In part one of this blog series on Behaviour Support Planning in residential aged care, we learned that the outcome from the Royal Commission’s recommendation number 17 was new regulations around restrictive practices. Residents are now required to have a Behaviour Support Plan in place if they have changed behaviours, or are at risk of restrictive practices. In part one, I took you on a brief journey through the first 3 stages of the Behaviour Support Planning process. These were:
- Collaborate and Identify
- Set Goals
In the residential aged care setting, having collaborated, identified the behaviour of concern; and following the assessment and goal-setting for the individual, the team will meet to plan and design best-practice and appropriate interventions.
In this leg of the journey we are going to revisit the first 3 stages, and explore the realm of intervention design using an illustrative case study.
Any interventions must be tailored to the individual and be based upon the comprehensive assessment information. Interventions are designed to address the causal factors, address the function of the behaviour, and to remove any restrictive practices.
In order to illustrate intervention design, a case study will be used. This case was first described and published in the evaluation of the first Sydney Behaviour Assessment and Intervention Service (BAsIS) (Turner & Snowdon 2009). Firstly, we will follow the process as outlined so far in part one of the blog ie. collaborate, identify the behaviour, conduct an assessment, and set goals for the individual. Then, we will proceed with design of interventions.
Bill (not his real name) was an 88-year-old widower with stroke related cognitive impairment, and probable vascular dementia. He had been living in the nursing home for 12 months due to not being able to care for himself at home. He was referred for vocally disruptive behavior, specifically loud calling out (bellowing) of “help”.
1. Collaborate & Identify
A meeting was held with staff and family, and information obtained about Bill, the behaviour of concern, and the impact on the nursing staff.
Nursing and care staff identified that the calling out was the behaviour of most concern. They reported this behaviour was distressing to other residents and their visitors.
Staff noted that Bill looked sad at times, and was rarely happy. His daughter commented that she frequently found Bill in his room alone with the door and curtains closed.
Bill was on an antipsychotic medication, Haloperidol 0.5 mg twice daily, at the time of referral.
The care staff said they had “tried everything”, including attending to Bill every time he called out; attending to him intermittently ie. some staff attended to him when calling out and some did not, and some said it depended on how busy they were; giving PRN analgesia ie. when staff considered he was in pain; leaving him in bed every alternate day; changing his chair and mattress; and wheeling him to another area when noisy.
Bill presented a worried, non-reactive affect. He acknowledged being unhappy, bored and lonely. He said at times he was frightened and scared of the “women who do this, that and the other to me.” He said his sleep was poor, denied any nightmares but said he had flashbacks to unpleasant war-time memories (he had been a Wellington bomber pilot in the Royal Air Force).
He scored 16 on the Cornell Scale for Depression in Dementia (CSDD), indicative of significant signs and symptoms of depression. There was no evidence of any psychotic phenomena. He scored 6 out of 28 on the Mini Mental State Examination (MMSE), consistent with significant cognitive impairment. Bill scored in the moderately to severely impaired range on the Clinical Dementia Rating Scale (CDR).
Bill was non-ambulant resulting from inactivity since admission to the nursing home, and he was incontinent of urine and feces. The GP had prescribed PRN analgesia for pain; the location and cause of which were not diagnosed. Bill scored 6 on the Abbey Pain Scale, consistent with mild chronic pain.
Bill had significant hearing impairment and did not wear a hearing aid. His loud voice was thought to be related to his inability to hear himself or others. His hearing impairment meant that staff had difficulty communicating with him and in discussing or understanding his needs. This added to his social isolation and sensory deprivation.
A functional analysis revealed that Bill had learned that he could obtain staff attention for calling out. Evidence for this was documented on the monitoring form. When care staff asked (in a loud voice) “what’s wrong Bill,” he said “nothing, I just wanted to see you again.” This indicated that the function of the behaviour was an attempt at engagement with another human, to meet Bill’s need for social contact ie. he was lonely; and also to communicate his distress.
It was a high frequency behaviour, and was not associated with any particular time of day.
Staff reported that Bill’s behaviour caused severe problems for the residential aged care facility (neighbours had reported it to the council), and they rated him as very stressful to care for. On the Cohen Mansfield Agitation Inventory Bill was rated as moderately disturbed (total score = 75).
A shower observation revealed that Bill was very distressed by the process. He was moved from the bed with a swing hoist to a flat metal trolley for the shower. Bill called out “help” 110 times during 30 minutes. In response to each of Bill’s calls for help, the care staff said “shh…..the baby’s sleeping”. On one occasion Bill responded “bugger the bloody baby!” There was no physical aggression. Within the 30 minutes, there was only one occasion each of reassurance and praise from the care staff.
The causal factors in Bill’s case were depression, fear, loneliness, pain and discomfort, sensory deprivation, cognitive and communication impairments, lack of meaningful activities, inappropriate shower procedure, and inadvertent reinforcement by staff of the vocally disruptive behavior.
You may have noted that restrictive practices were also being used with Bill. These were:-
1. Chemical restraint (antipsychotic medication for purposes of controlling behaviour); and
2. Seclusion (being left alone in a room with no way out and no access to help).
The goals for Bill were to:-
- Increase appropriate attempts at communication. This was the functionally equivalent replacement behaviour (FERB). This would subsequently minimise the frequency of calling out behaviour.
- Improve relationships with care staff
- Improve mood (ie. treat and manage the depression)
- Feel more calm and relaxed in the environment
- Engage in enjoyable and meaningful activities
- Improve sense of belonging in the nursing home
- Maximise sensory function (hearing)
Interventions were designed to address the causal factors, address the function of the behaviour, and to remove the restrictive practices. Each causal factor will be addressed.
Depression, fear, and loneliness
The anti-psychotic was ceased because Bill was not psychotic, and it was acting as a chemical restraint. An anti-depressant was recommended by the Psychogeriatrician, and subsequently commenced, to treat the depression.
Bill was to be seated near other residents for a short time each day; and be taken for walks in the wheelchair outside the nursing home each day. Staff were advised to reassure Bill of his safety on a regular basis.
Pain and discomfort
Regular analgesia was commenced. PRN (as necessary) analgesia is inadequate for people with dementia because it relies upon the staff deciding if and when the person is in pain, and this is variable. I once knew a Clinical Nurse Consultant who used to say that “PRN analgesia for people with dementia stands for “Pain Relief Never”.
Lack of meaningful activities
A program of individualised activities was devised, including looking through a photo album that was put together by Bill’s daughter, and looking at books about airplanes. Importantly, these activities required engagement with the staff. Sitting in the communal room as a passive participant during other activities was also recommended.
Inadvertent reinforcement of behaviour
The calling out behaviour had been reinforced on the strongest of all reinforcement schedules ie. intermittent reinforcement.
“The predominance of intermittent reinforcement schedules ….. introduces considerable variability in social behaviours. Often a person acts inappropriately because he may not know the particular schedule on which other people base reinforcement of his behaviour“.
Kanfer & Phillips (1970) p73.
The plan was to have staff attention contingent on time rather than calling out, and to increase positive reinforcement for Bill’s appropriate attempts at communication.
Staff were asked to seek out Bill, and talk to him briefly at hourly intervals, and to minimize attention to his calling out in between contacts, whilst ensuring his safety. An important concept here is that attention is not an “all or nothing” response. Staff were also asked to give additional positive attention to Bill when he was quiet, and when he made appropriate attempts at communication.
Inappropriate shower procedure
The showering procedure was changed. Specifically, a standing hoist and shower chair were used instead of a swing hoist and a flat trolley. This helped Bill to feel safe and more in control during the shower. Staff were advised how best to approach Bill for the shower ie. giving lots of priming (cueing about what’s about to happen), and brief verbal explanations. Staff were advised to nominate one carer for communicating during the shower, and educated on how to best communicate with Bill in a reassuring way during the shower. Staff were asked to cease saying “Sh….the baby’s sleeping”; and it was explained to them that the aim was to provide reassuring, reality orientation information and not add to Bill’s confusion.
Reality orientation information was provided on a large print chart that Bill was prompted to read regularly, as a form of both reality orientation and reassurance. This chart had the details of of Bill’s current living arrangements. Staff were to provide verbal orientation to time and place at least once per shift.
A hearing assessment was organized, and new hearing aids were obtained. Care staff were advised to put these in Bill’s ears each day, and reinforce their use.
The interventions were written into a Behaviour Care Plan template, together with the goals they were addressing. An education and training session with staff was conducted. In this session, rationale for the interventions was discussed, and staff had the opportunity to express any concerns or ask questions.
Behaviour always serves a purpose for the person; to express a thought or feeling, to meet a need, to achieve a positive outcome, or avoid something unpleasant. For Bill, the calling out behaviour was an attempt to make social contact, and to communicate how he was feeling ie. depressed, in pain, lonely and frightened. Ultimately, he was trying to help himself feel better, through the only means he had available, his voice.
This real life example of Bill has highlighted the main concepts underlying best-practice behaviour support intervention design. Good interventions must:-
- Be designed collaboratively and agreed upon by all stakeholders
- Be individualised
- Address the underlying biopsychosocial causal, contributing, and maintaining factors
- Address the function of the behaviour (usually an attempt to meet a need). What is this person trying to communicate or achieve with the behaviour? What is the function of their behaviour from their perspective?
- Focus on recognising and meeting the person’s needs
- Consider the impact of, and change if necessary, the environmental context, setting events, including the antecedents and consequences, of the behaviour
- Remove any restrictive practices
The next leg of the journey, part three of the blog series, will examine the complex topic of implementation of behaviour support plans within the residential aged care environment, continuing to use Bill as an illustrative case study.
Behaviour support planning is part of our core business. If you are committed to provide best-practice behaviour support for your residents, while meeting regulatory requirements; or if you would like to learn more about behaviour support planning, please contact us at Amazing Ageing Psychology on 9844-5403, or send an email enquiry through our website here.
Senior Clinical Psychologist
Amazing Ageing Psychology
Copyright © Jane Turner 2022
All images in this blog are used under license from Shutterstock.com
Kanfer, F. H., & Phillips, J. S. (1970). Learning Foundations of Behaviour Theory, Wiley International Edition: Sydney.
Turner, J., & Snowdon, J. (2009). An innovative approach to behavioural assessment and intervention residential care: A service evaluation. Clinical Gerontologist, 32:260-275.