Best Practices in the Mental Health Setting

The general role of a mental health nurse is to provide non-prejudiced and holistic care of the patient. Psychiatric nurses play an important role as members of a multi-faceted treatment team in providing health promotion, assessment of dysfunction, and prevention of further disabilities. Nurses work in collaboration with other disciplines including psychiatrists, physicians, psychologists, and social workers to provide a well-rounded and holistic approach to treatment. Leanne Cowin (2003) points out that the primary nursing care goal is the ongoing development of a therapeutic relationship with the patient.Therapeutic alliances between patients and staff are encouraged to help decrease the ongoing problems of aggressive behaviors displayed by patients on mental health units. As a result, nurses are utilizing the appropriate tools to manage aggressive conditions. Tools include involving patients in psychological therapies, engaging in techniques to manage challenging behavior, and most importantly, building therapeutic relations. Because the emphasis of mental health nursing is on the development of therapeutic alliances, strategically building relationships should create the foundation to handling aggression more effectively. (Duxbury, 2005)In managing challenging behaviors, the utilization of various tools, specifically, cognitive behavioral therapy, will allow nurses to be more capable of carrying out nursing tasks in safer environments. Cognitive-behavioral therapy is a key branch of the psychological therapies used in mental health settings. This type of therapy aims to predict and control behaviors using a variety of methods. It is concerned with the perception and belief systems and changing the way things are viewed to better an outcome. “This treatment approach aims to identify and modulate cognitive, behavioral, and physiological responses to perceived provocation though various treatments.” (Graham, 2005) The ultimate goal of cognitive-behavioral theory is to reduce anger episodes by understanding and observing personal anger patterns and using alternative methods to handling provocation. This approach to therapy generally relies on present experiences as opposed to past ones. It tends to directly reduce symptoms as well as apply strategies designed to build better problem-solving skills.In gaining insight of how patients cope with daily challenges, role-playing assists nurses in comprehending situations patients’ experience. (Hahn, 2006) Participants are encouraged to perceive aggression from an interactional and situative context. Situations consist of moments wherein patients are experiencing paranoid thought, hallucinations, delusions, and states of aggression or anxiety. Nurses also take into consideration that patients have a barrier they are learning to cope with: mental illness. Key skills involving role-playing are the use of communication and presentation toward the patient. Nurses are to demonstrate effective communication through articulating at the level and appropriateness of the patient and situation. Role-playing has been successful in keeping nurses aware of patients’ behavioral patterns.Additionally, proactive actions in observing factors of aggressive behaviors prevent circumstances from becoming uncontainable. It is important to effectively “calm down” an escalating condition and prevent situations. This can be done by moving a patient to a calmer area to assist them in focusing and working with the treatment team to reduce feelings of anxiety or agitation. Nurses can help to “talk out” with the patient to identify possible stressors and triggers and ways to reduce them. Approaching the patient calmly and cautiously and keeping a neutral position is also beneficial to avoiding escalation. Neutral positions help to decrease paranoid thoughts and keeps patients aware of their surroundings. It also helps them to focus on the situation at hand. Neutral positions consist of keeping hands visible and being aware of facial expressions as engagement occurs.Situations involving patients who have displayed threats to safety of themselves or others permit nurses to engage in de-escalation techniques. De-escalation has proven a valuable intervention that is used by nurses to help encounter problems of aggression and violence. By using de-escalation techniques, nurses are more aware of patients who are beginning to escalate and intervene early. To recognize early warning signs and involve the patient in discussions on how to avoid seclusion and restraint best is an extremely valuable exercise if the event allows. Early warning signs of increasing agitation include physical and verbal signs of increasing anxiety, pacing and excessive body movements, as well as an increase in volume and tempo of voice. (Cowin, 2003) De-escalation in combination with problem solving and conflict resolution is an effective, alternative method to keeping safety on the wards. The use of restraint and seclusion should be utilized as a last resort. According to Joy Duxbury (2005), the seclusion of psychiatric patients is viewed as a violation of human rights.As new practices are put into place, the numbers of incidents involving aggressive and violent behaviors decrease. Less restrictive practices, such as de-escalation, help nurses to develop better relationships with their patients. This tool illustrates nurses’ abilities to communicate effectively while keeping the respect of the patient. Utilizing improved judgment and being able to read situations early provides more secure environments for both nurses and patients on wards. Using a combination of all tools maintains and increases autonomy and dignity of patients. This in turn allows for more productive outcomes in maintaining safety and dignity among their patients. Giving patients options to “talk it out” and use of less punitive measures takes nursing forward to finding a therapeutic common ground between patients and the treatment team.Positive connections were found between utilizing tools specified and rates of violent incidents decreasing, enabling psychiatric nurses to work with their patients in a more productive manner. Using techniques such as de-escalation and cognitive-behavioral theory exercises the patients’ ability to use a reality-based sense of coping when discharged into the community. Well-trained mental health nurses can help find critical therapeutic common ground between patients and staff, which can help maintain safety for all on the wards. A new level of effectiveness between a nurse and their patient allows for alternative methods regarding aggression and violence. This team concept of transforming relationships with patients towards a holistic approach leads ultimately better quality lives for patients.ReferencesHahn, S., Needham, I., Abderhalden, C., Duxbury, J., & Halfens, R. (2006) The effect of a training course on mental health nurses' attitudes on the reasons of patient aggression and its management. Journal of Psychiatric and Mental Health Nursing, 13(2), 197-204. Retrieved Janurary 19, 2008, from CINAHL database. (Documentation ID: 2009145056).Duxbury, J., & Whittington, R. (2005) Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469-478. Retrieved January 25, 2008, from CINAHL database. (Documentation ID: 2005110112).Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M., & Hoot, S. (2003) De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12(1), 64-73. Retrieved January 25, 2008, from CINAHL database. (Documentation ID: 2003163724).Graham, G., & Saini, M. (2005) An evidence-based review of psychological treatments of anger and aggression. Brief Treatment and Crisis Intervention, 5(2), 229. Retrieved January 15, 2008, from ProQuest database. (Document ID: 859805811).A. INTERVENTION 1: DE-ESCALATION TO HELP ENCOUNTER PROBLEMS OF AGGRESSION AND VIOLENCEi. Disadvantage 1: There are differences between the views of staff and patients about reasons for aggression and its managementA need for training in how to communicate and facilitate collaboration is implied by patients; mental nursing staff believes the use of de-escalation is successful in preventing the development of violence. Patients, however, were not of this view, which suggests that it may be poorly implemented despite its reported use by nursing staff. While de-escalation is encouraged in training today, it does not address interpersonal difficulties prior to the occurrence of aggression or fundamental and organizational deficiencies. (Duxbury, 2005)ii. Disadvantage 2 – Inadequate training techniques involving de-escalation can lead to ineffective communication between patient and nursing staff furthering agitation and aggressive/violent actionsInexperienced staff managing de-escalation events can increase agitation, which can escalate into violent actions. Communication is key! Staff alternatively turn to non-therapeutic techniques (i.e. seclusion and restraints, PRN medications/ stat IM orders) to “defuse” and “contain” the situation promptly. This approach does not consider the patient’s autonomy and dignity. (Cowin,2003)B. INTERVENTION 2: BUILDING THERAPEUTIC ALLIANCES BETWEEN PATIENTS AND STAFF TO HELP DECREASE THE ONGOING PROBLEMS OF AGGRESSIVE BEHAVIORSi. Disadvantage 1: Difficulties arise with patients who suffer brain injuries and/or are severely illPatients who suffer from traumatic brain injuries have varying degrees of comprehension. TBI often results in lifelong impairments in physical, cognitive, and psychosocial function, even in so-called "mild" cases.” A substantial proportion of individuals who sustain mild TBI also experience "persistent postconcussive syndrome," in which neurocognitive deficits and emotional symptoms persist beyond 12 months' postinjury." The most common psychiatric disturbances following TBI include major depression, anxiety; personality and neurobehavioral changes such as impulsivity and aggressiveness; and substance abuse. (Nelson, 2007)ii. Disadvantage 2: Cultural/Language barriersThough interpreters are present to translate vital information towards recovery from the treatment team to the patient, an aspect of the holistic model is absent. A direct, one-on-one interaction with a patient who has a language barrier and their caretaker is considered necessary towards a more effective recovery. Ethnocentrism plays a role as well in keeping alliances from developing between client and staff. (Alverson, 2007) There is also significant commonality within ethnic groups as there are significant contrasts between ethnic groups in the illness discourse and experiences of illness and of treatment.Nelson, L., Rhoades, D., Noonan, C., & Manson, S. (2007) Traumatic brain injury and mental health among two American Indian populations. Journal of Head Trauma Rehabilitation, 22(2), 105-12. Retrieved May 12, 2008, from CINAHL database. (Document ID: 2009558514Alverson, H., Drake, R., Carpenter-Song, E., Chu, E., Ritsema, M., & Smith, B. (2007) Ethnocultural variations in mental illness discourse: some implications for building therapeutic alliances. Psychiatric Services, 58(12), 1541-6. Retrieved: May 12, 2008, from Proquest database. (Document ID: 2009744297)