INFIRMARY CARE: Managing Challenging Behaviours

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INFIRMARY CARE Managing Challenging Behaviours

• Pat Larson, MN, Nurse Practitioner
• Sherbourne Health Centre
• Toronto, Ontario
• plarson_at_sherbourne.on.ca
• The best way to find yourself is to lose
  yourself in the service of others M. Gandhi

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About this presentation.

• Context
• Behavioural Issues
• Prevention/planning
• Responding
• Discussion

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Context

• Solutions are unique to the setting
• Were a learning environment...
• Underpinning of values/principles
• Pro-active/Prevention based stance
• Responding in the moment
• Your contribution to our development
• An acknowledgement

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Sherbourne Health Centre

• Community based agency
• Partnerships (ie. Naturopathy, chiropractic)
• Infirmary
• Primary care programs
• Homelessness
• LGBTT community
• Newcomers
• Local community
• Health Bus (volunteer RNs, outreach)

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Sherbourne Health Centre Infirmary

• Community-based, stand-alone model
• 20 beds (9 open at present)
• Serves the Greater Toronto area
• Referrals self, community (shelters, drop-ins,
  community agencies and providers) and hospitals
  (12 in area)
• Opened April, 2007

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Staffing Model

• Community Health Worker (CHW) - 24/7
• RN 24/7
• Case Manager
• NP
• Consulting MD
• Manager and Admin Assistant
• Partnerships (housing worker, pastor)

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Values/Principles

• Program values
• Social justice
• Community/belonging
• courage
• Harm reduction
• Independence, self determination
• Participation in program, health care plan
• Trauma model
• Kindness AND therapeutic value

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Clients

• Homeless/underhoused
• Fractures, cardiac problems, diabetes, HIV,
  endocarditis, pneumonia, skin infections/celluliti
  s, osteomyelitis/bone infections, post
  surgically, post childbirth
• Majority also have substance use issues
• More men than women, but priorize women
• Most leave to go to shelters occasionally client
  is housed upon discharge

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Referrals

• Short term
• Maximum stay 3 weeks average 10 days
• Acute need
• Written, faxed referral
• Referee remains responsible for information
  transfer
• Hospital visits w/ some referred clients
• acuity
• ability to safely discharge clients

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Behavioural Issues

• Your setting
• Your experiences?
• Issues
• Anything you would like to share?
• Things we might address?

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Preventing Behavioural Issues

• Focus on referral
• Adequate resources to process
• Follow up with referees/client/supports
• Ask difficult questions are you barred?
• Program self-determination
• Ability to say no to clients
• Client meets program criteria?

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Antennae on High Alert

• Intent
• Primarily - planning/managing
• Consider - restriction
• Shelter restrictions
• Evidence or history of violent behaviours
• Referee reluctant to provide information or
  details
• Client vague/reluctant re details
• Evidence of difficulty participating in previous
  programs

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Planning with Clients

• Contingency Planning
• Frank
• Involve community supports
• Substance use
• How will you manage your cravings?
• Do you plan to use? How could you reduce your
  use?
• History of Violence or Barrings
• What will be different in this program?
• Risk from Partners/others
• Safety plan involve management/security
• Triggers
• What are your triggers? What is your plan to
  avoid? Manage?

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Rights and Responsibilities

• Discussions about
• Expectations
• Participation in program
• Consequences of not respecting responsibilities
• Independence
• Contracts
• Client developed
• Staff developed

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Harm Reduction

• No illegal substances on-site
• May use/imbibe, behaviour is the focus, not
  substance use
• What is your substance of choice?
• How can we help you not to use? To use more
  safely? To use less while youre ill?

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Trauma framework

• Understanding and re-framing of peoples life
  experiences
• Therapeutic responses
• Self responsibility
• Assist clients w/ coping strategies
• Trauma of being discharged
• Clients
• Staff

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Behaviours

• Attempts to triangulate - Manipulation
• Making unrealistic demands
• Youre not going to discharge ME, are you?
• Evasiveness
• Not being honest
• Not participating
• Refusing to meet w/ providers, to get out of bed,
  have treatments.

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Serious Adverse Behaviours

• Disrespect - intolerance
• Theft
• Threats
• Violence
• Smoking inside/risk of fire
• Substance use on the premises

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Physical Environment

• Clean, bright environment
• Minimal sharing of bedrooms
• Safe spaces, quiet areas
• Able to go outside (smoke, appointments)
• This is the nicest place Ive ever stayed.
• I feel like Im at the spa.
• On-site security
• EMR team care plans, rounds, reviews

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Inclusive Environments

• Diversity
• How do we live it?
• Social Inclusion
• Radical inclusion
• Respect, dignity
• Ambivalent responses to acceptance
• Resenting being cared for

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Stepwise Approach

• Accountability
• First episode - not meeting responsibilities
• Responsibilities, rules, consequences
• Repeat behaviours
• May result in discharge from program
• Serious issues (violence/threats/theft)
• Discharge from program,
• ? Charges?

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Responding to Behaviours

• All staff trained in Non violent Crisis
  Intervention
• Focus on understanding own responses
• Minimal staffing levels
• Timing of responses
• In the moment
• Can this wait? Should this wait?
• Can this be ignored?

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Issues of Responding

• Enforcer role (bouncer/security)
• Who should respond to client?
• Challenging particular behaviours
• Im not feeling comfortable with ..
• I need to speak with you about
• Alone versus with support
• Clarity
• Consistent messages
• Easier to say than do

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Responding

• Acknowledge clients efforts and progress
• Importance of humour
• Staff training and support
• Differences of opinions
• Staff cohesiveness on the big issues
• Recognizing when were inconsistent
• Addressing our inconsistencies

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Discussion

• Thank you for the opportunity!
• Feedback
• Discussion