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: http://callitaweasel.files.wordpress.com/2009/10/mongel_arch.jpg
Welcome folks back describe goals of session..and ask people what emotions these scenes evoke.do they know where these places are from?***Source of Garfield Image:
http://www.google.com/imgres?imgurl=http://treybig.org/Humor/mornings.jpg&imgrefurl=http://davidgillespie.wordpress.com/2008/04/24/thats-too-big-to-be-a-space-station/&usg=__kNnM7mixSZInIsH-mWRUhLGouYs=&h=350&w=550&sz=31&hl=en&start=5&zoom=1&itbs=1&tbnid=W9Gs58O27arYKM:&tbnh=85&tbnw=133&prev=/images%3Fq%3Dgetting%2Bout%2Bof%2Bbed%26hl%3Den%26sa%3DX%26rlz%3D1T4SKPB_enUS361US361%26tbs%3Disch:1%26prmd%3Div*Sources of photos: http://newsimg.bbc.co.uk/media/images/46506000/jpg/_46506420_m540379-nurse_and_elderly_patient-spl-1.jpg
Neurofibromatosis -- www.gfmer.ch/genetic_diseases_v2/gendis_detai...
Source of Photo: http://1.bp.blogspot.com/_8RuV7xq8D7g/Sw_yW9t8gPI/AAAAAAAABMg/deXA2A9GiCM/s1600/angry-lou.jpg
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*
