Acute Inpatient Psychiatric/Mental Health Nursing: Lessons Learned
13.5 Further Challenges
A number of studies report that many inpatients encounter traumatic experiences (e.g. physical/verbal aggression violence or sexual harassment) during previous admissions (Kumar et al. 2001; Walsh et al. 2003; Dean et al. 2007; Choe et al.
2008; Sturup et al. 2011; Hodgins et al. 2007; Katsikidou et al. 2013; van der Post et al. 2014). Sometimes this is one of the main reasons why clients disengage from mental health services (REF). Therefore, Walsh et al. (2003) highly recommend including routine victimization questions in admission interviews and during P/MH nurse-client encounters and interactions. The proportion of victimized clients appears to be higher than the number of violent patients in acute psychiatric wards.
For example, Fortugno et al. (2013) found a 38% victimization rate in a sample of 537 psychotic inpatients across Europe. They also found that patients in a state of mania appear the most likely victims due to their own temporary impulsive behav- iour and misjudging the boundaries of interpersonal actions.
Although the phenomenon of victimization is still under researched, some stud- ies give more detailed insights in the proportion of both verbal threats and physical violence among fellow patients. A British study conducted by Hodgins et al. (2007) found that almost 50% of the clients experienced serious verbally or physically threatening behaviour by fellow inpatients: this happened both to males (57%) and females (48%). In Greece, Katsikidou et al. (2013) found even higher victimization rates (59%). Urban inpatients appear to be much more at risk for victimization before and during the admission (Hodgins et al. 2007; Sturup et al. 2011). A study in a number of North American acute psychiatric wards reveals that approximately 22% of client population has been assaulted by fellow patients, at least once (Choe et al. 2008).
Maintaining a safe and therapeutic environment is an ongoing challenge for P/MH nurses in acute psychiatric wards. Not surprisingly most involuntary
admitted clients have mixed emotions about their stay in these settings (van der Post et al. 2014). Some clients can understand the clinical and legal decisions and believe that such actions prevented them from further harm, whereas others perceive the level of coercion as disproportionate and as a consequence of stay in an acute ward that is disengaged from the psychiatric services normally offered (Katsakou et al. 2012). These disclosures indicate the importance of the continuous promotion of therapeutic engagement in acute psychiatric wards.
Therefore, the prevention of boredom, hopelessness and lack of therapeutic options needs to be balanced with the prevention of overstimulation by over- crowded wards, violence and aggression or sexual harassment of fellow patients and illegal drug use (Quirk and Lelliot 2001). All these problems have been associated with poor treatment outcomes and unsafe situations in psychiatric wards.
Cutcliffe and Stevenson (2008) state that P/MH nurses have a long frontline tra- dition with caring for people in the peak of a crisis. The challenge for P/MH nurses in this context is to integrate relevant scientific knowledge with interpersonal and personified therapeutic approaches. This needs to be demonstrated in a nonjudge- mental way and focused on the understanding of hidden meaning of crisis behav- iour. On the other hand P/MH nursing care can be more effective when good practices are shared in the team and are replicable by most of the colleagues.
According to Berg and Hallberg (2000), high-quality therapeutic engagement impli- cates intensified presence in which preventing from gliding away in an overload of distress is the core element of our work. However, these therapeutic qualities often remain implicit and difficult to share in teamwork in caring for acute patients.
Dziopa and Ahern (2009) argue that if these interpersonal attributes remain vague, these will seriously impede high-level practice standards. Bowers et al. (2014) attempred to brigde some of these gaps by synthesizing the available evidence to minimize escalations in acute psychiatric wards. This research process led to the creation of the so-called “Safeward’’ model. In this process the materials were reviewed by a panel of experts. Eventually they found six conflict domains that can be influenced by P/MH nurses: (1) the group dynamics in the patient community, (2) patient characteristics, (3) regulatory frameworks, (4) staff characteristics, (5) physical environment in the hospital and (6) influences from outside the hospital. In those domains there are several triggers for imminent escalations that need to be addressed by nurses therapeutically. Early and preliminary attempts to evaluate the model using a cluster RCT, imitations notwithstanding, were undertaken by Bowers et al. (2015). Staff and clients, in 31 randomly chosen wards, participated in 15 randomly chosen hospitals. In the experimental condition, a reduced rate of conflict events of 15% was found, and the rate of containment events was reduced by 26.4%.
These findings encouraged some psychiatric settings in certain parts of Europe to embrace the model. Currently the Safewards model (Bowers et al. 2014) is trans- lated in at least five other European languages and actively used in clinical practice and nurse education. The Safewards toolkit enables P/MH nurses, for example, to coach daily group sessions in a structured way. The following agenda are used dur- ing those sessions:
1. Round of thanks and news, for example.
2. Round of news; staff explain events that have happened that might be confusing or distressing. This is used to assist the patients to psychologically understand each other’s behaviour or to understand the reasons why the staff act the way they do and ask everyone to watch over each other and keep each other safe.
3. Round of suggestions.
4. Requests: to offer the chance to offer suggestions as to how to get along with each other over the next period and pay attention to the requests and offers of each other.
13.5.1 Implementation of Sustainable Good Practices to Enhance Therapeutic Inpatient Care
Rix and Sheppard (2003) argue that although relevant evidence-based interven- tions to reduce coercive practices are available, they are infrequently used in acute psychiatric wards. They state that new approaches in such settings only seem to be used if there is an immediate clinical benefit for frontline workers, and supportive organizational conditions are promoted by all managers at vari- ous levels. This includes clinical leadership and management support and the involvement of patient representatives. Similar premises are echoed by Huckshorn (2004) and Colton (2010), both of whom have applied these views within organizational models to minimize coercion in acute psychiatric wards in the USA. These six core strategies led to an impressive reduction of seclusion in Pennsylvania (Smith et al. 2005) and were subsequently adopted internationally in New Zealand (O’Hagan et al. 2008), Australia (Ryan and Happell 2009) and Canada (Larue et al. 2009) and were more recently also tested successfully in Finland (Putkonen et al. 2013). In the USA, lessons learned from seclusion reduction programmes revealed that if the board of the hospital did not embrace interventions to reduce seclusion, all the efforts vanished in the end (Huckshorn 2004; Colton and Xiong 2010). Those authors state that organizational factors and leadership of administrators may have as much if not even more influence on coercion reduction as knowledge about the individual being exposed to con- tainment measures.
Given the previously discussed findings, the following three major goals continu- ously need to be on the radar of P/MH nurses working on acute inpatient units/wards:
1. Retention of the therapeutic, interpersonal relationship as the primary goal of care, with the knowledge and understanding that such actions serve as an inter- vention themselves in addition to creating the conditions in which other inter- ventions are contextualized/embedded.
2. Assessment and psychotherapeutic efforts targeted on the client’s previous, unhelpful experiences during crisis episodes.
3. Prevention of under stimulation (especially boredom) and avoidance of overstimulation.