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A major challenge faced by nursing staff face in nursing homes is dealing with aggressive behaviours exhibited by patients with dementia. Aggressive behaviours are common in patients with dementia and can result in injury to both staff patients in nursing homes. Staff caring for patients with dementia are particularly vulnerable to physical and verbal aggression which can lead to physical and emotional stain of nursing staff. Effects of aggression may jeopardise the care of the patient as they will be avoided by staff. The literature review provides a synthesis of literature from different databases mainly written by nurses with the aim of illuminating the nursing staff experiences and responses of being exposed to aggression in nursing homes. It will also explore the context in which aggression takes place and investigate the effectiveness of education and training in managing aggression. This review highlights the need for training and education for nursing assistants working in nursing homes. This will help in the advancement of future training and education programs to improve nursing staff understanding and knowledge of aggressive behaviours in patients with dementia. Finally there is call for future research on the problem of aggression in persons with dementia from an Irish perspective.
The aim of this literature review is to explore nursing staff experiences and responses in caring for dementia patients who exhibit aggressive behaviours. With more people growing older and living longer in Ireland more people will be requiring nursing home care. (Fahey et al.2007). This is an important area of research as the majority of people in nursing homes have dementia. Currently more than 44000 people in Ireland are living with Dementia and number is expected to rise by the year 2036 to 104000 (O’shea 2007). Dementia is defined by the American psychiatric association DSM-1V-TR (2000) as an overall decline in intellectual functioning including having difficulties with language, simple calculations, planning judgement and motor skills as well as loss of memory. According to Morgan et al. (2005) the progressive degeneration of the brain in dementia is often accompanied by behavioural disturbances. The most challenging behavioural disturbance associated with dementia is aggression .According to Egan et al. (2007) approximately 25% to 50% of individuals with dementia exhibit aggressive behavior at some time through the course of the disease. Aggressive behavior seems to be most prevalent in the moderate to severe stages of the disease when individuals are most likely to be residents of nursing homes. (Egan et al.2007). Aggression has been shown to be physically and emotionally demanding for nursing staff in nursing homes who are victims of aggression. (Shaw 2004). This paper will synthesize the research literature related to aggression by people with dementia in residential care settings, highlighting issues for nursing practice, and directions for future research in Ireland.
The author’s rational for choosing this topic is based on own personal experiences, having worked as a nursing assistant in a nursing home for the past seven years. The basis for undertaking this review on aggression in dementia is to assess the research relating to this topic, to obtain knowledge about nursing staff responses when working with clients who are aggressive in nature and to understand the context in which these behaviours take place. This is vital for nursing care as incidents of aggression continue happen on a day to day basis in the nursing homes. (Morgan et al.2005)
As a result of the vast scope of literature surrounding the area of aggression in dementia this review concentrates on data only relating to individuals with dementia who are in long term care units and nursing homes who have some form of dementia. This shows that this topic is popular with researchers especially nurses who represent the majority of the studies. Only articles written since 1999 to date with the exception of two articles, one from 1992 and another from1989 were used. Articles selected addressed specific areas to dementia, aggression and nursing staffs’ experiences. To identify literature specific databases were used which included CINAHL, Proquest, Pubmed, Ovid and Synergy alongside relevant journals. The keywords for the search were: dementia, aggression, caregiver, experiences, nursing home, and violence. To supplement the research found, cross-referencing was used until no further articles were found. The author then disregarded those articles that did not meet the required criteria. Primary sources provided the majority of the literature; though some secondary sources were used purely to broaden the overall body of knowledge. A number of recurring themes were identified by the author of this review. However due to the word restrictions the author focuses on three themes that were popular with the researchers. These themes are the experiences of the nursing staff, situations in which aggression is likely to take place and the effects of training and education on nursing staff. For the purpose of this review the term nursing staff will be used as an umbrella term for caregivers, nurses, nursing assistants and registered nurses. Nursing home will be used to represent long term care units and residential settings.
In keeping with Parahoos’ (2006) definition of a literature review, this paper will provide a critical summary and synthesis of knowledge regarding the nursing staff experiences when working with people with Dementia in nursing homes as a way of recognizing gaps in the literature that may call for future practical and empirical attention.
Aggression in the person with dementia
A common behavioral symptom of dementia is aggression. It is associated with frontotemporal dementia, cognitive decline, other behavioral psychological disturbances and greater dementia severity (Brodaty & Lee-Fay 2003). According to Patel and Hope (1992 p.457) Aggression in dementia is defined as ‘an overt act involving delivery of a noxious stimulus to another person which was not clearly accidental.’ Aggression as a symptom can exist independently or can be in conjunction with other disturbances such as psychosis or depression (Brodaty & Lee-Fay (2003). Aggression in Dementia may also be as a result of unmet physical needs such as pain infection, poor sensory perception and hunger. Inability to communicate these needs gives rise to aggression (Schreiner 2001). In general aggressive behaviors have been found to occur across allages of demented elderly but with a slightly higher frequency among males. (Gates et al.1999, Schreiner, 2001, Shaw 2004).
One of the most widely used instruments to measure aggression is the Cohen Mansfield Agitation inventory (CMAI) which codes 29 common agitated behaviors among the elderly with dementia (Cohen et al.1989). The two most common types of aggression that are explored in this review are verbal and physical aggression. Types of verbal aggression include the following: threats of physical harm, racial slurs, cursing, screaming, swearing, yelling and demeaning remarks. Physical aggression includes the following behaviors hitting, scratching, grabbing, pinching, twisting wrists, throwing objects and spitting. (Cohen Mansfield 1989, Gates et al. 1999, Shaw 2004). Because these types of behaviors are similar to the ones in the studies reviewed, they will not be listed again but will simply be referred to a physical and verbal aggression. The studies (Gates et al 1999, Brodaty & Lee-Fay 2003, Shaw 2004, McNesse et al.2009) examined by this review show that the incidence of verbal aggression is more than physical aggression.
Experiences and responses to incidents of aggression by nursing staff
According to McNesse et al. (2009) working with people who have dementia is associated with a high risk of experiencing broad range of aggressive behaviours. A high percentage of nursing staff find that physical and verbal attacks by an elderly client they are looking after can be one of the most difficult parts of their work which results in feelings of anger, sadness, ineffectiveness and powerlessness. These responses to aggression are not only triggered by the aggression but by the negative responses of other health professionals and administration staff working within nursing homes (Danesh et al.2008)
Gates et al. (1999) conducted a qualitative study in the USA to determine whether staff in Long term care units considered resident aggressiveness to be violence. The study which was carried out on a convenience sample of 54 caregivers and 6 director of nursing in which structured group interviews were used found that, incidents of aggression both physical and verbal happened on a daily basis and caregivers perceived them to be violence. Hurt, angry, sad, resentful, violated and fearful were some of the words used by the caregivers to describe how they felt after an incident of aggression. There was little or no emotional support from administration staff. Caregivers did not report incidents as they feared being blamed for the aggression and they also feared that their job would be threatened Caregivers viewed aggression as ‘part of the job’. These findings are also consistent with Shaw 2004, Danesh et al.2008, Issaksson et al, 2009.
Different Studies carried out in different countries settings, years consistently identify similar types of staff responses. Shaw (2004) carried out a qualitative grounded theory study in the USA via structured questionnaire of 15 nursing home staff. The objective of the study was to present the real world views on the conditions and context of resident aggression and realistic approaches used to prevent and handle aggression described by the nursing staff. Even though the purposive sample was very small, the results of the nurse’s experiences were consistent with those Of Gates et al. (1999). Staff also experienced the same forms of physical and verbal aggression which left them feeling hopeless and helpless and they still did not receive any emotional support from the administration staff. However there seems to be some improvement in reporting incidents as caregivers report all incidents of physical aggression. The study also found that even though verbal abuse troubled staff more than physical abuse it was not routinely documented.
A more recent study in Norway by Issaksson et al. (2009) with the aim to illuminate the experiences of 20 female caregivers’ exposed to violence in nursing homes shows that not much has changed in the last decade, Caregivers were still being exposed to daily physical and verbal aggression by patients and were simply accepting it as part of their job. Even though the sample was too small and biased as it only focused on female experiences only, the results are consistent with previous studies.
Unfortunately Studies by Gates et al.1999, Shaw 2004, Danesh et al.2008, & Issaksson et al (2009) revealed that nursing staff do not report incidents of patient to nurse aggression as they consider the aggression to be insignificant. Nursing staff who care for people with dementia who are aggressive regard it to be part of the job. Sharipova et al. (2008) survey study of the prevalence seriousness and work reporting violence in the Danish elderly care found that there was underreporting of aggression incidents. Only half of the incidents that were perceived to be serious and resulted in injuries were reported. The main reason for not reporting was that it would not make a difference and staff perceived it to be part of the job. The study also revealed that caregivers distanced themselves form the violent residents. This meant that patients were at risk as the quality of nursing provided to them became limited.
Another important finding from the literature is that caregivers experience a significant amount of stress, negative feelings and burnout as a result of the aggression in residential care homes (Gates et al. 1999) This can be supported by a study by Rodney (2000) study in Sydney which was based on the response of 102 male and female nursing staff who filled out a rating scale which assessed four areas of aggression. The purpose of the study was to examine the link between aggressive behaviours exhibited by people with dementia and nursing staff stress The results which were based on a hierarchical regression which revealed that patient aggression was significantly related to an in increase in nurse stress.
These results are consistent with a study by Evers et al. (2002) in the Netherlands that was based on 551 questionnaires by staff working in the LTC units which revealed that the more a caregiver worked, the more they were likely to experience aggression. The more the frequency of Physical aggression experienced by caregivers the more the chances of experiencing burnout. So far this theme has looked at the caregiver’s experiences and reactions to aggressive behaviours. It would be vital to understand why aggression happens.
An Understanding of the context in which aggressive behaviour occur
Examining the links that exist between various types of aggressive behaviours and other personal environmental parameters may help nursing staff understand the reasons for aggression.(Evers et al.2002) A number of studies (Gates et al.1999, Skovdahl et al 2003, Astrom, 2004 & Shaw 2004 ) have shown that most aggressive incidents are associated with personal care tasks. One such study is that by Gates et al.2003. The aim of this study was to describe the environment in which aggression occurs and to identify characteristics of the caregivers to assaults. The study revealed that the majority of incidents took place when caregivers were performing personal care tasks. 43% of the incidents took place whilst dressing and changing the patient, 26% while turning and transferring, 19% bathing, 12% feeding, 9% toileting and other reasons made up the remaining percentage. According to the study, aggression is usually a reaction to misinterpretation of intimate care. (Gates et al.2003) Patients misinterpreted intimate care as violation of personal space by the caregiver. However personal care is impossible to avoid when looking after demented patients but it seems to be the most important factor for prompting aggressive behaviour.
A study in Japan by Schreiner (2000) based on a sample of 391 patients found that patients who require more help with their personal care had significantly higher frequencies of aggressive behaviours. Nursing staff reported that most, if not all of the aggressive behaviours took place when patients were receiving personal care.
To gain an understanding of why patients misinterpret personal care as violation Somboontanont et al (2004) carried out a study to identify immediate antecedents of bathing related physical assaults based on a sample of 73 patients that were video tapped during 2 to 3 routine showers. The results suggested that patients were likely to react aggressively during the showers if caregivers were too hurried disrespectful, communicated negatively and did not explain to the client what they were doing. These results are consistent with Levin et al.( 2003 ) study which revealed that, worker attitude does contribute to the likelihood of an assault The study also showed that lack of respect for the residents, being short staffed or rushed and disregarding the patients preferences may hasten verbal or physical attack. When residents view care as dangerous or threatening, they become fearful and overwhelmed and sometimes aggressively resisted care to protect themselves. According to Shaw (2004) and Somboontanont et al. (2004) caregivers have multiple simultaneous demands from administration staff, patients and patients families that creates an atmosphere in which the care of the patient if often rushed
Another study from a caregiver’s perspective that’s consistent with these results is one by Skovdahl et al (2003) The study that was based on a small sample of 15 nursing staff. The study revealed that revealed that caregivers who reported incidents of aggression did not focus on therapeutic communication with the client but rather focused on accomplishing their tasks in the quickest possible time. These results posit the need for education and training for caregivers in order for them to understand the context in which aggression takes place and to be aware of the triggers that bring out aggression.
Effectiveness of education and training in managing aggression.
In the previous theme the author posits that nursing staff lacked the knowledge and skills to prevent aggression in nursing homes. This theme will address this issue. Hughes et al. (2008) carried out a study the UK to determine the factors about the knowledge of nursing in relation to care of the older person with dementia. The study was based on a self questionnaire by 254 care staff working in long term care units. The results showed that nursing staff who had received training in dementia and/or senior carers’ level of knowledge were associated with higher confidence. The study clearly shows that learning and knowledge can greatly improve competence and confidence of nursing staff in dealing with aaggression However the weakness of this study was that self administered questionnaires were used. With these types of questionnaires the researcher and the respondent do not interact and problems with questionnaire can not be corrected. The researcher cannot help the respondents to get clearer understanding of questions if needed.
A study that supports Hughes et al. (2008) findings is a study by Fitzwater & Gates (2000) in America. The study used a used a quasiexperimental design to test the how effective the education intervention was in reducing aggression toward caregivers in nursing homes in Ohio. Two nursing homes that had roughly the same number of beds were randomly selected. 20 caregivers, 10 in each group took part in the experiment. After the training caregivers were asked to complete an assault logbook for ten days. Results showed that there was a huge difference in the number of assaults experienced by the two groups. There were fewer assaults in the intervention group. The study indicated that the training had a positive effect on reducing the number of assaults in the intervention home. The more knowledge, skill training and good attitude, the greater the potential to maintain safety and prevent injury. The limitation of this study was that it was based on a small sample and there was lack of random sampling.
Gormely et al.(2001) conducted a study in the UK with the aim of providing evidence that behavioural strategies are effective in the management of aggressive behaviours for clients with dementia. The study was based on 62 patient and nursing staff pairs with half of the group representing the intervention group and the other the control group. Even though the sample was too small the results were consistent with those of Fitzwater & Gates (2003).The results indicated that behavioural strategies were effective in the management of aggressive behaviours in dementia. Beck et al.(2002) conducted a similar study which set to find the effects of behavioural interventions on disruptive behaviour in LTC unit residents with dementia. The results were in contrast with that of Gormely et al. (2001). The results of the study indicated that even though there was an increase in staff knowledge, there was no effect on disruptive behaviours after the intervention.
This paper has considered the phenomenon of aggressive behavior perpetrated by people with dementia in nursing homes. It is highly evident from the research literature that nursing staff frequently encounter verbal and physical aggression from residents with dementia. Not uncommonly these encounters result in emotional pain, physical injuries, need for medication, and lost work time. Unfortunately nursing staff have accepted aggression as part of their job as unavoidable and occurring on a daily basis.
The reflections of the nursing staff on their experiences can help researchers understand the common feelings when dealing with patients who are aggressive. A number of the studies (Gates et al 1999, Skovdahl et al. 2003 & Shaw 2004) have highlighted that nursing staff often under-report incidents of aggression perpetuated against them .It might be vital to establish a standardized reporting instrument developed by the nursing staff themselves. (Evers et al.2001) In this way a staff involved in incidents of aggression would be encouraged to report them which will not make them feel left out. Improved reporting of incidents will contribute to more accurate research findings for researchers which will help in developing new strategies to manage aggression.
According to An Board Altranais (2000) the aim of the nursing profession is to give the highest standard of care to patients. Patients should not be neglected simply because of their symptoms. This review highlighted that aggression mainly occurs when residents become overwhelmed with care and when carers invade their personal space. (Shaw, 2004) Strategies need to be developed to make personal care more therapeutic for individuals with dementia. Future research should try to determine staff characteristics and contexts that are associated with high incidence of aggression.
Most of the studies reviewed found evidence that an educational intervention can effectively decrease aggression against nursing staff. The results of the review concerning education intervention clearly support the need for further evaluation of educational strategies and their effectiveness in reducing aggression.
While it is certain that education and training appear to reflect good and common sense practice, there is no clear research evidence for the general effectiveness of any one educational approach. If nursing staff attempt to understand the meaning of the behavior and respond appropriately, this will enhance quality of life for the person with dementia and reduce the incidence of aggressive behaviors. This review has highlighted the need for further research in Ireland in the area of aggression and dementia.