Selected Issues in Mental Health Nursing Chia-Ling Mao

1. 1 Selected Issues in Mental Health Nursing Chia-Ling Mao & Marilyn Tagatac

2. 2 Introduction Significance Safety � self & clients Quality of care Background Extended roles of the nurse Myth of psychiatric treatment Patient�s right Ethical theories Nursing knowledge, technology advancement, work of professional organization -> expanding scope Psy Tx tends to be more coercive, less voluntary, less open to public awareness, pt�s level of competence, use of restraints, seclusionNursing knowledge, technology advancement, work of professional organization -> expanding scope Psy Tx tends to be more coercive, less voluntary, less open to public awareness, pt�s level of competence, use of restraints, seclusion

3. 3 Statutory and professional standards Standard of nursing practice � written document outlines minimum expectations for safe nursing practice Nurse practice act � defines the scope & limit of nursing practice Code of ethics � guideline for nurses regarding ethical conduct. Legislation - minimum expectation Protect N from liability for malpractice Protect N from liability for malpractice

4. 4 Critical Thinking in Mental Health Nursing 1. Parents demand that their child on a 72-hour hold, as a danger to self, be released to their custody to be evaluated by their child�s psychiatrist. You respond? 2. When would you administer medications without a patient consent? 3. Which is least restrictive - chemical or physical restraint?

5. 5 How would you advise? 911 - welfare check Mobile crisis team, Crisis Intervention Team 72-hour hold criteria, probable cause Danger to self Danger to others Gravely disabled Emergency admission: A 25-year-old man is seen standing on a rooftop. His employer calls the police and tells them the man had been behaving strangely. When the police arrive, the man states that he has special healing powers and no harm will come to him. The man believes the police have been provided to him as a courtesy, and he willingly accompanies them to a psychiatric facility Emergency admission: A 25-year-old man is seen standing on a rooftop. His employer calls the police and tells them the man had been behaving strangely. When the police arrive, the man states that he has special healing powers and no harm will come to him. The man believes the police have been provided to him as a courtesy, and he willingly accompanies them to a psychiatric facility

6. 6 Legal Issues Civil Rights: Commitment - Involuntary Commitment California�s LPS Act (1969) Criteria - Dangerous to self (DS) Dangerous to others (DO) Gravely Disabled (GD) Criteria is not the same in all states What is considered GD?

7. 7 Patient�s Legal Status Involuntary 72-hour hold, �5150� designated person authorized by law Tarasoff Law �duty to warn of threatened suicide or harm to others� 14-day, 180-day certification Conservatorship/ Public Guardian pt. unable to make own decisions

8. 8 Competence Determination Act Mini-Mental Status Examination Orientation Registration Recall Attention/ Calculation Language Alertness, attentiveness ability to process info thought processes ability to modulate mood and effect

9. 9 Patient�s Rights Confidentiality of records Least restrictive alternative to treatment Right to give or refuse consent for treatment What constitutes dangerous behavior that require meds to be given without patient consent? Freedom from restraint and seclusion Which is least restrictive - chemical or physical restraint?

10. 10 Violence A social problem that requires a public health approach - ecological model Macro-system � accounts for societal beliefs and cultural norms Micro-system � formal and informal social structures Exosystem � community level of influence Ontogenic development � individual factors including biological & neurodevlopmental factors Strongest predictor - a history of self-harm or injury to others Micro-system � formal and informal social structures ie neighborhood, schools, workplaces, Exosystem � community level of influence.\ which we have been exposed ; it has risk and protective factors. Risk factors ie lack of adequate housing, drug dealing in neighborhoods. Protective factors ie community-policing programs,Micro-system � formal and informal social structures ie neighborhood, schools, workplaces, Exosystem � community level of influence.\ which we have been exposed ; it has risk and protective factors. Risk factors ie lack of adequate housing, drug dealing in neighborhoods. Protective factors ie community-policing programs,

11. 11 Staff Rationale Chemical Restraints less physically restrictive longer-lasting effects allows pts to participate in other tx modalities more easily given (�Chemical restraint� is a contradiction.) Physical Restraints more immediate control;safety less invasive than medication allows patient to regain own control therapeutic choice for substance abuse

12. 12 Least Restrictive Alternatives Restraints have a negative influence on caregiving process. Dysfunctional - pt disempowerment (Janelli&Kanski, 1994) Utilize hierarchical interventions. Physical restraint is last alternative. Restraint to be used is based upon the individual client. Differing views result in contrasting staff interventions Numbers of restraint-associated deaths, mostly children and adolescentsNumbers of restraint-associated deaths, mostly children and adolescents

13. 13 Hierarchy of Least Restrictive Intervention 1:1 interaction/verbal redirection Decreased external stimuli (�quiet time�) PRN meds open seclusion locked seclusion (emergent meds) 2- point restraints 4-point restraints DOCUMENTATION is critical

14. 14 Being Restrained: a study of power and powerlessness (Johnson, 1998) Pt responses: anger, fear, resistance, humiliation, demoralization, discomfort, resignation, denial, and agreement We assume restrained pts are feeling frightened and out of control & that pts will feel relieved and safe with external limits.

15. 15 Power Struggles Take away all power and control; dehumanizing -basic protective human instinct taken away �We need to remember that restraining another person is a practice that renders another human being helpless. We need to use it as a last resort.�

16. 16 Violence in the Workplace Reflects increasing violence in society; incident is high and vastly under reported 75% of all psychiatric nursing staff assaulted at least once (Poster, 1996) Shorter hospital stays, sicker pts, budget cuts, understaffing, less community resources.

17. 17 Violence and Nurses Conflict between the roles of victim and caregiver Victims need time to pull back - anxiety, anger, vulnerability, PTSD, coping skills wholistic approach to the problem: examine the interaction of the assailant, others involved, & the environment (staffing levels) clinical, educational, & administrative support

18. 18 Unit Milieu and Violence Overcrowding, staff inexperience, provoking/controlling, poor limit setting, inconsistency Staff training critical - mandatory; team effort, coordination Staff need to be aware of their own feelings, responses; impact of staff behavior on pts. Hypervigilant about personal safety

19. 19 The Aggressive Patient Interventions Policy and practice; JCAHO S&R Standards Hierarchy of least restrictive intervention Staff aggressive physical response not allowed Goals Safe environment for everyone. Advocate and protect patient rights.

20. 20 Risk Factor for Aggression Major psychiatric disorders Personality disorders Med noncompliance Dual diagnosis Young males Low socioeconomic status Weapons Social isolation Criminal history History of violence Substance abuse

21. 21 Agitation, Aggression, Violence Agitation - hyperverbal, loud, pressured speech, pacing, hypervigilant, clenched fists, threatening stance, profanity Aggression - threat directed toward others (verbal, physical), assault Violence - outburst of physical force that abuses, injures, others or objects. Be able to anticipate reaction/bhv to possibly prevent agitation leading to aggression.

22. 22 Causes of Threatening Behaviors 1. Fear 2. Frustration 3. Manipulation 4. Intimidation Mental illness may impact the way person perceives and responds to the environment.

23. 23 Assault Cycle Triggering Escalation Crisis Recovery/depression phases (Table 14-1 Assault Cycle) (Table 14-2 Interventions based on the assault cycle)

24. 24 The 10 de-escalation commandments Be non-provocative � make contact, be calm, empathic Respect personal space Establish verbal contact � one communicator Be concise � get the attention but not confuse Identify the client�s wants and feelings � interpretation and validation Be non-provocative:Calm demeanor, facial expression, soft spoken, no angry tone, expressed empathy, relaxed stance, arms uncrossed, hands open Empathatic � base our care on what needs to be done or on what the pt is feeling; genuine concern, care or control 2. Respect personal space: 2X arms length, normal eye contact, offer a line of escape, expand space if paranoid, move if told to do 3. Establish verbal contact -orient the pt, use their first name, tell them who you are, establish you are keeping them safe, allow them no harm, help them regain control, one communicator 4. Be concise � talk low, slow, say it in less than 5 words � what�s going on? How can we help you? Repeat yourself, repeat yourself, get the pt�s attention, don�t confuse 5. Identify client�s needs and feelings- there is always a need behind their behavior; validat that need with the pt. �That must be frustrating�Be non-provocative:Calm demeanor, facial expression, soft spoken, no angry tone, expressed empathy, relaxed stance, arms uncrossed, hands open Empathatic � base our care on what needs to be done or on what the pt is feeling; genuine concern, care or control 2. Respect personal space: 2X arms length, normal eye contact, offer a line of escape, expand space if paranoid, move if told to do 3. Establish verbal contact -orient the pt, use their first name, tell them who you are, establish you are keeping them safe, allow them no harm, help them regain control, one communicator 4. Be concise � talk low, slow, say it in less than 5 words � what�s going on? How can we help you? Repeat yourself, repeat yourself, get the pt�s attention, don�t confuse 5. Identify client�s needs and feelings- there is always a need behind their behavior; validat that need with the pt. �That must be frustrating�

25. 25 de-escalation commandments (II) 6. Lay down the law � set limit, use (+) reinforcement 7. Listen � no argue, redirect to the issue at hand 8. Agree or agree to disagree � no power struggle 9. Have a strategic plan, a moderate show of force and be prepared to use it � team collaboration 10. Debrief with patient and staff 6. Lay down the law- set limits, offer choices, offer alternatives, establish consequences. Use positive reinforcements 7. Listen � no argue, redirect to the issue at hand, ignore challenging questions. Check understanding �Are you feeling scared?� 6. Lay down the law- set limits, offer choices, offer alternatives, establish consequences. Use positive reinforcements 7. Listen � no argue, redirect to the issue at hand, ignore challenging questions. Check understanding �Are you feeling scared?�

26. 26 Self-Protection Self control Be aware of your own feelings; �fight or flight�; �press your buttons� Self awareness/ assessment Physical/emotional balance Effective Evasion Observation strategy Position, distance self Allow an exit Never deal with an agitated client alone Remove self; summon help Knowledge deficits and biases of healthcare professionals are major factors limit domestic violence detection.Knowledge deficits and biases of healthcare professionals are major factors limit domestic violence detection.

27. 27 Nursing Interventionswith the Agitated Patient Meds PRN Anxiolytics - Ativan Typical/Atypical Antipsychotics - Haldol (po/IM), Risperidone, Zyprexa Communication Strategies Tips for Crisis Intervention

28. 28 Forensic client Evaluate defendant�s competency to stand trial & administer concomitant pretrial treatment

29. 29 Other violence Youth violence Intimate partner violence (IPV); Rape Child abuse Elder abuse Knowledge deficits including lack of avenue for referral, and biases of healthcare professionals limit detection of IPV. Rape by stranger � rate: 15% Rape trauma syndrome refers to a process that includes an acute disorganization phase and a long-term reorganization phase. Elder abuse � physical abuse, physical neglect, sexual abuse, psychological abuse or neglect, financial abuse, and violation of personal rights Knowledge deficits including lack of avenue for referral, and biases of healthcare professionals limit detection of IPV. Rape by stranger � rate: 15% Rape trauma syndrome refers to a process that includes an acute disorganization phase and a long-term reorganization phase. Elder abuse � physical abuse, physical neglect, sexual abuse, psychological abuse or neglect, financial abuse, and violation of personal rights

30. 30 Rape Rape is a crime Rape is under reported Perpetrator Stranger � 15% Date rape and acquaintance rape Sense of betrayal, self-blaming, � Marital rape ( a crime, but with evidence of force) Rape is under reported � wrong belief- it is a private and personal matter and fear of reprisal from the perpetrator Date rape does not happen just on the first date; it may occur during any stage of a relationshipRape is under reported � wrong belief- it is a private and personal matter and fear of reprisal from the perpetrator Date rape does not happen just on the first date; it may occur during any stage of a relationship

31. 31 Rape trauma syndrome � The first phase Acute phase of disorganization � days or weeks Response to rape, fear, anxiety, disbelief, anger, shock Physical signs- Sleep disturbance, nightmare, pains, body aches, fatigue, loss of appetite Ritual behaviors associate with ensuring safety Hyperalertness to potential danger Open response Vs. stoic response Irritability, difficulty concentrating, obsessive thought, tearfulness, anger, humiliation, guilt, shame RTS has Two phases process Ritual behaviors associate with ensuring safety including checking window and door locks repeatedly Hyperalertness to potential danger � scanning the environemnt continually for the rapist RTS has Two phases process Ritual behaviors associate with ensuring safety including checking window and door locks repeatedly Hyperalertness to potential danger � scanning the environemnt continually for the rapist

32. 32 Rape trauma syndrome � The second phase A long-term reorganization phase � integration and resolution of the experience Goal � regaining empowerment and reconnecting with others; learning new ways to feel safe again and to manage disturbing symptoms PTSD & others ie depression, anxiety disorders, substance abuse, sexual dysfunction disorders, dissociative identity disorder, borderline personality disorder anxiety disorders,ie agoraphobia, panic disorder anxiety disorders,ie agoraphobia, panic disorder

33. 33 Treatment for rape victims Psychopharmacologic interventions Antidepressant Antianxiety med Atypical antipsychotics Psychological interventions Behavioral therapy Cognitive therapy Individual therapy Group therapy, family therapy Biofeedback, relaxation training, assertiveness, hypnosis, body work (dance, massage, yoga�

34. 34 Ethical theories Utilitarianism Deontology Autonomy Beneficence Non malificence Fidelity Veracity Paternalism Justice

35. 35 Everyday ethics Interpersonal relationship - respect, caring Unconditional positive regard Request the search for human dignity

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