Preventing Threats and Violence in Elderly Homes

Elderly homes are places where elderly people live and should feel safe and cared for in their old age. Unfortunately, situations of threats and violence can sometimes arise, which can have serious consequences for the residents. Preventing and managing such situations is essential to create a safe and caring environment. In this article, we will explore strategies and methods to prevent threats and violence in elderly homes.

Understanding the Causes Behind Threats and Violence

To prevent threats and violence, it is important to understand the underlying causes of why they can arise. Some common factors.
- Dementia and mental disorders: Many elderly people suffer from dementia or other mental disorders, which can lead to confusion and aggressive behavior.
- Staff Training: Lack of knowledge in handling dementia and behavioral disorders can increase the risk of confrontations.
- Crowded Spaces: Premises where many people crowd in a small space or where the noise level can be disturbing can create stress, anxiety, and frustration in the residents.
- Communication Problems: Poor communication between staff and residents can lead to frustration and misunderstandings.

Prevention Strategies:

- Training: Everyone working in elderly homes should receive training on the specific needs of the elderly and how to manage challenging behaviors. This includes understanding dementia and other age-related diseases.
- Person-centered Care: Use a person-centered care model where each resident's individual needs and preferences are considered. This can reduce frustration and conflicts.
- Risk Assessment: If there are residents where the risk of irritation and outbursts is greater, an action plan can be formed to be prepared to handle the resident in the best way.
- Staffing and Resources: Ensure that there are enough staff and resources to meet the residents' needs. Often, there can be patterns of recurring turmoil. Perhaps additional staff is needed at a certain time of the day.
- Creating a Safe Environment: The design of the elderly home's environment should consider safety and security, including good lighting and secluded areas for different activities. Decorations and furniture arrangements can often reduce anxiety, wandering behavior, or disturbing noise levels.
- Follow-up, Event Analysis: After incidents, the elderly home should conduct a thorough evaluation to identify the causes of the event and take actions to prevent similar events in the future.
- Involving Residents and Relatives: Residents and their relatives should be involved in planning their care and actively participate in decision-making about their living situation.
- Advice and Support: Offer support and advice for both residents and staff to manage stress and conflicts in a healthy way.

Managing Situations Professionally:

If a threat or violence situation arises, it is important that the staff is well prepared to deal with it. This includes using mediation techniques, avoiding the use of force and physical violence, and always prioritizing the safety of the residents and the staff.

By investing in training, following best practices, and creating a safe and supportive environment, elderly homes can minimize the risk of threats and violence and ensure that residents can age with dignity and safety. This is a fundamental aspect of providing high-quality elderly care and respecting the residents' rights and dignity.

Right of Self-Defense

In healthcare, conflicts often arise. According to the Swedish Work Environment Authority, healthcare personnel are frequently exposed to threats and violence. There are methods and knowledge that reduce the risk of threats and violence in healthcare.

When threat and violence situations arise, we as healthcare personnel are often co-actors. It may be that we push too hard to change that wet and smelly incontinence pad or because we are stressed and don't take the time to stop, listen, and answer questions. Likewise, our body language can signal a negative attitude, irritation, or stress.

People with dementia are extra sensitive to stress and quickly pick up on moods. Mirror neurons exist in the brain. With these, we quickly read each other and make assessments of the situation. Aggressive behavior can occur without the employee understanding why. Regardless of the cause of the anger, we should try to understand why the situation arose.

We can often reduce anxiety and irritation by working with methods such as low-impact responses or activities that distract and calm. By conducting an event analysis after an incident, we can try to understand what happened and find alternative ways to respond to the anger if the situation arises again. Fatigue, side effects of medications, pain, annoying sounds, and light are things that can contribute to irritation.

When we notice that someone is getting angry, we can think about how we position ourselves in the room so that the resident does not feel cornered or that we ourselves are cornered. By seeing early signs, we can often calm the situation before the resident gets angry. It is also possible to ask a colleague to come and take over. It can serve as a break when the mood becomes irritated.

We are all unique individuals with different habits and wishes, and to be able to help someone, we must be responsive and have knowledge about different needs that exist. Many times, this can prevent problematic situations from arising. Occasionally, it is possible to transform anxiety and irritation into action. By putting a cloth in the hand of the person who is stroking with their hand, they may be able to help wipe the kitchen table. A soft voice and touch by massaging the hands, for example, can calm a restless person. Tactile massage is a method that can work. Soft, simple touches that release the hormone Oxytocin can have an effect with increased well-being in the form of peace and quiet, reduced pain, and stress.

The BPSD Register is a quality register that provides support in dealing with people with dementia where the person develops behavioral or psychological symptoms. There is much to learn from the BPSD Register. Working with it can provide good suggestions and insights on how we can prevent threats and violence from occurring. It also provides the business with action plans where various care measures are assessed with continuity and response plans that are based on the resident's individual and specific needs. Thereby, they become a good support for the staff in dealing with them.

Behaviors can be difficult to comprehend for the environment but are very relevant for the individual. The reactions can be perfectly natural if they are linked to noisy environments or the person with dementia has difficulty interpreting and understanding different situations. A difficult situation can be when residents get irritated with each other.

Healthcare personnel must then try to find ways to calm the situation. Should a situation arise where the risk of acts of violence is evident, there is something called the right of self-defense. The right of self-defense means that we have the right to defend ourselves to prevent someone from being a victim of a crime. We must not use more violence than necessary.
The use of violence to protect oneself or someone else can be tried in court and it is only afterwards that it becomes clear whether the action was correct or incorrect.

When Someone Becomes Threatening or Very Restless

Supervision by a BPSD team can be a measure to increase understanding of what causes the elderly to become restless or angry. A BPSD team are specialists in understanding and finding ways to relate to Behavioral and Psychological Symptoms in Dementia. That the staff group finds a safe way to relate to a restless, irritated, or scared resident usually calms the situation in itself. Enhanced staffing can also work.  

It happens that people with dementia disease are changed to the mind. The person may appear demented, but in essence, actually have a depression that leads to confusion. Residents can also become depressed, suicidal, or have paranoia or feel that the staff want to poison them. In the worst case, this can lead to threatening situations. It has happened that elderly people have jumped from the balcony. Good working methods and safe routines reduce the risk of threatening situations.

If someone suffers severely from a serious mental disorder and has an "unavoidable" need for psychiatric care and also opposes hospitalization, a doctor can write a care certificate. Unavoidable means that there are no other alternatives. Usually, it is the resident's doctor or emergency duty who writes the care certificate. Decisions about compulsory care are then taken by a psychiatrist. There should always be an assessment by two doctors, one of whom must be a psychiatrist. People with dementia are very rarely considered to meet the criteria for compulsory care.

The assessment of which interventions are necessary takes place in relation to the possibility of other interventions. Then the operation goes through the needs of the elderly, the support the elderly receive, and how it can be improved. It can be about enhanced staffing, activities, changed medication, and other measures that can be made. By having a person living in an elderly home already have a safe environment with staff around the clock, very rarely meet the criteria for psychiatric compulsory care.

Reflection - threats and violence
Care staff:
• Have you experienced situations where someone at the residence has become really angry?
• Do you have good ways of working with residents who become irritated?
• Are there good action plans to avoid threats and violence?
• How do you work with people who are despairing, terrified, or express suicidal thoughts?
• Have you ever received case handling?

Manager, nurse, occupational therapist, and physiotherapist:
• Do you have good routines for working with threats and violence?
• Are they known by all employees?
• Do you have access to necessary supervision?
• Are there routines for how you handle a resident who expresses suicidal thoughts?
• Are there routines for how you handle the need for a care certificate assessment?

Residents and relatives:
• Have you ever experienced anger or threat at the residence?
• Did the employees act in a good way?
In the chapter on risk management, there is more about preventive work, fire, and more.

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day