Leaders’ perceptions of staff-to-resident abuse in nursing homes: a qualitative study from Hunan, China

Staff-to-resident abuse in institutional settings demands political attention and evidence-based interventions. Leaders’ perceptions of such abuse can provide practical, policy-relevant insights. This study explores leaders’ perceptions of risk factors and prevention strategies for staff-to-resident abuse in institutional settings. Nineteen leaders from nursing homes in Hunan Province, China, were purposively recruited. Semi-structured qualitative interviews were conducted, and transcripts were analysed using content analysis. Participants exhibited a protective orientation involving both proactive and defensive attitudes. Leaders perceived several risk factors, spanning underqualified and overburdened caregivers, residents with complex care needs, suboptimal institutional management, and unsupportive socio-cultural contexts. Reported prevention strategies focused on workforce development, emotional support, operational supervision, external oversight and clearer regulatory structures. This study describes the subjective perceptions, attributions and institutional reasoning of a purposively selected sample of nursing-home leaders from Hunan Province rather than verifying objective causal mechanisms of elder abuse. Leaders’ narratives revealed a critical disconnect between institutions’ claims of absolute safety and the complex factors that they perceive as enabling abuse. Interpretive analysis suggests sustainable prevention would require moving from the reactive blame of individual staff toward proactive, multilevel approaches that strengthen caregiver wellbeing, organizational responsibility, and regulatory frameworks. Core actionable measures include standardized abuse response training, evidence-based workload optimization, and independent external oversight frameworks to mitigate staff-to-resident abuse.