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Introduction to a DVD

training package:

Dilemmas

Presented by Andrew Brennan &

Ruth Banner

Aim of the presentation:

Introduce the concept: A low-arousal

approach for de-escalation of challenging behaviour following an

Acquired Brain Injury

Rationale behind the concept

Evaluate current area of current

practice

Development of training DVD

How the training package is used

Clip of the DVD

Concept

Work on a Inpatient

Neuro Rehab Unit, more patients being admitted that have challenging

behaviour.

Demand on beds increasing, not always the right

environment for this patient group but demands on

service often means patients are admitted.

Large staff turn over and agency staff on the unit

means that there is often no continuity.

Trying to deliver training to this amount of staff currently extremely

difficult and time consuming.

Impact on staff – Increased sickness, stress and burnout.

Staff being injured. Increased need to develop a training

tool that will meet all the needs of the staff

on the unit.

Affects on patients – unable to participate in therapy and

mis-trust in staff if not handled appropriately.

Challenging behaviour

Rationale

Mobile & immobile patients – some

have cognitive deficits &

challenging behaviour.

Currently Minimal staff training on

challenging behaviour.

Training a large amount of people

can be difficult & time consuming.

Research literature identifies that

continuity in approach is essential,

To address lack of continuity in

approach

Overall aim was to produce a DVD

that will effectively engage staff for

training purposes and beneficially

impact on risk management.

Identify and justify why a

training tool is required

.

• In an area of high staff turnover, there is a need for

rolling programmes of competency-based training,

including responding to potentially violent situations.

• Understanding aggression and prevention can reduce

the number of behavioural incidents reported (Allen et

al 2002).

• Training with staff, should encourage staff to use a

non-aversive approach, focusing on positive

relationships to avert power struggles and avoid

escalating client behaviour (Giles et al 2005).

Justification for change in training

approach

Styles of staff interpersonal conduct can help avoid provoking a sense of both staff and patients’ powerlessness and depersonalisation, thus precipitating aggression.

It is no surprise that challenging behaviour causes an increase in emotional exhaustion and burnout of staff members.

It is not only therapists who have a role in behavioural management; nurses play a pivotal role in the provision of care to people with ABI.

Nursing staff have much more face to face contact with patients.

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Evaluate current area of

professional practice

An evaluation of the incident reports

filed following an incident where a

member of the team has been hit,

punched or pinched whilst working

with individuals that have had a

Acquired Brain Injury.

The kind of challenging behaviour

recorded on the Neuro Rehab Unit in

the last 12 months (Jan 2011 - Jan

2012)

Challenging behaviour

occurred when:

Aims of the DVD

There is no such product currently on the market.

Used as a stand alone package for refresher and new staff training.

Emphasise the interdisciplinary requirements of working with difficult behaviour.

Empathically show the emotional impact that both staff and patients experience in heated situations.

Illustrate how the low arousal approach works at the antecedent level (i.e. how someone in a high arousal, agitated, state is easily triggered by staff actions).

Define the low arousal approach: an immediate non-confrontational, non-critical and positive relational approach by staff to patients’ verbal outbursts, destructive behaviours (e.g. property damage) and physical aggression.

Illustrate de-escalation strategies for diffusing heated situations.

Development of the DVD

Content

Keeping a Cap on Staff Emotional Expression

Calmness and positivity – “Like a Swan”

Treating Patients with Dignity and Respect

Core skills described that help avoid triggering patients’

difficult behaviours

Staff Beliefs About Patients’ Behaviour

Illustrate that after ABI, normal levels of control over

events and

emotional states are far reduced. Difficult behaviour is not

deliberately personal or calculated. Ex-patient invited to

describe feeling states when showing aggression due to

confusion

This is One Discreet Part of Behavioural Management

Specific Scenarios

DVD will compare good and bad examples of staff relating

in situations where there is difficult patient behaviour.

There is currently no video based training

package available that addresses

challenging behaviour for inpatient wards

providing neurological inpatient

rehabilitation. At the time of writing, the

production of such a DVD package is nearing

completion.

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Scenarios

The DVD features a dramatised set of

scenarios considered typical of ward based

events when there are patients following an

acquired brain injury who show difficult to

manage behaviour, including those who are in

post-traumatic amnesia, and post-traumatic

confusional and agitated states. The DVD

features actors representing staff working with

patients showing such difficulties. They depict

dramatisations of how best to approach and

relate to patients during a difficult episode, and

also, how best not to approach patients in

such circumstances.

Interactive DVD

The DVD will be interactive; the viewer will be requested

to select one of two options for how best to approach a

patient’s difficult behaviour and, as part of the process,

will see both good and bad examples.

The underlying themes of the DVD emphasis staff

member’s need to maintain positive relations with

patients. This includes principals of treating them with

dignity and respect, maintaining a non-aversive, non-

confrontational and non-critical approach in the face of

difficult behaviour, and encourages simple shared

formulations of the reasons behind patients’ difficult

behaviour due to acquired brain injury.

Approaches

The examples of good practice in staff approaches shown by the DVD are informed by several documented approaches. Each approach has a likely degree of conceptual overlap with others; all promote quality relationships of carers towards patients that are conducive to better therapeutic outcomes.

Overlapping Approaches from:

These include: the Relational Neurobehavioural

Approach (Giles and Manchester; 2005);

Positive Behavioural Support (e.g. Allen, 2005);

the Low Arousal Approach (McDonnell, 2011);

attributional models of how staff relate to

patients (e.g. Weiner, 2006); and work that

highlights and manages the difficulties of high

expressed emotion between carers and patients

(e.g. Berry, Barrowclough and Haddock, 2010).

Participants in the Training

DVD

The roles played by actors, the DVD is presented by two of the ward’s own staff, an occupational therapist and nurse Ward Manager. It also features interviews with other staff and an ex-patient who himself, a few years earlier, had shown difficult behaviour whilst in a confusional state following brain injury. These features all intend to further enhance staff engagement and impact of the training.

DVD covers

The DVD intends to be short enough to be watched in a routine staff break or lunch time. It intends to be a non-academic exercise focussing on fundamental relational and interpersonal aspects of behaviour management and avoiding what might be described as more high level behaviour management methods, such as

behaviour analysis and modification

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Advantages

The potential advantages of the DVD lie in its flexibility and accessibility; staff do not have to book onto organised group based teaching sessions and can, instead, pick up the DVD to play on a computer or television. Furthermore, the dramatised images and associated narration intend to model ways of staff interpersonal relating to patients who are showing aggression, which isn’t normally a feature of training sessions. This method may also have advantages over written guidelines.

Clip of DVD

Summary

Questions?

References

Adams, D. & Allen, D. (2001) assessing the need for reactive behaviour management strategies in children with learning disabilities and server challenging behaviour. Journal Intellectual Disability Res. 45 (4): 335-43

Allen, D. Doyle, T. & Kaye, N. (2002) Plenty of gain, but no pain: a systems wide initiative. Ethical approaches to physical interventions. Kidderminster, BILD publications. 219 – 32.

Benson, B. Schaub, C. Conway, J. Peters, S. Strauss, D. & Helsinger, S. (2000) Applied Behaviour Management and Acquired Brain Injury: Approaches and Assessment. Journal Head Trauma Rehabilitation. 15 (4):1041-1060

Giles, G, M. & Manchester, D. (2006) Two Approaches to Behaviour Disorder After Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 21(2): 168-178

Giles, G, M. Wagner, J. Fong, L. & Waraich, B, S. (2005) Twenty-month effectiveness of a non-aversive, long-term, low cost programme for persons with persisting neurobehavioral disability. Brain Injury. 19(10): 753-764

Jacobson expressed emotion 2000 Jenkins, R. Rose, J. & Lovell, C. (1997) Physiological wellbeing of staff working with people who have challenging

behaviour. Journal of Intellectual Disability Research. 41. 502-511

Kaye, N. & Allen, D. (2002) Over the top? Reducing staff training in physical interventions. British Journal of Learning Disabilities. 30, 129-132

Luiselli, J, K. Pace, G, M. & Dunn, E, K. (2003) Antecedent analysis of therapeutic restraint in children and adolescents with acquired brain injury: A descriptive study of four cases. Brain Injury. 17:255-264

Peters, M, D. Gluck, M. & McCormick, M (1992) Behavioural Rehabilitation of the challenging client in less restrictive setting. Brain Injury. 6:299-314

Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and Language Therapists (2007) Challenging behaviour: a unified approach Clinical and service guidelines for supporting people with learning disabilities who are at risk of receiving abusive or restrictive practices. Royal College of Psychiatrists.

McDonnell, A. (2010). Managing aggressive behaviour in care settings: understanding and applying low arousal approaches. Chichester: Wiley-Blackwell

Mitchell, G. & Hastings, R, P. (2001) Coping, burnout, and emotion in staff working in community services for people with challenging behaviour. American Journal on Mental Retardation. 5, 448-459

Mott, S. Nagy, E. & O’Reilly, K. (2006) Behaviour support following acquired brain injury: An exploration of the role of the registered nurse. Journal of the Australian Rehabilitation Nurses Association. 9(4): 7-13

Toogod, S. (2009) Establishing a context to reduce challenging behaviour using procedures from active support: a clinical case example. Tizard Learning Disability Review. Volume 14 Issue 4.

Ylvisaker, M. Turkstra, L. Coehlo, C. Yorkston, K. Kennedy M. Sohlberg, M, M. & Avery J (2007) Behavioural interventions for children and adults with behavioural disorders after TBI: A systematic review of evidence. Brain Injury. 21(8): 769-805.