitive impairment and threatening to leave. The receiver operating characteristics of the revised tool with weighted scoring showed a good discriminant ability with satisfactory sensitivity and specificity at the recommended cut-off score of 4.

CONCLUSION

The revised six-item tool may be useful in identifying potentially aggressive residents newly admitted to long-term care homes.

Residents' Positive and Negative Relationship Networks in a Nursing Home

Person-centered care involves consideration of long-term care residents' lived experience, including social relationships. The current cross-sectional study investigated co-resident social networks in three units of a 94-bed Australian nursing home, including an 18-bed dementia-specific unit (DSU). Six care staff were interviewed. Chart, self-reported social isolation, and staff-reported social engagement data were collected for 36 residents ages 63 to 94 who consented to full participation. Fifty-five additional residents were included in observations. Median positive-to-negative network size ratios within units were 1.5:1 (Unit 1), 0.7:1 (Unit 3), and 0:1 (DSU). Moderate positive correlations existed between: perceived social support and total positive relationships [ρ(25) = 0.44, p = 0.03]; social withdrawal and total negative relationships [ρ(36) = 0.51, p = 0.002]; and objective social isolation and total negative relationships [ρ(22) = -0.44, p = 0.042]. Number and quality of relationships were associated with resident social withdrawal, perceived support, and isolation. High prevalence of isolation and negative relationships demonstrate the need for interventions. [Journal of Gerontological Nursing, 42(11), 9-13.].

The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes

BACKGROUND

Resident-to-resident elder mistreatment (R-REM) in nursing homes can cause physical and psychological injury and death, yet its prevalence remains unknown.

OBJECTIVE

To estimate the prevalence of physical, verbal, and sexual R-REM in nursing home residents and subgroups.

DESIGN

1-month observational prevalence study.

SETTING

5 urban and 5 suburban New York state nursing homes.

PARTICIPANTS

2011 residents in 10 facilities randomly selected on the basis of size and location; 83% of facilities and 84% of eligible residents participated.

MEASUREMENTS

R-REM was identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports.

RESULTS

407 of 2011 residents experienced at least 1 R-REM event; the total 1-month prevalence was 20.2% (95% CI, 18.1% to 22.5%). The most common forms were verbal (9.1% [CI, 7.7% to 10.8%]), other (such as invasion of privacy or menacing gestures) (5.3% [CI, 4.4% to 6.4%]), physical (5.2% [CI, 4.1% to 6.5%]), and sexual (0.6% [CI, 0.3% to 1.1%]). Several clinical and contextual factors (for example, lower vs. severe levels of cognitive impairment, residing on a dementia unit, and higher nurse aide caseload) were associated with higher estimated rates of R-REM.

LIMITATIONS

Most facilities were relatively large. All R-REM cases may not have been detected; resident and staff reporting may be subject to recall bias.

CONCLUSION

R-REM in nursing homes is highly prevalent. Verbal R-REM is most common, but physical mistreatment also occurs frequently. Because R-REM can cause injury or death, strategies are urgently needed to better understand its causes so that prevention strategies can be developed.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Resident Aggression and Abuse in Assisted Living

This article estimates the prevalence and identifies risk factors of resident aggression and abuse in assisted living facilities. We conducted multivariate analyses of resident-level data from an analytic sample of 6,848 older Americans in the 2010 National Survey of Residential Care Facilities. Nationwide, 7.6% of assisted living residents engaged in physical aggression or abuse toward other residents or staff in the past month, 9.5% of residents had exhibited verbal aggression or abuse, and 2.0% of resident engaged in sexual aggression or abuse toward other residents or staff. Dementia and severe mental illness were significant risk factors for all three types of resident aggression and abuse. Resident aggression and abuse in assisted living facilities is prevalent and warrants greater attention from policy makers, researchers, and long-term care providers. Future research is needed to support training and prevention efforts to mitigate this risk.