The Agitated Patient with Brain Injury and the Rehabilitation Staff: Bridging the Gap of Misunderstanding
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The Agitated Patient with BrainInjury and the Rehabilitation Staff:Bridging the Gap of Misunderstanding
Paula Montgomery, BSN RN CRRNMary Kitten, MSN RN CRRNChristy Niemiec, OTR
Patients with brain injury at theagitated stage of recovery present aunique challenge to rehabilitationstaff.The staff's patience is tested,andtheir personal comfort is threatenedfrequently during their interactionswith patients. How can a healthcareteam increase its comfort level andcompetence when working with thesepatients? Rehabilitation specialty pro-grams work effectively when all staffmembers are competent to understandand meet the daily challenges ofwork-ing with their patients. An education-al program about agitated patientswith brain injury targeted to certifiednursing assistants carried over to thestaff's job performance and to in-creased staffconfidence.
Address correspondence to PaulaMontgomery, BSN RN CRRN, Sa-cred Heart Rehabilitation Institute,E Facility, Room 2711, PO Box 392,Milwaukee, WI 53201-0392.
Sacred Heart Rehabilitation Institute in Milwaukee provides a broad spectrum ofcare, including a complete continuum of services for patients with brain injury. Agitat-ed patients can be found in any of the inpatient programs for patients with brain injury.We may treat agitated patients in our coma recovery program or in our acute brain in-jury program because agitation often occurs as patients emerge from comatose and min-imally responsive states to levels of increased arousal. Sacred Heart also offers a neu-robehavioralprogram that can accommodate patients whose stage of agitation isprolonged or particularly disruptive.
Management of the agitated patient with brain injury requires a highly specializedapproach. We identified a need for staff members to expand their knowledge about braininjury, particularly about the agitated phase of recovery from brain injury. Rehabilitationstaff at all clinical levels reported having experienced periods of frustration when work-ing with these patients, as their behavior was very difficult to manage. They also ex-pressed concern that we provide the most effective treatment plan. Certified nursing as-sistants (CNAs), in particular, often felt that patients were being deliberately manipulativeand that they actually could control their actions.
These staff comments and observations by nurse managers led to identifying a needto increase the staff's insight into why patients with brain injury become agitated andinto how to deal effectively with their difficult behaviors. An educational program, whichwas mandatory for the nursing assistants, was developed to meet these needs.
A secondary advantage of the program was that it helped our facility meet Joint Com-mission on Accreditation of Healthcare Organizations (JCAHO) standards. Section 4("Orientation, Training and Education of Staff") of the Accreditation Manual for Hospi-tals (JCAHO, 1994) deals with education, cross-training, and the ongoing competency ofstaff to serve specific patient populations. Cross-training was important for the facility,be-cause agitated patients with brain injury can be found in all of its three inpatient programs.
Program developmentA literature search identified research articles that address how staff should deal with
agitation in patients with brain injury. Several of the articles identified behavioral strate-gies for effective management of patients with brain injury, whereas others provided"dos and don'ts" (Booth, Doyle, & Malkmus, 1980; Hayden & Hart, 1986; Patterson &Sargent, 1990). Suggestions from the literature were incorporated into the content ofthe in-service educational program.
Many articles described specific examples of agitated behavior and examined anddiscussed neurological causes. However, few articles addressed the effectiveness of ed-ucational programs to teach patient management techniques.
Hayden and Hart (1986) said, "The agitated patient is a behavior-management chal-lenge, partly because the behavior is dramatic, frightening, and easily misunderstood byboth lay person (e.g., family members) and rehab specialists" (p. 207). During the in-ser-vice class, staff members expressed their fear and apprehension, as well as lack of under-
20 Rehabilitation Nursing > Volume 22, Number 1 JanlFeb 1997
standing of patient behavior. Many voiced frustration and a desireto know more to help these patients through a difficult time.
According to Patterson and Sargent (1990), "The importanceof staff morale and security cannot be overemphasized" (p. 249).Gans (1983) noted the frustration of staff members when deal-ing with agitated behaviors. He suggested team education toteach staff to understand patient behaviors and appropriate waysto set limits.
Limited information was available in the articles that we re-viewed on effective programs to help staff understand and dealwith agitation. We thus identified a need for staff education onthe subject. We used an interdisciplinary approach in planningthe in-service program, which was entitled, "Working with theAgitated Patient." The nursing staff and the occupational ther-apy and physical therapy departments participated in planning.The supervisors of these departments were consulted, and thein-service dates and times were posted in the hospital's month-ly education calendar. The program was offered at a variety oftimes to accommodate staff from all shifts. Flyers announcingthe program indicated that it was mandatory for CNAs to at-tend and that all other interested staff were welcome.
Occupational therapy and physical therapy staff were strong-ly encouraged to participate in the program, although they werenot required to attend. Staff in general expressed a strong in-terest in attending, and clinical supervisors made schedulechanges to accommodate multidisciplinary staff participationin the program.
Objectives, materials, content, and teaching methodsObjectives: The learning objectives of the program were as
follows: to describe the agitated phase of brain injury recovery to identify causes of agitation to recognize agitation as a stage of recovery for patients with
brain injury to identify strategies to care for agitated patients to describe acceptable and expected responses to agitated
and inappropriate patient behaviorMaterials: The teaching materials included overhead slides,
written handouts, a video, and case studies. During the class, avideo entitled Head Injury: Nursing Management ofAgitat-ed/Aggressive Behavior (Rehabilitation Nursing Foundation,1989) was shown. During the video, we asked the audiencemembers to sit in one position, without even shifting their weightor otherwise moving, to help them get a sense of the discom-fort and restlessness felt by patients who cannot do these thingsfor themselves (see Figure 1).
Content: We provided basic information about agitation andits causes, along with an outline that listed the types of behav-iors or deficits to expect, including these:
Confusion-The patient has generalized reactions, respondsinappropriately to stimuli, and is fearful due to an inabilityto interpret the environment.
Cognitive/attention deficits-The patient is distractible, givesrandom responses, processes information poorly, and hasdifficulty initiating responses.
Activity-The patient's activity is bizarre and nonpurpose-ful and is often aggressive or hostile.
Socially inappropriate behavior-The patient cannot con-trol impulses, is unable to inhibit inappropriate behaviors orforesee the consequences of actions, and exhibits egocen-tric behavior.Common misconceptions about agitated patients were ad-
dressed (Booth et aI., 1980); they included the following:1. He is mean. He is rude. He insulted me.2. A large number of people are needed to control an agitated
patient.3. He must be restrained at all times for everyone's safety.4. Ifhe is loud and noisy, yell at him to "be quiet."5. He needs medication to calm him down.6. He is too agitated to participate.7. He won't cooperate (Booth et al., p. 44).
We also addressed methods for decreasing the stimulationthe patient experiences as well as redirecting the patient's at-tention and setting limits. The first misconception-"He ismean. He is rude. He insulted me."-was emphasized to helpstaff understand that agitated patients are reactionary and thattheir actions and comments should not be taken personally.
We presented information that explains how, in patients withbrain injury, the limbic system works independently from thecortex, which normally suppresses inappropriate behavior (seeFigures 2 and 3). The return of autonomic functions that arenot controlled by the cortex was also addressed to show that pa-tients are not in control of their behavior at this stage and can-not be held accountable for their actions.
We developed a printed handout, "Working with the Agi-tated Patient," which included the following list of "dos anddon'ts":Do
Attempt to de-escalate the situation before it reaches a pointof physical aggression.
Use simple directions, such as "Don't hit," "Don't kick," andavoid scolding or belittling (e.g., "Now look what you did!").
Control your voice, keep calm, and do not yell. Remember the impact of short-term memory deficits (i.e.,
patients do not remember that someone "just told them"something).
Don't Take the comments and actions of patients personally, be-
cause they are not in control of their behavior. Initiate behavior modification without consulting the reha-
bilitation team (We differentiated actual behavior modifi-cation with consequences from simple limit setting).The teaching and learning strategies used for the l-hour pro-
gram were lecture, group discussion, and review of case stud-ies, as recommended by