MENTAL HEALTH

Reducing restrictive practice

in adult services: not only an issue
for mental health professionals
Greg Hext, Louise L Clark and Andreas Xyrichis

T
he issue of reducing the use of ‘restrictive practices’
in mental health and learning disability services is ABSTRACT
of national importance (Royal College of Nursing Reducing ‘restrictive practices’ is an issue of national importance, pertinent
(RCN), 2013; 2017; Department of Health (DH), to all NHS sectors, yet there is poor awareness of the issue in mainstream
2014; Care Quality Commission (CQC), 2017). adult services. Such practices potentially restrict a person’s rights to
Recent publications centre largely on the need to reduce choice, self-determination, privacy and freedom. Challenging behaviour is
restrictive interventions, such as physical restraint, seclusion often the result of unmet needs, communication difficulties or diagnostic
and the use of rapid tranquilisation, through positive behavioural overshadowing, but there is a common misconception that patients exhibit
support plans, post-incident reviews and training to challenge such behaviours because of their impaired intellectual abilities or mental
and change staff attitudes (Cockerton et al, 2015; Whyte, 2016; health problems. This article seeks to raise awareness of restrictive practices
Clark et al, 2017a; Reeves, 2017). This work is currently and suggest the way forward. It highlights the importance of good de-
confined to mental health and learning disability services, with escalation skills, which, if adopted early in therapeutic relationships, may help
little attention paid to adult field nursing practices, despite this reduce the occurrence of challenging behaviours and situations. Behavioural
issue being pertinent to all services. support plans that adopt a biopsychopharmacosocial approach (BPPS)
The CQC (2017) has highlighted the need for positive detail a range of interventions for managing challenging behaviours. Tailored
behavioural support plans for people with learning disabilities, support that follows a BPPS approach could reduce incidents of challenging
autism and/or mental health problems regardless of place of behaviour, reduce costly observation, improve the patient experience and
care. It stresses the importance of understanding factors that protect the patient’s liberty.
contribute to someone’s behaviour and calls for evidence
Key words: Restrictive practice  ■ De-escalation  ■ Biopsychopharmacosocial
that providers have a strategy, policy and procedures in
approach  ■ Challenging behaviour  ■ Behavioural support plans
place to manage challenging behaviours. Providers must
confirm that care records actively demonstrate that a holistic
(biopsychopharmacosocial (BPPS)) assessment has taken place. to the spotlight. The CQC (2017) quotes that it may take
The CQC (2017) does not differentiate between patients in action against a healthcare provider under the regulations set
the care of mental health, learning disability or adult nursing out in Table 1.
services, stating ‘all providers must take account of the DH Alongside the CQC requirements, there is a need to
(2014) guidance’. reduce the widespread use of one-to-one staffing adopted
Furthermore, a recent Law Commission (2017) review of for patients with mental health problems, dementia and/or
mental capacity and deprivation of liberty will undoubtedly learning disabilities in generic adult care environments. Not
help bring restrictive practices in generic adult services in only does this routine practice severely limit a person’s liberty
and exacerbate stigma, it comes at a significant financial cost
to the individual organisation and the wider health service.
Greg Hext, Lead Nurse, Marjory Warren Acute Medical Unit,
Charing Cross Hospital, Imperial College NHS Healthcare Trust, Restrictive practices
greg.hext@nhs.net A clarification must be made between restrictive practices and
Louise L Clark, Senior Teaching Fellow, Florence Nightingale restrictive interventions, whereby the former often result in the
Faculty of Nursing, Midwifery and Palliative Care, King’s College latter (Clark et al, 2017a; Reeves, 2017). When a culture of
© 2018 MA Healthcare Ltd

London control is adopted, as opposed to one of structure, restrictive

Andreas Xyrichis, Lecturer, Florence Nightingale Faculty of practices, which potentially restrict a person’s rights of choice,
Nursing, Midwifery and Palliative Care, King’s College London self-determination, privacy, freedom or freedom of movement,
Accepted for publication: March 2018 can result in unnecessary restrictive interventions (Whyte, 2016;
Clark et al, 2017a; Reeves, 2017).

British Journal of Nursing, 2018, Vol 27, No 9479

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.

 Table 1. Care Quality Commission (CQC) regulations relevant
access to the use of ordinary community facilities’ (Emerson,
to restrictive practice 2001). Challenging behaviour may be exhibited by anyone.
However, it is more commonly seen in people who have
The regulations CQC will take action
learning disabilities, dementia, mental health problems, those
Regulation 9: Person-centred care who have an acquired brain injury or who have had cerebral
Intends to make sure that people using When staff have not implemented vascular accident or similar intellectual impairment.
a service have care or treatment that is effective behavioural support plans Challenging behaviour may be exhibited through a variety of
personalised specifically for them actions, but the perception as to what constitutes such behaviour
Regulation 12: Safe care and treatment may differ from person to person. Aggressive behaviour,
Aims to prevent people receiving unsafe When staff have not assessed or which includes hitting, head-butting, threatening others with
care and treatment and prevent avoidable managed challenging behaviour effectively violence, screaming, scratching, spitting, biting, punching and
harm, or risk of harm kicking, is probably one of the more common conceptions
Regulation 13: Safeguarding service of challenging behaviour. It may also include self-injurious
users from abuse and improper behaviour, inappropriate sexualised behaviour (such as public
treatment masturbation, frottage or groping) or damage to property.
Focuses on safeguarding people who When staff have not taken reasonable There is a common misconception that patients exhibit
use services from experiencing any form steps to use the least-restrictive challenging or acutely disturbed behaviours because of their
of abuse or improper treatment while strategies to manage challenging mental health problem, learning disability or other clinical
receiving care and treatment behaviour
condition, when in fact this is often the result of unmet needs,
Regulation 17: Good governance communication difficulties or diagnostic overshadowing (While
Centres on making sure that providers When the provider has not audited and and Clark, 2009; Clark and Clarke, 2014). The latter is defined
have systems and processes that ensure monitored the number of challenging as the tendency of professionals to overlook the signs and
that they are able to meet requirements behaviour incidents or other positive symptoms of a secondary condition and, instead, attributing the
in the Health and Social Care Act 2016 behaviour support plan outcomes
behaviours to the primary condition, which may be a mental
Regulation 18: Staffing health problem, learning disability or other clinical condition.
The intention of this regulation is to make When staff are not suitably competent or It has been repeatedly highlighted that adult field pre-
sure providers deploy enough suitably skilled in positive behavioural support or registration nurse education does not fully prepare nurses to
qualified, competent and experienced supervised by people with the necessary address the needs of patients with mental health problems,
staff to enable them to meet all other experience
regulatory requirements described in the
learning (intellectual) disabilities or dementia in generic
Health and Social Care Act 2016 NHS settings (Clark, 2007; Hicks and Clark, 2011; While
and Clark, 2014; Clark et al, 2017b). Mencap reports (2007,
Source: Care Quality Commission, 2017
2012) have detailed serious shortfalls in care, including fatalities,
experienced by patients with learning disability in mainstream
There are recent examples to demonstrate that such inpatient services. Many of the cases involved patients who
interventions are avoidable. For example, work conducted at exhibited challenging behaviour, and the reports show that
a London mental health NHS trust (Whyte, 2016; Clark et nurses and other health professionals were ill-prepared to cope,
al, 2017a) showed how a reduction in restrictive interventions attributing this to a lack of robust education. As a result, there
was achieved through the use of multidisciplinary (MDT) have been calls for the pre-registration education of all health
positive behavioural support plans coupled with a staff training professionals to include consideration of the needs of people
programme to reduce the use of restrictive practices. with learning disabilities within generic health services (Michael,
A hospital admission in itself constitutes a restrictive practice 2008; Office of the Parliamentary Ombudsman, 2008).
(Clark et al, 2017a) as it removes a patient’s autonomy, control Hicks and Clarke (2001) argue that patients with mental
and the freedom to plan their own day. Inpatient routines and health issues, dementia or other forms of intellectual impairment
hospital rules contribute towards this and may induce fear are neglected in adult field pre-registration programmes, while
and uncertainty in patients who would not normally exhibit While and Clark (2009) found that all groups of patients with an
challenging behaviour (Whyte, 2016). Environmental aspects intellectual impairment are subject to diagnostic overshadowing,
may also contribute towards restrictive practices, including a do not receive optimum care and are stigmatised as a result
lack of privacy (shared bathrooms and lavatories), little flexibility of nurses' attitudes through minimal education. Any pre-
in mealtimes, exposure to excessive light and noise, lack of registration programme for health professionals should,
fresh air and exercise, and having to share space with staff, therefore, include these vulnerable groups, while emphasising
visitors and other patients. the skills and knowledge base that may be applicable to all
patient groups.
© 2018 MA Healthcare Ltd

Challenging behaviour The model used for positive behavioural support plans at
Challenging behaviour is defined as ‘culturally abnormal the London mental health NHS trust cited earlier built directly
behaviour(s) of such intensity, frequency or duration that the on the work of Clark and Clarke (2014) to address diagnostic
physical safety of the person or others is placed in serious overshadowing, unmet needs and communication difficulties
jeopardy, or behaviour that is likely to seriously limit or deny through the BPPS assessment process. This is a theory-driven,

480 British Journal of Nursing, 2018, Vol 27, No 9

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.

 MENTAL HEALTH

comprehensive approach that has been received well in practice ■■ ‘Connection’ with the patient
(Clark et al, 2017a); it has also been used as a teaching tool ■■ Balance between support and control
to expand the knowledge of both core trainee doctors and ■■ Non-punitive approaches
registered nurses. The BPPS model distinguishes itself by ■■ Empathy
stressing the importance of collaborative MDT assessment, ■■ A soft, calm and gentle approach.
planning and implementation in addition to careful analysis Arguably, such qualities are not the sole domain of good
of the patient’s environment. de-escalators, but should be qualities possessed by all nurses,
A pilot study conducted on a male psychiatric intensive care which, when adopted early on in the nurse-patient relationship
unit at the London mental health trust cited above showed the can help prevent the occurrence of many challenging behaviours
BPPS model to be cost-effective and time efficient: it reduces and situations.
the need for separate MDT assessments, with all team members The BPPS positive behavioural support plans, which were
contributing to a single person-centred plan (Clark et al, 2017a). piloted and implemented at the London mental health NHS
Its success ensured that this model was disseminated across the trust (Clark et al, 2017a) detail primary, secondary and tertiary
trust for use with patients who exhibited challenging or acutely interventions for the management of challenging behaviours,
disturbed behaviour. as recommended by the DH (2014):
■■ Primary interventions involve a series of individualised
De-escalation preventive measures adopted on a day-to-day basis to reduce
Good de-escalation prevents the occurrence of more serious the likelihood of challenging behaviours, an example of
incidents and should be instigated at the first sign of an escalating which is detailed in Box 1
situation. According to Price and Baker (2012), the qualities ■■ Secondary interventions relate to the first signs of a patient
of good de-escalators include: beginning to escalate in terms of their behaviour. A detailed
■■ The use of verbal and non-verbal skills person-centred plan is then used to describe effective de-
■■ Confidence without arrogance escalation methods to recognise and validate the patient’s
■■ Autonomy-confirming interventions distress and comfort (sometimes this can include medication)
■■ Use of appropriate humour ■■ Tertiary strategies within a mental health setting may relate

Table 2. Example of ABC (antecedent, behaviour, consequence) behavioural chart for patient Tilly Jones
(not her real name)
Date and time A (antecedent) B (behaviour) C (consequence) Actions taken

■■ Where did it happen? What occurred in detail? ■■ Who dealt with the Include client’s/significant
■■ Who was present? situation? others’ views and care-plan
■■ Patient’s status from ■■ What did they do? interventions
a biopsychopharmaco­ ■■ How quickly was it
social perspective resolved?
■■ Patient’s physical/
mental state

24/2/18 ■■ Admission to medical Patient has hidden a razor ■■ Razor removed by staff ■■ On-call doctor informed
03.20 assessment unit via blade and is attempting to nurse, belongings further ■■ 1:1 registered mental
emergency department cut left forearm searched and revealed health nurse (RMN)
at 01.10. Appears more hidden blades booked for early and late
intoxicated. Requires ■■ Patient was abusive shifts tomorrow
assessment to staff throughout the ■■ Will move to side room
■■ Extremely distressed on process ■■ Psychiatric liaison team
admission, threatening ■■ Refused vital signs informed and requested
to ‘cut herself’. Property being taken to further assess
searched and sharp ■■ Distressed and agitated
objects removed
■■ The patient has been
tearful, vocal and
aggressive towards staff

24/2/18 ■■ Patient was moved to Patient threw breakfast at Patient was administered ■R
 MN to continue to
08.50 side room at 07.30 RMN while shouting abuse diazepam 5 mg as required engage with patient and
© 2018 MA Healthcare Ltd

when RMN arrived for loudly. Patient claims she orally, having been calmed attempt vital signs
shift ‘is sick of being watched by senior nurse on shift. ■B
 ehavioural support plan
■■ Patient appeared to all the time’ Bed area was tidied to be initiated
be confused, and had and patient settled to a
no sleep throughout certain extent
the night

British Journal of Nursing, 2018, Vol 27, No 9481

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.

 Psychological Biological

■■ Hypertensive disease (chronic disease

■■ Emotionally unstable personality
register)
disorder (diagnosed 2007) ■■ Transient cerebral ischaemia
■■ 4x known suicide attempts
■■ Malignant neoplasm of caecum (1999)
(hospitalisation) ■■ Malignant neoplasm of colon (1999)
■■ Recent self-harm, including scarring of
■■ Cancer bowel (2008)
both forearms and legs ■■ R hemicolectomy & anastomosis
■■ Convictions for shoplifting x4
(2008)
■■ Drunk and disorderly behaviour, several
■■ Weight 53.2 kg, Height 1.55 metres,
occasions, known to the police and
BMI 22.1
emergency department (ED) staff
Environment ■■ Self-care/hygiene appears poor,
■■ Several admissions to mental health
clothing dirty/unkempt
Noise services, has a community psychiatric ■■ Currently intoxicated
nurse
No smoking ■■ Currently refusing food/fluid
■■ History of being sexually abused in
■■ Refuses vital signs/blood profile
Staffing shortages childhood

Responds to female staff

Other patients
■■ Clopidigrel 75 mg a day, loperamide
■■ Relationships, past and present, with
2 mg as required, rosuvastatin 10 mg
family are poor
■■ Housing: lives alone in housing
at night, lercanidipine hydrochloride
10 mg 1 a day, Adcal-D3 chewable 1
association bedsit
■■ On/off relationship with another
a day, diazepam 5 mg as required
■■ Smoker: 20 a day
mental health service user (female)
■■ Alcohol consumption above
■■ Receives benefits
recommended limits
■■ Recreational drug use: unknown
■■ Allergies: cetirizine and simvastatin

Social Pharmacological

Figure 1. Multimodal functional environment describing the four domains of the individual patient within their current environment

to using restrictive strategies such as seclusion and restraint. therein that may influence the patient’s wellbeing.
However, within a generic inpatient setting, the strategies It is important for the MDT to analyse findings from the
would probably involve calling a security team or using separate domains of the BPPS map and consider their impact
chemical restraint. and interactions with each other. The analysis provides the basis
Primary, secondary and tertiary interventions are developed of the behavioural support plan, including a summary, further
through a BPPS ‘map’ of the individual patient, analysis of the investigations, risk factors and primary, secondary and tertiary
environment and further information-gathering, such as the use support interventions, all of which are regularly updated and
of antecedent, behaviour, consequence (ABC) charts (Table 2), expanded on.
further medical investigations and gathering information from
carers and families. The way forward
Table 2 Figure 1, and Box 1 set out the BPPS behavioural There is now a pressing need to implement the agenda (CQC,
support plan in the format described by Clark and Clarke (2014) 2017) to improve the care of patients who exhibit challenging
using a fictitious patient in the adult nursing setting. The ABC behaviour in generic NHS settings. The inappropriate use
chart (Table 2) begins with the patient’s admission and details of restrictive practices and attitudes must also be highlighted
© 2018 MA Healthcare Ltd

further incidents of challenging behaviour to establish best to adult field nurses and generic MDTs, as well as to nurses
practice regarding behavioural management. This is followed working in mental health and learning disability settings.
by the BPPS ‘map’ contained within the multimodal functional Pre-registration programmes for all members of the MDT
environment (Figure 1) pertinent to the individual patient. This must recognise and prepare health professionals to cater for
represents the specific ward environment and the challenges the needs of patients with mental health problems, learning

482 British Journal of Nursing, 2018, Vol 27, No 9

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.

 KEY POINTS Declaration of interest: none
■■ There are legal, strategic and policy requirements for the care of patients Care Quality Commission. Brief guide: positive behaviour support for people
with challenging behaviour across the NHS with behaviours that challenge. London: CQC, 2017. https://tinyurl.com/
yaq8r6zo (accessed 26 March 2018)
■■ Challenging behaviour is often the result of unmet needs or a Clark LL. Learning disabilities within mental health services: are we adequately
communication problem, and not necessarily a direct result of a patient’s preparing nurses for the future? J Psychiatr Ment Health Nurs. 2007;
14(5):433–437. https://doi.org/10.1111/j.1365-2850.2007.01076.x
clinical condition Clark LL, Clarke T. Realizing nursing. A multimodal approach to psychiatric
nursing. J Psychiatr Ment Health Nurs. 2013; 21(6):564–571. https://doi.
■■ Restrictive practices by nurses may lead to, or exacerbate,
org/110.1111/jpm.12159
challenging behaviour Clark LL, Shurmer DL, Kowara D, Nnatu I. Reducing restrictive practice:
developing and implementing behavioural support plans. B J Mental Health
■■ Effective de-escalation is an essential component in the reduction of Nurs 2017a; 6(1):23–28. https://doi.org/110.12968/bjmh.2017.6.1.23
challenging situations Clark LL, Merrick I, O’Driscoll F, Lycett H, White R, White A. Template for
action for patients with intellectual disabilities in mental health services. B J
■■ Positive behavioural support plans that take a biopsychopharmacosocial Ment Health Nurs 2017b; 6(6), 279–85
approach have been shown to reduce incidents of challenging Cockerton R, O'Brien A, Oates J. Implementing positive and proactive care.
Ment Health Pract. 2015; 19(4):36–39. https:/doi.org/10.7748/mhp.19.4.36.
behaviour, reduce the need for 1:1 nursing care and promote efficient s21
multidisciplinary working Department of Health. Positive and proactive care: Reducing the need for
restrictive interventions. London: DH, 2014. https://tinyurl.com/plgdhw6
(accessed 26 March 2018)
Emerson E. Challenging behaviour. Analysis and intervention in people with
disabilities and other intellectual impairments. severe learning disabilities. 2nd edn. Cambridge: Cambridge University Press
2001: 3.
Because the use of a BPPS-based positive behavioural Hicks A, Clark LL. Care for people with an intellectual impairment or mental
support plan (Clark and Clarke, 2014) has been shown to health problems: moving forwards. Nurse Educ Pract. 2011; 11(3):165–167.
reduce these figures in mental health settings, Clark et al (2017a) https://doi.org/10.1016/j.nepr.2010.10.007
Law Commission. Mental capacity and deprivation of liberty. 2017. https://
argue that the model could benefit patients in mainstream tinyurl.com/yd6suuqz (accessed 26 March 2018)
inpatient NHS settings. The positive behavioural support plans Mencap. Death by indifference. 2007. https://tinyurl.com/ybg93yey (accessed 26
March 2018)
have been shown to be a useful arena for the joint education of Mencap. Death by Indifference: 74 deaths and counting. 2012. https://tinyurl.
both specialty doctors and registered nurses when piloted on a com/y93qwyuz (accessed 26 March 2018)
psychiatric intensive care unit. Michael J, Richardson A. Healthcare for all: the independent inquiry into access
to healthcare for people with learning disabilities. 2008. https://tinyurl.com/
In this case, MDT working resulted in a more collaborative, ydyxks7z
time-efficient approach to assessment and patient care, with reduced Parliamentary and Health Service Ombudsman. Six lives; the provision of public
services to people with learning disabilities. London: The Stationery Office,
rates of the use of rapid tranquilisation, seclusion and restraint 2009. https://tinyurl.com/y8tyyh4r
(Clark et al, 2017a). If BPPS-based positive behavioural support Price O, Baker J. Key components of de-escalation techniques: a thematic
plan were to be introduced alongside a short training and education synthesis. Int J Ment Health Nurs 2012; 21:310–19. https://doi.org/10.1111/
j.1447-0349.2011.00793.x
programme for adult field nurses and MDTs, the model is likely Reeves J. Reducing the use of restrictive interventions by changing staff attitudes.
to not only reduce rates of challenging behaviour but decrease Nurs Manage. 2017; 24(3):30–37. https://doi.org/10.7748/nm.2017.e1504
Royal College of Nursing. Draft guidance on the minimisation of and alternatives
the need for one-to-one care and enhance the patient experience. to restrictive practices in health and social care, and special schools. London:
In addition, broadening the knowledge of MDTs about patients RCN, 2013. https://tinyurl.com/y8eta3xn (accessed 26 March 2018)
Royal College of Nursing. Three Steps to Positive Practice. A rights based
with mental health problems, dementia and learning disabilities approach when considering the use of restrictive interventions. 2017. https://
may result in more meaningful therapeutic relationships and tinyurl.com/y7gkkkv5 (accessed 26 March 2018)
reduce staff fear, at the same time as reducing ignorance and While A, Clark LL. Overcoming ignorance and stigma relating to intellectual
disability in health care. J Nurs Manag. 2009; 18:166–72. https://doi.
stigma. Combining BPPS-based positive behavioural support plans org/10.1111/j.1365-2834.2009.01039.x
with MDT education can contribute further to the reduction of While A, Clark LL. Development of a competency tool for adult trained nurses
caring for people with intellectual disabilities. J Nurs Manag. 2014; 22(6):803-
restrictive practices and interventions, promotion of transferable 10. https://doi.org/10.1111/jonm.12002
skills and knowledge and, ultimately, improve the quality of the Whyte A. Challenging behaviour: finding another way. Nurs Stand. 2016;
care patients receive.  BJN 31(12):18–20. https://doi.org/10.7748/ns.31.12.18.s22

CPD reflective questions

■■ Consider some of our attitudes and practices as professionals in adult health that may contribute towards challenging
behaviour in patients
■■ Consider the impact that restraint, chemical and physical, has on the protection of a person’s liberty and wellbeing
© 2018 MA Healthcare Ltd

■■ Consider whether routinely broadening our approach to assessment, and comprehensively considering
biopsychopharmacosocial triggers for challenging behaviour, could change the attitudes and practices of health
professionals in the adult sector. Furthermore, as has been demonstrated in acute mental health settings, could this
reduce restrictive practice and enhance the protection of a person’s liberty?

484 British Journal of Nursing, 2018, Vol 27, No 9

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.

 MENTAL HEALTH

Box 1. Positive behavioural support plan

Name: Tilly Jones (not her real name) Trigger factors:
■■ When her needs are not met instantly, becomes angry and
Biopsychopharmacosocial (BPPS) summary: hostile
Tilly Jones is a 64-year-old female admitted via emergency ■■ Being ‘shut in a side room’ with 1:1 cover
department (ED) in an intoxicated state (smelling of alcohol), ■■ Not being able to smoke
brought in by police when found in the street. Refusal of
investigations (including vital signs and blood work) in ED, Management plan:
admitted for observation/assessment. History, medication and ■■ Move patient to bay (where there is television or other
diagnosis recorded through BPPS chart, as above. distractions)
Patient unable to co-operate with behavioural support plan. ■■ Contact community psychiatric nurse re discharge plan
■■ Initiate nicotine replacement asap
Further investigations: ■■ Encourage bathing and personal hygiene
Inpatient referral to the psychiatric liaison team
Primary interventions:
Risk factors (BPPS perspective): ■■ 1:1 session to clarify and validate thought content and process
■■ Intoxication with senior staff (preferably female)
■■ Poor self-care/hygiene ■■ Ongoing more in-depth 1:1 sessions with senior named nurse
■■ Social factors (not enhanced observation), to explore thoughts, feelings and
■■ Self-harm/suicidal ideation emotions (at least twice a day)
■■ Dehydration ■■ Use supportive interventions to increase adherence to
■■ Refusal of vital signs & blood works prescribed medication, food and fluids, attempt to gain consent
to administer intravenous Pabrinex can form part of 1:1 time
Known challenging behaviours: ■■ Encourage daily hygiene (please document if this is done/not
As above, in addition to verbal and physically aggressive done) to raise self-esteem
behaviour. ■■ Develop contract regarding behaviour with other patients to
enable socialisation and ensure good patient experience for
Information gathering (please tick): neighbouring patients
All patients have an antecedent, behaviour, consequence (ABC) ■■ Where possible, be nursed by females due to history of sexual
behavioural chart, bowel status, sleep and vital signs. abuse and poor relationships with men
ABC charts ☑ ■■ Negotiate attendance at group activities at least once a day
Bowel status ☑ (enhanced support team)
Intake/output charts ☑ ■■ Constantly observe for possession of sharp objects; consider
Menses charts ☑  Post menopause the use of elastic bands or ice to negate the desire to self-harm
Seizure charts ☑ ■■ Encourage friendships with other patients to provide activity
Sleep charts ☑ and a sense of belonging
Stool charts ☑
Secondary prevention strategies:
Vital signs: 4 hourly ■■ Communication and negotiation
■■ Use ward quiet space or supervised time off the ward with HCA
Observation level/frequency/comments: ■■ To use medications, as necessary, preferably oral
Moved from side room back to general bay (quieter, rehabilitation diazepam 5 mg
bay), remove RMN 1:1 cover and increase healthcare assistant
(HCA) input to bay (staff to be present in bay at all times). Tertiary prevention strategies:
■■ Reinstate 1:1 with HCA or RMN as per assessment

Did you know the British Journal

of Nursing and its sister titles
run nurse-led events throughout
the year?
They are CPD-accredited and held all over the UK
© 2018 MA Healthcare Ltd

For more information go to www.mahealthcareevents.co.uk

British Journal of Nursing, 2018, Vol 27, No 9485

Downloaded from magonlinelibrary.com by 130.238.007.040 on August 2, 2018.