Introduction to Understanding Challenging Behaviour, Personal Safety & De-escalation Strategies

1. Introduction to Understanding Challenging Behaviour, Personal Safety & De-escalation Strategies CITRUS team

2. Objectives • To give participants opportunity to examine the events that create challenging situations • To understand how the actions of others may impact on a persons behaviour • To examine possible reasons for challenging behaviours to occur • To identify appropriate responses to challenging incidents • To understand how or why a person may need to challenge their support/environment • To introduce the Agency procedure regarding supporting people who challenge • To examine the role that communication plays in supporting people who challenge and factors that affect behaviour • To ensure participants are aware of the need for accurate recording of behaviour and incidents

3. Group discussion • Do all staff need breakaway or physical intervention training? • IS THE USE OF PI LAWFUL? • Activity 1(pg 4)

4. C.I.T.R.U.S • Creative • Intervention • Techniques • in Response • to Untoward • Situations.

5. Group exercise • Is restraint an acceptable approach to difficult or risky situations • Always • Only as part of a care plan • Only as a last resort • Never • Activity 2 (pg 4)

6. CITRUS referral • Assessment based on evidence of incidents • Evidence includes:- • Risk assessments • Support plans • ABC charts • Incident reports • Health assessments • Care plan • Best interest meetings – consent • Clinical governance

7. Group work Read the article and consider the following See booklet Activity 2a (pg 4)

9. Levels of intervention • De-escalation of challenging behaviour • Breakaway • Physical intervention

11. First level • Primary Prevention • Addressing the root causes before they happened

12. Second level • Secondary Prevention • Reactive responses, de-escalation techniques

13. Third level • Tertiary Prevention • Physical interventions, post incident reviews & debriefs

14. Definitions Of Physical Intervention • By definition, a physical intervention involves direct contact between member of staff and a service-user BILD 2002

15. Definitions Of Physical Intervention • “Physical intervention implies the restriction of a person’s movement which is maintained against resistance • It is, therefore, qualitatively different from other forms of physical contact such as: • manual prompting • physical guidance • support which might be used in teaching or therapy” • Harris et al, 1996, p6

16. Definitions Of Physical Intervention • “In it’s broadest sense: restraint is taking place when the planned or unplanned, conscious or unconscious actions of care staff prevent a resident or patient from doing what he or she wishes to do and as a result is placing limits on his or her freedom” • Lyon and Pimor 2004

17. DEFINITION OF PHYSICAL INTERVENTION • There are two broad categories of Physical Intervention (PI): • Direct physical contact between a member of staff and a service user, • eg, • holding a person’s arms and legs to stop them attacking someone • The use of barriers, such as locked doors, to limit freedom of movementeg, • placing door catches or bolts beyond the reach of service users. • By definition, a physical intervention involves direct contact between member of staff and a service • BILD 2002 • “Physical intervention implies the restriction of a person’s movement which is maintained against resistance. It is, therefore, qualitatively different from other forms of physical contact such as manual prompting, physical guidance or simply support which might be used in teaching or therapy” • Harris et al, 1996

18. What is proactive • Describes what you are doing on a day to day basis to help minimise the likelihood of someone displaying challenging behaviour

19. Proactive interventions • PRIMARY PREVENTION • Minimise triggers • Changing the environment • Routine and structure • Boundaries • Teaching replacement skills • Interaction styles

20. What is reactive • How we respond to a person displaying challenging behaviour • A plan should be in place for this

21. Reactive Interventions • De escalation – redirection, distraction stance • Not responding to identified behaviours • Withdrawal • Breakaway techniques • Physical intervention techniques

22. Basic need • Is the person at risk of doing harm / injury to themselves or others?

23. scenarios • Chris • Kirsty • Amanda • Zetta • How would you respond to this situation? • What are your responsibilities? • What could be the legal outcomes • How is the person’s needs evaluated?Activity 3 (pg 6,7,8)

24. Group discussion • What was the action? • What could you be charged • with? • Which defense(s) could you • use? • Activity 3a (pg 9)

25. Scenario • Chris • Heightened mood • verbally abusive • throwing things • “ stay in your bedroom and don’t come out until I tell you” • FALSE IMPRISONMENT

26. SCENARIO • Amanda • attacks a male member of staff • unable to break away • use of physical intervention (standing hold) • BATTERY

27. SCENARIO • Kirsty has become physically aggressive. • You tell Kirsty in the heat of the moment • “I’m going to restrain you if you don’t stop it!” • ASSAULT

28. SCENARIO • Zetta • restraint and holding • Battery and False imprisonment

29. False Imprisonment • Seclusion • Confinement in a roomTying someone to a chairPreventing (by any means) a person leaving a room or building

30. Assault • Shaking a fist • Throwing an object • The threatened use of a restraining device

31. Battery • Touching • Holding • Pushing • Putting in bed

32. DEFENCES • There are a number of defences which may be put forward to justify the actions of carers implementing physical interventions which could otherwise be viewed as unlawful under the civil or criminal law

33. REASONABLE DEPENDS UPON: • The scale of the threat • The other options available • Feasibility of options • Likelihood of success • Ability to give consent

34. Defences • Statutory Justification • Prevention of a Breach of the Peace Duty of carePrivate Defence • Consent • Necessity

35. Policies and Procedures Breakaway and Physical Intervention Health and Safety Challenging Behaviour Supporting Staff involved in incidents Incident reporting Medication Risk assessment and management

36. Further Reading • C.I.T.R.U.S model • Human Rights Act 1998 • Management of Health and Safety at work regulations 1992 • BILD code of conduct and checklist for use of Physical Intervention

37. Break

38. Group discussion • From time to time we all present behaviours that ‘challenge’ people around us. • List something that irritates you? • How does it make you feel? • What do you do to help you deal with it? • What else can effect how you feel and re - act • Activity 4 (pg 13)

39. Group discussion • Define challenging behaviour • Activity 5a (pg 14)

40. Blunden and Allen (1987) have said: • “The term challenging behaviour is used to emphasise the fact that the issue is a challenge to those who provide services, and to the rest of society, not just a problem carried around by the individual. • The challenge is ours to provide effective ways of helping people to behave and express themselves in ways which are acceptable to Society”.

41. Emerson et al (1987/1995) suggests the following as a definition of severely challenging behaviour: • “Severely challenging behaviour refers to behaviour of such an intensity, frequency or duration that the physical safety of a person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously damage or delay access to and use of ordinary community facilities”.

42. Group discussion • What causes challenging behaviour? • Activity 5b (pg 14)

43. Causes of challenging behaviour • Communication difficulties • Boredom • Health issues – pain, illness • Mental health disorders • Epilepsy • Not being listened to • Inconsistent approach • No routine • Environment ie. Autism • Learned behaviours • Anxiety • Seeking interaction • Lack of choice • Personality clashes

44. Group discussion • Now we have defined challenging behaviour, take time in your groups to give examples you have either faced, may face or think could be challenging behaviour? • Activity 5c (pg 15)

45. Pica Excessive drinking Repetitive behaviours Self stimulating behaviours (rocking spinning etc) Physical aggression Inappropriate sexual behaviour Refusal to engage/participate Excess demanding Throwing things Intentional incontinence spitting Putting fingers or objects in body orifices Throwing or Smearing faeces Stripping off in public Verbal abuse/ aggression Self injury Excessive noise Isolation/withdrawal Self induced vomiting Ripping/damaging clothes Damage to property Discrimination/ swearing or abuse This list is not exhaustive Challenging behaviours

46. Recap • Ordinary behaviours / inappropriate setting. • Serious adverse consequences • Personal judgement • You need to be clear about why you think a behaviour is challenging.

47. Recap • Challenging behaviours are often extreme versions of quite ordinary behaviour. They challenge because they happen more often, last longer, or have greater intensity than other behaviours.

48. Recap • Services have a responsibility to respond positively and professionally to challenging behaviours.

49. Fight or Flight • In relation to conflict situations we have an in built safety mechanism commonly called ‘fight or flight’ response. It enables us to • quickly evaluate a potentially threatening situation and then take whatever action is necessary to stay safe.

50. Fight or Flight • Our behaviour in any pressure situation is linked to how we feel at the time, tired, fatigued etc, our attitudes beliefs and prejudices, genetic background, past experiences, family, up bringing and cultural background as well as present circumstances, all influence the way a situation is evaluated and thus responded to.