8.2 Mental Health Needs & Behavioral Interventions

In long-term care settings, physical health and mental health are deeply interconnected. To provide high-quality, holistic care, a Certified Nursing Assistant (CNA) must address both the physical and the psychosocial needs of residents. Psychosocial needs encompass emotional, social, intellectual, and spiritual well-being. A resident’s overall quality of life, recovery times, and cognitive function are heavily influenced by their mental state. Promoting mental health is a core requirement under the Oregon State Board of Nursing (OSBN) standards, which emphasize dignity, respect, and individualized care.

Maslow's Hierarchy of Needs in Nursing Practice

To prioritize and understand resident needs, caregivers utilize Maslow's Hierarchy of Needs. This framework arranges human needs into a pyramid, stating that basic physiological needs must be met before an individual can focus on higher-level psychological needs:

1. Physiological Needs: The absolute baseline for human survival, including oxygen, food, water, elimination, shelter, and sleep. The majority of a CNA's daily tasks—such as assisting with feeding, toileting, and bathing—are designed to meet these physiological needs.
2. Safety and Security: The need to feel safe from harm, both physically and emotionally. CNAs fulfill this need by using proper transfer techniques, locking wheelchair brakes, keeping call lights within reach, explaining procedures before starting, and maintaining a clean, hazard-free environment.
3. Love and Belonging: The need to feel accepted, loved, and connected to others. In a facility, residents can easily feel isolated. CNAs help meet this need by showing genuine warmth, actively listening, helping residents maintain contact with family, and encouraging participation in group activities.
4. Self-Esteem: The need to feel valued, respected, and independent. CNAs can boost a resident's self-esteem by offering choices (e.g., 'Would you like to wear the blue or the red shirt today?'), praising accomplishments, and protecting their privacy and dignity during personal care.
5. Self-Actualization: The highest level of the pyramid, representing the realization of one's full potential. CNAs assist with this by supporting residents' hobbies, creative outlets, and spiritual or religious practices, such as arranging transport to a facility chapel service or setting up a writing table.

Psychosocial Impacts of Institutionalization

Transitioning from an independent home to a long-term care facility is a major life crisis that involves multiple significant losses. Residents must adapt to a loss of independence, privacy, familiar surroundings, possessions, and often their role in the family or community. These losses can trigger a range of emotional responses, including grief, anger, depression, and a sense of helplessness.

Under Oregon Administrative Rules (OARs) and the federal Residents' Bill of Rights, residents have a legal right to self-determination and a dignified existence. CNAs play a critical role in mitigating the negative impacts of institutionalization by actively promoting resident independence and autonomy:

• Encouraging Self-Care: Even if it takes much longer, a CNA should encourage a resident to perform as much of their own care as possible (e.g., wash their own face, comb their own hair, or feed themselves). This maintains joint mobility and reinforces a sense of control and self-worth.
• Offering Meaningful Choices: Allow residents to decide when to go to bed, what to wear, and how to arrange their rooms. Respecting these small choices helps counter the feelings of helplessness that often accompany institutional living.
• Respecting Personal Space: Treat the resident's room as their private home. Always knock before entering, wait for permission to enter, and handle their personal belongings with care.

Depression and Anxiety in Older Adults

Depression and anxiety are common in long-term care but are NOT a normal part of aging. They are treatable medical conditions that, if left unmanaged, can accelerate physical decline and increase mortality.

• Identifying Depression: CNAs spend the most time with residents and are usually the first to notice changes in mood or behavior. Signs of depression include persistent sadness, social withdrawal, loss of interest in activities they once enjoyed, refusal to eat or participate in care, changes in sleep patterns (insomnia or sleeping too much), crying spells, and verbalizing feelings of worthlessness.
• Suicidal Comments and Self-Harm: If a resident makes comments about wishing to die, wanting to 'end it all,' or asking to be left alone to die, the CNA must take these statements seriously. Crucial Action: The CNA must report these comments to the licensed nurse immediately. Never dismiss suicidal remarks as attention-seeking or joke behavior. Ensure the resident's immediate safety and do not leave them unattended until a nurse or counselor takes over.
• Recognizing Anxiety: Anxiety is characterized by excessive worry, fear, and restlessness. Physical signs include a rapid heart rate, hyperventilation, sweating, muscle tension, and trembling. CNAs can assist by maintaining a calm environment, speaking softly, and sitting quietly with the resident.

De-escalation of Challenging and Aggressive Behaviors

When a resident becomes agitated, verbally aggressive, or physically combative, the CNA's primary goal is to ensure safety while diffusing the situation. Agitation is often triggered by physical pain, confusion, sensory overload, or frustration.

1. Maintain a Safe Distance: Stand at least an arm's length away from the resident. Never corner, crowd, or trap the resident, as this can trigger a fight-or-flight response. Ensure you have a clear path to the door.
2. Adopt a Non-Threatening Posture: Keep your hands open and visible at your sides. Avoid crossing your arms, putting your hands on your hips, or pointing your finger, as these are perceived as aggressive or confrontational gestures.
3. Control Your Voice: Speak in a slow, low-pitched, calm, and reassuring tone. Do not raise your voice, argue, or try to prove the resident wrong.
4. Use Active Listening and Validation: Acknowledge the resident's feelings rather than the behavior. For example, say, 'I see that you are angry, and I want to help you. Let's talk about what's wrong.'
5. Offer Redirective Choices: Redirect the resident's attention to a quiet activity or offer a simple comfort, such as a cup of warm tea or a walk in the garden, to help them regain a sense of control.
6. Step Away and Report: If the resident's behavior escalates and they present an immediate danger to themselves or others, the CNA must leave the room, ensure the environment is safe, notify the licensed nurse immediately, and document the incident.

Oregon Restraint Regulations and Documentation

Oregon regulations strictly prohibit the use of physical or chemical restraints for staff convenience or discipline. A restraint is any device, material, or chemical that restricts a resident's freedom of movement or normal access to their body. Restraints can only be applied under a specific physician's order for a diagnosed medical necessity, and their use is subject to strict monitoring and hourly checks.

CNAs must document behavioral incidents with absolute objectivity. Documentation must describe exactly what occurred without personal opinions or labels:

• Objective (Correct): 'Resident threw a plastic cup at the wall and shouted "get out of my room" when assistive care was offered.'
• Subjective (Incorrect): 'Resident was highly aggressive, uncooperative, and acting out during morning care.'

Oregon Headmaster/TMU Clinical Exam Focus

On the practical skills exam, candidates are graded on how they handle resident behavior and maintain safety. If the resident actor becomes uncooperative or refuses a skill during the test, the candidate must not force the care. They must stop the procedure, check for comfort and safety, explain the benefit of the task gently, and if the actor still refuses, report the situation immediately to the RN Test Observer. Safety and rights validation are critical components of the skills test scoring.