Jun 19, 2020

Resident aggression towards staff: ‘Is it just part of the job’?

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Aged care workers are, from time to time, the target of aggression from the residents they care for at work. Sometimes it is from residents who are living with dementia, who may find themselves unable to communicate their needs and lash out.

We often hear from our readers who work in aged care that these incidents are simply ‘part of the job’.

Aged care workers have reported residents push them, bite them, or run their walkers into them, causing fear, distress and physical injury. Some have even left their jobs due to these types of incidents.

In this article, we set out to find out what is expected and if this is simply ‘part of the job’ of an aged care worker, as many of our readers suggest? We also ask how these physical attacks can be minimised or avoided – and what happens when every strategy has been tried, but the physical attacks/incidents continue?

Person-centred care can help

Colin McDonnell, dementia consultant at Calvary Care, told HelloCare physical attacks/ incidents are often referred to as ‘responsive reactions’. They are usually a reaction to a resident’s ‘unmet needs’ and are commonly an expression of fear or frustration, and have no intent to harm.

He said the best way to prevent physical attacks or incidents is to get to know the person and deliver person-centred care. 

By talking to the person and their family, staff can get to know the resident’s history, know what makes them happy, know what makes them angry, and know how to communicate with them. Once armed with this knowledge, staff can learn how to avoid ‘triggers’ to emotional or aggressive responses.

“Ninety-three per cent of communication is body language and tone,” he said, explaining that using non-threatening movements and a soothing tone can help prevent aggressive situations from escalating or arising in the first place.

Incidents should be reported

Though some staff believe it is so, violence towards staff should not be thought of as ‘just part of the job’, Associate Professor in Ageing and Health at the University of Sydney, Lee-Fay Low, told HelloCare.

“We’ve had many staff show us bruises where they’ve been pinched, or tell us stories about pushing, hitting that they’ve experienced, particularly when trying to help with personal care.”

These incidents are “commonly” not reported, she said.

“These experiences are not acceptable in the workplace, and should be reported, discussed and preventative actions should be undertaken,” said Associate Professor Low.

More education is needed, she said. If staff are educated about these types of incidents they are more likely to be reported, and then the issues that cause them are more likely to be addressed, Associate Professor Low said.

Addressing violent responsive reactions requires both individual staff and the facility’s clinical team to identify what is causing the behaviours and to have a strategy for reducing the risk of them occurring. 

These strategies should form part of the person’s care plan, said Associate Professor Low. 

To execute a care plan for some residents, staff may need additional training, for example they may need training for supportive showering for residents who can become aggressive. 

Staff and management may need to consider changing the timing of showers, or who is undertaking showers if it’s thought that showering precipitates aggressive behaviours, Associate Professor Low suggested.

If additional advice or support is needed, Associate Professor Low suggested seeking help from Dementia Behaviour Management Advisory Service (DBMAS) or Dementia Australia’s Severe Behaviour Response Team (SBRT).

Workplaces must be safe

Both Leading Age Services Australia (LASA) and Aged & Community Services Australia (ACSA) told HelloCare employers have a responsibility to provide safe workplaces for their staff.

LASA CEO, Sean Rooney, told HelloCare that employers must identify any risks to staff, such as dementia patients who have shown behavioural and psychological symptoms. 

Employers must assess the risks and control them “as much as reasonably possible”. 

These measures must also be reviewed, especially in cases where there has been an incident, Mr Rooney said.

ACSA CEO, Patricia Sparrow, said, “comprehensive” resident assessments and care planning should include identifying behaviour triggers and management strategies for people with challenging behaviours.

Strategies should “provide staff with guidance on what to do should such behaviours occur, including how to de-escalate an aggressive behaviour episode, and how to respond… including by removing themselves from such a situation and seeking assistance.”  

Strategies should aim to “minimise the stress felt by the person with dementia as well as minimising the risk of episodes of aggression”, she said. 

Clear reporting procedures

Mr Rooney said it was also important that employers have clear reporting procedures for when incidents do occur. 

Staff must seek access to first aid or medical assistance if they require it, then report the incident immediately, with as much detail as possible, to management. 

“Aged care staff should discuss with their supervisor any concerns they have about working with particular residents, so that they can take appropriate action to manage risks and follow procedures around individual residents”, Mr Rooney said.

“Management needs to ensure staff are appropriately reporting incidents so that action can be taken to support them, to identify hazards, assess and control risks, and review any control measures that were already in place at time of the incident,” he said.

All incidents should be investigated, and procedures should be in place to guide employees on what to do when incidents are occurring and what to do immediately afterwards, Mr Rooney said.

Medication is not the answer

Mr McDonnell said antipsychotic medications simply increase the risk of falls and usually don’t stop aggressive reactions for those living with dementia.

Leading Age Services CEO, Sean Rooney, echoed that sentiment. 

“Chemical restraint with the use of psychotropic medications is sometimes used to manage behaviours. 

“However, this is not a favourable strategy and we strongly support other management strategies and the reduction of chemical restraint in aged care,” Mr Rooney told HelloCare.

Aged care not funded for severe cases

Mr McDonnell said when staff have done all they can to meet the resident’s needs but the resident continues to act out their frustrations in aggressive ways, facilities are often not funded for the extra level of care and support required. 

Mr Rooney said LASA supports the idea of higher funding for increased training and dementia management.

Mr McDonnell said he has worked in a facility where one resident lived in a six-bed unit with one-to-one care. “It was our duty of care,” he said, but it came at the expense of five beds left empty.

Sometimes the most severe cases mean a resident moves between hospital, psychiatric ward and aged care facility. “It’s really difficult for everyone,” Mr McDonnell conceded.

When all else fails 

Sometimes residents will have to leave a facility, Associate Professor Low said.

“If the facility cannot manage the resident such that they are a danger to staff after trying non-pharmacological and possibly pharmacological approaches, then they might be asked to leave. It happens,” she said.

“We have certainly encountered cases where the facility does not have the clinical expertise or staffing to care for the resident safely,” Associate Professor Low said.

The resident might be transferred to a more skilled and staffed facility such as a dementia specific unit, or in “extreme cases”, it might be appropriate to transfer them to a specialist unit, such as an SBRT. However, only a few of these places are available and they are short term places only, Associate Professor Low noted.

Ms Sparrow said providers often face “challenges” accessing specialist acute care services such as SBRT, especially in regional and rural areas.

Managing aggressive incidents for residents living with dementia is a highly complex area, it requires training, funding, experience and goodwill. It’s not easy. But violence at work is never acceptable. Staff who are concerned about aggressive residents should speak to their employer about it; it is certainly not ‘just part of the job’. 

Helpful strategies for managing aggressive incidents for those living with dementia can be found here.

Image: Heiko Küverling, iStock.

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  1. Most of the staff I work with hardly ever report aggressive behaviours as the RNs hate filling out incident reports. To make things worse the AINs are always blamed for the resident’s behaviour and a progress note always mentions in it that staff have been “re-educated”. Putting the blame on the staff again as management hate hearing they have aggressive and sometimes violent residents. I put the blame on all past and present governments for assuming it will be right mate! All the training in the world does not make us AINs professional physiology experts! What they need in all aged care facilities are security staff and emergency call buttons that staff can wear on their uniforms. You know. Like in public hospitals. There have been so many times when there are no staff to help in an emergency. The men are too small and not at all cut out to help when a situation pops up. If anything I have experienced scary behaviours in Dementia specific wings and the male staff have turned up and have done nothing!! Even they were too scared to intervene! All you experts, tell me what the best method is to deal with violent residents. Maybe we need to take a look at public hospitals to see how they deal with violent psychotic residents! It is not just staff at risk but other residents and visitors as well.

    1. There is no one answer for all the things that are wrong in the facility you work at.
      What happens in the hospital when an aggressive resident is transferred? They are drugged to the eyeballs, a few experts make an assessment while the ambulance is kept running to take them straight back to the nursing home where the drugs aren’t able to be used.
      The system is broken, if a resident has a diagnosis of dementia then he/she can’t access “elder persons mental health” options which is rediculous.
      No one could possibly document every incident but if we do not then we haven’t reached our legal obligation to report.
      Interestingly we read reports of falls, aggressive behaviour, loneliness, food etc in residential care but no one hears about the same incidents that occur every day when elderly are under the home care system.

      1. Well, you and people here, have raised pretty much what is wrong with residential care.

        Challenging behaviours, when they occur in hospital, are treated with antipsychotic meds. Then, sedated, the person is sent back to the facility. How often have I seen that happen. But if prescribed at the facility then there is an outcry about sedating residents and everyone is horrified.

        And of course if you have challenging behaviours, then don’t call the older persons mental health team – they are not interested. Dementia is not a mental illness, they say – conveniently forgetting that schizophrenia has almost certainly a biological basis located in brain structure.

        And in my experience, AINs are reluctant to report every incidence of aggression as; nothing will happen, I’ve been hit so many times I haven’t the time to fill out every form in detail and still get my work done, it’s part of dementia anyway, they can’t help it….. and so on.

        And calling DBMAS or SBRT usually ends up with advice we knew anyway.

  2. I take the point made byAnnonamous. It is a bit galling to work in a dementia unit and have an academic point out that being hit, kicked, punched and so on is not acceptable and propose a whole lot of remedies for resolving the situation. But to reflect on the comments.

    Yes, RNs hate filling out the forms. I do anyway. If you filled out a form for every instance of physical aggression then you would be filling out forms seemingly endlessly. Think of us poor RNs. All we do is give out pills, fill out forms, attend meetings on filling out forms to comply with increasing government regulation, do dressings, sign drugs in and sign drugs out, talk to relatives, talk to doctors, mange conflicts with AINs. And so on. Round and round. I often wonder what it must be like to interact with residents.

  3. It is not only in dementia wings that there is aggression and attacks on staff. Both physical and verbally, 20 years and still being told by residents I pay for you so just do it and don’t be stupid. I have been hit, punched, yelled and screamed at by non_demented residents by then residents living with dementia.
    I had one resident throw soup at me as he believed it was not hot enough and he had to wait too long.
    Family member are also abusive.

  4. Sounds exactly like the work the AINs do. Give out Meds and sign the med charts off. Deal with AIN conflicts, talk to the families and often doctors ask us questions or sometimes treat us like we were the lowest of the low. Then we have to do incident follow ups, call RNs for assistance, deal with all the behavioural issues of many different residents as well as their family members who put alot more stress on us while we try to do so much at the same time. Feed the residents, assist with toilet hygiene. Re-dress residents who are incontinent, clean and tidy bedrooms and bathrooms, clean toilet bowls with faeces all over the inside and out, re- direct wandering residents, re-direct residents who show aggressive behaviours towards other residents and then reassure both parties and then stay back and do all paper work and if we are lucky we can be out half an hour after our finishing time. No extra pay. The only thing we don’t do is dangerous meds, medical assistance or converse with doctors over medical terminology, or do professional progress notes that are out of our scope of training. We don’t do wound care but must inform RNs of a skin issue etc and progress that RN was notified as we need to cover ourselves! Is that enough!!

  5. To be fair though to all RNs as well, the work we all do in aged care seems extremely out of sinc with the wages and conditions that have been present in the public health system for years. Issues that have plagued this industry for years just keep getting put on the back burner to be dismissed. We just need Richard Colbeck to actually do his job and stop hiding from answering the important questions hard nosed journalists want to put to him. Seems his “boss” has gagged him and sent him to the dark recesses of parliament.

    1. Thanks for this. Sadly, most people in society have no idea of what RNs and AINs do in aged care. Most people have never been anywhere near a dementia unit and would have only driven by a nursing home.

      And please don’t think I was in any way minimising what AINs do. They are at the pointy end of all care in RACFs. I have the utmost respect for them and what they have to put up with.

      Nice hearing from you.

      1. You are a beautiful person Tony. Thanks for your input. Fingers crossed our lives in the industry get better one day and for all future people who go into this area of work. My hope for us all is that Aged Care and Child Care could be free for all.

  6. The residential faculty I work at, has zero protection from residents,who have serious triggers. I was assaulted by a resident, who was having a pychosis event,resulting in a suspected broken nose.. I rang the upstairs RN for help but was told to “lock the other residents doors and hide”!.. another time a male resident,followed me around calling me every swear word imaginable, trying to get into other residents rooms..again,I was told to “lock the doors of the other residents and hide.. the final assault resulted in my arm being jammed in between two doors resulting in severe bruising and skin tearing as a resident tried to push he’s way out…All in a space of 4weeks,these incident took place,yet only one incident report was filed!.. all staff recieved an internal email, stating that all incidents must be approved by management before being lodged, “as we have had too many reports this mth”!

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