Managing Distressed Behaviours with Older People in Care — Hygiene Tasks
Managing Distressed Behaviours, particularly with residents presenting combative resistance to basic personal hygiene care, is an increasingly common scenario in care homes for older people that we visit, in our training team’s experience.
Staff should have clear guidance on when and how this scenario is to be managed, including specific instructions about the procedures to be carried out for Managing Distressed Behaviours. Let’s look at what the guidance says.
What the Guidance Says
“Force may be necessary to provide basic care. For example, a person with dementia who develops incontinence may resist interventions to provide basic hygiene and skin care. Bathing and showering with the use of force or restraint may cause distress, and may need to be less frequent than might be ideal. On the other hand, the person may suffer and be stigmatised because of poor hygiene. Caregivers must strike a balance and only use force where necessary and proportionate. Repeated use of force is likely to need formal legal authority.”
— Mental Welfare Commission for Scotland: Right to Treat?
This guidance sets a clear framework: force may sometimes be necessary for basic care, but it must be proportionate, balanced, and legally authorised when repeated. The challenge for care homes is translating this principle into daily practice.
Five Key Issues for Care Homes
When we visit care homes, we consistently find that the gap between guidance and practice comes down to five specific areas. Each one deserves careful attention from managers and staff alike.
1. Creative Approaches
Are staff being given in-depth, appropriate, and relevant training in Managing Distressed Behaviours? There is an excellent training programme called “Bathing without a Battle” from the USA which explores the whole issue of resistance during attempts to bathe elderly service users in care services.
Are carers being exposed to these ideas? Are managers giving their care staff the opportunities and the responsibility to creatively approach these scenarios and to find the best, person-directed pathway for achieving the goal of cleanliness?
Click here to see our video summary of the key ideas in Bathing without a Battle.
Maximum certainty, minimum movement time, and minimum energy expenditure — Guthrie’s Law.
2. Risk Assessment
The manual handling considerations for physically restraining a resident who is resisting urgent and necessary intimate personal care should be addressed by a comprehensive risk assessment and a detailed, person-centred restraint protocol.
Are the staff in the home competent to carry out this Managing Distressed Behaviours assessment? Does the team have sufficient expertise in Behaviour, Communications, and Physical Interventions to carry out the intervention professionally? Without these foundations, the risk of injury — to both resident and staff — rises sharply.
3. Staffing
Are there enough staff available to carry out any such intervention safely? A deficit in the numbers of staff necessary to carry out a particular intervention safely will not be any kind of defence to charges which might arise if an intervention is carried out ineptly and causes an injury to the resident or to the staff.
⚠️ Warning: Understaffing is not a legal defence. If an intervention requires three people to be safe and you only have two, the decision to proceed anyway carries both clinical and legal risk.
4. Foreseeable Risk Requires a Formal Assessment
Where a resident is soiled and needs the attention of care staff to get cleaned up, but resists verbally and physically their efforts to do so, every step of the process to manage this scenario should be managed in a clear, ordered, and auditable way.
This kind of Managing Distressed Behaviours incident is foreseeable and it carries high risk. Therefore, it should be properly risk assessed and is likely to need a formal, written procedure and protocol for the times when it is invoked.
5. Time Issues in the Intervention
Often when we see that this scenario has been recognised and is frequently being encountered by staff, the care plan for the resident has included it. However, we often find that the care plan is vague on details.
It will stipulate that two or three staff must work with the resident to get them clean — under resistance if necessary and when all other options have been exhausted, of course — but the care plan rarely describes the procedure or methods which the staff should use to achieve the task.
What often results is a hodgepodge of different ways to wrestle the resident into various positions, with one member of staff risking injury herself in attempting to clean the subject while dodging blows and enduring scratches and pinches — all of which takes many minutes of high anxiety and stress for both the service user and the staff.
💡 Key takeaway: If force is required, it should be used to achieve its aim skilfully. Maximum certainty, minimum movement time, and minimum energy expenditure. When force is used skilfully, it requires less time, less energy, and creates greater safety and security for all involved. The question every care plan should answer: why is the detail so often missing?
Gerard O’Dea is a conflict management, personal safety, and physical interventions training consultant, helping care home staff and managers in Managing Distressed Behaviours professionally and efficiently while treating everyone involved with dignity and showing them respect. He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes, and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.
For more information: https://youtu.be/xUJacnkpU5o