The “Violent Resident”: A Critical Exploration of the Ethics of Resident-to-Resident Aggression

  • Alisa GrigorovichEmail author
  • Pia Kontos
  • Alexis P. Kontos
Symposium: Dementia


Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the “violent resident.” It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.


Dementia Citizenship Human rights Embodied selfhood Relationality 



  1. Adams, A., and S. Chivers. 2017. There’s no place like home: Designing for long-term residential care in Canada. Journal of Canadian Studies 50 (2): 273–298.Google Scholar
  2. Alzheimer Disease International. 2012. Overcoming the stigma of dementia. Accessed 8 July 2014.
  3. Armstrong, P., and T. Daly. 2004. There are not enough hands: Conditions in Ontario’s long-term care facilities. Toronto: Canadian Union of Public Employees Ontario Division and the National Research Department.Google Scholar
  4. Banerjee, A., T. Daly, P. Armstrong, M. Szebehely, H. Armstrong, and S. Lafrance. 2012. Structural violence in long-term, residential care for older people: Comparing Canada and Scandinavia. Social Science & Medicine 74(3): 390–398.Google Scholar
  5. Banerjee, A., P. Armstrong, T. Daly, H. Armstrong, and S. Braedley. 2015. “Careworkers don't have a voice:” Epistemological violence in residential care for older people. Journal of Aging Studies 33: 28–36.Google Scholar
  6. Bartlett, R., and D. O’Connor. 2010. Broadening the dementia debate: Towards social citizenship. Bristol, U.K.: The Policy Press.Google Scholar
  7. Basting, A.D. 2009. Forget memory. Baltimore, MD: Johns Hopkins University Press.Google Scholar
  8. Behuniak, S.M. 2010. Toward a political model of dementia: Power as compassionate care. Journal of Aging Studies 24(4): 231–240.Google Scholar
  9. Berry, B., L. Young, and S.C. Kim. 2017. Utility of the aggressive behavior risk assessment tool in long-term care homes. Geriatric Nursing 38(5): 417–422.Google Scholar
  10. Boersema, D. 2011. Philosophy of human rights. Boulder, CO: Westview Press.Google Scholar
  11. Brannelly, T. 2011. That others matter: The moral achievement—care ethics and citizenship in practice with people with dementia. Ethics and Social Welfare 5(2): 210–216.Google Scholar
  12. Burgener, S.C., K. Buckwalter, Y. Perkhounkova, and M.F. Liu. 2015. The effects of perceived stigma on quality of life outcomes in persons with early-stage dementia: Longitudinal findings: Part 2. Dementia 14(5): 609–632.Google Scholar
  13. Butler, J. 2016. Frames of war: When is life grievable? London: Verso Books.Google Scholar
  14. Carlson, L. 2015. Music, intellectual disability, and human flourishing. In The Oxford handbook of music and disability studies, edited by B. Howe, S. Jensen-Moulton, N. Lerner, and J. Straus, 37–53. New York: Oxford University Press.Google Scholar
  15. Carozza, P.G. 2003. Subsidiarity as a structural principle of international human rights law. The American Journal of International Law 97(38): 38–79.Google Scholar
  16. Chivers, S. 2015. “Blind people don't run”: Escaping the “nursing home specter” in Children of Nature and Cloudburst. Journal Aging Studies 34: 134–141.Google Scholar
  17. Clarke, J. 1990. Ways of thinking sociologically about health, illness, and medicine. In Health, Illness and Medicine in Canada, edited by J. Clarke, 15–35. Toronto: McLelland & Stewart.Google Scholar
  18. Cohen-Mansfield, J. 2013. Nonpharmacologic treatment of behavioral disorders in dementia. Current Treatment Options in Neurology 15(6): 765–785.Google Scholar
  19. Daly, T. 2013. Imagining an ethos of care within polices. practices and philosophy. In Troubling care: Critical perspectives on research and practices, edited by P. Armstrong and S. Braedley, 33–46. Toronto: Canadian Scholar’s Press.Google Scholar
  20. Daly, T., and M. Szebehely. 2012. Unheard voices, unmapped terrain: Care work in long-term residential care for older people in Canada and Sweden. International Journal of Social Welfare 21(2): 139–148.Google Scholar
  21. Daly, T., A. Banerjee, P. Armstrong, H. Armstrong, and M. Szebehely. 2011. Lifting the “violence veil”: Examining working conditions in long-term care facilities using iterative mixed methods. Canadian Journal on Aging 30(2): 271–284.Google Scholar
  22. de Medeiros, K., and A. Basting. 2013. “Shall I compare thee to a dose of Donepezil?”: Cultural arts interventions in dementia care research. The Gerontologist 54(3): 344–353.Google Scholar
  23. DeForge, R., P. van Wyk, J. Hall, and A. Salmoni. 2011. Afraid to care; unable to care: A critical ethnography within a long-term care home. Journal of Aging Studies 25(4): 415–426.Google Scholar
  24. DeNora, T., and G. Ansdell. 2014. What can’t music do? Psychology of Well-Being 4(1): 23.Google Scholar
  25. Department of Health (Ireland). 2011. Towards a restraint free environment in nursing homes. Accessed January 1, 2018.
  26. Ducak, K., M. Denton, and G. Elliot. 2016. Implementing Montessori Methods for Dementia™ in Ontario long-term care homes: Recreation staff and multidisciplinary consultants’ perceptions of policy and practice issues. Dementia 17(1): 5–33.Google Scholar
  27. Dupuis, S., J. Gillies, J. Carson, et al. 2012a. Moving beyond patient and client approaches: Mobilizing “authentic partnerships” in dementia care, support and services. Dementia 11(4): 427–452.Google Scholar
  28. Dupuis, S., E. Wiersma, and L. Loiselle. 2012b. Pathologizing behavior: Meanings of behaviors in dementia care. Journal of Aging Studies 26(2): 162–173.Google Scholar
  29. Dupuis, S., C.A. McAiney, D. Fortune, J. Ploeg, and L. D Witt. 2016. Theoretical foundations guiding culture change: The work of the Partnerships in Dementia Care Alliance. Dementia: The International Journal of Social Research and Practice 15(1): 85–105.Google Scholar
  30. Farmer, P., B. Nizeye, S. Stulac, and S. Keshavjee. 2006. Structural violence and clinical medicine. PLoS 3: 1686–1691.Google Scholar
  31. Ferrah, N., B.J. Murphy, J.E. Ibrahim, et al. 2015. Resident-to-resident physical aggression leading to injury in nursing homes: A systematic review. Age & Ageing 44(3): 356–364.Google Scholar
  32. Friedan, B. 1993. Fountain of age. New York: Simon and Schuster.Google Scholar
  33. Galtung, J. 1969. Violence, peace, and peace research. Journal of peace research 6(3): 167–191.Google Scholar
  34. Garand, L., K.C. Buckwalter, and G.R. Hall. 2000. The biological basis of behavioral symptoms in dementia. Issues in Mental Health Nursing 21(1): 91–107.Google Scholar
  35. Garand, L., J.H. Lingler, K.O. Conner, and M.A. Dew. 2009. Diagnostic labels, stigma, and participation in research related to dementia and mild cognitive impairment. Research in Gerontological Nursing 2(2): 112—121.Google Scholar
  36. Gimm, G., S. Chowdhury, and N. Castle. 2016. Resident aggression and abuse in assisted living. Journal of Applied Gerontology 37(8): 947–964.Google Scholar
  37. Good, B.J. 1994. Medicine, rationality, and experience: An anthropological perspective. Cambridge: Cambridge University Press.Google Scholar
  38. Graham, N., J. Lindesay, C. Katona, et al. 2003. Reducing stigma and discrimination against older people with mental disorders: A technical consensus statement. International Journal of Geriatric Psychiatry 18(8): 670–678.Google Scholar
  39. Grigorovich, A., and P. Kontos. 2018. Advancing an ethic of embodied relational sexuality to guide decision-making in dementia care. The Gerontologist 58(2): 219–225.Google Scholar
  40. Gutmanis, I., and L.M. Hillier. 2017. Geriatric cooperatives in southwestern Ontario: A novel way of increasing inter-sectoral partnerships in the care of older adults with responsive behaviours. Health & Social Care in the Community 26(1): e111–e121.Google Scholar
  41. Gutmanis, I., M. Snyder, D. Harvey, L.M. Hillier, and J.K. LeClair. 2015. Health care redesign for responsive behaviours—The Behavioural Supports Ontario experience: Lessons learned and keys to success. Canadian Journal of Community Mental Health 34(1): 45–63.Google Scholar
  42. Hall, L., and D. Kiesners. 2005. A narrative approach to understanding the nursing work environment in Canada. Social Science and Medicine 61(12): 2482–2491.Google Scholar
  43. Hattori, H., C. Hattori, C. Hokao, K. Mizushima, and T. Mase. 2011. Controlled study on the cognitive and psychological effect of coloring and drawing in mild Alzheimer’s disease patients. Geriatrics & Gerontology International 11(4): 431–437.Google Scholar
  44. Herskovitz, E. 1995. Struggling over subjectivity: Debates about the “self” and Alzheimer’s disease. Medical Anthropology Quarterly 9(2): 146–164.Google Scholar
  45. Human Rights Watch. 2018. “They want docile”: How nursing homes in the United States overmedicate people with dementia. Accessed March 1, 2018.
  46. Isin, E.F., and B.S. Turner. 2007. Investigating citizenship: An agenda for citizenship studies. Citizenship Studies 11(1): 5–17.Google Scholar
  47. Jennings, B. 2009. Agency and moral relationship in dementia. Metaphilosophy 40(3–4): 425–437.Google Scholar
  48. ____. 2014. Alzheimer's disease: Quality of life and the goals of care. In The Routledge companion to bioethics, edited by J.D. Arras, E. Fenton, and E. Kukla, 437–448. New York: Routledge.Google Scholar
  49. ____. 2016. Reconceptualizing autonomy: A relational turn in bioethics. Hastings Center Report 46(3): 11–16.Google Scholar
  50. Katz, S. 2013. Dementia, personhood and embodiment: What can we learn from the medieval history of memory? Dementia 12(3): 303–314.Google Scholar
  51. Kelly, F., and A. Innes. 2013. Human rights, citizenship and dementia care nursing. International Journal of Older People Nursing 8(1): 61–70.Google Scholar
  52. Kittay, E. 2005. At the margins of moral personhood. Ethics 116(1): 100–131.Google Scholar
  53. Kontos, P. 2003. “The painterly hand”: Embodied consciousness and Alzheimer’s disease. Journal of Aging Studies 17(2): 151–170.Google Scholar
  54. ____. 2012a. Alzheimer expressions or expressions despite Alzheimer’s?: Philosophical reflections on selfhood and embodiment. Occasion: Interdisciplinary Studies in the Humanities 4: 1–12. Accessed October 1, 2018.
  55. ____. 2012b. Rethinking sociability in long-term care: An embodied dimension of selfhood. Dementia 11(3): 329–346.Google Scholar
  56. ____. 2014. Musical embodiment, selfhood, and dementia. In Beyond loss, edited by L.C. Hydén, J. Brockmeier, and H. Lindemann, 107–119. New York: Oxford University Press.Google Scholar
  57. Kontos, P., and A. Grigorovich. 2018. Rethinking musicality in dementia as embodied and relational. Journal of Aging Studies 35: 49–58.Google Scholar
  58. Kontos, P., and W. Martin. 2013. Embodiment and dementia: Exploring critical narratives of selfhood, surveillance, and dementia care. Dementia 12(3): 288–302.Google Scholar
  59. Kontos, P., and G. Naglie. 2007. Bridging theory and practice: Imagination, the body, and person-centred dementia care. Dementia 6(4): 549–569.Google Scholar
  60. Kontos, P., G.J. Mitchell, B. Mistry, and B. Ballon. 2010. Using drama to improve person-centred dementia care. International Journal of Older People Nursing 5(2): 159–168.Google Scholar
  61. Kontos, P., A. Grigorovich, A.P. Kontos, and K.L. Miller. 2016. Citizenship, human rights, and dementia: Towards a new embodied relational ethic of sexuality. Dementia 15(3): 315–329.Google Scholar
  62. Kontos, P., K.L. Miller, and A.P. Kontos. 2017. Relational citizenship: Supporting embodied selfhood and relationality in dementia care. Sociology of Health & Illness 39(2): 182–198.Google Scholar
  63. Kontos, P., A. Grigorovich, A.P. Kontos, and K-L. Miller. 2018. Exploring relational citizenship at the intersection of creativity and dementia. In Facing dementia: Cultures of care, edited by H-P. Zimmerman. Zürich: Campus-Verlag.Google Scholar
  64. Lachs, M.S., J.A. Teresi, M. Ramirez, et al. 2016. The prevalence of resident-to-resident elder mistreatment in nursing homes. Annals of Internal Medicine 165(4): 229–236.Google Scholar
  65. Lin, S.Y., and F.M. Lewis. 2015. Dementia friendly, dementia capable, and dementia positive: Concepts to prepare for the future. Gerontologist 55(2): 237–244.Google Scholar
  66. Liu, C., M. Ruthirakuhan, S.A. Chau, N. Herrmann, A.F. Carvalho, and K.L. Lanctôt. 2016. Pharmacological management of agitation and aggression in Alzheimer’s disease: A review of current and novel treatments. Current Alzheimer Research 13(10): 1134–1144.Google Scholar
  67. Macpherson, H. 2016. Guiding visually impaired walking groups: Intercorporeal experience and ethical sensibilities. In Touching space, placing touch, edited by M. Dodge, 130–150. New York, NY: Routledge.Google Scholar
  68. Mark, B. 2002. What explains nurses’ perceptions of staffing adequacy? Journal of Nursing Administration 32(5): 234–242.Google Scholar
  69. Miller, E., and B. Johansson. 2016. Capability to paint and Alzheimer’s Disease: Relationship to disease stages and instructions. SAGE Open 6(1): 1–13.Google Scholar
  70. Miller, K.L., and P. Kontos. 2016. The use of elder-clowning to foster relational citizenship in dementia care. In Reimagining the human service relationship, edited by T.A. Andreassen, J.F. Gubrium, and P.K. Solvang, 158–177. New York, NY: Columbia University Press.Google Scholar
  71. Mitchell, G., S. Dupuis, and P. Kontos. 2013. Dementia discourse: From imposed suffering to knowing other-wise. Journal of Applied Hermeneutics: 1–19, Accessed October 1, 2018.
  72. Nedelsky, J. 2011. Law’s relations: A relational theory of self, autonomy, and law. Oxford, U.K.: Oxford University Press.Google Scholar
  73. Nolan, M., T. Ryan, P. Enderby, and D. Reid. 2002. Towards a more inclusive vision of dementia care practice. Dementia 1(2): 193–211.Google Scholar
  74. Nussbaum, M.C. 1997. Capabilities and human rights. Fordham Law Review 66: 273.Google Scholar
  75. ____. 2009. Frontiers of justice: Disability, nationality, species membership. Cambridge, MA: Harvard University Press.Google Scholar
  76. ____. 2011a. Capabilities, entitlements, rights: Supplementation and critique. Journal of Human Development and Capabilities 12(1): 23–37.Google Scholar
  77. ____. 2011b. Creating capabilities: The human development approach. Cambridge: Harvard University Press.Google Scholar
  78. Office of the Chief Coroner. 2016. Geriatric and Long Term Care Review Committee—2015 Annual Report. Accessed August 27, 2017.
  79. Office of the Seniors Advocate British Columbia. 2016. Resident to resident aggression in B.C. care homes. Accessed August 27, 2017.
  80. Ontario Ministry of Health and Long-Term Care. 2016. Developing Ontario’s dementia strategy: A discussion paper. Toronto, Ontario.Google Scholar
  81. Øye, C., F.F. Jacobsen, and T.E. Mekki. 2017. Do organisational constraints explain the use of restraint? A comparative ethnographic study from three nursing homes in Norway. Journal of clinical nursing 26(13–14): 1906–1916.Google Scholar
  82. Paternity, D.A. 2000. The micropolitics of identity in adverse circumstance: A study of identity making in a total institution. Journal of Contemporary Ethnography 29(1): 93–119.Google Scholar
  83. Penrod, J., F. Yu, A. Kolanowski, D.M. Fick, S.J. Loeb, and J.E. Hupcey. 2007. Reframing person-centered nursing care for persons with dementia. Research and Theory for Nursing Practice 21(1): 57–72.Google Scholar
  84. Postmedia Network. 2016. Wave of dementia behind 12 homicides has Ontario nursing homes pleading for help from province. Postmedia. Accessed September 1, 2017.
  85. Reid, D., T. Ryan, and P. Enderby. 2001. What does it mean to listen to people with dementia? Disability & Society 16(3): 377–392.Google Scholar
  86. RNAO (Registered Nurses’ Association of Ontario). 2012. Promoting safety: Alternative approaches to the use of restraints. Accessed January 1, 2018.
  87. Rosen, T., K. Pillemer, and M. Lachs. 2008. Resident-to-resident aggression in long-term care facilities: An understudied problem. Aggression and Violent Behavior 13(2): 77–87.Google Scholar
  88. Rosen, T., M.S. Lachs, J. Teresi, J. Eimicke, K. Van Haitsma, and K. Pillemer. 2016. Staff-reported strategies for prevention and management of resident-to-resident elder mistreatment in long-term care facilities. Journal of Elder Abuse & Neglect 28(1): 1–13.Google Scholar
  89. Seitz, D.P., S.S. Gill, N. Herrmann, et al. 2013. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: A systematic review. International Psychogeriatrics 25(2): 185–203.Google Scholar
  90. Shaw, M.M. 2004. Aggression toward staff by nursing home residents: findings from a grounded theory study. Journal of Gerontological Nursing 30(10): 43–54.Google Scholar
  91. Sher, J. 2015. Scourge of violence in Ontario nursing homes continues, according to committee. The London Free Press. Accessed September 1, 2017.
  92. Sifford-Snellgrove, K.S., C. Beck, A. Green, and J.C. McSweeney. 2012. Victim or initiator? Certified nursing assistants’ perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes. Research in Gerontological Nursing 5(1): 55–63.Google Scholar
  93. Snellgrove, S., C. Beck, A. Green, and J.C. McSweeney. 2013. Resident-to-resident violence triggers in nursing homes. Clinical Nursing Research 22(4): 461–474.Google Scholar
  94. Somers, M.R. 2008. Genealogies of citizenship: Knowledge, markets, and the right to have rights. Cambridge, UK: Cambridge University Press.Google Scholar
  95. Somers, M.R., and C.N.J. Roberts. 2008. Toward a new sociology of rights: A genealogy of “buried bodies” of citizenship and human rights. Annual Review of Law and Social Science 4: 385–425.Google Scholar
  96. Star Editorial Board. 2014. Ontario needs strategy for boom in elderly with dementia: Editorial. Toronto Star, Jan 12. Accessed 1 Sept 2016.
  97. Stutte, K., S. Hahn, K. Fierz, and F. Zúñiga. 2017. Factors associated with aggressive behavior between residents and staff in nursing homes. Geriatric Nursing 38(5): 398–405.Google Scholar
  98. Swaffer, K. 2014. Dementia: stigma, language, and dementia-friendly. Dementia 13(6): 709–16.Google Scholar
  99. Turner, B.S. 1993. Outline of a theory of human rights. Sociology 27(3): 489–512.Google Scholar
  100. Turner, B.S. 2009. A sociology of citizenship and human rights: Does social theory still exist. In Interpreting human rights: Social science perspectives, edited by R. Morgan and B.S. Turner, 177–199. New York, NY: Routledge.Google Scholar
  101. Twigg, J. 2000. Bathing: The body and community care. London: Routledge.Google Scholar
  102. ____. 2006. The body in health and social care. New York: Palgrave Macmillan.Google Scholar
  103. United Nations General Assembly. 1948. Universal Declaration of Human Rights. New York, NY: United Nations.Google Scholar
  104. United Nations Human Rights Council. 2014. Report of the Office of the United Nations High Commissioner for Human Rights: Thematic study on the right of persons with disabilities to live independently and be included in the community, U.N. Doc. A/HRC/28/37. Accessed March 1, 2018.
  105. ____. 2016. Report of the Special Rapporteur on the rights of persons with disabilities. U.N. Doc. A/HRC/34/58. Accessed March 1, 2018.
  106. United Nations Office of the High Commissioner for Human Rights. 2015. Background note: International standards on the right to liberty and security of persons with disabilities. Accessed March 1, 2018.
  107. Vidal, F. 2009. Brainhood, anthropological figure of modernity. History of the Human Sciences 22(1): 5–36.Google Scholar
  108. World Health Organization & United Nations Office of the High Commissioner for Human Rights. 2008. Human rights, health and poverty reduction strategies. Geneva, CH: Health Human Rights Publications Series.Google Scholar
  109. Wronka, J. 2007. Human rights and social justice: Social action and service for the helping and health professions. Thousand Oaks, CA: SAGE Publications.Google Scholar
  110. Young, I.M. 1993. Justice and the politics of difference. Princeton, NJ: Princeton University Press.Google Scholar
  111. ____. 2013. Responsibility for justice. Oxford University Press.Google Scholar

Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2019

Authors and Affiliations

  1. 1.Toronto Rehabilitation Institute-University Health NetworkTorontoCanada
  2. 2.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  3. 3.Department of Justice CanadaOttawaCanada

Personalised recommendations