Dr. Richard Juman
Dr. Richard Juman


With all the recent restrictions on psychotropic medications in skilled nursing facilities, many facilities find themselves struggling with a resurgence in unwanted resident behaviors that were previously well-managed by anti-psychotics, benzodiazepines and other drugs. When these medications are reduced or discontinued because of a gradual dose reduction (GDR), it is predictable that, in some cases, challenging behavior will re-emerge. Unless facilities have a plan to use non-pharmacologic interventions to prevent the recurrence of unwanted behaviors, many GDRs will fail.

Among the non-pharmacologic interventions facilities may consider are changes to environmental factors. This article, the first in a three-part series on the essentials of managing behavior in long-term care, explores seven environmental best practices that are associated with significant reductions in unwanted behavior. Subsequent articles will address how facilities should evaluate residents whose behaviors are problematic, and strategies for implementing behavior management plans to address those behaviors.

The ideal SNF environment

Some facilities seem to have a calm, warm environment that just “feels” less likely to precipitate or encourage disruptive behaviors. I’ve been in many facilities that manage to construct an appealing environment in which there are low levels of aggressive, disruptive or disturbing behavior. They aren’t constantly responding to problematic behaviors because they have figured out ways to proactively prevent them.

How do these facilities achieve this goal? Here are some SNF best practices I’ve observed that help create an environment that prevents and reduces unwanted behaviors:

  • Reduce noise level and stimulation. Many facilities have already done a great job at eliminating their unnecessary and disturbing overhead paging systems. The best facilities have gone the extra mile by installing quiet flooring and soothing lighting that can be dimmed at bedtime to help prepare residents for a good night’s sleep. And having a designated “quiet area” so residents can get away from noise and other agitating stimulation is a great option.
  • Give residents choices whenever possible. Long-term care residents lose the opportunity to make many everyday decisions that most people take for granted — like who gets to sleep in their room with them every night. Think hard about elements of a resident’s daily and weekly schedules that he or she might be allowed to self-determine without compromising the facility’s need to maintain order. A good rule of thumb is that the more choices a resident is permitted, the more satisfied he or she will be, and the less likely to engage in unwanted behavior.
  • Maintain stable staffing assignments. When I speak with post-acute workers I often ask: “If you were a long-term care resident, would you rather have a great nurse’s aide or a great doctor?” Everybody knows the answer to this question — even when I’m speaking to a room full of doctors. In many ways, the world “shrinks” as we age, and we become more focused on our own health and immediate surroundings. Nowhere is that truer than in the SNF, where for many residents their unit, or even their room, is their world. For residents, the importance of the CNA who enters their room daily to provide care and human contact cannot be overstated. Turnover is high in many facilities, so anything we can do to address it (which includes training staff to intervene successfully around behavioral disturbances) will help, as will being careful and mindful before we change CNA work assignments that separate residents from their regular caregivers.
  • Answer the call bell promptly. Nobody likes the helpless and frustrating feeling of being ignored. Those of us who live in the community know how it feels when our efforts to communicate or receive a service go unanswered. So we can almost understand what residents must feel when their call bell goes unanswered — almost, because we typically don’t find ourselves in the position of asking others to address a basic human need such us toileting, hunger, thirst or pain relief.
    Understanding that staff members are likely attending to other residents in these situations, do whatever can be done to respond to the call, even if it can’t be addressed right away. Telling a resident “I’m sorry Mr. Jones, I’m in the middle of helping somebody else, but I know you need me and will be back as soon as I can,” is a thousand times better than ignoring the call and letting Mr. Jones’s frustration and anger continue to escalate.
  • Make careful, conscious decisions about room assignments. Negative interactions between roommates when personalities, habits, tolerance for stimulation or schedules are not a good fit are commonly associated with poor outcomes and inappropriate behaviors. Optimally, room assignments in long-term care would be well-considered, mindful efforts to pair residents who might “hit it off” and become positive sources of support for each other. One caveat here is that any move for a nursing home resident, even a well-intended one, can be traumatic and disorienting for some residents. So, balance the desire to pair people optimally with the potentially negative impact on a resident who is moving from one room to another.
  • Provide adequate pain management. A person in pain is often agitated and a potential candidate for unwanted behavior, and unfortunately many nursing home residents deal with pain constantly. But we must also weigh our strategy for providing pain relief with a concern about the overuse of opioid therapy. It was recently reported that 1 out of 7 SNF residents are on some type of long-term opioid. Obviously, these medications have significant medical side effects and can blunt a resident’s ability and motivation to acclimate to the facility, connect with other residents and live the most meaningful life possible. Wherever practical, non-opioid pain medications and evidence-based non-pharmacologic strategies such as relaxation training, hypnosis and certain forms of psychotherapy should be employed.
  • Offer staff training. Nursing home staff are often overwhelmed by the range of behavioral disturbances and psychiatric issues that are now common in SNFs. Facilities that are unable to successfully improve unwanted behaviors are unappealing to residents and families, as well as staff members — who are then apt to leave. The good news is training staff to better understand disruptive behavior and to communicate with and de-escalate residents who are engaging in unwanted behaviors has a significant impact on both resident behavior and staff satisfaction. Going beyond these trainings by offering staff coaching about how subtle changes in posture, tone of voice and body language can impact on residents’ moods is an extra step that will help both staff and residents maintain a positive attitude.

These are actions any facility can take to help improve behavior. I encourage all facility leaders to think about their residents with concerning behaviors and consider whether making some simple environmental changes may have a positive impact.

Parts 2 and 3 of this series will focus on the strategies and techniques that can be used to help those individuals.

Richard Juman, Psy.D., is a psychologist and national director of psychological services with TeamHealth.