Soothing the strains in nursing homes.
Subject: Nursing homes (Management)
Nursing home patients (Psychological aspects)
Aggressiveness (Psychology) (Demographic aspects)
Interpersonal conflict (Research)
Author: Boscia, Ted
Pub Date: 09/22/2010
Publication: Name: Human Ecology Publisher: Cornell University, Human Ecology Audience: Academic Format: Magazine/Journal Subject: Health; Science and technology; Social sciences Copyright: COPYRIGHT 2010 Cornell University, Human Ecology ISSN: 1530-7069
Issue: Date: Fall, 2010 Source Volume: 38 Source Issue: 2
Topic: Event Code: 310 Science & research; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8050000 Nursing & Rest Homes; 8366000 Homes for Aged NAICS Code: 623 Nursing and Residential Care Facilities; 623312 Homes for the Elderly SIC Code: 8051 Skilled nursing care facilities; 8052 Intermediate care facilities; 8059 Nursing and personal care, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 266957293
Full Text: Last December, a 98-year-old Massachusetts woman became the oldest person charged with murder in state history for allegedly killing her centenarian roommate. The deadly assault followed a dispute over a piece of furniture the two nursing home residents shared.

Though an extreme case, the shocking incident brought to light a type of elder abuse that vexes nursing home residents, their families, and frontline caregivers: resident-to-resident elder mistreatment (RREM), a largely unstudied occurrence that takes the form of verbal attacks, physical violence, and, less commonly, sexual assault.

To better understand RREM, Human Ecology researchers, in collaboration with physicians at Weill Cornell Medical College, are midway through the first large-scale study of verbal and physical aggression among nursing home residents, a project funded by a four-year, $2.5 million grant from the National Institute on Aging. They are observing and interviewing residents and staff at 10 nursing homes in and around New York City to determine its prevalence, common triggers to violence, and the most promising treatments. The goal, according to study co-principal investigator Karl Pillemer, professor of human development, is to translate their findings into a set of non-pharmacological techniques to help nursing home staff defuse aggression between residents.

"Anyone who works in, lives in, or visits a nursing home will tell you that resident-to-resident aggression is a frequent, serious problem that is very difficult to deal with," said Pillemer, associate dean for extension and outreach in Human Ecology. "It's been known to be a problem for decades, yet it's largely overlooked by researchers, even though it causes great stress for residents and staff."

RREM in nursing homes adds more fuel to a combustible environment--what Pillemer calls "one of the highest conflict workplaces one can imagine." With 1.5 million Americans living in more than 16,000 nursing homes nationwide, according to the most recent survey on long-term care occupancy by the National Center for Health Statistics, finding research-based interventions to alleviate resident conflicts is critical to creating a safer, more positive setting for residents and workers.

The latest study follows in a long line of research by Human Ecology faculty to overcome the barriers to quality care in nursing homes, with particular emphasis on relieving the burdens of certified nursing assistants (CNAs). Other projects include an intervention to ease communication between long-term care staff and families, evaluation of a program to help nursing home residents return home or to other community-based settings (see sidebar), and a special program to train and retain CNAs--who provide about 90 percent of the care in nursing homes.

Many of the college's projects to improve eldercare originate from the Cornell Institute for Translational Research on Aging (CITRA), a National Institute on Aging-funded partnership among Human Ecology researchers, research clinicians at the Division of Geriatrics and Gerontology at the Weill Cornell Medical College, and researchers at the Cornell Institute for Geriatric Psychiatry in Westchester County.

"The opportunities to collaborate with Human Ecology add an entirely different dimension to our research, and it's a great marriage between the Ithaca campus and the medical college," said Mark S. Lachs, M.D., professor of medicine at Weill Cornell and principal investigator of the RREM study. "My expertise is in clinical care of older adults, but working with sociologists, psychologists, and gerontologists helps me to study and understand the broader concerns for the health of individuals in long-term care settings."

A stormy environment

In the typical nursing home, the circumstances are prime for RREM. Many residents suffer from brain disorders, such as dementia, that cloud their thinking and lower their inhibitions. They have limited private space, often living with a roommate and sharing dining areas, recreational rooms, and other areas. And they sometimes go long stretches without supervision as mounting fiscal pressures force nursing homes to cut back staff.

"All the conditions are present for conflict," said Lachs, author of a new book, Treat Me, Not My Age, a guide for older adults and their caregivers. "But we must remember that the perpetrators are victims and need to be protected, too. Because of their limited cognitive function, they are acting in ways that are largely out of their control."

In earlier research, Lachs, Pillemer, and medical student Tony Rosen documented 35 types of physical and verbal abuse among residents at a large urban nursing home. Screaming was the most common form of aggression, followed by such physical violence as punching and pushing.

"In cases of physical abuse, the harm is even greater because many older adults are physically frail, so it can be much more difficult to recover from an assault," Lachs added. "And verbal abuse can also have damaging mental and emotional effects for residents who may already be withdrawn because of their mental state."

With their current study, the team seeks to further characterize the many forms of RREM and to uncover patterns to abuse. Certain locations or times of day, for instance, maybe more likely to induce aggressive behavior. A previous study suggested that elevators, hallways, and other communal spaces were often the scene of increased hostility.

The research team is also examining staff strategies to cope with RREM as they develop and test possible interventions, including a training video and session for staff members to raise awareness of the issue and to share promising solutions.

"If we can pinpoint the precursors to this behavior, staff can better prevent it from occurring in the first place," Pillemer said. "These are extremely difficult situations, so just providing them with basic ideas that have been found to work can eliminate a lot of stress."

Easing the demands

For more than 20 years, Pillemer has observed CNAs across a variety of long-term care settings. They have, he says, one of the most demanding jobs in America, despite minimal preparation--usually a high school degree and 120 hours of training. They are overworked and prone to burnout, as evidenced by an annual staff turnover rate as high as 100 percent at some nursing homes. Still, we place one of our most vulnerable populations--older adults incapable of living alone and often afflicted with brain disease--in their care.

"For people in nursing homes, the quality of relationships with staff and the care delivered defines the entire experience," Pillemer said. "Certified nursing assistants are the backbone of the eldercare system, yet they work long hours with low pay and are often treated like second-class citizens. If we can improve their work life, quality of care will improve."

Pillemer and his fellow researchers in Human Ecology have adopted this as the guiding philosophy for many of their research and outreach programs.

Early on, they recognized that CNAs and family members of residents often clashed, with miscommunication common and both sides powerless to improve the relationship. Nursing staff were overwhelmed by requests from the families of the many residents under their care, whereas families often complained that their loved ones weren't receiving adequate direct care.

"Difficult interactions with families is a significant point of stress for CNAs and one of the prime reasons given when leaving the job," Pillemer said.

Out of this frustration came Partners in Caregiving (PIC), a unique research-based training program developed by Pillemer and collaborators for CNAs and family members across New York. The PIC sessions include trainings geared toward families and staff, with special emphasis on communication techniques, empathy, and resolving conflict. Pillemer also co-authored a manual, Partners in Caregiving, to extend the program to nursing homes nationwide. In a study, family members and staff showed significant improvements in their attitudes and behavior following the trainings.


In a related project, Pillemer and Rhoda Meador, associate director of extension and outreach in Human Ecology, studied the effectiveness of specially trained retention specialists in reducing turnover and staff shortages among frontline long-term caregivers. They examined 32 nursing homes in Connecticut and New York to compare facilities that used the model program with those that did not. Pillemer and Meador found that such programs greatly reduced CNA turnover in nursing homes, with many workers reporting that they felt more valued by their supervisors as a result. In other words, an additional investment in attention and resources for nursing assistants offered large payoffs for residents, workers, and administrators.

"Nursing turnover creates a very troubling cycle," Meador said. "The remaining staff take on more work, which adds to the stress and demands, which can lead to more turnover. The retention specialist project showed how a relatively minor adjustment could help to turn that cycle around."

All of the eldercare projects are a piece of the college's broader mission to improve the human condition at every stage of the life course.

"Human Ecology has a long history of examining the relationships between families and community institutions and systems of care, whether it's day care, schools, social support networks, or senior facilities. We're proud to carry on that tradition with our work." Pillemer said. "We have a rapidly aging population, so any steps we can take to improve eldercare are critical."

Human Ecology researchers aim to lessen aggression among residents, reduce staff turnover, and improve communication with families.

RELATED ARTICLE: For more information:

Mark S. Lacks

Rhoda Meador

Karl Pilierner
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