‘Challenging Behaviours’:
Development of a Conceptual Model
for Training in Staff-Client
Interaction
Gerry Farrell & Peter...
OVERVIEW OF PRESENTATION
• The concept of ‘Challenging Behaviour’
• Nurses’ responses to ‘challenging’ behaviours
• A new ...
‘Challenging’ behaviours
Covers a wide range of behaviours ranging from
aggression to eccentric habits…and will mean
diffe...
Staff working with patients who are
experienced as ‘challenging’ commonly
report negative feelings such as anxiety,
anger,...
Nurses’ Responses to ‘Challenging’
Behaviours – SOME STORIES!

• Ron (Medical ward)
• Marlene (Labour room)
• Timothy (Acc...
Why did the nurses behave differently in
respect to Ron and Timothy compared to
Marlene?

• Don’t have the skills or didn’...
Hospital Protocols & Zero tolerance
…leads to
maximum intolerance!
•
•
•
•

ZT constructs the perpetrators as the problem
...
A sign at the
entrance to an
acute care
inpatient unit.
Note…the
lack of a

Welcome!

http://www.latrobe.edu.au/nursing
Melbourne
Metro’s approach
to CBs
At least you get a
“Welcome aboard”!

http://www.latrobe.edu.au/nursing
NOTE: These rules are often
unenforced or, indeed,
unenforceable, and when
inconsistently applied upset
staff, passengers ...
Merseyrail, U.K.
Contrast this to
the previous
posters…

http://www.latrobe.edu.au/nursing
Implications
• At first sight ZT appears to protect nurses’
interests … but consider Ron and
Timothy’s story
– Ron is left...
What did Ron and Tim need?
• Ron needed the consolation the consultant
physician provided later that day – a hug
and a com...
Further implications of a ZT
approach
• Outsourcing leaves nurses deskilled in the
face of ‘experts’ who own training…circ...
What can be done!
• First, nurses (and other front-line clinicians) need a
change in attitude
• We know that patients and ...
But of course…
• Having the right attitude is not
enough…situations such as Ron’s and
Tim’s can present complex
and danger...
• Need to reclaim the management of problems
like Ron’s and Tim’s and not accept the
status quo
• Need to see their behavi...
Training required…but what sort?
Current training programs offer a smorgasboard of
content, without a clearly defined conc...
THE S. O. S. Domains
(Trigger points)

The Self
The characteristics &
The Self, e.g., s of practitioners
behaviourself-awa...
Domains

SVESOS Model

Self
Values

Understand how
challenging
behaviour is
influenced by…

Levels

Apply this
understandi...
Training programs – content &
delivery
•

Most striking implication of the model is that it explicitly recognises the
impo...
Further...
•

These other domains may be addressed more cheaply by exploiting the full
potential of the internet.

•

Most...
But remember…
• Can’t tell staff what to do in every situation

• The diversity of health care settings requires an
indivi...
Be Creative!
A man is admitted to a ward after he
created so much disturbance and
anxiety that police and dogs had to
be b...
…to the patient that if he would get into bed, she would see
about getting rid of all the people, the dogs and associated
...
PLAY VIDEO --- ANGRY MAN

Warn audience!

http://www.latrobe.edu.au/nursing
First reactions…How might you
respond?

RUN………….!
Or…

http://www.latrobe.edu.au/nursing
?Likely precipitating
factors/triggers for the man’s
outburst

http://www.latrobe.edu.au/nursing
Working together
Clinicians and Security personnel working together –
how can we strengthen the partnership?
• Are securit...
Interprofessional collaboration – some
considerations
Security staff

Clinicians







Busy – few staff
Training prima...
Working together –
Clinicians and Security
staff
‘Talk’
stage

Fine line – persuasion/physical restraint

How to turn
a po...
Quality indicators for the management of CB
See, e.g., Reducing Violence & Aggression in A&E
Through a Better Experience. ...
A few end thoughts…
•

The successful management of CB presents enormously complex judgments
and interventions on the part...
A recent study ….
Looked at a total of 26 ‘protective’ factors, ranging from questions relating to the…
•
physical aspects...
Finally…
•

Training needs to be much more than theoretical learning…instead
– Learners need time (on the job) to develop ...
References
•

Alexander, C. , Fraser, J. & Hoeth, R (2004) Occupational violence in an Australian healthcare setting,
impl...
Thank You!

http://www.latrobe.edu.au/nursing
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Gerry Farrell, La Trobe University: 50 'Challenging Behaviours': Development of a Conceptual Model for Training in Staff-Client Interaction

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Gerald Farrell, Adjunct Professor of Nursing, Faculty of Health Sciences, School of Nursing & Midwifery, La Trobe University, Melbourne delivered this presentation at the 2013 Safe and Secure Hospital Conference. The comprehensive program addressed the following issues:

Early intervention via early reporting of disruptive, aggressive, and bullying behaviour to minimise work place violence
An innovative training model to help clinicians, security and policy makers respond to the problems of challenging behaviours
Therapeutic sedation in the Emergency Department: Best practice in managing the highly agitated patient
A systems approach to the prevention of Occupational Violence and Aggression (OVA)
Contract management security: The change from in-house security to contract security
Role of the Risk Based Approach throughout the design process
Preventing and managing clinical aggression in the paediatric and youth health setting
The roles, functions and training provided by the Mental Health Intervention Team (MHIT), New South Wales Police Force
Interactions between Police, Health staff, Ambulance and Hospital Security and future directions
A Legal Perspective: Prevention and management of violence in hospitals
Code Grey responses - Are they legal?

For more information about the annual event, please visit the conference website: http://www.healthcareconferences.com.au/safehospitals

Published in: Health & Medicine, Business
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Gerry Farrell, La Trobe University: 50 'Challenging Behaviours': Development of a Conceptual Model for Training in Staff-Client Interaction

  1. 1. ‘Challenging Behaviours’: Development of a Conceptual Model for Training in Staff-Client Interaction Gerry Farrell & Peter Salmon Presenter: Gerry Farrell Honorary Fellow La Trobe University Melbourne http://www.latrobe.edu.au/nursing
  2. 2. OVERVIEW OF PRESENTATION • The concept of ‘Challenging Behaviour’ • Nurses’ responses to ‘challenging’ behaviours • A new training model • Working together – clinicians and security personnel http://www.latrobe.edu.au/nursing
  3. 3. ‘Challenging’ behaviours Covers a wide range of behaviours ranging from aggression to eccentric habits…and will mean different things to different people. http://www.latrobe.edu.au/nursing
  4. 4. Staff working with patients who are experienced as ‘challenging’ commonly report negative feelings such as anxiety, anger, guilt, fear, self-blame and powerlessness, as well as dissatisfaction with their jobs. http://www.latrobe.edu.au/nursing
  5. 5. Nurses’ Responses to ‘Challenging’ Behaviours – SOME STORIES! • Ron (Medical ward) • Marlene (Labour room) • Timothy (Accident &Emergency) http://www.latrobe.edu.au/nursing
  6. 6. Why did the nurses behave differently in respect to Ron and Timothy compared to Marlene? • Don’t have the skills or didn’t feel they had the skills • Ron and Timothy seen as less deserving, perhaps • Following hospital protocol • Roles of staff defined differently – handling CB part and parcel of midwives’ work • Etc… http://www.latrobe.edu.au/nursing
  7. 7. Hospital Protocols & Zero tolerance …leads to maximum intolerance! • • • • ZT constructs the perpetrators as the problem Has its roots in the US’s war on drugs in the 1980s A ‘get tough’ policy – CB is unacceptable behaviour Moves aggression/other ‘challenging behaviours’ outside the nurses’ remit • Catchy slogans • A cadre of new experts spawned and.. • Now invades nurses’ clinical lives in a number of ways, often without their awareness… http://www.latrobe.edu.au/nursing
  8. 8. A sign at the entrance to an acute care inpatient unit. Note…the lack of a Welcome! http://www.latrobe.edu.au/nursing
  9. 9. Melbourne Metro’s approach to CBs At least you get a “Welcome aboard”! http://www.latrobe.edu.au/nursing
  10. 10. NOTE: These rules are often unenforced or, indeed, unenforceable, and when inconsistently applied upset staff, passengers and anger patients. http://www.latrobe.edu.au/nursing
  11. 11. Merseyrail, U.K. Contrast this to the previous posters… http://www.latrobe.edu.au/nursing
  12. 12. Implications • At first sight ZT appears to protect nurses’ interests … but consider Ron and Timothy’s story – Ron is left feeling angry/alienated – Calling in security for Timothy probably fed his paranoia, making it more difficult to develop a therapeutic relationships. – Both families upset… http://www.latrobe.edu.au/nursing
  13. 13. What did Ron and Tim need? • Ron needed the consolation the consultant physician provided later that day – a hug and a comment to feel hopeful. • Timothy needed someone to sit down with him to try and make sense of what was in his mind. http://www.latrobe.edu.au/nursing
  14. 14. Further implications of a ZT approach • Outsourcing leaves nurses deskilled in the face of ‘experts’ who own training…circle of dependence • Therapeutic opportunities lost http://www.latrobe.edu.au/nursing
  15. 15. What can be done! • First, nurses (and other front-line clinicians) need a change in attitude • We know that patients and their relatives get upset/angry • Just as…Bar staff will sometimes need to manage drunks and… Retail staff will at times have to respond to rude customers http://www.latrobe.edu.au/nursing
  16. 16. But of course… • Having the right attitude is not enough…situations such as Ron’s and Tim’s can present complex and dangerous challenges… so need more than a ‘can do’ attitude! At first sight appears to protect nurses’ interests … but consider Ron and Timothy’s story http://www.latrobe.edu.au/nursing
  17. 17. • Need to reclaim the management of problems like Ron’s and Tim’s and not accept the status quo • Need to see their behaviour as requiring a clinical formulation and response, rather than (immediately) seeking outside help. http://www.latrobe.edu.au/nursing
  18. 18. Training required…but what sort? Current training programs offer a smorgasboard of content, without a clearly defined conceptual framework Need to….Move away from training that is formulaic and addresses interpersonal skills only Need training based on the complexity of the needs of patients displaying CB http://www.latrobe.edu.au/nursing
  19. 19. THE S. O. S. Domains (Trigger points) The Self The characteristics & The Self, e.g., s of practitioners behaviourself-awareness; interpersonal skills; attitudes; stress themselves crucial to understanding their role in CB CB The Situation/environment, e.g., The Other person, e.g., past the influence of others; noise aggression; current mental & physical state; stress The Situation The Other person What practitioners believe & think about the characteristics & behaviour of the ‘other’ person The physical environment & workplace culture. http://www.latrobe.edu.au/nursing
  20. 20. Domains SVESOS Model Self Values Understand how challenging behaviour is influenced by… Levels Apply this understanding to … Emotion Worth that learners attach to others. This ranges from altruism to prejudice. …one’s values. Emotional processes influencing learners’ responses to others. …one’s emotions. …ensure that professionally appropriate values influence one’s behaviour …manage one’s emotions in interactions. Other Situation Factors influencing peoples’ reactions to illness and care. Ways that the cultural and physical environment shape behaviour. Skills Complex skills needed for effective interpersonal interaction. …one’s …peoples’ repertoire of responses to illness communication and care. skills. …the cultural and physical environment. …acquire any new skills as needed. …manage the environment’s influence on others’ behaviour. … work with the other’s perspective. Legend The SOS in the name indicates three domains in which learners need to be trained. These include: influences on their behaviour that arise from within themselves (Self); the ways that the other person in interaction – i.e. clients – reacts to and perceives their health problems and care (Other); and the way that the environment influences staff-client interaction (Situation). The subscript VES indicates that the Self domain is further subdivided to include the practitioner’s Values, Emotional processes and Skills. In each domain, staff need both to understand the processes that influence clients’ behaviour, and to be able to apply this understanding to generate effective responses to clinical situations. http://www.latrobe.edu.au/nursing
  21. 21. Training programs – content & delivery • Most striking implication of the model is that it explicitly recognises the importance of domains of learning other than skills... • Towards one that acknowledges the crucial role of values and emotional responses, as well as understanding how the other person may be thinking and feeling. • The model offers a conceptual base for applying our knowledge of these domains to training – without ‘understanding’, staff will be unable to respond flexibly, using their knowledge to find new solutions to both old and new problems • Skills take time to learn, so our model suggests that investment in skill training can take place once other factors that determine whether practitioners can use their skills have been addressed. http://www.latrobe.edu.au/nursing
  22. 22. Further... • These other domains may be addressed more cheaply by exploiting the full potential of the internet. • Most learners when they enter training have a repertoire of kills for managing a range of interactions, some of which have the potential to be challenging • If the factors in the domains of ‘self’, ‘other’ & ‘situation’ are in place, then trainees will be able to draw on these ‘outside’ skills in CB encounters. http://www.latrobe.edu.au/nursing
  23. 23. But remember… • Can’t tell staff what to do in every situation • The diversity of health care settings requires an individualistic/creative approach http://www.latrobe.edu.au/nursing
  24. 24. Be Creative! A man is admitted to a ward after he created so much disturbance and anxiety that police and dogs had to be brought onto the ward. The situation remained extremely tense and frightening until a nurse suggested…. WHAT…! http://www.latrobe.edu.au/nursing
  25. 25. …to the patient that if he would get into bed, she would see about getting rid of all the people, the dogs and associated pressure and unpleasantness (Lowe, 1990 in Farrell & Gray 1992, p.71). Which had the following benefits…. Benefits: The nurse offers a compromise that ‘saves face’ for all concerned. She also strengthens her control of the patient’s behaviour – being in bed is incompatible with aggressiveness towards others. It may, in fact, further reduce his aggressiveness as he has time to cool down in a neutral environment. http://www.latrobe.edu.au/nursing
  26. 26. PLAY VIDEO --- ANGRY MAN Warn audience! http://www.latrobe.edu.au/nursing
  27. 27. First reactions…How might you respond? RUN………….! Or… http://www.latrobe.edu.au/nursing
  28. 28. ?Likely precipitating factors/triggers for the man’s outburst http://www.latrobe.edu.au/nursing
  29. 29. Working together Clinicians and Security personnel working together – how can we strengthen the partnership? • Are security staff part of an integrated team approach to the solutions for managing CB? • Do each subscribe to the same set of quality indicators for CB management? http://www.latrobe.edu.au/nursing
  30. 30. Interprofessional collaboration – some considerations Security staff Clinicians    Busy – few staff Training primarily focused on safety/security/action   Vague about who is in charge when called to an incident Views on management of the problem may differ to clinicians’    Unclear about their role responsibility clinical or security or both! Unsure about whose responsibility it is to ‘brief’ security staff Uncertain/scared when to call in security staff Views on management of the problem may differ to that of security staff http://www.latrobe.edu.au/nursing
  31. 31. Working together – Clinicians and Security staff ‘Talk’ stage Fine line – persuasion/physical restraint How to turn a potential firecracker into a damp squib ‘Action’ stage Note: It is not a given that ‘ACTION’ must occur after ‘TALK’ http://www.latrobe.edu.au/nursing
  32. 32. Quality indicators for the management of CB See, e.g., Reducing Violence & Aggression in A&E Through a Better Experience. DH, U.K. 2011 E.G., • • • • • • • Support NHS staff and organisations in reducing the incidence of violence and aggression towards staff within their communities Directly or indirectly reduce incidents of violence and aggression in A&E and in doing so reduce associated litigation costs experienced by the NHS to compensate claimants (staff, patients and visitors) via clinical negligence and/or personal accident benefits Deliver tangible cost savings, reducing the actual and associated costs of violence and aggression incurred by the NHS Help bolster staff confidence and satisfaction by making real and perceived improvements to healthcare environments and facilities Help deliver improved patient care through calmer environments Generate awareness and support a culture change among NHS staff and patients, focusing on mutual trust and respect Accelerate the identification and adoption of innovative design in NHS A&E departments. http://www.latrobe.edu.au/nursing
  33. 33. A few end thoughts… • The successful management of CB presents enormously complex judgments and interventions on the part of all staff. • Patients do not come in neat packages – each presents distinct challenges and the potential for joy and aggression. • Often staffs’ ‘people management skills’ can be a low priority. • Training can be ‘ expensive’ so it must be carefully targeted and evaluated. • Appropriate staff training is vital, but must be part of a wider organisational focus around quality patient care. http://www.latrobe.edu.au/nursing
  34. 34. A recent study …. Looked at a total of 26 ‘protective’ factors, ranging from questions relating to the… • physical aspects of work settings (e.g. high standard patient facilities to reduce their frustration and anxieties) to… • Staff training (e.g. training in communication skills, including de-escalation skills). …and found that there was More ‘Protection’ from assault when there was: • • • • a high standard of patient facilities sufficient staffing effective enforcement of policies, and when staff were provided with personal protective equipment (Farrell, Shafiei & Chan, 2012) • Quality nurse-patient relationships and working in supportive teams (Alexander & Fraser, 2004) • Psychosocial factors – supportive work environments/collaborative work cultures/good interpersonal relationships among staff (Camerino et al., 2008) Thus, managers have vital role to play! http://www.latrobe.edu.au/nursing
  35. 35. Finally… • Training needs to be much more than theoretical learning…instead – Learners need time (on the job) to develop an acute self-awareness and the requisite interpersonal skills and attitudes so that they can … – Develop imaginative, productive and the least aggressive ways possible in their relationships with patients (and others). http://www.latrobe.edu.au/nursing
  36. 36. References • Alexander, C. , Fraser, J. & Hoeth, R (2004) Occupational violence in an Australian healthcare setting, implications for managers. Journal of Healthcare Information Management. 49(6), 377-392. • Camerino, D. et. al., (2008) Work-related factors and violence among nursing staff in the European NEXT study: A longitudinal cohort study. International Journal of Nursing Studies. 45, 35-50 • Reducing Violence & Aggression in A&E Through a Better Experience. (2011) DH, U.K. – www resource. • Farrell ,G.A. , Shafiei, T. & Chan, S. (2012) Patient and visitor assault on nurses and midwives: an exploratory study of employer ‘protective’ factors. International Journal of Mental Health Nursing. doi: 10.1111/inm.12002 • Farrell ,G.A. , Shafiei, T. & Salmon, P. (2010) Facing up to ‘challenging behaviour’: a model for training in staff–client interaction. Journal of Advanced Nursing. 66(7), 1644–1655. • Farrell, G.A. & Salmon, P. (Dec.2009/Jan.10) Challenging behaviour: An action plan for education and training. Contemporary Nurse. 34(1), 110- 118. • Farrell, G.A. & Gray, C. (1992) Aggression: A nurses’ guide to therapeutic Management. Scutari Press, London. http://www.latrobe.edu.au/nursing
  37. 37. Thank You! http://www.latrobe.edu.au/nursing

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