Staff and relatives' perspectives on the aggressive behaviour of older people with dementia in residential care: a qualitative study

Abstract

Staff and relative perspectives on patient aggression in dementia care units are seriously under researched in the U.K. Any work that has been conducted has relied upon quantitative studies. Qualitative research on aggression management in older peoples services are rare. In-depth views that can offer insights into causation and management strategies are therefore under represented in the literature. In order to investigate this issue further we interviewed a number of nursing staff and relatives in four U.K. care homes in the North West of England. Using a combined approach of one-to-one interviews (for staff) and focus groups (for relatives) we explored their views as to the reasons for and ways of responding to aggressive behaviour. This was part of a larger study reported upon elsewhere. Using thematic analysis we found similar results from both staff and relatives and as such their views were categorized into two broad areas: causation and management. In regards to causation we noted three sub-themes; internal, external and interpersonal factors which are further subdivided in the paper and for management two broad categories: the compassionate approach and 'don't go in strong'. The results indicated that staff in the participating units embraced a person-centred approach to aggression management. They predominantly respond to aggressive incidents with interpersonal strategies, such as distraction as opposed to medication or restraint. Overall they adopt a person centre approach to patient care. Relatives were clear in their perceptions of aggression as an interpersonal challenge, which is compounded or mediated by the illness of dementia. Consequently they were positive in their views of staff using non-coercive interventions. While the results of this and our earlier study are promising suggesting a less invasive approach to this aspect of dementia care, given the limitations of a small sample, more research of a similar nature is warranted. Findings from multidimensional studies can then provide a sounder basis for health and social care education, and person centred informed practice to reduce the incidence of aggression through preventative strategies.

Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units

“…Aggression may be attributable to psychosocial-environmental factors or the complex interaction of patients, staff and inpatient unit culture influences [8]. It may be due to the inability of elderly patients with dementia to communicate their needs effectively [9], poor staff-to-patient interactions or the environment of care [9,10], overcrowding, lack of privacy, lack of activities, weak clinical leadership [11], being denied something [7], and restricting patients’ freedom [12]. …”

“…On the one hand, there are claims that aggression is associated with the person’s illness [9]. In particular, positive relationships have been reported between certain symptomatology, such as paranoid delusional thinking [5,16], impulsivity [17], dementia symptoms [2], depressive symptoms [13], and aggression.…”

“…Research into the use of restraint in elderly people has been conducted in general hospitals [28] and nursing home settings [9,10,29]. However, there has been little investigation of the use of these containment practices with elderly persons in old age psychiatry inpatient settings, and the rate and type of restraint use can vary, even within neighbouring units [30].…”

“…The implication of possessing negative attitudes toward aggression and adoption of containment measures is these approaches can culminate in adverse health outcomes for elderly patients in particular. For example, a survey and data set analysis of all nursing homes (N = 740) in Pennsylvania in the United States found a significant association between physical restraint use and subsequent deterioration in patients’ cognitive and activities of daily living performance and increased walking dependence [9,10,29]. …”

Factors Influencing Clinicians’ Attitudes about Aggression in Australian Acute Old Age Psychiatry Inpatient Units: A Cross Sectional Survey Design

“…Aggression may be due to psychosocial-environmental influences; the interaction of patients, relatives, and staff; the culture of the inpatient setting; or some combination of these (Hamrin, Iennaco, & Olsen, 2009 The first system is the microsystem, which incorporates the patient's interactions in the immediate setting (e.g., restricting patients' freedom in the inpatient unit (Papadopoulos et al, 2012) with other people (e.g., incapacity of elderly patients with dementia to communicate effectively (Duxbury, Pulsford, Hadi, & Sykes, 2013) and inadequate staff-topatient communication Pulsford et al, 2011), and with symbols and language (the semiotic system). Influences at this level include, for instance, service user characteristics (e.g., sociodemographic, psychological, personality and biological factors, symptomatology, and cognitive functioning) and his or her interactions with other patients, clinicians, and relatives.…”