Dealing with difficult behaviors: A risk-management specialist offers advice for managing these hazardous situations. (Feature Article).

Difficult resident behaviors can be observed in nearly all long-term care facilities. In most cases, they are the reason a family decides to place a loved one in a facility. Often a family expects that facility staff can change the behavior. Obviously, that is false.

When is a behavior difficult? When it puts the resident or others in danger, interferes with necessary care, and/or is socially unacceptable.

The causes of disruptive behavior can be classified into five categories:

1. Cognitive. A resident might at times become confused and disoriented. He/she might act out a violent episode from his or her past. He or she might believe that a staff member is there to hurt him, or is someone who has hurt him in the past.

Be aware of "where and when" a resident is cognitively. Don't enter a resident's world of violence, but do enter if it is a pleasant world.

2. Character based. A resident with a violent background will most likely carry that behavior into a facility. The end of life does not necessarily make that person nicer. Character problems are probably the most difficult to handle because of the long history of the behavior. Such a resident also tends to be the most violent. Be aware of this behavior and make sure that more than one staff member is available to manage this resident at all times.

3. Chronic-illness based. Some illnesses will cause significant pain. Pain will sometimes be reflected as a violent verbal or physical outburst. Some medications can also cause behavioral problems. Be sensitive to a resident's pain. Be aware also that each person has a different pain threshold. If the resident is complaining of pain, do as much as possible to relieve that pain. Check with the physician if a noted change of behavior occurs with the taking of medications or if a change in medication causes a significant change in behavior.

4. Substance abuse. A resident with a history of alcohol or drug abuse often shows aggressive behaviors during withdrawal from these substances. Know what substance the resident is addicted to. It might be necessary for the resident to receive specific counseling before entering your facility. Communication with family and physicians can assist in this.

5. Reactive. A common cause of injury to staff and residents is reaction by a resident to a situation that feels threatening, i.e., striking out at a staff member who surprises him or gets too close. Approach the resident so that the resident can see you. Get to the resident's eye level when communicating with him. Make sure the resident understands why you are there and what you plan to do. If a resident doesn't wish to be moved, don't.

Make sure that the temperature and lighting in the facility are pleasing to the resident (keeping in mind, of course, other residents' preferences). Speak to the resident with respect. Call the resident by name, or if appropriate, use a professional title, such as "doctor." Perhaps the resident has a nickname that he prefers.

Allow for "escape routes." We all have a "fight or flight" response to stressful situations. If the resident is not a danger to himself or others, allow that resident to "escape" from apparently stressful situations.

To break it down step by step, when dealing with difficult behaviors, we must:

* define the behavior we wish to manage, .

* create a plan of action to deal with it, act on the plan (conduct in-services with the staff and communicate with the family about it) and

* assess its cause,

Everyone, not just residents, can respond unpredictably to any given situation. When dealing with residents be creative, be safe, and use common sense when difficult behavior occurs.

* review the plan's results to determine if it is working, and change it if necessary.

Kevin Dugan is vice-president of Health Care Safety Specialists. For further information, phone [phone]. To comment on this article, please send an e-mail to [e-mail].