Working With People With Dementia - Essay Example

PHYSICAL RESTRAINT USE ON DEMENTIA PATIENTS Objective: The objective of this review was to arrive at an answer to the question "can physical restraints on dementia patients be avoided in emergency". The first aim was to determine emergency on the part of dementia patients and secondly the safety of the nursing staff who attend them. Design: Fourteen nursing journals in connection with physical restraints usage on dementia patients were examined. Results: Two main views are extracted from the reviews: emergency in terms of Aggression in dementia patients and safety related dilemma in nursing staff. Conclusion: Complete avoidance of physical restraints use on dementia patients is feasible only when their aggression recedes. INTRODUCTION: Physical restraints are applied to the dementia patients at the time of their aggression that leads to insecurity for them and the attending nurses. In view of nursing staff the physical restraints are applied on patients of dementia only as an intervention. (Koch Susan and Lyon Cheryl, 2001) Purely clinical emergency necessitating medical care on dementia patients does not pose any problem for the attending health staff and nurses. Dementia patients at this juncture are either passive or unconscious. Use of physical restraints on these types of patients does not arise. When the patients turn aggressive, the progress of medical attendance is blocked. This prompts the nursing staff to use physical restraints on the patients. Immediate attention towards reducing the aggression of the dementia patients dilutes the emergency in the atmosphere. Dementia patients suddenly turn hostile towards the attending nurses and agitate for reasons not known to the staff and not expressible by the patients. Agitation refers to a range of behaviors associated with dementia, including irritability, sleeplessness and verbal or physical aggressions. Often these types of behavior problems progress with stages of dementia, from mild to more severe. Pilot research studies designed to measure how agitation manifested, to measure the severity of agitation and to identify the nursing practices used to manage and their outcome revealed in the past that nurse actions triggered the majority of most highly rated episodes of agitated behavior in dementia patients. Search strategy: Three databases CINHAL, PROQUEST, AMERICAN JOURNAL OF GERIATRIC SOCIETY and BLACKWELL SYNERGY were searched using search terms 'dementia', 'physical restraints', and 'emergency'. On viewing the guidelines for using the physical restraints a book by Noreen Cavan Frisch is also found apt. Findings: On pressing the contents of the papers through the sieve of two main views extracted it is found that emergency arising out of aggressions of dementia patients is differently perceived by nurses and other beholders and safety related dilemma in nursing staff is due to the double sided pressure from both statutory enforcement and clinical guidelines for procedural therapy. EMERGENCY ARISING OUT OF AGGRESSIONS IN DEMENTIA PATIENTS: Gerry Farrel (2005) analyzed 28 aggression management-training programs and found that use of restraints on patients of mental health department is obligatory. Since the concentration of the research was mainly on industrial and other professional fields wherein aggression management programs are conducted, the stress of the same in mental health area is minimal although the authors made a mention that many of the AMPs did not address psychological aspects. (Gerry Farrell, Katrina Cubit, 2005) Some of the greatest challenges of nursing staff with the dementia patients are the personality and behavior changes that often occur. The nurses are given training to meet these challenges by using creativity, flexibility, patience and compassion. Before thinking of the decision to use physical restraints on the dementia patients so that treatment can take its smooth course, it is obligatory on the part of attending nurses to tactfully handle the troubling behavior of the patients. Trying to change the person and his behavior is mostly unsuccessful, since the behavioral change in the patients are due to brain disorder. Accommodating the behavioral change is to be preferred to controlling the behavior. Some underlying reasons for behavioral changes that are medically implicated such as the side effects of medications, hallucination, incontinence and pain has to be considered in favor of the dementia patients. Most importantly the behavior changes are triggered and does not occur out of the blue. The source that triggered such aggression in the patients is quite unable to be identified by the staff attending the patients even though they constantly attend them. By trying different approaches and different consequences the source may some time surface to the awareness of the nurses. Once the source of the aggression is identified, it is very easy for the staff to handle whatever be aggressive trend the patients exhibit. The key to manage difficult behaviors is simply to be creative and flexible all the time in the strategies to address a given problem. Any solution arrived at for a problem is not a rule in case of dementia patients. The same solution itself may become the source of the problem the other day. Creative and flexible strategies come to help at this stage for the nursing staff. A survey of threats made by Biran G. McKenna et al (2003) clearly depicted the endangering plight in which nursing staffs are working. The most common threatening behaviors exhibited by the patients in mental health area are verbal threats, verbal sexual harassment and physical intimidation. The team identified 22 incidents of assault requiring medical intervention. Male graduates and young nurses were mostly the preys to such aggressive patients. Use of physical restraints on such patients is thus made obligatory although many new incoming nursing candidates under go some undergraduate training in protecting against assault or in managing potentially violent incidents so that they want to equip themselves to meet the emergency arising out of dementia patient's aggression. May be the statutory inhibition against the use of physical restrains on the patients may be the back seat cause of such self-equipping strategies. (Biran G . McKenna, Suzette J.Poole, Naumai A. Smith, John H. Coverdale and Chris k. Gale, 2003) While taking the decision to use physical restrains on dementia patients and while executing and after it must be taken care to see that nursing staff are not guilt-struck. For this to be achieved the sense of self-confidence in them is necessarily to be inculcated. Studies made in the preceding years have landed at the point of accepting the need for special training in management of aggressive patients. The specifically trained nursing staffs were using physical restraints on the patients cognitively impaired at a considerably lesser degree. Meeting the needs of dementia patients that are many times revealed not verbally but by behavioral changes miss the attention of the attending nurses. Subsequent negligence arising out of such absence of feed back from the patients triggers the aggressive psyche in them. So, avoiding the aggression from patients must necessarily be carried out only through vigilant observation of the patients' mood and attitude. Christine R. Kovach's(2005) research on NDB model offers one of the best solutions to meet the behavioral problems in dementia patients. (Christine R. Kovach, Patrica E. Noonan, Andrea Matovina Schlidit and Thelma Wells, 2005) SAFETY RELATED DIELEMMA IN NURSING STAFF: In many cases of facing dementia patients' agitations, the nurses are at a bleak. This is possibly due to lack of special training for them in handling the situations in addition to the support of common laws for the patients. Although the use of physical restraints are customarily used on the dementia patients in time of utter need, the nursing staffs are still in dilemma to use the same or to come to a decision to use. The most common reason 90% for use of restraints on dementia patients was to prevent falls. (Jan PH. Hammers, Math JM. Gulpers and Willem Strik, 2004) Although the use of physical restraints on the cognitively impaired patients has inadequate effect of reducing their fall rates, bed rails, waist belt and chair with table are frequently used as physical restraints. Jan Hampers analysis point out that almost 90% residents were placed under restraints for more than 3 months. Possibility of triggering aggression in the patients is thus created. Use of physical restraints has to be meticulously followed considering the individual situations. Many healthcare institutions provide guidelines for the use of restraints on the patients with dementia. Univocally all the institutional reports emphasize the need to pre assess the behaviors of the dementia patients. Behaviors of the patients concerned should primarily be ascertained and only when the physician or nurse deems it fit to use the restraints on them, the devices can be used. Noreen Cavan Frisch(2001) lays a handful of humane guidelines regarding the use of physical restraints on the patients as an anger control assistance in somatic interventions, which hold good to the use of same on dementia patients as well. Some of the behaviors in Noreen's view forcing the use of restraints are: increased motor activity, verbal and physical threats, over responsiveness to stimuli and actual physical assault by the patients. The restraints must be checked before applying on the patients and should be seen that they are padded to avoid circulation problems and skin breakdown. Restraints must compulsorily be removed once in two hours for five minutes at least when they are to be used continuously for more than 2 hours. An utmost care must be paid to the nursing instruction that restraints should not be used as a measure of punishment on the dementia patients, since whatever the aggression or violence they exhibit are out of cognitive decline. (Noreen Cavan Frisch, Lawrence E.Frisch, 2001) The main reason for safety related dilemma in nursing staff is their less access to proper education of caring the patients. Frances Reed and Les Fitzgerald (2005) ascribe the nurses' lack of awareness of caring techniques to reduced achievement of Mental health Strategy goals. (Frances Reed and Les Fitzgerald, 2005) USE OF PHYSICAL RESTRAINST ON DEMENTIA PATIENTS IN THE TIME OF EMERGENCY: The over all review of the research bring us to come to a view that complete avoidance of physical restraints use in emergency is practically unfeasible and unadvisable too. A comprehensive search by David Evans et al (2002) positions itself in the researching field where many more researches are yet to be made in this direction. Out of the total 16 studies earmarked for evaluating the restraint minimization, only one RCT was identified, which landed the research team in the impossibility of gathering the statistical findings on the effectiveness of restraint minimization. (David Evans, Jacquelin Wood, Leonnie Lambert, 2002) CONCLUSION It is the combination of ignorance, inefficiency and irresponsibility on the part of caregivers and nursing staff that induces the overuse of physical restraints on the dementia patients. For want of space or safety many a staff prefer physical restraints to confinement of the dementia patients. Since placing physical restraints on them drastically reduces the movement of dementia patients, the very purpose of safety is many times shattered and the patients sustain injuries and higher eventualities. This is because of the reduced attention on the patients by the caregivers. The assumptions by the caregivers that physical restraints on the dementia patients will look into the safety issue by the devices leads to such heavy irregularities. Understanding the dementia patient's plight alone will fetch better results. If the use of physical restraints on agitating patients becomes obligatory, it will be yielding feasible outcomes only when used under personal care for restricted or limited spell of time. Albeit the use of physical restraints on dementia patients in times of emergency can not be outright rejected, nurses when offered suitable training in managing the dementia patients and usage of physical restraints are found to shine in the job of maintaining a laudable Mental Health Atmosphere. Reference list- Biran G . McKenna, Suzette J.Poole, Naumai A. Smith, John H. Coverdale and Chris k. Gale, 2003, " A Survey of Treats and violent behavior by patients against registered nurses in their first year of practice", International Journal of Mental Health Nursing, Vol 12(1), 56-63 Christine R. Kovach, Patrica E. Noonan, Andrea Matovina Schlidit and Thelma Wells, 2005, " A Model of Consequences of Need-Driven, Dementia-Compromised Behavior, Journal of Nursing Scholorship, Vol 37(2),134-140 David Evans, Jacquelin Wood, Leonnie Lambert, 2002, " A review of physical restraint minimization in the acute and residential care settings, Journal of Advanced Nursing, Vol 40(6), 616-625 Frances Reed and Les Fitzgerald, 2005, " The mixed attitudes of nurses to caring for people with mental illness in a rural general hospital", International Journal of Mental Health Nursing, 14(4), 249-257 Gerry Farrell, Katrina Cubit, 2005, "Nurses inder threat: A Comparison of content of 28 aggression management programs", International Journal of Mental Health Nursing, 14 (1), 44-53 Jan PH. Hammers, Math JM . Gulpers and Willem Strik, 2004, "Use of Physical Restraints with cognitively impaired nursing home residents", Journal of Advanced Nursing 45(3), 246-251 Koch Susan and Lyon Cheryl, 2001, International Journal of Nursing Practice 7(3):156-161) Noreen Cavan Frisch, Lawrence E.Frisch, 2001, "Psychiatric Mental Health Nursing", pp753, Thomson Delmar Learning Read More