The article I chose from the Journal of the American Psychiatric Nurses Association by Magnowski, S. & Cleveland, S. (2019) looked at the impact of milieu nurse-client shift assignments on monthly restraint rates on an inpatient child/adolescent psychiatric unit. Restraint is a significant issue in nursing practice because it poses a threat to safety and quality of care, corroborated by previous authors and studies. This project involved a quantitative, retrospective, and comparative design that analyzed 758 inpatients ages 5 to 18 years (18 if still in high school) on one of the units at Rogers Behavioral Health in the Midwest. The outcome shows that the milieu nurse-client shift assignments which provide structure, safety, consistency, and security leading to early intervention and de-escalation of aggressive behaviors are associated with lower monthly restraint rates compared to individual nurse-client shift assignments which focus on meeting individual client needs versus the needs of the group as a whole.
Journal Club critique form updated
Reference
Magnowski, S. R., & Cleveland, S. (2019). The Impact of Milieu Nurse–Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit. Journal of the American Psychiatric Nurses Association, 26(1), 86–91. doi: 10.1177/1078390319834358
I was intrigued by your article as my first experience with nursing was on a pediatric milieu unit. We were trained in a basic restraint system (Crisis Prevention Institute) which over time felt like it was overly used and abused in times of crisis. According to Keski-Valkama “clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion is too open to subjective assessment and interpretations.” (2010) Restraints in a psychiatric facility should be used for safety and prevention of violence but have often been left to an individual’s interpretation. Evidence shows restraints have potential to effect patient and nurses adversely; therefore the need for strategies to prevent and decrease the amount of restraint continues. Studies such as your chosen article benefit facilities to increase safety, structure and success rates of treatment without the further traumatizing of patients being restrained. Although guidelines for restraints and seclusion have evolved over the years it is still a challenge due to old ways of institutionalized care.
Cecilia,
In your current work, what procedures or interventions due you have to decrease restraint and seclusion? Do you feel the interventions used are effective? Have you seen a decrease over the years?
Keski-Valkama A. (2010). The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15 year study. Psychiatry, 64(2), 136-44.
Jlcarter7, thanks for your contribution. The use of restraints in aggressive patients can indeed be subjective; prevention is the ultimate goal. Based on my experience and the findings of Magnowski & Cleveland (2019), milieu nurse-client assignments, which promote milieu presence is useful in the management of aggression and inadvertently, reduction in the use of restraints. I do not have statistics showing whether or not restraint use has decreased over the years; this may be partly because the individual-client assignment is the status quo in most facilities. This technique of inpatient psych care has proven to be ineffective in maintaining a therapeutic milieu.
I have not had cause to use restraints on a patient in close to a year and can say that effective communication and milieu presence, which facilitates early recognition of aggression, are vital in this challenge.
Reference
Magnowski, S. R., & Cleveland, S. (2019). The Impact of Milieu Nurse–Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit. Journal of the American Psychiatric Nurses Association, 26(1), 86–91. doi: 10.1177/1078390319834358
Communication and empathy is core to mental health nursing. Evidence based practice again states that clients have better outcomes when nurses are respectful, provide supportive counseling, and use therapeutic communication. Therapeutic communication and supportive counseling do not come naturally to some caregivers. In the emergency department, it is reported that some patient’s feel demoralized, ignored, or embarrassed. The lack of comfort and long wait times in the emergency department lead to hostile patients and more like unnecessary restraints being used. The lack of rapport and empathy from the emergency department help the patient make the decision to delay or not establish follow up care. A study in a major hospital showed a crisis action team consisting of a psychologist, social worker, and nurse to come in and assess mental health patients. The team was available during day shift hours. The team was able to prevent unnecessary restraint use, decrease the amount of revisits, and quickly establish whether a patient needed or did not need admission. The team was also able to establish a follow up appointment for the patient if outpatient was appropriate. As well as, decreasing the needs of the emergency services staff. Overall, the crisis action plan was cost effective to the hospital. Rural hospitals would not be able to staff these members full time in the emergency department. Hospitals with inpatient psychiatric services could modify and place more responsibility on providers and social workers to increase satisfaction of patients and decrease the cost and readmission for hospital.
Saurman, E., Kirby, S. E., & Lyle, D. (2015). No longer “flying blind”: How access has changed emergency mental health care in rural and remote emergency departments, a qualitative study . BMC Health Services Research.
Sirotich, F., Durbin , A., & Durbin , J. (2016). Examining the need profiles of patients with multiple emergency department visits for mental health reasons: a cross-sectional study . Soc Psychiatry Psychiatric Epidemic.
What an interesting topic! While I find myself dealing with some mental health issues in my practice, I do not deal with problems that would require inpatient, nor with adolescents. I am familiar with milieu therapy and how nurses can play an active role in that. I found the position statement from the American Psychiatric Nurses Association on the use of seclusion and restraints. The statement “nurses provide effective treatment and milieu leadership to maximize the individual’s ability to effectively manage potentially dangerous behaviors” particularly stood out to me (American Psychiatric Nurses Association, 2017). It goes to show the direct impact milieu leadership can have on preventing or decreasing potentially dangerous situations. This was great information. Thank you for the work you do.
American Psychiatric Nurses Association. (2017). APNA position on the use of seclusion and restraint. https://www.apna.org/i4a/pages/index.cfm?pageID=3728