Description of DVD training package, ABI

1. 9/24/2012
Introduction to a DVD Aim of the presentation:
training package:  Introduce the concept: A low-arousal
approach for de-escalation of
challenging behaviour following an
Acquired Brain Injury
Dilemmas  Rationale behind the concept
 Evaluate current area of current
practice
 Development of training DVD
Presented by Andrew Brennan &  How the training package is used
 Clip of the DVD
Ruth Banner
Concept Rationale
 Mobile & immobile patients – some
Work on a Inpatient have cognitive deficits &
challenging behaviour.
Neuro Rehab Unit, more
patients being admitted
that have challenging
Currently Minimal staff training on
behaviour.

Affects on patients – unable
to participate in therapy and
Demand on beds increasing,
not always the right challenging behaviour.
Training a large amount of people
mis-trust in staff if not environment for this patient
group but demands on
handled appropriately.
service often means patients 
are admitted.
can be difficult & time consuming.
Challenging  Research literature identifies that
Staff being injured.
behaviour continuity in approach is essential,
Increased need to
develop a training Large staff turn over and
 To address lack of continuity in
approach
tool that will meet all agency staff on the unit
the needs of the staff means that there is often
on the unit. no continuity.
 Overall aim was to produce a DVD
that will effectively engage staff for
training purposes and beneficially
Trying to deliver training
to this amount of staff
Impact on staff –
impact on risk management.
currently extremely
Increased sickness,
difficult and time
stress and burnout.
consuming.
Identify and justify why a Justification for change in training
training tool is required approach
• In an area of high staff turnover, there is a need for Styles of staff interpersonal conduct can help
rolling programmes of competency-based training, avoid provoking a sense of both staff and
including responding to potentially violent situations. patients’ powerlessness and depersonalisation,
thus precipitating aggression.
• Understanding aggression and prevention can reduce
.
the number of behavioural incidents reported (Allen et Itis no surprise that challenging behaviour
al 2002). causes an increase in emotional exhaustion
and burnout of staff members.
• Training with staff, should encourage staff to use a
non-aversive approach, focusing on positive
Itis not only therapists who have a role in
relationships to avert power struggles and avoid
escalating client behaviour (Giles et al 2005).
behavioural management; nurses play a pivotal
role in the provision of care to people with ABI.
 Nursing staff have much more face to face
contact with patients.
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2. 9/24/2012
The kind of challenging behaviour
Evaluate current area of recorded on the Neuro Rehab Unit in
professional practice the last 12 months (Jan 2011 - Jan
2012)
An evaluation of the incident reports
filed following an incident where a
member of the team has been hit,
punched or pinched whilst working
with individuals that have had a
Acquired Brain Injury.
Challenging behaviour Aims of the DVD
occurred when: There is no such product currently on the market.
Used as a stand alone package for refresher and new staff
training.
Emphasise the interdisciplinary requirements of working with
difficult behaviour.
Empathically show the emotional impact that both staff and
patients experience in heated situations.
Illustrate how the low arousal approach works at the
antecedent level (i.e. how someone in a high arousal, agitated,
state is easily triggered by staff actions).
Define the low arousal approach: an immediate non-
confrontational, non-critical and positive relational approach by
staff to patients’ verbal outbursts, destructive behaviours (e.g.
property damage) and physical aggression.
Illustrate de-escalation strategies for diffusing heated
situations.
Development of the DVD
Content
 Keeping a Cap on Staff Emotional Expression
Calmness and positivity – “Like a Swan”
 Treating Patients with Dignity and Respect
 There is currently no video based training
Core skills described that help avoid triggering patients’ package available that addresses
difficult behaviours challenging behaviour for inpatient wards
 Staff Beliefs About Patients’ Behaviour
Illustrate that after ABI, normal levels of control over providing neurological inpatient
events and rehabilitation. At the time of writing, the
emotional states are far reduced. Difficult behaviour is not
deliberately personal or calculated. Ex-patient invited to
production of such a DVD package is nearing
describe feeling states when showing aggression due to completion.
confusion
 This is One Discreet Part of Behavioural Management
 Specific Scenarios
DVD will compare good and bad examples of staff relating
in situations where there is difficult patient behaviour.
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3. 9/24/2012
Scenarios Interactive DVD
 The DVD will be interactive; the viewer will be requested
 The DVD features a dramatised set of to select one of two options for how best to approach a
scenarios considered typical of ward based patient’s difficult behaviour and, as part of the process,
events when there are patients following an will see both good and bad examples.
acquired brain injury who show difficult to  The underlying themes of the DVD emphasis staff
manage behaviour, including those who are in member’s need to maintain positive relations with
post-traumatic amnesia, and post-traumatic patients. This includes principals of treating them with
confusional and agitated states. The DVD dignity and respect, maintaining a non-aversive, non-
features actors representing staff working with confrontational and non-critical approach in the face of
patients showing such difficulties. They depict difficult behaviour, and encourages simple shared
dramatisations of how best to approach and formulations of the reasons behind patients’ difficult
relate to patients during a difficult episode, and
behaviour due to acquired brain injury.
also, how best not to approach patients in
such circumstances.
Approaches Overlapping Approaches from:
 These include: the Relational Neurobehavioural
 The examples of good practice in Approach (Giles and Manchester; 2005);
staff approaches shown by the DVD Positive Behavioural Support (e.g. Allen, 2005);
are informed by several documented the Low Arousal Approach (McDonnell, 2011);
approaches. Each approach has a attributional models of how staff relate to
likely degree of conceptual overlap patients (e.g. Weiner, 2006); and work that
with others; all promote quality highlights and manages the difficulties of high
relationships of carers towards
patients that are conducive to better expressed emotion between carers and patients
therapeutic outcomes. (e.g. Berry, Barrowclough and Haddock, 2010).
Participants in the Training
DVD
DVD covers
 The roles played by actors, the DVD is  The DVD intends to be short enough to be
presented by two of the ward’s own staff, watched in a routine staff break or lunch
an occupational therapist and nurse Ward time. It intends to be a non-academic
Manager. It also features interviews with exercise focussing on fundamental
other staff and an ex-patient who himself, relational and interpersonal aspects of
a few years earlier, had shown difficult behaviour management and avoiding what
behaviour whilst in a confusional state might be described as more high level
following brain injury. These features all behaviour management methods, such as
intend to further enhance staff behaviour analysis and modification
engagement and impact of the training.
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4. 9/24/2012
Advantages
 The potential advantages of the DVD lie in its  Clip of DVD
flexibility and accessibility; staff do not have to
book onto organised group based teaching
sessions and can, instead, pick up the DVD to
play on a computer or television. Furthermore,
the dramatised images and associated narration
intend to model ways of staff interpersonal
relating to patients who are showing aggression,
which isn’t normally a feature of training
sessions. This method may also have
advantages over written guidelines.
Summary References
 Adams, D. & Allen, D. (2001) assessing the need for reactive behaviour management strategies in children with
learning disabilities and server challenging behaviour. Journal Intellectual Disability Res. 45 (4): 335-43
 Allen, D. Doyle, T. & Kaye, N. (2002) Plenty of gain, but no pain: a systems wide initiative. Ethical approaches to
physical interventions. Kidderminster, BILD publications. 219 – 32.
Questions?  Benson, B. Schaub, C. Conway, J. Peters, S. Strauss, D. & Helsinger, S. (2000) Applied Behaviour Management and
Acquired Brain Injury: Approaches and Assessment. Journal Head Trauma Rehabilitation. 15 (4):1041-1060
 Giles, G, M. & Manchester, D. (2006) Two Approaches to Behaviour Disorder After Traumatic Brain Injury. Journal of
Head Trauma Rehabilitation. 21(2): 168-178
 Giles, G, M. Wagner, J. Fong, L. & Waraich, B, S. (2005) Twenty-month effectiveness of a non-aversive, long-term, low
cost programme for persons with persisting neurobehavioral disability. Brain Injury. 19(10): 753-764
 Jacobson expressed emotion 2000
 Jenkins, R. Rose, J. & Lovell, C. (1997) Physiological wellbeing of staff working with people who have challenging
behaviour. Journal of Intellectual Disability Research. 41. 502-511
 Kaye, N. & Allen, D. (2002) Over the top? Reducing staff training in physical interventions. British Journal of Learning
Disabilities. 30, 129-132
 Luiselli, J, K. Pace, G, M. & Dunn, E, K. (2003) Antecedent analysis of therapeutic restraint in children and adolescents
with acquired brain injury: A descriptive study of four cases. Brain Injury. 17:255-264
 Peters, M, D. Gluck, M. & McCormick, M (1992) Behavioural Rehabilitation of the challenging client in less restrictive
setting. Brain Injury. 6:299-314
 Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and Language Therapists
(2007) Challenging behaviour: a unified approach Clinical and service guidelines for supporting people with learning
disabilities who are at risk of receiving abusive or restrictive practices. Royal College of Psychiatrists.
 McDonnell, A. (2010). Managing aggressive behaviour in care settings: understanding and applying low arousal
approaches. Chichester: Wiley-Blackwell
 Mitchell, G. & Hastings, R, P. (2001) Coping, burnout, and emotion in staff working in community services for people
with challenging behaviour. American Journal on Mental Retardation. 5, 448-459
 Mott, S. Nagy, E. & O’Reilly, K. (2006) Behaviour support following acquired brain injury: An exploration of the role of
the registered nurse. Journal of the Australian Rehabilitation Nurses Association. 9(4): 7-13
 Toogod, S. (2009) Establishing a context to reduce challenging behaviour using procedures from active support: a
clinical case example. Tizard Learning Disability Review. Volume 14 Issue 4.
 Ylvisaker, M. Turkstra, L. Coehlo, C. Yorkston, K. Kennedy M. Sohlberg, M, M. & Avery J (2007) Behavioural
interventions for children and adults with behavioural disorders after TBI: A systematic review of evidence. Brain
Injury. 21(8): 769-805.
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