Our search yielded 3876 references identified via databases and 246 references via supplementary search methods. After deduplication and title/abstract screening, we checked 141 full texts for eligibility. Finally, we included 46 studies reported in 47 references (one study was published in two separate reports) [35, 36] (figure 1).
Overall, the 47 study reports were published between 2000 and 2021, half of them since 2012 [13, 37–59]. Most of the 46 studies were conducted in the USA (n=9, 19.6%) [37, 39, 60–66], Norway (n=8, 17.4%) [43, 46, 47, 55, 57, 58, 67, 68], and the UK (n=7, 15.2%) [42, 48–50, 53, 54, 69]. The remaining studies took place in Israel (n=4, 8.7%) [35, 36, 40, 70, 71], Canada (n=3, 6.5%) [41, 72, 73], Taiwan (n=3, 6.5%) [74–76], Czech Republic (n=2, 4.3%) [77, 78], France (n=2, 4.3%) [52, 59], and Switzerland (n=1, 2.2%; this study addressed two of our review questions) [13, 51]. One study each (2.2%) was conducted in Germany [79], Korea [56], Portugal [45], Slovenia [38], Sweden [80], and Uruguay [44].
Types, prevalence, and associated factors of staff-to-resident abuse
We identified 28 studies to answer our first review question on the types, prevalence, and associated factors of staff-to-resident abuse [13, 35–39, 43, 45, 49–53, 55, 56, 59–65, 68, 73–75, 77–79]. Detailed data on every study are available in supplementary material S2 and summarised in the following subsection.
Twenty-two out of the 28 studies (78.6%) had a cross-sectional design [35–39, 43, 49, 50, 52, 53, 55, 56, 59, 62–65, 68, 73–75, 78, 79]. Four studies (14.3%) were secondary data analyses [13, 45, 60, 61]. One study each (3.6%) was a qualitative study [51] and a qualitative study combined with a secondary data analysis [77]. Overall, 24,419 participants and/or documents from 1,432 nursing homes (data available for 19 out of 28 studies; median 24, IQR 12 to 105, range 5 to 369) were included (median 470, inter quartile range (IQR) 172 to 963, range 23 to 4,599). In the majority of studies, participants were nurses and nursing aides, followed by relatives or persons responsible for nursing home residents. Most of the studies used random sampling (n=16, 57.1%) [13, 35–39, 43, 55, 56, 62–64, 68, 73–75, 78]. Five studies (17.9%) were based on a convenience sample [49, 52, 59, 65, 79], two studies (7.1%) on a complete sample [45, 60]. One study each (3.6%) used purposive [51] and snowball sampling [77]. Three studies (10.7%) did not report details on sampling [50, 53, 61]. All except one study (96.4%) used a retrospective reference time frame. This single study (3.6%) did not report details on reference time [56]. The reference time frame was mentioned in 20 studies (71.4%), varying between three months and unlimited, mostly one year (n=11/20, 55%).
One study (3.6%) [45] reported sociodemographic and health-related characteristics of victims of staff-to-resident abuse. None of the studies mentioned perpetrator-related characteristics.
Four out of 28 studies (14.3%) assessed a single type of abuse. Two of them investigated psychological abuse [74, 75], one study focussed on financial abuse [63], and one study on neglect [64]. Twenty-four studies (85.7%) assessed multiple types of abuse [13, 35–39, 43, 45, 49–53, 55, 56, 59–62, 65, 68, 73, 77–79], thereby covering two to eight types. Eighteen studies (64.3%) assessed psychological abuse [13, 35–38, 43, 44, 49, 50, 53, 55, 60–62, 73–75, 77–79]. Another 18 studies (64.3%) investigated physical abuse [13, 35–39, 43–45, 49, 50, 53, 55, 60–62, 73, 77–79]. Fifteen studies (53.4%) focussed on neglect [13, 35, 36, 43–45, 49, 50, 53, 55, 60–62, 73, 77–79], twelve studies (42.9%) on financial abuse [35–38, 44, 49, 50, 55, 60–62, 73, 77, 78], eleven studies (39.3%) on sexual abuse [35–37, 39, 44, 49, 50, 55, 60–62, 73, 78], and eight studies (32.1%) assessed other types of abuse [35–37, 44, 49, 50, 61, 62, 73, 77]. Six studies (21.4%) investigated abuse of unspecified type [51, 52, 56, 59, 65, 68].
For data collection, twenty-three out of 28 studies (82.1%) used a structured questionnaire [35–39, 43, 49, 50, 52, 53, 55, 56, 59, 61–65, 68, 73–75, 78, 79]. Two studies (7.1%) were based on multiple data collection methods. One of them used a structured questionnaire and a document analysis [13], the other one unstructured interviews and a document analysis [77]. One study each (3.6%) was based on structured interviews [51], document analysis [45], or did not report details on data collection methods [60]. Twenty-six studies (92.9%) used statistical methods for data analysis [13, 35–39, 43, 45, 49, 50, 52, 53, 55, 56, 59–65, 68, 73–75, 78, 79]. One study (3.6%) relied on qualitative phenomenological analysis and descriptive statistics [77], and one study (3.6%) used thematic analysis [51].
The prevalence of staff-to-resident abuse observed by staff was reported in nine out of 28 studies (32.1%) (Table 1; details on every study are available in supplementary material S2). The highest abuse rates observed by staff was related to abuse of unspecified type (51-76%) [53, 55, 78, 79] and lowest for sexual abuse (0-2%) [37, 49, 55, 78]. The prevalence of staff-to-resident abuse reported by abuse-committing staff was reported in eight out of the 28 studies (28.6%) (Table 1; details on every study are available in supplementary material S2). The highest abuse rates were committed by staff for inadequate care (87%) [67] and abuse of unspecified type (54-79%) [35, 36, 53, 55, 78, 79]. The prevalence of staff-to-resident abuse reported by nursing home residents and/or by others was reported in nine out of 28 studies (32.1%) (Table 1; details on every study are available in supplementary material S2). The highest abuse rates reported by residents and/or by others referred to psychological (4-99%) [38, 60–62, 74, 78] and physical abuse (<1-93%) [38, 39, 45, 60–62, 78], as well as to neglect (16-87%) [45, 60–62, 64].
Table 1
Prevalence per type of staff-to-resident abuse (observed, committed, reported)
Type of abuse | Prevalence | | |
| Observed by staff | Committed/self-reported by staff | Reported by residents and/or others |
Abuse of unspecified type + | 51-76% [53, 55, 78, 79] | 54-79% [35, 36, 53, 55, 78, 79] | 5-11% [78] |
Psychological | 20-62% [13, 37, 49, 55, 79] | 30-46% [43, 55, 78] | 4-99% [38, 60–62, 74, 78] § |
Physical | 3-30% [13, 37, 49, 55, 78, 79] | 6-40% [43, 55, 78, 79] | <1-93% [38, 39, 45, 60–62, 78] § |
Sexual | 0-2% [37, 49, 55, 78] | 0-1% [55, 78] | 6-40% [39, 60, 62] § |
Financial | 0-25% [37, 49, 55, 63] | 1-2% [55, 63] | 6-72% [38, 60–62] § |
Neglect | 9-58% [13, 49, 55, 78] | 1-77% [43, 55, 78] | 16-87% [45, 60–62, 64] § |
Other | 4-91% [37, 67] * | 87% [67] ** | 17-82% [61, 62] *** § |
Notes: + Including both observed and committed abuse for reference [53]; * Other types of abuse including inadequate care, caregiving abuse, and medication abuse; ** Other types of abuse including inadequate care; *** Other types of abuse including caretaking abuse, mistreatment; § Percentages correspond to the answers of participants having responded to items for reference [62]. |
Victim-related associated factors of staff-to-resident abuse were reported in twelve out of 28 studies (42.9%) (Table 2; details on every study are available in supplementary material S2). Perpetrator-related factors of staff-to-resident abuse were mentioned in 16 of the 28 studies (57.1%) (Table 2; details on every study are available in supplementary material S2). Institution-related associated factors were reported in eleven of the 28 studies (39.3%) (Table 2; details on every study are available in supplementary material S2).
Table 2
Associated factors (victim-related, perpetrator-related, and institution-related) per type of staff-to-resident abuse
Type of abuse | Associated factors (victim-related) | Non-associated factors (victim-related) |
Abuse (no details on type of abuse) | Behaviour * [39, 73] | Health and functional status [39, 73] |
| Health and functional status * [39, 56, 73] | Sociodemographic characteristics [39, 78] |
| Other: resident-to-resident abuse * [39] | |
| Sociodemographic characteristics * [39, 73] | |
| Behaviour ** [51] | |
| Health and functional status ** [51] | |
| Sociodemographic characteristics ** [51, 77] | |
Psychological | Behaviour * [13, 43, 78] | Behaviour [13] |
| Satisfaction with nursing home and care * [78] | Health and functional status [13, 35, 36] |
| | Satisfaction with nursing home and care [78] |
| | Sociodemographic characteristics [13, 35, 36] |
Physical | Behaviour * [43, 78] | Health and functional status [35, 36, 45] |
| Health and functional status * [78] | Sociodemographic characteristics [35, 36, 45] |
| Sociodemographic characteristics * [35, 36, 78] | |
Physical/psychological | Other: quality of life * [53] | Behaviour [53] |
| | Health and functional status [53] |
Neglect | Behaviour * [13, 43] | Behaviour [13, 64] |
| Health and functional status * [45, 64] | Health and functional status [13, 35, 36, 45, 64] |
| | Sociodemographic characteristics [13, 35, 36, 45, 64] |
| Associated factors (perpetrator-related) | Non-associated factors (perpetrator-related) |
Abuse (no details on type of abuse) | Attitude towards and experiences of abuse * [56] | Sociodemographic characteristics [56] |
| Characteristics of personal life and personality * [59, 79] | Job-related characteristics [52] |
| Coping strategies * [56, 79] | |
| Emotional strain and burnout * [52, 59, 79] | |
| Job-related characteristics * [52, 59, 75, 79] | |
| Sociodemographic characteristics * [75] | |
| Characteristics of personal life and personality ** [77] | |
| Coping strategies ** [51] | |
| Emotional strain and burnout ** [77] | |
| Job-related characteristics ** [51] | |
| Sociodemographic characteristics ** [51] | |
| Sociodemographic characteristics ** [77] | |
Psychological | Attitude towards and experiences of abuse * [35, 36] | Attitude towards and experiences of abuse [35, 36] |
| Characteristics of personal life and personality * [78] | Characteristics of personal life and personality [35, 36, 43, 78] |
| Coping strategies * [79] | Job-related characteristics [13, 35, 36, 43] |
| Emotional strain and burnout * [13, 35, 36, 74, 78, 79] | Sociodemographic characteristics [13, 35, 36, 43, 55, 74, 78] |
| Job-related characteristics * [13, 35, 36, 43, 74, 78] | |
| Sociodemographic characteristics * [13, 35, 36, 43, 55, 74, 78] | |
| Sociodemographic characteristics *** [50] | |
Physical | Attitude towards and experiences of abuse * [35, 36] | Attitude towards and experiences of abuse [35, 36] |
| Characteristics of personal life and personality * [43, 78] | Characteristics of personal life and personality [35, 36, 78] |
| Emotional strain and burnout * [35, 36] | Emotional strain and burnout [78] |
| Job-related characteristics * [43, 78] | Job-related characteristics [35, 36, 43, 78] |
| Sociodemographic characteristics * [43, 55] | Sociodemographic characteristics [35, 36, 43, 50, 55, 78] |
| Sociodemographic characteristics ***[50] | |
Physical/psychological | Emotional strain and burnout * [53] | |
Sexual | Sociodemographic characteristics *** [50] | |
Financial | Attitude towards and experiences of abuse * [63] | |
| Job-related characteristics * [63] | |
| Sociodemographic characteristics *** [50] | |
Neglect | Attitude towards and experiences of abuse * [35, 36] | Attitude towards and experiences of abuse [35, 36] |
| Characteristics of personal life and personality * [43] | Characteristics of personal life and personality [35, 36] |
| Emotional strain and burnout * [35, 36, 52] | Emotional strain and burnout [13, 35, 36] |
| Job-related characteristics * [13, 35, 36, 43, 52] | Job-related characteristics [13, 35, 36, 43, 52] |
| Sociodemographic characteristics * [55] | Sociodemographic characteristics [13, 35, 36, 43, 55] |
| Sociodemographic characteristics *** [50] | |
Other: Discriminatory abuse | Sociodemographic characteristics *** [50] | |
| Associated factors (institution-related) | Non-associated factors (institution-related) |
Abuse (no details on type of abuse) | Facility characteristics * [56, 60, 65] | Facility characteristics [60, 65] |
| Organization and culture of work * [56] | Organization and culture of work [60] |
| Resident-related characteristics * [56] | Staff-related characteristics [56, 60] |
| Staff-related characteristics * [60] | |
| Organization and culture of work ** [51, 77] | |
| Staff-related characteristics ** [51, 77] | |
Psychological | Facility characteristics * [43] | Facility characteristics [13, 35, 36, 43, 74] |
| Organization and culture of work * [13] | Organization and culture of work [13] |
| | Staff-related characteristics [13, 35, 36, 43] |
Physical | | Staff-related characteristics [35, 36, 43] |
Physical/psychological | | Facility characteristics [53] |
| | Staff-related characteristics [53] |
Neglect | Facility characteristics * [35, 36, 43, 64] | Facility characteristics [13, 35, 36, 43] |
| Organization and culture of work * [13] | Organization and culture of work [13] |
| Resident-related characteristics * [64] | Staff-related characteristics [13, 35, 36] |
| Staff-related characteristics * [35, 36] | Facility characteristics [35, 36, 43] |
Notes: * Associated Factors in quantitative studies with statistically significant results (p > 0.05 or 0.01); ** Associated factors in qualitative studies; *** Associated Factors in studies with statistically insignificant results (i.e., statistical significance was not available/applicable). |
Description and experience of staff-to-resident abuse
To answer our second review question on the description and experience of staff-to-resident abuse, we identified 14 studies [40–42, 44, 46, 54, 57, 58, 67, 69–72, 80]. Detailed data on every study are available in supplementary material S2 and summarised in the following subsection.
Ten out of 14 studies (71.4%) had a qualitative design [40–42, 44, 46, 54, 57, 58, 69, 72], three (21.4%) a cross-sectional design [67, 70, 71], and one study (7.1%) was a qualitative case study [80]. Overall, 1,250 participants were included (median 29, IQR 13 to 42, range 1 to 616) from 284 nursing homes (data available for eleven out of 14 studies; median 18, IQR 11 to 20, range 4 to 142). Mostly, nurses and nursing aides participated, followed by nursing home managers. The sampling strategy was predominantly purposive (n=5, 35.7%) [40–42, 44, 69] or not reported (n=4, 28.6%) [70–72, 80]. Three studies (21.4%) recruited on convenience [46, 54, 57] and one study each (7.1%) used a random [67] or theoretical sample [58]. In most of the studies, abuse was not specified (n=10, 71.4%) [41, 42, 44, 54, 67, 69–72, 80]. Two studies (14.3%) addressed physical, psychological, financial, and sexual abuse as well as neglect [57, 58]. Neglect [40] or sexual abuse [46] were focussed in one study (7.1%). Interviews (of different types) were the most common data collection method (n=11, 71.4%). Five of the interview-based studies used semi-structured interviews [40, 41, 54, 72, 80] and three studies relied on focus group interviews [42, 46, 58]. In one study, researchers used a structured interview [69]. One group of researchers combined focus group interviews with semi-structured interviews [57]. One study (7.1%) used a multi-methods approach combining interviews (not specified) and observations [44]. The three non-interview-based studies (21.4%) used a structured questionnaire [67, 70, 71]. For data analysis, three studies (21.4%) applied descriptive statistics [67, 70, 71]. Two of them additionally used regression analysis [70, 71]. Two studies each (14.3%) stated narrative analysis [54, 80], thematic analysis [41, 42], constant comparative analysis [57, 58] or did not specify the type of analysis [69, 72]. Two studies (14.3%) identified emerging themes without stating an explicit method [44, 46] and one study (7.1%) applied phenomenological analysis [40].
Five themes resulted from our analysis: (i) “Viewpoints on abuse”, (ii) “Tolerating abusive behaviours”, (iii) “Consequences and punishment”, (iv) “Reporting of abuse”, and (v) “Knowledge gaps”. (i) “Viewpoints on abuse” focused on abuse as a serious misconduct difficult to talk about. The conceptualization of abuse is often limited to physical abuse. Physical, sexual, and financial abuse are considered as most serious types of abuse. Abuse was described as contradicting leaders’ trust in their staff. Abuse might be intentional or unintentional. Harmful consequences of psychological abuse are not easy to identify. Sexual abuse could foster uncertainties of staff related to supporting residents with personal and intimate care. Abuse is often associated with negative feelings [41, 42, 44, 46, 57, 58, 72].
Two themes (ii and iii) reflect the ambiguity of participants confronted with abusive behaviour. (ii) “Tolerating abusive behaviours” was predicted by role conflicts, staff burnout, work stressors, and being married [70, 71]. (iii) “Consequences and punishment” referred to abuse as unacceptable practice requiring sanctions. Ridiculing a resident with dementia should result in advice and guidance of staff. Rough handling should entail verbal warning of staff. Stealing money requires dismissal and physical abuse should be reported to the police as a criminal offence [69].
(iv) “Reporting abuse” was associated with a potential for improvement.
Overall, participants characterized abuse as underreported. However, personal viewpoints of staff indicated that most carers are willing to anonymously report abuse. Based on the results of a nursing study cohort, the majority of participants stated that it is best to deal with abuse internally. Some participants would not report a resident’s abuse by a colleague since there are other ways to handle the situation. Other participants expressed fear to report abuse. They saw no use of reporting since nothing would change. Few participants did not feel brave enough to report abuse. Half of the participating nurses expected support from the management after reporting abuse. Two out of three stated that they would report abuse depending on its severity [42, 46, 58, 67]. (v) “Knowledge gaps” were related to a theoretical understanding of ‟neglect‟ and to staff education concerning sexual abuse [40, 46].
Interventions aiming to prevent staff-to-resident abuse
To answer our third review question on preventive interventions, we identified five studies [37, 40, 46–48, 51, 66, 76]. Detailed data for every study are available in supplementary material S2 and summarised in the following subsection.
Four out of five studies (80.0%) had a qualitative design [47, 48, 51, 66] and one study (20.0%) was quasi-experimental using a before-after design [76]. Overall, 149 participants were included (data available for four out of five studies; median 19, IQR 14 to 43, range 12 to 100) from 42 nursing homes (data available for four out of five studies; median eight, IQR four to 15, range three to 23). Mostly, nurses and nursing aides were recruited, followed by nursing home managers. Two studies (40.0%) used purposive sampling [51, 66]. One study each (20.0%) used a convenience [47] or a random sample [48] or provided no details on sampling [76]. Predominantly, abuse of unspecified type (n=3, 60.0%) [48, 51, 66]. One study each (20.0%) focussed on physical [47] or psychological abuse [76]. Interviews (of various types) were the most frequent method of data collection (n=4, 80.0%) [47, 48, 51, 66]. Two interview-based studies used structured interviews [51, 66], one relied on study semi-structured interviews [48], and another one on focus groups [47]. One study used a structured questionnaire (one week before and one week after the intervention) [76]. Two studies (20.0%) used grounded theory methodology for data analysis [48, 66]. One study each (20.0%) applied descriptive statistics combined with inferential statistics [76], systematic text condensation [47], and thematic analysis [51].
The intervention study used a before-after design [76]. Nurses and nursing aides performed the intervention designed by the research team and a trained graduate nurse in the role of a facilitator. Every week, eight 90-minutes group-sessions took place with ten to twelve nurses. The sessions were part of a multi-component framework, including education and mutual support. The programme addressed aging-associated problems related to managing residents’ health problems, institutional elder abuse, factors associated with caregivers’ abusive behaviour, relaxation and stress management, dealing with a stressful caregiving context, and obtaining personal resources. Each session started with a 30-minutes lecture on the topic, followed by 40 minutes of informal exchange and mutual support among group members. The last 20 minutes were dedicated to an integrative discussion. Outcomes were caregivers’ psychological abusive behaviours, perceived level of work stress, and knowledge in geriatric care. Statistically significant pre-post effects comprised decreased psychological abusive behaviour on the part of nurses and improved knowledge about gerontology nursing. Self-rated level of work stress did not significantly decrease.
Concerning the four qualitative studies, our analysis yielded four themes on preventive strategies with regard to staff-to-resident abuse: (i) “Image of nursing”, (ii) “Organisational management”, (iii) “Organisational culture”, and (iv) “Skills and competencies”. (i) “Image of nursing” was related to staff recruitment. Improving the image of the nursing profession proved to be important to prevent abuse [51]. (ii) “Organisational management” covered recruitment of more and qualified staff, rotation, and management strategies ensuring rapid response to abuse [51]. (iii) “Organisational culture” focussed the encouragement of an open, supportive, reflective, and cooperative team culture facilitating to learn from each other (e.g., by fostering open-mindedness in discussing ethical dilemmas) (Q3, S. 1: 302) [47, 48, 51, 66]. (iv) “Skills and competencies” covered the importance of competencies, ongoing training, and education [47, 51, 66].