Mental Health Incident - Essay Example

?Reflection: Mental Health Incident Introduction Reflection is one of the most essential elements of nursing practice. It helps provide a basis for changes which can be implemented into the practice and it also provides a basis for future improvements which can be made into the practice. In mental health care, reflection is also a valuable tool because it helps provide the practitioners with insight on their actions and the actions of their colleagues. This paper shall provide a reflection on an incident in the mental health unit where I undertook my placement. The Driscoll model shall be used as the reflection tool for this paper. Body: Driscoll reflective model What? A description of the event The purpose in returning to this situation is to review my actions and to evaluate whether or not these actions were in accordance with the standards of the practice. I also returned to this situation in order to establish areas of improvement and to evaluate how well I performed in the actual clinical setting. During one of my shifts in my mental health placement, I encountered an aggressive patient, who shall be referred to as Mr. Y, in order to protect his identity and maintain patient confidentiality. He was a 22 year old male patient diagnosed recently with schizophrenia. When I first approached him, he was very wary and nervous. I initially introduced myself to him and maintained a comfortable distance of about 4 feet. He was sitting on a stool looking angrily at anyone who approached him. His medication was due and I was tasked with administering it. Accompanied by my mentor, I approached the patient, introduced myself and said that his oral medication was due and I was there to help him take it. As I was talking, I noted that he was on the verge of aggression so I kept a safe distance from him. I waited for him to respond, but then he suddenly stood up and tried to lunge at me. I stepped away from him before he could grab me and my mentor and the other staff nurses immediately grabbed him before he could inflict any physical harm. The staff told me to proceed in giving him the medication. Since, it was an oral medication, it was difficult to administer as he clenched his jaw and tried to bite off my fingers. With some assistance from the staff members I was able to administer the medication. After the incident, he was immediately restrained and strapped to the bed. During the incident, I observed that I physically prepared myself for a possible attack from an aggressive patient, and that based on the quick response of the staff and my mentor, they were also expecting aggression from the patient. They also sensed possible aggression based on the demeanour of the patient before the incident. The assistance which was given to me during the incident was very much welcome because I would not have been able to handle the aggressive patient on my own. The main element I observed in the situation is the period of escalation from a possibly aggressive patient. The study by Beech and Leather (2003) indicate that the escalation of aggression can often be observed from the patient’s demeanour, his failure to cooperate with the staff and then finally his actual physical act of aggression. Dunn and colleagues (2007) discuss that there may be various interventions which could have been done to de-escalate his aggression and prevent the actual act of aggression. Dunn, et.al., (2007) also point out that the act of physically restraining the patient is often commonly used for these aggressive patients. Chemical restraints could have been administered however, the staff explained that chemical restraints might not interact well with his current medications. Melillo and Houde (2011) discuss the chemical restraints administered alongside psychopharmacological drugs can have adverse interactions and can cause further agitation and confusion. Stewart, et.al., (2009) also discuss that maintaining a therapeutic distance from mental health patients is crucial in the protection of one’s safety as well as the prevention of any negative reactions from mental health patients. At all times, I was fortunately able to maintain such a distance. So what? At the time the patient displayed aggressive behaviour, I became very anxious and nervous because I was afraid that I might actually get hurt and I was also concerned that I may have done something to trigger the aggressive incident. I also felt concerned for the safety of the patient during this period of aggression. I understood the need to use physical restraints on him, however, I still did not feel comfortable about the restraints being applied on the patient. I felt that the physical restraints may cause him physical injuries. In looking back on the incident, I feel that when I already noted signs of aggression, I should have tried to de-escalate the aggression first before I attempted to administer the medication. I saw the signs of possible aggression and yet I still tried to perform the intervention. As a result, I could have placed myself in danger of actual physical harm. I also knew that mental health patients often do not like taking their medications and the mere fact that I was trying to administer it to him may have triggered the act of aggression. As I was able to review my actions and my knowledge of aggressive mental health patients, my feelings have slightly changed. I now feel that I could have acted differently in order to manage the aggressive patient. When I maintained a therapeutic distance from my patient, I was able to protect myself from any physical harm. However, my mere act of trying to administer the medication may have triggered the aggression from the patient. Nevertheless, I was able to assist in administering the medication and eventually physically restraining him. My act of securing the guard rail also prevented any further injury from befalling the patient. From my actions, the good that emerged was mostly on the prevention of any physical harm from befalling myself, other staff members, and the patient himself. I was also able to administer his medication despite the patient’s aggression and I was able to assist the staff in restraining the patient. In assessing the incident, the application of physical restraints really troubled me. I am very much aware that if the patient did not have any mental health problems, using physical restraints would definitely not be advisable. However, as discussed by Levin and Hennessy (2004), in the case of schizophrenic patients who are manifesting aggressive behaviour, physical restraints are often a must in order to protect both the staff and the patient from any further physical harm. Despite the valuable benefits of using physical restraints on schizophrenic patients however, its application still troubles me. In relation to my colleagues, my experience with the patient was more nerve-wracking because it was my first time to encounter an aggressive patient. As such, I was more cautious in my actions and in mostly protecting myself from any aggression and any physical harm. My experience was also different from my colleagues in the sense that I was very much concerned about the use of physical restraints, but my colleagues were not. I believe that our feelings were different from each other because they encountered many aggressive patients and they have dealt with it mostly by being alert and by using physical restraints. In other words, they have had more experience in dealing with aggressive patients. This experience, I have yet to gain. Now what? This incident implies that in managing aggressive patients, as was mentioned in previous mental health studies, there is a period of escalation towards violence which has to be expected at all times (Dunn, et.al., 2007). According to Duxbury and Whittington (2005), mental health patients often manifest possible signs of impending aggression and nurses as well as other mental health professionals have to be vigilant in order to protect themselves and in order to reduce incidents of actual aggression. Duxbury and Whittington (2005) also discuss that in managing mental health patients, there is an expected therapeutic distance which has to be maintained. Mostly, this distance is much lengthier as compared to other individuals. Duxbury and Whittington (2005) also point out that paranoid schizophrenic patients often do not feel comfortable when other people would approach them too closely; and breaching their comfort zone can trigger acts of aggression. Hahn, et.al., (2008) discuss that applying physical restraints is often a necessary part of mental health care, however, it is more important to prevent any aggression before it manifests. Needhan (2004) points out that restraining often causes the patient to be less cooperative; moreover, it opens him to further physical risks. Needham (2004) also discusses that implementing a de-escalation intervention would be the better option for aggressive patients because it would eventually produce better patient outcomes and cause less stress to the staff. The incident also implies that for my colleagues, there is a need for us to coordinate well with each other in delivering mental health care. Oud (2006) supports the need for coordination when he discusses that in a coordinated mental health team, it is often easier and faster to handle uncooperative and aggressive patients. Dimitriadou and colleagues (2008) also point out that interprofessional cooperation is a crucial element of mental health care delivery. Under these conditions, communication is also an important element because communication provides the links between the different health professionals with different responsibilities and skills. Dimitriadou, et.al., (2008) further point out that communication can prevent any misunderstanding among the mental health professionals; and it actually allows for the efficient and speedy management of patient concerns. In the case of this mental health patient, the nonverbal communication of the group allowed them to sense the patient’s possible escalation into violence, one which they were able to manage before anybody got hurt. Videbeck (2010) emphasizes that inexperienced nurses can learn from experienced mental health nurses on how to prevent and to manage aggression from patients. The experienced nurses have the knowledge and expertise in managing these incidents which they have learned from years of experience ((Videbeck, 2010). In order to alter the situation, I would likely consider how I can implement a de-escalation intervention before attempting to administer the medication. Zarola and Leather (2006) discuss the importance of preventing escalation before any intervention is carried out on mental health patients. I would first find out the possible cause of aggressive signs from the patient by reviewing his chart and asking the nurse on duty why the patient was acting surly and angry. Nau and colleagues (2010) emphasize the importance of recognizing a possibly tense situation and the importance of maintaining a calm demeanour in attending to the patient during these times. I would maintain a respectful distance and avoid any sudden movements. I would speak calmly and I would try to get the patient to respond calmly to my queries. Nau, et.al. (2010) also point out the importance of not taking the actions of my patients personally. I understand that their behaviour is not personally directed towards me and their actions are just manifestations of their disease and mental health situation. Furthermore, Nau and colleagues (2010) stress that I should also try to view the situation from the patient’s viewpoint in order to better understand his aggressive actions. I should also always remain respectful towards the patient. Being mentally ill does not preclude their essential rights to be respected as patients. With the supervision of my mentor, I would likely allow the patient to vent his anger and frustration in some other way (Nau, et.al., 2010). I would ask him how he is feeling and what he was angry about. I would also ask him to talk about his feelings in order to release some of his anger and reduce his feelings of aggression. Irwin (2006) highlights the fact that by talking with the patient about his feelings, it is possible to gradually get the patient to relax and to get over his anger. Since his medication intake or any other intervention can be a trigger for his aggression, I could momentarily delay the administration of the medication until such time that he is less aggressive and more cooperative. Nau, et.al., (2010) further stress that throughout the de-escalation process, I should maintain a confident attitude in order to get the patient to cooperate with me. Hahn and colleagues (2008) have established in their studies on aggressive mental health patients that confidence is an important element of any nursing intervention because it helps prevent any medical errors and it helps inspire cooperation and trust in the patient. They further emphasize that where a patient is more trusting of his healthcare givers, he would also be more cooperative; moreover, the possibility of displaying any aggressive behaviour against his caregivers can be prevented (Hahn, et.al., 2008). In order to improve my management of aggressive patients, Hahn, et.al., (2008) underscore the importance of evaluating various interventions I can apply in order to de-escalate possible aggression. My priority would be the prevention of aggression; as pointed out by Needham, et.al., (2008) there is a significant amount of learning student nurses need to consider in order to master skills in de-escalation. Needham, et.al., (2008) further underline the importance of learning more about de-escalation and of gaining experience in activities which involve de-escalation. Practicing communication with potentially aggressive patients, according to Needham, et.al., (2008) can also help me manage these patient calmly and confidently in the future. By mastering de-escalation methods, I believe that the need to apply physical or chemical restraints on aggressive mental health patients would be reduced. As established in the study by Stewart, et.al., (2009), the risks for mental health professionals and other mental health patients becoming the victims of violence would also be reduced where de-escalation methods are mastered and implemented. I have come to understand that mental health nurses find it more time consuming to implement de-escalation techniques for their aggressive patients. Beech (2007) acknowledges that spending time with the patient and trying to reduce and defuse his anger is a time-consuming activity. Sometimes, it may take as short as minutes or as long as hours to defuse any aggressive tendencies for the patient. Beech (2007) has also established that overworked and understaffed nurses may not have the time to defuse or de-escalate aggressive patients. For them, simply physically or even chemically restraining the patient would be an easier and faster choice. However, it is a choice which is filled with issues and risks. Moreover, as revealed in the study by Beech (2007) easier and faster nursing management techniques do not necessarily mean best or most effective practices. It is important for mental health nurses to consider and master skills in de-escalation, and to consider these as norms and standards in the practice which have to be applied as an essential part of mental health nursing management. If I were to encounter this same situation in the future, I would likely attempt to de-escalate the aggression first. In the study by Parkes (2003), the author was able to establish that de-escalating the violence would likely produce better patient outcomes. Although it would take longer to implement, in the end, I would be dealing with a more communicative and cooperative patient. This patient is likely to cause less harm to himself and the staff. If I were to encounter this situation in the future, I would also be more confident in my actions and my demeanour. I firmly adhere to the importance of such confidence because as pointed out by Parkes (2003), confidence would likely inspire trust and confidence from the patient, thereby making him more cooperative in his care. Information I believe I would need in order to face the situation again would be data on de-escalation techniques for mental health patients. I would likely need knowledge on which de-escalation technique would work well for some patients, and what would not work well. I would also likely need information on the benefits and disadvantages of physical and chemical restraints on aggressive patients. Having this information would help me decide which interventions would best apply to aggressive patients. The best ways of getting information about the situation, should it arise again, would be through research and scholarly studies. These studies would have to be the published recently in order to ensure the timeliness of this information. I would also gain information from other staff members through observations and conversations with them. These nurses have the experience on how to best deal with aggressive patients. There are aspects of the actual clinical practice which cannot be read in any research or text which they can share with me. McKenna and Paterson (2006) revealed that another way of getting the information I would need to handle the situation should it arise again is to attend various trainings and seminars on how to deal with aggressive patients and how to de-escalate aggression for these patients. These trainings can provide up-to-date and practical interventions and information which I can apply in the future. Action Plan In managing aggressive patients, my action plan would first start with the observation of the patient, the review of his chart and the interview with the staff nurse to establish the causes of the patient’s aggression. I would then approach the patient calmly and confidently and introduce myself. I would ask him about what he is feeling and get him to open up about his anger and frustrations. After he has calmed down, I would then try to explain the importance of his taking his medications. As he has taken on a more cooperative attitude, he would likely take his medications without displaying any aggressive behaviour. References Beech, B., 2007. Aggression prevention training for student nurses: differential responses to training and the interaction between theory and practice. Nurse Education in Practice 8, 94–102. Beech, B., Leather, P., 2003. Evaluating a management of aggression unit for student nurses. Journal of Advanced Nursing 44 (6), 603–612. Dimitriadou A., Lavdaniti, M., Theofanidis, D., and Psychogiou, M., 2006. Interprofessional collaboration and collaboration among nursing staff members in Northern Greece. International Journal of Caring Sciences, 1(3), 140–146 Dunn, K., Elsom, S., Cross, W., 2007. Self-efficacy and locus of control affect management of aggression by mental health nurses. Issues in Mental Health Nursing 28 (2), 201–217. 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. Hahn, S., Zeller, A., Needham, I., Kok, G., Dassen, T., Halfens, R.J.G., 2008. Patient and visitor violence in general hospitals: a systematic review of the literature. Aggression and Violent Behavior 13, 431–441. Irwin, A., 2006. The nurse’s role in the management of aggression. Journal of Psychiatric and Mental Health Nursing 13, 309–318. Levin, B. and Hennessy, K., 2004. Mental health services: a public health perspective. Oxford: Oxford University Press. McKenna, K.J., Paterson, B., 2006. Locating training within a strategic organizational response to aggression and violence. In: Richter, D., Whittington, R. (Eds.), Violence in Mental Health Settings: Causes, Consequences, Management. Springer Science and Business Media, New York, pp. 231–251. Melillo, K. and Houde, S., 2011. Geropsychiatric and mental health nursing. London: Jones & Bartlett Publishers Nau, J., Halfens, R., Needham, I., Dassen, T., et.al., 2010. Student nurses’ de-escalation of patient aggression: A pretest–posttest intervention study. International Journal of Nursing Studies, 47, 699–708 Needham, I., 2004. A nursing intervention to handle patient aggression: the effectiveness of a training course in the management of aggression. Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Maastricht, Universiteit Maastricht, Maastricht Needham, I., Kingma, M., O’Brian-Pallas, Tucker, R., Oud, N., 2008. In: Proceedings of the First International Conference on Workplace Violence in the Health Sector: Together, Creating a Safe Work Environment, Kavanah, Amsterdam. Oud, N., 2006. Aggression management training programmes: contents, implementation, and organization. In: Richter, D., Whittington, R. (Eds.), Violence in Mental Health Settings: Causes, Consequences, Management. Springer Science and Business Media, New York, pp. 193–210. Parkes, J., 2003. The nature and management of aggressive incidents in a medium secure unit. Medicine, Science and the Law, 43, 69-74. Stewart, D., Bowers, L., Simpson, A., Ryan, C., and Tziggili, M., 2009. Manual restraint of adult psychiatric inpatients: a literature review. 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