Peer aggression and harm in care settings

By Dr Sara da Silva Ramos, Senior Research Fellow at Brainkind

 

Inspired by Brainkind’s Safeguarding and Safety Partnership Group, this month we focused our attention on research investigating aggression and harm between peers in care settings.

Peer harm, often referred to in the literature as resident-to-resident harm or abuse, or resident-to-resident aggression, has been defined by Rosen and colleagues [1] as any ‘negative and aggressive physical, sexual, or verbal interactions between long-term care residents [that are] unwelcome, and have high potential to cause physical or psychological distress in the recipient’ (p. 78). A recent report for SCIE (Social Care Institute of Excellence), further distinguishes between harm and abuse, with the difference being that ‘abuse occurs in relationships where there is an expectation of trust’ (Mitchell et al., p. 2) [2].

Peer harm, as any other harm, can take different forms, including physical, verbal or psychological, sexual, financial, and discriminatory. Research in residential settings also describes harm between peers involving privacy or property, for example, going into someone’s bedroom without their consent, or stealing or destroying someone else’s belongings.

If we were to ask the readers of this article whether different situations are part of ‘normal life’ in a care setting, a ‘private affair’, or ‘simply unacceptable’, their responses might differ depending on who is involved, and the nature of the harm, or potential harm:

• You see one patient shouting at another
• You see a family member of the patient taking something from their room
• You see one patient touching another
• You see staff speaking to a patient in a rush

This is to illustrate that harmful – or potentially harmful – situations between people, and in particular, between residents in a care setting, can sometimes be perceived as ‘part of life’, and therefore go under-reported. On the other hand, some of these situations might be appropriate. For example, relationships can grow and flourish between residents, so one patient touching another may, in some cases, indeed be part of life! Understanding the context is important. While we all must act to prevent harm, ‘stigmatising’ natural and positive interactions between residents could have a negative impact on people and the social environment.

Nevertheless, it is a fact that under-reporting has made research on how frequent harm between peers occurs (known as prevalence) very difficult and estimates imprecise. A ballpark figure from the review conducted by Mitchell and colleagues [2] suggests that approximately 20% of incidents of harm recorded in various services occurred between peers. The same review also found that verbal / psychological was the most reported type, and sexual harm the least reported.

The SCIE review also looked at risk factors and predictors of peer harm. These included both individual characteristics and aspects of the environment.

With regards to individual characteristics, research has found that cognitive impairment, both in the person who carried out the harm, and the person who is harmed, is associated with higher risk. Other factors associated with heightened risk of harm between peers included presence of behaviours of concern, disinhibition, and better mobility.

Higher levels of cognitive awareness were also associated with greater risk of harm between peers [3]. This may seem counter-intuitive for practitioners working with people with brain injury, as studies have found associations between lower self-awareness and higher prevalence of behaviours of concern, greater cognitive impairment, and other aspects of neurobehavioural disability such as poor social judgement and impulse control, all of which we just said are linked to heightened risk of peer harm [4 – 6].  However, one interview study which evidenced a link between higher cognitive awareness and higher risk of harm [7] found that it was the behaviour by residents who were more cognitively intact that produced ‘hurt feelings’ in those who were less cognitively intact, that is, more harm. Therefore, it is possible that higher levels of cognitive awareness may increase the risk of causing harm, while lower awareness may be linked to higher risk of being harmed. Another possibility is that the relationship between cognitive awareness and harm is not linear (e.g. the link could be different at different levels of cognitive awareness) or that it may depend on the type of harm (e.g. physical vs, psychological).

As readers might expect environmental factors such as staff shortages, limited staff training, larger proportions of patients with dementia in a service, limited availability of meaningful activities, crowded communal areas and noise, were all found to be linked to greater risk of harm incidents between peers.

While some assessment tools purposely developed to identify individuals at risk of becoming aggressive are available, a recent review by SafeWork New South Wales [8] found no evidence to recommend one over the other for identification of high risk. However, the Brøset Violence Checklist (BVC) [9] and Dynamic Appraisal of Situational Aggression (DASA) [10] were useful to screen out low risk individuals.

Mitchell and colleagues’ review [2] identified a number of studies that evaluated interventions aimed at reducing peer harm, including the SEARCH programme [11], and a staff intervention to prevent mistreatment between older people [12].

We could not end this month’s Research Digest without sharing eight top tips from SCIE on reducing peer harm in care settings [2]:

1. Assess all people supported for risk of being harmed or harming others
2. Account for, and manage, medical factors that could alter behaviour
3. Understand that ‘behaviour communicates needs’ (the test in bold is a reference to one of our rehab mantras <insert link to https://brainkind.org/rehab-mantras/>)
4. Have plans in place to support those at risk of harm (whether as a perpetrator or as a victim)
5. Get training and build confidence on managing behaviours of concern
6. Remember to regularly review medication
7. Record all incidents and support all involved (e.g. including the perpetrator and staff)
8. If peer harm persists, adopt a multi-agency approach to achieve a long-term resolution.

Something that became clear from the SCIE review, is that most research to date has focused on residential homes for older people and those with learning disabilities. As many of the risk factors that may lead to peer harm are prevalent in services for people with brain injuries, we need to do more work to understand how to best support them and their loved ones, as training and interventions currently available are not necessarily effective for everyone, or tailored for a younger population with acquired brain injury.

 

References

1. Rosen, Pillemer, & Lachs (2008). Resident-to-resident aggression in long-term care facilities: An understudied problem. Aggression and Violent Behavior, 13(2), 77-87.
2. Mitchell, Sheikh & Luff (2021). Resident-to-resident harm in care homes and other residential settings: a scoping review. Social Care Institute for Excellence. Retrieved 01 October 2025 from https://www.scie.org.uk/safeguarding/evidence/resident-to-resident-harm/
3. Ferrah, Murphy, Ibrahim, Bugeja, Winbolt, LoGiudice, …, & Ranson, (2015). Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review. Age and Ageing, 44(3), 356-364.
4. Buunk, Spikman, Veenstra, van Laar, P. J., Metzemaekers, van Dijk, … & Groen (2017). Social cognition impairments after aneurysmal subarachnoid haemorrhage: Associations with deficits in interpersonal behaviour, apathy, and impaired self-awareness. Neuropsychologia, 103, 131-139.
5. Dromer, Kheloufi, & Azouvi, (2021). Impaired self-awareness after traumatic brain injury: a systematic review. Part 1: assessment, clinical aspects and recovery. Annals of Physical and Rehabilitation Medicine, 64(5), 101468.
6. Williams, Wood, Alderman, & Worthington (2020). The psychosocial impact of neurobehavioral disability. Frontiers in Neurology, 11, 119.
7. Sifford-Snellgrove, Beck, Green, & 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.
8. Centre for Human Factors and Sociotechnical Systems at UniSC for SafeWork NSW (2023). Preventing work-related violence in NSW Hospitals A multi-level risk assessment toolkit. SafeWork NSW. Retrieved 01 October 2025 from https://www.safework.nsw.gov.au/__data/assets/pdf_file/0012/1210350/multi-level-risk-assessment-toolkit-for-preventing-work-related-violence-in-hospitals.pdf
9. Almvik, Woods, & Rasmussen. (2000). The Brøset Violence Checklist: sensitivity, specificity, and interrater reliability. Journal of Interpersonal Violence, 15(12), 1284-1296.
10. Ogloff, & Daffern (2006). The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behavioral sciences & the law, 24(6), 799-813.
11. Ellis, Teresi, Ramirez, et al. (2014) Managing resident-to-resident elder mistreatment in nursing homes: The SEARCH approach. The Journal of Continuing Education in Nursing, 45(3), 112−121.
12. Teresi, Ramirez, Ellis, Silver, Boratgis, Kong, … & Lachs (2013). A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies, 50(5), 644-656.