For this assignment the author will identify an incident within their area of practice and describe how the incident was managed. The aim is to describe how the incident could have been managed differently with reference to the public health model and contemporary practice in the prevention and management of aggression. Taking into account local and national policy on maintaining confidentiality as a healthcare professional, the names of people and places involved have been changed in order to allow any staff, service user and inpatient facility involved to remain anonymous.
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In the framework of this assignment the writer will reflect on an important episode in which he was able to manage and through self-control techniques. He will argue about the episode from the viewpoint of Public Health Model which is unsurpassed in describing the necessary steps for coping with and reducing violent confrontations in long-standing healthcare environments of the NHS, within the scope of;
- Primary prevention: measures undertaken to stop violent behavior prior to its occurrence.
- Secondary prevention: measures undertaken to stop violent behavior as soon as it is seeming to be about to happen
- Tertiary prevention: these are measures undertaken in the course of violence and once it has taken place to avoid or lessen the probable situation of bodily and emotional injury.
- The pertinent issues, laws as well as the legal implications in relation to the occurrence for the health personnel and Ms Perkins (a pseudonym) will be considered. In conclusion, a summary of the incident will be made, followed by recommendations to the National Health Service.
The incident took place on an eight-bed ward for female admissions in a small National Health Service (NHS) institution. Dorothy Perkins has a history of considerable antisocial conduct. She is a thirty five year old woman who has been nursed within this inpatient facility for almost three years and will be referred to as. Ms Perkins was admitted from Her Majesty’s Prison Service following ruling from the Crown Court that she requires a period of assessment after the attempted murder of her community care worker. Ms Perkins presents as floridly psychotic with underlying persecutory delusions and presents as unstable in her mood. Her view is that other people (staff, visitors, family and the common public) are plotting against her and attempting to murder her. Despite this, she is able to forge a level of therapeutic alliance with some staff members, in particular male staff members. She is verbally abusive and with her large physical stature is intimidating towards the other service users on the ward and staff members. Her abuse is usually targeted towards female staff members, and she has assaulted another female service user on the ward during this admission.
The multi-disciplinary team has ruled that any episodes of inappropriate conduct from Ms Perkins whilst she is around the communal areas of the ward must result in a period of ‘time-out’. In accordance with the Code of Practice to the Mental Health Act 1983 (1999), ‘time out’ is a behaviour modification technique which denies a patient, for a period of no more than 15 minutes, opportunities to participate in an activity or to obtain positive reinforcement immediately following an incident of unacceptable behaviour. Following the period of time out, Ms Perkins has the choice to then return to her original environment if she so wishes.
The author is a registered mental health nurse and commenced employment on the ward a few months after the admission of Ms Perkins. The author has developed a level of therapeutic relationship with Ms Perkins, although this is superseded by Ms Perkins’ regular changes in mood and mental state.
Ms Perkins declined the offer to attend the dining room for her lunch and wished to remain on the ward. Three service users were off the ward utilizing section 17 leave within the grounds or the community. They were due to return within the next twenty minutes. Including the author there were three staff members on the ward. In order to facilitate escorting the service users to the dining room the author was making telephone calls to other wards to ask for assistance with staffing levels. An Occupational Therapist agreed to assist the ward with her presence. Whilst on the telephone in the nursing office the author observed Ms Perkins shouting and verbally abusing another registered nurse. The registered nurse advised Ms Perkins that her behavior was unacceptable and inappropriate and asked her to spend a period of time out in her bedroom. Ms Perkins remained seated in the smoking room and continued with her tirade of verbal abusive. Her shouting could be heard around the ward and was distressing other service users. The escorting staff left the ward with the other service users, leaving the author, a registered nurse and an occupational therapist with Ms Perkins.
As the verbal abuse was directed at the other registered nurse, the author entered the area and attempted further verbal de-escalation in the hope that Ms Perkins would herself leave the area and retire to her room. This made no difference to Ms Perkins and her behavior continued in much the same way, if not increasingly louder. As Ms Perkins was refusing to leave the area and retire to her room for a period of time out, the next stage of her care plan was to be administered. This would be to physically remove Ms Perkins to her room where the time out period would then commence. The three staff members assessed that Ms Perkins was not being physically aggressive and this incident had been a common occurrence since the implementation of the time out plan a number of weeks ago. This occasion appeared no different to any other time and the expected outcome was that Ms Perkins would be removed from the smoking room using wrist/hand holds with which she would walk with staff to her bedroom.
The wrist/hand holds would not induce any pain and would act as a controlling measure in approved basic restraint just as the three staff members had each been taught in their workplace. The author signaled by non-verbal behavior to the other two staff members that they were to move closer to Ms Perkins and implement the restraint technique to remove her from the area. The author was leading the restraint. As the staff entered Ms Perkins field of personal space, she swiftly hit out and punched the author in the face. Although the author had been assaulted it was imperative to continue and remove Ms Perkins from the room. At this point the Occupational Therapist stood back from the area and observed the author and the other registered nurse remove Ms Perkins to her room with the use of approved wrist/hand holds. As in the training of approved control and restraint in the authors workplace, the was no staff member controlling Ms Perkins’ head, leaving the two staff members controlling the arms vulnerable to be head butted, spat at or susceptible to being kicked. Fortunately none of these occurred. Ms Perkins continued with her tirade of verbal abuse as she was being walked to her room. Once there, she remained in her room for the agreed time period and ceased from shouting verbal abuse.
Primary prevention is significant in prevention of violence prior to its occurrence. Health care professionals should be trained in order to enable them to avoid violent incidences through observing the behavior of patients and being aware of impending violent situations. This helps them to control the situation before it becomes too overwhelming to handle. The issue of violence in health care facilities has been ignored in many institutions. However, for this case, there were measures in place to deal with the violence before it could escalate although the healthcare personnel had ignored the possibility of physical confrontation from Ms Perkins, thereby allowing her a chance to attack the author. Ms Perkins was removed successfully from the ward to a private room where she cooled down and ceased from using her abusive language. The policy of dealing with violent incidences plays a significant role in the institution since the healthcare personnel have been trained to handle such cases. Institutions providing healthcare facilities need to engage a qualified person whose responsibility is to ensure that the policy of dealing with violence in the healthcare facility is helping the personnel in matters concerning violent situations (Braithwaite 2001 pp.35-38). In case it does not serve this purpose, it should be reviewed to ensure that staffs are able to prevent the escalation of violent situations and also to ensure that they are in a position to prevent violent situations by observing and understanding their patients.
There were early warning signs that the author had noted from Ms. Perkins such as the use of abusive language and shouting insults at another service user. These together with signs of discontentment, anger, tension and angry gestures are some of the signs of a potentially violent patient. When these occur, it is necessary for the healthcare personnel to be careful when dealing with such a patient. When Ms. Perkins seemed not to cool down, the author and other nurses intervened and decided to take her to a private room (Crowner 2000 pp.44-46). Physical intervention through leading her out of the ward by holding her wrist was viewed by the nurses as the only alternative after she declined to heed the warning that her behavior was unwelcome in the ward.
In the cultural context, it is usually necessary to have healthcare staff who feel appreciated and empowered. This can help in motivating them while in their duty dealing with many kinds of service users. When a healthcare staff is kicked by a violent patient, the morale is lost and he/she can not have the desired confidence while dealing with patients. The staff should be given the necessary attention as well as proper training in order for them to deal effectively with cases such as that of Ms. Perkins. There should be an all-inclusive approach for developing a strong culture of managing and preventing the occurrence of violence against staff and other service users by discontented patients. This culture should be developed through an integrated approach of understanding the physical environment, assessment of the risks associated with clinical practices, data collection about the incidences of violence amongst patients as well as formulation of policies that can assist in prevention of violence. Primary intervention was not used and therefore secondary prevention intervention had to be used (Davies & Frude 1999 pp. 76-79).
These are measures that are undertaken to stop violent behavior as soon as it is understood that it is about to happen. At time things might happen too fast and result in injuries if the necessary action is not taken in an equal swiftness. This is why it is usually important to capitalize on primary prevention which is easier and less risky. Communication with aggressive patients in order for them to cool down is necessary as a de-escalation procedure. However there should be a framework of approaching such a situation (Kemshall and Pritchard 1999 pp.56-57). The health care professionals should be trained and knowledgeable on how to assess the possibility of physical confrontation. This is because verbal de-escalation that may be misunderstood by the patient can result in worsening of the situation. The nurses should be trained on practical approaches in order to deal effectively with such a situation. They should be able to understand the possible stimulus that can lead to violence and injury.
The use of verbal de-escalation by the author only aggravated the situation with Ms. Perkins shouting even louder. The author should have assessed the situation and understood that verbal de-escalation could not work. He was not cautious once he led the others to hold Ms. Perkins that gave her a chance to slap the author. More over, the two health professionals were at the risk of being head butted or spit at due to lack of a person to take care of the head. It seems that it was only by sheer luck that the woman did not do any such thing. However, cooperation between the author and the registered nurse was important in order to move the woman from the room. It could have been difficult for one person to do it.
In the induction of staff in to the service, there should have been training on the different approaches of dealing with violent patients such as Ms. Perkins. This could have saved the author from the wrath of the violent patient. Training plays a significant role in preparing the nurse for violent situations (Mason & Chandley 1999 pp.71). The second nurse stood aside as Ms. Perkins was led out of the ward by the author and the other nurse. This is an indication of lack of proper training since if the three of them could have stood aside in the same way, the situation could not have been better. Short term training on aggression and management of violence and regular practices are important for healthcare workers. Apart from training on management of violent situations, nurses should be informed on the importance of exercising restraint. It was prudent for the author to maintain calm even after being attacked by Ms. Perkins. Without restraint, it would be hard to manage institutions that offer services to violent patients. There should be a well defined system of training that should incorporate all the needed skills for nurses and healthcare workers. The uniformity in the approach of dealing with violent patients would ensure that all the healthcare workers cooperate effectively when confronted with such situations.
The training programs meant to promote effective health care and professionalism in the healthcare are supposed to have a wide coverage of issues instead of covering only a particular behavioral intervention. Such kind of a curriculum can assist health care workers to acquire the desired knowledge, and competence in dealing with work place aggression. There should be a common goal and content of the training. Regular refresher courses should be provided in order for the healthcare workers to always be kept informed about the necessary actions to undertake once confronted with violent situations (Turnbull & Patterson 1999 pp.39-41).
There are several other ways that could have been used to manage the situation. These include;
- Further attempts of verbal de-escalation could have led to the possibility of Ms. Perkins cooling down and giving in to the pleas of the nurses.
- Before making a decision of moving Ms. Perkins out of the room, the nurses should have exercised some patience and restrain in order to prepare themselves for the action. This could have presented them a chance of strengthening the team; hence they could have avoided the incidence whereby the author was slapped and the situation where the Occupational Therapist was bewildered and stood aside.
- The registered nurse should have lowered the level of stimulus in Ms. Perkins by encouraging other service users to be a bit quiet. This is because Ms. Perkins most likely felt provoked by others people’s talk. The other service users were about to enter the ward when Ms. Perkins began shouting. The author should have caused a deliberate delay of the other service users in the kitchen in order for him and the other nurses to have ample time to deal with the situation without much noise. This could have been done through contacting the dining staff.
- Perkins behavior mainly was due to the fact that she felt unsafe in the service. She feared for her life and felt that other people were plotting to murder her. In this case, she could not be friendly to any health care staff that she thought was an obstacle to her plans of escape from the looming threats. This is a problem that could have been avoided during the time when she was engaged in the service. She should have been assured that her safety was guaranteed and therefore there was no reason for her to worry.
Another way of managing such a situation is through prior risk Assessment. It is important for healthcare workers to be aware of the risks that they might be exposed to in work places. In order for them to have such knowledge, risk assessment is of utmost importance to help understand the probable hazards and their consequences. With this understanding, the preparedness helps the health workers to react swiftly to emergencies that may arise (Krahe’ 2001 pp. 63-65). It is therefore necessary that risk assessment be offered as one of the essential courses in the curriculum. Ms. Perkins reaction that led her to attack the author caught him off guard. This is because he had not assessed the risk that was posed by the patient’s anger. He had concluded before making a proper analysis of the situation that Ms. Perkins could not engage him in physical confrontation. Secondly, if she had a sharp object hidden from the view of the author, she could have caused undesirable injuries on him.
Training on risk assessment is important since in such a case, the author could not have moved so boldly towards the aggressive woman. On the other hand, while leading her away in to the private room, they were not taking precautions against head butts which could cause serious injuries if the nurses could be caught unaware. The assessment can enable the nurses to analyze the strengths and weaknesses of the patient. They can also assist in understanding the stimulus towards the patient’s violence. The strategies for prevention of aggression can only be achieved once the root cause of violence is known. With this knowledge, it is easy to develop means to deal with the violent patients. Since every individual is unique in behavior, the assessment is usually planned according to specific reactions to particular stimulus (Willis & Gillet 2003 pp.54-57). Assessment may also be based on common reactions to a particular stimulus. All the health workers involved should participate in the risk assessment in order for them to act on a common framework.
The Secretaries of State for Health and Social Security (1989) recommended this participatory approach of risk assessment and most importantly the needs of the service user to be put in to consideration all the health care personnel should be equipped with a personal care plan that should serve as a guiding tool. In case of violent confrontations, the care plan should serve as a reference point for the necessary measures as analyzed in the risk assessment. The plan should contain some of the recent history concerning the behavior of the patient. For example the nurses and the author should have used the history concerning the behavior of Ms. Perkins analyzed to identify the most appropriate interventions should she turn out to be aggressive. It seems that they had some information about her behavior as observed since the time she was admitted, but they had not assessed the possibility of physical confrontation. Ms. Perkins’ perpetual regular changes in mood and mental state should have provided a starting point towards assessing the risks that she posed to the health workers (Blofeld 2004 pp. 78-81).
At the time of admission, Ms. Perkins should have been informed on her security situation. Failure to give her adequate information and assurance about her safety should have made her confident about being in the service, which would in turn eliminate the thoughts of conspiring with some staff members due to the fear of being attacked by other people whom she thought were planning to kill her. It was known that Ms. Perkins had regular changes of mood. Once she started developing a certain character that demonstrated her regular change of mood that usually made her develop an antisocial behavior that caused her to use abusive language, the nurses should have begun preparing for some confrontation. It is clear that informing her that her behavior was not acceptable in the ward could only raise her anger since she must have been cautioned earlier under similar circumstances that never helped change her behavior. Her change of mood was also evident when she refused to take her meal. Prior risk assessment should have assisted the nurses to prepare for any eventuality. The presence of the registered nurse whom Ms. Perkins was not used to could have triggered violence.
The author had commenced employment on the ward a few months after the admission of Ms Perkins. Although he had developed a level of therapeutic relationship with Ms Perkins, it was superseded by Ms Perkins’ regular changes in mood and mental state. This means that the author was not best placed in dealing with her. It is also most likely that he had not gone through the whole process of inception in the service. There should have been another person who had enough experience with the woman and to someone who could deal with her in the best way possible. This could have been the reason why he undermined the aggressiveness in her and he got slapped while unprepared. This can be equated to inexperience since the patient was admitted before the author commenced employment. The organization should ensure that there is appropriate inception for the staff before allocation of duties independently. Those who have not gone through complete induction in to the organization should be guided in order to avoid such circumstances.
It is always important in primary prevention in the organization in order to ensure that the patient is adequately informed in order to ensure that she understands the security issues surrounding her. The patient should also be informed on admission about the rules of the service. In this case, it is clear that Ms. Perkins was not adequately informed about the use of abusive language in the service. This would have made her to be cautious of the language that she could use in the service. The recommendation to the National Health Service is to ensure that risk assessment techniques are incorporated in the inception procedures for all staff in all the health service providers in order to protect health workers from violence in the work place. In the curriculum of health sciences, risk assessment should also be offered as a course.
- Blofeld, J. 2004. Independent Inquiry into the death of David Bennet. Cambridgeshire
- Strategic Health Authority. Cambridge.
- Braithwaite, R. 2001. Managing Aggression. Routledge
- Crowner, M.L. 2000. Understanding and Treating Violent Psychiatric Patients. Washington USA. American Psychiatric Press.
- Davies, W., & Frude, W. 1999. Preventing Face to Face Violence; Dealing with Anger and Aggression at Work. Leicester. APT Press.
- Department of Health, 1999. Code of Practice for the Mental Health Act 1983 (revised). UK
- Kemshall, H and Pritchard, J ed(s) 1999. Good Practice in working with Violence, Jessica Kingsley, London
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- Secretaries of State for Health and Social Security, 1989. Caring for People: Community Care in the Next Decade and Beyond. London
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- Willis, B., & Gillet, J. 2003. Maintaining Control; An introduction to the effective management of violence and aggression. Arnold. London