Inpatient psychiatric treatment: should we revive a shrinking system?
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Forecasting↗
Biomedical subjects
Kathleen R Delaney
Publications and source records attributed to Kathleen R Delaney.
Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment.
BACKGROUND: Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue. APPROACH: The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined. FINDINGS: The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy. RECOMMENDATIONS: Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.
Adolescent↗
Advanced practice psychiatric mental health nursing, finding our core: the therapeutic relationship in 21st century.
TOPIC: Increasingly, students from various professional backgrounds are enrolling in Psychiatric Mental Health (PMH) Nursing graduate programs, especially at the post-master's level. Faculty must educate these students to provide increasingly complex care while socializing them as PMH advanced practitioners. PURPOSE: To present how one online program is addressing these issues by reasserting the centrality of the relationship and by assuring it has at least equal footing with the application of a burgeoning knowledge base of neurobiology of mental illness. SOURCES: Published literature from nursing and psychology. CONCLUSIONS: The PMH graduate faculty believes that they have developed strategies to meet this challenge and to help build a PMH workforce that will maintain the centrality of the relationship in PMH practice.
Clinical Competence↗
Learning to observe in context: child and adolescent inpatient mental health assessment.
On child and adolescent inpatient psychiatric units, nursing staff have 24-hour exposure to patients, an excellent vantage point for observing behavior in a variety of situations and interpersonal contexts. How staff members respond to milieu behaviors depends in part on their judgment of what prompted a youngster's response and his/her ability to process the event and control the attendant emotions. To assess such aspects of a child or adolescent's presentation requires that staff appraise not just the presenting behavior but the patient's information-processing and affect-regulation abilities. One way this developmental knowledge can be embedded in practice is through assessment guides that contain observation cues for key issues related to how children/adolescents think, feel, and behave. This article sets down the rationale for the content and organization of such inpatient nursing assessment guides and suggestions for their dissemination to the unit staff.
Adolescent↗
Following the affect: learning to observe emotional regulation.
On inpatient psychiatric units, staff deal with children and adolescents whose affect escalates quickly and intensely. These same children experience strong emotions that they can neither understand nor explain. To intervene effectively, inpatient staff must understand the regulation issues underneath the escalated behaviors. Emotion Regulation theory and the developmental line of emotional understanding are useful concepts in assessing and intervening with these children and adolescents. Presented here are criteria to guide inpatient staff's assessment of children and adolescents with emotion regulation difficulties. The assessment cues are based in concepts of Emotion Regulation and emotional understanding and are accompanied by suggested intervention strategies.
Adaptation, Psychological↗
Learning to observe cognition, mastery, and control.
On inpatient psychiatric units, intervening with children and adolescents' behaviors demands an understanding of how they take in and process information. The third paper focuses on assessment cues that will help inpatient staff decipher patients' deficits and strengths in information processing, self-efficacy, and inhibitory control. Each assessment area is explained in the context of the supporting cognitive, neurobiologic, and social-learning theory. Inpatient interventions consistent with the assessment are explained and illustrated with clinical applications.
Adolescent↗
Learning to observe relationships and coping.
Milieu relationships provide the critical background presence to staff's attempts to motivate, regulate, and teach patients how to cope with stress. Forging a connection with hospitalized children and adolescents demands attention to how they respond to adults and engage with staff around milieu expectations. Assessment guides that deal with these issues are presented. Important aspects of children's relatedness are presented in the context of their working models of adults and the influence of these representations on their response to staff. Coping skills are explained with particular emphasis on behavioral coping strategies. Tied to the assessment process are interventions that emphasize staff's role in helping patients manage strong affects and avoid the use of nonproductive behavior regulation strategies.
Adaptation, Psychological↗
Top 10 milieu interventions for inpatient child/adolescent treatment.
Presented in this article are 10 interventions to deal with children and adolescents on inpatient psychiatric units. The 10 are divided into three categories: behavioral, cognitive, and affective. The interventions discussed are particularly relevant to staff in their efforts to help children and adolescents achieve control over their thoughts, feelings, and behaviors. Each intervention includes a summary of the theory that supports its efficacy, a brief explanation of the intervention, and methods for applying the technique in clinical situations.
Adolescent↗
Evaluating clinical competence of distant nurse practitioner students.
Developing and evaluating core clinical competencies of nurse practitioner students at distant clinical sites requires dialog among the student, the clinical preceptor and University faculty. Students enter our program with diverse backgrounds, experience and interests. Here we demonstrate an innovative online Clinical Development Scale (CDS) that gathers self assessment data from each student, analyzes, organizes and prioritizes competencies to be accomplished in a clinical practicum, produces midterm and final evaluation summaries from data contributed by both student and preceptor and displays action plans developed by students, for meeting deficient competencies for preceptor and faculty approval.
Clinical Competence↗
The psychiatric nurse practitioner 1993-2003: a decade that unsettled a specialty.
Between 1993 and 2003, a debate raged in psychiatric mental health (PMH) nursing. It was a decade of discourse about the role and titling of PMH advanced practice nurses. The PMH role evolution that occurred throughout this decade was driven by several forces, not all of which were in the control of PMH nursing. This article traces the multiple dynamics that prompted the evolution of the PMH nurse practitioner role, foremost the ascendancy of primary care and the influence of managed care. It also analyzes the conflict created by the American Nurses Credentialing Center PMH Nurse Practitioner examination that became a lightning rod for the disruption occurring in the traditional PMH role. Although the controversy surrounding PMH advanced practice nurse titling is beginning to clear, with the clarity comes a new set of problems for the development of the PMH workforce.
Certification↗
Patient characteristics and setting variables related to use of restraint on four inpatient psychiatric units for youths.
OBJECTIVES: This study examined the characteristics of children and adolescents who were restrained during brief inpatient psychiatric treatment and identified whether restraint use was related to the characteristics of the youths or to the setting-time of day, day of the week, place, or programming. Incidents related to restraint use were also examined. METHODS: Charts were reviewed for 100 youths who were admitted to four inpatient units between December 1998 and January 2000. RESULTS: Thirty-one youths were not restrained, 57 were restrained once or twice, and 12 were restrained three or more times. Youths were significantly more likely to be restrained if they were male, had multiple admissions to the facility during the study period, remained in the hospital longer, had been given a diagnosis of a psychotic disorder, or had a previous psychiatric hospitalization. Youths who were restrained were also more likely to be enrolled in special education or to be in foster care or in custody of the Department of Children and Family Services. Also, these youths were more likely to have a history of voicing suicidal ideation and attempting suicide. No single setting variable was significantly related to restraint use. Incidents that prompted restraint generally involved agitation, threats, or assaults. CONCLUSIONS: Youths who were at greatest risk of being restrained during brief inpatient treatment shared particular characteristics related to greater use of inpatient services, guardianship arrangements, special education placement, and history of suicide attempts. Inpatient staff members should remain particularly alert to the processing and regulation problems of these groups of patients.
Adolescent↗
Milieu management of a child with bipolar illness.
During inpatient psychiatric treatment, children with bipolar disorder may present particular management issues. They may experience intense periods of affect regulation that can spiral into frenetic, aggressive behaviors that are difficult to interrupt with de-escalation techniques. This case study presents such a child and the behavior patterns that resulted in seclusion and PRN medication. Also presented is the plan that staff derived which eventually helped this young boy regulate his behavior.
Adaptation, Psychological↗