Transcript Environmental Influences on Challenging Behaviors

Environmental Influences on
Challenging Behaviors
Eleanor S. McConnell, PhD, RN, GCNS, BC
Durham VAMC GRECC &
Duke University School of Nursing
August 24, 2010
Where are we?
What are we trying to accomplish?
Environments
•
•
•
•
•
Places where
People
Interact with
Things &
Other people
To do stuff…..OR
To get stuff done
Where are we?
What are we trying to accomplish?
Environments
•
•
•
•
•
Places where
People
Interact with
Things &
Other people
To do stuff…..OR
To get stuff done
Where are we?
What are we trying to accomplish?
Environments
•
•
•
•
•
Places where
People
Interact with
Things &
Other people
To do stuff…..OR
To get stuff done
Goals
• Increase awareness of how environment
influences behavior
– People without brain damage
– People with brain damage
(executive dyscontrol)
• Increase skill in evaluating
environment:
– Identifying aspects you can control
– Compensating for aspects you
cannot control
Three Main Ideas
1. Environment has more to do with
supporting challenging behaviors than
you’d think!
2. You have more influence over the care
environment than you know!
3. Analyzing and modifying environment is
a learned skill…
•
Practice, practice, practice
Approach
• Consider familiar in unfamiliar ways, using
evidence where it exists
• 360-degree look & analysis
– Look
– Listen
– Sense
• Look at how parts
of environment fit together
to affect behavior
• Apply to cases
Environment in Use
Objective attributes
– Lighting
– Noise level
– Things &
arrangement
– Chair height
– Access to objects
– Behavior of others
Personal Abilities
•Visual acuity & perception
•Hearing acuity
•Cognitive Level
•Impulse Control
•Strength/Flexibility/Dexterity
Perceived attributes
– What I see
– What I hear
– How I interpret what I
see and hear
B = f (P/E): Person-Environment Fit
Abilities
limited
Environmental
influences
greater
Brain Disease &
Ability to Use Environmental Cues
Dementia
See
Hear
Feel
Smell
Move
ABI
Visuomaybe
perceptual
disturbance
Verbal miscues maybe
Follows tactile
cues
Preserved
maybe
Gross motor+
Fine motor -
maybe
maybe
SMI
Yes – may be
hypersensitive
Yes
What environmental features strike
you in this environment?
•
•
•
•
Soft task lighting
Pictures - familiar
Quilt
Position of older adult
& caregiver
• What is supposed to
happen here?
What Behaviors are Supported in
these Environments?
•
•
•
•
•
Reminisce
Sleep
Reflect v…
Be active
Exercise
Places matter!
They often cue behavior and emotions
How Environments, People, Tasks
& Behaviors Come Together
Transactions
Tasks
Veteran
Things
Tasks
•Wake up
•Use toilet
•Get washed
•Get dressed
•Eat
•Do my thing….
Places
Behaviors
People
Transactions
Morning Care
•Waking up
•Cleaning up
•Setting up
•Tray service or
feeding
How these tasks &
transactions get
carried out may make
the difference between
a challenging behavior
and a smooth day!
Won’t Get Out of Bed
Tasks
Transactions:
How is wake up
approached?
Things:
Lighting; Music, Coffee, Bed-height
Veteran
with
Needs!
People:
staff with a certain approach
Places:
Veteran’s bedroom
Tasks, Things, People &
Transactions can each be altered
Transactions
Tasks
Veteran
Things
Places
People
Tasks
•Wake up
Things:
Coffee pot
Lighting
Music player
Washcloth
Behaviors
Staff:
Do
wake up
in new
manner
Transactions:
1. Smell coffee
2. Lights on
3. Music on
4. Warm washcloth
offered
Challenging Behavior:
Urinates in the wrong place
• What’s the 1st
thing you do
when you get
OOB in the AM?
• Where do you
do it?
• Is there a sink
there?
• Is the toilet near
the sink?
• If you were in
this
environment,
might you
mistake a trash
can for a toilet?
Let’s Eat!
Objective
attributes
• Glare?
–• Lighting
Clutter?
– Noise level
Cues to
–• Things
& Behavior?
• arrangement
Contrast?
–• Chair
height
Distractions?
–• Access
Noise to objects
– Behavior of others
• People
Environmental Layers
Meso
Macro
Micro
Mr. B
• 85 y.o. veteran with neurofibromatosis,
stroke, severe cognitive dysfunction, blind
• Behaviors:
– Sexual inappropriateness:
grabbed nurses breasts during AM care
– Crying out for no apparent reason
• What environmental influences do you
think might apply in this case?
Environmental Analysis
• Where does it happen?
– Only when receiving perineal care in bed
• What is the scene like?
– Lighting: poor
– Workspace: crowded
• What things are involved?
– Nurse leans over patient when washing
• What people are involved?
– Only happens with female nurses
• How do they approach?
– No use of PPA, HUH
Mr. N
• 72 y.o. with cognitive impairment, weight
loss
• Reported being hungry, yet ate very little
at each meal
• Weight loss of 5# in past month
Could the environment in
which he eats play a role?
Won’t Eat: Micro Environment
•
•
•
•
•
•
•
•
•
•
Place
Scene
Distractions
Noise
Things
Cues
Contrast
Physical support
People
Approach
Mr. O
•
•
•
•
Wants to go home
Angry outbursts
Secretive and paranoid
Won’t accept help with care
but can’t perform tasks adequately
Could anything in his
environment contribute?
Approach
Staff
controls
Veteran
Controls
Refuses care…
Lighting & Approach
Place & Approach
More Arrows in your Quiver….
Target: Challenging Behaviors!
Source: http://callitaweasel.files.wordpress.com/2009/10/mongel_arch.jpg