MDS Alert

Improve clinical care and boost morale by following the advice of a SNF medical director and psychologist who've been there and back.

It seems that everyone has a horror story about a particular resident who totally disrupts the operations of their facility. Maybe it is a demanding patient who insists that staff take an excessive amount of time doing personal care tasks that they are capable of doing on their own. Or maybe it is a resident who complains incessantly about certain staff members, splitting the staff into camps of "angels" and "devils." Or perhaps it is a patient who threatens staff and is even physically violent by throwing things at them.

Take cover: Like a tornado, residents like these wreak destruction and havoc in a facility, but there are proven strategies you can implement to minimize the damage, advise Rebecca L. Ferrini, MD, MPH, CMD, medical director, and Robert M. Gibson, PhD, JD, psychologist, at Edgemoor Hospital DP SNF in Santee, Calif.

"Your focus should be on working with your staff to have a plan to contain the damage, because you are not going to fix these difficult residents, some of whom may even be suffering from a long-standing personality disorder," Gibson said during the ""Difficult Patient or Personality Disorder" session at the AMDA Long Term Care Medicine conference in March.

Pay attention to staff reactions

Residents are often defined as "difficult" not because of what they do, but because of how they make staff feel and act, Ferrini noted. Do they make the staff feel inadequate? Ashamed? Angry? Incompetent? Hopeless? "Those are the kinds of feelings that we need to all pick up on as caregivers and realize that this is a situation that needs some intervention both for the resident and for the staff," she explained.

Background info: Ferrini suggested that staff who are dealing with difficult patients may find an article, written by James Groves, MD and published in the New England Journal of Medicine in 1978, helpful to understanding their strong negative reactions. Groves described four categories of difficult patients and the reactions they typically evoke --

1) dependent clingers who induce aversion;

2) entitled demanders who make you want to attack them;

3) manipulative help rejectors who make you feel depressed; and

4) self-destructive deniers who cause you to feel malice.

(The full text of the article, "Taking Care of the Hateful Patient," is available at: www.nejm.org/doi/pdf/10.1056/NEJM197804202981605.)

Staff members typically have these strong negative reactions to the behaviors of difficult patients because they are assuming that these individuals are "normal," Gibson explained. Recognizing that at least some of these residents have personality disorders often helps staff become more understanding and willing to work with these individuals.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) IV defines personality disorders as "an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture . . . and this enduring pattern is inflexible and pervasive . . . and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning." The DSM IV summarizes personality disorders into three clusters (see the slides on pg. 77).

Potential pitfalls: It can be difficult to categorize long-term care residents using the DSM, Gibson noted, because they are not working or doing a lot of things that individuals outside of a nursing facility normally do. "But I think that the disruption of the relationship between care providers is the social piece that applies here. And the key thing is that it is pervasive and inflexible," he said.

Although labeling a difficult resident with a personality disorder can be destructive, if it is done prudently it can help staff understand that they are dealing with a disorder rather than simply an unpleasant person. "It is key to remind staff that these behaviors are manifestations of an illness," Ferrini emphasized. "I find that if the staff think the person is doing it on purpose, they can get very angry, but if they think that it's part of their illness, they become more accepting," she said.

Make staff aware that these residents did not choose to have this problem, Gibson added. "I mean the people with personality disorders, as much as they make us angry and frustrated, we can walk away. In many cases these patients are in more pain than just about anyone I've ever seen," he said.

However, simply knowing that a difficult resident suffers from a personality disorder, will not magically fix that individual, Gibson warned. "Once you realize that you have a person with a personality disorder, the first thing you think is that you will simply call in a psychiatrist or psychologist who is the expert and can fix the problem for you," Ferrini said. "But what we have found is that although the psychologist can be really helpful in supporting the staff and providing us with background information, it turns out that this is not really a fixable problem."

LTC limitations: Gibson noted that the typical course for treating a personality disorder realistically just isn't going to happen in the long-term care facility. "It is clear that psychotropic medications won't work with these patients, and it is not the case that finding the right drug or the right psychiatrist for a consultation will fix the resident. These patients did not come to our facilities for that kind of treatment and we generally don't have the resources to treat them like they would be in the community," he explained.

Instead, staff needs to focus on managing the difficult resident's behavior through a system of positive and negative reinforcements (see the "Pearls for PD management" slides on pg. 77). The first step is to identify the specific behavior that is troublesome and approach it systematically. Staff should ask and answer the following questions: "What is the behavior? Why might it be happening? Who is it a problem for? What things make it worse? What things make it better? What are we doing now? Is any part of it working?"

Positive reinforcement: Often the key to identifying why a behavior is occurring is to find out what the resident is seeking through that behavior, Ferrini noted. "For instance, a resident who is very demanding of staff time may need more socialization, but they have poor social skills so they only socialize in a medical relationship where somebody is completely engaged in getting their point of view. The answer to that problem is to meet that need in some other, less destructive way."

"For example," Ferrini suggested, "you can tell the resident that if he does not make any complaints for an hour, a member of staff will come in to visit with them. If the resident is successful in doing this, a staff member should go in after an hour and very purposely say, 'Thank you for not bothering me because I was able to get my work done, and now I can take a break in my routine and sit and talk with you for a bit.' This process gives both the resident and the staff a sense of control," she added.

Initially doing this may be hard for staff, Gibson noted, because they are busy and often try to deal with the situation by avoiding the resident. Getting them to reward these difficult patients is actually counterintuitive, but it is very important for staff to understand and follow through on the necessity of rewarding the more desirable behavior rather than the negative behavior of acting out, he emphasized.

Power of compliments: Ferrini agreed that it can be hard for staff to do this. "They tell me, 'He's so bad, why do you keep telling him so many good things?' Well, because that's the behavioral plan and it works." Many difficult patients respond very well to compliments, so staff should make sure they are recognizing positive behavioral changes. "It's amazing how incredibly powerful compliments for some of these people can be because in many cases they don't ever hear anything good. So if they are actually doing something good, let them know. Behavior actually does improve," Gibson said.

However, he warned, some patients suffering from personality disorders may actually have trouble with compliments and they could make their behaviors even worse. "You've got to watch each patient's reaction to a certain reinforcer to make sure it is appreciated. If it turns out that it is the wrong thing for that individual, then you have to look at something else that hopefully will work better," Gibson added (see pg. 77 for a sample Behavior Management Care Plan).

Another key step is to instruct your staff members on how to appropriately and safely disengage from difficult residents. In particular, certified nursing assistants (CNAs) can find themselves in a situation, such as changing a resident's brief, where it would be unsafe for them to simply walk away. "So we work very specifically with staff and write into the resident's care plan the exact phrases that staff are to use to disengage from an abusive situation while also protecting themselves from an accusation of abuse," Ferrini explained.

"If something bad happens, we make it really clear how our staff can leave while also ensuring that the resident is safe. For instance, you can't leave someone in an unsafe position, but you can leave them undressed. You cover them with a blanket, lower the bed to the floor and tell them, 'I need to keep you safe, but I need to leave until you've calmed down," she said.

Although it is tempting to rotate staff with your difficult patients, this practice often makes the situation worse. "The problem with behavior management plans fundamentally is you need consistency 24-7. So if one CNA or other staff member caves in, you just blew it for however long," Gibson warned. "There's the tendency to want to appoint staff in a fair manner, but in some cases, certain staff members are actually very good in dealing with a particular individual who is difficult for everyone else."

Negative reactions: If this is the case, he recommends facilities consistently assign these staff members to these individuals. This allows the resident to develop the healing relationships that many individuals with personality disorders lack. "If we keep moving them, then it reinforces the idea that they are not able to connect to others," Ferrini said.

In many cases, that's the story of their life, Gibson added. "They start to establish connections and relationships with people and they fall apart. And they do it all over again, and that's been the pattern. And so in some ways, we may just be continuing that, which is going to continue the behavior and it's not got any chance in making things better," he explained.

So if at all possible, Gibson recommends, facilities maintain consistent staff assignments for difficult residents. "Just make sure you're not burning them out, because you don't want to punish good staff," he noted. One way to support staff members who are consistently assigned to the difficult patients is to acknowledge the successes that they are having. "When there's a success, go to the staff and tell them, 'You did a great job. You fixed them . . . Maybe it's only 20 percent better, but 20 percent is better than nothing.' That's the way to give them control, because you give them credit for the improvement that they make. You say, 'Bravo, to you'," Ferrini explained.

(Editor's note: An audio recording of Ferrini and Gibson's complete presentation and copies of their handouts are available from: www.prolibraries.com.)