Mental Health Nursing: Managing Challenging Behaviour - Essay Example

? Managing Challenging Behaviour in Mental Health Introduction This paper critically evaluates my transition program that involved training on managing people with challenging behaviours, particularly in a mental health setting. It seeks to demonstrate the skills that I acquired in the transition and how these skills have influenced my development and learning. Consequently, I evaluate the particular fields for further research and study that the acquired skills have elicited to promote my professional development. The primary information from this program would be supported by previous works by various scholars borrowed from books on mental health nursing and journals on mental health, mental health nursing and intellectual disability. Rationale There are various behaviours that people consider as challenging. Examples among those with learning disabilities include self injury, violence, ambivalence, sexual disinhibition, non-compliance and substance abuse (Callaghan & Waldock 2012). Considering adults with learning disability, Neno, Aveyard and Heath identified repetitive actions, screaming, shouting, running away and resisting care as some common challenging behaviour (2007). According to NHS (2012), challenging behaviour would be mostly observed among people who have conditions affecting the brain and communication like dementia and learning disability. Since communication defines human interaction with one another, its breakdown becomes a problem, leading to frustration which yields challenging behaviour. If it leads to an outcome desired by the victim, then it could be repeated over and over again. The challenges experienced with these behaviours could be as a result of the support given or denied and problems resulting from inability to understand the things happening in the environment and how to communicate what such persons want. Having seen people with challenging behaviours in almost all the areas I have been working from as nursing student, I feel that learning how to manage such behaviours would be of paramount importance in my future profession as a mental health nurse. 1. Undertake and critically evaluate your transition activity Among the key areas of challenging behaviours that I undertook to train on included an evaluation of some of the common challenging behaviours, risk assessment, risk reduction and incidence prevention and treatment for those exhibiting such behaviours including forceful restraint. In as much as there was some focus on the role of the community, much emphasis was laid on my role as a mental health nurse in managing such situations. Understanding these facts from my perspective as a mental health nurse would be critical in my future role when handling people with learning disabilities. As noted by Emerson and Hatton (2008), these are the people who are likely to exhibit such behaviours. Much of the observed phenomena were from my experience having interacted with people with challenging behaviour in most of my undertakings. However, in this transition program, the observed phenomena were qualified with credible citation of supportive theories and findings from various scholars. I adopted the proposition by Ritter and Lampkin (2012) who categorised the triggers of challenging behaviours into primary, secondary and consequent. According to these scholars, primary causes are a result of the service user’s mental illness such as aggression when such a person hears voices. Secondary triggers result from symptoms of an illness which results in the service user responding negatively against other persons. Finally, consequential triggers would be caused by mental illness which leads to seeking for attention. However, it has always been difficult for me to identify a single cause of challenging behaviours in a person. Perhaps, the argument by the Xeniditis, Russel and Murphy (2012) that there would not be a unitary common cause associated with these behaviours. Having understood the causes of these behaviours, the transition program sought to equip me with the necessary management skills. 2. Demonstrate comprehensive knowledge of study chosen for transition and its relevance to my area of professional practice as a mental nurse The initial task in this transition program was to understand the origin and usage of the term challenging behaviour. This term was adapted in the United Kingdom after its first use with The Association for People with Severe Handicaps (TASH) in the US aimed at curbing the stigmatisation associated with previously used definitions such as maladaptive or aberrant behaviour (Gates 2010). From my experience, I found out that pegging labels on people with learning disabilities causes the society to make decisions such as excluding such persons from the community’s activities because of their aberrant behaviours. Therefore, the usage of the term challenging behaviours enables carers and professionals, including nurses, to appreciate a functional approach in handling such behaviours. According to Emerson et al. (2010), challenging behaviour refers to behaviour that is abnormal in a culture with the frequency and intensity that could jeopardise the person’s physical security or that of others, or that which would likely cause a delay or limit use of access to ordinary community services. It could be considered as relatively objective with observable phenomena (Funnell, Koutoukidis, & Lawrence 2009). As earlier noted, I have encountered so many people with challenging behaviours in the course of my training as a mental nurse. Research studies in the UK have indicated that the prevalence for challenging behaviours ranges between 30% and 40% (WHO 2007). In the national survey, of pupils in day schools, 8.2% in England and Wales had challenging behaviours (Emerson & Hatton 2008). Of importance is that between 2% and 20% of those people with learning disabilities were found to display aggressive behaviour. This means as a mental health nurse, a lot of responsibility is pegged on me to understand the cause of challenging behaviours and possible effective management techniques. These skills would be critical in ensuring that these persons live in harmony with the rest of the society and reduce the risk of them harming others. This transition program provided me with the necessary skills in prevention, diagnosis and managing people with challenging behaviours. As a mental health nurse, my role is to ensure the promotion of mental health by assessing, diagnosing and then treating human responses in as far as psychiatric disorders and mental health are concerned (Basavanthappa 2011; Emerson et al. 2010). 3. Critically review how this transition activity has contributed to your own learning and skills development Certain medical and health conditions contribute to increased risk of challenging behaviours such as sleep disturbance, seizure disorders, psychiatric disorders and illnesses related to pain. However, the Challenging Behaviour Foundation (2008) notes the difficulty in distinguishing whether the behaviour is learned or a result of psychiatric illness. My training revealed that many other factors such as environment and learning cause challenging behaviours. Therefore, the carer nurse should be conversant with the possible causes for effective management of the behaviours. In fact, NHS (2012) argues that with early detection of the warning signs, behavioural outbursts could be prevented. According to the Department of Health (2008), there are two widely employed interventions in managing challenging behaviours; behavioural intervention and medication. I second the argument by Willner (2005) that behavioural intervention would be most effective in assessing and treating challenging behaviours. Parry (2008) categorises them into three, with primary prevention referring to interventions that would reduce the chances of first instance occurrence of the challenging behaviours. These could occur even without any indications of the challenging behaviour. On the other hand, secondary prevention involves realisation of the early stages in a sequence of behaviours that would most probably result into challenging behaviours and employing various strategies prescribed in the care plan of a service user to defuse the cycle and de-escalate it. This would normally be employed after the failure of the primary prevention strategies, with the service user beginning to exhibit signs of challenging behaviour. However, when both primary and secondary prevention interventions fail, then a reactive intervention could be used including restrictive physical interventions. This program taught me that physical intervention is legal and could be used when necessary, with The Royal College of Psychiatrists (2007) citing 50% usage among people with learning disabilities. It refers to forceful control of one’s behaviour using some physical force which could be employed by use of mechanical devices, physical contact or change in the environment (Department of Health 2008). By changing the environment, the service user could be locked in a supervised confinement with the aim of containing severely disturbed behaviour deemed to harm others (Department of Constitutional Affairs 2007). Other scholars refer to this change of environment as ecological adaptations where adjustments are made to the environment so as to minimise the chances of occurrence of the problem behaviour (Gates 2011; Hudson et al. 2003; Mansell, Ritchie & Dyer 2010). As a mental health nurse, I would not be expected to execute these physical interventions that involve direct physical contact. Instead, I should advise on its usage; assess the risk involved and probably intervene in situations where such persons injure themselves. As earlier indicated, challenging behaviours could be a result of psychological trauma. Understanding these underlying traumas and conflicts would be important in my quest to solving the presented challenges. Despite having been denied from people with learning disabilities for quite long, psychotherapeutic interventions have now been widely adopted as effective and applicable (Willner 2003). Elder, Evans and Nizette (2009) observed that psychotherapeutic relationships have been greatly valued among the mentally ill. “Cognitive behavioural approaches either individually or in groups have been applied in problems of anxiety, anger, aggression and offending; psychodynamic approaches may be effective in reducing psychological distress and interpersonal problems and increasing self-esteem as well as reducing offending behaviour” (Royal College of Psychiatrists 2007, p.34). Therefore, this group analytic approach, which has been widely adopted, would ease our tasks. I also learnt the existence of specialist treatment units for people with challenging behaviours as described by Dooher (2008) and Mullen (2009). Here, I would be expected to provide specialist resources, support and environmental control. However, the approach suffers the risk of modelling the problem behaviours of each other. In case of challenges with handling the challenging behaviour, NHS (2012) recommends that I seek for assistance from a specialist who would require that I keep a record of the service user and determine the pattern of behaviour exhibited. The specialist would be interested in the situation that triggers the behaviour, any early warning signs and the happenings after the event. Consistency in the selected technique would be critical in this case. The existence of these treatment units meant to me that there could be psycho-pharmacological interventions available. And indeed, according to Targatt (2003), psychopharmacology tops the list of primary treatment modes available to people with learning disabilities even though in the UK, such measures have been minimally used in dealing with challenging behaviours. In spite of its wide usage in behavioural management, there have been minimal studies to determine their effectiveness (Royal College of Psychiatrists 2007). In addition, very few studies compare the various medicines in terms of their effectiveness. Without a specific treatment prescribed for specific challenges in behaviour, it would be challenging for me to rely on this approach as a nurse. Nonetheless, it would be crucial to consider medication as a critical component of managing aetiological psychiatric symptoms and psychiatric disorders (BBC Health 2012; Mansell, Ritchie & Dyer 2010). Antidepressants would be recommended for an underlying depression, antipsychotic drugs for psychotic disorder and mood stabilisers for cyclical mood disorder. 4. Critically reflect on this transition activity to determine further areas for personal and professional development and how this might be taken forward through future research and or further study as a registered practitioner Therefore, from this transition program, it is evident that as a mental health nurse, I have greater responsibility in management of challenging behaviours. It is my duty to prevent, detect and manage any challenging behaviours. According to WHO, “nurses are core health-care providers and they need to be able to contribute effectively to mental health care” (2007, p.1). In practice, I would be expected to intervene in cases of ill-conceived services, insufficiently skilled staff or under-resourcing (Royal College of Psychiatrists 2007). But dilemmas in recommending interventions that I believe represent best practice exist. The intervention could be discredited and I take the full blame for unrealistic expectations. On the other hand, I could propose pragmatic interventions that would solve short term issues but leave out underlying problems. Hence, care managers and commissioners would not learn from the issues, causing their recurrence. This highlights the importance of mental health nurses in formulation of guidelines for care of people with learning disabilities. In execution of my mandates, I would be expected to adhere to laid down code of conduct. WHO (2007) gives an example of the International Council of Nurses Code and the UN guidelines that require all persons with mental illness to be protected and their healthcare improved. Nonetheless, there are legislations to also protect me in case of actions aimed for the good such as the Mental Capacity Act 2005 which protects me against liability with regard to my actions in healthcare, personal care and treatment of an incapacitated person. In this, I am protected in case of restraining a person believed to have had the potential of causing harm to others and if it was proportionate (Department of Constitutional Affairs 2005). From this transition program, I still find the distinction between challenging behaviours and mental health problems elusive as supported by Eapen, Lee and Austin (2012). Therefore, I would require adequate training to enable me key out mental health problems in service users and further identify the incidental relationship between mental health problems and challenging behaviours. The Department of Health (2008) also argues on the minimal utilisation of applied behavioural analysis (ABA) across nursing institutions. This observation calls for research to explain this phenomenon and what measures would encourage its use. My suggestions for enhanced use of ABA include the establishment of clinical protocols and guidelines within services to make sure that ABA would be used. Secondly, I would need advance training on usage of ABA technologies before practising. There should be contacts established with nursing institutions to ensure that research is conducted effectively and efficiently. Since it is evident that a mental nurse would have to deal with people from different cultural, social and economic backgrounds, understanding these factors would be critical in enhancing therapeutic relationship. Dooher (2008) appreciates that unlike the other mental health workers, nurses in this field develop long term relationships as they spend more time working with the patients. My roles would thus not only be limited to the wards but could also be extended to the community (Mullen 2009; Ritter & Lampkin 2012). I would therefore be expected to be equipped with social skills and communication skills as noted by The Challenging Behaviour Foundation (2008). With the rapid changes in mental healthcare, it would be crucial that I constantly update my knowledge in the field. The need for advancement and updating of knowledge in the field would persist for as long as the mental healthcare system keeps adopting new strategies of provision of healthcare among people with learning disabilities. A mentor would play a critical role in making me not only a safe but also an effective practitioner. This practical competence would give me the qualification for registration with Nursing and Midwifery Council, NMC as noted by Dooher (2008). Conclusion In this transition program, I trained on management of challenging behaviours exhibited in various manners in a mental health setting. This was propagated by my observance of various people exhibiting such behaviours in my undertakings as a nursing student. This has enlightened me on my roles which encompass diagnosing, assessing and treating human psychiatric disorders and upholding mental health. It has come to my attention that the various forms of challenging behaviours which include seizure disorders, sleep disturbance, seizure disorders and psychiatric disorders among others could be handled effectively through a combination of healthcare programs such as behavioural intervention, psycho-pharmacological, psycho-pharmacological and community based approaches. The rapid changing adoption of newer varied techniques means that I have to constantly search for knowledge in pursuit of greater and emergent behavioural challenges management skills. Reference Bassavanthappa, BT 2011, Essentials of mental health, Jaypee Brothers Medical Publishers, New Delhi, India. BBC Health 2012, Mental Health, viewed 27 September 2012, www.bbc.co.uk Callaghan, P & Waldock, H 2012, Emergencies in mental health nursing, Oxford University Press, Oxford, UK. 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