Understanding Challenging Behaviour - Sense Scotland · IN/TLC Challenging behaviour workbook 27 June 2008 Sense Scotland Page 1 of 9 Understanding challenging behaviour – Your

Continuous Professional Development

Training Workbook: Understanding

Challenging Behaviour

IN/TLC Challenging behaviour workbook 27 June 2008 Sense Scotland Page 1 of 9

Understanding challenging behaviour – Your underpinning

knowledge How would you define challenging behaviour? List five factors which could influence challenging behaviour: 1 2 3 4 5 What’s the difference between a ‘reactive’ and ‘proactive’ management plan? What are the key pieces of legislation and guidance that need to be considered when planning to support someone with challenging behaviour?


What should you do when responding to a ‘critical incident’ with a service user? Why is it important to discuss and reflect after involvement in a challenging behaviour incident? Why is it important to keep records of challenging behaviour? Why is it important to analyse behaviour records?


Why is it important to stay calm when a service user is distressed or angry? What are your strategies for staying ‘cool, calm and collected’? Why might it be unhelpful to use terms like ‘kicking off’ when describing challenging behaviour? Name……………………………….. Date…………………………… Workplace………………………………………………………………………………….… Reviewed by…………………………………….. Line manager Date…………….


Understanding Challenging Behaviour & CALM

Service user profiles

Please copy the blank profile on the following 2 pages and complete a copy for each service user you support.


Confidential Service user profile Date: Initials of service user: What does the person do that concerns us? What are the main things that trigger challenging behaviour for this person? What do you think this person is trying to tell us through their behaviour?


What actions should be taken in response to this person’s behaviour when it happens? Which CALM techniques are referred to in this person’s Physical Intervention Agreement, if they have one? How should you record challenging behaviour incidents and accidents for this person? Which documents should you use? Completed by…………………………………… Date……………. Reviewed by…………………………………….. Line manager Date…………….


Competency Rating Scale

Rating Scale Indicative level of competence

0 Has no prior knowledge or experience

1 Has limited knowledge, has only observed

2 Can participate and assist in this area. Has commenced

and is working on the associated learning package

3 Can safely and competently perform this area of practice

without supervision


Performance criteria

Self assessment score

Assessor Assessment score

How did I demonstrate this?

1 You communicate with others in a manner which is respectful and appropriate to their needs.

2 You maintain the environment in a way which promotes safety and communication opportunities

3 You take actions to maintain calmness and safety in a manner which minimises any restriction of movement and which does not deny people’s rights.

4 You take appropriate action to prevent triggers to challenging behaviour occurring and to enable individuals to find alternative ways of expressing their feelings.

5 You take constructive action to defuse challenging behaviour.

6 You call for any necessary assistance and support without delay.

7 You act in a manner which is likely to promote calm and reassurance and make this clear to all involved.

8 You complete records accurately and clearly and store them according to agency requirements.

9 You manage challenging behaviour in ways that are consistent with individuals’ support plans, risk assessment and physical intervention agreements

10 You can demonstrate use of CALM techniques appropriate to your workplace


Competency Statement Name…………………………………………….. Workplace……………………………………….. I can demonstrate my knowledge, understanding and skills in supporting individuals with challenging behaviours in my workplace. I can demonstrate my knowledge and understanding of intervention strategies, risk assessments and physical intervention agreements for the service users I support. I can demonstrate CALM techniques appropriate to the needs of individuals that I support. Signed…………………………………………………. Date ………………………. I confirm this person can demonstrate knowledge and understanding of the above. Signed…………………………………. Line Manager Date……………………..

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Course Participant Workbook All course participants must have completed the theoretical module and adhere to conditions of training & accreditation This workbook is supplied to course participants to facilitate learning and retention of Information. Reference should be made to and your own notes read in conjunction with, your agencies/units copy of the current CALM Physical Intervention manual.

Instructors in CALM accredited agencies may also issue participants with the relevant photocopied sections from the CALM PI manual, as required for their in house agency use only.

CALM Training Services Ltd. Elmbank Mill The Charrier

Menstrie Clackmannanshire

FK11 7BU Tel 01259 763681

Fax 01259 763699

All materials used on CALM Training courses are the copyright of CALM Training Services Ltd and should not be photocopied, reproduced, or used for any other purpose without the written permission of CTS. CALM & CALM Training are the registered trademarks of CALM Training Services Ltd.

DL Restricted Circulation - course participants use only CALM 06/1 DOC

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LEVEL 1 BASIC POSTURE (T1) ☺☺☺☺ C

LEVEL 2 TURNING (T2) ☺☺☺☺ G O GUIDING (T3) ☺☺☺☺ G M LEVEL 3 SECURE COMFORT HOLD (T5) ☺☺☺☺ P R DIRECTING (T6/1) ☺☺☺☺ L E LEVEL 4 FIGURE 4 (T9) ☺☺☺☺☺☺☺☺ I S SEATED (T11) ☺☺☺☺☺☺☺☺ A S CROSS HOLD (T6/2) ☺☺☺☺☺☺☺☺ N LEVEL 5 ARM/CHEST HOLD (T13) ☺☺☺☺ I C PUSH ESCAPE (T14) ☺☺☺☺ 2 PERSON HOLD (T18) ☺☺☺☺☺☺☺☺ E O SEATED HOLD (T21) ☺☺☺☺☺☺☺☺☺☺☺☺ N DE ESCALATE/COMFORT/COUNSEL/DEBRIEF/REPORT

For Specialist and Supplementary Techniques (See Supplementary Manual CALM 06/1)


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The view that physical restraint and de-escalation training are the answer to challenging behaviour is widespread. In academic terms, this is called a "Reductionist" perspective. It effectively reduces the problem of violence from service users to a staff skill deficit and implicitly assumes that ensuring adequate staff skill is the key to safe practice. Such simplistic "panacea thinking" is also attractive because it offers a "quick fix". Problem with aggression - train the staff!

Research confirms common sense. That such Reductionist training, far from reducing risk, often increases it! Effectively this approach ignored the factors within organisations that either increase risk to staff (i.e. inadequate resources, no policies, poor leadership, no staff support, no systems. poor risk assessment, no accountability etc) or fail to prevent violence. Equally, whether the PI training system is the CALM model or any other, staff often develop the perspective that "it doesn't work". This is effectively a self fulfilling prophecy because lack of confidence will then ensure that it does not.

Whether you think you can do it - or whether you think you can’t do it, you're probably right!

Equally the staff expectation may be that a short course in physical intervention will equip them with the ability to physically subdue any aggressive service user. This must be seen as both a naive and potentially dangerous assumption. Physical intervention must be considered in the context of Risk Assessment. Does physical intervention present a greater risk than non-intervention? This needs to be systematically determined. Nor can an organisation simply assume that a "hands off” policy is safer or offers greater legal defensibility. The "Duty of Care” may mean that failure to intervene may itself generate injury and litigation.

MANY FACTORS CAN COMPROMISE SAFE PI PRACTICE:- .

• Poor staff fitness & experience of sport, baseline levels are likely to be skewed towards the lower end of the normal distribution continuum

• Prior back or mechanical injuries

• Variations in the ability and willingness to learn (i.e. motivation)

• Rigid beliefs & prejudices

• Behavioural & affective differences

• Limited skill maintenance

• Limited training resources. (source:- University of Birmingham)

SERVICES MUST ENSURE A POSITIVE ETHOS:-

• There is a sense of identity and pride which is clear in the organisation

• The reception and ethos is welcoming

• Service users and staff members morale is good and helps to motivate

• The behaviour and discipline of service users fits with their age and stage of development

• There are appropriate expectations and praise is used by staff and service users

• Staff promote an ethos of achievement

• Equality and fairness are a central part of the organisation


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• Parents or carers and residential staff are encouraged to be involved in the service users' development and the life of the organisation

• Communication with other agencies and links with the community are effective

• Support is available to tackle the complicated needs of service users (where appropriate)

• Service users are seen as individuals with unique needs WHEN TO USE PHYSICAL INTERVENTION

Staff should consult the specific guidance for their service sector. However the following guidance issued for Scottish childcare services is of potential general significance.

"Physical restraint should be acts of care and control and be designed to make sure the young person and others are safe. If you manage them well, you can help young people (or other service users) to move away from automatic and habitual responses, to a position where they can better control their choices.

You should receive thorough guidance from your employer, in training programmes and at other times, about the actions you should take when restraining a child.

No matter which method your employer has chosen, you may only physically restrain a child when it is the only practicable means of securing the welfare of that child or another child and there are exceptional circumstances. You must reasonably believe that:-

• A child will cause physical harm to themselves or another person;

• A child will run away and will put themselves or others at risk of harm; or

• A child will cause significant damage which is likely to have serious emotional effect or create a physical danger

WHEN NOT TO USE PHYISICAL INTERVENTION You should not use physical restraint when;

• You can restore safety in another way

• You are not in control of yourself

• You consider it clearly unsafe to do so (for example the young person has a weapon)

• You know the young person has a medical difficulty that may be made worse by being restrained

• You consider there are not enough adults to restrain the child safely

• Even with enough adults you are not confident you can manage to restrain the child safely

• You are on your own with a young person, unless you assess restraining them to be the least risky action to take (in very rare circumstances)

You may come across dangerous or difficult situations which appear not to be covered by your employers physical restraint guidelines. Your employer should provide guidelines about personal discretion, and the likely effects particular action will have. These guidelines should include what you can do if you have used the techniques taught to you in training, found them ineffective and yet there is still an immediate danger."

(adapted from Holding Safely - SIRCC 2005)


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A SAFE SYSTEM EMPLOYING PHYSICAL INTERVENTIONS MUST INCLUDE:-

• Regular practice

• Clear agency policies on the use of physical intervention

• Unit protocols

• Individual care planning /Risk Assessment/ Functional analysis (Suitable techniques listed in individual care plans)

• Management support and ownership

• Effective liaison between management & CALM Training Services

• Effective complaints procedure/post incident de briefing/ incident recording

• Adequate occupational health arrangements

• Regular practice (attendance should be recorded)

RISK ASSESSMENT The Health and Safety legislation imposes a legal obligation on employers to adopt a "pro active" approach to foreseeable risk.(The Management of Health and Safety at Work Regulations 1999 - Regulation 3 - Risk Assessment)

Every establishment should have in place written risk assessments for: - 1. The establishment 2. Individual service users 3. Specific restraint events

DYNAMIC RISK ASSESSMENTS Staff involved in potential restraint events often have to make almost instant decisions whether to intervene or not. There is no substitute for discussion, planning and incident management rehearsal in ensuring such decisions are constructive and legally defensible. However where considering whether to employ restraint intervening staff must consider:-

• Level of threat:- - Aggressors' arousal & agitation - Size/weight/height - Degree of hostility - Behavioural history - Degree of personalised threat

• Aggressor's Motivation - Nature of grievance - Intoxication/substance abuse - Expectations

• Known Risks - Medical conditions - Vulnerabilities etc

• Environment - Hazards (potential weapons; obstacles, peers) - Exits (availability, proximity etc) - Sources of help (colleagues, potential diversions)

• Self - Degree of emotional control - Confidence - Competence - Motivation


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BEWARE of your own MINDSET! The literature (and our experience) on restraint suggests that the factor which most compromises safety during restraints are: - 1. Punitive staff attitudes ("I'll show you whose boss!”) 2. Fear (leading to indecisive action - or - conversely use of excessive force) 3. Misinterpretation (fatality case studies demonstrate the restrained person often

explicitly states " I cannot breathe", before dying. Staff did not believe them ) 4. Ignorance ( lack of knowledge of risk factors and symptoms of distress)

Take Statements of Distress Seriously! Danger is increased by; -

• Time:- The restraint goes on too long • Prolonged struggle:- Lactic acid may build up ( i.e. Acidosis )

• Ignoring distress:- Have a non involved staff member monitoring the subject at all times.

• Restricting Breathing :- Restricting the free movement of the diaphragm Signs of Distress

• Rapid and shallow breathing

• Laboured breathing

• Panting or grunting

• Statement of an inability to breathe

• Absence of breathing

• Limpness

• Discoloration of the face - ashen grey, dusky purple

• Vomiting

• Seizure The Ability to talk or move as indicative of an ability to breathe is a myth. If in any doubt about the persons welfare cease the restraint and get medical help immediately. AFTER A RESTRAINT. Let go progressively:- Follow the directions of the team leader ( No 1 ). Do not prolong a restraint longer than necessary. It is probably illegal and certainly it will compromise your relationship with the subject who is likely to view your actions as punitive. Communicate: - Keep statements short, slow, positive, re assuring, neutral tone, person centred Medical help: - May be necessary if injury or distress are suspected Protect the subject:- Dependent on circumstances the subject may need to be protected and isolated from the rest of the care group Value the person:- Regardless of the behaviour enhanced arousal has a psychological impact. The person will need re assurance that they are valued. Suspend the impulse to punish:- Restraint events often offer opportunities to promote insight and learning Post incident reviews:- Talk through the incident with the subject. It is an opportunity to promote learning and insights into behavioural patterns, emotional needs etc (see CALM theory) Report the incident:- using your employers procedures. Failure to do so may have considerable legal repercussions.


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De brief:- Participate in an individual and/or team de briefing. What can be learned about the adequacy of agency systems and how the incident has been handled? Emotional needs:- Some degree of distress and/or emotional reaction is common after a restraint event. Ensure all staff (including you) are offered support. This may include – time away from duties to compose themselves, medical help, peer support (i.e. tea and sympathy etc), contact with family, de briefing, counselling etc (see CALM Theory) Injury:- In the event of injury as a direct result of the use of CALM restraints, complete an injury form available from your CALM in house instructor or on request from CALM Training Services. Please e mail [email protected]. and send completed form to CALM Training Services, at address on front page of this handout. Restore relationships:- Act to resolve any sense of grievance or resentment – with the subject (tell them how you feel) – colleagues – managers etc – do this constructively, in a non blaming way intended to ensure everyone learns from the event. Police:- In situations in which a crime may have been committed (e.g. an assault) it may be appropriate to involve the Police. Staff should follow their employer’s policy.

RESTRAINT GOLDEN RULES • BEFORE Be competent - practice - maintain your accreditation - inform your manager of anything which compromises your competence Be familiar with agency arrangements, i.e. policy, procedures risk assessments, care plans etc Be prepared (Fail to prepare - prepare to fail!)

• DURING Communicate Ensure teamwork - 1 person only leads & talks - Other staff obey instructions unquestioningly -1 staff monitors the subjects welfare at all times - De escalate progressively

• AFTER Confirm the welfare of the subject - Get medical assistance if required - Report the incident - Hold a post incident review with the subject -Participate in staff/team de briefing - Be in touch with and constructively address your own emotional needs (i.e. Talk to someone) -Review the incident in Supervision. Fail to follow these rules. Safety will be compromised. In the event of injury liability may be generated

THE CALM SYSTEM IS BASED ON EXPLICIT CRITERIA:

• No deliberate use of pain.

• No pressure on, or across joints.

• Minimise risk to staff.

• Minimise square on contact (restrain side by side).

• Hierarchy of techniques (see diagram).

• Minimal hand movements between levels.

• Ergonomic principles (Moving & Handling).

• Restraint in a seated position (no routine taking to the floor).

The CALM system offers a menu of techniques, which can be tailored to the needs of specific services. Staff should only be taught and use the minimum number of techniques required. Techniques suitable for specific service users should then be included in care plans. Competence must be maintained through practice.


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REGULAR PRACTICE IS ESSENTIAL

In the absence of regulation the quality assurance arrangements underpinning CALM training are designed to maximise the legal defensibility of the programme and provide a robust defence in the event of injury and/or litigation. The components include: -

• All techniques subject to Bio Mechanical Evaluation

• Full Manual provided

• Independent External Verification

• Comprehensive National Data Base of accredited trainees & Instructors

• Time limited Certification (1 year)

• All techniques subject to ongoing Evaluation and Review.

• User agencies must supply an annual report and notify injuries The CALM system is hierarchical which allows the degree of restriction to be matched to the behaviour of the subject. This is intended to allow staff to demonstrate conformance to the legal principal of “Reasonable Force”. Where the use of force is justified, the staff response must be “proportionate” and the “Minimum” necessary. It must not significantly exceed the force being used by the aggressor, or exceed the harm, which it is intended to prevent. Restraint must also be applied for the minimum duration.

RISKS

Although there have been no serious injuries or indeed fatalities with the CALM system, which is now one of the most heavily evaluated training systems around, restraint related fatalities and injuries are a common but hidden problem. It is essential that the risks of intervention (and non-intervention) are constantly considered. You must:-

• Read the care plan of any service user who may need to be restrained.

• Consult and discuss this possibility with them

• Identify any pre existing risk factors (medical conditions etc )

• Consider your own ability and that of your team to intervene safely.

• Practice regularly & comply with your employers arrangements

• Review the environment and risk assess it. Are there hazards, available chairs, clear access, etc

• Agree clear procedures and plans BEFORE you intervene During restraints

• A single person must take the lead and give clear commands and instructions

• Be aware and avoid environmental hazards

• Monitor the use of restraint - observe the face for signs of distress

• Avoid compression of the chest at all times

• Observe the subject's colour and complexion

• Take any statement such as "I can't breath" seriously.

• Beware of possible intervention by peers

• Be aware of escape routes


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Conditions of Accreditation

Use of techniques only in appropriate situations and adherence to the conditions of use specified by the employing organisation.

• No techniques to be taught or demonstrated to individuals outwith the employing organisation without the written permission of CALM Training Services

• Any operational problems with the techniques to be reported to CALM Training Services through the appropriate line manager.

• Maintenance of individual competence through periodic practice with other accredited staff. Various safeguards are also in place to ensure that training in the physical intervention techniques is safe and enjoyable. When training all course participants must comply with the following conditions: -

Participant’s guidance notes: -

• Course participation is subject to fitness. All participants must have completed and returned the course application form (B1) prior to the course. Under no circumstances should anyone take part who is pregnant, or believes they may be pregnant.

• Follow all instructions, if unsure ask the Instructor for further guidance.

• Use only warm up techniques shown. Do not over strain.

• Report any injury no matter how minor to an instructor immediately. If you feel unwell stop and tell an instructor immediately.

• Report any ‘over enthusiasm’ to the instructor immediately.

• If your partner appears to be/or states that they are experiencing difficulty/pain or is unwell stop immediately and consult with an instructor.

• Emergency stop procedure. If an instructor calls out ‘STOP’ you must immediately stop and be still.

• If the instructor is absent for any reason do not practice any techniques.

• Do not experiment or employ variations of techniques or use any technique learned in a different context, either in practice or operational use.

• Practice safely. Avoid realism and consider the safety and comfort of your partner at all times.

• Trainees are required to attend the full programme. In the event of absence the participant may not be presented for accreditation.

• The course will start promptly at the time notified. Lateness may impede a participant’s ability to cover the required curriculum. In this event any participant arriving after the class has started may not be permitted to join the class. This will be at the discretion of the Instructor.

Be Professional Be Realistic Be Safe


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CORE CURRICULUM

NOTES:-

Level 1 ☺☺☺☺T1 - Basic Posture:-

Level 2 ☺☺☺☺T2 - Turning & T3 Guiding:-

Level 3 ☺☺☺☺T5 - Secure Comfort Hold:- ☺☺☺☺T6/1 - Directing (part1)

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Level 4 ☺☺☺☺☺☺☺☺T9 - Figure 4 ☺☺☺☺☺☺☺☺T11 - Seated Hold ☺☺☺☺☺☺☺☺T6/2 - Cross Hold

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Level 5 ☺☺☺☺T13 - Arm/Chest Hold ☺☺☺☺T14 - Push Escape ☺☺☺☺☺☺☺☺T18 - 2 Person Hold ☺☺☺☺☺☺☺☺☺☺☺☺ T21/3 - Seated Hold

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SUPPLEMENTARY TECHNIQUES (Included on basis of “by Risk Assessment only”)

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HIGH TARRIFF TECHNIQUES

(These techniques carry an enhanced risk and are Included on the basis of “by Risk Assessment” and only at written request of senior managers)

Documents

Understanding Challenging Behaviour - Sense Scotland · IN/TLC Challenging behaviour workbook 27 June 2008 Sense Scotland Page 1 of 9 Understanding challenging behaviour – Your