Violence Prevention in Patient Care For the Elderly

Table of contents

1. Introduction

2. What is violence?
2.1 Forms of violence against people in need of care
2.2 Personal/direct violence
2.2.1 Physical violence
2.2.2 Psychological violence
2.2.3 Financial exploitation
2.2.4 Restriction of free will
2.2.5 Neglect
2.3 Structural violence
2.4 Cultural violence

3. What are aggressions?
3.1 Physical forms of aggression
3.2 Non-verbal forms of aggression
3.3 Verbal forms of aggression

4. Figures, data, facts – violence against people in need of care

5. Reasons, causes and triggers of violence and aggression towards the person in need of care
5.1 Overwork of the nursing staff due to the structural conditions
5.2 Frustration of caregivers due to hierarchical ranking
5.3 Excessive demands placed on caregivers by those in need of care
5.4 Overwork of caregivers due to private influencing factors
5.5 Frustration of caregivers due to insufficient income
5.6 Burnout of nurses

6. Prevention and solutions against violence and aggression against people in need of care
6.1 Approaches from an operational perspective
6.1.1 Further training and coaching
6.1.2 Supervision
6.1.3 Annual employee appraisals
6.1.4 Personnel structures
6.1.5 Spatial structures
6.1.6 Scope for action
6.1.7 Staff meetings
6.1.8 Rewarding employees
6.2 Approaches from a private perspective
6.2.1 Self-help groups
6.2.2 Family counselling
6.2.3 Development of personal relief strategies
6.2.4 Coping with burnout
6.2.5 Dealing with aggression
6.3 Approaches from the official point of view
6.3.1 Medical Service of the Health Insurance Funds
6.3.2 Residential and care supervision

7. Conclusion

Bibliography

1. Introduction

I chose this topic because I have been confronted with the topic of violence in social institutions since my training as a registered geriatric nurse up to the present time through television, the Internet, and also newspaper articles, and thus my interest was aroused. I work as a residential area manager in a senior living facility and am, among other things, charged with the tasks of security protection of the staff as well as the residents.

Another reason for this choice of topic is that, as a senior nursing specialist, I would like to protect the staff and residents from so-called "short-circuit reactions" and show them ways in which, for example, violence and aggression caused by stress or other influencing factors can be prevented.

A third important reason for choosing this topic is demographic change. Based on the research findings of the German Federal Statistical Office, there will be a shortage of around 152,000 employees in the care sector in 2050. In 2025, around 940,000 employees will be needed, although only around 828,000 nursing staff will be available.¹ At the same time, however, the number of people in need of long-term care is expected to rise to 3 million in 2020 and to about 4.4 million in 2050.² This brief glimpse into demographic change alone increases the importance of protecting caregivers from imprudent actions as well as from criminal acts in order to keep them highly motivated in elder care until, their retirement age.

I would like to show with this work, how violence and aggression in the stationary old person care by coworkers opposite care patients can be counteracted and by which indications coworkers ready for violence can be recognized early. Further I would like to explain the terms force and aggressions and which force - and aggression forms there are at all.

Thereupon I asked myself the question, which reasons, causes and triggers lead to force and aggression opposite protection inferiors and by which manifestations force can occur.

Within my literature research I was looking for media reports about violence in inpatient geriatric care. Due to the low number of reports, my interest increased again and led to further questions.

Is violence in inpatient geriatric care communicated about or is it a taboo topic?

At what point does violence begin?

How far does an act of violence have to be carried out for the public to talk about it?

Do the high demands on staff and the constant shortage of personnel lead to acts of violence against those in need of care?

How can violence, perpetrated by nursing staff, be prevented?

Is a concept of violence prevention in inpatient facilities helpful?

2. What is violence?

As a layman, I understand the term violence to mean actions or behaviors that are intentionally carried out against one's own person or other persons, animals and objects and that lead to damage. I am aware that violence can cause not only physical damage but also psychological damage. Violence includes not only physical attacks but also the injury caused by constant verbal attacks of the person under protection. In the search for a uniform definition of the term I did not achieve any success.

Johan Galtung, using peace and conflict research, defined the term as follows:

"Violence occurs when people are influenced in such a way that their current, somatic and mental realization is less than their potential realization."³

Participants in the EU project "Civil Courage in Geestendorf (Action Courage against Violence)" defined violence as "Any means used to impose one's will on another person or to make him/her do something he/she does not want, that is, the assertion of power."⁴

Another truthful definition describes the term violence as follows:

"The term violence includes actions, processes and scenarios in which or which influence, change and/or harm is exerted on people, animals or objects. What is meant is the capacity to perform an action that strikes at the inner or essential core of a matter or structure."⁵

One of the most significant and popular definitions is that of the World Health Organization and reads as follows:

"The intentional use of threatened or actual physical coercion or psychological power against one or another person, group, or community that results in either actual or high probability of injury, death, psychological harm, maldevelopment, or deprivation."⁶

2.1 Forms of violence against people in need of care

Acts of violence are always multifaceted and occur in conjunction with multiple forms of violence. Often, financial exploitation is paired with the restriction of free expression/restriction of freedom, or physical violence is paired with psychological violence.⁷ In the following elaboration, three main forms of violence, with their associated subgroups, are named and explained.

2.2 Personal/direct violence

Personal or direct violence is limited to a specific action or inaction and includes the intended physical or psychological harm to people, living beings or property.⁸ In the following analysis, the various forms of direct violence, such as physical violence, psychological violence, financial exploitation, restriction of the free expression of will and neglect, will be explained in detail.

2.2.1 Physical violence

The term physical violence includes a variety of actions that deliberately inflict pain and injury on the other party (the person in need of care) and cause great suffering. Physical violence is evident in the form of hitting, biting, hair-pulling, immobilization, compulsive restraint, sexual abuse, the administration of non-prescribed medication such as psychotropic drugs to immobilize the person, etc. The worst and most extreme form or consequence of physical violence is the use of force. The worst and most extreme form, or consequence of physical violence, is the killing of a person.⁹

2.2.2 Psychological violence

In contrast to physical violence, psychological violence does not leave any visible external damage or injuries, but does have internal psychological and traumatic consequences. The aforementioned form of violence mainly involves the verbal psychological sphere. This form of violence manifests itself in intimidation, shouting, insults and verbal abuse, threats of violence, violation of the sense of shame, threats of institutionalization and removal from the home, and concealment of abuse from outsiders. Evidence of psychological violence is expressed in the form of isolation, depression, anxiety, mental confusion, sleeplessness and the use of violence against nursing staff as a protective mechanism.¹⁰

2.2.3 Financial exploitation

The financial exploitation of people in need of care and assistance can occur in a variety of ways, such as withholding income such as pensions, cashing in on services not rendered, stealing valuable jewelry or other saleable items, selling the medications of deceased nursing home residents, etc. It can be assumed that the financial exploitation is exercised in conjunction with the physical and/or psychological violence and also the restriction of free will.¹¹

2.2.4 Restriction of free will

In social institutions, the free will of residents in need of care is known to be often restricted. This form begins already with the decision of the place of residence against the wishes and needs of the residents. Immobilizing the resident, for example, when he or she is confined to bed and wants to be mobilized into a wheelchair but receives no assistance, is also part of the restriction of free will. Furthermore, restraining measures such as raising the bed rail, attaching a therapy table to the wheelchair, locking the resident in a room, attaching Velcro to the wheelchair to secure the feet, and using restraining straps to secure the resident to the bed are also part of restraining free will.¹²

2.2.5 Neglect

Neglect means omission of actions. In particular, it refers to actions that would be appropriate for the situation as a reaction to a recognizable wish or need of the recipient of violence, but are not carried out. Neglect can be active and passive.

Passive neglect is defined as failure to act because a situation of need was misjudged. Lack of insight, ignorance and lack of qualifications on the part of caregivers can lead to malnutrition, incorrect positioning, development of pressure ulcers, dehydration or isolation of the patient.

Active neglect is defined as deliberately and knowingly incorrectly applied actions such as inadequate feeding and hydration, failure to change incontinence materials, failure to perform positioning, and withholding of necessary medications by responsible caregivers.¹³

2.3 Structural violence

The term structural violence refers to a "covert" form of violence that can exist indirectly and thus independently of persons. However, indirect violence often promotes real action. Structural factors enable a variety of the direct forms of violence. Due to laws and regulations, nursing homes are subject to certain rules.

The following examples fall under structural violence in care:¹⁴

- lack of support from family caregivers
- insufficient staffing
- overuse, underuse or misuse of care for those in need due to lack of training and continuing education for the care professions
- inadequate and institutionalized regional care for sick people, leading to non-treatment and need for care
- forced living in a nursing home due to lack of regional alternatives and shortened stays in hospitals
- living with a stranger in a room
- lack of privacy in institutions
- institutions that prioritize security over self-determination
- daily structures that are dictated by the institutions and are not based on the wishes of the residents
- lack of state and public control of institutions

2.4 Cultural violence

There is a rather negative prejudice against old people and old age in general. In the media, old people are characterized by illness, loss of mental abilities, need for help and care, and poverty. Young people and adults make statements such as "I don't want to grow old" or "the older you get, the sicker you get.

The job description of geriatric care is also not accepted and recognized in society. The decisive factor for this point of view is the nursing care and support of old people in need of care, who can no longer go to the toilet alone, are incontinent, can no longer care for themselves independently, and who are completely mentally and physically degraded. This situation is discriminatory against people in need of care and is unacceptable.

If society were to communicate about health, financial security, mobility and a wide range of life activities, the concept of cultural violence against old people in need of care would no longer exist.¹⁵

3. What are aggressions?

The definition of aggression is like the definition of violence. There is no uniform definition of the term. The word aggression comes from the Latin words aggredi or aggredior and has two different meanings, which are translated as follows: to approach, to approach, to attack/attack, or to approach/start/attempt.¹⁶

Zimbardo defines the term as follows: "Aggression in humans is defined as physical or verbal action carried out with the intent to injure or destroy. Violence is aggression in its extreme and socially intolerable form."¹⁷

Another definition was developed by Fröhlich in which he defined aggressiveness as "a general and comprehensive term for clustered hostile behavior expressed in verbal or physical attacks, or the predominance of hostile rejecting and oppositional attitudes in humans."¹⁸

Selg also tried his hand at the term, formulating the following definition: "An aggression consists in the delivery of harmful stimuli directed against the organism or an organism surrogate; an aggression may be overt (physical/verbal) or covert (fantasized), it may be positive (approved by the culture) or negative (disapproved)."¹⁹

Aggression can occur in a wide variety of ways and is classified into three forms. Misinterpreted aggression by the other person is also possible, as in non-verbal aggression.

Every person thinks about positive and also negative events and unconsciously distorts the facial features. Such situations have a confusing effect on the interlocutor opposite and can lead to emotional outbursts such as anger or even fears. This as an example, which consequences happen with applied aggression forms. In the following execution of the work the physical, non-verbal and verbal forms of the aggression are explained.

3.1 Physical forms of aggression

The physical form comes from a physical impairment. Actively by hitting, scratching, biting or other abuse, passively they are characterized by neglect as the omission of acts of care, such as the refusal to take food and liquid, as well as the failure to administer the necessary medication.²⁰

3.2 Non-verbal forms of aggression

Non-verbal forms are a tense facial expression, tense posture, hasty nervous gesticulation, restless finger play, aversion to eye contact, frantic arranging of clothing, and pulling the corners of the mouth outward.²¹

3.3 Verbal forms of aggression

Verbal forms are expressed in insults and insults with raised voices against the resident, black humor at the expense of the resident as well as refusal of communication.²²

4. Figures, data, facts – violence against people in need of care

An extensive and significant German study proved in 1995 that out of 2600 respondents aged 60 and older, 3.4% experienced physical violence, 2.7% neglect or substance abuse, 1.3% economic exploitation, and 0.8% verbal aggression. An extrapolation in the aforementioned age group of 60 to 75 years showed that approximately 340,000 people suffered physical violence at least once a year.²³

Furthermore, the study concluded that psychological aggression is far more prevalent than physical violence. One in four respondents said they had experienced verbally aggressive behavior or other non-physical forms of aggression by people close to them in the past 12 months.²⁴

The World Health Organization estimates that at least 4 to 6% of elderly people in economic countries are neglected or even abused in their homes. However, only a few violent incidents and situations are documented and on record, as there tends to be a long-standing relationship between the perpetrator and the victim. These are not only acts of violence by caregivers, but also by family caregivers.²⁵

It is estimated that one-third of all people in need of care suffer throughout their lifetime from the effects of neglect, such as dehydration due to lack of hydration or pressure ulcers due to failure to change position.²⁶

In 1995, the first study concerning the aforementioned problem was published in the Federal Republic of Germany and stated that around 600,000 people between the ages of 60 and 75 are victims of at least one act of physical violence.²⁷

In 2003, the Medical Service of the Health Insurance Funds conducted quality audits in a total of 807 outpatient care services and 793 inpatient care facilities and identified various care errors and deficiencies, which are listed in the following elaboration:²⁸

- incontinence care deficiencies affected one fifth of inpatients
- 43% had quality deficits in pressure ulcer prophylaxis
- 41% had insufficient nutrition and fluid intake
- 30% of gerontological psychiatric residents were under cared for
- 9% of the measures restricting freedom did not comply with legal requirements
- 12% of the documentation regarding the administration of medication was incorrect
- 22% of the administered medications were not correct
- 33% of social care did not meet the wishes and needs of the residents

In another study, caregivers mostly described themselves as emotionally exhausted and overwhelmed. The percentage of caregivers is high, at 70 percent. More than 70 percent of respondents said they themselves began acts or omissions that could be classified as violent or problematic in some other way, or had observed such acts in other caregivers. As examples, the nurses cited psychological and physical abuse, psychosocial or nursing neglect, as well as measures that deprived them of their freedom.²⁹

Based on a U.S. study, a total of 577 caregivers were surveyed in 1989, of which a total of 81 percent experienced psychological violence and 36 percent physical violence.³⁰

According to police crime statistics, older people are relatively rarely victims of violent crime. This staggering statement is based only on police-reported charges. In 2012, 12,053 people aged 60 and up were victims of violent crime. The aforementioned number comprises 5.2 percent of all victims of violent crime.³¹

5. Reasons, causes and triggers of violence and aggression towards the person in need of care

In order to be able to prevent violence and aggression in inpatient care for the elderly and to design the necessary prevention programs and solutions, it is necessary to research the causes and triggers as well as the reasons so that a company can act in a targeted manner and provide high-quality work for the benefit or protection of the residents and employees.

Based on a German study, nursing staff described themselves as frustrated, exhausted, exhausted and overwhelmed.³² These reasons alone for using violence make it clear that many facilities do not have the desired work structures or do not allow employees to participate in training, education and continuing education as required.

The following points describe the causes that lead to frustration among nursing staff and can trigger acts of violence, both consciously and unconsciously.

5.1 Overwork of the nursing staff due to the structural conditions

Each facility has its specifications and rules to which it must adhere, such as deploying enough staff and providing enough tools. Unfortunately, the numbers on the papers differ with reality. A calculated staffing ratio may confirm the required number of caregivers, but the real number of caregivers who are on site is not presented.

Due to staff shortages, nurses are exposed to double workloads. They have their fixed duty roster, but have to take on additional duties, such as those of employees who have fallen ill. This includes not only day shifts but also night and weekend shifts. Night shifts in particular lead to exhaustion and frustration among nurses.

The area of responsibility is enormously high in night duty, since in most cases only one nurse is assigned per ward and this nurse must make decisions independently in emergencies and also act. The day-night rhythm, or wake-sleep rhythm, is also affected and disturbed by the constant change of shift work.

In addition to the design of duty rosters, break times are another factor that promotes exhaustion and frustration. In the nursing professions, it is impossible to take an undisturbed and restful break. In many facilities, staff are forced to take work phones and nurse call devices with them on breaks without being able to turn them off. A nurse must always be available and respond immediately when residents call for help, doctors make spontaneous rounds, emergencies occur, supervisors call for interviews, or colleagues call for support for actions/assistance with residents.

In addition, caregivers are regularly under stress and have time constraints due to staffing shortages. If such stress factors persist for an extended period of time, nurses are at risk for burnout.

5.2 Frustration of caregivers due to hierarchical ranking

In many inpatient facilities, nurses are subjected to enormous pressure from supervisors. There are power struggles, harassment and bullying. Many managers make leadership mistakes that have a counterproductive effect on the nursing staff.

5.3 Excessive demands placed on caregivers by those in need of care

Every inpatient facility must demonstrate qualified staff and always keep their qualifications up to date. Due to the lack of personnel and the high cost of training, many facilities are not able to offer and conduct regular training and continuing education. Exactly these mentioned factors overtax the nursing staff, because they lack knowledge about disease patterns and the corresponding measures, because they do not work in a health-promoting way and damage their bodies in the process, and because they do not behave professionally towards the residents. The nursing staff are overtaxed, reacting aggressively and not professionally, for example, with residents suffering from dementia. They cannot behave individually due to a lack of training.

5.4 Overwork of caregivers due to private influencing factors

As already mentioned in the previous sections, nurses work in shifts and have to show flexibility, stamina and commitment. In many relationships and families, these factors lead to disputes and stress.

Due to private pressures from life partners and family members, aggression and frustration arise among caregivers. They are torn when work calls and the family turns against the work. The ones who suffer are then the residents. Under pressure, caregivers perform the work as quickly as possible, only to be back with the family on time afterwards to do them justice then as well. As a result, many employees are not aware of how they have ultimately dealt with the resident or how they have cared for or treated them.

Furthermore, nursing errors occur under pressure, such as forgotten positioning, low feeding of food/fluids, and incorrectly administered or non-administered medications.

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¹ cf. Bundesinstitut für Berufsbildung/Statistisches Bundesamt, 2010, internet source

² cf. Forschungsinstitut Betriebliche Bildung, 2010, internet source

³ cf. Galtung, 1993, zit. in Cordula Schneider, Gewalt in Pflegeeinrichtungen, 2005, p. 5

⁴ cf. EU-Projekt Zivilcourage in Geestendorf, Aktion „Mut gegen Gewalt“, 2005, internet source

⁵ cf. Wikipedia, Definition Gewalt, internet source

⁶ cf. Weltgesundheitsorganisation, internet source

⁷ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 4

⁸ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 4

⁹ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 5

¹⁰ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 5

¹¹ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 5

¹² cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 6

¹³ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 6

¹⁴ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 8

¹⁵ cf. Laura Seidel, Handeln statt Misshandeln, Gewalt an alten Menschen, Band 14, 2007, p. 8

¹⁶ cf. Hirsch, 2000, p. 19, zit. in Cordula Schneider, Gewalt in Pflegeeinrichtungen, 2005, p. 21

¹⁷ cf. Zimbardo, 1995, p. 425, internet source

¹⁸ cf. Fröhlich, 1994, S. 44, zit. in Cordula Schneider, Gewalt in Pflegeeinrichtungen, 2005, p. 21

¹⁹ cf. Selg, 1997, p. 4, zit. in Christine Förster, Handeln statt Misshandeln, Gewalt in der institutionellen Altenpflege, Band 16, 2008, p. 10

²⁰ cf. Altenpflegeschüler, Gewalt in der Pflege, internet source

²¹ cf. Altenpflegeschüler, Gewalt in der Pflege, internet source

²² cf. Altenpflegeschüler, Gewalt in der Pflege, internet source

²³ cf. Wetzels et al., 1995, Landespräventionsrat NRW, 2006, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggression in der Pflege- Ein Kurzüberblick, 2009, p. 14, internet source

²⁴ cf. Görgen in Görgen, p. 14, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 15, internet source

²⁵ cf. Handeln statt Misshandeln, Pressemitteilung vom 09. Juni 2008, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 10, internet source

²⁶ cf. Handeln statt Misshandeln, Pressemitteilung vom 09. Juni 2008, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 10, internet source

²⁷ cf. Handeln statt Misshandeln, Hirsch, ohne Jahr, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 14, internet source

²⁸ cf. Schmidt/Schopf, 2005, S. 8, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 15, internet source

²⁹ cf. Görgen et al., 2006, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 14, internet source

³⁰ cf. Pillmer & Moore, 1989, Landespräventionsrat NRW, zit. in Gefahren für alte Menschen, Basisinformationen und Verhaltensweisen für Professionelle im Hilfesystem, Angehörige und Betroffene, 2006, p. 8, internet source

³¹ cf. Polizeiliche Kriminalstatistik, 2012, internet source

³² cf. Görgen et al., 2006, zit. in von Hirschberg, K.-R.; Zeh, A.; Kähler, B., BGW Forschung, Gewalt und Aggressionen in der Pflege- Ein Kurzüberblick, 2009, p. 14, internet source