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Aggression in Nursing
A time to look closely at aged care?
Katrina Cubit
PhD Candidate, School of Nursing & Midwifery, University of Tasmania, Launceston TAS
Gerry Farrell
Head, School of Nursing & Midwifery, University of Tasmania, Launceston TAS
Article Text
The extent and impact of workplace aggression in the health care sector is now widely discussed in the literature (Whitley, Jacobson & Gawrys 1996; International Labour Office, International Council of Nurses, World Health Organisation & Public Services International 2002; Wells & Bowers 2002; Farrell & Bobrowski 2003), which now also acknowledges the existence of horizontal violence in nursing (Farrell 1997, 1999).
Australian health care staff, like their counterparts overseas, are at high risk of being assaulted in their workplace (Mayhew 2000:19-20), so much so that State and Federal Occupational Health and Safety requirements have been amended to now include provision of a safe and harassment free workplace. Industry standards, particularly in mental health settings, are now recommending that all staff undertake compulsory training for dealing with potentially violent and aggressive situations (Victorian Department of Human Services, Health and Community Services Union, Australian Nursing Federation & Victorian Healthcare Industry Association 2003).
However, much of the literature addressing aggression in nursing focuses on the acute care sector, such as, Accident & Emergency and Mental Health Care units. If we are to provide a comprehensive picture of the problem of aggression at work in the health care sector, we need to widen our gaze to include the aged care setting too, especially residential aged care.
Given current estimates suggest up to 80% of people in residential care may have dementia (AIHW 2004) and, that up to 90% of those residents exhibit behavioural changes (Tariot & Blazina 1994; Tariot 1999), including verbal disruption; physical aggression; repetitive actions or questions; resistance to personal care; sexually inappropriate behaviour; refusal to accept services; problems associated with eating; socially inappropriate behaviour; wandering or intrusiveness; and sleep disturbances (National Dementia Behaviour Advisory Service 2003:8), perhaps it is now timely to focus some of our attention to the issue of aggression directed toward nurses working in the residential aged care sector.
Preliminary results from our own studies into Behaviours of Concern in Dementia (Cubit & Farrell 2005) suggests that nearly 30% of care staff experience physical aggression from residents with dementia more than once per day. Not surprising therefore, that Grealy (2005) reported resident resistiveness and aggression in Australia to be the cause of care staff injury for 32.8% of compensable claims and 39.3% of unreported injuries.
Moreover, physical aggression was reported by 20% of staff as causing the most disruption to the work environment, while 35% of care staff reported physical aggression as the resident behaviour causing them most personal distress (Cubit & Farrell 2005).
Aggressive behaviour has been suggested as having a negative effect on staff demonstrated by: increased absenteeism and sick leave of nursing staff, property damage, decreased productivity, security costs, litigation, workers' compensation, reduced job-satisfaction, recruitment and retention issues (Gates, Fitzwater & Meyer 1999:14; Hoel, Sparks & Cooper 2000; Evers, Tomic & Brouwers 2002).
Additionally, verbally and physically aggressive behaviours impact significantly on recruitment and retention of nurses (Farrell & Bobrowski 2003). This compounds issues already faced by nurses working in residential care such as lack of wage parity; increasing resident acuity; dissatisfaction within the workplace; and an already mobile workforce (Cheek et al. 2003).
For far too long close scrutiny of the nature and extent of aggression in the residential aged care context has been left on the back burner. Recognition of the unique challenges faced by nurses and carers working with people who have dementia must be addressed. It must be recognised that the extent and management of aggression, violence and problematic behaviour directed towards care staff by people with dementia is a significant and complex issue both for staff, the residents with dementia and their families (Gates et al. 1999; Robinson, Adkisson & Weinrich 2001; Hyer & Ragan 2002; Gates, Fitzwater & Deets 2003; Skovdahl, Kihlgren & Kihlgren 2003, 2004). Given our rapidly ageing population the situation is likely to be compounded over the years if these issues are not addressed today.
References
AIHW (2004) The impact of dementia on the health and aged care systems, AIHW Cat. No AGE 37 Ageing and Aged Care Unit, Australian Institute of Health and Welfare, Canberra: AIHW.
Cheek J, Ballantyne A, Jones J, Roder-Allen G and Kitto S (2003) Ensuring excellence: an investigation of the issues that impact on the registered nurse providing residential care to older Australians. International Journal of Nursing Practice 9(2): 103-111.
Cubit K and Farrell G A (2005) Behaviours of concern in dementia: a survey of care staff in residential aged care. Unpublished.
Evers W, Tomic W and Brouwers A (2002) Aggressive behaviour and burnout among staff of homes of the elderly. International Journal of Mental Health Nursing 11: 2-9.
Farrell G and Bobrowski C (2003) Preliminary Results of the Scoping Workplace Aggression in Nursing (SWAN) Survey, Tasmanian School of Nursing, Launceston.
Farrell GA (1997) Aggression in clinical settings: nurses' views. Journal of Advanced Nursing 25(3): 501-508.
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Gates D, Fitzwater E and Meyer U (1999) Violence against caregivers in nursing homes - expected, tolerated, and accepted. Journal of Gerontological Nursing 25(4): 12-22.
Gates DM, Fitzwater E and Deets C (2003) Development of instruments to assess assaultive behavior in nursing homes. Journal of Gerontological Nursing 29(8): 37-45.
Grealy J (2005) Can improvements be made in dementia care and OHS? INsite - The Aged Care Industry Newspaper, June/July, South Australia. 12-13. www.dpspublishing.com.au.
Hoel H, Sparks K and Cooper C (2000) The cost of violence and stress at work and the benefits of a violence and stress-free working environment, University of Manchester Institute of Science and Technology, Manchester. www.ilo.org/public/english/protection/safework/whpwb/econo/costs.pdf.
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International Labour Office; International Council of Nurses; World Health Organisation and Public Services International (2002) Framework Guidelines for Addressing Workplace Violence in the Health Sector, International Labour Office, Geneva.
Mayhew C (2000) Preventing client-initiated violence: a practical handbook, Research and Public Policy Series No 30, Australian Institute of Criminology, Canberra.
National Dementia Behaviour Advisory Service (2003) ReBOC: Reducing behaviours of concern, Alzheimer's Association (SA) Inc.
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Tariot PN (1999) Treatment of agitation in dementia. Journal of Clinical Psychiatry 60(Supplement 8): 11-20.
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Victorian Department of Human Services; Health and Community Services Union; Australian Nursing Federation and Victorian Healthcare Industry Association (2003) Industry standard for the prevention and management of occupational violence and aggression in Victoria's mental health services, Victoria.
Wells J and Bowers L (2002) How prevalent is violence towards nurses working in general hospitals in the UK? Journal of Advanced Nursing 39(3): 230-240.
Whitley GG, Jacobson GA and Gawrys MT (1996) The impact of violence in the health care setting upon nursing education. Journal of Nursing Education 35(5): 211-218.
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