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This study explored the beliefs and organisational contexts of  nursing aide (caregivers henceforth) assaults and their subsequent reporting of these events.

Although this data is a pretty specific cohort and setting (rural nursing homes), the social and systems lenses that the authors take, and the silence resulting from blame attributions have broader applications.

Providing context:

·       86% of nursing home residents with dementia were found in one study to display a form of aggression over one week, with 51% being physically aggressive

·       In attribution theory for causality, events that are unexpected, negative, or important probe people to search for why it occurred. It’s noted that “Three dimensions of causality have been described: locus (internal factors within the person vs. external environmental factors), stability (modifiable vs. non-modifiable), and controllability (whether or not the cause is under the volitional control of the person whose behavior is being explained)”

·       These causal characteristics affect our expectations of future events, emotional reactions, distress, and behaviour. E.g. attribution of events to nonmodifiable factors can lead to a sense of hopelessness and an expectation that the outcome will continue to occur

·       People actively involved in interactions “might make attribution errors, because they tend to overlook environmental or situational factors as causes of the other’s behavior, and instead attribute them to stable dispositional or internal qualities of that person”

·       Therefore, relevant modifiable factors of the environment etc. that may contribute to resident aggression may be overlooked

Results

Interviews with caregivers revealed:

·       Organisational-level factors that constrained caregiver practices, affected their interactions with residents and created a context that put them at risk for physical assault

·       These organisational factors also affected their willingness to report the events

·       Key factors were grouped into three themes: 1) “frustration at being blamed for causing aggression”, 2) “lack of action to address the problem” and 3), “a desire for respect and involvement in decision making”

1)      Aggression and feeling blamed for assaults

The caregivers reported that they felt that they were being blamed after reporting aggressive behaviour from residents (usually to nursing supervisors).

Caregivers felt that their approach was questioned following reports of aggression, like, being prompted on what they did for the resident to become aggressive, or as one person put it “What did you do wrong?”.

Quoting the paper, several caregivers “described how being hit by a resident, and then being blamed for it, made them upset and angry”. In this instance what they needed most was for their experience to be validated, to be comforted and supported, rather than being blamed.

Caregivers want the incident to be investigated but “first they want their feelings to be acknowledged”. This is compounded because other staff don’t have the first-hand experience for caring for aggressive residents as the caregivers do.

Initially in the data it appeared that the caregivers believed that physical aggression was just an expected part of their job. This was later clarified to mean that while some aggression is inevitable, what upsets them the most is the perception by some staff that it’s just part of their job.

2)      Lack of Acknowledgement and Action

A perceived and persistent lack of action following their reports of aggressive incidents further reinforced their perception that other staff simply expect them to “quietly tolerate aggressive resident behavior”.

Caregivers reported that they had been documenting the more severe and aggressive behaviours in formal reports for years but “they do not know what happens to the reports once they are submitted”. They believe that reports aren’t investigated or followed up upon and hence, “see no evidence that anyone is concerned or interested in what happened”.

Many noted that they had given up reporting because they end up feeling blamed for the incident and formal reporting has no effect.

This long-standing perceived lack of action affected their relationships. For one it refinforced a perception that “they are at the bottom of a hierarchy and that their work is not valued”. As those more directly interfacing with aggressive residents, they want to be consulted and acknowledged.

Sometimes they believe that their ideas about why the resident was aggressive are brushed off, and some residents’ family members also don’t accept that their loved one can be aggressive.

3)      Desire for Respect and Involvement

Another central theme was caregivers’ desire to be acknowledged; instead, they perceived themselves to be at the bottom of the organisational hierarchy. As one person put it, “we are the grunts”.

While many factors were observed that result in resident aggression, caregivers reported that they seldom have control over them. These caregivers remarked to be “systematically trained to be at the bottom of the hierarchy, and that organizational practices and policies that exclude them from participating in decision making”.

Organisational factors involved a lack of time for care, especially with residents with dementia who need more time and staffing levels. Caregivers felt to be rushed through all aspects of care. While this was more efficient for the business, it led to more agitation among residents.

Moreover, “Rigid institutional routines that required care to be completed according to a pre-determined schedule contributed to rushing of care and to agitation and aggression” of residents. Here, caregivers lacked the flexibility to deliver individualised care.

Findings indicated that to address the issue of caregiver assault, “there must be a shift in focus away from the behavior of [individuals] to the broader system level”. Hence, a range of situational, environmental and organisational factors were linked to resident aggression “[indicating] that attribution error is occurring at a broader system level”.

Problematically, when failures occur there may be an “implicit assumption … that the person closest to the failure was the cause”. That is, unreliable and erratic performance of people at the sharp end primarily cause accidents. This judgement is made with the benefit of hindsight and outcome.

The belief of accidents due to “isolated blunders of individuals” is said to “[mask] the deeper story—a story of multiple contributors that create the conditions that lead to operator errors”. In this case, “attributing physical aggression to the behavior of [individuals] … masks the underlying systematic factors that [put workers at risk]).

These “simple folk models” of performance in complex settings, with multiple factors, interacting goals and conflicting restraints that confront workers can lead to the “blame and train” response.

·       These findings highlight how caregivers have unique and considerable knowledge about care in the field, “but they are unable to operationalize it because of “blunt end” factors”. These factors include: inadequate staffing

·       rigid routines and policies

·       limited dementia care skills of care providers in positions of authority

·       limited funding for continuing education programs for all providers, and

·       an organizational culture where physical assault is accepted as part of the [caregivers] job”.

The authors argue that pursuing “ the deeper and complex story behind “human error” often reveals imbalances between the demands that practitioners face and the resources available to meet them”. Such errors should be seen as signals of the need for change in the organisation.

Based on prior research about the criticality of opening up effective two-way communication and engagement across organisations, they found that three quarters of the studies that were reviewed, new knowledge was provided to staff “without any organizational or system support or change” to support that knowledge.

Authors: Morgan, D. G., Crossley, M. F., Stewart, N. J., D’Arcy, C., Forbes, D. A., Normand, S. A., & Cammer, A. L. (2008). Qualitative Health Research, 18(3), 334-346

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Study link: https://cchsa-ccssma.usask.ca/ruraldementiacare/publications/Taking%20the%20Hit%20paper%20as%20submitted.pdf

LinkedIn post: https://www.linkedin.com/pulse/taking-hit-focusing-caregiver-error-masks-risk-aide-ben-hutchinson-3gw8c