The power of routine and special observations: producing civility in a public acute psychiatric unit

Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit

Despite their widespread use, typical visual observation practices are not evidence-based and adverse events - such as self-harm and absconding - still occur even under the most intense forms of observation. This study aimed to (i) develop and implement an engagement-focused systematized model of clinical risk management in an adult acute psychiatric inpatient unit; and (ii) prospectively evaluate its effect on rates of violence, self-harm, absconding, sexually inappropriate behaviour, and seclusion. A new model of engagement-focused clinical risk management was developed using a participatory action research framework and implemented in an adult acute psychiatric inpatient unit. Using a mirror-image design, rates of violence/aggression, self-harm, absconding, sexually inappropriate behaviour, and seclusion were compared before and after implementation, and staff satisfaction levels were measured. The clinical engagement-based model was introduced, and 1087 admissions before implementation (24 months) were compared with 965 admissions post-implementation (18 months). The new model was associated with significantly reduced rates of absconding (pre: 10.5/1000 occupied bed days, 95% CI [9.0, 12.1] compared with post: 6.5/1000 occupied bed days [5.2, 8.1], P < 0.001) and seclusion (pre: 43.7/1000 occupied bed days, 95% CI [40.6, 46.9] compared with post: 30.9/1000 occupied bed days [27.9, 34.1], P < 0.0001). Rates of aggression, deliberate self-harm, and sexually inappropriate behaviour were non-significantly decreased. Findings suggest that this engagement-focused model of clinical risk management in an adult psychiatric inpatient unit significantly reduced adverse patient events and was preferred by staff over current practice. Other psychiatric inpatient facilities may see a reduction in adverse events following the introduction of this well-tolerated risk management model.

The Importance of Being Acceptable - Psychiatric Staffs' Talk about Women Patients in Forensic Care

Currently, women comprise about ten percent of those sentenced to psychiatric forensic clinics in Sweden. Those who are sentenced to forensic care because of offending and violent behaviour have already taken a step away from the usually expected female behaviour. On the other hand, there are many women in forensic care who have not committed crimes, but who instead self-harm. Studies have identified a gender bias in diagnosing and care in psychiatric settings, but there are few studies conducted on women in forensic care. The present study therefore examined how the situation of women patients and female norms are expressed in the staff's talk about these women during verbal handovers and ward rounds at a forensic clinic in Sweden. The aim was to explore how psychiatric staff, in a context of verbal handovers and ward rounds, talk about women who have been committed to forensic psychiatric care, and what consequences this might have for the care of the patients. The content of speech was examined using audio recordings and a method of analysis that was inspired by thematic analysis. The analysis identified that the staff talked about the women in a way that indicates that they expected the women to follow the rules and take responsibility for their bodies in order to be regarded as acceptable patients.

Assistants in nursing working with mental health consumers in the emergency department

Nursing students, regardless of setting, require skills in working with people with mental health issues. One way to provide students with learning opportunities within the context of limited undergraduate mental health content and lack of mental health placements is through employment as assistants in nursing (AIN). The purpose of the study was to investigate the use of AINs employed in an emergency department in South Australia to supervise (continuous observation) mental health consumers on inpatient treatment orders. Twenty-four participants took part in the study, with AINs (n = 8, all studying in an undergraduate nursing programme), nurse managers (n = 5), and nurses (n = 11) participating in semi-structured interviews. Data were analysed using thematic analysis. Themes focused on (i) the AIN role, their practice, boundaries or restrictions of their role, and the image consumers have of AINs; (ii) learning through experience, where the AIN role was a practical opportunity to learn and apply knowledge obtained through university studies; and (iii) support, which focused on how AINs worked with nursing staff as part of the healthcare team. Overall, participants believed that AINs played an important role in the ED in supervising consumers on involuntary mental health treatment orders, where their unique role was seen to facilitate more positive consumer experiences. The AIN role is one way for nursing students to develop skills in working with people with mental health issues.

[The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study]

The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study Abstract.

INTRODUCTION

Psychiatric Special Observation (PSO) is an intervention often used by nurses to prevent service users of harming themselves or to protect others. The intervention ranges between control and therapy and is resource intensive. Despite the widespread use of PSO, there is still no data on the practice of the intervention in Switzerland.

AIM

What is the current practice of PSO in adults in psychiatric hospitals in the German-speaking part of Switzerland?

METHOD

Descriptive cross-sectional study. Nurses from inpatient psychiatric services in the German-speaking part of Switzerland completed a questionnaire based on a concept analysis of PSO.

RESULTS

538 questionnaires were analysed. PSO was more often conducted intermittent than as constant observation. In more than one out of four cases, suicidality reasoned as a cause for prescription. Nurses generally used standardized instruments to assess the risk of harming oneself or others. The duration of PSO lasted eight hours or more in three out of four cases. In every fifth case, there was no validation of the need of the intervention taking place during one shift. Nurses have a neutral attitude towards the intervention and are experiencing no or weak negative feelings during performance of PSO.

CONCLUSIONS

The results suggest that there is an inconsistent performance of PSO in Switzerland as well as in other countries. The validation of the need of the intervention is insufficient. To facilitate PSO as a justified performance, the preparation of an interprofessional guideline is recommended.

Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings

Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non-forensic acute mental health settings. The "Attitudes towards PRN medication use survey" was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.

Being Subject to Restrictions, Limitations and Disciplining: A Thematic Analysis of Individuals' Experiences in Psychiatric Intensive Care

The aim of this study was to describe individuals' experiences of being hospitalized in psychiatric intensive care units (PICUs). Four participants who had previously been admitted in a PICU were interviewed using open-ended questions. The data were analyzed using thematic analysis. Analysis resulted in a synthesis of the various ways patients experienced limitations: (1) Descriptions of Being Limited in the Environment, (2) Descriptions of being Limited in Interactions with Staff, (3) Descriptions of Being Limited in terms of Access to Information, and (4) Descriptions of Having Limited Freedom and Autonomy. Hospitalization is experienced as a life-changing event that shows a kaleidoscopic view of limitation. We stress that the conceptualization of limitation must be considered due to its historical origins, sociopolitical aspirations, and philosophy of care. Thus, nurse practitioners and nursing leaders are advised to put the patient's experience at the center of care, and to involve and integrate patients throughout the recovery process.

The Impact of Nursing Protocols on Continuous Special Observation

BACKGROUND

Continuous Special Observation (CSO) is commonly ordered for patients at risk to injure themselves or others and involves assigning staff to monitor one patient at all times. CSO is intrusive, costly, and often has deleterious effects on patient care. Two nursing protocols were developed as alternative interventions to CSO. The first protocol, Psychiatric Nursing Availability (PNA), was designed to treat patients having suicidal or self-injurious thoughts. The second protocol, Psychiatric Monitoring and Intervention (PMI), was designed to prevent violent and impulsive behavior. These protocols had their genesis in a model that encourages nursing autonomous decision making.

OBJECTIVE

Identify the impact PNA and PMI had on the number of CSO and their duration.

STUDY DESIGN

Nine-year descriptive retrospective analysis of CSO, PNA, and PMI. The data were collected from the unit 15-minute rounding sheets. Descriptive analyses were performed. Interrupted time series analysis was used to determine how the protocols affected frequency and duration of CSO.

RESULTS

PNA did not significantly affect CSO; however, PMI did affect its use. There was a downward trend in the number of CSOs after PMI was implemented by 0.07 episodes per month ( p = .0111). The median duration of CSO dropped from 66 hours to 33 hours after PMI was implemented ( p = .0004).

CONCLUSION

PMI had the greatest impact on CSO. PMI had a secondary effect of increasing staff availability on the unit that affected CSO's use. The model of nursing care may have influenced this reduction in CSO.

Power and resistance within the hospital's hierarchical system: the experiences of chronically ill patients

AIMS AND OBJECTIVES

To explore experiences of chronically ill patients and registered nurses when they negotiate patient care in hospital settings. Specifically, we explored how social and institutional discourses shape power relations during the negotiation process.

BACKGROUND

The hospital system is embedded in a hierarchical structure where the voice of the healthcare provider as expert is often given more importance than the patient. This system has been criticised as being oppressive to patients who are perceived to be lower in the hierarchy. In this study, we illustrate how the hospital's hierarchical system is not always oppressing but can also create moments of empowerment for patients.

DESIGN

A feminist poststructuralist approach informed by the teaching of Foucault was used to explore power relations between nurses and patients when negotiating patient care in hospital settings.

METHODS

Eight individuals who suffered from chronic illness shared their stories about how they negotiated their care with nurses in hospital settings. The interviews were tape-recorded. Discourse analysis was used to analyse the data.

RESULTS AND CONCLUSIONS

Patients recounted various experiences when their voices were not heard because the current hospital system privileged the healthcare provider experts' advice over the patients' voice. The hierarchical structure of hospital supported these dynamics by privileging nurses as gatekeepers of service, by excluding the patients' input in the nursing notes and through a process of self-regulation. However, patients in this study were not passive recipients of care and used their agency creatively to resist these discourses.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to be mindful of how the hospital's hierarchical system tends to place nurses in a position of power, and how their authoritative position may positively or adversely affect the negotiation of patient care.

New risks: the intended and unintended effects of mental health reform

In crisis situations, the authority of the nurse is legitimised by legal powers and professional knowledge. Crisis stakeholders include those who directly use services and their families, and a wide range of health, social service and justice agencies. Alternative strategies such as therapeutic risk taking from the perspective of socially inclusive recovery policy coexist in a sometimes uneasy relationship with mental health legislation. A critical discourse analysis was undertaken to examine mental health policies and guidelines, and we interviewed service users, families, nurses and the police about experiences of accessing services. For those who attempt to access services early in crisis, as is suggested to lead to a better outcome, provision of services and rights appear to be reversed by an attempt to exclude them through practices that screen them out, rather than prioritising a choice in access.

Mental health nurses' perceptions of good work in an acute setting

Frequently, research and conference papers explore difficult or problematic areas of practice that can inadvertently render daily nursing accomplishments invisible and create the perception of a discipline in crisis. In this qualitative study, we explore the views of registered nurses about achievements in the workplace and good nursing work in an acute inpatient mental health setting in Sydney, Australia. Mental health nurses were asked a series of questions about their experiences and understanding of what constitutes good nursing work as well as their sense of optimism about their work. A total of 40 structured face-to-face interviews were completed. Among the responses to questions about achievements and good nursing practice, five broad themes were identified: i) teamwork; (ii) interpersonal interactions with patients; (iii) providing practical and holistic support to patients; (iv) patients' mental health improvements; and (v) optimism-pessimism continuum. Findings contribute to a discussion of good nursing work in acute mental health settings, as well as self-perceptions of optimism and hopefulness, which are important contributors to positive, supportive health-care settings and patient recovery.

Panoptic power and mental health nursing-space and surveillance in relation to staff, patients, and neutral places

Mental health nurses use manifest and latent approaches for surveillance and observation of patients in the context of mental health care. Patient spaces in mental health organizations are subtly linked to these different means of surveillance. This article investigates these approaches, focusing in particular on the variety of spaces patients occupy and differences in the intensity of observation that can be carried out in them. The aim is to elaborate on space and surveillance in relation to the patients' and nurses' environment in psychiatric nursing care. Places where patients were observed were operationalized and categorized, yielding three spaces: those for patients, those for staff, and neutral areas. We demonstrate that different spaces produce different practices in relation to the exercise of panoptic power and that there is room for maneuvering and engaging in alternatives to "keeping an eye on patients" for nurses in mental health nursing. Some spaces offer asylum from panoptic observations and the viewing eyes of psychiatric nurses, but the majority of spaces in mental health nursing serve as a field of visibility within which the patient is constantly watched.

Latent or manifest observers: two dichotomous approaches of surveillance in mental health nursing

Background. Surveillance is a central activity among mental health nursing, but it is also questioned for its therapeutic value and considered to be custodial. Aim. The aim of this study was to describe how mental health nurses use different approaches to observe patients in relation to the practice of surveillance in psychiatric nursing care. Methods. In this study, Spradley's twelve-step ethnographic method was used. Results. Mental health nurses use their cultural knowing to observe patients in psychiatric care in various ways. Two dichotomous approaches were identified: the latent and the manifest approach. Discussion. Different strategies and techniques for observing patients are structured along two dichotomies. The underlying relationships between these two different dichotomous positions transform the act of observing into surveillance. This is further developed in a theoretical model called the powerful scheme of observation and surveillance (PSOS).

Ethnographic research into nursing in acute adult mental health units: a review

Acute inpatient mental health units are busy and sometimes chaotic settings, with high bed occupancy rates. These settings include acutely unwell patients, busy staff, and a milieu characterised by unpredictable interactions and events. This paper is a report of a literature review conducted to identify, analyse, and synthesize ethnographic research in adult acute inpatient mental health units. Several electronic databases were searched using relevant keywords to identify studies published from 1990-present. Additional searches were conducted using reference lists. Ethnographic studies published in English were included if they investigated acute inpatient care in adult settings. Papers were excluded if the unit under study was not exclusively for patients in the acute phase of their mental illness, or where the original study was not fully ethnographic. Ten research studies meeting our criteria were found (21 papers). Findings were grouped into the following overarching categories: (1) Micro-skills; (2) Collectivity; (3) Pragmatism; and (4) Reframing of nursing activities. The results of this ethnographic review reveal the complexity, patient-orientation, and productivity of some nursing interventions that may not have been observed or understood without the use of this research method. Additional quality research should focus on redefining clinical priorities and philosophies to ensure everyday care is aligned constructively with the expectations of stakeholders and is consistent with policy and the realities of the organisational setting. We have more to learn from each other with regard to the effective nursing care of inpatients who are acutely disturbed.

Patient restrictions: are there ethical alternatives to seclusion and restraint?

The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses' (n = 22) and physicians' (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The participants believed that the decision-making process for managing patients' aggressive behaviour contains some in-built ethical dilemmas. They thought that patients' subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients' aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent.

The meaning of care on a locked acute psychiatric ward: Patients' experiences

BACKGROUND

The deinstitutionalization of psychiatric care has led to a concentration of patients to fewer wards. This leads to difficulties in separating voluntarily and involuntarily admitted patients, and there is a risk that the interest in safeguarding patients' autonomy will decrease.

AIMS

The aim of this study was to elucidate the meaning care has to patients on a locked acute psychiatric ward. The study was performed on a ward for patients with affective and eating disorders who were admitted both voluntarily and involuntarily.

METHODS

Interviews were conducted and analysed using qualitative content analysis.

RESULTS

The results show that to the patients, care had contradictory qualities some alleviated their suffering while others contributed to stress. The alleviation from suffering originated from the experiences of strengthened integrity and self-determination, from being supported, and having a place of refuge on the ward. In contrast to this, there were experiences of being dependent and trapped because of lack of influence and choice, and being controlled.

CONCLUSIONS

In conclusion, this qualitative study shows that to the patients, care can mean being disciplined in a way that risks undermining the alleviation of suffering that care can provide. It is thus important to be observant when it comes to manifestations of control in care. The study also shows that the support of fellow patients has a value as a complement to the care given by staff members and next of kin, something that needs to be further investigated.