Neurological Practice - Seminar.

"Practical strategies for managing challenging behaviour following brain injury."
Blacker DD, McLaren S, Royal Hospital for Neuro-disability.


Challenging behaviour can be defined as: behaviours that seriously compromise a persons ability to engage and appropriately, productively and socially interact with their environment. 


Active challenging behaviours: 

• Overt and observational behaviours that can potentially cause harm to self or others (both pysical and verbal)

Passive challenging behaviours:

• An absence or lack of a particular type of behaviour. This could involve failing to express our wants, needs or feelings or communicating them in an indirect or apologetic way.

Inappropriate social behaviours:

• Sexualised behaviours.
• Disinhibition. 
•  Impulsive actions.
• Socially disruptive.

There is a need for OTs and those dealing with service users displaying challenging behaviour to have a good understanding of behaviours and need to react with a mix of proactive (long term) and reactive (short term) strategies.

Common strategies to manage challenging behaviours:

• Control and restraint (last resort). (Can cause social withdrawal and/or escalate the behaviour.)
• Sedation and medical intervention.
• Time out.
• Punishments.
• Breakaway techniques.
• Verbal de-escalation = negotiation, calming methods.
• Hierarchy  of techniques from less restrictive to control and restraint.
• Need to teach consequences of behaviour.
• Slow down movements.
• Think about how you sounds and what they are thinking.
• Options - what can be done?
• Plan for the situation.
• Change the environment - minimise negative stimulation, provide positives (meaningful and productive activities), provide structure and predictability.
• Change oursleves - Get to know your service users, build a rapport with them, use simple and clear language, provide personal space, alter your approach if necessary, don't offer things you can not give, get to know their behaviours and triggers.

De-escalation through communication:

More top tips:

• See the person not the problem.
• Look at the individual and their strengths.
• Be creative and flexible.
• Meaningful activities are a must!
• Provide explicit rewards.
• Help the individual to increase self esteem and control.
• Positive attitudes towards the patients.
• Task demands to consider: Activity as distraction, grade and adapt, re-direct individuals to positive/socially acceptable activities.
• Skills training to consider: Rebuild skills, teach more socially appropriate behaviour, coping strategies (anger and stress management etc.), alternative means of communication, use of props.

Remember:

Behaviour has a meaning!! Find it..


p.s. Sorry about the different colours in this post - I can't seem to get rid of them!! 

Forensic Forum - Paper Session.

“Horticulture and pet care in a medium secure unit: a growing success.” 

Bowen C, Kent and Medway NHS and Social Care Partnership Trust.

This paper described a gardening and pet care programme which has been developed and implemented within a Medium Secure Unit. Service users at the unit are given the opportunity to engage in horticulture activities and in the active care of animals such as rabbits, chickens and goats.

The OT described that the development of skills which these programmes enable provides a sense of wellbeing for service users. Boosts confidence, social interaction and engagement. As well as decreasing depression and anxiety – providing an outlet for frustration and tension and also building on a sense of relaxation.

Further benefits of the programmes which have been recognised include:

• Sense of achievement.
• Service users become better at planning and sequencing.
• Helps relieve boredom.
• Service users can work at their own place - idea for grading and adapting.
• Service users are able to get off the ward and get some fresh air.
• Increasing routines, structure and responsibility.
• Problem solving skills increased.
• Increased feelings of empathy.

There are also many ways in which these programmes can be developed in the future:

• Ward based groups and individual horticulture activities.
• Pet residents on the ward.
• Photography opportunities.
• Wildlife and conservation.
• Art groups.
• Picnics.
• Weather station - meteorology. 
• Involvement of more service users and also families, partners, friends etc.

This paper session got me thinking as to the benefits of Pets in forensic settings. My final university placement was a role emerging placement in a male foreign nationals Prison. I had thought about the introduction of pets - in particular fish, after reading an interesting article on the benefits of introducing fish onto the wings. Unfortunately I cant not find the article! Will keep looking. However after doing a quick "google" search on pets in Prison I found a couple of interesting articles.

1.  "Washington State Correctional Center For Women -Prison Pet Partnership Program" (http://prisonp.tripod.com/) Women in this American Prison have the opportunity to care for and train dogs that will assist disabled people. The women learn how to train, groom and board dogs within the prison walls. One really interesting paragraph from the link given is this:

"The Prison Pet Partnership Program gives inmate trainers the opportunity to learn valuable pet industry-related vocational skills to use in finding employment when they resume their lives outside of prison. They are able to work toward Pet Care Technician certification, levels one and two, through the American Boarding Kennels Association. They are also able to obtain Companion Animal Hygienist certification under the auspices of the World Wide Pet Supply Association. At this time, 100 percent of the inmates who have been released have found employment. Additionally, over the past three years the recidivism rate has been zero."

2.  "Jail house flock- Allowing inmates to keep pets in prison is more than just a reward for good behaviour - it can also teach old dogs new tricks." (http://www.guardian.co.uk/theguardian/2001/aug/25/weekend7.weekend3)

 I would definitely recommend reading the above article is you have a few minutes. Observations made from allowing service users to care for pets, in this case birds, include a reduction in violence and service users being on "report", an increased engagement and willingness to learn skills such as reading in order to learn how to care your their pets more effectively and also increasing social skills and co-operation. Further more the article states that in an American study, service users who had opportunities to care for pets:

"...needed only half the medication of their petless peers, and there were no suicide attempts, compared with eight on the other ward (without pets)."

I find it really interesting and encouraging that programmes such as these can have such a beneficial effect on the rehabilitation of forensic service users. This is definitely an area which I feel OTs can get involved with and develop!!

Forensic Forum - Paper Session.

Vocational Rehabilitation within Forensic services.

“The development of a vocational pathway in forensic services.” Pollard K Northumberland, Tyne and Wear NHS Foundation Trust.

“Real work matters on a high dependency ward within a high secure environment.” Robertson CJ, Russell S, West London Mental Health NHS Trust, First Step Trust UK.

“Are you bored? Looking at boredom in a forensic in-patient setting.” Ayles K. Kent and Medway NHS and Social Care Partnership Trust.

Key points from these papers:

• There are many barriers for forensic patients wanting to maintain or find employments, these could include: Self image, Societal preconceptions, lack of appropriate/transferable skills, inappropriate behaviours, mental health problems, anxieties.
• Pre-vocational skills are needed in order to build on achieving an occupation/paid employment. Steps in order to achieve this could include group work, individual goal plans to achieve existing therapeutic programmes, developing social skills, employ-ability and personal development programs.
• Promote work as part of recovery and eventual inclusion into society.
• Create paths which make patients seem and feel as if they have left the ward.
• Importance of social skills/social inclusion when leading groups. Eventually as OTs to facilitate the group rather than to lead.
• Boredom in forensic units is extremely high and can stem from occupational deprivation (as defined in a previous blog entry). Within the study on boredom participants revealed that they perceived and described being bored as a negative emotion. - "frustrating", "worthless", "numb" etc.
• Few patients within the unit engaged in solitary time in their rooms as they feared it would be viewed negatively by staff.
• Patients revealed that previous coping strategies to boredom where illegal and/or antisocial - as a forensic OT one challenge lies in replacing these coping strategies which positive ones.
• Recommendations for tackling boredom:

1. Ensure activities are interesting and meaningful.
2. Introduce new/taster sessions to help patients.
3. Make clear links between groups and the skills acquired.
4. Provide adequate activities for those without leave from the ward.
5. Increase resources, including people, evenings and weekends.
6. Enhance work experience opportunities.
7. Explores additional opportunities for education.
8. Increase access to books and DVDs.

Forensic Forum - Paper Session.

“Establishing a work-based learning programme: vocational rehabilitation and forensic learning disabilities.”

Smith A, Petty M, Outhgton I, Alexander RT. Partnerships in Care, Learning Disabilities Services.

Some top tips which I gathered from this paper session!

• Develop as life like a work environment as possible.
• Enable social and life skills.
• Work opportunities need to be meaningful and relevant to them in order to be of relevance.
• Increase self esteem and confidence by promoting independence and autonomy.
• Accompany work skills with educational skills for example reading, writing and numeracy.
• Patient reflection is important in order to help them to identify how they have improved and what skills they have.
• Always need to consider risk management. (Individual and environmental risk assessment.)

The authors of this paper session have also published a journal article in the British Journal of Occupational Therapy. The reference for it is here if you are interested in reading it:

Smith A, Petty M, Oughton I and Alexander R (2010) "Establishing a work-based learning programme: vocational rehabilitation in a forensic learning disability setting." British Journal of Occupational Therapy. 73(9) pp. 431-436. 

Neurological Practice - Paper Session.

"Exploring the concerns and unmet needs of stroke survivors at six months."

Crow JN, Kilbride C. Imperial College Healthcare NHS Trust.

30.06.11

From this study it was revealed that there are six main areas of concern for stroke patients at six months post-stroke. The six areas are as followed:

1.     Loss = pre-stroke lives, independence, identity etc.

2.     Future uncertainty.

3.     Lack of information provision.

4.     Fear - another stroke, recovery, being a burden etc.

5.     Lack of therapy input - in particular vocational rehabilitation and psycho-social elements.

6.     Abandonment and isolation.

I was pretty shocked when I heard of these six areas. Most of them, for example numbers 1,2,4 and 6 I feel that you are almost always going to get to some degree due to the nature of a stroke and the outcomes of them. However for numbers 3 and 5 I feel that these are areas which can and should be stopped from occurring. I am aware that service provision and the NHS in general is rather stretched at the moment but these are two areas which I think OTS could really make an impact in. OTs are well suited to be both advocates and actively signpost patients to other professionals and services who can provide them with the right information and services which can help aid their recover and increase their general well-being.

Occupational Therapists help individuals live a life which is not dominated by disability.

Forensic Forum - Paper Session.

“The use of reflection for OTS in a forensic personality disorder unit.”

Rawdon CP, Stiles S, Northumberland Tyne and Wear NHS Trust.

There are many different uses and positives to reflecting, one being that effective reflection can inform clinical reasoning and deepen understanding of the behaviours of the above defined clinical group.

Within this paper Gibbs model of reflection was used by both staff and patients.

Staff reflection – Why?

·         Transfererance of emotions

·         Boundaries

·         Entitlement

·         Behaviours

·         Stops taking work/emotions home.

How?

·         Supervision

·         Reflective practice

·         Informal reflection

·         Humour

·         Peer reflection.

Patient reflection – why?

·         Enables ‘enlightenment’

·         Helps them clarify and make sense of things.

·         Helps them to visually and cognitively see problems and the solutions.

When using reflective methods with patients it is important to be careful of patient discomfort when flaws are laid out in front of them – no one likes to come face to face with their flaws! Also try and minimise as much as possible the feeling of always being watched/scrutinized and judged.

I really liked the idea of this paper, which was to encourage both MDT and patient uptake in reflective practice however I think the chosen model could be altered. From my personal opinion although I think that the Gibbs model has some definite positive points there are so many other, newer, models out there which could be utilised. For example I like Driscolls cycle (2000) as it is a more simplified model and would suit a wider range of patients perhaps, especially if they have any cognitive or processing difficulties. Also Johns model of reflection (1994) has been helpful over my three years of studying.