Effective Strategies for Managing Behavioral Challenges in Infirmary Care

1. INFIRMARY CARE: Managing Challenging Behaviours Pat Larson, MN, Nurse Practitioner Sherbourne Health Centre Toronto, Ontario plarson@sherbourne.on.ca “The best way to find yourself is to lose yourself in the service of others” M. Gandhi

2. About this presentation…. • Context • Behavioural Issues • Prevention/planning • Responding • Discussion

3. 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

4. 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)

5. 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

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

7. 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

8. 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

9. 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

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

11. 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?

12. 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

13. 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?

14. Rights and Responsibilities • Discussions about • Expectations • Participation in program • Consequences of not respecting responsibilities • Independence • Contracts • Client developed • Staff developed

15. 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?”

16. 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

17. 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….

18. Serious Adverse Behaviours • Disrespect - intolerance • Theft • Threats • Violence • Smoking inside/risk of fire • Substance use on the premises

19. 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

20. Inclusive Environments • Diversity • How do we live it? • Social Inclusion • “Radical inclusion” • Respect, dignity • Ambivalent responses to acceptance • Resenting being cared for

21. 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?

22. 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?

23. 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

24. 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

25. Discussion Thank you for the opportunity! Feedback Discussion