INFIRMARY CARE: Managing Challenging Behaviours Pat Larson, MN, Nurse Practitioner Sherbourne Health Centre Toronto, Ontario
[email protected] “The best way to find yourself is to lose yourself in the service of others” M. Gandhi
About this presentation…. Context Behavioural Issues Prevention/planning Responding Discussion
Context Solutions are unique to the setting We’re a learning environment... Underpinning of values/principles Pro-active/Prevention based stance Responding “in the moment” Your contribution to our development
An acknowledgement
Sherbourne Health Centre
Community based agency
Partnerships (ie. Naturopathy, chiropractic…)
Infirmary Primary care programs
Homelessness LGBTT community Newcomers Local community Health Bus (volunteer RNs, outreach)
Sherbourne Health Centre Infirmary Community-based, stand-alone model 20 beds (9 open at present) Serves the Greater Toronto area Referrals – self, community (shelters, drop-ins, community agencies and providers) and hospitals (~12 in area) Opened April, 2007
Staffing Model Community Health Worker (CHW) - 24/7 RN – 24/7 Case Manager NP Consulting MD Manager and Admin Assistant Partnerships (housing worker, pastor…)
Values/Principles
Program values
Social justice Community/belonging courage
Harm reduction Independence, self determination Participation in program, health care plan Trauma model Kindness AND therapeutic value
Clients
Homeless/underhoused Fractures, cardiac problems, diabetes, HIV, endocarditis, pneumonia, skin infections/cellulitis, osteomyelitis/bone infections, post surgically, post childbirth Majority also have substance use issues More men than women, but priorize women Most leave to go to shelters; occasionally client is housed upon discharge
Referrals
Short term
Maximum stay 3 weeks; average ~ 10 days Acute need
Written, faxed referral Referee remains responsible for information transfer Hospital visits w/ some referred clients
acuity ability to safely discharge clients
Behavioural Issues Your setting Your experiences?
Issues Anything you would like to share? Things we might address?
Preventing Behavioural Issues
Focus on referral
Adequate resources to process Follow up with referees/client/supports Ask difficult questions “are you barred?”
Program self-determination
Ability to say no to clients Client meets program criteria?
Antennae on High Alert
Intent
Primarily - planning/managing Consider - restriction
Shelter restrictions Evidence or history of violent behaviours Referee reluctant to provide information or details Client vague/reluctant re details Evidence of difficulty participating in previous programs
Planning with Clients
Contingency Planning
Substance use
“What will be different in this program?”
Risk from Partners/others
“How will you manage your cravings?” “Do you plan to use? How could you reduce your use?”
History of Violence or Barrings
Frank Involve community supports
Safety plan; involve management/security
Triggers
“What are your triggers? What is your plan to avoid? Manage?
Rights and Responsibilities
Discussions about
Expectations Participation in program Consequences of not respecting responsibilities Independence
Contracts
Client developed Staff developed
Harm Reduction No illegal substances on-site May use/imbibe, behaviour is the focus, not substance use “What is your substance of choice?” “How can we help you not to use? To use more safely? To use less while you’re ill?”
Trauma framework Understanding and re-framing of people’s life experiences Therapeutic responses
Self responsibility
Assist clients w/ coping strategies Trauma of being discharged
Clients Staff
Behaviours Attempts to triangulate - “Manipulation” Making unrealistic demands
“You’re not going to discharge ME, are you?”
Evasiveness Not being honest Not participating
Refusing to meet w/ providers, to get out of bed, have treatments….
Serious Adverse Behaviours Disrespect - intolerance Theft Threats Violence Smoking inside/risk of fire Substance use on the premises
Physical Environment Clean, bright environment Minimal sharing of bedrooms Safe spaces, quiet areas Able to go outside (smoke, appointments) “This is the nicest place I’ve ever stayed.” “I feel like I’m at the spa.” On-site security EMR – team care plans, rounds, reviews
Inclusive Environments
Diversity
Social Inclusion
How do we live it? “Radical inclusion” Respect, dignity
Ambivalent responses to acceptance
Resenting being cared for
Stepwise Approach
Accountability First episode - not meeting responsibilities
Repeat behaviours
Responsibilities, rules, consequences May result in discharge from program
Serious issues (violence/threats/theft)
Discharge from program, ? Charges?
Responding to Behaviours
All staff trained in Non violent Crisis Intervention
Focus on understanding own responses
Minimal staffing levels Timing of responses
In the moment Can this wait? Should this wait? Can this be ignored?
Issues of Responding “Enforcer” role (“bouncer/security”…) Who should respond to client? Challenging particular behaviours
“I’m not feeling comfortable with ..” “I need to speak with you about…” Alone versus with support
Clarity
Consistent messages Easier to say than do
Responding Acknowledge client’s efforts and progress Importance of humour Staff training and support Differences of opinions
Staff cohesiveness on the big issues Recognizing when we’re inconsistent Addressing our inconsistencies
Discussion Thank you for the opportunity! Feedback Discussion