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Received: 21 November 2016 Accepted: 17 May 2017 DOI: 10.1111/opn.12158
ORIGINAL ARTICLE
Formal caregivers’ experiences of aggressive behaviour in older people living with dementia in nursing homes: A systematic review Adelheid Holst MSc, RN1 | Lisa Skär PhD, RN, Professor 2 1 Faculty of Professional Studies, Nord University, Bodø, Norway
Aim: The purpose of this study was to investigate formal caregivers’ experiences of
2
aggressive behaviour in older people living with dementia in nursing homes.
Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden Correspondence Lisa Skär, Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden. Email:
[email protected]
Background: Aggressive behaviour symptoms among older people living with dementia are reported to be prevalent. As aggressive behaviour includes both verbal and physical behaviours, such as kicking, hitting and screaming, it causes an increased burden on formal caregivers. Professionals experiencing this aggression perceived it as challenging, causing physical and psychological damage, leading to anger, stress and depression. Methods: A systematic review was conducted. A search of published research studies between 2000 and 2015 was conducted using appropriate search terms. Eleven studies were identified and included in this review. Results: The analysis resulted in four categories: formal caregivers’ views on triggers of aggression, expressions of aggression, the effect of aggressive behaviours on formal caregivers and formal caregivers’ strategies to address aggression. The results show that aggressive behaviour may lead to negative feelings in formal caregivers and nursing home residents. Conclusion: The results of this study suggest that having the ability to identify triggers possibly assists caregivers with addressing aggressive behaviour. Aggressive behaviour might also affect quality of care. Implications for practice: Results from this systematic review indicate that caregivers prefer person-centred strategies to handle aggressive behaviour among older people, while the use of pharmaceuticals and coercion strategies is a last resort. KEYWORDS
aggressive behaviour, behavioural and psychological symptoms of dementia, dementia, nursing, nursing home, qualitative, systematic review
1 | INTRODUCTION
age 60 years to around 10 per cent at age 80 years (Holmes, 2012). Incidents of dementia are increasing as the global population ages,
Dementia is a general term for a syndrome including a range of
posing a great challenge for the future of health care (United Nations,
chronic or progressive organic brain diseases that are characterised
2015). The number of incidents was estimated to be 35.6 million
by difficulties of short-term memory and other cognitive deficits
in 2010 and is expected to nearly double every 20th year, to 65.7
(World Health Organization [WHO], 2016). The main risk factor for
million in 2030 and 115.4 million in 2050 (Berr, Wancata, & Ritchie,
dementia is age, with prevalence increasing exponentially after the
2005; Sosa-Ortiz, Acosta-Costillo, & Prince, 2012). Dementia affects
Int J Older People Nurs. 2017;1–12.
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cognitive functions often followed by non-cognitive symptoms, referred to as behavioural and psychological symptoms of dementia (BPSD), (Holmes, 2012). Non-cognitive symptoms include aggression, agitation, anxiety, irritability, depression, apathy, delusions, hallucinations and aberrant motor behaviour (Song & Oh, 2015). People living with dementia often express or manifest unidentified needs through a socially inappropriate or unusual behaviour including these symptoms (Cohen-Mansfield, 2013). Up to 90 per cent of people living with dementia experience one or more symptoms of BPSD during the development of the syndrome (Dettmore, Kolanowski, & Boustani, 2009; de Oliveira et al., 2015). Aggression is reported to be prevalent in 25 to 50 per cent of people living with dementia and is associated with early institutionalisation (Dettmore et al., 2009; Lykesetos et al., 2000). Aggressive behaviour includes both verbal and physical behaviours, such as kicking, hitting and screaming, which cause an increased burden on caregivers (Miyamoto, Tachimori, & Ito, 2010). Non-cognitive symptoms, further, influence aspect of daily life for older people with dementia and especially experiences of quality of life (Johansson, Marcusson, & Wressle, 2015). This depends on the change the person goes through, that is, from having the ability to independently carry out activities related to daily life to live in addiction, which may be a dramatic shift for many people (Hellström, Andersson, & Hallberg, 2004). Older people living with dementia with cognitive impairments possibly also lack understanding from people around them, which would make it difficult for them to express and communicate their needs (Miyamoto et al., 2010). Aggressive behaviour might therefore be a way of expressing their feelings. The complexity of aggressive behaviour is thus perceived as challenging, causing physical and psychological damage to caregivers experiencing the behaviour and may lead to anger, stress and depression when taking care of the older person (Irwin, 2006). Caregivers might be both family members (informal caregivers) and healthcare professionals (formal caregivers) and as experience of aggression among older people living with dementia is subjective, the behaviour possibly be interpreted differently depending on the rela-
What does this research add to existing knowledge in gerontology? • Aggressive behaviour among older people with dementia is a complex and challenging issue for formal caregivers. • Aggressive behaviour causes an increased burden on formal caregivers. • Aggressive behaviour has a negative effect on formal caregivers’ self-esteem and leaves them feeling overwhelmed with feelings of resignation, fatigue, apathy and hopelessness. What are the implications of this new knowledge for nursing care with older people? • Formal caregivers need the ability to identify triggers for aggressive behaviour to be able to address aggression as it may affect experiences of quality of care among older people with dementia. • Formal caregivers need knowledge about person-centred strategies to handle aggressive behaviour among older people as it can replace pharmaceuticals and coercion strategies. How could the findings be used to influence policy or practice or research or education? • A greater understanding about the topic of aggressive behaviour and the psychological and physical distress formal caregivers’ experiences could address how policy and practice caring will change. • Education for formal caregivers to handle aggressive behaviour among older people with dementia is important as negative feelings exposed by the behaviour may affect formal caregivers’ feelings towards the older person with dementia and effect care given.
tionship with the older person (Moniz-Cook & Clarke, 2011). Informal caregivers are often the elderly closer and possibly will easily interpret signals on aggression than formal caregivers (Musich, Wang, Kraemer,
Formal caregivers working in nursing home settings who had
Hawkins, & Wicker, 2017). To address aggressive behaviour, a person-
experienced aggressive behaviour from older people living with de-
centred perspective is to recommend as aggressive behaviour symp-
mentia reported feelings of fears for their safety (Scott, Ryan, James,
toms result when the person living with dementia has unmet needs or
& Mitchell, 2011a) and feelings of powerlessness and resignation
is engaging in self-protective behaviours and hostile actions (Kovach,
(Åström et al., 2004). Aggressive behaviours also have been reported
Noonan, Matovina Schildt, & Wells, 2005). A person-centred perspec-
to be associated with formal caregivers’ experiences of stress and
tive means to understand the reasons behind the behaviour and to
mental health problems (Kunik et al., 2010). According to Åström et al.
be able to recognise and handle the symptoms (Ekman et al., 2011;
(2004) and Buchanan, Christenson, Ostrom, and Hofman (2007), for-
McCormack & McCance, 2010). From a formal caregiver’s perspec-
mal caregivers who experience aggressive behaviour are more likely
tive, it is therefore important to be familiar with the different ways in
to rely on pharmacological treatment or isolation of the person with
which dementia can be present and the challenge of providing care
dementia or might ignore requests for help or assistance. As a result,
and support for people with the condition and their families (Dening &
aggressive behaviour symptoms have negative effects on the quality
Babu Sandilyan, 2015). Establishing a close relationship with the older
of care for older people living with dementia in nursing homes (Buhr
person living with dementia helps formal caregivers handle aggressive
& White, 2006). To deliver high quality of care to older people with
behaviour, especially in the nursing home setting (Hirata & Harvath,
dementia, it is important to increase our knowledge about formal
2016).
caregivers’ experiences of aggressive behaviour. A systematic review
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of the literature may be used as a base for knowledge for formal care-
and 13 October 2015). The applied search terms were as follows:
givers to identify triggers for aggressive behaviour and support devel-
dementia, aggressive behaviour, nursing home, qualitative, Alzheimer,
opment of handling plans that replace pharmaceuticals and coercion
experiences, caregiver, formal caregiver and nurs*. The search covered
strategies.
the period between 2000 and 2015 to get the latest published studies in the field and included qualitative peer-reviewed studies written in English. In addition, in order to maximise the efficiency of the
1.1 | Aim
search process, sources were cross-referenced and manual abstract
The aim of this study was to investigate formal caregivers’ experi-
searches were conducted for the reviewed studies (Polit & Beck,
ences of aggressive behaviour in older people living with dementia in
2012). The inclusion criteria for this review were set as follows: (i)
nursing homes.
formal caregivers’ experiences of aggressive behaviour among older people with dementia living in nursing homes; (ii) studies published between 2000 and 2015; (iii) qualitative design; (iv) peer-reviewed
2 | METHOD
studies; and (v) language of the studies to be in English. Studies on aggressive behaviour between older people with dementia and in-
A systematic literature review of qualitative studies was conducted,
formal caregivers’ experiences were excluded. The search process is
addressing the research question. Qualitative content analysis de-
described in Figure 1.
scribed by Graneheim and Lundman (2004) was used to analyse the
The first author conducted the search process and held frequent
included studies. The design comprises descriptions of qualitative
discussions with the co-author throughout the process to reach an
research findings on a particular phenomenon and considerations of
agreement on the search terms. The search process produced 3026
variations. Eleven relevant studies were identified and analysed.
studies. The inclusion criteria and the removal of duplicate titles were used for title selection and reduced the number to 151 stud-
2.1 | Search process and quality appraisal of studies
ies. References were then cross-referenced manually and manual abstract searches were conducted, which resulted in the inclusion
The search was conducted electronically with guidance of the
of six more studies. After reading the abstracts of the 157 studies,
Preferred Reporting Items for Systematic reviews and Meta-
130 abstracts were rejected due to irrelevance to the research topic
Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman,
and that they did not meet the inclusion criteria. The remaining 27
2009). Before beginning the search process, the researchers iden-
studies then were read through to get a sense of the content, and
tified the research question and topic using keywords in three
this resulted in that 16 more studies were excluded as they were
international literature databases. Data were gathered from the
not performed in a nursing home context. The remaining 11 studies
databases CINAHL, MEDLINE and Scopus (between 24 July 2015
were then checked for scientific quality using the Critical Appraisal
The literature search in databases yields potentially relevant studies n = 3,026 Studies screened after excluding duplicates and including from the created search alerts n = 151 Studies remaining for closer review n = 157
Studies reading as a whole n = 27
Studies undergoing quality appraisal n = 11 F I G U R E 1 Flow chart of search result
Studies included in the final review n = 11
Studies excluded not meeting the inclusion criteria or being a duplicate n = 2,875
Studies included after crossreferenced manually and manually abstract search n=6 Studies excluded after examining title and abstract n = 130 Studies excluded as they not were performed in a nursing home context n = 16
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Skill Programme (CASP, 2013). The specific CASP tool used in this study was specifically developed for qualitative research. The CASP included 10 questions that can be answered yes, no or can’t tell.
2.3 | Findings The studies included in this literature review were published between
Several italicised prompts are given after each question and these
2000 and 2015 and conducted in the United States of America (n = 2),
are designed to remind why the question is important. According to
Sweden (n = 6), Canada (n = 1), Australia (n = 1) and Switzerland
question 6 - whether the relationship between the researcher and
(n = 1). The methodologies of the studies included content analysis
participants been adequately considered. In all 11 studies, the authors
(n = 7), thematic content analysis (n = 2), grounded theory (n = 1) and
had critically examined their role and potential bias during sampling
phenomenological hermeneutic method (n = 1). The studies contained
recruitment and data collection. According to question 7—whether
in total 311 formal caregivers, such as nurses, assistant nurses, as-
ethical issues had been taken into consideration, three of the studies
sistants and care workers. The studies focus on perceptions of ag-
(Janzen, Zecevic, Kloseck, & Orange, 2013; Ostaszkiewicz, Lakhan,
gressive behaviour, violence in nursing homes, managing agitation,
O’Connell, & Hawkins, 2015; Shaw, 2004) were not approved by
behavioural disturbances, explanations for residents’ aggression and
an ethical committee, but they have discussed ethical issues such
coping strategies for dealing with aggression. The content in the stud-
as informed consent and confidentiality in their studies. Therefore,
ies was analysed views on triggers of aggression, expressions of ag-
question 7 was answered as can’t tell in the CASP tool, for these
gression, the effect of aggressive behaviour on formal caregivers and
three studies. However, not every item had the same importance for
formal caregivers’ strategies to address aggression. Each category
the studies’ quality; therefore, no scoring system was used for qual-
contains two subcategories (Table 4) illustrated with citations from
ity appraisal as recommended. The authors held frequent discussions
the studies.
about the focus of the studies and the main methodology issues that would damage the quality of findings. The results for CASP are presented in Table 1. Finally, the 11 studies were included in the review based on their scientific quality in all domains including aim and
2.4 | Formal caregivers’ views on triggers of aggression
scope, design, analysis process, presentation of findings, relevance
This category describes formal caregivers’ views on triggers for ag-
and transferability (Table 2).
gressive behaviour among older people with dementia living in nursing homes. The category has been divided into two subcategories: inter-
2.2 | Qualitative content analysis The selected studies were analysed using qualitative content analysis (Graneheim & Lundman, 2004). Qualitative content analysis is a research method that aims to provide a systematic and objective
nal and external triggers.
2.4.1 | Internal triggers Responses in the studies (Foley, Sudha, Sloane, & Gold, 2003;
means to make valid interpretations from written, verbal or visual
Graneheim, Hörnsten, & Isaksson, 2012; Isaksson, Åström, &
data to describe a specific phenomenon at manifest level (Polit &
Graneheim, 2008; Janzen et al., 2013) suggest that some somatic dis-
Beck, 2012). The selected studies for review were analysed in several
eases possibly cause confusion and agitation, leading to the triggering
steps. Firstly, the studies were read as open-mindedly as possible to
of aggressive behaviour. Such diseases include arthritis, hearing loss,
obtain a sense of the content. Then, meaning units were identified
sleeping deprivation, infections and hallucinations. Another trigger of
and extracted from the text based on their relevance to this study’s
aggressive behaviour potentially be the perception that formal car-
aim. Meaning units consisted of words, statements, sentences and
egivers are rough in their treatment of residents (Graneheim et al.,
phrases that contained aspects related to experiences of aggressive
2012). The caregivers in the studies suggested that identifying and
behaviour among older people with dementia. Totally, 277 mean-
treating somatic disease is one strategy for preventing aggressive
ing units were identified. They were then condensed, which means
behaviour. The studies also suggest that triggers are internal. If resi-
that the text was shortened without compromising its integrity.
dents feel fear or are overwhelmed by their environment, aggressive
After condensing the meaning units, each meaning unit was labelled
behaviour possibly be triggered. “Violence often occurred when the
with a code. Codes can be related to a phenomenon, an event or
residents neither recognised nor understood what was happening in
discrete objects and should be understood in relation to the context
activities of daily living, such as being fed, dressed or helped to the
(c.f. Graneheim & Lundman, 2004). The codes were then abstracted
toilet. They became frightened and expressed their frustration as vio-
and sorted into categories based on their similarities and differences.
lence” (Graneheim et al., 2012, pp. 157).
An agreement regarding the analysis was reached among the authors
In the studies (Foley et al., 2003; Graneheim et al., 2012), some of
after a process of a back and forth movement between the whole
the formal caregivers describe residents who do not recognise care-
and parts of the reviewed studies text, reflections and discussions.
givers, themselves, or their own behaviour, which cause fear and lead
Examples of meaning units, condensed meaning units, codes and cat-
to agitation and aggressive behaviour. In addition, studies (Kristiansen,
egories are shown in Table 3. According to Graneheim and Lundman
Hellzèn, & Asplund, 2006; Zeller, Dassen, Kok, Needham, & Halfens,
(2004), creating categories is the core feature of qualitative content
2011) describe residents’ dependency on caregivers as a factor that
analysis.
leads to aggression. Residents who may once manage daily living
X
X
X
X
X
X
X
X
X
X
Graneheim et al. (2012)
Isaksson et al. (2009)
Isaksson et al. (2008)
Janzen et al. (2013)
Kristiansen et al. (2006)
Ostaszkiewicz et al. (2015)
Shaw (2004)
Skovdahl et al. (2003)
Skovdahl et al. (2004)
Zeller et al. (2011)
N
Ct
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
2. Is a qualitative methodology appropriate?
Answers, Y = Yes, N = No, Ct = Can’t tell.
a
X
Y
Foley et al. (2003)
Studies: Author(s)/year
Answersa
1. Was there a clear statement of the aims of the research?
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
3. Was the research design appropriate to address the aim of the research?
CASP Screening questions for qualitative studies
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
4. Was the recruitment strategy appropriate to the aim of the research?
T A B L E 1 Overview of quality appraisal using CASP for the included studies
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
5. Was the data collected in a way that addressed the research issue?
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
6. Has the relationship between researcher and participants been adequately considered?
X
X
X
X
X
X
X
X
Y
N
X
X
X
Ct
7. Have ethical issues been taken into consideration?
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
8. Was the data analysis sufficiently rigorous?
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
9. Is there a clear statement of findings?
X
X
X
X
X
X
X
X
X
X
X
Y
N
Ct
10. How valuable is the research?
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T A B L E 2 Overview of reviewed studies Author, year of publication, country
Method of analysis
Design and participants
Aim of the study
Findings
Foley et al. (2003), USA
Qualitative design with structured interviews. 19 nursing staff, 4 activity coordinators or social workers and 9 unit coordinators
To examine the relationships among demographic and behavioural characteristics of 70 residents, management techniques of the staff and family participation in the management of persons with severe behavioural problems.
Content analysis
Unpredictable aggression particularly difficult to control. Non-pharmacological techniques associated with greater chance of success, physical restraints used as last resort.
Graneheim et al. (2012), Sweden
Qualitative design with interviews. 41 caregivers at 3 nursing homes, 10 Registered Nurses, 23 enrolled nurses, 8 nurses’ aid.
To explore female caregivers’ perceptions of reasons for violent behaviour among nursing home residents.
Qualitative content analysis
Reasons for violence are complex, caregivers need to see the person behind the behaviour, and interventions should be individually tailored
Isaksson et al. (2009), Sweden
Qualitative design with interviews. 20 caregivers in 3 nursing homes.
Illuminate female caregivers’ experiences of being exposed to violence in nursing homes.
Qualitative content analysis
Caregivers experienced a loss of control and had preconceived ideas about violent behaviour. These experiences may influence caregivers’ interactions with residents
Isaksson et al. (2008), Sweden
Qualitative design with interviews. 41 caregivers from 3 nursing homes.
Illuminate how female caregivers in nursing home perceive violence.
Qualitative content analysis
Perceiving an action as violent is subjective. Violence is perceived as challenging and can be seen as intentional or excusable relative to own experiences and attitudes.
Janzen et al. (2013), Canada
To investigate the perception of Qualitative study design long-term care staff regarding the guided by Van Manen’s hermeneutic phenomenology, current use of non-pharmacological intervention for reducing agitation in with focus groups. 44 staff seniors with dementia and to identify members from 5 long-term facilitators and barriers that guide care units, which of 3 had long-term care implementation. secure dementia units.
Content analysis
For managing agitation, both medication and non- pharmacological interventions were used. Barriers to NPI use were lack of time, low staff-to-resident ratio and varies in effectiveness NPIs.
Kristiansen et al. (2006), Sweden
Qualitative design with narrative interviews. 20 care staff.
Describing assistant nurses’ experiences of job satisfaction, where their work involves taking care of residents suffering from dementia and elements of aggressiveness and psychomotor agitation.
Qualitative content analysis
Narrations of exposure, insufficiency as well as devotion to residents. Pressure needs to be relieved in order to increase the well-being of the nurses.
Ostaszkiewicz et al. (2015), Australia
Qualitative exploratory and descriptive design with focus groups. 30 nurses from 3 long-term care units.
Describe nurse’s experiences of caring for people with behavioural and psychological symptoms of dementia in long-term care and care facilities and strategies nurses used to deal with the symptoms.
Content and thematic analysis
Five interrelated themes: Difficult work conditions; BPSD is an everyday encounter; Trying to make sense of BPSD; Attempting to manage BPSD; and Feeling undervalued.
Shaw (2004), USA
Exploratory and descriptive design, based on grounded theory using semi- structured interviews. 15 nursing home staff from 6 facilities.
Illustrate the “real-world” view from the perspective of direct care staff of the conditions and context of residents’ aggressions and practical strategies staff use to prevent and manage aggression.
Grounded theory methods
Staff experiences aggressive behaviour from residents on a daily basis, as well as multiple demands from administrators, nurses, residents and their families
Skovdahl et al. (2003), Sweden
Qualitative design with interviews. 15 caregivers from 3 units.
Study caregivers’ reflections about and attitudes to behavioural and psychiatric symptoms of dementia and how they dealt with the symptoms.
Analysis with phenomenological hermeneutic approach
Two main themes: A need for balance between demands and competence, and a need for support. (Continues)
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T A B L E 2 (Continued) Author, year of publication, country
Method of analysis
Design and participants
Aim of the study
Findings
Skovdahl et al. (2004), Sweden
Qualitative design with interviews. 9 caregivers from two units, from 2 different nursing homes
Obtain insight into the reasoning of the caregivers who had reported problems when dealing with older people with dementia and aggressiveness and those who did not relative to their respective video-recorded interactions with these residents.
Thematic content analysis
Two main ways of thinking, one group were more focused on their duties and seemed unwittingly to prevent positive interactions with caregiver, the other group were self-critical and sustained positive interactions with resident.
Zeller et al. (2011), Switzerland
Qualitative design with focus groups. 30 caregivers from nursing homes
Explore caregivers’ perspectives regarding the conditions and situations of resident aggression and practical strategies caregivers use to deal with aggression.
Qualitative content analysis
Caregivers use a broad spectrum of interventions for reducing aggression. Caregivers rarely linked practical with theoretical knowledge about aggressive behaviour
T A B L E 3 Examples of meaning units, condensed meaning units, codes and categories Meaning units
Condensed meaning units
Codes
Categories
Removing the resident from a potentially volatile situation or otherwise decreasing stimuli were loss commonly used that specific activities on interpersonal approaches
Removing the resident from volatile situation, decreasing stimuli loss commonly used
Decreasing stimuli
Caregivers strategies for handling aggression
In addition, most of these caregivers spontaneously expressed their feelings for the resident and describe her as complaining, demanding, never satisfied, sly, spiteful or consciously provocative
Feelings for residents as complaining, demanding, never satisfy, sly, spiteful, provocative
Negative feelings for residents
The effect of aggressive behaviour on caregivers
T A B L E 4 Overview of categories and subcategories
et al., 2011) as a frequent trigger of aggression. Residents sometimes feel that their personal space is limited. All of the formal caregivers
Categories
Subcategories
Formal caregivers` views on triggers for aggression
Internal triggers
Expressions of aggression
Physical aggression
from intrusions into their personal space, aggressive behaviour occurs
Verbal aggression
frequently” (Zeller et al., 2011, pp. 2473).
The effect of aggressive behaviour on formal caregivers Formal caregiver strategies to address aggression
External triggers
Formal caregivers emotions
interviewed described invasion into personal space, “It is unavoidable, given the necessity to administer personal care to residents – as a particularly difficult moment in the caring process. When residents suffer
In the studies (Graneheim et al., 2012; Janzen et al., 2013; Ostaszkiewicz et al., 2015; Skovdahl et al., 2004; Zeller et al., 2011), for-
Formal caregivers feelings towards residents
mal caregivers describe residents’ not understanding their own needs or
Person-centred care
being able to communicate them. Residents feel restricted because the
Pharmacological strategies and coercive actions
wards were locked and they felt homesick, but they might not leave the ward and so they became anxious and sometimes violent with an aggressive behaviour (Graneheim et al., 2012). “The formal caregivers describe the dementia as a reasons for aggressive behaviour: “The disease”
activities on their own become dependent on help from formal care-
potentially have left violent behaviour as the only way for residents to
givers to manage simple tasks, such as intimate care, getting dressed
express their feelings, I do not want it like this” (Graneheim et al., 2012,
and going to the bathroom. Caregivers also mentioned that having to
pp. 157).
wait for help due to the caregivers’ workload may trigger agitation and aggression (Graneheim et al., 2012). Requiring help with intimate care has also been described by caregivers in the studies (Graneheim et al.,
2.4.2 | External triggers
2012; Janzen et al., 2013; Kristiansen et al., 2006; Ostaszkiewicz et al.,
External triggers are described in the studies as triggers in the en-
2015; Shaw, 2004; Skovdahl, Kihlgren, & Kihlgren, 2003, 2004; Zeller
vironment, such as actions, activities and physical factors in the
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surroundings. Furthermore, both over- and under-stimulation have
at you. Verbal abuse is a kind of violation. It is violence against one’s
been cited as external triggers of aggressive behaviour (Graneheim
soul” (Isaksson et al., 2008, pp. 1663).
et al., 2012; Janzen et al., 2013; Skovdahl et al., 2003). Spending time with other residents and formal caregivers also influences the resident’s state of mind. The formal caregivers interviewed in the studies described small and crowded facilities as a cause of agitation and ag-
2.6 | The effect of aggressive behaviour on formal caregivers
gressive behaviour. They stated that older people sometimes become
This category describes how aggressive behaviour evokes strong
stressed and frustrated in such small and crowded spaces. Both resi-
feelings in caregivers, such as feelings of fright, uncertainty, tired-
dents and caregivers experienced discomfort in these places.
ness and negative feelings regarding job satisfaction, self-esteem and
Also, lack of consideration of formal caregivers due to their lack of
older people with dementia. The results are presented in the following
time and resources and heavy workloads might cause the residents to
subcategories: caregivers’ emotions and caregivers’ feelings towards
feel mistreated and become agitated. An insufficient number of peo-
residents.
ple on staff would exacerbate the above-mentioned problems. The caregivers stated that several triggers may occur simultaneously and that sometimes, there is no obvious trigger, making it hard to identify
2.6.1 | Formal caregivers’ emotions
what causes aggressive behaviour (Foley et al., 2003; Graneheim et al.,
The formal caregivers in the studies (Isaksson, Graneheim, & Åström,
2012; Janzen et al., 2013; Shaw, 2004).
2009; Kristiansen et al., 2006) stated that their work with older people with dementia takes almost all of their energy, which results in
2.5 | Expressions of aggression This category describes expressions of aggression in the following two subcategories: physical and verbal aggression.
feelings of fatigue and exhaustion. Working with people who display aggressive behaviour makes work even harder and caregivers often feel depleted of all energy (Kristiansen et al., 2006). The studies (Isaksson et al., 2009; Kristiansen et al., 2006; Shaw, 2004; Skovdahl et al., 2004) describe how difficult it is for caregivers to go to work
2.5.1 | Physical aggression Physical aggression is often described by the caregivers in the stud-
every day knowing that residents will display aggressive behaviour and violence related to dementia. One caregiver stated, “I arrive in the morning and say, ‘good morning’ and everything is okay… and then
ies (Foley et al., 2003; Janzen et al., 2013; Kristiansen et al., 2006;
suddenly I get punched… I think it is horrible, things being like this”
Ostaszkiewicz et al., 2015; Shaw, 2004; Skovdahl et al., 2004) as
(Isaksson et al., 2009, pp. 49).
kicking, punching, pinching or throwing items. Some of the studies
The formal caregivers (Janzen et al., 2013; Kristiansen et al., 2006;
(Ostaszkiewicz et al., 2015) claim that physical aggression occurs on a
Ostaszkiewicz et al., 2015; Zeller et al., 2011) have described how
daily basis, which caregivers have described as unexpected and shock-
working with aggressive behaviour leads to feelings of shock and
ing. Physical aggression is also sometimes very fierce and may result
astonishment, and the anticipation of being exposed to aggression
in visible damage and marks on the caregiver. “Some of the wounds
makes them feel exhausted and resigned, without hope that the situ-
inflicted on caregivers described in the studies were so severe that
ation will change. Exposure to aggressive behaviour makes caregivers
the caregivers required medical care and had to be absent from work:
feel like failures and questions their own competence and profession-
“The challenge lies in the caregivers” way of relating to being physi-
alism. They have also expressed fear that management and their col-
cally hurt, insulted, abused, and offended. The violence is perceived as
leagues would think that they might neither handle the workload nor
painful, leaving marks and bruises on the body, visible for anyone to
control the situation. Although they understand that aggression is a
see” (Isaksson et al., 2008, pp. 1662).
symptom of dementia, the formal caregivers in the studies (Graneheim et al., 2012; Isaksson et al., 2008, 2009) expressed feeling hurt and
2.5.2 | Verbal aggression
disappointed when exposed to aggressive behaviour. One caregiver stated, “Even though we know that they are mentally unstable and
Isaksson et al. (2008) indicate that verbal aggression is not docu-
unaware of what they are doing or saying, if they verbally abuse you,
mented as frequently as physical aggression, although formal caregiv-
you still feel that -hurt” (Ostaszkiewicz et al., 2015, pp. 6).
ers have reported that it is equally frequent. This lack of reporting is due to workplaces lacking procedures for documenting verbal aggression. Verbal aggression consists of threats, false accusations of
2.6.2 | Formal caregivers’ feelings towards residents
neglect, racial and sexual slurs, screaming and name-calling. Although
The caregivers in the studies (Isaksson et al., 2008, 2009; Skovdahl
verbal aggression does not leave visible marks, the caregivers in the
et al., 2003, 2004) expressed that aggressive behaviour affects
studies perceived it to be challenging. They find it more difficult to
their feelings towards the residents. In addition to feelings of fright,
protect themselves from verbal aggression than from physical aggres-
they have sometimes developed feelings of disgust and reluctance
sion, even though they try to block out the words. “With violence,
(Isaksson et al., 2009). Some of the formal caregivers in the studies
one often think of punches. But it is having four-letter words thrown
(Isaksson et al., 2008, 2009) stated that the aggressive behaviour was
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intentional and that the residents knew exactly what they were doing.
2003; Janzen et al., 2013; Ostaszkiewicz et al., 2015) emphasised
Some believed the behaviour to be a result of personality traits being
that it should be used sparingly and that other strategies should be
exaggerated by the dementia. Still, most caregivers in the studies be-
attempted before resorting to the use of medication. Some of the car-
lieve that the behaviour is unintentional and a symptom of dementia,
egivers stated that pharmaceuticals and coercive actions sometimes
but mentioned that it still evokes negative feelings towards the ag-
make aggression worse.
gressive residents. These negative feelings towards residents may, in some cases, affect the quality of care. Some of the caregivers reported avoiding residents who were aggressive and that aggressive behav-
3 | DISCUSSION
iour affects the interaction between them and the residents. One formal caregiver stated, “I started to treat her a little bit differently. It was
The purpose of this study was to investigate formal caregivers’ experi-
like I got the devil inside me and I started being sarcastic towards her”
ences of aggressive behaviour in older people living with dementia in
(Isaksson et al., 2009, pp. 48).
nursing homes. The results show that formal caregivers perceive dealing with aggression as a challenge. Aggression that appears suddenly and without any visible cause created feelings of uncertainty and fear.
2.7 | Formal caregiver strategies to address aggression
The results describe also that formal caregivers found it important
This category describes how the formal caregivers handle aggression
egies to address aggressive behaviour. Research (Enmarker, Olsen, &
identifying triggers for regaining a sense of control and develop strat-
by reducing or preventing aggressive behaviour. The results are pre-
Hellzén, 2010; Whall et al., 2008) stated that aggressive behaviour is
sented in two subcategories: person-centred care and pharmacologi-
connected to different triggers such as a premorbid personality, the
cal strategies and coercive actions.
person’s mental health status and personal care events. Formal caregivers need therefore knowledge and understanding about aggres-
2.7.1 | Person-centred care
sive behaviour and its management to satisfied good nursing care (Enmarker et al., 2010).
The formal caregivers in the studies (Foley et al., 2003; Janzen et al.,
The results in this review describe formal caregivers’ ambivalent
2013; Ostaszkiewicz et al., 2015; Shaw, 2004; Skovdahl et al., 2003,
feelings about completing tasks because they know that they will most
2004; Zeller et al., 2011) highlighted person-centred care as the best
likely experience aggressive behaviour while trying to help and take
strategy for preventing and calming aggression. They expressed
care of the patient. Eriksson and Saveman (2002) state that confronting
that knowledge of residents’ life history and personalities is neces-
aggressive behaviour takes time and formal caregivers might feel help-
sary to calming them down and reducing agitation and aggression.
less and frustrated when time is lacking for personal care. Lack of time
Acknowledging their individuality and adjusting care and activities to
also results in frustration with routines and makes it difficult for formal
each individual’s needs have been expressed to be the most effec-
caregivers to feel that they are providing quality care, as was described
tive strategy for preventing frustration and agitation in dementia pa-
in this review. As aggressive behaviour, possibly be one way for older
tients. Treating the residents with respect, making them feel in control
people with dementia communicating their needs, formal caregivers
and including them in everyday activities also prevent agitation. One
need the ability to identify early triggers, related to persons at risk for
caregiver stated, “Calling them by name, inviting them to (do) things,
this behaviour, for the onset of negative effects in caring situations.
being respectful, and treating them like they are a part of the family,
A person-centred approach is pointed out by Enmarker et al. (2010)
so you (staff) are not creating any agitation to begin with” (Janzen
as one way for formal caregivers to manage aggressive behaviour in
et al., 2013, pp. 157).
daily living caring situations instead of pharmacological interventions
Furthermore, the studies (Foley et al., 2003; Ostaszkiewicz et al.,
as first-line options for treatment, which also is consistent with de-
2015; Shaw, 2004) describe different approaches to preventing and
mentia guidelines (Azermai, 2015; Cohen-Mansfield, 2013; Kales,
de-escalating aggressive behaviour. Some approaches are making eye
Gitlin, & Lyketsos, 2014). The approach means to see each patient as
contact, using relaxed body language and communicating with a low
an individual with a unique life history and needs from a holistic per-
and calm voice. The formal caregivers were also conscious of support-
spective that encourages patient participation, fosters empowerment
ing each other by taking turns approaching the aggressive resident,
and entails treating the patient with respect and dignity, despite illness
giving each other time off to calm down and encouraging each other
(Egan et al., 2007; Ekman et al., 2011). However, communicating with
to cope with aggressive behaviour.
people who lives with dementia requires formal caregivers to have knowledge and solid communication skills, including using verbal com-
2.7.2 | Pharmacological strategies and coercive actions The use of pharmacological treatment has been described as an effec-
munication in combination with a non-verbal communication by giving a look or a glance, for example, to motivate and influence patients in a caring situation (Cohen-Mansfield, 2013). When formal caregivers know, what needs the person has and how these are expressed, the
tive strategy for de-escalating aggression and has often been used in
care can be planned more individual and thereby reduce aggressive
acute situations; however, most caregivers in the studies (Foley et al.,
behaviour (Enmarker et al., 2010).
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HOLST and SKÄR
10
In this review, it was described that when formal caregivers view
The systematic literature review was based on data collected from pri-
individual residents as “patients” and in terms of tasks that must be
mary source studies on formal caregivers’ experiences with aggressive
complete, it leads to feelings of frustration and anger in residents
behaviour among older people with dementia. Thus, the findings in
triggering an aggressive behaviour. Enmarker et al. (2010) stated that
the present study reflect the quality of the data collected in the orig-
sometimes, formal caregivers seem to be unaware of their own role
inal studies. To measure the selected studies’ quality, the tool CASP
in triggering aggressive behaviour. Formal caregiver’s approach pos-
(CASP, 2013) was used and the PRISMA (Moher et al., 2009) guide-
sibly triggers or increases aggression, especially if it is characterised
lines was used as an additional resource for checking on whether this
by stress or haste (Miyamoto et al., 2010). According to Edberg et al.
review included sufficient studies. Systematic literature reviews may
(2008), the older patient’s mood mirrors the formal caregiver’s mood,
be criticised for removing the original study’s findings of their context.
and the patient can therefore sense stress, haste and changes in the
Most of the included studies were performed in European countries
formal caregiver’s voice and body language. In this literature review,
(n = 7) and included a wide range of formal caregivers from different
lack of competence was also described as a trigger for residents’ ag-
long-term care facilities, including those with and without dementia
gression. Lack of knowledge about dementia is known as a source of
care units. The difference in care units indicates that the severity of
strain for formal caregivers that reflects their attitudes and can cause
aggressive behaviour may vary, which would affect formal caregivers’
aggressive behaviour among people with dementia (Morgan, Stewart,
experiences with aggressive behaviour. The formal caregiver’s levels of
D’Arcy, Forbes, & Lawson, 2005; Rodney, 2000). Performing care with
education also vary, which might affect how they address aggression
lack of knowledge and feelings of uncertainty worries formal caregiv-
and choose strategies for dealing with it. However, the validity of this
ers that their colleagues may think that they are unprofessional and
review rests in its interpretive logic, where the findings of the research
incompetent to perform their job, which in turn also can cause stress
reports were reframed and exhibited in the study results (Sandelowski
affecting the older person (Holst, Edberg, & Hallberg, 1999).
& Barroso, 2007). Furthermore, to enhance trustworthiness and im-
The findings in this review indicate that formal caregivers consider
prove credibility, the authors had a constant dialogue during the
dealing with aggressive behaviour, whether physical or verbal, as part
analysis process, which is in line with Polit and Beck (2012) recom-
of the job duties of working in dementia care. The behaviour was there-
mendations. The fact that qualitative studies in this area are sparsely
fore sometimes seen as unavoidable and something that they must
performed strengthens the meaning to compile the research to get a
simply accept and deal with. Similar findings have been described by
picture of the knowledge in the field. The findings in this review might
Sandvide, Åström, Norberg, and Saveman (2004) that state that formal
be an early step in designing and conducting further studies in the
caregivers view aggressive behaviour as an inevitable constituent of
area.
the daily work in dementia care. However, aggressive behaviour is still a serious issue, as the behaviour causes formal caregivers both physical injury and psychological trauma in the form of stress. According to Rodney (2000) and Morgan et al. (2005), there is an association between formal caregiver experiencing stress and meeting with people with dementia and aggressive behaviour. Aggressive behaviour further shown in this review causes a great deal of strain and burden on formal caregivers who expressed feel-
Implications for practice • The negative feelings that results from being exposed to aggressive behavior affects formal caregivers’ feelings towards the residents.
ings of fear and uncertainty and thereby become resigned and over-
• Formal caregivers needs strategies for dealing with aggres-
whelmed. Feelings of fatigue, apathy and hopelessness lead also to
sive behavior such as, use a person-centred approach.
the development of negative feelings towards residents. According to Todd and Watts (2005), formal caregivers’ assumptions about the reasons for aggressive behaviour determine their responses to the behaviour. On the one hand, they report that formal caregivers who believe that the behaviour is unintentional are more willing to help and
• Knowledge and education about how a person-centred approach can address aggressive behavior and replace pharmaceuticals and coercion strategies and decrease negative effects on formal caregivers are needed.
demonstrate empathy. However, formal caregivers who believe that aggressive behaviour is intentional are more likely to withdraw and reject the aggressive person and resent having to help those (Scott, Ryan, James, & Mitchell, 2011b). This study has several limitations. Firstly, the search strategy selected original studies only published in English language between the years 2000 and 2015. Studies from other language might reveal similar or different findings. No grey literature was included in this review, but there is no consensus on whether systematic reviews should integrate this type of literature. However, it is possible that more studies could have been included if we had expanded the literature search.
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How to cite this article: Holst A, Skär L. Formal caregivers’ experiences of aggressive behaviour in older people living with dementia in nursing homes: A systematic review. Int J Older People Nurs. 2017;00:1–12. https://doi.org/10.1111/ opn.12158
