Challenging Behaviour

I thought it was time I reflected on what I percieve is a complex and common issue I have been experiencing whilst working in the spinal unit.

The topic of:

"CHALLENGING BEHAVIOUR"

A good starting point is the definition...Good old wikipedia

Behaviour or behavior (see American and British spelling differences) refers to the actions of a system or organism, usually in relation to its environment, which includes the other systems or organisms around as well as the physical environment. It is the response of the system or organism to various stimuli or inputs, whether internal or external, conscious or subconscious, overt or covert, and voluntary or involuntary.

Then on a google search of "behaviour and spinal cord injury" -1,240,000 results

I have to keep reminding myself about the word "adjustment"

Adjustment is defined as adapting to a new condition. Everyone makes adjustments during their lifetime. Some of the conditions that you adjust to may be planned and you have time to think about how you are going to react to the situation. For example, you may have to make adjustments in your work hours when you start a new job. Other events may be a surprise, and you are forced to adjust to an unplanned event.

"Adjustment" and SCI...

A spinal cord injury (SCI) is one of the most devastating of all traumatic events. It results in a loss of some or all of an individual’s sensation and movement. It is common for individuals who are newly injured to have health problems. Plus, it takes time to build enough strength to be able to fully participate in daily activities.

Individuals who are newly injured will likely experience grief. This is a period of mourning that is similar to that following the death of a loved one. The difference is that you are grieving the loss of your sense of touch along with your ability to walk or use your hands. You will likely experience many different thoughts and feelings after injury. Some may seem extreme and others mild. There is no step-by-step grieving process, but some thoughts and feelings are common after injury.

Seeing that feelings are directly related to behaviour its obvious that almost everyone who has a SCI must have a change in behaviour at some stage post injury and during recovery.

Therefore it is vital that I am able to deal with behavioural changes/responses within a therapy session.

So where am I at now???

I get very frustrated when dealing with challenging behavours. I feel inadequately prepared to deal with behavioural outbursts, and I feel I lack the abililty to be assertive and respond to behavioural outbursts. It almost feels like Im too immature to deal with this - especially when working with client who have alot more maturity.

New Learning......

I feel everyday I am experiencing some type of interaction with clients that could have gone better - directly related to challenging behaviour usually impacted by environmental stimulus or as a direct result of the grief process.

How am I going to develop my professional skills?

Well firstly taking note of all of them and talking about them in supervision is key

Then analysing/relflecting on each experience and identifying how I could have dealt better with the situation in order to learn through my experiences.

Talking to the team psychologists - having a session or organising a session for the OT's about this issue.

I think its important to remember that i am probably not the only OT or team member that struggles with this issue and I want to remind myself that it is an important learning area and it will assist my professional development and growth.

Learning about OZ funding

Specialised Equipment Essential for Discharge (SEED)

The Specialised Equipment Essential for Discharge (SEED) commenced on 1 July 2008 to provide timely access to the essential equipment required to facilitate discharge to a community setting. SEED was formerly known as the Specialised Equipment Setup Program (SESUP).

SEED is available to eligible people receiving specialist inpatient rehabilitation for a catastrophic spinal cord, or acquired brain injury or illness in a NSW Public Hospital.

SEED is an enhancement of the Spinal Set-up Fund and has been developed in response to a recommendation made in the Review of the Program of Appliances for Disabled People (PADP), released in November 2007.

SEED will operate under the auspice of the PADP, administered by EnableNSW and will be available to eligible clients during the period of inpatient rehabilitation, until 6 months following discharge, for equipment required to facilitate discharge.

SEED will provide equipment such as wheelchairs, adjustable beds, hoists and shower and toileting aids. People currently receiving inpatient rehabilitation for a spinal cord injury or acquired brain injury interested in seeking further information about SEED should discuss their query with a member of their rehabilitation team.

Leaving one job and starting a new

So its been a while since I reflected on this blog.

I have resigned from my position as rotational occupational therapist after 2 years in rheum/rehab/acute/medical/ortho/surgical.

I reflect on the growth and professional development over the last 2 years.

I feel i have developed a wide range of knowledge about the OT role in acute and rehab settings.

I have developed fluent assessment skills and my clinical decision making is sound. I have worked hard on developing my commnication skills and maturity, and I have thrived in supporting and helping other colleagues.

I have developed into a strong driver and advocate for OT and interdisiplinary assessment/treatment. I have inititated and engaged in many quality projects and been praised for my ability to bring issues to senior members to activiely resolved problems.

I am going into a new position that will have its own set of clinical demands, with lots of learning and problem solving. One I am looking forward to alot

Will reflect again once commencing this position, but just for now i feel i have the necessary key skills to learn and develop in this specialised setting.

J x

Working on Rehab

Team members (OT)

I have found that my team members are more than happy to listen and discuss my patients with me. They freely offer their opinion and talk about similar cases that help me.

Allied health team members

I am fortunit to have had time with some experienced physio's and work interdisiplinary on numerous occasions. It has allowed me to confirm my reasoning and gain a wide reasoning base - e.g. the physios observations often prompt me to guide my observations to look at different occupational performance components.

I am beginning to understand more of the SLT role and some of their intervention techniques. However, i am struggling to understand the overlap between cognitive function and communication and the boundaries between OT/SLT when assessing cognitive function.

Caseload management

I feel i am managing to divide and manage my patients better than when i first started on rehab. I am keeping more up to date with my lower priority patients.

Goal setting

I am goal setting with my patients but i wish to work on more specific goal setting e.g. more smart. I wish to use my planning time to look at smart goals on shorter time periods e.g. 1 or 2 weeks so i can keep track of them and make them achieveable.

Support

I feel adequately supported in clincial work with my team members. Most have time and are interested in discussion about patients. I realise my lack of emotional support at this time needs to be also focused on. I am lucky to have support at work for this but I need to look at challenging my personal beliefs in the work place to ensure I develop professionally

Skill development

I am gaining confiendence with dense stroke patients with the support of my experienced colleagues.

Family meetings and case conferences (including articulation when communicating).

I realise that sometimes things just have to be said - even if the patient doesnt want to hear it or if it makes them feel upset/angry. I wish to take a case and plan what i am going to say and get some feedback from a peer as to how i articulated it - perhaps this could be done prior with an OT and after with a PT/SW e.g. asking them - do you think the way i articulated my input was appropriate/honest but considerate of others emotional needs?

Inservice Ideas...

Inservice ideas

Food for thought

How can we promote occupation in the acute setting?

What are the benefits? What are the implications?

Would occupation assist with recovering from an acute medical condition?

What evidence is out there? If any?

How could this happen? What could it involve?

What components of occupational performance could we focus on?

What occupations would be appropriate?

Would groups be effective on the acute wards? What type?

Could a survey indicate the needs of our patients during a stay?

Is there time?

MDT dynamics

What happened?

I had been working with a patient, who was admitted from home after having a fall and came into hospital with a UTI.

I had completed a SAP with her, and reviewed her pre and current occ performance and decided to see her after the weekend to organise a h/v due to her hx of falls and her decline in mobility.

I had documented this in the notes and then attended the MDT mtg on Monday. When the doctor talked about this patient he really had no idea about this patient (her background, falls hx, and how she was managing).

He said I think we need to look at rehab for this lady. I spoke up by saying “I don’t think she is far off her baseline/preadmission occ performance I mentioned that I had planned to do a home visit with this patient early week to assess her safety at home.. But I was not listened to. The doctor asked the “us” (looking at the PT) to review her ?appropriate for rehab.

The next day, I reviewed the notes and the PT had not analysed the plan. i.e. had not mentioned if she was appropriate or not for rehab. I asked the PT how her session went with the patient.

She replied “you were right she is much better this week, probably not appropriate for rehab as yes I think this is how she was before she came in”. I wondered to myself – well why didn’t you document that.

I documented the discussion and met with the patient to get her perspective of being ready for going home, she agreed she was ready and also gave consent for a f/u home visit one day post to ensure she was in a safe environment.

My reflection on this:

I felt I wasn’t being listened to in the MDT with regards to the OT perspective and plan.

I realise one of my roles is “discharge planner” however, I felt in this situation that I was the co-ordinator between PT, and OT – almost summarising the input and sorting the plan for discharge. I felt like I was going over and beyond to sort this lady out – for a few reasons

The medical team didn’t listen to me re: my input and plans from OT perspective

The PT’s analysis wasn’t clear.

How could I have dealt with this better? What will I do next time?

I could have asked the PT to document her view of ?appropriate for rehab as asked in the MDT, however I think it was still appropriate to document that we had that discussion.

I could have talked to the medical team post MDT re: the OT plan

I could have provided feedback to the MDT i.e. The OT and PT had been working with the patient, and that if we felt necessary we would talk to them about rehab appropriateness.

Basically I wanted to say that I felt undermined and that my input was irrelevant – Maybe I should have said that to the Dr/Consultant – knowing that perhaps that could have had a negative impact on OT

Cultural Safety

Yesterday I attended a cultural safety, ethics and rehab presentation which sparked a few reflections on my current practice.

The phrase power relationship - applys alot to working in an acute medical ward where health professionals are seen as having more power over their patients.

This doesnt settle well with me. I wish to relflect and explore whether I as a professional impose power on my patients.

Also I am aware of an article from the NZJOT titled "Cultural Safety, Kawa Whakaruruhau: An occupational therapy perspective". This article really reinforces what the speaker (an occupational therapist) was emphasising

a) the importance of being aware, sensitive and safe in attitude and behaviour

b) the importances of understanding yourself (as a person and professional)and the systems in which they work and live towards cultural competence

c)not ignoring sociopolitical and power relationships that margalinise so many groups in society

I guess what I am trying to say is that being culturally safe is more than knowing about values and beliefs and customs of spectific cultures.

Its about...

Ot's understanding themselves (identify, attitudes, values, beliefs) and how those influence their working relationship with others in context of family, social and work groups. Its also involves broader terms of sociopolitical understandings (impact of poverty on occupation)

Overall an understanding of the person, environment and occupation are all important for cultural safety.

So how can I ensure I am practicing in a culturally safe manner?

a) not forcing a value system on a client

b)exposing the client to a range of possibilites

c) the client is the one who makes the choice

d) being open to the clients ideas, feelings and thoughts - and being open to repsonding to them

http://www.otboard.org.nz/pdfs/Cultural_Safety_Article.pdf