Strategies for Working with Combative Residents

Nora O’Brien, executive director, Willow Towers Assisted Living and Willow Gardens Memory Care

Working with combative residents can be a significant challenge, and in these instances, staff education, training, and preparation are key to helping to keep everyone safe.

From understanding the causes of the behavior to implementing procedures and staff trainings, there are many ways that senior care facilities can support their staff and residents when tensions rise.

Understanding the Basis of the Behavior

Nora O’Brien, executive director of Willow Towers Assisted Living and Willow Gardens Memory Care in New Rochelle, New York, highlights the importance of redefining some of the words used to describe this behavior.

“We use words like disruptive and aggressive, but our goal is to get away from some of those labeling words. It’s important to focus on behavior symptoms; it’s not the person, it’s the disease. The person didn’t behave like this before they were affected.”

O’Brien explains that there are many challenges with these types of residents, because they’re experiencing anxiety and depression, they’re resistant to care, and they can be impulsive.

Dr. Jim Dan, MD, geriatric clinical advisor and member of the Senior Helpers Board of Directors, highlights that aggressive and combative behaviors always have a root cause, which is most commonly dementia, mental health disorders, and delirium. He notes that it’s important for caregivers to recognize that these are manifold causes, and that those causes need to be diagnosed and treated by appropriate professionals.

Training Staff to Successfully Work with Residents

Staff preparation and training is key to helping staff navigate these types of situations. “One of the most important things is to reduce the situations that create some agitation by preventing the problem in the first place,” says O’Brien. “Across our entire campus, we train our staff to bring out the best in our residents. We have a very low turnover, which makes a very big difference, because we know our residents and they know us. The staff really know what triggers some of those behaviors.”

O’Brien explains that she trains staff in all aspects of dementia. Staff learn communication skills so they can effectively communicate with each other, with residents who don’t have dementia, and with residents who do. Staff also learn de-escalation techniques, and O’Brien notes that the facilities are looking into crisis intervention techniques.

O’Brien also highlights their strategic decision to partner with the Alzheimer’s Foundation of America. “They’ve come in and trained all of our staff members from every department, including administration, dietary, and housekeeping. Everyone who works in our building has gone through the training,” she says. “We do quarterly training internally, and annually the Foundation comes in an helps us. Our staff believe they’re comfortable and confident in interacting with patients with dementia because of that training.”

Techniques to Maximize Safety

Safety is a major concern in some of these situations, and thorough preparation can help to keep both staff and residents safe. Dr. Dan recommends that caregivers focus on staying calm, communicating in reassuring and respectful tones, and focusing on a de-escalation technique that they’ve learned in their training. “Only rarely is physical restraint necessary to ensure the safety of the patient and others,” he says. “In that case, there are also proper techniques that can be utilized. This will almost always require proper training and a team effort.”

O’Brien explains that her staff focus on acting immediately to reduce the risk of harm. “We want to teach our staff how to get in there safely, keep themselves safe, and keep others safe. We’re lucky that there’s lots of research out there that’s helping us to best work with residents with dementia.”

Staff need to be able to focus on themselves first when they find themselves in these situations. O’Brien highlights the importance of staff making sure that they’re calm and avoiding using words that could upset the resident even more. Staff need to move slowly and respect a resident’s personal space. Maintaining soft eye contact and not turning their back on the resident is essential.

O’Brien also emphasizes the importance of how staff speak. “You really want to speak in very short phrases and in a normal tone. Stay very to the point. Our goal is really to calm and comfort residents, and we have to ask for assistance when that’s needed. Having a wonderful team around you is so important.”

When dealing with these challenging situations, the whole team – even across different departments – can help. O’Brien advocates for having the same philosophy across all lines of the business. “Everyone has to speak the same words, we all have to make sure that our interventions are consistent and calm, and we need to make sure that our staff feel that they have everything they need to handle that situation, and someone to go to if a situation is beyond what they can handle,” she says. Putting this degree of thought and preparation in ahead of time ensures that staff have the tools they need to act as a team when situations do arise.

Paige Cerulli

Paige Cerulli is a contributing writer to i Advance Senior Care.