This is the first qualitative study of resident-on-resident aggression (RRA) in nursing home settings using focus groups of staff and residents to characterize the spectrum of associated behaviors. We found that all employee groups and residents had experience with RRA and that respondents are willing to discuss it. Our study further found that RRA is a common, varied, complex phenomenon. Consistent themes emerged from these in-depth focus groups regarding the types, triggers, circumstances, and management strategies.
Our strategy of including residents and employees with varied job responsibilities in focus groups proved to be informative. Additionally, different shifts and staff categories witnessed different types of RRA with in a host of provocative contexts. By including this variety of staff members with different experiences, we were able to integrate their insights to more fully understand and characterize RRA.
We are aware of only two previous studies of RRA; neither collected detailed information from staff in a prospective fashion. Shinoda-Tagawa et al (2004) conducted a case-control study comparing Massachusetts victims of RRA (identified through the state’s ombudsman program) to “violence free” controls.[32
] The study used only official reports to the State Department of Health for case finding and relied on the data in the Minimum Data Set (MDS) for background information. Thus, its results were subject to underreporting and non-standard reporting policies and practices in different institutions. Also, MDS data is unreliable and error-prone.[33
] Several Minimum Data Set (MDS) derived factors were more common in subjects experiencing RRA: male sex, behavioral disturbance (especially wandering), moderate functional dependency, and cognitive impairment. Lacerations, bruises, and fractures were common injuries. RRA occurred most commonly in patient rooms but was also common in the dining room and hallways.
Our research group demonstrated that 5.6% of members of an established elder cohort in New Haven, Connecticut had police contact after institutionalization, with 89% of these contacts resulting from RRA.[34
] Indirectly, this finding suggested that the problem was potentially significant. This study also suggested a preliminary typology for RRA including unprovoked assault, invasion of space, male unbonding, competition for resources, and breaking point.
Our study expands on this work; focus groups represent a rich source of primary data providing significant insights into RRA, including clinical detail not available in previous studies. Participants described afternoons as the most common time period for the occurrence of RRA and attribute this to fatigue of the daytime primary care staff, disruption during the shift change, as well as resident fatigue and potentially boredom / lack of activity. Participants described RRA as occurring in nearly all public and private spaces, suggesting that this phenomenon is not confined predominantly to intimate care settings (e.g., bathrooms) as suggested by much of the extant literature. The most frequent locations were dining rooms where residents congregate, and resident rooms, where many nursing home patients spend most of their time. A wide variety of verbally, physically and sexually aggressive behavior were described, suggesting that RRA is phenomenologically complex and may not represent a unitary syndrome.
Reactions to calling out or noise-making behavior were the most commonly described trigger. Patients with dementia can exhibit calling out behaviors such as singing, moaning, repetitive speech, or screaming, and this vocally disruptive behavior occurs in 11–30% of nursing home residents.[35
] It is among the most challenging behaviors for nursing home staff [35
] and can trigger anxiety and agitation in other residents.[36
] Because our study also identified other triggers such as intolerance of cognitively impaired residents and aggressive behavior towards wanderers, it appears that the commingling of non-demented and demented residents may be a significant factor that contributes to RRA. Teresi and colleagues found that non-impaired residents living with or near demented residents had higher rates of living situation dissatisfaction.[38
] While RRA was not investigated in the study, features that seemed to contribute to dissatisfaction and demoralization included agitated behaviors, noise, and other disturbances reported to be caused by suite or unit mates.
Many of the most common reasons or triggers for RRA resulted from challenges with adjustment to a communal living environment, including territoriality, impatience, and jealousy. The frustration driving these aggressive episodes may derive from the lack of control and choice that many nursing home residents feel they have over their everyday lives.[39
] Territoriality, another frequently mentioned reason in this study, is a common behavior among institutionalized patients and was described in the literature nearly three decades ago.[40
] It is rooted in attempts of residents to exert control and convert public space into private space.[41
] This situation, named “competition for resources,” was identified as the most common typology for RRA requiring police intervention in our previous study.[34
] Empowering CNAs to personalize care and to customize daily routines to suit the desires of individual residents may reduce these behaviors.[39
One notable challenge of communal living that commonly leads to RRA is conflict between roommates. The challenges of adjusting to life in close quarters with a stranger are known to anyone who has lived in a college dormitory. This is exacerbated in a nursing home setting, where rooms may be very small with only curtains separating the occupants and roommate changes may be frequent. Evidence exists that older adults overwhelmingly prefer private rooms to shared rooms.[42
] Studies underscore the importance of this preference, with one finding that, for a cohort of assisted living and nursing home residents, “private room and bath” was rated most important of the 12 features evaluated, ahead of “a safe place to live,” “access to medical care,” and “good food.”[43
] A recently published analysis suggests that private rooms lead to better psychosocial and clinical outcomes for nursing home residents and that these factors should be considered in facility design and construction.[44
] Our findings support and provide further evidence for this argument, as RRA may be an element contributing to poor adjustment and satisfaction when residents are congregated.
Future studies may evaluate other potential triggers for RRA. Research suggests that visual[45
] and hearing[46
] impairment may increase nursing home resident agitated behaviors, though the findings on vision are not unequivocal.[48
] Therefore, these impairments may have an effect on RRA. Sensory impairment, by increasing disorientation, may also alter the type of RRA in which residents engage, making verbal more likely than physical. It is important to evaluate longitudinal patterns of RRA to understand the phenomenon more completely. For example, weekends and holidays, with the reduction in structured events, may have more RRA occurrences. One participant noted:
Dietician #2: …maybe they’re sitting around with nothing to do, and that’s when they get on each other’s nerves.
Studies also have shown that residents with poor quality of relationships were more likely aggressive, suggesting that poor family relationships and relationships within the nursing home may be a predictor for RRA behaviors.[49
] Our study found that loneliness and a feeling of abandonment were among the triggers for RRA. Understanding the impact of these and other triggers on the phenomenon will assist in developing effective interventions.
Many of the clinical phenomena described highlight the potential complexity of RRA and the variety of issues that must be addressed to successfully prevent it. CNAs, while trying to discourage territoriality among residents to prevent altercations, also attempt to create routine for cognitively impaired patients. This routine often includes placing them in the same seat each day. Research indicates that cognitively impaired nursing home residents are less able to deal with a change in habits, as their coping skills may be depleted, leading to behavioral problems.[50
] This paradigm, ironically, pits two strategies for RRA management against each other.
Only limited guidelines and training materials exist for staff prevention, intercession, and management of RRA, so staff have developed a large variety of formal and informal strategies to attempt to manage this phenomenon. Many of these strategies are innovative, and several have been successful at reducing RRA. A first step to developing comprehensive evidence-based interventions involves examining these techniques in greater detail. This study also suggests that all staff types witness RRA and attempt to intervene, as these events can occur without warning and frequently happen when primary care staff are not immediately available to assist. Therefore, while successful interventions may primarily involve primary care staff, such as CNAs, nurses, and physicians, all staff with resident contact can assist if properly trained and should be included in strategies to protect residents.
This study has several limitations. The qualitative data preclude making conclusions about the quantitative aspects of the incidence, prevalence, or severity of RRA. Many of our conclusions are based on coding transcripts and counting code frequencies. Although this is an established research technique,[26
] counts and their interpretation may be affected by the subjective way in which the transcripts are divided into blocks and the relative length of different focus groups.[30
] Also, comments made most frequently by focus group participants may not necessarily represent the most important themes.[51
] Despite these limitations, by conducting a large number of focus groups with a significant cross-section of the facility’s employees, we reduced the possibility that results would be dramatically affected by a single focus group or methodological choice during coding.
As all our research was conducted at a single long-term care facility, our findings may not be generalizable to all nursing homes. Also, all staff and resident participants were recruited by facility administrators, thus this was not a stratified random probability sample. Further, as in any study of this kind, self-reporting of RREM incidents may be unreliable. Nursing home staff only witness a small sample of resident interactions, and staff may be biased informants, especially when they are the targets of aggression.[52
] Nevertheless, these groups are the front-line witnesses of the phenomenon with the greatest potential to provide insights into its characteristics.
Episodes of RRA are probably common and detract from quality of life in long-term care; incidents may also predispose nursing homes to state and federal sanctions and civil lawsuits. We hope that this report will encourage further study of RRA, ultimately leading to prevention and intervention strategies to minimize the adverse consequences of the phenomenon.