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 pro­grams work effectively when all staffmembers are competent to understandand meet the daily challenges ofwork­ing with their patients. An education­al program about agitated patientswith brain injury targeted to certifiednursing assistants carried over to thestaff's job performance and to in­creased staffconfidence.

Address correspondence to PaulaMontgomery, BSN RN CRRN, Sa­cred 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. Agitat­ed 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 in­jury program because agitation often occurs as patients emerge from comatose and min­imally responsive states to levels of increased arousal. Sacred Heart also offers a neu­robehavioralprogram 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 work­ing with these patients, as their behavior was very difficult to manage. They also ex­pressed concern that we provide the most effective treatment plan. Certified nursing as­sistants (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 Com­mission on Accreditation of Healthcare Organizations (JCAHO) standards. Section 4("Orientation, Training and Education of Staff") of the Accreditation Manual for Hospi­tals (JCAHO, 1994) deals with education, cross-training, and the ongoing competency ofstaff to serve specific patient populations. Cross-training was important for the facility,be­cause 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 strate­gies 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 ed­ucational programs to teach patient management techniques.

Hayden and Hart (1986) said, "The agitated patient is a behavior-management chal­lenge, 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-ser­vice 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 deal­ing 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 re­viewed 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 ther­apy 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 month­ly 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 at­tend and that all other interested staff were welcome.

Occupational therapy and physical therapy staff were strong­ly encouraged to participate in the program, although they werenot required to attend. Staff in general expressed a strong in­terest 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 ofAgitat­ed/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 discom­fort 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 behav­iors 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 nonpurpose­ful and is often aggressive or hostile.

• Socially inappropriate behavior-The patient cannot con­trol impulses, is unable to inhibit inappropriate behaviors orforesee the consequences of actions, and exhibits egocen­tric 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 at­tention 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 pa­tients are not in control of their behavior at this stage and can­not be held accountable for their actions.

We developed a printed handout, "Working with the Agi­tated 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 modifi­cation 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 stud­ies, as recommended by Kelly (1992). We chose the lecture for­mat because we had to get the information across to a largegroup. Group discussion and case studies allowed for partici­pants' input and discussion of problem-solving strategies re­garding specific behaviors. We encouraged participants to askquestions during the program to help them with specific patientsituations and to promote the transfer of learning to patient care

Rehabilitation Nursing> Volume 22, Number I • JanlFeb 1997 21

The Agitated Patient with Brain Injury

Figure 1. Overhead Slides Used During the In-Service Program

Slide 1: Sensory Input Experienced by the Patient with Brain Injury During Early Recovery

• • • • • • • • •• • • • • • • • •• • • • • • • • •• • • • • • • • •

"Dr. Smith,please call the operator."

WHAT THEPATIENT HEARS

• • • • • •

"My head hurts."

"Where is the chart for thepatient in 12B?"

BEEP-BEEP-BEEP

"Bob Barker,Come on down!"

"Aaah!!"

"My bottom hurts."

"I have to go to the bathroom."RING! RING!

Slide 2: Sensory Input Attended to by a Person Without Brain Injury

• • • • • • • • •• • • • • • • • •• • • • • • • • •• • • • • • • • •• • • • •

"What time is the conferencefor the patient in 14B?"

WHAT THESTAFF HEARS

Note: Graphics from Corel GALLERY Clipart Catalog (Version 1.0) [Computer software]. (1994). Salinas, CA: Corel Corporation.

22 Rehabilitation Nursing· Volume 22. Number I • JanlFeb 1997

situations. One of the most common concerns was that agitat­ed patients were aware of their behavior and that their actionswere deliberate. An example brought up by one CNA was thata patient who, according to her description, was "playing in hisBM just to get on my nerves and put me behind in my work." Weresponded to her comment by explaining that if the patient hadtruly been aware of his or her actions, that would have been anunlikely activity for the patient to voluntarily choose to do. Wealso reviewed the fact that the patient's brain would have hadto have all of its centers working and connected to deliberate­ly manipulate a staff member in this manner. Furthermore, welet the staff know that if a patient is truly able to manipulatestaff, then the patient is not in the agitated phase of recoverybut is actually functioning at a higher level of recovery. We alsoanswered questions that were posed by the group about appro­priate responses to these types of situations.

EvaluationThe program was attended by staff from a variety of disci­

plines. The 73 participants included 40 CNAs, 12 registerednurses, 9 therapy aides, 5 licensed practical nurses, 3 physicaltherapists, 2 occupational therapists, 1 occupational therapy stu­dent, and 1 pastoral care staff member.

All participants were asked to evaluate the program. Fifty-

Paula Montgomery is coordinator ofnursing development at Sa­cred Heart Rehabilitation Institute in Milwaukee. Mary Kitten is as­sistant professor of nursing at Alverno College in Milwaukee.Christy Niemiec is senior occupational therapist at Sacred HeartRehabilitation Institute in Milwaukee.

eight participants completed evaluations. The overall evalua­tion of the program was positive. Eighty-seven percent of theparticipants either "agreed" or "strongly agreed" that the in­formation presented was pertinent to their learning needs. Nine­ty-one percent of the participants either "agreed" or "stronglyagreed" that the objectives were met. The following are some ofthe written comments we received: "great information," "Couldthis be a CEU [sic] offering?," "very pleased," "I learned a lot,""informative and useful to the work area."

A few participants stated that they would have liked morediscussion. They also expressed a need for guidance as to howstaff could control their own behavior when caring for agitatedpatients. One staff member suggested that our facility publisha pamphlet on caring for the agitated patient that could be usedby patients' families, but we indicated that family educationmaterials on the subject are already available through our braininjury program.

Discussion of staff members' questions during the programhelped them understand why patients with brain injury act asthey do. After the in-service program, staffmembers expresseda higher confidence level and an increased comfort level abouttheir ability to manage agitated patients. Clearly, this was a re­sult and a benefit of the educational program.

We, as well as nursing staff supervisors, informally observedstaff after the in-service program. We noted that the team col­laborated more when problem solving and developing writtenprotocols for behavior management. Staff members openly ex­pressed frustrations and were quick to ask for suggestions andprovide necessary support for each other. They also attempted

continued on page 39

Rehabilitation Nursing> Volume 22, Number 1 • JanlFeb 1997 23

merited clearly that the patient has one-on-one supervision. Theprocess of weaning and the subsequent termination of one-on­one supervision should be outlined as well. Education given tothe patient and the family, outcomes of interdisciplinary meet­ings, and any contact between the patient and an individual teammember should also be noted.

ConclusionManaging patients who need one-on-one supervision re­

quires a comprehensive and cohesive interdisciplinary approach.Successful supervision can result in increased compliance andparticipation, as well as decreased acting out, falls, confusion,and agitation. Flexibility in providing for patients' needs andfrequent team meetings to reevaluate the plan of care are im­portant to ensure quality patient outcomes. It is important thatall team members follow the individual patient's behavior man­agement plan to provide for his or her continuity of care. Ear­ly assessment and intervention not only ensure that patients'safety will be improved but also help patients attain their reha­bilitation goals in the shortest possible time.

ReferencesBurke, W.H., & Wesolowski, M. (1992). Applied behavioral analysis in

head injury rehabilitation. Center Ossippee, NH: New Medico Head InjurySystem.

Corrigan, 1., & Mysiw, W. (1988). Agitation following traumatic head in­jury: Equivocal evidence for discrete stage of cognitive recovery. Archives ofPhysical Medicine and Rehabilitation, 69,487-492.

Herbal, K., Schermerhorn, L., & Howard, 1. (1990). Management of agitatedhead injured patients: A survey of current techniques. Rehabilitation Nursing,15,66-69.

Malkmus, D., Booth, B.J., & Kodimer, C. (1980). Rehabilitation of thehead injured adult: Comprehensive cognitive management. Downey, CA: Pro­fessional Staff Association of Rancho Los Amigos Hospital, Inc.

Patterson, T., & Sargent, M. (1990). Behavioral management of the agi­tated head trauma client. Rehabilitation Nursing, 15, 248-249.

Williams, L., Morton, G., & Patrick, C. (1990). The Emory cubicle bed:An alternative to restraints for agitated traumatically brain injured clients. Re­habilitation Nursing, 15, 30-33.

Suggested ReadingRehabilitation Institute of Chicago. (1983). A manual ofbehavioral man­

agement strategies for traumatically brain injured adults. Chicago: Author.

Both authors are affiliated with Long Beach Memorial Rehabili­tation Hospital: Deborah Riedel is team leader, and Vance Shawis a staffnurse.

The Agitated Patient with Brain Injurycontinued/rom page 23

to help the situation by reminding each other and patients' fam­ilies that these patients with brain injury were truly not in con­trol of their actions and that engaging in a power struggle withthem was nonproductive. Furthermore, a nursing assistant whowas concerned about the manner in which a nurse respondedto an agitated patient felt comfortable enough to talk directlyto the nurse about the nurse's behavior. The nursing assistantsaid that she felt confident about discussing this with the nursebecause of what she had learned from the in-service program.

All nursing employees attend a yearly competency evalua­tion program that reviews pertinent skills. To address ongoingcompetency in accordance with JCAHO standards, we addeda review about caring for agitated patients to the program. Theprogram includes a poster about the "dos and don'ts" of caringfor an agitated patient as well as about the difference betweenbehavior modification and limit setting. This information is pre­sented to all nursing staff during small group discussions. Nurs­ing staff members are also required to explain the differencebetween behavior modification and limit setting, as well as pro­vide examples of each.

ConclusionThe l-hour in-service program opened the door to further

staff education. The review of myths related to the care of pa­tients in the agitated phase of recovery from brain injury wasmost helpful for the staff. After the in-service program, staffshowed through their comments as well as by their interactionswith patients that they understood that patients do not act "thatway" intentionally.

As a result of this program, staff interactions with patientshave been affected positively. Patients with brain injury in theagitated phase of recovery now benefit from increased staff un­derstanding of their problems.

ReferencesBooth, B., Doyle, M. & Malkmus, D. (1980). Meeting the challenges of

the agitated patient. In Rehabilitation ofthe head injured adult: Comprehen­sive management (pp. 43-46). Downey, CA: Professional Staff Association ofRancho Los Amigos Hospital, Inc.

Corel GALLERY Clipart Catalog (Version 1.0) [Computer Software].(1994). Salinas, CA: Corel Corporation.

Gans, J. (1983). Hate in the rehabilitation setting. Archives ofPhysical Med­icine and Rehabilitation, 64, 176-179.

Hayden, M., & Hart, T. (1986). Rehabilitation of cognitive and behavioraldysfunction in head injury. Advances in Psychosomatic Medicine, 16, 194-229.

Joint Commission on Accreditation of Healthcare Organizations. (1994).1995 accreditation manual for hospitals. Oakbrook Terrace, IL: Author.

Kelly, K. (1992). Nursing staffdevelopment: Current competence, futurefocus. Philadelphia: Lippincott.

Patterson, T., & Sargent, M. (1990). Behavioral management of the agi­tated head injury client. Rehabilitation Nursing, 15,248-249.

Rehabilitation Nursing Foundation. (1989). Head injury: Nursing man­agement ofagitated/aggressive behavior (video). Skokie, IL: Author. (Editor'snote: Available from Rehabilitation Nursing Foundation, 4700 W. Lake Avenue,Glenview, IL 60025-1485, 800/229-7530, fax 847/375-4825.)

AcknowledgmentThe authors thank Kari Schmidt, MS RN C CRRN, for her

help in planning the in-service program and for her encour­agement and assistance in pursuing this endeavor.

Rehabilitation Nursing. Volume 22, Number I • JanlFeb 1997 39