A Team-Based Comparative Case Study of Violence Across Care Settings for Older Adults in Two Canadian Provinces

Abstract

Violence can lead to physical and psychological harm, emotional exhaustion, and burnout for paid and unpaid carers. Concomitantly, being regarded as violent, aggressive, or difficult can have a direct impact on older adults’ sense of self, care relationships, and quality of care. Current research on violence and aging lacks systemic understanding of the environments and multi-level factors that precipitate or inhibit violent interactions across settings of long-term care. This research involves a multi-jurisdictional comparative research study of violence in home care and long-term care settings in two Canadian provinces (Manitoba and Nova Scotia). Study participants will include older adults, family carers, and care workers. Data collection will involve five phases, starting with document analysis and provincial surveys, and followed by remote interviews (including photo-elicitation), digital diaries, and observations. The integration of mixed methods data and comparison across provinces will generate rich explanations of the multi-level influences on violence and responses to violence as well as guide the development of an anti-violence policy framework in partnership with knowledge users. The study is approved by five university ethics committees and health authorities in each jurisdiction. All phases will be guided by a knowledge user advisory committee including older adults, family carers, healthcare workers, unions, long-term care organizations, and other relevant stakeholder groups from Manitoba and Nova Scotia. Results will be reviewed by the knowledge user advisory committee and made available through a series of reports, presentations, and journal articles.

Strengths and limitations of this study

All phases of the study will be developed in collaboration with knowledge users to ensure the relevance and application of the research.

The study will provide a systems perspective on violence and responses to violence by examining policies, practices, and experiences of diverse actors across home care and long-term residential care settings.

The study will enhance understandings of the multi-level and site-specific factors that influence violence and safety through an integrated mixed-method case study approach.

Where apposite, comparisons will be made within and across provinces as well as between care settings; the benefit of comparing policy and practice across provinces is gleaning best practices for the development of an anti-violence framework.

The recruitment strategy and use of different technologies to facilitate remote data collection may act as a barrier to participation for some older adults.

Introduction

During the COVID-19 pandemic, international attention has been directed to the failure of long-term care systems to ensure the safety of older adults and workers. Specifically, attention has been paid to understaffing in residential care, poor wages for care workers, and neglect of residents, which in the case of the pandemic had devastating effects on the lives, and deaths, of millions of aging persons globally (e.g., Cousins, 2020; Kim, 2020; Lombardo et al., 2020). Less attention has been paid, however, to longstanding issues of violence as a continuing health and safety issue. This is of particular concern in Canada, where visits to long-term residential care have been largely restricted during the pandemic and public health mandates have discouraged interaction with others outside one’s household (Government of Canada, 2020). Across the care continuum, older adults, family/friend carers, and care workers have been managing with fewer hands to provide support and fewer eyes to provide oversight, raising questions about whether and how pre-existing issues of violence are being addressed.

Over the past decade, media coverage (Funk et al., 2020; Herron et al., 2020), government inquests (Chartier, 2015), and research have drawn attention to the failure of violence prevention strategies to protect the health and safety of older adults and carers (Herron & Wrathall, 2018). Recent meta-analyses have found that worldwide, 19.33% of healthcare professionals have experienced workplace violence from patients or visitors (Li et al., 2020). More specific to long-term care, one Canadian study found that 90% of residential care workers experienced physical violence from residents or their relatives and 43% experienced violence daily (Banerjee et al., 2012). One US study in ten long-term care facilities found that 20% of residents experienced some form of violence from another resident in a 1-month period (Lachs et al., 2016). In addition to documenting different types of violence in residential care settings, some research has begun to explore the hidden experiences of family carers responding to aggression while providing care at home (Herron & Rosenberg, 2017). One American review of research on violence toward carers from a person living with dementia estimated that 20% of carers experience severe aggression while caring for a person living with dementia at home (Wharton & Ford, 2014). Moreover, family carers may hide experiences of violence at home because of fear that the person for whom they care will have difficulty accessing formal supports (Herron & Rosenberg, 2017; Herron & Wrathall, 2018).

It is clear from previous research that violence is all too common across long-term care settings. However, research has seldom examined violence from a systems level perspective, looking at the policies, practices, and experiences of different actors across settings. Instead, research, policy, and training have focused on managing individual and interpersonal factors or “triggers” influencing different forms of violence, particularly in residential care settings (Duxbury et al., 2013; Enmarker et al., 2011). This approach pathologizes violence as a behavioural response associated with dementia and implicates care workers and family members in managing the risk of violent actions, implicitly blaming them for responding the wrong way (Funk et al., 2019; Herron et al., 2019). Recognizing that violence is not just an interpersonal problem, some scholars have applied the concept of structural violence to identify how staffing levels, workload, and the task-oriented nature of care create conditions for violence in long-term care (Baines & Cunningham, 2013; Banerjee et al., 2012; Ferrah et al., 2015). These studies have made a valuable contribution to understanding violence experienced by paid workers (particularly in residential care), but they tend to incorporate less consideration of older adults’ experiences. In addition, only limited attention is paid to less regulated environments, such as home care (see Karlsson et al., 2019), where a growing number of people are living with multiple complex chronic conditions that include dementia, and where different strategies may be required to address violence. What is missing from current research on violence in later life is a multi-level comparative approach to understanding how and why violent situations occur across contexts of care, as well as how different practices and policies might mitigate and prevent violence across settings and relationships of care. By applying a systems level approach to the study of violence across long-term care settings, this research aims to contribute to the development of an anti-violence framework that is flexible enough to respond to manifold contexts.

Conceptualizing Violence

Violence within settings of care for older adults has been variously referred to as abuse, challenging behaviors, behavioral disturbances, aggression, responsive behaviors, and violence (Bradford et al., 2012; Caspi, 2015; Dupuis et al., 2012; Enmarker et al., 2011; Granenheim et al., 2005; Nakaishi et al., 2013). Each of these terms encompass a range of actions—including verbal, physical, relational, and sexual acts—that may cause physical, emotional, or psychological harm to another person (Vincent-Höper et al., 2020). Most of these terms focus on individuals’ actions with limited consideration of the role of social practices, institutional culture, and environment. Notably, the term responsive behaviour has helped shift attention to the situations and environments within which violent actions occur (e.g., layout of care facilities, congestion, noise, and social relations), to address stigmatizing labeling practices toward people living with dementia; it represents an attempt to remove the focus from dementia as the “cause” behind the behavior (Caspi, 2015; Dupuis et al., 2012). However, in practice, even the use of this term can sometimes inadvertently reinforce the stigmatizing disease frames it was meant to address. For this study, we engage with a broad definition of violence that includes behaviors that may result in social, emotional, sexual, and/or physical harms, which ultimately inhibit individual self-development and self-expression. Although violence may emerge or manifest in interpersonal interactions in particular situations (Fleming, 2012), it is influenced by a broad range of meso-level (e.g., organizational and community culture) and macro-level (e.g., government policies) forces that impinge on victims’ experiences and responses to violence across different spaces (DeVerteuil, 2015; McGarry & Walklate, 2015). Moreover, our definition emphasizes the importance of context and processes in understanding experiences, interpretations of, and responses and adaptations to violence (Collins, 2008; Spencer et al., 2019).

Objectives

Guided by the definition above, our research will explain how and why particular features of local care environments and broader organizational and policy decisions influence (i.e., reinforce or inhibit) violent actions among older adults and carers. The goal is to inform the development of more effective violence prevention strategies across systems, settings, and relations of care. The specific research objectives are to

document and compare how differing settings of care shape experiences of and responses to violence among older people, family/friend carers and paid care workers;

scan and assess the overall effectiveness of specific individual, regional, and organizational strategies, across settings and in two Canadian provinces, for limiting violent situations and promoting safety; and

develop an anti-violence policy framework in partnership with knowledge user collaborators in these two provinces.

Research Design and Methods

The study involves a comparative case study methodology, which is ideal for understanding how and why violent situations occur within and across specific jurisdictional, organizational, social, and physical contexts of care (Baxter & Jack, 2008; McManners, 2016). Case study research moves beyond description or prevalence estimation to explore multiple influences and explanations of violence in-depth, in context, over time, and through intensive analysis of data from multiple sources (Flyvbjerg, 2006). A comparative case study approach will address the need for both transferable theoretical insights and tangible solutions by advancing our knowledge about the complex dynamics of violence across different case study sites at multiple levels.

At the macro-level, we compare two provincial cases: Manitoba and Nova Scotia. These jurisdictions were selected because of their balance of commonalities and differences. Both provinces are experiencing demographic shifts toward population aging and increasing demand for home and residential care services. Both are facing challenges in effectively serving large geographically dispersed rural older populations outside relatively few major urban settings. A key difference is that Nova Scotia exclusively contracts private (for-profit or not-for-profit) agencies to deliver home care services, whereas Manitoba primarily employs government employees to manage and deliver services. Both provinces have a mix of publicly funded non-profit and for-profit residential care facilities with more than 100 beds (typical of most Canadian facilities), as well as smaller facilities, providing fertile ground for exploring how the challenges of violence prevention vary in relation to facility organization and scale. Finally, our approach will allow us to explore the influence of different government regulations and responses to violence in care between these two Canadian provinces.

The second comparative dimension of this study involves the more localized structures, settings, and relations of care. Specifically, by examining differences between residential long-term care facilities and publicly funded home care, we will explore how features of these places (and the care relations they entail) shape interactions among older people and carers, with implications for experiences of, and responses to, violence. Within each setting, we will explore specific strategies for limiting violent situations and promoting safety, with the aim of enhancing violence prevention strategies across settings.

Integrated Knowledge Translation

The case study design is guided by a knowledge user advisory committee comprised of diverse stakeholder groups from each province including older adults and family carers, home and long-term care organizations, the Alzheimer Society, and healthcare union representatives. Members of the knowledge user advisory committee were selected based on subject matter expertise, gate keeper status in select sites, and broader advocacy work. Older adults and carers participating on a volunteer basis are given a yearly honorarium to recognize their contribution to the research. The committee meets monthly to provide advice on study methods and research instruments; assist with identifying relevant policies, procedures, and training materials for review; discuss potential fieldwork cases; and provide feedback on preliminary findings as well as means of disseminating and applying research (e.g., changing policies and practices). Ultimately, the regular guidance of the knowledge user advisory committee is meant to ensure the quality, relevance, and application of the research for diverse older adults and care providers.

Recruitment

Study participants include care workers, family carers, and older adults receiving home care or long-term residential care in Manitoba or Nova Scotia. To ensure the study is accessible to each participant group, a broad range of recruitment strategies will be used, as described below. In the current context of the COVID-19 pandemic, both recruitment and data collection will largely take place remotely, in compliance with public health regulations and to minimize impact on human resources in the long-term care sector, which has seen a large proportion of COVID-19 cases (CIHI, 2020).

Sequential Mixed Methods Data Collection

Data collection will involve five sequential phases, beginning with document analysis and provincial surveys, followed by remote interviews, digital diaries, and observations. Primary data collection will begin in Manitoba in July of 2021 and then in Nova Scotia in April of 2022 to enable the research team to focus on the specific characteristics of each provincial case and strengthen the iterative process of inquiry, self-correction, and validation across the cases.

Document analysis in both Manitoba and Nova Scotia is underway and will continue as new documents are identified in subsequent research phases. Document analysis is a systematic method of reviewing both print and electronic material that is particularly suitable for qualitative case studies that integrate multiple methods (Bowen, 2009). Substantively, we have deployed critical discourse analysis to understand how care settings are described, the broader sociopolitical context in which care settings are embedded, and the power relations at play in constituting care, carers, and aging persons (Ainsworth & Hardy, 2004; Fairclough, 1992). The knowledge user advisory committee assisted with the selection of relevant provincial, regional, and organizational policies and procedures, as well as legal documents, reports, and training materials for review. Additional documents will be identified through internet searches and reviewing the reference lists of retrieved documents. The document analysis will provide data on the policy contexts within which research participants provide or receive care. Specifically, we will examine how violence and responses to violence are defined and framed across care settings and relationships within provincial, regional, and organizational policy documents. In addition, our analysis aims to identify dimensions of violence and violence prevention that are absent from current policy. Moreover, the way violence and responses to violence appear and are framed at provincial and organizational levels, as well as the silences in documents, will inform in-depth analysis of the experiences of different individuals and groups in subsequent phases of the research.

In phase two, a purposeful sample of care workers, family carers and older adults will be recruited through relevant non-profit organizations serving older adults, active living centers, listservs (e.g., healthcare worker unions), websites (e.g., Alzheimer Society), and social media to complete a 10-minute survey. In addition, some older adults may be recruited through family carers participating in the study (i.e., snowball sampling).

The survey will be made available online, but older adults will also have the option of completing the survey over the phone to make the research accessible to participants who may have less access to reliable internet services and limited digital literacy. Participants will meet several inclusion criteria: they must be providing or receiving care (paid or unpaid) in home or long-term care settings and they must live in Manitoba or Nova Scotia. After completing the screening process, they will be asked some demographic questions (e.g., age, gender, racial identification, urban or rural residence) and respond to a modified version of the Conflict Tactics Scale (CTS; Straus et al., 1996), which asks participants about the frequency of different acts of violence in different contexts and relationships of care. In addition, the questionnaire will also collect information about policies and practices in relation to violence prevention from care workers. All survey instruments have been reviewed by the knowledge user advisory committee several times over a 6-month period as well as by an accessibility consultant to ensure the relevance and accessibility of the questions. Information collected in this phase will be used to examine the prevalence of different forms of violence in diverse relationships and contexts of care. It will also confirm relevant policies and practices for preventing violence from the perspective of healthcare workers. Consistent with integrated mixed methods design (Creswell & Plano Clark, 2011; Fetters et al., 2013), subsequent qualitative phases of the research will build upon and extend information gathered from surveys. The survey will be used to identify participants for in-depth follow-up interviews to explore further explanations of violent experiences.

Next, interested survey participants who identify themselves as having experienced some form of violence will be contacted to take part in remote, semi-structured qualitative interviews. They will have the option of taking part in the interview using either an online communication platform or telephone. Remote interviews will offer participants privacy as well as an opportunity to discuss and explain their experiences of violence to the degree that they feel comfortable. Based on earlier qualitative research which suggests that basic themes can emerge in datasets with as few as six interviews and saturation can occur after 12 interviews given enough shared participant characteristics, we aim to recruit a sample of 12 older adults, 12 care workers, and 12 family/friend carers providing or receiving residential long-term care, and a similar sample providing or receiving home care in each provincial jurisdiction (see Figure 1) (Guest et al., 2006). This large qualitative sample (N = 144) will enable the research team to explore the diversity of meanings and experiences of violence as well as safety, providing insights into differing perspectives within groups (i.e., older adults, carers, and care workers) and contexts (i.e., home care, residential care, Manitoba, and Nova Scotia) but also revealing common explanations.

Figure 1.

Integrated sequential research design protocol.

The design of the interviews varies among the participant groups, recognizing their different experiences, contexts, and potential constraints on their participation. Interviews with older people and family carers will involve two shorter interviews (30–45 minutes) to build rapport, obtain rich descriptions, and enable older adults, including adults living with dementia who are receiving care to participate. Older adults receiving care will have the option of having a support person present during their interviews. The first interview will focus on eliciting detailed information about the contexts in which people live or provide informal care as well as meanings and experiences of safety. Building on the survey data, they will be asked to describe violent situations they identified having experienced in the survey. In the second interview, utilizing photo-elicitation (Harper, 2002), older adults and carers will be asked to take pictures of the place they receive or provide care (e.g., pictures of their room or outdoor space). They will be asked not to take pictures of other people and to choose up to three photographs to share with the research team. Participants’ photographs will be used as prompts for discussion to elicit descriptions of places of care and the actions and feelings associated with those places to enrich understandings of the meaning of safety from the perspective of older adults and carers. Indeed, given the remote nature of data collection, photo elicitation will provide rich insights about contexts of care without the researcher being present to observe the context themselves.

Interviews with care workers will last 1 hour and will include descriptive questions and elicitive prompts, starting with a mental tour of the participant’s workplace and workday, followed by questions about the culture and values promoted in the workplace or program. Building on data collected in the survey, participants will be asked to describe and explain how training and policies influence their work and describe violent situations that they identified having experienced in the survey. Finally, the interview will also ask participants to reflect on the meaning of safety for themselves and for the older adults for whom they provide care.

In addition to interviews, paid care workers involved in the survey will be invited to record a daily digital diary. In our previous research, we used this method to collect sensitive and rigorous data from family carers in an unobtrusive manner as events happened over time (Herron et al., 2018). Care workers will be invited to record their daily work experiences, interactions, and feelings for a 2-week period using a semi-structured guide accessed on a secure web platform from a phone or other digital device. They will be prompted to record experiences of violence as well as when and where they felt safe throughout the day. They will have the choice of writing or audio recording their response as well as including photographs of their work environments. Designing the diaries to ensure flexibility in how, what, and when participants record their entries will contribute to data quality, offering participants opportunities to reflect on their own terms, and using different media to describe their experiences close to the time and place in which they occurred. This method addresses limitations associated with a single interview such as forgetting details, feeling judged, or pressured to provide what they perceive to be the “right” answer to a question. The diarists will act as proxy observers during a period where observation by the research team is not possible due to public health restrictions. This information will provide a foundation for the final phase of data collection.

The final phase of data collection will involve in situ observations in four selected long-term residential care sites (two in each province), identified in collaboration with the knowledge user advisory committee. Observations will not take place in homes for home care (community) settings; however, photographs of the sites and multiple interviews with older adults and carers will be used to collect contextual information. Our previous research has already documented subtle daily forms of aggression at home, which are difficult to observe directly and may relate in part to the isolation of older adults (Herron et al., 2019). As part of the process of crystallization of data collection and analysis (Ellingson, 2009; Maree & Westhuizen, 2009; Richardson & St. Pierre, 2005), the goal of the observations in long-term care facilities is to see what happens in settings of care to triangulate with what documents say should happen, and what interview participants tell us is happening. Rather than focus exclusively on a narrowly defined set of violent incidents or actions (that tend to be the focus of violence prevention strategies), our observations will focus more broadly on the context and interactions in places (see below), in line with our conceptualization of violence. In addition, observational methods in residential settings will address an important gap in research on violence in long-term care, which often focuses on the voices of carers without considering the experiences of older residents living with dementia, which may be better captured through observations rather than traditional interviews (Armstrong & Lowndes, 2018). For these reasons, we plan to proceed with in situ observations in long-term care facilities when it is safe to do so.

The observations will take place over a 2-week period and follow a semi-structured guide focusing on the daily life and interactions in each of the sites, providing rich description of the social, organizational, and physical environments—including lounges, dining rooms, hallways, and other high traffic areas. Specific sites for this research will not be identifiable and all persons being observed will provide written/informed consent or assent (with consent of a third party). On site observations will facilitate the analysis of practices and interactions as they unfold and are repeated (or differ) in a specific environment and situations. Ultimately, observations will help us develop richer understandings of social and organizational influences on violence involving older adults, considering the experiences of different actors in the care environment.

Data Handling and Analysis

The integration and comparison of themes from these multiple forms of data across settings will be guided by a focus on identifying case-specific complexities to help understand how jurisdictional, organizational, social, cultural, and physical features influence violence as well as the success of violence prevention strategies. Data analysis will occur during the data collection period to support the refinement of research instruments and methods (see Charmaz, 2006; Strauss & Corbin, 1997). For example, we will be able to refine questions about violence and prevention strategies based on information obtained from documents and surveys. The interview and diary data will also inform observations, for example, directing us to sites and times of day where we should focus our observations. Throughout all phases of the study, data management and comparative incident and case-specific analysis of data will be supported by QSR NVivo software.

Analysis will involve comparing individual experiences in places as well as relationships and situations where violence occurs within and across data sources. This will begin with (a) comparing what participants describe as violent incidents/interactions and responses/strategies in specific long-term care environments and relationships. We will also (b) compare environments and situations that are described as safe. We will move from (c) comparisons within case study sites and (d) within similar settings of care to (e) comparing findings between different types of settings and then finally (f) comparing findings across provincial jurisdictions/policy environments.

The principal investigator, co-investigators involved in fieldwork, a post-doctoral fellow, and graduate trainees will work collaboratively to identify and define thematic codes within and across cases. They will present preliminary codes and code reports to the rest of the team and discuss interpretations as well as identify and resolve coding inconsistencies through consensus. Then findings will be presented to the advisory group and organizational partners through reports and presentations to identify promising practices for violence prevention on an ongoing basis.

Ethics

Given the sensitive nature of research on violence, and the potential risks to participants, the research design incorporates multiple strategies to uphold participant safety and to ensure ethical practice. The collaborative approach to the study will support ethical conduct by enhancing the clarity of consent forms and research instruments as well as identifying case-specific risks based on knowledge users’ familiarity and understanding of different settings. The multiple qualitative methods that comprise the study design afford participants different degrees of choice and control in what they say, record, and do, which is crucial to protecting privacy and mitigating emotional harm. Consent forms for all phases of the study identify potential risks and provide clear descriptions of what research participation entails. We anticipate that some observational participants will not be able to provide informed consent due to cognitive or other impairments. In such cases, we will seek proxy consent from a designated relative, while also practicing ongoing process consent (Dewing, 2002). Participants’ thoughts and feelings will remain private and confidential. If the researchers learn or see that a participant is in immediate danger, they will, however, be compelled to disclose this information to relevant authorities. As such, our ethical approach is fundamentally processual and provisional, subject to reconsideration based on emergent ethically important moments that invariably arise over the course of research (González-López, 2011; Guillemin & Gillam, 2004; Pollock, 2012; van den Hoonaard & van den Hoonaard, 2012).

Additional resources will also be provided to participants (e.g., referrals to support) so that if they need support or wish to discuss their experiences of violence, they have the information to do so. In addition to these procedural ethics protocols, the research team will also use weekly research meetings to reflect on, question, and address unanticipated ethical issues as well as debrief with trainees. During the observation phase of the research, team debriefing meetings will occur at the end of each observational session (i.e., daily) to support situational and relational ethics as well as overall data quality (Tracy, 2010).

Rigor and Proposed Outcomes

Guided by a comprehensive conceptualization of violence that emphasizes the role of context and multi-level processes, the team-based comparative case study protocol will provide rich, detailed, and complex data to inform future violence prevention strategies. Importantly, integrated knowledge translation will facilitate more relevant and precise data collection, provide input on early findings to enhance credibility, and support the practical application of findings. The learning that is already taking place as a part of this approach is a core outcome of this project. Another strength of the study design is the diversity of voices included in the knowledge user advisory committee and the proposed sample. In contrast to previous research, the study examines the experiences of different actors involved in care relationships across different long-term care settings contributing to relational, contextual, and systematic understandings of violence. By integrating mixed methods findings from document analysis, surveys, interviews, digital diaries, and observations in these care settings, the study will provide concrete detail and thick description of multi-level features influencing violence, including structural factors (e.g., state and organizational policies and practices) as well as day to day site-specific factors that influence experiences and responses to violence. Finally, through a largely remote design, the study will document violence that has become even more hidden in the context of COVID-19 because of physical distancing and other restrictions on visiting people outside one’s primary residence. Ultimately, the study aims to strengthen existing violence prevention strategies that fall short of protecting the safety of older adults and carers across long-term care.