How caregivers respond to aged-care residents' aggressive behaviour: a recent study of caregivers working in dementia units and residential care facilities in the Christchurch area showed most experienced verbal and physical aggression daily. There is an obvious need for further training and support for caregivers encountering these difficulties.
A pilot study, using qualitative research methods, was undertaken in Canterbury in 2003 to explore the attitudes and responses of residential caregiving staff to aggressive behaviour from residents. The research was conducted with Canterbury Ethics Committee approval. Differences between the experiences of staff in generic residential care facilities and dementia care units have also been examined. This article provides a broad overview of the research findings. The findings will be discussed in more detail in subsequent papers.
Twenty-five caregivers were interviewed in-depth--12 from dementia units and 13 from general residential care facilities. The caregivers were all women and their ages ranged from under 20 to over 60 years. The average age was 40-49 years. Most of the women were of New Zealand European background. Only a quarter of participants were of a different ethnic background, either Maori or first generation British/European. Four of the 25 caregivers had completed a general polytechnic certificate or diploma, but nearly three quarters of all the people interviewed had left school with no format qualifications. Age and education trends were similar to those found in a recent survey of New Zealand residential care homes. (7)
In all, participants were employed in 14 residential care facilities within the greater Christchurch area. Their length of experience in residential caregiving spanned from just under one year to more than ten years, although the time participants had worked in residential care was on average two to five years. Several people had had experience working in both generic facilities and dementia care units. Participants worked day, night or mixed shifts. Nearly art were employed for at least 30 hours a week.
As found in overseas studies, caregivers reported having experienced aggression from residents in their daily work. (1,2) The amount of aggression encountered varied considerably among caregivers. One person had experienced only limited verbal aggression in the previous 12 months, white others reported experiencing verbal and/or physical aggression daily. The most serious incidents involved assaults resulting in injury and intimidation.
Caregivers differed as to whether they thought physical aggression from residents was worse than verbal aggression. Examples of aggression were defined as:
"On the physical side there's the pinching, the punching, the kicking, the biting, the advancing towards other people, the throwing of articles and things and using them as missiles ... and on the verbal side there's a lot of very, very nasty sarcastic verbal abuse, used in various ways." (Int. 4) "Aggressive for me is when a resident may be really going for you. Like has beamed on you, is focused on you, and they're coming after you. Or they're going after another resident. That to me is aggressive." (Int. 6)
When comparing physical and verbal aggression, nearly everyone working in a dementia unit thought physical aggression was more difficult to tolerate, whereas staff in generic units tended to be more upset by verbal insults. Reasons which were given for verbal aggression making a greater impact included difficulty in forgetting offensive comments and the unanticipated nature of verbal abuse. The unexpectedness of hurtful words caught people off guard and unable to prepare themselves for their impact.
Verbal aggression was reported as occurring more frequently than physical aggression, and entailed swearing, personally insulting remarks or, occasionally, threatening to kill. Several staff mentioned sexual innuendos being made by residents, although this was not always regarded as aggressive behaviour. Physical acts of aggression included pinching, kicking, scratching, hitting out and throwing objects. Six caregivers talked of receiving bruises from kicks or hitting. Staff in dementia units reported more aggression than those in generic units. Several women spoke of being constantly aware of the potential for assault.
Differing emotional reactions
Aggressiveness from residents aroused mixed emotional responses. A few caregivers talked of being frightened by specific incidents. This fear was quite intense and ongoing white these aggressive residents remained in the facility. Some caregivers were angry with themselves for not having foreseen the trouble and avoided it, especially if another resident had been harmed. Others felt frustrated that the care and protection they were offering in good faith to residents was being rejected. A number of participants expressed a sense of irony in having been hurt by very frail old people.
The differing emotional reactions were linked to caregivers' understanding of aggression. A major emphasis in interviews was that the aggression of people with dementia could not be blamed on these residents. People were victims of their condition or reacting against an unfavourable situation. A number of caregivers considered that aggression was part of the job, often caused by physiological changes to the brain. When difficult behaviour was interpreted in this way, caregivers tended to accept aggression as a "natural" phenomenon to be tolerated, rather than a problem to try and change. Other explanations for aggression were that this was the resident's way of gaining control over their life in a communal setting, or that there had been a change in the resident's medical condition. Caregivers who linked their understanding of aggression to these explanations usually suggested responses that aimed at changing the behaviour.
The most frequently mentioned method for handling the situation was to walk away from a resident who had been aggressive. Several caregivers talked of being able to detect warning signs of when a resident was becoming agitated. They could then take steps to prevent violent behaviour. Some staff members believed that workplace demands did not always enable them to avert aggression in the way they would have wished. Recent research suggests that time pressure at work has a significant negative impact on the physical and therapeutic care given to residents and perceptions of their quality of life. (8)
Reporting practices appear to vary among caregivers and residential care facilities. Everyone interviewed spoke of procedures for writing incident reports and verbally reporting aggressive behaviour. Incidents in which there was serious harm to a staff member or resident were all formally recorded. Uncharacteristic and persistently difficult behaviour from a resident tended to be spoken about at changeover time or written down in notes. Variations occurred in reporting verbal aggression and also physical assaults that caused little or no visible damage. Participants used a number of different strategies to manage aggressive behaviour from residents. Reporting was viewed as an important and helpful requirement and used as a way of protecting staff and patients, as follows:
Firstly, to protect the resident: "It's up to the caregiver to be able to report so that things can be looked at to try and protect [the residents]." (Int.5)
Secondly, to protect other staff: "And all the behaviours are documented because the next person needs to know, and that's really important." (Int.23)
Thirdly, to protect themselves legally, psychologically and from perceptions of incompetence: "I document everything. Then I'm safeguarding myself because if something happens to somebody else, you say "That person did that today. " (Int.4)
As a safety valve: "And of course I don't bottle it up inside me. I do the right thing and report it." (Int.16)
Following an assault by a resident: "I wrote "her wrist might be a bit red" ... the other staff said that's absolutely fine, cause they knew you had to protect yourself." (Int.8)
The most commonly noted support for managing aggressive behaviour was that received from other caregivers. Everybody spoke of discussing incidents with colleagues or being assisted by other caregivers after an incident. A number of people referred to the teamwork among staff and their appreciation of this in handling difficult situations with residents. Staff who worked on night shifts or weekends mentioned that there was less support available in the facility than during a day shift or on weekdays.
Over three-quarters of the participants talked of the support they received from senior staff or management. Registered nurses and managers were usually regarded as approachable and helpful. However, some caregivers preferred to discuss their problems with their colleagues rather than taking them to management. While several people found family and friends supportive for talking through aggressive incidents, this also raised confidentiality issues for them and sometimes limited what they could discuss.
Nearly all the participants had completed, or were in the process of completing, courses related to residential caregiving. Half had finished at Least one course in the Aged Care Education home-based programmes. Others had been enrolled in courses from different training providers. Caregivers also often referred to their in-service training. Although courses covered general and dementia caregiving, they were not always seen as having been particularly helpful in dealing with critical incidents that had arisen at work. This is because the courses were perceived to have limited content on managing aggression or abusive behaviour. A number of caregivers thought that the best way of Learning was through on-the-job experience.
Several caregivers expressed a wish for further training or support to manage aggression encountered in their daily work. Suggestions included:
* introducing a buddy system of two to three weeks for new staff members;
* providing training by people experienced in working with aggression;
* making more information on dementia available to staff;
* distributing a newsletter for caregivers covering issues such as aggression.
This research project has involved a comparatively small number of residential workers in the Christchurch area and does not purport to represent caregiving staff generally. The findings raise issues around the downplaying of aggression experienced by workers, perceptions of training, levels of support received, and variability in reporting practices. Further research is required to explore these aspects of residential care more fully.
(1) Goodridge, D. M., Johnston, P. & Thomson, M. (1996) Conflict and aggression as stressors in the work environment of nursing assistants: Implications for institutional elder abuse. Journal of Elder Abuse and Neglect; 8: 1, 49-67.
(2) Goergen, T. (2001) Stress, conflict, elder abuse and neglect in German nursing homes: A pilot study among professional caregivers. Journal of Elder Abuse end Neglect; 13: 1, 1-26.
(3) Astrom, S., Bucht, G., Eisemann, M., Norberg, A. & Saveman, B-I. (2002) Incidence of violence towards staff caring for the elderly. Scandanavian Journal of Caring Sciences; 16, 66-72.
(4) Astrom, S.. Karlsson, S., Sandvide, A., Bucht, G., Eisemann, M., Norberg, A. & Saveman, B-I. (2004) Staff's experience of and the management of violent incidents in elderly care. Scandanavian Journal of Caring Sciences; 18, 410-416
(5) Rogers, M. C. (2000) Nursing home caregivers and their perceptions about residents' disruptive behaviors. Unpublished PhD, Ohio State University, Ohio.
(6) Shaw, M.M.C. (1998) Nursing home resident abuse by staff: Exploring the dynamics. Journal of Elder Abuse and Neglect; 9: 4, 1-21_.
(7) Kiata, L., Kerse, N. & Dixon, R. (2005) New Zealand Medical Journal; 118, 1214. http://www.nzma.org.nz/journal/118-1214/1445.
(8) Pekkarinen, L., Sinervo, T., Perata, M-L. & Elovaino, M. (2004) Work stressors and the quality of life in long-term care units. The Gerontologist; 44: 5, 633-644.
Daphne Manderson, RN, ADN, BA, MED (dist), PhD, is a senior Lecturer at the Christchurch Polytechnic Institute of Techology's School of Nursing.
Verna Schofield, PhD, is a Senior Research Fellow in the Department of Social Work at the University of Canterbury.