As more residents lash out, providers seek interventions

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Long-term care nurses have always had astronomical injury rates. That holds true today more than ever – but with a twist. The cause of many injuries has changed.

Combative behavior has become so common that many caregivers are analyzing the causes and trying new ways of training to alleviate it.

"Three to four years ago, transferring patients was our biggest problem," says Loren Salvietti, administrator of Quaboag on the Commons, West Brookfield, MA. But even though she and other staff members made headway alleviating that issue, they found incident reports of worker injuries still kept coming.

"Last year, we realized our newest problem was resident violence," Salvietti says. Staff members were being scratched, hit, bitten and pulled by residents.

The staff at Springside of Pittsfield in Pittsfield, MA, had the same problem.

"We had a resident who looked like someone we wouldn't be able to manage," recalls administrator Darrell Carlson of a violent patient.

Long-term caregivers have become all too familiar with combative residents, the majority of whom suffer from dementia caused by advanced forms of diseases such as Alzheimer's and Huntington's, experts say. The problem is only worsening as baby boomers are poised to flood every level of senior care.

"Most facilities will have at least one or two, and some may have more," Carlson says.

At-risk workers

In an industry rife with staff turnover, it is valid to worry that even one resident's aggressive behavior is enough to make caregivers feel "vulnerable, threatened," according to Anna Ortigara, vice president of the Campaign for Culture Change of the Life Services Network in Illinois.

"Resident violence can be seen from two angles, in my opinion," Ortigara says. "Staff members need to understand the aggressive behavior as communication from the resident with dementia and then recognize that the residents are expressing their unmet needs."
For example, a man suffering from dementia may interpret a caregiver waking him up for breakfast as an intruder in his home. He may try to protect himself by kicking, hitting and screaming. These are common situations that staff members must be prepared to understand and settle with minimal force, Ortigara says.

Educating and maintaining consistent staffing is essential to build this understanding and to create relationships between caregivers and residents. When residents become familiar with caregivers, they do not communicate aggressively as often, and when caregivers become familiar with their residents, they can interpret behavior more effectively, experts point out.

"Dementia care is about person-centered, relationship-based care, and to do that, facilities need consistent staff, and the organizations need to value and respect their staff and support them to be in those relationships with residents," Ortigara says.

Many facilities recognize the need for staff preparation and have reached out to experts for help.

Dr. David Lennox, founder and president of Quality Behavioral Solutions in Holliston, MA, for example, visits facilities to conduct safety analyses and two-hour "Geri-Care" sessions. He teaches 15 to 20 caregivers at a time skills to reduce and prevent combative behavior, such as wrist pulls, without injuring themselves or the residents.

Right touch needed

Lennox says it's important to have a "kinder, gentler program," designed specifically to assist care for geriatrics, who are more sensitive, more fragile, sustainable to falls, and experience cognitive disabilities.

Although Lennox's price tag for for-profit organizations is $1,240 and non-profit organizations $1,040, some administrators say the cost is worth the staff satisfaction and incident reduction.

Patricia Hewitt, senior nursing mentor on all floors at Quaboag on the Commons, said she noticed a change almost immediately after seeing the program. Incident reports have dropped to just one per month from 20 during the same time frame. Nursing aides have told Hewitt and other administrators that the program has helped


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