“Mrs. Jones” is in the middle of the dayroom, once again engaging in verbal abusiveness that disrupts the residents, families and staff on her unit. When Rosa, the CNA, notices this, she immediately responds by gently chastising Mrs. Jones for her behavior, reminding her why it is inappropriate, and encouraging her to always talk to her fellow residents in a respectful manner.
But a few hours later Mrs. Jones is using inappropriate language again, now during an activity run by the therapeutic recreation department. The recreation therapist’s intervention is to let Mrs. Jones know that her behavior will not be tolerated in the group and ask a nearby staff member to take Mrs. Jones back to her room.
Later in the day, when the behavior happens again, the head nurse on the unit is the first to spot it. She tells Mrs. Jones that she needs to stop and that if she hears that kind of language again she will have to call the resident’s daughter to let her know.
Finally, towards the end of the shift, a housekeeper comes upon Mrs. Jones as she is using abusive language. She distracts Mrs. Jones by reminding her that they both come from the same country of origin and asking her if she remembers the most important national holidays in their shared homeland.
These scenarios highlight why it is so difficult for skilled nursing facilities to foster behavior change in residents who engage in unwanted behaviors. Although it might be argued that none of the staff responses were problematic on their own, it’s easy to see that the facility had inadvertently established an essentially random program of responses to this particular resident’s behavior. Each time Mrs. Jones acted inappropriately, staff members responded in a different way. And just think about how many staff members might be called upon to respond to Mrs. Jones’s next episode: nursing staff, administrators, nursing supervisors, social workers, dieticians, recreation therapists, housekeepers, physicians and other consultants are all likely to be at least occasional participants in the effort to manage these unwanted behaviors.
In the vast majority of SNFs there is a lack of structured behavior management planning, meaning any staff member who comes upon an inappropriate behavior must, in the moment, figure out the best way to respond. So Mrs. Jones’s behavior may receive 10 or 15 different responses, depending on which staff member is the first to address it. If we wanted to create an environment in which an unwanted behavior goes on forever, we could not come up with a better strategy.
In effect, skilled nursing facilities often inadvertently establish what is known as an “intermittent, variable-ratio reinforcement schedule” in which a behavior is occasionally, and unpredictably, rewarded. It’s the most powerful pattern possible if you are interested in maintaining a behavior. We can compare this to what happens in casinos. Gamblers know that there is always the possibility that their next bet will be a winner. They know that, even if they are on a losing streak, the next roll of the dice could be the one that changes their fortune. And in animal studies, if you want to maximize a behavior you connect it to a reward that is randomly administered. This is essentially the way that behaviors are responded to in most facilities, virtually guaranteeing that any problematic behavior will be intermittently and inadvertently rewarded, and as a result will persist indefinitely.
For example, the “threat” to call Mrs. Jones’s daughter — intended to discourage the verbal outbursts — may actually backfire. Perhaps Mrs. Jones’s daughter will come in the next day to discourage her from verbally abusing her fellow residents and staff. But perhaps she will also bring in one of her famous cherry pies? Or, even better for Mrs. Jones, bring her favorite granddaughter?
The only way change inappropriate behavior over time is to ensure that it is no longer rewarded — that it is disconnected from any goal that the resident would perceive as desirable. It’s a simple concept whose implementation is not simple. Such an undertaking requires the development and implementation of a behavior management plan including an agreed-upon approach to the resident’s unwanted behavior. Ideally, a consulting psychologist should quarterback this effort with input from all members of the interdisciplinary team. Once the team has thoroughly reviewed the behavioral history and discussed the interventions that were previously attempted, the team agrees to one form of response with a seemingly high likelihood of success. One technique is to identify the staff member who has the most successful interactions with the resident and develop a behavior plan modeled on those effective interventions.
Once the team selects the initial approach that will be utilized when the unwanted behavior occurs, it’s critical to communicate the chosen response to all members of the team — on all three shifts — and inform any staff members who may come into contact with the resident. Just like at the casino, if you hit the jackpot once in a blue moon, you will continue to gamble. In the post-acute setting, if an unwanted behavior even occasionally receives a rewarding response, it will continue to be exhibited.
When initiating a behavior management plan, it’s important to recognize that there may be a trial and error period. It is not always intuitively obvious which staff response has the best chance of success. At times, the first response chosen may turn out to be one that inadvertently reinforces or even exacerbates the unwanted behavior. But it’s important to stick with a manner of responding for a sufficient amount of time before attempting another method. This is particularly true when working with residents with dementia. For these residents, a significant number of staff interventions may be required before the resident comes to understand that their behavior is no longer operating in their best interest. So it’s important to stick with a chosen staff response to unwanted behavior for long enough to provide an adequate number of experiences for the resident before deciding that another response should be attempted.
It’s also important to recognize that a behavior management plan is not something we do to the resident, but rather something that we do with the resident. We want to involve the resident to the greatest extent possible. Remember, the resident is trying to express a need or reach a goal through their behavior, albeit inappropriately, but there is almost always a more prosocial way for the resident to achieve that end. The psychologist and all staff members who are involved with the resident will be working with her to demonstrate there is a way for her to meet her needs that doesn’t involve inappropriate behavior.
As part of this collaboration, it’s important to recognize that staff tend to avoid “difficult” residents, and as a result predominantly interact with them when they are behaving problematically. Staff members should be encouraged to “catch the resident doing something right” and recognize that behavior. This promotes frequent positive reinforcement of the behaviors we want to increase, as opposed to just trying to decrease negative behaviors.
For example, perhaps Mrs. Jones has come to connect her unwanted behavior to a visit from her daughter. Would it be feasible to involve her daughter in the behavior management plan so that she agrees to visit her mom after a certain amount of time passes without the unwanted behavior? We want to get to the point at which Mrs. Jones’s CNA tells her: “You know, we’ve all noticed that you’ve been so respectful to everyone around here for three days. I’m going to call your daughter to let her know, and I’m going to ask her if she will visit you tomorrow and bring that cherry pie. Keep it up!”
Historically, facilities’ inability to effectively manage behavior through these types of plans is one of the key factors behind the overuse of antipsychotic medications in post-acute care. Do non-pharmacological behavior management plans always work? They don’t, because some residents are simply too cognitively impaired or psychiatrically compromised to benefit. In these cases, the fact that a thoughtful and thorough behavior management plan was attempted can serve as a clinically appropriate rationale for the use of psychotropic interventions.
One last point: I’ve found that an unexpected benefit to helping a facility become adept at behavior management is that it is extremely empowering for staff, who are often frustrated by their inability to have an impact on inappropriate resident behavior. When behavior is “managed” by an anti-psychotic, staff members don’t feel empowered, and there is no learning involved for the resident. In contrast, when interdisciplinary teams become adept at changing resident behavior without psychotropics, it’s an extremely positive outcome not only for the resident but for the staff as well. That is true culture change in action.
Written by: Richard Juman, PsyD, National Director of Psychological Services for TeamHealth
