Removal from stimuli for crisis intervention: using least restrictive methods to improve the quality of patient care.

The use of seclusion or seclusion and restraints (S/SR) may affect patients negatively, even if controlling their behavior in the short run, by placing them in the "victim" role and fostering a corrosive atmosphere of patient-caregiver mistrust and alienation. This project's goal was to reduce the use of the most restrictive measures by increasing the use of the less restrictive removal from stimuli (RFS). Verbally and even physically threatening patients in a psychiatric intensive care unit were removed from stimuli if their behaviors were not sustained and they ultimately cooperated with staff. RFS was deemed successful when a patient did not need more restrictive measures following its use. The data for this study were obtained by tabulating RFS and S/SR utilization rates for a year. Frequencies, measures of variance, ratios, and t ratios were used to analyze the data. The use of RFS and other nonrestrictive measures to reduce patient stress and frustration resulted in decreased utilization of seclusion and restraints. The frequency and severity of negativistic, aggressive behaviors of patients were also observed to have diminished.

The homicidal patient: when a plan of care violates standards of care.

1. The nursing care of an extraordinarily dangerous patient may necessitate implementing a treatment plan that should never be used under normal circumstances. 2. The subject whose case is described in this article presented management problems that required a plan violating accepted standards of care. 3. Although ultimately successful, the plan's restrictive mode (and the stress of coping with this patient) wearied nursing staff members and caused divisions among the staff and multidisciplinary team.