Psychiatric Emergencies in Medical Settings
Detecting a psychiatric situation in a non-psychiatric setting has become a challenge in many healthcare provision settings. First, the nurses are setback by unfamiliar situations, thus leading them to the next challenge where they are unable to act or react to such settings. The FOCUS-PDCA models can be used in order to improve such cases as evident in Mr. X’s situation.
Part A FOCUS and PDCA
FOCUS
In order to improve the performance of nurses in non-psychiatric units when faced with psychiatric related situations, the first step is to find a process that will support improvement. This should be accompanied by first finding “what” needs improvement (Risal & Sharma, 2013). According to the scenario in Mr. X’s situation, nurses do not know how to handle patients who present other symptoms than what is considered as “normal” in the given unit. For example, these nurses do not know how to handle patients who present symptoms that make them to react violently or make verbal expressions that are not connected to pain. In this scenario, the nurses do not know how to handle patients presenting psychiatric symptoms as made evident by Mr.X’s case.
Finding the solution to this challenge can only be made possible by organizing a team. Since this situation relates to cases. The team should include as many personnel in the psychiatric unit as possible. However, it should not be exclusive to such. Other personnel from non-psychiatric unit should be included. It would even be better if the person with experience in both units was included (Risal & Sharma, 2013). A general doctor or a senior nurse would be appropriate. Such personnel would guide the nurses in differentiating between normal expressions and those expressions that need psychiatric attention. There leader should be a senior nurse as he/she commands authority. A physician may also take this position as he/she also has such authority. The facilitator can be a regular nurse who is experienced. The recording position may also be given to a regular nurse. This is to ensure that the data gathered is properly posted for further analysis. There should be additional team members who should act as “extra eyes” or observers.
Nurses are mainly considered as general. However, like any other specialty, diverse nurses are better in specific areas. In majority of the cases, nurses who have a specialty in the psychiatric cases are mainly found in the psychiatric unit. Furthermore, many people (including nurses unfortunately) mainly believe that psychiatric cases are obvious even to the normal person. They therefore assume that these patients will be obviously directed to the psychiatric wing just as the laboring woman is directed to the labor unit. Due to such assumption, they hardly expect and prepare for psychiatric cases in non-psychiatric units. As a result, such nurses are confused and unable to act when such cases finally appear. Additionally, the training workshops or refresher courses mainly focus on what is frequently encountered. They do not direct the needed resources to the rare scenarios (Gilbert, 2012).
The cause and effect diagram:
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The above diagram shows that the main challenge or effect is the nurses’ challenge in dealing with psychiatric cases in non-psychiatric units. People, equipment, procedures, and policies contribute to the existence of this challenge. The sub causes leading to the main effect include ignorance, lack of training, the confinement of the necessary equipment to a specific unit, lack of defined and exclusive policies and procedures.
Developing an improvement plan is the most effective may of dealing with such a situation. The first step in the plan is to appreciate that the problem is in existence. This will be done by raising awareness of the problem within and among the nurses. The next step is to familiarize the nurses with such cases as much as possible. This can be done by shuffling the nurses between the units. This is mainly between the psychiatric and non-psychiatric units (Gilber, 2012). In-patient X’s situation, the nurses drifted back when they saw Mr. X behave the way he did. They looked at him as though he was a ghost. By placing such nurses in the psychiatric unit, they will be able to view such scenarios as “normal’ even when they come across them in non-psychiatric units. This shuffling action should be accompanied by training and workshops. Evaluations should also be done in order to assess the number of nurses who are actually familiar with psychiatric related signs and symptoms. The other step will be to place specific procedures and policies relating to such circumstances (Olshaker et al., 1997). Equipment should not only be present, but it should also be made available to all units in the hospital in case of such scenarios. In the near future, the nurses will be equipped both physically and mentally for the emergence of such scenarios.
PDCA
The improvement plan is to train and equip the staff, and develop procedures and policies relating to such circumstances. The recording member of the team should be very active during this part. The drafting of the procedures and policy or policies will also take place during this part. The training of the nurses will take place in various steps. As indicated above, they will be shuffled between the psychiatric and non-psychiatric units. However, this will take place after the physical assessment and training has taken place. The special team will be set for the drafting of the policies and procedures (Oshaker et al, 1997). This will include an expert in making of policies and their implementation, an administrator, a surveyor and an observer. The leader of the initial team will also act as the leader in this team. The facilitator will mainly deal with the training of the nurses. Constant evaluations and rectifications will work together to avoid future risks.
The assessment, training and evaluation will take two weeks. Here, the nurses will be given some refresher courses on how to handle such cases. They will also be physically placed in the psychiatric unit and the non-psychiatric unit in order to familiarize them to such scenarios. An arrangement will be made for them to encounter such scenarios in the non-psychiatric unit in order to push for more practices. However, a distinction should be made between the practice period and the normal running of work. During the third week, the nurses will be trained on the policy and procedures that have been fashioned. In this same week, they will put into practice these procedures and policies so that the policy makers and implementers can detect any shortcomings and challenges relating to the policies. After the full approval of the policy and procedures, the fifth week should start the grace period. This grace period provides room for mistakes and corrections before the official policy statement.
There are certain steps that can be used in order to check whether the plan worked. Collection of data during the practice period is quite relevant. This will present the action and reaction relating to the patients’ actions, nurses reactions in relation to the policies and procedures and the outcomes (Gilbert, 2012). This information can be filled in a data sheet or at the back of the patients’ medical chart/information sheet. The time date and unit should be recorded. The data should be frequently analyzed in order to gather as much information as possible for the decision making process.
Unit Protocol
- If the symptoms of the patient do not result in the “normal” ailments dominant in the unit, do not panic. Better, do not show the patient that you are panicking.
- Calm the patient by use of words before administering any drug. This should be done by reassuring the patient that he/she is in a safe place especially is he/she is panicky. This should be accompanied by calling for assistance. A physician should also be called at this point.
- If the patient is violent, and cannot be handled by one or two persons, he should be held to the bed before administering any drug, in case of any negative reactions.
- A physician should authorize the patient’s transfer to the psychiatric unit.
- If the physician fails to come in the recommended time, the nurse should take the patient to the psychiatric unit or call a psychiatric doctor.
NOTE: The patient should not be drugged to sleep before he/she is attended by a physician no matter the violence or physical reactions of the patient. The nurse should remain as calm as possible during the whole process (Risal & Sharma, 2013; Gilbert, 2012).
References
Gilbert, S. B. (January 01, 2012). Beyond acting out: managing pediatric psychiatric emergencies in the emergency department. Advanced Emergency Nursing Journal, 34, 2.)
Olshaker, J. S., Browne, B., Jerrard, D. A., Prendergast, H., & Stair, T. O. (1997). Medical clearance and screening of psychiatric patients in the emergency department. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 4, 2, 124-8.
Risal, A., & Sharma, P. P. (January 01, 2013). Psychiatric morbidity patterns in referred inpatients of other specialties. Jnma; Journal of the Nepal Medical Association, 52, 189.)
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