Table Of ContentCaregivers’ experiences with aggressive behaviour of
nursing home residents
Citation for published version (APA):
Zeller, A. (2013). Caregivers’ experiences with aggressive behaviour of nursing home residents. [Doctoral
Thesis, Maastricht University]. Maastricht University. https://doi.org/10.26481/dis.20130612az
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Published: 01/01/2013
DOI:
10.26481/dis.20130612az
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Caregivers’ experiences with aggressive behaviour
of nursing home residents
Caregivers’ experiences with aggressive behaviour of nursing home residents
Adelheid Zeller
ISBN
Cover photo: Nicole Achermann (2013), with permission
Printing: Schmid-Fehr AG, CH-9403 Goldach
CAREGIVERS’ EXPERIENCES WITH AGGRESSIVE BEHAVIOUR
OF NURSING HOME RESIDENTS
DISSERTATION
To obtain the degree of Doctor at the Maastricht University,
on the authority of the Rector Magnificus, Prof. dr. L.L.G. Soete
in accordance with the decision of the Board of Deans,
to be defended in public on Wednesday June 12th, 2013 at 10.00 hours
by
Adelheid Zeller
SUPERVISORS
Prof. dr. G.J. Kok
Prof. dr. T. Dassen, Charité, Universitätsmedizin, Berlin, Germany
CO-SUPERVISOR
Dr. R. J.G. Halfens
ASSESSMENT COMMITTEE
Prof. dr. J.M.G.A. Schols (chairman)
Prof. dr. J.P.H. Hamers
Prof. dr. H. Nijman, Radboud University Nijmegen
Prof. dr. D. Richter, Bern University of Applied Sciences, Switzerland
Prof. dr. R. Ruiter
Content
Chapter 1
General Introduction 9
Chapter 2
Aggressive behavior of nursing home residents: a systematic
literature review 27
Chapter 3
Nursing home caregivers’ explanations for and coping
strategies with resident’ aggression: a qualitative study 47
Chapter 4
Nurses experiences with aggressive behaviour of nursing home
residents: a cross-sectional study in Swiss nursing homes 67
Chapter 5
Dealing with aggressive behaviour in nursing homes: caregivers’
use of recommended measures 91
Chapter 6
Factors associated with resident aggression toward
caregivers in nursing homes 115
Chapter 7
General discussion 133
Chapter 8
Summary 149
Samenvatting 155
Zusammenfassung 163
Acknowledgements 171
Curriculum vitae 173
Chapter 1
General Introduction
9
1.1 Introduction
Aggressive behaviour of residents in nursing homes is an ongoing and important issue for
caregivers who work in direct contact with residents. The risk of caregivers experiencing ag-
gression from nursing home residents is high, with prevalence rates averaging 60-80% (Ger-
berich et al. 2006, Franz et al. 2010). Moreover, the European Nurses Early Exit Study (NEXT-
Study) demonstrated that nursing staff in geriatric wards experience the third highest fre-
quency of aggression of all clinical settings; only nurses in psychiatric and emergency wards
were more often confronted with aggression (Camerino et al. 2008). Sometimes aggressive
behaviour results in physical injuries. A study in US nursing homes revealed that 34% of nurs-
ing assistants had received physical injuries from assaults by residents (Tak et al. 2010).
Reasons for resident aggression are multifaceted and related to resident factors, charac-
teristics and competencies of the caregiver, and environmental aspects (Gates et al. 2003).
Regarding resident factors, the relation between dementia and aggressive behaviour is one
of the most widely discussed aspects, as people suffering from dementia are particularly
vulnerable to aggression. Several studies confirm an association between residents’ cogni-
tive impairment and the occurrence of aggressive behaviour (Talerico et al. 2002, Voyer et
al. 2005, Pulsford & Duxbury 2006, Testad et al. 2007). At an advanced stage of dementia,
people typically become unaware of time and place, have difficulty recognising relatives and
friends, have an increasing need for assisted self-care, and experience behaviour changes
that may escalate and include aggression (World Health Organisation (WHO) 2012). Oh et al.
(2004) compared aggressive with non-aggressive residents and found that aggressive resi-
dents had significantly more cognitive impairment, and had stayed longer in the nursing
home than non-aggressive residents.
Nevertheless, residents without a diagnosis of dementia also show aggressive behaviour
(Gates et al. 1999, Schmidt et al. 2012) and therefore further associated factors should be
discussed, such as caregiver characteristics and competencies in dealing with aggressive be-
haviour. Studies show a correlation between caregivers’ burnout, age, staff ratios as well as
occupational strain and experienced resident aggression (Gates et al. 2003, Isaksson et al.
2008). In addition, caregivers’ competencies in dealing with resident aggression may influ-
ence the interaction between resident and caregiver. Caregivers with more clinical experi-
ence and a higher level of professional training more often use need-based approaches to
minimize aggression, whereas caregivers with less experience tend to use more chemical or
physical restraint (Nakahira et al. 2009).
Furthermore, environmental factors should be taken into consideration, as we know
that people suffering from dementia are sensitive to changes in their environment (Hall &
O'Connor 2004). It is known for example that mandatory overtime and the lack of time for
10
appropriate support of residents in activities of daily living result in a significantly higher
proportion of physical assaults (Tak et al. 2010). Also stimulants like a public location, olfac-
tory stimulation, or media use as part of the physical environment can trigger aggressive
behaviour by residents (Yeom & Watson 2009). Due to their way of giving care and perform-
ing other activities in nursing homes, caregivers shape or create the residents’ environment.
The mode of routine daily care activities significantly affects aggressive behaviour and the
quality of life of people living in nursing homes (Dettmore et al. 2009).
It is well known that caring for residents with aggressive behaviour is a demanding task
and associated with high burden and stress for caregivers in nursing homes (Gates et al.
2003, Morgan et al. 2005). Aggressiveness is one of major factors causing distress for care-
givers and is related to a high rate of burnout and a lower quality of general health (Schmidt
et al. 2012). Possible emotions of caregivers experiencing resident aggression are anxiety,
shame, guilt, anger or resignation (Gates et al. 2003, Needham et al. 2005b, Lundström et al.
2007). In some cases caregivers become aggressive towards residents and neglect residents’
wishes and/or needs (Aström et al. 2004). Graneheim et al. (2005) describe the interaction
with people suffering from dementia and behavioural disturbances like aggression as a bal-
ancing act between contradictory positions; namely, meeting the person in my versus
her/his world, feeling powerless versus capable, and feeling rejected versus accepted. For
some caregivers aggressive behaviour seems to be a ‘natural’ consequence and they consid-
er these events as unavoidable, irresolvable and as an inevitable constituent of daily work
(Gates et al. 1999, Sandvide et al. 2004).
Despite the well-known increase in people suffering from dementia and the expected
increase in behavioural symptoms like aggression, aggression in Swiss nursing homes has
been sparsely investigated. Most available studies focus on mental health care (Needham et
al. 2005a, Abderhalden et al. 2007) and hospitals (Hahn et al. 2012). Therefore the main goal
of this dissertation is to explore caregivers’ experiences with resident aggression in nursing
homes. This thesis investigates the experiences of caregivers with resident aggression as well
as caregivers’ strategies and measures for dealing with aggression. Finally, factors associated
with the occurrence of resident aggression will be examined.
In the following section the theoretical background of this thesis will be described. Start-
ing with the background of resident aggression and followed by describing models explaining
the occurrence of resident aggression and strategies caregivers used to handle it. Next, the
implications for research and practice are described followed by the research questions
which guided this thesis. This chapter ends with a short overview of the contents of the dis-
sertation.
11
Description:Chapter 6. Factors associated with resident aggression toward caregivers in nursing homes 115. Chapter 7. General friends, have an increasing need for assisted self-care, and experience behaviour changes that may escalate and shame, guilt, anger or resignation (Gates et al. 2003, Needham et
