This study used wave 1 (2024) data from the nursing home and assisted living surveys collected by the National Dementia Workforce Study (NDWS) [10]. The NDWS is a multiyear, federally funded data infrastructure initiative designed to generate nationally representative data on the US dementia care workforce. The study conducted a 2-stage cluster sampling design of establishment- and individual-level participants from nursing homes and assisted living facilities to produce probability-based estimates of the national dementia care workforce population [11]. Survey weights were developed by NDWS statisticians and survey designers to permit nationally representative inference at the organization and staff levels, accounting for complex survey design, stratification, and clustering.

This study was approved by the University of Alabama at Birmingham Institutional Review Board (IRB-300015390). This analysis and reporting adhered to the Reporting of Studies Conducted Using Observational Routinely-Collected Data (RECORD) statement for the reporting of studies conducted using observational data.

Our primary dependent variable was the presence or absence of physical or verbal aggression. To classify physical or verbal aggression, we used question 42 on the nursing home and assisted living surveys, which reads “In your job at this community over the past year, how often have you experienced the following?” We assessed the presence of physical aggression using subitem I, which reads “Hitting or other physical aggression from residents,” and verbal aggression using subitem J, which reads “Yelling or other verbal aggression from residents.” Potential responses were “never,” “rarely,” “sometimes,” and “often.” We dichotomized these variables as “not frequently” (encompassing “never” or “rarely”) and “frequently” (encompassing “sometimes” or “often”) because the original distribution did not meet the proportional odds assumptions of the Brant test, precluding analysis via linear or ordinal logistic regression.

Training was operationalized to reflect respondents’ perceived preparedness to manage aggressive behaviors in residents with dementia rather than the presence or absence of specific training modalities. Although the NDWS wave 1 surveys include items assessing exposure to formal and informal dementia-specific training (items NH4 and NH5 for nursing homes and AL4 and AL5 for assisted living facilities), these items ask broadly about training. Because the primary focus of this analysis was preparedness to handle aggressive behaviors, we used the global preparedness items (NH6 and AL6), which ask respondents whether their training prepared them to care for residents with dementia. These items capture respondents’ self-assessment of readiness rather than training format and were therefore better aligned with our analytic objective of examining perceived preparedness for challenging behavioral situations.

Independent variables included sex, age, race, ethnicity, feeling well-prepared by training to manage participant behaviors, rurality, and licensure. Licensure was determined by currently holding a registered nurse or licensed practical nurse license, whereas “nonlicensed” encompassed all other nonlicensed staff, including certified nursing assistants, home health aides, and medication assistants. We also included variables for directly working with residents and being a double-duty caregiver, where a staff member also provided care for an adult child at home.

Table 1 shows the variables and their item numbers and operationalizations.

The dementia care workforce in nursing homes (n=896,320) was primarily female (828,558/896,320, 92.4%), White (440,158/896,320, 49.1%), and non-Hispanic (778,249/896,320, 86.8%), with a mean age of 41.49 (SD 12.65) years. Less than half (365,452/896,320, 40.8%) reported frequently experiencing physical aggression from residents, whereas more than half (470,536/896,320, 52.5%) reported frequently experiencing verbal aggression from residents. More than two-thirds (614,561/896,320, 68.6%) reported feeling that their training prepared them well to manage resident behaviors.

The dementia care workforce in assisted living facilities (n=738,856) was primarily female (631,070/738,856, 85.4%), White (490,181/738,856, 66.3%), and non-Hispanic (650,020/738,856, 88%), with a mean age of 41.36 (SD 13.94) years. More than one-quarter (198,964/738,856, 26.9%) reported frequently experiencing physical aggression from residents, whereas just under one-third (223,343/738,856, 30.2%) reported frequently experiencing verbal aggression from residents. Almost three-quarters (527,621/738,856, 71.4%) reported feeling that their training prepared them well to manage resident behaviors.

Table 2 shows the participant characteristics.

In univariate modeling in nursing homes, race (P=.03) and training preparedness (P=.002) were associated with experiencing physical aggression. Family caregiver status (P=.04) and training preparedness (P=.01) were associated with experiencing verbal aggression.

In univariate modeling in assisted living facilities, race (P=.002) and training preparedness (P<.001) were associated with experiencing physical aggression. Sex (P=.02), race (P=.002), and training preparedness (P<.001) were associated with experiencing verbal aggression.

Table 3 shows the univariate modeling results.

In the fully adjusted model estimating the likelihood of reporting frequent physical aggression in nursing homes, feeling well-prepared by training for managing resident behaviors (odds ratio [OR] 0.40, 95% CI 0.223-0.711; P=.01) was associated with a lower likelihood of reporting frequent physical aggression.

In the fully adjusted model estimating the likelihood of reporting frequent verbal aggression in nursing homes, feeling well-prepared by training for managing resident behaviors (OR 0.50, 95% CI 0.299-0.844; P=.02) was associated with a lower likelihood of reporting frequent verbal aggression.

In the fully adjusted model estimating the likelihood of reporting physical aggression in assisted living facilities, feeling well-prepared by training for managing resident behaviors (OR 0.14, 95% CI 0.036-0.556; P=.01) and being a family caregiver (OR 0.19, 95% CI 0.043-0.778; P=.03) were associated with a lower likelihood of reporting frequent physical aggression.

In the fully adjusted model estimating the likelihood of reporting verbal aggression in assisted living facilities, working in a direct care role (OR 5.09, 95% CI 1.223-21.194; P=.03) was associated with a higher likelihood of reporting frequent verbal aggression, and feeling well-prepared by training for managing resident behaviors (OR 0.07, 95% CI 0.014-0.354; P<.001) and being a family caregiver (OR 0.18, 95% CI 0.061-0.516; P<.001) were associated with a lower likelihood of verbal aggression.

Table 4 shows the regression modeling results.

In both nursing homes and assisted living facilities, training programs for handling resident behaviors were associated with a lower likelihood of experiencing physical aggression, and in assisted living facilities, these training programs were associated with a lower likelihood of experiencing verbal aggression.

Prior work emphasizes the importance of dementia-specific training to manage resident behaviors. Livingston et al [14] demonstrated in a systematic review of 33 studies that aggression can be mitigated through caregiver activities, especially person-centered approaches to care that systematically support resident behaviors. Other reviews have found that aggression prevention in residential facilities requires staff to be equipped with knowledge and skills to intervene early to prevent situational escalation into physically or verbally aggressive behaviors, although Seitz et al [15] concluded that large-scale studies of staff training in nursing homes and residential facilities should examine whether these results are robust beyond protocol-driven interventions. Our results indicate that, on a nationally representative scale, there is an association between a reduced frequency of aggressive behaviors and perception that trainings prepared staff to manage participant behaviors. While the cross-sectional nature of the NDWS precludes causal speculation, other work has hypothesized that training that includes early recognition and intervention for problematic behaviors can reduce aggression in residents with dementia [16,17].

Our finding that being a double-duty caregiver, or caring for a person at home, was associated with a reduced likelihood of experiencing aggressive behaviors in assisted living facilities was initially surprising. However, this correlation could be due to their experience in understanding and recognizing escalating cascades of behaviors when caring for another person in the home [18]. Limited literature exists to determine the specific skills that double-duty caregivers apply in both home and long-term care settings, although a future study could determine the influence of home-based caregiving on long-term care strategies to manage aggression.

The large, well-conducted survey methodology and robust weighting procedures provide strength to our findings. However, care is needed in the interpretation of results due to the cross-sectional nature of the study; causality cannot be assumed. Our findings indicate that perceived training efficacy for managing resident behaviors was linked to a decrease in the frequency of aggressive incidents; however, the specific elements of the training contributing to this effect remain undetermined. On the other hand, staff experiencing lower aggression may create the perception that their training sufficiently prepared them to manage resident behaviors. Future interventional work should determine the causal path. Additionally, the study power was limited by the initial sampling frame rather than the weighted sample. There could have been aspects of the study sample that biased the results, although the robust weighting procedures and clustering in the survey design should mitigate this effect. We treated training preparedness as dichotomous due to small cell sizes in the “not at all prepared” group. While this speaks to the level of training received at nursing homes and assisted living facilities, future work should determine whether there is a stepwise change between similar categories as there could be a meaningful difference between feeling not at all prepared and somewhat prepared.

In a nationally representative sample of the dementia care workforce, effective training programs were associated with worker-reported reduced experiences of physical and verbal aggression in both nursing homes and assisted living facilities. The specific components of training programs that may support effectiveness remain unknown.