infirmary care: managing challenging behaviours pat larson, mn, nurse practitioner sherbourne health...
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INFIRMARY CARE: Managing
Challenging Behaviours
Pat Larson, MN, Nurse PractitionerSherbourne Health Centre
Toronto, [email protected]
“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 We’re 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/cellulitis, 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 you’re ill?”
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Trauma framework Understanding and re-framing of people’s
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
“You’re 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 I’ve ever stayed.” “I feel like I’m 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
“I’m 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 client’s efforts and progress Importance of humour Staff training and support Differences of opinions
Staff cohesiveness on the big issues Recognizing when we’re inconsistent Addressing our inconsistencies
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DiscussionThank you for the opportunity!
Feedback
Discussion