Version: / 2
Author: / Prepared by Eithne Ni Dhomhnaill and Andrea O’Reilly, Nursing Matters & Associates.
Adapted for Local use by:
Issue Date: / July 2012
Review date: / July 2014
Authorised by:
1.0Policy Statement
Residents presenting with behaviours that are challenging will be cared for in a manner that is underpinned by a person-centred approach and evidence based practice. This policy should be read in conjunction with the Centre’s policy on the use of restraint.
2.0Purpose
The purpose of this policy is to ensure that all staff in the Centre, in particular healthcare staff, are aware of appropriate interventions to effectively care for residents with behaviours that are challenging.
3.0Objectives
3.1To ensure that nurses are familiar with appropriate assessment and care planning approaches for residents with behaviours that are challenging.
3.2To guide staff in caring for residents withbehaviours that are challenging while ensuring the residents live their lives with dignity and withina secure place of residence.
4.0Scope
This policy applies to all staff in the Centre, in particular nursing staff, healthcare assistants and any other health care professionals involved in providing direct care to residents. This policy covers self injurious behaviours often seen in residents with dementia.
5.0Definitions
5.1Behaviour that challenges has been described as behaviour that “causes stress or distress to the person with the behaviour or any number of other people interacting with them including other residents, care staff, family and friends”. (New South Wales Department of Health, 2006).
5.2Agitation is defined as “inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual. Agitated behaviours have been divided into three subtypes: aggressive behaviours: physically non-aggressive behaviours, such as pacing; and verbal agitation, such as constant repetition of sentences” (Cohen-Mansfield, 2005).
5.3Delirium: A disturbance in consciousness with reduced ability to focus, sustain, or shift attention; a change in cognition or the development of a perceptual disturbance that develops over a short period of time and tends to fluctuate during the course of the day (American Psychiatric Association, 2000).
5.4Self injurious behaviours: in nursing home residents over 65 includes self-pinching, scratching, and banging one’s fist against objects and is often associated with dementia rather than depression.(Wojnar et al., 2009)
6.0Responsibilities.
Actions
/Responsible Person.
This policy will be disseminated to and read by all staff in the Centre.
/Person in Charge / Director of Nursing.
A record will be kept of all those who have signed the policy acknowledgement forms.
/Person in Charge / Director of Nursing.
Where a new version of this policy is produced, the previous version will be removed and filed away.
/Person in Charge / Director of Nursing.
An explanation of this policy will be given on induction to all nursing and care staff and any other health care professional involved in providing direct care to residents. /Person in Charge / Director of Nursing.
Nurses will be provided with the opportunity to attend training /updates on management of behaviours that are challenging every two years or where there is a significant change to practice in this area.
/Person in Charge / Director of Nursing.
Every resident will be screened for a history or presence of behaviours that are challenging as part of their initial assessment
/Admitting nurse and/or designated nurse.
Assessment and care planning for the care of residents with behaviours that are challenging will be carried out as per this policy.
/All registered nurses.
Provision of care to residents with behavioursthat are challenging will be carried out as per this policy.
/All nursing and care staff.
Each resident presenting with a history or presence of behaviours that challenge will have ABC / Behaviour Monitoring completed.
/Designated nurse.
Residents with behaviours that challenge, which could pose a risk to themselves or others will have a risk assessment of the behaviour completed.
/All registered nurses.
All nurses and healthcare staff will inform the Person in Charge/Director of Nursing if they feel they need instruction on caring for residents with behaviours that are challenging.
/All registered nurses and healthcare assistants.
Changes in a resident’s condition will be reported to the staff nurse in charge or Person in Charge/Director of Nursing and changes to care will be communicated to all relevant healthcare professionals.
/All nurses, care assistants and other healthcare professionals involved in the resident’s care.
7.0Pathway for Management of Long Standing Behaviours that are Challenging.
8.0Type of Triggers That May Influence Behaviour.
9.0Assessment Protocol.
9.1For planned admissions, any existing behaviours that challenge should be identified during the pre-admission process. Recognition of the residents needs in relation to his/her behaviour will aid in identifying the suitability of the Centre to meet these needs.
9.2On admission, the admitting and/or designated nurse should complete the Admission Assessment form to further identify any behaviours that are challenging.
9.3Where a resident presents with a behaviour that is challenging, the safety and welfare of the resident, other residents and staff is paramount, therefore the nurse should identify any potential risks to those mentioned by using a generic risk assessment form e.g. risk assessment for violence and aggression, self harm, absconsion, sexually inappropriate behaviour. An attempt to address and reduce the identified risks should be carried out straight away.
9.4To complete a risk assessment, the nurse should identify:
1)The Hazard: identify and describe the behaviour that the resident exhibits that has the potential to cause harm.
2)Who could be Harmed and How: identify those persons who could be harmed by the behaviour and how they could be harmed if exposed to the behaviour.
3)Existing Control Measures: identify existing interventions that are in place to prevent the harm from occurring.
4)The Likelihood or chance of the harm occurring (almost certain, likely, possible, unlikely or rare).
5)The Severity or reasonable and foreseeable worst case scenario of the level of harm that may occur as a result of the behaviour (Catastrophic, Major, moderate, minor or negligible).
6)Risk Rating: The likelihood of harm occurring combined (multiplied) with the severity to produce a level of risk or a risk rating. Once a risk rating has been generated, the nurse will be able to identify and prioritize which interventions require further addressing or any additional control measure to bring the risk down to as low as is reasonably practicable.
7)Additional Risk Measures: The nurse should enter any additional control measures required and based upon this new information re-assess the severity and likelihood to generate a new risk rating (until these additional controls have been implemented the level of risk will remain as per the first risk rating).
9.5Every resident presenting with a behaviour that is challenging should be assessed to identify the cause of the behaviour. This can be achieved by using a Behaviour Monitoring Log / ABC Chart for a period of 7 days. The Behaviour Monitoring Log should identify and record the following:
- Antecedents
- When & where did the behaviour occur?
- What was the person doing immediately before the behaviour occurred?
- What was happening around the person at the time?
- Who was present?
- Behaviours
- Describe the behaviours e.g. hitting, biting, throwing objects, screaming, hoarding, constant questioning,cursing, shadowing.
- Consequences
- What was the consequence of the behaviour for the resident, for staff and for other residents?
- What interventions were implemented and how did the resident respond to these interventions?
9.6Having completed the Behaviour Monitoring Log for a 7 day period, the log should be analysed to identify:
1.Triggers to the behaviours e.g. time of day, a particular room or person, noise levels, loneliness, boredom, room temperature, personal care activity.
- Type of or patterns to the behaviours the resident displays.
- Interventions that are successful and unsuccessful when responding to the resident’s behaviour.
9.7Where the 7 day Behaviour Monitoring Log has not provided sufficient information for analysis, it may be recommenced for a further 7 days.
9.8The resident should also be assessed for any other contributing factors that may influence his/her behaviour.
9.8.1The resident should be assessed for visual, hearing or language deficits that may be contributing to the behaviour.
9.8.2The assessment should include knowledge about the resident’s previous lifestyle, occupation, hobbies and interests and any major life events that may be contributing to the behaviour.
9.8.3The resident and /or representative and other relevant healthcare workers should be included in assessment and care planning.
9.8.4Assessment information should be used to identify triggers and/or underlying emotions behind the behaviour.
9.8.5Nursing staff should attempt to identify what the resident is trying to communicate behind the behaviour.
9.9Where the resident presents with an acute confusion / behaviour that is challenging of recent onset, such as days / hours this may indicate the presence of delirium. Assessment should be carried out to identify the cause of the delirium.
9.9.1The signs and symptoms of delirium may include:
Patchy memory
Delusions and hallucinations
Spatial disorientation
Increased or decreased activity levels
Disordered sleep/wake cycle
Clouded consciousness
Changed level of alertness
9.9.2Some common causes and contributing factors to delirium include:
Dehydration
Urinary tract infections
Constipation
Infections
Pain
Anxiety
Tumours
Vitamin deficiencies
Electrolyte imbalance
Physical stresses
Altered environment
Psychological stressors
Medications
Malnourishment
Impaired hearing and vision
Depression
9.9.3Assessment should include the following parameters:
Assess for underlying cause:
Assess for presence of pain.
Review of medications.
Urinalysis.
Vital signs.
Nursing staff should liaise with GP re need for other tests – eg. Full Blood Screen /Electrocardiograph; sputum culture; chest x-ray; digoxin levels.
Assess for constipation and / or dehydration.
10.0Care Planning Protocol.
10.1Care planning for residents with behaviours that are challenging should include:
◙Indentifying the behaviours that the resident displays.
◙Identifying any known triggers to the behaviour.
◙Interventions to remove or reduce these trigger factors.
◙Appropriate and inappropriate response interventions when the resident displays the behaviour(s).
◙Provision of a therapeutic environment.
◙Provision of appropriate sensory stimulation.
◙Individualised reassurance.
◙Reorientation if appropriate.
◙Maintenance of consistency of caregivers.
◙Use of sensory aids as appropriate.
◙Minimal changes in location.
◙Provision of care for meeting basic needs.
◙Communication needs /methods.
10.2Development of the care plan should include the resident and/or representative in accordance with requirements for informed consent.
11.0Re-assessment.
11.1The resident should be re-assessed every three months or with the changing condition and needs of the resident.
11.2Following re-assessment the residents care plan should be reviewed and any changes required should be documented and implemented.
12.0Guidelines for Management of Behaviours that are Challenging.
12.1Caring for residents with behaviours that are challenging requires a holistic and individualised approach.
12.2Many behaviours can be prevented by providing effective person-centred care which accommodates individual differences and requires a thorough understanding of the resident including his/her cultural and religious/spiritual background; his/her sense of identity and life experiences.
12.3Person-centred care and understanding the resident as a unique individual is imperative to inform the effective assessment, treatment and delivery of appropriate interventions that are tailored to a residents specific needs.
12.4Knowledge of the resident, triggers and behaviours that precede an episode of behaviour that is challenging can allow staff the opportunity to diffuse the situation.
12.5Roberts et al (2005) identified three broad reasons as to why a person may exhibit a behaviour that is challenging and staff should take these into consideration when assessing and caring for a resident with challenging behaviours.
- To get something e.g. lonely and needs attention or help, needs food or drink or to be taken to the toiled but can’t communicate.
- To get away from something e.g. too noisy, too hot, too many people in the room, the resident doesn’t like the food, the resident doesn’t like the person/people, the resident doesn’t like the care procedure.
- Internal/sensory e.g. soothing pain, reducing boredom, feeling ashamed, feeling scared, seeking sensory stimulation.
12.6Tips and techniques when caring for a resident with behaviours that are challenging are as follows:
Stop! Think about what you are about to do and consider the best way to do it. Plan and explain to the resident - Who you are, what you want to do and why.
Smile! The resident may mirror your relaxed and positive body language and tone of voice.
Go slow! Staff may have a lot to do and are in a hurry but the resident isn't.
Go away! If the resident is resistive or aggressive but is not causing harm to themselves or others, leave them alone. Give them time to settle down and reapproach later.
Give the resident space! Any activity that involves invasion of personal space increases the risk of assault and aggression. Every time a staff member provides care for a resident he/she is invading the resident’s personal space.
Stand aside! Always provide care from the side not the front of the resident where the staff member can be an easy target to hit, kick etc.
Distract the resident! Talk to the resident about things he/she enjoyed in the past and give him/her a face washer or something to hold while you are providing care.
Keep it quiet! Check noise level and reduce it. Turn off the radio and TV.
Don’t argue! The resident is right and you are wrong! The brain of aresident with dementia tells him/her that he/she can't be wrong.
(Loddon Mallee Regional Dementia Management Strategy, 2001)
12.7When a resident is displaying behaviours that are challenging, the staff member should attempt to communicate with the resident in an attempt to identify what he/she is thinking or feeling e.g. is the resident hungry, thirsty, tired, lonely, bored, too hot, too cold, in pain, etc.
12.8Staff should always respond to the emotion being communicated by the behaviour, not the behaviour itself.
12.9Staff should try to put themselves in the resident's situation. Look at their body language and imagine how they might be feeling and what they might be trying to express.
12.10Staff should seek to comfort the resident both verbally and, if appropriate, by gentle physical contact. It is important that touching is appropriate and not interpreted as an invasion of space. Some people do not like being touched and will react adversely.
12.11The staff member should attempt to interrupt and deflect the resident. This may be achieved by trying to get the resident to focus on another person, task or situation or using humour. Doing something different can often be enough to deflect the behaviour and to change the focus of a residents attention.
12.12Dexbury (2005) identified poor communication to be a significant precursor of aggressive behaviour.
12.13How staff appear and behave are key variables in preventing the onset and escalation of behaviours that are challenging. It is necessary for staff to be aware of their communication skills. When caring for a resident with behaviours that are challenging, staff should try to:
Appear calm, relaxed and friendly.
Not appear rushed or in a hurry.
Not to fake attention.
Be aware of his/her tone, volume and rate of voice.
Speak clearly and calmly.
Be aware of non verbal communications, e.g. hand gestures, facial expressions.
Maintain eye contact but do not stare or show anger.
12.13.1Residents who resist care such as washing and dressing and toileting/changing of incontinence wear should be approached in a friendly manner. If the resident resists, then leave the resident if safe to do so and try again a short time later. Always take time and work at the residents pace. Use distraction techniques such as giving the resident a facecloth or towel to hold. Explain every maneuver to the resident is clear and simple language and offer visual aids to prompt understanding, such as showing the resident a towel when washing or a toilet roll when toileting.
13.0Behaviour that challenges -Intervention Guideline.
Presenting Problem / InterventionAGGRESSION
May be related to:
_ Pain
_ Frustration
_ Infection
_ Fear
_ Confusion
_ Psychosis
_ Excessive stimuli
_ Change of environment
_ Poor communication techniques
_ Loss of control
_ Drug reaction / Potential strategies include:
_ Distraction
_ Diversion
_ Staff training in managing and approaching residents (Crisis Prevention Intervention Training).
_ Peaceful environment
_ Music
_ Exercise
_ Avoidance of identified triggers
_ Appropriate levels of light
_ Reassurance with familiar objects
_ Family support
_ Noise and crowd reduction
_ Assessment of family, social, psychological and occupational history
_ Socialisation
NB: when a resident becomes disturbed, the senior nurse on duty may arrange for the resident to be accompanied to a non-stimulating and safe environment in the interests of the resident and staff.
Seclusion must not used as a strategy for aggressive behaviour in the home.
AGITATION
May be related to:
_ Anxiety
_ Pain
_ Discomfort
_ Constipation/Incontinence
_ Grief
_ Change of environment
_ Inappropriate medication regimes
_ Restraint / Potential strategies include:
_ Modification of the environment
_ Provision of lounge chairs and sofas for companionship
_ Reassurance
_ Stimulation
_ Regular exercise
_ Signposting – cues
_ Asking the person if there is anything wrong
_ Distraction
_ Contact and closeness, where appropriate
_ Reducing crowding
ANXIETY
May be related to:
_ Interpersonal symptoms
_ Change of environment
_ Grief
_ Pain
_ Isolation
_ Excess stimuli / Potential strategies include:
_ Distraction
_ Diversion
_ Support – social interaction
_ Exercise
_ Asking the person what is worrying him/her
_ Reassurance – familiar objects
_ Counselling/cognitive behaviour therapy
_ Reducing excessive stimuli
_ Increased involvement and collaboration with family and friends
Presenting Symptom / Interventions
PSYCHOTIC SYMPTOMS
Psychotic Symptoms include:
_ Delusions
_ Hallucinations
_ Paranoid ideation
May be related to:
_ Misinterpretation of the environment
_ Drug toxicity/interactions
_ Visual or hearing impairment
_ Physical illness / Potential strategies include:
_ Emotional support
_ Avoiding fatigue – induce rest periods
_ Personalise environment/ belongings
_ Clear communication
_ Always keeping an open mind
_ Reducing stimulation and external stimuli eg TV, radio
_ Listening to their concerns and offer reassurance; however do not reinforce the delusions/paranoid
ideations. This needs to be applied with respect for and sensitivity to the individuality of each situation.
_ Investigating if there is any reality to what the person is saying
WANDERING
May be related to :
_ Pacing associated with agitation
_ Restlessness associated with
pain, anxiety frustration
_ Effect of medication
_ Stress
_ Boredom
_ Fear/loneliness
_ Isolation
_ Depression / Potential strategies include:
_ Asking the person what they are
looking for or where they want to go
_ Identification
_ Use of alarms and monitors
_ Creating safe wandering opportunities
_ Walking programs
_ Exercise
_ Safe return programs
_ Diversions/distractions
_ Reminiscence therapy
_ Participating in household activities
SLEEP DISTURBANCES
Include sleep – wake cycle
problems
May be related to:
_ Pain/joint stiffness
_ Poor mattress comfort
_ Nocturia
_ Noise / Potential strategies include:
_ Investigate the night-time environment, including practices of night-staff disrupting residents’ sleep
_ Creation of a sleeping environment
_ Night lights
_ Warm milk
_ Relaxation music
_ Caffeine restrictions
_ Limit daytime sleeping
_ Increase daytime activity.
Adapted from New South Wales Department of Health (2006).Guidelines for working with people with behaviour that challenges in residential aged care facilities.