Adult Psychiatric Unit Research Articles

The safety of nurses during the restraining of aggressive patients in an acute psychiatric unit

Objective: The aim of the study was to describe patterns of injuries sustained by nurses during the restraining of aggressive patients and to identify factors in the restraining process that can be modified to improve the safety of nurses during restraining. Design: Within‑method triangulation was used in this study and involved two quantitative data collection methods. Setting: An adult acute psychiatric unit in Victoria, Australia. Subjects: Seven male and twenty‑six female nurses. Main outcome measures: The outcome measures are patterns of injuries and ways of reducing injuries. Results: Incident reports showed more than half of all injuries occurred in the afternoon shift and during the holding stage of restraining. Eighty percent of the injured nurses sustained multiple injuries. Questionnaire results showed that restraining was associated with an estimated increased risk of being injured of 25% (RR = 1.25, 95% CI= 0.97 to 1.61, p > 0.05). The proportion of injuries was higher among female nurses (52.38%) compared with male nurses (28.57%), (RR=0.51, 95% CI = 0.15 to 1.74, p > 0.05). Lack of group co‑ordination was perceived as the main contributor to injury. Introducing easier restraining techniques and increasing the training period were identified as ways that might improve the safety of nurses. Conclusion: Most injuries occurred at the holding stage of restraining and in the afternoon shift. Many participants sustained multiple injuries and most of the injuries were caused by physical assaults. There is need for improving group coordination during restraining to increase the safety of nurses.

Enclosed Versus Open Nursing Stations in Adult Acute Care Psychiatric Settings: Does the Design Affect the Therapeutic Milieu?

Specific efforts by hospital accreditation organizations encourage renovation of nursing stations, so nurses can better see, attend, and care for their patients. The purpose of this study was to examine the effect of nursing station design on the therapeutic milieu in an adult acute care psychiatric unit. A repeated cross-sectional, pretest-posttest design was used. Data were collected from a convenience sample of 81 patients and 25 nursing staff members who completed the Ward Atmosphere Scale. Pretest data were collected when the unit had an enclosed nursing station, and posttest data were collected after renovations to the unit created an open nursing station. No statistically significant differences were found in patient or staff perceptions of the therapeutic milieu. No increase in aggression toward staff was found, given patients' ease of access to the nursing station. More research is needed about the impact of unit design in acute care psychiatric settings.

Affective Spectrum Disorders in an Urban Swedish Adult Psychiatric Unit: A Descriptive Study

Background. Several studies have found that patients with affective-/anxiety-/stress-related syndromes present overlapping features such as cooccurrence within families and individuals and response to the same type of pharmacological treatment, suggesting that these syndromes share pathogenetic mechanisms. The term affective spectrum disorder (AfSD) has been suggested, emphasizing these commonalities. The expectancy rate, sociodemographic characteristics, and global level of functioning in AfSD has hitherto not been studied neglected. Material and Method. Out of 180 consecutive patients 94 were included after clinical investigations and ICD-10 diagnostics. Further investigations included well-known self-evaluation instruments assessing psychiatric symptoms, personality disorders, psychosocial stress, adaptation, quality of life, and global level of functioning. A neuropsychological screening was also included. Results. The patients were young, had many young children, were well educated, and had about expected (normal distribution of) intelligence. Sixty-one percent were identified as belonging to the group of AfSD. Conclusion. The study identifies a large group of patients that presents much suffering and failure of functioning. This group is shared between the levels of medical care, between primary care and psychiatry. The term AfSD facilitates identification of patient groups that share common traits and identifies individuals clinically, besides the referred patients, in need of psychiatric interventions.

Adolescent Admissions to Adult Psychiatric Units: Patterns and Implications for Service Provision

The aim of this study was to investigate patterns of child and adolescent admissions to an acute adult psychiatric unit in a rural city. Correlates of admissions were then considered in terms of service reform for this vulnerable, under-resourced group. The study reviewed consecutive clinical records of children and adolescents who were admitted to an acute general psychiatric inpatient unit over a 6 year period (N = 332). Patients generally experienced numerous pre-admission psychosocial stressors; there were many abuse histories and/or juvenile justice involvement. The principal diagnosis was varied and comorbidity was common. Maori patients were over-represented. The majority of admissions occurred out of working hours and more than half came from rural areas. There was high usage of the Mental Health Act on admission. Common causes of admission were self-harm and suicidal behaviour. The majority of the admitted adolescents required follow up by child and adolescent mental health services after discharge. We identified several reform possibilities, including up-skilling emergency and adult mental health staff in child and adolescent mental health, exploration of alternatives to admissions and specialist service coverage.

P03-531 - Service users’ satisfaction in an acute adult psychiatric care unit- a qualitative survey

IntroductionService users’ satisfaction survey adds an important consumer perspective to the evaluation of various services and treatment progression. In fact survey may be the only means for clients to express their views about the improvement required in the existing services and the new services that are needed or developed.AimTo ascertain the service users’ views admitted to a large acute adult psychiatric care unit.MethodologyWe conducted a qualitative survey of service users’ views by using a questionnaire specifically designed to assess their views of the service they received from the Acute in patient care team in a secondary care hospital. The questionnaire was distributed to all service users in the unit prior to their discharge during the period from 1st November to 31st December 2009.ResultsResults show that the majority of service users have overall satisfaction with the performance of the acute inpatient care team.Some of the positive comments made were about the team members being extremely helpful, understanding, committed, highly trained and safe environment. Service users’ responses suggested some improvements to the service such as shorter gaps between reviews, quicker liaison with other agencies, awareness among the nursing and allied staff regarding confidentiality and provision of information leaflets.ConclusionThese findings could be further strengthened by conducting a validated questionnaire on larger sample and can be extremely helpful in planning future services

The Effect of Songwriting on Knowledge of Coping Skills and Working Alliance in Psychiatric Patients: A Randomized Clinical Effectiveness Study

The purpose of this study was to determine the effects of a songwriting intervention on psychiatric patients' knowledge of coping skills and working alliance. Participants were randomly assigned to scripted and manualized experimental (n=48) or control (n=41) conditions. The experimental condition was a group psychoeducational music therapy songwriting session concerning coping skills while the control condition was a group psychoeducational session concerning coping skills. Both conditions were single-session therapy with patients on an acute adult psychiatric unit. Results indicated no significant between group differences in measures of knowledge of coping skills, consumer working alliance, or perception of enjoyment (p>.05), although the experimental condition tended to have slightly higher mean scores than the control group for these measures. There was a significant between group difference in measures of therapist working alliance (p<.001), with the therapist scoring the experimental group higher than the control group. Although the music therapy group had a higher mean rate of previous psychiatric hospitalizations, their perception of enjoyment scores were still higher than those of the control condition, a finding incongruent in the literature. Furthermore, despite the increased number of previous hospitalizations, the music therapy condition had higher attendance rates than the control condition, thus possibly providing incentives for funding. It seems that group songwriting about coping skills can be as effective a psychosocial intervention as traditional talk-based psychoeducation to teach psychiatric inpatients how to proactively manage their illness. Additionally, music therapy can be as effective as talk-based psychoeducation in establishing working alliance. Implications for clinical practice, limitations, and suggestions for future research are provided.

An audit of resuscitation status decisions in an older adult psychiatric unit

An audit of resuscitation status decisions in an older adult psychiatric unit

Nursing Practices Recorded in Reports of Episodes of Seclusion

The purpose of this study is to describe the nursing practices recorded in reports of patient episodes of seclusion, with or without restraints, in a specialized psychiatric facility in Quebec. The reports for all adult patients secluded (n = 4863) in a psychiatric unit between April 1, 2007 and March 31, 2009, were examined. Descriptive analyses were performed. The main reasons for seclusion were agitation, disorganization, and aggressive behaviour. The alternative methods that were attempted included stimulus reduction, extra medication, and working with the patient to find a solution. Few families were notified about their relation's seclusion. More hours of seclusion were reported in the evening and at night. Our results are comparable to those obtained by other investigators. Some of the variables have not been the subject of much research: for example, health conditions during seclusion with or without restraint and partnerships with family members. Our findings also suggest that, in their analyses, studies should differentiate between cognitive-impairment and adult-psychiatry units as well as long-term seclusion and short-term seclusion. The information reported by the nurse makes no distinction between short-stay and long-stay adult psychiatric units. Only one psychiatric facility was investigated in this study, precluding generalization.

Preventive child‐focused family work: development of instrument in adult psychiatry

It is well-known that a parent's mental disorder has a significant psychosocial influence on the development of her or his children. This study reports the development process and psychometric testing of the preventive child-focused family work (PCF-FW) questionnaire in adult psychiatric settings. The PCF-FW instrument was developed to measure support for parenting, dependent children and family relationships in order to promote child development and mental health in adult psychiatry. A 133-item PCF-FW questionnaire was developed; the content validity, construct validity and reliability of the instrument were ensured by expert review, pilot test and internal consistency. The final instrument was distributed to all nurses (n= 608), including registered nurses (n= 373) and practical mental health nurses (n= 235), working in 45 adult psychiatric units in five university hospitals in Finland. Some 51% of all nurses responded. Correlation variables in each subscale varied between 0.1 and 0.8. Cronbach's alpha coefficients were 0.55-0.95 in each subscale, demonstrating the moderate to excellent internal consistency of the instrument. The Cronbach's alpha coefficient for the entire instrument was 0.94. In spite of some caveats, such as possible response biases, the present study suggests that the PCF-FW instrument is a valid and reliable tool for studying preventive child-focused family working in adult psychiatry.

Predicting Falls Among Psychiatric Inpatients: A Case-Control Study at a State Psychiatric Facility

Predicting Falls Among Psychiatric Inpatients: A Case-Control Study at a State Psychiatric Facility

Solution Proposed for Severe ED Overcrowding

Solution Proposed for Severe ED Overcrowding

The Impact of VA and Navy Hospital Collaboration on Medical School Education

The U.S. Department of Veterans Affairs (VA) is the largest single provider of medical education in the United States and is often the preferred training site for medical students and residents. However, changing priorities of patients and the marketplace are forcing medical schools and the VA to consider new ways of practicing medicine and relating to each other. This article reviews the value of that relationship. The authors describe a VA and Department of Defense sharing agreement and the development of a federal medical center as well as the involvement of a local medical college and the impact on education. The federal medical center will provide more clinical services to veterans, active duty service members, and their beneficiaries. Trainees see a variety of young adults of both genders and are exposed to behaviors and pathology not commonly seen in typical general adult inpatient VA psychiatric units. The federal facility will provide accessible, high quality health care for active duty and veteran patients. It benefits trainees by enriching their training experience and allowing students and residents to receive a comprehensive clinical experience by caring for diversified patients with a wide range of pathology.

Do nurses working in adult psychiatry take into consideration the support network of families affected by parental mental disorder?

The aim of this study was to gain information about registered and practical mental health nurses' activities concerning support network of families affected by parental mental illness. Data were collected using a structured questionnaire distributed to all 608 practical and registered mental health nurses working in adult psychiatric units in five Finnish university hospitals. A total of 311 nurses returned completed questionnaires (response rate 51%). Sixty per cent (n = 222) of registered nurses and 36% (n = 88) of practical mental health nurses responded. Information about family relationships and socio-economic situation was gathered regularly by all nurses. The nurses' individual characteristics, such as being a parent, further family education and use of family-centred care, were significantly related to their activeness in discussing the family's support network with the parents. Discussing family relationships and families support networks forms part of patient care in adult psychiatric nursing with families with dependent children (under 18 years of age). Nurses can work directly with the parents to aid them to strengthen their support network for themselves and their children.

Challenges Faced by Inpatient Child/Adolescent Psychiatric Nurses

Inpatient nurses work to engineer an environment in which patients and staff are physically and psychologically safe. A recent research study on an adult psychiatric unit examined the dimensions involved in keeping the unit safe. The four dimensions included ideology, people (staff and patients), space, and time. In this article, we discuss how these dimensions apply to real-world efforts to keep child and adolescent inpatient units safe. We also discuss the challenges nurses face within each of these safety dimensions, including those arising from fluctuating acuity, staffing formulas, surveillance of physical space, and entrenched unit cultures.

Implementing child‐focused family nursing into routine adult psychiatric practice: hindering factors evaluated by nurses

The aim of this study is to describe nurses' evaluations of factors that are hindering implementation of child-focused family nursing (CF-FN) into adult psychiatric practice. In addition, it explains the nurses' evaluations of the hindering factors related to the hospital organizational structure, the individual nurse, nursing and family. There is an increasing amount of families with dependent children in adult psychiatry. Although these families have long-term benefits from preventive family interventions, implementation of CF-FN is not routine mental health practice. Data were collected via a questionnaire-survey completed by Registered Psychiatric Nurses (n = 223) and practical Mental Health Nurses (n = 88) from 45 adult psychiatric units in five Finnish university hospitals. The response rate was 51%. Family-related factors, such as families' fears and lack of time, were considered as 'most hindering' to CF-FN. Nurses who used a family-centred approach and had further family education considered most of the factors as 'less hindering' in comparison to other nurses. To meet the needs of the families in mental health services, it is essential to develop nursing intervention methods such as CF-FN. There is a need for further education and use of family-centred care to develop this preventive approach. The results of this study could be considered when developing mental health services and family interventions for families with parental mental illness.

Mood Stabilizer Loading Versus Titration in Acute Mania: Audit of Clinical Practice

The aim of the present study was to investigate whether the use of a loading strategy with lithium or valproate followed recommended practice and second, whether this had any impact on indicators of outcome in acutely manic inpatients. A 12 month retrospective review of admissions to two adult psychiatric units in Auckland, New Zealand, was conducted. Demographic, legal status, psychiatric admissions, outcome indicators (length of stay, intensive care and seclusion use) and medication data were collected for all patients with a diagnosis of acute bipolar mania who started mood stabilizer treatment within 3 days of admission (n=93). Serum levels and adverse effects were also recorded. In 46.2% of admissions a loading strategy was prescribed, and lithium was the treatment choice in two-thirds of admissions. Serum levels were taken inconsistently, particularly for valproate. No difference was found between loading and titrating for the assessed outcomes in routine practice; average length of stay was 30.2 days; most patients (71.0%) spent time in intensive care (average 8.4 days) and 33.3% spent time in seclusion. More adverse effects occurred with loading (51.2%) compared to titrating (36.0%), particularly with lithium. The literature supports a strong link between rapidly attained high serum levels and positive outcomes. The present study found inconsistent and infrequent measurement of levels, which was not in accord with recommended practice. Frequent monitoring of serum levels to support dosing decisions is important to inform better clinical decision making, especially when a loading strategy is used. This may explain the less than optimal outcomes (with respect to rapid resolution of mania and hospital discharge) that were found, irrespective of dosing strategy.

Mental health professionals' attitudes towards consumer participation in inpatient units

Consumer participation has been a major focus in mental health services in recent years, but the attitudes of mental health professionals towards this initiative remain variable. The purpose of this study was to describe mental health professionals' attitudes towards mental health consumer participation in inpatient psychiatric units. The Consumer Participation and Consultant Questionnaire was used with a non-probability sample of 47 mental health professionals from two adult inpatient psychiatric units situated in a large Australian public general hospital. Ethics approval was obtained from a university and a hospital ethics committee. Data were analysed using SPSS, Version 12. Overall, respondents had favourable attitudes towards consumer participation in management, care and treatment, and mental health planning. They were less supportive about matters that directly or indirectly related to their spheres of responsibility. The type of unit that the respondents worked in was not a factor in their beliefs about consumer participation. Recommendations are made about the development of guidelines for consumer participation in inpatient units, the educational preparation of mental health clinicians, and the need for mental health professionals to reflect on, and discuss their own beliefs and practices about, consumer participation.

Experiences of stigma and discrimination endured by people suffering from schizophrenia.

Objective:It is important to understand stigma in India, given its varied culture and mixture of rural and urban populations. Information from western literature cannot be applied without considering the sociocultural differences.Aims:The research aimed to study the subjective experiences of stigma and discrimination undergone by people suffering from schizophrenia in rural and urban environments in India.Settings and Design:Patients were selected from the outpatient services of six adult psychiatric units of the National Institute of Mental Health and Neurosciences (NIMHANS), India, and from the six outreach centers located in rural areas.Materials and Method:Two hundred patients diagnosed with schizophrenia were selected from rural and urban areas. The experiences of stigma and discrimination were assessed using a semi-structured instrument.Statistical Techniques:Both quantitative and qualitative analyses were done.Results:Significant differences were seen between rural and urban respondents. Urban respondents felt the need to hide their illness and avoided illness histories in job applications, whereas rural respondents experienced more ridicule, shame, and discrimination. The narratives provide direct views of patients, supporting the key findings.Conclusion:Mental health programs and policies need to be sensitive to the consumers’ needs and to organize services and to effectively decrease stigma and discrimination.

Factors influencing seclusion rates in an adult psychiatric intensive care unit

Seclusion of psychiatric inpatients is used as a last resort in managing disturbed behaviour. Research on factors contributing to its use is limited. The aim of this study was to examine the effect of a change in unit size and other variables, such as time of day and nursing workload, on the rates of use of seclusion in an intensive care inpatient psychiatric unit. Rates of seclusion were examined in randomly selected nursing shifts across three time periods; one before and two after a change in the size of the unit. Effects on seclusion rates of size, shift and four nursing workforce variables were explored using multivariate analysis. Unit size, shift and nurse hours together explained 23% of the variance in seclusion use. Of particular significance was the change from a 20 bed unit to two separate 10 bed units. The findings have implications for the organisation of inpatient psychiatric units. Smaller units may allow better management of disturbed behaviour.

The DEBIT trial: an intervention to reduce antipsychotic polypharmacy prescribing in adult psychiatry wards – a cluster randomized controlled trial

Clinical guidelines advise against prescribing more than one antipsychotic with limited exceptions. Despite this, surveys continue to report high antipsychotic polypharmacy rates. The aim of the study was to investigate the effectiveness of a multi-faceted intervention in reducing prescribing of antipsychotic polypharmacy on general adult psychiatry wards, compared with guidelines alone. A pragmatic cluster randomized controlled trial recruited 19 adult psychiatric units (clusters) from the South West of England. Participants were all ward doctors and nurses. The multi-faceted intervention comprised: an educational/CBT workbook; an educational visit to consultants; and a reminder system on medication charts. The odds of being prescribed antipsychotic polypharmacy in those patients prescribed antipsychotic medication was significantly lower in the intervention than control group when adjusted for confounders (OR 0.43, 95% CI 0.21-0.90, p=0.028). There was considerable between-unit variation in polypharmacy rates and in the change in rates between baseline and follow-up (5 months after baseline). The intervention reduced levels of polypharmacy prescribing compared to guidelines alone although the effect size was relatively modest. Further work is needed to elicit the factors that were active in changing prescribing behaviour.