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Managing challenging behaviors

November 1, 2009
by Diana Waugh, BSN, RN
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If I can just find the right external device I know I can change the person's internal motivation to move, I just know it!” It seems obvious, even to the most casual observer, that making a person who has to go to the bathroom buzz the call button when they move will take away their need to toilet. Or how about the person with cognitive loss who thinks the dog needs to go out? Anyone with a modicum of intelligence would know that making them buzz when they move will instantly make them forget about their beloved dog and stop moving, right? Of course right…or is it?

Across the country, facilities and organizations are espousing a change in the culture of long-term care that gives credence to the wishes of the person. It would be assumed then that in light of this belief system, use of devices that are purposely constructed to thwart a person's wishes would immediately be discontinued. But use of external devices to change internal motivation continues. Justification for their use continues. Incident reports for falls with an alarm in place continue. Heated discussions regarding their use continue.

The juxtaposition of the focus on the person with the continued use of a psychological restraint is inexplicable. It is true we as a country have been censured from using psychological intimidation on terrorist suspects in our military establishments. Soldiers have been imprisoned for using that technique. Yet, in long-term care facilities, use of devices that function in the same manner for the confused person continues.

The seemingly justifying question always is: But what else can we do to keep them safe? Perhaps the question needs to be: How can I help them help me to understand their motivation for moving and then help them meet their goal? Unless and until the focus shifts from safety at all costs to the staff goal of determining what the person's reason for moving is and then helping them accomplish that goal, we will continue to be unsuccessful in managing motivated behaviors, many of which lead to falls.

Perfect climate

The climate is perfect for this shift in thinking. The Center for Medicare & Medicaid Services has stated loudly that the use of alarms has the potential to annoy others hearing it ring. The culture change movement and the focus on the person speak very loudly to the value of the individual's wishes, regardless of cognition. We listen when the alert person shares their wishes and their motivation. But how is it possible to learn the motivation for the confused person? All behavior is motivated. Employing that philosophy allows caregivers to empower the person to be successful rather than employing devices that make everyone feel less than successful. Once this belief is accepted, the rest is easy.

The obvious motivations of physical needs, i.e., hunger, thirst, position change, and elimination can be anticipated and met immediately. Current widely used physical assessments set the staff response timetable based on the person's normal pattern of eating, drinking, moving, and eliminating. Adding psychosocial assessments sets the stage for staff to really know the person. Sharing that knowledge with all caregivers empowers everyone with an understanding of the psychosocial reasons for resident behaviors. Armed with knowledge of the person, preemptive interventions based on their likes, their dislikes, and their past occupation and activities that gave them a purpose will continue the process of determining their internal motivation.

Begin with the simple aspects of what the person likes to see, smell, taste, touch, and hear, as well as three stories that make them happy. This provides the staff with a very solid foundation of information and leads to supportable care planning.

The planning of care for the person simply includes using those psychosocial aspects in a preemptive approach. Sharing this information with all staff along with the directive that they initiate the conversations, the songs, the smells when the person is calm, supports the goal of keeping them calm. This simple approach to treating the person as a motivated individual with individual social components is easy, can be performed by all staff, and allows both the person and the caregiver to feel their day has a purpose. Buzzing will change from devices to the heartfelt hum of people making a difference in each other's lives.

Diana Waugh, BSN, RN, is owner of Waugh Consulting, Waterville, Ohio, specializing in consulting for nursing homes. She has served on faculties in all types of nursing programs, managed a regional rehabilitation program, served as a DON, and worked as a long-term care consultant for more than 19 years.

To send your comments to the editor e-mail mhrehocik@vendomegrp.com.

Long-Term Living 2009 November;58(11):11

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