Managing the Acutely Agitated and Psychotic Patient - Case Study Example

Analysis of a Perceived Bullying Situation Paper Student: Institution: Descriptive Account Frank (pseudonym), a 21-year-old man, had been admitted to the psychiatric unit for a court-ordered psychiatric assessment. Frank has a long history with the justice system, including drug abuse, robbery with violence, sexual assault and other juvenile felonies. Nevertheless, Frank’s records indicated that he has a history of multiple residential placements in rehabilitation centres, as well as prior psychiatric hospitalizations. During the handover to the clinic, the case manager reported that the patient was manifesting aggressive and threatening behaviour towards witnesses and court officials during court sessions. Furthermore, Frank had violated the terms of his latest probation having engaged in violent outbursts at home. As I directed Frank to one of the rooms for assessment, he began to make verbal threats to other patients and staff in the unit. Once we entered the room, Frank managed to maintain behavioural control for a while. However, he was frustrated and lost control when I asked him about his engagement with the legal system and substance abuse. He started making gang-related threats as he walked around the room, and stated emphatically that he preferred to be rearrested and send back to jail than spend his time with a “foolish” nurse who knows nothing. At this moment, I stood up, placed my hands on the hips and looked into the patients eyes directly. I threatened to report him to the authorities if he failed to cooperate or resort to physical violence. In response, Frank became more agitated and turned his back away from me. He also refused to talk and instead focus on the charts across the wall. Structured Reflection The case of Frank presented above exemplifies the challenge that the majority of nurses encounter when dealing with aggressive patients. In essence, patients with mental limitations sometimes manifest aggressive behaviour that may harm staff, other patients, themselves, or property. The consequences of this aggression may be severe to the point of compromising effective care or cause nurse absence (Daffern, Howells, & Ogloff, 2007). Antonius et al. (2010) have shown that aggressive behaviour is prevent in psychiatric settings and affected individuals often direct this behaviour towards clinicians and other vulnerable patients. According to Ferns (2007), patients are the principal perpetrators of aggressive behaviour directed at nurses, followed by patients’ relatives, friends or visitors. Much as all health care workers are at risk of aggressive behaviour from patients, nurses are the most affected clinicians. The primary bullying behaviour demonstrated by Frank was verbal abuse. The majority of nurses (68% to 98%) have cited verbal abuse from patients as the most prominent form of bullying throughout their nursing career (Kynoch, Wu, & Chang, 2009). Physical abuse also occurs in some cases, but is not as common as the former behaviour (Daffern, Howells, & Ogloff, 2007). Soyka et al. (2007) have identified a myriad of factors that cause aggressive behaviour in patients. Some of these factors include an underlying psychiatric condition, personality disorders, and effects of drug abuse. From the case study, Frank had a history of drug abuse and psychiatric hospitalization. Therefore, the patient’s aggression stems from an underlying mental disorder that has not been diagnosed and treated adequately. Moreover, Frank would walk around the room while throwing his hands in the air when asked specific questions. In addition, he would refuse to talk and just stare at the charts on the walls. In the first instance, Frank’s body language was a manifestation of frustration, agitation and impatience. Nordstrom and Allen (2007) have indicated that psychotic patients normally become agitated when asked question on subjects they consider uncomfortable. Accordingly, these patients communicate non-verbally by pacing around, throwing items. Secondly, Frank’s refusal to talk was a clear non-verbal indication that he has lost interest in the treatment. In fact, he turned away and fixed his eyes on the wall. According to Daffern, Howells and Ogloff (2007), the refusal to talk or turning away communicates emotional disengagement. Based on the case study, I reacted to Frank’s inappropriate behaviour by threatening to report him to the authorities if he became violent towards me or refused to cooperate as required. This form of communication was inappropriate because Frank had stated early that he would have preferred to go back to jail than be at the hospital. In effect, he even thought that I was foolish. As such, reporting Frank to his case manager would have probably led to re-institutionalisation. On the contrary, Jonker et al. (2008) has opined that threatening aggressive patients destructs the entire situation and only serves to exacerbate the aggression further. Threatening an aggressive patient also discourages the patient to control his or her violent impulses (Jansen et al., 2006). As the case has indicated, Frank became more agitated when I threatened him and he refused to cooperate completely. Finally, non-verbal communication between nurses and patients accounts for approximately 55% percent of all interactions. This form of communication may take different forms in care settings. Nonetheless, the recognition of non-verbal expressions is critical managing aggressive behaviours (MacDonald, 2009). The non-verbal communication that I displayed in this case was looking at Frank straight in the eye and placing my hands on the hips. In the first instance, Frank could have interpreted my staring in his eyes as a challenge. In consequence, this action would have aggravated the situation further. On the other hand, placing hands on my hips would have indicated emotional distance or reluctance to help (Marcinowicz, Konstantynowicz, & Godlewski, 2010). Frank’s response to my body language was refusal to talk, as well as turning his back away. Developing Professional Practice The healthcare industry has increasingly become violent and healthcare workers are the frequent targets of aggressive behaviour. The majority of cases involving aggressive patients have been largely associated with psychiatric units. Victims of aggression and violence often report suffering from post-traumatic stress, anxiety, increased alcohol or drug dependence, fatigue and poor psychological health (Kynoch, Wu, & Chang, 2009). Violent and aggressive patient behaviours have broad consequences for both employers and nurses. For instance, hospitals incur massive financial costs in terms of staff turnover, litigation and compensation claims (Nordstrom & Allen, 2007). Thus, it is essential to adopt strategies for managing aggressive patients sufficiently against a backdrop of the aforementioned consequences. Aggression in clinical contexts is an intricate issue that requires thorough considerations for optimal monitoring, measurement and intervention. Furthermore, the diverse definitions of aggressive behaviour with no clear consensus demonstrate the difficulties encountered when classifying violent patient behaviour (Antonius et al., 2010). Additional complexities may arise considering the subjective nature of clinical documentation and reporting of aggressive and violent incidents (Bernstein & Saladino, 2007). Furthermore, nurses who witness the same aggressive incident offer accounts that differ considerably (Jonker et al., 2008). Thus, these complexities bring to the fore the need to make careful reflections when dealing with aggressive behaviour among patients. Prevention Strategies Three causal models have been formulated to stress the diverse origins of workplace aggression and violence in nursing. First, the internal model highlights the influence of patient factors in occupational violence. These factors include substance abuse, mental illness, gender and age. Second, external models emphasize the role played by factors external to the patient in the aggressive event. Such factors include staff ratios, space, temperature, overcrowding and time of the day. Thirdly, the situational model explores patient aggression by studying the correlation between external and internal variables identified beforehand. At the core of this framework is the belief that a combination of various factors may create an environment that affects the nurse-patient interaction negatively (Hills, 2008). In respect to the three models, the management of aggressive behaviour among patients requires a combination of prevention approaches, including seclusion and restraint. Nonetheless, the tendency to restraint and seclude aggressive patients has been contentious over the years (Hellerstein, Staub, & Lequesne, 2007). San Miguel and Rogan (2009) have found out that poor communication and environmental factors underpin violent and aggressive behaviour among patients. In other cases, Levy-Storms (2008) has reported that the “controlling” nature of clinicians undermines meaningful patient-clinician relationship. Therefore, Belcher and Jones (2009) have claimed that these issues points towards staff training and education in the management of violence and aggression. Even though there have been a shift towards the incorporation of de-escalation techniques in nursing practice, nurses continue to manage aggressive incidents reactively rather than proactively Nau et al., 2007). According to Aled (2007), the majority of training courses promote the principles of reactivity, which focus more on traditional strategies. These approaches include rapid sedation, restraint, seclusion and breakaway techniques. However, Jasmine (2009) has shown that nurses who have developed sound interpersonal skills through violence management training increase their theoretical knowledge of the early warning signs and triggers of aggressive behaviour. Rosenberg and Gallo-Silver (2011) have extended this notion by stating that well-developed interpersonal communication improves nurses’ confidence when they encounter violent situations. Moreover, the incorporation of risk identification and management strategies into ongoing and routine communications prevents aggressive behaviour (Bernstein & Saladino, 2007). One of the ways to accomplishing this goal is by interacting with patients in calm, respective and professional manner. Secondly, nurses should provide information coherently and explain procedures clearly, so that patients can understand the mutual expectations of acceptable behaviour (Rosenberg & Gallo-Silver, 2011). Thirdly, the provision of patient-centred care that meets individual nursing needs and promotes self-regulation is crucial in preventing patient aggressiveness. Fourthly, clinicians should use tailored and holistic care plans that incorporates a myriad of strategies for dealing with and preventing substance withdrawal, stress and disturbed behaviour (Belcher & Jones, 2009). Action Plan If a similar situation arose again, I would approach it differently by adopting psychological interventions that would help the aggressive patient to control his or her behaviour. However, it is imperative to note that psychological techniques to aggressive behaviour are not possible in the absence of communication techniques (Antonius et al., 2010). Therefore, I will have to first develop communication skills and proficiencies that help aggressive patients to express their anger in non-destructive ways. The reason for making this assertion is based on the lessons I learned from the case study. First, I approached the situation inappropriately by threatening the patient. Secondly, I realized that I had not nurtured the necessary competencies to handle an aggressive patient efficiently. Aggressive patients have the tendency to speak loudly and use abusive language just like in the case of Frank. Hence, it is crucial for nurses to communicate in a manner that calms down the patient. If I encounter an aggressive patient in the future, I will talk to him or her in a low voice and a reassuring tone. Kynoch, Wu and Chang (2009) have found out that aggressive patients increase their impulsive behaviour when nurses shout at them because they consider such an action as a challenge or competition. In the same vein, I would be empathetic to the patient and try to understand his or her situation instead of being judgmental. According to Nordstrom and Allen (2007), the level of agitation reduces significantly when clinicians validate and acknowledge aggressive patients’ feelings, in addition to reassuring them of unwavering support. As mentioned already in the preceding sections, the recognition and management of non-verbal communication are critical in handling an aggressive patient. The mistake I made when dealing with Frank was disengaging from the care process through non-verbalized body language. Hence, I would portray a relaxed and calm posture in the future when providing care to an aggressive patient. Nevertheless, I would desist from using impulsive and nervous gestures, as well as keep my eyes lower or at the same level as those of the patient. MacDonald (2009) has demonstrated that a relaxed and non-imposing posture is less threatening to the patients. Consequently, the patient interprets this body language as the nurse’s willingness to help him or her. Most importantly, I will be more assertive when faced with a similar situation in the future. When I reflect back to the case study, I realize that I was not self-confident enough to handle the situation competently. The main problem is that I kept directing Frank’s actions without giving any rationale. For instance, I threatened to report the patient if he did not cooperate instead of letting him recognize the significance of collaborating in nursing care. Daffern, Howells and Ogloff (2007) have identified assertive behaviour as the bridge between the continuum of passive and aggressive behaviour. Assertiveness does not only communicate a sense of self-awareness, but also conveys respect for the other patient. In relation to future practice, I will express assertiveness by making the aggressive patient realize that his or her behaviour is irrational while at the same time respecting their personal space. References Aled, J. (2007). Putting practice into teaching: An exploratory study of nursing undergraduates' interpersonal skills and the effects of using empirical data as a teaching and learning resource. Journal of Clinical Nursing, 16(12), 2297-2307. Antonius, D., Fuchs, L., Herbert, F., Kwon, J., Fried, J. L., Burton, P. R. S... & Malaspina, D. (2010). Psychiatric assessment of aggressive patients: A violent attack on a resident. American Journal of Psychiatry, 167(3), 253-259. doi:10.1176/appi.ajp.2009.09010063. Belcher, M., & Jones, L. K. (2009). Graduate nurses' experiences of developing trust in the nurse-patient relationship. Contemporary Nurse, 31(2), 142-152.    Bernstein, K. S., & J. P. Saladino (2007). Clinical assessment and management of psychiatric patients' violent and aggressive behaviours in general hospital. MEDSURG Nursing, 16(5), 301-310. Daffern, M., Howells, K., & Ogloff, J. (2007). What’s the point? Towards a methodology for assessing the function of psychiatric inpatient aggression. Behaviour and Research Therapy, 45, 101-111. Ferns, T. (2007). Factors that influence aggressive behaviour in acute care settings. Nursing Standard, 21(33), 41-45. Hellerstein, D. J., Staub, A. B., & Lequesne, E. (2007). Decreasing the use of restraint and seclusion among psychiatric inpatients. Journal of Psychiatric Practice, 13(5), 308-317. Hills, D. (2008). Relationship between aggression management training, perceived self-efficacy and rural general hospital nurses’ experiences of patient aggression. Contemporary Nurse, 31, 20-31. Jansen, G. J., Dassen T. W., Burgerhof J., & Midel, B. (2006). Psychiatric nurses’ attitude towards inpatient aggression: Preliminary report of the development of attitude towards aggression scale (ATAS). Aggressive Behaviour, 32, 44–53. Jasmine, T. J. X. (2009). The use of effective therapeutic communication skills in nursing practice. Singapore Nursing Journal, 36(1), 35. Jonker, E. J., Goossens, P. J. J., Steenhuis, I. H. M., & Oud, N. E. (2008). Patient aggression in clinical psychiatry: Perceptions of mental health nurses. Journal of Psychiatric and Mental Health Nursing, 15, 492-499. Kynoch, K., Wu, C. J., & Chang, A. M. (2009). The effectiveness of interventions in the prevention and management of aggressive behaviours in patients admitted to an acute hospital setting: A systematic review. JBI Library of Systematic Reviews, 7(6), 175-223. Levy-Storms, L. (2008). Therapeutic communication training in long-term care institutions: Recommendations for future research. Patient Education & Counseling, 73(1), 8-21. MacDonald, K. (2009). Patient-clinician eye contact: Social neuroscience and art of clinical engagement. Postgraduate Medicine, 121(4), 136–144. Marcinowicz, L., Konstantynowicz, J., & Godlewski, C. (2010). Patients' perceptions of GP non-verbal communication: A qualitative study. British Journal of General Practice, 60(571), 83–87. Nau, J., Dassen, T., Halfens, R., & Needham, I. (2007). Nursing students’ experiences in managing patient aggression. Nurse Education Today, 27(8), 933-946. Nordstrom, K., & Allen, M. H. (2007). Managing the acutely agitated and psychotic patient. CNS Spectrum, 12(17), 5-11. Rosenberg, S., & Gallo-Silver, L. (2011). Therapeutic communication skills and student nurses in the clinical setting. Teaching & Learning in Nursing, 6(1), 2-8. San Miguel, C., & Rogan, F. (2009). A good beginning: The long-term effects of a clinical communication programme. Contemporary Nurse: A Journal for the Australian Nursing Profession, 33(2), 179-190. Soyka, M., Graz, C., Bottlender, R., Dirschedl, P., & Schoech, H. (2007). Clinical correlates of later violence and criminal offences in schizophrenia. Schizophrenia Research, 94, 89-98.   NSG3CIN – Challenging Interactions in Nursing Developing Professional Practice paper – 2000 words (50% of overall subject mark) INDIVIDUAL GRADING AND FEEDBACK FORM Student Name: Student ID: STUDENT CHECKLIST (self-assess before submitting assignment) Tick when completed: 1 Descriptive account [250 words] Comprehensive and clearly presented descriptive account of the challenging communication encounter that succinctly sets the scene of the incident. Provides a detailed account of the verbal and non-verbal dialogue. √ 2 Structured reflection Critical analysis [650 words] Demonstrates excellent evidence of a process of reflection. Using extensive relevant literature to identify and critically analyse key issues within the challenging situation. √ 3 Developing Professional Practice [1100 words] Demonstrates the ability to incorporate an excellent overview of the situation. An in depth and practical integration of relevant literature, which demonstrates therapeutic use of self. Contextual application of relevant models and frameworks to develop Professional Practice considering a variety of broader issues. √ *Literature/ Sources Meet minimum number and type specified. Each source is relevant and credible. √ *Referencing APA 6 style (see La Trobe University library website for guidelines). √ *Presentation Professional language throughout with correct spelling and grammar Each page contains header with page numbers, subject and student details Text presented in Times New Roman or Arial font size 12, with double spacing and clearly delineated paragraphs. √ *Word limit Each element meets prescribed word limit. √ * Failure to meet the above requirements in your paper will result in loss of marks. NSG3CIN – Challenging Interactions in Nursing Assessment 3 Developing Professional Practice (50% of overall mark) Individual grading and feedback sheet Student Name: ____________________________Student ID: ____________________ Criteria Excellent (80-100%) Very good (70-80%) Good (60-70%) Fair (50-60%) Poor ( Read More