1. Melanie Sturman-Floyd MSc RGN Moving and Handling Lead
Moving and Handling Challenges in Dementia Care: Rights, Restraints and Responsibilities Moving & Handling People DLF 2017
Melanie Sturman-Floyd MSc RGN
Moving and Handling Lead

2. Aims and Objectives In this session the learner will be able to:
Be aware of dementia statistics
Be aware of incidents related to distressful behaviours.
Understand difference between challenging behaviour and distressful behaviours.
What are behaviours.
Identify behaviours.
Identify appropriate strategies to manage distress.
List legal responsibilities
List appropriate and inappropriate practices.

3. Dementia Statistics
In the UK there are approximately, 800,000 people diagnosed with dementia. (Alzheimer’s Society 2016)
Current cost to health and social care £23million and expected to rise to £27million by (Alzheimer’s Society 2016)
80% of people living in residential and nursing homes are diagnosed with dementia (Alzheimer’s Society 2013).

4. Violence and aggression
Health and social care staff are often exposed to violence and aggression in the work place.
Increased risk of injury to employees working with individuals who have dementia/LD/Mental health (Berry 2010, Skills for Care 2013).
Risk of injury is foreseeable so organisations need to put steps into place to manage the risks.

5. Violence and Aggression
Aggression and violence are terms often used interchangeably; however, the two differ.
 Violence can be defined as the use of physical force with the intent to injure another person or destroy property.
Aggression is generally defined as angry or violent feelings or behaviour

6. Injuries reported to HSE
Main non fatal acidents reported by eployers
4.8 million working days lost

7. Legal case 2011 Norfolk County Council care home.
Carer sustained an arm injury after being punched and pulled by an elderly resident.
Claimant won the case on the basis there were insufficient systems in place to protect the employee from injury.
Lack of risk assessment identifying behaviour.
Insufficient training to manage risks and protect employee.
Overall legal costs and compensation £60,000

8. Is it challenging behaviour?
Commonly used terms in health and social care:
Challenging behaviour
Behaviour that challenges
Harmful behaviour
Distressful behaviour

9. Definition of Behaviour
"culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy (wiki) OR Any non-verbal, verbal or physical behaviour by a person which makes it difficult to deliver good quality care (NHS Protect).

10. What is a behaviour?
Behaviour is a response to an action, environment, stimulus or a person.
Example if a stranger grabbed you, how would you respond?
Reasons
Although some times challenging the behaviour is usually for a reason.

11. Types of Non-Verbal Behaviour
Agitation
Facial expressions
Intimidating body posture
Cornering
Invading body space
Declining to move
Passivity
Walking
Following someone

12. Types of verbal behaviour
Talking loudly
Swearing
Crying
Repetitive statements
Repetitively asking questions
Making personal comments
Racist speech

13. Types of Physical Behaviour
Kicking
Hitting
Punching
Grabbing
Pushing
Undressing
Self harm
Absconding
Non-compliance
Spitting
Hair pulling

14. Reasons for challenging behaviour
Always a reason for behaviour Usually behaviour is a response to: Environment Person Stimulus Distress

15. Temperamental Factors
High intensity of emotional responding
Poor adaptability to new situations
Sudden changes of movement and directions
Reaction to other patient/residents distress

16. Biological or Physical Factors
Organic brain dysfunctions
Poor sleep
Hearing Difficulties
Visual Difficulties
Pain
Parkinson’s Disease
Dementia
Learning Disability
Drug or alcohol related
Psychosis or personality disorder

17. Social Factors Poor quality care Care tasks Pre operative period
Post surgery
Rejection
Environments
Learning histories
Lack of staff engagement
Cultural, gender preferences

18. Emotional factors Experiences of failure Dependency on others
Poor self-esteem
Unmet needs, toilet, pain, thirst
Lack of meaningful activities

19. Cognitive Factors Poor problem-solving skills
Poor communication skills
Inability to remember new information/instructions
Poor social skills
Boredom
Fear
Memory loss
Frustration

20. Examples of Behavioural Triggers
Turning in bed
Getting out of bed a different side
Lighting causing shadows
Colour – staff clothing and environmental
Race
Gender
Not having face to face transfer
Inability to push down on arms of chair
Communication
Direction of movement
Fear

21. Behavioural Tracking or Monitoring
What is the “ABC” Approach
A = Antecedent
B = Behaviour
C = Consequence
Action and Review

22. The ‘ABC’ Approach Understanding what is a behaviour
Understanding and identifying the antecedent. (Be Specific)
Documenting the behaviour, (hit, grab, verbal)
Managing the consequences
Who was affected.

23. Triggers/Antecedents
Often behaviour comes with a warning.
Sometimes there is no warning.
Easiest approach is to observe, identify what is happening at the time behaviour is expressed.
Behavioural distress is inventible in health and social care and organisations are expected to have systems in place to manage distress and reduce risk of injury/harm to patient and staff.

24. Look out for Precursors
Sometimes behaviour can occur without warning and should try and identify precursors
Examples:
Tense facial expressions
Walking
Body tension
Increased breathing
Refusal to communicate
Not having eye contact or prolonged eye contact
Threats
Gestures

25. Strategies De-Escalation Do nothing Leave and return
Better understanding
Observations – recording
Physical intervention

26. Legal Framework Common Law Equality Act 2010 Human Rights Act 1998
The Mental Health Act 1983 (amended 2007)
The Mental Capacity Act 2005
Deprivation of Liberty Safeguards
Health and Safety at Work Act
Manual Handling Operations Regulations

27. Legislation – Mental Capacity Act 2005
Applies to everyone involved in the care, treatment and support of people aged 16 and over who are unable to make all or some decisions for themselves.
Designed to protect and restore power to those vulnerable people who lack capacity.
Covers important decision-making relating to an individual's property, financial affairs, and health and social care.

28. Deprivation of Liberty Safeguards DOLS
The Deprivation of Liberty Safeguards is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm.

29. DOLS – Deprivation of Liberty Safeguards
The Mental Capacity Act allows restraint and restrictions to be used – but only if they are in a person's best interests.
Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are called the Deprivation of Liberty Safeguards.
The Deprivation of Liberty Safeguards can only be used if the person will be deprived of their liberty in a care home or hospital. In other settings the Court of Protection can authorise a deprivation of liberty.
Care homes or hospitals must ask a local authority if they can deprive a person of their liberty. This is called requesting a standard authorisation.

30. Office of Public Guardian (OPG)
Protects people who may not have the mental capacity to make certain decisions for themselves, such as about their health and finance.
taking action where there are concerns about an attorney or deputy
registering lasting and enduring powers of attorney, so that people can choose who they want to make decisions for them
maintaining the public register of deputies and people who have been given lasting and enduring powers of attorney
supervising deputies appointed by the Court of Protection, and making sure they carry out their work in line with Mental Capacity Act
looking into reports of abuse against registered attorneys or deputies

31. Human Rights Act 1998
Article 2 – Right to Life – taking steps if your life is at risk.
Article 3 – Freedom from torture and inhumane or degrading treatment.
Article 5 – Right to Liberty and Security.
Article 8 – Respect for your family and private and family life.
Article 14 – protection from discrimination.
Abuse
Hoisting against will, removing couple with dementia from double bed, exposing individuals
No one shall be deprived of his or her liberty [unless] in accordance with a procedure prescribed in law'.

32. Equality Act 2010 Replaced the Sex Discrimination Act 1975
Race Relations Act 1976
Disability Discrimination Act 1995
Aims to legally protect people from discrimination and ensure people are not treated less favourably than others.

33. Understanding Interventions/restraint
What is restraint?
What is intervention?
Should restraint or interventions be used are there other ways?
De-escalation
Minimal and safe interventions

34. Acceptable Interventions
Resident/patient may ask for bed rails because they are afraid of falling out of bed.
Care homes/wards may have code access to doors to prevent residents, who lack capacity from entering.
Care staff may sometimes have to decide quickly to restrain/safe hold if there is a risk of physical harm to themselves, the resident or others.

35. Unacceptable Interventions
Holding a resident/patient down physically or stopping them from doing something they want to do.
Using wheelchair safety strap without risk assessment.
Using bed rails without risk assessment.
Using a tilt and space chair to stop someone from moving in a chair rather than postural management.

36. Unintentional Interventions
Use of chairs that are too low or deep and prevent a person from transferring independently.
Using a bed that is too low or high for someone to transfer independently.

37. Other examples of intervention
Physical – 1 or more employees holding the resident, blocking the movement.
Mechanical – use of bed rails and safety straps.
Technological – use of door alarms, pressure pads, tagging.
Chemical – inappropriate use of prescribed/over counter medication.
Psychological – depriving choice, constantly telling resident not to do something.

38. Lawful intervention Intervention is only lawful if its use is:
1)    Reasonable
2)    Proportionate
3)    Necessary
4)    No more intervention than is necessary in the circumstances
5) Least restrictive option to be used and for shortest time necessary
Used if threat to people or property

39. Can you justify interventions?
Can you justify why interventions are required?
Are you making a decision in the person’s best interest?

40. Are interventions necessary?
Do you need to use interventions?
Consider is there a risk to yourself, resident/patient or other people.
Balance duty of care versus neglect.
Any intervention should be used in the minimalist way possible and for the shortest time possible, (Sturman- Floyd 2013)

41. What is reasonable?
Is the level of intervention reasonable to be used on an older person with dementia or someone with tissue viability, arthritic conditions?
Have you considered the risk of bruising, fracture and possible skin damage?

42. Is the intervention proportionate?
Consider employee stature and strength.
Is it acceptable for a 1.85m male weighing 105kgs to restrain/safe hold a elderly lady with dementia who is 1.54m and weighs 54gs?
Equally reverse it, 1.54m female weighing 54kgs trying to restrain a 1.85m male weighing 105kgs.

43. Interventions to reduce behaviour
Communication, clear, language, verbal, on verbal
Distraction/diversion.
Equipment, reduce hoisting interventions.
Type of spreader bars
Use of in bed positioning systems, i.e. Wendy Lett/mattresses.
Gap fill strategies, during sit to stand (frame or person) and turning within the bed (bed rails).
Minimal touch.
Communication from staff

44. Appropriate interventions
Care staff may sometimes have to decide quickly to restrain/safe hold if there is a risk of physical harm to themselves, the resident/patient or others.
Is it necessary?
Is it reasonable?
Is it justifiable?
Is it proportionate?

45. Inappropriate management
Holding a resident/patient down physically or stopping them from doing something they want to do.
Using wheelchair safety strap without risk assessment.
Using bed rails without risk assessment.
Using a tilt and space chair to stop someone from moving in a chair rather than postural management.
High level of force

46. Consequences of not addressing challenging behaviour
Ineffective delivery of care Over reliance of anti-psychotic behaviour Increase in staff and patient injuries Reductions in staffing Higher staff turnover Managing training resources Failure legal duty to protect staff and patients from harm. Increased complaints and litigation Unmet care needs
Reduction in staffing due to stress, injuries, lack of confidence, low morale

47. Safe moving and handling
Use appropriate moving and handling equipment.
Do not use a stand aid as a mechanical “drag” lift.
May need to use in-chair sling.
Use of bed rails.
Use of in-bed positioning systems, i.e. Wendy Lett.

48. Front assist transfers

50. Cocoon method

51. Turning within bed

52. Oval Glide Boards to fit slings

53. Turning in bed
Lift turn sheets
Twin sheet/Topsheet/Wendy Lett

54. Posture management
Look at appropriate seating – is it correct height to facilitate standing, postural support, lateral support
Contractures – increase pain, is this a trigger? Consider sleep systems, pillows, wedges.

55. Difficulties with hoisting
NRLS – identified 15 incidents where individuals have come to harm following a fall from a sling.
Hoisting can be traumatic for individuals.
What are the triggers for distress?
Pain
Incorrect sling
Spreader bar
Changes of positions
Repetitive hoisting

56. Do you still see this?

57. Generic Risk Assessment
Falls are foreseeable and steps should be put into place to manage risks.
Completion of generic risk assessment for all tasks helping person up from the floor.
Dependency
Equipment options
Number of staff/handlers
Any actions to
consider
Independent
Backward chaining 1
Behaviour, compliance, mobility, function, size, shape
Need Assistance
2-chairs
Mangar Elk
Mangar Camel
Raizer
Stand Up
1-2
Dependence
Hoist
2-3

58. Mangar Camel Criteria Functional Independence Measure Benner
Useful for people who have behavioural challenges
Person does not have to be fully compliant
Person can be rolled onto Camel
Person can be slide onto Camel
Does not need sitting balance or trunk control 3
Competent

59. Raizer Chair by Lift Up/AAT Mobility
Criteria
Functional Independence Measure
Benner
Useful for people who have behavioural challenges
Person does not have to be fully compliant
Does not need sitting balance or trunk control
Reduction of moving and handling
Person does not need to be rolled
Person can be quite passive
Least disruptive
1 handler
2-3
Competent

60. Supporting from the floor

61. Hoisting solutions
Think of sling – is it a trigger for pain and discomfort?
Fabric for ease of fitting and comfort
Style of sling
Spreader bar – width, type
In-chair style sling
Repetitive hoisting – care home minimum interventions in a 12 hour day (Sturman 2017).

62. Bed Rails Bed rails useful as a gap fill strategy
Often there is a clash between use of low level beds and bed rails
Leave bed rail in down position when person is left unsupervised.

63. What is reasonable? Elderly client with severe dementia
Does try to scratch herself and carers
Constantly calling out, shouting and kicks out
Having bed care
How long should someone go without any personal care or change of pad?
Balance duty of care and neglect.
What is reasonable?
Is it justifiable?
Is it necessary and proportionate?

64. Interventions Established no MC
Best interest decision – GP, family, carers, home manager.
What is reasonable force?
Use of mittens to cover hands.
Use of pillow or duvet to cover hands.
Possible use of bed rails and bumpers during handling tasks as long as carers posture not flexed.
Give soft object to hold
Use of permanent in bed positioning system to reduce manual handling interventions.

65. Case Study
80 year old resident in care home with pressure ulcer grade 4
Community Nurses have provided high level dynamic mattress and advised care staff to turn the resident every 2 hours.
Care staff report difficulties with turning during the night due to distressful behaviours.

66. Strategies to reduce risk of distress.
Is it necessary to turn the resident every two hours when she is on a dynamic mattress?
Would in-bed positioning systems reduce the risk of distressful behaviours?
Introduction of lateral turning systems – TOTO or lateral turning mattresses.

67. Thank you for listening to my seminar. My contact details are: melanie
Thank you for listening to my seminar. My contact details are: