Nursing Home Violence: Occurrence, Risks, and Interventions
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Ryan C.W. Hall, MD, Richard C.W. Hall, MD, and Marcia J. Chapman
Author Affiliations: Dr. Ryan Hall is an Affiliate Instructor at the University of South Florida, and is a 2006 Rappaport Fellow; Dr. Richard Hall is Courtesy Clinical Professor of Psychiatry, University of Florida, and Affiliate Professor, Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa; and Ms. Chapman is Research Assistant to Dr. Richard Hall.
Nursing Home Violence Prevalence
Nursing assistants working in long-term care facilities have the highest incidence of workplace violence of any American worker, with 27% of all workplace violence occurring in the nursing home (NH).1,2 Aggressive and violent behavior, which is often seen in the NH, includes repetitive demands, verbal outbursts, sexual advances, and physically aggressive acts2,3-6 (Table I). Over time, such behavior creates a stressful environment for other residents and staff. Nursing home studies show that repetitive patterns of aggressive disruptive behavior occur regularly in 43-85% of NHs surveyed.3,7,8 This prevalence is likely an underestimate due to many episodes of aggression not being reported (ie, an estimated 55-80% of violent episodes).2
Staff surveillance studies show that 70% of NH staff are assaulted at least one time per month.5 Certified nursing assistants (CNAs) are physically assaulted on average nine times a month.5,8,9 Approximately half of all NH staff have been injured by these attacks at least once during their careers, with 38% of those who are injured requiring medical treatment for the injury.2,5,8
Research has indicated that 75% of assaults against NH staff occur during periods of close staff–resident contact, such as during resident transfers/turning (26-33%), or when assisting with activities of daily living (ADLs), such as dressing changes (43%), toileting (9%), feeding (12%), and bathing (19%).3,5,10 Assaults reported during these times include grabbing/pinching/hair pulling (38-40%), scratching/biting (4-28%), hitting/punching (12-51%), pushing/shoving (8-8.2%), hitting with object/throwing objects at staff (3-9%), kicking (2-27%), and spitting (1-11%).2,3,5 Typical verbal aggression includes verbal insults (18.1%), verbal threats (10.7%), and sexual advances (0.7%).3 In a study by Gates et al,10 5% of aggressive behavior (including verbal and physical assaults) resulted in injury to the staff.
Patient Risk Factors for Violence
The residents most likely to assault NH staff are those diagnosed with a dementia or other organic brain syndrome.5,10 Residents with mild-to-moderate cognitive impairment are 2.59 times more likely to physically assault staff as compared to cognitively-intact residents, while residents with a “severe cognitive impairment” are 8.26 times more likely to become aggressive.3 What is interesting is that the odds ratio for verbal assaults is much lower in individuals with severe dementia, respectively 1.85 for mild-to-moderate impairment and 1.48 for severe cognitive impairment.3 This indicates that residents with dementia may be much more likely to attack without the typical verbal escalation that is seen in cognitively-intact residents, and, therefore, may be more dangerous.
The two most common medical diagnoses found in individuals who assault staff are Alzheimer’s dementia (approximately 90%) and cerebrovascular incidents (approximately 5%).2,10 This is not surprising since some studies have indicated that 70% of individuals with dementia experience agitation.
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