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Reducing Off-Label Use of Antipsychotic Medications by Engaging Staff in Individualizing Care to Reduce Resident Distress

Facilitator Instructions for Starter Exercise

WHAT: This exercise helps staff see the world through their residents' eyes by personalizing their residents' experience. It gives staff information about how to understand what residents are communicating so staff can respond effectively. Then they can think through how to make it happen.

WHY: Change is hard. Successful change requires discussion about why and how. Use this discussion to find out how the staff closest to the resident, who will implement a new approach, think it will work best. Have on-going discussions as the change evolves.

HOW: This guide includes discussion prompters to use after the personalized experience first to draw out staff's experience and reflections, and then to hear their ideas on how to do it. Allow time for each discussion. Hear from everyone. Ask for responses from quieter people. It may be tempting to brush off staff members who are openly skeptical, but putting into play major changes requires that concerns be welcomed as a contribution to the effort's success; get to the root of the concern, and note it as an area to keep an eye on.

RESOURCES: Toolkit Tip Sheet and Video Clip on Reducing Off-Label Use of Antipsychotic Medications by Engaging Staff in Individualizing Care

Entire Toolkit and Webinar Series available at Pioneer Network store.

Review tip sheet and video clip on Reducing Off-Label Use of Antipsychotic Medications By Engaging Staff in Individualizing Care

Time: 10 - 20 minutes, depending on discussion time


To provide a personal understanding of how the world might seem if we had serious memory impairment so we can understand how residents' behaviors make sense.

Have everyone form pairs

Tell the group this is an imagination exercise.

Read the following out loud to group:

It is 3:00 and you are going to meet the school bus and get your son. You do this every day and you know he will be scared and upset if you are not there. But as you go meet the bus, a stranger stops you and tells you that you cannot go.

In pairs discuss:

What would you do? How would you feel?

Invite people to share with the whole group. Most will talk about how strongly this made them feel as they relate to the parental drive that this touches. Some will share that they would get physical if someone tried to stop them from caring for their children.

The group will naturally recognize that this is what residents sometimes feel. It's a normal reaction, normal behavior.

Once we have this kind of understanding, we have a better way of understanding our residents' behavior.

Explain: Residents are communicating through their behavior. Geriatric psychiatrist
Susan Wehry, MD explains that we need to:
  1. Understand what is being communicated
  2. Differentiate between Agitation and Aggression
  3. Address the needs being expressed

Agitation = self-referred = HELP ME
  • Slapping thighs
  • Clapping
  • Yelling
  • Screaming 
  • Self-referred

Something is wrong with me
Do something!

Aggression = other-referred = STOP
  • Hitting out
  • Kicking
  • Pinching
  • Biting
  • Threatening 
  • Swearing
You're scaring me, hurting me
Leave me alone!

Ask the group: In the scene we just imagined when you were headed to get your child at the bus and a stranger stopped you:
  1. What were you communicating?
  2. Was your response agitation or aggression?
  3. How would staff best address the need being expressed?

In pairs share:

Give examples of how you work with residents now where you know just what to do so they feel safe and you don't provoke a distressed reaction.

Have an open group discussion of examples of good ways to respond.

When a resident is agitated, we go in gently and ask, "what do you need?"
When a resident is aggressive, we back away and say, "sorry, I'll come back later."
The best practice is to try and figure out:
  • What is happening for the person?
  • What is the person trying to communicate?

Begin the discussion on how to make it happen.

Where should we start?

What would we need to make this work?

Download Facilitator Instructions for Reducing Antipsychotics (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.