Behavior plans in in-patient rehab: how to use them best

“Challenging behavior”, “Behavioral outbursts”, “That patient is behavioral- so be careful!”. You may have heard these terms and phrases over the course of your clinical career. Problematic as this terminology is- after all, behavior is simply a form of communication that we have to translate- clients who present with distressed behavior need delicate and compassionate care to ensure that their needs are met. And so many facilities and therapists may find themselves reaching for: a behavior plan!

Behavior challenges aren’t just limited to those people who have sustained a traumatic brain injury (TBI).  Persons who have sustained a cerebrovascular accident (CVA), have a progressive degenerative neurological disease (i.e., Parkinsons’ Disease), and even those with metabolic encephalopathy (due to sepsis, uncontrolled diabetes, etc.) can all have disruptions and changes in behavior- and may benefit from the skilled application of a behavior plan.

Behavioral changes are not intentional, and more often than not the person cannot necessarily control how they behave or react to their environment and those people in it.  But this can be a very challenging for both medical professionals and caregivers alike as we are all human and we all have feelings ourselves.  Being able to separate the behavior of someone recovering from a neurological injury from the person that they were prior to admission is a skill that is acquired and refined overtime for medical professionals and can be almost impossible task for the person’s loved ones to accomplish. 

So the questions are… how do we (the professional) assist with managing someone’s behavior throughout the course of their rehabilitation stay?  How do we promote stable and consistent behaviors that will improve their outcomes and their ability to live in the community?  How do we empower the person’s loved ones to be an active participant in this process?  There is no easy answer, or ‘one size fits all’ approach to these questions.      

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As the professional, we need to take a step back and look at the whole patient and all aspects of their care – we cannot just be concerned with our therapy session, or the small slice of time we have with the patient and call it a day.  We need to assist and empower all members of the care team to promote stable behavior in order for our patient to regain as much function as possible. 

One way to assist with promoting stable behavior throughout their rehabilitation is by making a behavior plan.  A behavior plan, in this sense, is essentially a list of strategies to assist staff members with having effective and productive interactions with someone who is having behavior difficulties following some type of injury.  It does not have to be complicated, have several pages, or even multiple parts.  It does require some work, though!  There is no standard cookie cutter approach to behavior management and a behavior plan needs to be tailored to a person’s needs, their current environment, and also to the caregivers of the person. 

Before an ongoing behavior plan can be formulated, something called the stability triangle should be considered. 

The Essential Brain Injury Guide 5.0 defines the stability triangle as a construct which is useful when identifying treatment priorities and establishing a treatment plan.  The stability triangle specifies three primary areas that must be addressed in order to for overall stability to be established and maintained, and it is applied in an ongoing manner to organize and guide treatment efforts at all phases of rehabilitation and recovery (EBIG 5.0).  The structure of the triangle itself emphasizes that each element if interdependent, yet without any one side, stability is ultimately or eventually compromised. 

The three sides to the stability triangle are:  establishing medical stability, establishing behavioral stability, and developing a stable activity plan.  Medical stability entails managing pain, sleep disturbance, seizure disorder, vestibular issues, medication use are just a few items to consider with medical stability. Behavioral stability entails addressing problematic behaviors such as mood instability, refusal, verbal and physical aggression, and a laundry list of other things.  A stable activity plans refers to empowering and enabling the individual to have meaningful interactions and routines.   All three sides are important, and the triangle cannot exist without each portion, but for the purposes of the discussion here, the focus is going to be on establishing stable behavior. 

Establishing behavioral stability is an ongoing process and needs to be managed by an interdisciplinary team. 

As it was mentioned before, we do not practice in silos and need to communicate and work with each other.  The first step in formulating a behavior plan is assessment.  In inpatient rehabilitation, our ‘assessment period’ is usually the first few days after admission – we are able to capture our patient’s current level of function, write goals, and formulate our plan of care.  As the patient progresses through the treatment plan, goals are adjusted, and the plan continues.  Unfortunately, behavioral assessment is not that cut and dry – it is a fluid process. 

A person’s behavior can change based on a variety of factors including, but not limited to, pain, fatigue, and time of day.  Formal assessment tools can be utilized (such as the Agitated Behavior Scale), but informal assessment (such as observation) should also be considered.  You can also assign a Rancho Level of Cognitive Functioning if appropriate to better identify someone’s current level of functioning.  Assigning someone a Rancho level can help provide common language between professionals and give you a starting point for management.

It is also important to get to know the person – call their loved ones and inquire about likes/dislikes, preferred food items, prior sleep schedule, prior hobbies, and ask someone to bring in familiar pictures and items from home.  Conferring with the person’s family and friends is part of the assessment process – remember, you want to consider the whole patient and not just their new state of being from their injury.  Having personal items from home can be incorporated into the person’s rehabilitation routine and also assist with behavior management when needed.  The assessment process will assist you with identifying how to be proactive for this person as opposed to reactive, meaning it will help you identify how to ‘get ahead’ of a person’s behavior as opposed to having to work ‘damage control’ if things get out of hand. 

After your ongoing, interdisciplinary assessment is complete, then you can move onto putting together a formal plan of action. 

You need to determine how and where you would like this plan to ‘live.’  Is it going to be an electronic document in the electronic medical record, or do you want a written paper plan that stays with the patient?  Keep in mind that these details may seem trivial, but if you want your colleagues to refer and use the plan for your patient you need to make it easily accessible.  A well written, thorough behavior plan is not any good if no one knows where to find it! 

When it comes to structuring a behavior plan, remember to keep it simple.  You want to make the plan easy to read and easy to follow.  One of your colleagues should be able to glance over the plan and take away the main points without much of a headache. 

The following items should be categories included in a behavior plan:  Supervision Level; Elopement Risk; Environmental Modifications; Signs of Escalation; Diversional Activities; Preferred Staff, family members, personal information (foods, drinks, conversation topics, music, etc.). 

  • Supervision level refers to if the person needs frequent check-ins (every 15 or 30 minutes) or if the person needs a 1:1 staff member for safety.  It’s helpful to indicate this on the plan to ensure that all members of the team know what the expectation is for that patient – to ensure that they are being provided the amount of supervision and support they need to maintain stable behavior. 
  • Elopement risk refers to whether or not the person is at risk for leaving the facility, especially if the person is very physically able.  Again, doing this helps communicate the person’s current status to all members of the team in order to help keep the person safe. 
  • Environmental modifications refer to what things can be done to the person’s surrounding area to help promote and maintain stable behavior.  Things like dim lights, private room, low sound, no tv, limited visitors, toileting schedule, and a set therapy schedule are all items that should be included in the environmental modifications category.  It is important that you consider items that can be modified at your particular facility and include them as options on the behavior plan. 
  • Signs of escalation refer to those things that a patient may demonstrate prior to having a behavioral episode or outburst.  These will vary from person to person, but some items to include as options on your behavior plan form could be yelling, cursing, hitting, refusing care, refusing food, restlessness, and kicking.  Again, it is important to have these items on a behavior plan so all staff members participating in someone’s care know what to be on the lookout for – remember, we want to be PROACTIVE. 
  • Preferred staff, family members, and personal information are pretty self-explanatory and definitely items that need to be included on someone’s behavior plan.  Having these people identified ahead of time will assist with everyone being proactive in finding those staff members who have a good rapport with the person in the event there is a behavioral issue.  Lastly, personal information refers to those items that someone prefers – food, music, pictures, etc. that can be comforting to someone in a time of crisis.

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Once you have determined where your behavior plan is going to live (paper form vs. EMR) and how it is going to be structured, you need to implement it!  Now this part sounds simple enough – educate staff members, and then you are done – but it is not that easy.  The education of your colleagues has to be thorough and often – one quick in-service is not going to be enough.  Every staff member who is going to be participating in that person’s care – from the doctor to the nurse to environmental staff need to be on board with what works for that person.  You need to empower everyone to present themselves as a consistent, united front. 

The more consistent you are with utilizing the behavior plan the more likely behavioral stability will be promoted.  Family members also need to be educated as to where to find the plan, how to read the plan, and how to put the plan into action.  It may be helpful to schedule an early family training so they can see how you (the experienced clinician with good patient rapport) interact with and manage that person.  Lead by example! 

As the person is progressing through their plan of care and their treatment goals are being updated, the person’s behavior plan should also be updated.  The person’s needs will evolve over the course of their rehab stay and their behavior plan should reflect that.  Ongoing education with staff members and family is also optimal, to ensure everyone is a continued united front with promoting stable behavior.  By implementing and being consistent with utilizing behavior plans we can promote behavioral stability and maintain the stability triangle.  Remember, all sides of the stability triangle are needed to achieve good patient outcomes, which is why we do what we do as clinicians… we want to see people get better and get back to their lives!

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