Interprofessional Conflict Over Agitation Management on a Rehab Unit
You are the rehabilitation psychologist on an inpatient unit. Mr. T is a 34-year-old man 3 weeks after a moderate TBI. He is agitated in the evenings, has pulled at his IV line twice, and has yelled at staff. The physiatrist has ordered a new antipsychotic and asks you to 'get behavioral control' before discharge planning next week. Nursing is documenting 'noncompliant' and 'manipulative.' The speech therapist says he 'won't participate' in afternoon sessions. His wife says he is 'not himself' and is frightened. Discharge is planned to home with his wife in 6 days.
1. How do you respond to the physiatrist's request for 'behavioral control'?
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Reframe from 'control' to assessment and a functional behavioral formulation. Before any behavioral plan, establish the likely drivers: post-traumatic agitation, pain, sleep disruption, overstimulation in the evening, communication deficits, and possibly delirium or medication effects. Recommend a delirium/medical screen and a medication review before attributing the behavior to 'noncompliance.'
Clarify roles: you can contribute a behavioral assessment and plan, but 'control' is not a psychological intervention and not a discharge criterion. Propose a multicomponent plan (environmental modification, scheduled rest, reduced evening stimulation, communication supports, consistent staff response) and data collection (ABC logs) so the team can see what is driving the behavior.
Be direct that a new antipsychotic without a formulation is a medication decision for the physiatrist, but that the behavioral plan should not wait on it and should not be framed as obedience training.
2. Nursing documents 'manipulative' and the speech therapist says he 'won't participate.' How do you intervene?
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Treat these as team cognition problems, not just patient problems. 'Manipulative' and 'won't participate' are conclusions that close off assessment. Use a non-blaming, curiosity-based approach: ask nursing what happens right before the yelling and what usually works; ask the SLP what the afternoon sessions look like and whether fatigue or overstimulation is a factor.
Offer concrete alternatives: replace 'manipulative' with a description of the behavior and its function in the chart; move demanding sessions to the morning; build in rest; use a consistent response script across staff. Model the language in the chart yourself so others can copy it.
If the SLP is being blamed, protect the interprofessional relationship by focusing on the fit between the schedule and his capacity, not on who is at fault. The goal is a shared formulation, not a winner.
3. Discharge to home with his wife is planned in 6 days. What is your role, and what do you flag?
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Your role is to ensure the discharge plan is safe, realistic, and supported, and that the wife is not set up as an unpaid, untrained caregiver for an agitated adult.
Flag: (1) the evening agitation pattern is not resolved and will be harder to manage at home; (2) the wife is frightened and needs psychoeducation, a crisis plan, and respite options; (3) a 6-day timeline may be too short if the formulation is still incomplete - recommend a conditional discharge with follow-up and a clear re-evaluation point.
Provide the wife with concrete strategies (de-escalation, reducing stimulation, when to call for help) and ensure she knows she is not expected to manage alone. Coordinate with the team on a follow-up appointment and a named contact. Document the risks and the plan; if the team proceeds despite unresolved risk, state your concerns in the record and recommend ethics or team review.