I think there are a number of issues around all of that too.
We did find when we were doing our research that there was very inconsistent flagging. Not every facility uses flagging. In some cases, it's felt that it's stigmatizing, so they want to find ways of communicating to the staff that a person may have aggressive tendencies without stigmatizing the person. We heard a lot of different ideas on how all of that might be handled.
The big problem is that you might have someone who was acting very aggressively on a previous shift. If that information is not passed along to the new shift coming in, they can be in danger. There are a number of health care worker occupational groups that are not in on the nurses' huddles at the beginning of a shift, where you talk about what's going on with the various patients and residents. For people working as PSWs or dietary staff, there needs to be some mechanism for them to know that they may be walking into a situation that could be dangerous. If you have someone who is being aggressive, you need to look at all those ways in which you might be able to de-escalate this.
We did hear about people who were chronically aggressive, where people just knew that they would need to have three or four people go in. A football player with an acquired brain injury would require four staff people to hold him down while they changed his incontinence brief and that sort of thing. It's important to know these things, and sometimes you do need additional staff.
Besides all of these strategies we've heard about today that you can use for people who have dementia, there are other people who are aggressive for other reasons. They may be in terrible pain. They may be fearful. We need to look at what's going on there.
For the flagging, I think it's unfortunate that it may sometimes stigmatize, but I think we absolutely have to be doing it for the safety of the health care worker.