Management of violence

. Management of disturbed/violent behavior in-patient in psychiatric units was started to deal with systems arising such a attempted suicide, drug addiction, acute alcohol intoxication, violence and occurrences of delusions, panic attacks and some changes in the behavior in the mentally ill patients (Soyka, 2000).  This resulted to the formation of emergency psychiatry that monitors the occurrences and nature of these symptoms and other appropriate treatments and prevention measures. (Crighton, 1995, p22). Violent in this case refers to using or tending to use aggressive physical force or involving unlawful exercise of force. Aggressive act or behavior means being forceful, attacking without provocation. Violent/aggressive behavior in inpatients therefore means use of force by these people in different setups and is characterized by factors such as psychotic symptoms, non-compliance with medication and treatment, and drug abuse (Shah, Fine berg and James, 1991). Guidelines on management of Disturbed/ violent behavior in inpatients settings and emergency departments for mental health assessment was started by NICE in collaboration with NCC-NSC.The guidelines provide that before any treatment was carried, risk assessment was very assential. This is a very important part of care and treatment of all patients (simon, 1992,p50).

Risk assessment provides the positive predictive validity of short-term psychiatric in inpatient-disturbed behavior (Haller and Deluty, 1988). The assessment should focus on static factors such as history of violent behavior, demographic information and diagnosis without taking an individual service user needs into consideration (Sheridan etal, 1990). Most patients with severe aggressive behavior have been admitted in special closed rooms. These patients are normally confined in a closed room that may be locked to protect others from significant harm (Brizer, 1989, p49). This is seclusion and it means the supervised confinement of a patient in a room, which may be locked to protect others from significant harm (Melo, 1991). However seclusion should be used as the last resort for the shortest time possible and the clinicians are not suppose to view it as a punishment to the patient. Other risk management should also be observed by the clinicians like placing alarms in the room to report any emergency help needed (Schwarz, 1970).

The inpatients that are highly involved with the disturbed aggressive and violent behaviour have been found to be females (Lance etal1995).  More young ladies have been found to fall victims of patients with violent behaviour as compared to old ones (Lalla, 1995, p76).  Schizophrenic patients normally require a lot of care and the mode of treatment should be as fair as possible.  If at all any force or pressure is to be applied then it is supposed to be done according to the legal requirements governing and protecting the rights of the patients (Infatino and Musingo, 1985).

The violent and aggressive behaviour in patients admitted in psychiatric wards do normally occur in the day  (Elbadri and Mellosop, 2002, p399).  Probably this has not been explained however most of stress is experienced when the victims do interact with quite a big number of people.  These people are believed to be contributors of a lot of stress and therefore triggering the occurrence of the violent and aggressive behaviour.  The most commonly form of illness found in these patients is schizophrenia where diagnosis proves that nurses are also victims (Melo, 1991, p70).  This could occur due to counter transference during the intervention process.

The rate of the violent behavior in the inpatients also varies according to the cultural background of the patient (Davis, 1991).  This shows that socio-cultural factors are very important issues that should be checked when dealing with the behaviour in patients.

For example blacks and minority ethnics groups in America are found to be highly involved in the aggressive violent behavior (Simon, 1992, p63).  This is because of the high occurrence of racial discrimination in the area. Blacks and minority ethnic service users must therefore identify aboard member to take specific responsibility for all matters relating to equality and diversity (Fottrel, 1980). The responsibilities must include the nature and adequacy of service provision in relation to the short-term management of disturbed behavior. Training should therefore be provided on all matters of equality and diversity, monitoring service usage by ethnicity and consultation with local blacks and minority ethnic groups (Jamesetal, 1990).

The intervention and prevention measures should be less resistant and all the strategies should be fair to everybody (El-Badri and Mellsop, 2002).  However various measures have been put into place to reduce the occurrence of the aggressive behaviour.  The prevention can be more effective when the medication is done in the psychiatric wards (Davis, 1991).  The inpatients are locked and the clinician and his team offer effective medication.   Community intervention has been found not to yield any substantial result because most of the activities involved are too complex and complicated and therefore wanting close supervision.  This can only be done by knowledgeable and skillful clinicians (Schwarz, 1978, p53).

Most of aggressive behavior in the in-patient units mostly involves patients with schizophrenia and bipolar disorders.  These patients have been found to have acute psychotic or manic (Davis, 1991, p585).  There is evidence that a history predict the future occurrence of violence behavior.  For example psychiatric patients who have been found to misuse drugs have shown a significant risk factor for aggression and disturbed behavior.

The selected scenario is violent behavior in chronic schizophrenia and inpatient psychiatry.  These are the most affected inpatients however psychiatric patients have responsibilities as well as rights.  They are supposed to take part in the treatment process and to respect the rights and needs of other people (Melo, 1991, p80).  As citizens they are expected and should observe legal procedures that are provided to monitor and control their conduct in court especially when they fall in crime.  In most settings physicians and clinicians have fallen in violence or assaults by the patient.  They argue that acts of violence against the person or property are not common in psychiatric settings and therefore require a special condition when providing guidance in the area (Tardif, 1989, p75).

The following are some of the factors that might be considered during the management of violent/disturbed behavior among these patients, in inpatient suffering from schizophrenia.  The violence incidence of the behaviour normally occurs in different set ups.  These set ups may include emergency rooms, psychiatric wards, during home visits or in community hospitals.  These incidences actually vary from minor verbal assaults to long threatening attacks that occasionally might result in serious physical injury or deaths always are in state aggression.  They therefore require a highly knowledgeable doctors or psychiatrics to attend to them. (Cantwell, 1999, p151).

However the intervention process might be challenged with a number of problems.  The team may be threatened by the patients, which might interfere with the clinician’s spirit of maintaining fairness in the intervention process.  The clinician may develop a feeling of objection and counter transference in the process.  This therefore makes the management decision to become very complex and complicated (Atakan, 1995, p594).  The team that is supposed to accompany the clinician may include family members, friends to help in the intervention process.  The whole management and intervention process is very cumbersome and therefore a number of issues have to be addressed for effective treatment measures to take place.

Normally before treatment is done the history of the occurrence of the behaviour has to be recorded down (Schwarz, 1970, p197).  The safety of the patient and the clinician plus should be assured.  The various clinical issues also will be required to be addressed. If not properly handled the whole process might be poor.  When the violence or assault takes place proper assessment of the patient’s mental status should be done.  This should include the mental functioning processes, appropriate security measures, physiotherapy and behavioral approaches (Yudofsky, 1986, p37).  The treatment team should therefore come up with a suitable plan to take an effective measure on the security measures and steps to be followed during the intervention process .The clinician is expected to have a record of the patient’s history on the occurrence of the aggressive behavior.  The history should include the records of previous treatment details, history of the violence, degree of the occurrence of the behavior and some of the consequences of the incident of the victim.  The records of past psychiatric diagnosis and measures he used in place should also be crosschecked (Simon, 1992).

This means that management decision should not only be based on one or two factors should but a number of issues on the management are considered.  If legal action has been initiated, clinical staff should ensure that the various victims are supported throughout the process (Yudofsky, 1986, p36).  The legal system requires that the patient should be presented to the court.  The police, lawyers and the family members are expected to come before the court and make a statement .If the incident happen in an institution such as schools and colleges, the administration should be informed as soon as possible if legal action has been verified and taken. The students and any responsible staff should inform the patient that the complaint has been recorded and the police are supposed to investigate in the issue concerning it (Lanza, 1983,p43).  Patients normally have the right to counsel, the staff should inform the lawyer if in any case he might request for the counseling services.  Otherwise counseling is not supposed to be given without the consent of the lawyer.  Appropriate measures should be made to cooperate with the law enforcement officers when the trying to help the patient.

Gender needs (WHO, 1992) must be taken into consideration in the management of disturbed /violent behavior in psychiatric inpatient settings. For example women are more likely be self harm and suffer from depression while men are more likely to experience earlier onset and more disabling cases schizophrenia (Latta, 1995,p86). Women mental health needs should be conducted in relation to an individual woman’s experience, beliefs, struggles as well as her ethnic group, age and sexual performance.

Another factor that should be looked into is the training of the staff.  The clinician and the team need to be trained on appropriate skills to manage the disturbed behaviors in a psychiatric setup (Cantwell, 1999, 152).  Training should be provided on the various intervention procedures.  The training is normally carried on the awareness of racial discrimination, spiritual needs, gender differences and cultural differences.  The training has been offered by the National Health Services (NHS) Security management Service (SMS) (Mellsop, 2000,p399). They have also come up with a training curriculum that can effectively be used in the management of the violence.  The National Institute for Mental Heath in England (NIMHE) is also drawing up a formatted scheme for trainers. (Sheridan, 1985, p77).

The staff also needs to be aware of the legal procedures that authorize the use of various intervention measures.  The guidance of Mental Health Act Code of practice should be followed.  This is the only policy that guides the staff should any risk and threat occur.  During physical intervention the staff should be able to protect their eyes, necks and heads (James, 1990, p846).  A team member should be selected to lead the staff in providing physical security.  Direct pressure should not at any point be applied to the patient during the application of physical intervention.  The force applied should be fair and reasonable and if possible should be less harmful as possible. (James, 1990,p852).

Oral medication may also be provided for rapid tranquillization.  The rapid tranquillization is very important sine it provides a state of calmness thereby reducing the risk that might be posed on the service users and other team members (Fottrel, 1980).  This should be followed with giving some ample time for clinical responses between oral doses of medication for rapid tranquillization (Lance, 1995, p610). Doses for rapid tranquillization as also accepted however this must be done upon following its legal framework. The manufacturer’s guidelines should be followed to avoid the risk of death and any other problem that might occur (Link,1992).  This means that a specialist from pharmacy and poisons Board should assess the nature of the drugs used if they satisfy the current marketing system.

Conclusion.

The short-term management of Disturbed/violent behavior in inpatient can only be effective if NICE guidelines are observed. This should start with risk assessment, consideration of gender differences and close supervision of the legal framework governing the process. With proper training of supportive staff the intervention process can be properly managed. Otherwise since the introduction of the NICE guidelines cases of Disturbed /Violent behavior in patients with mental illness has been in the decline.

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