week 4 assignments

J Clin Nurs. 2020;29:3425–3434. wileyonlinelibrary.com/journal/jocn  |  3425© 2020 John Wiley & Sons Ltd

Received: 6 February 2020  |  Revised: 25 May 2020  |  Accepted: 5 June 2020 DOI: 10.1111/jocn.15380

O R I G I N A L A R T I C L E

The relationship between personality traits, caring characteristics and abuse tendency among professional caregivers of older people with dementia in long-term care facilities

Weichen Chen RN, Postgraduate Student  | Fan Fang RN, Postgraduate Student  | Yu Chen Dr, Professor of Nursing | Jin Wang RN, Postgraduate Student | Yuanmin Gao RN, Postgraduate Student | Julan Xiao RN, Postgraduate Student

Weichen Chen and Fan Fang contributed equally to this work.

School of Nursing, Southern Medical University, Guangzhou, China

Correspondence Yu Chen, School of Nursing, Southern Medical University, No. 1023, Shatainan Road, Baiyun District, Guangzhou 510515, Guangdong Province, China. Emails: [email protected]; [email protected]

Funding information Construction project of Teaching Quality and Teaching Reform (Open Online Courses) both in Guangdong Province and in Southern Medical University, Grant/Award Number: ZL201904. Higher Education Reform Project of Southern Medical University, Grant/ Award Number: JG201931 and JG201955. Education and Teaching Achievement Award Cultivation project of Southern Medical University, Grant/Award Number: School word〔2019〕46. College Innovation and Entrepreneurship (Employment) Education Project in Guangzhou, Grant/ Award Number: Higher Education in Guangzhou〔2019〕15.

Abstract Aims and objectives: To explore the relationship between personality traits, caring characteristics and abuse tendency among professional caregivers of older people with dementia in long-term care facilities in China. Background: Elder abuse is a serious global health problem and human right violation with high incidence among older people with dementia. There are many investiga- tions about impact factors of risk of abuse among family caregivers of older people with dementia. However, in long-term care facilities, the situation of abuse tendency needs further investigation. Design: Cross-sectional study. Methods: An observational survey was conducted according to the STROBE check- list. We investigated 156 professional caregivers of older people with dementia in three long-term care facilities in Guangzhou, China. Participants completed a de- mographic questionnaire, the Caregiver Abuse Screen (CASE) and the Neuroticism Extraversion Openness Five-Factor Inventory (NEO-FFI). Data were analysed using Mann–Whitney U tests, Kruskal–Wallis tests, Spearman's rank correlation and logis- tic regression analyses. Results: Over half of the participants (51.9%) reported abuse tendency to the older people with dementia. There was a significant negative correlation between the car- egivers' agreeableness scores of NEO-FFI and their CASE scores. Multivariate logis- tic regression analyses highlighted that protective factors of abuse tendency were caregivers' agreeableness, care recipients' source of finances and their duration of dementia while higher care difficulty and presence of older people's behavioural and psychological symptoms of dementia (BPSD) were the risk factors. Conclusion: Caregivers' agreeableness personality trait and the caring characteris- tics of older people with dementia may be relevant to abuse tendency in long-term

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1  | INTRODUC TION

The World Alzheimer Report 2018 estimated that there are 50 mil- lion people living with dementia worldwide, and the number will rise to 152 million by 2050 (Alzheimer's Disease International, 2018). Dementia is characterised by a progressive decline in memory and skills necessary to carry out everyday activities (Li, 2011). Older people with dementia suffer from cognitive impairment and chal- lenging behaviours. They are often dependent on others with activities of daily living (ADLs) causing increased workload to their caregivers, making them a vulnerable population for abuse (Yan, 2014). A previous study showed that caregivers of older peo- ple with dementia were more likely to experience burnout, poten- tially resulting in abuse and neglect of the older people they cared for (Thomas, 2001).

Elder abuse is recognised as a serious global health problem and human rights violation with high incidence among older people with dementia (Yon, Mikton, Gassoumis, & Wilber, 2017). It has been widely described as “a single or repeated act, or some inappropriate action, occurring within any relationship where there is an expec- tation of trust, which causes harm or distress to an older person” (Chen, 2019; Lachs & Pillemer, 2015). Elder abuse can result in serious health consequences for the victims, including increased morbidity and mortality (Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998; Schofield, Powers, & Deborah, 2013), institutionalisation (Lachs, Williams, O'Brien, & Pillemer, 2002), hospital admissions (Dong & Simon, 2013) and negative effects on families and society at large (Wang, Sun, Zhang, & Ruan, 2018).

A researcher points out that it is crucial to screen the risk of abuse for preventing elder abuse (Feng & Liu, 2010). Estimates of the prevalence of elder abuse of older people in nursing home range from 8%–11% (Wang, Meng, et al., 2018). A recent study showed that 53.2% (n = 340) of caregivers of older people with dementia in long-term care facilities reported a CASE score more than three, in- dicating a risk of abuse (Zeng et al., 2018). The number of older peo- ple being abused is expected to increase, given that many countries are experiencing a rapid increase in the ageing population (Gallione et al., 2017).

2  | BACKGROUND

Many previous studies have explored the risk of abuse in developed countries (Acierno et al., 2010; Biggs, Jill Manthorpe, Tinker, Doyle, & Bob Erens, 2009; Compton, Flanagan, & Gregg, 1997; Thomas, 2001). However, little research has been conducted to understand the situa- tions in developing countries. Studies have reported that the population of older people with dementia in China will exceed 10 million by 2025 (Wu et al., 2013; Xiao et al., 2014). Chinese people follow the Confucian culture of “Respect the Older and Love the Young” (Xiao, Shen, & Paterson, 2013). Elder care has long been provided by adult children at home where abuse is not acceptable according to the traditional moral standard of the society. However, in recent years, with the growth of population mobility and decreased family size, many adult children are unavailable to provide care for their parents. As a result, long-term care services for the older people with nonfamilial caregivers have been de- veloped rapidly. However, most caregivers in long-term care facilities in China are old with inadequate education. They often lack of the coping skills when older people with dementia display challenging behaviour and have low self-care ability (Chen et al., 2019; Zhang & Xiang, 2015).

care facilities. Further study with a larger sample size is needed to validate such a correlation. Relevance to clinical practice: Older people with dementia are at high risk for abuse. Prospective caregivers could pay more attention to developing their own agreeable- ness. The managers might establish monitoring system for reducing the abuse.

K E Y W O R D S

abuse tendency, long-term care facilities, older people with dementia, personality traits, professional caregivers

What does this paper contribute to the wider global clinical community?

• This study suggested high prevalence of abuse tendency among caregivers of older people with dementia in long- term care facilities.

• Professional caregivers' agreeableness was negatively correlated with abuse tendency in our study. This indi- cated the agreeableness as favourable characteristic in caring for older people with dementia.

• The managers of long-term care facilities should strengthen mental health education and disease training for professional caregivers so as to enhance their care skills and professional ethics.

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Factors associated with risk of abuse of older people with dementia include the caregiver's physical and mental health (Cooper, Selwood, et al., 2010), care burden and fatigue (Cooper, Blanchard, Selwood, Walker, & Livingston, 2010), self-care ability (Cooper, Selwood, et al., 2010) and the psycho-behavioural symp- toms (Wiglesworth et al., 2010) of older people with dementia. A recent research identified individuals' intrinsic factors of both abusers and abused which could lead to the likelihood of abuse. It also proposed a relationship between personality traits of care- givers and their risk of abuse (Liu, Wang, Gu, Liu, & Yang, 2017; Zhu, 2015). Personality traits along with mental health and healthy interpersonal relationships were found to be factors that are most closely linked to abusive behaviours (Jiao, Yang, Luo, & Qiang, 2017). Previous studies have also found the relationships among personality traits, empathy (Wang & Li, 2017), job burnout (Liu, Li, Wang, Qi, & Li, 2012) and mental health (Su & Jiang, 2014) among caregivers. However, limited research has examined the direct relationship between the personality traits and abuse ten- dency among professional caregivers of older people with de- mentia in long-term care facilities.

In addition, few studies investigating the abuse tendency of older people with dementia in long-term care facilities in China have focused on external factors such as demographic variables and caring characteristics. Internal factors such as personality traits that may affect risk of abuse remain unclear. The research questions of the current study were to examine abuse tendency among professional caregivers of elder Chinese people with de- mentia in long-term care facilities and to explore whether profes- sional caregivers' personality traits and the caring characteristics are associated with it.

3  | MATERIAL S AND METHODS

3.1 | Study design

A cross-sectional survey referring to STROBE checklist (Data S1) was carried out to explore status of personality straits, caring character- istics and abuse tendency among professional caregivers of older people with dementia and to examine the association among them.

3.2 | Setting and participants

Professional caregivers of older people with dementia in three long- term care facilities in Guangzhou, PR China, were recruited for the study. The inclusion criteria for participants were as follows: (a) car- ing for people over 60 years old who had been diagnosed with at least one type of dementia, including Alzheimer's disease, vascular dementia, dementia with Lewy bodies; (b) have been educated and trained in dementia care; (c) caring for an elder with dementia for at least 1 month; (d) more than 18 years old; (e) being able to com- municate; and (f) being able to give voluntary informed consent. The

exclusion criteria were as follows: (a) caregivers who are patients' family members or friends; (b) caregivers who had mental issues. Sample size was determined as being at least 121 according to Kendall's sample calculation equation: sample numbers = max (di- mension number × 10) × [1 + (10%–20%)]. Also, in logistic regression, the recommended criterion of sample size is that EPV (events per variable) should be at least 10 to ensure a robust result (Peduzzi, Concato, Kemper, Holford, & Feinstein, 1996).

3.3 | Data collection

Data were collected from July 2018–October 2018. A total of 165 paper questionnaire were filled in by the professional caregivers and collected on the spot. Assistance was offered by the researcher to the participants who were not proficient in reading and had difficul- ties with filling out the survey. The screening criteria of the ques- tionnaire were the sameness of the answers and the omission of more than 15%. Finally, 156 professional caregivers completed the questionnaire and the response rate was 94.54%.

3.4 | Instruments

3.4.1 | Demographic variables

A self-designed demographic questionnaire was employed to col- lect general information about the study participants and their care recipients. It included two parts. The first part pertained to the caregiver's gender, age, care service time, care recipients' number, educational level, job satisfaction and caring difficulty for older peo- ple with dementia. The second part pertained to the care recipients' source of finance, duration of dementia, the older people's behav- ioural and psychological symptoms of dementia (BPSD) and their self-care ability.

3.4.2 | The Caregiver Abuse Screen for the Elderly

The Caregiver Abuse Screen for the Elderly (CASE) was used to measure the caregivers' risk of abuse. It was developed by Canadian researchers Reis and Nahmiash (Reis & Nahmiash, 1995) in 1995 based on neutral theory and was translated into Chinese and tested by Feng (2010). The scale consists of eight closed questions and one open question. A score of one was given to an answer of “Yes,” and a score of zero was given to an answer of “No” for each question. A total score ≥ 3 indicates risk of abuse. This was based on Feng's (2010) study which showed that those professional caregivers with a CASE score ≤ 2 did not display any abuse behaviours. The validity and reli- ability of the scale were tested with good results as the Cronbach's alpha coefficient was 0.77 in Reis & Nahmiash's study (1995) and was 0.68 in this study. Given the word “risk of abuse” was too sensitive to the caregivers, likely causing their refusal to participate in the study,

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the Chinese version of the scale (Feng & Liu, 2010) was renamed as “the elders' life experience questionnaire.”

3.4.3 | Neuroticism Extraversion Openness Five- Factor Inventory

Neuroticism Extraversion Openness Five-Factor Inventory (NEO- FFI; Costa & Mccrae, 1990; Kurylo & Stevenson, 2011) was applied to identify the participants' personality traits. It was developed based on the Big Five personality trait model, including five major personality factors: neuroticism, extraversion, openness, consci- entiousness and agreeableness. The scale consists of 60 items with 12 items for each personality factor, respectively. A five-Lik- ert scale was used for each item with a score of one for “strongly disagree” and a score of five for “strongly agree.” The question- naire was tested with good reliability and structural validity in a group of Chinese College students as the mean Cronbach's alpha coefficient of each dimension was 0.73 (Yao & Liang, 2010) and was 0.71 in this study.

3.5 | Data analysis

Data were analysed using SPSS statistical software (version 19.0, SPSS). All data were analysed for normal distribution using Shapiro– Wilk test. If data followed normal distribution, the data were de- scribed using mean and standard deviation. Otherwise, the data were described using median and interquartile range. The data were analysed depending on nonparametric tests included Kruskal–Wallis and the Mann–Whitney U tests according to the number of groups. The relationships between personality traits and abuse tendency were examined by Spearman's rho correlation analysis. A univariate binary logistic regression analysis was carried out to identify the con- tribution of variables in predicting abuse tendency. The total CASE scores were set up as a dichotomy which was used as a dependent variable for the univariate binary logistic regression analysis (0 = no abuse tendency; 1 = abuse tendency as per score ≤ 2 and score ≥ 3, respectively). All variables were included in the univariate logistic re- gression, and the variables which significantly influenced the abuse tendency were used for the multivariate logistic regression analysis. The entry and removal cut-offs for the stepwise regressions were based on p values of .05 and .1, respectively.

3.6 | Ethical considerations

This study is a graduation project which had been reviewed by the ethics committee of our university and ethics approval was gained. The study was approved by each long-term care facility. A per- mission from all managers and written informed consent of all the participants were obtained. Participants were informed before the

study began that the information would have been maintained con- fidentially and anonymously.

4  | RESULTS

4.1 | Distribution of professional caregivers' CASE scores

The CASE scores of the professional caregivers ranged from 0 to 8 with a median of 3 and interquartile range of 3. Among all the profes- sional caregivers, 51.9% were scored more than 3 points, indicating an inclination towards elder abuse. Percentage distribution of car- egivers' CASE scores is demonstrated in detail in Table 1.

4.2 | Characteristics of professional caregivers, participants and their CASE scores

Among the 156 professional caregivers enrolled in the study, 91% were women. The mean age of the participants was 48.33 (SD = 7.01) years. The professional caregivers had provided elderly care service for an average of 33.65 (SD = 42.22) months. An educational level of elementary school or illiterate educational level accounted for 34.6% of professional caregivers. Regarding care recipients, the mean du- ration of dementia was 64.69 (SD = 45.97) months and 46.2% had behavioural and psychological symptoms. The results in Table 2 also showed that professional caregiver' CASE scores have significant difference on their caring recipients' number, caring difficulty, care recipients' source of finance, duration of dementia, BPSD and self- care ability by using the Kruskal–Wallis and the Mann–Whitney U tests (all p values < .05).

TA B L E 1   Distribution of CASE scores of professional caregivers (n = 156)

Items n (%)

Score

0 23 (14.7%)

1 21 (13.5%)

2 31 (19.9%)

3 38 (24.4%)

4 12 (7.7%)

5 17 (10.9%)

6 7 (4.5%)

7 2 (1.3%)

8 5 (3.2%)

Median (P25–P75) † 3 (1–4)

Mean ± SD‡ 2.73 ± 1.99

Minimum~Maximum 0~8

Note: Descriptive statistics. †Median (25%–75%); ‡Standard deviation.

     |  3429CHEN Et al.

4.3 | Subscales scores of the NEO- FFI of professional caregivers and correlation with CASE scores

The mean scores on the subscales of the NEO-FFI of the professional caregivers were 30.93 (SD = 5.65) for neuroticism, 41.90 (SD = 4.91)

for extraversion, 37.36 (SD = 4.36) for openness, 45.76 (SD = 4.27) for conscientiousness and 44.79 (SD = 4.96) for agreeableness. In the correlation test, there was a significant negative correlation be- tween the caregivers' agreeableness subscale scores and their CASE scores (r = −.282, p < .01). No statistically significant correlation was identified between the other subscales scores of the NEO-FFI and the CASE scores. The results are detailed in Table 3.

TA B L E 2   The characteristics of caregivers, care recipients and CASE scores (n = 156)

Variables n (%)† CASE M (P25–P75)

‡ χ2 p

Caregivers

Gender Male 14 (9.0) 2 (1,3) 1.040 .308

Female 142 (91.0) 3 (1,4)

Age ≤44 years old 31 (19.9) 2 (1,3) 2.519 .284

45~59 years old 122 (78.2) 3 (1,4)

≥60 years old 3 (1.9) 3 (3,3.5)

Care service time ≤12 months 75 (48.1) 2 (1,3) 3.461 .326

13~36 months 38 (24.4) 3 (1.75,5)

37~60 months 14 (9.0) 2.5 (1.5,5)

≥61 months 29 (18.6) 3 (2,3.5)

Care recipients' number

1~5 persons 114 (73.7) 3 (1,4) 3.866 .049*

≥6 persons 41 (26.3) 2 (0,3)

Education level Primary school or below 54 (34.6) 3 (1.75,3) 1.050 .789

Middle school 85 (54.5) 2 (1,4.5)

High school 15 (9.6) 3 (1,4)

College or above 2 (1.3) 1.5 (1,2)

Job satisfaction Not very satisfied 6 (3.8) 3 (1,3) 6.994 .136

General 69 (44.2) 3 (2,3.5)

Relatively satisfied 65 (41.7) 2 (1,4.5)

Very satisfied 16 (10.3) 0.5 (0,4.5)

Caring difficulty Not difficult 4 (2.6) 0.5 (0,2) 39.479 <.001**

Not very difficult 18 (11.5) 1 (0.3)

General 79 (50.6) 2 (1,4)

Relatively difficult 48 (30.8) 3 (2.25,5)

Very difficult 7 (4.5) 3 (3,5)

Care recipients

Source of finance Totally depend on self 46 (29.5) 3 (1,3) 6.081 .048*

Partly depend on self 89 (57.0) 3 (1,5)

Totally depend on adult children 21 (13.5) 2 (1,2.5)

Duration of dementia

≤12 months 15 (9.6) 5 (3,5) 11.390 .003*

13~60 months 68 (43.6) 3 (1,4)

≥61 months 73 (46.8) 2 (1,3)

BPSD No 84 (53.8) 2 (1,3) 17.800 ＜.001**

Yes 72 (46.2) 3 (2,5)

Self-care ability Inability to care themselves 68 (43.6) 2 (1,4) 6.022 .049*

Partial self-care 73 (46.8) 3 (2,4)

Completely self-care 15 (9.6) 1 (0,3)

Note: Descriptive statistics; Kruskal–Wallis and Mann–Whitney U tests. †number (%); ‡CASE Median (25%–75%); *p value < .05; **p value < .01.

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4.4 | Logistic regression analysis of influencing factors for abuse tendency

Univariate binary logistic regression analysis included all modalities of each dimension listed in Table 2, and seven variables were chosen as affecting factors to the response variable. Upon these results, a multivariate binary logistic regression analysis for these significant variables was conducted and the results showed that five fac- tors were statistically significant. They are “duration of dementia,” “agreeableness,” “source of finance,” “care difficulty” and “BPSD.” According to the OR estimates, protective factors against abuse ten- dency included the following: “Source of finances” (OR = 0.481), with lower odds of being abused for care recipients who were financially dependent on their adult children than those who were financially independent; “duration of dementia” (OR = 0.525), with lower odds of being abused for care recipients with dementia for more than 61 months than those with dementia for less than 12 months; and “caregiver's agreeableness” (OR = 0.873), with lower odds of being abused by agreeable caregivers than by less agreeable ones. Risk factors for abuse tendency included “psycho-behavioural symptoms (BPSD)” (OR = 3.853), with higher odds of being abused for care re- cipients with psycho-behavioural symptoms than those without, and “care difficulty” (OR = 4.651), with higher odds of being abused by caregivers who have self-reported difficulties in providing care than those who haven't. The results of uni- and multivariate logistic re- gression analysis are shown in Tables 4 and 5.

5  | DISCUSSION

The current study found that 51.9% of the professional caregiv- ers in long-term care facilities have a tendency of abusing older people with dementia. This rate is much higher than that among caregivers of the general older population with dementia (3.2%– 27.5%; Fang & Yan, 2016). Dementia is characterised by decreased memory, cognitive deficits and decreased self-care ability. As an elder's dementia progresses, there is a further decline in his/her cognitive and behavioural abilities. The needs for care with daily life therefore increase, resulting in huge care burden on their car- egivers. In China, the daily responsibilities of professional caregiv- ers in long-term care facilities cover a wide range of activities and their workload can be very high (Han & Shi, 2016). In addition,

some older people with dementia often display BPSD, such as vio- lations, yelling, swearing or violent beatings towards caregivers, which increases the physical and mental strain on the caregivers (Yang & Shen, 2015). Coping negatively with such a challenging job is likely to lead to risk of abuse.

Interestingly, our results indicate that professional caregivers in long-term care facilities were less abusive than family caregivers in Wang's research (Wang, Sun, et al., 2018). This may be explained that they were usually under the supervision of managers or other professional staff in the workplace. Conversely, family caregivers look after older people with dementia at home without external su- pervision. This may lead to a greater risk of abuse (Chen, 2019). In addition, caregivers in long-term care facilities were more profes- sionally trained than family caregivers do. Education provides better knowledge and skills in caring for older people with dementia and coping with their behaviours, ultimately leading to decreased work pressure and then risk of abuse (Alt, Nguyen, & Meurer, 2011). On the other hand, family caregivers normally fulfil the caring responsi- bility 24 hr a day, 365 days a year, without way out or break, unlike professional caregivers who can leave and find another line of work. They carry too much care burdens and pressure, so are more likely to become abusive (Yang, 2013).

Regarding personality traits, the professional caregivers of the current study reported highest scores of conscientiousness. Agreeableness was scored the second highest, while neuroticism (M = 30.93, SD = 5.65) was scored the lowest. These results are simi- lar to those of previous studies on personality traits of nurses (Wang & Li, 2017). According to the Big Five personality model (Kurylo & Stevenson, 2011), caregivers with high conscientiousness scores have greater self-discipline and sense of responsibility. Professional caregivers with high scores in the agreeableness dimension are more likely to express sympathy, to be willing to help care recipients and to focus on the inner feelings of themselves. The neuroticism dimen- sion reflects personality traits associated with negative emotions, such as anxiety, depression, hostility and impulsivity. The profes- sional caregivers in the current study have given the lowest scores for this dimension, indicating that they were mentally stable, possess good interpersonal relationships and care for others.

According to results from the multivariate logistic regression analysis, the item of “Source of finances was dependent on their adult children” was considered as the protective factor for abuse. This indicates that the adult children provide life necessities for their

Personality traits Mean ± SD† Minimum Maximum r‡ p

Neuroticism 30.93 ± 5.65 12 47 0.052 .518

Extraversion 41.90 ± 4.91 27 55 −0.148 .065

Openness 37.36 ± 4.36 21 52 −0.080 .322

Conscientiousness 45.76 ± 4.27 37 60 −0.049 .542

Agreeableness 44.79 ± 4.96 33 58 −0.282 <.001**

Note: Descriptive statistics; Spearman correlation analysis; †Standard deviation; ‡Spearman's rank correlation coefficient; **p value ＜ .01.

TA B L E 3   The scores of NEO-FFI of professional caregivers and correlation with CASE (n = 156)

     |  3431CHEN Et al.

parents with dementia, taking some of the burden off the profes- sional caregivers at the facility, and ultimately decreasing the risk of abuse (Yan, Chan, & Tiwari, 2015). In addition, “Source of finances dependent on adult children of older people with dementia” serves as additional supervision to professional caregivers, thus reduces the abuse tendency. In addition, an existence of psycho-behavioural symptoms, the long duration of dementia and high degree of care difficulties also influenced the abuse tendency among professional caregivers. The results of the current study suggest that the longer is the duration of dementia/symptoms, the lower seems the abuse tendency. The reason may be that in the early stage of dementia, due to the corresponding lack of knowledge and skills related to care of older people with dementia and the progress of the syndrome (Zhu, Lin, Shi, & Chen, 2016), caregivers do not adjust well to the new role when they are more prone to psychological burden and stress (Chen et al., 2019). As the time of care gets longer, the more experi- enced the caregiver is, the care recipient may be less at risk of abuse (Huang, 2017). In addition, as the relationship with the care recipient is closer, the caregiver is more likely to have compassion (Yuan, Lin, Chu, & Zhou, 2019). However, few previous studies have established an explicit relationship between duration of dementia and the risk of abuse. These hypotheses need to be tested in future research. As the cognitive ability and self-care ability of care recipients deterio- rate, and psycho-behavioural symptoms appear hard to be managed, the risk of safety issues such as running away and falling can increase

caregiver burden and care difficulties, which leads to an increase in the abuse tendency.

Agreeableness had a negative significant correlation with CASE scores among professional caregivers, as indicated by the related correlation. Also, it seems was a significant protective factor against the abuse tendency, as indicated by the multivariate logistic regres- sion. In other words, the more agreeable the participant is, the less was the risk of abuse. Personality traits play a critical role in think- ing and behaviour (Jiao et al., 2017). Individual responses to pres- sures and situations are greatly influenced by them. Previous studies (Wang & Li, 2017) have shown that nurses with a higher score of agreeableness have greater empathy. According to the Big Five per- sonality model (Kurylo & Stevenson, 2011), professional caregivers with higher scores of agreeableness were able to empathise with the feelings of older people with dementia, increasing their willingness to help their patients. A previous study also found that professional caregivers with higher scores on agreeableness tend to be more al- truistic by showing respect for older people with dementia, without expecting anything in return, voluntarily increasing the welfare of their patients. This process leads to good nurse–patient relation- ships (Huang, Huang, Song, Huang, & Huang, 2017).

There are several limitations with this study. First, a convenience sampling of 156 participants is unable to represent the general pop- ulation of professional caregivers of older people with dementia in long-term care facilities. The conclusion based on the results of the

B SE Wald p OR†

95% CI‡

Lower Upper

Age (caregivers) 0.070 0.026 7.101 .008** 1.073 1.019 1.129

Work satisfaction −0.623 0.232 7.196 .007** 0.536 0.340 0.845

Source of finance −0.521 0.260 4.001 .045* 0.594 0.357 0.990

Care difficulty 1.550 0.303 26.247 <.001** 4.712 2.604 8.525

Duration of dementia

−0.009 0.004 5.130 .024* 0.991 0.984 0.999

Agreeableness −0.153 0.038 16.473 <.001** 0.858 0.797 0.924

BPSD 1.017 0.333 9.343 .002** 2.765 1.440 5.307

Note: Univariate binary logistic regression analysis; †Odds ratio; ‡Confidence interval; *p value ＜ .05; **p value ＜ .01.

TA B L E 4   Univariate logistic regression analysis of influencing factors of abuse tendency among professional caregivers (n = 156)

B SE Wald p OR†

95% CI‡

Lower Upper

Source of finance −0.732 0.335 4.244 .039* 0.481 0.240 0.965

BPSD 1.349 0.459 8.635 .003** 3.853 1.567 9.042

Care difficulty 1.537 0.339 20.528 <.001** 4.651 2.392 9.042

Duration of dementia

−0.645 0.330 3.819 .051 0.525 0.275 1.002

Agreeableness −0.136 0.048 8.171 .004** 0.873 0.795 0.958

Note: Multivariate binary logistic regression analysis; †Odds ratio; ‡Confidence interval; *p value ＜ .05; **p value ＜ 0.01.

TA B L E 5   Multivariate logistic regression analysis of influencing factors of abuse tendency among professional caregivers (n = 156)

3432  |     CHEN Et al.

current study only applies to our study setting and needs further verification. Second, the CASE scale relies on self-reporting of care- givers, which may inevitably cause response biases. Third, there are no studies correlating CASE scores with actual abuse incidents and it is considerable about the generalisation of results.

6  | CONCLUSIONS

The current study found that more than half of the participants were at risk of abusing tendency to the older people with dementia. Personality traits play a critical role in abuse tendency among pro- fessional caregivers of older people with dementia in long-term care facilities. Specifically, the agreeableness dimension of personality traits is negatively correlated with abuse tendency. The character- istics of care recipients' source of finances and duration of dementia are the protective factors while their psycho-behavioural symptoms and caregivers' care difficulty are the risk factors related to the abuse tendency in long-term care facilities. Further research with a larger sample size is needed to validate such a correlation.

7  | RELE VANCE TO CLINIC AL PR AC TICE

The current study found that there is a high prevalence of abuse ten- dency among professional caregivers of older people with dementia in long-term care facilities. Importantly, the results also found that personality traits are related to the abuse tendency among profes- sional caregivers. This knowledge can be used by managers to increase awareness of how different people cope differently caring for peo- ple with dementia and help them to be aware of risks and signs of potential abuse. Moreover, long-term care facilities should establish a three-level monitoring system of abuse. The levels should include the following: (a) focusing attention on the daily behaviour of professional caregivers; (b) establishing a system to report incidents of abuse ten- dency or abuse; and (c) protecting older people of dementia through supervising the professional caregivers. The managers of long-term care facilities may also strengthen mental health education and dis- ease training for professional caregivers, thus increasing their aware- ness and knowledge of elder abuse (Alt et al., 2011) to enhance their care skills and professional ethics. In addition, long-term care facili- ties should combine medical care with nonmedical treatment for older people with dementia to delay the progression of dementia and the weakening of their self-care ability. The government should strengthen legislation and relevant policies to protect the rights and interests of the older people, especially those who lack self-care ability.

ACKNOWLEDG EMENTS The authors thank the patients, relatives and healthcare person- nel who participated in this study. We also acknowledge the sup- port of Affiliated brain hospital of Guangzhou Medical University, Guangzhou Shouxing Building and Guangzhou Haizhu District Baizhang Nursing Center. We are specially grateful to Dr. Ning

Wang, Dr. Xueling Yang, Dr. Ying Guan, Dr. Fei Peng and Professor Roger Watson for their help with the revision of the manuscript.

CONFLIC T OF INTERE S TS The authors declare they have no conflicts of interest.

AUTHOR CONTRIBUTIONS Study design: Weichen Chen, Yu Chen; data analysis: Weichen Chen, Fan Fang, Jin Wang, Yuanmin Gao; and manuscript preparation: Weichen Chen, Fan Fang, Yu Chen, Julan Xiao.

ORCID Weichen Chen https://orcid.org/0000-0002-1484-2554 Fan Fang https://orcid.org/0000-0002-6203-7824

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SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Chen W, Fang F, Chen Y, Wang J, Gao Y, Xiao J. The relationship between personality traits, caring characteristics and abuse tendency among professional caregivers of older people with dementia in long-term care facilities. J Clin Nurs. 2020;29:3425–3434. https://doi. org/10.1111/jocn.15380

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