DISTRIBUTED SIMULATION PROJECT

Managing Challenging
Behaviours

Facilitators
Joy Hills | RN, BSN, MSN (Cancer), SpecCertCR (Onc)
Heather Bridgman | B(Psych) Hons, DClinHlth Psych
Mark Kirschbaum | B(Pharm), Grad Dip Clin Pharm
Merylin Cross | RN Dip. N.Ed. BA (Hons), PhD
Teaching and learning methods
This presentation:
1. was developed by an interprofessional team including nurses,
psychologists and a pharmacist.
2. is designed to be given face to face in small groups. This workshop
involves a presentation and scenario-based simulated learning
activities.
3. preferably this would be a half day workshop facilitated by a health
professional with experience in this field.
4. is targeted to all healthcare professionals and support staff.
5. includes a reflective debrief that will reinforce learning outcomes.
6. includes an evaluation that should be conducted at the end to inform
quality improvement.
7. requires; a computer with internet connection and projector, and
butchers’ paper and pens.
Suggested program schedule
Time Duration Topic Method of Delivery
0900 or 1300 hrs 15 minutes Introduction
0915 or 1315 hrs 45 minutes Part 1a – Understanding Powerpoint
challenging behaviours Case Studies
Video
Group Activities
1000 or 1400 hrs 15 minutes Break

1015 or 1415 hrs 30 minutes Part 1b Powerpoint

Physiological and Clinical Learning
Pharmacological reasons for
challenging behaviour
30 minutes Part 1c
Monitoring and managing
behaviour
1115 or 1515 hrs 60 minutes Part 2 – Managing conflict Powerpoint
Scenarios
1215 or 1600 hrs 45 minutes Debrief and Conclusion
Workshop outline
Part 1a
Understanding challenging behaviour

Part 1b
Physiological and Pharmacological reasons for
challenging behaviour

Part 1c
Assessing, monitoring and managing challenging
behaviour

Part 2
Managing conflict- Communication and negotiation
strategies
Objectives
On completion of this activity you should have:
• Increased confidence in managing challenging behaviours.
• An understanding of how one’s own behaviour can affect
others.
• Gained skills to defuse challenging situations with the aim of
negating the need for physical interventions
• Gained an understanding of the causes of challenging
behaviour.
• Developed an awareness of the importance to work within the
law and to follow organisational policies and procedures.
• An understanding of the importance of debriefing and self-care
following incidents involving challenging behaviour.
Part 1a

Understanding challenging
Behaviour
What is challenging behaviour?
Definition:
• “Behaviour of such intensity, frequency or duration that the physical
safety of the person or others is placed in serious jeopardy or behaviour
which is likely to seriously limit or deny access to the use of ordinary
community facilities”

• Centre for Developmental Disability Health Victoria June 2005, Fact

Sheet: Challenging Behaviour, www.cddh.monash.org/assets/fs-
challengbev.pdf (Accessed August 14, 2013).
Activity 1
• What are some of the issues/ challenging
behaviours that people present to your facility with?
• What challenging behaviours have you or your co-
workers had to deal with in the past 12 months?

Group brain storm

Activity 1
Have you considered?

• Substance abuse
• Aggressive behaviour
– Phone
– Threatening and intimidating behaviour
– Bullying
– Mental health presentations
• Anti-social behaviour
– Verbal abuse
– Swearing
– Yelling
Challenging behaviour
• Aggression/violence • Other challenging
• Passive aggression behaviours include:
• Forceful refusal to • Anything that causes offence
co-operate or distress
• Harassment (bullying, racism, • Is life threatening
stalking) • Threatens the emotional
• Mental health – irrational well-being of others
behaviour, confusion, • Does not comply with
disorientation, delusions organisational policy or
• Alcohol and drug abuse procedure
Activity 2
What factors contribute to aggression?
In groups, discuss what these factors could be.

Consider:
• Physical
• Social
• Illness
 Activity 2

Have you considered?

Physical Social Illness

• Frustration • Isolation • Infections including
• Sleep deprivation • Financial • Urinary tract
• Hypoxia pressures infections
• Dehydration • Grief • Pain
• Disability • Language • Anxiety
• Trauma e.g. head • Culture • Stroke
injury, concussion, • Self-esteem • Central Nervous
amnesia, • Peer pressure system disorders
• Cerebral irritation • Perceptions • Mental illnesses
• Self harm • Cancer
• Diabetes
Activity 3
• Describe a challenging situation
involving a mental health presentation.

Group activity
Activity 3
Have you considered?

• Walk-in clients, their friends or family members

– Eg Schizophrenia, intoxicated clients
– Lack of access to medical history
– Feelings of fear, apprehension or anxiety
• Confused, disoriented and dementia patients/ family
members
– Difficult to manage
• Follow up care, ‘revolving door,’ ‘frequent flyers’
Schizophrenia
• Schizophrenia is a chronic, debilitating disorder,
characterized by an inability to distinguish between
what is real and what isn’t.
• A person with schizophrenia experiences
hallucinations and delusional thoughts and is unable to
think rationally, communicate properly, make decisions
or remember information.
• Schizophrenia is a complex interplay of genetics,
biology (brain chemistry and structure) and
environment.
 Schizophrenia
• Characteristic symptoms: Two or more of the following,
each present for much of the time during a one-month
period (or less, if symptoms are remitted with treatment).
– Delusions
– Hallucinations
– Disorganised speech pattern
– Grossly disorganised behaviour (e.g. dressing
inappropriately, crying frequently) or catatonic
behaviour
– Negative symptoms: Blunted affect (lack or decline in
emotional expression/response), alogia (lack or
decline in speech), or avolition (lack or decline in
motivation)
Schizophrenia and substances
• Significant Comorbidity
• ‘self-medication’ common with nicotine, alcohol,
cocaine and marijuana
• Due to impairments in insight and judgment,
people with schizophrenia may be less able to
judge and control the temptations and resulting
difficulties associated with drug or alcohol abuse.
Schizoaffective disorder
A diagnosis that includes symptoms resembling a
mood disorder together with symptoms of
schizophrenia, particularly psychosis and social
withdrawal.
The main types of associated mood disorder include:
• bipolar (characterised by manic episodes or an
alternation of manic and depressive episodes) and
• unipolar (characterised by depressive episodes).
Schizoaffective disorder
• Psychotic symptoms - losing touch with reality,
hallucinations, delusions, disorganised thoughts, chaotic
speech and behaviour, anxiety, apathy, blank facial
expression, inability to move.
• Manic symptoms - increased social, sexual and work
activity, rapid thoughts and speech, exaggerated self-
esteem, reduced need for sleep, risky behaviours,
impulsive behaviours such as spending sprees, quick
changes between mood states such as happiness to anger.
• Depressive symptoms - loss of motivation and interest,
fatigue, concentration difficulties, physical complaints such
as headache or stomach ache, low self-esteem, suicidal
thoughts, loss of appetite, insomnia.
Psychosis
• Psychosis – a state of being in which a person loses touch with
reality and experiences hallucinations, delusions or thought
disorder.

• Psychotic episode – a temporary event in which a person

experiences symptoms of psychosis:
– Delusions
– Hallucinations
– Disorganized speech
– Grossly disorganized or catatonic behaviour
Bipolar disorder
• Characterized by constantly changing moods.
• A person with bipolar disorder experiences
alternating “highs” (mania) and “lows” (depressed
mood).
• The periods of mania and depression vary from
person to person – many people may only
experience very brief periods of these intense
moods (and may not even be aware that they have
bipolar disorder).
Bipolar disorder
• Bipolar I – ‘classic’ type of bipolar disorder. Individuals experience
both manic and depressive episodes of varying lengths.
• Bipolar II – less severe manic episodes than bipolar I; however,
their depressive episodes are the same.
• Cyclothymia – is a chronic but milder form of bipolar disorder
characterized by episodes of hypomania and depression that last for
at least two years.
• Mixed episodes – mania and depression occur simultaneously.
Individuals might feel hopeless and depressed yet energetic and
motivated to engage in risky behaviors.
• Rapid-cycling – bipolar individuals experience four or more
episodes of mania, depression or both within one year.
Personality disorders
• Characterized by long-lasting rigid patterns of thought and
behaviour.
• The inflexibility and pervasiveness of these patterns can
cause serious problems and impairment of those afflicted.
• An enduring pattern of inner experience and behaviour that
deviates markedly from the cultural norm.
• Onset of the pattern can be traced back to – at least – the
beginning of adulthood.
• To be diagnosed as a personality disorder, a behavioural
pattern must cause significant distress or impairment in
personal, social, and/or occupational situations.
Borderline personality disorder
A pervasive pattern of instability in interpersonal
relationships, self-image and emotions
Symptoms
• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal
relationships
• Identity disturbance
• Impulsivity in at least two areas
• Recurrent suicidal behaviour
• Emotional instability
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Transient, stress-related paranoid thoughts
Major depressive disorder
• A person who suffers from MDD must have either a depressed
mood or a loss of interest or pleasure in daily activities
consistently for a period of at least 2 weeks
• This mood must represent a change from the person’s normal
mood
• Social, occupational, educational or other important functioning
must also be negatively impaired by the change
• A major depressive episode is also characterized by the presence
of 5 or more of the following symptoms:
Characteristics of a major depressive disorder
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all, or almost all,
activities Significant weight loss when not dieting or weight gain
• Insomnia (inability to sleep) or hypersomnia (sleeping too much)
• Psychomotor agitation or retardation most days
• Fatigue or loss of energy most days
• Feelings of worthlessness or excessive or inappropriate guilt nearly
every day
• Diminished ability to think or concentrate, or indecisiveness, nearly
every day
• Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide
Anxiety disorders
• Anxiety, worry, and stress are a part of life.
• Anxiety is a necessary warning signal of a
dangerous or difficult situation. Without anxiety,
we would have no way of anticipating difficulties
ahead or preparing for them.
• Anxiety becomes a disorder when the symptoms
become chronic and interfere with our daily lives
and our ability to function.
Anxiety disorders
• Generalized Anxiety Disorder (GAD)
• Panic Disorder (including panic attacks)
• Social phobia (also known as social anxiety disorder)
• Specific phobias (also known as simple phobias)
• Obsessive-compulsive disorder (OCD)
• Posttraumatic stress disorder (PTSD)
Autism Spectrum Disorders
Criterion based on the DSM-5 (2013)
A. Deficits in social- emotional reciprocity
Social Communication • E.g. showing, sharing enjoyment, returning a social
(need to meet all 3 for smile, difficulty responding to and initiating social
diagnosis) interactions
Deficits in non-verbal communicative
behaviours
• E.g. poor eye contact, difficulty recognizing and
interpreting other’s facial expressions
Deficits in developing, maintaining and
understanding relationships
• E.g. difficulties establishing and maintaining
relationships, difficulty adjusting behaviour to changing
social situations
Autism Spectrum Disorders
Criterion based on the DSM-5 (2013)
B. Stereotyped or repetitive motor movements, use of objects, or
Restricted, Repetitive speech
patterns of behaviour, • E.g. Echolalia (“parroting”), repetitive hand movements, lining
interests or activities up objects, pedantic speech, whole of body movements
Insistence on sameness, inflexible adherence to routines, or
(need at least 2/4 for a
ritualized patterns of verbal or nonverbal behaviours
diagnosis)
• E.g. insistence on rigidly following specific routines, repetitive
questioning about a topic, compulsions and difficulty with
transitions
Highly restricted, fixated interests that are abnormal in
intensity or focus
• E.g. preoccupations, obsessions, attachment to unusual
objects and a narrow range of interests
Hyper- or hypo reactivity to sensory input or unusual interest
in sensory aspects of the environment
• E.g. aversion to tactile inputs, odd responses or atypical focus
on sensory input, high pain tolerance
Autism Spectrum Disorders DSM5

C. Symptoms must be present in the early developmental

period (but may not fully manifest until social demands
exceed limited capacities, or may be masked by learned
strategies later in life)
D. Symptoms together limit and impair everyday functioning
E. Not better explained by intellectual disability or global
developmental delay.
Dementia
Dementia is not one specific disease. It is a
collection of symptoms caused by disorders
affecting the brain.
• Brain function is affected enough to interfere
with the person’s normal activities of daily life
Dementia affects
• thinking
• memory
• mood
• behaviour and the ability to perform everyday
tasks.
Dementia
Alzheimer's disease, one form of dementia, is characterized by the
development of multiple cognitive deficits manifested by:
Memory impairment
One (or more) of the following cognitive disturbances:
• Deterioration of language may be manifested by difficulty
producing the names of individuals and objects (aphasia)
• An impaired ability to carry out motor activities (such as
combing their hair) despite intact motor abilities, sensory
function and comprehension of the required task (apraxia)
• A failure to recognize or identify objects despite intact
sensory function (agnosia)
• A disturbance in executive functioning (e.g., planning,
organizing, sequencing, abstracting)
Assessing behaviour
It is important to recognise risk factors:
• Physical Conditions
• A history of aggression/violence/acting out
• Hallucinations
• Drug and alcohol abuse
• Incorrect use of medication
• Feelings of paranoia
• Feelings of entrapment and powerlessness
• High levels of frustration
• Lack of impulse control
• Anxiety arising from conscious /subconscious conflicts
• Delusions of persecution
• Use of inappropriate defence mechanisms (e.g. lying, projected hatred)
Part 1b

Physiological and
Pharmacological reasons
for challenging behaviour
Physiological reasons
• Some physiological reasons for challenging behaviour can be mistaken
for mental illness eg:
• Diabetes
• Hypoglycaemia
• Hypoxia
• Na depletion
• Metabolic alkalosis leads to Na excretion
• Hormones
• Hypothermia
• Sleep deprivation/Insomnia
• Sepsis
• Toxaemia
Physiological reasons
Depleted Na+/over hydration
Causes Symptoms
• Sports people • Nausea/vomiting
• Elderly • Headache
• Diuretics • Confusion
• Burns • Lethargy
• CF • Fatigue
• Cirrhosis • Restlessness
• Diabetes • Irritability
• Glucocorticoid deficiency
• Liver failure
• Pneumonia
• Hypothyroidism
Physiological reasons
Hypoxia
Causes Symptoms
• CO poisoning Onset Rapid/ severe
• COPD • Ataxia
• Sleep apnoea • Confusion
• Post surgical • Disorientation
• Reduced O2 intake • Hallucinations
• Narcotics/reduced respiration • Behaviour changes
• Cardiac failure Onset Gradual/chronic
• Pulmonary embolism • Light headedness
• Fatigue, Anorexia
• Numbness/paraesthesia
Physiological reasons
Diabetes
Causes Symptoms
• Hypoglycaemia • Adrenergic
• Ketonuria – Dysphoria
– Leads to Na loss – Sweating
• Ketoacidosis – Anxiety
– Leads to Na loss – Pallor
– Hyperventilation – Dilated pupils
• Neuro-glycopenic
– Personality changes
– Ataxia
– Automatic behaviour
Physiological reasons
Hormones
Causes Symptoms
• Menopause • Menopause
– Depression
• Addison's disease
– Irritability
• Testosterone (natural or abuse) – Memory loss ‘senior moment’
• Hyperthyroidism – Mood disturbance
– Insomnia
• Testosterone
– High levels leads to aggression
• Hyperthyroidism
– Anxiety
– Hyperactivity
– Irritability
– Psychosis/paranoia (T3 storm)
Physiological reasons
Insomnia
Causes Symptoms
• Drugs • Irritability
– Stimulants • Fatigue
– Withdrawal from sedatives
• Behavioural problems
• Pain
• Long term negative health
• Fear, stress, anxiety outcomes
• Disturbed circadian rhythm
• ABI (Acquired Brain Injury)
Pharmacological reasons
• Pharmacology is merely an artificial method of
altering normal physiology or pathophysiology
• Drugs that alter behaviour do so via normal
and explainable pathways
• Many drugs, both legal and illegal can cause
challenging behaviour
Pharmacological reasons
Steroids
Prednisolone. From the 1950’s reports of
• Hypomania, depression, irritability, anxiety, insomnia,
overt psychosis
• Relates to Cushing's syndrome (increased cortisol)

Androgenic steroids eg Testosterone

• Clear link between testosterone (above physiological
levels) and aggression
Pharmacological reasons
Hormones
Clomid
• Patient often already facing emotional distress
• Improves ovulation by altering normal hormonal
responses.
• Can cause: Anxiety, sleep disturbance, mood
swings and irritability
• Other related drugs cause depression, mania,
irritability and thinking problems
Pharmacological reasons
Aciclovir (high dose)
• Hallucinations, depersonalisation, confusion, insomnia,
hyperaesthesia

Atenolol
• Nightmares, confusion, violent behaviour

Baclofen (used for chronic back pain)

• Hallucinations, paranoia, mania, anxiety, confusion, depression
Pharmacological reasons
Ketamine
• Hallucinations, delirium, nightmares, crying, change in body image

Levodopa
• Symptoms are most frequent in the elderly and with prolonged use
• Hallucinations, paranoia, delirium, agitation, nightmares, night
terrors, hypomania, depression

Methylphenidate
• Hallucinations, paranoia
Pharmacological reasons
Drug problems on withdrawal
• Benzodiazepines
• Opioids
• Alcohol
• Tobacco
Consider:
• the additive effects of poly-pharmacy
• the expanded excretion time related to ageing/ renal or
liver function impairment
Pharmacological reasons
Amphetamines
• Amphetamine induced psychosis
• Very similar to acute phase of schizophrenia
• 15% may never completely recover
• Easy to make analogues
Part 1c

Assessing, monitoring
and managing
challenging behaviour
Assessing and monitoring behaviour
• Observing, assessing and monitoring behaviour can be required
of health professionals and community workers in a range of
situations and for a number of purposes.
• Behaviour can provide useful information about clients for the
purpose of:
• Identifying and recognising triggers and patterns of behaviour
• Identifying escalating behaviour
• Monitoring a client’s changing coping skills
• Tracking behaviour modification
• Referring and/or reporting/documenting behaviour to a
Psychologist, GP, other staff; and
• Communicating with a clients’ family and/or friends.
Monitoring behaviours
Formal Informal
• Use of Behavioural observation Observe for:
charts to observe and monitor • Pacing
the client’s behaviour for a
• Agitation or fidgeting
period of time
• Raised voices
• Checklists and inventories
• Certain tone of voice
• Case notes
• Sighing or rolling of the eyes
• Defensive posture – arms crossed
• Clenched fists
• Withdrawn or unusually quiet
• Staring in a confronting manner
Unacceptable behaviour
It is likely that rural health workers
will, at times, be confronted with
people who exhibit unacceptable
behaviour.
It is important to keep your own
behaviour in check by remaining
calm and objective so that you can
assess the situation clearly and
respond appropriately.
When confronted with conflict, ask yourself
some important key ‘P’ questions
• Proof?
• Possibilities?
• Positive aspects?
• Perspective?
• Personalising the situation?
• Panic paralysis?
• Problem solving?
• Persistence?
• Put it aside for a while?
Ask yourself some key ‘P’ questions
• Proof Is your perception of the situation the same as others around you?
• Possibilities Is it possible that you are misinterpreting the situation?
• Positive aspects Is there any positive aspect of this situation that can provide
some comfort?
• Perspective Do I have this in perspective? Is anyone in danger of being hurt?
• Personalising the situation Am I taking this too personally?
• Panic paralysis Am I panicking? Or Over-reacting?
• Problem solving What options do I have to control and defuse this situation?
• Persistence Have I given up too soon on a strategy I was using to change or
manage the situation?
• Put it aside for a while Can I take some time out so that when I return later I
will be calmer and more able to deal with it more effectively?
Policies and procedures
• Every organisation will have policies and
procedures in place that describe
techniques to ensure personal safety and
the safety of any clients or colleagues
caught up in the situation
• You need to follow these as much as
possible in the moment
• All workers need to be clear about what
techniques they can use to ensure their
own personal safety and the safety of
clients/colleagues in the event of
aggression or violence
Risk process
Preventing an aggressive incident
Before an incident employers and
employees need to implement preventative
measures

Question
What preventative measures does your
facility employ?
Conflict escalation curve
Agression scenario
Early warning signs
• Rapid breathing
• Clenched fists and teeth
• Flared nostrils
• Flushed expression
• Pacing
• Repetitive movements,
• Loud talking or chanting, swearing excessively,
• Aggressive gestures, veiled threats, verbal abuse, unprovoked
outbursts of anger or emotion or
• Panic, restlessness and clinging to staff
Signs of escalation
• Argues frequently and intensely
• blatantly disregards ‘normal’ behaviour
• obsessional thinking and behaviour
• throw/sabotages/steals equipment or property
• makes overt verbal threats to hurt others
• rage reactions to frustration
• violent or sexual comments sent via email,
voicemail, SMS or letter and
• blaming others for any difficulties
Urgent signs
• Severe distress
• History of substance abuse/ violence
• Marked changes in psychological functioning:
– exotic claims (losing touch with reality),
– social isolation or poor peer relationships,
– poor personal hygiene and
– drastic changes in personality
• Fascination with weapons
Preventing escalation
To prevent escalation of unacceptable behaviour consider:
• Keep calm
• Use active listening to find out what the problem is
• Acknowledge the concerns/emotions of the client
whether you agree with them or not (validation)
• Use positive language and avoid negative language
• Let them know you want to help them
• Let them know the consequences of their behaviour if it
continues or escalates
• Seek help from co-workers or the client’s family/ friends
Manifestations of violence
• Involvement in physical confrontations or assault (including self-
harm)
• Damage/Destruction of property
• Display of /or use of weapons
• Evidence of sexual assault
• Arson
• Suicide risk
Managing aggressive behaviour
If a client becomes violent, aggressive or threatening:
• Follow your organisation’s procedures
• Clear the space as much as possible (make it as safe as possible)
• Remove others from the scene (danger)
• Speak to the client in a clear, non-provocative manner
• Give the person enough personal space/ maintain a safe distance
• Use voice and eye contact to attempt to maintain the balance
• Use diversion if possible – a change of focus, distraction, or interrupt
train of thought
• Contact/Inform other staff as soon as possible (duress alarm)
• Call emergency response teams if needed (e.g. police, ambulance,
mental health response teams)
Danger and safety zones

Zone 1 The distant safety zone, where you cannot be reached by a punch or
kick.
Zone 2 The close safety zone, where the aggressor cannot effectively deliver a
major blow to you with their knees, elbows or head.
Zone 3 The danger zone, where an employee can be struck forcibly.
Helpful tips
• The following may help you to deal with aggressive clients:
• An individual who is violent is more likely to move straight ahead,
less easily sideways and with difficulty backwards
• Avoid standing directly in front of the aggressor and stay away
from the danger zone
• Keep you posture relaxed and stand slightly off centre to the
aggressor’s weaker (non-dominant side). Though this can be
hard to determine it is usually opposite to the hand they write
with.
Helpful tips
• Adopt a safe, defensive stance: Stand with feet
slightly apart to maintain balance. If an attack seems
likely, ensure the dominant leg is slightly to the rear,
knee bent and other leg slightly forward of the body
and bent slightly. This will minimise the likelihood of
being knocked to the ground.
• Maintain visual contact. Never turn your back on a
person behaving aggressively.
• Use eye contact carefully, as too much direct eye
contact can be interpreted as challenging.
• Walk away. If the situation seems totally
uncontrollable, leave as quickly as possible and go to
a safe place
Managing an aggressive incident
• Agencies usually have specific procedures in
place to deal with crisis situations including acts
of verbal abuse, intimidation, bullying, violence
and aggression.
• Regardless of the procedures in place to support
workers in a crisis situation, it is also important
that aggressive incidents are managed at an
agency level.
Managing an aggressive incident
• During an incident, staff involved must use strategies that will
assist the client to regain control, and prevent injury
• to worker(s)
• to the client
• to others and
• to property

• Question
What strategies can you use?
Following an aggressive incident
After an incident, a debriefing needs to be
conducted with all of those involved.
Debriefing can be provided on a group or an
individual basis.

Question
What supports are in place at your facility
following an incident?
Part 2

Managing conflict
Interacting with clients
• Know in advance what you • Make eye contact
want to communicate before • Monitor the client’s response
you say it (mental rehearsal) • Use appropriate language to
• Consider the words you will suit the client
use, the tone of voice and non- • Be specific, clear and precise
verbal issues such as body
language • Summarise your message
periodically, checking that the
• Do not assume your client client has understood.
understands your meaning –
seek clarification and look for
feedback
• Keep your message simple
• Speak clearly
Listening skills
• We tend to confuse listening with hearing
• Hearing is a natural process but effective listening is a skill that
requires energy and effort.
Listening for meaning
• Listen with the intention of understanding what the client
is really saying and feeling.
• Tune into the other person’s internal viewpoint and don’t
assume you know how they feel or what they mean
• Messages can contain an underlying meaning.

Example – when a client asks “Do you like my painting?’ on

one level the meaning is clear and you could answer ‘yes’ or
‘no’; but on another level the person may want support and
positive feedback.
Respect others’ viewpoints
• Respect clients as individuals with rights to their own
thoughts and feelings
• This does not mean we have to agree with everything
they say – just that we respect what they say as their
version of reality
• Accepting others also means allowing them to grow
and develop on their own terms
• Cultural differences can be challenging
Effective listening
• Concentrate fully
• People generally speak at 150-160 words a minute
• But we are capable of listening at up to 600 words a minute
• To receive a message effectively we need to focus the extra
brainpower available and concentrate hard
• Clear away any baggage (deal only with the now)
• Use active listening (clarify, paraphrase, summarise)
• Check that you are picking up the message correctly
• Give feedback at the end of the message
Scenario
• ‘John’ presents to your facility. He appears agitated and unkempt. You
notice the smell of alcohol. He leans over the reception desk and speaks
to you in a loud, aggressive tone demanding to see the doctor
immediately about his mother.

• What are you thinking?

• How could you respond?

Reducing conflict
Workers can use positive communication
strategies for problem solving, including:
 Advising and evaluating
 Reassuring and supporting
 Questioning and probing
 Paraphrasing and understanding
Advising and evaluating
• Advice should be given tentatively, when it is timely
and relevant
• People are essentially the experts on their own lives
and with appropriate encouragement can take the
tentative advice and come up with solutions that fit
their own situation
• This strategy also encourages ownership rather than
having advice imposed
Reassuring and supporting
• When you rush in with support and reassurance, this often
denies the other person’s feelings.
• While there are times when people need to be reassured
as to their value and worth, often reassurance and support
just serve to inform the client that they shouldn’t be feeling
as they do (e.g. ‘don’t feel so bad’, ‘cheer up’, ‘in time you’ll
forget about it’).
Questioning and probing
• Questioning is an important skill for resolving conflict and
tension and finding solutions
• To use questions skilfully, it is important to understand the
difference between open and closed questions
• Open questions encourage people to answer in greater
length and in more detail
• Closed questions require only a simple yes or no answer
• Probe beyond a brief response
• Use silence to get expanded responses
Paraphrasing and understanding
• The benefits of paraphrasing and understanding
indicate that this is the optimum way of supporting a
client to clarify their thoughts.
• It is important to reflect back to the client what they have
said, and identify whether what they are saying has
been interpreted accurately by you and others.
Scenario
• ‘John’ is 49 and has just discovered that his mother is terminally ill. He
has had schizophrenia since age 22 and has lived with his mother since
then. She has been his main carer.

• What are you thinking?

• How would you respond?

Assertiveness
Each human being has rights:
• You have the right to be human and take full responsibility for your
decisions and actions
• You have the right to be wrong
• You have the right to tell others what you are thinking and feeling
• You have the right to change your mind
• You have the right to stand in judgement of your thoughts and
actions
• You have the right to express yourself without intimidation or guilt
• You have the right to not accept responsibility for others
Characteristics of assertiveness
• The assertive person states clearly what they are
thinking and feeling
• There is no apology for expressing emotions and
thoughts
• The assertive person refuses to be manipulated by
false guilt
• The assertive person respects the rights of others
Confronting conflict assertively
Keep it short
• ‘I hear you’, ‘I understand’…
Slow down
• your words will be more powerful and effective
Deepen your voice
• slow your speech and make an effort to relax and
you will hear your voice deepening
Use a firm tone
• remain firm and assertive (practice)
Paraphrase
• Summarise what the other person has said.
Confronting conflict assertively
Use descriptions
• Describe the facts /omit opinions
Confirm the facts
• If not entirely sure paraphrase and ask for confirmation
• Check what they are saying… ‘Are you saying… ? If I heard you correctly,
you are…. ? Am I right in thinking…? So, you are telling me/ feeling…? Is this
what you mean…?’
Keep in check –
• Never interrupt someone’s conversation
• Never answer for another person
• Don’t lose eye contact - unless to maintain it would be rude or culturally
insensitive
• Don’t label or judge people or ideas
• Don’t play psychologist /attempt to work out others’ problems.
Examples of invalidation
• Avoid invalidation: patronising/belittling/ dismissing someone’s feelings /
behaviour
• ‘Don’t worry’
• ‘Calm down’
• ‘Turn that frown upside down’
• ‘You shouldn’t feel that way’
• ‘Nobody else feels like that’
• ‘It’ll be okay’
Negotiation
• Negotiation is a process of arriving at a mutually satisfying outcome
through discussion, bargaining and compromise
• However, negotiation can be very difficult if you are dealing with
someone who is angry and aggressive
• The most effective way to deal with anger is to respond thoughtfully,
while remaining focused on your goals
• Negotiation is not about winning; it is about solving the problem in a way
that protects the relationship between you, the organisation and other.
Negotiation
• When responding to an angry client you should focus on any areas
of agreement, then state where you stand on the issue while
empathising with the client
• Focus on the issue / don’t try to defend yourself or the organisation
• You will not change a client’s mind by arguing or debating
• Try to negotiate solutions/ negotiate a satisfactory compromise
• Obviously a win-win situation would be ideal but if this is not
possible then seek a solution that is reasonable
Negotiation techniques
• Keep calm when speaking, take a deep breath and use self-soothing
thoughts to keep your own anger and anxiety under control
• When you relax your tone of voice, the client’s anger may start to
subside as well
• Calmly assert yourself and listen to the needs of the client
• If you don’t listen, you are less likely to be able to assist them
• Don’t become side-tracked into defending yourself and don’t take
the anger personally even if it seems personal.
Negotiate for resolution
1. Identify the apparent conflict or problem
2. Understand and explore the conflict/problem
3. Identify the actual conflict
4. Identify alternatives
5. Explore alternatives
6. Choose course of action
7. Implement course of action
8. Evaluate
Identify the issues
• Understand and explore the conflict/problem
• who or what is causing the conflict/problem?
• when does it occur?
• how long has the problem/conflict been occurring?
• in what situation does this occur?
• what evidence will indicate it has been resolved?
• what feelings are involved?
• is there conflict in values or attitudes?
Explore the alternatives
• Who is involved?
• What is the ‘cost and effort’ of the solution?
• What are the advantages and disadvantages of the possible solution?
• What are the consequences of each alternative?
• How do the parties involved feel about each option?
• What are the feelings of the parties involved?
Choose a course of action
• List the alternatives that are probable and improbable
• List the alternatives that need more information before
judgement is passed
• Choose one or two alternatives or strategies to trial
• Identify the steps involved for the group or individual to
achieve the solution
• Identify what will constitute a level of success
• Assign responsibilities for implementing the decision
Evaluation
Evaluation is continual
– If the outcome does not lead to the desired goal, new goals may need to
be identified/ negotiated
– Ask questions of the party:
• How well did they do?
• What did I learn?
• Am I satisfied?
• What could I have done differently?
Negotiation techniques
If a client stays angry or becomes overly aggressive:
1. Make it clear that you are willing to discuss the problem, but do not
become argumentative
2. Keep calm and repeat to the client that you are there to listen to them
3. Be mindful of nearest exits and access to help
4. Terminate the discussion if the other person remains angry (e.g. ‘We
don’t seem to be getting anywhere at the moment, I’ll have to speak
with my supervisor’)
5. Call security or the police if you feel threatened
6. Leave the situation immediately if you feel in imminent danger.
Example
• ‘I agree with you that it is unfair. You shouldn’t have to wait an hour when
you made an appointment one month ago. I also understand that you are
busy and it is difficult to sit and wait when you have other matters to
attend to.
• Unfortunately staff numbers are low today so we cannot see you
immediately. I apologise for the inconvenience.
• Would it be possible to come back later or make another appointment
later in the week so you won’t have to wait as long?’
Remember
• Attend fully to the client
• Use empathy
• Listen carefully to what they are saying
• Stay with them until they are calmer
• Don’t interrupt
• Seek information
• Check your understanding by paraphrasing
Scenario
• It is 7pm. There is one RN on duty. John is still demanding to see the
doctor about his mother.

• What are you thinking?

• How would you respond?

Reporting and recording incidents
• Any unacceptable behaviour must be recorded and kept on file
• This includes any formal observation and monitoring records
• Records can then be analysed and any specific patterns identified
for future reference or action
• An Incident Report needs to be filed following an incident of
challenging behaviour.
• A copy of this Incident Report should be kept on the client’s file as
well as being submitted to the appropriate manager for follow-up.
• Question – When/ under what circumstances would you file an
incident report?
Completing an incident report
An incident report needs to include: including detailed description of
• Time, date and location of the any high-risk activities
incident
• Type of incident – abuse, threat, • Nature of injuries/damage
assault sustained
• Who was abused/threatened or • Contributing causes
assaulted, and their role • Potential or actual costs
• Client/person who committed the • Corrective action taken
act and relevant details
• Follow-up recommendations
• How the incident arose and
• Name, designation, date and
progressed
signature of reporter
• Activity underway at the time,
Self care
• Employee Assistance Program (EAP)
• CRANA Confidential 24-hour Support Line 1800 805 391
• Debriefing
• Social support
• Relaxation
• Physical activity
Summary
• Be aware of potential triggers and early warning signs indicating the
potential for challenging behaviours
• Be aware of your own reaction and behaviour and its effect on others
• Be aware of policies and procedures to minimise risk
• Use active listening skills, probing and paraphrasing to confirm your
understanding of the situation
• Aim to negotiate assertively to defuse the situation
• Maintain safety of self and others
• Attend to formal reporting requirements
• Seek support and debriefing
Useful websites/books
www.cci.health.wa.gov.au
beyondblue.org/
www.psychologytools.org/
www.dhhs.tas.gov.au/mentalhealth/useful_links_and_contacts
www.mifellowship.org/

Keane, B. and Dixon, C. (2001). Caring for people with Problem

Behaviours. Ausmed Publications. Melbourne.
Robinson, A., Spencer, B., and White, L. (2007). Understanding Difficult
Behaviors: Some practical suggestions for coping with Alzheimer's disease
and related illnesses. Eastern Michigan University. Michigan.
References
• Australian Medicines Handbook 2014, Australian Medicines Handbook Pty Ltd; Adelaide
• Cava, R. 2003, Dealing with difficult situations: At work and at home, Pan Macmillan Australia, Sydney.
• Centre for Developmental Disability Health Victoria June 2005, Fact Sheet: Challenging Behaviour,
www.cddh.monash.org/assets/fs-challengbev.pdf (Accessed September 2013).
• www.communitydoor.org.au
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM5), 5th ed.
Washington DC.
• Hiam, A. 2003. Motivational management: Inspiring your people for maximum performance, AMACOM, American
Management Association, New York.
• Hogan, M., Przybylowicz, T. and Vacek, J. 2013. Mental Health Nursing. 3rd Ed. Pearson. Boston.
• Hungerford, C., Clancy, R., Hodgson, D., Jones, T., Harrison, A., and Hart, C. 2012. Mental Health Care: An
introduction for Health Professionals. John Wiley and Sons. Australia.
• Jackson, P.Z. & McKergow, M. 2002. The solutions focus: The simple way to positive change, Nicholas Brealey
Publishing, London.
• Johnson, D.W. 2008, Reaching Out, Interpersonal Effectiveness and Self Actualization. 10th ed., Pearson, United
States.
• Keane, B. & Dixon, C. 1999, Caring for people with problem behaviours, AUSMED Publications, Melbourne.
• Kinney, J 1996, The dynamics of threat management, in G. Vandenbos & E. Bulatao (Eds.), Violence on the job:
Identifying risks and developing solutions, pp.299–313, American Psychological Association, Washington DC.
• Leather, P, Brady, C, Lawrence, C, Beale, D, & Cox, T (Eds.) 1999, Work-related violence assessment and
intervention, Routledge, London.
References
• Malouf, D. 2002, Power up your people skills: Communicating in the new millennium, Allen & Unwin, NSW.
• Mayhew, C. 2000. Preventing client-initiated violence. A practical handbook. Australian Institute of Criminology Research and Public
Policy Series No. 30, Canberra.
• McGrath, H. & Edwards, H. 2000 Difficult personalities: A practical guide to managing the hurtful behaviours of others. Choice Books,
NSW.
• Meadows, G., Farhall, J., Fossey, E., Grigg, M., McDermott, F., and Singh, B. 2012. Mental Health in Australia: Collaborative
Community Practice. 3rd Ed. Oxford University Press. South Melbourne.
• Mental Health Association of NSW Fact Sheets. http://www.mentalhealth.asn.au/home/item/62.html (accessed September 11, 2013)
• Merritt, L. 2003, Talking the talk: communicate with persuasion, panache and passion, Choice Books, NSW.
• Nair, M. and I. Peate 2013. Fundamentals of applied pathophysiology [electronic resource]: an essential guide for nursing and healthcare
students. (2nd ed.). Edited by Muralitharan Nair and Ian Peate, Chichester, West Sussex ; Ames, Iowa : Wiley-Blackwell, 2013.
• Office of Multicultural Affairs 1994, Consulting the multicultural way: Guidelines for APS managers consulting and negotiating with non-
English speaking background groups, Australian Government Publishing Service, Canberra.

Web links and video clips

• www.dhhs.tas.gov.au/mentalhealth/about_mental_illness/fact_sheets_about_mental_illness
• Centre for Developmental Disability Health Victoria. www.cddh.monash.org/products-resources/advice.html
• Active listening video: http://www.youtube.com/watch?v=4VOubVB4CTU
• Aggressive scenario: http://www.youtube.com/watch?v=7cZDfWcIitg
• Poor communication video: http://www.youtube.com/watch?v=W1RY_72O_LQ