Aggressive behaviors among older adults living in a health care facility is a problem that affects caregivers and facility residents alike. From 2013 to 2017, the U.S. Government Accountability Office noted a concerning trend: state reporting systems show an increase in aggressive incidents.1 A recent study conducted in New York showed that over the course of just one month, 15.2 percent of residents experienced resident-to-resident aggression of some form.2 Agitated residents can quickly turn into a physical danger for themselves, other residents, visitors, and staff. With the proper education and tools to manage high-stress conflict situations safely, staff can safeguard residents while helping to avoid a reportable event. This article shares best practices and tips for de-escalating aggressive behaviors in residents.
Train Staff on De-escalation Techniques
Training staff proactively is key to effective de-escalation. Advance preparation empowers staff to act confidently when a situation with an agitated resident emerges. At a minimum, training should include:
- How to approach residents with patience and empathy by taking the time to listen to residents’ concerns, validating their feelings, and responding with compassion and understanding.
- How to maintain a safe distance while interacting with agitated residents to avoid making them feel threatened or cornered into a position.
- How to calmly approach residents to build rapport and create a safe and trusting environment, reducing the probability of aggressive outbursts.
Remain Calm and Use Active Listening
Demonstrating a calm demeanor helps begin the de-escalation process and can even help prevent an agitated resident from achieving an aggressive state. Staff can model a calm demeanor by taking slow and deep breaths, maintaining open body language, and using reassuring facial expressions. Staff should read the same cues from the resident’s body language and adjust their approach appropriately. This helps to ensure that staff are humanizing the care process and recognizing the resident as a person with needs and feelings, not tasks that need to be completed.
Use Clear Language and Repeat Back to Show Understanding
Using soft tones, speak slowly and choose simple language, which helps to avoid confusion that can lead to agitated behaviors. Educate staff on how to show empathy, and acknowledge the resident’s feelings by practicing active listening. This may involve restating what the resident said, asking open-ended questions, and using nods or brief verbal affirmations, such as “I see.” These actions help to validate the resident’s emotions. Additionally, allowing residents to express themselves without interruption and summarizing what they said helps them feel heard and respected.
Identify Triggers and Provide Choices
Another crucial step is identifying the root cause of why the resident is upset. After reviewing and ruling out obvious triggers, look at the possibility of an unmet need that the resident cannot communicate that may have prompted the distress. Interviewing staff and assessing the resident may reveal the cause or provide insight into what preceded the behavior. Ask staff to look for patterns. Do certain times of the day, activities, or foods appear to trigger the resident?
Involving family can also help to provide insight on potential triggers. It can also be a way to help calm the resident. Sometimes calling a loved one will ease the resident because a familiar voice may be soothing.
Staff can prevent behavior escalation by offering residents options. Offering choices gives residents a sense of control. It also can redirect a resident’s attention from a fixation on something that may be upsetting or triggering. Providing a choice shows that the staff respect residents’ rights and autonomy, which can lessen feelings of hopelessness that underpin many outbursts.
After identifying potential triggers, staff must attempt to prevent them. Train staff to update the resident’s care plan to reflect triggers and interventions to address those instigations. Effective communication is necessary to ensure all staff know how to avoid triggers while caring for a resident.
Staff should continually add all effective interventions to the resident’s care plan and update it if any further incidents occur. Train staff to ensure all interventions are resident centered. Documentation should show care-planned interventions in use, along with their effectiveness. If a care-planned intervention appears to be no longer effective, the care-plan team should first discuss potential changes with the direct care staff. If an intervention has become futile, remove it from the care plan and put new interventions in place.
Debrief with Staff
Debriefing can be one of a nurse leader’s most important tasks. Interviewing staff who directly care for the resident will elicit information from the epicenter of the incident. Debriefing also shows genuine concern for staff, their safety, and their perspectives on what worked well. Open discussions of shared experiences promote peer support and strengthen the bond among team members.
Debriefing sessions can also reveal crucial knowledge gaps. Once they have identified deficits, nurse leaders can develop additional training, provide resources, and clarify processes that may need improvement. Regular and effective debriefings can have a positive impact on the frontline caregivers, which will, in turn, lead to better clinical outcomes for the residents.3
Conclusion
De-escalating aggressive behaviors in residents requires a comprehensive approach involving the entire care team, residents, and their families or loved ones. This holistic approach helps achieve greater insight and design effective strategies that are tailored for each resident.
By recognizing triggers and early signs of aggression, the care team can preemptively address issues before they escalate to the next level. Conduct ongoing, interactive education for staff to ensure they have the tools and confidence to safely de-escalate agitation in residents. Support systems for both residents and staff are essential—but honing de-escalation skills will lead to a safer environment for both residents and staff.
Lauren Stenson, MSN, RN, CNDLTC, QCP, DNS-CT, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).
References
1. Government Accountability Office. (2019). Nursing homes: Better oversight needed to protect residents from abuse. https://www.gao.gov/products/gao-20-259t
2. Pillemer, K., Teresi, J. A., Ramirez, M., Eimicke, J., Silver, S., Boratgis, G., Meador, R., Schultz, L., Kong, J., Ocepek-Welikson, K., Chang, E.-S., & Lachs, M. S. (2024). Estimated prevalence of resident-to-resident aggression in assisted living. JAMA Network Open, 7(5). https://doi.org/10.1001/jamanetworkopen.2024.9668
3. Evans, T. R., Burns, C., Essex, R., Finnerty, G., Hatton, E., Clements, A. J., Breau, G., Quinn, F., Elliott, H., Smith, L. D., Matthews, B., Jennings, K., Crossman, J., Williams, G., Miller, D., Harold, B., Gurnett, P., Jagodzinski, L., Smith, J., Milligan, W., Markowski, M., Collins, P., Yoshimatsu, Y., Turull, J. M., Colpus, M., Dayson, M., Weldon, S. (2023). A systematic scoping review on the evidence behind debriefing practices for the wellbeing/emotional outcomes of healthcare workers. Frontiers in psychiatry, 14, 1078797. https://doi.org/10.3389/fpsyt.2023.1078797