The incident which I have chosen for my Nursing Project happened on the last day of my learning difficulties placement. It involved a young Autistic man, who I will refer to as ‘John” throughout my assignment. This is to protect the client”s identity, this is in accordance with the UKCC Code of professional conduct (1992) clause 10:
“Protect all confidential information concerning patients and clients obtained in the course of professional practice and make disclosures only with consent, where required by the order of a court or where you can justify disclosure in the wider public interest.”
One incident which I believe highlights the problem I will address, involved myself bathing ‘John”. This was not the first time that I had bathed a person during the placement, however, the difference this time was that while I was washing ‘John”, he would display elf-injurious behaviour by slapping his face and then repeating the phrase ‘stop slapping face”. I chose this incident from my clinical diary as I feel that the self-injurious behaviour that ‘John” exhibited is an interesting and difficult Nursing problem and one, which affected my ability to care for him.
Rather than focussing on the self-injury specifically related to ‘John”s” case, I will examine the possible ways to manage self-injurious behaviour, especially in persons with learning disabilities.
To manage this problem effectively, a multi-disciplinary approach is required, but for the purposes of this essay I will look at the problem from a Nurse”s perspective. I will begin by giving a brief description of self-injurious behaviour and the possible causes. I will then highlight the different techniques available to Nurses for the management of this behaviour.
Murphy and Wilson(1985) define this as:
“Any behaviour initiated by the individual, which directly results in physical harm to that individual.”
As is apparent in the literature, self-injurious behaviour is referred to as any behaviour that can cause tissue damage, such as bruises, redness, and open wounds. The most common forms of these behaviours include head banging, hand biting, head-slapping, and excessive scratching.
There are two main sets of theories on the subject and these concentrate on physiological or social causes.
The main physiological theories are:
Self-injurious behaviour releases beta-endorphins in the person”s brain. Beta-endorphins are opiate like substances in the brain, which provide the person with some pleasure when released.
Sudden episodes of self-injury may be caused by sub-clinical seizures. Sub-clinical seizures are not typically associated with the behaviours of normal seizures by they are characterised by abnormal EEG patterns.
May be caused by over arousal such as frustration. Self-injury acts as a release, and thus lowers arousal.
Self-injury may be a form of self-stimulatory, stereotypic behaviour.
Some people exhibit self-injury to escape or avoid a task.
Self-injurious behaviour may be used as an attention-seeking device.
An incident that involved ‘John” which illustrated the difficulty in managing self-injurious behaviour, was when an object he was obsessed with, was removed. This was using a punishment strategy which I will discuss later. This was thought to be the best course of action, but it lead to ‘John” being restrained for nearly an hour, followed by him being sedated with an intra-muscular injection of chlorpromazine. What can learned from this is that it demonstrates the need for careful assessment of the individual. As highlighted by Murphy and Wilson(1985):
“The treatment selected will depend on how the self-injurious behaviour originally developed and what factors maintain it.”
There are a wide variety of different strategies or factors involved in treating or managing self-injurious behaviour. These include restraint, pharmacotheraphy, behavioural therapy, inter-personal strategies, normalisation and environmental factors. I will now examine in turn each of these strategies or factors.
This is the most effective way of dealing with self-injurious behaviour in an emergency but there are a number of problems that can arise.
Firstly, restraint raises some ethical questions, such as does someone have the right to injure themselves? This dilemna and others related to this topic are difficult to answer, but in general we make the assumption that the client is not capable of choosing for themselves. Secondly, the use of restraint present devaluing images of the client. Thirdly, they involve the violation of personal space which is usual for everyday social interaction.
This can lead to a detrimental effect on the nurse/client relationship. Furthermore, there is the risk of injury to staff and to the client. Also there is the possibility of staff being accused of abuse, this is highlighted by Jones and Eayrs(1993):
“Care staff may well face allegations of client abuse associated with the use of restraint.”
There are some drawbacks in the use of restraint but it is an essential tool available to the Nurse in the management of Self-injurious or challenging behaviour.
A number of drug treatments were used at Woodlands namely Chlorpromazine and Hapliperidol. These were reasonably effective but with these drugs there are serious side effects. As stated by Bernstein et al(1994):
“Serious side effects include symptoms similar to those of Parkinson”s disease, such as muscle rigidity, restlessness, tremor and slowed movement.”
These side effects can be treated with anti-Parkinson drugs.
When trying to manage inappropriate behaviour using psychoactive drugs they should only be used as an integral part of the client”s programme. For example to combine Pharamacotherapy with other strategies such as behavioural treatments.
In general behavioural approaches to treatment seem to be the most effective and long lasting ways of managing violent and aggressive behaviour. A reason for this is suggested by Murphy Wilson( ):
“The fact that the ‘learned behaviour hypothesis” is one of the most convincing hypotheses for explaining the development of self-injurious behaviour.”
This term covers a variety of different approaches but some of the main methods are positive reinforcement, modelling, extinction, aversive conditioning and punishment.
This means, in the context of my essay, reinforcing or strengthening any behaviour that is not self-injurious. An example of this is raised by Bernstein et al (1994):
” Autistic children, who, use very little language, were rewarded with grapes, popcorn, or other items for saying ‘please”, ‘thank you” and ‘your welcome” while exchanging crayons and blocks with a therapist.”
This is defined by Bernstein et al(1994) as:
“The gradual disappearance of a conditioned response or operand behaviour due to elimination either of the association between conditioned and unconditioned stimuli or of rewards for certain behaviours.”
In the case of treating self-injurious behaviour it can be effective, but it is not always possible to use this method, because, firstly the client may seriously injure himself before the behaviour disappears. Secondly, if the reason for the behaviour is self-stimulation, it may not be possible to remove the source of reinforcement.
This is basically a method of therapy in which desirable behaviours are demonstrated as a way of teaching them to clients.
This method employs classical conditioning principles to link physical or psychological discomfort with undesirable behaviours. An example of this by Bernstein et al(1994) is:
“Alcoholics might be allowed to drink after taking a nausea-producing drug, so that the taste and smell of alcohol are associated with nausea rather than the usual pleasurable feelings.”
This was used extensively at woodlands. The main way in which clients were relaxed was through the use of a ‘sensory room.” This was basically a room that contained various lights, music and tactile objects designed to relax the client. The ‘sensory room” was extremely effective at woodlands and was an invaluable apparatus in the management of violent or aggressive behaviour.
This kind of strategy involves penalising any behaviour considered to be inappropriate. These were used at Woodlands, sometimes they were effective, but in one case regarding ‘John” it seemed to make matters worse, leading to him to require to be sedated. In general punishment strategies should be used in conjunction with reinforcement of desirable and non-injurious behaviours.
This is an important strategy in the treatment of challenging behaviour. It is the way in which a Nurse communicates verbally or non-verbally with the client. It is recognised that inappropriate behaviour from carers can instigate or maintain aggressive behaviours. The important factors as indicated by my research are eye contact, posture, touch and how the nurse actually speaks to the client. From my research I have found that there is a great deal of contradictory advice when dealing with an aggressive client. For example there is some evidence that remaining calm is the best thing to do but Breakwell(1989) cited by Jones and Eayrs(1993) suggests that:
“The assailant who shouts is shouted at: calm intensity is greeted with equal intensity.”
What is obvious is that when dealing with a client, interpersonal strategies are extremely important, but there is no right or wrong way.
This is defined by Bank-Mikkelson (1980) cited by Murphy and Wilson(1985) as the need to:
” Create an existence for the mentally retarded as close to normal living conditions as possible”
This means to make conditions of education, housing, work and leisure to as near normal as possible and to bring greater equality of rights, obligations and responsibilities under law. Although it is not necessarily related with the treatment of someone who presents challenging behaviour, it is an important factor in considering the overall care of the client.
This is providing an environment safe from potential factors, which may cause challenging behaviours. Some of these negative environmental factors may be things like loud noise, absence of attention, aggression from other residents, isolation or not enough space.
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