"The reasons that lead to violence in care are complex and complicated"

Dr. Suhr, where does violence in health care actually begin and how does it manifest itself?

Dr. Ralf Suhr: Abuse of elderly patients in need of care can have many different faces. Aside from physical abuse or verbal aggression, this also includes invading someone’s privacy, financial exploitations, restricting someone’s freedom of choice and freedom of movement but also neglect. The abuse actually doesn’t just begin with hitting. Conversely, caretakers can also be affected by violent behaviors, for instance in the form of insults or aggravated assaults from patients requiring care. This might be caused by illness but could sometimes also be the side effects of certain drugs.

Nevertheless, generally the reasons that ultimately lead to violence are complex and complicated and exceedingly depend on a person’s disposition. It is known, however, that – among others – stressful situations can promote problematic situations. That’s why the early detection of stressful situations before they escalate, plays a major role in abuse prevention. Against this backdrop, the ZQP developed an Internet portal to prevent violence. Here you can find substantiated information, stress relief options, practical tips as well as contact details on nationwide crisis phone numbers for anyone involved in care at www.pflege-gewalt.de.

What are the reasons for violent behavior?

Suhr: The reasons that ultimately lead to problematic or rather violent situations are varied and depend on the circumstances. However, escalations rarely occur suddenly and without any signs – in most cases, aggression and violence are based on an extensive prior history. In addition, we also know of a number of mutually induced factors that increase the risk of violence in health care settings. From the patient’s point of view, these risk factors include high level care for instance, cognitive or mental disorders as well as "provocative behavior", that being distinct agitation or aggressiveness as it occurs in a person with dementia. For caregivers, work overload is primarily a significant factor. In addition, existing difficult relationships or conflicts are being identified as further risk factors to an escalating pattern of violence. The lack of a supportive network can also lead to challenging or rather violent actions.

How can the potential for abuse be reduced in everyday care and actively prevent these types of conflict situations?

Suhr: Above all, successful violence prevention measures and the provision of adequate assistance require awareness of the problem to be able to identify abuse and aggression in health care as such. Alternative action cannot be presented until then. This primarily includes factual education that takes an objective look at the phenomenon of abuse in health care without focusing on questions of guilt and criminalizing the issue. To do this, a climate for open discussion needs to be created to be able to address the topic in a transparent yet discerning manner. This is the only way prevention measures can effectively start where they are required.

However, studies on the effectiveness of violence prevention measures are still incomplete. It is essential to acquire more comprehensive data on the effects of the individual interventions and measures. Evaluated intervention programs for avoiding physical restraint measures are already available. One definitive form of guidance for caretakers, for instance, is provided by the German evidence-based guideline titled "Interventions to Prevent Physical Restraints in Professional Elder Care Services", www.leitlinie-fem.de.