Unfortunately, these and other studies revealed that staff are often unable to predict who the weapon carriers are.

Several administrative, organizational, and environmental factors have been associated with violent injuries in the workplace. These include limited training in the management of violent behavior (e.g., containing or restraining an assailant); staffing levels and patterns, including the use of agency nursing staff; and the day shift tour of duty. Hospital administrators and nurse managers must facilitate staff awareness of the potential for violent situations and enhance the capability to deal with them effectively.

Nursing Homes

Nursing staff, particularly NAs in nursing homes, are also subject to abuse by residents. Studies about the incidence of aggressive resident behavior in nursing homes are sparse, but the few studies available suggest that the presence of behavioral problems is a matter of concern (Zimmer et al., 1984; Beck et al., 1991).

Management of aggressive resident behaviors presents difficult care problems for nursing staff. Researchers have documented frequent incidence of aggressive behavior displayed by residents including physical and verbal abuse (Everitt et al., 1991). Sometimes aggressive resident behaviors are violent. In a study of 101 nursing homes and intermediate care facilities, Winger and colleagues (1987) found 84 percent of residents in nursing home and 54 percent of residents in intermediate care facilities displayed behavior that endangered self and others. Meddaugh (1987) reviewed charts and incidence reports on 72 residents in a skilled nursing facility and found that 26 (27 percent) residents abused staff 1 to 2 times in a 3-month period. Lusk (1992), in an exploratory study, found a variety of injuries such as black eye or torn shoulder cuff requiring surgical repair from residents' aggressive behaviors as reported by nurse aides. Rudman and colleagues (1993) in their study of two Department of Veterans Affairs nursing facilities found a higher incidence of physically aggressive behavior in facilities with a greater percentage of neurologic and psychiatric patients. In a study of 124 residents in 4 nursing homes, Ryden and colleagues (1991) found that 51 percent of aggressive behavior was physical, 48 percent verbal, and 4 percent sexual.

The committee notes that one feature of Alzheimer's disease and other cognitive and emotional impairments found among older patients is lack of cooperation with efforts to provide personal care. For instance, the behavior could include for some patients violent resistance to undressing and bathing. The issue is that the patients are not so much engaging in unprovoked violence against nursing staff, rather residents may believe they are defending themselves against what they perceive to be unwanted touching and personal assault. The regimentation of institutional life makes many patients uncooperative and some of them

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