The Case for Behavior Management

Published by Journal of Contemporary Long Term Care, May 2000

MH Problems of Nursing Home Residents

Behavior is the means by which people attempt to meet basic needs. Many resident behaviors are ineffective or even bizarre attempts. According to the Surgeon General's Report on Mental Health (Chapter 5 Older Adults), up to two-thirds of residents in nursing homes suffer an identifiable mental disorder including dementia, depression, late-onset schizophrenia or anxiety. The risk of suicide also significantly increases with age.

Of course, anyone who has worked in long term care already knows how hard it is to provide optimum quality of life to residents suffering from, or exposed to, the behaviors associated with mental illness. While well prepared to deal with the medical needs of the frail elderly, skilled nursing facilities are generally less equipped to provide proper care for mental illness.
Hands-on care providers, as well as others (including primary care physicians) may hold the mistaken belief that mental illness and dysfunctional behaviors are "inevitable effects of old age." While the enlightened among us know better, these archaic attitudes persist.

Residents are capable of constructive change, however, even when struggling with chronic physical and mental illness. With proper behavior management training and support, staff can learn to recognize and modify the biomedical, psychosocial and environmental factors, which interact to shape the behavior of residents.

Typical Approaches

Various approaches to behavior management have been utilized in the long-term care industry. Historically, physical and chemical restraints were used to control a wide range of behaviors. This approach provided short-term convenience at a significant cost to resident rights, quality of life and safety. More recently, facilities have relied on behavioral consultants such as psychiatrists, psychologists and social workers to "treat" residents with dysfunctional behavior.

Psychiatric involvement often led to increased use of psychoactive medications, which conflicted with facility goals to reduce the use of those medications. Reliance on outside consultants also reinforced staff perceptions that behavior problems required external expertise and were "not our responsibility." The best of these consultants provided some training to available staff during the consultation, but of necessity that training was hit or miss.

The weakness of this approach lies in the inconsistency with which resident behavioral treatment has been integrated into care planning. Additionally, the compensation rate has been a disincentive for qualified professionals to visit facilities, creating lack of access to this resource especially in rural settings.

Short-term staff training has been one of the most recent efforts by the industry, with mixed success. The periodic in-service and "crisis-response" approaches have been used to deal with behavior problems in reaction to an injury or poor survey results for behavioral indicators. Such training might provide a short-term "fix" for an immediate crisis, but it generally does not prevent future problems.

Another common approach is the "specialized program," in which staff working with residents of an Alzheimer's, dementia, or behavior unit receive additional training in behavior management. This training improves the care of residents on that unit, but does not address the behavioral needs of residents in other units.

Given the Surgeon General's estimate of the prevalence of mental health problems in nursing homes, it would make more sense to have a specialty unit for the one-third of the residents without mental health or behavioral difficulties.

Systems Approach to Behavior Management

Given the shortcomings of these approaches, what is needed is an expansion of the quality of life vision and mission to encompass behavioral care. In 1998, the Pennsylvania Department of Health mandated that behavior management would become a focus of surveyors in Pennsylvania.

That led the Pennsylvania Association of County Affiliated Homes (PACAH) to promote a more systematic approach to behavior management among member facilities. With grant funding from the County Commissioners Association of Pennsylvania, PACAH selected GeroServices, a Pittsburgh-based psychology and consulting practice, to develop a behavior management system for resident care.

The goal was to design a system that would be flexible enough to meet the needs of individual facilities and could be implemented through a time-limited consultation and training program.

A guiding principle behind the development of the behavior management system was that each facility has different leadership, staff and physical plant resources. This variability in the culture of the facility was considered a significant factor in developing an approach to behavior management for the industry.

The components of the behavior management system had to be flexible and responsive to the individual culture of each facility while remaining cost effective and efficient. The basic components of the system follow sound program development methods, whether used to install a behavior management system or institute a new wound care program.

Leadership Development

The consulting team first worked closely with the administrator and key management to designate a team of key staff members that would lead the project.

A seminar, workbook and PowerPoint presentation introduced the leadership group to behavior management principles and practices. The seminar also included strategic planning and organizational development issues that would need to be addressed for success of the project.

GeroServices found that a visible and informed administration is key to a facility's success in implementing a behavior management system. The administrator, with the assistance of strong middle managers, must identify the mission and vision clearly, communicate it to all facility staff and work with key-stakeholders throughout the program development process.

Facilities that were the least successful were frequently those in which administrators were drawn away by other priorities and delegated too much of the responsibility. A few notable exceptions involved facilities with very strong middle management leadership.

Good leaders have a realistic sense of the strengths of their team. Some facilities were not prepared to develop and implement a new program due to deficits in basic meeting skills, communication skills, time management skills, or severe interdepartmental conflicts.

One anticipated obstacle, understaffing, turned out to be less of an issue than expected. Even facilities with severe staffing problems were effective when basic leadership skills were present.

Policy and Procedure

The backbone of a systematic approach to behavior management is the development of formal policy and procedure. Accordingly, one of the products of the initial work with the management team was written policy and procedure.

Based upon information and decisions elicited from the group, the consultants generated the procedures for carrying out behavior management, within the existing culture and practices of the facility. A critical first step, the written procedure laid the foundation to implement the program.

Based upon their experience with the first dozen facilities, GeroServices developed templates for behavior management policy and procedure that could easily be adapted to meet the needs of individual facilities. This was further refined into a computer program or "policy and procedure wizard." The wizard produced a customized policy and procedure based on the answers to thirty questions provided by facility management during the leadership seminar. The wizard allowed management to produce a complete draft of a behavior management policy and procedure in a few hours.

The final outcome of the leadership seminar was a detailed action plan for the project with objectives, resources, accountability and dates established.
Staff Training

All staff must be trained to an appropriate level of knowledge about the behavioral science that constitutes the core of behavior management.

Two levels of training materials were developed for the program. A basic course provided nursing assistants and other direct care staff, such as dietary and activity aides, housekeepers and maintenance staff, with the essential concepts and application of behavior management. These staff members, who provide nearly 80% of one-to-one contact, are often in the best position to notice and report changes in behavior. They can assist in carrying out interventions by implementing new approaches and responses to the resident.

The basic course was organized according to the behavior management process: identifying residents with problem behaviors, assessing behavior, designing and implementing behavioral interventions and evaluating interventions. The course also taught observation and documentation skills and discusses the ethics of behavior management.

An advanced course offered more in-depth training suitable to management and professional staff members. It provided the care plan team and nursing professionals with a foundation in behavioral psychology and the biomedical, psychosocial and environmental context of common resident behavioral problems.

The materials developed for both courses utilized ample illustrations and real case examples in an audiotape/workbook format. They were designed to be taught through classroom training or individual self-study.

A trainer's guide assisted the in-service coordinator in planning and implementing a facility-wide training effort. Many facilities found it more manageable to target a few units at a time and distribute the total training effort over several months' time.

Skill Building

The next step in the process was to develop the competence and confidence of the staff in applying behavior management principles to actual cases.

Following the facility's in-service training with the course materials, the consultants conducted skill training during four sessions. Skill training was designed to help staff members apply what they had been learning through the course material to the "real world" of the unit.

Using a case conference model, the consultants led a cross section of care planners and hands-on care givers through the process of behavior management for an actual resident with behavioral problems.

The first session focused on identifying a good case for behavior management, clarifying the target behavior and determining a practical method for conducting a baseline assessment of the behavior.

The second session focused on interpreting the baseline data and designing a realistic behavioral intervention. The third session reviewed the results of the intervention and identified any problems in the approach that would need to be corrected. Organizational problems, such as lack of inter-staff communication, cooperation and consistency, were the most common obstacles requiring mid-course correction.

The final session again reviewed the progress of the intervention, as well as the entire skill-training process and generated recommendations for modification of the policy and procedure, as needed.

Program Promotion and Support

By the end of the skill building phase, and termination of the consultation and training sessions, the facilities were generally prepared to expand the scope of their program to include their remaining units.

The general success of the project made expansion to other units more effective, as staff promoted the benefits to one another. While many facilities were well prepared to carry on independently, others were less prepared.

To assist the facilities after the system was implemented, GeroServices initiated a telephone support service. Most calls have involved technical questions about the design of interventions for difficult cases. Less often, the questions involved staff or organizational development issues.

GeroServices also provided a monthly newsletter and other promotional materials to assist facilities in promoting behavior management. On their own, facilities have generated a wide range of effective program promotion and staff incentive ideas.

Results and Benefits

To date, forty-five facilities have implemented the GeroServices behavior management system. Another twenty-eight are in progress. Of the cases piloted, almost three-fourths were resolved positively with significant improvement in the target behaviors. Of these, about half were resolved by simple changes in staff approach and response behaviors, while the others required more sophisticated or complex interventions. About a fourth of the cases were not resolved successfully. This group includes those suffering deteriorating medical condition (including death), failure of staff follow-up, communication or consistency and unexplained or other failures.

Most facilities continue to use the training materials and follow the system. Some have made this training mandatory for all new hires. Management and direct care staff have reported:
(1) an increased sense of empowerment in working with behavioral problems,
(2) reduced use of restraints and psychoactive medications, and
(3) success stories of once recalcitrant behavior problems which are now well managed.

Perhaps the most important outcome is the increased sense of competence and confidence observed, as nurses, aides and other staff report that, "Mrs. Smith isn't really a problem anymore, not if you know how to approach her."

Dr. Wyckoff is a psychologist with over thirty years of clinical and consulting experience. He founded GeroServices in 1988 with the mission to apply psychological principles to quality of life issues in the long term care industry.

Linda Wyckoff is an attorney. She co-developed the GeroServices Behavior Management System. Linda consults with long term care facilities in behavior related areas.

Katherine Heart is a specialist in health education and curriculum development. She develops GeroServices products and services, and consults in the area of behavior management and abuse prevention.

Source: GeroServices, Inc.