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A systems approach to behavior management.

Applying psychological principles to quality - of a life issues in the LTC industry

IT'S A TYPICAL DAY. STAFF COMPLAINTS ABOUT MR. S's DEMANDING and abusive behavior are pouring in. Mrs. B was found urinating in the hallway again. Her roommate, Mrs. F, refuses to be bathed and has stopped eating. There goes the exit alarm, which probably means that Mr. T is trying to elope again. And, of course, the surveyors just walked through the front door.

In the fast-paced, medically complex, and regulation-packed environment of skilled nursing facilities, resident behavior may get little extra attention unless it disrupts the delivery of routine care or clearly represents a threat to safety. In fact, resident behavior is an essential indicator of well being, providing vital clues to medical and mental health status and psychosocial adjustment. It is as important to monitor the behavior of each resident, and to know how to respond to behavioral changes, as it is to check vital signs regularly for symptoms of illness.

Mental health problems of residents

Behavior is the means by which people attempt to meet basic needs. Many resident behaviors are ineffective or even bizarre attempts. According to the Surgeon General's Report on Mental Health, [1] up to two thirds of residents in nursing homes suffer an identifiable mental disorder including dementia, depression, late-onset schizophrenia, or anxiety. The risk of suicide also significantly increases with age.

While well prepared to deal with the medical needs of the frail elderly, SNFs are generally less equipped to provide proper care for mental illness. Hands-on care providers, as well as others (including primary-care physicians) may hold the mistaken belief that mental illness and dysfunctional behaviors are inevitable effects of old age. Residents are capable of constructive change, however, even when struggling with chronic physical and mental illness. With proper behavior-management training, staff members can learn to recognize and modify the biomedical, psychosocial, and environmental factors, which interact to shape the behavior of residents.

Typical approaches

Various approaches to behavior management have been utilized in the long term care industry. Historically, physical and chemical restraints were used to control a wide range of behaviors. This approach provided short-term convenience at a significant cost to resident rights, quality of life, and safety.

More recently, facilities have relied on behavioral consultants such as psychiatrists, psychologists, and social workers to treat residents with dysfunctional behavior. Psychiatric involvement often led to increased use of psychoactive medications, which conflicted with facility goals to reduce the use of those medications. Reliance on outside consultants also reinforced staff perceptions that behavior problems required external expertise and were "not our responsibility." The best of these consultants provided some training to available staff during the consultation, but of necessity that training was hit or miss, The failure of this approach lies in the inconsistency with which resident behavioral treatment has been integrated into care planning. Additionally, the compensation rate has been a disincentive for qualified professionals to visit facilities, creating lack of access to this resource especially in rural settings.

Short-term staff training has been one of the most recent efforts by the industry, with mixed success. The periodic in-service and crisis-response approaches have been used to deal with behavior problems in reaction to an injury or poor survey results for behavioral indicators. Such training might provide a short-term fix for an immediate crisis, but it generally does not prevent future problems.

Another common approach is the specialized program, in which staff members working with residents of an Alzheimer's, dementia, or behavior unit receive additional training in behavior management. This training improves the care of residents on that unit, but does not address the behavioral needs of residents in other units. Given the Surgeon General's estimate of the prevalence of mental health problems in nursing homes, it would make more sense to have a specialty unit for the one-third of the residents without mental health or behavioral difficulties.

Systems approach to behavior management

Given the shortcomings of these approaches, what is needed is an expansion of the quality-of-life vision and mission to encompass behavioral care. In 1998, the Pennsylvania Department of Health mandated that behavior management would become a focus of surveyors in Pennsylvania. That led the Pennsylvania Association of County Affiliated Homes (PACAH) to promote a more systematic approach to behavior management among member facilities.

With grant funding from the County Commissioners Association of Pennsylvania, PACAH selected GeroServices, a Pittsburgh-based psychology and consulting practice, to develop a behavior management system for resident care. The goal was to design a system that would be flexible enough to meet the needs of individual facilities and could be implemented through a time-limited consultation and training program.

A guiding principle behind the development of the behavior management system was that each facility has different leadership, staff, and physical plant resources. This variability in the culture of the facility was considered a significant factor in developing an approach to behavior management for the industry. The components of the behavior-management system had to be flexible and responsive to the individual culture of each facility while remaining cost effective and efficient.

The basic components of the system follow sound program-development methods, whether used to install a behavior-management system or institute a new wound care program.

Leadership development

The consulting team first worked with the administrator and key management to designate a team of key staff members that would lead the project. Typically the administrator, assistant administrator, DON, ADON, and directors of social services and activities participate. Other managers, such as the directors of medicine, pharmacy, dietary, maintenance, security, and finance, are also encouraged to participate. Participation of representatives from line-level nursing staff and therapies is also encouraged. While this is a large group (often eight to 35 people), it is important to understand that this program is intended to change the culture of the facility, and all key stakeholders must be involved for optimal success.

A seminar, workbook, and PowerPoint presentation introduced the leadership group to behavior-management principles and practices. The seminar also included strategic planning and organizational development issues that would need to be addressed for success of the project. These include a discussion of the formal structure of the organization with an authority chart, a review of vision and mission statements, identification of essential stakeholders, internal and external constraints, internal and external resources, and key strategies for working with stakeholders.

Administration is key

A visible and informed administration is key to a facility's success in implementing a behavior-management system. The administrator, with the assistance of strong middle managers, must identify the mission and vision clearly, communicate it to all facility staff members and work with key stakeholders throughout the program-development process. Facilities that were the least successful were frequently those in which administrators were drawn away by other priorities and delegated too much of the responsibility. A few notable exceptions involved facilities with very strong middle-management leadership.

Good leaders have a realistic sense of the strengths of their team. Some facilities were not prepared to develop and implement a new program because of deficits in basic meeting skills, communication skills, time-management skills, or severe interdepartmental conflicts. One anticipated obstacle, understaffing, turned out to be less of an issue than expected. Even facilities with severe staffing problems were effective when basic leadership skills were present.

Policy and procedure

The backbone of a systematic approach to behavior management is the development of formal policy and procedure. Accordingly, one of the products of the initial work with the management team was written policy and procedure. Based upon information and decisions elicited from the group, the consultants generated the procedures for carrying out behavior management, within the existing culture and practices of the facility. A critical first step, the written procedure laid the foundation to implement the program.

Naturally, such a written procedure would have to be customized for each facility, depending upon the facility's communication practices and role assignments. It would include policy and procedure that define behavior management and specify how cases are identified and assessed; how an intervention is designed, implemented and evaluated; how staff training is carried out, and how a behavioral crisis is addressed.

Templates for behavior-management policy and procedure that could easily be adapted to meet the needs of individual facilities were developed. These were further refined into a computer program or "policy and procedure wizard." The wizard produced a customized policy and procedure based on the answers to 30 questions provided by facility management during the leadership seminar. The wizard allowed management to produce a complete draft of a behavior-management policy and procedure in a few hours.

The final outcome of the leadership seminar was a detailed action plan for the project with objectives, resources, accountability, and dates established.

Staff training

All staff members must be trained to an appropriate level of knowledge about the behavioral science that constitutes the core of behavior management. (See "Courses of action," facing page.)

Two levels of training materials were developed for the program. A basic course provided nursing assistants and other direct care staff, such as dietary and activity aides, housekeepers, and maintenance staff, with the essential concepts and application of behavior management. These staff members, who provide nearly 80 percent of one-to-one contact, are often in the best position to notice and report changes in behavior. They can assist in carrying out interventions by implementing new approaches and responses to the resident.

A trainer's guide assisted the in-service coordinator in planning and implementing a facility-wide training effort. Many facilities found it more manageable to target a few units at a time and distribute the total training effort over several months' time.

Skill building

The next step in the process was to develop the competence and confidence of the staff in applying behavior-management principles to actual cases. Following the facility's in-service training with the course materials, the consultants conducted skill training during four sessions. Skill training was designed to help staff members apply what they had been learning through the course material to the real world of the unit. Using a case conference model, the consultants led a cross-section of care planners and hands-on caregivers through the process of behavior management for an actual resident with behavioral problems.

The first session focused on identifying a good case for behavior management, clarifying the target behavior, and determining a practical method for conducting a baseline assessment of the behavior. The second session focused on interpreting the baseline data and designing a realistic behavioral intervention. The third session reviewed the results of the intervention and identified any problems in the approach that would need to be corrected. Organizational problems such as lack of inter-staff communication, cooperation, and consistency were the most common obstacles requiring midcourse correction. The final session again reviewed the progress of the intervention, as well as the entire skill-training process, and generated recommendations for modification of the policy and procedure, as needed.

By the end of the skill-building phase, and termination of the consultation and training sessions, the facilities were generally prepared to expand the scope of their program to include their remaining units. The general success of the project made expansion to other units more effective as staff members promoted the benefits to one another.

While many facilities were well prepared to carry on independently, others were less prepared. To assist the facilities after the system was implemented, GeroServices initiated a telephone support service. Most calls have involved technical questions about the design of interventions for difficult cases. Less often, the questions involved staff or organizational development issues.

Results and benefits

To date, 45 facilities have implemented the GeroServices behavior-management system. Another 28 are in progress. Of the cases piloted, almost 75 percent were resolved positively with significant improvement in the target behaviors. Of these, about half were resolved by simple changes in staff approach and response behaviors, while the others required more sophisticated or complex interventions. About a fourth of the cases were not resolved successfully. This group includes those suffering deteriorating medical conditions (including death); failure of staff follow-up, communication, or consistency; and unexplained or other failures.

Most facilities continue to use the training materials and follow the system. Some have made this training mandatory for all new hires. Management and direct care staff have reported: (1) an increased sense of empowerment in working with behavioral problems, (2) reduced use of restraints and psychoactive medications, and (3) success stories of once-recalcitrant behavior problems that are now well managed. Perhaps the most important outcome is the increased sense of competence and confidence observed, as nurses, aides, and other staff members report that, "Mrs. S isn't really a problem anymore, not if you know how to approach her."

Dr. Wyckoff is a psychologist with more than 30 years of clinical and consulting experience. He founded (Pittsburgh; 412-421-7400) in 1988 with the mission to apply psychological principles to quality-of-life issues in the long term care industry. Linda Wyckoff is an attorney who consults with long term care facilities in behavior-related areas. Katherine Heart is a specialist in health education and curriculum development.


(1.) Mental Health: A Report of the Surgeon General, Chapter 5 Older Adults and Mental Health,

Courses of action

The basic course requires six lessons. Each lesson takes 30 to 45 minutes to complete. The materials for this course retails for $75 for a set of workbooks and tapes. Additional workbooks are available for $20 each. This includes the scoring service for the tests and CEUs, where applicable.

The advanced course has 12 lessons. Each lesson takes approximately 45 to 60 minutes to complete. The set of tapes and workbooks retails for $150, with additional workbook sets available for $60 each. This also includes the test-scoring service and CEUs. where applicable.
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Publication:Contemporary Long Term Care
Date:May 1, 2001
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