APNA 29th Annual Conference Session 2033.1: Thursday, October 29, - - PDF document

APNA 29th Annual Conference Session 2033.1: Thursday, October 29, 2015 Houston 1

The Transformation of Pediatric Psychiatric Nursing Practice to Enhance Therapeutic Outcomes

Thomas Houston, RN, BSN Maria Tietcheu, RN, MSN, PMHNP Bruce Steakley, RN, BSN

Purpose

Learning Objectives:

1. Identify behaviors and triggers that frequently lead to aggressive outbursts or agitated incidents. 2. Describe interventions on the unit that staff have implemented to improve patient outcomes. 3. Foster a change in nursing care from a behavior modification mindset to a more proactive supportive method.

The speaker has no conflicts of interest to disclose.

Introduction

• Six bed pediatric psychiatric inpatient research unit at

the National Institutes of Health (NIH), Bethesda, MD

• Two areas of study for research protocols

– Severe Mood Dysregulation (SMD) – Childhood Onset Psychosis (CHP)

• Voluntary study for children and adolescents

APNA 29th Annual Conference Session 2033.1: Thursday, October 29, 2015 Houston 2

Research Process

• Screening protocol
• Admission to the unit
• Medication taper/medication free phase
• Diagnosis formulation: appropriate for study?
• Study protocol

– Study medication – Data gathering

• Discharge process

Evolution of Our Practice

• Establish unit rules
• Determine safe or not safe
• Seclusion or restraint
• Respond to aggression
• Take control
• Categorize by diagnosis
• Negative Reinforcement
• Stereotype
• Exclusion
• React, Watch
• Follow rules/schedules

What We Did What We Do

• Unit guidelines, maintain flexibility
• Determine patient needs/ capabilities
• Quality time, relationships
• Interpret aggression as an expression of need
• Give control
• Symptom profile
• Advocate
• Understand neurobiology
• Therapeutic relationships
• Anticipate, Observe
• Recognize transitions

Case Study

• Patient A, 2005
• Nursing Style: Rigid

behavior modification

• Reacted to his behavior
• Overestimated his

capacity

• Inappropriate expectations

set him up for failure

• Patient B, 2015
• Nursing Style: Strength based,

skill focused, and supportive

• Anticipated his needs
• Symptom profile created to

determine capacity

• Set small, realistic, achievable

goals with immediate reward

APNA 29th Annual Conference Session 2033.1: Thursday, October 29, 2015 Houston 3

Triggers That Lead To Aggressive Outbursts

• Saying “no”
• Transitions
• Time alone
• Family and peer interactions
• School
• Lack of structure
• Asking beyond their capacity
• Past experience with seclusion and restraint

Current Nursing Interventions

• Developing a symptom profile
• Identifying the patients capacity
• Weighing patient needs vs. staff/unit needs
• Developing and communicating individualized patient

care plans

• Engaging in partnered relationships
• Providing one to one staff to patient care as indicated

Accommodations Utilized

3.08 12.1 13.25 12.51 8.93 7.87 13.79 24.44 4.76 9.76 6.42 16.18 5.77 23.17 5 10 15 20 25 30 Other Structured Room Time Peer Relationship Negotiating Assist with Menus Meals in Room Separate Meals/Activities/Planning/Free-Time Structured Room Time with Staff Present Reduced Stimulation Staff Assistance with Family Contact Staff Presence Until Asleep Supervised ADL's Extra Staff Presence During Transitions Limited Group Activities 1:1 order

Percentage Used During Stay 2013/2014

APNA 29th Annual Conference Session 2033.1: Thursday, October 29, 2015 Houston 4

Enhanced Therapeutic Outcomes

0.17% 0.24% 0.16% 0.26% 0.00% 0.00% 0.10% 0.20% 0.30% 0.40% 0.50% 2010 2011 2012 2013 2014

Seclusions and Restraints per Actual Patient Days

NIH

Implications for Future Practice

• Changing the mindset from reactive to proactive

nursing care

• Recognizing behaviors that lead to aggressive
• utbursts
• Providing supportive interventions
• Improve staff to patient ratio

References

• American Psychiatric Nurses Association. (2014). Position Statement: The Use of Seclusion

and Restraint. Retrieved from http://www.apna.org

• Hert, M. D., Dirix, N., Demunter, H., & Correll, C. U. (2011). Prevalence and Correlates of

Seclusion and Restraint use in Children and Adolescents: A Systematic Review. European Child & Adolescent Psychiatry, 20, 221‐230.

• Pogge, D. L., Pappalardo, S., Buccolo, M., & Harvey, P. D. (2013). Prevalence and Precursors of

the use of Restraint and Seclusion in a Private Psychiatric Hospital: A Comparison of Child and Adolescent Patients. Administration and Policy in Mental Health, 40, 224‐ 231.

• Valenkamp, M., Delaney, K., & Verheij, F. (2014). Reducing Seclusion and Restraint During

Child and Adolescent Inpatient Treatments: Still an Underdeveloped Area of Research. Journal of Child and Adolescent Psychiatric Nursing, 27, 169‐174.