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Residents with Combative Behavior in Long Term Care

Residents who exhibit combative behavior in long term care pose care challenges to staff and other residents. Combativeness is not usually directed at the individual caregiver nor is it a personal attack on the caregiver as a person, but, usually, a mechanism the resident uses to communicate a need, want, or desire, when they cannot articulate this verbally.

Caregiver education and training can enhance knowledge in identification of certain behaviors, which may preclude an actual combative episode. By understanding extrinsic and intrinsic factors and triggers, which may contribute to the resident's escalation in behaviors, caregivers can implement strategies that will address the resident's predisposition to certain triggers, which in turn can potentially minimize the risk of injury to resident and staff.

Resident-to-Resident Aggression (RRA)

In addition to staff, residents may also be aggressive towards other residents. Careful resident assessment, along with recognition of individual resident triggers, and observation of extrinsic factors should be carefully considered. These factors may impact RRA and should be utilized when identifying and implementing appropriate interventions.

Resident Combativeness: Contributing Factors

Certain activities and situations may contribute to resident combativeness. The more prevalent activities include activities of daily living, inability to verbalize needs, lack of sleep, visual and hearing impairments, physical impairments, disabilities, or lack of control of bodily functions, and environmental factors may initiate combative behaviors. The resident's perception of reality may be altered due to cognitive or health issues and they may perceive the most non-threatening assistance by healthcare staff as threatening. Change of shift can be a difficult time for some residents as well.

Staff should be mindful of their own approaches to residents. Handling residents in a hurried manner or using quick, deliberate movements or gestures can startle residents. Using a loud, directive voice to communicate to the resident can make the resident feel vulnerable and may be perceived as demeaning. This also takes control away from the resident and may escalate combative behaviors.

Strategies to Reduce Combativeness

At the time of admission, an assessment should be completed related to any prior history of combative behavior. This assessment should detail the type of behavior and any known triggers for this behavior. This assessment should be completed with a family member or the resident’s responsible party, if able.

A tool utilized in long term care is the Brøset Violence Checklist. The checklist can be used as part of the assessment upon admission to the facility or any time during the resident's stay. The purpose of the checklist is to assist staff to determine in advance, if the resident is at risk for combative or aggressive behavior so appropriate interventions or strategies can be implemented.

  • Evaluate the resident and the situation.
  • Enlist the assistance of family to provide feedback on past behaviors or life experiences that may be contributing to the combative episode.
  • Identify what potentially caused the behavior.
  • Initiate interventions; there may be a need to trial a variety of interventions.
  • Prevention/De-escalation:
    • Maintain your composure: Be aware of your emotions, tone, and body language.
    • Approach: Respond calmly and express support, use positive and friendly facial expressions. Always approach the resident from the front, not the back.
    • Active listening: Engage the resident to determine needs when possible.
    • Effective verbal responding: Clarify understanding. Use a gentle, relaxed tone.
    • Redirection: Provide options of other activities or places if possible.
    • Stance: Maintain eye level. Keep arms at sides. Be sure to be at a safe distance if potential for combative behavior exists.
    • Do not initiate physical contact if the resident’s behavior is escalating. Touching can trigger violence in some residents.
    • Positioning: Ensure the resident is comfortable.
    • Allow for adequate time to address the situation. Do not jump to conclusions. Input from others on the team is helpful; however, fully assess the resident, situation, and environment.
    • Consider resident stress management interventions and diversionary activity.
  • Implement the resident care plan interventions and communicate patient needs to staff in order to minimize or eliminate behaviors. When formulating a plan for addressing combative behavior, consider:
    • Work closely with the entire care-giving team including family to develop a plan for successful management, containment and, where possible, prevention of combative incidents.
    • Make your goals realistic. You may not be able to stop all behavior problems, but you may be able to minimize or reduce them. Goals to consider:
      • Attend to safety of the resident with combative behavior.
      • Provide support by having all caregivers stay alert to give aid in combative behavior situations.
      • Increase awareness of behavior that may give clues to the onset of an aggressive act.
      • Strive for containment with efforts to decrease the frequency, intensity, and duration of combative behavior.
  • Evaluate staff response to any episode: Evaluate if the behavior improved or did it escalate in response to staff response and actions.
  • Implement education and training based on findings from episodes. Look for patterns and trends in these episodes. Address needs identified by review of any patterns and trends. It is important to work as a team when addressing a combative episode. Safety of the resident and staff member is paramount. Interventions that have shown success in addressing combativeness should be shared. Staff member's insight in caring for residents is useful to all staff. Adopt approaches that have proven successful in avoiding or minimizing combative behavior.


Combative episodes affect both residents and staff on many levels. Resident and family satisfaction can be affected by the manner in which combative episodes are handled and addressed by the facility. It is essential that administration support staff communication of successful interventions and strategies to improve overall facility combativeness.

Combativeness in long term care may always be present; however, by implementing staff education and training necessary to identify triggers which increase combativeness, staff may be able to implement strategies to reduce resident combativeness.


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Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff, 2008

Workforce Safety & Insurance, 2003

Understanding and dealing with resident aggression: exploring the extent, causes, and impact of aggressive outbursts and how to handle them, 2004

Combative Behavior. (2003, June). [Brochure]. Retrieved from

Alzheimer's Behavior Management,, 2012 Almvik, R. Woods, P. & Rasmussen, K. (2007), Assessing risk for imminent violence in the elderly; the Brøset Violence Checklist. International Journal of Geriatric Psychiatry, 22, 862-867