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1.  Using Qualitative Methods to Develop a Measure of Resident-to-Resident Elder Mistreatment in Nursing Homes 
International psychogeriatrics / IPA  2013;25(8):1245-1256.
Background
Despite expansion of research on elder mistreatment, limited attention has been paid to the development of improved measurement instruments. This gap is particularly notable regarding measurement of mistreatment in long-term care facilities. This article demonstrates the value of qualitative methods used in item development of a Resident-to-Resident Elder Mistreatment (R-REM) measure for use in nursing homes and other care facilities. It describes the development strategy and the modification and refinement of items using a variety of qualitative methods.
Methods
A combination of qualitative methods was used to develop close-ended items to measure R-REM, including review by a panel of experts, focus groups, and in-depth cognitive interviews.
Results
Information gathered from the multiple methods aided in flagging problematic items, helped to highlight the nature of the problems in measures, and provided suggestions for item modification and improvement.
Conclusions
The method employed is potentially useful for future attempts to develop better measures of elder mistreatment. The employment of previously established measurement items drawn from related fields, modified through an intensive qualitative research strategy, is an effective strategy to improve elder mistreatment measurement.
doi:10.1017/S1041610213000264
PMCID: PMC4178930  PMID: 23506835
qualitative methods; measure development; resident-to-resident elder mistreatment; long-term care
2.  Managing resident to resident elder mistreatment (R-REM) in nursing homes: the SEARCH approach 
This article describes an educational program to inform nursing and care staff in the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM, as such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The aim of the SEARCH approach is to support staff in the identification and recognition of R-REM, and suggesting recommendations for management. The education program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how the SEARCH approach can be used by nurses and care staff to manage R-REM in nursing homes. Resident- and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.
doi:10.3928/00220124-20140223-01
PMCID: PMC4178932  PMID: 24548656
3.  Verbal and Physical Aggression Directed at Nursing Home Staff by Residents 
Context
Little research has been conducted on aggression directed at staff by nursing home residents.
Objective
To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.
Design
Prevalent cohort study.
Setting
Large urban nursing homes.
Participants
Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.
Main Outcome Measures
Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.
Results
The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).
Conclusion
Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.
doi:10.1007/s11606-012-2284-1
PMCID: PMC3631060  PMID: 23225256
nursing home; dementia-related behaviors; elder abuse; staff mistreatment
4.  Effects of Electronic Health Information Technology Implementation on Nursing Home Resident Outcomes 
Journal of aging and health  2011;24(1):92-112.
Objective
To examine the effects of electronic health information technology (HIT) on nursing home residents.
Methods
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
Results
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
Discussion
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
doi:10.1177/0898264311408899
PMCID: PMC3677697  PMID: 21646551
Long-Term Care; Technology; Quality of Care
5.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Background
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
Objectives
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
Design
The design was a prospective cluster randomized trial with randomization at the unit level.
Methods
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
Results
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
Conclusions
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
doi:10.1016/j.ijnurstu.2012.10.010
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
6.  Sexual Aggression between Residents in Nursing Homes: Literature Synthesis for an Underrecognized Issue 
Evidence exists suggesting that most sexual aggression against older adults occurs in long-term care facilities. Fellow residents are the most common perpetrators, often due to inappropriate hypersexual behavior caused by dementing illness. This resident-to-resident sexual aggression (RRSA) is defined as sexual interactions between long-term care residents that in a community setting would likely be construed as unwelcome by at least one of the recipients and have high potential to cause physical or psychological distress in one or both of the involved. Although RRSA may be common and physical and psychological consequences for victims may be significant, this phenomenon has received little direct attention from researchers to date. We review the existing literature and relevant related research examining elder sexual abuse and hypersexual behavior to describe the epidemiologic features of this phenomenon, including risk factors for perpetrators and victims. Preventing and managing sexual aggression in nursing homes is made more challenging due to the legitimate and recognized need for nursing home residents, even those with advanced dementing illness, to sexually express themselves. We discuss the ethical dilemma this situation creates and the need to evaluate the capacity to consent to sexual activity among residents with dementing illness and to re-evaluate capacity as the diseases progress. We offer suggestions for managing RRSA incidents and for future research, including the importance of designing effective interventions.
doi:10.1111/j.1532-5415.2010.03064.x
PMCID: PMC3625650  PMID: 20840462
aggressive behavior; sexual abuse; nursing homes; sexual behavior; dementia
7.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
Purpose:
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Results:
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
Implications:
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
doi:10.1093/geront/gnr107
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
8.  Self-neglect in Older Adults: a Primer for Clinicians 
Journal of General Internal Medicine  2008;23(11):1841-1846.
Self-neglect in older adults is an increasingly prevalent, poorly understood problem, crossing both the medical and social arenas, with public health implications. Although lacking a standardized definition, self-neglect is characterized by profound inattention to health and hygiene. In light of the aging demographic, physicians of all specialties will increasingly encounter self-neglectors. We outline here practical strategies for the clinician, and suggestions for the researcher. Clinical evaluation should include attention to medical history, cognition, function, social networks, psychiatric screen and environment. The individual’s capacity is often questioned, and interventions are case-based. More research is needed in basic epidemiology and risk factors of the problem, so that targeted interventions may be designed and tested. The debate of whether self-neglect is a medical versus societal problem remains unresolved, yet as health sequelae are part of the syndrome, physicians should be part of the solution.
doi:10.1007/s11606-008-0717-7
PMCID: PMC2585676  PMID: 18649111
self-neglect; older adults; clinical guidelines
9.  Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff 
OBJECTIVES
To more fully characterize the spectrum of RRA.
DESIGN
A focus group study of nursing home staff members and residents who could reliably self-report.
SETTING
A large urban, not-for-profit long-term care facility in New York City
PARTICIPANTS
7 residents and 96 staff members from multiple clinical and non-clinical occupational groups.
MEASUREMENTS
16 focus groups were conducted. Content was analyzed with nVivo 7 software for qualitative data.
RESULTS
35 different types of physical, verbal and sexual RRA were described, with screaming and/or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents’ rooms, and in the afternoon, though it occurred regularly throughout the facility at all times. While no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the issue.
CONCLUSION
RRA is a ubiquitous phenomenon in nursing home settings with important consequences for affected individuals and facilities. Further epidemiologic research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.
doi:10.1111/j.1532-5415.2008.01808.x
PMCID: PMC2755096  PMID: 18637979
nursing home; dementia-related behaviors; focus groups

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