Learning Objectives Identify the components of the Tidal Model - - PDF document

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 1

Use of a Tidal Model Informed Program to Improve Patient Satisfaction and Decrease Chemical Restraints on an Adult Inpatient Psychiatric Unit at a Community Hospital

Phyllis Cratty, RN, BSN Brittany Chabak, LCSW, MPH

*The speakers have no conflicts of interest to disclose

Learning Objectives

• Identify the components of the Tidal Model utilized

in this practice change

• List the Tidal Model informed methods that clinical

nurses used to assist in the development of therapeutic nurse‐patient relationships and in the reduction of patient violence

• Identify the role of guided journals in augmenting

the recovery process

We Had Problems

• Lack of daily structure for patients
• Low patient satisfaction scores
• High utilization of chemical restraints
• Lack of recovery oriented approach

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 2

Tidal Model

• Recovery‐oriented approach designed for acute inpatient

mental health settings

• 3 main points

– Importance of therapeutic relationship – Healing comes from telling our stories – Our lives are ever changing

• Studies indicated

– Decrease in patient aggression1,2,3 – Decrease in physical restraints1,2,3 – Increase in patient satisfaction4

1Gordon et al., 2005; 2Lafferty & Davidson, 2006; 3Berger, 2006; 4Cook et al., 2005

Image: http://tejasforyou.blogspot.com/2012/02/sagar‐kusumagraj.html

Incorporation of Tidal Model Elements

• Centrality of the patient’s narrative

– Guided journal – Recovery‐focused 1:1

• Emphasis on therapeutic patient‐staff

relationships

• Types of groups

– Solutions, Recovery, Information

Role of Nurses

• Recovery focused one‐to‐ones

– Listening to a patient’s story; their “lived experience” – Empathizing and understanding – Empowering patient to make changes

• Facilitate medication groups
• Assist patients in the use of guided journals
• Enforce unit structure

“It is the relationship that heals” – Yalom, 1980

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 3

Guided Journals

• Developed by our staff with feedback from patients
• Empowers patients by giving them space to tell and
• wn their story
• Engages patients in treatment outside of groups
• Main components:

– Daily thought‐provoking questions – Recovery plan – Daily goals – Medications – Resources

Outcome Measures

• Patient satisfaction scores
• Patient Aggression Records

Highly agree Agree Neutral Disagree Highly disagree The group discussions were helpful Date Time Patient Information Medication Diagnosis Place Sticker Here



Hadol



Ativan



Thorazine



Other



Bipolar Disorder



Psychotic Disorder



Schizophrenia



Dementia



IDD/MR



Personality D/O



Other ______

Outcomes: Patient Satisfaction

• Data

– 8 months pre and 10 months post implementation – 2 “post months” were outliers and excluded (N₁ = 8; N₂ = 8)

• Analysis

– Independent two‐sample t‐test assuming unequal variances – Testing H0: µ1 = µ2 HA: µ1 ≠ µ2 ; α<0.05

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 4

Outcomes: Patient Satisfaction

• Findings

– 18% increase in patients marking “Highly agree” and “Agree” on surveys – P= 0.0001; statistically significant suggesting rejection of H0

50 60 70 80 90 100 1 2 3 4 5 6 7 8 Percentage of Positive Patient Satisfaction Ratings Month

Patient Satisfaction

Pre Post

Outcomes: Chemical Restraints

• Data

– 5 months pre and 6 months post (N₁ = 5; N₂ = 6) – IM/PRN Now medications administered between the hours of 8am‐5pm weekdays only – Only first 5 PRN/IM medications per patient per admissions counted in data

• Analysis

– Independent two‐sample t‐test assuming unequal variances – Testing: H0: µ1 = µ2 HA: µ1 ≠ µ2

α<0.05

Outcomes: Chemical Restraints

• Findings

– 40% decrease in IM/PRN Now medications weekdays 8am – 5pm – P=0.009 – Statistically significant suggesting rejection of H0

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 5

Discussion of Findings

• Logic Model of 2013 for Tidal Model Project

– Proposed a 15% increase in patient satisfaction ratings – Proposed a 20% decrease in IM/PRN Now meds

• Must also consider other variables

– Small sample sizes – Increased staff‐patient ratio during day – Time of year

• Can this change be sustained?

Recent Program Changes

• Expansion of group program

– Evenings and weekends – Aides and nurses facilitating more groups

• Journals in every patient’s Welcome Packet

Future Implications

• Additional nursing staff

– More time to develop relationships with patients – Float nurse on evening and night shifts – Greater presence on the unit

• Increase regulation of group topics
• On‐going training and assessment of adherence

to program components

APNA 30th Annual Conference Session 2041: October 20, 2016 Cratty 6

“Mental health nurses have great

• pportunities to impact positively on

the health and well‐being of people they provide care for through using the ‘nurse‐patient’ relationship as a therapeutic tool to promote recovery and help people live the lives they want to lead”

– McAndrew et al., 2014

Questions?