Prevention of violence and aggression among patients

Prevention of violence and aggression among patients Lene Schwartz Margit Reimers Knudsen Director of Nursing Development Consultant, MPH Psychiatric Hospital ”Fjorden” Psychiatric Center County of Roskilde County of West Zealand Denmark Denmark The Health Promoting Hospital network conference in Moscow 2004 “Investing in health for the future”

Purpose…….. The purpose of developing quality assurances programs to improve staff's competences in dealing with aggression and violent behaviour among psychiatric patients: • To assure the human rights of the psychiatric patient according to “Law of force use in the Psychiatry” • To improve quality of care for the potential violent patient • To improve working environment

The Law Law of loss of liberty and other forces in the Psychiatry Law nr. 331 of 24. of May 1989 According to law announcement of 2.of December 1998

The Law The area of the Law §1 Loss of liberty and use of other force in connection with hospitalization, stay and treatment in a psychiatric ward must only be performed according to the regulations in this Law. Section 2. By force in this Law means use of steps, which the patient are against.

Any coercive measure can only take place, if the person of which the coercive measures are used upon are mentally sick or in a state of mind that can be comparer with mentally sickness, and where it would be irresponsible not to carry out a coercive measure. Before a coercive measure are carried out one must try to obtain a treatment agreement, which the patient freely can accept. Loss of freedom are considered as something very serious in our democratic society. Therefore it has been naturally to renew the Law of force in the psychiatry, so the measures are in level with the norms of a modern society. With loss of freedom every citizen in Denmark has a constitutional right to be put in front of a judge within 24 hours after the loss of freedom. The Constitutional Law are suspended, when a mentally sick person lose his/hers freedom in connection to a compulsory detained hospitalization. To complement this this law have certain control measures, which regulates the doctors authority to authorize any coercive measures. When is the Law used?

Compulsory hospitalization compulsory hospitalization can only be performed by a doctor, who is not employed at the psychiatric ward, where the patient are compulsory hospitalized. The police, who take part in a compulsory hospitalization, must approve the hospitalization as legally. It is relatives or the Public who demand a compulsory hospitalization. Before a compulsory hospitalization one must by all means try to motivate the person for a Voluntary hospitalization. The patient can not be accepted in the ward, before the doctor at the hospital have approved the medical foundation of the compulsory hospitalization.

When can a person be compulsory hospitalized? • If a person are dangerous to himself or to other people • That a person needs treatment and that it would be irresponsible to omit the treatment. Compulsory hospitalization take place in a secured psychiatric ward by assistance of the police. The compulsory hospitalization must be registered and reported to the medical officer of health and the ministry of health. The patient can always complain if compulsory hospitalized.

Compulsory restraining: The same conditions as by a compulsory hospitalization must be followed. A person can be hold back, if the person must be treated for his mental sickness, or he is in danger of hurting himself or others due to his mental sickness. Be aware of, that both hospitalization and holding back the patient demands, that the patients state of mind are treatable. This Law only leaves possibility for placement of a person, when treatment is needed. Treatment must be seen in a wide perspective. It is considered important to take good care of any mentally sick person, as mentions above. Compulsory treatment of any kind must according to the Law only be used if all attempt of getting the patients approval has failed.

Compulsory - treatment: During admission in a psychiatric ward compulsory treatment can be necessary to impose. Before this can be effectuated, the same conditions as with compulsory hospitalization must be followed. It means that the person who is in question of receiving compulsory treatment must be mentally sick or in a state of mind that can be compared to mentally sickness. The Law instruct any practitioner to avoid the use of force, at any circumstance possible. The chief doctor must be sure that it is not possible to motivate the patient for voluntarily treatment. Compulsory treatment can be necessary : • acute treatment with calming medicine in case of acute psychotic anxiety. • treatment of long duration of a mentally sickness with approved medication. • a special form of compulsory treatment can also be decided by the doctors in charge, if a person due to mentally sickness will not allow herself necessary somatic treatment, because his state of mind tells him that he deserved to die. (typically if the patients have a severe depression or similarly)

Compulsory – treatment and Compulsory fixation: Every compulsory treatment must be registered and and reported to the medical officer of health and the ministry of health. Planned compulsory treatment (not acute) will mostly be postponed, if the patient wants to Complain about the planned compulsory treatment to the patients complaints board. Compulsory fixation: The Law leaves the possibilityto strap down a patient with a belt around the waist tied to the bed. If necessary, the use of hands- and foots traps or gloves too. These situations occurs when it is not possible to make a deal with the patient because the mentally sickness blocks for communication. It is rare that these situations appears, where strap down a patient is necessary. The staff are trained to prevent that these situations arises during special designed courses.

Compulsory fixation and Physical use of force: Compulsory fixation of any kind must according to the Law only be used if all attempt of getting the patients approval has failed. Compulsory fixation of any kind must be registered and reported to the medical officer of health and the ministry of health. And again the patient can always complain about any compulsory treatment to the patients complaints board. Physical use of force: Physical use of force means when the staff holds the patient physically. It will be used if necessary to Carry through a compulsory treatment, compulsory fixation, avoid aggressive behaviour, avoid self-destructive Acts or avoid the patient to leave the ward. The same rules as with any other use of force are to be followed strictly according to the Law, and again the patient can always give a complain to the patients complaints board. The Staff must be trained to choose working situations which avoids or reduce the use of physical force As much as possible. Any use of physical force must be registered and reported to the medical officer of health and the ministry of health.

Patient adviser: It can be difficult to cope with ones situation as hospitalized. Most people are put in a sort of crisis in connection with hospitalization. When one is hospitalized due to psychiatric problems and are exposed to compulsory treatment or any kind of used force it can be rather dramatic and therefore more difficult to estimate ones situation. With this Law the government have made sure that people in this situation get qualified help from a patient adviser, who can advise about use of force and how to complain to the patients complaints board. The patient advisor can if necessary write the complaint for the patient and post it as well. The patient advisor is a kind of advocate for the patient. the advisor must make sure that the patient are not exposed to any used force, not necessary. The advisor see the patient within the first 24 hours and visit the patient during his stay at the ward at least once a week. The staff must inform the advisor of any use of force against his patient, and according to the Law the advisor must participate in the patients complaints board meetings concerning his patient.

Access to complaints: All patients, who are exposed to use of force have access to make a complaint to the patients complaints board. The patients complaints board handles complaints concerning: • Compulsory hospitalization • Compulsory restraining • compulsory – treatment • Compulsory fixation • Physical use of force The board consist of a chairman (a lawyer), a doctor and a representative of the coordinating invalid organisations (mostly a representative from the patient organisation called SIND). The chairman must make sure that the patients complaints and situation are assed according to common and medical information's and make sure that the legal aspect are followed. The board aim for agreement in decisions.

Who is the potential aggressive patients? • Schizophrenic patients • Psychotic patients • Patients with Personal Disorders • Organic brain damaged and retarded patients • Senile Dementia patients • Drug and alcohol abusers

Other circumstances of importance: • Social status and environment • Gender and age • Violent behaviour during earlier hospitalizations

Frame of programs The programs are designed to meet local needs, but the main content is the same. The programs are divided into 2 parts: • a theoretical part and a practical part • duration of the programs: • takes 4 days in County of Roskilde • takes 5 days in County of West Zealand

Development of violent behavior within psychotic patients Emphasising the psychosis, in order to understand Psychotic reality ------------- Discrepancy --------------- Real reality Despair Desolation Unapproachableness Isolation Worsening of the psychosis Violence / self destruction

Elements of the theoretical programs • Active listening • Create a safe and calm environment for patients • Verbal and non – verbal language • How to handle conflicts • How to set limitations • Awareness and attitudes and behaviour • Possibility for “follow up” days

Elements of the practical part of the programs • Release techniques • Avoidance techniques • Pacifying techniques • The right of self – defence • Practical training in how to act in threatening and violent situations

Effects These effects are based on the evaluation of several programs/courses during the last 3-4 years. • Increased safety for staff and patients • Less use of force • Less use of tranquilizing medicine • More freedom to the patients • Better working environment • Better working satisfaction • Increased self-esteem amongst the patients

Prevention of violence and aggression among patients