Posted at 10.15.2018
During my clinical in psychiatric ward I had been asked by one of the rn to go along with that nurse in patients room who was just accepted in the ward. Whenever we entered the area the nurse directly asked the patient to move and change her home clothes and wear clinic clothes. The individual become very intense and violent, while the nurse forcefully required the individual in washroom and threatened the patient to change her clothes usually she'd call her husband and a male personnel, following this comment by the nurse, the patient tried to hit the nurse and in end result the nurse pushed the patient. I got observing all this, and was obligated to avoid the nurse and I asked her to be light rather than being so rude with the patient. In her response, she said "let me do whatever I am doing. She comes to psychiatric ward every second day to get admitted, I understand better how to take care of her".
This unpleasant incident was the eye-opener for me and urged me to create on this issue of restorative communication as a health promoting practice and how this practice helps in dealing with the aggressive and violent patients. It really is one of the main skills which a nurse can develop is therapeutic marriage using their clients. Though it is important atlanta divorce attorneys nursing niche but healing communication is particularly essential with the patients demanding psychiatric care, in order to apply nursing process effectively and perform successful treatment. In my newspaper ahead I'll discuss about hostility among psychiatric patients, using of verbal and non-verbal communication techniques as a mental health promoting practice. Furthermore, I'll discuss nursing process and finally I will be giving some suggestions.
Aggression is identified by the North american Psychological Connection as ''tendencies performed by one individual (the aggressor) with the purpose of harming someone else (the sufferer) who is believed by the aggressor to be motivated to avoid that harm". A Swiss research studies that 47% (n = 114) experience risks which 37% had been attacked one or more times in psychiatric nursing adjustments (Abderhalden et al. , 2002) as cited in Nau, Dassen, Halfens, Needham 2007. Assault result in stress and stress among psychiatric nurses and thus they leave the job or may act and communicate rude with patents. Corresponding to Zernike and Sharpe, 1998 as cited in Nau, Dassen, Halfens, Needham 2007 it is well known that associated with verbal and physical hostility staff experiences emotions such as annoyance, anger, feeling injure, dread, resentment, helplessness, nervousness and discomfort.
In order to bring a big change in any practice it is essential to apply medical process. Though, in the problem mentioned above I was not directly involved to apply nursing process. However, there are things possible which could have done to control over that situation that i will discuss further. Nursing evaluation is important step to predict patient's habit. Although, one cannot effectively anticipate the upcoming situation stuart (2009) has given the hierarchy of intense and violent patient's habit added as (Appendix A) that can be a helpful tool in evaluating aggressive patient. Additionally, staurt (2009) discussed early behavioral signs including motor agitation sings such as pacing, failure to sit still, clenching fists, Increased respiration and catatonia, additionally, verbal signs may be there like verbal risks, intrusive demands, noisy talk and paranoia. Evaluation of influence is also important which includes anger, irritability, extreme nervousness and euphoria. There could be the change in level of consciousness like dilemma, disorientation, and memory space impairment. However in my circumstance nurse was unable to assess these behaviors. After evaluation planning is a critical step in which nurse plans for interventions based on the situation and next comes the intervention phase.
There are several theories on aggression which includes psychoanalytical, behavioral, and cognitive ideas. In accordance with the scenario mentioned above I am going to discuss one of the cognitive ideas. Beck 1976 as cited in Boyd 2005 proposed that cognitive schema such as judgments, self-esteem, and objectives influence angry responses. If extreme patient perceived any situation as intentional, unprovoked, dangerous, and identified offender as undesirable the recipient's response will be exaggerated. Likewise, for the reason that particular case nurse was threatening the patient credited to which patient's aggression was intensified and ends up with assault.
There are types of interventions which can be implemented to manage aggressive action in psychiatric configurations in order to market mental wellbeing of patients. . Stuart (2009) has given the continuum of nursing interventions in controlling aggressive tendencies added as (Appendix B). These interventions can be divided in precautionary, anticipatory and containment strategies. Preventive strategy includes patient education, do it yourself understanding and assertive training. Anticipatory strategy includes verbal and nonverbal communication, medications and behavioral changes. Milieu strategies include environmental changes. Furthermore, crisis management techniques and containment approaches for occasion restrain and seclusions are being used as last resort if despite all strategies competitive behavior persists. In addition, these interventions can also divide as biological, interpersonal and psychological domains distributed by Boyd (2005) added as (Appendix C). However, in my paper scheduled to word count limit and corresponding to my situation, I'll only talk about verbal and non verbal communication techniques which fall under psychological domains and anticipatory strategy.
Psychological interventions help patients to accomplish control over their intense behaviors. In addition, these interventions also eradicate the need for chemical substance or mechanical restrains and communication strategies are significant involvement which can prevent turmoil situation. Relating to Gerloff and Shannon as cited by boyd 2005 in recent years, interest has arisen in expanding communication techniques that promote the appearance of anger in non-destructive ways.
According to study done by Chen, Hwu, and Williams (2005) the nurses indicated that their most typical methods of management of aggression were use of the isolation room, medications, and physical restraints. However, I am going to discuss some of the therapeutic communication skills in controlling aggressive behavior. Intense patients often speak loudly and use bad words therefore, it's important that nurse speak in a calm and low tone and do not raise their words in response because this might perceive as competition and additional skyrocket impulsive circumstances. Furthermore, nurse should avoid improper smiling and laughing and really should use simple, short and easy phrases. However, the case mentioned above evidently claims that nurses shouted on patient and in effect physical violence occurs. Secondly, acknowledging and validating patient's feelings and reassuring them that staff will there be to help them is one the nice strategy which can reduce the level of agitation, because thus giving authorization to patients to speak their feelings and concerns without interruption. Furthermore, this may also reduce patient's thoughts of isolation. Though, in the above mentioned case nurse did not allow patient expressing her emotions nor recognize her will. Finally, nurse should converse patients so that encourages them to have control on the violent impulses. It helps in facilitating personal control because patients may be happy to eliminate themselves from over stimulating environment. Conversely, in previously listed circumstance nurse threatened the individual which destructed the whole situation.
Nonverbal communication techniques of the nurse are also important in controlling patient's aggressive habits. Staurt (2009) recommended some non verbal communication techniques, which include calm and tranquil position with nurse's mind lower than the patient's head. It is less intimidating to patient which communicates that nurse is willing to help patient. Conversely, practical sides and nurses impend in the patients and hands across the upper body are the good posture which communicates reluctance to help and psychological distance. Furthermore, nurses should avoid scary, anxious and impulsive gestures. Therefore, nurse's hands should be placed open and out of wallets. Nurse's should also keep their eyes at the same level as those of patients or lower in order to permit patients to talk from an equal level and patient wouldn't normally feel inferior. Aggressive patients need four times more personal space than non-aggressive prone people. Interruption into personal space can be perceived as a danger and aggravate hostility. Hence, staurt (2009) recommended that nurses should continue to be at an angle to the patient to be able to respect patient's need for personal space. Therefore, it is importance for the nurse to observes patient's actions for occasion clenched fists, tensing of cosmetic muscles and leaving the nurse which give hints that patient is sense threatened and could get intense so that to perform early on interventions. However, in all these case rather providing space to patient the nurse was having patient's hand and moving her in the toilet to improve her clothes. Furthermore, nurse's expressions were intimidating to the patient which was demonstrating unwillingness to help. Finally comes analysis phase, it is important that nurse must evaluate that patient has maintained control over ambitious feeling, thoughts, action and actions. Lastly, before discontinuing the treatment let patient know that which behavior is satisfactory and how to control over there aggression.
Along with the above mentioned interventions one of quite strategies is the fact that nurse should behave within an assertive manner. The midpoint of the continuum which operates from passive patterns to hostility is assertive behavior. According to Stuart (2009) "assertive habit conveys a sense of self-awareness but also communicates admiration for other person. " (p. 574). Additionally, assertive people always speak evidently and conspicuously. There gestures are non-threatening and they maintain appropriate eye-contact and respects personal space. Furthermore, assertiveness helps people in refusing an irrational need. However, they always give justification for particular action. If I reflect back that situation the nurse was continually requesting patient to wear medical center clothes without providing reasonable rationale. Rather being assertive nurse was behaving rude to patient.
There was one study done in Pakistan in yr 2006 by Iqbal, Naqvi, and Siddiqui which targeted to review the inpatient violence in psychiatric patients and its management. The study concluded that out of 393 patients, in almost all of the circumstances (14%) physical restraints and seclusions are being used to control hostile situation or it is sometimes done with the mixture of chemical restrains like heloperidole and benzodiazepines which predicted (44%). Though, there's a risky of abuse fastened with physical restraints. However, writers havent given other solutions to control competitive and violent patients like communication skills. Therefore, more studies are needed in Pakistan to apply proper management of aggression in order to improve patients mental well being.
This Scholarly newspaper proved to be a good learning quest for me; because there have been few perceptions that have been attached with psychiatric patients, and especially those who are aggressive and violent. This were largely build while i heard harsh comments each day over from nurses that XYZ patient is violent so avoid going in there rooms, they are dramatic, these are attention seekers, do not speak to them etc. However, this isn't the fact. There must be some bio-psycho-social factors attached behind that aggression. Therefore it is essential for nurse to comprehend them and intervene accordingly. Furthermore I explored new opportunity of restorative communication specifically with hostile patients as a health promoting practice. Although I had not been in a position to apply medical process mentioned above but this would defiantly help me whenever I'll deal with hostile patients. Furthermore, for the very first time I learned all about the psychiatric progress directive that was previously not known to me. This is one of the strategies which could assist the patient when they are unable to take part in their treatment decision.
In recommendation, I'd like to point out that nurses employed in the psychiatric ward should be skilled in dealing with psychiatric patients. Nau, Dassen, Halfens, Needham 2007 recommended that psychiatric ward nurses should be able to find and remove factors behind aggression, to interpret aggressive situations accurately, to de-escalate and also to manage their own recognized stress. This can be only done If there are proper training programs arranged which increases awareness, enhance self confidence in working with aggressive patients somewhat disregarding or blaming them, ways of deal in appropriate manner via communication skills like assertiveness and empathy. In addition, there must be a safety policy in clinic for patients and staff who package with competitive clients and proper ordinance recommendations, however mental health ordinance for Pakistan 2001given by chief executive muhammad rafiq tarar will not addressed the issue of managing ambitious clients without needing physical and chemical restraints.
In conclusion, I would like to state that the nurses are in best position to effect a result of a change in traditional kinds of practices. To conclude the scenario of previously listed patient, I think it was a nurse responsibility to oblige by patient's will. Therefore, nurse shouldn't have forced the patient to change her clothes or threat her because this function of the nurse increased patient's aggression. Rather, behaving in peaceful, delicate, non-judgmental manner. Nurse also needs to have heard the individual concerns and given space to patient so as to avoid physical violence. However, communication is building block for the healing relationship. Therefore, to be able to intervene effectively in managing patient's hostility the nurse should use proper verbal and non-verbal communication techniques.