Aged care workers are, from time to time, the target of aggression from the residents they care for at work. Sometimes it is from residents who are living with dementia, who may find themselves unable to communicate their needs and lash out.

We often hear from our readers who work in aged care that these incidents are simply ‘part of the job’.

Aged care workers have reported residents push them, bite them, or run their walkers into them, causing fear, distress and physical injury. Some have even left their jobs due to these types of incidents.

In this article, we set out to find out what is expected and if this is simply ‘part of the job’ of an aged care worker, as many of our readers suggest? We also ask how these physical attacks can be minimised or avoided – and what happens when every strategy has been tried, but the physical attacks/incidents continue?

Person-centred care can help

Colin McDonnell, dementia consultant at Calvary Care, told HelloCare physical attacks/ incidents are often referred to as ‘responsive reactions’. They are usually a reaction to a resident’s ‘unmet needs’ and are commonly an expression of fear or frustration, and have no intent to harm.

He said the best way to prevent physical attacks or incidents is to get to know the person and deliver person-centred care. 

By talking to the person and their family, staff can get to know the resident’s history, know what makes them happy, know what makes them angry, and know how to communicate with them. Once armed with this knowledge, staff can learn how to avoid ‘triggers’ to emotional or aggressive responses.

“Ninety-three per cent of communication is body language and tone,” he said, explaining that using non-threatening movements and a soothing tone can help prevent aggressive situations from escalating or arising in the first place.

Incidents should be reported

Though some staff believe it is so, violence towards staff should not be thought of as ‘just part of the job’, Associate Professor in Ageing and Health at the University of Sydney, Lee-Fay Low, told HelloCare.

“We’ve had many staff show us bruises where they’ve been pinched, or tell us stories about pushing, hitting that they’ve experienced, particularly when trying to help with personal care.”

These incidents are “commonly” not reported, she said.

“These experiences are not acceptable in the workplace, and should be reported, discussed and preventative actions should be undertaken,” said Associate Professor Low.

More education is needed, she said. If staff are educated about these types of incidents they are more likely to be reported, and then the issues that cause them are more likely to be addressed, Associate Professor Low said.

Addressing violent responsive reactions requires both individual staff and the facility’s clinical team to identify what is causing the behaviours and to have a strategy for reducing the risk of them occurring. 

These strategies should form part of the person’s care plan, said Associate Professor Low. 

To execute a care plan for some residents, staff may need additional training, for example they may need training for supportive showering for residents who can become aggressive. 

Staff and management may need to consider changing the timing of showers, or who is undertaking showers if it’s thought that showering precipitates aggressive behaviours, Associate Professor Low suggested.

If additional advice or support is needed, Associate Professor Low suggested seeking help from Dementia Behaviour Management Advisory Service (DBMAS) or Dementia Australia’s Severe Behaviour Response Team (SBRT).

Workplaces must be safe

Both Leading Age Services Australia (LASA) and Aged & Community Services Australia (ACSA) told HelloCare employers have a responsibility to provide safe workplaces for their staff.

LASA CEO, Sean Rooney, told HelloCare that employers must identify any risks to staff, such as dementia patients who have shown behavioural and psychological symptoms. 

Employers must assess the risks and control them “as much as reasonably possible”. 

These measures must also be reviewed, especially in cases where there has been an incident, Mr Rooney said.

ACSA CEO, Patricia Sparrow, said, “comprehensive” resident assessments and care planning should include identifying behaviour triggers and management strategies for people with challenging behaviours.

Strategies should “provide staff with guidance on what to do should such behaviours occur, including how to de-escalate an aggressive behaviour episode, and how to respond… including by removing themselves from such a situation and seeking assistance.”  

Strategies should aim to “minimise the stress felt by the person with dementia as well as minimising the risk of episodes of aggression”, she said. 

Clear reporting procedures

Mr Rooney said it was also important that employers have clear reporting procedures for when incidents do occur. 

Staff must seek access to first aid or medical assistance if they require it, then report the incident immediately, with as much detail as possible, to management. 

“Aged care staff should discuss with their supervisor any concerns they have about working with particular residents, so that they can take appropriate action to manage risks and follow procedures around individual residents”, Mr Rooney said.

“Management needs to ensure staff are appropriately reporting incidents so that action can be taken to support them, to identify hazards, assess and control risks, and review any control measures that were already in place at time of the incident,” he said.

All incidents should be investigated, and procedures should be in place to guide employees on what to do when incidents are occurring and what to do immediately afterwards, Mr Rooney said.

Medication is not the answer

Mr McDonnell said antipsychotic medications simply increase the risk of falls and usually don’t stop aggressive reactions for those living with dementia.

Leading Age Services CEO, Sean Rooney, echoed that sentiment. 

“Chemical restraint with the use of psychotropic medications is sometimes used to manage behaviours. 

“However, this is not a favourable strategy and we strongly support other management strategies and the reduction of chemical restraint in aged care,” Mr Rooney told HelloCare.

Aged care not funded for severe cases

Mr McDonnell said when staff have done all they can to meet the resident’s needs but the resident continues to act out their frustrations in aggressive ways, facilities are often not funded for the extra level of care and support required. 

Mr Rooney said LASA supports the idea of higher funding for increased training and dementia management.

Mr McDonnell said he has worked in a facility where one resident lived in a six-bed unit with one-to-one care. “It was our duty of care,” he said, but it came at the expense of five beds left empty.

Sometimes the most severe cases mean a resident moves between hospital, psychiatric ward and aged care facility. “It’s really difficult for everyone,” Mr McDonnell conceded.

When all else fails 

Sometimes residents will have to leave a facility, Associate Professor Low said.

“If the facility cannot manage the resident such that they are a danger to staff after trying non-pharmacological and possibly pharmacological approaches, then they might be asked to leave. It happens,” she said.

“We have certainly encountered cases where the facility does not have the clinical expertise or staffing to care for the resident safely,” Associate Professor Low said.

The resident might be transferred to a more skilled and staffed facility such as a dementia specific unit, or in “extreme cases”, it might be appropriate to transfer them to a specialist unit, such as an SBRT. However, only a few of these places are available and they are short term places only, Associate Professor Low noted.

Ms Sparrow said providers often face “challenges” accessing specialist acute care services such as SBRT, especially in regional and rural areas.

Managing aggressive incidents for residents living with dementia is a highly complex area, it requires training, funding, experience and goodwill. It’s not easy. But violence at work is never acceptable. Staff who are concerned about aggressive residents should speak to their employer about it; it is certainly not ‘just part of the job’. 

Helpful strategies for managing aggressive incidents for those living with dementia can be found here.

Image: Heiko Küverling, iStock.

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