Running head: EVIDENCE BASED PRACTICE 1

Student Name: Nicie Velancia Pinheiro

Title of assignment: Evidence based practice in Psychiatry

Word count: 1917

EVIDENCE BASED PRACTICE 2

Evidence-Based Practice in psychiatry

Evidence-Based Practice (EBP) is essentially an approach that endeavors to resolve

healthcare problems. The basis of EBP is an incorporation of the best possible current

evidence available coupled with patient preferences, the patient’s data and clinical expertise

(Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2014). EBP leads to high quality,

reliable healthcare which improves overall patient outcomes. It also leads to a reduction in

the variations in care, subsequently in costs (Melnyk, Gallagher-Ford, Long & Fineout-

Overholt, 2014).

EBP facilitates the usage of intervention strategies for various patients in the diverse

clinical setting including psychiatry (Xie, Zhou, Xu, Ong & Govindasamy, 2017).

An inquiring attitude and a favorable environment are essential for EBP. Steps of

EBP are: 1) Ask a question by following PICO(T) pattern, 2) Choose the best evidence,

3) Analyze the evidence, 4) Amalgamate the evidence with patient preferences and skill,

5) Evaluate the results of the EBP with the practice change 7) Disseminate detailed

information about the change (Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2014).

Ask

It is important to ask a good question which aids in finding the most appropriate

solutions. PICO (T) format is an excellent tool for constructing a question covering all

aspects of a search question as it is precise, simple and clear (Borg Debono et al., 2013). ‘A

PICOT format consists of Population (P), Intervention or issue of interest (I), Comparing

intervention (C), Outcome (O), and Time of implementing intervention’ (Eid & Qan'ir,

2016). This method is helpful in finding the best current clinical evidence rapidly and

efficiently. (Eid & Qan'ir, 2016).

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A clinical question in Psychiatry

In aggressive psychotic patients, is physically restraining, compared to other options

of management, the best way to protect the patient and others from harm during an aggressive

behavioral outburst?

PICOT Format

P – Patient Aggressive psychotic patient

I – Intervention Physical restraint

C – Control Other options of management

O – Outcome Safety of patient and others

T – Time Aggressive behavioral outburst

Acquire

Use plurals, synonyms, and spelling judiciously using minimum terms (Oh, 2016).

An evidence hierarchy is a guide to find trustworthy answers to clinical questions.

Systematic reviews are known to provide the best evidence (Szajewska, 2018)

‘For intervention questions, systematic reviews and meta-analyses are followed by (in

descending order of evidence strength) Randomized Control Trials (RCTs), cohort

studies, case-control studies, case series studies, and lastly, expert opinions or theories

and basic research’ (Szajewska, 2018).

Search to acquire evidence on the chosen topic was done using keywords of the

Question which are ‘aggressive psychotic patient’ and ‘physical restraint’. The Ebscoshot

database showed 55 results, out of which three titles were relevant, but these could not be

accessed. The Informit database did not show any results. Google scholar database provided

a wide range of articles. Articles concerning reasons why physical restraint is discouraged,
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those which dealt with alternatives to physical restraint and suggestions on management of

aggressive patients were considered. Articles were then selected according to their relevance.

Appraise

Careful and systematic examination of research for assessing its reliability, quality

and relevance in a specific situation is called critical appraisal (Truluck & Leggett, 2016). As

quality research uses meticulous methodologies, minutiae of ‘research design, data collection,

and analysis methods’ are to be analyzed. To decide initially regarding the validity of the

article, observe if the study has a clearly directed query. Secondly, evaluate for use of valid

methods to address the question. Thirdly, note the importance of study results. Besides this,

assess if the results of the study are applicable to use for the needed population (Truluck &

Leggett, 2016). A systematic review is an assessment and a combination of many studies to

find a solution to a particular issue (Truluck & Leggett, 2016). It consists of well-defined

stages -

Currency: All six articles are published within the past four years.

Relevance: After obtaining a variety of information, the most relevant evidence answering

the clinical question was chosen.

Authority: Information about the authors is clearly mentioned in the articles.

Accuracy: All the information provided has been supported by evidence.

Purpose: The purpose of each article is clearly mentioned by the author and is not biased.

Apply

Physically restraining patient has been greatly used in the past for the management of

acute agitation (Pacciardi, Calcedo & Messer, 2019). Currently, international policies seek to

decrease restraint interventions as it is unlawful, according to international human rights

legislation (Cusack, Cusack, McAndrew, McKeown & Duxbury, 2018). Also, it may lead to

aspiration, asphyxia, and thrombosis (Bowman & Jones, 2016). Moreover, patients who have
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been previously restrained, avoid professional help until agitation increases in severity. This

is because of the past bad experience of being restrained (Pacciardi, Calcedo & Messer,

2019).

During an aggressive outburst, the aim of management is to calm the patient rapidly,

avoid forceful restricting measures, form a therapeutic alliance, and formulate an appropriate

treatment plan (Vieta et al., 2017).

Modification of the environment

The first requirement is to minimize external stimuli like noise, light or any other

uncomfortable elements (Vieta et al., 2017). Maintain a safe distance respecting the patient’s

personal space. Dangerous objects should be removed. Direct eye contact for a long time

and body language can be perceived as threatening by an aggressive patient. Such a patient

should not be visited by a single person (Garriga et al., 2016).

Verbal de-escalation technique

The necessary components of a verbal de-escalation technique include various aspects

of healthcare (Vieta et al., 2017). Preferably, only one person should interact with the patient

who converses in a soft, reassuring manner and responds calmly yet firmly while sidetracking

conflicting issues. A free, honest, truthful, non-judgmental conversation is important. This

would result in fostering trust, building a rapport and improving a patient’s self-confidence

(Vieta et al., 2017). Therefore, simple language, open-ended questions, repetitions, and

paraphrasing should be used. Behavioral limits have to be set and made known. In the case

of signs of violence, restrictive measures can be adopted. First, a warning can be given that

such behavior is not permitted and peacemaking by cajoling can be done (Vieta et al., 2017).

Pharmacological interventions

Pharmacological interventions are an option when the above measures to calm the

patient fail (Garriga et al., 2016). However, environmental modifications and verbal de-
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escalation techniques should be continued throughout the pharmacological intervention

(Vieta et al., 2017). The cause of agitation should be investigated before selecting an

appropriate medication. The choice of medication should be decided according to easiness for

administration. The medication chosen should have a minimum risk of harmful effects and

low interaction with other drugs given to the patient (Garriga et al., 2016). Intramuscular

and intravenous routes of administration are selected if the patient is uncooperative for an

inhaled or oral route (Vieta et al., 2017).

Physical restrain

Last resort, if a patient does not calm down is physical restraint. The patient, as well

as his relatives and the local authorities, have to be informed, as a person’s freedom is being

restricted. The patient should accept the restraint as beneficial for himself and not as a

punishment. When the patient is being restrained, no verbal de-escalation techniques should

be used. At least five staff members are required for a patient who is not cooperative. Such a

patient has to be held by the shoulders, knees, ankles, forearms, and legs and placed on the

bed while his head has to be held by another person. Approved instruments for restraint

should be used for the lower and upper limbs and the abdomen. It is crucial to observe the

patient every fifteen minutes for at least two hours in the beginning and subsequently after

every hour till the restraint continues. If intramuscular medication is used, the level of the

patient’s consciousness has to be ascertained periodically. Care should be taken to keep the

patient’s bed at an angle of thirty degrees. The constant change of position and refastening of

restraining instruments should be done for circulation and to avoid sores. Ensure that proper

food and water are given to the patient. The patient’s body position on the bed, mobility,

physical cleanliness, privacy, and a constant rapport are other factors to be considered.

Moreover, the patient should be checked several times for his/her clinical status. The purpose

is the removal of the physical restraint gradually, as the patient shows signs of improvement.
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Expected patient behavior should be explained to the patient before the release of restraint.

Removal of restraint should be done in the presence of a minimum two healthcare personnel

(Vieta et al., 2017).

After the period of agitation, feedback should be obtained from the patient, family and

the therapeutic team about every aspect and stage of the procedure. The patient should be

encouraged to share his/her personal experience of the procedure. This creates awareness of

one’s own mental state and reduces any distress caused (Vieta et al., 2017). It leads to a

positive connection between the therapeutic team and the patient. Thereby, encouraging the

patient to be receptive to future treatment and seek help in the initial stages of restlessness.

Evaluate or Audit

Aim of the audit is to educate healthcare professionals and improve strategies to

manage aggressive outbursts in psychotic patients. At the start of an audit, the organization

must clearly declare the resources allotted for the project, for example, the required software

and the hardware. The organization also asserts means for the clinical training of staff.

Customize the audit project team by involving psychiatrists, nurses and patient attendants

involved in restraining patients. (Esposito & Canton, 2014).

‘Indicators, criteria, standards, and definition of intervention strategies’ are selected

(Esposito & Canton, 2014). Indicators here are the number of restless patients during a given

period of time, the number subjected to physical restraint, the duration of restraint applied

and the use of other measures for the safety of the patient. Criteria for measurement include

use of verbal de-escalation; modification of the environment, harm caused to the restless

patient, pharmacological intervention like intramuscular or intravenous injections, sublingual

or inhaled formulations. The standard of care to be achieved for each criterion is usually

indicated in percentage with higher and lower limit stated. Criteria and standards are to be
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derived from the best evidence. All of these are to be discussed clearly with the project team

and described in intervention strategies (Esposito & Canton, 2014).

Disseminate

Some interactive means of dissemination and implementation are mentorship,

conferences, and workshops whereby, different professionals and stakeholders are

enlightened about the proposed change through the evidence base (Darnell et al., 2017).

Workshops conducted for concerned health care workers and professionals on the topic of

physical restraint based on the above evidence base can make an impact on acquiring skills to

calm a restless patient. This will also lead to professional development (Darnell et al., 2017).

Mentoring in real practice by ward in charge is essential for successful outcomes concerning

the safety of a psychotic aggressive patient (Darnell et al., 2017).

Conclusion

It is important to embrace a culture of EBP as it leads to high-quality patient care

outcomes. A PICO format is useful in asking the right question. The next step of EBP is to

acquire the best quality research evidence. A thorough appraisal of the acquired evidence is

done by using the CRAAP acronym which stands for Currency, Relevance, Authority,

Accuracy, and Purpose. This appraised evidence has to be applied to answer the PICO

question. Evaluation or Audit is done next to educate healthcare workers and stakeholders to

improve patient care strategies. Finally, the evidence base knowledge is disseminated to

induce a change in practice.

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References

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Xie, H., Zhou, Z., Xu, C., Ong, S., & Govindasamy, A. (2017). Nurses’ Attitudes towards
Research and Evidence-Based Practice: Perspectives from Psychiatric Setting. JOJ
Nursing & Health Care, 3(5), 001, 002. doi: 10.19080/jojnhc.2017.03.555624

Borg Debono, V., Zhang, S., Ye, C., Paul, J., Arya, A., & Hurlburt, L. et al. (2013). A look at
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Oh, E. (2016). Synthesizing Quantitative Evidence for Evidence-based Nursing: Systematic

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Szajewska, H. (2018). Evidence-Based Medicine and Clinical Research: Both Are Needed,
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Pacciardi, B., Calcedo, A., & Messer, T. (2019). Inhaled Loxapine for the Management of
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S, B., & Jones, R. (2016). Sensory Interventions for Psychiatric Crisis in Emergency
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Bowman, S., & Jones, R. (2016). Sensory Interventions for Psychiatric Crisis in Emergency
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Garriga, M., Pacchiarotti, I., Kasper, S., Zeller, S., Allen, M., & Vázquez, G. et al. (2016).
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