How Prevalent Is Resident Aggression toward Nursing Staff?

Aggressive behaviors from residents toward nursing home staff—or resident-to-staff aggression (RSA)—is one of the greater safety concerns among the long-term care workforce, but has received relatively minimal research attention. While many initiatives in the last several years have tackled the crucial topic of keeping nursing home residents safe from aggression, RSA is a poorly understood phenomenon. RSA can be either physical or verbal aggression, and negatively impacts direct care staff through injury, stress, and reduced job satisfaction. It also reduces the quality of care for residents whom staff suspect of potential aggression. A study in the Journal of General Internal Medicine presents a study of the prevalence of RSA in five large nursing homes in New York City.

The researchers interviewed 282 certified nursing assistants (CNAs) about the behavior of more than 1,500 residents; the residents were assessed for general disordered behavior (such as wandering during the day), mood symptoms and mood status, performance with activities of daily living, and cognition. The types of RSA behaviors were examined, and residents who had exhibited RSA were statistically compared to those who hadn’t in order to identify which individual-level factors were associated with RSA within the sample.

In all, 15.6 percent of residents in the sample had exhibited RSA in the previous two weeks, most of which was either verbal or a combination of verbal and physical aggression. Over three-fourths of RSA occurred in the resident’s room, and, contrary to what was expected, RSA was more likely to occur during morning care rather than later in the day (or during the “sundowning” period of increased confusion in the evening). Clinical factors associated with increased likelihood of engaging in RSA were greater need for assistance with activities of daily living, greater emotional disturbance, and higher severity of general disordered behavior. Non-Hispanic white residents were more likely than minorities to engage in RSA toward the CNAs, over 90 percent of whom were from minority backgrounds.

Although the study was not designed to examine staff responses to RSA, research staff observed strategies used to prevent or minimize aggression, such as identifying and managing personal conflicts between residents, and distracting residents who were becoming aggressive. Further research may help identify ways to prevent RSA, which would benefit direct care workers and residents.


Lachs MS, Rosen T, Teresi JA, et al. Verbal and physical aggression directed at nursing home staff by residents. Journal of General Internal Medicine (2013). 28(5): 660–667.


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