3/20/2015. All presenters are employees of Northeast Rehabilitation Hospital Network

Transcription

1 March 26, 2015 BIA-MA Annual BI Conference All presenters are employees of Northeast Rehabilitation Hospital Network Tricia Desrocher PT, MS: Erin Fabian PT, DPT; Susan Riley OTR/L, CBIS; Pam Ayotte CTRS/L; Ryan Dumigan PT, DPT Participants will be able to identify 2-3 internal and/or external factors influencing behavior Participants will be able to identify 3 qualities which enhance therapeutic use of self Participants will be able to identify three examples of verbal, nonverbal, and environmental factors that may influence behaviors. It should be stressed here that as with neurological causes, behavior problems caused by environmental factors are not the fault of the individual who has sustained brain injury. The fault lies in the environment accidentally strengthening inappropriate behaviors instead of appropriate responses. Unfortunately, the rehabilitation environment itself often is responsible for reinforcing behavior problems. This can happen when cues are confusing or unclear, or when consequences for behavior problems accidentally reward the individual (Brain Injury Association of America) The Foundations of Behavior Model: chosen to demonstrate the various internal and external factors that contribute to behavior. Attempts to define how a person s values, environment, interactions with others, medical and psychological factors contribute to behavior. Our responsibility is to have an understanding of these components to work with the individual to promote positive behavioral outcomes and the best healing experience to those in our care. Competence in the Healthcare environment is defined as the assessment of the following attributes: Knowledge; Actions; Professional Standards; Internal Regulation and Dynamic State. CARF and TJC certification: Standards require that we assess and validate and track and maintain or improve the competency of our staff. 1

2 The three domains of competence Technical Critical Thinking Interpersonal Tricia Desrocher PT, MS, CSRS Understand a patient s educational history Last grade completed; performance, learning problems, ADHD, ADD Issues can affect speed of new learning, or promote confusion, frustration or reduced effort Understand a patient s history of psychiatric issues Previous diagnoses(depression, anxiety) may be made worse with ABI Consider ongoing mental health issues Know that learning may take increased time Provide more opportunity for repetition and practice Provide more concrete tasks and situational supports to master new learning Address ongoing mental health problems 2

3 After ABI, various medical problems can have an impact on cognition and behavior Poor sleep Increased pain levels Poor ability to regulate temperature Worry or fear regarding loss of bowel or bladder control Swallowing difficulties Be knowledgeable about a patient s neurological AND medical conditions Monitor sleep closely Address pain Ensure that room temperatures are appropriate for the patient Address continence issues Manage dysphagia Depression Anxiety Substance abuse Perception of their problems Value of treatment Cognitive issues Confusion Neglect Language problems and aphasia Memory issues Reduced Self-Awareness Tendency towards wandering Understand area of brain injured and effect on mood Address pre morbid substance abuse habits and educate on post injury effects of substance use Staff provide opportunities for choice/options: provide respect; acknowledge feelings, questions Address cognition, neglect Address reasons for wandering: boredom, selfstimulation Factors that trigger agitation/aggression Situations matter: overstimulation, overcrowding too much noise Too many restrictions: lack of space/choice/freedom Negative interactions with staff: staff inflexible, negative communication style, too much staff rotation Negative interactions with other patients Negative interactions with families 3

4 Pinpoint specific environmental triggers to agitation and modify them Provide a structured environment and consistent routines Make eye contact and face the patient when talking to the patient Allow extra time for the patient to respond to questions and directions. Susan B Riley OTR/L The use of one s personality traits as a therapeutic tool. The use of oneself in such a way as one becomes an effective tool in the rehabilitation process How we act when a behavior occurs is vital to what happens next. Therefore, do not underestimate the power of your therapeutic use of self. How one acts when a behavior occurs predicts the tone of the reaction and the direction of the interaction thereafter. We can shut someone down or open the person up. We can acknowledge someone or ignore the person. Our action to the behavior will drive the person s reaction. Person #1: Elderly female patient who walks up to the nurses station and begins to explore some paper on the desk. Staff member action possibility 1. Millie, LEAVE that alone and go sit down! Person #1: Millie becomes angry, agitated, or sad and behaves accordingly. Staff member action possibility 2: Hi Millie, it is so nice to see you. How about you come sit with me and help me to fold these towels while I write my notes? Person #1: Millie feels noticed, important, and needed and happily engages in the activity. 4

5 Recognition of the individuality of the patient. Respect for the dignity and rights of each individual. Empathy-entering the experience of another individual without the loss of one s own sense of separateness. Humility A relaxed manner Flexibility Self-awareness / insight Humor Self-disclosure CARING Treating the patient as a person, not as an illness. This requires understanding the whole person, their unique life experiences, values, concerns, and perspectives on their health and illness Compassion Sensitivity to the pain and brokenness of another Competence The right knowledge, skill, judgment, and attitude CONFIDENCE How one presents him/herself; A quality that builds trust. CONGRUENCE Being honest, true to one s word and actions, genuine and authentic 5

6 EMPATHY Attempting to feel what the patient is feeling; the intellectual identification with or vicarious experiencing of the feeling, thoughts or attitudes of another BODY LANGUAGE Personal Space: Be aware of a patient s need for personal space. Invading someone s personal space can be perceived as threatening. BODY LANGUAGE Kinesics: Body movements and posture. Non verbal communication is dependent on body language, eye contact, facial expressions, and hand gestures Paraverbal Communication: Verbal communication depends on words and sounds. Nonverbal communication consists of messages that are conveyed without the use of words. Paraverbal communication in the vocal part of speech, minus the words one uses. Paraverbal communication consist of: Tone: avoid inflections of impatience, condescension etc. Volume: keep the volume appropriate for the situation Cadence: the rate and rhythm of speech. Empathic Listening It is an active process to discern what a person is saying. It is a powerful tool for building relationships with the individuals under your care. By taking the time to listen, you not only demonstrate your commitment to them, but you also communicate the message that they are people of value and worth. Empathic listening is one of the best ways to strengthen trust and rapport with those in your care. Conscious use of self that is different from a spontaneous response that is typical in our daily reactions. Different from rapport. 6

7 The more we train ourselves to remain clear and present in the moment, the more easily we can access our own wisdom and use ourselves most therapeutically in any given moment. Doing this is truly an art form, and we all have to figure out how to use our own unique brushes. The more present in-themoment we are, the more likely we are to take the right action in any given moment. Verbal communication is an important tool in how we as professionals present ourselves to our patients. Verbal interaction is usually our first interaction with the people in our care. How we utilize our verbal skills can influence the course of our interactions with our patients. Erin will elaborate further on how Verbal Communication can influence behavior. Erin Fabian PT, DPT Communication is a trained and accomplished skill People form feelings about others based on the speech content (verbal) or behavior watching (non-verbal). 7

8 Communication during medical interviews plays a large role in patient adherence, satisfaction with care, and health outcomes (Ngo-Metzger et al, 2006) Verbal and non-verbal communication skills are important in rapport and trust between patients and health care professionals (Hall et al, 1995) (Roter et al, 2006) Documented to increase recovery rates Sense of safety and protection Improved levels of patient satisfaction Greater adherence to treatment options Reassure relatives that patients are receiving the necessary treatment Considered best practice (McCabe and Timmins, 2006) Definition: one person sends a message to another via speech Start and finish with what the listener needs to know Limit amount of information Don t use unnecessary words Relate message to the listener Be direct Extend the appropriate greeting to every patient with whom you come in contact Introduce yourself and your role in their care First impressions have significant impact Ask patient how they would like to be addressed Varying volume adds character Speak loud enough to be heard With hearing loss louder is not always better Do not be too loud or too soft 8

9 Pitch is the frequency of speech Raising the pitch of your voice signals uncertainty or a question Lowering the pitch can give you a more authoritative sound Speed of talking Rate of speech affects how people interpret the words Varying the rate can add interest to the conversation Slower rate is better overall especially for people that need increased processing time Enunciate each sentence, phrase and word Speaking clearly conveys competence, confidence, and intelligence If articulating is difficult for a person they can improve this by speaking slower than normal or by increasing volume and chunking Keep words to a minimum Try to only use necessary words Too few words can come across cold/rude Make your message clear Refrain from jargon or too much information Be truthful Use a balanced view point: pro/con to avoid bias Differentiate fact vs. opinion Be consistent Word choice influences the quality of communication Choose words that are familiar, unambiguous, and easily understood Use encouraging words Be polite Concrete vs. Abstract 9

10 Pauses allow time for processing incoming information Take time to listen Especially helpful when making an important point Look for feedback during this time: body language, facial expression Listen carefully and uncritically Allow the patient to show they have understood what was said Observe to assess the message is received correctly Avoid completing sentences or suggesting a word when they pause Consider the patient s viewpoint Paraphrase back the message communicated to you Keep an open mind Be objective Do not try to think of your next question while the patient is answering Pause as needed to observe Give one cue at a time Giving multiple cues at one time might cause confusion Closed Questions: Seek only one to two word answers Useful for focusing the discussion or clarifying Open Questions: Broaden the scope of response Demand further discussion Encourage conversation Only one person speaking at a time If several people in the room, allow one person to speak, then allow silence and time for a response 10

11 Summarize the important messages Can set the tone of the encounter Closing a conversation too abruptly may cause the person to feel rushed or not heard Musculoskeletal PT s and patients with back pain Study demonstrates that content of verbal communication during physical therapy encounters can be categorized and measured providing clinicians with feedback on their communication skills More experienced clinicians spent more time asking history/background probes more advice/suggestion and less restatement Less-experienced staff had increased prevalence of talking concurrently and interrupting patients. (Roberts et al, 2013) Non-Verbal Behavior and Communication Non- Verbal Communication and Strategies for conveying Empathy, Attention and Respect Ryan Dumigan PT, DPT Non-Verbal Communication Non-Verbal Communication Is the process of communicating through sending and receiving wordless cues. Which is sometimes mistakenly referred to as body language (Kinesics). Non Verbal communication encompasses: use of voice, touch, distance, appearance, physical environment, use of informal spaced as well as body language. Through involved awareness of the components communication Empathy encompasses a broad range of emotional states. It is the capability to appreciate, understand, and accept another person's mind state emotions. 11

12 Ways of conveying empathy: Listen attentively: By turning off the TV, putting down your paper work, or draw the curtain. Let your body language convey empathy. Maintain close proximity (but not too close), don't fidget, and look at the patient. Ways of conveying empathy: Validate your patients emotions: Immediately agree with the patient and convey your acceptance of the patients emotions. Offer your patient support: Go beyond words to convey willingness to help Empathic Statements I can see how important this is to you. I understand this can be frustrating. I know this process can be confusing. I d like to help you if I can. Let s see if we can solve this together. Your Attention Using Non-verbal communication to show your attention: Eye contact Head nodding Appropriate body posture Attention: Try to avoid such things as: Standing with your hands on your hips (the superman pose) Standing with your arms crossed Multitasking Appearing rushed Body Language Facial Expression Gestures Paralinguistics Proxemics (personal space) Haptics Kinesics (body movements) 12

13 Non Verbal Communication Remember both nonverbal and verbal communication are paramount in conveying empathy, respect, and attention which may help you avoid many potentially high- conflict situations. Pam Ayotte CTRS/L Environment should not be static Changing the environment to meet the individual needs of each patient, not changing the patient to meet the needs of the environment Environment can influence behavior and in turn can be influenced by the patients behavior Generally the environment is more amenable to change rather than the patient Systematic and deliberate use of the physical environment is a part of Behavior Management Allowing patients control of managing their environment as appropriate and safe 13

14 Suggests an individuals optimal adaptation happens when there is a balance between their ability to cope and the level of environmental demands that are placed on them The behavior becomes maladaptive, when the individual does not achieve balance i.e.; activity too challenging or under stimulating Reduce level of stimulation in environment Quiet, private room Limit unnecessary noises Limit number of visitors/staff Provide therapies in room or quiet treatment space Tolerate restlessness when possible Allow patient to move as appropriately/safely Patients room or treatment space that is too cluttered, distracting or difficult to navigate both visually and physically A physical environment that is too complex that the patient cannot read and/or respond to environmental cues Presence of others in treatment sessions can be distracting, confusing and over stimulating Loud noises, too much conversation Bright lighting Extreme temperatures Clutter on walls and furniture Too many staff/visitors at once Internal-discomfort, pain and/or fatigue Patients preferred music can be utilized as a relaxation technique in their room Music Therapy can assist with gains in motor, speech and language, and cognition More research is indicated re: Music Therapy s impact on mood and depression 14

15 Prior to admission, liaison will identify TBI patients via Pre-Admit notices Rancho level will be assigned to patient prior to admission based on screen completed in acute care and then communicated to TBI team members Each patient will have a colored gear sign outside their door with Rancho level Each Rancho level grouping will have their own color Each patient will be given colored wristband which matches the color/level of the room sign All staff including housekeeping and maintenance are educated on process as well as what to expect/do for each level The Physiatrist is responsible for writing MD orders when Rancho level changes Both gear sign outside room and wristband gets changed to appropriate level and color Rancho Level groupings: I-III IV V VI VII VII-X 15