manifest their feelings in particularly hostile mannerisms and verbal abuse (Everitt et al., 1991).

Violence toward staff may be to some extent an indicator of poor quality of care. Patients in some instances may be reduced to violence as the only way to gain control over their environment. The problem here may be the lack of recognition of good nursing practice in (1) designing nursing home environments that stimulate residents to take responsibility for their own behavior, and (2) rewarding individual staff initiative as opposed to rewarding conformity to make life easier for staff.

In summary, the evidence to date suggests that violence directed at health care workers in hospitals and nursing homes is a significant and growing issue for worker safety, peace of mind, and ultimately good patient care. The committee concludes that it is critical that health care institutions implement strategies to prevent such assaults on workers and that they provide adequate security especially in the high-risk departments (such as emergency room areas or psychiatric units). It also concludes that staff training in effective ways to control violent patients is essential as part of a long-term strategy by which health facilities and institutions can prevent or minimize the harms that may stem from violence and abuse directed at health care workers.

Violence and Abuse Against Patients and Residents

Physical, verbal, and psychological abuse can and does occur in all settings, from hospitals and nursing homes to personal residences, and it can be inflicted by family members as well as health care personnel (including nursing staff). Relatively little has been written about abuse of the elderly in the peer-reviewed medical and health policy literature, although some discussion of this issue of abuse has appeared (Lachs and Pillemer, 1995).

Nursing Homes

What attention has been given to this problem over the years has tended to focus on abuse by NAs working in nursing facilities, and the issue, particularly in nursing homes, is receiving increasing amounts of attention in local and national media. The Gannett News Service, for instance, prepared a series of articles on the topic in February 1994, that were picked up by various newspapers around the country. Requests for further information on the series led Gannett to compile all the articles in an 8-page special investigative report (Eisler, 1994).

Reports of abuse in the press range from neglect, humiliation, and theft to battery and even rape (e.g., Allen, 1994; Bernardi, 1994; Eisler, 1994). Similarly, in the first half of 1995, the 20/20 television news magazine, using hidden cameras, produced a segment documenting abuse. Other investigators have characterized the behavior of NAs as rude, neglectful, uncaring, insulting, and some-

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