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Resolving Resident Conflict – Combative Behavior [Part I] Residents in long-term care may experience chronic cognitive impairment or confusion which may manifest into combative behavior. It is imperative to recognize that a resident’s combativeness could be the residents’ effort to communicate need for care. Healthcare professionals must always be mindful that the behavior is not personal in nature; as in emotional feelings of dislike or misplaced, unwarranted fear. Communication issues can occur when a resident has limited (receptive) abilities that fail to translate to a normal dialog appropriately. Reduced information processing speed and capacity can be attributed to problems with comprehension. Even simplified sentences can put a strain on residents’ brain processing resources to assimilate more information than he/she is capable of understanding. Aging adults may also be (expressively) compromised with less ability to form comprehensible sentence structures, largely due to declining working memory capacity. The healthcare professionals’ ability to assess, understand and take action to prevent combative behavior “before it occurs” will significantly reduce communication breakdowns and help the resident to be more fully accepting of his/her personal care. What is Combative Behavior? Any physically aggressive act that causes or is intended to cause hurt or damage to another person or object and even to self may be an indicator of combative behavior. Some types typically encountered in long-term care may include: Physical acts- punches, fighting, kicks to endanger others Resisting care- aggressively hampering efforts to accomplish ADL’s (bathing or dressing) Verbal aggression- arguing, cursing, threatening or accusing Catastrophic reaction- sudden mood swings, outbursts, or lack of self-control What may cause combative behavior? Psycho-social: Resident feels threatened by life changes and frustrated at a perceived loss of control. Unable to communicate adequately, a resident may misinterpret efforts to provide care or may be unable to control his/her feelings, or may withdraw from interaction due to conflicting thought processing. Environmental: Room lighting that is either too bright or too dim, blaring radios, television, intrusive central facility intercom announcements, clutter or constant staff traffic distractions, unanticipated room changes or routine changes, lack of consideration for how the resident likes his/her belongings arranged or reorganizing without resident involvement. Other areas that should be respected include the halls, nursing stations, dining rooms and any and all locations residents can easily navigate as part of their daily living. Dementia: A declining brain disorder affecting both personality and thought processing. It is an organic brain disease caused by a number of illnesses (including Alzheimer’s) that is considered progressive in which the afflicted individual begins to lose touch with reality and is unable to understand the world they have found themselves surrounded by. Unskilled care-giving: Staff unknowingly contribute to behavior issues when they take a position of authority, display gestures that startle or frighten, administer care roughly or in hurried fashion, display impatience, or speak in loud or demeaning conversation. Multi-faceted underlying illness: A comprehensive assessment must be done to determine the probability of other underlying medical illnesses that further contributing to aggressive behavior; and may include non-organic external elements such as alcohol or drugs abuse, medication interactions and lack of sleep. Interventions – The 'Never List' for Resident Agitation 101 NEVER enter a residents’ room in numbers of two or more staff members as it may put the resident in defensive mode. If safety is a concern, ask a supporting staff member to wait outside the room NEVER wear a stethoscope, hanging earrings or shiny jewelry around your neck. NEVER ask the resident to do more than two or more tasks at once; keep your instructions to one-step at a time. NEVER approach a resident quietly by surprise. Allow him/her to see you coming. NEVER forget to introduce yourself every time with a smile; even when your resident knows you. NEVER display your emotions through body posture; emotions are easily expressed non-verbally in body language. NEVER speak to your resident while competing with multiple stimulus such as a radio, television or music. NEVER take action to do something before explaining what you are about to do it in simple terms; ascertain that he/she understands. NEVER approach a wheelchair bound resident face on for your own safety. NEVER underestimate that the resident may also be just as confused and surprised by his/her own behavior as you are. NEVER correct or point out word usage errors expressed by your resident; use visual cues at this time Never, never instruct or state limits when dealing with an agitated resident. Be particularly mindful of certain command statements in the heat of the moment as they only tend to escalate the level of resident transgression: NO – STOP THAT DON’T DO THIS DON’T DO THAT PUT IT DOWN NOW LEAVE IT ALONE STOP GETTING UP While it is impossible to anticipate how one resident may interact with another resident and or staff member, each facility must be prepared to handle difficult interpersonal or behavioral issues. The goal is to prevent escalation from resulting into physical altercations. Behavior modification techniques and strategies must be a standard in-service education for all staff members to develop expertise in dealing with conflict and/ or other related issues involving safety and well being. When aggressive behavior is mismanaged, it affects families, staff and disrupts other residents. But when handled in a respectful, positive way, conflict can be quickly dissipated and restore peaceful harmony within the community. QUIZ 1. TRUE or FALSE A resident’s combative behavior is often a sign that he or she does not like you or is afraid of you. 2. TRUE or FALSE Resisting care, verbal aggression, fighting and catastrophic reactions are common forms of combative behavior. 3. TRUE or FALSE Dementia, the type seen in organic brain diseases such as Alzheimer’s, is the only true medical cause of combative behavior. 4. TRUE or FALSE Combative behavior often occurs when a resident is unable to communicate adequately, misinterprets efforts to provide care or is unable to control feelings. 5. TRUE or FALSE Loud television, speakers or people coming and going, and very bright light do not really trigger combative behavior. 6. TRUE or FALSE Unanticipated room or routine changes can trigger combative behavior. (ANSWERS: T, F, T, F, T, F) Next Week: Part II – Discover Patterns That Lead to Outbursts Have a topic request or question for Celeste? Send them over to celestechase@activitydirector.org Join the Activity Consultants Help Desk or Share the Link with a Friend.. BUY Now Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. We envision facilities that feel like homes and that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. 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