In coming decades, the proportion of Canada’s aging population will double as the baby boomers reach age 65. Older Canadians will represent approximately 28 per cent of the population by 2060 (Statistics Canada, 2010). As a consequence of this demographic shift, the demands for long-term care (LTC) will continue to rise (Alzheimer Society, 2010).
LTC homes, or nursing homes, where older adults can live and receive support services (i.e., nursing care; Canadian Institute for Health Information [CIHI], 2013), are home to the frailest of seniors. The majority of these residents are over age 80 (Statistics Canada, 2011; Turcotte & Schellenberg, Reference Turcotte and Schellenberg2007) and display complex behavioural disturbances (CIHI, 2008; Patel & Hope, Reference Patel and Hope1993; Spector, Fleishman, Pezzin, & Spillman, Reference Spector, Fleishman, Pezzin and Spillman2001) due to a heightened incidence of chronic disability and cognitive impairment (Beck, Rossby, & Baldwin, Reference Beck, Rossby and Baldwin1991; Caffrey et al., Reference Caffrey, Sengupta, Park-Lee, Moss, Rosenoff and Harris-Kojetin2012; Rovner et al., Reference Rovner, German, Broadhead, Morriss, Brant and Blaustein1990) that may result in expressions of aggression (CIHI, 2008; Smith, Gerdner, Hall, & Buckwalter, Reference Smith, Gerdner, Hall and Buckwalter2004). Although the rate of institutionalization has remained about the same in Canada since 1981 at seven per cent (Ramage-Morin, Reference Ramage-Morin2006), residents in LTC homes tend to be frailer and more dependent on others to provide care than they were a decade ago (McGregor & Ronald, Reference McGregor and Ronald2011), and therefore are more vulnerable to abuse from both staff and each other.
Nevertheless, elder abuse research within LTC homes has focused on abuse within the resident-caregiver relationship. There are no prevalence or incidence studies of institutional abuse in Canada, and there are less than a handful of smaller studies devoted to the topic (McDonald et al., Reference McDonald, Beaulieu, Harbison, Hirst, Lowenstein, Podnieks and Wahl2012). Data from the United States detailing reports from nursing home staff suggest that expressions of verbal and physical aggression from residents are alarmingly frequent (Gates, Fitzwater, & Meyer, Reference Gates, Fitzwater and Meyers1999; Gates, Fitzwater, Telintelo, Succop, & Sommers, Reference Gates, Fitzwater, Telintelo, Succop and Sommers2004). For example, nearly 20 per cent of certified nursing assistants experienced physical violence from residents on a daily basis (Astrom, Bucht, Eisemann, Norberg, & Saveman, Reference Astrom, Bucht, Eisemann, Norberg and Saveman2002). Given that physical and verbal aggression is relatively common within LTC homes, there is growing evidence that residents can be aggressive towards fellow residents – a phenomenon that is surprisingly under-represented in the literature.
In light of the ongoing debate about definitions of the other forms of abuse, it should come as no surprise that defining resident-to-resident abuse is problematic (McDonald, Reference McDonald2011). Some researchers use such terms as resident-to-resident elder mistreatment (Lachs, Backman, Williams, & O’Leary, Reference Lachs, Bachman, Williams and O’Leary2007), or resident-to-resident aggression (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Rosen, Pillemer, & Lachs, Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008), resident-to-resident violence (Snellgrove, Beck, Green, & McSweeney, Reference Snellgrove, Beck, Green and McSweeney2013), resident-to-resident relational aggression (Trompetter, Scholte, & Westerhof, Reference Trompetter, Scholte and Westerhof2011), and resident-to-resident abuse (Castle, Reference Castle2012; CIHI, 2008; Ramsey-Klawsnik, Teaster, Mendiondo, Marcum, & Abner, Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Zhang, Page, Conner, & Post, Reference Zhang, Page, Conner and Post2012). Table 1 reports the various terms and definitions used to describe resident-to-resident abuse. The use of different terms is likely related to the embryonic state of this form of violence and perhaps the desire to avoid labeling the older person as an abuser.
Table 1: Terms and definitions
At the outset, little is known about what acts constitute this form of aggression (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012), making abusive incidents hard to identify. Furthermore, aggression between residents is hard to classify because the violence does not entirely fit into typical definitions of elder abuse. Both the perpetrator and victims can suffer harm, and the perpetrator is likely to be confused and usually not responsible for an ostensibly unprovoked act. Some researchers view this violence as a separate category within the group of agitated behaviors associated with dementia and other chronic mental health illnesses in nursing home residents (Shah, Dalvi, & Thompson, Reference Shah, Dalvi and Thompson2005; Snowden, Sato, & Roy-Byrne, Reference Snowden, Sato and Roy-Byrne2003). In addition, the conceptualization of elder abuse usually entails a relationship of trust that may or may not be relevant in resident-to-resident abuse. In this light, intervention takes on a different meaning with no proven approaches. For the purpose of consistency in this article, the term resident-to-resident abuse is used and refers to “abuse of one resident in the nursing home (long-term care home) by another resident” (Castle, Reference Castle2012, p. 340). This abuse can be verbal, material, physical, psychological, and/or sexual in nature (Castle, Reference Castle2012; Rosen, Pillemer, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). Currently, there has been no attempt to systematically assess the problem’s breadth in Canada, despite the potential harmful consequences of such abuse.
Given the knowledge gap on this important topic, we undertook a scoping review to gain a better understanding of resident-to-resident abuse in LTC homes for residents. Whereas there has been increased awareness on elder abuse issues within LTC homes (Hirst, Reference Hirst2000; Hirst, Reference Hirst2002; Pillemer & Moore, Reference Pillemer and Moore1989), very few research initiatives have focused on resident-to-resident abuse directly. Much of this research (e.g., Allen, Kellett, & Gruman, Reference Allen, Kellett and Gruman2003; Jogerst, Daly, & Hartz, Reference Jogerst, Daly and Hartz2005; Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Zhang et al., Reference Zhang, Schiamberg, Oehmke, Barboza, Griffore and Post2011) spans different perspectives (e.g., official reports; anecdotal evidence from family, residents, or nursing staff) and identifies and analyses only a small component of resident-to-resident abuse (e.g., abuse type; triggers or risk factors). Therefore, we initiated a scoping review to elucidate the overall experience of resident-to-resident abuse in LTC homes.
The aims of this scoping review were to (1) characterize the nature and extent of resident-to-resident abuse in LTC homes; (2) examine factors that increase risk of initiating or becoming victim to resident-to-resident abuse; (3) identify the frequency with which resident-to-resident abuse occurs in LTC homes; (4) identify strategies for minimizing resident-to-resident abuse; and (5) identify gaps in knowledge. A second goal of the review was to provide an estimate of the extent of resident-to-resident abuse in Canadian LTC homes through a secondary data analysis of alleged and reported cases of abuse in Canadian LTC homes in 2011. The aims were to determine the frequency of resident-to-resident abuse and to assess if the data were reflective of the scoping review results. By reviewing these issues and data reports, we have formulated recommendations for future research, clinical practice, and policy with the intention of raising awareness of this phenomenon while propelling action to decrease its incidence.
Methods
Scoping Review
A scoping review was conducted to examine resident-to-resident abuse within LTC home settings. Whereas systematic reviews aim to evaluate the methodology and findings of included studies (Rumrill, Fitzgerald, & Merchant, Reference Rumrill, Fitzgerald and Merchant2010), scoping reviews map existing literature in order to examine the nature of research activity, disseminate research findings, and identify research gaps within the literature (Arksey & O’Malley, Reference Arksey and O’Malley2005). As such, scoping reviews can be useful for identifying trends and areas in need of future and more focused research, and might inform whether the state of a field is ready for a full systematic review.
Methods for conducting this scoping review followed the five main steps outlined by Levac, Colquhoun, and O’Brien (Reference Levac, Colquhoun and O’Brien2010), which provided recommendations to enhance the original scoping review framework developed by Arksey and O’Malley (Reference Arksey and O’Malley2005). The five steps are as follows: (1) identify the research question; (2) identify relevant studies; (3) select the study; (4) chart the data; and (5) collate, summarize, and report results.
Search Strategy
In consultation with an expert librarian, we developed a search strategy. We searched a total of nine electronic databases, including four peer-reviewed and five grey-literature databases. The four peer-reviewed databases included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, PsycINFO, and AgeLine. The five grey-literature databases included the (a) Institute for Scientific Information (ISI) Social Sciences Citation Index, (b) ISI Conference Proceedings Citation Index – Social Science & Humanities, (c) ProQuest Dissertations & Theses – Full Text, (d) the Canadian Institute for Health Information, and the (e) U.S. National Institutes of Health. In addition, we also completed a manual search of the references in the selected articles/reports for inclusion in the scoping review. To maximize information retrieval, both subject headings and key terms were systematically searched. Table 2 shows a complete list of search terms used.
Table 2: Search terms for literature on resident-to-resident abuse
a Universal or wild card terms.
b Resident-to-Resident Abuse.
c Resident-to-Resident Elder Mistreatment.
Inclusion and Exclusion Criteria
The inclusion criteria for this review were abstracts published in English and after 1985. The search in both the peer-reviewed and grey-literature databases was carried on until 30 April 2013. Included sources from the peer-reviewed literature were qualitative and quantitative studies, published abstracts, and literature reviews. Included sources from the grey literature were theses/dissertations, reports, and other sources that identified barriers to, or provided guidelines for, researching and preventing resident-to-resident abuse within an institutional setting. Among sources (from both the peer-reviewed and grey literature) that were excluded were those that (1) had no content on resident-to-resident abuse; and (2) focused on residents in a non-LTC home setting, such as a hospital or a psychiatric facility.
Data Extraction
Figure 1 outlines how article selection was conducted. First, electronic databases, including peer-reviewed and grey-literature databases, were searched to identify abstracts examining resident-to-resident abuse. Second, two authors independently reviewed each abstract to identify relevant studies that met the inclusion criteria. In cases where the two reviewers either could not achieve consensus for inclusion/exclusion or were unsure of the suitability of an abstract, a third reviewer was brought in to mediate.
Figure 1: Article selection process
Following the recommendations put forth by Levac et al. (Reference Levac, Colquhoun and O’Brien2010), we conducted a descriptive numerical summary, whereby selected abstracts were collated into a form we designed that identified key study characteristics. The information collated included the following: (a) author, (b) year of publication, (c) country of origin, (d) study design and characteristics, (e) outcome measures, and (f) main finding/conclusions. This process was undertaken by one author, and reviewed by another member of the team. Using the main research questions for the present review as a guide for summarizing the findings from the studies, the following categories were generated: (1) extent of resident-to-resident abuse; (2) setting and timing of abuse; (3) type of abuse; (4) initiator and victim characteristics; (5) triggers of resident-to-resident abuse; (6) staff and resident responses to the abuse; and (7) outcomes of resident-to-resident abuse. A separate category was later created for “interventions for resident-to-resident abuse”. The categorization of findings was done in an iterative process, whereby two authors met to discuss the findings listed in the extraction table, as well as the initial drafts of the manuscript, to ensure that the categories were sufficiently expansive to capture the core findings of each included abstract. This approach is consistent with a directive content analysis (Potter & Levine-Donnerstein, Reference Potter and Levine-Donnerstein1999).
Secondary Analysis of Canadian Resident-to-Resident Abuse Data
To date, no prevalence data has been collected on resident-to-resident abuse in Canada or in most countries. In a preliminary attempt to estimate the magnitude of the problem in Canada, we conducted a secondary analysis (Kiecolt & Nathan, Reference Kiecolt and Nathan1985) on a non-random data set collected by a media organization that turned it over to the Institute for Life Course and Aging, University of Toronto. The data consisted of data reports and a redacted data set on alleged and reported cases of abuse in Canadian LTC homes in 2011. These data were obtained from various Ministries across the country through publicly available documents or via the Access to Information Act of Canada (R.S.C, 1985, C-A1). From these various sources, data were obtained from various health regions across Canada, which have representation from some or all of the country’s health regions except from the Yukon, Northwest Territories, or Nunavut. The data comprised sections from publicly available documents, copies of individual case report forms from various LTC homes in a province, or summarized reports of abuse from the health regions in a particular province. From these data, we extrapolated preliminary estimates of resident-to-resident abuse (by our examining the coding in the forms, and/or reading the open comments on the forms) and calculated frequencies of resident-to-resident abuse (and types of abuse in some cases).
Results
Resident-to-Resident Abuse Scoping Review
A total of 784 abstracts were identified. After reviewing the abstracts, only 32 articles satisfied all the inclusion criteria. Six studies were classified as grey literature, and the remaining 26 studies were peer-reviewed. Studies took place in the United States (n = 29), Canada (n = 2), and the United Kingdom (n = 1) and included a range of methodologies, including cross-sectional surveys or interviews with staff and/or residents (n = 14), retrospective case analyses (n = 10), literature reviews (n = 3), commentaries or reports (n = 2), a narrative analysis (n = 1), a case control study (n = 1), and a randomized cluster trial (n = 1). With the exception of one study, which examined resident-to-resident abuse in an assisted living facility (Trompetter et al., Reference Trompetter, Scholte and Westerhof2011), all articles examined resident-to-resident abuse within LTC homes or nursing home facilities. Methodological characteristics and major findings from each study can be found in Table 3.
Table 3: Summary of resident-to-resident abuse abstracts
a The findings and conclusions from each study described in this table are those most pertinent to resident-to-resident elder abuse.
b Grey literature.
APS = adult protective services.
ES = Effect size.
ORS = ombudsman reporting system.
RR = resident-to-resident.
RRA = resident-to-resident abuse.
RREM = resident-to-resident elder mistreatment.
RRV = resident-to-resident violence.
Extent of Resident-to-Resident Abuse
A cross-sectional survey of nursing home staff reported that 16.4 per cent of residents were involved in incidents of resident-to-resident abuse (Rosen, Lachs, Pillemer, & Teresi, Reference Rosen, Lachs, Pillemer and Teresi2012), and 62 per cent of nursing home incident reports involved resident-to-resident abuse (Malone, Thompson, & Goodwin, Reference Malone, Thompson and Goodwin1993). Furthermore, a qualitative study (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012) aiming to reconstruct major forms of resident-to-resident abuse reported 122 events in a two-week period, which were identified in three nursing facilities. These facilities encompassed 53 units, seven of which were dementia care units and seven of which were short-stay units (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012).
The remaining research examining the number of resident-to-resident abuse events in nursing facilities (Allen et al., Reference Allen, Kellett and Gruman2003; Jogerst et al., Reference Jogerst, Daly and Hartz2005) relied largely on official complaints made to reporting bodies including ombudspersons, adult protective services, or law enforcement. Reports to the ombudsperson suggested that resident-to-resident abuse rates represented the second highest reported abuse after physical abuse by non-residents (Jogerst et al., Reference Jogerst, Daly and Hartz2005); however, other reports indicated only five per cent of ombudsperson cases were classified as resident-to-resident abuse (Allen et al., Reference Allen, Kellett and Gruman2003), representing the least-reported abuse form.
Prospective studies examining adult protective services reports (Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster & Roberto, Reference Teaster and Roberto2004; Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007) focused exclusively on sexual abuse, with one study (Teaster & Roberto, Reference Teaster and Roberto2004) noting that 68.8 per cent of sexual abuse perpetrators were other residents. Adult protection services reports also confirmed that nursing home residents were the most often substantiated perpetrators of sexual abuse (Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007).
One mixed-methods study examining law enforcement cases indicated that nearly 90 per cent of cases in nursing homes that involved police were considered resident-to-resident elder abuse (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007). Furthermore, a retrospective case report study found that resident-to-resident abuse represented 15 per cent of sexual abuse cases examined in civil court (Burgess, Dowdell, & Prentky, Reference Burgess, Dowdell and Prentky2000).
Reported rates of resident-to-resident abuse appear to vary depending on the source. Two dissertations (one cross-sectional survey study, one qualitative study) examining resident perspectives of bullying and aggression in the nursing home environment suggested that resident-to-resident bullying or aggression represented 46 to 60 per cent of incidents described by residents (Lapuk, Reference Lapuk2007; Wood, Reference Wood2007). However, a cross-sectional survey study (Trompetter et al., Reference Trompetter, Scholte and Westerhof2011) surveying nursing home residents found that only 19 per cent of residents self-reported as victims of resident-to-resident abuse. With regard to stakeholder perceptions, staff from the same study (Trompetter et al., Reference Trompetter, Scholte and Westerhof2011) reported that 41 per cent of residents were victims of such abuse, whereas two cross-sectional telephone survey studies found that family members of nursing home residents indicated that only 0.1 per cent of residents were victims of resident-to-resident abuse (Zhang et al., Reference Zhang, Schiamberg, Oehmke, Barboza, Griffore and Post2011) whereas 10 per cent of residents were perceived to be victims of non-staff abuse (Zhang et al., Reference Zhang, Page, Conner and Post2012).
Setting and Timing of Resident-to-Resident Abuse
A qualitative study (Lapuk, Reference Lapuk2007) found that nursing home residents stated that resident-to-resident abuse could occur “anywhere” in the home; however, the most common location of abuse was in residents’ rooms. Data from a variety of study types (cross-sectional survey; Malone et al., Reference Malone, Thompson and Goodwin1993; qualitative; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; case-control; Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004) have confirmed that a significant proportion of abuse (38% to 48%) occurs in the resident’s room. Publicly shared spaces within the facility were also common locations of resident-to-resident abuse (Lapuk, Reference Lapuk2007; Malone et al., Reference Malone, Thompson and Goodwin1993): 17 to 47 per cent of abuse occurred in dining halls, 15 to 26 per cent of abuse occurred in hallways, and 13 to 15 per cent of abuse occurred in the TV lounge or common room (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004).
Nursing home residents also stated that resident-to-resident abuse could occur at “any time” of the day (Lapuk, Reference Lapuk2007; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). However, days/afternoons (24% to 46%) and evenings (10% to 50%) were the most commonly noted times when abuse was initiated (Malone et al., Reference Malone, Thompson and Goodwin1993; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). Abuse during night hours accounted for only three to four per cent of abuse (Malone et al., Reference Malone, Thompson and Goodwin1993; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008).
Type of Resident-to-Resident Abuse
As shown in Table 4, five categories of resident-to-resident abuse were identified across the various studies: verbal, physical, psychological, sexual, and material exploitation. Cross-sectional survey (Castle, Reference Castle2012) and qualitative (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008) studies found that verbal abuse was the most frequent form of resident-to-resident abuse, often displayed through cursing or yelling (Castle, Reference Castle2012, Lapuk, Reference Lapuk2007; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). Physical abuse, including pushing and punching, was also frequently identified by staff and residents (Castle, Reference Castle2012; Lapuk, Reference Lapuk2007; Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). However, more extreme forms of physical violence, including smothering, bending arms, and slamming fingers in doors, were less common (Castle, Reference Castle2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008).
Table 4: Common types of resident-to-resident elder abuse
A qualitative study (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008) reported that sexual abuse between residents was much less common. Cross-sectional survey studies (Castle, Reference Castle2012; Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster & Roberto, Reference Teaster and Roberto2003, Reference Teaster and Roberto2004) reported that sexual abuse was often expressed as unwelcomed sexualized kissing or fondling.
Resident-to-resident psychological abuse and material exploitation has been studied less extensively, with only four studies exploring this type of resident-to-resident abuse. However, nursing home staffs have reported that threats and intimidation techniques are recurrent forms of resident-to-resident abuse (Castle, Reference Castle2012; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). Furthermore, theft of possessions (Castle, Reference Castle2012; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008) and theft of food (Koehn, Kozak, & Drance, Reference Koehn, Kozak and Drance2011) were common forms of material exploitation.
Initiator and Victim Characteristics
A number of studies have identified factors that increase the likelihood of a resident becoming an initiator or victim of resident-to-resident abuse (see Table 5). From these studies, a profile emerges. Individuals at high risk include female residents (Burgess & Phillips, Reference Burgess and Phillips2006; Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster & Roberto, Reference Teaster and Roberto2004) who are cognitively impaired (Burgess et al., Reference Burgess, Dowdell and Prentky2000; Burgess & Phillips, Reference Burgess and Phillips2006; Malone et al., Reference Malone, Thompson and Goodwin1993; Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Rosen, Lachs, & Pillemer, Reference Rosen, Lachs and Pillemer2010; Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004; Sifford-Snellgrove, Beck, Green, & McSweeney, Reference Sifford-Snellgrove, Beck, Green and McSweeney2012; Teaster & Roberto, Reference Teaster and Roberto2004) and who exhibit wandering behaviours (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004; Sifford-Snellgrove et al., Reference Sifford-Snellgrove, Beck, Green and McSweeney2012). Survey and qualitative studies, however, note that victims of resident-to-resident sexual abuse appear to have physical impairments that limit independent mobility (Rosen et al., Reference Rosen, Lachs and Pillemer2010; Teaster & Roberto Reference Teaster and Roberto2004, Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007).
Table 5: Victim and initiator characteristics
Less attention has been given to identifying initiator characteristics. What little research that has been done has suggested that male residents are more likely to initiate resident-to-resident abuse (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster & Roberto, Reference Teaster and Roberto2003, Reference Teaster and Roberto2004; Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007). The influence of gender on resident-to-resident abuse was especially evident in situations of “male unbonding”, a term that has been used to describe incidents with two males, who are known to be argumentative, engaging in “fisticuffs” over inconsequential issues (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007).
Individual characteristics of residents, including personalities and histories, affected resident-to-resident abuse (Clough, Reference Clough1999; Lachs et al., Reference Lachs, Van Haitsma, Teresi, Pillemer, Haymowitz and Del Carmen2010). Qualitative studies (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Sifford-Snellgrove et al., Reference Sifford-Snellgrove, Beck, Green and McSweeney2012) have found that residents with pre-morbid prejudices and racial and stereotypical opinions were often perpetrators of resident-to-resident abuse. Specifically, one review (Clough, Reference Clough1999) noted that the majority of abuse perpetrators have strong personalities with short tempers and are “more with it”, having sharp memories and little empathy and patience for other residents. A qualitative study (Sifford-Snellgrove et al., Reference Sifford-Snellgrove, Beck, Green and McSweeney2012) yielded similar findings, and also that perpetrators had a more pronounced lack of empathy and patience for residents who were more cognitively impaired.
Triggers of Resident-to-Resident Abuse
Despite the fact that some acts of aggression and violence between residents appeared to be unprovoked, in a qualitative (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012) and mixed-methods study (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007), researchers have identified a number of factors that trigger resident-to-resident abuse. Invasion of personal space and other challenges associated with communal living were commonly noted triggers across a variety of studies (Clough, Reference Clough1999; Lachs et al., Reference Lachs, Van Haitsma, Teresi, Pillemer, Haymowitz and Del Carmen2010; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013). Specifically environmental issues such as crowding, TV volume/channel, room temperature, and lighting were major concerns noted in several studies to have fueled aggression between residents (Koehn et al., Reference Koehn, Kozak and Drance2011; Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Lachs et al., Reference Lachs, Van Haitsma, Teresi, Pillemer, Haymowitz and Del Carmen2010; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013).
Social environments within the facility also triggered resident-to-resident abuse. Communication barriers between residents (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013), agitated residents with loud outbursts (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008), residents displaying long-standing disruptive behaviours (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Lapuk, Reference Lapuk2007), and exclusionary social cliques (Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013) have been identified by staff and residents as factors that foster environments conducive to resident-to-resident abuse.
Furthermore, hostile actions – including violence, sexual aggression, and theft – have been shown to provoke abusive responses from the targeted resident (Koehn et al., Reference Koehn, Kozak and Drance2011; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013).
Staff and Resident Responses to Resident-to-Resident Abuse
While the main concerns of residents surrounding resident-to-resident abuse focus on their own safety and privacy, one qualitative study (Lapuk, Reference Lapuk2007) noted that many residents believed that resident aggression was an unavoidable element of nursing home living. To protect themselves from resident-to-resident abuse, residents indicated they would call staff for assistance, try to diffuse the aggressive situation themselves, or avoid known aggressive residents altogether (Lapuk, Reference Lapuk2007).
Qualitative studies (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Sifford, Reference Sifford2010) and a cross-sectional study (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012) have provided an overview of staff strategies. For instance, nursing staff, like residents, have also developed a number of self-initiated responses to manage and prevent resident-to-resident abuse (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). The most common response has been to separate the residents (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012), either by re-directing them with other meaningful activities (Sifford, Reference Sifford2010), physically intervening, changing the resident’s room, or temporarily removing residents from the environment (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012). Talking calmly to residents (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012), explaining the nature of communal living, and encouraging compromise (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008) have also been common techniques to manage resident-to-resident abuse.
Although researchers have found instances where staff would notify the nurse (Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008), rarely do staff consult with a physician or psychiatrist to manage the aggressive behaviours between residents (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012).
Outcomes of Resident-to-Resident Abuse
One review article (Rosen et al., Reference Rosen, Lachs and Pillemer2010) found that victims of resident-to-resident abuse tended to be reluctant or unable to report abusive incidents. Furthermore, retrospective (Burgess & Phillips, Reference Burgess and Phillips2006) and prospective case studies (Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007) found that many sexually abusive situations were difficult to substantiate due to cognitive impairment present in both victims and initiators.
Qualitative findings (Lapuk, Reference Lapuk2007) illustrated that nursing home residents view aggression in residents as a symptom of dementia. Indeed, in situations of resident-to-resident sexual abuse, staff often viewed perpetrators as victims of their degenerative brain disease (Rosen et al., Reference Rosen, Lachs and Pillemer2010; Tripp, Reference Tripp2011). In resident-to-resident sexual abuse cases, 35 per cent of abuse victims did not receive any interventions (Teaster et al., Reference Teaster, Ramsey-Klawsnik, Mendiondo, Abner, Cecil and Tooms2007), and only 11 to 12 per cent received psychological and physical treatment (Teaster & Roberto, Reference Teaster and Roberto2003, Reference Teaster and Roberto2004). Due to insufficient evidence, the majority of perpetrators were not arrested, prosecuted, or convicted (Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008; Teaster & Roberto, Reference Teaster and Roberto2003, Reference Teaster and Roberto2004).
Victims of resident-to-resident abuse and bullying experienced a decline in overall psychosocial health. Self-reported victimization was associated with a reduction in life satisfaction and a greater risk for depression, anxiety, loneliness, low self-esteem, and overall negative mood (Trompetter et al., Reference Trompetter, Scholte and Westerhof2011; Wood, Reference Wood2007). In addition, victims of resident-to-resident abuse were shown to be four times more likely to experience neglect from nursing home staff (Zhang et al., Reference Zhang, Schiamberg, Oehmke, Barboza, Griffore and Post2011). However, in their review article, Rosen, Pillemer, et al. (2008) noted that there have been no longitudinal studies on the long-term health implications of being victims or initiators of resident-to-resident abuse, nor were any studies identified for the present review.
Only one case-control study (Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004) examining visible injuries – which occurred when residents inflicted physical abuse on other residents – found that residents were most likely to receive lacerations and bruises to the head or face region and upper extremities. Furthermore, residents who wandered or were verbally aggressive were more likely to be injured (Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004). Unsurprisingly, residents in Alzheimer’s units were three times more likely to be injured (Shinoda-Tagawa et al., Reference Shinoda-Tagawa, Leonard, Pontikas, McDonough, Allen and Dreyer2004). Data from a retrospective case study (Malone et al., Reference Malone, Thompson and Goodwin1993) indicated that residents residing in Alzheimer’s units have higher incidences of aggressive behaviours when compared to residents in the rest of the facility (Malone et al., Reference Malone, Thompson and Goodwin1993).
Interventions for Resident-to-Resident Abuse
A prominent recommendation in the literature highlighted the need for staff and family to receive education and training on resident-to-resident abuse to enhance protection of residents in nursing facilities (Koehn et al., Reference Koehn, Kozak and Drance2011; Robinson & Tappen, Reference Robinson and Tappen2008; Teaster & Roberto, Reference Teaster and Roberto2003; Teresi et al., Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013; Williams, Reference Williams2004; Zhang et al., Reference Zhang, Page, Conner and Post2012). Teresi et al. (Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013) evaluated a resident-to-resident elder mistreatment staff intervention-training program. They found that staff who received the training experienced a significant increase in recognition and documentation of resident-to-resident abuse, which resulted in more resident-to-resident elder mistreatment events being reported.
Resident-to-Resident Abuse in Canada – Secondary Data Analysis
The data reports, along with the redacted data set, described a wide range of abuse cases that included resident-to-resident abuse, staff-to-resident abuse, and resident-to-staff abuse. Data and/or reports were obtained from Newfoundland and Labrador, Prince Edward Island, New Brunswick, Nova Scotia, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia. No data from the Yukon, Northwest Territories, or Nunavut were available for analysis (see Table 6). The total number of incidents of alleged/reported abuse in LTC homes was 23,472. The total number of resident-to-resident abuse cases in 2011 was 6,455, representing 28 per cent of all abuse cases (see Table 6).
Table 6: Resident-to-resident abuse (RRA) rates in Canada
a Data report obtained through the Access to Information Act of Canada (R.S.C, 1985, C-A1).
b Redacted intake forms obtained through the Access to Information Act of Canada (R.S.C, 1985, C-A1).
c Data report “Rapport Semestriel des Incidents et Accidents Survenus Lors de la Presetation Des Soins et Services de Santé au Québec”; http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2012/12-735-01W.pdf.
d Data report “Long-Term Care Task Force on Resident Care and Safety May 2012 An Action Plan to Address Abuse and Neglect in Long-Term Care Homes”; http://longtermcaretaskforce.ca/images/uploads/LTCFTReportEnglish.pdf.
Of the redacted data, abuse incident report forms (n = 662) were obtained from four locations in Canada: Saskatchewan (n = 64); Manitoba (n = 290); New Brunswick (n = 56); and Nova Scotia (n = 252). Of these reports, 192 were clearly identified as resident-to-resident abuse (29%). According to the data, the most prevalent types of resident-to-resident abuse reported were physical abuse (104 cases); physical and verbal abuse (37 cases); sexual abuse (36 cases), and verbal abuse (13 cases). The nature of two cases was not described.
Discussion
The purpose of this scoping review was to gain a better understanding of the current level of knowledge related to resident-to-resident abuse in order to inform practice, research, and policy in Canada. The review identified a relative paucity of literature on the topic (27 peer-reviewed articles; 5 grey-literature articles), with only two studies being from Canada, including an unpublished master’s thesis and one qualitative report. The majority of records (75%) were retrospective case studies, qualitative reports with in-depth interviews, reviews, and commentaries. The rest of the studies were mainly non-random, cross-sectional surveys, and only one intervention study. Of these studies, only 14 (44%) focused exclusively on resident-to-resident abuse. By itself, the scoping review provides us with a good sense of the research “landscape” on this topic, and suggests that a systematic review on resident-to-resident abuse would be premature at this time.
The findings from the scoping review detail the significant burden of resident-to-resident abuse to its victims, perpetrators, family members, and staff working in LTC homes, and the redacted data provide a crude overview of the issue in Canada, which indicates that the problem is extensive. Without doubt, there is a clear need to develop stronger action on a number of fronts to better understand this ignored form of violence which, from anecdotal reports, continues to take people’s lives, and to identify means to help minimize its occurrence. The redacted data set on resident-to-resident abuse in Canada provides some indication that this type of abuse makes up approximately one-third of reported abuse cases. Similarly, data from the National Ombudsman Reporting System in the United States for all 50 states from 2000 to 2011 suggest that resident-to-resident abuse represents 21 per cent of abuse cases in nursing homes, a lower figure than reported for Canada using the non-random data. The problem, however, is that these figures do not necessarily represent a complete picture of nursing home abuse, wherein allegations can be reported to a number of different authorities, including adult protective services, the ombudsman, or law enforcement (Jogerst et al., Reference Jogerst, Daly and Hartz2005). Based on the findings of the scoping review and secondary data analysis, a number of suggestions relevant to clinical practice, research, and policy in Canada can be derived.
Recommendations for Research
Overall, the need for further research on resident-to-resident abuse in Canada is apparent. The literature, along with the redacted data set, suggest that the incidence of resident-to-resident abuse accounts for approximately one-third of all cases, and includes a diverse range of aggressive physical, verbal, psychological, and sexual behaviours (Castle, Reference Castle2012; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008). Given issues with the data and the challenges in obtaining clear estimates from the literature, there is a demonstrated need to get a better depiction of its incidence and prevalence in Canada. At the least, there is a need for a national prevalence study, and at best, a prospective cohort study should be conducted to document the phenomena. There are 10 robust studies that examined the prevalence of institutional abuse worldwide, but not one of these studies considered resident-to-resident abuse (McDonald, Reference McDonald2011). There are no extant prospective cohort studies anywhere, indicating that geriatricians and gerontologists are missing evidence of a significant form of violence.
Successful implementation of such studies would require the development of outcomes that not only captured the range of resident-to-resident abuse types but also articulated contributing precipitating factors (e.g., location, time, and resident and perpetrator characteristics) and outcomes of the abusive incident (e.g., documented in chart, medical care provided/required, law enforcement involvement, and family members informed). Although multi-site national studies are needed, pilot work in one province on the prevalence of resident-to-resident abuse, and associated outcomes, should be first conducted in order to inform larger national-scale studies.
More importantly, there is a need to develop more intervention studies to reduce/prevent the occurrence of resident-to-resident abuse. The study by Teresi et al. (Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013) has provided some evidence on the benefits of staff training for reducing resident-to-resident abuse, but further research is needed to empirically evaluate the effectiveness of staff-developed responses to resident-to-resident abuse (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012). Additionally, the multitude of resident-to-resident abuse triggers, such as environmental factors, warrants additional research examining the manipulation of these factors for preventing resident-to-resident abuse (Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012).
The high number of qualitative studies on resident-to-resident abuse serves as an excellent resource for informing the selection of appropriate outcome measures. In addition to physical and psychological outcomes, the economic burden of resident-to-resident abuse should also be documented. The associated costs of resident-to-resident abuse, both direct (e.g., police services or additional health care) and indirect (e.g., lost productivity of family members caring for resident-to-resident abuse victims) are potentially staggering, and their documentation may be useful for spurring changes within the health care system.
Recommendations for Policy
A national strategy is needed to address resident-to-resident abuse in Canada. Although research is needed to help inform policy, potential actions that could be undertaken to achieve this goal include developing nationwide standardized abuse reporting practices within LTC homes, developing recommendations for how LTC homes can foster environments to minimize the risk for resident-to-resident abuse, and to inform legislation on how to manage occurrences of resident-to-resident abuse.
LTC homes in the United States have been criticized for adopting unplanned approaches to care due to the lack of guidelines for reporting and documenting abuse (Teresi et al., Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013), and the same could be said about Canada. The implementation of a minimum data set in Canada may prove helpful in establishing the incidence and prevalence of resident-to-resident abuse across different regions in Canada, providing insight on the magnitude of the problem. Furthermore, such a data set could provide data on abuse trends over time, identify factors that are correlated with and predict resident-to-resident abuse, and may assist in identifying targets for intervention. These data have significant policy implications because they would help determine the human and financial resources needed to contain the problem.
Whereas LTC homes are required to provide an environment wherein residents are free from all forms of abuse and neglect, including that between residents (Tripp, Reference Tripp2011), there are a dearth of guidelines and recommendations available for LTC homes to consider when developing policies to fulfill this mandate. For example, guidelines pertaining to crowding and space configuration (Clough, Reference Clough1999; Lachs et al., Reference Lachs, Van Haitsma, Teresi, Pillemer, Haymowitz and Del Carmen2010; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013), staffing levels to reflect behavioural needs of clients (Teaster & Roberto, Reference Teaster and Roberto2003; Williams, Reference Williams2004), and types and frequency of activities available to residents (Sifford, Reference Sifford2010; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013) may all be helpful in reducing the incidence of resident-to-resident abuse. Although not covered in the institutional elder abuse literature (i.e., Cohen, Halevy-Levin, Gagin, Priltuzky, & Friedman, Reference Cohen, Halevy-Levin, Gagin, Priltuzky and Friedman2010), organizational and management theories may provide useful insights into the organizational and systematic characteristics of LTC homes that lead to resident-to-resident abuse (McDonald et al., Reference McDonald, Beaulieu, Harbison, Hirst, Lowenstein, Podnieks and Wahl2012). Staff quotas, staff mix, management policies and protocols, and governance and ownership would be issues to consider within some acceptable theoretical framework like institutional theory (McDonald, Reference McDonald2008).
An important aspect of resident-to-resident abuse requiring further clarification pertains to the legal implications of such abuse. Currently, there is low involvement of the criminal justice system, including the police, in abuse cases in LTC (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007), especially in resident-to-resident sexual abuse cases (Burgess & Phillips, Reference Burgess and Phillips2006; Ramsey-Klawsnik et al., Reference Ramsey-Klawsnik, Teaster, Mendiondo, Marcum and Abner2008). There need to be clear guidelines on when authorities should be called in to investigate cases of resident-to-resident abuse, and police should have procedures to rely upon to help determine what action to undertake with the perpetrator of the abuse (e.g., when to arrest or what to document). Further policies are needed to assist health care staff and policing bodies in working with resident-to-resident abuse perpetrators who have dementia and may not know what they have caused (Tripp, Reference Tripp2011). Laying charges in these situations makes little sense, but holding the organization responsible may be more sensible.
Recommendations for Practice
Several authors have suggested that staff training and education are mechanisms that can be used to help reduce resident-to-resident abuse (Robinson & Tappen, Reference Robinson and Tappen2008; Teaster & Roberto, Reference Teaster and Roberto2003; Teresi et al., Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013; Williams, Reference Williams2004); however, only one study has formally evaluated a training intervention program for nursing staff on knowledge, recognition, management, and reporting of resident-to-resident abuse events (Teresi et al., Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013). The longitudinal evaluation of the program demonstrated that participating nursing staff were more knowledgeable of what constitutes and contributes to resident-to-resident abuse and thoroughly documented more resident-to-resident abuse events (Teresi et al., Reference Teresi, Ramirez, Ellis, Silver, Boratgis and Kong2013). Detailed documentation of resident-to-resident abuse can allow for effective care strategies that reflect the trends of abuse within a specific institution to be developed and implemented. Although training staff seems to be the common solution to most institutional mistreatment, there likely need to be other approaches that go beyond subtly blaming staff that have to do with the organization and governance.
Due to the diversity of resident-to-resident abuse forms, triggers, and outcomes, management of these events will require patient-centered interventions that consider both needs and characteristics of residents (Lachs et al., Reference Lachs, Bachman, Williams and O’Leary2007; Lapuk, Reference Lapuk2007; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013) and reflect the environmental factors present in the facility (Clough, Reference Clough1999; Lachs et al., Reference Lachs, Van Haitsma, Teresi, Pillemer, Haymowitz and Del Carmen2010; Pillemer et al., Reference Pillemer, Chen, Haitsma, Teresi, Ramirez and Silver2012; Rosen, Lachs, et al., Reference Rosen, Lachs, Bharucha, Stevens, Teresi and Nebres2008; Snellgrove et al., Reference Snellgrove, Beck, Green and McSweeney2013). Furthermore, it is critical that an interdisciplinary approach to care be implemented to assist in the management of resident-to-resident abuse. Whereas one study indicated that nursing staff rarely consulted with physicians and psychiatrists to assist with the management and prevention of mistreatment (Rosen et al., Reference Rosen, Lachs, Pillemer and Teresi2012), this collaboration may prove to be valuable in working with patients who suffer from cognitive impairments and display many behavioural outbursts that trigger resident-to-resident violence. Part of the enduring problem is that physicians tend to avoid working in LTC because of the nursing home culture that makes teamwork difficult (Kapp, Reference Kapp2010).
Limitations
This scoping review described the nature, extent, and frequency of resident-to-resident abuse in LTC homes but did not provide an in-depth review of the literature, nor did it assess the quality of the studies identified. Additionally, scoping reviews include an optional final step that involves consultation with key stakeholders, practitioners, and policy makers (Levac et al., Reference Levac, Colquhoun and O’Brien2010). This step, not included in our scoping review, may have provided additional insight into resident-to-resident abuse. Finally, although efforts were made to conduct a thorough scan of both the peer-reviewed and grey literature, it is possible that not all pertinent records were identified on this topic.
The redacted data set on resident-to-resident abuse in Canada provides some indication that this type of abuse makes up approximately one-third of reported abuse cases, but this data is extremely limited on a number of fronts. Firstly, the standards, forms, and times when alleged/reported resident-to-resident abuse cases are documented varied dramatically within and across provinces, and data were not collected from all 88 health regions across the country. Additionally, some provinces and their regions have more detailed data collection forms and are more diligent with collecting and reporting data than are other areas. Consequently, significant amounts of data were missing, or were pooled together due to challenges in obtaining the data (e.g., cost associated with obtaining data). Taking into consideration the size of a province (population), and the proportion of nursing home residents in each province, the issue of abuse in institutions, including resident-to-resident abuse, is likely under-reported. As a result, abuse seems to be a larger issue in some provinces, when in fact it may be that some provinces are more responsible in documenting and reporting the estimates of abuse, and providing details on the type of abuse that occurred. Further, the delivery of health care was not consistent across provinces. In particular, the province of Quebec had many other health services integrated with LTC. In short, the data are incomplete and uneven and only provide a glimpse of what may be occurring in Canada.
Conclusion
Resident-to-resident abuse is a serious societal issue that is under-researched and requires further investigation in order to minimize its occurrence, and strategies developed to appropriately manage its consequences. Although dementia and other mental health issues are contributing factors to the occurrence of resident-to-resident abuse, health care professionals and authorities should not use them as an excuse for inaction against resident-to-resident abuse. Older adults living in LTC homes should expect a living environment that preserves their dignity, well-being, and safety. As such, further action by researchers, health care professionals, and policy makers is needed to reduce resident-to-resident abuse and other types of abuse in LTC homes.
