day 3 friday 18 december 2015 the right to liberty and security how to avoid restraint- relationship...
DESCRIPTION
Restraints …Restraints and seclusion have no therapeutic value they are not a treatment the causes of death are frequently: asphyxiation, strangulation, cardiac arrest, fire or smoke inhalation, drug overdose, drug interactions and choking… it would be incumbent upon the state to protect them from being injured, traumatized and abused…TRANSCRIPT
Day 3Friday 18 December 2015
THE RIGHT TO LIBERTY AND
SECURITYHow to avoid restraint-relationship and trust
buildingCome evitare la
contenzione costruzione di relazioni
di fiducia
LIVIA dott.ssa BICEGODIRIGENTE
INFERMIERISTICA COMMISSIONE PER
L'ELIMINAZIONE DELLA CONTENZIONE
AAS1 TRIESTE
Restraint
Restraint causes severe injuries to the patients and death...
… rules to make safe restraint as much as possible
number of nurses
‘thecniques’ to catch the patients
priority of the parts of the body to immobilize and tie
type of restraint tools to be used
monitoring of breath and cardio-circulatory system...
recommendation to use it as little as possible
only in the ‘necessity status’...
considered traumatic but necessary by the majority...
Restraints
…Restraints and seclusion have no therapeutic value
they are not a treatment the causes of death are frequently:
asphyxiation, strangulation, cardiac arrest, fire or smoke inhalation, drug overdose, drug interactions and choking…
it would be incumbent upon the state to protect them from being injured, traumatized and abused…
TSOcompulsory treatment
‘necessity status’- Art.54 do not oblige at all to the
patient’s restraint
Restraint
A relevant issue. In spite of the relevant amount of declarations anddenouncements from many countries and official papers from many international councils, it still remain active and practiced.
In Italy, in the units for acute patients inside the General Hospitals – SPDC – the restraint is largely practiced.
In 85% of SPDC in Italy there are restraint tools that have been used once or more.
Restraint
Seclusion and restraints are imposed onpsychiatric patients for reasons that are not therapeutic: to curtail a patient’s movement to compensate for having inadequate staffavoid providing appropriate clinical interventionsto force a patient to comply with the staff’s wishesto impose penalties on patient behaviors….
Toward an open door, no restraint practice
No restraint and open door:
the first step
of
de-institutionalisation
The meaning of closed door The meaning of restraint
Closed door = prison = guilty condamned secluded
Responsibility about detention careful about risk of escape
Closed door/ restraint = measure of seclusion
Safety measure a ‘right’ and ‘irreplaceable’... by the relatives ... by the patients...
The Meaning of open doorThe meaning of no restraint
Opened door: you are not guiltyYou have not committed any crime
You are in hospital and not in jailYou are here because of your illness
You as soon as possible come back at home
The message is directed also to the family and the other people
The Meaning of open doorThe meaning of no restraint
Each professional cannot disagree with this message
Each professional to pursue this fundamental change of humanisation
Never again gaoler
inspector guardian
Restraint
it's illegal
but also
a mark of technical and organizational incompetence
The question:
How is possible to make realistic this change?
The question is realistic,but not impossible to solve
How is practically possible to get good therapeutic goalswithout restraint that is considered traumaticbut necessary by the majority?
Freedom
Dignity
Responsibility
Democracy
Key words
Freedom is therapeutic
How to avoid restraintRelationship and trust building
What do we need?All we need is ...
From “treating illness” to a response to tangible needsalso psychological and subjective needs
organizations of human services featured by programsprovided by resourcesbased on relationswhich define the pathways of the “demand” for mental health as a “circuit”
All we need is ...
Services that promote...
eliminate of any form of stigmatisation discrimination and exclusionengage to actively improve full rights of citizenship for the mentally ill personsa coherent and unique organisation as a wholea strict co-ordination of actionsa links with the other services of communityaccessibility and mobility of services and the ability to respond to a wide variety of crises and needs
Services that promote...
All we need is ...
Crisis preventionArrive before the crisis...Continuity of care...Responding to crisis in the community...Crisis management is not a special or separate programCrisis comes into immediate contact with a system of resources/optionsIntake for problems / not for diagnosisA low threshold of accessNo selection No waiting listAvoiding bureaucratic obstacles to accessing servicesResponses quick and flexible
Services that promote...
PARTECIPATION AND EMPOWERMENT
Partecipation to modifications of a mental health service
All we need is …
No barriers between operators/usersNo to roles/spacesReduce the compartmentalisation Open door, even for compulsory treatmentsShare together and live togetherNegotiate for everythingContract everything of acceptance/admission with the userContinuous effort to obtain complianceBe accountable for everythingCare through a relationship based on trustInclusion of the user in crisis in both structured and non-structured activitiesPoint of reference open 24 hrsA team that has a contractual relationship with him/her
All we need is ...
All we need is ...Integrated and comprehensive response (social and medical)
Know individual history, needs and wishes
Ability to “READ” the meaning of
requests and events
Personal Investment/Involvement
Openess To User
“USER Friendly”… establishing a relationship
More concretely...Factors who make possible the open door
Factors who make possible no restraint
The ‘human’ factor makes the difference... an adequate number of professionals work together without many distinctions of roles (nurses, doctors,
social workers, psychologists, occupational therapists, support staff...)
the goal of all, all with the same goal: maintain the ‘open door’
Un'etica condivisa
The professionals must be share the goalTrained about the therapeutical, ethical, political meaningConfrontation must be going to the bitter end
NO Restraint
No restraint is a choice of a ‘system as a whole’
In the regulations of MHD of Trieste it has been wrote in an unequivocal manner, regarding the rights of the users, that they, among others, have the right to not receive noxious actions for their own physical integrity and dignity, specifically by means of whatever instrument of restraint
there is the principle that not to be restrained... is a right of mentally ill citizens requiring a therapeutic
treatment
Factors who make possible the open door
When a patient tries to leave and you can not for his own good ...
negotiations 'to the bitter end'
A firm attitude, welcoming embrace, no violent tackle by all staff
... They were able to resolve conflicts
Some preliminary questions :
No restraint is a program of a single ward staff or is shared by leadership and all professionals?
Does the staff work contemporarily inside the structure and the community?
Are there connections with other health structures?
Are there relations with the police or other safety agencies?
Factors who make possible the open door
Keeping promisesUnderstand the needsMeet demandsMeet the needsIt is better the small size A protocol with emergency ward, Police or other safety agenciesorganisation of the staff ability and competencean adequate number of people to be present at worka daily planning one or more internal meetings knows and analyze each personal, familiar, clinical history...
Factors who make possible the open door
Daily meetings with the patients discussion about the single programs ... and also about the open door... explaining the meaning of it searching for collaboration of all patients
Factors who make possible the open door
If some difficulties are going on or a patient escaped, the staff should be discuss the event also in meeting with patients
Analyzing why and how to normalize the situation collective plan to prevent similar events a staff person - alone or with some patient as volunteer- stay
near the door the accident can occur the accident cannot be avoided by means of closing
doors
Open door and no restraint a ‘closed door’ represents a ‘relational’ and ‘therapeutic’
barrier reinforces the sterotype of danger doesn’t recognize makes damage to the rights of patients is a mark of bad professional skill an intelligent organisation of the staff and of daily work in the
ward some changes in the system reduction of the size of wards working in and outside the institution agreements and protocols with other agencies Responsibility directly involving the patients in decision good professional skill recognizes the rights of patient
Restraint
education and training of professionals general vision of its own mission, technical
competence, ethics proper availability of resources organization model of services a whole of intervention procedures on
crisis states
NO Restraint
In the Health Agency whose MHD of Trieste is part, the issue of restraint is considered very important also out of psychiatry
A lot of researches, meetings and professional training have been organized (with prevalence of nurses) about it.
In 2006 a research in all rest houses of province wascarried out , aimed to know the relevance of restraintamong the institutionalized elderly and to purpose alternatives
ITALY today...
DOCUMENTO BIOETICA 2006
RACCOMANDAZIONI ALLE REGIONI 2009
STOP OPG 2014
DOCUMENTO BIOETICA 2015...
Restraint
Approaching the problem in this way is the result of the heritage from Franco Basaglia
A tradition of respect of the rights and values of the human being
TODAY is coherent and aligned with all national and international declarations against the practices destroying the human dignity.
The global approach to the person in her historical dimension (psychological, social, biological)
Ethical principles of health profession not consistent with restraint.
The professionals in mental health must not be ‘ prison guards’, or experts in the ‘restraining art’
Dati 2015...
TSO 2015 - Giornate di accoglienza e/o ricovero in TSO nel DSM
TSO 2015 - Giornate di accoglienza e/o ricovero in TSO nel DSM
TSO - Trend nel DSM dell'ASS1 negli anni 2011 - 2015
Serie storica 1996 - 2015 – Persone e giornate in TSO
Serie storica 1996 - 2015 – Luoghi dei TSO
Serie storica 1996 - 2015 – Tasso giornate e persone/100.000 residenti
THE FREEDOM IS THERAPEUTIC !
Serve un paradigma centrato sulla relazione e sull'accoglienza dell'altro e non sulla prestazione
The paradigm of illness is broken in favor of that of the person.
La forza dell'alleanza terapeuticaRelazione instancabileNegoziazione ad oltranzaNessuna pregressa esperienza negativa per
favorire il riaggancioEliminare il pessimismo terapeuticoAttenzione ai luoghiIntrodurre la possibilità, la guaribilità,la visione del
possibile e della soluzioneLinguaggi adeguati ed appropriati Restituzione dei vissutiRiconoscimento dei vissutiRestituzione con etica
Come fare?
Non rimuovere mai la soggettivitàRestituire e riconoscere il valore degli attiLotta alla pandemia di stigma e pregiudizio
Con questo documento le Regioni intendono migliorare la qualità delle cure nell’ambito psichiatrico.Raccomandazioni alle Regioni: modificare conoscenze, atteggiamenti, risorse, gestione, organizzazione per portare a valore zero il numero delle contenzioni.1:Monitorare a livello regionale il fenomeno
2:Monitorare a livello regionale i comportamenti violenti
3: Formazione di tutti i soggetti coinvolti, sanitari e non, per arrestare i fenomeni di escalation.4:Definire e garantire standard di struttura e di processo
5:Valutare l’impatto delle iniziative di informazione, di formazione e di appropriatezza organizzativa6:Promuovere pratiche di verifica e miglioramento della qualità
7:Trasparenza delle strutture di cura (accessibilità, vivibilità, accoglienza, informare sulle procedure e garanzie, facilitare la comunicazione con l’esterno)
The Mission of MHD
• The MHD shall operate for the elimination of any form of stigmatisation, discrimination and exclusion concerning the mentally ill persons.
• The MHD is engaged to actively improve full rights of citizenship for the mentally ill persons.
• The MHD shall ensure that the community mental health services of the LHC have a coherent and unique organisation as a whole, through a strict co-ordination of actions and links with the other services of LHC, particularly with general health districts and emphasizing the relationships with the Community and its institutions.