MANAGING DIFFICULT BEHAVIOURS IN THE

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1 MANAGING DIFFICULT BEHAVIOURS IN THE HOSPITAL EMERGENCY DEPARTMENT: THE USE OF CIGARETTE BREAKS WITH MENTAL HEALTH PATIENTS Euan Donley Eastern Health Psychiatric and Emergency Dept Response Team. Monash University PhD Candidate

2 PART OF PHD BY PUBLICATION Donley, E. (2012). Back Again? Drugs, emergency care, and the frequent presenter. Of Substance, Vol 10 (1); p Donley, E. (2012). Identifying and managing persistent complainers. Law Society Journal, Vol. 50; p Donley, E. (2013). Suicide risk of your client: Initial identification and management for the Allied Health Professional. Journal of Allied Health, 42 (1)

3 BACKGROUND - Hospital sites smoke-free Mental health patients have higher rates of smoking, and poorer mortality and health. Mental health patients use EDs more often than general population. Mental health patients present to ED in crisis (e.g. psychotic, suicide risk, aggressive, involuntarily at times). ED is the first place of a smoking ban. Anecdotally ED staff provide cigarette breaks when requested.

4 AIM / RESEARCH QUESTION Investigate the extent to which ED staff provide cigarette breaks for mental health patients as a means of alleviating or preventing difficult behaviours and explore why ED staff practice this given smoke-free policy guidelines. What extent and reason do ED staff provide cigarette breaks to mental health patients in order to manage difficult behaviours?

5 METHOD A mixed method analysis. Chosen as this is considered well suited to health studies. Mixed methods is uses both qualitative and quantitative data. 110 surveys distributed, 92 returned. A range of expertise and professions (those with less than one year experience excluded) consistent with ED staffing.

6 RESULTS FIGURE 1: PREVALENCE OF USING CIGARETTE BREAKS IN ED FOR MENTAL HEALTH PATIENTS TO ALLEVIATE DIFFICULT BEHAVIOURS ACCORDING TO ED STAFF % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Q2 Yes Q2 No Q3 Yes Q3 No Q5 Yes Q5 No

7 FIGURE 2: ED STAFF PERSPECTIVE ON NRT AS A HELPFUL ALTERNATIVE FOR ED MENTAL HEALTH PATIENTS. 8.70% 4.30% 37.00% 50.00% Q10 Never Q10 Sometimes Q10 Often Q10 Always

8 FIGURE 3: DECLINING OF CIGARETTE BREAK HAS RESULTED IN ESCALATION OF DIFFICULT BEHAVIOUR Q7 No Q7 Yes 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% %

9 FIGURE 4: ADVERSE EVENTS AFTER BEING PROVIDED WITH OUTDOOR CIGARETTE BREAK (N = 17 / 92) 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Absconded Self-harm attempt More aggression Obtain illicit drug Fall

10 FIGURE 5: DO YOU PROVIDE MENTAL HEALTH PATIENTS WITH EDUCATION ON SMOKING CESSATION? Q10 Never Q10 Sometimes Q10 Often Q10 Always

11 FIGURE 6: WOULD YOU BE WILLING TO PROVIDE MENTAL HEALTH PATIENTS WITH EDUCATION ON SMOKING CESSATION? Q11 Yes Q11 No

12 FIGURE 7: NO SMOKING ON HOSPITAL GROUNDS IS A GOOD MESSAGE TO SEND TO THE COMMUNITY / SMOKE FREE WORKPLACE IS VALUABLE. Q13 N Q13 Y Q12 N Q12 Y 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% %

13 COMMENTS FROM PARTICIPANTS I feel the smoking policy should be more flexible for mental health patients as it can alleviate difficult behaviours. However, the no smoking policy on hospital grounds message may get confusing to the general public if they see patients smoking while hospital staff are in attendance. (Doctor). Tokenistic message with having staff smoking on street corners of the hospital (SW3). I think it is extremely irresponsible to sacrifice the health of nurses or security guards who have to escort mental health patients outside to smoke. Smoking outside the hospital looks awful to the public and butts are always littered around (RN4).

14 CONT... I d rather the risk of occasional second hand smoke outdoors, than the risk of an aggressive patient in a crisis inside the ED. I think other patients would too. NRT is next to useless in a crisis and the suggestion itself can anger some patients. So at times we give them diazepam to replace one addiction with potentially another. (SW3)

15 CONT... I understand cessation of smoking should be encouraged but I do not believe it should be forced upon patients at a stressful time. (RN2). When in ED they are often at their most vulnerable and stressed, or not even aware of where they are. I don t think trying to change behaviour at this time is very feasible. (OT2). Usually they will be agitated and non-compliant (RN2.).

16 CONT... It can be a difficult situation because technically we are sending these patients off the grounds...although it may not be ideal, it would be more practical to have a designated area that is safer. (RN2). We need an area where they can go safely. We are not going to change behaviours re: smoking in ED. (RN4).

17 DISCUSSION Various risk issues: not allowing CB can result in difficult behaviours, allowing CB can result in absconding. Short term risk of difficult behaviour, long-term risk of poor health due to smoking. Education: staff willing to provide but there are barriers. Patient compliance, patient in crisis, four hour targets. Nature of crisis: A poor time to begin smoke ban. NRT: Not addressing the psychological component of addiction.

18 CONT... Smoke-free area: Controversial as a hospital area but mental health units already have smoking areas in some networks. Would be designed to reduce immediate risk, and provide educational material. Follow up: Referrals required for smoking cessation support. In a nutshell: Participants support smoke-free policy in principle but exceptions are made regularly. Participants chose secondhand smoke over aggression as a risk. A crisis is not a good time to start smoking cessation for patients, NRT is not considered helpful at this time, and staff do not have the time or resources for education. More thought needs to go into smoking on hospital sites due to poor compliance by ED staff and patients, and the complex nature of addiction and crisis. END / THANK YOU