Least restrictive measures: alternatives to four-point restraints and seclusion.

Following the review and discussion of alternative measures in the use of four-point restraints and seclusion on an acute psychiatric inpatient unit, the staff increased the use of "least restrictive" measures with aggressive patients. This involved increased attention to escalating behavior and using alternatives. Although early recognition did not guarantee success in every situation, patients were included in making choices and being in control of which option to take. When staff became more knowledgeable about the use of alternatives, they were more comfortable offering patients choices and did not wait until restraints and seclusion were necessary. It was beneficial to review the rationale for the use of seclusion and restraints with both patients and staff. Specific approaches for early recognition and intervention focused on verbal control, limit setting, and decreased stimulation. It is important that staff have a clear understanding of their range of treatment strategies from most to "least restrictive" measures during stressful times when patients become confused, angry, or frightened and may lose control. Patients must be made aware of their choices during this cycle and understand the consequences of their behavior. Planning educational inservice programs for staff to address this content and share approaches to specific situations can be effective. Staff debriefing following an incident is crucial to discuss reactions to the use of restraints and seclusion and to plan for the use of alternative measures in the future. All patients need a chance to express themselves. As staff we must take time to stop, look, and listen. We must be aware of our own thoughts and feelings and think of choices. What are the ¿least restrictive¿ measures? We need to work with patients in considering a range of measures without taking unnecessary risks or disregarding issues. We must work with our patients so that we all can learn a valuable lesson. Why not give our patients a chance?

Caring for rape victims: its impact on providers.

Students in the health professions are working with a variety of anxiety-provoking patients, such as victims of child abuse or sexual assault, suicidal and terminally ill patients. Faculty have a responsibility to assist these students in maximizing the growth potential of the experience. This study, involving 22 female and three male students at the University of New Mexico Colleges of Nursing and Medicine, examines the effects of such an experience. Each participant worked on a Sexual Assault Response Team at the Bernalillo County Medical Center for an average of 8.6 months; each saw an average of 16 rape victims for whom they provided counseling services and assisted in medical care and gathering evidence. All of the students reported heightened awareness of their own vulnerability. They began to develop cognitive and behavioral strategies to cope with the possibility of being raped. Approximately one third of the subjects developed symptoms similar to those experienced by rape victims. Those who did not develop symptoms attributed it to being able to work through their feelings at team meetings. Students became more aware of their attitudes toward rape victims, both positive and negative. Moreover, the most significant change they experienced was in their own perception of themselves as care givers; they felt more confident and competent, both in medical and counseling areas. Faculty are encouraged to meet weekly with students involved in such experiences.