Authentic Engagement

And the reduction of patient aggressionAuthentic Engagement1ObjectivesUpon completion of this in-service, participants will be able to :Examine consequences of being exposed to client aggressionDescribe research addressing aggression Identify authentic engagement components to improve inpatient psychiatric nursing practice and prevent escalation in client aggressionDemonstrate the implementation of authentic engagement during a role play sessionIntroductionAuthentic engagement: A core concept in reducing seclusion and restraintReducing seclusion rates is challenging and typically requires the implementation of multiple interventions (Gaskin, Elsom, & Happell, 2007). Finfgeld-Connets Nursing Theory of Authentic Engagement provides tools to help prevent client aggressive behavior.

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Centers for Medicare & Medicaid Services' (CMS) position:Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff or others (Bowers, McCullough &Timmons, 2003).

Interventions from the seclusion and restraint reduction work group at Fletcher Allen Health Care1700 Resident ReportStress and coping toolTherapeutic planSupplementing Pro-act

4Levels of aggressive behaviorAgitation- nervous excitement, excessive motor or verbal activity, irritability and uncooperativeness (Zeller & Rhoades 2010)Aggression- a readiness to attack or confrontAssaultSimple assault- has ability and shows intent to injure, however threat would not require medical attentionAssault and battery- has the ability and shows intent to injure, and makes physical contactAggravated assault- Is separated from simple assault because there is an intent to seriously injury. This injury would require immediate medical attention.

Nurses ability to assess patients who are agitated and then to effectively engage them can prevent agitation from progressing to verbal and physical aggression (Foster et al., 2007; Zeller & Rhoades, 2010; Finfgeld-Connett, 2009).

5Assessment of agitationExperienced psychiatrist and psychiatric nurses have been shown to be able to accurately predict violent behavior. One study found that psychiatrist and psychiatric nurses correctly predicted violent behavior in 82% and 84% respectively, of newly admitted psychiatric patients(Zeller &Rhoades, 2010 p.420)

Potential tools for the assessment of agitation:Aggressive Behavior scaleAgitated behavior scaleBrief agitation rating scalePositive and negative syndrome scale-excited componentsRyden aggression scaleOvert aggression scaleOvert agitation severity scale.(Zeller &Rhoades, 2010)

----- Meeting Notes (10/23/13 09:00) -----This speaks to the importance of vauling the experience of ourselves and our co workers. 6Factors contributing to patient aggressionInternalThese include individual patient variables such as age, gender and serious mental illness diagnosisSuggested that young males are most prone to violenceExternalLimited space or privacy, overcrowding, hospital shifts and raised temperatures Staff experience, gender and training also have an impact on patient escalationHandover periods and meal times are problematicSituationalA combination of internal and external factors. (Duxbury, 2002)Aggression on inpatient psychiatric units can have multiple causes such as patients needs not being met, acute psychosis, paranoia or mania and the use of seclusion and restraint (Foster et al., 2007).

7Consequences of being exposed to Inpatient Unit aggressionStaffMental health second most violently victimized group (Finfgeld-Connett, 2009)61% of nurses working in psychiatric settings had been physically assaulted in their career(Zuzelo, Curran & Zeserman, 2012). Interdependent relationship with staff burnout Physical injuriesEmotional damage

Again the message that aggression is harmful to nurses. Nurse There is evidence that supports that certain ways of interacting with the patient are more effective than others.

For example the use of restraints to control aggressive behavior can result in nerve injury, sudden death and asphyxiation8Consequences of being exposed to Inpatient Unit aggression

PatientsCan result in seclusion or restraint Psychological injuries resulting from activation of traumatic memories of pervious incidence of abuse and violence(Bonner et al. 2002)Physical injuriesPatient aggression may delay discharge or make placement more difficult 9Why it is so important to reduce aggressionFoster et al. (2007) write, daily exposure to swearing, threats and verbal abuse can cause lasting emotional damage to nursing staff (Foster et al., 2007 p. 146). This emphasizes the need for interventions that take place during the agitation phase of an incident rather than waiting for the verbal or physical aggression.

10Literature REVIEW of research evidenceTherapeutic interventions for aggression

Staff and patients had different beliefs about the causes of aggressionPatients-poor communication the number one precursor to aggressionStaff- patient illness the number one cause(Duxbury &Wittington, 2002)

Duxbury preformed a study researching staff and patient views of the management of aggression on inpatient units. Findings revealed a clear distinction between the waystaff and patients view both the problem and the response. Patients view present staffapproaches as controlling and believe that environmental and poor communicationfactors underpin aggressive behavior. Staff, conversely, attribute aggressive behaviorto internal patient and external factors, which may explain the reason for approachesused.

Embodied moment-pliability, the professionals ability to be at the same time close as well as distant, active as well as passive, willing to wait as well as take action(Carlsson, Dahlberg, & Drew, 2000 p. 542). Specifically, the embodied moment is the here and now moment that happens between a nurse and a patient when the patient is demonstrating agitated behavior.

12Therapeutic interventions for aggression (Continued)Effective de escalators are open, honest, supportive, self-aware, coherent, non-judgmental and confident without appearing arrogant (Price & Baker, 2012 p.312).Successful management of aggression involves creativity and flexibility.Tailored to specific patient needs (Price & Baker, 2012).Embodied moment (Carlsson, Dahlberg & Drew, 2000).

Embodied moment-pliability, the professionals ability to be at the same time close as well as distant, active as well as passive, willing to wait as well as take action(Carlsson, Dahlberg, & Drew, 2000 p. 542). Specifically, the embodied moment is the here and now moment that happens between a nurse and a patient when the patient is demonstrating agitated behavior.

13Therapeutic interventions for aggression (Continued)Early intervention is key in success.Acting proportionately to the risk the patient is presenting (Bowers, McCullough &Timmons, 2003).Soft, calm and gentle tone of voice and appearing calm (Ryan & Bowers, 2006) Balance support and control (Delaney and Johnson, 2006)Stressed the importance of offering face saving alternative to violence (Gertz, 1980)

Some of the interventions provided are increasing staff to patient ratios, providing psychiatric emergency response teams, treatment plan improvement, changing the facility environment and staff education.

Sullivan 2005 successful program to reduce violence in a large psych hospital in NYCThey attribute the success of their program to be in part a result of providing staff with the therapeutic tools to approach violence prone patients differently (Sullivan et al., 2005 p. 64). 14Effectiveness of training programsThere is a lack of research that identifies evidenced-based components of aggression management programs (AMP). One review suggested that there is lack of consistency between the content covered between AMPs and that there is a lack of evidence surrounding the ability of these programs to change staff behavior (Farrell & Cubit, 2005).

15A comparison of MOAB and pro-actMoabPro actEmphasizes planning and teamwork YesTeaches prevention yesyesIncludes de-escalation techniques yesyesAddresses triggers and alternatives yesyesEmployees critical thinking and problem-solving techniques yesyesKeeps patient at the center of care, attempts to meet the underlying patient need yesFocuses on problem behavior yesyesEmphasizes patient rightsyesTeaches self-awareness yesIncludes documentation component yesTeaches techniques to defend and subdue yes(Osborn, 2013)This is a comparison chart originally developed by Pat Osborn after auditing the pro act training Modifications were made after meeting with a MOAB instructor from FAHC.

16Authentic Engagement: methodological considerations Meta-synthesis of 15 qualitative research articles for nursing management of aggressionData included direct quotes, coding schemes and discussion Authentic engagement was the core category around which the data was organized. From this work, the author proposed a model of therapeutic responses to patient agitation. (Finfgeld-Connet, 2009)On this slide I will give more detail about the qualitative support of the ability of the therapeutic alliance to reduce aggression. Limitations: only English language articles were used and only one researcher coded the data

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(Finfgeld-Connet, 2009)

Wide rage of studies for example18Model of therapeutic and non therapeutic responses to patient aggression

(Finfgeld-Connet, 2009)

I might challenge that there is a loss of control. Nurses should be intervening well before a loss of controlExhibiting agitation. 19Model for Therapeutic responsesEscalating of patient needsFinfgeld-Connett asserts that aggressive episodes are preceded by an escalating series of stages where patient needs go unmet. Aggression was defined as any verbal or non verbal behavior that is threatening or actually results in harm to nursing personnel (Finfgeld-Connet, 2009 p. 530)As agitation increases the patients cognition decreases. This highlights the importance of acting early. Behavioral precursors include: agitation, suspiciousness, ill-directed frustration, disorganization and resistance to therapeutic regiments (Ryan and Bowers, 2006).

Patients fear confinement and losing control over their lives.

21Responses stylesTherapeuticIntuitivePatient's needs are immediately understoodAdaptable interventions match these needsEmergentActing in a carefully measured wayRely on education and trainingNon-TherapeuticInflexibleThe use of rigid rules and physical methods to control patient behavior.Excessively task orientedDisengagedNurse managers are authoritarian, but distantAdministrative abandonment(Finfgeld-Connet, 2009)

22Authentic EngagementFinfgeld-Connet found that authentic engagement was a core component of both the intuitive and emergent therapeutic response styles. Becoming and staying genuinely connected to the patientKeep communication lines open, while being steady and dependableThis person to person bond helps patients to regain control. (Finfgeld-Connet, 2009)

Situational contextAggression is a way to express feelingsCan serve as a catalyst to get things done, if the underlying need can be identifiedTherapeutic interventions may fall outside the standardized rules and guidelines. Appreciation for the patient strange worldAwareness of general environment milieu, such as noise levels and other patients on the floor

(Finfgeld-Connet, 2009)

Click here for more informationIt is scary to be outside the rules, and that is why the team is so important. We are less likely to be hung out to dry if we consult with each other. Is there a way to get this need met. For example the pt. that would take a medication from a tech but not the nurse.

Treating the pt as a human. Choice

Visual HA never let family stay, but let the SO stay overnight 24reciprocityApproach a situation with recognition and reciprocity rather than a sense of self-importance or superiority. Help patients maintain a sense of dignity by bargaining and negotiation. Show respect and fair mindedness. Letting patient know what you are doing ahead of time. (Finfgeld-Connet, 2009)

25Limit settingThe importance of a well organized and predictable milieu. Group schedule, rounds, favorsClearly communicate that inner control is expected from the patient. If the patient is unable to do this then external control will be necessary. Matching the response to the level of dangerousness. (Finfgeld-Connet, 2009)

Effective behavioral control approaches include separating patients, denying requests and withdrawing privileges. (Finfgeld-Connet, 2009 p.534)Judicious use of seclusion and restraint

26Team workEffective multiple disciplinary teams plan ahead and talk openly about how to manage patients who have an increased potential for violence.The team approach is also important for direct care staff. Staff debriefings(Finfgeld-Connet, 2009)

27Non therapeutic responseNurses feel demoralized and traumatized, which may become a self-perpetuating cyclePatients feel mistreated and ignored. Erodes patient trust that the hospital is a place where they can get help in a time of crisis (Duxbury, 2002) Poor management of aggression and the Impact on the unit BurnoutAbsenteeismReassignmentResignation.28Implementation components of Authentic engagementSituational contextProviding a low stimulation roomProviding pre packaged food to a paranoid patientReciprocityNegotiating with patients who may want a restricted item, instead of saying no try to look for a way to balancing safety and patient preferenceLimit settingClearly communicate that inner control is expected in the patient handbookThere are times when negotiation is not appropriateTeamwork Charge nurses attending 1700 Resident reportFinding the balance between reciprocity and limit setting is a team effort. Finfgeld-Connet suggest that quantitative methods are needed to evaluate the effectiveness of educational programs based on the authentic engagement model

The balance between reciprocity and limit setting requires more initial effort, however avoiding aggressive events is a greater benefit

29Authentic engagement in practiceAligning with the patient who wanted to be discharged. Negotiating with a patient refusing to have a photo taken

There maybe nothing we can do but I have seen it be meaningful when they feel understood.

www.proprofs.com30

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31Potential BarriersThe belief that seclusion is the only way to keep the unit safe. Disempowerment of nursing staff. Difficult to describe the balance between limit setting and reciprocity in words. Stressors in a nurses personal life Incomprehensible underlying patient needs. 32ConclusionAuthentic Engagement is one interventional model that can help nursing staff to intervene before a patient become aggressive. There are many causes of aggression that are outside of our control. For example, the long wait times for court order medication. However, authentic engagement techniques provides a pathway to more effective care and a safer work environment.

Preventing aggression is in everyones best interest.Nursing staff less fear at work, less burn out, less injuriesPatients less trauma, shorter hospital staysInstitutional compliance with CMS regulations

----- Meeting Notes (10/23/13 09:40) -----read slide first then play clip33ReferencesBonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465473.Bowers, L., Nijman, H., Simpson, A., & Jones, J. (2010). The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology, 46(2), 143148. doi:10.1007/s00127-010-0180-8Carlsson, G., Dahlberg, K., & Drew, N. (2000). Encountering violence and aggression in mental health nursing: A phenomenological study of tacit caring knowledge. Issues in Mental Health Nursing, 21(5), 533545.Delaney, K. R. (2009). Reducing Reactive Aggression by Lowering Coping Demands and Boosting Regulation: Five Key Staff Behaviors. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 211219. doi:10.1111/j.1744-6171.2009.00201.xDuxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9(3), 325337.Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469478.

ReferencesFarrell, G., & Cubit, K. (2005). Nurses under threat: a comparison of content of 28 aggression management programs. International journal of mental health nursing, 14(1), 4453.Finfgeld-Connett, D. (2009). Model of Therapeutic and Non-Therapeutic Responses to Patient Aggression. Issues in Mental Health Nursing, 30(9), 530537. doi:10.1080/01612840902722120Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. The British Journal of Psychiatry, 191(4), 298303. doi:10.1192/bjp.bp.106.034538Gertz, B. (1980). Training for prevention of assaultive behavior in a psychiatric hospital. Hospital and Community Psychiatry, 31, 628-630May, B. (2010). Orlandos nursing process theory in nursing practice. In M. R. Alligood & A. M. Torney (Eds.), Nursing theory: utlization & application (4th ed., pp. 337357). Maryland Heights, MI: Mosby Elsevier.Orlando, I. J. (1990). The dynamic nurse-patient relationship. New York, New York: National League for Nursing.Price, O., & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21(4), 310319. doi:10.1111/j.1447-0349.2011.00793.x

ReferencesSAMHSA Seclusion and Restraint - Statement of the Problem and SAMHSAs Response. (n.d.). Retrieved September 8, 2012, from http://www.samhsa.gov/seclusion/sr_handout.aspxScanlan, J. N. (2009). Interventions To Reduce the Use of Seclusion and Restraint in Inpatient Psychiatric Settings: What We Know So Far a Review of the Literature. International Journal of Social Psychiatry, 56(4), 412423. doi:10.1177/0020764009106630Sullivan, A. M., Bezmen, J., Barron, C. T., Rivera, J., Curley-Casey, L., & Marino, D. (2005). Reducing Restraints: Alternatives to Restraints on an Inpatient Psychiatric Service/Utilizing Safe and Effective Methods to Evaluate and Treat the Violent Patient. Psychiatric Quarterly, 76(1), 5165. doi:10.1007/s11089-005-5581-3Zeller, S. L., & Rhoades, R. W. (2010). Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clinical Therapeutics, 32(3), 403425. doi:10.1016/j.clinthera.2010.03.006Zuzelo, P. R., Curran, S. S., & Zeserman, M. A. (2012). Registered Nurses and Behavior Health Associates Responses to Violent Inpatient Interactions on Behavioral Health Units. Journal of the American Psychiatric Nurses Association, 18(2), 112-126.

Picture ReferencesSlide 4 http://www.southernpoliceequipment.com/shop/default.asp?h=c&c=13&id=1684Slide 6www.telegraph.co.uk/news/worldnews/northamerica/usa/8296557/Remains-of-thousands-of-patients-found-at-One-Flew-Over-the-Cuckoos-Nest-institution.htmlSlide 9www.creativitypost.com/psychology/must_one_risk_madness_to_achieve_geniusSlide 12www.hrea.org/erc/Library/primary/Opening_the_Door/workshop16.htmlSlide 15www.proact.com; http://www.moabtraining.com/main.phpSlide 25heartlandwriting.wordpress.comSlide 27www.fineartamerica.com/featured/red-ants-teamwork-peerasith-chaisanit.htmlSlide 30www.proprofs.comSlide 31http://www.finest.se/userBlog/?uid=39305&beid=2486574

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mailto:firelight33@gmail.com?subject=AE presentationRole play Practice session: 30 minutesA patient demanding dischargeA patient refusing a search after coming back from a passDenial of a request for pain medicationA patient who is disorganized and psychoticAn intrusive patient

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