Twenty-month effectiveness of a non-aversive, long-term, low-cost programme for persons with persisting neurobehavioural disability

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

The relational neurobehavioral approach: can a non-aversive program manage adults with brain injury-related aggression without seclusion/restraint?

PURPOSE

The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. New data on interventions used in the RNA and on how the RNA interventions can be used with patients with acquired brain injury (ABI) who have differing levels of functional impairment are provided in this paper.

METHOD

The study was conducted over a 6-week period in a secure 65-bed program for individuals with ABI that is housed in two units of a skilled nursing facility (SNF). Implementation of the RNA was compared between two units that housed patients with differing levels of functional impairment (n = 65 adults). Since this was a hierarchical clustered dataset, Generalized Estimating Equations regression was used in the analyses.

RESULTS

RNA interventions used to manage the 495 aggressive incidents included the following: Aggression ignored, Closer observation, Talking to patient, Reassurance, Physical distraction, Isolation without seclusion, Immediate medication by mouth, Holding patient. Different interventions were implemented differentially by staff based on level of functional impairment and without use of seclusion or mechanical restraint.

CONCLUSIONS

The RNA can be used to non-aversively manage aggression in patients with brain injury and with differing levels of functional impairment. Programs adopting the RNA can potentially manage brain injury-related aggression without seclusion or mechanical restraint. Implications for Rehabilitation The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. RNA methods can be used to manage aggression in patients with brain injury who have differing levels of functional impairment. Successful implementation of the RNA may allow for the management of brain injury-related aggression without seclusion or mechanical restraint.

Revisiting the neurofunctional approach: conceptualizing the core components for the rehabilitation of everyday living skills

BACKGROUND

Introduced in the 1980s, the neurofunctional approach (NFA) is one of the few interventions designed primarily for clients with severe deficits following traumatic brain injury (TBI). Specifically the NFA was intended for those individuals who were limited in their ability to solve novel problems or generalize skills from one setting to another and whose lack of insight limited their engagement in the rehabilitative process. DESCRIPTION OF THE APPROACH: The NFA is a client-centred, goal-driven approach that incorporates the principles of skill learning and promotes the development of routines and competencies in practical activities required for everyday living. Programmes based on the NFA are developed specifically to meet each client's unique needs, using a range of evidence-based interventions. RECENT EVIDENCE: Recently the NFA has been found to be more effective than cognitive-retraining for some individuals with moderate-to-severe TBI who have deficits in activities of daily living. This paper aims to define the core features of the NFA, outline the theoretical basis on which it is founded and consider implications of the findings for rehabilitation after TBI in general. The NFA is highly relevant for clients living in the community who require a case manager to direct an integrated, rehabilitation programme or provide structured input for the long-term maintenance of skills.

Staff-reported antecedents to aggression in a post-acute brain injury treatment programme: what are they and what implications do they have for treatment?

Research in psychiatric settings has found that staff attribute the majority of inpatient aggression to immediate environmental stressors. We sought to determine if staff working with persons with brain injury-related severe and chronic impairment make similar causal attributions. If immediate environmental stressors precipitate the majority of aggressive incidents in this client group, it is possible an increased focus on the management of factors that initiate client aggression may be helpful. The research was conducted in a low-demand treatment programme for individuals with chronic cognitive impairment due to acquired brain injury. Over a six-week period, 63 staff and a research assistant reported on 508 aggressive incidents. Staff views as to the causes of client aggression were elicited within 72 hours of observing an aggressive incident. Staff descriptions of causes were categorised using qualitative methods and analysed both qualitatively and quantitatively. Aggression towards staff was predominantly preceded by (a) actions that interrupted or redirected a client behaviour, (b) an activity demand, or (c) a physical intrusion. The majority of aggressive incidents appeared hostile/angry in nature and were not considered by staff to be pre-meditated. Common treatment approaches can be usefully augmented by a renewed focus on interventions aimed at reducing antecedents that provoke aggression. Possible approaches for achieving this are considered.

Rehabilitation Approaches to the Management of Aggressive Behaviour Disorders after Acquired Brain Injury

Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.

Long-Term Accommodation and Support for People With Higher Levels of Challenging Behaviour

The purpose of the present article is to describe the issues associated with providing lifelong accommodation and support to people with severe brain injury, neurobehavioural disability, and overt challenging behaviours. In particular, the article focuses on two groups of people within an Australian context: (a) those who live in community settings but whose behaviour is not adequately managed even by specialist outreach behaviour management services, and (b) those who are confined to aged care residential facilities and who show challenging behaviour. These groups bring to the fore different lifelong behaviour management issues. At present, if community-based clients seriously offend or have an adequate psychiatric diagnosis, they may be placed in heavily secured psychiatric units or prison. Otherwise, by default, they will reside in less restrictive options such as family homes and shared supported accommodation. We will argue that the current service system lacks the ability to apply appropriate structure and control to many clients with serious challenging behaviours, and propose that specialised facilities would make an important addition to the service system. Conversely, young clients confined to residential aged care facilities live in impoverished environments that often contribute to challenging behaviour that can be enormously disruptive, distressing, and unsafe. We will review the recent Australian State and Federal Government initiative aimed at transitioning some young people out of nursing homes, and we raise considerations for future service development. There are many individuals with the potential to make significant gains in a tightly structured setting before returning to the community, while others will manage well with long-term placement in a setting designed for residents with neurobehavioural disability. Case studies and service data are used to support these arguments, and key elements of accommodation and rehabilitation models for those in need of long-term neurobehavioural support are described.

The effects of enhanced program review and staff training on the management of aggression among clients in a long-term neurobehavioral rehabilitation program

OBJECTIVE

This article examined the effects of staff training, staff support groups, and increased client behavior monitoring on the rate of physical aggression toward peers and objects in an older neurobehavioral population treated in a long-term neurorehabilitation program.

METHODS

During the 15 months of data collection, programmatic enhancements were introduced including: Staff training and support groups, comprehensive assessment and individualized program development, and client-centered weekly and systemic monthly behavior management review. Incidents of physical aggression were assessed using staff report. Data were corroborated using multiple sources including, medical records, written incident reports, and Overt Aggression Scale-Modified for Neurorehabilitation - Extended (OAS-MNR-E).

RESULTS

A total of 267 clients were present in the facility during the reporting period. The clients had neurobehavioral disability of various origins, 73% had a psychiatric diagnosis in addition to one or more medical diagnoses, and 58% had a dementia diagnosis. An already low rate of incidents of physical aggression per client month (0.02) was reduced by 77% following the implementation of programmatic enhancements.

CONCLUSION

Enhanced systematic behavioral review of clients provided concurrently with staff training in non-aversive principles and ongoing staff support groups reduced the incidents of behavioral disregulation in older persons with psychiatric diagnoses, medical comorbidities, and neurobehavioral disabilities.

Cognitive versus functional approaches to rehabilitation after traumatic brain injury: commentary on a randomized controlled trial

I describe the findings of one of the largest randomized controlled trials (RCTs) of rehabilitation after traumatic brain injury (TBI) ever conducted, examine the theoretical relationship between cognitive and functional rehabilitation after TBI, and describe the historical preference for cognitive (top-down) rather than functional (bottom-up) interventions. I also contrast the goals and principles of cognitive rehabilitation and of the neurofunctional approach of Giles and Clark-Wilson (1993; Giles, 2005)--a bottom-up approach. Findings of the RCT provide empirical support for both functional and cognitive interventions following acute TBI. In addition, they provide evidence that each type of intervention offers significant advantages for a specific subpopulation. The clinical implications of these findings for occupational therapy practitioners are discussed.

Assessing adaptive behaviour in the post-acute setting following traumatic brain injury: Initial reliability and validity of the Adaptive Behaviour and Community Competency Scale (ABCCS)

PRIMARY OBJECTIVE

Present the rationale for adaptive behavior rating and introduce the Adaptive Behaviour and Community Competency Scale (ABCCS), a comprehensive and detailed measure of adaptive behaviour, for use with persons with traumatic brain injury (TBI) in the post-acute period.

METHODS AND PROCEDURES

Direct-care staff with limited exposure to the ABCCS, completed it twice, two weeks apart, about persons with TBI who were resident in diverse community settings. Other measures to assess validity were administered concurrently.

RESULTS

Intraclass Correlation Coefficients (ICC) for interrater and test-retest reliability of the ABCCS were excellent (ICC=0.9681 and 0.9860 respectively). Evidence for convergent and divergent validity with comparison measures was strong with highly significant correlations with scales measuring similar content (Rho=0.613-0.919) and weak correlations for scales measuring dissimilar content (Rho=0.318-0.397).

CONCLUSIONS

The ABCCS is a reliable and a valid indicator of functioning post-acute TBI and is straightforward enough to be used by direct-care staff.

Overview and inter-rater reliability of an incident-based rating scale for aggressive behaviour following traumatic brain injury: The Overt Aggression Scale–Modified for Neurorehabiltation–Extended (OAS-MNR-E)

PRIMARY OBJECTIVE

The presentation and evaluation of the Overt Aggression Scale-Modified for Neurorehabilitation-Extended (OAS-MNR-E).

RESEARCH DESIGN

Inter-rater reliability study using data collection procedures mirroring clinical practice.

METHODS AND PROCEDURES

Fifteen clinical staff representing five different disciplines received a 30-minute orientation to the study and a 30-minute overview of the OAS-MNR-E. There were 34 patients who engaged in a rateable behaviour and were observed by two raters. There were 199 observed aggressive behaviours during the 6-week study period.

MAIN OUTCOMES AND RESULTS

All sub-scales of the OAS-MNR-E had high percentage agreement (>92%) and the kappa statistic was uniformly excellent (>0.77). Multiple ratings within a sub-scale resulted in lower reliabilities. Incidents with multiple interventions were of longer duration. Interventions were on average more intrusive when used in combination than when used singly.

CONCLUSIONS

The OAS-MNR-E can be easily incorporated into facility routines and is reliable. The rating tool reported here can provide data that assists in programme design, evaluation and treatment planning.

Prevalence, characteristics and causes of aggressive behaviour observed within a neurobehavioural rehabilitation service: Predictors and implications for management

PRIMARY OBJECTIVE

To describe the characteristics and determinants of aggressive behaviour observed within a neurobehavioural unit.

RESEARCH DESIGN

Statistical analysis of a database of routinely administered clinical measures, including the Overt Aggression Scale-Modified for Neurorehabilitation.

METHODS AND PROCEDURES

Records of aggressive behaviour shown by 108 patients over 14 days were studied. Patient characteristics were also captured using 23 items from the Rehabilitation Institute of Chicago-Functional Assessment Scale. Four factors were identified: 'communication', 'cognition/function', 'neurobehavioural disability' and 'mood & self-esteem'. Relationships between patient characteristics, external factors and their interactions with aggression were examined.

MAIN OUTCOMES AND RESULTS

Many (5548) episodes of aggression were recorded. Whilst most comprised verbal aggression, 729 physical assaults were made on others. Aggressive behaviour typically followed staff prompting or no obvious antecedent. Medical intervention was rare, most aggression was managed by staff not reinforcing this behaviour. Over 80% of physical assaults were made by people rated as having severe symptoms of neurobehavioural disability and poor communication.

CONCLUSIONS

Neurobehavioural units require sufficient staff resources to engage patients in purposeful activities as these were associated with the least severe aggression. Despite increased OAS-MNR usage, a standardized methodology for investigating aggression is required to ensure compatibility between datasets.

Managing aggression in a psychiatric hospital using a behaviour plan: a case study

This paper focuses on the critical role of nursing in implementing a behaviour plan in a psychiatric hospital. The plan was implemented with a 40-year-old man with a long history of aggression towards others and self. The study used a single-subject research design with baseline and intervention phases (AB Design). Data were collected on (1) frequency of incidents of aggression towards others and self; (2) use of restrictive interventions to manage aggression (i.e. restraints, pro re nata medication, 1:1 special observation); and (3) frequency of staff injury. The data show a decrease in frequency of aggression towards others and self, a concurrent reduction in the use of restrictive interventions to manage aggression, and a decrease in incidents of staff injury. The behaviour plan helped staff maintain a safe and therapeutic milieu. The behaviour plan has given the patient an opportunity to learn positive replacement behaviours and skills, and the opportunity eventually to leave the hospital to live in a less restrictive community home.

Two Approaches to Behavior Disorder After Traumatic Brain Injury

A 3-stage model of intervention is used to contrast the philosophy and treatment practices of 2 behavioral approaches to behavior disorder following traumatic brain injury. The first referred to here as the Operant Neurobehavioral Approach developed from neuropsychology and learning theory. The second referred to as the Relational Neurobehavioral Approach builds on the nonaversive behavioral techniques of the Operant Neurobehavioral Approach. It also incorporates principles of motivational interviewing, places more overt emphasis on the therapeutic relationship, and targets staff attributions for aggression in staff training. The strengths and weaknesses of both approaches are discussed. It is suggested that the Relational Neurobehavioral Approach is more likely to engage and/or reengage clients with traumatic brain injury who are resistant to behavior change. Research implications are discussed including the need to measure the fidelity of all intervention variables.