Managing Challenging Behaviours - National Health Care for the

January 6, 2018 | Author: Anonymous | Category: Science, Health Science, Cardiology
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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 

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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   

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Social justice Community/belonging courage

Harm reduction Independence, self determination Participation in program, health care plan Trauma model Kindness AND therapeutic value

Clients  

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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? 

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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  

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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 

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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 

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“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 

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Staff cohesiveness on the big issues Recognizing when we’re inconsistent Addressing our inconsistencies

Discussion Thank you for the opportunity! Feedback Discussion

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