Addressing workplace violence in nursing homes and long-term care
The CNA and aide experience
Certified nursing assistants and patient care aides in long-term care facilities report some of the highest workplace violence exposure rates among all nursing roles. The physical nature of direct care — bathing, toileting, repositioning — creates frequent close-contact interactions with residents who may be confused, frightened, or in pain, and who may respond with aggression. Because this population is chronically understaffed relative to acuity, workers often cannot take the time needed for the careful, patient-paced approaches that reduce resistance and aggression.
The workforce implications are severe. CNA turnover in long-term care already exceeds 70 percent annually in many facilities — among the highest of any occupational category. Workplace violence is a significant driver of this turnover. Workers who experience repeated assault without organizational response — or who hear from colleagues that reporting generates no result — leave. Their departure increases workload for remaining staff, which increases stress and burnout, which further increases turnover.
- OSHA Long-Term Care Workplace Violence Guidelines
- AHA, 'The Burden of Violence to U.S. Hospitals,' 2025
Dementia-related aggression: a different intervention model
Resident-on-staff aggression in nursing homes must be differentiated between dementia-related behavioral expressions and intentional acts of aggression. Dementia-related aggression — striking out during personal care, yelling, biting — reflects neurological impairment rather than intent. The prevention and response approaches are fundamentally different: environmental modification, care timing adjustments, person-centered care techniques, and behavioral assessment are the appropriate interventions, not primarily security measures.
This distinction does not mean dementia-related aggression should be dismissed or unreported. Every incident generates injury risk for staff regardless of resident intent, and systematic tracking of dementia-related aggression events reveals patterns that inform care planning modifications — which times of day generate most resistance, which staff interactions are most frequently associated with aggression, which environmental conditions increase agitation. The clinical and safety reporting systems need to work together to capture and analyze this data.
Staffing and violence: the direct correlation
Research consistently shows a direct correlation between staffing ratios and workplace violence rates in long-term care. When CNAs are responsible for more residents than safe care standards recommend, they cannot take the time required for person-centered approaches that reduce aggression. Rushed care generates more resistance. When staff are stretched across too many tasks, they cannot respond quickly to early signs of agitation that, addressed promptly, would not escalate to assault.
WPV reporting data that captures staffing levels at the time of incidents provides the evidence base for staffing arguments to leadership. An analysis showing that 70 percent of resident-on-staff assaults occur during understaffed shifts is more persuasive than a general argument about safe staffing — it connects the staffing decision directly to a documented safety outcome.
Building a reporting culture in LTC
Long-term care facilities that successfully build reporting cultures share common characteristics: leaders who respond visibly to reports, reporting systems simple enough to complete during a shift, regular review of aggregate WPV data at department head meetings, and genuine non-punitive policies backed by consistent practice. The non-punitive policy is particularly important in LTC, where power differentials between leadership and frontline staff are pronounced and where CNA workers are often hesitant to document concerns about resident behavior for fear of affecting resident care plans or family relations.
State reporting requirements for LTC workplace violence are expanding. Organizations that establish robust internal reporting infrastructure now are better positioned for regulatory compliance as requirements evolve — and they generate the operational data that actually reduces violence over time.
- OSHA Long-Term Care Workplace Violence Guidelines
- CMS Long-Term Care Survey Guidance
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