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Excerpted from the Introduction of Caring for People with Challenging Behaviors: Essential Skills and Successful Strategies in Long-Term Care, by Stephen Weber Long, Ph.D.
Copyright © 2005 by Stephen Weber Long. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the author.
Up to 80% of nursing home residents are described as having moderate to severe behavior problems. In fact, behavior problems are a primary reason for family members deciding to place a loved one in a nursing home.
Many people who begin working in nursing homes are surprised by how often they see, experience, or hear about nursing home residents behaving in difficult ways. It is quite common for residents to yell, shout, scream, resist what staff members try to do with them, and threaten or insult others. It is also fairly common for residents to hit, kick, scratch, or even bite.
In a typical nursing home, addressing these difficulties is a daily part of the staff’s work. Many staff members describe dealing with the problem behaviors of residents as the most difficult part of their jobs. These challenging behaviors are sometimes aimed at other residents. Frequently, however, they are aimed at staff.
Caring for People with Challenging Behaviors: Essential Skills and Successful Strategies in Long-Term Care is intended as a guide for nursing home staff to help reduce or eliminate many of residents’ typical behavior problems. In this book, the term behavior problem refers to any behavior that causes emotional or physical harm. It can be harmful to either the person engaging in the behavior or to someone else. From this point of view, a resident’s hostile behavior aimed at someone else is a behavior problem. If a resident’s behavior hurts someone else unintentionally, it is still considered a behavior problem. In addition, behaviors related to depression, anxiety, or fear can be problematic.
This book details techniques for successfully addressing such behavior. The effectiveness of these skills is increased when nursing home staff, supervisors, physicians, and administrators have a common understanding of the skills and their importance. The more each staff member supports others’ use of the skills, the more effectively the skills can be used by everyone. That is why this book was written for all the people who work inor will be working ina nursing home, regardless of job title or role. Whether you are an administrator, a supervisor, or a hands-on caregiver and whether you are a student or a veteran in the field, this book is intended for you.
Caring for People with Challenging Behaviors can also assist mental health professionals who provide consultation to administrators and staff on how nursing home staff may best approach a difficult situation with a particular patient. The principles and skills on which this book is based can be used to create workable treatment plans that address common troubling behaviors.
Caring for People with Challenging Behaviors can be a valuable part of training programs as well. It may be used as the basis for in-service training of staff, supervisors, and administrators. It may also be used as part of the overall training of those who are preparing to begin work in a nursing home.
Often, when a nursing home resident behaves in a troubling way, the resident’s behavior is related to an illness such as Alzheimer’s disease. Problem behaviors are also sometimes related to other conditions that are more often thought of as mental illnesses, such as depression or schizophrenia. Physical pain or discomfort can also influence a resident to behave in difficult ways. Sometimes a resident’s challenging behavior is related to lifelong attitudes, habits, or personality. The methods described in this book are appropriate for use with individuals whose behavior stems from any of these issues.
Whenever a mental or physical illness seems to be contributing to a resident’s problem behavior, it is important to seek the advice of appropriately qualified health care professionals. Even in cases when a mental or physical illness is not clearly involved, it is important to consult with trained and experienced health care or mental health care professionals if a behavior problem is persistent. Caring for People with Challenging Behaviors is not intended to replace the advice of physicians, nurse practitioners, social workers, psychologists, or any appropriately trained professionals. It is important that the skills described in this book be a central part of treating the problem, regardless of cause. They really are skills for all those who help in the nursing home, whether day-to-day staff, medical specialists, or administrative staff.
Chapter 1 discusses why nursing home residents do what they do. The chapter looks at major influences on behavior through specific examples of how physical functioning, thinking, feeling, existing behavior, and interactions with others can affect what a nursing home resident does. Chapter 1 ends with a discussion of coping with stress. It also describes the importance of increasing the number of pleasant things that happen for us each day as one approach to managing stress.
Chapter 2 looks at ways of encouraging residents’ positive behaviors and is illustrated with examples. The chapter is based primarily on three ideas: 1) the more a behavior is reinforced, the more it will occur; 2) the more a resident’s positive behavior is reinforced, the less often the resident will engage in difficult behavior; and 3) the resident’s experience of interactions with us can be the most valuable source of reinforcing positive behaviors. This chapter shows the steps of active listening, a communication skill to develop an empathic, emotional understanding of residents. Such listening and understanding reinforces many positive behaviors, as it encourages the resident to value his or her relationships with us. Other ways of encouraging positive behaviors are explored as well: allowing residents to make choices and praising, complimenting, or acknowledging positive behavior. The chapter ends by discussing the stress management technique of progressive muscle relaxation.
Chapter 3 is about problem solving. It describes a way of looking at situations particularly interpersonal interactions (or “relationship situations”) to understand what might trigger or reinforce a resident’s difficult behavior. Knowledge of possible triggers and reinforcers can be used to help the resident reduce or eliminate those challenging behaviors. The chapter describes a two-step process for helping reduce frequent demanding or attention-seeking behavior. Chapter 3 contains several examples of staff members successfully using the problem-solving steps to help individuals eliminate or reduce problem behaviors. In addition, the chapter describes how to work with residents in solving problem behavior. Chapter 3 also explains the importance of “holding on,” or containing our reactions to residents’ difficult behavior. Finally, mental imagery is explored as a stress management technique.
The main point of Chapter 4 is to look more deeply at dealing with the stress related to residents’ difficult behavior. The chapter examines how our thinking and feeling can be affected by residents and how our own habits of thinking can cause or add to stress. This chapter is about taking control of our own thoughts and feelings in order to feel less stressed by residents’ challenging behavior. How we deal with such stress directly influences how effectively we address the problem behaviors. In addition, Chapter 4 considers how our feelings about residents and difficult behavior can help us in understanding and responding to residents. The chapter concludes by describing a breathing-focused technique for deepening relaxation and stress management.
Chapter 5 examines things that can interfere with the effective use of the techniques described in Caring for People with Challenging Behaviors. These factors include our own personal obstacles to effectively using the techniques, the nursing home environment itself, and societal attitudes toward aging and illness. The chapter provides ways of addressing these different obstacles and encourages us to see ourselves, the nursing home, and society as parts of a system what we do affects the other parts of the system and can promote positive change. Chapter 5 ends by considering the importance of good relationships in managing stress and offers ways to improve relationships.
Chapter 6 is a guide to treatment planning for a resident’s behavior problem. The chapter presents a five-step treatment plan guide for individual staff members and a five-step treatment plan guide for interdisciplinary treatment teams. In addition, Chapter 6 describes a way of integrating educational material based on Caring for People with Challenging Behaviors into the day-to-day routine of the nursing home, an approach aimed at increasing or deepening all staff members’ familiarity with effective techniques for addressing problem behaviors. This approach is also aimed at prevention of many behavior problems because prevention is the best possible treatment. Finally, Chapter 6 can be a useful tool for mental health professionals called on for consultations in cases involving problematic resident behaviors.