It's been estimated that in any given year, approximately twenty percent of the Australian population suffers from mental health conditions. As this figure represents one fifth of the country’s entire population, there is no doubt that services need to operate at their best.

Health authorities need to meet increasing demands and ensure mental health patients are continuously receiving a high quality of care. However certain conditions within the mental health spectrum require extra care as patients can present with challenging behaviours, which can sometimes occur within the health setting before doctors and nurses (1).

What is challenging behaviour?

Challenging behaviour can be defined as any behaviour of an individual which has the potential to cause physical or psychological harm to themselves, another person, or to property around them. It does not have to be deliberate acts – some patients who suffer from mental health conditions can express challenging behaviour unintentionally.

Such behaviour, whether intentional or not, can act as a barrier between the patient and healthcare providers attempting to deliver care and support. Such behaviour can also compromise the safety of staff and other patients in an in-patient setting (2)

What triggers challenging behaviour in mental health patients?

To better understand how to deal with challenging behaviours, healthcare providers should appreciate the factors which trigger such actions in their patients. Research suggests that patients will express challenging behaviour as a result of either intrinsic or extrinsic factors (2);

• Intrinsic factors can be personal feelings, thoughts, emotions and health status - both mental and physical.
• Extrinsic factors will be the environment and people around them who can trigger a behavioural response.

It is recommended that patient treatment rooms should offer a comfortable and reliable environment to minimise patient stimulation and chances of aggression. Mental health patients should be offered activity rooms and spaces in which they can partake in group interactions, therapies, and have recreation time together. If patients require seclusion, they should be relocated to an open and safe space which also allows nurses and doctors to observe clearly (3).

Patient assessments

Any healthcare provider who is in direct contact with mental health patients should be adequately trained and briefed beforehand on how to carry out risk assessments with patients, and what the management strategy would be to deal with different behavioural scenarios.

It is advised that a structured and sensitive interview is carried out with patients themselves and their carers (when appropriate), regarding triggers, any warning signs and behavioural changes which signal the patient is feeling overstimulated, and any possible management techniques which have been previously successful.

Healthcare providers need to be sensitive and understanding to cultural and personal differences which could be misunderstood in a hostile situation (3).

How to deal with challenging behaviours

Depending on the intensity of the situation and behaviours being displayed, the following techniques can be employed to de-escalate the situation (3).

• De-Escalation: This is behaviour which is intended to prevent the situation from turning violent and upsetting. De-escalation consists of verbal communication with the patient; the healthcare provider should offer their undivided attention, remain non-judgemental and focus on the feelings of the patient at hand. It is important to speak clearly, positively and keep the lines of communication open so that the patient can calm down and gain trust in the healthcare professional dealing with them.
• Physical Intervention And Restraint: This method should only be considered once de-escalation methods have been exhausted or found to be ineffective. If physical intervention and restraint is to take place, it is advised that the period of physical intervention remains as short as possible in order to maintain the dignity of the patient and minimise physical and psychological damage to all those involved. Staff who are involved in the physical intervention and restraint team should be regularly trained and receive refresher courses.
• Patient Seclusion: Seclusion for mental health patients should be avoided whenever possible as it can compromise patient dignity. However when patient seclusion is deemed absolutely necessary, then the patient should be kept under observation and reviewed every two hours. All of their basic needs must be met within the seclusion room, including warm bedding, clothes, food and drink, as well as toilet and washing facilities. Staff should explain the reasoning behind patient seclusion in depth to the patient and later in documentation.
• Pharmacological Intervention: As each drug comes with specific risks and has different properties, any medication used to sedate a patient displaying challenging behaviour should be carefully taken into consideration beforehand. Ideally, this method should be the last course of action, however in situations where it must be used, oral medication should be offered first. This is to allow the patient a chance to take it voluntarily. If the patient denies, then parenteral medication may be administered. The reasoning for using pharmacological interventions should be explained in depth to the patient and later in documentation.

Whichever intervention is used, it is important to discuss and document what has happened in patient records and incident reports. This practice can help in understanding how to solve future challenging behaviour situations for the particular patients (3).

Sources:

MH Australia
SA Health
Health WA