Look to community experts to create a behavior management inservice
Local social services office can provide invaluable information, contacts
When teaching staff about behavior management, many agencies don’t think to tap the most knowledgeable community resources. At Pine View Home Health in Black River Falls, WI, home health staff received input from their own educators and administrators, but they also consulted Nancy Laabs, a certified social worker with Jackson (WI) County Health and Human Services.
Although Laabs had often worked with home health agencies in the area, she says it was the first time she’d been asked to speak to staff on behavior management. "This is the first time in 16 years of working I guess I’ve ever done anything on behaviors," she says. "We do it every day in our jobs, but I’ve never done a formal presentation."
Laabs’ presentation was part of a larger behavior management inservice that gave staff opportunity to role-play and discuss behavior management problems that come up on the job, says Terri Hernandez, RN, BSN, administrator of Pine View Home Health. Others involved with the inservice included Dena Johnson, RN, director of nursing, and Beth Johnson, supportive home care coordinator.
The need for such training is clear, Hernandez says, because home care staff continually care for patients who are mentally ill, developmentally disabled, or incompetent. She says staff do not always know when they visit a client if there is going to be a problem in the household. Part of their role is to be alert for indications of both physical and mental problems that may require the intervention of a nurse or a social worker.
"We consider home care providers to be an extra pair of eyes and ears," Hernandez says. "They aren’t only helpers who are there doing the work for [clients], but also to be aware if someone isn’t cognizant of what’s going on around them or if they seem extremely confused about things."
Laabs says it’s important for all health care providers to think in terms of the patient’s needs when trying to sort out unfamiliar behavior. She presented Abraham Maslow’s famous hierarchy of needs, which begins with basic needs such as food and shelter and progresses to more complex ones such as esteem and self-actualization.
"Basically, [clients’] needs are the same as ours, but they have some different hitches because we work with a diverse group of people," Laabs says. "We work with people who are developmentally disabled, physically handicapped, and frail elderly."
Sorting out behavior
When patients’ behavior changes, staff should ask questions that get to the root of possible problems. Are the patients in pain? Are they overstimulated? Have they been through too many recent changes? Are the tasks being asked of them too complicated? For patients who are nonverbal, as many developmentally disabled people are, look to their behavior for clues.
"We look to see if this is happening with [every aide who] goes in there, or is it just a particular worker or a particular time of day," Laabs says. "We just try to figure out why that behavior is happening and try to make changes accordingly."
The problem, when finally uncovered, can be hard for providers and social workers to deal with, particularly when the client is in a protective environment with restrictions designed to keep the person safe.
"We have a client who is a frail elderly gentleman. He is developmentally disabled," Laabs says. "We went to court for guardianship and protective placement because he’s running out of fuel oil and wasn’t able to take care of himself. He wasn’t eating right."
Through the efforts of her agency and a home health agency, a guardianship was arranged, and the man was able to get limited services.
"But one of the things that the judge did not do was to take his driver’s license away," she says. "Everyone says he shouldn’t be driving, but we tried to go over that and look at how important it was to him. He does drive very slowly, he hasn’t had any accidents, and that’s just something we have to accept, whether we agree with it or not."
She says clients’ sexual behavior — as long as it is with consenting adult partners — is another area in which providers sometimes must defer to clients’ needs. "People who are developmentally disabled, or under guardianship, or frail elderly, that sexual need doesn’t go away. We have to understand and tolerate it, even though our values would say differently. Those are tough issues for providers.
"The guidelines that we have used for years in human services include treating people with dignity and respect, to consider the client like a boss," Laabs explains.
Hernandez says a useful segment of the inservice dealt with handling power struggles in the home, providing real-life examples and nuts-and-bolts tips.
"We talked about strategies and problem-solving, and also did some role-playing within the group," Hernandez says. "We asked that it be a very interactive session, and asked that the home care providers talk about how they had felt at certain points that they themselves had a lot of anger.
"It often was the frustration of working with someone who you consistently try to help by setting boundaries, and how frustrating that can sometimes be."
She gives an example of a recent power struggle involving her agency to show how a calm, client-oriented discussion can help defuse a difficult situation. One client, who received nearly round-the-clock care, had a history of attempting to manipulate caregivers. When that strategy didn’t work, Hernandez says, she would call the agency and request a different caregiver.
"She will say, You know, our personalities just don’t get along. I’d just prefer that she [the caregiver] not come out.’ Well, now she’s got a list of six to eight people who she’s refusing to let come into the house."
When the client again asked for a new caregiver, the agency instead set up a meeting with the client, her social worker, and agency personnel, including the caregiver in question. The home care provider told the client how worried she was about the client’s safety in the home when she was transferring the client.
"I worry that if you fall, not only will you get hurt but it could mean that you would need to leave your home," the provider told the woman. "Not only would you get hurt very badly, but I love my job, I love what I do, and I could get hurt, too."
Hernandez says the meeting helped the client understand the importance of her safety and the safety of the workers in the home.
Although no names were revealed during the inservice to protect clients’ confidentiality, many staff recognized situations their peers described. "They would recognize it and say, Oh, that’s happened to you, too? That’s how you handled this? I thought she was just doing those things with me,’" Hernandez says.
She says the group also talked about working with family members and the underlying causes of some behavior problems within families, such as guilt about being distanced from the client.
Accentuate the positive
While it was important to allow home care providers to vent, steps were taken to keep the inservice from descending into a gripe session. "We covered the material first and were very specific about how important patients’ rights are," Hernandez says. "In response to complaints about clients we would say, Yeah, that’s true but, gee, how do you think you would feel if . . . ."
The inservice included role-playing exercises, with those administering the training taking part first. "The social worker and the supportive home care coordinator did one first, and then we invited a couple people [from the class] in, usually with a staff member," Hernandez says. "We didn’t really put two home care providers [in front of the group] on their own. We thought that would be a little too intimidating."
The training also provided home care workers with a number of tips for handling patients who are combative or belligerent:
• Clarify what you’re saying. It’s important to make sure that both parties understand each other and that an unintended conflict isn’t arising from a miscommunication.
• Be aware of personal space. When a person is acting out, it’s a good idea to keep a 1½- to 3-foot distance. Not only is providing the client with personal space calming, it also puts the home care provider out of striking distance.
• Watch your body position. Even if your words are meant to be soothing or nonjudgmental, your posture and body positions can send a negative message. Avoid crossing your arms, standing with hands on hips or making direct eye contact, all of which can be challenging to an angry person. "The more an individual loses control, the less he listens to your words and starts paying attention to your body instead," Hernandez says.
• Allow the client to vent, but set limits on behavior. Hernandez says it’s helpful to clearly restate rules in a calm voice: "John, I understand that you’re very upset, but you cannot push me like that or holler that way. If you do, I’m going to need to call so-and-so, or I’m going to need to leave."
• Ignore challenge questions that are intended to be argumentative. For example, some clients may say things like, "You’re only a nursing assistant. How do you know?" or "Who do you think you are?" Hernandez says she advises staff to redirect the conversation to the issue at hand. "When you answer those questions, you fuel the power struggle."
• Above all, stay calm. Give yourself and the client the opportunity to come up with a reasonable agreement. Remain professional and don’t allow anger to dictate what you say or how you say it. "When you’re in that instance, you’re upset and you’re worried and you’re scared, and so things fly out of your head and you don’t know what to do," she says.
In some instances, it may be useful to leave the client alone so everyone can calm down, Laabs says. But that doesn’t mean the home care pro vider should simply walk out and drive away.
"We try to tell the worker first just try to leave the room," she says. "You’re there, but you’re not there. Be there but be out of their face. We might say, Go outside, go on the porch for 10 or 15 minutes.’ You know they’re going to be OK for that period of time. With someone with dementia, you might come back in 10 minutes and they might have forgotten what was going on."
If a person becomes agitated or angry, it might help to bring in a family member or friend who is good at calming the person down, Laabs adds.
In the most severe cases, a worker who believes she may be at risk of injury or attack should immediately call for help from the nurse, social worker, or even the sheriff’s department if necessary, she says.
A team effort for patient care
Laabs emphasized the importance of a team approach to dealing with patients with behavior problems. Often, patients who are developmentally disabled or have dementia or mental illness already have a social worker assigned to them.
"[Social workers] generally have scheduled visits they make with their clients, but there may be something in the interim that the home care provider would see that they need to make the social worker and the nurse aware of," explains Hernandez.
Laabs says communication is vital. "We want to approach that person as consistently as possible," she says. "Another benefit is sharing ideas. What works for one person can oftentimes work for another person. They just never thought about doing it that way."
She says she hopes the presentation made it easier for home health staff to contact her office directly if they have a problem or want to discuss ideas about how to deal with a patient they’re both helping. "I think it opens up the door for the care provider to call," she says. "It’s another resource for them."
At a time when health workers on all fronts are so pressed for time, she wishes she had more time for such joint efforts. "It’s too bad that we don’t have more time for us as agencies working together to sit down and take two hours and talk about it ourselves," Laabs says. "We maybe should do this more on a regular basis, once a year or something."
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