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Is your staff ready for violent residents? Appropriate training is a necessity--but what are its ingredients?

Where would you feel safer working, a nursing home or a coal mine? According to the Occupational Safety & Health Administration (OSHA), you and your employees may be better off in a coal mine--or a paper mill, steel mill, or warehouse. Last year, nearly a quarter of a million workplace injuries occurred in nursing homes.

As administrators are well aware, much of this has to do with nursing aides and other senior-care staff spending much of their time lifting residents from beds or chairs, as well as picking up and moving equipment and supplies. Today, however, another safety issue is assuming nearly as much importance in the nursing home: workplace violence.

As nursing homes admit more residents with Alzheimer's disease, psychiatric disorders, and other conditions often associated with challenging behaviors, staff are faced with increasing incidents of resident violence. This has contributed to a spike in workers' compensation costs for America's nursing homes and other senior living residences, which pay more than a billion dollars in workers' compensation premiums and claims every year. Moreover, violence is likely a contributing factor to today's high double-digit staff turnover rates.

Facility caregivers can be particularly vulnerable to incidents of violence because their jobs require them to put the welfare of residents ahead of their own. When violence breaks out, they often have to rush in quickly, shielding potential victims or intervening with attackers before they can injure themselves or others. This can lead to a variety of staff injuries, ranging from minor to debilitating.

The key to protecting staff is appropriate staff training. While it's true that most senior care residences already have training programs of this sort in place, most don't include sufficient education on those behavioral issues that are unique to senior populations in institutions. Training programs can also be inappropriate when they fail to consider the special challenges of working with physically frail seniors. As a result, many so-called "crisis management" programs teach staff skills that are not compatible with seniors' needs, long-term care regulations, or staff's well-being.

To be effective, training programs should transcend traditional care safety topics and provide caregivers with the fundamental skills for preventing, minimizing, and managing challenging behaviors in the elderly. The four basic elements of a successful training program include:


An emphasis on helping caregivers understand the causes of challenging behavior in elders. Staff should know what neurologic, organic, and medical conditions are tied to certain behaviors. They should also be trained to recognize the variety of physical, social, and treatment-based stimuli that can evoke or provoke challenging behavior--including aspects of their own behavior as staff. Additionally, training in the behavioral antecedents, precursors, or "early signals" that residents exhibit prior to violent episodes can help staff intervene prior to a dangerous escalation of an incident.

A focus on basic techniques for interacting with behaviorally challenged residents. This includes teaching staff proper positioning of themselves vis-a-vis residents who are behaviorally challenging, verbal communication skills, and ways to supplement verbal requests with helpful gestures and other visual cues. Such training should stress the importance of allowing seniors sufficient time to process requests from staff and teach deescalation strategies applicable to the developing and evolving agitation often exhibited by seniors.

Competency in procedures that can decrease the occurrence of challenging behaviors. Many proven reinforcement-based procedures often go unused, including but not limited to:

* Behavioral momentum--requesting and reinforcing behaviors that are highly probable just prior to requesting a less probable behavior. For example, if Mrs. Smith resists going to the dining room, but is always compliant with the process of raising her arms, putting on her sweater, and standing up, staff can go through this process, praising Mrs. Smith at each step, and then request that she then proceed to the dining room, praising her when she does so.

* Reinforcement of alternative behaviors--i.e., reinforcing behaviors other than the challenging behavior or brief periods of time during which the challenging behavior does not occur. For example, if Bill attempts to stand up from his wheelchair every 30 minutes so that the nurses will rush to him and urge him to sit down, the nurses can instead approach him every 20 to 30 minutes to praise him for remaining seated, eventually increasing the time between visits.

* Behavioral chaining--dividing tasks (for instance, ADLs) into small steps, and prompting and reinforcing completion of each step, subsequently and gradually "fading" the prompts and reinforcement as the resident completes the steps smoothly.

Demonstrations of safe and therapeutic behavioral-crisis management strategies. For managing dangerous situations, staff must be trained in techniques that are safe for fragile elderly residents, safe for the staff providing care, and "behaviorally neutral" so that they won't increase the likelihood of future behavioral issues through inadvertent reinforcement. Absent direct, hands-on training in specific and especially designed strategies, staff are left with unapproved, untrained, and/or potentially abusive techniques to stop aggression and other behavioral challenges. Effective training programs should address the most commonly encountered forms of violence, including but not limited to:

* Grabbing and scratching

* Striking out, hitting

* Pushing, shoving

* Throwing/breaking objects

By enhancing training to address senior-specific issues and strategies, senior care residences can reduce the potential for neglect and abuse and increase residents' independent functioning, in addition to reducing their and staff's injuries. While training, in and of itself, won't eliminate workplace violence and injuries, it can have a significant impact and across-the-board benefits.


David Lennox, PhD, is President of Quality Behavioral Solutions, Inc. (QBS), based in Holliston, Mass. QBS provides behavioral training, consultation, and program development services to long-term care settings throughout the United States. For further information, phone (866) 429-9211 or visit To comment on this article, please send your e-mail to For reprints in quantities of 100 or more, call (866) 377-6454.
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Title Annotation:featurearticle
Author:Lennox, David
Publication:Nursing Homes
Date:Oct 1, 2004
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