Behavior management in nursing homes

Michael C. LaFerney | 02/01/2016

Not a job for nurses, says this psychiatric clinical nurse specialist.

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Ellen, an elderly patient on a long-term care unit, suffers from trichotillomania. She has been pulling her hair out and now has several bald patches. Attempts to stop her from giving in to the urge have been futile. Telling her to stop has yielded only short-term success, and selective serotonin reuptake inhibitors (SSRIs) and anxiety medication have not worked.
Laferney author imageKen, a 47-year-old patient with dementia and blindness, impulsively gets out of his chair and walks forward, at times walking into other residents and walls. Because he is a risk to himself and others, he is placed near the nurses’ station so they can quickly redirect him back to his chair when needed. He gets angry when frequently told to sit down. Medication has not slowed him down but has increased his risk of falling.
Bruce, a chronic paranoid schizophrenic patient, is addicted to cigarettes. In his facility, smokers are taken to the patio four times a day to smoke. Bruce often tries to smoke as many cigarettes as he can in the 20-minute time allotment and occasionally damages the tips of his fingers by smoking cigarette butts until there is virtually nothing left of them. Other times, he refuses to come back inside until he has completed smoking his last cigarette. A few times, he has become aggressive when someone attempts to end his smoking. This has become a daily ritual that is quite time-consuming for members of the nursing staff.
A nursing problem, by default
These are just three examples of behavior issues that take caregivers’ time in long-term settings. Other behavior problems include yelling, wandering, sexually inappropriate behaviors, and hoarding, to name a few. These issues often become the domain of nursing-staff members who are there to deliver nursing care and are not specifically trained for behavior management. Many patients with these issues are referred for psychiatric evaluations but, unfortunately, there is no pharmacological treatment for the majority of DSM-5 diagnoses and no FDA-indicated medication for these behaviors.
Many behaviors seen in long-term care seem to have no purpose or easily determined cause. Often, patients have cognitive deficits or mental illnesses that make insight-directed counseling impossible. Sometimes, a nurse can determine through trial and error why a patient is uncomfortable or agitated, but the vast majority of causes or behavior triggers are undetermined.
No simple solutions
Staff members have tried to end Ellen’s hair pulling by having her wear a hat or hairnet. She takes them off. Mittens were suggested, but they are viewed as a form of restraint and not allowed.
Ken disrupts nursing duties with his constant getting up and needing to be redirected. At times, a one-to-one special—assigning one staff person to stay with the patient at all times—is used, but administration regards this as a too-costly solution. Activities help keep him still for short periods but can’t compete with his constant attempts to wander. A merry walker was suggested to allow Ken to wander freely without bumping into walls and injuring himself, but administration views this as a form of physical restraint and does not allow it.
Bruce has been sent to the emergency room a few times when he responded in a threatening manner to efforts to interrupt his smoking, but he was immediately sent back to the nursing home, because his actions were not seen as a danger to others or evidence of a true psychiatric issue. At times, he has been kept inside and not allowed to smoke, which has only increased his anger and paranoia.
Applied behavior analysis
What can be done to help nurses better manage issues such as these? Is it asking too much for nurses in long-term care settings to have these responsibilities while delivering nursing care? Is there a more cost-effective way?
Applied behavior analysis (ABA) is a process by which behavior is viewed as having a functional relationship to the environment. Why a patient exhibits a particular behavior is viewed as an important factor in determining the course of treatment. Behaviorists look at antecedents, consequences, and general settings associated with certain behaviors. As a result, they are often able to provide a system of reinforcers—i.e., tokens, praise, and other rewards—that encourage acceptable behavior and discourage—eliminate, if possible—troublesome behaviors. Applied behavioral analysts, also known as ABA therapists, are specialists in behavior management.
Several nursing homes are now bringing applied behavior analysis into their facilities to aid patient management. While nursing often looks at the behavioral issues of dementia and other mental disorders as part of the disease process, ABA therapists view such behaviors as an interaction between the patient and his or her environment. Accordingly, they seek to help staff manage patient behaviors by designing environments that are more conducive to behavioral control, identifying antecedents to behavior issues, and designing a system of reinforcers that is better able to influence behavior.
Facilities for head-injured patients have used ABA for years with success. In most of these facilities, as behavioral specialists and aides have focused on managing behavior issues, nurses have been able to focus their attention on delivering nursing care.
This model could also be successful in many nursing homes, but it must be implemented correctly. Some hire an ABA therapist as a consultant and then expect nursing to carry out the behavioral plans. This approach often is ineffective because expecting nurses and certified nurse’s aides to document behavior and carry out interventions, in addition to other duties, is asking too much.
I am not in favor of reducing nurse staffing levels, but having a few behavioral aides to complement nursing staff might allow for more effective use of the staff. It is my hope that this model is adopted so nursing can provide the care that patients in long-term care facilities need but don’t get, often because of having to constantly deal with interruptions caused by behavior issues. 
Michael C. LaFerney,PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.
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