NEW YORK NURSE: September 2010
“I work on a telemetry unit on the 3-11 shift. Occasionally we will admit patients with mental health co-morbidities. We have policies and procedures in place that include the use of restraints to handle patients if they become aggressive, but we’d also benefit from tips to help de-escalate problems when they occur.”
A patient admitted to rule out a cardiac diagnosis who also has a history of mental health issues can increase staff anxiety. The evening shift is often busier than other shifts, with increased admissions and less staffing, adding to a volatile environment. Restraint and seclusion policies are often helpful when the staff is well versed in their proper use, but they can also lead to a higher incidence of patient death or injury.
Since the Joint Commission began examining sentinel events in 1996, which have included deaths of physically restrained individuals, they have advocated intervention standards based on prevention and for the use of restraint to be a last resort used only after less restrictive measures are exhausted (Joint Commission, 2009, [electronic document] Hospital Accreditation Program Requirements).
Medical-surgical or telemetry units are not necessarily equipped with the appropriate staffing or equipment to safely intercept an aggressive patient and the patient’s perception of the situation may increase the chance of aggressive behavior. Nurses need to know how to intervene effectively to ensure patient and staff safety by having a set of skills to de-escalate the situation.
The nursing process already provides nurses with information that can help them identify a patient at risk for aggression.
By performing a comprehensive assessment at the time of admission, the nurse can identify corresponding nursing diagnosis. This allows the nurse to communicate the needs of the patient to the provider and support the patient with timely nursing intervention, such as establishing a therapeutic relationship with the patient, as well as provider-ordered interventions. The process can culminate in clear documentation to provide guidance to colleagues and evaluation of the outcomes.
Another tool, similar to the techniques used in hostage negotiation, is called the third-person approach. This tool requires specific training and should be utilized judiciously to ensure patient and staff safety.
A “third party” or “third person” is a trained nursing staff member who was not present at the start of the dispute or conflict. A person who was involved in the conflict may be perceived, from the patient’s perspective, as being part of the problem. The ideal third person is someone who knows the patient well and with whom the patient has a certain degree of rapport (Su, 2010, De-escalating the Aggressive Patient).
Facility support in recognizing the need for and implementing this type, or any other type of training, is crucial. Verbalize your team’s concerns and ask for support and training in using other methods, supported with evidenced-based practice and research, to handle aggressive or violent patients. As always, involve your nurse representative for advice and support for your concerns with this or any other workplace issue.
This is a sample of the questions NYSNA’s experts answer each day. The advice given is specific for the situation described and may not be applicable generally. If you have questions about your own work setting, it is recommended that you contact your NYSNA nursing representative or the Education, Practice, and Research Program, 11 Cornell Road, Latham, New York 12110-1499 or call 800-724-NYRN, ext. 282.