**Prevention & Management of Disruptive Behavior (PMDB)**

**FY 2008 -- Denver Medical Center & NHCU**

**What is PMDB? -** A behavior management system designed to help
provide for the best possible care and welfare of assaultive,
disruptive, or out-of-control persons\-\-- even during their most
violent moments.

**Definition of Disruptive Behavior:** Any unacceptable behavior that
causes the routine operations of the VA Eastern Colorado Health Care
System (ECHCS) to be interrupted, impeded, or result in an unsafe
environment.![](media/image1.png){width="1.3138888888888889in"
height="1.238888888888889in"}

-   **All threatening and/or inappropriate behavior**

-   **Verbal or non-verbal**

-   **With or without an intent to inflict harm**

-   **Use of physical force to violate, damage, or**

> **abuse another person or property**

-   **Use of weapons or other instruments to threaten or inflict bodily
    harm**

-   **Can take the form of sarcasm, profanity, threats, loud &
    belligerent verbalizations, refusal to follow reasonable requests or
    the use of physical force or violence**

-   **Use of weapons or other instruments to threaten or inflict bodily
    harm**

**Zero Tolerance:** ECHCS has zero tolerance for disruptive, threatening
or violent behavior. Demonstration of these behaviors will result in
immediate action. Incidents will be investigated. Clinical,
administrative, and possibly, legal action will be taken as warranted.

**Predisposing and Precipitating Factors:** Predisposing and
precipitating factors may contribute to disruptive behavior.

**Predisposing Factors**

*Diagnoses:* Major Mental Illness: Schizophrenia, Bipolar Disorder, Post
Traumatic Disorder, Substance Abuse

Geriatrics/ Dementia

Personality Styles

History of Violence

**Precipitating Factors**

Loss of Independence

Loss of Control

Loss of Privacy

Loss of Choices

Fear of Pain

Confusing Environment

Noisy or Overcrowded Environment

Long Waits

Inflexible Process

**Prevention is Key:** There are several things you can do to help
prevent disruptive behavior: *Recognize Predisposing and Precipitating
Factors, Develop Rational Detachment, Provide Exceptional Customer
Service, Assess Your Environment, & Assess Yourself.*

-   **Rational Detachment:** the ability to stay in control of one's own
    behavior and not take acting-out behavior personally

    -   Recognizing that the acting-out episode is not about you

    -   Maintain your professionalism

    -   Do not precipitate or contribute to a patient's acting-out
        behavior

-   **Exceptional Customer Service** is based on knowing who our
    customers are, what is important to them, and how we can best serve
    them.

    -   Allow the other person to express their concerns

    -   Be empathetic

    -   Avoid being defensive

    -   Use a problem-sharing approach

    -   Avoid blaming others

    -   Do not adopt a "It's not my job approach"

    -   Follow through

-   **Assess Your Environment**

    -   Do you have conditions in your environment that may contribute
        to disruptive behavior i.e. long waits, crowded areas, poor
        lighting, high noise level?

    -   Are there any potential weapons in your work area?

    -   Can you locate the nearest exits?

    -   Where is the nearest phone?

    -   Do I have staff back up?

    -   What is the plan in your work area?

-   **Assess yourself** by asking am I contributing to the escalating
    tension in this
    situation?![](media/image2.jpeg){width="2.4479166666666665in"
    height="1.7694444444444444in"}

**Interventions for Disruptive Behavior**

-   **Be aware of signs and symptoms of stress**

    -   A noticeable change in behavior

    -   The person doesn't take in as much information

    -   The person is less aware of surroundings

    -   Pacing, finger drumming, hand wringing

    -   Staring off into space, looking "dazed"

    -   Acting suspicious

    -   Appearing fearful or anxious

    -   Acting in a manner that is unusual for that person

-   **Verbal intervention is the best first step**

    -   Remain calm and convey a willingness to help

    -   Allow person to ventilate their concerns

    -   Use simple sentences

    -   Paraphrase what was said, convey that you heard the message

    -   Convey the expectation that the other person can control their
        own behavior

**[DO]{.underline}**

Remove audience

Stay on topic

Maintain eye contact

Be appropriate to person's culture

Listen empathetically

Be patient

Remain calm

Set limits

Allow venting

Remain at least 18-36 inches from person

**[DON'T]{.underline}**

Complicate the issue

Be judgmental

Invade their personal space

Raise your voice

Use sarcasm

Be condescending

Debate

Laugh at the person or the problem

Use threats

Get into a power struggle

Patronize

-   **Paraverbal communication**: It is not always ***what*** you say,
    but ***how*** you say it.

> Avoid negative inflections and sarcasm.

-   Volume should be appropriate for distance and situation

-   Use even rate and rhythm

-   Show interest by your facial expressions and posture

-   Give undivided attention to other person

-   Allow silence

-   Use appropriate eye contact

-   Convey calmness- don't fidget

![](media/image3.jpeg){width="6.050694444444445in" height="2.25in"}

-   **Rising Stress Levels**: Behavior may escalate as a person's stress
    approaches severe level.

    -   The person begins to lose the ability to rationalize

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    -   The person may become belligerent and challenge authority

        -   Threatens others

        -   Increasingly loud and boisterous behavior

        -   Harmful or dangerous behavior

    -   As a person's stress rises and that individual begins to lose
        control, it is important for staff to set limits on behavior:

        -   Set limits on behaviors- not feelings

        -   Keep limits simple, reasonable, clear, and enforceable

        -   State the positive choice before the consequence

**Therapeutic Containment:** When stress levels reach panic, the person
experiences total loss of control. The person is a danger to themselves
and to others.

-   **[Call Code 3 by dialing ext. 3911]{.underline}**

-   Move away from the acting-out individual

-   Move any patients to a safe area

-   Wait for the arrival of the Code 3 team and VA police and brief them
    on the situation

-   Unless you have been specially trained in therapeutic containment,
    do not attempt to restrain individual.

**Debriefing:** Following any Code 3 or episode of disruptive behavior,
there are several important things to do:

-   Discuss episode with your supervisor

-   Debrief with other staff the events

-   Complete a patient safety report

-   Document event in patient's chart in an objective and professional
    manner