Management of Actual and Potential Aggression

Skills Demonstration 2

A training needs analysis has been conducted on MAPA (Management of Actual and Potential Aggression) Training. Three specific learning outcomes have been chosen and from this a training workshop has been put together. The following piece of work will begin by introducing the rationale and aims for the choice of topics and display evidence of a lesson plan and schedule. It will then go on to reflect on the planning and implementation of the training workshop and conclude with recommendations for improvement.

The MAPA Training Workshop has been designed to enhance an understanding and give knowledge of how to manage disruptive, aggressive and/or violent behaviour. It aims to ensure that everyone involved in crisis situations, which include disruptive, challenging, or violent behaviour, can maintain the Care, Welfare, Safety and Security of all involved. In conjunction with this it is intended that on completion of the workshop participants will have gained a significant knowledge in and developed a range of psychological and physiological responses to behaviour that when implemented in a care setting will assist them in reducing the potential harm disruptive, aggressive and/or violent behaviour can cause. In conjunction with this it will teach management and intervention techniques to safely and professionally respond to and support an individual should a behaviour escalate. It too will provide the participant with a knowledge of how to correctly record Behavioural Incidents, this in turn will assist in determining and understanding why behavioural Incidents occur.  

Drawing on the above, having outlined the aims of the MAPA Workshop this therefore leads to examining the rationale as to why such a training needs analysis is required. The Muiriosa Foundation places a great emphasis on Staff Training and development. The Organisation acknowledges that training presents a prime opportunity to expand the knowledge base of all employees by introducing and teaching new skills and strengthen skills that perhaps employees need to improve; an employee who receives the necessary skills is therefore better able to perform their job and deliver the highest quality standard of care to the individuals they support.  Appendix 3 within the Policy on Employee Education, Training and Development identifies different training topics and is a tool for managers and Persons In Charge to determine if input in training in different areas and aspects of the work is a priority for the employees in their area (Muiriosa Foundation Policy on Employee Education, Training and Development, July 2018, Issue 3). MAPA Training is one of areas that is identified on this particular template. The Muiriosa Foundation provides a service of person centred care and support to individuals with Intellectual Disability. Each Individual presents with different needs, some more complex than others and sometimes individuals may display behaviours of concern. It is therefore an essential requirement for the staff providing care and support in such services to receive MAPA training.

In addition to the above it too is important to state the reasons that lead to the rationale in providing and implementing MAPA training in such services where an individual may display behaviours of concern. The specific service design is led by The Organisations Policies on ‘Listening and Responding to Individuals who display Behaviours of Concern, Risk and the Individual Service User and Risk Management Policy Overarching Framework. This is conjunction with Local Protocols and Risk Assessments would establish the need for MAPA Training. It assists staff; in line with the Positive Behaviour Support Team to develop strategies within the ‘proactive and reactive plan’ and learn blocking techniques and holds in order to safely respond to and manage behaviours of concern. MAPA Training too places an emphasis on effects on both the individual and the staff member following an incident of behavioural concern. It provides a forum to demonstrate and advise participants on debriefing following an incident and creates an awareness for the importance of staff supervision and support.

Having examined and given an account of the aims and rationale and therefore in order to put the MAPA Training workshop together three learning outcomes from the rationale have been chosen in order to devise the lesson plan. These are as follows; Develop Strategies in the form of the proactive and reactive plan so as to safely respond to and manage behaviours of concern, Learn the different techniques such as blocking and holds which may be sometimes required for the safety of both the individual and the staff member and finally the importance of debriefing and supervision following an incident of behavioural concern. For the purposes of an easier understanding of the learning outcomes the lesson plan will now be set out with the use of headings.

Developing Strategies to safely respond to and manage behaviours of concern and devising the proactive and reactive plan.

In order to safely respond to and manage behaviours of concern it is essential to examine the precipitating factors and identify the ‘triggers’ that may cause an individual to behave in the ways they do. This is best explained in terms of the ‘Integrated Experience’. This is a model that is used to outline Crisis Development/ Behaviour Levels and Staff Attitudes/ Approaches to these behaviours (www.crisisprevention.com).  For the Purposes of this workshop the following is an outline of how the proactive and reactive plan is devised by interpreting and basing it on the Integrated Experience. This is an example of what the proactive/ reactive plan may look like. It will outline the 4 Levels of Behaviour and follow with the Staff Attitudes and Approaches to each one and state what a proactive or reactive measure is. It is based on supporting an individual with a diagnosis of significant intellectual disability, autism and very limited verbal communication. Examples used are specific to this individual and how they present prior to and when behaviour is escalating.

Level One: Anxiety

The individual here presents with a significant change in their behaviour. Examples include; hand sniffing, laughing when looking for items/ making requests, faster movement and becoming heavy handed; throwing items, banging doors etc.

Attitude/ Approach:

In order to best manage and respond to anxiety a proactive approach of aiming to de-escalate the behaviour at this point is that of a supportive attitude. This is best re-iterated to the individual through gentle reassurance in the form of simple phrases such as ‘its ok and you need to be calm’ in conjunction with pictorial aids displaying the ‘calm’ gesture.

Level 2: Defensive:

At this stage the individual starts to loose rationale. Verbal requests become louder and are directed at staff. The level of intensity of banging and throwing items raises.

Attitude/Approach:

As the level of intensity of behaviour begins to rise staff at this point staff need to adopt a supportive attitude and a direct approach. Staff need to understand and aim to interpret what may be the trigger of this behaviour. For example using the following language ‘I know you may be stressed and anxious waiting for John to come in but he will be here soon and he will give you the picture of what we are going to do today.

Level 3: Risk Behaviour

The individual is now at a point their ability to understand and reason is gone. Behaviour begins to escalate and the individual may engage in risk behaviours such as Self Injurious Behaviour. This may present in the form of punching their face, biting their hand and also may attempt to display physical and verbal aggression towards staff.

Attitude/Approach:

Physical Intervention may be required at this time. That is in the form of the ‘Low Level Mapa Hold’ in order to safely remove the individual from the environment to a safer place in an aim to prevent any injury to themselves or staff.

Level 4: Tension Reduction

At this point the individual has calmed down and the behaviour incident has ended. Their levels of physical and emotional energy have significantly decreased.

Attitude/Approach:

Now is the time to begin to re-establish communication with the individual and create a therapeutic rapport. It is important to move on from the incident once it has ended and observe for pre-curser signs and monitor the individual for any pain they may be experiencing following Self Injurious Behaviour. (www.crisisprevention.com).

MAPA Blocking and Hold Techniques

For the purposes of this piece of work two blocking and one hold technique will be discussed as these are the ones that are most relevant to the examples used in the above paragraph to outline the pro-active and re-active plan.

1. The Supportive Stance: The Supportive Stance is a position held by staff keeping a distance of one-leg-length standing at an angle avoiding standing in a challenging position. It allows the staff member to maintain and manage interpersonal communication when there is a change in an individual’s behaviour.
2. Blocking a Hit or a Strike: The staff member will raise their arm to block the hit or strike and move away from the individual.
3. The ‘Low Level Mapa Hold’: In order to safely direct the individual to a safer environment the staff member carries out this hold as follows. They place one foot in line with the individual’s foot and their hands on each of the individuals arms just above the elbow and direct the person out of that room. This is a procedure that can only be used when prescribed by and wrote up by the Positive Behaviour Support Team (www.crisisprevention.com).

Before moving on to the outline of what the schedule of the training workshop will look like lastly this piece will look at the last of the three chosen learning outcomes.

The Importance of Debriefing and Supervision following an incident of Behavioural Concern

Experiencing an incident of behavioural concern can be stressful and traumatic for both the individual in crisis and the staff member. As stated above the importance of re-establishing the therapeutic rapport with an individual is vital. It too cannot be emphasis the important of a supervisor to take aside the time to de-brief with a staff member following an incident. There are many different benefits to de-briefing. It can determine the level of impact both physically and emotionally that a staff member has experienced, it aids in assisting with relieving stress as soon as possible following an incident and will therefore lift staff morale (www.hse.ie). Ongoing Supervision is also essentially a reflective exercise in relation to each staff members practice and also provides a forum for identifying new skills and knowledge (www.iriss.org.uk).

Schedule for 2 Hour MAPA Training Workshop

09.00- Brief Introduction to Course

09.15- Description of Crisis Development and Levels of Behaviour to link with an

 Understanding of the attitudes and approaches in response and the pro-active and re-

 Active plan.

09.45- Discussing and demonstrating of blocking techniques and the ‘Low Level Mapa

 Hold’.

10.30- Evaluation of Training Workshop and question time.

11.00- Workshop Concludes.

In order to conduct the above workshop the following were identified as the essential resources to carry out the task.  Firstly to prepare a point presentation outlining the learning outcomes and determining the lesson plan and give as handouts to all participants. There would also be a need for mats when practicing blocking techniques and holds.

Having identified the learning outcomes, devised the lesson plan created the schedule and carried out the training workshop the focus is now to reflect on all of the above and the planning and implementation of the workshop. This will done in terms of an in line with Gibbs Reflective Cycle. Gibbs reflective Cycle is a popular model and includes 6 stages of reflection as follows;

Description: The reflection here is based on a brief analysis of a two hour MAPA Training Workshop.

Feelings: A sense of confidence was sought from delivering this workshop, due to the facilitators experience and knowledge in the field it was felt that the planning of information to be shared would be of great benefit to the participants.

Evaluation/ Analysis: There was both positives and negatives to the training workshop. Participants voiced through evaluation forms that they felt a lot of good information was shared but perhaps two hours was not enough to cover all information as it ran over by approximately 30 minutes.

Conclusion/ Action Plan: Drawing on the above going forward the workshop will be extended by one hour in order to give adequate time to accurately cover all learning material (Dye,V, 2011)

To conclude the following  recommendations have been identified going forward in terms of carrying out a MAPA Training Workshop and are  in line with the points made in the above paragraph relating to ‘Evaluation/Analysis’ and ‘Conclusion/ Action Plan’. A second trainer might be of assistance with larger groups when demonstrating blocking techniques and holds. It may also be beneficial for not only front line staff but also managers/ Persons In Charge to attend training to create more of an awareness and be able to better relate to staff when de-briefing following incidents of behavioural concern.

Bibliography

Books:

• Dye, V. (2011) ‘Reflection, Reflection, Reflection. I’m thinking all the time, why do I need a theory or model of reflection? in McGregor, D. and Cartwright, L, (ed.) Developing Reflective Practice: A guide for Beginning teachers . Maidenhead McGraw-Hill Education (pp.217-234).

Websites:

• Crisis Prevention Institute, 2018, Nonviolent Crisis Intervention, assessed 2/12/18, https://www.crisisprevention.com.
• Health Service Executive, 2018, Supporting staff following an adverse event, assessed 3/12/18,
• https://www.hse.ie.
• Iriss, 2018, Achieving Effective Supervision, assessed 3/12/18, https://www.iriss.org.uk.

Policies and Procedures:

• Muiriosa Foundation; Policy on Employee Education, Training and Developmen, July 2018, Issue 3.