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