The Management of Restraint and Seclusion for Aggression in Psychiatric Patients in Inpatient Units - Essay Example

? The Management of Restraint and Seclusion for Aggression in Psychiatric Patients in Inpatient Units By of [Word Count] [Date] Blog Nursing Management of Restraint The nursing incident under review involved a 64-year psychiatric patient called Jane. Although initially nonviolent, Jane turned aggressive during normal sampling for tests and punched the nurse who was collecting samples for the tests. On becoming excessively aggressive, the patient was secluded and further restraint to minimize harm to her, her loved ones and the facilities’ staffs and other clients. However, these interventions are rather controversial and the family members opposed their use just as health care and legal professionals and the public continue to question their therapeutic capacities. Consequently, their use is questioned and opposed in equal measures. Instead, aggression management strategies such as individualized safety plans, patient-specific and focused restraint management and prevention, staff notification of restraint and seclusion phenomena, official briefing and debriefing about restraint and nursing staff mentoring are encouraged. In applying these interventions, a nurse leaders and managers should work with all other stakeholders, especially other medical and nursing staff and the families or caretakers of the patient. Consultative approach to leadership would have been quite appropriate for dealing with Jane’s situation. Transformational leadership theory, which postulates that great leadership emerges in cases of problems and encourages collaboration and teamwork, could also apply in this situation. In addition, the contingency theory, which expects leaders to different behaviours and contexts or circumstances are and react accordingly is also appropriate for handling Jane’s aggression. This paper proposes strategies likely to help eliminate or reduce the use of restraint and seclusion as the first choice measures whenever a psychiatric patient turns aggressive on self or others. Introduction For many nurses working in psychiatric inpatient units, violence and aggression are common phenomena. Aggression continues to pose serious challenges to psychiatric inpatient unit nurses despite the many modern and universal methods and strategies of restraint (Schacht, 2006). The two most commonly used interventions applied in the treatment and management of violent and disruptive conducts in psychiatric patients are seclusion and intervention (Anderson & West, 2011). Notably, the application and management of these nursing interventions vary from one country and institution to another. The central role played by these interventions have been largely highlighted in quite a number of nursing and health care studies and literatures, with most of the authors citing numerous recommendations for managing and reducing mental patient aggression (Peterson, 2004). In most of the studies and literatures, the effects of seclusion and restraint on mental illness patients and the prevention of seclusion and restraint or the reduction of their use are among the most highlighted aspects of seclusion management (The Joint Commission, 2008). Whereas seclusion refers to retaining and placing a mentally ill inpatient in a room so that the immediate aggressive clinical situation is contained, restraint entails the use of different techniques that are custom-made to confine a mentally person to specific body motions (Cruzan, 1992). Despite the difference in meaning, both seclusion and restraint are measures generally used with the aim of preventing further injuries to patients, harm to nurses and to reduce violence and agitation (Centers for Medicare & Medicaid Services, 2006). This paper explores the appropriate management and leadership strategies for handling restraint of mentally ill inpatients by nurses. The following case study of an aggressive patient will form the basis of the proposed aggression management strategies outlined in the paper. Sample Case Jane (name changed for confidentiality) is 64 years old and has no significant medical history. Her husband took her to her physician after he suspected her of behaving more confused than she normally was. According to the diagnosis by the physician, Jane was drowsy, disoriented and confused about the date, including the current year. Her blood pressure was 110 / 70 mmHg and her pulse was 90 bpm while her body temperature was 38.5 degrees Celsius. It was recommended that she be admitted to the inpatient unit upon which the findings of the earlier diagnosis were confirmed. In addition, chest X-ray was normal. However, while the pre-registration house officer (PRHO) was taking a routine blood tests and cultures from Jane, she suddenly became rather distressed, started shouting and punched the PRHO in the face. Jane’s is just one of the many aggressive psychiatric inpatients that nurses encounter in their practice. In general, these situations are managed by sorting out the fever, encouraging the patient to rest, calming the patient and obtaining consent to start treatment (Hockenbury, 2004). In more serious cases of aggression, interventions such as seclusion and restraint are often applied. However, seclusion and restraint are quite controversial techniques. Theoretical Basis Restraint and seclusion are theoretical based on whether they are therapeutically valid procedures or not. That is, questions have been raised on whether restraint and seclusion are merely measures by which nurses and other health care providers manage and contain emergency situations in psychiatric settings (National Technical Assistance Center, 2007). What is more, some people are of the opinion that restraint and seclusion are used by nurses as punishment for psychiatric patients. In fact, the frequency and effectiveness of these measures in managing and reducing aggressive incidents in mental inpatients is not yet fully established (National Institute of Mental Health, 2009). Lamentably, little work has been done and published on the efficacy and effectiveness of subjecting psychiatric inpatients to restraint and its effects on both nurses and patients (Yehuda & Agassi, 1983). In the few studies that have interviewed psychiatric patients placed under restraint, the various helpful and unhelpful factors associated with restraint have been largely explored (O'Connell et al., 2009). Importantly, the aftermath of restraint incidents has been an area of focus for many authors and researchers. A general finding in these studies and literatures is that restraint has quite intense emotional impacts on patients and psychiatric inpatient nurses (Rawcliffe et al., 2002). The other notable finding is that while patients crave nurses’ attention, nurses do not give this much needed attention (Mullins, 2010). Among the reported feelings among restrained patients is distress, feelings of being upset, isolated and ashamed in the aftermath (Bell, 2011). Although patients reportedly value post-restraint incident briefing, rarely is such service offered. Hence, many psychiatric patients live with the fear of the possibility of being restrained again due to little of no post-incident briefing or counseling (Cuijpers, 2003). In some cases, patients and nurses report the reawakening of memories of past traumatic experiences after restraint incidents (Sharfstein, 2008). Leadership Theories and Perspectives in Nursing One of the theories of leadership that is largely applied and effective in nursing and other social spheres is transformational leadership theory. This theory postulates that leaders should embrace and cause positive change in an organisation and its followers. That is, a leader should direct and support change, setting good examples for his or her subordinates to follow. To achieve positive organisational and individual change, a leader requires being passionate, energetic and enthusiastic, concerned and involved in the entire work process and wellbeing of workers (Simmel, 2006). In health and other social setting, leadership perspectives that modify organisational behaviour and promote change for a better working and social life are highly regarded (Vikram & Prince, 2010). In fact, sociologically, leadership should be basically viewed in regards to an individual’s character and pre-eminence in behaviour, values, norms and customs (Lees, 2007). To drive these behaviours and norms and ascendancy to leadership, one requires superior strength, tact, intelligence. In addition, sociological theories postulate that a person striving to be a leader develops the capacity to set new objectives, present new and bigger expectations (Lees, 2007). These goals and expectations should be intended to bring out the unique and noble potentials of the individual and the group. The psychological and sociological perspectives of leadership expect that social workers be pro-change. In fact, this trait would be quite effective in current time in which the health and social care sectors are facing imminent organisational and culture change (Buchanan & Huczynski, 2010). Social and health care workers and leaders should not be bombarded with these changes; instead, they should be part of the external and internal forces that drive change in their respective professions. Nursing and social sector leaders should embrace value-based systems, which are some of the outcomes of the current change experienced in health and social care (Buchanan & Huczynski, 2010). In addition, nurses and other social workers cannot ignore the need for and the importance of accountability in rehabilitation and the requisite action steps for dealing with different health and social issues. Handling Diversity in Health and Social Care Diversity in the nursing workforce is the other aspect of nursing that a health care leader should be conversant with. Otherwise, it could prove difficult to achieve personal and organisation objectives (Buchanan & Huczynski, 2010). It is of the essence that a leader ensures this diversity exists for benefits such as provision of culturally diverse and adequate and competent care to the diverse client base. In addition, a nursing leader can exploit this diversity to expand health care access to areas hitherto blocked from such services. Furthermore, the pool of nursing managers and policymakers is likely to be expanded, implying better services for the diverse population (Schermerhorn, 2010). Leaders should thus initiate and implement far-reaching reforms in the health care sector to achieve a diverse health care workforce and satisfied diverse clients. The Importance of Leadership Skills, Competencies and Team Work Nurses dealing with the aggressive psychiatric inpatients should also possess several leadership skills and competencies, which include but are not limited to self-assessment and sharp perception (Greene et al., 2006). Whereas self-assessment would ensure that a nurse evaluates own strengths and shortcomings and initiates corrective measures, sharp perception will help a leader nurse to understand subordinates’ perceptions of him or her (Taylor, 2010). The other qualities of good leadership in nursing are responsiveness to group and individual needs, knowledge of the facility, team-building, negotiation, motivation and goal-setting skills all of which are crucial for managing psychiatric nursing facilities (WHO, 2005). Armed with these skills, qualities and competencies, a nurse is best placed to deal with interventions such as seclusion and restraint for aggressive psychiatric patients (WHO, 2005). Team work in nursing setting is quite crucial and would assist in managing psychiatric patients. Among the benefits of team work to psychiatric nurses include increasing the timely and fast completion of work effectively and efficiently. The second importance of team work to psychiatric nurses is delegation of duties, based on team members’ weaknesses and strengths (Kutz, 2011). Proficiency at dividing tasks is thus of unparalleled importance. Sharing of ideas and giving support to one another are the other benefits of team work for nursing and social workers (Kutz, 2011). Finally, team work helps attaining synergy, complimenting individual weakness, increased productivity and the building of new and improved skills and working culture. To develop these leadership skills and competencies, one may apply several strategies. First, one must take the initiative to go beyond the current responsibilities and take on more challenging tasks. That is, one could implement projects and tasks outside the current job description, of course with the consent of the boss or team members (Fatchett, 2012). The second strategy for acquiring leadership skills and competencies is critical thinking. Critical thinking and the ability to foresee potential problems before they occur enhance one’s chances of being assigned high-profile tasks. Effective communication, especially listening and the ability to motivate colleagues are the other strategies that may sharpen one’s leadership skills and competencies in nursing and other social workplaces (Agassi, 1996). Finally, being a good follower, handling conflicts, discipline, constant learning and skills at delegating duties could drive one to achieve leadership skills (Rissmiller & Rissmiller, 2006). Approaches to the Management of Restraint and Seclusion There are quite many interventions that may be used to restrain Jane and other aggressive psychiatric unit inpatients to avoid further injuries to herself and those around her such as nurses and family. Several approaches and methodologies to the management of restraint are in use by different states and professional organisations across the globe (Senior & Swailes, 2010). A key feature of these strategies is their core aim of minimizing restraint and seclusion usage in psychiatric inpatient units for managing cases of aggression of these facilities’ patients (Huckshorn, 2006). The main among these strategies are individualized safety plans, patient-specific and focused restraint management and prevention, staff notification of restraint and seclusion phenomena, official briefing and debriefing about restraint and nursing staff mentoring among others (Porter, 2002). The use of peer advocates is the other commonly recommended strategy for managing and preventing restraint and seclusion use in psychiatric inpatient units (Hosman, 2006). The first step in the strategies for preventing and managing restraint and seclusion in psychiatric inpatients is the determination and definition of the problem to be addressed (Sarnecky, 1999). Although inpatient mental and behavioural health units often apply restraint and seclusion to prevent violent patients from harming themselves and people around them, these interventions are always associated with several risks to patients and nurses (Brooks, 2007). It is for these risks that governments and professional mental health organisations have set standards and regulations that restrict the use of these interventions to emergency situations only (Hans-Ulrich & Jacobi, 2005). The calls for non-physical management of aggressive conducts by mentally ill persons have been on the rise in recent times (Patel & Heginbotham, 2007). Despite the national and international efforts at reducing the use of restraint and seclusion, individual psychiatric inpatient units have largely lagged behind in the implementation of non-physical interventions to aggression in inpatient units of behaviuoral health problems (Huckshorn & LeBell, 2009). Recommended Strategies for Managing Restraint A recommended approach to managing the use of restraint and seclusion for psychiatric inpatients should encompass many strategies that promote individualized safety plans, staff notification, formal briefing and debriefing, peer advocates and nursing staff mentoring among other strategies (McAfee & Mitruski, 2006). The following section highlights the crucial components of restraint management program that an inpatient unit for psychiatric patients should design and implement. First, the concept of individualized safety and health plan should be highly weighted (Widiger & Sankis, 2000). In this regard, once a patient is admitted in an inpatient facility, it is of the essence that the nurses, physicians, patients and their loved ones or caregivers collaborate in developing a treatment plan that would serve the specific interests and needs of the patient (Marquis & Huston, 2009). The inclusion of a patient’s treatment preferences in such a plan is of paramount importance. In including this treatment strategy, the secret to success is applying a method that would ensure a calm environment even if a patient becomes aggressive (Atkinson, 2006). Among these strategies are; de-escalation technique, sensory modulation intervention, de-escalation locations, staff wrap-up, executive partners on call programs, peer support specialists, formal briefing and debriefing and staff mentoring. De-escalation Techniques and De-escalation Location Whereas de-escalation techniques refer to interventions targeting caregivers’ reactions to aggression in psychiatric patients, de-escalation locations refers to the use of neurobehavioural houses designed to contain autistic adolescents (Stuart, 2006). In de-escalation techniques, caregivers are advised to respond to aggressive inpatients using calm voice and leave patients to themselves or lead them to their rooms to calm them down (Olds et al., 2007). Similarly, caregivers are advised to apply therapeutic communication techniques while addressing patients who are likely to turn aggressive. In de-escalation locations strategy, the room used for aggressive psychiatric patients should be installed with gentle multisensory stimulations (NASMHPD, 2005). Importantly, the surrounding of the room should have calming and threat-free settings. In fact, in some facilities, there are special rooms fitted with calming furniture such as soft rocking chair and fish tanks to give patients calming or quiet time (Weller & Eysenck, 1992). Conclusion Restraint and Seclusion continue to be key professionalism and ethical challenges to nurses working in psychiatric facilities’ inpatient units. 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