In the United States there are 1.7 million incidents each year where workplace violence has taken place (Mattingly, 1994-2011). Twelve percent of the incident involved a healthcare worker or a mental health worker (Mattingly, 1994-2011). In the Midwest sixty seven percent of nurses have been physically assaulted at least once within six months (Mattingly, 1994-2011). For the longest time they have been using only chemical restraints and seclusion and restraints as an intervention for dealing with agitated patients (Mattingly, 1994-2011). This has been an intervention used by healthcare workers for a long time. They use this method to deal with aggressive agitated patients in both the emergency room and the psychiatric hospitals (Mattingly, 1994-2011). A new method that has been introduced is de-escalation. According to International Journal of Mental Health Nursing the definition of de-escalation is the gradual resolution of a potentially violent and or an aggressive situation through the use of verbal and physical expression of empathy, alliance and non-confrontational limit setting that is based on respect (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Most health care workers do not have the skills needed to care for the mentally ill population. This paper will discuss: what causes this problem; what is the nurse role in caring for the patient; other alternatives and the outcomes and how a nurse would use these interventions in practice .
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There are several factors that cause healthcare providers to face difficulties while dealing with aggressive and mentally ill patients. Nowadays they have been working under limited conditions (Bigwood & Crowe, 2008). These units lack teamwork, leadership and they are much very unorganized (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Hospital units are overcrowded. In many regions, in order to get a bed in the psychiatric hospital, patients have to wait in the emergency room until a bed becomes available (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This ends in an overcrowded emergency room, low staffing ratio, the nurse is unable to exercise patience, and the patient is becoming increasingly agitated because they are confined to a bed in a little corner of an emergency room (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Hospitals are not taking the time to properly train these healthcare providers that are caring for this group (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). They are also unorganized when it comes to delegating functions and roles to the staff (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). In a crisis situation when a patient is agitated, if functions and roles are delegated everyone would be able to know what part they will partake in the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Without this training the healthcare provider tends to lack the confidence in caring and dealing with these patients (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003).
There are interventions to take when it comes to de-escalating a patient. The role of the nurse is to recognize the warning signs (Townsend, 2006). People do not just start off escalated. It starts off with small stages. The patient may become anxious. This may be a sign of impeding danger or threat that the patient faces discomfort (Townsend, 2006). They may start pacing, which is a back and forward movement (Townsend, 2006). Patients usually pace as a way to deal with stress or anxiety. They might exhibit excessive body movements which include: tremors, non-purposeful movements and shaking (Townsend, 2006). They also increase the volume and tempo of their voice, and their facial expression (Townsend, 2006). Recognizing these signs can help eliminate an escalating situation (Townsend, 2006) (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003).
Special skills are needed when it comes to de-escalating a patient. The most important intervention is to ensure safety(Townsend, 2006). Make sure the patient and the other patients are safe on the unit (Townsend, 2006). To ensure safety, remove the patient from the environment (Townsend, 2006). If that is not possible, remove the other patients from the environment (Townsend, 2006). Remove any potentially dangerous items from the area immediately (Townsend, 2006). Remove any staff that might be agitating the patient. Identify and remove stressors and remove them from them from the vicinity. The main goal in this situation is to reduce the stimuli (Townsend, 2006).
Healthcare providers will need to learn how to communicate with the patient. Communicating with the patient will involve verbal skills, which is called verbal de-escalation and nonverbal skills. The definition of verbal de-escalation is a complex therapeutic interactive process’ in that it is the act of talking to the patient and decreasing the patient from disturbed and excitability (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). The key to verbal de-escalation is knowing how to talk to an individual to calm them down. When de-escalating a situation make sure open ended questions are asked and open ended statements are made (Townsend, 2006). This will allow the patient the opportunity to express themselves and tell the healthcare provider what is wrong (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Make sure you find a calm space for the patient (Townsend, 2006). This will reduce the stimuli. Always avoid confrontation and judgmental comments to the patient. When talking to the patient give the patient your undivided attention (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Giving someone undivided attention involves facing them directly and giving them direct eye contact (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Speak in a calm tone. Make your presence is known by introducing yourself and your title. Your posture should be relaxed and comfortable (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). A defensive stance like arms around the waist or the hands are not visible can send a threating message to the patient (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Make sure statements will be reiterated to let the patient know that you were actively listening to them (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This will help clarify unclear information. The healthcare provider should be compassionate. At the same time they should be firm. They should not make promises or challenges. Keep statements clear and concise(Townsend, 2006). Lengthy and complex statements are avoided because the patient is mostly focused on one thing at a time (Townsend, 2006). It is also important to identify two types of escalated patients (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Always keep in mind that some patients will try to gain control of the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). They will try to be manipulative (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). It is the duty of the healthcare provider to allow the patient to take responsibility for their own actions and to regain control of themselves or the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). In any situation, the most common solution to any problem is respect. Showing respect to anyone goes a long way.
There are other alternative interventions that are used other than de-escalation: medication, seclusion and restraints. Medication is also considered to some people as a chemical restraint. Some healthcare providers use it as way to control and restrain a patients’ behavior (Bigwood & Crowe, 2008). The patient does not have any control over their body. A chemical restraint contains Haldol a typical antipsychotic and Ativan a benzodiazepine (Mattingly, 1994-2011). This shot has been known to put a patient down for several hours. Patients have to be monitored very closely to ensure safety and to detect the adverse effects that are involved with the typical antipsychotic medication (Bigwood & Crowe, 2008). Anti-psychotics block dopamine receptors in the body (Unbound Medicine, 2000-2011). It mainly works on the positive symptoms that patients are affected by (Townsend, 2006). The side effects of typical antipsychotics can be anything from seizures, blurred vision, respiratory depression, constipation, dry mouth, neuroleptic malignant syndrome, tardative dyskinesia (Unbound Medicine, 2000-2011). They are called extrapyramidal symptoms. While the patient is on this medication the nurse needs to monitor the patients’ vital signs, assess the mental status of the patient, assess for positive and negative symptoms, and assess intake and output to monitor bowel and bladder function (Unbound Medicine, 2000-2011). Monitor the patient’s laboratory reports, mainly the complete blood count with differential and liver function tests (Unbound Medicine, 2000-2011). These should be monitored during drug therapy (Unbound Medicine, 2000-2011). Benzodiazopines depresses the CNS and increases GABA in the body (Unbound Medicine, 2000-2011). This drug puts patients at risk for psychological and physiological dependence (Mattingly, 1994-2011).
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Seclusion and Restraint is another alternative way to control a patient. It is also known as timeout (Townsend, 2006). It is supposed to be used as a tool to guarantee safety to both staff and the patient involved. It has proven to cause more harm physically and psychologically to the patient (Bigwood & Crowe, 2008). These are intended to be used as a last resort for patients that are posing harm to themselves or others (Bigwood & Crowe, 2008). The procedure taken to administer this means of safety can be very risky (Bigwood & Crowe, 2008). Staff and patients tend to become injured as a result of this procedure (Bigwood & Crowe, 2008). Although at times nurses cannot avoid seclusion and restraints they need to administer them with care and compassion. That would include making sure that the patients basic needs are met. Have the patient stay in seclusion and restraints for a very limited time, at least until the patient has calmed down and can guarantee safety (Townsend, 2006). Again the nurse should monitor the vital signs, nutritional status, mental status when the patient is restrained (Townsend, 2006).
Applying de-escalation to nursing practice will decrease the amount of injuries in mental health hospitals and emergency room (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This will provide the nurse with the confidence in dealing with the mentally ill population. Patients’ needs will be able to be met more efficiently, because the nurse will be educated on how to care for them and how to communicate with the patient.
In practice, a nurse will treat mentally ill patients like any other type of person in society. This will consist of treating the patients with respect and ensure them with safety. The main thing to remember is that a nurse can never go wrong with taking the time to assess their patient. It will paint a picture of what is going on with a patient. With that, a nurse will be able to notice the early warning signs of an agitated patient. By doing so, their needs will be addressed. The patient may request medication or the patient may just be hungry. Nurses should continue to take classes to learn a lot more communication techniques on how to communicate with these particular types of patients. Giving them undivided attention and showing them that they are cared for as a patient, will ensure and verify that nurses has a lot of compassion in what they do. My passion is taking care of the mentally ill.
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