A Qualitative Exploration of Resident-to-Resident Aggression (RRA) in Long-Term Care Dementia Units

Background and Purpose: Resident-to-resident aggression (RRA) is the most common form of institutionally-based interpersonal violence that occurs in long-term care (LTC) facilities. RRA is associated with physical injury, poor psychosocial status, and an unpleasant or threatening day-to-day LTC living environment among residents. While existing literature has focused on examining RRA in the general LTC environment, there is a knowledge gap regarding how RRA manifests in specific units within LTC facilities, most notably, dementia-specific units. This qualitative study, informed by a socio-ecological framework, explored the nature of RRA within dementia-specific LTC units, including its sub-types, locations, and triggers.

Methods: Eight semi-structured focus groups were conducted with nursing staff (n=16), social workers (n=3), food service staff (n=1), personal support workers (n=13) and directors/coordinators (n=4) in the dementia units of two large urban LTC facilities. Focus group participants worked in dementia-specific or dementia behavioural support units and had a high level of exposure to inter-resident relational dynamics. Focus groups were audiotaped and transcribed verbatim. Using principles of grounded theory, an iterative and constant comparison approach was used to code the data. To enhance trustworthiness, two independent researchers coded the data using NVIVO software and cross-checked codes to arrive at common themes. An audit trail was kept through memoing, research meeting notes and the NVIVO analysis record.

Results: Data analysis provided information regarding RRA phenomenology in dementia-specific units. RRA sub-types included physical aggression such as hitting and pushing, and verbal aggression such as yelling and swearing. RRA locations primarily included areas of close social proximity such as the dining room and near the elevators. Participants expressed the unique challenges of addressing dementia-related RRA such as the influence of temporal factors (e.g. “sun downing”) and the possibility of any internal psycho- or physiological processes (e.g. pain) or external environmental conditions (e.g. noise) becoming a triggering stimuli for a resident. Participants tempered the role of intention in dementia-related RRA by suggesting that the lack of cumulative and relational memory in dementia residents lessens the possibility that previously-held ill-will, grudges, tensions or conflicts between residents would be remembered.  Participants indicated a preference towards preventative interventions such as behavioural assessments and profiles, monitoring periods, interprofessional sharing of notes, and interviews with residents’ families that can help identify a resident’s triggering stimuli and likelihood of aggressive responses.

Conclusions and Implications: This study revealed the distinct nature of RRA within dementia-specific units of LTC facilities.  Findings provide basic phenomenological knowledge necessary for future research on the topic and inform the development of interventions to reduce or prevent RRA between residents with dementia in the LTC context. Social workers’ increased understanding of dementia-related RRA can facilitate the development of holistic interventions that focus more generally on residents’ wellbeing by addressing their unmet needs rather than simply diffusing aggressive behaviour in isolation.