Attitudes toward dementia‐related aggression among staff in Japanese aged care settings

Aim and objective. This study investigated attitudes of Japanese aged care staff toward aggression by people with dementia. Relationships between staff attitudes, professional characteristics and clinical practice were explored. Background. Aggressive behaviour is often demonstrated by people with dementia and may be influenced by many factors including an inability by the individual to appropriately express their needs, difficulties with assessment, as well as organisational and practice issues. Design. Survey. Method. Twenty‐seven facilities/organisations located in the western and middle parts of Japan were surveyed. Staff (n = 675) employed in these facilities provided personal and professional information and completed the Attitudes Towards Aggression Scale. Results. Staff who were older, had more clinical experience, higher education and/or a higher position reported more positive attitudes towards patient aggression. Staff with negative attitudes towards patients who are aggressive reported using chemical and/or physical restraint more often than staff with positive attitudes. Conclusions. Dementia education as well as restraint policy will be useful in addressing negative staff attitudes, in particular it may help to reverse the myth that restraint is necessary for staff protection. Furthermore, staff counseling may help to reduce stressors and to change staff negative attitudes towards people with dementia who display aggression. Relevance to clinical practice. The findings show that negative staff attitudes may adversely affect clinical decision making and patient care. Measuring attitudes can identify areas requiring education or skill development and enable changes in attitudes to be monitored over time.     

Aggressive behaviour by people with dementia in residential care settings: a review

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.     

Impact of a person-centred dementia care training programme on hospital staff attitudes,role efficacy and perceptions of caring for people with dementia: A repeated measures study

BackgroundPeople with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care.ObjectivesThis study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia.DesignA repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4–6 weeks post-baseline), and following Intermediate level training (T3: 3–4 months post-baseline).SettingOne NHS Trust in the North of England, UK.Participants40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses.MethodsAll participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (0.5 day) and Intermediate (3 days), delivered over a 3–4 months period. Staff demographics and previous exposure to dementia training were collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES).ResultsThe training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADQ between baseline and after completion of Foundation level training, but not for either of the other measures.ConclusionsTraining acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy.     

Aggressive behaviour on acute psychiatric wards: prevalence, severity and management

AIM: This paper reports a study to investigate the nature and prevalence of inpatient aggressive behaviour directed at staff and other patients and, in the case of patient self-harm, the methods used by nursing staff to manage this. BACKGROUND: Aggressive behaviour poses a threat to the physical and psychological health of psychiatric nursing staff. The fear that results from working in a climate of potential danger can also have a damaging impact on patient care. METHODS: Nursing staff on five acute inpatient wards in one hospital in the United Kingdom collected data on aggressive incidents using the Staff Observation Aggression Scale - Revised during a 10 month period from June 2001 to April 2002. RESULTS: There were 254 incidents of aggression recorded. Staff were most commonly targeted and were involved in 57 x 1% of incidents. The most frequent provocation of the aggression was the patient being denied something such as leave from the ward (29 x 5% of incidents). The most frequent means used by patients was verbal aggression (60% of incidents), the most frequent outcome for the victim was feeling threatened (59% of incidents), and verbal interventions were used most frequently to manage the aggressive behaviour (43 x 7%). Despite many incidents involving verbal aggression in both staff- and patient-targeted aggression, 35 x 9% of incidents involving staff and 25% of incidents involving other patients resulted in seclusion. CONCLUSION: It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.     

The impact of psychosocial training on staff attitudes towards people living with dementia: A systematic review

Background

As the prevalence of dementia increases, the need for appropriately trained and skilled care teams also increases. Staff attitudes towards people living with dementia have a significant impact on caregiving behaviours and staff and resident outcomes. Training within care settings is a potential way of improving staff attitudes towards residents in their care.

Objectives

This review aimed to (i) assess the effectiveness of psychosocial training in improving care staff attitudes towards dementia; and (ii) examine the content and focus of training.

Method

The review was conducted following PRISMA guidance and the protocol was registered on PROSPERO prior to conducting the review. A comprehensive search of peer-reviewed literature was undertaken using CINAHL, Medline and PsycINFO from inception to March 2021. All papers were evaluated using a quality appraisal tool.

Results

Ten studies met inclusion criteria and were of variable quality. However, six studies found significant improvements in staff attitudes towards dementia following staff training. The studies varied in terms of training focus and included behavioural, communication and cognitive-based approaches.

Conclusions

Staff training could be an effective method of improving staff attitudes towards dementia in care settings. Further research adopting high-quality randomised controlled designs to further explore staff attitudes following psychosocial training would make a valuable contribution to the literature base.     

Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk

This study investigated the aggressive behaviour of all mentally ill patients within a whole psychiatric hospital with a catchment area of 325 000 inhabitants over a 1-year period (i) to assess the 1-year prevalence and characteristics of aggressive episodes and index inpatients, and (ii) to identify predictors of patients at risk by a multivariate approach. Staff Observation of Aggression Scale was used to assess aggressive behaviour. Characteristics of index inpatients were compared with those of non-index inpatients. Logistic regression analysis was applied to identify risk factors. A total of 171 out of 2210 admitted patients (7.7%) exhibited 441 aggressive incidents (1.7 incidents per bed per year). Logistic regression analyses revealed as major risk factors of aggression: diagnoses (organic brain syndromes OR = 3.6, schizophrenia OR = 2.9), poor psychosocial living conditions (OR = 2.2), and critical behaviour leading to involuntary admission (OR = 3.3). Predictors of aggressive behaviour can be useful to identify inpatients at risk. Nevertheless, additional situational determinants have to be recognized. Training for professionals should include preventive and de-escalating strategies to reduce the incidence of aggressive behaviour in psychiatric hospitals. The application of de-escalating interventions prior to admission might be effective in preventing aggressive behaviour during inpatient treatment especially for patients with severe mental disorders.     

Nursing home staff attitudes towards residents with dementia: strain and satisfaction with work

BACKGROUND: Occupational and resident characteristics affect levels of staff stress and satisfaction in nursing homes, and levels of staff turnover are high. Working with more cognitively impaired residents, especially on day shift, is associated with high levels of stress in nursing home staff. Workload is highly predictive of the experience of burden and job pressure, while these outcomes vary according to whether staff work full- or part-time. AIMS: To investigate the attitudes of nursing home staff towards residents, strain related to dementia care and satisfaction with work and their associations with demographic, occupational and behavioural disturbance in the home. METHODS: A cross-sectional design was adopted, using a self-completion questionnaire survey of 253 nursing home staff from 12 nursing homes in Sydney's eastern suburbs, and behavioural assessment of all 647 residents from 11 of the 12 homes. Staff attitudes and strain were measured using the Swedish Strain in Nursing Care Assessment Scale and satisfaction using the Swedish Satisfaction with Nursing Care and Work Assessment Scale. RESULTS: Staff members' five most prevalent perceptions of residents with dementia were that they are anxious, have little control over their difficult behaviour, are unpredictable, lonely and frightened/vulnerable. The five attributes staff found most difficult to cope with were being aggressive/hostile, having little control over their difficult behaviour, being stubborn/resistive, deliberately difficult, and unpredictable. Although 91% of staff reported that they were happy in their job, a quarter reported that residents provided no job satisfaction. The five satisfaction statements most agreed with were "The patients/residents at work nearly always receive good care", "It is important to try and enter into the way patients experience what happens to them", "Relatives are given enough information about care and treatment", "I enjoy my current work situation" and "Our work organisation is good". There were significant differences between homes in levels of strain related to dementia care that were not accounted for by the level of behavioural disturbance. CONCLUSIONS: Nursing home staff tended to perceive residents in more negative than positive ways. Staff were generally satisfied with their work. Factors other than resident behavioural disturbance are important influences in nursing staff strain.     

Person-centered dementia care in acute hospital wards—The influence of staff knowledge and attitudes

Person-centered dementia care practices in acute hospital wards are suboptimal and not commonly measured. Although previous research has indicated that the work environment of staff influences their perceptions of person-centeredness, few studies have examined how their personal attributes, such as their level of dementia knowledge and attitudes, influence their person-centered dementia care practices. A questionnaire was distributed to test the relationship between staff perceptions of person-centered dementia care and their dementia knowledge and attitudes in general medical wards. The results showed that staff with better dementia knowledge were significantly more critical about the extent they were using evidence-based guidelines and external expertise. Staff with better attitudes perceived themselves as using more individualized care practices. The findings demonstrate that to enhance person-centered dementia care in acute hospitals, staff training programs should develop both their intellectual and interpersonal skills to improve their knowledge and attitudes.     

Education in geriatric medicine for community hospital staff

Community hospitals provide many services for older people. They are mainly managed by nursing staff, with some specialist input. Little is known about education provided in these facilities. Most education in geriatric medicine is provided in hospitals, despite most elderly care being provided in the community. The authors surveyed senior nursing staff in Irish community hospitals to examine this area in more detail. Staff in all 18hospitals in the Health Service Executive (South) area were invited to participate. The response rate was 100%. Sixteen of the 18 respondents (89%) felt staff did not have enough education in geriatric medicine. Just over half of hospitals had regular staff education sessions in the area, with a minority of sessions led by a geriatrician, and none by GPs. Geriatrician visits were valued, but were requested only every 1-3 months. Staff identified challenging behaviour and dementia care as the areas that posed most difficulty.     

The use of life story work with people with dementia to enhance person-centred care

mckeown j., clarke a., ingleton c., ryan t. & repper j. (2010) The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing 5 , 148–158 Background. Person-centred care has been linked with quality of care but difficulties remain in person-centred care being implemented in care practice. This study explores the use of life story work to enhance person-centred care with people with dementia. Aims and objectives. The study investigates how life story work is: understood and developed in practice; experienced by all participants and affects the delivery and outcomes of care. Design and methods. The experience of older people with dementia, family carers and care staff in using life story work was explored within an NHS Health and Social Care Trust. A multiple case study design was adopted within a constructivist approach. Semi-structured interviews, observation, conversations were employed. Findings. Life story work has the potential to: enable care staff to see the person behind the patient; allow family carers to uphold their relatives’ personhood; enable the voice of the person with dementia to be heard, verbally and non-verbally; be enjoyable for all concerned and enable the person with dementia to feel proud about themselves and their lives. Conclusion and implications for practice. Life story work has the potential to enhance person-centred care for older people with dementia and their families. Taking a practice development approach ensures that life story work can be implemented sensitively and is sustained in practice.     

Explanatory models of dementia: links to end-of-life care

We will describe four models used to understand dementia: as a neurological condition; as a neuro-psychiatric condition; as a normal part of ageing; and seeing dementia from a person-centred perspective. Adopting the last of these allows an engagement with palliative care that has the potential to enrich the end-of-life experience of people with dementia, of their families and of the professional care staff who work with them. In this article, it will be argued that our perceptions of what is possible for practising person-centred care at the end of life are constrained by the paradigms we work within. There is developing evidence about how approaches to end-of-life care for people with dementia can move beyond what was, at best, therapeutic pessimism and at worst ill-treatment towards something that optimizes the capacities of those with dementia and mobilizes imaginative care practice.     

Sliding doors: Did drama-based inter-professional education improve the tensions round person-centred nursing and social care delivery for people with dementia: A mixed method exploratory study

This educational intervention takes place when the population of older people with dementia is increasing. Health and Social care professionals must work jointly in increasingly complex contexts. Negative attitudes towards older people are cited as a contributor to poor care delivery, including the use of dismissive and/or patronising language, failing to meet fundamental needs and afford choice. ‘Sliding Doors to Personal Futures’ is a joint, drama-based, educational initiative between NHS Education Scotland and the Scottish Social Services Council, delivered using interprofessional education (IPE) towards encouraging person-centred health and social care.This paper considers whether ‘Sliding Doors’ had an impact on social work and nursing students' attitudes to older people, person-centred care and interprofessional collaboration. Two groups of third year students were studied; one from nursing and one from social work. A mixed methods approach was taken and attitudes and attitudinal shifts measured and discussed.Quantitative results demonstrated that social work students made positive attitudinal shifts in some questionnaire items and collectively the social work students were more person-centred than nursing students in their care approaches. The qualitative data however, drawn from focus groups, illuminated these results and highlighted the link between the ability for a professional to be person-centred and the conceptual view of risk within the particular profession. Risk acceptance, the theoretical position of social work, may facilitate person-centred care, whereas the perceived risk-averse nature of the nursing profession may inhibit it. Students' attempts to understand the quantitative results, without understanding the restrictions and parameters of each other's profession, led them to revert to stereotypes and negative views of each other as practitioners.The paper concludes that there is an important difference between nurses' and social workers' frames of reference. It is suggested that IPE in its current form will not impact positively on outcomes for older people, unless both professions can openly acknowledge the reality of their professional contexts and develop an understanding of each other's professional restrictions, opportunities and aspirations.     

An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective.     

Aggressive and violent incidents: perceptions of training and support among staff caring for older people and people with head injury

Background. Reported rates of workplace violence are increasing and studies of violence and aggression to health service staff in the United Kingdom have largely focused upon mental health and accident and emergency units. The study of violence and aggression in other specialties has been neglected. This paper reports the findings from a survey of staff perceptions of training and support in an elderly care and head injury unit. Aims and objectives. Staff in a care of older people and head injury unit, half of whom were nurses, were surveyed to identify their experiences of violence and aggression in the workplace, their receipt of training, the relevance of training and knowledge of support services. Methods. An anonymous semi‐structured questionnaire was sent to all nursing, therapy and psychology staff in the unit. Quantitative data were analysed by SPSS and content analysis was adopted for the qualitative data. Results. Just over half the participants had experienced an incident of violence or aggression in the past 12 months. Training was judged to be relevant by almost 90% of respondents but was not always delivered in line with trust guidance. Staff who had been involved in incidents were more likely to identify training needs. A higher percentage of nurses than other professions were involved in incidents, but they were not as aware of the staff support department as other professional groups. Conclusions. The findings indicate that care of older people and head injury units should examine more closely the delivery of staff training on violence and aggression, and invite staff to identify their training needs. A national survey of approaches to staff support may be worthwhile. Relevance to clinical practice. Staff who had received training judged it to be relevant to their working situations, but outstanding training needs should be identified and addressed. Confidential staff support facilities should be well publicized.     

Person-centred care for people with dementia: a quality audit approach

This paper addresses the concept of person-centred care for people with dementia by consideration of an audit process using dementia care mapping as the audit tool. It is argued that this tool is best for identifying the lived experiences of the people in receipt of care. As a result it is able to identify the overall culture of care and its level of 'person-centred' approach. The audit was conducted on 12 units, half of which were day units and the others catering for inpatients. Five patients were mapped on each day for a 4-day period. The results give some idea of the quality of care and identify where improvement is necessary. Scores such as well-being values and the Dementia Care Index give clear signposts to the level of person-centred care and highlight where staff development is necessary. Recommendations are given to aid on-going planning.     

Staff attitudes towards older patients with cognitive impairment: need for improvements in acute care

nilsson a., lindkvist m., rasmussen b.h. & edvardsson d. (2012) Journal of Nursing Management  20, 640–647 Staff attitudes towards older patients with cognitive impairment: need for improvements in acute care Aim To explore the attitudes held by staff working in acute care units towards patients aged 70 years or older with cognitive impairment, and to explore factors associated with negative attitudes. Background Hospital staff attitudes towards older patients with cognitive impairment are of concern as older people are the main hospital users, and because staff attitudes influence care quality and uptake of evidence-based care. Method A cross-sectional survey design was used to collect data from staff (n = 391). Results Staff attitudes were not explicitly negative. However, higher perceived strain in caring for older patients with cognitive impairment, higher perceived prevalence of these patients in the ward, being younger and working as an assistant nurse were associated with negative attitudes. A majority of staff reported that these patients received the best possible care, but few reported formally assessing cognitive status or working with evidence-based care protocols. Conclusion Staff characteristics associated with negative attitudes were described and staff perception that patients received best hospital care, despite limited cognitive assessments and care guidelines, indicate areas for improvement. Implications for nursing management Supporting young staff and assistant nurses, and implementing cognitive assessments and evidence-based guidelines can promote positive attitudes and best practice.     

District nurses' involvement and attitudes to mental health problems: a three-area cross-sectional study

Aims and objectives. The main aims of this study were to obtain information on the extent of staff contact and input with mental health problems and to determine their experience, training and attitudes to such problems. Background. Historical changes and policy shifts have resulted in primary care providers playing an increasing role in the care of mental health problems. Such problems are common within community settings and a major cause of suffering and disability. District nurses in particular are likely to encounter a high level of psychological co‐morbidity in their patients. Information is lacking on their involvement, attitudes and specific training for this area of their work. Design and methods. A cross‐sectional study was conducted of the staff of district nursing services in three areas, Jersey (Channel Islands), Lewisham and Hertfordshire, using a postal questionnaire. Results. Questionnaires were sent to 331 staff; 66% responded. Community and district nurses estimated a 16% prevalence of mental health problems among their patients, most commonly dementia, depression and anxiety disorders. Staff noted participation in a wide range of psychological care activities, but identified a lack of training for this aspect of their role (three‐quarter of nurses had received no such training during the past five years). They reported a willingness to develop their understanding and skills by means of educational programmes. Attitude measures revealed generally optimistic views concerning depression treatment, a rejection of deterministic attitudes about this condition and confidence in the role of district nursing staff in managing such problems. Conclusions. The need for primary care mental health training is widely noted and based upon consistent evidence of the limited detection and treatment of these problems. This study has employed quantitative methods to clarify the extent and nature of district nursing staff involvement in this area of practice and indicates that training needs are acknowledged by community nurses from geographically distinct settings. Relevance to clinical practice. Staff are interested in developing knowledge and skills pertinent to the psychological problems of their patients and their views reveal a consensus that the most important areas for learning are recognition of mental disorders, anxiety management, crisis intervention and pharmacological treatments for depression.     

A study of incidents of violence towards staff by patients in an NHS Trust hospital

The aim of the study was to survey the degree and the extent of violence towards nursing staff by patients within a hospital environment. The information gathered will form a basis for future reference once the care packages are developed in the community. The study investigated the number of recorded incidents of aggression towards nursing staff by patients ( n = 164) in an NHS Trust hospital for one year (October 1993–September 1994). The degree of recorded incidents of aggression was analysed using the Overt Aggression Scale. The results showed that the degree of aggression was mostly moderate to mild and occurred mostly in the Learning Disability Unit. Male staff were more involved in actual recorded incidents than expected in the given population. Health care assistants were more likely to be involved in aggressive incidents than any other grade of staff. There were significant findings in the time and location of the recorded aggressive incidents.
The study, therefore, highlights the need to report and record incidents, the need for ongoing training, skilful management of resources and the recognition of environmental factors that can lead to patients' violence and aggression towards nursing staff.