Contribution of an institutional accompanying person to the reporting of 3 episodes of violence by a hospitalized patient at the Moussa Diop clinic of the Fann psychiatry department, in Dakar by Dr Racky WADE- KANE in Journal of Clinical Case Reports Medical Images and Health Sciences

 Contribution of an institutional accompanying person to the reporting of 3 episodes of violence by a hospitalized patient at the Moussa Diop clinic of the Fann psychiatry department, in Dakar by Dr Racky WADE- KANE in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

 Introduction:

 At the Fann Psychiatry department, institutional accompanying person is often very close to patients. Sometimes, they are the only ones to witness pathological attitudes or behaviors coming from patients. Thus, we will study the contribution of an institutional accompanying person to the detection of 3 episodes of violence in a hospitalized patient and then formulate recommendations.

Methodology:

 Our study is qualitative and was carried out at the Moussa Diop clinic of the Fann psychiatry department. We relied on the case of a patient who benefited from two presentations, one of which was taken from a summary of the medical file written by the medical team and the other described orally by her institutional accompanying person named FN during a semi-structured interview.

Results:

 Presentation of the medical file: This is a 54-year-old patient treated for dysthymic schizophrenia with a medical history of 3 hospitalizations. During his last hospitalization, no episode of aggression or violence was mentioned in his medical file. She is known to be very calm by caregivers.

Presentation of the patient by the institutional accompanying person FN:

 “Madame was very violent. With each hospitalization, she can end the life of her accompanying if the latter does not flee.” She specifies: “During her last hospitalization, I narrowly sketched the chair with which she wanted to smash my head. The first 3 days of each hospitalization are permanent insecurity for me, it’s our job, what should we do? However, in the days that follow she becomes cooperative.”

Conclusion: 

Due to the undefined working conditions of the institutional accompanying person, episodes of repeated violence by a patient were not transmitted to the caregivers. Which makes these recommendations for this clinical case a priority to help them in the exercise of their functions.

Introduction

 At the Fann Psychiatry department, support for psychiatric patients is a model of social or community psychiatry which complements the already existing range of care [1]. In 1961, Collomb and al. realized that the imported Western asylum model was inconsistent with reality and the traditional values held by the patient in Senegal. They came up against the resistance of patients and the inaccessibility to the genesis of the disorder or the understanding of the disorder. They observed a structure of traditional African societies centered on the group,on the collectivity, the values which underlie it (solidarity, community, priority given to the relationship) which never separate the individual from his social group of reference [ 2,3]. This led them to develop a new approach to psychiatric assistance inspired by the socio-cultural conditions specific to the country (Senegal). Thus, accompanying person for hospitalized patients was introduced and then institutionalized in 1968 before becoming widespread in 1971. With the main objective of providing the patient with a normal and harmonious family and social environment, an essential climate for their development [1-3]. The patient hospitalized at the Moussa Diop clinic in Fann can benefit from either a family accompanying or an institutional accompanying person when members of the patient's family are not available. Institutional accompanying person is very close to patients and spend a lot of time with them. However, these institutional accompanying persons currently communicate little with doctors about the accompanied patient. They often transmit to the psychiatrist requests for discharge from hospitalization made by the patient or his family. Sometimes, they are the only ones to witness pathological attitudes or behaviors coming from patients, but they may not inform the caregiver of this situation. Thus, we will study the contribution of an institutional accompanying person to the reporting of 3 episodes of violence by a patient in hospitalization and then formulate some recommendations.

Methodology 

Our study is qualitative and was carried out at the Moussa Diop clinic of the Fann psychiatry department. We relied on the case of a patient who benefited from two presentations, one of which was taken from a summary of the medical record written by the medical team and the other described orally by her institutional accompanying person named FN during a semi-structured interview.

Results

 Presentation of the medical record: 

This is a 54-year-old patient followed for dysthymic schizophrenia with a medical history of 3 hospitalizations in the same division for similar reasons. During her last hospitalization, she followed her treatment calmly with a good progression of psychotic symptoms until her discharge after 15 days. No episodes of aggression or violence are mentioned. She is known to be very calm by caregivers.

Presentation of the patient by the institutional accompanying person FN at the request of the medical team: 

She begins with: “Madame was very violent during her first 3 days of hospitalization. With each hospitalization,she can end the life of her institutional accompanying if the latter does not flee.” She specifies: “During her last hospitalization, I narrowly sketched the chair with which she wanted to smash my head even though I didn’t see it coming. It was the same with the 2 other hospitalizations that preceded it. The first three days of each hospitalization are permanent insecurity for me, it’s our job, what should we do? However, in the days that followed, she became cooperative and adapted well to the rest of her hospital stay. In any case, her family will have to find another accompanying person for her if she returns to hospital because I am getting older.”

Comments

 Presentation of the medical record: 

We note that the episodes of violence during this hospitalization were not noted in the medical file. It is the same for the first two hospitalizations which preceded it. Indeed, we can understand the absence of detection of episodes of violence by caregivers, by the fact that after prescription of medication by the doctor and their administration by the nurse, the latter return to see other patients in hospitalization. There is no surveillance camera in the institution either. Added to this is FN's psychological and physical "capacity to cope", which was reflected in the absence of counter-violence coming from her. Counterviolence is defined as an inappropriate or disproportionate reaction, dangerous for the aggressor.

Presentation of the patient by the institutional accompanying FN:

 Most often, it is FN who stays with the patient and during this period there may be a reappearance of the symptoms which motivated the hospitalization. When it comes to an episode of violence, it is often unpredictable, and events unfold very quickly before the caregiver is informed. With this risky situation, FN is trying to find immediate ways to protect itself. She specifies that she narrowly sketched the chair thrown by the patient. For past hospitalizations, she had fled when leaving the cabin. This demonstrates in her, the absence of technical training in simple self-defense to be able to protect herself. Through her presentation, FN claims that it is her work that requires her to confront this violence and that she should not complain about it to either the caregivers or the patient's relatives. Which reflects the lack of understanding of its role in the institution. Also, she fears being described as incompetent by the patient's relatives and that the support will be withdrawn from her and entrusted to someone else, hence her silence. The presentation described by FN reflects her psychological experience faced with the violence of the patients she witnesses in the course of her work. She feels permanently insecure with apprehensions that resurface each time a violent patient is hospitalized. To deal with this violence, she has put strategies in place such as resilience. She says, “the risk is during the first 3 days of hospitalization after which the medications begin to take effect”. It thus raises the reflection that should be made by caregivers on the use of physical restraint which is not authorized in the Fann psychiatric service. Another strategy is now his avoidance of supporting violent patients

Recommendations

 • Official definition of the status and prerogatives of institutional accompanying person. • Training in simple self-defense techniques.

 • Systematic participation of institutional accompanying person in patient visits, not only for requests for hospital discharges.

 • Setting up a listening space to allow institutional accompanying person to share their daily experiences. 

• Reflection and introduction of supervised physical restraint on medical prescription within the institution. 

Conclusion

 Due to the undefined working conditions of the institutional accompanying person, episodes of repeated violence by a patient were not transmitted to the caregivers. Which makes these recommendations for this clinical case a priority to help them in the exercise of their functions.

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