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essay 范文Table of Content
Seclusion and Restraint Prevention in Acute Psychiatric Inpatient Setting................................2
Introduction ................................................................................................................. 2
Causes of Aggression .................................................................................................. 3
Prevention of aggression .........................................................................................................4
Risk Prediction......................................................................................................... 4
Leadership toward Organizational Change.............................................................. 5
Workforce Development.......................................................................................... 5
De-escalation Kit ..................................................................................................... 7
Improve Reporting................................................................................................... 8
Advanced Crisis Management ................................................................................. 9
Conclusion...........................................................................................................................10
Reference.......................................................................................................................12
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essay Seclusion and Restraint Prevention in Acute Psychiatric Inpatient Setting
Introduction
Aggressive incidents committed by patients are a major concern in mental health
inpatient settings (Maguire & Bryan, 2007). Nurses in mental health services are more
likely to be victims of violence or aggression (Needham et al. 2004). Aggression and
violence can be very traumatizing for the victims. The consequences of staff receiving
verbal or physical abuse can result in the staff being no longer able to continue his/her job
and requiring counseling (Rew & Ferns, 2004). Rippon (2000) supported that staff
experienced workplace violence may manifest symptoms of post-traumatic stress
disorder including anxiety, impaired work performance and insomnia (cited by Rew &
Ferns, 2004). There is a direct relationship between aggression and sick leave, burn out
and staff turnover among nurses.
A frequent reaction to patient aggression is the implementation of seclusion and physical
restraint. These practices have recently become the target of intense public criticism and
the focus of scientific scrutiny (Needham et al., 2004).#p#分页标题#e#
According to Haimowitz, Urff & Huckshorn (2006), each use of restraint poses an
inherent physical and psychological danger to the client and to the staff who administer
them. If the nurses used physical contact intervention as soon as situation arises, nurses
should view it as failure. There is a need for psychiatric nurse to use interventions that are
more therapeutic (Delaney, Cleary, Jordan & Horsfall, 2001).
The use of systematic risk assessments to predict aggressive behaviour or alternative
methods to manage aggressive patient have been proposed to achieve this objective
(Needham et al., 2004). Supporting and training staff in recognition of conflict situations
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and de-escalation techniques should be a priority in the healthcare service in order to
minimize risks to staff and clients with mental health problems.
The purpose of this article is not to provide a systematic review on interventions but to
propose interventions that may help to decrease seclusion and restraint as well as
aggressive incidents in the acute psychiatric ward.
Causes of Aggression
Duxbury (2002) identified three broad models of causation of violence as the nature
patient aggression is likely multifactorial.
The patient risk factor, aggression is mainly caused by the aggressive persons
mental illness and/or personality. Davison (2005) supported that inpatients that
are young, having a history of violence and being involuntarily admitted are at
risk of becoming violent.
essay The environmental risk factor- the persons physical and social environment is the
main cause of aggression. Report from the Royal College of Psychiatrists
mentioned that there are three important factors: the physical facilities provided
for the patients, visitors and staffs; the experience, training, supervision and
number of staff; and the policies in place to manage the clinical environment
(cited by Davison, 2005).
The situational risk factor- some studies show that staffs with professional mental
health training are less likely to be assault whereas others report that experienced
staffs are at higher risk because they are more likely to be involved in restraint.
Staffs who are namely rigid, authoritarian and custodial attitudes and a lack of
respect towards patients also have higher risk to be a victim (Davison, 2005).
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Prevention of aggression
The most effective way to manage aggression is to prevent it where possible. There are
several ways help reduce risks associated with physical restraint, rapid tranquillization
and seclusion.
Risk Prediction
Key activities of mental health nurses working in acute psychiatric inpatient settings are
to attempt to prevent aggressive incidents and to stop such incidents if they occur
(Duxbury, Hahn, Needham & Pulsford, 2008). Very often aggression is sudden and
unpredicted. Staffs working in clinical area find it very stress because they are not sure
who has the higher risk of anger outbreak. Researchers have worked and still working to
develop a reliable tool to predict violence (Beech & Bowyer, 2004). Almvik, Woods &
Rasmussen (2000) mentioned that use of short-term predictive instruments and improving
knowledge about aggression allowing early intervention will help to reduce level of stress.
Almvik & Woods (1999) have been seeking to develop tools to predict short-term
aggression. The growing number of research conducted to identify potential violent
individual in psychiatric setting indicates that the need for predictive tools. With these
aids, valuable resources can be better used, and thus, staff and patients will be less
exposed to violence.
There are several assessment tools available. Risk assessment tool like HCR-20 are not
designed to assess immediate risk of violence and have mainly been validated in forensic
populations. It can take several hours to complete (Almvik, Woods & Rasmussen, 2000).
There is a need to look for a quick, user-friendly instrument to predict risk and it must be
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reliable and valid for the targeting population. Almvik, Woods & Rasmussen (2000) had
done a study to examine the clinical validity and reliability of the The Brøset Violence
Checklist (BVC), as well as to examine the differences between the violent and
not-violent individuals and to study the effectiveness of the variables in predicting
violence. Almvik, Woods & Rasmussen (2000) conclude that the BVC is useful in
predicting violence within the next 24-hour period. More specifically, it is 63% accurate
in predicting that violence will occur within the next 24 hours and 92% accurate in
predicting that violence will not occur (Almvik, Woods & Rasmussen, 2000, p.1292).
Leadership toward Organizational Change
There are growing evidence supported that many restraint and seclusion events occur due
to the wards rigid policies regarding attendance at activities, wake and sleep times,#p#分页标题#e#
smoke breaks, meal times, and other rules designed to keep order but individual needs
or the signs and symptoms of mental illness are neglected. Facility leadership need
procedures in place that provide guidance to empowered staff to make decision to
suspend institutional rules and procedures in order to resolve conflicts to avoid the use
of restraint and seclusion (Huckshorn, Urff & Huckshorn, 2006).
Workforce Development
Training courses have been conducted to avoid eruptions of anger, to reduce the risk of
injury, to minimize the need for harsh coercive measures, and to help the patient control
themselves better (Needham et al. 2004). Staffs working in the ward are handling the
potential aggressive patient directly and it is very important that the nurses must possess
the knowledge and skills that are compatible with the demands of the task. Training gives
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the staffs opportunity to develop and practice skills for individualizing treatment planning
to help specific high-risk individuals (Haimowitz, Urff & Huckshorn, 2006).
Haimowitz et al. (2006) emphasized that staff must be able to understand the experiences
of seclusion and restraint; address the common myths in the use of restraint; introduce the
rationale and characteristics of trauma informed care; educate on the neurobiological and
psychological effects of trauma; and describe an alternative approach to manage
aggressive patient.
Bowers, Brennan, Flood, Lipang & Oladapo (2006) suggested that low conflict
environments are not achieved through high levels of containment, but through better
staff attitudes and working practices. Bowers identifies staffs positive appreciation of
patients; staffs ability to regulate their own natural emotional reactions towards patients
and the creation of an effective structure (rules and routine) for ward life as three
important factors in staff behaviour for the production of low-conflict, therapeutic
psychiatric wards (cited in Bowers et al. 2006). Bowers et al. (2006) further determined
that the three factors are dependent upon: (1) the staffs perception on mental illness and
their role in delivery of care; (2) moral commitments (e.g. non-judgemental, nursing
professionalism, humanism, honesty); (3) use of cognitive-emotional self-management
methods; (4) interpersonal skills; (5) Teamwork to achieve cohesion, consistency and
mutual support; and (6) clinical supervision and learning opportunities provided by the
organization.
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De-escalation Kit
Cowin et al. (2003) defined de-escalation as the use of verbal and physical expression of
empathy, alliance and non-confrontational limit setting with respect to achieve the
resolution of a potentially violent and/or aggressive situation.
Regardless of patient acuity, de-escalation is a key to reduce violent incidents on units as
well as seclusion and restraint. Greystone Park Psychiatric Hospital (GPPH) and the
School of Nursing of the University of Medicine and Dentistry of New Jersey (UMDNJ)
implemented the Four S Model (safety, support, structure, and symptom management)
with the De-escalation/Alternative to restraint flow sheet as the framework to organize
nursing interventions and improve patient care at the hospital. The
De-escalation/Alternative to Restraint Flowsheet helps staff understand what behaviours
to observe are and what interventions should be used.
In the 4 S model, safety is defined as interventions that help secure patients physical and
emotional well-being (e.g. reduce unpleasant stimulation). Support refers to interventions
that decrease patients distress or anxiety and increase their experience of being
understood. Structure helps restore clients functional levels after stabilization. An
example of providing structure is helping client set behaviour contract and remind client
expectations of hospital community life. Symptom management addresses symptoms and
prevents negative outcomes. Interventions include stress management, relaxation
techniques, diversionary interventions, grounding techniques, education/review resources
and medication (Chabora, Judge-gorny & Kim, 2003).
Maier mentioned two types of threat that mental health staff may face: threats that are
because of escalation and threats that are used as part of manipulation and control. The
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first type of threatening behaviour is defined as hot and the second is cold. To handle
the hot threat, staff must be able to recognize early signs of aggression and try to gain
sufficient time for the client to regain control of himself or herself before the situation
escalate into an aggressive event. This can be achieved by implementing the interventions
in the 4 S model. However, Maiers suggest that reaction towards client who uses threat
to gain control by manipulating staffs is to document all threats and discuss the event#p#分页标题#e#
with security experts, such as the police if required. The rationale of such reaction is to
encourage patients to take responsibility for their own behaviour (cited by Cowin et al.,
2003).
Improve Reporting
In IMH, staff nurses are writing most of the reports on patients mental state. Enrolled
nurses and healthcare attendants who also spend a lot of time with patients but they
usually verbally relate information about patients behavior to staff nurses and others.
Nolan & Citrome (2008) supported that if a therapy aid manages an aggressive incident
(e.g. verbal aggression) without assistant from other team members, the incident may not
be reported. Therefore, the current problem is some aggressive behaviour are not
witnessed by or reported to staff, those witness most of the aggressive behavior have less
opportunity to report what they see.
Treating aggression in clients with mental disorders depend on accurate detection,
description, and classification of behaviour. Improved reporting may have the
unanticipated effect on reducing physical aggression in the ward, perhaps by promoting
early recognition and intervention in events that might otherwise escalate into more
serious aggression (Nolan & Citrome, 2008).
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Nolan & Citrome (2008) conducted a study to determine the effectiveness of improving
reporting in Clinical Research and Evaluation Facility (CREF) at the Nathan Kline
Institute in USA. The therapy aids were required to document patients location, activities
and signs of aggression in the Patient Monitoring Form (PMF). In order to simplify and
encourage report on aggression, codes were added to the form: VA stands for verbal
aggression; PO for physical aggression against object; PAP for physical aggression
against persons and SAG for self-directed aggression. The researchers used audio and
video recording to detect the aggressive incidents in the unit. At the end of study period,
they compared the detected incidents with the reported incidents in the PMF. There was
an improvement in the reporting of aggressive incidents and decrease in physical
aggression.
Advanced Crisis Management
The Roadmap to a Restraint-Free Environment developed by the National Association of
Consumer/Survivor Mental Health Administrators (NACSMHA) and published by the
Substance Abuse and Mental Health Services Administration support the use of advanced
crisis management (ACM). The ACM allows a person to specify in advance actions to be
taken during times when he or she is unfit to make decisions. ACM is part of the#p#分页标题#e#
Wellness Recovery Action Plan (WRAP).
The ACM instructs the client to:
1. Identify events that might trigger or increase symptoms.
2. List things the client can do to relieve symptoms.
3. Make a list of early warning signs before crisis.
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4. Create a list of supporters who can take over responsibility for him/her and make
decisions in his/her behalf.
5. Write down the medication that the client prefers to take and reason for choosing
those medications.
6. List the treatments that the client would prefer in a crisis.
7. Describe what are the actions indicate supporters can stop using this plan.
The program believes that individuals naturally occurring crisis management techniques
can be used provided the plan is documented before the crisis occurs. Symptom
management and self awareness is a central element in the treatment.
Conclusion
It is difficult to determine the effectiveness of each intervention separately a lot of
interventions are implemented at the same time. Emmerson et al. (2007) implemented an
aggression management strategy included improve staff communication, new acute
pharmacological treatment protocols, mandatory staff aggression management training,
personal alarms and aggression risk assessment tools. One year after the introduction of
the strategy, there was a reduction of 40% in aggressive incidents and a 56% reduction
in staff injuries in 2005 compared to 2003 levels (Emmerson et al. 2007, p115).
Based on Needham et al. (2004) research outcome, there is significant decrease of
coercive measures after implementation of risk assessment tool followed by staff training.
Bowers et al. (2006) worked on improving staffs attitude and working practices. No
significant change in containment method use but there were significant decrease in
conflict occurred, with falls in aggression, absconding and self-harm. Further studies are
required to examine the effectiveness of these interventions in the ward if they are
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implemented locally. In the writers opinion, staff training and leadership are the most
important interventions to reduce use of seclusion and restraint in the ward. When the
managers and staffs are motivated to improve the quality of care, the rest of interventions
can be implemented properly.#p#分页标题#e#
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References
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Almvik, R., Woods, P., & Rasmussen, K. (2000). The Broset Violence Checklist:
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Delaney, J., Cleary, M., Jordan, R. & Horsfall J. (2001). An exploratory investigation
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Duxbury J. (2002). An evaluation of staff and patient views of and strategies employed to
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Needham, I., Abderhalden, C., Meer, R., Dassen, T., Haug, H.J., Halfens, R.J.G. &
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