An Understudied Issue
By Lynn McDonald, PhD and Sander L. Hitzig, PhD
Over the past two years, there have been several reports in the media of aggression between residents of long-term care homes. In some instances, these aggressive acts have led to serious injuries and death. This was the case for Mr. Frank Piccolo, who was living in a long-term care facility because of Parkinson’s disease and dementia. On the evening of February 18, 2010, Mr. Piccolo was severely beaten in his wheelchair on two separate occasions by another resident. Because of his ailments, he was unable to move or call for help. The severity of the attack left him slumped over in his wheelchair, bloodied with scratches and bruises from being repeatedly hit over the head with a wooden activity board. The perpetrator, a woman who also had dementia, was found not culpable for these assaults. Mr. Piccolo died three months later.
Resident-to-resident aggression is a growing phenomenon in long-term care homes. It has significant implications for the safety of residents and presents challenges to the long-term care system. Aggressive acts can be physical (e.g., pushing, shoving), verbal (e.g., yelling, threatening), sexual (i.e., any unwanted sexual act, such as kissing or fondling) or material (e.g., stealing), all of which will negatively affect the health and well-being of residents.
What the research tells us
Surprisingly, the issue of resident-to-resident aggression has been vastly under-researched. Preliminary reports on the available Canadian data suggest that resident-to-resident aggression makes up one-third of all reported incidents across long-term care facilities. For instance, data obtained through the Access to Information Act of Canada found there were nearly 23,500 reported incidents in Canadian long-term care homes in 2011. Of those cases, 6,445 (28%) were classified as aggressive acts occurring between residents. However, there are no robust studies providing exact data on how often resident-to-resident aggression occurs. We also do not have a good understanding of who is most likely to be aggressive, who is at the greatest risk for being a victim, where and when such aggression occurs and, more importantly, why it occurs.
It is difficult to study this issue for a number of reasons. First, such aggression is relatively new and is becoming more prominent as greater numbers of our aging population require the support of long-term care. Based on the current figures for people living in such facilities, it is projected that more than half a million Canadians will require long-term care by 2031. If current system-level issues (e.g., chronic staff and bed shortages) remain constant, it will become progressively more difficult for long-term care staff and facilities to meet the increasingly complex needs of residents. As a result, the development and implementation of adequate models of care will be constrained, which is likely to result in more aggressive acts occurring between residents.
Defining the problem
Second, there is no consensus on what constitutes this type of behaviour or how to properly label it. People working in the field of dementia often describe aggressive acts between residents as “responsive behaviours”—behaviours that arise because of an unmet need in an individual, causing the person to act out. For example, if a resident becomes increasingly frustrated with the loudness of the television in a common area, but is unable to effectively communicate this to others (staff or residents), the build-up of frustration might cause him or her to lash out at another nearby resident. However, “responsive behaviours” is a term that does not capture the breadth of resident types in long-term care, since not all residents who commit aggressive acts have dementia.
Other labels in use include resident-to-resident violence, resident-to-resident relational aggression, resident-to-resident elder mistreatment and resident-to-resident abuse. Although all of these terms describe the event, they might not be adequate for explaining why it occurs. In addition, they can place undue stigma on the perpetrator.
“Resident-to-resident abuse” might be inappropriate since most definitions of abuse and neglect include an expectation of trust on the part of the victim in relation to the perpetrator. If the presence of dementia is a contributing factor, then both the perpetrator and victims can suffer harm. In addition, the terms “resident-to-resident abuse” and “resident-to-resident violence” place negative connotations onto the perpetrator by suggesting an intent behind the act—thus making the aggressor culpable for a supposedly unprovoked act.
Regardless of the terminology, studies and media reports on resident-to-resident aggression have shown that, despite the significant trauma resulting from these acts, clinical staff and legal authorities do not have a framework for addressing their consequences. For example, if the perpetrator is deemed liable, should the police arrest that person and should he or she go to trial? If so, will the trial find that the person is not responsible for his or her actions because of dementia? Overall, the field needs a common working definition of this issue in order to move forward with meaningful studies on how to describe, manage and hopefully prevent aggressive acts. This might, in turn, lead to better clinical and legal accountability frameworks.
Although the problem is understudied and models of care to address aggressive acts are required at the practice and policy levels, various groups have acted on this serious resident safety issue. Some research has been spearheaded by the Institute for Life Course and Aging at the University of Toronto. This has included organizing projects and meetings with input from Canadian and international experts in elder abuse, resident-to-resident aggression, dementia care, and health services and policy to gain consensus on a definition of aggression in long-term care; decide on the topics that should be investigated to better understand its occurrence; and actively develop approaches to prevent it.
The first major meeting on resident-to-resident aggression was held in May 2014, and included representatives from medicine, nursing and social work, as well as advocates (e.g., family council/elder abuse representatives) and researchers, all of whom were working to address this issue. From this large stakeholder event, the term “resident-to-resident aggression” was selected, and was defined as: negative, aggressive and intrusive verbal, physical, sexual and material interactions between long-term care residents that in a community setting would likely be unwelcome and potentially cause physical or psychological distress or harm to the recipient.
The use of “resident-to-resident aggression” allows for the inclusion of a target of the aggressive act, while emphasizing the potential for physical and emotional harm resulting from the act. The selection of a unified term can help to clarify how the issue should be measured across studies, which can facilitate comparisons of the results from different research projects.
In terms of priorities, there was consensus on moving forward projects that aim to develop and assess environmental interventions for preventing the occurrence of resident-to-resident aggression, including the identification of environmental risk factors; and studies to gain a better understanding of the scope of the problem.
Environmental interventions might act on not only the physical setting, but also the cultural and social surroundings—for example, the shared beliefs held by staff at a facility. One approach to changing the “environment” could be to provide education and training to staff on strategies for preventing resident-to-resident aggression. Similarly, enacting policies to support staff training
on this topic could facilitate a reduction in the number of cases.
With regard to the physical environment, there is a need to
better understand how spaces are configured and to optimize communal living conditions for people with a variety of physical
and cognitive impairments.
Studies aimed at describing the scope of the problem can help identify who is likely to perpetrate aggression, who is at most risk of being a victim, and where and when such aggression is most likely to occur. Having an understanding of the “who,” “where,” “what” and “when” can lead to important insights on why resident-to-resident aggression occurs, and thus contribute effective strategies for its prevention.
Practice and policy
At the practice and policy levels, a number of organizations have developed best practice guidelines, educational approaches and other resources to address aggression between residents. For instance, the Registered Nurses’ Association of Ontario (www.rnao.ca) has a number of clinical best practice guidelines that can serve to address issues of violence in the workplace and for preventing and addressing the abuse and neglect of older adults. Similarly, the National Initiative for the Care of the Elderly (www.nicenet.ca) hosts an annual knowledge exchange for practitioners that has dedicated sessions related to dementia care and aggression in long-term care homes.
The Ontario Ministry of Health and Long-Term Care
(www.health.gov.on.ca), the Ontario Long Term Care Association (www.oltca.com) and the Alzheimer Society of Canada
(www.alzheimer.ca) also have a number of activities underway
and accompanying resources dedicated to preventing and managing resident-to-resident aggression. Overall, resident-to-resident aggression is now recognized as a significant health
and safety issue for residents of long-term care at all levels,
which is the first step towards its prevention.
Despite the increased recognition that resident-to-resident aggression is a regular occurrence in long-term care homes, there is still a considerable amount of work to be done. People in long-term care homes represent our frailest and most vulnerable members of society and deserve the best of care. But if this is the case, why are the rates of physical, verbal and sexual assaults so high? This is unacceptable. Immediate action is needed to develop and implement strategies so that the type of terrible assault Frank Piccolo endured never happens to another person living in long-term care.
Lynn McDonald, PhD, is a professor at the University of Toronto Factor-Inwentash Faculty of Social Work and Director of the Institute for Life Course and Aging.