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2. Introduction. SignificanceSafety self
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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
36. 36