Environmental Influences on Challenging Behaviors Eleanor S. McConnell, PhD, RN, GCNS, BC Durham...
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Transcript of Environmental Influences on Challenging Behaviors Eleanor S. McConnell, PhD, RN, GCNS, BC Durham...
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…..ORTo get stuff done
Where are we?What are we trying to accomplish?
Environments• Places where • People• Interact with• Things &• Other people
Where are we?What are we trying to accomplish?
Environments• Places where • People• Interact with• Things &• Other people
To do stuff…..ORTo get stuff done
Where are we?What are we trying to accomplish?
Environments• Places where • People• Interact with• Things &• Other people
To do stuff…..ORTo 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 togetherto affect behavior
• Apply to cases
Environment in UseObjective attributes
– Lighting– Noise level– Things &
arrangement– Chair height– Access to objects– Behavior of others
Perceived attributes– What I see– What I hear– How I interpret what I
see and hear
Personal Abilities•Visual acuity & perception
•Hearing acuity•Cognitive Level•Impulse Control
•Strength/Flexibility/Dexterity
B = f (P/E): Person-Environment Fit
Brain Disease & Ability to Use Environmental Cues
Dementia ABI SMI
See Visuo-perceptual disturbance
maybe Yes – may be hypersensitive
Hear Verbal miscues maybe Yes
Feel Follows tactile cues
maybe
Smell Preserved maybe
Move Gross motor+
Fine motor -
maybe
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
BehaviorsPeople
PlacesVeteran
Transactions
Tasks
TransactionsMorning Care•Waking up•Cleaning up•Setting up•Tray service or feeding
Tasks•Wake up•Use toilet•Get washed•Get dressed•Eat•Do my thing….
Things
How these tasks & transactions get carried out may makethe difference betweena challenging behaviorand a smooth day!
Won’t Get Out of Bed
People:staff with a certain approach
Places:Veteran’s bedroom
Veteran with
Needs!
Transactions:How is wake upapproached?
Tasks
Things:Lighting; Music, Coffee, Bed-height
Tasks, Things, People & Transactions can each be altered
BehaviorsPeople
PlacesVeteran
Transactions
Tasks
Transactions:1. Smell coffee2. Lights on3. Music on4. Warm washcloth
offered
Tasks•Wake up
Things
Things:Coffee potLightingMusic playerWashcloth
Staff:Do wake upin new manner
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!• Glare?• Clutter?• Cues to Behavior?• Contrast?• Distractions?• Noise• People
Objective attributes– Lighting– Noise level– Things &
arrangement– Chair height– Access to objects– Behavior of others
Environmental Layers
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
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