We begin by thanking our contributors to this special edition on inpatient psychiatric treatment. Their research and clinical innovations define areas of practice that are critical to the development of the specialty. The methods used in the data-based articles will inform our thinking about innovative research and data collection schemes; ones which will advance the science and practice of inpatient nurses.
The work of inpatient nurses is rarely documented in detail. The research of Sneed, Torkelson and Alnatour maps out how inpatient nurses spend their day and the myriad of responsibilities that nurses address in the service of a safe, effective unit. The authors parse out a nurse's day and the time spent in various role functions. They ask an important question: the impact of these role demands on nursing satisfaction. Their results yield important insights on role functions nurses believe distance them from meaningful patient contact and what aspects of their role they believe should be expanded. The authors suggest that inpatient nurses could use these data to explore how they are spending time on a typical day and then how they might realign their position closer to their image of the ideal inpatient nursing role.
An alternative way to examine how inpatient psychiatric nurses deal with their job demands is by assessing the relationship of nurses’ burnout to their perceptions of the work environment (strengths/limitations). To this end, Drs. Hanrahan and Aiken apply the state of the art in work environment measurement to psychiatric inpatient treatment. They ask how nurses view their work environment and how these perceptions are related to nurses’ sense of role fulfillment. Using a large sample of psychiatric nurses, employed in 67 hospitals, they demonstrate the relationship of particular aspects of the work environment to psychiatric nurses’ degree of burnout, e.g., emotional exhaustion, depersonalization. The results highlight the importance of good staffing levels and skilled managers to achieve proximal benefits (reduce burnout), which downstream effect nurse retention and patient outcomes.
For the last two decades, inpatient psychiatric nurses have focused on the issue of restraint and seclusion. Dr. Mary Johnson provides an analysis of the various strategies have been used to eliminate restraint use and reduce the incidence of aggression on inpatient units. Her integrative review of 46 studies carefully documents the evolution of two lines of research: restraint/seclusion reduction and violence/aggression reduction. By carefully summarizing the findings of these studies within the context of their methodological issues, Dr. Johnson sets a direction for future research in this area; i.e. the development of interventions that are complex enough to address the nature of staff-patient interaction yet structured enough to invite replication in a variety of inpatient settings.
Amidst efforts to reduce containment measures, nurses continue to use seclusion and restraint in emergency situations. In the last decade several protocols have been developed to guide nurses on the use of seclusion/restraint. Larue, Pait, Racine, Menard and Goulet explores nurses’ adherence to these protocols, describing nursing interventions during episodes of seclusion and how they relate to best-practice guidelines. Larue et al analyze interview data from nurses involved in seclusion, to evaluate nurses’ response to aggressive incidents, their rationale, and their behavior during and post incident. The research team's content and linguistic analysis of interviews provides a unique insight into seclusion practices highlighting when actions, assessments and responses are not congruent with the intent of the protocol.
To address these critical issues of work environment, containment measures, and role demands nurses will need to find their voice; define their practice and create cultures where they might engage in the interpersonal aspects of psychiatric nursing. We are fortunate to have a series of articles that will offer direction for this endeavor. Dr Philip Barker's Tidal Model provides an excellent guidance for, as he states, what needs to be done to enable the process of recovery. Dr Barker ties together concepts familiar to psychiatric nurses (the lived experience, the role of the narrative, empowerment), and demonstrates how they serve as a platform for inpatient nursing practice. The Tidal Model is a conceptual keel that should help nurses return to an interpersonal paradigm of care; a place where they should feel quite at home.
Nurses seeking to grasp the consumer's story and lived experience will also find support from peer specialists. Gayle Bluebird provides an excellent explanation of the peer specialist role, its history and their potential to help consumers deal with the acute episode of illness. Peer specialists bring unique skills and perspective to the inpatient arena, particularly how to join with consumers and come to a mutual agreement on what they need and what is considered helpful. Ms. Bluebird explains how training and building support for the role will assure that peer specialists reach their full potential on the inpatient team. Ms. Bluebird provides unique insight into this innovative role; an understanding that will be a useful guide for nurses and administrators as they begin to put this role into place.
Buccheri, Trygstad, Buffum, Lyttle, and Dowling suggests another strategy for joining with consumers during their hospital stay, a self-management of auditory hallucinations program designed for use on inpatient units. This is a comprehensive program that includes components aimed at increasing nurses’ awareness of the phenomena, patient self-assessment tools, the self-management intervention and a guide for sharing information with caregivers. Self management is considered one means of empowerment over illness, and thus an important tool for consumers. Dr. Buccheri provides an excellent orientation to self management and a practical guide for inpatient nurses who wish to implement the program. Her case examples demonstrate the practical aspects of implementation as well as how to assess outcomes of the program.
These are exciting prospects for changing cultures on inpatient units, one where patients find both safety and healing. Kathleen Regan has helped create such a culture on the unit where she practices and in her article she recounts how the unit staff moved towards trauma informed care, their strides and stumbles. Then something perhaps unexpected happens. Amidst the excitement of creating a culture of patient-centered care, staff is met with emerging dilemmas around children's rights. Detailed in this article is how the staff examined the ethics of forced medications, particularly when the interdisciplinary team decides a child is to be medicated against her will. Ms. Regan brings the reader through two cases, where events mounted that compelled staff to examine the rights of a child to refuse medication and their role in the process.
We all strive to create inpatient units that are safe and healing. Inpatient nurses are dedicated individuals who have adjusted their practice to the demands of brief stays, rapid patient turnover, increased documentation and open admission policies. Their traditional focus of interpersonal, patient-centered care may have become a bit lost in the flurry of twenty-first century change. It is time for inpatient nurses to reclaim their voice and control over their practice. Certainly it is time for psychiatric mental health nurses to incorporate recovery and patient centered care into the landscape of inpatient treatment. These articles provide a wonderful roadmap for the initiative.