This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

Do we need help?

Let’s look at two other ‘categories’ of challenging behaviour:

  • Behaviours that we can cope with;
  • Behaviours that are beyond our ability or authority.

Behaviours that we can cope with

These are behaviours that fall within our own skill set and area of expertise. For example a care home resident refusing to bathe from time to time. It is well within the authority of the staff to decide how best to handle it. However, if the refusal is accompanied by signs of depression or dementia for example then the larger multi-disciplinary team may well need to be involved.

For example, I remember working with a young drug-user who simply stopped going to bed. Instead he would sleep in the communal lounge on the settee. Speaking with him (not ‘to’ him, by the way) seemed to make him more determined to sleep in the lounge, even though the settee was too short and uncomfortable. So we decided simply to stop mentioning it.

We provided an alternative area for other service-users and ignored the fact that he was sleeping in the communal lounge altogether. We didn’t even mention it when he started to complain of back pain. We simply suggested that he might want to see his GP about pain relief. He didn’t make the appointment but he did stop sleeping on the settee.

The decision to stand back and wait for him to learn ‘the lesson of experience’ was ours to make and the situation was remarkably easy to resolve. Often ‘the path of least resistance’ really is the way to deal with things that are within our remit to solve.

Behaviours that are beyond our ability or authority to cope with

When I was a community psychiatric nurse I had a client who regularly called me reporting that she’d taken an overdose and asking for an ambulance. Actually I’ve had several clients who did that over the years.

The more I responded the more frequently she called. She didn’t always tell the truth (sometimes she had overdosed and sometimes she hadn’t) but I had no way to know in advance.

I wanted to stop responding to these situations because by reacting to the phone calls I was only making things worse. However, I needed the support of the multi-disciplinary team first. So I called a meeting involving all the relevant workers, the service-user herself and (with permission) her brother was also present

We decided upon a new care plan. Essentially we all agreed (including the service-user) that if she was able to call me she was also able to call an ambulance if that was what she needed. We therefore agreed that I would expect her to do precisely that in the future. If she called me reporting an overdose I would advise her to call an ambulance and remind her of our scheduled appointment time (which may be some time in the future).

The behaviour stopped working for her and she stopped. She called in these circumstances only twice more before changing tack and talking about her real problems instead. I’m not going to pretend that the problem she presented next was easy to resolve by any means but at least we got to focus upon the thing that mattered instead of a haze of challenging behaviours that served only to distract us both from the real work we had before us.

The point here is that although I ended up doing precisely what I thought was right I needed the backing of the multi-disciplinary team first. Their ‘blessing’ was important.

Sometimes we need others to get involved when we discuss what we need to do about a situation. There’s no problem with that – it’s just appropriate.

Incidentally this doesn’t mean that the decision not to respond to my overdosing service-user was a ‘team decision’. It was always my decision how to respond when I picked up the ‘phone (and I could have changed my mind had circumstances demanded it). Team meetings don’t take away our responsibility for our own decisions – if you’re ‘on the spot’ you decide what to do – but they do make those decisions easier to defend if we need to. My decision was safer because I had discussed the situation with the team and they had agreed with my strategy.

Had I not discussed the situation with the multi-disciplinary team and my client really had overdosed I’d have had a hard time explaining my actions to the ensuing inquiry. As it was – had she come to grief (she didn’t but she might have) I’d have been able to defend my decision precisely because of the involvement of the team.

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