Minimizing Seclusion and Restraint in Youth Residential and Day Treatment Through Site-Wide Implementation of Collaborative Problem Solving

ABSTRACT

Despite a growing understanding of the need to reduce seclusion and restraint (S/R) in all types of youth psychiatric facilities, published accounts of success in the psychological literature have been limited to inpatient facilities. Furthermore, existing publications on successful S/R reduction rarely include details about implementation that would be helpful to other agencies looking to follow their lead. This article presents the case of one multiservice agency that reduced S/R rates in youth residential and day treatment programs after adopting the Collaborative Problem Solving (CPS) approach. It includes detailed information on implementation, data illustrating the reduction of S/R after CPS implementation, and discussion of possible benefits to youth outcomes and organizational costs.     

Assessment of Hospital-Related Stress in Children and Adolescents Admitted to a Psychiatric Inpatient Unit

PROBLEM: The assessment of hospital-related stressors experienced by child and adolescent patients on a psychiatric inpatient unit. SUBJECTS: Child and adolescent inpatients (N = 40) admitted to an acute, short-term psychiatric unit. METHODS: A newly developed stressor survey was administered to subjects to identify the most problematic stressors. Correlation analyses were used to assess associations between hospital-related stress and adjustment variables. FINDINGS: Broad domains and specific items of the most problematic hospital-related stressors were revealed. Also, higher levels of hospital-related stress were consistently associated with poorer hospital-based adjustment. CONCLUSIONS: Implications for treatment include identifying hospital-related stressors for individual patients and providing interventions to enhance coping.     

Assessing the Educational Needs of Mental Health Nurses Working in an Adolescent Inpatient Psychiatric Ward in Japan

PROBLEM: In Japan, preregistration education is not sufficient to prepare nurses to work as child adolescent mental health nurses. METHODS: Nominal group technique (NGT) using focus group discussions, and Knowles' Adult Learning Theory, were used to examine the continuing educational needs of nurses in a Japanese adolescent mental health unit. FINDINGS: Nurses caring for adolescent patients with mental health issues need continuing education. This research demonstrates the utility of nominal group technique in needs analysis in this context. CONCLUSIONS: Educational priorities include instruction on patients' developmental stage, promoting patient self‐sufficiency, and strategies for meeting the needs of families. A family‐centered care approach is recommended.     

The Influence of Anger‐arousal Level on Attribution of Hostile Intent and Problem Solving Capability in an Individual with a Mild Intellectual Disability and a History of Difficulties with Aggression

Background Recent studies have suggested that cognitive biases may play an important mediating role in aggressive outbursts from people with mild intellectual disabilities (IDs). Essentially, some individuals may frequently perceive other people as acting towards them in a hostile fashion. This biased perception may develop through repeated adverse experiences, and may make them more likely to respond, likewise, in an aggressive manner. These studies have led to the development of a cognitive behavioural model of aggression, incorporating factors both intrinsic and extrinsic to the individual. This study aimed to explore one facet of this model: a putative relationship between anger‐arousal level, problem‐solving ability and perception of hostile intent in others. Method Single‐case methodology was utilized, and a 44‐year‐old man with a mild ID and a history of difficulties with aggression participated. A series of vignettes, containing potentially provocative social interactions, were read to the participant. His perception of hostile intent, and suggestions of possible behavioural responses were recorded as dependent variables. Anger‐arousal was manipulated, through autobiographical recall, as a dependent variable. Results Although not conclusive, results indicate that anger‐arousal may act in an interactive fashion to increase perception of hostile intent. No effect of anger‐arousal was observed on problem‐solving ability; however, floor‐effects in the task used may provide an explanation for this. Conclusions A high level of anger‐arousal may exacerbate the probability of a frequently aggressive individual perceiving others as acting in a hostile manner. However, future research should take the limitations of this study into account, and continue development of a cognitive model of frequent aggression in those with a mild ID.     

Staff representations and tobacco‐related practices in a psychiatric hospital with an indoor smoking ban

The present study describes representations about smoking and practices related to patient smoking among staff of a large public psychiatric hospital. A survey was performed using a specially designed questionnaire. The return rate was 72.4% (n = 155). A large proportion of staff recognized the importance of both smoking status and mental health for patient's well‐being (46.9%), and believed that smoking cessation was possible for psychiatric patients (58.6%). However, the role of the psychiatric hospital was perceived as providing information (85.3%) and helping to diminish cigarette consumption (51%), rather than proposing smoking cessation (29.5%). Staff daily practice included reminding patients of smoking restrictions (43.9%), managing cigarettes (46.5%), and nicotine replacement therapy (24.3%). A principal component analysis of tobacco‐related practices revealed two main factors (59.8% of variance): basic hospital actions (factor 1) and more specialized interventions (factor 2), which were significantly associated with higher worries about personally developing smoke‐related illnesses (Spearman r = 0.38, P < 0.0001). Compared with non‐smokers, smokers reported higher perceived vulnerability to develop an illness due to tobacco and a higher level of worry about this. The discussion highlights the need to redefine roles and expectancies of mental health staff, and improve training and collaboration with experts, in order to improve efficiency concerning tobacco issues.     

Patients’ experiences of isolation in psychiatric inpatient care: Insights from a meta‐ethnographic study

Historically, people with mental ill‐health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill‐health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients’ experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta‐ethnographic synthesis. The findings were twofold: ‘being admitted to prison’ and ‘having access to shelter’. The experience of isolated care as prison‐like symbolizes patients’ longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill‐health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self‐stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.     

Psychiatric nurses' lived experiences of working with inpatient care on a general team psychiatric ward

To reveal the meaning of being a nurse working with inpatient care on a team psychiatric ward in Sweden, 22 psychiatric nurses were interviewed and the transcribed texts were analysed by means of latent content analysis. Three themes emerged from the analysis: developing a working relationship with the patient in everyday caregiving; encountering and handling the unforseeable in daily living; and struggling with professional independence and dependency. Developing a working relationship with the patient in everyday caregiving meant that the nurse-patient relationship was the foundation of the caregiving and included being with, as well as doing for, and with, the patient. Four different approaches in daily caregiving were revealed: networking, teaching, containing and protecting. The nurses' approaches in the nurse-patient relationship alternated between being an 'expert' and a 'collaborator'. Encountering and handling unforeseeable situations meant that the nurses were exposed to and had to be prepared for unpredictable situations where they were on their own, handling sometimes strong emotional reactions and relying on their own ability to act. Struggling with professional independence and dependency meant that the nurses seemed to lack professional confidence, although they had many responsibilities, but also less authority to decide about overall care planning. Contextual aspects such as organizational hindrance, unsatisfactory work-environment and co-operation difficulties were illuminated. The result indicates the need for a stable and predictable organizational structure if nurses are to manage the demanding nurse-patient relationships that everyday caregiving requires. A question highlighted by this study is whether multidisciplinary team organization has been effectively developed in Sweden, as uncertainty about the roles and responsibilities of nurses was apparent.     

Smoking cessation and serious mental illness: a service evaluation of a drop‐in stop smoking clinic on an acute in‐patient unit

Aims and objectives. To evaluate the effect of a stop smoking clinic on the quit rates of patients admitted to an acute in‐patient unit. Background. The relationship between poor physical health and severe mental illness is well established. High rates of smoking appear to play an important causal role in the excess morbidity and mortality in this population. Stop smoking interventions for the general population are clinically effective and cost‐effective. There is a small but promising evidence base for effective interventions to help people with a mental illness who wish to stop smoking but these have mostly been tested with community patients rather than acute in‐patients. Methods. A service evaluation of a drop‐in stop smoking clinic on an acute mental health in‐patient unit was conducted. Patients’ smoking status was measured at baseline and four weeks after their quit date using patient self‐report and an expired breath carbon monoxide reading. Results. Over a six‐month evaluation period, 46 patients set a quit date and 13 (28·3%) were abstinent at the four‐week follow‐up stage, verified by a carbon monoxide reading (χ² = 33, df = 1, sig p < 0·0001). Conclusions. This small‐scale evaluation has shown a drop‐in stop smoking intervention to be feasible, acceptable and associated with positive outcomes; further research with larger, more representative samples is required. Relevance to clinical practice. Enforcing smoke‐free legislation is a contentious issue on mental health in‐patient units, and there is a paucity of research to guide nursing practice in this area. An admission period in a smoke‐free environment provides a crucial opportunity to offer smoking cessation treatment. With appropriate resources, expertise and support, it appears possible to apply smoking cessation interventions that are successful within the general population to mental health patients during an acute admission.     

Effects of case‐based learning on communication skills,problem‐solving ability,and learning motivation in nursing students

The purpose of this study was to explore the effects of case‐based learning on communication skills, problem‐solving ability, and learning motivation in sophomore nursing students. In this prospective, quasi‐experimental study, we compared the pretest and post‐test scores of an experimental group and a nonequivalent, nonsynchronized control group. Both groups were selected using convenience sampling, and consisted of students enrolled in a health communication course in the fall semesters of 2011 (control group) and 2012 (experimental group) at a nursing college in Suwon, South Korea. The two courses covered the same material, but in 2011 the course was lecture‐based, while in 2012, lectures were replaced by case‐based learning comprising five authentic cases of patient–nurse communication. At post‐test, the case‐based learning group showed significantly greater communication skills, problem‐solving ability, and learning motivation than the lecture‐based learning group. This finding suggests that case‐based learning is an effective learning and teaching method.     

Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital

OBJECTIVE: The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth. METHODS: The hospital staff received training in March 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 and March 2007. Data were collected on demographics, including age, gender, ethnicity, number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints. RESULTS: Four hundred fifty‐eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy‐nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints), with average number of episodes 3.5/patient (range 1–28). Thirty‐seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%). CONCLUSIONS: This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health Program Directors six core strategies based on trauma informed care.