Working with People with ABI : 2.WORKING WITH ABI : f) Person centred Goal directed

Working with people with acquired brain injury

f) Person centred Goal directed

i)
Intro
ii)
Person
Centred
iii)
Goal
directed
iv) Identify
& prioritise
issues
v)
Setting
goals
vi)
Monitor-
ing
vii)
Toolkit
B

Person centred

In a person centred approach the person with the ABI

Is an equal partner in planning, developing and accessing services to appropriately their needs.

A person centred approach aims to:

Be client focused,
Promote independence and autonomy,
Provide choice and control and
Be based on a philosophy of collaboration and teamwork.
It takes into account your needs and views and builds relationships with your family members.

Goal directed

Goals are what the person with the ABI wants to achieve.
Goals belong to ther person with the ABI, not to workers, clinicians or service providers.

Rehabilitation programs exist so that therperson with the ABI can achieve your goals. Rehabilitation goals typically focus on improvement.

Perople with ABI have life goals after rehabilitation – including maintain goals and prevent deterioration.

ii) Person centred

You are an equal partner in planning, developing and accessing services to appropriately meet your needs.

A person centred approach puts you and your family at the heart of all decisions. It aims to:

Be client focused,
Promote independence and autonomy,
Provide choice and control and
Be based on a philosophy of collaboration and teamwork.
It takes into account your needs and views and builds relationships with your family members.

A person centred approach gives people:

valued roles
participation and belonging in the community
freely given relationships
greater authority over decisions about the way they live
genuine partnership between the service, themselves and/or their family and allies
individualised and personalised support arrangements.

Person-centred approaches require that organisations:

have a committed leadership that actively instills the vision of a person-centred approach at all levels
have a culture that is open to continual learning about how to implement a person-centred approach
consciously hold positive beliefs about people with a disability and their potential
develop equal and ethical partnerships with people with a disability and their families
work with people to individually meet each person’s needs so that they can be in valued roles in valued settings
develop appropriate organisational structures and processes

Signs of a person centred approach

There are many signs of person centred approaches; and signs of approaches that are not person centred. Some examples are:

Signs of a person centred approach

Making sure the person and their friends and family are central to identifying needs.
Focussing on the future e.g. identifying that a person will need to cook in their own home.
Asking the person what they should most like.
Enabling people to have lots of experiences so they can make informed choices
Thinking not only about choice, but also about how people can have more control over their own lives.
Expecting that everyone is born into a common humanity and deserves a ‘good’ life
Service providers recognise that the person/family has important knowledge about their own needs and about how these are best met.
Supporting the person to have valued roles in the community

Signs of NOT being person centred

Thinking about the person mainly in terms of what they cannot do.
Focussing only on the present, e.g. identifying that a person must learn to cook.
Telling a person what the decision is after it has been made.
Expecting that people will immediately be able to make good decisions without support.
Expecting that people with a disability cannot have lives like other people.
Expecting that having a disability means having more in common with each other than with other citizens.
Service providers holding all the power and controlling what happens to the person.
Supporting the person only in the role of service client or other non-valued roles, fitting the person into activities and programs.

iii) Goal directed

Goals

Goals are what the client wants to achieve.
Goals belong to you, not to workers, clinicians or service providers.
Rehabilitation programs exist so that you can achieve your goals. Rehabilitation goals typically focus on improvement.
Clients have life goals after rehabilitation – including maintain goals and prevent deterioration.
Attendant care, when required, is part of achieving your goals.

Benefits of setting goals

Setting client goals:

Helps you motivate yourself – i.e. it is easier to work towards achieving your goals when those goals are explicit and you are clear about what you are wanting to achieve.
Makes it clear to everyone what the you are wanting to achieve.
Makes it easier for everyone working with you to work together as a team and coordinate their efforts to achieving the goals.
Makes it easier for everyone to see how well things are working: Are the goals being achieved?

Individual service plans

Individual service plans are needed so that the steps needed to achieve the gaols are documented and everyone involved is working together.

Individual service plans:

Start with your goals
Establish the steps needed to achieve your goals
And then design the actions and services needed to achieve the steps.

To be useful goals must describe what's to be achieved

Useful goals describe what the client wants to achieve, not what the client or service provider is supposed to do. The program describes what is to be done.

Jill’s goal: To be able to care for her child independently.

Jill’s program: Jill does her home exercise program and attends occupational therapy sessions.

She does this because she wants to be able to care for her child independently.

Sometimes goals do not reflect what the client wants to achieve in their life. For example if Jill’s goal were written as: To do the home exercise program each day and attends occupational therapy each week this would not be an appropriate goal, as it is focussing on what Jill has to do, not what she wants to achieve.

iv) Identifying and prioritising issues

The keys to identifying and prioritising issues are:

Coming up with ideas - how do you help the individual do this?
Recognizing the skills and strengths of the individual
Supporting the individual in prioritising issues

Helping the individual identify what they want to work on

The first step is to identify issues the individual wants to work on or areas they want to improve. The more meaningful or relevant the issue or activity is to the individual the greater the chance of success. When trying to enable the individual to identify areas to work on, ask an open question.

For example,

"What would you like to work on?"
"What do you think stops you from doing what you want to?"

Open ended questions provide the individual with the most control and helps independent decision making.

If the individual is not able to generate their own ideas or issues or areas to work on, you need to ask a question that has an option or alternative.

For example,

"What is a bigger issue, your temper or your memory?"
"Would you prefer to work on being able to prepare an evening meal or get your washing done?"

These questions still allow the individual to make their own decision. The number of options that are provided depends upon the individual's ability to manipulate information, reason and remember the options provided.

If the individual cannot remember information, another strategy is to write down the issues or alternatives and then work through them on paper. This allows the individual to refer to the information independently as required. This decreases their dependence upon the worker's memory and equips them with another strategy they can use in situations whenever their memory limits what they are doing.

Questions that might help you help the client identify their issues

These questions assist the support worker to understand the barriers to independence for the individual with a brain injury. However, it is essential that they identify their own issues and give them a priority for goal setting. The worker takes a supportive, not directive role in the complete process.

See Toolkit B Promoting Independence for examples.

Recognizing skills and strengths

Always recognise the skills the person has and try to find out how they previously performed the activity. Ask them to describe the process they would go through to do an activity. Again start with open ended questions.

For example,

"How would you go about doing that?"
"What do you think you need to do that?"
"Have you done it before?"
"How have you done it previously?"
"Can you remember how you have done it before?"

Asking open ended questions like this enables the individual to have control and demonstrates that support workers recognise the individual has abilities. It shows those working with the individual how much of an idea they have. Support or assistance needs can then be determined. If necessary provide simple or brief plans and ask them for more information.

For example,

"How are you going to do this?"
"What did you mean when you said this?"
"How are we going to do it?"
"What do you need to do it?"
"Is there anything you can look at that will give some help?"

Such questions enable the individual to organise themselves and their environments. This provides them with the opportunity to share their knowledge. Insight can be gained into how they used to do things so they can be helped to do these things this way again, if it is feasible.

(c) Copyright - See: Toolkit B. Working Together Promoting Independence - www.TBIStaffTraining.info

v) Tips for setting goals

The following are tips for setting goals when working with people with ABI.

Factors to consider when developing goals

Client centred not staff actions
Goal development vs goal imposition
Giving exact behavioural description of goals
Stating goals positively rather than negatively
Creating short-term goals vs long-term goals
Looking at improvement vs maintenance.

Writing goals

Remember: Goals need to be specific, measurable and time limited.

Some examples are:

I will remember all my appointments in 2 weeks
I will have enough food in my house for all my needs for 2 weeks.
I will keep track of when my bills are due and pay them on time within two weeks.
I will identify places to keep things in my house so I don't lose them, in one month.

To achieve each of these goals would require developing strategies (and identifying any necessary resources).
For example to achieve: I will have enough food in my house for all my needs for 2 weeks
will required:

menu plan
shopping list
work with support worker
etc

The following are too broad and general to be useful goals:

independently use public transport
increase opportunities for social interaction
improve arm function
improve personal hygiene
improve cooking skills

How to deal with unrealistic goals

allow learning through experience (consistent with cognitive abilities and achievable goals)
develop compensatory strategies
investigate alternatives
set priorities
break into smaller steps
give clear feedback about progress/lack of progress
don't challenge unrealistic goals, try and focus on achievable smaller goals
link achievable goals with unrealistic goals (rather than challenging unrealistic goals)

TOOL 12: Essential survival tips for working with people with ABI

Useful goals

Setting goals is an art.
Useful goals have some of the following characteristics:
                                Specific
                                Measurable
                                Achievable
                                Relevant
                                Time-bound
Goals are more likely to be achieved when:
There are steps and an action plan that map out what has to be done to achieve the goal.
When the degree of achievement of the goals is monitored and the action plan is adjusted to better achieve the goal.

Specific

A goal is what the client is aiming for.

When a goal is specific the client knows what to aim for, when and how much.
For example, ‘John will join his friends on a fishing trip’ is specific, ‘John will increase his social interactions’ is not.
For example “Beating your best time at walking” is specific where as “doing your best” is not.

“Measurable”

It must be possible to identify when the goal has been achieved (“measurable’).

For example, these are “measurable” goals:

Jill will return to work 20 hours per week over 4 days by end March 2014.
Jack will host a dinner party including cooking a two course meal for himself and three friends at his home within 12 weeks.
Karen will perform the family grocery shop every week.
Jack will walk from home to the bus stop with a walking stick and stand-by assistance.

It is possible to know when these goals have been achieved.

These goals are not measurable (and therefore not useful goals):

Jack will increase his contribution to family life.
Jill will increase her community participation.

Achievable

Useful goals must be achievable goals.

Ideally, goals should be achievable but challenging.

What is achievable for a client will depend on many factors, e.g. the nature and impact of their injury, what they could do previously, their age, social situation, resources available and so on.
It is useful to think about shorter and longer time frames. What is an achievable 3 to 6 month goal and what’s a goal in the longer term.

Relevant

Useful goals are relevant to the client.

When asked: ‘Is this goal something you want to work towards?’ or ‘Is this goal important to you?’, or ‘Does this goal matter to you?’ the client should answer “Yes”.

If the client doesn’t answer “yes” the goal probably isn’t relevant to them or they are not seeing the connection between the goal and what they are really wanting to achieve.

Time-bound

Goals must be time-bound to be useful.

When will the goal be realistically achieved? Without a time frame, there is less urgency to start taking action towards achieving the goal. This is best specified by a date, rather than by a length of time e.g., ‘by February 2013’, rather than ‘in 3 months’ time’.

Action Plan

For goals to be useful for the client, goals need an action plan that maps the steps and actions needed to achieve the goal.

The action plan is driven by the goal.

Monitoring achievement

For goals to be useful for the client the degree of achievement needs to be regularly monitored and the action plan modified if necessary.

(c) Copyright - See: Toolkit B. Working Together Promoting Independence - www.TBIStaffTraining.info

vi) Monitoring: How to ask about how things are going?

This is one of the most difficult things for a person with a brain injury to do. They may not ask themselves questions about what they are doing and therefore may not realise if they are making a mistake. Questions can be asked to draw their attention to what they are doing and how they are doing it.

For example,

"How long do you have to leave that for?"
"When do you need to check it?"
"Is it time to check it?"
"Is that how you would normally do that?"
"What did the instructions say to do?"
"Are they the same?"

At the end of the activity, it is useful to get the individual to reflect on what they did, how they did it, what went well, what didn't go as planned and if there is any way they would change it next time. For some people with a brain injury it may be difficult for them to remember this information.

This is where information and feedback can be provided about how they went. It is important to highlight what they did well as well as what they had difficulty with. It is much easier to give good feedback as compared to areas of difficulty. Ask them questions about their own performance.

For example,

"How do you think you went?"
"Did everything go as you wanted it to?"
"What did you think you did well?"
"What areas could you improve on?"

If they are unable to recall in detail how they went, prompt them about their performance in a specific area where improvement could happen or which was a strength.

For example,

"What about when the chips were spitting fat?"
"What did you do?"
"Do you think it was smart to throw water on them?"
"What could you have done that would have been better?"
"Do you think that turning down the heat may be a better idea next time?"

The type of input provided does not have to be as clinical as these questions sound. By knowing what needs to be looked for and enabling the individual to be doing this, the questions asked and how they are asked, will become second nature. It is imperative the helper knows what the individual is working towards in the activity, what the individual is wanting to achieve. Consistency is the key.

Everyone, paid or unpaid carer, family and rehabilitation professionals should all be working with the individual toward their goals, using the same strategies.

(c) Copyright - See: Toolkit B. Working Together Promoting Independence - www.TBIStaffTraining.info

vii) Toolkit B - “Getting it all Together” Working Together Promoting Independence

Toolkit B - “Getting it all Together” Working Together Promoting Independence is a resource for workers working with people with TBI.

It is on the wet site www.TBIStaffTraining.info

The resources in the kit have been designed to be used by people with TBI. It is also relevant for working with most people with ABIs.

The Kit contains practical information and tools the worker can use to assist an individual with a brain injury to:

Identify issues and set priorities
Set goals
Develop strategies to achieve the goals
Monitor progress.

The Kit includes tools and tips for practical strategies on everything from working with memory problems to doing the laundry. All the tools, tips and worksheets can be printed to give to the person with the ABI.

The Kit has been designed to be relevant throughout the lifespan and the changes experienced in different life stages.

This Kit aims to increase the independence, control, decision making and responsibility taken by individuals who have a brain injury, in day to day activities.

Individuals who have a brain injury and who have trialed sections of the Kit stated:

"It helped me to work out the little differences and do something about them"
"I realised how I can now help myself and not rely on others"
"I now know where all my money is going"
"I wish I had this years ago- it helps with the little things. Like remembering where I put things, how to use my diary and calendar- everything!"
"I only had to use the sections I needed to- getting out in the community and looking at getting back to work" .

(c) Copyright - See: Toolkit B. Working Together Promoting Independence - www.TBIStaffTraining.info