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Environmental Influences on Challenging Behaviors

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Environmental Influences on Challenging Behaviors. Eleanor S. McConnell, PhD, RN, GCNS, BC Durham VAMC GRECC & Duke University School of Nursing August 24, 2010. To do stuff….. OR To get stuff done. Where are we? What are we trying to accomplish?. Environments Places where People - PowerPoint PPT Presentation

Text of Environmental Influences on Challenging Behaviors

  • Environmental Influences on Challenging BehaviorsEleanor S. McConnell, PhD, RN, GCNS, BCDurham VAMC GRECC & Duke University School of NursingAugust 24, 2010

  • Where are we?What are we trying to accomplish?EnvironmentsPlaces where PeopleInteract withThings &Other people

  • Where are we?What are we trying to accomplish?EnvironmentsPlaces where PeopleInteract withThings &Other people

    To do stuff..ORTo get stuff done

  • Where are we?What are we trying to accomplish?EnvironmentsPlaces where PeopleInteract withThings &Other people

    To do stuff..ORTo get stuff done

  • GoalsIncrease awareness of how environment influences behaviorPeople without brain damagePeople with brain damage (executive dyscontrol)Increase skill in evaluating environment:Identifying aspects you can controlCompensating for aspects you cannot control

  • Three Main IdeasEnvironment has more to do with supporting challenging behaviors than youd think!You have more influence over the care environment than you know!Analyzing and modifying environment is a learned skillPractice, practice, practice

  • ApproachConsider familiar in unfamiliar ways, using evidence where it exists360-degree look & analysisLook Listen SenseLook at how parts of environment fit together to affect behaviorApply to cases

  • Environment in UseObjective attributesLightingNoise levelThings & arrangementChair heightAccess to objectsBehavior of others

    Perceived attributesWhat I seeWhat I hearHow I interpret what I see and hearPersonal AbilitiesVisual acuity & perceptionHearing acuityCognitive LevelImpulse ControlStrength/Flexibility/Dexterity

  • B = f (P/E): Person-Environment Fit

  • Brain Disease & Ability to Use Environmental Cues

    DementiaABISMISeeVisuo-perceptual disturbancemaybeYes may be hypersensitiveHearVerbal miscuesmaybeYesFeelFollows tactile cuesmaybeSmellPreservedmaybeMoveGross motor+Fine motor - maybe

  • What environmental features strike you in this environment?Soft task lightingPictures - familiarQuiltPosition of older adult & caregiverWhat is supposed to happen here?

  • What Behaviors are Supported in these Environments?ReminisceSleepReflect vBe activeExercisePlaces matter! They often cue behavior and emotions

  • How Environments, People, Tasks & Behaviors Come TogetherBehaviorsPeoplePlacesVeteran TransactionsTasksTransactionsMorning CareWaking upCleaning upSetting upTray service or feeding

    TasksWake upUse toiletGet washedGet dressedEatDo my thing.ThingsHow these tasks & transactions get carried out may make the difference between a challenging behavior and a smooth day!

  • Wont Get Out of BedPeople: staff with a certain approachPlaces: Veterans bedroomVeteran with Needs! Transactions:How is wake up approached?TasksThings:Lighting; Music, Coffee, Bed-height

  • Tasks, Things, People & Transactions can each be alteredBehaviorsPeoplePlacesVeteran TransactionsTasksTransactions:Smell coffeeLights onMusic onWarm washcloth offeredTasksWake upThingsThings:Coffee potLightingMusic playerWashclothStaff:Do wake up in new manner

  • Challenging Behavior:Urinates in the wrong placeWhats 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?

  • Lets Eat!Glare?Clutter?Cues to Behavior?Contrast?Distractions?NoisePeople

    Objective attributesLightingNoise levelThings & arrangementChair heightAccess to objectsBehavior of others

  • Environmental Layers

  • Mr. B85 y.o. veteran with neurofibromatosis, stroke, severe cognitive dysfunction, blindBehaviors: Sexual inappropriateness: grabbed nurses breasts during AM careCrying out for no apparent reasonWhat environmental influences do you think might apply in this case?

  • Environmental AnalysisWhere does it happen?Only when receiving perineal care in bedWhat is the scene like?Lighting: poorWorkspace: crowdedWhat things are involved?Nurse leans over patient when washingWhat people are involved?Only happens with female nursesHow do they approach? No use of PPA, HUH

  • Mr. N72 y.o. with cognitive impairment, weight lossReported being hungry, yet ate very little at each mealWeight loss of 5# in past monthCould the environment in which he eats play a role?

  • Wont Eat: Micro EnvironmentPlaceSceneDistractions NoiseThingsCuesContrast Physical supportPeopleApproach

  • Mr. OWants to go homeAngry outburstsSecretive and paranoidWont accept help with care but cant perform tasks adequatelyCould anything in his environment contribute?

  • Approach

  • Refuses careLighting & ApproachPlace & Approach

  • More Arrows in your Quiver.Target: Challenging Behaviors!Source:

    Welcome folks back describe goals of session..and ask people what emotions these scenes they know where these places are from?***Source of Garfield Image:*Sources of photos:

    Neurofibromatosis --

    Source of Photo:

    Ok, lets examinee this photo for a moment. Looks like a fairly typical situation. A caregiver is providing oral care to an older gentleman. This is Mr. Blue. He is an 84 year old man with Parkinsons disease, osteoarthritis, cataracts, and a variety of other medical problems. Considering his medical diagnoses, take a moment and consider this photo and think about the oral care situation that you observe here. Now, I would like to ask you to identify at least 3 things that are wrong with this picture. Silver Bluff RN leadership and direct care giving staff knew they could do better, but they recognized the need for a systematic approach. *May substitute a tool-box analogy and imagery instead*

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