Nursing aide reports of combative behavior by residents with dementia: results from a detailed prospective incident diary

Objectives: This study examined nursing aides' (NAs) perspectives of specific incidents of combative behavior from nursing home residents with dementia, particularly their attributions for the behaviors.

Design: This research is part of a larger mixed-method study exploring combative behavior as experienced by NAs. The data for this component were collected using a cross-sectional survey design. NAs used a prospective event-reporting log or "diary" to record consecutive incidents of combative resident behaviors.

Setting: Eleven rural nursing homes located in a mid-Western Canadian province.

Participants: Eighty-three full-time, part-time, and casual NAs.

Measurements: NAs used the diary instrument to document details of each incident of combative behavior over a 144-hour period. Findings from the diaries were explored in subsequent focus groups (reported elsewhere).

Results: The 83 NAs reported 409 incidents linked to residents with dementia, with a range of 1 to 28 incidents per aide. The frequency of incidents in the preceding month was reported as follows: none (11.1%), 1-5 times (58.7%), 6-10 times (11.1%), more than 10 times (19.0%). Most incidents occurred in residents' rooms (65%) during personal care, with the most frequent behaviors reported as slapping, squeezing, punching or hitting, and shoving. The main perceived causes of the behavior were cognitive impairment and residents not wanting care. NAs reported they could control or modify the cause in only 3% of incidents, and they were not optimistic about preventing future combative behaviors. They continued to provide care in 89% of incidents.

Conclusion: In the diaries, NAs identified resident-related factors (cognitive impairment and not wanting care) as the main causes of combative behavior, and they reported having no control over these factors. In the focus groups conducted to explore diary findings, NAs reported system-level factors, also beyond their control, which affected their practices and increased their risk of exposure to combative behavior. Taken together, the results of this research program suggest a need for a broad multifaceted strategy aimed at addressing the modifiable risk factors, which includes recognizing NAs as equal partners in a team process backed by strong organizational support and commitment.