Identify Behaviours of Concern and Plan Responses

Behaviours of concern are defined as behaviours of such intensity, frequency and duration that the physical safety of the person or of others is placed, or is likely to be placed, in serious jeopardy; or behaviours which are likely to seriously limit the use of, or result in the person being denied access to, ordinary community facilities, services and experiences.

Behaviours of concern are also referred to as “challenging behaviour”. However, the term “behaviours of concern” is more widely accepted, as the term “challenging behaviour” implies that the client is inherently problematic due to the behaviours presented (Jorgensen et.al, 2023). Using the term “behaviours of concern” has greater benefits for clients as it encourages workers to externalise the behaviour from the client and approach these behaviours with greater intention to understand and support the client (Jorgensen et.al, 2023).

The biopsychosocial model can be used to understand the reasons for clients presenting with behaviours of concern (Chen, 2022). This model suggests that there are biological, cognitive and social factors that may lead to behaviours of concern. These factors may also influence one another, and a client may be experiencing more than one factor at the same time.

Biopsychosocial Factors

Biological Factors

• Physical Health
• Mental Health
• Medication or intoxication

Biological factors underlying behaviours of concern include the client’s physical and mental health. A client with poor physical health could present with behaviours of concern to communicate the discomfort and pain they are experiencing. Clients may also use behaviours of concern to communicate dehydration and hunger. This is especially so for clients with limited communication skills due to physical health and intellectual disabilities. Behaviours of concern could also signal an underlying mental health disorder such as depression. Clients who are experiencing side effects from medication, alcohol or other substances that impact the client’s physical functioning may also present with behaviours of concern.

Psychological Factors

• Psychological state
• Personal beliefs and attitude
• Coping skills

Psychological factors involve the client’s psychological state, personal beliefs and attitudes, and coping skills. When determining the reasons for behaviours of concern, the worker may consider the client’s psychological state. For example, clients who are in a state of fear due to the anxiety of being in an unfamiliar environment could lead to behaviours of concern. On the other hand, clients who are in a state of boredom could also present with behaviours of concern. How the client is perceiving a situation can lead to behaviours of concern. For example, negative attitudes towards healthcare services due to poor experiences could lead to frustration and thus behaviours of concern. The worker may also consider the client’s coping skills, where some clients may have lower tolerance levels to stimulus such as noise or bright light. Clients with fewer coping skills may also have difficulty managing stressful situations.

Social

• Relationships
• Communication skills

Social factors include the client’s ability to communicate and the client’s social relationships. As discussed previously, clients with limited communication skills may have difficulty expressing their needs and may turn to behaviours of concern to communicate their unmet needs. The lack of support network or presence of caregiver could lead to clients feeling unsupported and isolated, which could lead to behaviours of concern.

Clients may present with a variety of behaviours of concern. Below are examples of the various presentations of behaviours of concern:

Aggression

Aggression involves angry and hostile behaviour. Examples of aggressive behaviour include verbal abuse and threats, as well as physical behaviours such as biting, spitting, scratching, kicking, hitting, throwing objects or damaging property, sexual harassment or assault.

Aggression could lead to staff members experiencing physical injuries and negative psychological consequences. In addition to high levels of stress, staff members who were exposed to aggression or violence may experience anxiety and post-traumatic stress disorder symptom, as well as lower levels of job-satisfaction (Verhaeghe et al., 2014). Repeated exposure to aggression or violence was also found to negative impact quality of care given to clients as workers reported lower levels of compassion towards clients (Malenfant et al., 2022).

Confusion or other Cognitive Impairment

Clients presenting with confusion or other cognitive impairment may experience visual or tactile hallucinations, difficulty interpreting visual stimuli, thus making it difficult for them to understand their surroundings (Grover & Avashti, 2018). Older clients are at a higher risk of experiencing confusion and cognitive impairment when engaging in healthcare services. Identifying confusion and cognitive impairment is crucial as it suggests the presence of more complicated health issues (Grover & Avashti, 2018). Confusion was found to be associated with the presence of severe illness, sensory impairment, malnutrition and dehydration. The use of medication such as sedatives and narcotics was also found to be associated with confusion.

Intoxication

Intoxication refers to the state when the client is affected by one or more psychoactive drugs or alcohol (Department of Health Victoria, 2023). This influences the client’s mental state and presentation, which makes it difficult for workers to identify underlying mental or physical disorders. Intoxicated clients may have a lower sense of inhibition or control which could result in an increased risk of harm towards themselves, other clients, and workers.

Intrusive Behaviour

Intrusive behaviour involves a client invading the personal space of other clients or staff members. This includes looking through other people’s belongings and overly personal conversations.

Manipulation

Manipulation refers to behaviour that deceives others for personal gain and is done without concern for the victims (Porter, 2006). Manipulative behaviour is commonly presented in clients diagnosed with borderline personality disorder (Day et al., 2018). In addition to the use of threats and intimidation, manipulative behaviour involves clients threatening to make official complaints against workers when they feel that they were not treated in the right way, despite being given appropriate service by the worker. Manipulation could lead to workers feeling frustrated and distrust between client and worker, which leads to barriers to service delivery and care (Day et al., 2018).

Noisiness

Noisiness involves clients making excessive noise, such as screaming, strange noises, and loud complaints. Excessive noise was found to be associated with increased stress in both workers and other clients. A noisy environment can also make it difficult for workers to hear and communicate with other clients, thus leading to miscommunication and poor service delivery (Mariconte & Giliberti, 2015).

Self-Destructive Behaviour

Self-destructive behaviour involves behaviour that is self-injurious such as cutting, hair pulling, biting, or burning. Emotional distress and lack of surrounding support from staff or carers was found to lead to self-destructive behaviour in clients. Clients presenting with self-destructive behaviour are at higher risk of future self-harm and suicidal behaviour.

Inadequate training and negative attitudes towards self-destructive behaviour was found to be associated with stress and burnout in workers. For example, failure to understand the reason for self-destructive behaviour could lead to workers having difficulty empathising with clients who engage with self-destructive behaviour and feelings of frustration.

Verbal Offensiveness

Verbal offensiveness refers to language that is taboo and impolite. Verbally offensive language is often used to express anger and frustration and could also evoke feelings of anger and anxiety in others. This includes insults, swear or curse words, threats, and foul language (Stone et al., 2010). Aggressive swearing that was directed to workers was found to be associated with high levels of distress which negatively impacted care for clients (Kapoor, 2016). However, it is important to consider that verbal aggression may not contain swear words and that swear words could be said in a way that does not involve negative intent (Kapoor, 2016).

Wandering

Wandering is commonly observed in patients with cognitive impairment. For example, dementia significantly impacts the brain’s ability to carry out day-to-day activities. Wandering may lead to clients leaving the organisation’s premises and getting lost. This is unsafe as lost clients may not have the ability to convey information or ask for help due to cognitive impairment caused by the disease (Varadharajan et al., 2018). Clients may also wander into unsafe locations or cause a breach in security. For example, hospitals may have laboratories that store unsafe materials. (Varadharajan et al., 2018). Clients who wander into patient rooms could violate the privacy of other clients.

When identifying, recognising, or responding to behaviours of concern, workers need to work in line with organisation policy and procedures. Workers should be aware of legal and ethical considerations that are stated in organisation policies and procedures. This included information surrounding the worker’s duty of care, human rights, and work health and safety laws.

Duty of Care

Duty of care refers to the worker’s responsibility to protect clients from harm and risk (McKenzie et al., 2001). It is a legal responsibility that workers take the reasonable steps to prevent harm and protect the safety of the client and other members of the public. It is important for organisations to have policies and procedures to ensure to ensure workers have a clear understanding of how they can implement their duty of care within the organisation and the limits of their role. It is important that workers practise within the limitations of knowledge and skills to ensure safety for both worker and client.

Recording and reporting incidents of behaviour of concern is also part of a worker’s duty of care. Behaviour changes in clients should also be recorded and reported. Client information should be recorded and reported in line with the organisation’s policy and procedures to ensure confidentiality and to protect the client’s privacy.

Human Rights

While the Human Rights Act (1998) encompasses a variety of rights, there are several rights which are more likely to be engaged in the context of healthcare practice.

These rights are:

• The right to life
• The right not to be tortured or treated in an inhuman or degrading way
• The right to respect for private and family life, home and correspondence
• The right to not be discriminated against in relation to any other rights

A human rights approach to responding to behaviour of concern emphasises balancing the rights of clients and workers. The organisation and workers should consider human rights in the policies and procedures, as well as during practice (Bailey et al., 2010).

Human rights should inform the organisation’s policy and procedures on behaviours of concern, where policies and procedure should involve the core principles of fairness, equality, dignity and autonomy. Organisations should have a commitment to empowering workers and clients by ensuring workings have the knowledge and skills required to uphold human rights while managing behaviours of concern. Being aware of human rights allows workers to have a clear sense of responsibility and accountability when responding to behaviours of concern. Upholding human rights when responding to behaviours of concern places greater attention to non-discriminatory practice and encourages the understanding of diversity.

Work Health and Safety

Work health and safety laws aim to ensure the safety of workers and others in the workplace. The organisation or business has the primary responsibility to ensure that workers and clients are not exposed to physical or psychological health and safety risks. Similarly, the worker has the responsibility to take reasonable care of their own health and safety in the workplace. Workers should also consider the health and safety of others who may be affected by their actions and cooperate with work health and safety policies as stated by the organisation.

Being able to identify and plan for potential instances of behaviours or concern increases the safety of workers and clients. If there is a known risk, an appropriate response should be pro-actively developed in line with organisational policies. Implementing planned responses can help prevent behaviours from escalating.

Before implementing a planned response, risks that could lead to behaviours of concerns should first be identified and managed. Environmental and client factors can increase the risks of potential instances of behaviours of concern (WorkSafe Victoria, 2019). Environmental factors generally involve the physical environment the client is in, while client factors include client characteristics or emotions or needs the client is communicating. These factors can be generally found in the Workplace Health and Safety Guidelines of your state.

Environmental Risk Factors

Long wait times for service or crowded environments, such as waiting rooms, can contribute to increased risks of clients presenting with behaviours of concern. This could be due to noise which can be irritating or overwhelming, thus leading to increased stress and aggression. Furthermore, messy environments, poor temperature regulation or overly harsh or bright lighting can be overstimulating, thus leading to feelings of anxiety.

To respond to potential instances to behaviours of concerns due to long wait times and crowded environments, organisations may consider the use of ticketing systems and provide enough sitting and staff members to support periods of high service demand. To reduce noise levels, organisations should avoid loud volumes of communal area televisions and radios. The use of glare-free lighting and ensuring adequate ventilation can reduce feelings of anxiety and stress.

Another environmental risk factor that can lead to potential instances of behaviours of concern is volatile and emotional situations. For example, family disputes or child protection issues. Such situations lead to increased levels of stress and anxiety, and thus increases the risk of potential behaviours of concern.

To address volatile emotional situations, organisations should provide private areas for clients to manage such situations. Staff members should ensure privacy and safety of clients by directing clients in volatile situations to these areas.

Client Risk Factors

Biopsychosocial factors also increase the risk of potential instances of behaviours of concern (Chen, 2022). Underlying biological factors such as, physical health issues, side effects from medication, alcohol or other drugs, can increase a client’s risk for presenting with behaviours of concern. Similarly, psychological factors such as cognitive impairment, mental health difficulties, psychological state and poor coping skills can increase potential instances of behaviours of concern. Finally, social factors such as the lack of social support and limited communication skills can increase risks of clients presenting with behaviours of concern.

To respond to client risk factors, workers need ensure that they are assessing the client for the various underlying factors that contribute to behaviours of concern according to the organisation’s policy and procedures. If such factors are present, workers may prevent further escalation by engaging with the client and explaining care actions in a slow and calm manner (Work Safe Western Australia, 2018). Workers should empower client by including them in decision making processes whenever possible. Workers should also minimise isolation and boredom.

Prolonged exposure to behaviours of concern can lead to high levels of stress, anxiety and burnout in workers. Accordingly, maximising the availability of appropriate staff and resources when planning responses to behaviours of concern can reduce the negative impacts of exposure to behaviours of concern.

Support from supervisors and co-workers

Workers may consult with their co-workers and supervisor when deciding on planned responses to behaviour of concern or after conducting planned responses (Hussum et al., 2020). For example, a worker may consult with the supervisor or other work colleague if they are unsure about what a client is attempting to communicate. This would allow the worker to carry out the appropriate planned response and prevent an escalation. Being able to quickly access support from supervisors was found to be more beneficial than exclusively consulting with co-workers, where workers reported lower levels of stress and burnout.

The Client’s Family and Caregivers

The client’s family and caregivers are an important part of the client’s care network. Communicating with the client and caregivers to understand the client’s support needs can minimise behaviours of concern and allow for better planned responses (Bohart et al., 2019). To ensure the client’s privacy and confidentiality, workers should follow organisational policy and procedure surrounding informed consent to sharing client information to family and caregivers.

Specialist staff members

Certain client presentations of behaviours of concern may be outside of the workers role and responsibility. If a client were presenting with serious medical concerns underlying the behaviour of concern that go beyond the scope of the worker’s role, contacting and referring the client on to a specialist staff member to address these concerns is necessary. Depending on the organisation, access to specialist members may be available to help manage these concerns. Workers should follow referral guidelines and processes as stated on the organisation’s policies and procedures.

If there is immediate danger or harm to the worker, client or other members of the public, workers should contact security or the police for assistance. A Duress response team may also be present in some organisations to manage such incidents.

Physical resources

In addition to staff members, organisations can provide physical resources to minimise behaviours of concern.

Adequate space for clients and workers

The organisation should provide appropriate indoor and outdoor areas to allow staff and clients. This would allow clients or staff to have safe and private area to calm down from stressful situations.

Secure storage

The organisation should provide secure storage for potentially dangerous items, such as medical and kitchen equipment. Secure storage may be also provided for client and workers to store their personal belongings.

Cleaning and first-aid supplies

Cleaning and first-aid supplies should be stored in a manner that is easily accessible for workers. This is to allow workers to promptly clean up damaged glass or rubbish, as well as to respond to minor injuries.

Duress alarms

Duress alarms should be installed in areas that are accessible for staff members. This would allow staff members to request security and emergency staff members when there is serious and immediate harm towards the client, worker, and other members of public.

When responding to behaviours of concern, workers should prioritise the safety of themselves, the client and others. Maintaining safe distance from the client presenting with potentially aggressive or violent behaviour is a simple but important way to prevent physical assault. Onlookers may also be redirected to another location for safety. This allows the client presenting with the behaviour of concern a quiet and safe environment to calm down.

While the use of effective communication and careful understanding of the client’s needs can minimise behaviours of concerns, it is important that workers assess the current risk of safety according to organisation policies and procedures. Workers should be aware of the organisation’s policies and procedures of when and how to seek support. In situations where there is high and immediate risk, workers should engage security staff, or the duress response team may be required to protect the safety of the client, staff and others.

In this section of the module we have provided you with an introduction to the elements of effective communication. You learned about the components of communication and how learning styles can affect the way in which we communicate. You also learned about some of the common barriers to effective communication and some of the potential ways that they can be resolved.