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Shaping innovative services: Reflecting on current and future practice
JCPSLP Volume 19, Number 2 2017 113
3 Resources for safety
When working in this setting it is important that staff have
access to duress systems, such as electronic duress tags
which silently alarm and notify the rest of the team for
whom, and where, immediate assistance is required.
Immediate access to security, while not available in all
services, is also a great resource for teams working with
patients who have BOC.
4 Understanding your role so you can be
an effective resource
Every person in the team within an ABI unit has a role to
play in supporting patients with BOC, and their fellow team
members. The role of each team member may vary
according to a range of factors. For example, if you have
strong rapport with a patient you may be one of the people
involved in approaching the patient first, using strategies
from the behaviour plan. Knowing your limitations and your
level of confidence is vital in these situations, as it is not
appropriate to intervene directly if you feel you lack the skills
to do so. Everyone has an important role to play; this may
be manning the door and directing the rest of the team or
redirecting other patients or families away from a potentially
inflammatory situation.
5 Utilise colleagues or professional
services as a resource to de-brief
Working with patients with BOC can be very stressful for
staff. It is important to utilise available resources, and be
aware of your own and your colleagues’ well-being needs.
Debriefing after an incident, whether you are directly
involved or not, is important. Talking with colleagues, or
utilising other more formalised supports, such as group
employee assistance program debriefing, or individual
employee assistance programs can assist staff to effectively
manage being involved in a challenging situation.
6 The psychiatry team resource
Access to a psychiatrist and a psychiatry nurse in an ABI
unit is a tremendous resource for patients and staff alike.
Patients with ABI often have complex mental health
histories and they can require a range of medications as
well as psychiatric insights to help support their recovery
and reduce BOC. For the speech-language pathologist and
the broader team these team members are a wealth of
knowledge.
7 The environment as a resource to
manage BOC
A secure environment is generally required for patients with
BOC and ABI. Having an enriched environment (e.g., highly
personalised room, bringing in a pet dog to visit), and
Dr Delwyne Stephens is the grade 4 speech
pathologist in the Acquired Brain Injury (ABI) Unit
at Caulfield Hospital, Alfred Health. She is part of a
team of allied health, nursing, medical and psychiatric staff
who provide sub-acute rehabilitation to patients with severe
– catastrophic brain injury. Unfortunately many patients
who experience severe brain injury also exhibit behaviours
of concern (BOC). The team in the Brain Injury Unit are
highly skilled in the management of patients who present
with behaviours of concern. Below is a list of suggestions
complied by Dr Stephens based on her experiences as to
how a speech pathologist can either be a resource in an
ABI team or utilise resources to support an ABI team to be
effective when working with patients who have BOC.
1 Know what a BOC is
Being aware of the kinds of behaviour you might encounter
in a specialised, secure brain injury unit is important.
Working in this kind of setting is not for everybody. If you
are applying to work in this kind of setting, ask for a tour of
the service. Ensure you understand the complexity of the
patients and your role in the team.
Challenging behaviours commonly occur in health care
settings; for example when patients have a dementia,
when families demonstrate aggressive behaviour, or when
a person is drug or alcohol affected. In an acquired brain
injury unit, behaviours of concern are commonly displayed
by younger people with brain injury, who may also have a
complex background including a drug or alcohol history,
psychiatric illness, and/or trauma background. These
patients are often mobile. Behaviours of concern in this
setting can include verbal or physical aggression towards
staff or families, threats of self-harm, unpredictable
behaviours which may cause harm to the person or staff,
psychotic symptoms (e.g., delusions), absconding, severe
confusion and high levels of distress. Usual strategies for
staff who encounter patients or families with aggressive or
violent behaviour may not be appropriate or effective with a
patient who has BOC resulting from ABI.
2 Tailored behaviour plans are a resource
for the team
An effective approach to managing BOC is for the treating
team to meet and develop a behaviour management plan.
In the ABI Unit at Caulfield hospital this is coordinated by
the psychology and neuropsychology teams. The treating
team meets and provides input into the types of behaviours
that have been observed, and what has and has not
worked. Pharmacological review is undertaken by the
medical, nursing and psychiatry members of the team and
adjusted if necessary. The behaviour plan is disseminated
to all staff working in the unit, and is effectively utilised to
support patient behaviour. The plan is regularly reviewed
and adjusted accordingly.
Top 10 resources
Supporting patients with behaviours of concern in an
acquired brain injury unit setting
Delwyne Stephens