Psychiatric policy and procedures are crucial to keeping everyone in a facility safe – and if we want them to work, they need to be more individual and less institutional.

I was reading an article in Healthcare Design about the balancing act between design and safety in mental health units or facilities, and I was struck by this line:

“A design approach for psychiatric facilities focused totally on the elimination of potential safety hazards for the patient will lead to an environment of care that is inhospitable, institutional, and unlivable.”

This got me thinking about our approach to the individuals in our care in general, and especially about conversations about hospital safety and managing escalating behaviors.

Policies and rules in psychiatric settings have to provide for the safety of individuals and staff — that is paramount — but I sometimes wonder if we’ve become “inhospitable, institutional, and unlivable” with our rules, policies, and protocols.

I was thinking about how many stories I’ve heard where a crisis has occurred that is linked directly to a rule infraction that led to a power struggle that ultimately never had to happen.

The movement toward a more person-centered, individualized treatment approach I think is a good one. It calls us, though, to examine our institutional way of interacting with individuals.

Here are a few ways I think we can make this transition easier.

4 tips for shifting from an institutional approach to an individualized treatment plan approach

1. Create a new language

The language we use says a lot to the individuals in our care. How can we change the way we not only label, but address the individuals we're caring for?

Consider:

Are they patients or residents?
Are they there for care and healing, or were they “Baker Acted”?
Are they “frequent fliers,” or are they suffering from chronic illness?
Do all of your rules or policies spell out what people “can’t do,” or do they offer the options that are available to the individuals in your care?

Additionally, what language do you use in your documentation?

For example, would you write:

“Mr. Jones was pacing all over the unit disrupting others and making them all anxious. Staff directed him to stop disrupting others.” ?

Or would it read:

“Mr. Jones was exhibiting signs of anxiety through pacing. In an attempt to alleviate his anxiety without disrupting others, we offered to walk with him in an open area of the unit, away from others.”

2. Re-evaluate rules and policies

How flexible can you be while still providing for the necessary safety of everyone? I often ask organizations concerned with hospital safety, “Why do you have that rule?” or “Who does that rule benefit?”

As staff, it’s easy for us to get caught up in rules that exist simply because they always have. It’s also easy to cling to rules that make it easier or more convenient for us as staff. I really sometimes have to chuckle when I hear “Well, if I let them do it (have it, not do it, etc.), then they’ll all want to do it...”

I was in a psychiatric hospital for individuals who have been found not guilty of crimes by reason of mental disease and we had this discussion of a crisis that had erupted into a really ugly outcome all over an individual requesting a glass of milk in the night.

When asked why she didn’t just get the individual a glass of milk, the staff member involved responded by saying, “Because then everyone will get up and expect a glass of milk in the night.”

There’s a new rule on that unit, and I can assure you that not everyone is getting up requesting milk all night.

Let’s face it — this facility is home for these individuals. They will not likely ever leave. Can you get up at night and get a glass of milk in your home?

3. Choose wisely what you insist upon

We cannot always give individuals what they want or what they’re asking for, or maybe we just can’t right at the time they’re requesting it. In fact, people don’t have to do anything we request of them, so we have to be creative and flexible in deciding which of our rules are negotiable, and which are non-negotiable.

When considering the non-negotiables, what options can we offer around them?

For example, because you can’t allow individuals to smoke inside the hospital unit, do you have a smoking area outside, or do you eliminate smoking but offer alternatives like nicotine patches or gum?

As another example, we want to promote good hygiene, but instead of insisting that individuals shower at a particular time of the day (i.e., in the morning), can we create shower times throughout the day that allow individuals to select the time of day that feels the best for them? Adding flexibility takes away the need for the individuals in our care to get into power struggles with us (and us with them).

4. Practice limit setting

As I mentioned, we can’t make others do anything. Limit setting is borne of this realization. I also think power struggles come about often because parties in the communication loop feel like they do not have any power or say in a situation. The more we can provide the individuals in our care with options, choices, flexibility, and collaboration in their daily lives, the easier everything becomes for all of us. I really believe that ultimately “power given is power gained.”

Staff fear being “out of control.” I did. I still do sometimes. But my experience has shown me that the more I’m able to offer positive choices that are clear, reasonable, and enforceable in a way that empowers others to be in control of their behavior and their situation, the more successful I am in de-escalating a situation.

But limit setting is not intuitive. It’s a skill we need to practice. Try out these phrases:

“First... then...”
“If you are able to... then I will...”
“We have options. Let’s talk about what they are.”

Thinking through the language I would use — thinking about the words I would choose when I’m calm and rational — and practicing that with a colleague — better equips me for the crisis moment when everyone’s fears and anxieties are high.

At the end of the day, we are all really in the “people” business, and by approaching our business with understanding and empathy, we can make a more positive impact on the lives of the individuals we care for.

Do your staff face verbal abuse from patients? Check out CPI Verbal Intervention™ Training.

Psychiatric Policy and Procedures: 4 Tips for Shifting From Institutional to Individual