Acute Inpatient Psychiatric/Mental Health Nursing: Lessons Learned
13.3 Promising Intervention? Engagement as a Counteraction to Containment
In the last decade some evidence emerged that the ongoing investment in practice development and especially enhancing the therapeutic engagement in acute psychi- atric wards can reduce containment measures (Mistral et al. 2002; Bowers et al.
2006; Bowers et al. 2014). Another interesting study conducted by O’Malley et al.
(2007) showed that containment measures went down by 23% following therapeutic skills improvements in the nursing workforce in acute psychiatric wards. These competences can, for example, be used in engaging the client in establishing joint de-escalation prevention plans to avoid last resort interventions. There is promising evidence that joint early recognition plans designed with patients can be helpful (Fluttert et al. 2010; Smith et al. 2005). In fact a meta-analysis (de Jong et al. 2016) on RCTs of interventions to reduce compulsory admission revealed that joint crisis plans are one of the few options that could be effective in bringing about this reduc- tion. The process of co- creating a joint crisis plan can start during the admission phase and be refined with the community mental health nurse after discharge to prevent a future compulsory hospitalization. In this process clients are asked which circumstances could trigger escalations and what would be the preferred approaches of mental health staff and relatives or friends in these situations.
For clients that are temporarily unable to collaborate in establishing a joint crisis plan, structured short-term risk assessment by nurses can be beneficial to prevent unnecessary escalations. In this way P/MH nurses can consistently objectify the early signs of the risks of escalations and discuss these in a nonjudgemental way with the patient and colleagues. This approach can promote safety for clients,
visitors and staff. Given the significant results of two-cluster randomized clinical trial (RCT) in the nursing domain conducted by Abderhalden et al. (2008) and van de Sande et al. (2011), this evidence-based approach could inform ‘best practice’
guidelines and/or standards. There is robust evidence that such structured approaches can result in fewer escalations and containment measures in acute psychiatric wards.
Once the client is more stable, the step of co-creating a joint crisis plan can be tried again. In this context P/MH nurses could also discuss the risk patterns that they have observed to support a sound joint crisis plan.
For acute psychiatric wards that host mainly involuntary clients, establishing and maintaining therapeutic engagement may face additional difficulties. One of the impeding factors is that clients in the peak of a psychotic crisis can temporarily lose psychological insight (Pini et al. 2001). On the other hand McEvoy et al. (2006) found that ongoing attempts to invest during this crisis phase in therapeutic engage- ment can work once the symptoms are in remission. An example of co-creation of inpatient therapeutic care is perhaps how service users, carer umbrella organiza- tions, P/MH nurses and doctors form a new consensus framework for high and intensive care by means of mapping methodology (Trochim 1989; van Mierlo et al.
2014). In the Netherlands this consensus process was followed by several pilots and factor analysis rounds that eventually resulted in the national validation of a high and intensive care accreditation evaluation scale. Below, an overview how these criteria may be transferred to 21 essential competences that P/MH nurses based should demonstrate in such settings:
1. Demonstrate low-threshold initiatives to engage with patients (early rec- ognition of alarming signs and be truly available).
2. Using transparent clinical reasoning when protocols are not applicable in a certain situation.
3. Tailor-made clinical use of evidence-based intervention and research- based theories.
4. Support the patient’s individual recovery process.
5. Empower the patient’s strengths and capacities as much as possible.
6. Utilizing the admission as an important part of the recovery process.
7. Systemic approaches in care co-ordination created together with relatives and community health services.
8. Tailor-made use of relevant evidence-based multidisciplinary guidelines.
9. A proficient contribution in the diagnostic process and the evaluation of the stabilization process.
10. Adequate use of risk evaluation instruments.
11. Using best practice approaches in negotiating, conflict mitigation and de- escalation interventions.
12. Safeguarding the person’s safety of patients and colleagues.
In any western country, mental health practitioners have the moral obligation to follow relevant guidelines to manage crisis behaviour in the least restrictive way (Glick et al. 2008; NICE 2015). In this context the four principles of bio- medical ethics (Beauchamp and Childress 2013) are also important to keep in mind:
1. Non-maleficence 2. Autonomy 3. Beneficence 4. Confidentiality
For example, self-inflicted injuries can result in containment measures when clinicians assess that the client has temporary control and that his/her behaviour will harm himself/herself. In these types of escalations, psychosocial stressors are not isolated from dysfunctional neurobiological processes; in fact both often play a key role in aggressive and self-destructive outbursts (Doihara et al. 2008;
Groholt and Ekeberg 2009). Therefore P/MH nursing staff need to minimize/
prevent unnecessary self-harm if the client becomes overwhelmed by acute psy- chosocial stressors, severe mood or anxiety symptoms (Soloff and Chiapetta 2012). For example, impulse control problems are well-known manifestations in clients suffering from (so-called) post-traumatic stress (Elbogen et al. 2008), borderline personality problems (Benvenuti et al. 2005) and severe mood symp- toms (Hendin et al. 2010). Neglecting these aspects may result in a decline of psychosocial functioning, stigma and a vicious cycle of the use (increase) of containment measures. This may well become problematic for the client and P/
MH nurses and can seriously impede the therapeutic relationship or even pro- voke patients to disengage from mental health services in the future.
13. Safe practice of break away and manual restraint techniques.
14. Using adequate protocols for medication, using patient information and monitoring side effects.
15. Monitoring and guidance in addiction issues.
16. Using proficient knowledge on health-care law including patient’s rights.
17. Ability to provide adequate psychoeducation about stress, coping and mental illness.
18. Supporting the patient to co-create joint crisis plans.
19. Reflection on action and the provision of adequacy to colleagues.
20. Adequate use of suicide prevention strategies according to evidence- based guidelines.
21. Adequate registration of containment measures and debrief and evalua- tion of these with the patients.
13.4 Further Challenging Situations Encountered