Management of Challenging Behaviours

Question 1

BPD

Answer 1

• pervasive pattern of instability in interpersonal relationships, self image, affects, marked impulsivity in 5 or more areas
  
  • frantic events to avoid real or imagined abandonment
  • pattern of unstable and intense interpersonal relationships alternating between extremes of idealisation and devaluation
  • identity disturbance - markedly and persistently unstable self image or sense of self
  • impulsivity in at least two areas that are potentially self damaging
  • recurrent suicidal behavior, gestures, threats or self mutilating behavior
  • affective instability due to a marked reactivity of mood
  • chronic feelings of emptiness
  • inappropriate intense anger or difficulty controlling anger
  • transient stress related paranoid ideation or severe dissociative symptoms

Question 2

Splitting

Answer 2

• information needs to be shared
• need to ensure they are aware of which nurse they should be speaking to each shift, rather than allowing for speaking to preferred nurses
• document behaviour, frequency and duration of behviours
• redirecting back to their nurse
• continuity in responses
• client needs to be informed of treatment plans and included in developing plans
• all involved parties need to meet regularly to develop and review treatment
• avoid putting patients into boxes based on what is expected for their diagnosis, avoid treatment predictions
• encourage appropriate behaviour
• avoid placing blame on the client

Question 3

Management Plans

Answer 3

• client demographics
• suicide and self harm history, including chronic and acute patterns
• overall history and understanding of the client
• consideration of risk, and how the team and client work with this
• consideration about what is helpful and what is not helpful with risk management
• agreed purpose to overall treatment approach, with a guide as to how these may be best achieved
• risk assessments
• provide verbal limits and redirections
• ensure client has a copy of the plan
• consistency and continuity in responses
• set limits and boundaries where behaviour is inappropriate
• share this information with all relevant parties
• zero tolerance to violence and aggression
• remove from environment if escalating, remove stimuli, decrease emotions
• duress alarms for staff if aggression / violence common

Question 4

Nursing skills

Answer 4

• promoting emotional literacy
  
  • assisting with knowing and understanding emotions, ways to monitor and regulate feeling states
• clarifying thought ambiguities and mental processing problems
  
  • recognising abnormalities and difficulties in thinking and processing, learning over time how to distinguish their own stream of consciousness from realities and intentions in others minds
• developing a tolerance to being alone
  
  • have abandonment anxiety, can trigger reactions to avoid being alone, assisting clients to understand the relationship between anxiety and acting out, develop ways of tolerating periods of aloneness
• developing a tolerance for relationships
  
  • are quite poor in managing interpersonal boundaries and closeness, create the new experience of being understood and respected, developing security in the therapeutic relationship, demonstrate that secure attachment is possible
  • support families and friends in relationship repairs, assist client to understand patterns behind interpersonal difficulties and develop insight and problem solving

Question 5

Risk management

Answer 5

• static risk factors - historical factors that don’t change over time, personal history, past history, family history
• dynamic risk factors - use of drugs / alcohol, treatment adherence, clinical acuity, current psychosocial stressors
• future risk factors - based off projections of first two factors, what ma be anticipated based off past and present
• suicide / self harm, past and present issues
• aggression / harm to others
• absconding / wandering
• vulnerability / issues with finances, accommodation, disability, personal traumas
• non-adherence
• substance abuse
• fire risk
• falls
• medical conditions / allergies / reactions
• protective factors
  
  • engagement in treatment, sense of safety while receiving care, impulse control, ability to cope with stress, conflict resolution skills, resilience, sense of purpose / responsibility, connectedness, personal beliefs / spirituality, general health, support services in place, support from family / carers

Question 6

Teamwork issues

Answer 6

• teamwork based approaches
  
  • helping where needed, sharing the load
  • team nursing / buddy systems
  • ensuring patient load is evenly spread
  • leadership
  • debriefing
  • behavioural management plans
  • consequences for actions
  • team building / team bonding activities

Question 7

Managing BPD with a team

Answer 7

• ensure consistency with nursing staff for care
• gender sensitive nursing
• rotate staff - avoid staff burnout
• focus on the behavior, not the person
• get to know the patients story - deeper level of understanding surrounding situation
• being non-judgemental and supportive to clients
• ensuring behavioural management plans are adhered to, by all staff and client
• identify triggers and stressors for the client
• be aware of own beliefs and values and how these may impact

Question 8

Recovery plans

Answer 8

• recovery - process of moving towards achieving wellbeing and a satisfying life or the process of maintaining a stable level of wellbeing
• client centred recovery plans
  
  • individualised goals - focused on clients strengths and empowering them
  • encouraging self management, being responsible for own treatment
  • recognising own strengths
  • education about illness, medication, relapse prevention, signs and symptoms to look for, community support services
  • equal partner in development of the plan, active participant
  • dynamic process, always changing to meet new situations, life changes, new goals
• if under section 12 / 14 (involuntary), need treatment plan - have no ability to make own decisions

Question 9

Treatment plans vs recovery plans

Answer 9

• treatment plans
  
  • structured set plan, with risks and goals identified, medications and care is prescribed, nursing interventions stop and prevent problems, directed by clinicians
  • all about saying what must happen, client has no say, if unable to have insight into their own care
• recovery plans
  
  • more about being client centred, client driven, about what they want, able to make better choices, use coping strategies
  • recovery is about a journey that continues when they’re discharged, client can own their own successes in treatment, used with voluntary patients and people who have insight