Resident-to-Resident Aggression: Reviewing Risk Factors and Ways to Prevent and Reduce Their Occurrence
The frequency of Resident-to-Resident Aggression (RRA) in nursing homes and assisted living centers is growing. Recent research published in the Annals of Internal Medicine and titled“The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes,”indicates that at least 20% of nursing home residents in the United States were at some time involved in RRAs. These incidents typically involve a cognitive impairment or diagnosis of dementia in one or both of the involved residents.Most of these incidents seem to be unprovoked and were most often triggered by communication issues or a perceived invasion of personal space.
The increase in RRAs resulting in death or serious injury raises a flag of concern about the need for more attention to be directed toward intervention and prevention.
Here are a few incidents that have received broad-based publicity—
A 56-year-old resident in a Houston nursing home who shared a room with three other men, used his wheelchair armrest to beat two of his roommates to death.
In a similar incident, a New York nursing home resident used a wheelchair leg rest to beat his roommate to death.
A Kentucky resident killed another resident using a pen and an electrical cord.
In Georgia, a woman strangled her roommate to death.
New Hampshire was the location of another death after a resident strangled another resident who subsequently died from the assault.
While these RRA examples all occurred in nursing homes, similar incidents have occurred in hospitals and assisted living centers too. Also, these RRAs are not happening just in the United States, but in Canada, Australia and throughout the world.
Not insignificant is the effect that RRAs have not just on the residents directly involved in an incident, but on other residents as well.
The language that is used to explain and define RRAs can vary, but it is usually defined as “negative and aggressive physical,sexual or verbal interactions between long-term care residents that would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient.” RRAs may involve physical, verbal and sexual abuse and tend to cause emotional and/or physical harm. It should be noted that not all RRA occurrences are “abusive.” This is the case when there is no willful intent to cause harm. Examples of RRAs would include—conflicts between roommates, breaching of personal space and privacy, harassment and verbal bullying, unwelcomed sexual behavior, using another resident’s personal belongings without consent and destroying another resident’s personal possessions.
Some of the contributing factors, causes and triggers of RRAs may fall into one of these categories:
- Resident’s background (gender, birth order, occupation, aggressive personality, depression, dementia, mental illness, delusions & hallucinations and substance abuse);
- Physical and/or medical conditions (pain, constipation, UTI, incontinence, memory loss, disorientation, inability to communicate and hearing or visual loss);
- Situational issues and triggers (frustration, boredom, fatigue, invasion of personal space, seating arrangement, intolerance of others, repetitive speech, unwanted entry into personal space, roommate conflicts, racial or ethnic comments or slurs);
- Physical environment (noise, crowdedness, lack of privacy, inadequate signage, narrow or dead-end hallways, lighting that is too bright or too dim, temperature that is too hot or cold, television and elevators); and
- Staff-related issues (low staff-resident ratio, burnout, insufficient training, inappropriate “Elderspeak” approaches, ignoring early warning signs & triggers, underreporting, poor quality of documentation and assessment, tense relationships, language and cultural mismatches).
Here are some strategies suggested by Dr. Eilon Caspi that can help a provider be in a better and more proactive position regarding RRAs—
- Employ the right people and support them.
- Train staff in communication techniques and in RRA recognition and prevention strategies.
- Address RRA in the provider’s Policies and Procedures.
- Recruit and train volunteers to strengthen supervision.
- Promote empathy and compassion between residents.
- Hold monthly Resident and Family Council Meetings.
- Set realistic admission criteria.
- Conduct pre-admission behavioral evaluations.
- Strengthen reporting policy and quality of documentation.
- Improve the roommate selection process and monitor existing assignments.
It should also be noted that the healthcare provider’s Social Workers can play a key role in effectively addressing an RRA through—Assessment, Intervention and Social Work-Nursing Collaboration.
Studies also have found that a person-centered approach to the management and prevention of these incidents is crucial, and all residents, regardless of the type of healthcare setting they reside in, are entitled to a safe environment, support for their individuality and dignified,respectful treatment.
