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B e h a v i o u r a l C a r e P l a n n i n g f o r V i o l e n c e P r e v e n t i o n

P a r t i c i p a n t G u i d e

P r o v i n c i a l V i o l e n c e P r e v e n t i o n C u r r i c u l u m

M A R C H , 2011

Copyright and Liability statement The British Columbia (BC) Provincial Violence Prevention Curriculum Team, comprised of representatives from all BC health authorities, BC’s primary healthcare unions, the Occupational Health and Safety Agency for Healthcare (OHSAH) in BC, and WorkSafeBC, produced this curriculum as a project of the Provincial Violence Prevention Steering Committee (PVPSC). The curriculum was developed, through a consultative process and a review of accepted best practices, for use by British Columbia health authorities and healthcare partners. These modules are intended for classroom use, facilitated by qualified violence prevention trainers. The PVPSC and the Curriculum Team shall not be liable for any damages, claims, liabilities, costs or obligations arising from use of these materials. © 2011 Provincial Health Services Authority (PHSA). All rights reserved. The PHSA encourages the copying, reproduction, and distribution of this curriculum to promote violence prevention in healthcare workplaces, provided that the PHSA is acknowledged. However, no part of this publication may be copied, reproduced, or distributed for profit or other commercial enterprise, nor may any part be incorporated into any other publication, without written permission of the PHSA.

T A B L E O F C O N T E N T S Acknowledgements .............................................................................................................. 2 Course introduction ............................................................................................................... 4

Course objectives ................................................................................................................. 4 The use of the term “violence” ............................................................................................... 4

Behavioural care planning introduction ................................................................................. 5 How behavioural care planning addresses the risk of violence .................................................... 5

Behavioural care planning process ........................................................................................ 6 Step 1: Assess ....................................................................................................................... 6

Gather existing information ................................................................................................... 6 Describe the behaviour ......................................................................................................... 6 Identify the underlying causes of target behaviour ................................................................... 8

Step 2: Plan .......................................................................................................................... 9 Plan interventions ................................................................................................................ 9

Steps 3 & 4: Implement and Evaluate ................................................................................. 11 Step 3: Implement the interventions .................................................................................... 11 Step 4: Evaluating the care plan .......................................................................................... 11

Course Summary ................................................................................................................. 12 Appendix 1– Looking for underlying causes ........................................................................ 13 Appendix 2– Examples of interventions for target behaviours ............................................ 14 Appendix 3 – Service provision agreements ........................................................................ 21 Appendix 4 – Care planning scenarios ................................................................................. 22

Acute Care ........................................................................................................................ 22 Residential Care ................................................................................................................. 22 Community Care 1 ............................................................................................................. 22 Community Care 2 ............................................................................................................. 23

Appendix 5 – Tracking tools ................................................................................................ 24

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This Violence Prevention Curriculum was developed as a project of the Provincial Violence Prevention Steering Committee (PVPSC) to fill a need for effective, recommended and provincially-recognized violence prevention training for all British Columbia healthcare workers across a range of care settings, including affiliate organizations. The Curriculum includes eight online and five classroom modules. The PVPSC wishes to acknowledge the generous support and commitment of the management and the subject matter experts representing the following health authorities and healthcare unions. Without their expertise the development of this curriculum would not have been possible.

§ British Columbia Nurses’ Union § Union of Psychiatric Nurses of BC § Hospital Employees’ Union § Health Sciences Association of BC § Fraser Health Authority § Interior Health Authority § Vancouver Coastal Health Authority § Northern Health Authority § Vancouver Island Health Authority § Providence Health Care § Provincial Health Services Authority § WorkSafeBC § Occupational Health and Safety Agency for Healthcare (OHSAH) in BC

The PVPSC would also like to acknowledge the British Columbia Ministry of Health funding received through the Joint Quality Worklife Committee, and the financial support provided by OHSAH for the Provincial Violence Prevention Curriculum Project. The copying, reproduction and distribution of sections of this guide to promote effective Violence Prevention activities in the Healthcare Industry is encouraged; however, the current owner, the Provincial Health Services Authority (PHSA), should be acknowledged. Written permission must be received from PHSA if any part of this curriculum is used for any other publication. This curriculum, whether in whole or in part, must not be used or reproduced for profit. This course has been developed by Andrea Lam, Ana Rahmat, Chris Back, Charles Ballantyne, Dailaan Shaffer, David Bell, Deb Niemi, Helen Coleman, Joe Divitt, Kathryn Wellington, Lara Acheson, Larry Bryan, Leslie Gamble, Lynn Vincent, Marg Dhillon, Marty Lovick, Michael Sagar, Peter Dunkley, Phil Goodis, Rob Senghera, Sheile Mercado-Mallari, Sherry Moller and Tara McDonnell. Specific contributions were made by: Nicola Walker and Shannon Campbell (classroom module Behavioural Care Planning for Violence Prevention); Carole Capper (classroom module Personal Safety Strategies for Physical Violence and Advanced Team Response); Shayna Hornstein (online and classroom module content on the fight/flight/freeze response and self settling strategies); and Matt Hilderman (Advanced Team Response).

Bringing a group of subject matter experts to the table to develop a curriculum such as this takes vision, passion and a diversity of experience and practice. The creators of this curriculum drew on their skill and knowledge of the following disciplines:

§ Mental Health and Addictions § Occupational Health and Safety § Social work § Healthcare Violence Prevention programs § Geriatric care § Nursing § Psychiatry § Physical strategies and team response training

Course materials designed by Brad Eastman and Tanya Schecter. Photographic contributions by fotografica studio ltd. This curriculum was developed during 2010 by the Provincial Violence Prevention Curriculum Team at Vancouver, British Columbia, Canada.

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C O U R S E O B J E C T I V E S Behavioural Care Planning is an effective and proactive way of addressing the risk of violence. It incorporates violence prevention interventions and concepts (e.g., de-escalation techniques, personal safety strategies) you've learned from previous modules. By the end of this course, you will be able to:

§ Explain the benefit of incorporating violence prevention interventions into behavioural care planning

§ Develop and revise a behavioural care plan by: § Recognizing and describing target behaviours § Incorporating interventions that address the risk of violence to workers while

minimizing the risk of harm to patients

This course will cover: § Why use de-escalation? § The behavioural care planning process (APIE):

§ Assess § Plan § Implement § Evaluate

T H E U S E O F T H E T E R M “ V I O L E N C E ”

Violence is defined as “Incidents where persons are abused, threatened or assaulted in circumstances related to their work, involving a direct or indirect challenge to their safety, well-being or health.” Source: BC Provincial Violence Prevention Steering Committee (PVPSC)

Violence also includes any risks to personal safety from aggressive behaviour, domestic violence, harassment, bullying, intimidation, and threats. For the purposes of this course, violence is defined as any violent behaviour:

§ That is intentional § That is not intentional due to illness/injury § That is not intentional where the aggressor lacks the mental capacity to demonstrate

intent, often called aggression. SOURCE: Vancouver Coastal Health Code White Emergency Response Policy

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H O W B E H A V I O U R A L C A R E P L A N N I N G A D D R E S S E S T H E R I S K O F V I O L E N C E Violence is rarely unpredictable. Behavioural care planning focuses on:

§ Maintaining both the safety of staff and the quality of patient care by identifying the factors that contribute to violent behaviours

§ Decreasing the frequency or intensity of the behaviour and preventing future behaviour escalation

§ Preventing secondary complications that may result from the behaviour e.g., compromising relationships with others, being abused by others, being physically restrained

§ Integrating violence prevention interventions into care plans During this course, we will be referring to the care planning process, with a focus on behavioural care planning.

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The four general steps of the care planning process (APIE) are:

§ Assess § Plan § Implement § Evaluate

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G A T H E R E X I S T I N G I N F O R M A T I O N Sources include:

§ The patient and their observed behaviour. § Family and friends of the patient (ask about changes in behaviour, instances where they

experienced violence). § Workers with different interactions with patients such as support service staff, security,

physicians, psychiatrists, and other health care professionals. § Violence alerts, previous records, other relevant documentation (e.g., incident reports). § Information from other services (e.g., home support, paramedics and other care

facilities).

D E S C R I B E T H E B E H A V I O U R Accurately describing a patient’s behaviour is a critical step in the assessment process because it helps you to:

§ Identify the underlying causes of a behaviour and develop specific interventions for the patient.

§ Anticipate behaviours before you interact with the patient. § Use interventions to maintain safety while providing quality patient care (e.g., limit

setting, consistent care approach). § Assess the level of risk to yourself and others in the area and identify behaviours that

pose the highest risks. § Determine if there is a change in behaviour or if there are patterns of behaviour (e.g.,

changes in intensity, frequency or duration), and adjust the care plan accordingly.

Describe patient behaviour by noting:

§ What the patient did (e.g., physical actions) § What the patient said exactly, even if it is vulgar, as relevant to the incident

§ The intensity/severity, frequency and duration of the behaviour § At whom or what the behaviour was directed

Remember to be as specific and objective as possible and do not use subjective terms like aggressive +++ Source: IH Medical Legal Charting Tips and Practice Standard for Registered Nurses and Nurse Practitioners, CRNBC. Here are some examples of how patient behaviour could be described objectively in the chart:

Objective examples (do this)

Subjective examples (don’t do this)

Mrs. Smith yelled at RCA Jon (“I’m going to get you fired – you are completely useless!”) when he tried to enforce the patient’s bedtime (9:30 pm).

Patient is verbally abusive.

Mr. Frank groped and pinched Mrs. L’s right breast; he undressed completely in the common area, and asked Nurse Jane to sleep with him.

Patient is sexually inappropriate.

Mr. Brown told Nurse Jane that he had “friends” and knew where she lived. He called her “an incompetent bitch.”

Patient is aggressive +++.

Assessment Activity 1: Describing Behaviours

Practice identifying and describing target behaviours.

Watch the video segment “Leave When it’s Unsafe” from the WorkSafe DVD “Be Sure … Be Safe: Safety in the Healthcare Workplace.” Describe the patient’s behaviour specifically and objectively.

Target behaviours Once you have described the observed patient behaviours, identify which of those behaviours pose the greatest risk of violence and select them for intervention. These are called “target behaviours.” SOURCE: Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice. Once you’ve assessed the patient’s target behaviours, you can prioritize the interventions based on:

§ The level of risk of harm to workers, the patient, and/or other patients associated with the target behaviours you identified

§ The likelihood of the behaviour occurring again

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When determining the potential risk posed by a patient, it is important to evaluate their behaviour in the following four areas (these were previously discussed in the online Care Planning online module):

§ Mental/emotional state § The nature of their behaviour § Ability to inflict harm § Their ability to communicate.

A history of violence increases the risk of the violent behaviour reoccurring. Even if it was a single event, an alert should be initiated. It is critical that a care plan containing a patient’s history, stressors and ways of monitoring is put in place immediately. This care plan and the level of risk needs to be communicated to all workers. I D E N T I F Y T H E U N D E R L Y I N G C A U S E S O F T A R G E T B E H A V I O U R There are often multiple underlying causes of target behaviour(s). Look at the situation holistically to identify underlying causes, e.g., medical, physiological, environmental, emotional, etc. Targeted interventions can be planned to manage the risk while providing care to the patient. For example, when a patient who has dementia shows sudden behavioural change, an assessment is needed to determine the underlying cause of this change. Is the behavioural change related to their dementia or is it an underlying physiological condition? The change could be a result of any of the following:

§ A urinary tract infection, § Hypoxia, § Diabetes, § Depression, § A change in their environment, or, § Many other conditions

Asking the questions in Appendix 1 may help you identify the underlying reasons for target behaviours. Determine the pattern of behaviour Identifying the timing, frequency, and duration of the behaviours can help you determine why a behaviour is occurring. Behaviour tracking tools may help to identify stressors and underlying causes of behaviour. For example, you may learn that Mr. Smith is agitated when he is bathed in the morning, but not in the evening.

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P L A N I N T E R V E N T I O N S Once you’ve described the target behaviours and assessed them to determine both the underlying causes and the level of risk, the next step is to plan violence prevention interventions. It is crucial that you:

§ Identify what needs to happen right away to keep everyone safe. § Eliminate specific risk factors, if possible. § Determine what interventions can be applied to minimize the risk to workers, the patient

and others, if the risk can’t be eliminated § Write specific instructions to staff to ensure that interventions are effective and to ensure

a consistent care approach. § Document the following in the behavioural care plan:

§ Target behaviours § Possible underlying causes § Possible stressors § Interventions/instructions to staff § Desired outcomes § Timelines for review

Interventions should:

§ Address target behaviours. § Be clearly described and address the intensity of target behaviour(s). § Be applied consistently by all workers. § Be prescriptive (e.g., describe what to say when limit setting). § Focus on encouraging the desired behaviour § Include consultation with the patient and/or family as needed. § Include consultation with a multi-disciplinary team as needed.

Remember:

§ Interventions must address the level of risk. Workers have the right to refuse unsafe work (follow OHS Reg 3.12-3.13 process).

§ Take into consideration the patient’s right to refuse care.

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Behavioural care planning activity

Select or develop violence interventions using the blank template for this activity (30-45 minute activity)

Apply the entire assessment and planning process to develop violence interventions for a scenario. Develop a behavioural care plan that:

§ Describes target behaviours § Describes underlying causes and/or stressors § Plans interventions for target behaviours § Includes a date for review

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S T E P 3 : I M P L E M E N T T H E I N T E R V E N T I O N S Once you've determined interventions for target behaviours, implement them by:

§ Incorporating planned interventions into the daily care routine. § Ensuring relevant information about risks and interventions is readily available and

communicated to other workers (e.g., housekeeping staff) to keep them safe. § Ensure that all workers understand their role in consistently following the behavioural

care plan. S T E P 4 : E V A L U A T I N G T H E C A R E P L A N Keeping the behavioural care plan accurate and up to date is important for maintaining worker and patient safety and for providing quality care. It is important to review and revise the behavioural care plan when:

§ There is a change in status (behaviour subsides or escalates) or activity level § Scheduled, e.g., at regular intervals § An incident occurs

If the care plan is not meeting desired outcomes: § Conduct further assessment § Involve a multidisciplinary team § Consider alternate interventions § Involve site management (e.g., if a service provision agreement is required – see

information in Appendix 3) § Consider obtaining a referral to external resource (e.g., regional tertiary or provincial

services) If the behaviour has subsided there is no guarantee that it will not re-emerge. Be aware of ongoing possible risks and do not remove the violence intervention from the care plan as it may be of use with future interventions.

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In this course, you have learned to:

§ Explain the benefit of incorporating violence prevention interventions into behavioural care planning

§ Develop a behavioural care plan by: § Recognizing and describing target behaviour § Incorporating interventions that address the risk of violence to workers while

minimizing the risk of harm to patients

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Question Rationale Could the behaviour have been a result of the patient’s: § Mental health? § Cognitive state? § Physical health? § Medication? § Disease process?

Further clinical evaluation of the patient’s health is required to rule out and/or identify specific conditions that may be causing the target behaviour.

Did the person exhibit warning signs before the target behaviour occurred?

By examining what was happening when escalating behaviours were observed, you may be able to gather more information about what contributed to or caused the target behaviour. Usually the target behaviours appear in more subtle forms before they escalate.

Does the person have an explanation for their behaviour?

Asking the person about their view of situation will help you get a sense what they were feeling and responding to when the target behaviour occurred.

Was he/she aware of the consequences of their actions?

If the person was unaware of the consequences of their actions, their behaviour may be a result of a clinical or physiological condition (i.e., cognitive state, reaction to medication, disease process).

Did the behaviour have a purpose?

In most situations, target behaviour will have a meaning. Some common examples of reasons behind target behaviour include: § An unmet need, e.g., need to go to the bathroom, hunger,

thirst § Frustration due to an inability to communicate verbally, lack

of privacy, etc. § Physical discomfort due to an infection, pain, dehydration,

constipation, itchy skin, etc. § Fatigue § Fear, e.g., patient is startled because they didn’t hear or

see the worker approaching

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Interventions for All Care Sectors INTERVENTIONS WHILE PROVIDING PERSONAL CARE – ALL SECTORS Because personal care is a stressor for patients, ensure that thorough assessments are done to determine the stressors for that particular patient. Outline specific interventions to minimize these stressors in the care plan.

Intervention Rationale

BEFORE BATHING

§ Ensure that the patient is transported to the bathing area in a comfortable and safe manner

§ Assess the patient to determine if they are ready for a bath i.e., Are they upset, in pain, or stiff?

§ Ensure that the room is warm, free from drafts and that the water is consistently warm

§ Consider alternatives such as bathing in their room or using a bed or towel bath if necessary

This ensures patient comfort and safety, allows staff to improve patient comfort and mobility, and reduces the amount of stress the patient experiences

§ Check documentation (i.e., care plan) to familiarize yourself with specific precautions or methods of bathing

§ Obtain information about the patient’s hygiene and personal history

This ensures that staff are aware of potential risks and take precautions when bathing the patient

WHEN BATHING

§ Have one staff member provide bathing care if it is safe to do so

§ Keep the person in a sling, to provide support and comfort

§ Cover the person to maintain dignity and comfort with a towel or clothing item and wash underneath

This ensures patient privacy and reduces patient stress

§ Proceed in a calm, gentle manner; don’t rush § Explain what you are going to do § Monitor the person’s responses and respond accordingly § Start bathing the person’s body core first, and move out

to their arms and legs § Wash the patient’s hair last or on a different day § Modify the shower spray so that it is gentle

This helps to reduce the level of stress the patient is experiencing

§ Offer the patient a washcloth to hold in their hand This decreases the risk of being grabbed

§ Offer the person choices e.g., Would you like to unbutton your shirt or would you like me to help you?

§ Provide the patient a washcloth to bathe themselves

This promotes patient independence gives the patient a sense of control

SOURCE: National Guidelines Seniors’ Mental Health, 2006 or Rader et al. Bathing without a Battle

Interventions Before/During Meals


BEFORE MEALS

§ Assist the patient to the bathroom § Establishing a meal routine that is quiet and simple § Ensure that the meal environment is comfortable with soft

lighting, music, tablecloths and flowers § Arrange seating so that compatible patients are at the

same table § Seat patients so they have their own personal space

§ This helps ensure patient comfort

§ Have the patient dine with a small group of people or on their own

§ This reduces confusion and overstimulation

DURING MEALS §

§ Direct and cue patients to feed themselves § Assistance only when needed § Be respectful of the patient’s ability to feed themselves -

refrain from cleaning up after the patient

§ This promotes independence

§ Simplify tray options to a single bowl and spoon if needed § Present food in an understandable and familiar manner § Present food that looks appetizing and one or two items

at a time for individuals with cognitive impairment § Remove clutter such as too many dishes or table

ornaments

§ This reduces confusion

Interventions For Clothing Patients


§ Simplify the number and type of items being worn § Give the patient ample time to clothe themselves § If another staff member is assisting, avoid speaking to

the other person § If the patient is resistant, assess the situation and

consider trying again another time § Listen to the patient and constantly evaluate their

response

§ This reduces confusion and stress

§ Leave some clothing items until later if necessary § This reduces the risk of over exertion

§ Offer 1-2 items to select from § Allow the person to do as much as they can for

themselves § Cue and direct the patient by prompting one step at a

time § Praise the patient’s accomplishments

§ This promotes independence and gives the patient a sense of control

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Transferring Interventions

Interventions for Assisting to the Bathroom


§ Follow the patient’s care plan § Listen to the patient and constantly evaluate their

response § Explain what you are going to do and what you are doing

in short steps; pause and allow them time to absorb what was said

§ Provide reassurance that you are not going to let them fall, that you know how to operate the equipment

§ Try to distract the patient by talking about something important to them or playing music etc.

§ If the person becomes unsafe to transfer due to agitation, stop and leave the person alone (if safe to do so) and try again later

§ This reduces confusion and stress


BEFORE ASSISTING TO THE BATHROOM

§ Check documentation (i.e., care plan) to familiarize yourself with specific precautions or methods of bathing

§ Obtain information about the patient’s hygiene and personal history

§ This ensures that staff are aware of potential risks and take precautions when bathing the patient

§ If the patient is mobile, direct the person into the bathroom

§ This promotes independence

WHEN ASSISTING TO THE BATHROOM

§ Allow the patient to do as much for themselves as possible

§ Praise the patient’s efforts

§ This promotes patient independence

§ Explain what you are going to do then what you are doing § Try distracting the patient by talking about something

important to them or playing music etc. § Explain what you are going to do and what you are doing

in short steps; pause and allow them time to absorb what was said

§ If unable to change all soiled items at one time-leave it and try again later

§ This reduces patient stress

§ Avoid assisting two people or more in the same bathroom § Avoid talking to your co-worker other than to

communicate needs

§ This ensures patient privacy and reduces stress

§ Use terms like “pad” instead of “diaper” § This is respectful language


PERSONAL SAFETY Use specific personal safety skills when providing care to keep safe from physical violence (e.g., keeping at least a leg’s length away, maintaining a ready posture at all times)

This intervention helps ensure that workers take preventive measures to stay safe when providing care

Back off as soon as you encounter resistance, try later or have someone else try; be flexible when providing care

This intervention gives staff the flexibility to provide care when the patient may be more receptive to care and decreases the risk of the patient responding negatively

COMMUNICATION AND DE-ESCALATION

Reduce environmental stimuli by promoting a soothing and safe environment

This intervention helps limit the distractions and potential stressors (e.g., noise, other patients) that may be affecting the patient

Move patient to quieter area without isolating yourself

This intervention helps limit the distractions and potential stressors (e.g., noise, other patients) that may be affecting the patient and provides privacy

Apply active listening techniques to validate the patient’s concerns and to find out more about the patient (i.e. the patient’s likes/dislikes, the patient’s history etc.)

This intervention helps prevent the patient from escalating while gathering valuable information that will help identify patient stressors

Use distraction techniques to redirect the patient to a related topic or concern

This intervention helps prevent the patient from escalating while allowing workers to continue to provide care safely.

Report to the person in charge and document what you observe and what was tried

This intervention helps staff communicate the effective methods of de-escalating/distracting a patient while providing care safely

Identify and document signs of escalating behaviour, specific stressors, care needs, de-escalation and/or distraction methods that have worked well

This intervention helps workers communicate the effective methods of de-escalating/distracting a patient while providing care safely

Ask family member to sit with patient and help out if safe to do so

This intervention helps to settle the patient by having the presence of a person that they are familiar with and trust; the person can also distract or settle the patient if they become upset

Limit setting can be modified to reflect the intensity of the behaviour i.e., more severe consequences should be enforced for more harmful behaviours

This intervention helps to de-escalate the patient by letting them know that it is okay to feel the emotion they are experiencing but it is not okay to continue the behaviour they are exhibiting.

Plan for team presence/stand-by for specific care or signs of target behaviour

The presence of a team can help de-escalate the situation but the team can also intervene immediately if the situation escalates

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Two person care can be used as an intervention when the patient has been assessed and: § Exhibits behaviours (e.g., patient

strikes out, bites, grabs or resists during personal care) that can be safely managed by one person, while the second person provides care

§ Is not cognizant of their behaviour (e.g. if it results from dementia, brain injury, etc.); or the patient requires the presence of two caregivers to prevent escalation (e.g. consistent approach, reinforce limit setting, etc.)

In a two person model of care, one person provides the hands-on care, such as bathing, dressing changes etc., while the second person monitors and/or manages the patient’s behaviour based on the patient assessment and specific strategies outlined in the care plan. Examples of these strategies include: § Monitoring / observing patient

behaviour during care § Distraction § Gentle containment of limbs § Assisting the patient to maintain a

specific position during care § Use of soothing words / tone of voice,

singing § Eye contact Two person care must be complemented with other interventions to avoid putting two workers at risk.

This intervention helps workers provide care safely; one worker provides care and is responsible for communicating with the patient while the other worker provides support

Constant one on one care - is sometimes used as an intervention when caring for patients who exhibit behaviours which pose a high safety risk to health care providers. Constant one on one care cannot be the only control measure used to manage the patient’s behaviour, as the lone caregiver would be at high risk of injury.

This intervention ensures that a patient, that poses a risk for violence to themselves or others, is monitored constantly. In high risk situations (the patient has a history of violence or has been assessed as high risk using a Patient Violence Risk Assessment), early identification of escalating behaviour and early use of violence prevention strategies (e.g. de-escalation techniques, Code White Team Response, PRN medications, Security, police, etc.) will enhance the safety of all others in the area.


The use of constant one on one care must be based on a thorough assessment of the patient. Clear strategies for identifying, preventing and/or managing the target behaviours must also be outlined in the care plan and communicated to the constant one on one care provider. A constant one on one care provider should be knowledgeable of: § Early signs of escalating behaviour

(specific to the patient being observed) § Specific de-escalation techniques to use

with the patient § When and how to call for help § What to observe if restraints have been

applied (based on organizational policy)

OTHER INTERVENTIONS

Request consultation with multi-disciplinary team (e.g., traumatic brain injury program, mental health and addictions, geriatrician, psychiatrist, social worker)

Specialists or care providers from other disciplines may be able to: § Diagnose underlying conditions that may be causing

the violent behaviour § Identify and/or provide specialized, effective

interventions that are specific to the patient

Hold a collaborative, problem solving meeting with the patient, family, advocates, community resources, translator, etc.

Help to recognize the patient’s individual, social and cultural needs

Use PRNs as needed (e.g., before care)

This intervention is a preventive measure that helps settle the patient and ensure patient comfort (e.g., provide pain medication before being transferred) to reduce the risk of violence to staff and others

Consider ways to limit patient access to substances (e.g., alcohol, drugs) that cause or contribute to their target behaviour, (e.g.., where possible restrict visitor access, patient passes, etc.). If it is not possible to restrict the patient’s access to these substances, then consider a service provision agreement or other intervention.

This intervention prevents the patient from accessing substances that cause or contribute to their target behaviour

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Interventions Specific to Community Care Intervention Rationale

Make pre-visit phone calls to check for the presence of specific risks (e.g., client and/or family/friend sobriety)

This intervention allows workers to identify the presence of risks in the client’s home ahead of time and take precautions to stay safe

Schedule home visits during daylight hours only

This intervention ensures that workers travel when environmental conditions bright which allows them to identify potential risks in their environment (i.e., individuals that may be hiding)

Schedule alternate means of care (e.g., meeting a client in a public space or in the office instead of their home)

This interventions ensures that workers are not interacting with clients in private where they may not access to help

Ensure that the client or client’s family remove objects that could be used as weapons or that can be harmful to the patient or others

This intervention prevents the patient from using their possessions that may be potentially dangerous to themselves or staff (e.g., weapons, drugs)


Initiate process for transferring the patient to a facility that has better resources for more specialized assessment and treatment planning (e.g., to a regional or tertiary acute care facility)

If available, this intervention ensures worker and patient safety by transferring the patient to a facility where specialized care may be provided

Remove or secure objects that could be used as weapons or that can be harmful to the patient or others. If removing objects plan for when these will be returned to the person, as appropriate (for example, if they are removing a walker or cane, or substituting cutlery, dishes and other objects that may be used as weapons with paper and plate equivalents, secure lamps, chairs, TV’s, etc)

Search and secure a patient’s belongings (as per your organization’s policies and procedures)

This intervention prevents the patient from using their possessions that may be potentially dangerous to themselves or workers (e.g., weapons, drugs)

Use restraints or seclusion as per your organization’s policies and procedures, and medical orders

This intervention prevents the patient from physically harming themselves, staff and other patients when the patient has the physical ability and demonstrated intent to harm themselves and/or others

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Service Provision Agreements (the agreement) are being used in healthcare settings as a way to address challenging and difficult patient behaviour. The agreement is a means of setting limits around target behaviours that pose a safety risk to health care providers, the environment and other patients. They are usually entered into when other measures have not been successful in assisting the patient to change their behaviour. The goal of the agreement is stated as the desired behaviour, not as the behaviour to be stopped. Asking for desired behaviours is more effective than listing undesirable behaviours. For example, “will speak respectfully to staff” rather than “will not swear at the staff”. An effective agreement incorporates all parties working together to achieve mutual goals. An essential component of an agreement includes statements of responsibility from the patient, and the organization, e.g., “We expect this from you, and you can expect this from us…” Creating and entering into an agreement requires the inclusion of Senior Management/Risk Management, the Patient, a family member/advocate, physician and other members of the multi-disciplinary team as appropriate, e.g., nurse, social worker, therapist, etc. The goal is to modify specific behaviours. It is important not to demean or overwhelm the patient. The goal is not to make the person a model patient. However, clear consequences for not meeting the specific expectations in the agreement must be outlined. Management, physician, and care providers should meet in private with the patient/family member/advocate to discuss mutual responsibilities and develop the agreement together. The agreement should never be written without patient input and then forced on the patient. An effective agreement also identifies a staff person to provide support to the patient to reach or accomplish the goals and monitor progress. This person can also serve as a resource or “sounding board” for the patient. The agreement should contain dates for review and progress monitoring. The agreement can be mutually renewed, amended or extended, until the targeted behaviour is changed so that staff can safely provide care. The agreement should be kept as part of the client record as a resource for subsequent admissions. All parties involved in fulfilling terms of the agreement should sign the contract. A Service Provision Agreement can be a very effective tool for modifying target behaviours. If the agreement is ineffective in altering the patient behaviour, alternate means of providing care should be explored, and in some cases dismissal of the patient may have to be considered. Senior Management and Risk Management must be involved if the patient is to be dismissed from the service. SOURCE: http://www.esrdnetwork.org/assets/pdf/conflict/RVContractArticle-reformatted11-03.pdf

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A C U T E C A R E

Mr. E is a 47 year old man who is in hospital for investigation of an abdominal mass and he is in a four bed room. He has a history of acting aggressively towards staff during previous hospitalizations. Mr. E’s records indicate that Mr. E has sworn at and intimidated staff and other patients, broken furniture, and thrown objects (e.g., utensils, dishes and food) at staff. He was scheduled to receive blood for his very low haemoglobin but the type and screen was not done, delaying the procedure. Mr. E’s C.T. scan has also been rescheduled, likely to the following day. Staff are busy caring for a very sick patient on the unit and it is lunchtime. Mr. E. is clearly distressed by the delays. He has been scowling and angry at staff and other patients since being admitted. Mr. E. on yelled at the nurse (“What the hell is wrong with this place?! I want to get out of this hell hole!”) when she informed him that his C.T. scan was rescheduled. He has been restless and pacing in his room since yesterday. When a care staff member returns after lunch to provide care to Mr. E, Mr. E swears at the care staff member (“Get the hell out!!!”) and throws his food tray at the wall. R E S I D E N T I A L C A R E

Mrs. S. is an eighty year old woman who has a history of Alzheimer’s disease and severe osteoarthritis. She has become increasingly confused, over the last few weeks. She can become physically aggressive during personal hygiene. Whenever caregivers brush her teeth or wash her face, she tries to bite whoever is working with her. Workers always provide care in pairs, but she still manages to bite at times. At this point, some workers are very reluctant to care for her. Outcome one week later: § Mrs. S’s behaviour intensifies; she frowns and pulls away during any type of personal care, and

when any worker tries to provide care that requires contact with or near Mrs. S’s head she strikes out with clenched fists. Mrs. S tries to bite workers more frequently and with more force when they attempt to wash her face and brush her teeth.

§ Two more care aides are bitten that week and are required to fill out employee and patient incident

§ Care staff refuse to work with Mrs. S unless she is medicated § Patient’s daughter is upset about her mother’s care, and voices complaints to staff about over-

sedation and staff approach, and has contacted the facility’s management and the local media about the care of her mother

C O M M U N I T Y C A R E 1

Mr. X is a 78-year-old retired rancher, who lives in a rural area with his 42-year-old son. Mr. X recently fell and fractured his right hip. After surgical repair and a lengthy hospital stay, due to a post-operative wound infection, he was discharged home, with a referral for home support for wound care and personal hygiene assistance. When the home support agency did a pre-visit screening over the phone, several risk factors were identified. It was determined that Mr. X, is a heavy smoker and requires home oxygen, is a gun collector, who owns two large dogs. A home support supervisor had difficulty

accessing the property because of the aggressive behaviour of the dogs. Mr. X angrily said “I don’t need a visit every day, and do what I tell you to do, when you are in my home!” During the visit Mr. X’s son sat in the room, staring at the supervisor, without talking or participating in any conversation.

C O M M U N I T Y C A R E 2

Sam arrives at the clinic, looking very upset, and says, “I am here to get my injection.” You reply, “Your appointment was yesterday. I can book one for tomorrow.” Sam says, “Look, I need to get my injection NOW.” He bangs his fist on the counter while moving closer to you. “The last time I came in here, the woman who saw me could figure out that I needed immediate attention…SO WHAT’S YOUR PROBLEM? Obviously, you’re not the queen of compassion, but can’t you see that I need that injection now!!?” You are juggling phone calls, client arrivals and, in between, you are transcribing psychiatric assessments to help out the other clerks because they are swamped. This client has regular weekly appointments for his anti-psychotic injection but he missed his regular appointment yesterday. The nurse who normally gives him his injection is busy with other clients today. You are grateful for the plexi-glass divider between you and the client because he looks like it wouldn’t take much for him to hit you.

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We’ve included examples of several tracking tools in use at various organizations for you. Haro Park Centre Behavioural Flow Chart DATE_______________ RESIDENT’S NAME_________________ Care provided Resident Behaviours A -‐ Medication given 1 -‐ Lying/sitting 11 -‐ Pacing B -‐ Assessed by Physician 2 -‐ Standing 12 -‐ Crying C -‐ Assessed by Nurse 3 -‐ Quiet 13 -‐ Cursing D -‐ Food Provided 4 -‐ Sleeping 14 -‐ Yelling E -‐ Fluids Provided 5 -‐ Mumbling 15 – Threatening F -‐ Toiletted incoherently G -‐ Hygiene/personal care provided 6 -‐ Singing 16 -‐ Biting H -‐ One to one 7 -‐ Disrobing 17 -‐ Banging on wall/door 8 -‐ Purposeless 18 -‐ Clinging behaviour movements 9 -‐ Incontinent 19 -‐ Spitting 10 -‐ inappropriate toiletting MN = Multidisciplinary Notes ******Chart any possible triggers for behaviour in appropriate box below: 07:00

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