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Toxic substances, including detergents and cleaning substances, must be kept in locked boxes, dispersed in limited quantities, and carefully overseen by the cleaning staff who bring these substances by cart onto the unit. Bathroom curtain rods must be designed to break if subject to any significant weight. Closet rods must also meet this specification. Wooden rods harden with age and can bear more weight, making J-hooks a desirable alternative (Libby, 1992). Finally, exposed pipes in low-security areas should be covered or rendered inaccessible.
Units should consider instituting "environmental rounds," in which clinicians and members of the plant and operations department inspect the unit. Established parameters for inspection, including those just mentioned, would be examined and new problems addressed as they arise.
An important unit procedure is the search of the patient's belongings. Sharps (pointed or bladed instruments) and flames (matches, lighters, and cigarettes) must be confiscated from the suicidal patient. All patients must surrender prescriptions and over-the-counter medications. Suicidal patients must surrender any substances that could be put to deleterious use (e.g., art supplies, detergents, dyes, etc.). Belts, shoelaces, and other articles of apparel represent dangerous devices for suicidal patients. However, staff must weigh the danger of these objects against the dehumanization of stripping patients of everyday elements of attire and convenience.
The use of the body search should be restricted to patients at high risk for suicide. A body search is intrusive and potentially humiliating or stimulating to vulnerable patients. Room searches, on the other hand, may be done with less concern and are one way the staff can demonstrate their rigor and commitment to safety.
Observation of the patient is fundamental to all inpatient units and is typically a dimension of nursing policy and procedure. Increments of observation should be specified and procedures articulated. One-to-one observation (constant observation) should be defined as either "at arm's length" (i.e., immediately next to the patient) or under the continuous eye of the staff. Typical increments of observation then proceed from 5- to 15- to 30-mm checks. Checks may be recorded either by staff or by the patient (self-checks), depending on clinical goals. Orders for intensive observation probably would last no longer than 24 hr and, optimally, require daily physician examination of the patient.
Supervision of the patient is different from observation and may warrant its own policy and procedure. Certain patients may require, for safety, supervision of their use of sharps and flames. Other patients may not be safe in the kitchen area because of the many materials and instruments that can be used for self-destruction. Bathroom use will need to be supervised for all patients who are on one-to-one status and for some patients who cannot safely be allowed access to pipes, rods, and pools of water. Finally, some patients may have "open areas" supervision, which indicates that they are safe in public areas where people are present, but they cannot be trusted to not secrete themselves away when alone. Staff supervision can be effective only for limited periods of time (i.e., hours to days) because of the limited capacity to control anyone, and in fact it should be in place for only a limited period of time, because prolonged supervision can invite regression.
By definition, privileges must be earned. The patient must demonstrate the clinical capacity to merit the lifting of restriction. Inpatient units are the opposite of a democracy; freedom is not inherent to life on an inpatient unit, especially for the involuntary or dangerous patient. Instead, restriction is normative and freedom is granted as a privilege when the patient has shown alliance, self-control, and responsibility for safety.
The patient's privileges (and passes) should also be consistent with his or her legal status. A patient committed to the unit by court order, for example, should have privileges consistent with the court's action, or there should be documentation as to why privileges do not conform to the court's order.
Passes may also be accompanied or nonaccompanied. It is important to distinguish accompaniment for support from accompaniment for safety. Many patients will benefit from pass accompaniment but will not be unsafe without it. Patients who require accompaniment for safety (those at risk of escaping or causing themselves harm) should be accompanied by staff adequate in number and strength to maintain safety.
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