Care strategies

All staff who are involved in providing care need the skills and confidence to manage challenging behaviour as it occurs, as well as strategies to prevent it in the long term.

Managing emergency situations

In an emergency or potentially dangerous situation, those displaying challenging behaviour require the same level of care and attention as anyone else, regardless of their clinical condition and where it takes place. The person may be acutely ill and require immediate, essential treatment, and this must be the primary consideration.

In these situations, having effective strategies for managing challenging behaviour helps prevent it from reducing the ability of staff to provide care. Important principles are:

  • Safety is paramount. Staff should be careful to minimise the danger and risk of injury to themselves and others.
  • Staff need to be skilled in de-escalation; this will often allow them to manage a challenging episode and reduce the frequency of pharmacological or physical intervention.
  • Good verbal and non-verbal communication skills are vital for reducing distress or anxiety.
  • Staff should be supported to move away from a task-focused way of working, toward being compassionate, empathetic, reassuring and understanding about distressing situations from the patient or service user’s perspective.

You can refer to this aide memoire for staff on a practical approach to de-escalating and managing an emergency situation.

Longer-term care

Where individuals remain in treatment or care for longer, staff have the opportunity to develop more sophisticated and comprehensive strategies for individualised care. These strategies should include the following:

  1. Involve family and carers: Encourage family contact to take place as often as possible. Ask family members and carers for information and involve them in certain care tasks where possible. Give them advice on how to interact with the individual and what to expect from the possible effects of their condition and treatment.
  2. Gather information: Learn about the person’s medical history and functional ability, as well as important life events, family history, previous occupations, interests/hobbies, likes and dislikes, normal routines, and spiritual, cultural and religious needs and practices.  Ask families and carers. Record triggers, precursors and challenging episodes (see the section on Understanding challenging behaviour for more information).
  3. Group meeting to plan care: Ensure that all staff caring for the individual are involved in planning care and understand their role. Involve the individual, family and carers where possible. Discuss overall care objectives, possible care strategies and follow-up care. Think about the effect of staff interactions, routines and environmental factors.
  4. Initiate care plan: Make sure all staff, family members and carers are aware of the care plan and know its aims and objectives.
  5. Plan communication strategies: Plan your communication with the individual. Make sure you know the treatment objectives, and agree them with the person (if appropriate). Use appropriate language and non-verbal communication. Be aware of barriers to understanding. Negotiate, explain and avoid confrontation. Use speech and language therapists or find creative solutions to aid communication if needed.
  6. Adapt environment: Consider adapting the environment to make it more homely or therapeutic. Address any disorientation or way-finding problems (particularly important is the finding the way to the bed, ward and toilet). Limit excessive noise, light and crowds.  Address under- or over-stimulation.
  7. Activity programme: Involve occupational therapists, volunteers, other staff, family and carers in planning and delivering activity programmes, which promote health and well-being and avoid boredom and loneliness. Match activities to the person’s interests or former occupation.
  8. Independence and mobility: Maintain dignity and promote self confidence. Encourage the person to do as much as possible for themselves.
  9. Normalise sleep-wake cycles: Provide exercise, stimulation and daylight during the day, in order to encourage sleep at night. Offer help and reassurance with toileting and orientation at night.
  10. Nutrition: Make sure that the individual has adequate food and drink, and consider whether they are able to feed themselves or may need assistance.
  11. Document, monitor and evaluate: Review the care plan daily and make changes when necessary. Communicate changes to all staff.

Some real-life examples of how these strategies have been used to improve care for patients and service users can be found in the Case Studies section.

Communication – talking AND listening

Converse Talk through
Empathise Avoid confrontation
Listen Defuse
Understand Keep promises
Question Enquire
Be transparent Reinforce
Negotiate Check understanding

Non-verbal communication can sometimes be more important than verbal communication:

Tone of voice  
Eye contact Movement
Facial expressions Personal space
Stance and posture Use of touch

This communication tool  may be useful.

Debriefs

Following an episode of challenging behaviour, staff should be given the chance to participate in a debrief, particularly if the episode was serious. A debrief allows staff to reflect on the incident and share their reactions and feelings in a supportive environment. It also provides a valuable learning opportunity to change practice.

While it is vital to allow staff to consider what might be learned from the experience, educational objectives should be covered in a separate meeting from one which is focused on helping staff deal emotionally with the incident (otherwise the debrief could end up with a punitive tone).

Debriefs can be formal or informal and in some cases staff may simply wish for the incident to be acknowledged. For more serious incidents, it may be appropriate to allow some time to pass before arranging a debrief, as trauma can take some time to fully manifest itself.

Follow-up sessions may be helpful in preventing or reducing the severity of post-traumatic stress disorder (PTSD), depression, anxiety or general psychological morbidity caused by the incident.

The patient or service user should also be given the opportunity to debrief, along with any family members or carers, if this is appropriate.

sample staff debrief template can be found in the Resources section.

For further information on care strategies, please consult the full guidance document.