Physical abuse resulting from poor care, such as skin breakdown, rough handling, or inattention to bowel and urinary elimination needs, is another serious problem that can occur in institutions. This type of physical abuse may be inflicted by health care personnel who are not well qualified (Baker, 1977). Citing the dearth of research regarding maltreatment of residents of nursing homes, Pillemer (1988) provides a theoretical model of maltreatment as the outcome of staff members' and patients' characteristics as these are influenced by aspects of the nursing home environment and by certain factors exogenous to the facility. As highlighted in the model and supported by a review of the literature, staff who are at more risk for abusive behaviors toward the institutionalized elderly are more likely to be young (Penner et al., 1984), have lower levels of education (Baltz and Turner, 1977; White, 1977), be male (U.S. Department of Justice, 1985; Straus, 1986), have the least experience (Penner et al., 1984), and be under more stress (Heine, 1986). More recently, Pillemer and Hudson (1993) report an evaluation of a model abuse prevention curriculum for nursing assistants, showing high satisfaction with the program and reduced conflict and abuse of residents. Cassell (1989) also suggests that physicians sometimes abuse their elderly patients when they employ their power in a manner they believe to be in the best interests of the sick.

Just as residents can suffer at the hands of staff, nursing staff are also subject to abuse by residents. Studies about the incidence of aggressive resident behavior in nursing homes are sparse, but the few available studies suggest that the presence of behavioral problems warrants concern (Zimmer et al., 1984; Beck et al., 1991). Sometimes aggressive resident behaviors are violent and may cause fear in nursing staff as well as harm. Management of aggressive resident behaviors presents difficult care problems for nursing staff. In a study of 101 nursing home and intermediate care residents in Veterans Administration (VA) facilities, Winger and colleagues (1987) found 9 percent of nursing home and 34 percent of intermediate care residents had no aggressive behaviors, while 84 percent of nursing home residents and 57 percent of intermediate care residents had behaviors that endangered themselves or others. A study by Everitt and coworkers (1991) documented that the three most distressing resident behaviors nursing staff encountered were physical abuse, verbal abuse, and wandering. Lusk (1992), in an exploratory study, found NAs reporting a variety of injuries (e.g., black eye, torn shoulder cuff requiring surgical repair) from residents' aggressive behaviors, while another study comparing physically aggressive behavior in two Department of Veterans Affairs nursing homes found more instances of aggressive behavior in the home with a greater percentage of neurologic and psychiatric patients (Rudman et al., 1993). Meddaugh (1987) reviewed chart and incident reports to investigate the aggressive behavior of 72 residents in a skilled nursing facility. Twenty-six staff members (27 percent) were abused by a resident 1 to 2 times in a 3-month period. In a study of 124 residents in 4 nursing homes, Ryden and colleagues (1991) found that 51 percent of aggressive behavior was physical,

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