Goal: gain skills on how to assess a difficult behavior
Know the key components how to describe behavior
- Specific: observable, clear, concise, complete, and measurable.
- Simple: as few words as possible, not difficult words.
Understand excess vs deficit behavior
Specific and simple descriptions
The first step in managing behavioral challenges is to describe the behavior using (1) specific and (2) simple language.
Specific descriptions tell others exactly what the behavior looks or sounds like. Specific terms are (a) observable, (b) clear, (c) concise, (d) complete, and (e) measurable. By measureable, the behavior can readily be counted or timed. For example, the patient pinched staff (hard enough to leave a mark) twice while changing the patient’s absorbent briefs. The patient spat once on staff (saliva left the patient and landed within one foot of staff – with no other object nearby). The patient yelled at another patient (i.e., they raised their voice at a much greater volume than commonly used in speech – so much so every word could be easily interpretable by the person in the next room).
Simple descriptions use as few words as possible, and the words are not too difficult to understand, free of jargon. Keeping your behavioral descriptions specific and simple makes it easier for you and other people to accurately observe and keep track of the behavior.
Exercise 1
Listen to the audio file and write down a specific and simple description Show Transcript
Nurse Paul: Hi Dr. Joe Smith. Patient of yours has been agitated since supper. She had Ativan last night with a similar situation. She calmed down quickly after taking Ativan. I was wondering if she could get it again.
Dr. Smith: Yes, potentially. Could you tell me more about her agitated behavior?
Nurse Paul: After supper, she was just pacing back-and-forth in the hall. When I asked her to go back to her room, she was kind of violent.
Dr. Smith: Violent, you said. Could you tell me more about that?
Nurse Paul: I was trying to grab her arms, so I can take her to her room. She shook my hands off and yelled at me “I don’t need help”. That was kind of irritating.
Dr. Smith: Let me think about it a little bit, I will get back to you shortly on our decision.
A patient pacing in the hall after super. When a nurse tried to take her back to her room by grabbing her arm, the patient shook the nurse’s hands off and yelled “I don’t need your help”. This happened the night before. Patient was given Ativan the night before, calmed down quickly after medication was given.
Excess vs deficit behavior
Once the behavior has been defined specifically and simply, then ask yourself: Is this a behavioral (a) excess or (b) deficit? Even though the answer is usually obvious, it’s still important to think about this question. Behavioral challenges are always too much or too little of something. Most often, the behavior is occurring too much or too little in the eyes of others. Ultimately, they are more bothered by the behavioral excesses or deficits.
With behavioral excesses, we see too much behavior of a particular type. For example, when the person asks the same question dozens of times over the course of a day, it is excessive. While there are no hard and fast rules, most individuals would agree that asking the question no more than 2 or 3 times in a day would not be deemed excessive. Of course, physical aggression is always considered excessive. Most individuals adopt a zero-tolerance policy when it comes to physical aggression because it places everyone – including the patient – in harm’s way.
With behavioral deficits, we see too little behavior of a particular type. For example, while it is acceptable refusing to participate in bathing from time to time, we would regard an individual’s self-care as deficient (or a deficit) if he or she refused to bathe for the last 10 days in a row.
Exercise 2
Mark excess or deficit after each behavior
1. Asking not to eat lunch every hour for a morning
2. Refusing to eat three times a day
3. Keep yelling out loud “help” while seating in the hall
4. Not saying anything when staff walk by and say hi to patient
5. Spit at staff every time someone wakls by
6. Pacing between room and nurse station 5 times in a hour
7. Sitting on the floor in a corner and barely moving
Useful Tips
When staff call you about a patient, suitable questions to ask would be:
(1) What does the behavior look like? Please describe it to me. For example, is the patient hitting others with a closed fist, is he or she pinching staff or other patients hard enough to leave a mark, is he or she hitting others with their leg or foot, etc.?
(2) If appropriate, how long does the behavior last? For example, is he or she screaming for 5 seconds, nonstop for 5 minutes, intermittently (i.e., screaming for about 10 seconds, stopping for approximately 10 seconds, then screaming again for 10 seconds), etc. Of course, descriptions of behavior don’t have to be as exact as this; however, the more exact the better. Being more exact means a more reliable behavioral description.
When you get a call about a patient with dementia displaying significant behavioral challenges – particularly aggression – seldom will the caller be calm. Chances are, callers are in over their heads. In those instances, we are challenged ourselves not to escalate emotionally along with them.
Before helping caregivers, one needs to know more about the behavior they’re talking about. While agitated behavior is a common complaint on the part of caregivers, the term, “agitation,” provides little by way of what the behavior actually is. Is the so-called agitated behavior physical aggression, involving striking, pinching, or spitting on others? Does it concern nervously pacing? Does it entail asking the same questions many times over? Simply: One does not know anything, really, by using the term agitated behavior. To be fair, using the term agitation implies a sense of urgency. Using the term agitation implies the behavior is very upsetting to others – perhaps, however, not everyone. Namely, what might be so-called agitated behavior for one provider might not necessarily be for another. Not every provider, for example, might see repetitive questions as agitated behavior. They might go so far as to come to ignore the behavior; seeing it as relatively harmless. On the other hand, if a provider is especially distracted or annoyed by the behavior, he or she might deem it agitated.
The first step in managing behavioral challenges is to describe the behavior using (1) specific and (2) simple language. Specific descriptions tell others exactly what the behavior looks or sounds like. Specific terms are (a) observable, (b) clear, (c) concise, (d) complete, and (e) measurable. By measureable, the behavior can readily be counted or timed. For example, the patient pinched staff (hard enough to leave a mark) twice while changing the patient’s absorbent briefs. The patient spat once on staff (saliva left the patient and landed within one foot of staff – with no other object nearby). The patient yelled at another patient (i.e., they raised their voice at a much greater volume than commonly used in speech – so much so every word could be easily interpretable by the person in the next room).
Simple descriptions use as few words as possible, and the words are not too difficult to understand, free of jargon. Keeping your behavioral descriptions specific and simple makes it easier for you and other people to accurately observe and keep track of the behavior.
Pretend that you are in oceanographer and just dredged up a new life form from the bottom of the ocean. As a scientist, you would not say the creature was agitated when you transferred it into the aquarium. Rather, you might say, when touched by an external object, it fills with water like a balloon and emits an inky substance that clouds the water.
To test whether your behavioral description is specific and simple enough, imagine giving the written description to another individual does not know anything about the patient. After reading the behavioral description alone, would he or she be able to identify the behavior of interest? If your description is unclear, you may want to consider re-writing it and testing it out a second or third time.
So, when staff call you about a patient, suitable questions to ask would be: (1) What does the behavior look like? Please describe it to me. For example, is the patient hitting others with a closed fist, is he or she pinching staff or other patients hard enough to leave a mark, is he or she hitting others with their leg or foot, etc.? (2) If appropriate, how long does the behavior last? For example, is he or she screaming for 5 seconds, nonstop for 5 minutes, intermittently (i.e., screaming for about 10 seconds, stopping for approximately 10 seconds, then screaming again for 10 seconds), etc. Of course, descriptions of behavior don’t have to be as exact as this, however, the more exact the better. Being more exact means a more reliable behavioral description.
Once the behavior has been defined specifically and simply, then ask yourself: Is this a behavioral (a) excess or (b) deficit? Even though the answer is usually obvious, it’s still important to think about this question. Behavioral challenges are always too much or too little of something. Most often, the behavior is occurring too much or too little in the eyes of others. Ultimately, they are more bothered by the behavioral excesses or deficits.
With behavioral excesses, we see too much behavior of a particular type. For example, when the person asks the same question dozens of times over the course of a day, it is excessive. While there are no hard and fast rules, most individuals would agreed that asking the question no more than 2 or 3 times in a day would not be deemed excessive. Of course, physical aggression is always considered excessive. Most individuals adopt a zero-tolerance policy when it comes to physical aggression because it places everyone – including the patient – in harm’s way.
With behavioral deficits, we see too little behavior of a particular type. For example, while it is acceptable refusing to participate in bathing from time to time, we would regard an individual’s self-care as deficient (or a deficit) if he or she refused to bathe for the last 10 days in a row.