INFIRMARY CARE: Managing

Challenging Behaviours

Pat Larson, MN, Nurse PractitionerSherbourne Health Centre

Toronto, Ontarioplarson@sherbourne.on.ca

“The best way to find yourself is to lose yourself in the service of others” M. Gandhi

About this presentation…. Context Behavioural Issues Prevention/planning Responding Discussion

Context Solutions are unique to the setting We’re a learning environment... Underpinning of values/principles Pro-active/Prevention based stance Responding “in the moment” Your contribution to our development

An acknowledgement

Sherbourne Health Centre Community based agency

Partnerships (ie. Naturopathy, chiropractic…) Infirmary Primary care programs

Homelessness LGBTT community Newcomers Local community Health Bus (volunteer RNs, outreach)

Sherbourne Health Centre Infirmary Community-based, stand-alone model 20 beds (9 open at present) Serves the Greater Toronto area Referrals – self, community (shelters, drop-

ins, community agencies and providers) and hospitals (~12 in area)

Opened April, 2007

Staffing Model Community Health Worker (CHW) - 24/7 RN – 24/7 Case Manager NP Consulting MD Manager and Admin Assistant Partnerships (housing worker, pastor…)

Values/Principles Program values

Social justice Community/belonging courage

Harm reduction Independence, self determination Participation in program, health care plan Trauma model Kindness AND therapeutic value

Clients Homeless/underhoused Fractures, cardiac problems, diabetes, HIV,

endocarditis, pneumonia, skin infections/cellulitis, osteomyelitis/bone infections, post surgically, post childbirth

Majority also have substance use issues More men than women, but priorize women Most leave to go to shelters; occasionally client is

housed upon discharge

Referrals Short term

Maximum stay 3 weeks; average ~ 10 days Acute need

Written, faxed referral Referee remains responsible for

information transfer Hospital visits w/ some referred clients

acuity ability to safely discharge clients

Behavioural Issues Your setting Your experiences?

Issues Anything you would like to share? Things we might address?

Preventing Behavioural Issues

Focus on referral Adequate resources to process Follow up with referees/client/supports Ask difficult questions “are you barred?”

Program self-determination Ability to say no to clients Client meets program criteria?

Antennae on High Alert Intent

Primarily - planning/managing Consider - restriction

Shelter restrictions Evidence or history of violent behaviours Referee reluctant to provide information or details Client vague/reluctant re details Evidence of difficulty participating in previous

programs

Planning with Clients Contingency Planning

Frank Involve community supports

Substance use “How will you manage your cravings?” “Do you plan to use? How could you reduce your use?”

History of Violence or Barrings “What will be different in this program?”

Risk from Partners/others Safety plan; involve management/security

Triggers “What are your triggers? What is your plan to avoid? Manage?

Rights and Responsibilities Discussions about

Expectations Participation in program Consequences of not respecting responsibilities Independence

Contracts Client developed Staff developed

Harm Reduction No illegal substances on-site May use/imbibe, behaviour is the focus,

not substance use “What is your substance of choice?” “How can we help you not to use? To use

more safely? To use less while you’re ill?”

Trauma framework Understanding and re-framing of people’s

life experiences Therapeutic responses

Self responsibility Assist clients w/ coping strategies Trauma of being discharged

Clients Staff

Behaviours Attempts to triangulate - “Manipulation” Making unrealistic demands

“You’re not going to discharge ME, are you?” Evasiveness Not being honest Not participating

Refusing to meet w/ providers, to get out of bed, have treatments….

Serious Adverse Behaviours Disrespect - intolerance Theft Threats Violence Smoking inside/risk of fire Substance use on the premises

Physical Environment Clean, bright environment Minimal sharing of bedrooms Safe spaces, quiet areas Able to go outside (smoke, appointments) “This is the nicest place I’ve ever stayed.” “I feel like I’m at the spa.” On-site security EMR – team care plans, rounds, reviews

Inclusive Environments Diversity

How do we live it? Social Inclusion

“Radical inclusion” Respect, dignity

Ambivalent responses to acceptance Resenting being cared for

Stepwise Approach Accountability First episode - not meeting responsibilities

Responsibilities, rules, consequences Repeat behaviours

May result in discharge from program Serious issues (violence/threats/theft)

Discharge from program, ? Charges?

Responding to Behaviours All staff trained in Non violent Crisis

Intervention Focus on understanding own responses

Minimal staffing levels Timing of responses

In the moment Can this wait? Should this wait? Can this be ignored?

Issues of Responding “Enforcer” role (“bouncer/security”…) Who should respond to client? Challenging particular behaviours

“I’m not feeling comfortable with ..” “I need to speak with you about…” Alone versus with support

Clarity Consistent messages Easier to say than do

Responding Acknowledge client’s efforts and progress Importance of humour Staff training and support Differences of opinions

Staff cohesiveness on the big issues Recognizing when we’re inconsistent Addressing our inconsistencies

DiscussionThank you for the opportunity!

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Discussion