Combative behavior in a long-term care setting refers to a resident exhibiting physical or verbal aggression, which can include hitting, pushing, shouting, or threatening language. This behavior is often a response to an underlying distress the resident cannot communicate effectively, not a deliberate act of malice. For the nursing assistant (NA) providing care, these incidents can be emotionally and physically taxing, requiring a systematic approach focused on safety and resolution. The primary goal in these situations is to protect both the resident and the staff, while recognizing that the aggression is symptomatic of an unmet need or condition.
Prioritizing Immediate Safety and Situation Assessment
The immediate priority when a resident becomes combative is securing the physical safety of the nursing assistant and others. This requires the NA to maintain personal safety by quickly creating physical distance from the resident, ideally a minimum of two arm lengths away. Maintaining an unobstructed exit route is important, ensuring the NA can leave the area if the aggression escalates to a dangerous level.
Scan the environment rapidly to identify potential hazards or objects the resident could use to harm themselves or others. If possible, gently and calmly move other residents out of the immediate area to a safer location. If the NA cannot safely de-escalate the situation alone, or if the resident poses an immediate threat, the NA must call for backup from the supervising nurse or another team member without delay.
Employing Verbal and Non-Verbal De-escalation
Effective de-escalation begins when the nursing assistant maintains a calm demeanor and controls their body language. The NA should adopt a non-threatening stance, such as standing at an angle to the resident with hands visible and relaxed, avoiding crossed arms or pointing gestures. Approaching the resident from the front, where they can clearly see the caregiver, helps to reduce surprise and the perception of being cornered.
In verbal communication, a calm, low, and steady voice is most effective, as a loud or authoritative tone can increase the resident’s anxiety and fear. Since lengthy messages can be confusing, use short, simple sentences. The NA should validate the resident’s expressed emotion by saying something like, “I see you are very upset,” without agreeing with or condoning the aggressive action.
Active listening involves giving the resident full attention and using body language to show they are being heard. Offering limited, simple choices, such as “Would you like to sit in your chair or stand by the window?” can restore a sense of control and reduce frustration. Avoid arguing or confronting the resident’s reality; instead, focus on redirection to a more positive activity. Environmental adjustments, such as reducing noise or dimming bright lights, can also lessen sensory overstimulation that may be contributing to the agitation.
Identifying and Addressing Contributing Factors
Combative behavior is frequently a form of communication, indicating an unmet physical, emotional, or environmental need. Common triggers relate to physical discomfort the resident cannot articulate, such as chronic pain or confusion caused by a urinary tract infection (UTI). Aggression may also be a side effect of certain medications, including sedatives or pain relievers, or a manifestation of delirium.
Cognitive conditions like dementia can lead to confusion, paranoia, and fear, causing the resident to misinterpret harmless care as a threat. “Sundowning,” where confusion and agitation worsen in the late afternoon or evening, is a common trigger. Environmental factors like excessive noise, a rushed approach, or a change in routine can also lead to an outburst. Identifying these underlying factors through careful observation is necessary to develop long-term prevention strategies.
Essential Documentation and Reporting Procedures
Following a combative incident, the nursing assistant must immediately report the event to the supervising nurse. This report ensures the nurse can assess the resident for injury, medical changes, and the need for immediate intervention. The NA is responsible for accurate and objective documentation of the incident in the resident’s record.
Documentation must be completed promptly, including factual details rather than opinions or subjective judgments. The charting needs to specify the exact time, location, the objective description of the resident’s behavior, the NA’s specific response, and the outcome of the interaction. This detailed record informs the interdisciplinary team and allows for necessary adjustments to the resident’s care plan to prevent future episodes.