5. Module 4 · Understanding challenging behaviour

5.2. Application: detective work in practice

Application

Detective work in practice

This page shows the search for a cause at work, step by step. It also gives you a simple observation form and phrases to adapt. Use them as a starting point. Every person and every team is different, and a form helps only if it is used and read.

Worked example: Mrs Weber and the morning wash

Return to Mrs Weber from the beginning of this module. The team says she is “aggressive in the mornings”. Instead of a label, a carer, Nadia (fictitious), decides to look closely for one week. Figure 4.3 shows what she writes down. The form uses four questions from the detective principle: when and where, what came before, what the behaviour was, and what helped.

Observation form with example entries for Mrs WeberObservation form (example entries, fictitious)When, whereWhat came beforeBehaviourWhat helpedMon 7:30, bathroomHelped out of bed, shirt offPushes hand away, shoutsWarm towel on shouldersMon 7:30, bathroomGrimaced on raising right armHolds right shoulderStopped, went slowlyWed 7:45, bathroomCold room, door openShivers, hits outHeater on, door closedWed 7:45, bathroomCarer came from behindStartled, shoutsGreeted from the frontFri 14:00, loungeSat in same chair for hoursRubs shoulder, calls outShort walk, cushionPattern in this sample: shoulder pain, a cold room and being approached from behind.
Figure 4.3: An observation form with fictitious example entries. Source: own illustration.

Read the table as Nadia would. The pattern points to three possible causes: pain in the shoulder, a cold room and the way she is approached. Notice what Nadia does not do. She does not decide that she has found the one true cause. She writes “possible” and chooses small changes that cost little and carry no risk.

  1. Record. Write down what you see, not what you think. “Pushes hand away” is an observation. “Is aggressive” is a judgement.
  2. Look for the pattern. After a week: always the same time, the same place, the same movement or the same person?
  3. Make a list of possible causes. Here: pain, cold, being startled.
  4. Report. The suspected pain goes to the nurse in charge, who decides how the doctor is informed. You do not decide on medicine.
  5. Change one thing at a time. Warm the room, greet from the front, work slowly, give a warm towel. Changing everything at once makes it unclear what worked.
  6. Check and share. After a few days, was there a change? Write it into the care plan so the next shift knows.

In this example the mornings became calmer after a few days, and the doctor was asked to look at the shoulder. This is a typical story, but it is not a promise. Sometimes nothing changes, and the search continues with the next possible cause. That is part of the work and not a failure.

Phrases to adapt
SituationYou might say
Person pushes your hand awayStep back, lower your voice: “I am here to help. We can go slowly. Tell me if something hurts.”
Person shouts or calls out“You are upset. I am staying with you.” Then look for the cause quietly.
Colleague says “she is just aggressive”“What happened just before? Let us note it for a few days.”
Reporting to the nurse in charge“Mrs Weber holds her right shoulder at every wash. I think she may be in pain. Can you check?”
Exercise (voluntary self-check). Mr Petrov (fictitious), 79, is restless every evening between 5 and 7. He walks the corridor, tries every door and sometimes shouts. A colleague suggests asking the doctor for a sedative “just for the evenings”. Write down three possible causes you would look into, one thing you would change in the surroundings, and what you would write on an observation form.
Hint 1
Use the four areas: body, feelings, surroundings, relationship. What happens in the building between 5 and 7? Think of meals, shift changes, noise and light.
Hint 2
Remember the “sundowning” example from the detective principle. Also ask: Has Mr Petrov drunk and eaten enough? Does he need the toilet? Is he in pain after a day of sitting? What did he usually do at this time of day in his life?
Suggested answer
Possible causes: tiredness and overstimulation at the end of the day, the noise of shift change, a need for security, the old habit of walking home from work, thirst or a full bladder, or pain after sitting. Changes: softer light and less noise in the corridor, a quiet task or familiar music, a walk with a carer, a drink and a snack. Observation form: time, place, what came before, what he did, what helped. Do not decide on a sedative yourself. If the distress continues after these steps, the team discusses it with the doctor, who decides, and any longer-term use needs special care and is recorded.
In German practice you will hear …
  • Herausforderndes Verhalten – challenging behaviour; the older term is “Verhaltensauffälligkeiten” or “Verhaltensstörungen”, which many teams now avoid because it blames the person.
  • Unruhe – restlessness; “Hinlauftendenz” is the urge to walk or leave.
  • Sedierung / Ruhigstellung – sedation or keeping a person quiet with medicine; “Ruhigstellung” sounds harsher and is often used critically.
  • Bedürfnis – need, unmet need.
  • Beobachtungsbogen – observation form.
  • Bezugspflege – primary nursing, where one carer knows a resident especially well.
  • Fallbesprechung – case discussion in the team.
  • Pflegedokumentation – care documentation, where observations and agreed approaches are written down.