Practice Tips

Residents who exhibit aggressive behavior pose care challenges to staff and other residents. Aggression is rarely directed at the individual caregiver but is usually a mechanism the resident uses to communicate a need, want, or desire when they cannot articulate this verbally. In addition to staff, residents may also be aggressive toward other residents.

Causes of Aggressive Behavior

There are many causes of aggressive behavior in residents. Underlying medical, psychological, or social conditions can lead to outbursts. Residents who are non-verbal or confused may become combative while trying to express their needs.

• Medical issues: Aggression can result from an untreated medical condition that the resident cannot communicate. For example, a resident could have a urinary tract infection (UTI), which is causing discomfort, but the resident cannot share the fact that they are in pain.
• Psychological issues: Residents with dementia are disoriented and confused and can become fearful when staff attempt to provide care, leading to aggression. Depression and other psychological issues can cause residents to feel hopeless and lash out at others.
• Social issues: Interpersonal relationships and conflicts can lead to combative behavior. Unresolved issues with family members, staff, or roommates can result in an aggressive episode.

Organizational Risk Factors

A facility's staffing levels, organizational policies, and staff training can positively or negatively affect resident behavior. Low staffing levels and high staff turnover leads to higher stress levels among staff. When staff is stressed and overworked, they cannot take the necessary time with residents who might be agitated or confused. High staff stress levels can increase aggression in residents.

Strategies to Reduce Aggressive Behavior

• Behavioral assessment: An assessment should be completed on admission to identify any prior history of combative behavior, including details of the type of behavior and any known triggers. If possible, a family member or the resident's responsible party should be involved in the assessment. The Brøset Violence Checklist can be used as part of the admission assessment or any time during the resident's stay. The purpose of the checklist is to assist staff in determining if the resident is at risk for combative or aggressive behavior. Family members can provide feedback on past behaviors or life experiences that may contribute to hostile episodes.
• Resident care plan interventions: If a resident's behavioral assessment identifies a potential for aggressive behavior, interventions should be developed and documented in the resident's care plan.
  • Communicate individual interventions to staff to help minimize or eliminate the behavior.
  • Work closely with the care team, including family, to develop a plan to manage, contain, and where possible, prevent 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.
• Staff training: Long-term care facilities should provide their staff with training on recognizing and responding to violence in the workplace, including violence perpetrated by residents. The team should receive education on medical, psychological, and social factors that might trigger an act of aggression. Awareness of underlying causes of aggression can assist staff in identifying and addressing these causes before a situation escalates.
• Empathy: Employing empathy and "walking a mile" in a resident's shoes can go a long way to help staff understand how a resident might feel and react to situations they do not understand and may find threatening. Moving to a long-term care facility requires a big adjustment for most residents. They might feel the loss of independence, loneliness, and isolation. Residents with cognitive impairment can be anxious and fearful. Empathizing with the individual can help staff approach them with compassion and employ strategies to minimize outbursts.
• Prevention: Your organization's goal should be to minimize violent episodes and prevent them before they start. Some strategies staff can employ to avoid or reduce violent episodes include:
  • A mindful approach: Staff should be aware of how they approach residents. Rushing residents or using quick, deliberate movements can startle them. Using a loud, authoritative voice can make the resident feel vulnerable and may be perceived as demeaning. Feeling a lack of control can escalate combative behavior.
  • Make a connection: Before initiating resident care, take a few moments to connect with the resident by talking about something you know interests them. This connection can help the resident feel more comfortable and cooperative.
  • Keep them informed: Tell the resident what care you plan to provide before reaching for them or touching them. Even residents with dementia can benefit from hearing a soothing explanation.
  • A gentle touch: Begin with a gentle touch before initiating care. For example, gently touch the resident's hand and tell them your care plan.
  • Time-out: If the resident becomes agitated, consider taking a short break to allow things to settle down.
• De-escalation: When confronted with situations where the resident is becoming combative or has begun to be combative:
  • Maintain your composure: Be aware of your emotions, tone of voice, and body language.
  • Stance: Maintain eye contact, keep arms at your sides and maintain a safe distance if the potential for violence exists.
  • No physical contact: Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some residents.
  • Approach: Always approach the resident from the front and not the back. Respond calmly and provide support with positive and friendly facial expressions.
  • Effective verbal responding: Use a gentle, relaxed tone to clarify and understand the resident's immediate needs.
  • Redirection: Provide options for other activities or places if appropriate.
  • Do not make assumptions: Listen to the resident and determine what they are concerned about rather than assuming you know the situation. A minor fix could eliminate further escalation.
  • Environmental control: If a resident is becoming violent, assess the surrounding areas and move other residents to a safer location and, where possible, remove objects the resident could use to harm themselves or others.
  • Teamwork: Staff communication is an essential tool in addressing combative behavior. Staff should share information about situations that might be troubling a resident or techniques that have helped de-escalate a resident in the past.

Evaluate Each Episode

• Evaluate staff responses to violent episodes. Determine if the resident's behavior improved or escalated in response to staff actions.
• Implement education and training based on findings, looking for patterns and trends in the episodes.
• Address identified needs by reviewing and sharing successful staff interventions. Adopt approaches that have proven effective in avoiding or minimizing combative behavior.

Post Event

After an event, it is essential to recognize the traumatic effect of aggression on everyone involved. Following an episode, your organization should debrief to address all parties' concerns, including other residents, family members, and staff.
When a staff member is involved in a violent event, they may experience physical and emotional trauma. Your organization should have processes in place to support staff who have been the victim of a resident's aggressive act.

Summary

Combative episodes affect both residents and staff on many levels. Resident and family satisfaction can be affected by how the facility addresses aggressive behavior. Facilities must evaluate events and identify strategies to reduce combative behavior. It may not be possible to eliminate all episodes; however, your organization can reduce the incidence of violence by implementing staff education and training.

References

Potentially Modifiable Resident Characteristics That Are Associated With Physical or Verbal Aggression Among Nursing Home Residents With Dementia, 2006

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

Workforce Safety & Insurance, 2003 http://www.WorkforceSafety.com

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

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

https://www.verywellhealth.com/how-to-respond-to-combative-behavior-from-dementia-97987

https://www.health.state.mn.us/facilities/patientsafety/preventionofviolence/docs/brosettoolutilizationarticle.pdf

https://www.helpguide.org/articles/alzheimers-dementia-aging/alzheimers-behavior-management.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5225613/