Long-Term Care Survey Alert

Tailor interventions to the level of behavior.

To care for cognitively intact residents who lash out due to mental illness or anger issues, you need a plan long before you're in the thick of an aggressive episode.

The goal: Teach staff how to intervene at each stage of behavior as it escalates toward potential aggression. That's the approach used by Crisis Prevention Institute (CPI) in Brookfield, WI, which identifies four levels of behaviors in training staff to preempt physical aggression.

The first level occurs when a person shows a change in behavior, expressing anxiety or agitation. To address that stage, the staff person asks herself how she can be supportive to that particular patient, says Judith Schubert, president of CPI. Providing individualized support and empathetic listening will help the individual understand that staff is there to help her deal with her challenges, says Schubert. "This helps promote a sense of self-control instead of communicating that the person is out of control," she adds.

Supportive intervention helps prevent the person from escalating into a more irrational state, which represents the second level of behavior. At this level, the individual may become verbally aggressive and defiant, Schubert says. And his irrational thinking makes it difficult for him to recognize staff's supportive efforts. If the person's emotions continue to escalate, his irrational thinking may lead him to a third level of behavior where he acts out in physically aggressive ways, she adds.

Staff can, however, help defuse the person at the second level by being calm, direct and offering the person choices to help him calm down. For example, you might offer the person an opportunity to go for a walk with a trusted staff person to reduce his agitation or participate in a calming activity that he enjoys.

When the verbal escalating occurs, staff should intervene quickly, offering the resident choices while he still has some control. The third level of behavior involves further escalation to potential physical aggression, a scenario that staff must manage very carefully using a risk assessment approach and training (for details, see the next Long-Term Care Survey Alert).

The fourth level of behavior encompasses the aftermath of an episode of irrationality.

Beware: This period may seem like the calm after the storm, but don't be misled. Staff can make the mistake of thinking, "Oh good, the person has stopped yelling or hitting or whatever he or she was doing," Schubert cautions.

But if the person is "afraid, confused or embarrassed," she could spiral back into a crisis mode, she says.

Thus, staff should use this time to help the person understand what happened and how to do things differently in the future -- "you want to capture that teachable moment."

Proactive strategy: Use the debriefing with the resident to help your staff reflect on their own practice in order to help prevent further incidents, suggests Michael Partie, president of Therapeutic Options Inc. in Newark, DE. For example, does the resident only get attention or privacy when he behaves aggressively?

Partie finds that sometimes staff's actions inadvertently provoke aggressive episodes, or the way in which the facility provides services creates the conditions in which aggression can occur.

Example: Howard Smith, a team leader at a tertiary psychiatric facility in British Columbia with a geriatric unit has found that having people line up for meals can lead to aggression. Thus, the facility has eliminated all line-ups. You can do that by extending meal times and using other creative arrangements.