Behaviour Management: Behaviour Management: Partnering To Bridge The Partnering To Bridge The

Continuum Continuum

Presented by: Nancy Boaro, MN, CNN(C), CRN(C)Presented by: Nancy Boaro, MN, CNN(C), CRN(C)KareyKarey--Anne Fannon, BA, BST, RRPAnne Fannon, BA, BST, RRP

ObjectivesObjectives

Review some of the behaviours exhibited by Review some of the behaviours exhibited by patients with Acquired Brain Injury (ABI)patients with Acquired Brain Injury (ABI)Demonstrate the effective use of behavioural Demonstrate the effective use of behavioural assessment and strategies assessment and strategies Identify key success factors to transitioning Identify key success factors to transitioning patients with ABI related behaviours across patients with ABI related behaviours across sectorssectors

Our Frame of ReferenceOur Frame of ReferenceToronto RehabToronto Rehab

Toronto Rehab is CanadaToronto Rehab is Canada�’�’s s largest provider of adult largest provider of adult rehabilitation servicesrehabilitation servicesMember of the ABI NetworkMember of the ABI NetworkABI unitABI unit

27 beds27 bedsSecuredSecuredLarge interprofessional Large interprofessional team with dedicated team with dedicated behavioural support staffbehavioural support staff

Common Behavioural IssuesCommon Behavioural Issues

Sexual Sexual inappropriatenessinappropriatenessAgitationAgitationAggressionAggressionWandering Wandering Exit seekingExit seeking

ImpulsivityImpulsivityPerseverationPerseverationInitiation deficitInitiation deficitConfusionConfusion

Challenges Across ContinuumChallenges Across Continuum

Staffing levels and skill mixStaffing levels and skill mixAddressing patient resource intensityAddressing patient resource intensityLeast restraint philosophyLeast restraint philosophyAccess to monitoring devicesAccess to monitoring devicesAccess to secured unitAccess to secured unitALC pressuresALC pressures

Timing it RightTiming it RightGap between acute care and inpatient rehabGap between acute care and inpatient rehabMedical stability vs. rehab readiness and Medical stability vs. rehab readiness and ability to actively participate and benefit ability to actively participate and benefit from rehab settingfrom rehab settingCognitive status / level of recoveryCognitive status / level of recoveryLimited ability to institute Limited ability to institute advanced behavioural strategies advanced behavioural strategies to facilitate community transitionto facilitate community transition

JudyJudy�’�’s Storys Story

Judy, age 25, developed an anoxic brain injury Judy, age 25, developed an anoxic brain injury after an overdose of cocaine after an overdose of cocaine She had a prolonged stay in ICU and was She had a prolonged stay in ICU and was transferred to a general medicine unit 12 weeks transferred to a general medicine unit 12 weeks post injurypost injuryVery supportive motherVery supportive mother

Physical DeficitsPhysical Deficits

Moderate weakness in Moderate weakness in all limbsall limbs2 person assist to 2 person assist to transfertransferSignificant balance and Significant balance and coordination challengescoordination challengesIncontinent Incontinent 11--2 person assistance 2 person assistance with all ADLswith all ADLs

Cognitive DeficitsCognitive Deficits

Consistently oriented Consistently oriented to self onlyto self onlyUnintelligible speechUnintelligible speechPoor carry over of Poor carry over of new learningnew learningImpaired insight and Impaired insight and judgmentjudgmentVery impulsiveVery impulsive

Behavioural BarriersBehavioural BarriersPhysical AgitationPhysical Agitation

Constantly movingConstantly movingBacking into staff with wheelchairBacking into staff with wheelchairNot sleepingNot sleepingResisting personal careResisting personal careHittingHitting

Verbal AgitationVerbal AgitationPatient calling out frequentlyPatient calling out frequently

Facilitating Acute Care Facilitating Acute Care ManagementManagement

OnOn--site assessment and consultation site assessment and consultation Toronto Rehab / West Park ABI Toronto Rehab / West Park ABI ProgramProgram

Psychiatric consultationPsychiatric consultationFocus on titrating pharmacological Focus on titrating pharmacological restraintsrestraints

Interprofessional team collaborationInterprofessional team collaboration

Behavioural AssessmentBehavioural AssessmentMedical reviewMedical review

infections /adverse medication infections /adverse medication side effectsside effects

Direct observationDirect observationBehavioural data recording formBehavioural data recording form

Identify antecedents / triggersIdentify antecedents / triggersAgitation Behaviour Scale (ABS)Agitation Behaviour Scale (ABS)Interviewed patientInterviewed patient�’�’s mothers mother

PrePre--morbid behaviour, copingmorbid behaviour, coping

Her Individualized Care PlanHer Individualized Care PlanStrategiesStrategies

Private roomPrivate roomDetailed daily scheduleDetailed daily scheduleEnhanced Enhanced communication strategiescommunication strategiesToileting / pain Toileting / pain management routinesmanagement routinesMinimize restraint useMinimize restraint useSleep hygieneSleep hygiene

ApproachApproachTeam leaderTeam leaderTherapeutic use of the 1:1Therapeutic use of the 1:1Regular team Regular team communication and communication and adjustment of behaviour adjustment of behaviour planplanOngoing external Ongoing external consultation with TR staffconsultation with TR staff

OutcomeOutcome

After 6 weeks, behaviours significantly reducedAfter 6 weeks, behaviours significantly reducedPatient able to engage actively in short therapy Patient able to engage actively in short therapy sessionssessionsTransferred to TR for inpatient ABI rehabTransferred to TR for inpatient ABI rehabAble to actively participate in therapyAble to actively participate in therapyPatient transitioned to LTCPatient transitioned to LTC

Important Considerations for Important Considerations for SuccessSuccess

Act early!Act early!Communication regarding Communication regarding behavioural strategies utilizedbehavioural strategies utilizedDuring transition, keeping the During transition, keeping the lines of communication openlines of communication openBehaviour Therapist involvement Behaviour Therapist involvement in application review processin application review processPatient orientation to the unit Patient orientation to the unit prior to transferprior to transfer

Let�’s Focus On�…

Promoting behaviour changeMembers of the ABI Rehab TeamRehab continues outside scheduled therapy sessionsTeam communication

Let�’s Focus On�…

Transitioning with support to the discharge settingABI and Behaviour EducationCase Example

Promoting Behaviour ChangePromoting Behaviour Change

Changing the EnvironmentChanging the Environment

Environment

Physical Environment:

Internal Environment:

Interpersonal Approach:

The TeamThe Team

ABI SurvivorABI SurvivorInpatient Rehab TeamInpatient Rehab TeamFamily and FriendsFamily and FriendsCommunity TeamCommunity Team

Community team members such Community team members such as family members, rehab support workers, as family members, rehab support workers, caregivers at home are:caregivers at home are:Encouraged to be involved in the patientEncouraged to be involved in the patient�’�’s s rehab on the unitrehab on the unitObserve and learn the strategies used by the Observe and learn the strategies used by the inpatient rehab team. inpatient rehab team.

The TeamThe Team

Rehab Occurs Off the UnitRehab Occurs Off the Unit

Weekend visits home with Weekend visits home with familyfamilyTransfer skills to oneTransfer skills to one�’�’s future s future discharge environmentdischarge environmentPractice functional activities Practice functional activities with community team with community team members such as the rehab members such as the rehab support worker.support worker.

Team CommunicationTeam Communication

Case Conferences:Case Conferences:ABI survivor, ABI survivor, Inpatient rehab teamInpatient rehab teamFamily members and friendsFamily members and friendsCommunity TeamCommunity Team

Transition to Discharge Setting

Accompanied by rehab therapist or other healthcare professional familiar with the patient.Discharge reports and recent behaviour management plans are forwarded to the community team and family members.

ABI and Behaviour Education

Workshops to External Healthcare ProvidersIntroductory Presentations to OT and Nursing Students.Learning Modules for Rehab Staff

GerryGerry�’�’s Story s Story

Gerry, age 30, was an unbelted driver in a motor Gerry, age 30, was an unbelted driver in a motor vehicle rollover. He was ejected from his vehicle and vehicle rollover. He was ejected from his vehicle and experienced a catastrophic brain injury.experienced a catastrophic brain injury.Subdural hemorrhage and bilateral frontotemporal Subdural hemorrhage and bilateral frontotemporal hemorrhage (brain bleeds).hemorrhage (brain bleeds).Diffuse axonal injuryDiffuse axonal injuryMultiple body fracturesMultiple body fracturesVery supportive family and girlfriend.Very supportive family and girlfriend.

Physical Deficits Physical Deficits Left sided deficitsLeft sided deficitsPoor trunk controlPoor trunk controlWears dynaWears dyna--slpints at night slpints at night for foot contracturesfor foot contracturesUses a tilt wheelchairUses a tilt wheelchairRequires two person assist Requires two person assist to transferto transferHypersensitive to touchHypersensitive to touch

Cognitive DeficitsCognitive Deficits

Impaired short term Impaired short term memorymemoryHighly distractibleHighly distractibleNot oriented to time or Not oriented to time or placeplacePoor insight into his Poor insight into his deficitsdeficitsPoor motor planningPoor motor planningSlow to process Slow to process informationinformation

Behavioural Barriers Behavioural Barriers Physical Aggression:Physical Aggression:

HittingHittingKickingKickingGrabbingGrabbingBitingBiting

Verbal Agitation:Verbal Agitation:Yelling ObscenitiesYelling Obscenities

Poor Motor Planning SkillsThree nurses are assisting Gerry with morning care. All are speaking to him. Gerry has his leg bent. He is asked to straighten his leg.Gerry responds, �“I will, give me a second�…OK!�” Gerry pulls on his pant leg and bends his knee upward as opposed to straightening it.

Poor Motor Planning Skills

Nursing asks Gerry again to straighten his leg. When he does not follow through, nursing provides physical assistance, straightening his leg for him.Gerry yells and swears at nursing staff, �“What are you doing! You�’re hurting me! Stop!�”Gerry grabs the nurse and hits her forcefullyon the upper arm.

Slow Processing Speed and Too Much Information to Process

Gerry is lying on his left side, holding the left bedrail with his right hand. Staff ask Gerry to roll onto his right side.Gerry states, �“OK, give me a second. I�’ll do it in a minute!�” Gerry remains lying on his left side holding tight onto the bedrail.

Slow Processing Speed and Too Much Information to Process

Staff removes his hand from the bedrail and tries to physically roll Gerry onto his right side.Gerry yells and swears at staff, �“What are you doing!!!�”He pulls staff�’s hand toward his mouth and bites her.

Behavioural StrategiesBreak a task down into small steps and provide simple instructions.Give Gerry two minutes to process the information and carry through with the step.Always inform Gerry what is happening around him.DistractionChange in Physical Environment

Transition Home

During inpatient rehab admission:Community Rehab Support worker introduced three weeks before Gerry�’s discharge home to promote rapport building and introduce behavioural strategies to be generalized to the discharge environment.Family also educated on these strategies to be used at home during weekend visits.

Transition to HomeTransition to Home

Discharge reports provided to case manager and Discharge reports provided to case manager and community team.community team.Rehab Support Worker transitions home with Rehab Support Worker transitions home with Gerry.Gerry.Family Education: Updated behavioural Family Education: Updated behavioural strategies and recommendations.strategies and recommendations.Updates re: GerryUpdates re: Gerry�’�’s physical and cognitive s physical and cognitive improvements.improvements.

ReviewThe members of an ABI Rehab Team go beyond the Inpatient Team.Rehab occurs during all periods of the day, everyday.Team communication is an essential component to transferring of rehab skills outside the inpatient environment.ABI and Behaviour Education sessions help to expand knowledge for healthcare professionals as well as family members.

Take Home MessagesTake Home Messages

Keys to successfully behaviour Keys to successfully behaviour management are:management are:

Early interventionEarly interventionOngoing behaviour assessmentOngoing behaviour assessmentCommunication across the continuumCommunication across the continuumClient Client �–�– centred approachcentred approach

Questions?

Contact InformationContact Information

Nancy BoaroNancy BoaroAdvanced Practice Leader, Neuro ProgramAdvanced Practice Leader, Neuro Program

Toronto RehabToronto Rehab416416--597597--3422 ext. 37723422 ext. 3772

boaro.nancy@torontorehab.on.caboaro.nancy@torontorehab.on.ca