What triggers violence in long-term care homes?
Researchers say institutional conditions, routines, and forced care may be driving violence against both residents and staff in long-term care homes

Violence against residents and staff in Canadian residential care facilities is not new, and evidence suggests it remains a significant problem. Statistics Canada reported that 1,530 seniors were victims of police-reported violence in nursing or retirement homes in 2019. A separate 2021 CIHR-funded study found that 97.2% of long-term care workers surveyed experienced some form of violence from residents and 53.2% experienced violence from residents’ relatives in the past year.

Dr. Rachel Herron, Professor and Canada Research Chair in Rural and Remote Mental Health, Brandon University, wonders why violence persists in long-term care homes despite years of warnings and violence prevention initiatives. “What is it about these environments,” she asks, “that might promote violence? Conversely, what might reduce violence, or get rid of it altogether?”

Between 2020 and 2024, Dr. Herron and her team analyzed 45 policy documents, conducted more than 250 online surveys, interviewed 55 staff and residents and spent four weeks observing daily interactions and care practices in long-term care homes in Manitoba and Nova Scotia.

“What is novel about this study,” says Dr. Herron, “is taking an environmental or even an ecological perspective on the problem of violence, rather than seeing it simply as an interpersonal problem between individuals.”

The research team defines violence as acts that may cause social, emotional, sexual, or physical harm. Incidences can range from name calling to slapping, punching, choking, or sexual groping.

But the team found that violence in long-term care homes is not always deliberate. Sometimes it emerges from the tension between safety, efficiency and a resident’s right to refuse care. For older adults, especially those living with dementia, even routine tasks such as bathing, dressing or taking medication, can become frightening when they do not understand, accept, or consent to what is happening and are expected to comply with routines without acknowledgement of their wishes. Dr. Herron found that forcing care in those moments can escalate distress into violence and what some may consider a form of involuntary treatment or even abuse.

The larger challenge, she says, is rethinking how institutional care can, in a sense, be less institutional.

The research team observed one facility that developed a “non-forced care” policy. The home prohibits the use of force when caring for residents, even when staff deem it is for the residents’ own good—such as changing a diaper—recognizing that violence can escalate when staff override residents’ choices about their own bodies and care.

“What I think made the concept of non-forced care particularly meaningful,” says Dr. Herron, “was that family members, staff and management all recognized the problem. They said, you know, staff are getting hurt way too much, but on the other hand, we are traumatizing people by trying to provide care before they feel ready or safe to accept help.”

Dr. Herron believes a non-forced care policy could be a promising practice but acknowledges that implementing it can be difficult. “It’s not necessarily earth-shattering,” she says, “and yet it can be surprisingly hard to carry out because many homes lack the staffing levels and culture of care needed to support a more flexible model.” There can also be resistance from both staff and residents’ families, she says, who may view allowing residents to refuse care as a form of neglect or abuse.

Dr. Herron and her team hope to expand their research by working with long-term care homes to explore how non-forced care can be implemented in other health care settings. The goal is to shift away from strict routines and efficiency toward greater dignity, personalization and comfort in care.

At a glance

Issue

More than 250,000 Canadians currently live in long-term care homes. That number is expected to increase sharply in the next decade as the population ages. This trend is concerning given the documented increase in violence against both residents and staff in these settings. Violence in long-term care homes is often viewed as unavoidable because of dementia, understaffing and burnout.

Research

Dr. Rachel Herron and her team spent four years studying long-term care homes in Manitoba and Nova Scotia to better understand what triggers violence and how it can be prevented. They identified one promising approach: “non-forced care”, a model that recognizes residents’ right to refuse or resist care.