Perth Hospital has a 32 bed mental health ward comprising 8 locked beds and 24 open beds. Unfortunately, this ward has a history of poor outcomes for both staff and patients. In 2017, the Health Department’s Office of Safety and Quality enlisted the services of an outside agency to assess and report on the quality and safety of this ward. The final report presented data from the last five years, and identified the following main inadequate management issues that are most influencing the poor outcomes of the ward. Extracts from the report have been provided to illustrate the issues:
Core issue: High levels of conflict on the ward resulting in overuse of containment interventions “The use of as required or PRN regimens of psychotropic medication for disturbed behaviour, distress or agitation is widespread in Perth Hospital’s mental health wards. Nurses are often unnecessarily reliant on the use of PRN medication regimens for behaviour management. 23% of inpatients received at least one PRN dose of psychotropic medication during their stay, rising to 50% among those in the locked ward. Almost 80% of patients received PRN psychotropic medication at some time over a one month period. The main reason for administration was agitation or anxiety and most of the medication administration was initiated by nurses. This method of prescribing allows nurses to administer medication rapidly in acute situations or at the patient’s request, but it can allow the administration of high or above recommended doses. It can also be seen as punitive or disempowering by patients, who already feel subservient to nursing and medical staff. This method of administration can cause staff to rely too heavily on pharmacological treatments, although this may also be due to the lack of alternative non?pharmacological techniques and strategies employed by nurses to manage agitation, distress, challenging behaviours, and aggression. In 2016, 152 complaints were made by patients about the lack of activities on both the locked and open wards, lack of exercise, no outings, and boredom. It was interesting to note that when renovation painting of the open ward meant patients had to spend a few days in the gym or the garden, nursing staff reported that they halved the use of PRN medication. Management of patients was easier than usual because staff ensured that every patient was kept active during the renovations. Staff from both the open and locked wards complained that lack of activities for patients was a major issue and were strongly of the view that this affected the behaviour of patients and the wards as a whole. Staff advised that there was more aggression between patients on the ward and hence more PRN and seclusion being used when there was nothing for the patients to do”
“One of the things that doesn’t get talked about very much is the trauma of the staff. We talk about the trauma paradigm for our clients or people in recovery. But not very often in my 20 years of work in the field of mental health have I heard much about what happens to us, the workers and I think that’s an area where we need to do some work. I’ve seen some pretty traumatic things from when I first started 20 years ago. Some of those things still haunt me that I’ve seen.” ? Female nursing staff member
Regarding restraining patients: “When you get to that point you feel as though you have failed. It seems like you’ve missed something when you could have prevented it beforehand. I never liked doing that, but it’s about maintaining safety and you just never want that to happen….you feel like you’ve failed. There’s always something you could have seen earlier if you had been there a little sooner, if you had known the client a little better. You could have prevented the situation.” ? Male nursing staff member
“When I was restrained by the nurses, it was the culmination of escalated situations based on my feeling totally without choices, and not in control at all. [However,] it became a ‘war of words’ all about who had the power. I was restrained and forcibly injected. I did not speak to anyone for the next two days, and developing any sort of trusting relationship with the nurses was seriously delayed.” ? Male patient
"The restraint made me feel even more angry because it hurt me and made me worse. I would like staff to respond in a different way such as give you more options during the step before - they act too quickly." – Female patient
1. Analyse the assessment and treatment of mental illness in the community and acute settings via health care teams and specifically the roles of individuals within those teams;
2: Identify appropriate psychosocial interventions in caring for people with major mental health disorders; and
3: Critically analyse legal and ethical principles that influence and constrain health care professionals in mental health contexts
Overview of functional behavioral solution
- Maintain therapeutic relationship between nurse and patient by inculcating positive values, attitudes and behavior to nurses
- Increase involvement of patient in daily activities by proving task according to patient’s strength and interest and engaging them in meaningful activities
- Encourage participation of students in recreational and relaxation activities to improve skills and reduce psychological distress (Milne, 2015).
Process of evaluation of functional behavioral solution
- Assessment of therapeutic relation between nurse and patient by review of total number of conflicts cases between nurse and questioning patients regarding formation of trusting relationship with nurses (Evans, 2016).
- Evaluation of benefits of patient’s involvement in daily activities by assessment of level of distress and aggression and scoring satisfaction with care (Halter, 2017).
- Assessment of replacement strategies by observing improvement in social interaction of patient and self-esteem.
Evaluation in relation to ABC-FR pathway
The evaluation of each solution according to ABC-FR pathway can be done in the following ways:
- For therapeutic relationship: Before (Patient is hurt andangry with nurse)-Behavior (Patient spends more time with nurse)- After (patient develops trusting relationship with nurse)
- For involvement in daily life activities: Before (Patient isdistressed and aggressive)-Behavior (patient takes part in entertaining activities)- After (distress and aggression level reduced)
- For involvement in relaxation activities: Before (Patient isbored)- Behavior (Patient engage in cooking session): (boredom reduced and increase in social interaction) (Milne, 2015)
Evaluation in relation to Safewards model’s domain
- Staff team: Impact of internal structure on outcome
- Physical environment: Impact of outside environmenton outcome
- Outside hospital: Impact of family on outcome
- Patient community: By judging interaction with otherpatient
- Patient characteristics: By observing symptoms ofdepression
- Regulatory framework: Influence of legal framework(Whitmore, 2017)
Data collection to demonstrate result
- Improvement in depression score before and after the intervention represented in bar graph
- Improvement in self-esteem and interest by self-esteem checklist
- Benefits of relaxation activities represented by development of new skills in patient
Self esteem checklist
Self critical thinking
Difficulty making significant decisions as a result of self doubt
Avoidance of situations that are to be criticized
Difficulty making friends and maintaining relationships
Efficacy of the data
Efficacy of the data will be judged by:
- Preciseness of psychological outcomes
- Specificity of improvement in social skills
- Complete detail regarding improvement in self-esteem (Halter, 2017)
Finding evidence for efficacy of the behavioral solution
Efficacy of behavioral solution will be evaluated by:
- Looking at improvement in depression and stress level score
- Assessing patient’s experience regarding satisfaction with care
Finding evidence for efficacy of the behavioral solution
- Judging the impact of recreational activities on skill development in patient
- Evaluating nurse-patient relationship by decrease in the number of conflict incidents.
Evans, E. C. (2016). Exploring the nuances of nurse-patient interaction through concept analysis: impact on patient satisfaction. Nursing science quarterly, 29(1), 62-70.
Halter, M. J. (2017). Varcarolis' Foundations of Psychiatric-Mental Health Nursing-E-Book: A Clinical Approach. Elsevier Health Sciences.
Milne, D. (2015). Training Behaviour Therapists (Psychology Revivals): Methods, Evaluation and Implementation with Parents, Nurses and Teachers. Routledge
Whitmore, C. (2017). Evaluation of Safewards in forensic mental health: a response. Mental Health Practice (2014+), 20(8), 26.