(Formerly Association of Psychiatric Nurse Managers)
May 2001

PATIENT ESCORTS IN PSYCHIATRY
A draft discussion paper prepared by the
Association of Psychiatric Nurse Managers
“When we treat man as he is we make him worse than he is, when we treat man as if he were already what he potentially could be, then we make him what he should be” –
Goethe.
Introduction
Psychiatric Nursing can be described as a human activity that facilitates the interpersonal, the emotional, behavioural, cognitive and spiritual needs of the person.
These needs are facilitated through the nurse patient interpersonal relationship. This relationship is built on understanding and respect, it enables the patient to improve personal functioning and it is recognised to be the most significant factor in the treatment process.
At times this therapeutic relationship takes on a compulsory nature where freedom is curtailed or limited. On such occasions a balance must be established between safety requirements and individual rights and civil liberties. Great care is needed to insure the non-punitive use of such interventions and to maintain the quality that this relationship requires.
The practitioner insures the integrity of the client patient relationship in difficult times through their professional training and experience, always aware of the benefits and risks associated with procedures used.
Psychiatric Nurses have a duty of care and are accountable for their practice to those who use services, to their employing authority, and to their professional body.
Professional accountability requires that nurses be aware of what is expected of them, particularly in the more challenging and difficult areas of practice.
Psychiatric Nurses in their practice, should at all times be concerned to add value to the lives of those using the service, their practice should allow for individual choice enhancing dignity and respect, minimising the stigma traditionally associated with their practice.
In areas of difficult clinical practice the practitioner needs the direction of clear policy and procedure, this is particularly true in situations where individual liberty and freedom is curtailed or withdrawn.
Nursing Escorts in Psychiatry should be seen not as a punitive intervention, but rather the purpose of this increased level of therapeutic involvement is to insure the personal safety of the individual, prevention injury, reducing danger or threat in so far as that is possible to both the individual and the community.

POLICY
A.
CRITERIA FO PROVIDING ESCORTS
Legal:
In all matters relating to involuntary detention, the requirements and the regulations of the Mental Treatment Act 1945 will be complied with.
Clinical:
If a person lacks mental capacity resulting in impaired judgement, or is assessed from their expressed behaviour or intent to be a possible danger to themselves or others, the doctor/professional under whose care the patient is placed will at all times act in accordance with clinical judgment and in the best interest of the patient.
B.
CONTENT OF CIRCUMSTANCES IN WHICH AN ESCORT MAY BE
NECESSARY
1.1
When the need for a patient escort is indicated, its provision will be in the context of patient treatment. It will be undertaken with due regard and sensitivity to the individual’s rights and civil liberties.
1.2
A patient escort will be undertaken as a dimension of therapeutic activity or as a contingency in the behavioural management of patients in circumstances where there may be a danger of harm to self or others.
1.3
To assist with the conveyance of a person for whom an appropriate application and recommendation for admission to an approved mental treatment centre has been completed. [NB. Role of G.P.]
1.4
To return a patient to hospital, who may have absented themselves or absconded, and whose infirmity or mental state is a cause of concern.
1.5
To return a patient to an approved treatment centre who has been on conditional discharge (Parole / Trial leave) and who has failed to return, or needs to be returned.
1.6
To accompany a patient from one treatment centre to another.
1.7
To accompany a patient attending consultations and appointments as necessary.
1.8
To assist in conveying a person resident in one of the boards’ community residences, who has suffered a relapse and lacks insight, and who needs to be in a more supportive care environment. Here the procedure for patient admission will apply.
1.9
A patient escort may also to be seen in the context of the professional Mental
Health Service providing assistance and support to the General Practitioner, as is stated in the Green Paper on Mental Health Legislation. Here the General
Practitioner is in the role of the primary provider of continuing care to the patient in the community and for whom he is responsible.

C.
GOOD PRACTICES/ PRIORITIES FOR STAFF IN PROVIDING
PATIENT ESCORTS
2.1
An escort will be provided as a last resort, and only when it is clear that all other intervention strategies have been exhausted.
2.2
To preserve the physical safety of the individual, minimising or preventing danger to the individual or others.
2.3
To observe the patients’ mental state and behaviour, and to record observations in writing.
2.4
Using effective communication and conversation skills, to interpret and respond appropriately to the patient as he/she presents.
2.5
To display a high level of tolerance and control in a non-authoritarian manner, allowing for personal choice and freedom, enlisting the active support of relatives in so far as that is possible.
2.6
To recognise and give the required attention to the need for safety and security of both staff and patient, thereby minimising the risk of injury to both staff and patient.
Training
2.7
To be skilled in predicting, preventing and containing potential acts of physical violence.
2.8
To be trained in the proactive management of aggressive behaviours.
D.
PRACTICE AND PROCEDURE
3.1
In all cases when an escort is requested the Clinical Director and the Chief
Nursing Officer (or their assigned deputies) will be informed. They will mandate the escort team deciding on the personnel required, it may include
Nursing, Medical and other disciplines.
3.2
In deciding on the personnel making up the escort team, the Clinical Director/
Chief Nursing Officer or their assigned Assistants, will rely on their own knowledge of the patient and/or the advice of relevant sector team personnel.
The escort team should include, where possible, a nurse or key worker who is familiar with the patients’ case. The Patients’ General Practitioner will be involved where appropriate.
3.3
A team leader will be identified at the outset by the Chief Nursing Officer or the delegated Assistant Chief Nursing Officer. The team will function with clear leadership and role definition, there will be clear communication with the patient, and excessive force will be avoided at all times.

3.4
The escort team leader so assigned will be responsible for co-ordinating the escort duty. On completion of the assignment a written report will be prepared for the Chief Nursing Officer. This report will refer to any difficulties encountered or potential difficulties, which are not covered in the existing policy.
3.5
The escort team will exercise sound professional judgement to minimise risk, and make every effort to secure the patients’ good will, trust and confidence, securing their co-operation.
3.6
As a rule the escort team should not forcibly enter the persons’ home/room. It is important at all times to operate with the owners’ permission, and within the law. [Working in good faith where there is a question of danger to self/another].
3.7
All episodes of escort duty are to be entered in the patients’ clinical case file.
3.8
A minimum of two staff should be involved in all cases; the composition of the escort team is relative to the situation.
3.9
In cases where the escort team is exposed to serious danger, the escort should withdraw and seek the advice from the appropriate senior nurse manager on the next course of action. This contact should be established from the scene of the escort, by use of the mobile cellular phone provided.
3.10
An appropriate gender mix is decided for each case.
3.11
The person who is the subject of the escort should be identified to the escort team; the General Practitioner has a role here.
3.12
Communication with the person who is the subject of the escort should be clear and direct.
3.13
One member of the escort team is nominated to dialogue with the person; others may become involved as appropriate or as directed by the escort leader.
3.14
Noting the circumstances specific to section E below, the Gardai will be informed in all other cases that an escort is taking place, it is expected that they be on stand by should their involvement become appropriate.
3.15
In HSE areas where is has been the practice to provide an escort for the purposes of conveying persons for whom an application has been received, and a recommendation for detention has been made, but who refuse to go voluntary to the approved mental treatment centre. A procedure specific to this circumstance is written in E below.
The Health Act 1970, specifies that the HSE have a duty to provide services, could be amended to deal with this circumstance, or alternatively the new Mental Health
Legislation could provide for such a provision.

E.
SPECIFIC PROCEDURE
Where an escort is provided for the purposes of conveying a person for admission to an approved treatment centre, this is more the exception than the rule.
In a case where a person for whom an application and a recommendation for treatment under the Mental Treatment Act to an approved treatment centre has been made, and where that person refuses to co-operate, the Clinical Director of the service shall take the following action.
4.1
The Clinical Director/Chief Nursing Officer shall ask a member of the appropriate sector team (key worker) to persuade the person to co-operate with the admission. The General Practitioner will have a key role in this action.
4.2
If the person continues to be uncooperative, the Clinical Director will apply for a court order to convey the person to the treatment centre.
4.3
On foot of the court order, the Gardai will assist the escort team in their task.
TRANSFER OF PATIENTS
The Mental Treatment Act 1945 made provision for the transfer of patients from one place to the other under Section 205, 206 of the Act.
Acknowledgements
South Eastern Health Board.
North Eastern Health Board.
Mid-Western Health Board.
Association of Psychiatric Nurse Managers
13 th
May 2001