Caring for nursing home residents who exhibit difficult behaviors presents enormous challenges for their health care providers. The prevalence of problematic behaviors and suggestions for coping with residents who manifest these behaviors are frequent topics in nursing journals. The purpose of this article is to offer a framework that can be used for understanding and coping with resident problematic behaviors.
The prevalence of problematic behavior among nursing home residents has been well-documented. Several studies suggest that from 23% to 79% of residents manifest behaviors that are problematic for their caregivers, families and at times, themselves (Kolanowski, Hurwitz, Taylor, Evans, & Strumpf, 1994; Marx, Cohen-Mansfield, & Werner, 1990; Rantz & McShane, 1994; Roper, Shapira, & Chang, 1991; Ryden, Bossenmaier, & McLachlan, 1991). Various definitions of problematic/disruptive behaviors are included in the literature. The author draws upon the framework developed by CohenMansfield and Billig (1986) which defines problematic/disruptive behavior as inappropriate verbal, vocal or motor activity which interferes with the staff's abilities to deliver care. It includes, but is not limited to, combativeness, angry outbursts and repetitive yelling.
It has been reported that 63% to 94% of the nursing home population is comprised of residents with cognitive impairments or neuropsychiatrie conditions (Feldt & Ryden, 1992). Residents with deficits in these areas are limited in their abilities to communicate and make their basic needs known. Quite often, experiences of internal stimuli (such as pain) are manifested through an external response (striking out). Finding meaning in behaviors that are perceived as difficult is often subjective and influenced by the caregiver's experiences and education. In some nursing homes, 80% to 90% of care is provided by nursing assistants (Cohn, Horgas, & Marsiske, 1990). In their study on educating nursing assistants, Feldt and Ryden (1992) discovered that fewer than 28% of nursing assistants that they interviewed reported receiving education in handling threatening behaviors. They also found that the nursing assistants were eager to participate in nursing interventions once they understood the behavior and had a clear sense of the treatment goals.
The nursing literature is replete with articles that offer effective approaches to resident behaviors (FiIley, 1995; Fine & Rouse-Bane, 1995; Hay, Hay, Howell, & Szwabo, 1994; Maletta, 1988; Negley & Manley, 1990; Nelson, 1995; Teri & Logsdon, 1990), but these approaches are often not internalized by the reader and are frequently dismissed. A common reason given for this dismissal is that the solutions offered take time to implement. Comments expressed are "We don't have time to visit with her" and 'It takes too much time to find out if his behavior has a pattern." A response to these comments is a resounding yes...working with residents exhibiting difficult behaviors does take time, a lot of it.
How the time factor is used is determined by the choices the caregiver makes. In their article on mechanical restraints in nursing homes, Werner and colleagues (1989) reported that 47% of residents who presented behavioral problems were restrained. Additional articles (Fletcher, 1990; Kallman, DenineFlynn, & Blackburn, 1992; Schnelle, Simmons, & Ory, 1992; Thomas, Redfern, & John, 1995) indicate that both mechanical and chemical restraints continue to be frequently used, in spite of the 1987 OBRA guidelines. If the time spent sitting with a resident is questioned, then the time required to deliver other aspects of care must also be challenged. It takes time to request, apply and document use of a physical restraint. It takes time to request, transcribe, give and document a medication. These choices are sometimes made when staff perceive there are no other options, and their usage can lead to feelings of burnout and increased absenteeism, two additional reducers of time.
Conversely, caregivers can view the behaviors as a challenge that piques their curiosity and draws on their individual uniqueness. Effectively coping with difficult behaviors requires understanding, creativity, flexibility and listening with the "third ear." All of these require time, the commodity health care providers often perceive as lacking. It is the author's opinion that effective utilization of time is inherent in the role of caregiver.
Webster included several sentences when defining nurse, one of which is "to take special care of; to nourish, foster and develop." Each of these verbs describes actions which require time. In an attempt to crystallize the concept that understanding resident behaviors is a process where time is inherent, an acronym, TIME, was developed that describes the essential components required of caregivers when working with residents: Together: Investigate, Measure, Empathize.
The care of nursing home residents depends on the collaborative efforts of numerous people. Optimal care is best orchestrated when the various players - dietitians, physical therapists, nurses, nursing assistants, social workers, and families work together and share information from each of their unique perspectives. is particularly true in the area of assessing and understanding resident problematic behaviors. Statements such as "he only acts that way after his physical therapy session" or "she never does that on the night shift" are common and remind carethat perceptions and interpretations vary. A resident might relate to one person in a manner that at first appears mystifying. This behavior is later understood when people who are familiar with the resident work together by providing the "missing puzzle piece" through sharing explanatory information.
Working together is particularly important so that consistency in resident/caregiver interactions is experienced. The best treatment plan will be threatened if consonance among caregivers is lacking. Inconsistent responses and approaches cause uncertainty for the resident and frustration for the caregiver. The importance of working together for consistency is illustrated by the following situation:
Mr. B. had the habit of kicking and hitting when asked to stay out of bed so that he could attend his occupational therapy assignment. When this behavior occurred, the responses by the nursing staff were varied and unpredictable. Some ignored his behavior; some tried to humor him; some hesitated to answer his light; some confronted his behavior with verbal reproaches; some let him go to bed and miss his therapies. The result was a situation that left the staff and the resident feeling frustrated.
The situation was helped by gathering as many caregivers as possible together and planning an approach that was therapeutic in nature and could be consistently applied. The causes of behavioral problems are multifaceted and complex. Seeking input from as many people as possible encourages ownership in the treatment plan and increases its chances for success.
The investigative process begins by identifying the problem behavior. This might seem a superfluous statement, but it is necessary for clarity of purpose and direction. Through working together, the caregivers define the behavior in objective, observable, measurable terms, while avoiding generalities. The statement "she dresses inappropriately" needs to be replaced with "she put her slip on over her dress." Clearly delineating the problem decreases ambiguity and increases success by focusing on one behavior at a time.
Once the problem has been identified, the caregivers can investigate the behavior's meaning. A behavioral concept learned in basic psychiatric nursing courses is the principle: All behavior has meaning. Inhérent in this concept is the belief that behavior is goal-directed and can be understood. The investigative process seeks to understand the meaning within the behavior by prefacing questions with what, when, where, and who. What triggers the behavior? What happened before the behavior started? When does it occur? Where does it take place? Who was there when it happened? Whose problem is it? What happens after the behavior occurs? What are the consequences? Detennining the answer to these questions reinforces the importance and benefit of receiving input from all team members.
Investigating the possible causes of behavioral problems is extremely important as many of the causes are treatable if recognized. Beginning steps are to conduct a thorough physical examination to rule out physiological factors and to compile a comprehensive past history from family and significant others (Foreman & Grabowski, 1995). Time invested in detennining the causes of the behavior is well spent and places the emphasis on understanding the behavior rather than judging the behavior. The investigation continues by considering each of the "7 Ds" as possible contributors: Drugs, Depression, Delirium, Dementia, Distress, Disease process, Dysfunctional coping. There are numerous articles that give guidance on each of these conditions (Filley, 1995; Foreman & Grabowski, 1995; Hay, Hay, Howell, & Szwabo, 1994; Maletta, 1988; Miller, 1995; Nelson, 1995; O'Connor & Eggert, 1994; Rantz & McShane, 1994; Teri & Logsdon, 1990).
Finding meaning in behaviors that are viewed as problematic is often subjective and influenced by the caregiver's experience and education. As stated earlier, the process for understanding requires diligence, patience and thoughtful assessment of cumulative objective and subjective data. This assessment process is made easier by using quantitative and qualitative tools that assist caregivers in measuring resident behaviors
Numerous authors have introduced quantitative tools that measure the occurrences of specific behaviors and elicit numerical data (Mungas, Weiler, Franzi, & Henry, 1989; Rader & Harvath, 1991; Ray, Taylor, Lichtenstein, & Meador, 1992; Ryden, Bossenmaier, & McLachlan, 1991; Sultzer, Levin, Mahler, High, & Curnmings, 1992; Sorrentino, 1992). Measurement tools need to be concise, easy to use, and require minimum time to complete if they are to be helpful in the empirical domain. A Behavior Monitoring Chart described by Rader & Harvath (1991) uses a coding system to measure resident behaviors every two hours over a 24-hour period. This chart could easily be altered to measure behaviors as to rates of occurrence and intensity. Another quantifying tool is the Disruptive Behavior Rating Scale (Mungas, Weiler, Franzi, & Henry, 1989), which was designed to require minimal time to complete and was found helpful by staff when communicating resident behaviors to the primary provider.
Additionally, there are empirical situations where narrative information is helpful in assisting caregivers with developing a planned management program. Effectively utilizing qualitative information is complicated by current documentation practices. In nursing homes and hospital settings, the resident/ patient chart which is used for documentation has entries written in a top to bottom format, making it difficult for patterns to emerge. The importance of being able to visually observe patterns and directions is why temperatures, blood pressures and weights are routinely graphed. The ability to visualize patterns is important when measuring problematic behaviors where knowledge of antecedents to the behavior and consequences from the behavior is necessary. A facility may want to develop daily, weekly, monthly or yearly data collection sheets which allow the reader to pictorially see behavioral patterns. In Minnesota, samples of these summary sheets can be obtained by writing to the State Department of Human Services.
In the recently popular book The 7 Habits of Highly Effective People, Stephen Covey states, "The essence of empathie listening is not that you agree with someone, it's that you strive to fully understand that person" (Covey, 1989). Another way of phrasing it is that to empathize means getting inside another person's frame of reference. As a caregiver, it means trying to see the situation from the resident's viewpoint. The following situation illustrates this concept:
A few years ago, the author received a consult that described a resident who became assaultive whenever his briefs were changed. The nursing staff were doing all the right things.. .explaining what they were going to do; going slow; approaching from the front; but the behavior continued. They asked if the author could come and observe the next time his briefs were changed. The resident was lying in bed when the staff came into his room to complete the task of changing his brief. When we consider the situation from the resident's perspective, we can see where there is reason for misinterpretation. We all receive cues from our environment and our immediate surroundings. Toileting is not a function that is associated with bedrooms. Sleeping is associated with bedrooms. Sexual activity is associated with bedrooms. The solution was to walk him into a bathroom where the environment would provide appropriate cueing messages and then change his briefs. This practice took more time and energy, but the agitated behavior decreased.
There is currently no patient classification system or staffing methodology approach that lists empathizing as a task worthy of reimbursement. However, nurses who practice it and residents who receive it, understand and herald its value.
The presence of problematic behaviors among nursing home residents is a phenomenon that is anticipated to increase. The changing demographics of the aging population (U.S. Congress, 1991) is expected to further burden existing programs. Present staffing patterns are often based on patient classification systems that have not kept pace with the changing health care needs of clients. Patterned after the industrial engineering approach, emphasis is placed on tasks rather than assessment, on doing for rather than teaching with. The inadequacies of this approach become glaringly apparent when caring for residents with problematic behaviors.
Placing excessive importance on task performance can result in seeking immediate solutions for problematic behaviors. There is no magic wand that will transform a demanding resident into an appreciative consumer. There is no magic pill that will change years of ineffective coping into constructive interactions. There is, however, a resident that compels nurses to apply honed assessment skills and challenges each caregiver's creativity. Considerable thought was taken by the author to avoid using the term "to manage", as this often implies "to control." Nurses can invite behavior change through encouraging, teaching and mentoring, but only the resident can truly manage the behavior. These activities require a significant amount of time and energy, and their inclusion in nursing practice needs to be valued by nurse administrators. This concept is recognized by the "doers" in the empirical arena and needs to be a reality for administrators who are constantly faced with budget constraints. The value of nursing assessments and interventions must be fortified with adequate compensation if residents are to receive the quality of care they deserve...neither of these activities can be accomplished without an investment of time.
The purpose of this article was to provide a framework that nurses could use when striving to understand and cope with problematic resident behaviors. A framework helps nurses organize knowledge so that it is readily available and can be used as a mental "checklist". A unique method for conceptualizing a frequently encountered nursing challenge, utilizing the acronym TIME, was introduced. After reading this article, the statement "we don't have enough time" can be replaced with the following acknowledgment. Coping with resident problematic behavior does take time, but by systematically applying the steps of Together: Investigate, Measure, and Empathize, nurses can work toward a solution that increases the chances of successfully coping with the situation.
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