Melanie Sturman-Floyd MSc RGN Moving and Handling Lead

1. Moving and Handling Challenges in Dementia Care:Rights, Restraints and ResponsibilitiesMoving & Handling People DLF 2017 Melanie Sturman-Floyd MSc RGN Moving and Handling Lead

2. Aims and Objectives In this session the learner will be able to: • Be aware of dementia statistics • Be aware of incidents related to distressful behaviours. • Understand difference between challenging behaviour and distressful behaviours. • What are behaviours. • Identify behaviours. • Identify appropriate strategies to manage distress. • List legal responsibilities • List appropriate and inappropriate practices.

3. Dementia Statistics • In the UK there are approximately, 800,000 people diagnosed with dementia. (Alzheimer’s Society 2016) • Current cost to health and social care £23million and expected to rise to £27million by 2018 (Alzheimer’s Society 2016) • 80% of people living in residential and nursing homes are diagnosed with dementia (Alzheimer’s Society 2013).

4. Violence and aggression Health and social care staff are often exposed to violence and aggression in the work place. Increased risk of injury to employees working with individuals who have dementia/LD/Mental health (Berry 2010, Skills for Care 2013). Risk of injury is foreseeable so organisations need to put steps into place to manage the risks.

5. Violence and Aggression • Aggression and violence are terms often used interchangeably; however, the two differ. • Violence can be defined as the use of physical force with the intent to injure another person or destroy property. • Aggression is generally defined as angry or violent feelings or behaviour

6. Injuries reported to HSE

7. Legal case 2011 • Norfolk County Council care home. • Carer sustained an arm injury after being punched and pulled by an elderly resident. • Claimant won the case on the basis there were insufficient systems in place to protect the employee from injury. • Lack of risk assessment identifying behaviour. • Insufficient training to manage risks and protect employee. • Overall legal costs and compensation £60,000

8. Is it challenging behaviour? • Commonly used terms in health and social care: • Challenging behaviour • Behaviour that challenges • Harmful behaviour • Distressful behaviour

9. Definition of Behaviour "culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy (wiki) OR Any non-verbal, verbal or physical behaviour by a person which makes it difficult to deliver good quality care (NHS Protect).

10. What is a behaviour? Behaviour is a response to an action, environment, stimulus or a person. Example if a stranger grabbed you, how would you respond? Reasons Although some times challenging the behaviour is usually for a reason.

11. Types of Non-Verbal Behaviour • Agitation • Facial expressions • Intimidating body posture • Cornering • Invading body space • Declining to move • Passivity • Walking • Following someone

12. Types of verbal behaviour • Talking loudly • Swearing • Crying • Repetitive statements • Repetitively asking questions • Making personal comments • Racist speech

13. Types of Physical Behaviour • Kicking • Hitting • Punching • Grabbing • Pushing • Undressing • Self harm • Absconding • Non-compliance • Spitting • Hair pulling

14. Reasons for challenging behaviour Always a reason for behaviour Usually behaviour is a response to: Environment Person Stimulus Distress

15. Temperamental Factors • High intensity of emotional responding • Poor adaptability to new situations • Sudden changes of movement and directions • Reaction to other patient/residents distress

16. Biological or Physical Factors • Organic brain dysfunctions • Poor sleep • Hearing Difficulties • Visual Difficulties • Pain • Parkinson’s Disease • Dementia • Learning Disability • Drug or alcohol related • Psychosis or personality disorder

17. Social Factors • Poor quality care • Care tasks • Pre operative period • Post surgery • Rejection • Environments • Learning histories • Lack of staff engagement • Cultural, gender preferences

18. Emotional factors • Experiences of failure • Dependency on others • Poor self-esteem • Unmet needs, toilet, pain, thirst • Lack of meaningful activities

19. Cognitive Factors • Poor problem-solving skills • Poor communication skills • Inability to remember new information/instructions • Poor social skills • Boredom • Fear • Memory loss • Frustration

20. Examples of Behavioural Triggers • Turning in bed • Getting out of bed a different side • Lighting causing shadows • Colour – staff clothing and environmental • Race • Gender • Not having face to face transfer • Inability to push down on arms of chair • Communication • Direction of movement • Fear

21. Behavioural Tracking or Monitoring What is the “ABC” Approach A = Antecedent B = Behaviour C = Consequence Action and Review

22. The ‘ABC’ Approach • Understanding what is a behaviour • Understanding and identifying the antecedent. (Be Specific) • Documenting the behaviour, (hit, grab, verbal) • Managing the consequences • Who was affected.

23. Triggers/Antecedents Often behaviour comes with a warning. Sometimes there is no warning. Easiest approach is to observe, identify what is happening at the time behaviour is expressed. Behavioural distress is inventible in health and social care and organisations are expected to have systems in place to manage distress and reduce risk of injury/harm to patient and staff.

24. Look out for Precursors • Sometimes behaviour can occur without warning and should try and identify precursors • Examples: • Tense facial expressions • Walking • Body tension • Increased breathing • Refusal to communicate • Not having eye contact or prolonged eye contact • Threats • Gestures

25. Strategies • De-Escalation • Do nothing • Leave and return • Better understanding • Observations – recording • Physical intervention

26. Legal Framework • Common Law • Equality Act 2010 • Human Rights Act 1998 • The Mental Health Act 1983 (amended 2007) • The Mental Capacity Act 2005 • Deprivation of Liberty Safeguards • Health and Safety at Work Act • Manual Handling Operations Regulations

27. DOLS – Deprivation of Liberty Safeguards • The Mental Capacity Act allows restraint and restrictions to be used – but only if they are in a person's best interests. • Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are called the Deprivation of Liberty Safeguards. • The Deprivation of Liberty Safeguards can only be used if the person will be deprived of their liberty in a care home or hospital. In other settings the Court of Protection can authorise a deprivation of liberty. • Care homes or hospitals must ask a local authority if they can deprive a person of their liberty. This is called requesting a standard authorisation.

28. Office of Public Guardian (OPG) • Protects people who may not have the mental capacity to make certain decisions for themselves, such as about their health and finance. • taking action where there are concerns about an attorney or deputy • registering lasting and enduring powers of attorney, so that people can choose who they want to make decisions for them • maintaining the public register of deputies and people who have been given lasting and enduring powers of attorney • supervising deputies appointed by the Court of Protection, and making sure they carry out their work in line with Mental Capacity Act • looking into reports of abuse against registered attorneys or deputies

29. Understanding Interventions/restraint • What is restraint? • What is intervention? • Should restraint or interventions be used are there other ways? • De-escalation • Minimal and safe interventions

30. Acceptable Interventions Resident/patient may ask for bed rails because they are afraid of falling out of bed. Care homes/wards may have code access to doors to prevent residents, who lack capacity from entering. Care staff may sometimes have to decide quickly to restrain/safe hold if there is a risk of physical harm to themselves, the resident or others.

31. Unacceptable Interventions Holding a resident/patient down physically or stopping them from doing something they want to do. Using wheelchair safety strap without risk assessment. Using bed rails without risk assessment. Using a tilt and space chair to stop someone from moving in a chair rather than postural management.

32. Unintentional Interventions Use of chairs that are too low or deep and prevent a person from transferring independently. Using a bed that is too low or high for someone to transfer independently.

33. Other examples of intervention Physical – 1 or more employees holding the resident, blocking the movement. Mechanical – use of bed rails and safety straps. Technological – use of door alarms, pressure pads, tagging. Chemical – inappropriate use of prescribed/over counter medication. Psychological – depriving choice, constantly telling resident not to do something.

34. Lawful intervention Intervention is only lawful if its use is: 1)    Reasonable 2)    Proportionate 3)    Necessary 4)    No more intervention than is necessary in the circumstances 5) Least restrictive option to be used and for shortest time necessary Used if threat to people or property

35. Can you justify interventions? Can you justify why interventions are required? Are you making a decision in the person’s best interest?

36. Are interventions necessary? Do you need to use interventions? Consider is there a risk to yourself, resident/patient or other people. Balance duty of care versus neglect. Any intervention should be used in the minimalist way possible and for the shortest time possible, (Sturman-Floyd 2013)

37. What is reasonable? Is the level of intervention reasonable to be used on an older person with dementia or someone with tissue viability, arthritic conditions? Have you considered the risk of bruising, fracture and possible skin damage?

38. Inappropriate management Holding a resident/patient down physically or stopping them from doing something they want to do. Using wheelchair safety strap without risk assessment. Using bed rails without risk assessment. Using a tilt and space chair to stop someone from moving in a chair rather than postural management. High level of force

39. Consequences of not addressing challenging behaviour Ineffective delivery of care Over reliance of anti-psychotic behaviour Increase in staff and patient injuries Reductions in staffing Higher staff turnover Managing training resources Failure legal duty to protect staff and patients from harm. Increased complaints and litigation Unmet care needs

40. Safe moving and handling • Use appropriate moving and handling equipment. • Do not use a stand aid as a mechanical “drag” lift. • May need to use in-chair sling. • Use of bed rails. • Use of in-bed positioning systems, i.e. Wendy Lett.

41. Front assist transfers

43. Cocoon method

44. Turning within bed

45. Oval Glide Boards to fit slings

46. Turning in bed • Lift turn sheets • Twin sheet/Topsheet/Wendy Lett

47. Posture management • Look at appropriate seating – is it correct height to facilitate standing, postural support, lateral support • Contractures – increase pain, is this a trigger? Consider sleep systems, pillows, wedges.

48. Difficulties with hoisting • NRLS – identified 15 incidents where individuals have come to harm following a fall from a sling. • Hoisting can be traumatic for individuals. • What are the triggers for distress? Pain Incorrect sling Spreader bar Changes of positions Repetitive hoisting

49. Do you still see this?

50. Generic Risk Assessment Falls are foreseeable and steps should be put into place to manage risks. Completion of generic risk assessment for all tasks helping person up from the floor.