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 evaluating environment: –Identifying aspects you can control –Compensating for aspects you cannot control

6. 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

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 together to affect behavior Apply to cases

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

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

10. Brain Disease & Ability to Use Environmental Cues DementiaABISMI SeeVisuo- perceptual disturbance maybeYes – may be hypersensitive HearVerbal miscuesmaybeYes FeelFollows tactile cues maybe SmellPreservedmaybe MoveGross motor+ Fine motor - maybe

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 People PlacesVeteran Transactions Tasks 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…. Things How these tasks & transactions get carried out may make the difference between a challenging behavior and a smooth day!

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

15. Tasks, Things, People & Transactions can each be altered Behaviors People PlacesVeteran Transactions Tasks Transactions: 1.Smell coffee 2.Lights on 3.Music on 4.Warm washcloth offered Tasks Wake up Things Things: Coffee pot Lighting Music player Washcloth Staff: Do wake up in new manner

16. Challenging Behavior: Urinates in the wrong place What’s the 1 st 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! Glare? Clutter? Cues to Behavior? Contrast? Distractions? Noise People Objective attributes –Lighting –Noise level –Things & arrangement –Chair height –Access to objects –Behavior of others

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?

25. Approach

26. Refuses care… Lighting & Approach Place & Approach

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