Archives of Gerontology and Geriatrics 61 (2015) 277–284

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Individual and contextual determinants of resident-on-resident abuse in nursing homes: A random sample telephone survey of adults with an older family member in a nursing home§ Lawrence B. Schiamberg a,*, Levente von Heydrich b, Grace Chee a, Lori A. Post c a

Department of Human Development and Family Studies, Michigan State University, 552 West Circle Drive, East Lansing, MI 48824, United States Department of Health and Human Services, Baker College, 1020 South Washington Street, Owosso, MI 48867, United States c Department of Emergency Medicine, Yale University, 464 Congress Avenue, Suite 260, New Haven, CT 06519, United States b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 11 June 2014 Received in revised form 13 April 2015 Accepted 5 May 2015 Available online 12 May 2015

Few empirical investigations of elder abuse in nursing homes address the frequency and determinants of resident-on-resident abuse (RRA). A random sample of 452 adults with an older adult relative, 65 years of age, in a nursing home completed a telephone survey regarding elder abuse experienced by that elder family member. Using a Linear Structural Relations (LISREL) modeling design, the study examined the association of nursing home resident demographic characteristics (e.g., age, gender), health and behavioral characteristics (e.g., diagnosis of Alzheimer’s Disease, Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), types of staff abuse (e.g., physical, emotional), and factors beyond the immediate nursing home setting (e.g., emotional closeness of resident with family members) with RRA. Mplus statistical software was used for structural equation modeling. Main findings indicated that resident-on-resident mistreatment of elderly nursing home residents is associated with the age of the nursing home resident, all forms of staff abuse, all ADLs and IADLs, and emotional closeness of the older adult to the family. ß 2015 Elsevier Ireland Ltd. All rights reserved.

Keywords: Resident-on-resident elder abuse Elder abuse in nursing homes Structural equation modeling LISREL design Nursing home social climate Latent variable modeling

1. Introduction While the problem of elder abuse in nursing homes has received increasing attention and research scrutiny (Schiamberg et al., 2011, 2012;[12_TD$IF] Zhang, Schiamberg, Oehmke, Barboza, Griffore, Post, & Mastin, 2011), relatively little attention has been given to an important dimension of the problem – resident-on-resident elder abuse in nursing homes RRA (Rosen, Pillemer, & Lachs, 2008). RRA has been defined as, ‘‘negative and aggressive physical, sexual or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient’’ (Rosen, Lachs, et al., 2008, p. 78). While much public attention and as well, an increasing level of research, has been directed at elder mistreatment in nursing homes, such mistreatment has been typically been associated with nursing home staff as

§ This research was supported by a grant from the Centers for Medicaid/Medicare Services. #CFDA 93.778 to Michigan State University. * Corresponding author at: Department of Human Development and Family Studies, 552 W. Circle Drive, Michigan State University, East Lansing, MI 48824, United States. Tel.: +1 517 432 8293. E-mail address: [email protected] (L.B. Schiamberg).

http://dx.doi.org/10.1016/j.archger.2015.05.003 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.

the primary perpetrators. However another mode of mistreatment may be as, or more, serious than staff abuse – specifically the abuse of nursing home residents by other residents RRA. Observations by professionals spending a fair amount of time in nursing homes, and interviews of older adult residents, indicate a disturbing frequency of mistreatment among residents, including emotional abuse (e.g., verbal threats, name calling, humiliating) and physical abuse (e.g., shoving, pushing, kicking) (Morgan, Cammer, Stewart, Crossley, D’Arcey, Forbes, and Karunanayake, 2012). Although more research has been done on both elder abuse perpetrated by family members in community settings (Baker, 2007; Lachs & Pillemer, 2004) and by staff in nursing homes (Schiamberg et al., 2011, 2012), much less is known about RRA in nursing homes (Shinoda-Tagawa et al., 2004). Evidence from government reports suggest the failure of many nursing homes to adequately protect residents from other residents (Rosen, Pillemer, & Lachs, 2008). RRA has been documented to occur in both public and private areas of nursing homes, potentially at all times of day or night (Rosen, Lachs, et al., 2008). More specifically, Rosen, Lachs, et al. (2008) found that 70% of incidents occurred in the common living areas, such as patient lounges while 30% of incidents occurred in the patient’s room. As to prevalence of RRA in nursing homes, data

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from the Centers for Medicare and Medicaid Services indicate that approximately 88,000 Massachusetts nursing home residents exhibited aggressive behaviors (likely including RRA and resident aggression directed at staff) in a 1-week period (Iglehart, 2001; Shinoda-Tagawa et al., 2004). While similar data is available from other states, there are no definitive analyses of the national prevalence rates, or risk factors for RRA in nursing homes. 2. Description of the problem The problem of RRA has several important dimensions and characteristics, which are essential for both an understanding of RRA and for the development of effective research and policies for addressing the problem. Consistent with an ecological perspective to elder abuse in nursing homes (Schiamberg et al., 2011), a review of RRA research will be organized around two key contextual dimensions of the older adult nursing home experience: (1) the nature of the focal resident-on-resident relationship (e.g., individual older adult characteristics, such as mental health disorders or cognitive impairments) and (2) the contributions of contexts more distal to the focal resident-on-resident relationship (e.g., the quality of the relationship between the older adult nursing home residents and their family members) (Miller & Rosenheck, 2006; ShinodaTagawa et al., 2004). 2.1. The nature of the focal resident-on-resident relationship 2.1.1. Older adult individual characteristics While most common RRA injuries involve physical abuse, including lacerations, fractures and bruises, there is limited data on other types of RRA (e.g., psychological abuse, such as verbal intimidation, yelling, name-calling, or verbal denigration of a person) as well as the characteristics of residents who are victimized by other residents (Lachs, Bachman, Williams, & O’Leary, 2007; Rosen, Lachs, et al., 2008; Shinoda-Tagawa et al., 2004). Individual characteristics associated with RRA include gender (i.e., males more likely to be abused), dementia-related behavioral disturbances (e.g., wandering), cognitive impairment (e.g., psychosis), provocative behavior (e.g., being verbally abusive), and inappropriate social behavior (e.g., making offensive noises or gestures) (Shinoda-Tagawa et al., 2004; Rosen, Lachs, et al., 2008). Such individual risk factors may be exacerbated by maladaptive behaviors such as wandering may serve as triggers for RRA (Shinoda-Tagawa et al., 2004; Rosen, Lachs, et al., 2008). There is evidence that cognitive impairments are associated with behavioral disturbances that cause residents to exhibit aggressive behaviors (Lachs et al., 2007; Zhang, Page, Conner, & Post, 2012). This circumstance is even more ominous given that cognitive impairment may be present in as many as 80–90% of nursing home residents and that well over 50% of those residents have dementing illnesses (Lachs et al., 2007). Pre-existing cognitive deficits such as dementia may markedly delay or distort older adult information processing, in turn impairing communication and making those individuals more vulnerable to RRA (Burgess, Dowdell, & Prentky, 2000; Rosen, Lachs, et al., 2008). 2.2. Triggering situations and behaviors When older adult residents with dementia are congregated together in close proximity in large nursing homes, there is evidence that crowding may induce aggressive behavior between nursing home residents (Morgan and Stewart, 1998; Rosen, Lachs, et al., 2008; Rudman, Bross, & Mattson, 1994). Triggers for such abusive behaviors frequently include agitation resulting from close contact, invasions of personal space, or noise and other disturbances caused by unit mates or roommates (Lachs et al., 2007).

Furthermore, individuals with Alzheimer’s dementia, exhibiting related wandering behavior, are three times more likely to be injured by another resident (Shinoda-Tagawa et al., 2004). Some additional ‘‘triggers’’ related to cognitive decline include moaning, pressured and repetitive speech, or screaming. In addition, another symptom of cognitive decline, which may trigger RRA is an inability to compromise around alternate preferences and to effectively communicate preferences. Residents who were more likely to be abused were more likely to be physically independent, although more cognitively impaired. Older adults who were attacked or victimized had to be physically independent in order to be able to interact with the abuser and to be involved in altercations with the abuser (Shinoda-Tagawa et al., 2004). Conversely, residents who were less likely to be victimized were found to be either cognitively intact enough to avoid trouble or too physically dependent to get into trouble (Shinoda-Tagawa et al., 2004). 2.3. The contributions of contexts more distal to the focal resident-onresident relationship The impact of distal factors on RRA includes both factors within the nursing home context and factors beyond that context. While there is limited data specific to RRA for the impact of distal factors to the immediate resident-on-resident relationship, there is precedent in for their consideration of distal factors outside the nursing home context. Specifically, there is evidence that the likelihood of physical abuse by nursing home staff may be reduced by close emotional relationships between older adult nursing home residents and significant family members (Schiamberg et al., 2011, 2012). Consideration of within- nursing- home distal factors derives, in part, from research on nursing home environments or, more specifically, a nursing home climate of violence, which might predispose individuals in group settings toward violence. Research previously cited on environmental ‘‘triggers’’ of RRA in nursing homes (e.g., agitation due to crowding, invasion of privacy) represents the impact of distal factors, beyond the resident-onresident relationship, which might increase the likelihood of RRA (Shinoda-Tagawa et al., 2004). An important and largely unexplored dimension of such a climate of violence is how aggression may well be socialized as a general and unfortunate learning process which creates a negative social climate conducive to individual violence, in this case, in the immediate resident-on- resident context. One potential aspect of nursing home climate of violence, in the sense that its existence may contribute to a climate of violence and RRA, is existence of staff abuse and related socialization of residents to violence. Although there is some evidence for an association of staff abuse to RRA (Zhang et al., 2012), that evidence has either been specific to staff physical abuse (Schiamberg et al., 2012) or thought to be related to family member reporting of RRA based on family dissatisfaction with a nursing home. Social learning theory posits that individuals learn from both direct experiences with rewards and punishments as well as from behavioral examples or the modeling of others (Bandura, 1983). In addition to imitation and modeling of aggression, individuals may construct aggressive ‘‘scripts’’ as guides for behavior and addressing real or perceived social problems. These scripts can be activated automatically in various situations, often unconsciously, creating strategies for responding to perceived problematic encounters with others residents of a nursing home, possibly leading to RRA (Bennett, Farrington, & Huesmann, 2005). 3. Purpose of study The review of RRA research has generated several primary research questions. With reference to the immediate context of the

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resident-on-resident relationship, what is the impact on the likelihood of RRA of victim ADL and IADL limitations? For more distal contexts, beyond the immediate resident-on-resident relationship, yet still within the direct nursing home experience of the older adult, what is the impact on the likelihood of RRA the occurrence of various types abuse by nursing home staff? At the most distal contextual level (i.e., both beyond the immediate resident-on-resident context and beyond the immediate nursing home experience), what is the impact on the likelihood of RRA of the quality of the older adult/family relationship (e.g., close emotional ties between the older adult nursing home resident and his/her family)? The general aim of this study was to examine the risk factors for RRA from an ecological perspective, moving from the immediate context of the resident-on-resident interaction to more distal contexts. More specifically, at the immediate contextual level of the resident-on- resident interaction, the study addressed risk factors of RRA such as the presence of ADL/IADL limitations and chronic physical and neurological illnesses. At more distal contexts (i.e., outside the immediate resident-on resident relationship), the study examined the impact on RRA of the history and cooccurrence (over the previous 12 months) of staff abuse and family relationships/cohesion (at the resident/family contextual level). 4. Materials & methods 4.1. Overall study design and sampling procedures The Michigan Survey of Households with Family Members Receiving Long Term Care Services was funded by a grant from the Center for Medicare/Medicaid (Medicaid Services Grant #92390), U.S. Department of Health and Human Services (Post, 2006). This was a randomized telephone survey of adults living in Michigan who had a relative currently receiving long-term care services (i.e., any paid service to assist the family member to do normal daily activities, in either a facility or a community setting). It was undertaken explicitly to provide randomly selected baseline data on abuse, exploitation and neglect, and long-term care services in both facilities residential community settings. For the entire survey, there were 1002 respondents who had a relative of any age in a nursing home. Using a computer-assisted interview system (CATI), interviews were conducted by the professional staff of Schulman, Ronca and Bucuvalas, Inc. from October through December, 2005. Data for the entire survey were based on telephone interview responses from family members, rather than from the older adult nursing home residents themselves. This was done for several reasons: (1) the inherent difficulty of accessing a population of older adult nursing home residents; (2) the risk for potential human-subjects violations due to the inability to obtain informed consent from cognitively impaired individuals; and (3) the older adult’s disabilities such as dementia or communication problems (frequently associated with nursing home placement), that could seriously limit the accurate reporting of abuse. Although the survey design was cross sectional, it allowed for collection of histories of such factors as disability, health, abuse, neglect, and exploitation. For example, some survey questions provided respondents a time boundary such as the previous twelve months or, in some instances, the full duration of the long-term care residence. 4.2. Final analytical sample – use of family members as proxies The final analytical sample (N = 452) for this study included respondents with relatives 65 years of age and older living in a

Table 1 Characteristics of respondents. Variable

Frequency

Percentage

Spouse Sibling Adult child Parent Grandchild Daughter/son-in-law Niece/nephew Mother/father-in-law Self Friend Other relative Attorney TOTAL

34 29 188 2 67 34 31 14 1 7 40 5 452

7.5 6.4 41.6 0.4 14.8 7.5 6.9 3.1 0.2 1.5 8.8 1.1 100

nursing home, who answered questions about resident-to resident or non-staff abuse. As indicated in Table 1, study respondents were overwhelmingly family members (97%), with an adult child being the most frequent category of family member (41.6%). Family members who were responsible for a person in long term care were the targeted sample, rather than the older adult long term care residents, for several reasons: (1) residents of institutions are typically difficult to access and may feel exceeding uncomfortable or possibly threatened by responding to study questions on sensitive topics such as abuse; (2) informed consent, as well as accurate reporting of the nursing home experience would be particularly difficult to obtain from individuals with challenges directly related to their placement in nursing homes – e.g., communication disorders or cognitive impairments such as dementia. Family members have been found to be effective proxies for several reasons. (1) There is evidence that family members are particularly good observers and reporters of abuse. Family members were, in fact, the best and most accurate reporters of instances of confirmed abuse for state Adult Protective Services programs (Teaster, Dugar, Otto, & Mendiondo, 2006). (2) Since the current investigation did not identify the family respondents by name, relative family members could respond to sensitive abuse questions without fear of reprisal (unlike, as mentioned, older adult residents themselves), which is the largest predictor of unreported abuse (Allen, Kellett, & Gruman, 2004; Hawes and Kayser-Jones, 2003). (3) Although families could have under reported instances of elder abuse in nursing homes such under reporting was less than from other forms of elder abuse data collection (e.g., ombudsmen, Adult and Protective services or other agencies). (4) Furthermore, because of their continued access to older adult residents (in contrast to other reporting systems), family members under reporting was significantly compensated for by their increased likelihood to report long term, more persistent and therefore more serious elder abuse rather than occasional abuse. (5) Finally, the analytical sample of the study was restricted to the knowledgeable family members, or adults, responsible for overseeing the care of the older adult nursing home resident. In turn, this provided some reassurance not only of the quality of family reporting but reduced the likelihood of major differences in accuracy of reporting across all types of relatives (e.g., siblings, adult children). While specific sensitivity analyses of relative types might be of interest, meaningful comparisons would be reduced in this sample (n = 452) since the vast majority of adult respondents were adult children/grand children (56%) while other relative groups were too small (none over 8%) for meaningful comparison. Future research with much larger sampling of all relatives categories might be useful if such comparisons are of interest.

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4.3. Measures and variables Outcome variable: RRA or mistreatment Resident-on-resident mistreatment was defined as any direct or indirect action performed by non-staff member in nursing homes that affects the physical survival, welfare or health of elderly nursing home residents, causing pain, unnecessary suffering or health deficiency. The non-staff mistreatment endogenous variable (RRA) was measured using two direct manifest variables: ‘‘Now we want to talk about mistreatment by persons in the care setting that are not staff or care givers. (1) How many incidents would you say this person has ever experienced in a long-term care setting?’’ and (2) ‘‘Thinking just about the last 12 months, how many incidents would you say they have experienced? (Mistreatment by persons in the care setting that are not staff or care givers.)’’. These two variables are measured on a five-point scale ranging from 1 (none) to 5 (more than 10 times). 4.4. Predictor variables This study utilized three categories of predictor variables: (1) Resident- on-resident contextual factors (e.g., victim individual characteristics such as age, gender, ADL/IADL measures); (2) Older adult/nursing home staff contextual factors-beyond the immediate resident-on-resident context, yet within the older adult’s nursing home experience (e.g., history and co-occurrence of nursing home staff abuse); (3) Older adult/family relationship contextual factors – beyond both the immediate resident-on-resident relationship and the older adult’s nursing home context (e.g., perceived closeness or emotional ties between the older adult and the family). 4.5. Resident-on-resident contextual level predictor variables – older adult characteristics Age was the chronological age in years of the elderly nursing home resident. Gender was a binary variable, with 1 = male 2 = female. The following direct indicator variables were used to measure the ADL/IADL (latent variable): ‘‘Can the person perform the following ADLs without help? (a) bathing, (b) dressing, (c) getting around inside, (d) toileting, (e) getting in or out of bed or a chair, (f) eating, (g) shopping, (h) light housework, (i) using the telephone, (j) money management, (k) meal preparation, and (l) taking or keeping track of medication.’’ The measurement level of these variables was categorical ordinal, having the value of 1 if the condition in question was present or a value of 0 otherwise. 4.6. Diagnosis of Alzheimer’s disease and other dementias ‘‘Has this person been diagnosed as having any of the following medical conditions? a. Alzheimer’s disease or b. Other dementias such as dementia related to stroke. The measurement level of these variables was categorical ordinal, having the value of 1 if the condition in question was present or a value of 0 otherwise. 4.7. Older adult/nursing home staff contextual level predictor variables – types of staff abuse The following variables measured the various forms of elder abuse (Staff Abuse latent variable) committed by nursing home staff members. These variables were measured on a five point Likert scale where 1 = No abuse; 2 = One or two incidences; 3 = Three to five; 4 = Six to ten; and 5 = More than 10. Physical abuse: ‘‘Let’s start with incidents of physical mistreatment by staff or other care givers such as striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, or burning. How many such incidents would you say this person has ever

experienced.’’ Restraint abuse and forced activities: ‘‘Now, I am interested in other types of caretaking mistreatment by staff or care givers such as over – administration of drugs, withholding or delaying of drugs, inappropriate use of physical restraints, unjustified force feeding, inappropriate toileting. How many such incidents, would you say this person has ever experienced.’’ Verbal mistreatment: ‘‘Now I want to talk about incidents of verbal mistreatment by staff or care givers such as yelling, cursing or swearing, insults, threats, intimidation, humiliation, or harassment. How many such incidents, would you say this person has ever experienced.’’ Emotional or psychological mistreatment: ‘‘Now we want to talk about incidents of emotional or psychological mistreatment by staff or other care givers such as being treated disrespectfully or like a child, not allowing the person to have contact with family or friends, giving the silent treatment. How many such incidents, would you say this person has ever experienced?’’ and ‘‘Now, we want to discuss incidents of sexual misconduct by staff or other care givers such as forced sex, sexual contact without consent, sexual coercion, and unwanted touching. How many such incidents, would you say this person has ever experienced?’’ 4.8. Older adult/family contextual level predictor variable – family emotional ties Family ties measuring direct variable: ‘‘How would you characterize the closeness of your relationship with this person? Please give me a number between 1 and 10 that represents the closeness of your relationship where 1 = emotionally distant and 10 = emotionally close. 5. Scales and instruments The measurement instrument administered to respondents (the relatives of elderly nursing home residents) consisted of 31 items assessing various dimensions associated with the life experiences of elderly nursing home residents. Responses to most measures were elicited on a 5-point Likert-type scale anchored by 1 (none) and 5 (more than 10 times). The scale was formed by averaging the items and scored such that higher values indicated a higher level of both non-staff and staff abuse of elderly nursing home residents. In our study, the Cronbach’s alpha for the items was 0.95, the mean was 1.2358 and the SD was 0.6384. 6. Mathematical definitions of the model The structural relationships between the latent factors modeled in this study (see Fig. 1) will be given by the following mathematical equations: PðY ¼ 1jX ¼ xÞ ¼ PðY  > t jxÞ ¼ 1  PðY  < t jxÞ; (Raykov, 2005; Raykov & Marcoulides, 2006), wheret is an unknown threshold, Y* is the underlying latent normal variable, Y is a random vector of criterion variables, and X is the random vector of predictor variables. Therefore, the Elder Physical Abuse endogenous latent variable, modeled as a linear function of its predictors, can be expressed as: PðY ¼ 1jX1 ¼ x1 and X2 ¼ x2Þ ¼ Fða þ b1x1 þ b2x2 þ b3x3    þ bzxzÞ; or  1

F½PðY ¼ 1jX1 ¼ x1 and X2 ¼ x2Þ ¼ a1 þ b1x1 þ b2x2 þ b3x3    þ bzxzÞ

[(Fig._1)TD$IG]

L.B. Schiamberg et al. / Archives of Gerontology and Geriatrics 61 (2015) 277–284

281

Fig. 1. Structural path model of RRA determinants.

where F is the CDF (cumulative distribution function) of the standard normal distribution, a and b’s are unknown constants (parameters).

rejected, implying that the there exist admissible parameter values with which the model reproduces perfectly the population covariance matrix. Model fit measures [(1) RMSEA = 0.024, (2) CFI = 0.992, and TLI = 0.992] suggest a good fit.

7. Results 7.1. Characteristics of the older adult sample (see Table 2) The demographic breakdown of nursing home residents whose relatives completed the questionnaire was largely Caucasian (91.4%). Some 72% of nursing home residents were females and almost two-thirds (64.8%) of all nursing home residents were widowed. Every resident suffered from at least one physical, cognitive, and psychiatric disability, and a significant number had more than one disability or disease (e.g., 38% were diagnosed with Alzheimer’s disease and 78.8% suffered from one or multiple forms of cognitive illnesses). Over 83% of elderly nursing home residents suffered from one or multiple ADL limitations. A significant proportion of nursing home residents (21.7%) exhibited behavior problems that increased the likelihood of being physically abused. Survey respondents (typically family members) overwhelmingly (93%) reported close emotional ties with their relatives placed in nursing home. Findings of the study indicated that, based on the respondent reports, 16.8% of elderly nursing home residents were subject to RRA (see Table 2). 7.2. LISREL data modeling results and other specific study outcomes (see Fig. 1) 7.2.1. Overall model fit Weighted least square parameter estimator (WSLMV) was used. The input readings were terminated normally and the model was identified and converged. This yielded admissible solutions. The overall model fit was adequate (x2 = 85.466; with 68 degrees of freedom; p = 0.0747). Based upon the relatively high p-value (p > 0.05) the model’s null hypothesis [Ho: S = S(g)] is not

Table 2 Older adult characteristics and RRA frequency. Variable Gender Male Female Ethnicity Caucasian African American Asian American Hispanic/Latino Native American Middle Eastern Other Education Level No formal schooling High school or less Bachelor degree or less Graduate degree Marital status Single-never-married Married Widowed Divorced Health/functional status Alzheimer’s disease Psychiatric diagnoses Cognitive problems ADL limitations (at least one) Behavior problems Age 65–74 75–84 85+ RRA frequency

Frequency

Percentage

121 331

26.8 73.2

413 29 1 1 1 1 1

91.4 6.4 0.2 1.3 0.2 0.2 0.2

3 324 77 26

0.7 85.8 8.8 4.7

31 100 293 28

6.9 22.1 64.8 6.2

169 57 354 344 97

38 12.8 78.8 83.7 21.7

52 185 215 76

11.5 40.9 47.6 16.8

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7.3. Significant latent variables: (1) ADL/IADL and (2) staff abuse Two significant latent variables were identified in the model: (1) ADL/IADL and (2) Staff Abuse. Having a greater number of limitations in performing both ADLs and IADLs predicts an increase in RRA (g = 0.049; t-value = 2.227; p = 0.049). Staff abuse as a latent factor increased the likelihood of RRA (g = 0.562; t-value = 2.020; p = 0.043 (see Table 3 and Fig. 1). Taken individually, multiple types of staff abuse of older adult nursing home residents increased the likelihood of RRA. Results indicated statistical significance for staff physical abuse (l = 1.241; t-value = 1.96; p = 0.05), for staff emotional abuse (l = 0.501; t-value = 5.012; p = 0.000) and for staff restraint abuse (l = 0.315; t-value = 2.722; p = 0.006). Model factorial loadings on the respective latent variables (measurement dimensions) in Table 3 indicate that all of the parameter estimates are significantly different from zero (at p < 0.05 or better) as indicated by t-values well in excess of 1.96 in absolute terms. 7.4. Other significant risk factors in the model

Table 4 Structural relationships among latent variables. Latent variables

g

t-Values

p-Value (Two-tailed significance)

2.020 2.227

0.043 0.049

Estimates RRA on Staff abuse ADL/IADL

0.562 0.049

Table 5 Older adult characteristics and RRA. Predictor independent variables

b

t-Value

p-Value (Two-tailed significance)

2.00 0.685 3.185 1.387 0.903

0.049 0.494 0.001 0.165 0.367

Estimates Age Gender Emotional closeness to relatives Dementia Alzheimers

0.008 0.038 0.029 0.074 0.050

Demographic factors. Results indicated mixed findings for victim demographic characteristics such as age and gender. Age is inversely related to RRA (b = 0.008; t-value = 2.00; p = 0.049) and it is statistically significant. Gender does not have a direct influence on RRA. Individual health factors. A diagnosis of Alzheimer’s Disease or a diagnosis of another type of dementia does not significantly increase the likelihood of RRA (Table 4). Older adult/family context. Close emotional ties with relatives increases the likelihood of RRA (p < 0.05). (b = 0.029; t-value = 3.185; p = 0.001) (see Table 5).

estimates suggest the severity of the problem, highlighting the importance of identifying and confirming the risk factors that contribute to RRA (Lachs et al., 2007; Pillemer et al., 2011; Zhang et al., 2012). Some of these risk factors include: victim related demographics, staff abuse experiences which may, in turn, reflect systemic group processes shaping a nursing home climate of violence, individual performance limitations in ADLs and IADLs, and quality of older adult/family relationships (e.g., emotional closeness between the older adult in the nursing home and his/her relatives at home) (Olson & Gorall, 2003).

8. Discussion

8.1. Predictors and risk factors of RRA

The present study explored multiple risk factors, both in the immediate bi-focal relationship context and more distal contexts, influencing the likelihood of RRA in nursing homes. Our findings suggest that mistreatment of nursing home residents by other residents is a significant problem that has far-reaching ramifications, with an incidence rate of 16.8% among the individuals sampled (see Table 2). As well, other studies of the incidence

8.1.1. Demographic factors Age was inversely and significantly related to RRA. This finding suggests that as nursing home residents age, they are less likely to be victimized by other residents, or to perpetrate such violence against other residents. This finding is consistent with other research suggesting older adults who are less likely to be involved in RRA either had sufficient cognitive resources to avoid trouble or were too physically challenged to get into abusive encounters (Shinoda-Tagawa et al., 2004). As well, this might seem counterintuitive as one might expect older adults, experiencing limitations or dependencies due to physical decline generally associated with increasing age, would be more vulnerable to RRA than younger residents. However, it is may be the case that, in some nursing homes, such age-related declines as reduced physical mobility or significant cognitive incapacities in fact lead to fewer unmonitored interactions with other residents that might trigger RRA. Significant cognitive impairments and individual pathology (e.g., severe depression) as well as significant physical mobility limitations (a finding of this research), frequently associated with increasing age such as Alzheimer’s Disease, are managed in special nursing home Alzheimer’s units. To the extent that they function effectively, such separate units within the nursing home closely monitor older residents, isolating and protecting them from abusive encounters with other residents (National Institute of Mental Health, 2008).

Table 3 Model factor loadings: specific measurement indicators. Measurement side manifest indicator variables ADL Help bathing Help dressing Help moving Help toileting Help out of chair IADL Help shopping Help working Help with phone Help budgeting Help meal preparation Staff abuse Physical abuse Physical abuse frequency Restraint abuse Restraint abuse frequency Sexual abuse Verbal abuse frequency Verbal abuse Emotional abuse 1 Emotional abuse 2

l

t-values

p-Value (Two-tailed significance)

1.00 1.242 0.830 0.892 0.715

N/A 11.517 12.240 14.279 9.825

N/A 0.000 0.000 0.000 0.000

0.994 1.062 0.867 0.792 1.073

11.776 14.827 11.921 8.631 12.567

0.000 0.000 0.000 0.000 0.000

1.00 0.437 1.587 2.227 1.623 3.176 3.176 2.936 2.688

N/A 2.171 2.108 2.030 2.099 2.014 2.014 2.140 2.065

N/A 0.030 0.035 0.042 0.036 0.036 0.044 0.032 0.039

Estimates

8.1.2. Health/behavioral characteristics of older adults This research pointed to the critical importance of having physical limitations in performing both ADLs and IADL in predicting RRA. ADL limitations have a powerful positive linear effect on the likelihood of RRA. While previous studies have demonstrated a significant interaction between older adult ADL

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limitations as a risk factor in RRA (Schiamberg & Von Heydrich, 2009; Zhang et al., 2012) or in staff abuse (Schiamberg et al., 2012), relatively few studies have specifically considered the relationship of both ADL and IADL limitations to RRA. Using both ADLs and IADLs taps a more complete range of activities, and related limitations, that either ADLs or IADLs, taken alone. This is particularly important for capturing a full range of limitations in activities throughout the nursing home that may be associated with RRA. As well the finding of this investigation that ADL/IADL is not only a significant latent variable but that all of the indicators of that variable (i.e., the specific types of ADL and IADL) may be particularly important in understanding the diversity of activities or triggers that might prompt RRA. It is useful therefore to differentiate how ADLs and IADLs play out in RRA and in other abusive encounters, particularly staff abuse. Since staff/older adult relationships and resident-to-resident relationships are governed by different interpersonal expectations, ADL/IADL limitations may differentially trigger staff-resident abuse or RRA. For example, in the case of staff physical abuse, ADL/IADL limitations related to staff abuse were significantly associated with only one ADL limitation – need help moving (Schiamberg et al., 2012), while all ADL/IADL limitations were significantly related to RRA in the current investigation. This probably reflects the organized character of staff-resident relationships in nursing homes such that nursing home staff/older adult interactions occur in the delivery of a range of services requiring professional/physical contact. For example, such contact may involve staff assisting residents with mobility needs, in turn, sometimes exposing staff to aggressive older adult verbal and physical behavior that may, in turn, trigger necessary and sometimes overly vigorous restraint of the older adult. However, resident-on-resident relationships occur in a diversity of circumstances and settings such that a broad range of ADL/IADL activities and related limitations may generate RRA. Specifically, RRA might occur in varied nursing home settings including residential rooms, hallways, restrooms, and recreational rooms in which multiple ADL and IADL limitations might lead to such incidents of aggression as intentional wheelchair collisions in hallways. These findings are consistent with previous research on RRA, which identified both multiple settings and major themes of RRA (e.g., invasion of privacy and/or personal integrity by other residents, uncompromising preferences on selection of television channels), which could involve the impact of an array of ADL and IADL limitations (Pillemer et al., 2011). 8.1.3. Staff abuse of older adults as a distal context to RRA: a possible indicator of a climate of violence in nursing homes The current investigation found that RRA was closely associated with all measured forms of staff abuse (e.g., physical abuse, sexual abuse, forced restraint of older adults, psychological abuse, emotional abuse) or more specifically with a history of exposure to staff abuse over the course of the older adult’s stay in the nursing home. While an association of staff abuse with RRA has been found in the current investigation as well as in several other studies, the explanation for that association is not entirely clear (Schiamberg & Von Heydrich, 2009; Zhang et al., 2012). Given the finding of staff abuse as one of two major latent variables in this study, one possible explanation for the direct impact of staff abuse on RRA might be that pervasive staff abuse, over time, creates or contributes to an environment or climate of violence wherein where older adults experience caregivers who address or resolve frustrating caregiving situations with abusive behavior. In turn older adults can learn or model these abusive behaviors applying them to their own resident-to-resident experiences.

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The dynamics of such an institutional climate of violence are consistent with social learning theory and research which involve group processes wherein individuals can learn aggression and violence – in this case abusive behavior – by observing and modeling those behaviors (Bandura, 1977). As well the social learning perspective suggests that opportunities for learning aggression and violence in nursing homes could also include the direct experience of staff abuse. As multiple studies of learned violence in a variety of settings and circumstances suggest, responses of learned aggression and violence often are elevated in the hierarchy of individual responses to first order, sometimes automatic, responses or guides/scripts on how to behave and solve social challenges, in this case in resident-to resident relationships. Aggression and violence scripts may play an important role in the lives of elderly individual placed into group nursing homes settings, sometimes necessitating sharing and compromise in crowded settings. It is important to note that this scenario of learned violence attributed to an institutional climate of violence was not directly measured in this study. What is suggested herein is a possible scenario based on what is currently known about the learning of violence in group and institutional settings. To the investigators’ knowledge, there are no known studies of the dynamics of staff abuse in nursing homes as a factor related to RRA. 8.1.4. Older adult family context This study illustrates for the first time the importance of family dynamics in understanding a contextual basis for RRA. One might have expected that such emotional closeness would lead to reduced RRA, perhaps consistent with previous research on staff abuse wherein emotional closeness of older adult residents to family members was associated with a reduction in likelihood of staff abuse (Schiamberg et al., 2012). However, in the case of RRA, older adult resident emotional closeness to family members operated to increase, rather than decrease, the likelihood of RRA. Several factors may help explain the differential impact of emotional closeness wherein it decreases staff physical abuse while, in the current investigation, it increases RRA. To begin, family emotional closeness coupled with increased family visitation may serve to increase self-monitoring by nursing home staff which might reduce the likelihood of staff physical abuse of residents (Schiamberg et al., 2012). On the other hand RRA is a much more diffuse event, potentially occurring in a diversity of nursing home locations among a variety of nursing home residents and, in turn, somewhat more difficult to directly influence or control by staff. Another possible explanation is that emotional closeness leads to more regular visits, increased attention of family members to the nursing home situation, and the possible provision of amenities or gifts to older adult residents increasing, as an unintended consequence, the likelihood of envy and theft by other residents, and RRA. Thus, increased emotional closeness with family may have the ironic consequence of increasing RRA in an institutional climate or nursing home culture sometimes associated with the invasion of privacy and the unauthorized use or even theft of older adult property (e.g., magazines, snacks or other resources provided by family members) (Pillemer et al., 2011). Other research has identified theft of nursing home resident property by staff or others, including residents, as an under studied and largely under emphasized context of elder abuse in nursing homes as well as a major complaint of families of nursing home residents (Harris, 1999; Harris & Benson, 2000). These findings coupled with the results of the current investigation again point to the importance of the nursing home culture in understanding the occurrence of RRA.

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9. Conclusions: study limitations and future directions Given that nursing home residents of Caucasian ancestry composed the main sample body (83%) findings might not accurately represent the existing situation in various multicultural communities (Taylor, 1994). In addition, data collected in this study reflects the knowledge, perceptions, and possibly the misperceptions of the relatives of older adults in nursing homes. Further, while data was collected on individual older adult residents of nursing homes, no data was collected on the characteristics of other residents in that specific nursing home nor was data collected using specific measures of nursing home social climate of violence. Using a particularly sensitive analysis procedure of structural equation modeling (SEM), this investigation identified major factors relating to RRA, incorporating both the immediate context of RRA and identifying more distal contexts. Based on the findings of this study, there is need for future research identifying the dynamic pathways that initiate, and in turn might prevent, RRA. As well, based on the findings of this study, further research is necessary to explore and verify the individual dynamics underlying the possible impact of institutional/nursing home climates of violence of the modeling in supporting or reducing RRA. Conflict of interest statement The research for this manuscript was supported by a grant to Michigan State University in 2005 from the Centers for Medicaid/ Medicare Services (#CFDA 93.778). The analyses and writing of this paper are entirely the work of the manuscript authors. The manuscript authors (L. Schiamberg, L. von Heydrich, G. Chee, and L. Post) have no conflicts of interest with any organizations or people, including relationships with funding source, or financial interests that would, in any way, influence the analyses or interpretations of the findings and conclusions of this paper[1_TD$IF]. References Allen, P. D., Kellett, K., & Gruman, C. (2004). Elder abuse in Connecticut’s nursing homes. Journal of Elder Abuse and Neglect, 15, 19–42. Baker, M. W. (2007). Elder mistreatment: Risk, vulnerability and early mortality. Journal of the American Psychiatric Nurses Association, 12(6), 313–321. Bandura, A. (1983). Psychological mechanisms of aggression. In R. G. Geen & E. I. Donnerstein (Eds.), Aggression: Theoretical and empirical reviews, Vol. I. Theoretical and methodological issues (pp. 1–40). New York: Academic Press. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. Bennett, S., Farrington, D. P., & Huesmann, L. R. (2005). Explaining gender differences in crime and violence: The importance of social cognitive skills. Aggression and Violent Behavior, 10(3), 263–288. Burgess, A. W., Dowdell, E. B., & Prentky, R. A. (2000). Sexual abuse of nursing home residents. Journal of Psychosocial Nursing and Mental Health Services, 38(6), 10–18. Harris, D. P. (1999). Elder abuse in homes: The theft of patient’s possessions. Journal of Elder Abuse & Neglect, 10(3/4), 141–151. Harris, D., & Benson, M. (2000). Theft in nursing homes: An overlooked form of elder abuse. Journal of Elder Abuse & Neglect, 11(3), 73–90.

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