More than 90 per cent of aged care staff had been subject to some form of aggression from residents, such as hitting, kicking, pushing or verbal abuse, according to a survey by the New South Wales Nurses and Midwives’ Association.

Some 29 per cent of 282 respondents said they had witnessed resident-to-staff abuse as often as once or twice a week, while 20 per cent said they saw resident-to-resident abuse at the same frequency.

The survey did not ask respondents whether they had witnessed staff-to-resident abuse.

The union said its findings were consistent with rates reported in research in Europe and Canada, suggesting the phenomenon was not unique to Australia.

In 2014, a survey of 269 nurses by Australian Catholic University found that 36 per cent of respondents reported being physically assaulted by a resident or family member in the past five shifts, a similar number reported experiencing a threat of assault and 29 per cent reported being emotionally abused.

The union’s report survey said staff who were constantly at risk of abuse from residents could become emotionally distressed and detached from residents, reducing their ability to provide person-centred care which was essential in the management of challenging behaviour.

Some 61 per cent of respondents said they feared repercussions if they reported an incident of assault, which the union said was consistent with previous research undertaken with assistants in nursing that found they feared they would be blamed for the incident or found management unresponsive to their concerns.

Resident-to-resident aggression could have a significant impact on both residents and staff. While it was acknowledged that managing aggression was one of the most challenging areas for staff, many facilities lacked guidance in this area, the report said.

While screening tools had value in the identification of the risk of aggression, and could be undertaken as part of the admission process, there was little evidence they were being used to inform staffing and skill mix within aged care, it said.


The reporting of elder abuse required urgent change, the report concluded. It called for better staff training and the establishment of a “federal regulatory framework” to give aged care providers clarity in what constituted elder abuse and the expectations for staff training and reporting systems.

Initiatives such as the Dementia Behaviour Management Advisory Service added value in this area but more could be done to identify, assess and manage complex behavioural issues associated with dementia within the workplace.

“Increased staff awareness through the development of specialist training and support roles within facilities and through peripatetic services could have value in assisting aged care providers and staff to manage challenging behaviours. However, good care comes at a cost and appropriate staffing resources are required to ensure strategies are effective and residents are adequately assessed and supervised.”

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  1. Unfortunately whilst we continue to see behaviour as a symptom of a condition rather than an expression of unmet need we will continue to see statistics such as these. Creating pseudo hotels with staff seen as little more than hospitality servants does not help either. The industry needs a radical rethink on issues such as “BPSD” and what is the most effective models to deliver truly person centred care that meets the human needs of people, then we will see a very different workplace for our staff and living environment for our elders. It is telling that the initial response is to fall straight back into our medical model of more assessment and management! As an industry we need a paradigm shift that stops trying to manage behaviour and starts meeting unmet needs.

    David Sheard has developed in his model a paradigm where each “incident” is treated as a complaint against the service. Food for thought!

  2. “……36 per cent of respondents reported being physically assaulted by a resident or family member in the past five shifts…..”

    Simply solution to being assualted by a family member. Call the police.

  3. I appreciate the comment by JasonB, and whilst I respect the work done by David Sheard, there is a problem assuming that “…each “incident” is treated as a complaint against the service.”

    It may be that the incident is telling us more about what is going on internally (physically and/or mentally) for the person with a dementia. Mike Bird once said to me that the ‘trigger’ for a violent outburst in the person with a dementia may be a line from a song heard on the radio which evokes painful memories.

    That has little or nothing to do with the serivce but it does suggest that we need first to know about the person qua person. That is the starting point.

  4. Shock? Horror? Not really.

    I first worked in a dementia unit 30-odd years ago. Challenging behaviours were the same then as they are now. But back then, we had adequate numbers of well trained registered nurses and enrolled nurses.

    Potential escalation of behaviour was noted early and diverted quickly by experienced RNs & ENs who knew what they were doing.

    Nowadays, providers have a personal carer working alone in the dementia unit… and then wonder why they got assaulted.

  5. I am an Age Care nurse. I read with interest your article on aggression and feel you are missing a perspective.
    Most carers in residential settings are Certificate 3 qualified. This makes them well qualified to report on challenging behaviours but not so well informed on the drugs available to manage them. It has been my experience that doctors do not spend enough time analysing behaviours in order to prescribe the best interventions and carers are not confident or knowledgeable enough to report them and request better help. If a behaviour is not well managed the carer often feels unnecessarily guilty instead of realising that aggression is a legitimate part of dementia and should be recognised as such.
    Fault, if any, lies with a system reluctant to use drugs such as Oxazepam, Risperidol, Mirtazapine etc to any great extent. To use these drugs is not to admit failure. They have limited half lives and can be very successful in contributing not only to the smooth care of residents but also their happiness. Residents benefit greatly when they are calm, compliant, and able to be cared for more easily.
    Another important consideration is that Residential facilities use minimum staff, making time management an important issue. It is naive to suggest that carers spend those few extra moments when so many are being cared for by so few. To suggest management of dementia caused aggression is simply a matter approach is insulting.
    No-one wants to see over medicated residents but we do not live in a utopia where 1:1 nurse ratios are practised. Pharmacological intervention remains a valuable resource that should be more readily accepted. For the sake of residents and well as staff.

    Christine Robey

  6. Unfortunately aggressive behaviour has become part and parcel of aged care especially in dementia specific units. Staff are told to report these aggressive incidents, but nothing is ever done about it. There is a lack of support from supervisors and management and a great lack of training for staff to deal with these behaviours. I believe more training should be given to staff in this area and a self defence course should also be made mandatory, there are such courses available, but of course this costs money which organisations are not willing to spend, even if it means safer working environment for their staff and their residents. I don’t believe giving more drugs to residents with aggressive behaviour is a good long term solution, offering more stimulating activities could be a good answer. If you have ever worked in a secure dementia unit you will understand why the incident of aggression can occur, you have people locked up in one area, left to sit in front of the television for hours or to wander up and down the same corridor day after day. These people become stir crazy and I am of the believe that aggression can be a result from this. I do not blame carers for this situation, as they are run of their feet to meet deadlines, finish reporting before the end of shift etc. Person centered care is a great ideal, but unfortunately is not a reality in everyday aged care. Maybe if it were we would have a lot less unhappy aggressive residents.

  7. And here lies the problem. It’s clear that not everyone gets it.

    Christine, dear colleague, your conviction that “aggression is a legitimate part of dementia” and your eagerness to break out the Benzo’s require some adjustment.

    Its time for everyone to learn the distinction between aggression and agitation. If you keep pushing someone to have a shower when they’ve already refused three times, you probably deserve to get hit. (how would you react to a stranger barging into your room at 6am, switching on the bright lights and trying to drag you out of bed while babbling at you in an unintelligible accent…if they talk to you at all?)

    The pharmacological knowledge of Cert 3 staff or their ability to report BPSDs aren’t the problem. Awareness, prevention and de-escalation are the skills we’re looking for.

    I wonder just how many of those ‘qualified’ Cert 3s could rattle off the full social and medical history of each of their residents, list their known behavioural triggers and the specific strategies employed to manage them?

    Sure, medication can sometimes play an important role..but not as important as having sufficient numbers of staff with excellent English skills and a deep understanding of those in their care. Cranking up the PRNs isn’t the way to address problems associated with inadequate staffing.

    Alan and JasonB can see the real problem. We need skilled care staff…and plenty of them.

  8. Dave, I agree that medical intervention is not necessarily the answer.

    The key lies in supporting the direct care staff (PC’s) with training in how to identify the triggers to the behavior, and to recognise the levels of escalation, so that they can respond appropriately. This is not covered in a Cert III in Aged Care, and requires interpersonal skills such as communication and self awareness.

    By developing staff skills, and practicing true person centered care, we can manage conflict before it reaches a crisis point where someone is being hurt. We need to focus on the triggers and how to respond rather than just the behavior itself.

    It is sad that in the aged care industry, many staff believe that being kicked, pinched and sworn at is a part of their job! This often prevents staff from reporting because they feel they may be judged for not ‘coping with the job’ as well as others might, or that there will be no follow up from their supervisors.

    There is an excellent training program available that the aged care organization I work for is actively providing for staff, called Maybo. As a facilitator of this training I receive a great deal of positive feed-back from staff about the value of the training and how it develops their skills to manage conflict and abuse. As well as the theory behind managing conflict as a first response, it also covers physical interventions and disengagement skills that are designed to protect staff whilst not harming a resident or client.

    We have seen a direct increase in reporting of issues of abuse, threat and assault across the services that have received this training, which in turn has resulted in a higher level of review and response.

  9. Meeting the needs of residents that are stressed because they can’t express themselves when they need to go to the toilet, they can’t wait until the next shift. Agitation because the resident has unmet needs like too much noise around them, they are thirsty and need a drink, have been sitting in the same position for ages, haven’t been moved to another area for change of scenery, not enough staff to cover their needs, its handover time and the resident wants your attention now, shifts that are already in the throws of residents that have unmet needs, wandering, shouting, trying to catch someones attention, leading to stressed staff and more stressed residents. Its a vicious circle that can witnessed at many age care facilities. Lack of staff training, only in house by trainers that don’t even know what or why they are training other Cert 3. One trainer recently said “I make it to fake it”. God help the residents, and the student Cert 3’s. I left for a calmer world.

  10. OMG. Mandatory self defence training for carers…so if we cant manage them, fight them?

    The dementia unit Carole described belongs in One Flew Over The Cuckoo’s Nest. How is this occurring in 2016?

    Is anyone from the AACQA reading these responses? At least one of you gave these guys a ‘pass’ at their last accreditation.

    Surely I’m not the only one who is appalled by the misconceptions held by these carers?

    It’s all going really well out there, isn’t it?

  11. I feel some age care facilities are not protecting the rights of workers well so many times the staff are abused in many ways by family members. Can you tell me where I can find this type of advice, info and guidelines?

  12. When are we going to address staff ratios……more staff to give time and unrushed personal care…..more staff ……..stop treating Cert Iii and Cert IV as nothing more than skivvies and food service waiters….I certainly did not train for this.I am an intelligent carer who even though I am not medicine endorsed can still understand drugs and medications and am sick of being locked out of important carer issues and treatments because I am not a nurse. Only thing I get at handover is “whose pad was changed and at what time…..belittling..disrespect….after all I am the one who sees my residents 7 1/2 hours per day 5 times a week…. More staff. More involvement we are not idiots….

  13. I would just like to say that abuse either physical or verbal from a resident suffering a mental illness or any type of dementia I can fully understand and deal with without complaint , as long as the behaviour is logged in daily notes and staff are made aware of the behaviours to expect it can be dealt with. But what myself and many other staff members are subjected to by a resident that has no mental problem is unacceptable every day at least three times a day staff are verbally abused and sworn at called names and told we are bloody useless both racially and sexually discriminated against at every level when we are doing our very best to provide care. When complaints are made to managers we are just fobbed off and they try to find some excuse for the behaviour. the staff handle this abuse very well but at times it gets to the point where many workers have left in tears as this is a large person it requires at least three staff to assist and if we are not all there to help instantly which is almost impossible as usually there are only a total of three on the floor. I feel more staff would help this situation but will not solve it until residents are also made aware of their responsibilities towards workers especially when all they are trying to do is help in the best possible way they can. we are certainly not in this job for the money it is for love of being able to help and care for someone well certainly for me anyway.

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