As part of continued work in implementing our new dementia and delirium strategy at the Trust, a bespoke piece of work is underway to better identify and support patients who display behaviours of concern (BOC) within the organisation.

There is often a perception that some of our most challenging patients are those who are violent and aggression in a deliberate manner, but in many cases, patients with cognitive impairments such as dementia, delirium, learning disabilities or autism, can exhibit behaviours of concern. Whilst the total number of patients presenting with behaviours of concern has not changed over the past two years, there has been an increase in staff reporting challenging incidents on DATIX.

Listening to staff

To better support both patients and staff in these scenarios, Ged Jennings, learning disability nurse is on a 12-month secondment, leading a project to better shape our organisational response to behaviours of concern. It is focused on three key areas of development: workforce, training and clinical management.

Ged is currently supporting staff at Broadgreen Hospital, where typically 70% of patients have cognitive impairment, to understand their training needs and support the cultural change required to ensure staff feel confident in de-escalation of behaviours of concern and able to use cognitive therapies (such as distraction and reminiscence therapy). He is being supported by Graham Lamph, Consultant Nurse for Dementia and Delirium, and the wider Dementia team, who will continue this work being developed more widely across the Trust as part of their core duties.

Ged said: “Speaking with staff at Broadgreen about how they feel in caring for patients with behaviours of concern has been really insightful. A lot of colleagues have said they felt scared, as they don’t know how to appropriately manage these patients and have experienced challenges in the past. Through fear, our reactions in these situations can often be to either medically calm a patient down or call security to help manage – which can trigger past trauma in a patient.”

Through speaking to security team about behaviours of concern, Ged was informed that many security colleagues had not received trained in basic levels of understanding of cognitive impairment, which would enable them to take a different, tailored approach for these patients: “It’s important to improve the training on offer so we can better support all colleagues to feel empowered to safely manage challenging situations involving patients with cognitive impairment.”

Next steps

As part of this piece of work, improving access to training to support staff in de-escalating behaviours of concern is currently being reviewed by the Learning and Development team. Ged has also facilitated study days for Broadgreen ward staff, to increase their knowledge and confidence in how to de-escalate situations and support vulnerable patients. The sessions looked at using distraction or reminiscence therapies – as an alternative to using medication or calling security.

The final element is to implement the standardised Trust-wide ABC behaviour chart for patients who exhibit behaviours of concern, to analyse and understand behavioural outbursts in patients with cognitive impairment:

  • 'A' stands for antecedents, which are triggers or environmental factors that occur before the behaviour
  • 'B' refers to the behaviour itself
  • 'C' refers to the consequences of the behaviour.

The chart can help identify potential causes of concerns or emerging themes, which can inform the development of a plan to further support that patient with any changes or care needs. It also supports faster patient discharge, as often social care partners can often require an ABC to understand what a patient’s true behaviours are, in order to support them appropriately. Training for the use of the ABC charts is currently being offered across all sites.

Ged said: “Managing behaviours of concern is about quickly, safely and in the least restrictive manner possible, making it a safe environment for both the patient and staff. It’s an important part of the new dementia strategy that we further support and develop our workforce. By ensuring they’re skilled in de-escalation techniques and communicating differently, patient care will improve, and the risk of people being hurt lessens. I hope we can develop and put tangible change in place here at LUHFT.”

As part of continued work in implementing our new dementia and delirium strategy at the Trust, we are working to better identify and support patients with cognitive impairments such as dementia, delirium, learning disabilities or autism, who exhibit behaviours of concern. Learning disability nurse, Ged Jennings, is leading a bespoke piece of work to better support both patients and staff in these scenarios, and in July 2023 held two study days for staff at Broadgreen – where typically 70% of patients have cognitive impairment.

Attended by 70 staff from a range of roles, the sessions aimed to increase their knowledge and confidence in how to de-escalate situations and support vulnerable patients. During the two days, staff were advised about how best to use communication tools and also non-pharmaceutical interventions, such as distraction or reminiscence therapies, to calm a patient and aid compliance with their care.

Ava Milligan, a student nurse, said: “The behaviours of concern session was very in depth and educational, and helped with my understanding of de-escalation. It was a fantastic learning opportunity and as a student I will no doubt find this useful in my career as a nurse.”

Jeanette McNally, a nurse at Broadgreen, said that the session was useful in understanding how to better de-escalate physical incidents: “I care for a lot of dementia patients and there have been occasions in the past where I’ve not known what to do or been scared to try and de-escalate an incident where it’s been physical. I want to provide the best care for my patients – but safety for both you and the patient is important. The session has been really interesting and I’ve learnt new techniques.”