Physical intervention in older adult psychiatry: an audit of physical ailments identified by physiotherapists and the implications for managing aggressive behavior

A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour

AIMS

This systematic quantitative review identifies and summarizes the current knowledge and effects of training interventions for managing patients' challenging behaviour.

BACKGROUND

Challenging behaviour is an acknowledged worldwide healthcare problem and its management can have a huge impact on quality of care. Evidence-based training interventions that focus on managing challenging behaviour are needed, but few tools for the systematic evaluation of these interventions are currently offered.

DESIGN

A quantitative systematic review following the 2008 Centre for Reviews and Dissemination guidelines.

DATA SOURCES

CINAHL, Scopus, PsycInfo, PubMed and Cochrane were searched using the same terms for papers published in English from 2005-2015.

REVIEW METHODS

Studies were assessed for quality and risk of bias, according to the Cochrane Effective Practice and Organisation of Care Group criteria. A narrative summary was conducted.

RESULTS

We included 17 studies and evaluated 16 training interventions. Interventions were classified into four key themes: disengagements, communication, controlling behavioural symptoms and restrictive measures. Our review showed that interventions were more likely to decrease violent incident rates and increase staff confidence than change staff attitudes or increase knowledge. The elements of competence used to manage challenging behaviour were measured unilaterally. The evidence provided by studies was largely weak.

CONCLUSION

The variety of measurements used in the studies made comparing the effectiveness of the training interventions difficult. An individual's competence to manage challenging behaviour needs to be defined and a comprehensive scale for evaluating competence is also needed. Patient safety should be included in future evaluations.

Are physical intervention techniques likely to cause pain or injury when applied to manage the severely aggressive older adult? A survey of physiotherapist's expert views in the UK

AIM

To establish whether a professional consensus can be established amongst musculoskeletal physiotherapists or whether they believe certain physical intervention techniques would cause pain or injury if applied to an older adult.

BACKGROUND

Physiotherapist involvement in the context of a multidisciplinary team framework to develop adaptive techniques as required for complex physical presentations has resulted in lower injury rates than in working-age adults. Physiotherapists are experts in anatomy and human movement and are ideally placed to contribute to the safe application of physical intervention in older adults.

DESIGN

A survey design was used.

METHOD

A questionnaire was developed and tested to ascertain the physiotherapist's opinions of the likelihood of each technique causing the patient pain and/or injury. The lead author distributed 41 questionnaires to physiotherapists in two busy hospitals in the UK.

RESULTS

Thirty-four (83%) of physiotherapists returned the completed questionnaires. The physiotherapists had particular concerns about the use of wrist flexion and kneeling on the older adult in prone causing pain and/or injury. Some other techniques that we have advocated in our earlier research were approved by many of the respondents, e.g. supporting the forearm with both hands proximal to the wrist joint. None of the physiotherapists had attended a physical intervention course or applied it in the clinical setting, thus enabling them to analyse the techniques purely from a biomechanical movement perspective. Implications for nursing practice are discussed.

CONCLUSIONS

It is anticipated that this research will stimulate nurses and course providers to develop patient group-specific physical intervention techniques and thus reduce the risk of causing them pain and/or injury.

RELEVANCE TO CLINICAL PRACTICE

This study reaffirms the heightened risks associated with applying restraint techniques to older adults. An issue that needs to be addressed is whether the duty of care which is explicit and implicit within the relationship between nurse and patient is to be fully discharged. It also reinforces prior research that has called for patient-specific physical intervention techniques and highlights some commonly used techniques that may have a deleterious effect on aggressive older adults. It also identifies the professional support that physiotherapists can offer to teams implementing physical intervention techniques within the context of clinical practice.