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Environmental Influences on Challenging Behaviors

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

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Environmental Influences on Challenging Behaviors

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  1. Environmental Influences on Challenging Behaviors Eleanor S. McConnell, PhD, RN, GCNS, BC Durham VAMC GRECC &Duke University School of Nursing August 24, 2010

  2. To do stuff…..OR To get stuff done Where are we?What are we trying to accomplish? • Environments • Places where • People • Interact with • Things & • Other people

  3. Where are we?What are we trying to accomplish? • Environments • Places where • People • Interact with • Things & • Other people To do stuff…..OR To get stuff done

  4. Where are we?What are we trying to accomplish? • Environments • Places where • People • Interact with • Things & • Other people To do stuff…..OR To get stuff done

  5. Goals • Increase awareness of how environment influences behavior • People without brain damage • People with brain damage (executive dyscontrol) • Increase skill in evaluatingenvironment: • Identifying aspects you can control • Compensating for aspects youcannot control

  6. Three Main Ideas • Environment has more to do with supporting challenging behaviors than you’d think! • You have more influence over the care environment than you know! • Analyzing and modifying environment is a learned skill… • Practice, practice, practice

  7. 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

  8. Environment in Use • Personal Abilities • Visual acuity & perception • Hearing acuity • Cognitive Level • Impulse Control • Strength/Flexibility/Dexterity Objective 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

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

  10. Brain Disease & Ability to Use Environmental Cues

  11. 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?

  12. What Behaviors are Supported in these Environments? • Reminisce • Sleep • Reflect v… • Be active • Exercise Places matter! They often cue behavior and emotions

  13. How Environments, People, Tasks & Behaviors Come Together Behaviors Transactions Tasks Veteran Places Things People • Transactions • Morning Care • Waking up • Cleaning up • Setting up • Tray service or feeding • Tasks • Wake up • Use toilet • Get washed • Get dressed • Eat • Do my thing…. How these tasks & transactions get carried out may makethe difference betweena challenging behaviorand a smooth day!

  14. Won’t Get Out of Bed Tasks Transactions: How is wake upapproached? Veteran with Needs! Things: Lighting; Music, Coffee, Bed-height People:staff with a certain approach Places:Veteran’s bedroom

  15. Tasks, Things, People & Transactions can each be altered Behaviors Transactions Tasks Veteran Places Things People • Tasks • Wake up • Transactions: • Smell coffee • Lights on • Music on • Warm washcloth offered Things: Coffee pot Lighting Music player Washcloth Staff: Do wake upin new manner

  16. 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?

  17. Let’s Eat! • Objective attributes • Lighting • Noise level • Things & arrangement • Chair height • Access to objects • Behavior of others • Glare? • Clutter? • Cues to Behavior? • Contrast? • Distractions? • Noise • People

  18. Environmental Layers

  19. 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?

  20. 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

  21. 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?

  22. Won’t Eat: Micro Environment • Place • Scene • Distractions • Noise • Things • Cues • Contrast • Physical support • People • Approach

  23. 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?

  24. Approach

  25. Refuses care… Lighting & Approach Place & Approach

  26. More Arrows in your Quiver….Target: Challenging Behaviors! Source: http://callitaweasel.files.wordpress.com/2009/10/mongel_arch.jpg

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