Behavioral Interventions

In healthcare settings, clients, staff members, and visitors may face risks of injury due to clients inappropriate or abnormal behavior. Therefore, it is important for nurses to recognize clients who are at risk for displaying such behaviors and implement strategies for prevention and management.

In this learning experience, learners will acquire knowledge and insights into behavioral interventions. This includes a focus on identifying clients who may exhibit inappropriate or abnormal behaviors, and employing behavior modification techniques and interventions to both prevent and manage these behaviors effectively.

8.1 Assessment of Clients for Inappropriate or Abnormal Behavior

Nurses should assess clients across the lifespan for various types of inappropriate or abnormal behavior, considering developmental age, specific behaviors, and their underlying reasons (Burke, 2023):

• Infant: May become listless due to a lack of bonding with parents or failure to develop trust.
• Toddler: Might act defiantly as a part of developmental milestones, such as during toilet training.
• Preschool Child: Could be withdrawn because of neglect or abuse.
• School-Age Child: May bully others due to underlying psychological issues, like low self-esteem.
• Adolescent: Could exhibit suicidal tendencies secondary to the distress caused by a deformity or disfigurement.
• Adult: Might act impulsively and may experience suicidal or homicidal thoughts due to depression, possibly triggered by job loss.
• Elderly: Can become aggressive, either verbally or physically, and display anger, often as a result of dementia.

According to Burke (2023), additional risks factors for these behaviors include:

• A personal history of engaging in these behaviors.
• Living in a family or environment characterized by dysfunction and violence.
• A lack of adequate support systems, or the complete absence of such systems.
• Poor coping strategies, along with issues in impulse control and self-control.
• Psychiatric illness that presents symptoms such as hallucinations and delusions.

Triggers:

Along with gathering information about their clients' behaviors, nurses should identify the triggers that caused these behaviors to understand if they are disruptive or dangerous to the clients themselves, as well as others (Burke, 2023). For example, behavior could range from yelling at another client to physical aggression towards a visitor or staff member. Triggers social factors can stem from various sources, including and:

• Environmental conditions, like uncomfortable temperatures that are too hot or too cold.
• Physical factors, such as fatigue, fever, pain, illness, or sensory impairments like visual and auditory issues.
• Psychological factors, which may encompass psychiatric disorders, psychological trauma, and histories of abuse or neglect.

Assessments:

Nurses assess their clients for inappropriate or abnormal behaviors by examining changes in appearance, mood, and psychomotor behaviors (Burke, 2023):

• Changes in Appearance: Observation should focus on the client's hygiene, grooming, gait, posture, and the appropriateness of their clothing. Normal behavior typically includes being well-groomed, having normal posture, and wearing attire suitable for the weather and setting. For instance, inappropriate attire might be a female client visiting a community clinic in winter dressed in a revealing evening gown.
• Mood and Affect: These are assessed through the client's verbal and nonverbal communication. Nurses should observe whether the client's is sad, flat, and depressed or if it is happy and elated.
• Psychomotor Behaviors: This involves observing whether the client maintains eye contact, displays grimacing, or exhibits unusual sounds and movements. For example, a client who is agitated, angry, restless and/or hostile may pace.

Conducting a psychological assessment is crucial for nurses, which includes assessing clients' level of consciousness using the Glasgow Coma Scale and their cognition using the Mini-Mental State Examination (MMSE) (Burke, 2023).

• Level of Consciousness:
• Alert: Clients respond appropriately to questions and follow commands.
• Confused: Clients required assistance to respond properly, exhibiting poor judgement, thinking, and/or disorientation to their environment.
• Lethargic: Clients are very drowsy but aroused with verbal or tactile stimulation.
• Obtunded: Clients respond slowly to repeated stimuli.
• Stuporous: Clients respond with groans or grunts to very deep stimuli.
• Comatose: Clients do not respond to any stimuli.
• Level of cognition is assessed by evaluating:
• Orientation to time, day, person, and place.
• Grounding in reality.
• Memory, including:
• Long-term or remote memory.
• Recent or intermediate memory.
• Immediate or short-term memory.
• Understanding of their illness.
• Speech characteristics, like quality and speed.
• Ability to abstract, referring to the ability to think about concepts and ideas beyond concrete and immediate experiences.

Psychological assessments are adapted for different age groups, such as children, adolescents, and the elderly (Burke, 2023). The approach varies as follows:

Children and Adolescents:

• Assess their disposition and coping mechanisms.
• Evaluate their emotional state, including potential eating disorders and risk for suicide.
• Consider their stage of growth and development and ability to meet related challenges.

For the elderly, use standardized tests to assessment:

• Depression: Use the Geriatric Depression Scale.
• Pain in Advanced Dementia: Apply the Pain Assessment in Advanced Dementia Scale.
• Pain Assessment: Employ tools like FACES and McGill Pain Assessment.
• Alcoholism: Use the geriatric version of the Michigan Alcoholism Screening Test.

When assessing clients, it is important to be kind and unbiased. Adherence to healthcare facility policies and procedures for documenting and reporting assessment findings is crucial. Collaborate with other healthcare team members, as interventions are often based on the data gathered from these assessments.

8.2 Behavior Modification

Behavioral modification and therapy are recognized as treatment modalities for clients with mental illness (Kaplan Nursing, 2023). These approaches are based on the premise that psychological issues are learned behaviors, and thus, problematic behaviors can be rectified through relearning. During behavior modification, positive behaviors are reinforced through rewards and praise, while negative behaviors, such as acting out are met with negative reinforcement (Burke, 2023). According to Kaplan Nursing (2023), two primary treatment methods include:

• Operant Conditioning: This involves using rewards to promote positive behaviors, eventually making these rewards more significant than external reinforcement.
• Desensitization: Often used in the treatment of phobias, this method allows clients to gradually become accustomed to what they perceive as threatening.

8.3 Behavioral Management Techniques

Nurses employ a variety of behavioral management techniques to care for clients exhibiting inappropriate or abnormal behavior, with the primary goal being prevention of such behaviors (Burke, 2023). These techniques aim to help clients gain control on their behavior. According to Burke (2023), effective prevention strategies include:

• Providing a safe and supportive environment.
• Setting clear expectations and achievable goals for each client.
• Maintaining consistency in schedules and routine, such as bedtime.
• Identify and remove the factors that prompt inappropriate or abnormal behavior. This can be achieved, for instance, through Milieu therapy. According to Burke (2023), this mental health treatment modality helps clients become aware of their feelings, take responsibility, and improve their functioning and coping. The treatment focuses on:
• Creating social and physical environments that are positive.
• Organizing structured activities and groups.
• Implementing interventions using a one-on-one approach.
• Encourage clients to engage in socializing and enjoyable activities.
• Implement alternative and complementary interventions, such as music or pet therapy.
• Promote physical activity and teach stress and relaxation techniques like deep breathing and meditation.

Additionally, Burke (2023) describes further behavior management techniques nurses can utilize:

• Contracting: The client signs a written agreement outlining clear expectations, including do's and don'ts.
• Modeling: A psychological therapist demonstrates appropriate behaviors for the client to observe and then practice.
• Desensitization: Clients are intentionally, systematically, and progressively exposed to stimuli in a supportive environment, helping them learn to cope with these stimuli.
• Operant Conditioning: Clients received praise and rewards for exhibiting appropriate behavior.
• Aversion Therapy: Clients lose privileges as a consequence of inappropriate behavior.

If prevention strategies are unsuccessful and clients display inappropriate or abnormal behavior, nurses should work in tandem with other healthcare team members to implement the following interventions (Burke, 2023):

• Promptly de-escalate the behavior.
• Establish and adhere to clear boundaries.
• Encourage and reinforce improvements by rewarding and praising the clients.
• Maintain eye contact with the client, ensuring both parties are at the same level.
• Use a calm voice and body language, giving clear and concise instructions to the client to cease the behavior.
• Help the client manage and diffuse intense emotions or disorders, such as anger, hostility, or anxiety, through physical activities like walking.

Additionally, it's important to follow the healthcare facility's policies and procedures for assessing, documenting, and evaluating behavioral interventions.

After completing this learning experience, the learner will have acquired deeper insights into behavioral interventions. The main goals are to prepare learners for successful performance on the NCLEX examination and to enhance their skills in caring for their clients.

After reviewing the provided resources, identify areas where further improvement is needed. Concentrating on these areas will significantly increase their competence in both preventing and managing inappropriate or abnormal behaviors in clients.

• Burke, A. (2023, September 27). Behavior Interventions: NCLEX-RN. https://www.registerednursing.org/nclex/behavioral-interventions/#assessing-clients-appearance-mood-psychomotor-behavior-identifying-responding-inappropriate-abnormal-behavior
• Kaplan Nursing. (2023). NCLEX-RN Content Review Guide: Preparation for the NCLEX-RN Examination (9th ed.). Kaplan Test Prep.

Readings

• Sutton, J. (2021, June 3). The Birth of Online Behavioral Interventions. https://positivepsychology.com/behavioral-interventions/

Videos

• Level Up RN. (2021, August 4). Relaxation Techniques: Milieu, Group, and Behavioral Therapy | @LevelUpRN [Video]. YouTube. https://youtu.be/6EAcTjUzhNI