Free Health Essays - Risk Symptoms Management
Risk is the possibility of beneficial and harmful outcomes and the likelihood of their occurrence in a stated timescale, risk is fundamentally about uncertainty the variation in possible outcomes and the inability to predict with 100% accuracy the outcome of a situation. It is also about weighing up the likelihood of the different outcomes arising. This assignment will critically discuss the nurse’s role in the risk management of Peter, who was admitted in an acute psychiatric ward after a knife attack on a passer-by (see appendix 1).
The Sainsbury Centre for Mental Health (2000) asserts risk in mental health as the likelihood of an event happening with the chance of or beneficial outcomes for self or others. Some of the behaviours that bring about risk include suicide, self-harm, neglect, aggression and violence. Due to the unprovoked attack with a weapon by Peter, he poses a risk and can be regarded as dangerous. Paterson and Start (2001) have discussed the incongruence between claims that have been made that the number of killings by people experiencing mental illness increased following the acceleration of the government’s community care programme in 1991 and the statistical records of authoritative research from the same period.
In 1994, 61 of the 479 convictions for homicides in England were by people who were mentally ill (Department of Health DH, 1998). Bonta et al (1998) disputed evidence that psychiatric diagnosis was the best predictor of dangerousness. Clinical variables such as psychosis had the weakest correlation with recurrent episodes of violence. A good assessment about dangerousness has, in essence always been about risk assessment.
Using the National Institute for Clinical Excellence (NICE), (2002) guidelines, the essay critically discusses the management of Peter’s care and discusses the discharge planning process for him. The assignment will also critically analyse the effectiveness of the community support networks using current research.
Peter is experiencing many possible symptoms, they are classed into positive and negative symptoms of psychosis. Brooking (2003) describes positive symptoms as those that show abnormal mental functions for example hallucinations, this means hearing, seeing, feeling, smelling, or tasting things that are not real. Peter experiences auditory hallucinations, hearing voices is the most common.
Peter also exhibits negative symptoms as he has lost interest in self care and socialization. Negative symptoms according to Brennan, (2004), includes lack of emotion, low energy, lack of interest in life, low motivation affective flattening, inappropriate social skills or lack of interest or inability to socialize with other people or to make friends or keep friends, or not caring to have friends, social isolation.
Peter therefore poses a risk of developing or could be suffering from a psychotic illness such as schizophrenia and may be in hospital for a longer period (xxxxx). The relationship the nurse develops with the user is accorded high value by users of mental health service, and is one of the core values underpinning the chief nursing officers’ review of mental health nursing (DH, 2006).
The government is currently considering the reclassification of cannabis to a class B, in response to concerns about the psychosis link (DH, 2006). Caring for Peter requires a full risk assessment in order to establish the appropriate care for him.
Risk and Risk assessment
Risk assessment is used with service users for whom it is judged probably that they are vulnerable to harm themselves or others and that the degree of probability is above that which all humans are constantly exposed (Ryan, 1999). Grounds (1995) suggest that clinical risk assessment is not about making accurate prediction but about making informed, defensible decisions about dangerous behaviour.
The test is not about accuracy, but how defensible the decision is in terms of social realities and current scientific knowledge. Assessments, planning, implementing, and evaluating constitute the nursing process (Baker 2001). The nurse would commence the assessment stage by collecting information about Peter. This can be achieved through accessing past records, self-report from Peter at the initial interview.
Information could also be obtained from significant others such as family, friends and the police concerning the unprovoked knife attack on a passer-by. The nurse would also incorporate information from other professionals who are involved in the care delivery process for Peter such as consultants, general practioner, carers, occupational therapists and others.
It takes 7-30 days for cannabis to fully metabolize in the body (DH, 2006) hence clinician can be criticized for a mis-diagnosis in this case peter could have been assessed before the cannabis fully metabolises therefore you may end up with wrong diagnosis.
This risk assessment form addresses the clinical symptoms and behaviour symptoms that indicate risk. Barker, (2001), citing the Department of Health (DOH), (1999) states that there are three areas of highest concern in the context of risk namely violence towards others, self-harm and severe self neglect.
Voilence and aggression
According to Doyle (1996) says violence is an act that is intended to cause serious physical and psychological harm to oneself, others or property. It is a serious physical attack with an intention of causing harm (Graham, 2001). Research has shown that prevalence of suicidal risk is much greater than that of violence despite media reports that risk of violence is greater MIND (2006).
It is evident that the public at large believe mentally ill patients are dangerous and are fearful of them mainly due to the attitude and reporting of the media (Stark et al, 2004). The fears of the public may reflect an inaccurate and exaggerated view of the association between mental illness and violence.
According to Morgan (1998) something has to take place for behaviour to happen. A risk formulation is a statement that describes the circumstances and indicators that indicate an increased likelihood of a person in specific risk behaviour (Turnbull and Paterson, 1999). The formulation identifies that Peter is at a very high risk of violent assault and verbal aggression during his stay in hospital. Barker, (2001) views that the best predictor of future behaviour is past behaviour. In this context Peter’s assault on a passer-by indicate future violence.
The use of a weapon the knife is also another indicator, in addition, his command hallucinations and the response to the voices are also indicators of violence. Moreover, taking drugs especially cannabis is another indicator. Furthermore, Peter poses a risk of triggering other patients to act in a violent manner by his wide gesticulations and shouting of obscenities and abuse. There is an abuse risk indicator to Peter himself from carers, professionals and other patients because he is dishevelled, dirty and incoherent in his expressions.
Peter might be resorting to drug use as a coping strategy from the command hallucinations. Barker (2001) asserts that patients have got their own coping strategies in relation to their illness. However, Morgan, (2000) state that misuse of drugs and alcohol are indicators that correlate with violence. This analysis of risk factors will then help the nurse formulate a plan for action for Peter’s recovery.
Risk assessment
Effective risk assessment still entails the nurse and other clinicians investigating the person’s (Peter) current mental state and environmental circumstances and weighing up these up together with a number of actuarial factors associated with increased risk (Alberg et al, 1996) in order to make decisions that will ultimately affect their care, supervision and autonomy.
These problems are compounded by the false-positive prediction, however (Alberg, 1996), asserted that risk assessment cannot expect to accurately predict violence, but instead should aim to produce clinically defensible decisions on the probability of violence. Forensic risk assessment aims to assess whether or not a patient is a risk to themselves or to others in terms of serious violence, sexual violence, dangerousness, absconding and recidivism in the past, now or in the future (Kettles, 2004).
An assessment outcome is referred to as false positive if a risk that has been predicted to exist does not happen while false negative when risk is predicted not to (or barely) exist but happens. Actuarial indicators (risk factors) are the particular features of illness, behaviour or circumstances that lead to an increased risk. Crighton, (1995) argued that mental illness may be an irrelevant variable in the prediction of violence as research show’s these factors are the same for the general population with those with a diagnosis of mental illness.
The actuarial indicators of violence are gender (male), age (teenage to twenties), lower social class, substance abuse and history of violence. Crighton (1995) added that screening mentally ill patient for actuarial predictive factors generates a high level of false positives resulting in infringement of the rights of patients.
Management
The Mental Health Act (1983) is a piece of statute law in United Kingdom which provides for people suffering from a mental disorder to be detained in hospital and have their disorder assessed or treated against their wishes. This act is primarily there in the interest of the patient and the public at large and is reviewed and regulated by the Mental Health Act Commission (MHAC). Peter was brought in to the hospital under the powers of Section 136 of this act that allows a police officer to take a person whom they consider to be mentally disordered to a place of safety. Section 136 allows for further assessment (Section 2) and treatment (Section 3) to be implemented.
This is a legislative way of managing risks that Peter poses. Risk management aims to minimise the likelihood of adverse events within the context of the overall management of an individual, to achieve the best possible outcome, and deliver safe, appropriate, effective care (Ryan, 1999). Peter made an unprovoked attacked on a passer-by with a knife. This is an act of violence which put him and the public at great risk therefore he needs to be detained.
NMC Code of Professional Conduct (2004) asserts that as a nurse we have a duty of care for our service users. Visitor restrictions and random room searches in the ward could minimise drug access. Some mental health services are working with local police to prevent the extent of drug taking and dealing activity by using Drug Sniffer Dogs as a means of risk management (Rolfe and Cutcliffe, 2005).
Management of risk does not eliminate risk clinicians have to plan some of the strategies of risk management which include early intervention, service users having daily living activities to reduce boredom with the occupational therapist, good rapport between service user and nursing staff, having patients advocate during conflicts and an effective justice procedure (patients rights) but for the purpose of this assignment the author will focus on medication and seclusion. Assessing the intensity of care for the service users particularly when being observed, observation varies from level of closeness, general closeness and special closeness according to NICE guidelines.
The use of medication during an acute phase of psychosis is seen as a crucial treatment to initiate recovery process (White et al 2007). The role of the nurse is to support the user in making the choices about their medication that works for them (Jones and Jones 2007).
Risk could be managed by the use of rapid tranquilizers and or seclusion as a last resort when dealing with violent behaviour. The Royal College of Psychiatrists (RCP)has recently published clinical practice guidelines on the management of violence. The review of the safety and efficacy of medication in the management of violence was systematic. The vast majority of research deals with the safety and efficacy of different agents in the treatment of difficult, disturbed, agitated or aggressive behaviour.
The recommendation is that if rapid tranquillization is indicated because psychosocial methods of intervention have failed or are insufficient or inappropriate, benzodiazepines alone, or combined with an antipsychotic if a treatment effect is also required, can be used with a reasonable degree of safety for managing violent behaviour (RCP, 1997). The most common rapid tranquilizers or drugs used are diazepam, haloperidol, chlorpromazine, droperidol, lorazepam and nitrazepam.
Rapid tranquillisation (also called urgent sedation) is the use of medication to reduce anxiety or agitation of a patient and reduce the risk to self and/or others whilst allowing comprehension and response to spoken messages throughout (NICE, 2002). Medication may suppress the active symptoms such as delusions and hallucinations that can drive some mentally ill individuals to violence.
The algorithm for rapid control of acutely disturbed service users within the (NICE) guidelines suggests that the first intervention used should be non-pharmacological methods, talking the service user down, distraction and seclusion. Seclusion is defined by NICE (2002) as the supervised confinement of a patient in a room, which may be locked to protect others from significant harm. Moreover seclusion is the enforced isolation of a patient in a locked room and is another method of managing patients who are behaving in a violent manner.
Its aim is to contain severely disturbed and violent behaviour which is likely to cause harm to others. However, seclusion should be used as a last resort and for the shortest possible time. There was a tendency by staff to jumping on to restraint, sedation and seclusion rather than using de-escalation as a preventive strategy in the management of aggressive behaviour (Meehan et al (2006). Seclusion is seen primarily as a means of dealing with severely disturbed behaviour where there is an immediate danger to the patients or others (Royal College of Nursing Society of Psychiatric Nursing, 1997).
This method of management has been criticized on both therapeutic and moral grounds, at times its occurrence has doubtless been a reflection more of a poor patient-staff ratio than of therapeutic necessity. This is against the NICE (2000) guidelines which stresses that seclusion is not to be used as a threat or part of a treatment programme, cover for shortage of staff. It must also be avoided where there is any risk of suicide or self-harm.
The neglect of personal hygiene and personal appearance is a common occurrence among psychiatric service users. Peter has a risk of self-neglect as he has not been attending to his personal hygiene and hence dishevelled and dirty. Peter requires different levels of assistance in order to care for his hygiene, token economy programmes have also been shown to be effective in increasing service users personal grooming, such as face washing, shaving, tooth brushing and dressing neatly. Good therapeutic relationship with Peter can be the starting point in order to promote intervention engagement.
One-to-one sessions with Peter are essential to create such relationship and enabling and empowering him to make informed decisions about his hygiene (Norton, 1998; Kelly and Byrne, 2006). Bandura’s theory states that many individuals believed that aggression produces reinforcements. These reinforcements can formulate into reduction of tension, gaining financial rewards, gaining the praise of others, or building self-esteem. Specific targets selected for attack are determined by social learning factors.
He also states that the triggers and consequences like positive or negative reinforcements determine the behaviour. In Peters’s case it was violence and aggression, therefore the nurse could eradicate or minimize triggers such as the command hallucinations, thus negative reinforcement (Beck, 1993). Diversionary strategies like listening to a walk man with earphones or talking to the nurse or other professionals at the time of the hallucinations could be suggested to Peter.
Alternatively, the things that Peter likes could be made available to him as a reward for, or maintenance of good behaviour, thus positive reinforcement. Moreover, Barker (2001) suggests that therapists should possess skills of getting inside the client’s cognitive world and empathize while at the same time retaining objectivity. The nurse could then engage with Peter into psycho-education, as a coping strategy for his past experiences, during his lucid moments.
Discharge planning
In preparation for Peters discharge in the community a key worker has to be allocated who will explore service users perception of the services they receive and their preferences in the community, and to prepare them mentally to face the outside world. The nurses have a key role in educating the service user and their carers about the discharge and continuity of care provided. A Community Psychiatric Nurse (CPN) should visit Peter on the ward to develop a trusting relationship.
The CPN has a duty of care to support Peter, Winefield and Harvey (1994) surveyed 121 carers of those with mental health problems and found the main stated needs were as follows, less social isolation, to know that there are others in the same situation, information about the illness and treatment, advice about coping strategies, familiarity with mental health resources.
Peter will be placed on an Enhanced Care Programme Approuch (CPA) due to his complex needs that require multi-professional and or agency input to meet them. (CPA) Meetings (Clinical Reviews) monitor progress and decide on a discharge programme. CPA was introduced in 1991 (DH, 2000), as a framework for the organization of community mental health care, including procedures for differentiating and managing patients according to their levels of risk, with measures of community supervision applied to patients of particularly high risk (Gordin, 2004).
The CPA is an important approach that is intended to secure an assessment care planning, monitoring and review for people who may potentially be treated in the community; and to ensure communication between health and social care through case management, in line with Section 117 of the Mental Health Act (1983), which gives the statutory authorities a duty to made arrangements for a person's continuing support and care (DH, 1995, Ryan et al., 1991).
It shall be the District Health Authority and local social services authority to provide, in co-operation with relevant voluntary agencies, after-care services for Peter until they are satisfied that he no longer needs such services. A further piece of legislation, the Mental Health (Patient in the Community) Act 1995, created supervised discharge whereby a person can be legally required to reside at a certain place and attend for treatment.
Peter needs a referral to alcohol and drug addiction services to reduce his risk of drug abuse (CAMHS). He can attend community relapse prevention groups to avoid a relapse, social worker to find appropriate agencies that are recruiting so he can be in work (as a distracting technique) and he can feel as part of the society.
Social workers engaged in discharge planning coordinate discharge for patients by collaborating with the patient, family, health care team, and community resources. The social worker is involved with the early identification and assessment of the patient’s needs and implements timely discharge plans that result in continuity of care and efficient use of hospital and community resources such as. In preparation for discharge the nurse will need to provide users with knowledge about the treatment available, and empower the user with skills in managing side effects of treatment if and when they occur (Gray et al 2005)
Conclusion
The role of the nurse in risk management for Peter would be working collaboratively, eliciting user information, provision of information, clarifying user understanding and empathy, are a mechanism used to provide quality care.
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