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Jumping the hurdles of mental health care wearing cement shoes: where does the inpatient psychiatric nurse fit in?
Journal of the American Psychiatric Nurses Association
Jumping the Hurdles of Mental Health Care Wearing Cement Shoes: Where Does the Inpatient Psychiatric Nurse Fit In? Will D. Benson, RNC, MSN, and Leslie Briscoe, RNC, MSN Are inpatient psychiatric nurses stagnant in their practice? Delaney’s (2002) article on the topic might lead to the assumption that inpatient psychiatric nursing personnel have no foundation for practice. This article elaborates on the skills and knowledge that inpatient nurses have and the circumstances under which those skills are performed and knowledge applied. Although the ability to articulate a framework for practice varies, this is not equivalent to stagnation of practice or neglect of care. Based on their educational backgrounds, inpatient psychiatric nurses use various approaches and knowledge for care. Inpatient psychiatric nursing is relevant and dynamic. (J Am Psychiatr Nurses Assoc [2003]. 9, 123–128.)
D
elaney (2002), in an article about inpatient psychiatric nursing, commented that much of the work of psychiatric nursing is accomplished by oral tradition. Indeed, verbal interaction and engagement in the nurse-patient relationship are the vehicles through which nurses teach, counsel, listen, mentor, and guide patients to calmer, safer, and healthier states of mind. However, much of the work of inpatient psychiatric nursing involves other aspects of care. For the purpose of this article, it may be said that psychiatric staff nurses are key players in providing nurturance and hope that someone is listening and caring, while understanding the frustration of the mental health system and the human suffering that is caused by mental disorders. One might wonder, then, what body of knowledge guides the work of the inpatient psychiatric nurse. Historically, nurses have always been in the forefront of providing care for the mentally ill—from the 19th century asylums, to PepWill D. Benson, RNC, MSN, is a psychiatric staff nurse at Akron General Medical Center and a graduate nursing student at University of Akron, in Akron, Ohio. Leslie Briscoe, RNC, MSN, is a psychiatric staff nurse at Akron General Medical Center and a graduate nursing student at University of Akron, in Akron, Ohio. Reprint requests: Will D. Benson, RNC, MSN, 1081 Tommy St. NW, North Canton, OH, 44720. Copyright © 2003 by the American Psychiatric Nurses Association. 1078-3903/2003/$30.00 ⫹ 0 doi:10.1016/S1078-3903(03)00160-5
August 2003
lau’s (1952) theory of interpersonal relations, to Lego’s (1998) belief in nurse psychotherapists. Peplau’s theory provided the framework for the practice of psychiatric nursing yesterday and still guides practice today. Nurses in inpatient settings have varying abilities to extrapolate the knowledge that is evident in their practice, but that does not negate the value or quality of care delivered. Nor does an inability to articulate inpatient psychiatric nursing translate into stagnation of practice or erosion of daily patient care. It is increasingly evident that it is far more than theoretical knowledge that informs the practice of expert nurses. If experience is not just the passage of time, then it must include a complex collection of memories, experiences, interactions and relationships in context, which merge and gel to form the knowledge generated from our practice, which continues to inform it. (Crook, 2001, p. 4) WHAT SKILLS DO PSYCHIATRIC NURSES PROVIDE? Expert nurses exhibit certain skills, such as communicating effectively, modeling appropriate behavior, reducing patients’ anxiety and fear, promoting patients’ communication, structuring patients’ activities and time, managing environmental stimuli and stressors, setting therapeutic limits, leading groups, monitoring treatment, mobilizing resources, teaching, providing a safe environment, managing crises, advocating, and reducing stigma (McCabe, 2000). Because the nurse-patient relationships formed in the acute inpatient setting are characterized as brief, intensive, and symptomAPNA Web site: www.apna.org 123
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oriented, these skills are considered vital (Hummelvoll & Severinsson, 2001).
Paying attention to seemingly psychotic rambling or somatization can result in profound discovery. Critically listening to patient’s somatic perceptions and exploring these issues by data gathering and physical examination can be life-saving. Paying attention to seemingly psychotic rambling or somatization can result in profound discovery. The following statements are anecdotal complaints from patients, with actual physical findings in parentheses: “Japanese torture contraptions are sending shocks into me and on my legs.” (bilateral lower extremity edema with cellulitis and ulcerations) “My brain is burning.” (on-going low level seizures) “My heart is breaking.” (chest pain) “I’m walking on glass.” (epidermal cracking and injury on the plantar surface of the foot) “I can’t sit still. Help me!” (acute akathisia) “I can’t feel my legs. I can’t walk.” (acute spinal compression fractures) “I have death coming out of me.” (diarrhea)
Patients with psychiatric illnesses try to make sense of unusual physical manifestations or discomfort. However, because of poor reality testing, they will offer bizarre descriptions or psychotic interpretations of these sensations. Unfortunately, the stigma of being mentally ill is often enough to invalidate these physical complaints to the biased listener. Korn, Currier, and Henderson (2000) conducted a retrospective chart review of patients who presented at an emergency department with psychiatric complaints. The authors concluded that emergency departments can rapidly triage a patient with a psychiatric complaint and no medical concerns. These patients only need a limited physical examination and no related laboratory or radiographic testing. The findings obtained from this study should be viewed with caution as they suggest less than adequate screening for psychiatric patients who offer no physical complaints. Providing safety is the top priority. There are multiple layers of safety. Physical safety involves the protection of the patient from harm from self and others. This includes other patients, staff, and physicians. The expert staff nurse is an advocate of physical safety. Novice and seasoned physicians have been known to order inappropriate combinations or doses of medications. Knowledge of expected drug actions, drug-to-drug interactions, side effects, and management of medical comorbidity is crucial for patient safety. The expert nurse routinely reviews laboratory findings to evaluate for electrolyte imbalances, drug toxicity, and other hematologic changes or abnormalities. 124 APNA Web site: www.apna.org
It is also vital to provide emotional safety. Many psychiatric medications alter absorption, distribution, metabolism, and excretion of other drugs and change hemodynamic balance (Wynne, Millard, & Woo, 2001). The safe administration of medications and the mechanics of delivering a pill is more than an act of giving the right dose of medication to the right patient at the right time. What makes a nurse an expert in medication administration is the ability to verbally and skillfully deliver a medication in such a way that the patient learns and develops trust. Why would a patient who is paranoid take a medication if he or she believes it is poison? Even though a patient with delusions believes medication may be poison, the art of nursing provides a way for the patient to agree to take it. Whether it is sitting with the patient to allow him or her time to decide, reflecting on the years of rapport established between the patient and nurse, or speaking gently the words, “I would never do anything to harm you. My job is to keep you safe,” this leap of faith by the patient is often a first step toward symptom relief and recovery. THE PROBLEMS OF BEHAVIOR MANAGEMENT Another nuance of inpatient care revolves around the involuntary patient who is resistant to or refuses care. Two studies have identified the unpredictable nature of acute psychiatric inpatient nursing (Cleary, Edwards, & Meehan, 1999; Hummelvoll & Severinsson, 2001). In addition, psychiatric staff nurses contend with high rates of assaultive patient behaviors (Flannery, Fisher, Walker, Littlewood, & Spillane, 2001). Patient and staff injuries are a perpetual concern in violent situations. The constant sense of uncertainty is a factor in the nurse-patient relationship. “Putting out fires” often describes the context in which nursing work occurs. Barker’s (2001) Tidal Model of psychiatric nursing best describes the fluid nature of the human experience and the unpredictable nature of the caring environment. Although researchers disagree on the therapeutic value of restraints and seclusion, there is a consensus that they can-
Knowledge of expected drug actions, drug-to-drug interactions, side effects, and management of medical comorbidity is crucial for patient safety. not be eliminated altogether and that further research must be completed. One study (Marangos-Frost & Wells, 2000) indicated that restraint use was more complicated than is conveyed in the literature and presented an ethical dilemma to staff nurses. Their research identified several themes related to the decision to use restraints: the framing of the situation/potential for imminent harm; the unsuccessful search for alternatives to physical restraints; and the conflicted nurses and the contextual conditions of restraint. Restraint use has a profound effect on the patient population and their caregivers. However, the decision dilemma of use Vol. 9, No. 4
Journal of the American Psychiatric Nurses Association
versus non-use, which is not often a clear one, is frequently resolved when patients present a clear risk for imminent harm to themselves or others.
Benson and Briscoe
tive practices of experienced and skilled psychiatric nurses that are characteristic of expertise in clinical judgment. (p. 658)
THE THERAPEUTIC MILIEU
ASSESSING PATIENT NEEDS
In the Scope and Standards of Psychiatric-Mental Health Nursing Practice (American Nurses Association, 2000), Standard Vb states that the psychiatric-mental health nurse “provides, structures and maintains a therapeutic environment in collaboration with the patient and other health care clinicians” (p.34). In other words, the nurses share this responsibility with other members of the therapeutic community as well as with patients. Although there are structured components to the therapeutic milieu, such as community meetings, group therapy, and psychoeducational classes, there are unstructured elements also. Flexibility and the ability to “go with the flow” is often an attribute of the expert nurse. Echternacht (2001) reported on the concept of “fluid group,” in which the nursing staff gains valuable information about patients simply by becoming a part of the milieu, observing patients, and interacting spontaneously. Thomas, Shattell, and Martin (2002) found that patients derived essential meanings from hospitalization generally through the unstructured components and peer relationships. Hospitalization for these patients represented refuge and safety from the daily struggle against self-destructive impulses, caring, and acceptance by surrogate family, affirmation of identity, normalizing effect on self-judgment, and subsequently a sense of self-worth and hope for the future. These are what a therapeutic milieu should accomplish. Milieu management consists of manipulating the environment to provide the least level of stress and greatest benefit
Investigators (Hummelvoll & Severinsson, 2001; Olofsson & Jacobsson, 2001) have identified common needs of psychiatric inpatients whether they were admitted voluntarily or involuntarily. These needs included safety and security; sleep and rest; some meaning or understanding of their suffering; and respect from the staff. The basic data gathering process can often take 2 to 3 days for a multidisciplinary
Flexibility and the ability to “go with the flow” is often an attribute of the expert nurse. to the greatest number of patients. Coordinating room assignments and finding suitable roommates are aspects of this concept. Room assignment is critical when considering the psychotic or paranoid patient. Tolerance or intolerance of others must be accurately assessed in an attempt to keep other patients out of harm’s way. Rapid de-escalation of disruptive patients is critical to provide the rest of the patient population with a sense of safety on the unit. Johnson and Hauser (2001) identified the expert psychiatric nurse’s pattern of action when de-escalating a patient: The skills of noticing the patient, reading the patient and the situation, knowing where the patient is on the continuum, understanding the meaning of the behavior, knowing what the patient needs, connecting with the patient, and matching the intervention with what the patient needs at the moment are not step-by-step activities, but rather are the highly skilled, nonreflecAugust 2003
Advanced practice behavioral health nurses have the skill and knowledge to mentor, provide structured supervision, develop educational programming specific to inpatient care for patients and staff, conduct research, and raise the bar for inpatient care. team. Formulation of a plan of care is rudimentary and focused on target symptoms, such as suicidal ideation, aggressive behavior, hallucinations, or delusions, rather than the stressful situation that precipitated the inpatient admission. Noncompliance with previous treatment, substance abuse, situational stress, interpersonal relationship discord, or ineffective case management are common precipitants to admission. Meanwhile, the staff nurse must attempt to manage the patient’s care with limited data, based on the premise of providing a safe and secure environment in which the patient can rest and achieve stabilization. The use of antidepressant, antipsychotic, anxiolytic, and mood-stabilizing medications are the rule, rather than the exception, in the hospitalized client. The prevailing assumption is that outpatient care has failed. Psychotropic medications often take 4 to 6 weeks to reach therapeutic levels (Wynne et al., 2001). The practice of “start low and go slow” rarely applies when rapid medication stabilization occurs in the hospital setting. Effectiveness of response often cannot be evaluated before increases are ordered. Side effects from higher dosages often occur with rapid increases, which often leads to noncompliance after discharge. Unfortunately, use of as-needed (PRN) medications has been underresearched and under-emphasized as a nursing function. Usher, Lindsay, and Sellen (2001) reported a lack of clarity surrounding the decision-making process regarding the use of PRN medications. Nurses also exhibited poor documentation related to target behaviors and subsequent changes as a result of PRN medication use. Hummelvoll and Severinsson (2001) warn that, because of high patient turnover rates and shortened inpatient lengths of stay, there is too little time to get to know the patients and evaluate the problems,
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placing priority on the medical model and rapid usage of medication. As stated earlier, psychiatric staff nurses possess varying abilities in articulating their practice. They do, however, possess the ability to apply their knowledge in practice. Among nursing staff there is often considerable diversity of knowledge, training, and experience, which emerges as variations in skill and quality of care. Inpatient care involves a working knowledge of pharmacology, microbiology, neurology, pathophysiology, biochemistry, human behavior, crisis intervention, and other areas that are essential in understanding and treating psychiatric patients in the hospital setting. However, the scope of inpatient psychiatric care cannot be defined by a simple list of competencies. When providing care, there are other factors that cannot be controlled by the nurse.
discouraged colleague commented about today’s inpatient psychiatric nursing, “I’ve never worked so hard to do so little for so many. And that breaks my heart” (L. Jacobs, September 15, 2002). Practically speaking, this vulnerable population of inpatient mentally ill does not provide large amounts of revenue for hospitals or clinics. Many newly diagnosed mentally ill clients are unemployed and uninsured. Adolescents in their late teens experiencing a first psychotic break, aggressive or highly disorganized patients, and geriatric patients with mental status changes frequently need labor-intensive nursing care and often require one-to-one interaction to provide the safest and least restrictive environment. Unfortunately, vulnerable populations in society that seemingly produce little and need much rarely receive endowments or extra funds.
THE HURDLE OF MANAGED CARE
SUPPORT FOR NONPHARMACOLOGICAL INTERVENTION, RESEARCH, AND TRAINING
In both the public and private sector of behavioral health, the best treatment for the patient has been replaced with the most cost-effective treatment. Stone, Curran, and Bakken (2002) compared different models of economic analyses. They found that the perspective from which the cost is evaluated has significant bearing on the outcome of the cost analysis. A patient will measure cost in ease of service, time spent, perceived quality of care, and money spent. Insurers analyze revenue versus expenditures. Actual economic value reflects the societal perspective in relation to the resources consumed. Inpatient psychiatric care has reflected a trend of shorter lengths of stay, with rapid progression to partial hospitalization programs and intensive outpatient care. Shanley (2001) suggested that both consumers and psychiatric nurses have much in common in terms of their powerlessness and their sense of being undervalued. The current focus of inpatient psychiatric nursing has been directed toward rapid stabilization of the patient. The nursing process has been controlled by individual institutional values, state and federal regulation about least restrictive environments, and eligibility for third-party reimbursement rather than evidence-based practice. Care management, a new subspecialty in nursing, has been designed to communicate with insurance companies and provide reviews of patients’ progress and confidential issues, with the hopes that the hospital and physician will receive payment for the care the patient was provided. This business approach to healthcare is perhaps a quick fix for reimbursement problems but does not address the greater societal issues of improving the quality of care for patients and prevention of rehospitalization. Over the past 10 years, managed care contractors have limited payment for mental health care. Insurance parity wars are being fought out on the floor of Congress and do not appear to be resolved quickly. Meanwhile, limited visits with large patient copayments and lifetime limits force patients to be discharged sooner and sicker with less follow-up care available. A 126 APNA Web site: www.apna.org
Neither psychiatric nursing research nor practice has kept up with the rapid changes in behavioral healthcare. Patients must cope with being assigned to an unfamiliar nurse every shift, living in an unfamiliar place, relinquishing privacy, sharing rooms and bathroom facilities, adjusting to behavioral disruptions, rapid transfers to less acute settings with yet again new staff, rapid titration of medication, and discharge while still sick. A brief hospital stay filled with multiple interviews, medication adjustment, diagnostic testing, and care planning often leaves little time for the patient to actually rest and process the crisis leading to admission. Investigators (Cleary et al., 1999) found the environment to be a significant factor in the nurse-patient relationship. A literature review yielded little research in the provision of comfortable modern surroundings to those who are suffering with acute mental illness. Having a quiet private place to communicate with patients enhances the relationship. Research on auditory hallucinations has been successful in identifying precipitants and effective nonpharmacological interventions (Lakeman, 2001). Nursing offers patients the opportunity to learn practical strategies to cope with, often continuous, internal stimulation. Delaney (2002) stated, “the road to advanced practice
Other professionals within mental health systems appreciate and value the closeness that psychiatric nurses have with their patients. nursing leads out of the hospital.” This practice deserves reviewing. There is a need for advanced practice nurses on inpatient psychiatric units. Advanced practice behavioral health nurses have the skill and knowledge to mentor, provide structured supervision, develop educational programming specific to inpatient care for patients and staff, conduct research, and raise the bar for inpatient care. In Vol. 9, No. 4
Journal of the American Psychiatric Nurses Association
other words, the advanced practice nurse has the potential of giving inpatient nurses a voice. Lakeman (2001) and Cleary et al. (1999) support clinical supervision and specific skills training to improve the quality of nursing care. Advanced practice nurses are in a position to provide these needed functions. CONCLUSION McCabe (2000) suggested that nurses must bridge the past knowledge of psychiatric nursing from the days of Peplau to the current psychoneurobiologic theories. In addition, she recommends a reconceptualization of the core psychiatric nursing content to reflect a more specific focus on the current state of the specialty and identification of critical clinical competencies. Nursing academia is guilty of providing less and less education focused on the care of the acutely mentally ill, effectually diluting psychiatric nursing out of existence. Many programs are integrating psychiatric nursing into therapeutic communications and groups for nonpsychiatric patients (Perese, 2002). How will novice nurses ever get the chance to see or experience this very special population if they are not exposed to them? Perese reported that nursing students who are given the opportunity to work with mentally ill clients became more aware of the similarities between themselves and their clients. How can others be taught to value and respect this consistently stigmatized part of society if nurses do not embrace, research, and care for the mentally ill community. Setting a national research agenda will focus the nursing profession on outcomes, care delivery models, access to care, and care practices. Direct care psychiatric nurses are not mentored in the art of publication or research. Undergraduate nursing schools have varying degrees of emphasis on research and nursing theory. What psychiatric staff nurses do excel at is skilled intervention with the mentally ill. Maybe it is too simplistic to assume that the practicing staff nurse knows a need exists to articulate in writing the art of caring. Employers rarely offer time, incentive, or encouragement to work on such endeavors to advance the practice of nursing unless it benefits the institution. Magnet status for more facilities may provide the funding and expertise needed to investigate and provide innovative care designs for nursing. In addition, research on the nursing care for the acutely mentally ill must be valued and supported to be carried out. Nursing research takes time, money, and commitment to look at innovative ways to improve, intervene, measure, and evaluate the patient’s response to care and a caring environment. Advanced practice nurses are a vital key to the improvement of inpatient psychiatric care. Many inpatient units provide excellent care for their clients while others only marginally meet standards. Currently, inpatient psychiatric nurses are like ships tossed about in a storm of budget constraints, staffing shortages, limited continuing education, and higher patient acuity. They are subject to institutional August 2003
Benson and Briscoe
directive, patient needs, and their own personal and professional guidelines to provide the best possible care given the resources and restrictions available. In many cases the resources are few and the restrictions are numerous, giving the staff nurse few practical options. An advanced practice nurse in the inpatient setting would be a valuable asset and one that institutions should consider in a time when staff nurses are asked to deliver consistent, satisfactory service to patients and to develop professionally. Are inpatient psychiatric staff nurses stagnant in their practice? There is no time for stagnation. Nursing is the only profession that maintains a presence in the inpatient unit, 24 hours per day, 365 days per year. People with mental health problems have come to expect psychiatric nurses to relate to them as a professional and a concerned person. Inpatient staff nurses are expected to anticipate patient needs and react accordingly. Other professionals within mental health systems appreciate and value the closeness that psychiatric nurses have with their patients. They rely on nurses to provide them with information that will affect their professional judgment. “Psychiatric staff nurses are the most flexible and accessible workforce available to patients to bridge the gap between intimate and professional knowledge and, in doing so, cement mental health services together” (Jackson & Stevenson, 2000, p 386.).
REFERENCES American Nurses Association (2000). Scope and standards of psychiatricmental health nursing practice. Washington, DC: American Nurses Publishing. Barker, P. (2001). The Tidal Model: Developing an empowering, personcentered approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8, 233-240. Cleary, M., Edwards, C., & Meehan, T. (1999). Factors influencing nursepatient interaction in the acute psychiatric setting: An exploratory investigation. Australian and New Zealand Journal of Mental Health Nursing, 8, 109-116. Crook, J.A. (2001). How do expert mental health nurses make on-the-spot clinical decisions? A review of the literature. Journal of Psychiatric and Mental Health Nursing, 8, 1-5. Delaney, K. (2002). Inpatient psychiatric nursing: Set up to stagnate? Journal of the American Psychiatric Nurses Association, 7, 39-44. Echternacht, M.R. (2001). Fluid group: Concept and clinical application in the milieu. Journal of the American Psychiatric Nurses Association, 7, 39-44. Flannery, R., Fisher, W., Walker, A., Littlewood, K., & Spillane, M. (2001). Nonviolent psychiatric inpatients and subsequent assaults on community patients and staff. Psychiatric Quarterly, 72(1), 19-27. Hummelvoll, J., & Severinsson, E. (2001). Coping with everyday reality: Mental health professionals’ reflections on the care provided in an acute psychiatric ward. Australian and New Zealand Journal of Mental Health Nursing, 10, 156-166. Jackson, S., & Stevenson, C. (2000). What do people need psychiatric and mental health nurses for? Journal of Advanced Nursing, 31, 378-388. Johnson, M., & Hauser, P. (2001). The practices of expert psychiatric nurses: Accompanying the patient to a calmer personal space. Issues in Mental Health Nursing, 22, 651-668.
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Korn, C., Currier, G., & Henderson, S. (2000). “Medical clearance” of psychiatric patients without medical complaints in the emergency department. Journal of Emergency Medicine, 18, 173-176. Lakeman, R. (2001). Making sense of the voices. International Journal of Nursing Studies, 38, 523-531. Lego, S. (1998). The application of Peplau’s theory to group psychotherapy. Journal of Psychiatric and Mental Health Nursing, 5, 193-196. Marangos-Frost, S., & Wells, D. (2000). Psychiatric nurses thoughts and feelings about restraint use: A decision dilemma. Journal of Advanced Nursing, 31, 362-369. McCabe, S. (2000). Bringing psychiatric nursing into the twenty-first century. Archives of Psychiatric Nursing, 14, 109-116. Olofsson, B., & Jacobsson, L. (2001). A plea for respect: Involuntarily hospitalized psychiatric patients’ narratives about being subjected to coercion. Journal of Psychiatric and Mental Health Nursing, 8, 357-366.
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Peplau, H.E. (1952). Interpersonal relations in nursing. New York: Putnam. Perese, E. (2002). Integrating psychiatric nursing into a baccalaureate nursing curriculum. Journal of the American Psychiatric Nurses Association, 8, 152-158. Shanley, E. (2001). Common experiences of mental health nurses and consumers: Ingredients of a symbiotic relationship? Australian and New Zealand Journal of Mental Health Nursing, 10, 243-251. Stone, P., Curran, C., & Bakken, S. (2002). Economic evidence for evidencebased practice. Journal of Nursing Scholarship, 34, 277-282. Thomas, S.P., Shattell, M., & Martin, T. (2002). What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16, 99-107. Usher, K., Lindsay, D., & Sellen, J. (2001). Mental health nurses’ PRN psychotropic medication administration practices. Journal of Psychiatric and Mental Health Nursing, 8, 383-390. Wynne, A.L., Millard, M., & Woo, T.M. (2001). Pharmacotherapeutics for nurse practitioner prescribers. Philadelphia: Davis.
Vol. 9, No. 4
Jumping the Hurdles of Mental Health Care Wearing Cement Shoes: Where Does the Inpatient Psychiatric Nurse Fit In? Will D. Benson, RNC, MSN, and Leslie Briscoe, RNC, MSN Are inpatient psychiatric nurses stagnant in their practice? Delaney’s (2002) article on the topic might lead to the assumption that inpatient psychiatric nursing personnel have no foundation for practice. This article elaborates on the skills and knowledge that inpatient nurses have and the circumstances under which those skills are performed and knowledge applied. Although the ability to articulate a framework for practice varies, this is not equivalent to stagnation of practice or neglect of care. Based on their educational backgrounds, inpatient psychiatric nurses use various approaches and knowledge for care. Inpatient psychiatric nursing is relevant and dynamic. (J Am Psychiatr Nurses Assoc [2003]. 9, 123–128.)
D
elaney (2002), in an article about inpatient psychiatric nursing, commented that much of the work of psychiatric nursing is accomplished by oral tradition. Indeed, verbal interaction and engagement in the nurse-patient relationship are the vehicles through which nurses teach, counsel, listen, mentor, and guide patients to calmer, safer, and healthier states of mind. However, much of the work of inpatient psychiatric nursing involves other aspects of care. For the purpose of this article, it may be said that psychiatric staff nurses are key players in providing nurturance and hope that someone is listening and caring, while understanding the frustration of the mental health system and the human suffering that is caused by mental disorders. One might wonder, then, what body of knowledge guides the work of the inpatient psychiatric nurse. Historically, nurses have always been in the forefront of providing care for the mentally ill—from the 19th century asylums, to PepWill D. Benson, RNC, MSN, is a psychiatric staff nurse at Akron General Medical Center and a graduate nursing student at University of Akron, in Akron, Ohio. Leslie Briscoe, RNC, MSN, is a psychiatric staff nurse at Akron General Medical Center and a graduate nursing student at University of Akron, in Akron, Ohio. Reprint requests: Will D. Benson, RNC, MSN, 1081 Tommy St. NW, North Canton, OH, 44720. Copyright © 2003 by the American Psychiatric Nurses Association. 1078-3903/2003/$30.00 ⫹ 0 doi:10.1016/S1078-3903(03)00160-5
August 2003
lau’s (1952) theory of interpersonal relations, to Lego’s (1998) belief in nurse psychotherapists. Peplau’s theory provided the framework for the practice of psychiatric nursing yesterday and still guides practice today. Nurses in inpatient settings have varying abilities to extrapolate the knowledge that is evident in their practice, but that does not negate the value or quality of care delivered. Nor does an inability to articulate inpatient psychiatric nursing translate into stagnation of practice or erosion of daily patient care. It is increasingly evident that it is far more than theoretical knowledge that informs the practice of expert nurses. If experience is not just the passage of time, then it must include a complex collection of memories, experiences, interactions and relationships in context, which merge and gel to form the knowledge generated from our practice, which continues to inform it. (Crook, 2001, p. 4) WHAT SKILLS DO PSYCHIATRIC NURSES PROVIDE? Expert nurses exhibit certain skills, such as communicating effectively, modeling appropriate behavior, reducing patients’ anxiety and fear, promoting patients’ communication, structuring patients’ activities and time, managing environmental stimuli and stressors, setting therapeutic limits, leading groups, monitoring treatment, mobilizing resources, teaching, providing a safe environment, managing crises, advocating, and reducing stigma (McCabe, 2000). Because the nurse-patient relationships formed in the acute inpatient setting are characterized as brief, intensive, and symptomAPNA Web site: www.apna.org 123
Benson and Briscoe
Journal of the American Psychiatric Nurses Association
oriented, these skills are considered vital (Hummelvoll & Severinsson, 2001).
Paying attention to seemingly psychotic rambling or somatization can result in profound discovery. Critically listening to patient’s somatic perceptions and exploring these issues by data gathering and physical examination can be life-saving. Paying attention to seemingly psychotic rambling or somatization can result in profound discovery. The following statements are anecdotal complaints from patients, with actual physical findings in parentheses: “Japanese torture contraptions are sending shocks into me and on my legs.” (bilateral lower extremity edema with cellulitis and ulcerations) “My brain is burning.” (on-going low level seizures) “My heart is breaking.” (chest pain) “I’m walking on glass.” (epidermal cracking and injury on the plantar surface of the foot) “I can’t sit still. Help me!” (acute akathisia) “I can’t feel my legs. I can’t walk.” (acute spinal compression fractures) “I have death coming out of me.” (diarrhea)
Patients with psychiatric illnesses try to make sense of unusual physical manifestations or discomfort. However, because of poor reality testing, they will offer bizarre descriptions or psychotic interpretations of these sensations. Unfortunately, the stigma of being mentally ill is often enough to invalidate these physical complaints to the biased listener. Korn, Currier, and Henderson (2000) conducted a retrospective chart review of patients who presented at an emergency department with psychiatric complaints. The authors concluded that emergency departments can rapidly triage a patient with a psychiatric complaint and no medical concerns. These patients only need a limited physical examination and no related laboratory or radiographic testing. The findings obtained from this study should be viewed with caution as they suggest less than adequate screening for psychiatric patients who offer no physical complaints. Providing safety is the top priority. There are multiple layers of safety. Physical safety involves the protection of the patient from harm from self and others. This includes other patients, staff, and physicians. The expert staff nurse is an advocate of physical safety. Novice and seasoned physicians have been known to order inappropriate combinations or doses of medications. Knowledge of expected drug actions, drug-to-drug interactions, side effects, and management of medical comorbidity is crucial for patient safety. The expert nurse routinely reviews laboratory findings to evaluate for electrolyte imbalances, drug toxicity, and other hematologic changes or abnormalities. 124 APNA Web site: www.apna.org
It is also vital to provide emotional safety. Many psychiatric medications alter absorption, distribution, metabolism, and excretion of other drugs and change hemodynamic balance (Wynne, Millard, & Woo, 2001). The safe administration of medications and the mechanics of delivering a pill is more than an act of giving the right dose of medication to the right patient at the right time. What makes a nurse an expert in medication administration is the ability to verbally and skillfully deliver a medication in such a way that the patient learns and develops trust. Why would a patient who is paranoid take a medication if he or she believes it is poison? Even though a patient with delusions believes medication may be poison, the art of nursing provides a way for the patient to agree to take it. Whether it is sitting with the patient to allow him or her time to decide, reflecting on the years of rapport established between the patient and nurse, or speaking gently the words, “I would never do anything to harm you. My job is to keep you safe,” this leap of faith by the patient is often a first step toward symptom relief and recovery. THE PROBLEMS OF BEHAVIOR MANAGEMENT Another nuance of inpatient care revolves around the involuntary patient who is resistant to or refuses care. Two studies have identified the unpredictable nature of acute psychiatric inpatient nursing (Cleary, Edwards, & Meehan, 1999; Hummelvoll & Severinsson, 2001). In addition, psychiatric staff nurses contend with high rates of assaultive patient behaviors (Flannery, Fisher, Walker, Littlewood, & Spillane, 2001). Patient and staff injuries are a perpetual concern in violent situations. The constant sense of uncertainty is a factor in the nurse-patient relationship. “Putting out fires” often describes the context in which nursing work occurs. Barker’s (2001) Tidal Model of psychiatric nursing best describes the fluid nature of the human experience and the unpredictable nature of the caring environment. Although researchers disagree on the therapeutic value of restraints and seclusion, there is a consensus that they can-
Knowledge of expected drug actions, drug-to-drug interactions, side effects, and management of medical comorbidity is crucial for patient safety. not be eliminated altogether and that further research must be completed. One study (Marangos-Frost & Wells, 2000) indicated that restraint use was more complicated than is conveyed in the literature and presented an ethical dilemma to staff nurses. Their research identified several themes related to the decision to use restraints: the framing of the situation/potential for imminent harm; the unsuccessful search for alternatives to physical restraints; and the conflicted nurses and the contextual conditions of restraint. Restraint use has a profound effect on the patient population and their caregivers. However, the decision dilemma of use Vol. 9, No. 4
Journal of the American Psychiatric Nurses Association
versus non-use, which is not often a clear one, is frequently resolved when patients present a clear risk for imminent harm to themselves or others.
Benson and Briscoe
tive practices of experienced and skilled psychiatric nurses that are characteristic of expertise in clinical judgment. (p. 658)
THE THERAPEUTIC MILIEU
ASSESSING PATIENT NEEDS
In the Scope and Standards of Psychiatric-Mental Health Nursing Practice (American Nurses Association, 2000), Standard Vb states that the psychiatric-mental health nurse “provides, structures and maintains a therapeutic environment in collaboration with the patient and other health care clinicians” (p.34). In other words, the nurses share this responsibility with other members of the therapeutic community as well as with patients. Although there are structured components to the therapeutic milieu, such as community meetings, group therapy, and psychoeducational classes, there are unstructured elements also. Flexibility and the ability to “go with the flow” is often an attribute of the expert nurse. Echternacht (2001) reported on the concept of “fluid group,” in which the nursing staff gains valuable information about patients simply by becoming a part of the milieu, observing patients, and interacting spontaneously. Thomas, Shattell, and Martin (2002) found that patients derived essential meanings from hospitalization generally through the unstructured components and peer relationships. Hospitalization for these patients represented refuge and safety from the daily struggle against self-destructive impulses, caring, and acceptance by surrogate family, affirmation of identity, normalizing effect on self-judgment, and subsequently a sense of self-worth and hope for the future. These are what a therapeutic milieu should accomplish. Milieu management consists of manipulating the environment to provide the least level of stress and greatest benefit
Investigators (Hummelvoll & Severinsson, 2001; Olofsson & Jacobsson, 2001) have identified common needs of psychiatric inpatients whether they were admitted voluntarily or involuntarily. These needs included safety and security; sleep and rest; some meaning or understanding of their suffering; and respect from the staff. The basic data gathering process can often take 2 to 3 days for a multidisciplinary
Flexibility and the ability to “go with the flow” is often an attribute of the expert nurse. to the greatest number of patients. Coordinating room assignments and finding suitable roommates are aspects of this concept. Room assignment is critical when considering the psychotic or paranoid patient. Tolerance or intolerance of others must be accurately assessed in an attempt to keep other patients out of harm’s way. Rapid de-escalation of disruptive patients is critical to provide the rest of the patient population with a sense of safety on the unit. Johnson and Hauser (2001) identified the expert psychiatric nurse’s pattern of action when de-escalating a patient: The skills of noticing the patient, reading the patient and the situation, knowing where the patient is on the continuum, understanding the meaning of the behavior, knowing what the patient needs, connecting with the patient, and matching the intervention with what the patient needs at the moment are not step-by-step activities, but rather are the highly skilled, nonreflecAugust 2003
Advanced practice behavioral health nurses have the skill and knowledge to mentor, provide structured supervision, develop educational programming specific to inpatient care for patients and staff, conduct research, and raise the bar for inpatient care. team. Formulation of a plan of care is rudimentary and focused on target symptoms, such as suicidal ideation, aggressive behavior, hallucinations, or delusions, rather than the stressful situation that precipitated the inpatient admission. Noncompliance with previous treatment, substance abuse, situational stress, interpersonal relationship discord, or ineffective case management are common precipitants to admission. Meanwhile, the staff nurse must attempt to manage the patient’s care with limited data, based on the premise of providing a safe and secure environment in which the patient can rest and achieve stabilization. The use of antidepressant, antipsychotic, anxiolytic, and mood-stabilizing medications are the rule, rather than the exception, in the hospitalized client. The prevailing assumption is that outpatient care has failed. Psychotropic medications often take 4 to 6 weeks to reach therapeutic levels (Wynne et al., 2001). The practice of “start low and go slow” rarely applies when rapid medication stabilization occurs in the hospital setting. Effectiveness of response often cannot be evaluated before increases are ordered. Side effects from higher dosages often occur with rapid increases, which often leads to noncompliance after discharge. Unfortunately, use of as-needed (PRN) medications has been underresearched and under-emphasized as a nursing function. Usher, Lindsay, and Sellen (2001) reported a lack of clarity surrounding the decision-making process regarding the use of PRN medications. Nurses also exhibited poor documentation related to target behaviors and subsequent changes as a result of PRN medication use. Hummelvoll and Severinsson (2001) warn that, because of high patient turnover rates and shortened inpatient lengths of stay, there is too little time to get to know the patients and evaluate the problems,
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placing priority on the medical model and rapid usage of medication. As stated earlier, psychiatric staff nurses possess varying abilities in articulating their practice. They do, however, possess the ability to apply their knowledge in practice. Among nursing staff there is often considerable diversity of knowledge, training, and experience, which emerges as variations in skill and quality of care. Inpatient care involves a working knowledge of pharmacology, microbiology, neurology, pathophysiology, biochemistry, human behavior, crisis intervention, and other areas that are essential in understanding and treating psychiatric patients in the hospital setting. However, the scope of inpatient psychiatric care cannot be defined by a simple list of competencies. When providing care, there are other factors that cannot be controlled by the nurse.
discouraged colleague commented about today’s inpatient psychiatric nursing, “I’ve never worked so hard to do so little for so many. And that breaks my heart” (L. Jacobs, September 15, 2002). Practically speaking, this vulnerable population of inpatient mentally ill does not provide large amounts of revenue for hospitals or clinics. Many newly diagnosed mentally ill clients are unemployed and uninsured. Adolescents in their late teens experiencing a first psychotic break, aggressive or highly disorganized patients, and geriatric patients with mental status changes frequently need labor-intensive nursing care and often require one-to-one interaction to provide the safest and least restrictive environment. Unfortunately, vulnerable populations in society that seemingly produce little and need much rarely receive endowments or extra funds.
THE HURDLE OF MANAGED CARE
SUPPORT FOR NONPHARMACOLOGICAL INTERVENTION, RESEARCH, AND TRAINING
In both the public and private sector of behavioral health, the best treatment for the patient has been replaced with the most cost-effective treatment. Stone, Curran, and Bakken (2002) compared different models of economic analyses. They found that the perspective from which the cost is evaluated has significant bearing on the outcome of the cost analysis. A patient will measure cost in ease of service, time spent, perceived quality of care, and money spent. Insurers analyze revenue versus expenditures. Actual economic value reflects the societal perspective in relation to the resources consumed. Inpatient psychiatric care has reflected a trend of shorter lengths of stay, with rapid progression to partial hospitalization programs and intensive outpatient care. Shanley (2001) suggested that both consumers and psychiatric nurses have much in common in terms of their powerlessness and their sense of being undervalued. The current focus of inpatient psychiatric nursing has been directed toward rapid stabilization of the patient. The nursing process has been controlled by individual institutional values, state and federal regulation about least restrictive environments, and eligibility for third-party reimbursement rather than evidence-based practice. Care management, a new subspecialty in nursing, has been designed to communicate with insurance companies and provide reviews of patients’ progress and confidential issues, with the hopes that the hospital and physician will receive payment for the care the patient was provided. This business approach to healthcare is perhaps a quick fix for reimbursement problems but does not address the greater societal issues of improving the quality of care for patients and prevention of rehospitalization. Over the past 10 years, managed care contractors have limited payment for mental health care. Insurance parity wars are being fought out on the floor of Congress and do not appear to be resolved quickly. Meanwhile, limited visits with large patient copayments and lifetime limits force patients to be discharged sooner and sicker with less follow-up care available. A 126 APNA Web site: www.apna.org
Neither psychiatric nursing research nor practice has kept up with the rapid changes in behavioral healthcare. Patients must cope with being assigned to an unfamiliar nurse every shift, living in an unfamiliar place, relinquishing privacy, sharing rooms and bathroom facilities, adjusting to behavioral disruptions, rapid transfers to less acute settings with yet again new staff, rapid titration of medication, and discharge while still sick. A brief hospital stay filled with multiple interviews, medication adjustment, diagnostic testing, and care planning often leaves little time for the patient to actually rest and process the crisis leading to admission. Investigators (Cleary et al., 1999) found the environment to be a significant factor in the nurse-patient relationship. A literature review yielded little research in the provision of comfortable modern surroundings to those who are suffering with acute mental illness. Having a quiet private place to communicate with patients enhances the relationship. Research on auditory hallucinations has been successful in identifying precipitants and effective nonpharmacological interventions (Lakeman, 2001). Nursing offers patients the opportunity to learn practical strategies to cope with, often continuous, internal stimulation. Delaney (2002) stated, “the road to advanced practice
Other professionals within mental health systems appreciate and value the closeness that psychiatric nurses have with their patients. nursing leads out of the hospital.” This practice deserves reviewing. There is a need for advanced practice nurses on inpatient psychiatric units. Advanced practice behavioral health nurses have the skill and knowledge to mentor, provide structured supervision, develop educational programming specific to inpatient care for patients and staff, conduct research, and raise the bar for inpatient care. In Vol. 9, No. 4
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other words, the advanced practice nurse has the potential of giving inpatient nurses a voice. Lakeman (2001) and Cleary et al. (1999) support clinical supervision and specific skills training to improve the quality of nursing care. Advanced practice nurses are in a position to provide these needed functions. CONCLUSION McCabe (2000) suggested that nurses must bridge the past knowledge of psychiatric nursing from the days of Peplau to the current psychoneurobiologic theories. In addition, she recommends a reconceptualization of the core psychiatric nursing content to reflect a more specific focus on the current state of the specialty and identification of critical clinical competencies. Nursing academia is guilty of providing less and less education focused on the care of the acutely mentally ill, effectually diluting psychiatric nursing out of existence. Many programs are integrating psychiatric nursing into therapeutic communications and groups for nonpsychiatric patients (Perese, 2002). How will novice nurses ever get the chance to see or experience this very special population if they are not exposed to them? Perese reported that nursing students who are given the opportunity to work with mentally ill clients became more aware of the similarities between themselves and their clients. How can others be taught to value and respect this consistently stigmatized part of society if nurses do not embrace, research, and care for the mentally ill community. Setting a national research agenda will focus the nursing profession on outcomes, care delivery models, access to care, and care practices. Direct care psychiatric nurses are not mentored in the art of publication or research. Undergraduate nursing schools have varying degrees of emphasis on research and nursing theory. What psychiatric staff nurses do excel at is skilled intervention with the mentally ill. Maybe it is too simplistic to assume that the practicing staff nurse knows a need exists to articulate in writing the art of caring. Employers rarely offer time, incentive, or encouragement to work on such endeavors to advance the practice of nursing unless it benefits the institution. Magnet status for more facilities may provide the funding and expertise needed to investigate and provide innovative care designs for nursing. In addition, research on the nursing care for the acutely mentally ill must be valued and supported to be carried out. Nursing research takes time, money, and commitment to look at innovative ways to improve, intervene, measure, and evaluate the patient’s response to care and a caring environment. Advanced practice nurses are a vital key to the improvement of inpatient psychiatric care. Many inpatient units provide excellent care for their clients while others only marginally meet standards. Currently, inpatient psychiatric nurses are like ships tossed about in a storm of budget constraints, staffing shortages, limited continuing education, and higher patient acuity. They are subject to institutional August 2003
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directive, patient needs, and their own personal and professional guidelines to provide the best possible care given the resources and restrictions available. In many cases the resources are few and the restrictions are numerous, giving the staff nurse few practical options. An advanced practice nurse in the inpatient setting would be a valuable asset and one that institutions should consider in a time when staff nurses are asked to deliver consistent, satisfactory service to patients and to develop professionally. Are inpatient psychiatric staff nurses stagnant in their practice? There is no time for stagnation. Nursing is the only profession that maintains a presence in the inpatient unit, 24 hours per day, 365 days per year. People with mental health problems have come to expect psychiatric nurses to relate to them as a professional and a concerned person. Inpatient staff nurses are expected to anticipate patient needs and react accordingly. Other professionals within mental health systems appreciate and value the closeness that psychiatric nurses have with their patients. They rely on nurses to provide them with information that will affect their professional judgment. “Psychiatric staff nurses are the most flexible and accessible workforce available to patients to bridge the gap between intimate and professional knowledge and, in doing so, cement mental health services together” (Jackson & Stevenson, 2000, p 386.).
REFERENCES American Nurses Association (2000). Scope and standards of psychiatricmental health nursing practice. Washington, DC: American Nurses Publishing. Barker, P. (2001). The Tidal Model: Developing an empowering, personcentered approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8, 233-240. Cleary, M., Edwards, C., & Meehan, T. (1999). Factors influencing nursepatient interaction in the acute psychiatric setting: An exploratory investigation. Australian and New Zealand Journal of Mental Health Nursing, 8, 109-116. Crook, J.A. (2001). How do expert mental health nurses make on-the-spot clinical decisions? A review of the literature. Journal of Psychiatric and Mental Health Nursing, 8, 1-5. Delaney, K. (2002). Inpatient psychiatric nursing: Set up to stagnate? Journal of the American Psychiatric Nurses Association, 7, 39-44. Echternacht, M.R. (2001). Fluid group: Concept and clinical application in the milieu. Journal of the American Psychiatric Nurses Association, 7, 39-44. Flannery, R., Fisher, W., Walker, A., Littlewood, K., & Spillane, M. (2001). Nonviolent psychiatric inpatients and subsequent assaults on community patients and staff. Psychiatric Quarterly, 72(1), 19-27. Hummelvoll, J., & Severinsson, E. (2001). Coping with everyday reality: Mental health professionals’ reflections on the care provided in an acute psychiatric ward. Australian and New Zealand Journal of Mental Health Nursing, 10, 156-166. Jackson, S., & Stevenson, C. (2000). What do people need psychiatric and mental health nurses for? Journal of Advanced Nursing, 31, 378-388. Johnson, M., & Hauser, P. (2001). The practices of expert psychiatric nurses: Accompanying the patient to a calmer personal space. Issues in Mental Health Nursing, 22, 651-668.
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Korn, C., Currier, G., & Henderson, S. (2000). “Medical clearance” of psychiatric patients without medical complaints in the emergency department. Journal of Emergency Medicine, 18, 173-176. Lakeman, R. (2001). Making sense of the voices. International Journal of Nursing Studies, 38, 523-531. Lego, S. (1998). The application of Peplau’s theory to group psychotherapy. Journal of Psychiatric and Mental Health Nursing, 5, 193-196. Marangos-Frost, S., & Wells, D. (2000). Psychiatric nurses thoughts and feelings about restraint use: A decision dilemma. Journal of Advanced Nursing, 31, 362-369. McCabe, S. (2000). Bringing psychiatric nursing into the twenty-first century. Archives of Psychiatric Nursing, 14, 109-116. Olofsson, B., & Jacobsson, L. (2001). A plea for respect: Involuntarily hospitalized psychiatric patients’ narratives about being subjected to coercion. Journal of Psychiatric and Mental Health Nursing, 8, 357-366.
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Peplau, H.E. (1952). Interpersonal relations in nursing. New York: Putnam. Perese, E. (2002). Integrating psychiatric nursing into a baccalaureate nursing curriculum. Journal of the American Psychiatric Nurses Association, 8, 152-158. Shanley, E. (2001). Common experiences of mental health nurses and consumers: Ingredients of a symbiotic relationship? Australian and New Zealand Journal of Mental Health Nursing, 10, 243-251. Stone, P., Curran, C., & Bakken, S. (2002). Economic evidence for evidencebased practice. Journal of Nursing Scholarship, 34, 277-282. Thomas, S.P., Shattell, M., & Martin, T. (2002). What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16, 99-107. Usher, K., Lindsay, D., & Sellen, J. (2001). Mental health nurses’ PRN psychotropic medication administration practices. Journal of Psychiatric and Mental Health Nursing, 8, 383-390. Wynne, A.L., Millard, M., & Woo, T.M. (2001). Pharmacotherapeutics for nurse practitioner prescribers. Philadelphia: Davis.
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