1. Gates, Donna EdD, MSN, MSPH, RN

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"I would rather sling McDonald's than hamburgers at work as a nurse's aide in a nursing home." This statement by a director of nursing, made during one of the studies on nursing home violence that my research team has conducted, speaks volumes about the working conditions many aides endure. As a group, they have less education than all other professional care-givers, yet they provide most of the direct care to patients in nursing homes. A nurse's aide's job is physically and emotionally demanding: nursing home residents include some of the most fragile of all patients, and their cases are complex and challenging. Among industries with more than 100,000 annual cases of worker injuries and illnesses, "nursing and personal care facilities" rank first in the incidence of illnesses and injuries and first in the incidence of assaults, according to the U.S. Bureau of Labor Statistics.


When I began to study violence in nursing homes eight years ago, some in gerontology took offense at our team's use of the word "violence." Most violent patients have dementia, and it's unknown whether they intend to cause harm. Yet when nurse's aides in our focus group's study, described in the April 1999 issue of the Journal of Gerontological Nursing, were asked to describe workplace violence, most talked about the verbal and physical abuse they endured from residents, describing how it made them afraid, angry, anxious, ashamed, or a combination of these. They felt that their RN coworkers and directors of nursing were indifferent to the violence they experienced; at times they were even reprimanded for the incidents. More recently, we surveyed 138 nurse's aides in six nursing homes about assaults they'd endured by residents (being slapped, punched, kicked, spat at, scratched, or bitten). The findings, first published in the November-December 2002 issue of the Journal of the American Medical Directors Association, included:


* 59% were assaulted at least once a week

FIGURE. Nurses aides... - Click to enlarge in new windowFIGURE. Nurse's aides need the support of RNs in reducing workplace violence.

* 16% were assaulted daily


* 51% had been injured during an assault


* 38% had received medical attention for an assault-related injury



We also found that a higher incidence of assaults was significantly related to higher levels of job-related stress and anger. Although we don't know which occurred first, we do know that neither assaults nor anger and stress enhance the nursing home environment. Indeed, when care-givers are angry or "stressed out," they may become verbally or physically abusive to residents, or negligent in care. Studies of caregivers in various settings, including hospitals, long-term care facilities, and community settings, have also found a relationship between high levels of occupational stress and burnout. Symptoms of burnout can be physical and emotional; the caregiver loses pleasure in work, begins to withdraw from others, and may even come to view patients as objects.


What's the solution? In an as yet-unpublished study, we found that an intervention based on social cognitive theory reduced the incidence of assaults. The intervention involved teaching 138 nurse's aides how to problem-solve in situations in which residents are likely to become agitated. The aides learned how to recognize early signs of agitation in residents and how to prevent or manage it.


Improved support for aides in nursing homes, especially regarding workplace violence, might mitigate the high rate of staff turnover in that setting. (A 2002 American Health Care Association survey found that the turnover rate among certified nurse assistants in nursing homes was about 71% nationwide.) Staff RNs and directors of nursing can do much to improve the work environment for nurse's aides. Even a monthly discussion group can help.


Nurse's aides need the support of RNs in reducing work-place violence. It should never be tolerated as "just part of the job."