Difficulties with Teens: Can Nursing Consultation Help? by Kathryn R. Puskar, DrPH, RN, CS, and Kathryn Wargoe, MSN, RN
Childlyou th prob l m s and psychiatric hospital iuz-
tions are increasing. A literature r e v i m suggests that there is an increased need for more nurses with
Kathryn R. Puskar, DrPH, R N , CS, is Director and Assistant Professor, Graduate Program in Psychiatric Mental Health Nursing, University of Pittsburgh. Kath y n Wargoe, M S N , R N , is a graduate student, Psychiatric Mental Heath Nursing, School of Nursing, University of Pittsburgh, and works on an adolescent inpatient unit.
the knowledge and skills necessay to work in this specialty area. The review also suggests that providing psychiatric nursing consultation services is one way to help direct care staf to strengthen or develop these skills. The authors describe a consultation project that took place on a neully developed 15-bed adolescent program in a 30-bed private psychiatric hospital . They examine the effectiveness of consultation sessions, ascertained through both zwbal and writ-
ten eualuntions of staff members. The outcome suggests that psychiatric nursing consultation swslices
can be an important contribution in expanding the knowledge base of direct care staf (child care specialists and nurses) zuho work with the hospitalized adolescent psychiatric patient.
34
As the adolescent psychiatric inpatient population increases, so does the need for psychiatric nurses specialized in adolescent care. A conservative estimate from the Office of Technology Assessment‘s Report on Children’s Mental Health in 1986 concluded that at least 7.5 million children (12%)were in need of some sort of mental health service (Committee of the Institute of Medicine [CIM], 1989).Nearly half these chddren are deemed severely disordered or handicapped by their mental illness. However, a series of recent studies suggested that prevalence may now range between 17% and 22%, or 11-14 million chddren, depending on a variety of factors (CIM). Statistics show that in addition to those with diagnosable mental disorders, 4,924 young people between the ages of 15 and 24 killed themselves in 1987, and more than a million people in that age group make suicide attempts each year (Ritzer, 1989). A suicide attempt is not a diagnosis; it is associated with different causative factors and diagnoses such as major depressive disorder, aggression, conduct disorder, associated physical illness (including pregnancy), drug and alcohol abuse, parental psychatric Illness, marital conflict, and parent-child conflict (Trautman, 1989).Teenage substance abusers have also increased in numbers, along with children who are at risk for mental illness because of environmental factors such as poverty, inadequate care, parental illness, death, and divorce (Pothier, 1988).Hospitals have developed additional programs in order to meet the demand of adolescents in need of inpatient psychiatric treatment. More professionals are needed who have the knowledge, skill, and training to work with children, adolescents, and their families (Pother). JCPNVol. 5, No. 3, July-September,1992
A group called Advocates for Child Psychiatric Nursing emerged in 1972 after child psychiatric nurses voiced the need for such a national organization. Membership now totals approximately 400. Advocates for Child Psychatric Nursing participates in the Coalition of Psychiatric Nursing Organizations, along with the Society for Education and Research in Psychiatric Mental Health Nursing, the ANA Council on Psychiatric Mental Health, the American Psychiatric Nurses Association, and the National Nursing Society on Addictions. Because adolescent psychiatric nursing is itself a specialty, direct care nurses often require additional education in order to provide care and treatment for 13-18 year olds. Consultation services from nurses who are specialists in this area could be used to educate nurses who have chosen to work with adolescents. Consultation could be crucial to the survival of an adolescent program.
States (National Association of Private Psychiatric Hospitals [NAPPHI, 1989). According to data from the National Institute of Mental Health (NIMH, 1986), 112,215 children under age 18 were hospitalized for mental illness in all settings-state hospitals, general hospitals, private psychiatric hospitals, multiservice centers. Private psychiatric hospitals have become an important part of the mental health delivery system for children and adolescents. NAPPH and Medicare compiled data suggesting there were an estimated 403 private psychiatric hospitals in the United States (NAPPH). NIMH reported in 1986 (NAPPH) that 38% of admissions to private hospitals were children under age 18.
In 1986 38%of admissions to private Literature Review
hospitals were children under age 18. Child/Youth Problems A study by Brandenburg, Friedman, and Silver (1988) of the prevalence of emotional disturbance among children has been conducted in seven communities around the world, includingthe United States, since 1988. The tool used was the multimethod-multistage approach of rating scales followed by psychiatric interview. The studies were of sufficient magnitude to provide stable estimates of overall prevalence. The researchers suggested that ”in addition to similar methods of identifying cases in the community, the studies also reflect greater standardization of diagnoses through the use of operational criteria applied responses given to structured or semistructured interview schedules” (Brandenburg et al., p. 21). Based on the instrumentation and outcome of these studies, Brandenburg et al. concluded that the prevalence rates of emotionally disturbed children ranged from 14%-20%, and that behavioral disturbances are more likely to be severe and persistent rather thantransient. The Bureau of Census estimated in 1986 that there were 63,184,000 children under age 18 in the United JCPNVol. 5, No. 3, July-September,1992
ChildAdolescent Psychiatric Nursing McBride (1988) explained that in order for child psychiatric nursing to become a force in improving health care, several steps need to be taken. According to McBride, two of these steps were to increase research, especially in evaluation research to document the costeffectiveness of nursing interventions, and to involve child psychiatric nursing in the development of a classlfication system for psychiatric and mental health nursing. ’This is important in the subspecialty iden-g its own professionaldomain” (McBride, p. 62). According to the American Nurses Association on Psychiatric and Mental Health Nursing (1985), “The generalist is a nurse who is educated at the basic level for entry into professional nursing practice. A nurse generalist who practices child and adolescent psychiatric and mental health nursing needs to refine clinical skills through ongoing supervision of practice (p. 5). The nurse 35
Difficulties with Teens: Can Nursing Consultation Help?
provides a therapeutic environment in collaboration with the client, the farmly, and other health care pro-viders.” The nurse uses psychotherapeutic interventions to promote health, prevent Illness, and facilitate rehabditation. Fulfilling the profession’s obligations to improve the quality of care occurs when the psychiatric nurse is able to meet the necessary criteria of the standards of practice.
The increasing prevalence of
child/adolescent emotional disturbances and psychiatric hospitalizations means more nurses are needed who are competent
psychmtric clirucal nurse specdst (Opie, 1988). S u m m a r y of the Literature The review of literature suggests that the increasing prevalence of child/adolescent emotional disturbances and psychiatric hospitalizations means more nurses are needed who are competent in the knowledge and skills necessary to work in the specialty area. Opie (1988) explained, however, that not all nursing students receive direct experience with psychiatrically impaired children and adolescents. Registered nurses educated at the basic level for entry into professional nursing practice are generalists, and may not have the knowledge and skills necessary to work with the child/adolescent psychiatric inpatient. The literature also suggests that psychiatric nursing consultation is one way to help staff members develop and strengthen their skills.
in the knowledge and skills necessary to The Consultation Project
work in the specialty area. Assessment of Need
According to the Standards of Practice developed by the American Nurses Association on Psychiatric and Mental Health Nursing (19851, the clinical specialist in psychmtric mental health nursing is a ”nurse who holds a minimum of a mastefs degree, has had s u p e W hcal experience at the graduate level, and demonstrates depth and breadth of knowledge, competence, and skdl in the practice of chdd and adolescent psychatric and mental health nursing. . . The chical s p a k t may assume any of the roles of the generalst, in addtion to other roles, one of whch is ‘consultant to professional and non-pre fessional individuals or groups concerned with the general welfare, education,and care of children”’ (pp. 5-6). Registered nurses provide the great bulk of inpatient care. They have been most often the professionalsresponsible for the management and maintenance of the d e u . It is the nurse who is expected to implement the program. A need exists for greater collaboration with and use of the 36
This project took place in a newly developed 30-bed private child / adolescent psychiatric hospital in southwestern Pennsylvania. The adolescent program was a 15-bed inpatient unit. Adolescents were admitted for a variety of problems such as: oppositional/conduct disorders, affective disorders, suicidal gestures and attempts, schizophrenia, personality disorders. The staff consisted of psycluatrists, psychologsts, a nurse coordinator, staff nurses, child care specialists, and social workers. Plan for Consultation
Initially, the Director of Medical Services and the Drrector of Nursing requested consultation sessions to be for one hour a week over a threemonth period. In fact, the consultation period lasted seven months because of continued identified needs of the staff and approval from the Director of Medical Services, Director of Nursing, and Program Coordinator. JCPNVoL 5, No. 3, July-September,1992
Prior to meeting with the staff, an initial planning session was held with the Director of Nursing, Program Coordinator, and Director of Medical Services to discuss the specific focus of the consultation sessions. The Medical Director wanted clinical consultation for the staff to include such topics as: staff overreacting to patients; assistance in utilizing a team approach, nurses working with child care specialists; working with the adolescent and learning what to expect from her or him. After the planning meeting, the Director of Nursing and Program Coordinator requested individual consultation sessions. These meetings focused on information regarding the adolescent psychiatric inpatient and also on methods of helping staff members strengthen or develop skills necessary to provide quality care.
ConsultationProcess During the first consultation session, six staff nurses identified their perceived needs when working with adolescents. Learning contracts-brief questionnaires examining concerns of nurses, their goals for the experience and what they wanted to learn-were completed at that time. The learning contracts were part of the consultation assessment phase, and provided direction for some of the consultation meetings. According to the six learnjng contracts (seeFigure 11, all the nurses had concerns surrounding three major mas: (1) limit setting and acting-out behaviors, (2) consistency of therapeutic interventions and developing a therapeutic milieu, and (3) establishing effective communication with patients and other staff members. One staff member was interested in learning how to become more assertive; another wanted to learn ways of strengthening patients’ positive behavio~to use as a tool in their treatment. The first consultation session included a basic review of adolescence according to three key concepts, the “Three Is” of intimacy, identity, and independence (Lidz, JCPN Vol. 5, No. 3, July-September,1992
Figure 1. Percent of Concerns Reported by Nurses Employed on an Adolescent Unit 100%
Limit-setting/acting-out behavior
90%
’5 VI
80%
70%
60%
Increasing positive behaviors
0
g 50% 2 &J 40% .Id
30% 20%
10%
Concerns of Nurses on an Adolescent Unit
1968). Erikson (1963) described adolescence as a psychosocial stage between childhood and adulthood, and between the morality learned by the child and the ethics to be developed by the adult. The group discussed the common occurrence of anger and hostility on adolescent units. Also, a case of a patient on the unit was reviewed: Billy B., a 16-year-old white male, was diagnosed with oppositional/defiant behavior. He presented an angry affect and was using vulgar language, slamming doors, threatening staff on the unit, and throwing objects at staff and other patients. All the nurses requested information on acting-out behaviors by adolescents. It was explained to the staff that, depending on the degree to which the patient was experiencing and expressing these feelings, a variety of interventions was possible, ranging from observing the patient’s behavior, to verbal interventions, to the use of physical restraints (Wilson & Kneisl, 1988).When the adolescent’s acting-out behavior was neither selfdestructive nor physically harmful to others, three 37
Difficulties with Teens: Can Nursing Consultation Help?
important objectives were to (1)communicate positive expectations to the patient, ( 2 ) discover the reason for and meaning of the patient’s behavior, and (3) explore with the patient possible alternative methods of expressing feehgs (Loomis, 1970).Adolescents need space and usually do not like to be touched (although it is necessary to touch them during physical restraint). In appropriate situations where the adolescent’s behavior is not totally out of control, giving choices is important, such as permitting adolescent patients to walk to seclusion on their own, rather than being helped by the staff. Articles regarding nursing interventions with angry patients, limit setting, and acting-out behaviors by adolescents were provided for staff to review during the initial session. A discussion and videotape regarding crisis-intervention strategies were also part of a separate consultation meeting.
All the nurses identified the need for information regarding consistency of therapeutic interventions and developing a therapeutic milieu.
An additional 14 consultation sessions concentrated on the other major areas of concern identified by chdd care specialists and nurses. For example, all the nurses wanted more information on limit setting with adolescents. The consultant presented information to staff members on how limit setting can help adolescents better understand and follow the rules within the miheu. Staff members learned that adolescent behavior may include unpredictability, competitive struggling, and testing of limits (Puskar, 1981). According to Puskar, ”Adolescentswho experience a m b i p t y about role, conhcting emotions, and ambivalence of independence and 38
dependence, do not need an environment or structure that consists of double messages, unclear rules, and uncertainties” (p. 15).These are some reasons why structure in the milieu is important in treating the adolescent. The attendees learned that although adolescents often express inpstice at limits, they are asking for h u t s as an indication of caring. During periods of acting out or outof-control behavior and the need for limit setting, adolescents can often establish control over their own behavior more easily if adults w i t h their environment are in control of themselves and the situation. This control is essential for talung a proactive, patient-centered approach to resolving conflict rather than a reactive, emotional one (Montgomery, 1987). Staff members were encouraged to think in terms of a problem behavior rather than a problem patient-to define offending behavior and then confront the behavior, not the person (Montgomery). Limit setting should have as its emphasis the development of the adolescent’s responsibihty for his or her own behavior (Long, 1985): ”Limit-testing during adolescence is a process of reality testing, whch is important for the adolescent’s future development” (p. 24). Roleplaymg sessions with staff utilized information on difficult patients on the unit. All the nurses identified the need for information regarding consistency of therapeutic interventions and developing a therapeutic milieu. Some of the reasons that explain the importance of the peer-group setting for inpatient milieu treatment include: adolescents’ need for peer acceptance, their overwhelming uncertainties and fears, and their ever-changing attitudes and behaviors about identity (Wilson & Kneisl, 1988). A review of consistency of therapeutic interventions toward patients included a discussion on the importance of free-flowing verbal and written communication regarding the status of patients on the unit throughout the shift and the importance of adequate communication from shift to shift. The consultant reviewed the community itself on the unit, with its various functions and structure, along with ways in which the milieu was therapeutic for the adolescent patient. JCPNVoL 5, No. 3, July-September,1992
All the nurses identified a third major concern: the need for more information regarding effective communication, both with patients and among staff members. Staff members learned they needed to understand that, in adolescence, feelings and conflicts tend to be acted out rather thanverbalized in socially acceptable ways. The consultant explained that staff members can obtain many clues by observing behavior, dress, or environment when communicating with adolescents (Wilson & Kneisl, 1988).Also, u t h i n g skills of interviewing and using nonverbal cues are important points to remember. Staff members working with adolescents must be skilled in dealing with four major types of communication commonly used by adolescents-silence, arguing, testing, and refusing. Positive approaches to the nurse-adolescent relationship include ”the establishment of a therapeutic alliance, the use of reality-based limits, and an emphasis on insight-producing communication techniques” (Long, 1985, p. 26). The group discussed examples of each technique. In order to help the staff communicate more effectively with each other (nursenurse, nursechild care specialist), the following skills that promote understanding of self and others were reviewed: (a) listening, (b)leading, (c)reflecting, (d) summarizing, (e) confronting, (0 interpreting,and (g) informing (Brammer, 1979).The group reviewed job descriptions of the nurse and child care specialist in order to increase their knowledge of the responsibilities of each position. They discussed the importance of staff being able to work together as a team in a milieu setting. The team approach is especially needed in situations where each patient would have a primary nurse and a primary child care specialist assigned for the duration of the hospitalization. One staff nurse was interested in becoming more assertive. Information was presented regarding knowing oneself and doing self-assessments of how effectively one can deal with patients and staff in various situations. Role-playing sessions were used to practice assertive techniques. The sessions were useful since adolescents benefit from assertive, honest feedback from staff. One nurse requested information on positive reinforcement-iving attention for positive behaviors. The consultant explained that positive behaviors were likely J O NVoL 5, No. 3, July-September,1992
to continue if the staff acknowledged and gave praise, rather than pay attention to the patient only during times of negative behavior. Positive reinforcement also is a method of building self-esteem. Other learning needs identified by the combined group of nurses and child care specialists were documentation of observation; role of the charge nurse; dealing with the quiet, withdrawn, or suicidal adolescent; support and feedback from supervisors; and the use of groups in the milieu. Group discussion focused on case studies specific to each learning need and on the importance of staff members supporting each other on the unit. Information was presented regarding the use of groups and how they can help patients practice problemsolving skills, recognize the opinions of others, and have clearer realization of ways one’s personality and actions appear to others. Various functions of the group leader were reviewed.
Other learning needs were documentation of observation; role of the charge nurse; dealing with the quiet, withdrawn, or suicidal adolescent; support and feedback from supervisors; and the use of groups in the milieu.
In a discussion on special observations for suicidal patients, this case was discussed: Susan C., an 18-year-old white female, had a history of depression and two previous suicide attempts. Susan presented a flat affect and current suicidal ideation. She would engage in conversation only when approached. 39
Difficulties with Teens: Can Nursing Consultation Help?
Therapeutic interventions with depressed, suicidal patients and differences in therapeutic observation, q5minute observation, constant observation, and special constant observation were defined. Therapeutic interventions that need to be actively taught include positive coping skills, use of outside resources, engaging the patient in problem solving, and involving the family: "Cogmtivebehavioral approaches also meet the need for brevity and activity" (Trautman, 1989, p. 3-260). One consultation session consisted of the film, "Everybody Rides the Carousel (part 11)" (Hubley & Hubley, 1976),based on the stages of Enk Enkson's life cycle . Discussion focused on tasks specific to adolescence as itlustrated in the film.The group also explored issues relating to identity, identity confusion, intimacy, independence, and multiple career options of the adolescent. Staff members understood they needed to remember ambivalence was a normal response to life situations in even the most troubled adolescent (Fox, 1980). Fox further states that staff members continually need to assess their own ambivalence toward adolescents, because self-awareness can be a vital component of the therapeutic relationshp.
Evaluation
During the h a 1 meeting, staff were given evaluation questionnaires regarding their experience in the consultation sessions. The results suggested that staff benefitted from the session. Staff members reported that they especially benefitted from the individual case studies of problems related to the d e u , d e u content in general, and also from the film on adolescence. Staff members made recommendations to have staff nurses and child care specialists present from the begiruung of the sessions, if possible, and to have more time for the meetings so additional material could be covered.
The adolescent consultation project described in ths article assessed the needs of nursing staff working with 40
adolescents in a recently opened private psychiatric hospital. During the initial meeting, nurses gave input regarding their needs and concerns through learning contracts. At additional sessions, both nurses and child care specialists verbally addressed their learning needs. Consultation sessions were evaluated during the last meeting. This project examined the effectiveness of consultation sessions in expanding the knowledge base of staff members involved in the meetings.
Conclusion Appropriate treatment for adolescents involves using special knowledge and skills during interventions. Findings from this consultation suggest that the concerns of adolescent psychiatric nurses and cluld care specialists are important in recognizing the need for an expanded knowledge base. The evaluation questionnaires from this project showed the nursing consultation sessions were positive and useful for staff members. Psychiatric nursing consultation services assisted staff members to increase their knowledge about adolescents and helped them to be at ease in their professional roles. The Medical Director stated he was pleased with the gains made by the staff, both individually and as a group. A limitation of t h s project was that only one adolescent unit was involved, and that concerns and learning needs were addressed by six nurses-evident through learning contracts, and verbally by a combined group of nurses and child care specialists. One can speculate, however, that because these nurses and child care specialists had concerns when working with adolescents, other nurses and child care specialists working in this area may have the same or additional concerns. More studies are needed involving additional adolescent units a n d staff members: these studies could examine whether dormation from consultation sessions was utilized by the staff involved, and whether the interventions were cost-effective. Also, patient behaviors and outcomes of treatment before and after consultation need to be explored. JCPNVoL 5, No. 3, July-September,1992
References
Puskar, K. (1981). Structure for the hospitalized adolescent.]ounlal of Psychiatric Nursing and Mental Health Seruices,19(7), 13-16.
American Nurses Association. (1985). Standards of child and adolescent psychiatric and mental health nursing practice (pp. 5-6,12, 14). Kansas City, M O Author.
Ritzer, L. (1989, October 22). Experts note suicide warning signs, give reasons for increase among teens. Obmer-Reporter, pp. A-1, A-2.
Brammer, L. (1979). The helping relationship: Process and skills (2d ed.). E n g l e w d Cliffs, NJ: RenticeHall. Brandenburg, N., Friedman, R., & Silver, S. (1988). The epidemiology of childhood psychiatric disorders: Recent prmhce findings und inethdologic issues. Tampa, n:University of South Florida, Research & Training Center for Improved servicesfor Emotionally Disturbed Children. Committee of the Institute of Medicine (Division of Mental Health and Behavioral Medicine).(1989).Research on children and adolescents with mental, behavioral, and developmental disorders. Washington, DC: National Academy Press.
Trautman, P. (1989). Spechc treatment modalities for adolescent suicide attempters. In Report of the secretary's task force on youth suicide, Vol. 3: Prevention and intervention in youth suicide (DHSS Publication No. ADM 89-1623,3-253-3-261). Washington, Dc:US. Government Printing Office. Wilson, H., & KneisI, C. (1988).Applying the nursing process with adolescents. Psychiatric nursing (3d ed.) (pp. 956974). Reading, MA: Addison-Wesley. Reprints of this article are available from UMI Article Clearinghouse: 800/521-0600. From Alaska & Michigan: call collect 313/761-4700. From Canada: 800/343-5299.
Erikson, E. (1963).Childhood and society.New York Norton. Fox, K. (1980). Adolescent ambivalence: A therapeutic issue. ]ournul of Psychiatric Nursing and Mental Health S m i e s , 18(9),29-33. Hubley, J. (Producer), & Hubley, F. (Director).(1976). Everybody rides the carousel,Part I1 [Film].Santa Monica, CA: Pyramid Films.
Advocates for Child Psychiatric Nursing, Inc.
Lidz, T. (1968).The person. New York Basic Books Long, K. (1985).Pitfalls to avoid and positive approaches in the nurseadolescent relationship.Perspectives in Psychiatric Care, 23(1), 22-26. Loomis, M. (1970). Nursing management of acting-out behaviors. Perspectives in Psychiatric Care, 8(4), 168-173. McBride, A. (1988).Coming of age: Child psychiatric nursing. Archives in Psychiatric Nursing, 2(4), 5 7 4 . Montgomery, C. (1987). How to set limits when a patient demands too much. Amm'can ]ournu/ of Nursing, 87,365-366. National Institute of Mental Health. (1986).A n update on child and adolescent psychiatric hospitalization (unpublished survey). Rockville, MD: Author. Opie, N. (1988).Improving nursing care senices for children and ad* lescents with severe emotional disorders. Iournal of Child and Adolescent Psychiatric and Mental Health Nursing, 2(1), 14-19. Pother, P. (1988). Child mental health problems and policy.Archizvs of Psychiatric Nursing, 2,185169. JCPNVol. 5, No. 3, July-September,1992
What organization sets the standards for child and adolescent psychiatric and mental health nursing? ACPN Join other nurses in your clinical specialty for networking, information exchange, and professional growth in ACPN. Join ACPN and receive JCPN as a membership benefit. For more information, call 800/352-2441 or 904/474-9231. Or write to: ACPN National Office, 437 Twin Bay Drive, Pensacola FL 32534
41
Childlyou th prob l m s and psychiatric hospital iuz-
tions are increasing. A literature r e v i m suggests that there is an increased need for more nurses with
Kathryn R. Puskar, DrPH, R N , CS, is Director and Assistant Professor, Graduate Program in Psychiatric Mental Health Nursing, University of Pittsburgh. Kath y n Wargoe, M S N , R N , is a graduate student, Psychiatric Mental Heath Nursing, School of Nursing, University of Pittsburgh, and works on an adolescent inpatient unit.
the knowledge and skills necessay to work in this specialty area. The review also suggests that providing psychiatric nursing consultation services is one way to help direct care staf to strengthen or develop these skills. The authors describe a consultation project that took place on a neully developed 15-bed adolescent program in a 30-bed private psychiatric hospital . They examine the effectiveness of consultation sessions, ascertained through both zwbal and writ-
ten eualuntions of staff members. The outcome suggests that psychiatric nursing consultation swslices
can be an important contribution in expanding the knowledge base of direct care staf (child care specialists and nurses) zuho work with the hospitalized adolescent psychiatric patient.
34
As the adolescent psychiatric inpatient population increases, so does the need for psychiatric nurses specialized in adolescent care. A conservative estimate from the Office of Technology Assessment‘s Report on Children’s Mental Health in 1986 concluded that at least 7.5 million children (12%)were in need of some sort of mental health service (Committee of the Institute of Medicine [CIM], 1989).Nearly half these chddren are deemed severely disordered or handicapped by their mental illness. However, a series of recent studies suggested that prevalence may now range between 17% and 22%, or 11-14 million chddren, depending on a variety of factors (CIM). Statistics show that in addition to those with diagnosable mental disorders, 4,924 young people between the ages of 15 and 24 killed themselves in 1987, and more than a million people in that age group make suicide attempts each year (Ritzer, 1989). A suicide attempt is not a diagnosis; it is associated with different causative factors and diagnoses such as major depressive disorder, aggression, conduct disorder, associated physical illness (including pregnancy), drug and alcohol abuse, parental psychatric Illness, marital conflict, and parent-child conflict (Trautman, 1989).Teenage substance abusers have also increased in numbers, along with children who are at risk for mental illness because of environmental factors such as poverty, inadequate care, parental illness, death, and divorce (Pothier, 1988).Hospitals have developed additional programs in order to meet the demand of adolescents in need of inpatient psychiatric treatment. More professionals are needed who have the knowledge, skill, and training to work with children, adolescents, and their families (Pother). JCPNVol. 5, No. 3, July-September,1992
A group called Advocates for Child Psychiatric Nursing emerged in 1972 after child psychiatric nurses voiced the need for such a national organization. Membership now totals approximately 400. Advocates for Child Psychatric Nursing participates in the Coalition of Psychiatric Nursing Organizations, along with the Society for Education and Research in Psychiatric Mental Health Nursing, the ANA Council on Psychiatric Mental Health, the American Psychiatric Nurses Association, and the National Nursing Society on Addictions. Because adolescent psychiatric nursing is itself a specialty, direct care nurses often require additional education in order to provide care and treatment for 13-18 year olds. Consultation services from nurses who are specialists in this area could be used to educate nurses who have chosen to work with adolescents. Consultation could be crucial to the survival of an adolescent program.
States (National Association of Private Psychiatric Hospitals [NAPPHI, 1989). According to data from the National Institute of Mental Health (NIMH, 1986), 112,215 children under age 18 were hospitalized for mental illness in all settings-state hospitals, general hospitals, private psychiatric hospitals, multiservice centers. Private psychiatric hospitals have become an important part of the mental health delivery system for children and adolescents. NAPPH and Medicare compiled data suggesting there were an estimated 403 private psychiatric hospitals in the United States (NAPPH). NIMH reported in 1986 (NAPPH) that 38% of admissions to private hospitals were children under age 18.
In 1986 38%of admissions to private Literature Review
hospitals were children under age 18. Child/Youth Problems A study by Brandenburg, Friedman, and Silver (1988) of the prevalence of emotional disturbance among children has been conducted in seven communities around the world, includingthe United States, since 1988. The tool used was the multimethod-multistage approach of rating scales followed by psychiatric interview. The studies were of sufficient magnitude to provide stable estimates of overall prevalence. The researchers suggested that ”in addition to similar methods of identifying cases in the community, the studies also reflect greater standardization of diagnoses through the use of operational criteria applied responses given to structured or semistructured interview schedules” (Brandenburg et al., p. 21). Based on the instrumentation and outcome of these studies, Brandenburg et al. concluded that the prevalence rates of emotionally disturbed children ranged from 14%-20%, and that behavioral disturbances are more likely to be severe and persistent rather thantransient. The Bureau of Census estimated in 1986 that there were 63,184,000 children under age 18 in the United JCPNVol. 5, No. 3, July-September,1992
ChildAdolescent Psychiatric Nursing McBride (1988) explained that in order for child psychiatric nursing to become a force in improving health care, several steps need to be taken. According to McBride, two of these steps were to increase research, especially in evaluation research to document the costeffectiveness of nursing interventions, and to involve child psychiatric nursing in the development of a classlfication system for psychiatric and mental health nursing. ’This is important in the subspecialty iden-g its own professionaldomain” (McBride, p. 62). According to the American Nurses Association on Psychiatric and Mental Health Nursing (1985), “The generalist is a nurse who is educated at the basic level for entry into professional nursing practice. A nurse generalist who practices child and adolescent psychiatric and mental health nursing needs to refine clinical skills through ongoing supervision of practice (p. 5). The nurse 35
Difficulties with Teens: Can Nursing Consultation Help?
provides a therapeutic environment in collaboration with the client, the farmly, and other health care pro-viders.” The nurse uses psychotherapeutic interventions to promote health, prevent Illness, and facilitate rehabditation. Fulfilling the profession’s obligations to improve the quality of care occurs when the psychiatric nurse is able to meet the necessary criteria of the standards of practice.
The increasing prevalence of
child/adolescent emotional disturbances and psychiatric hospitalizations means more nurses are needed who are competent
psychmtric clirucal nurse specdst (Opie, 1988). S u m m a r y of the Literature The review of literature suggests that the increasing prevalence of child/adolescent emotional disturbances and psychiatric hospitalizations means more nurses are needed who are competent in the knowledge and skills necessary to work in the specialty area. Opie (1988) explained, however, that not all nursing students receive direct experience with psychiatrically impaired children and adolescents. Registered nurses educated at the basic level for entry into professional nursing practice are generalists, and may not have the knowledge and skills necessary to work with the child/adolescent psychiatric inpatient. The literature also suggests that psychiatric nursing consultation is one way to help staff members develop and strengthen their skills.
in the knowledge and skills necessary to The Consultation Project
work in the specialty area. Assessment of Need
According to the Standards of Practice developed by the American Nurses Association on Psychiatric and Mental Health Nursing (19851, the clinical specialist in psychmtric mental health nursing is a ”nurse who holds a minimum of a mastefs degree, has had s u p e W hcal experience at the graduate level, and demonstrates depth and breadth of knowledge, competence, and skdl in the practice of chdd and adolescent psychatric and mental health nursing. . . The chical s p a k t may assume any of the roles of the generalst, in addtion to other roles, one of whch is ‘consultant to professional and non-pre fessional individuals or groups concerned with the general welfare, education,and care of children”’ (pp. 5-6). Registered nurses provide the great bulk of inpatient care. They have been most often the professionalsresponsible for the management and maintenance of the d e u . It is the nurse who is expected to implement the program. A need exists for greater collaboration with and use of the 36
This project took place in a newly developed 30-bed private child / adolescent psychiatric hospital in southwestern Pennsylvania. The adolescent program was a 15-bed inpatient unit. Adolescents were admitted for a variety of problems such as: oppositional/conduct disorders, affective disorders, suicidal gestures and attempts, schizophrenia, personality disorders. The staff consisted of psycluatrists, psychologsts, a nurse coordinator, staff nurses, child care specialists, and social workers. Plan for Consultation
Initially, the Director of Medical Services and the Drrector of Nursing requested consultation sessions to be for one hour a week over a threemonth period. In fact, the consultation period lasted seven months because of continued identified needs of the staff and approval from the Director of Medical Services, Director of Nursing, and Program Coordinator. JCPNVoL 5, No. 3, July-September,1992
Prior to meeting with the staff, an initial planning session was held with the Director of Nursing, Program Coordinator, and Director of Medical Services to discuss the specific focus of the consultation sessions. The Medical Director wanted clinical consultation for the staff to include such topics as: staff overreacting to patients; assistance in utilizing a team approach, nurses working with child care specialists; working with the adolescent and learning what to expect from her or him. After the planning meeting, the Director of Nursing and Program Coordinator requested individual consultation sessions. These meetings focused on information regarding the adolescent psychiatric inpatient and also on methods of helping staff members strengthen or develop skills necessary to provide quality care.
ConsultationProcess During the first consultation session, six staff nurses identified their perceived needs when working with adolescents. Learning contracts-brief questionnaires examining concerns of nurses, their goals for the experience and what they wanted to learn-were completed at that time. The learning contracts were part of the consultation assessment phase, and provided direction for some of the consultation meetings. According to the six learnjng contracts (seeFigure 11, all the nurses had concerns surrounding three major mas: (1) limit setting and acting-out behaviors, (2) consistency of therapeutic interventions and developing a therapeutic milieu, and (3) establishing effective communication with patients and other staff members. One staff member was interested in learning how to become more assertive; another wanted to learn ways of strengthening patients’ positive behavio~to use as a tool in their treatment. The first consultation session included a basic review of adolescence according to three key concepts, the “Three Is” of intimacy, identity, and independence (Lidz, JCPN Vol. 5, No. 3, July-September,1992
Figure 1. Percent of Concerns Reported by Nurses Employed on an Adolescent Unit 100%
Limit-setting/acting-out behavior
90%
’5 VI
80%
70%
60%
Increasing positive behaviors
0
g 50% 2 &J 40% .Id
30% 20%
10%
Concerns of Nurses on an Adolescent Unit
1968). Erikson (1963) described adolescence as a psychosocial stage between childhood and adulthood, and between the morality learned by the child and the ethics to be developed by the adult. The group discussed the common occurrence of anger and hostility on adolescent units. Also, a case of a patient on the unit was reviewed: Billy B., a 16-year-old white male, was diagnosed with oppositional/defiant behavior. He presented an angry affect and was using vulgar language, slamming doors, threatening staff on the unit, and throwing objects at staff and other patients. All the nurses requested information on acting-out behaviors by adolescents. It was explained to the staff that, depending on the degree to which the patient was experiencing and expressing these feelings, a variety of interventions was possible, ranging from observing the patient’s behavior, to verbal interventions, to the use of physical restraints (Wilson & Kneisl, 1988).When the adolescent’s acting-out behavior was neither selfdestructive nor physically harmful to others, three 37
Difficulties with Teens: Can Nursing Consultation Help?
important objectives were to (1)communicate positive expectations to the patient, ( 2 ) discover the reason for and meaning of the patient’s behavior, and (3) explore with the patient possible alternative methods of expressing feehgs (Loomis, 1970).Adolescents need space and usually do not like to be touched (although it is necessary to touch them during physical restraint). In appropriate situations where the adolescent’s behavior is not totally out of control, giving choices is important, such as permitting adolescent patients to walk to seclusion on their own, rather than being helped by the staff. Articles regarding nursing interventions with angry patients, limit setting, and acting-out behaviors by adolescents were provided for staff to review during the initial session. A discussion and videotape regarding crisis-intervention strategies were also part of a separate consultation meeting.
All the nurses identified the need for information regarding consistency of therapeutic interventions and developing a therapeutic milieu.
An additional 14 consultation sessions concentrated on the other major areas of concern identified by chdd care specialists and nurses. For example, all the nurses wanted more information on limit setting with adolescents. The consultant presented information to staff members on how limit setting can help adolescents better understand and follow the rules within the miheu. Staff members learned that adolescent behavior may include unpredictability, competitive struggling, and testing of limits (Puskar, 1981). According to Puskar, ”Adolescentswho experience a m b i p t y about role, conhcting emotions, and ambivalence of independence and 38
dependence, do not need an environment or structure that consists of double messages, unclear rules, and uncertainties” (p. 15).These are some reasons why structure in the milieu is important in treating the adolescent. The attendees learned that although adolescents often express inpstice at limits, they are asking for h u t s as an indication of caring. During periods of acting out or outof-control behavior and the need for limit setting, adolescents can often establish control over their own behavior more easily if adults w i t h their environment are in control of themselves and the situation. This control is essential for talung a proactive, patient-centered approach to resolving conflict rather than a reactive, emotional one (Montgomery, 1987). Staff members were encouraged to think in terms of a problem behavior rather than a problem patient-to define offending behavior and then confront the behavior, not the person (Montgomery). Limit setting should have as its emphasis the development of the adolescent’s responsibihty for his or her own behavior (Long, 1985): ”Limit-testing during adolescence is a process of reality testing, whch is important for the adolescent’s future development” (p. 24). Roleplaymg sessions with staff utilized information on difficult patients on the unit. All the nurses identified the need for information regarding consistency of therapeutic interventions and developing a therapeutic milieu. Some of the reasons that explain the importance of the peer-group setting for inpatient milieu treatment include: adolescents’ need for peer acceptance, their overwhelming uncertainties and fears, and their ever-changing attitudes and behaviors about identity (Wilson & Kneisl, 1988). A review of consistency of therapeutic interventions toward patients included a discussion on the importance of free-flowing verbal and written communication regarding the status of patients on the unit throughout the shift and the importance of adequate communication from shift to shift. The consultant reviewed the community itself on the unit, with its various functions and structure, along with ways in which the milieu was therapeutic for the adolescent patient. JCPNVoL 5, No. 3, July-September,1992
All the nurses identified a third major concern: the need for more information regarding effective communication, both with patients and among staff members. Staff members learned they needed to understand that, in adolescence, feelings and conflicts tend to be acted out rather thanverbalized in socially acceptable ways. The consultant explained that staff members can obtain many clues by observing behavior, dress, or environment when communicating with adolescents (Wilson & Kneisl, 1988).Also, u t h i n g skills of interviewing and using nonverbal cues are important points to remember. Staff members working with adolescents must be skilled in dealing with four major types of communication commonly used by adolescents-silence, arguing, testing, and refusing. Positive approaches to the nurse-adolescent relationship include ”the establishment of a therapeutic alliance, the use of reality-based limits, and an emphasis on insight-producing communication techniques” (Long, 1985, p. 26). The group discussed examples of each technique. In order to help the staff communicate more effectively with each other (nursenurse, nursechild care specialist), the following skills that promote understanding of self and others were reviewed: (a) listening, (b)leading, (c)reflecting, (d) summarizing, (e) confronting, (0 interpreting,and (g) informing (Brammer, 1979).The group reviewed job descriptions of the nurse and child care specialist in order to increase their knowledge of the responsibilities of each position. They discussed the importance of staff being able to work together as a team in a milieu setting. The team approach is especially needed in situations where each patient would have a primary nurse and a primary child care specialist assigned for the duration of the hospitalization. One staff nurse was interested in becoming more assertive. Information was presented regarding knowing oneself and doing self-assessments of how effectively one can deal with patients and staff in various situations. Role-playing sessions were used to practice assertive techniques. The sessions were useful since adolescents benefit from assertive, honest feedback from staff. One nurse requested information on positive reinforcement-iving attention for positive behaviors. The consultant explained that positive behaviors were likely J O NVoL 5, No. 3, July-September,1992
to continue if the staff acknowledged and gave praise, rather than pay attention to the patient only during times of negative behavior. Positive reinforcement also is a method of building self-esteem. Other learning needs identified by the combined group of nurses and child care specialists were documentation of observation; role of the charge nurse; dealing with the quiet, withdrawn, or suicidal adolescent; support and feedback from supervisors; and the use of groups in the milieu. Group discussion focused on case studies specific to each learning need and on the importance of staff members supporting each other on the unit. Information was presented regarding the use of groups and how they can help patients practice problemsolving skills, recognize the opinions of others, and have clearer realization of ways one’s personality and actions appear to others. Various functions of the group leader were reviewed.
Other learning needs were documentation of observation; role of the charge nurse; dealing with the quiet, withdrawn, or suicidal adolescent; support and feedback from supervisors; and the use of groups in the milieu.
In a discussion on special observations for suicidal patients, this case was discussed: Susan C., an 18-year-old white female, had a history of depression and two previous suicide attempts. Susan presented a flat affect and current suicidal ideation. She would engage in conversation only when approached. 39
Difficulties with Teens: Can Nursing Consultation Help?
Therapeutic interventions with depressed, suicidal patients and differences in therapeutic observation, q5minute observation, constant observation, and special constant observation were defined. Therapeutic interventions that need to be actively taught include positive coping skills, use of outside resources, engaging the patient in problem solving, and involving the family: "Cogmtivebehavioral approaches also meet the need for brevity and activity" (Trautman, 1989, p. 3-260). One consultation session consisted of the film, "Everybody Rides the Carousel (part 11)" (Hubley & Hubley, 1976),based on the stages of Enk Enkson's life cycle . Discussion focused on tasks specific to adolescence as itlustrated in the film.The group also explored issues relating to identity, identity confusion, intimacy, independence, and multiple career options of the adolescent. Staff members understood they needed to remember ambivalence was a normal response to life situations in even the most troubled adolescent (Fox, 1980). Fox further states that staff members continually need to assess their own ambivalence toward adolescents, because self-awareness can be a vital component of the therapeutic relationshp.
Evaluation
During the h a 1 meeting, staff were given evaluation questionnaires regarding their experience in the consultation sessions. The results suggested that staff benefitted from the session. Staff members reported that they especially benefitted from the individual case studies of problems related to the d e u , d e u content in general, and also from the film on adolescence. Staff members made recommendations to have staff nurses and child care specialists present from the begiruung of the sessions, if possible, and to have more time for the meetings so additional material could be covered.
The adolescent consultation project described in ths article assessed the needs of nursing staff working with 40
adolescents in a recently opened private psychiatric hospital. During the initial meeting, nurses gave input regarding their needs and concerns through learning contracts. At additional sessions, both nurses and child care specialists verbally addressed their learning needs. Consultation sessions were evaluated during the last meeting. This project examined the effectiveness of consultation sessions in expanding the knowledge base of staff members involved in the meetings.
Conclusion Appropriate treatment for adolescents involves using special knowledge and skills during interventions. Findings from this consultation suggest that the concerns of adolescent psychiatric nurses and cluld care specialists are important in recognizing the need for an expanded knowledge base. The evaluation questionnaires from this project showed the nursing consultation sessions were positive and useful for staff members. Psychiatric nursing consultation services assisted staff members to increase their knowledge about adolescents and helped them to be at ease in their professional roles. The Medical Director stated he was pleased with the gains made by the staff, both individually and as a group. A limitation of t h s project was that only one adolescent unit was involved, and that concerns and learning needs were addressed by six nurses-evident through learning contracts, and verbally by a combined group of nurses and child care specialists. One can speculate, however, that because these nurses and child care specialists had concerns when working with adolescents, other nurses and child care specialists working in this area may have the same or additional concerns. More studies are needed involving additional adolescent units a n d staff members: these studies could examine whether dormation from consultation sessions was utilized by the staff involved, and whether the interventions were cost-effective. Also, patient behaviors and outcomes of treatment before and after consultation need to be explored. JCPNVoL 5, No. 3, July-September,1992
References
Puskar, K. (1981). Structure for the hospitalized adolescent.]ounlal of Psychiatric Nursing and Mental Health Seruices,19(7), 13-16.
American Nurses Association. (1985). Standards of child and adolescent psychiatric and mental health nursing practice (pp. 5-6,12, 14). Kansas City, M O Author.
Ritzer, L. (1989, October 22). Experts note suicide warning signs, give reasons for increase among teens. Obmer-Reporter, pp. A-1, A-2.
Brammer, L. (1979). The helping relationship: Process and skills (2d ed.). E n g l e w d Cliffs, NJ: RenticeHall. Brandenburg, N., Friedman, R., & Silver, S. (1988). The epidemiology of childhood psychiatric disorders: Recent prmhce findings und inethdologic issues. Tampa, n:University of South Florida, Research & Training Center for Improved servicesfor Emotionally Disturbed Children. Committee of the Institute of Medicine (Division of Mental Health and Behavioral Medicine).(1989).Research on children and adolescents with mental, behavioral, and developmental disorders. Washington, DC: National Academy Press.
Trautman, P. (1989). Spechc treatment modalities for adolescent suicide attempters. In Report of the secretary's task force on youth suicide, Vol. 3: Prevention and intervention in youth suicide (DHSS Publication No. ADM 89-1623,3-253-3-261). Washington, Dc:US. Government Printing Office. Wilson, H., & KneisI, C. (1988).Applying the nursing process with adolescents. Psychiatric nursing (3d ed.) (pp. 956974). Reading, MA: Addison-Wesley. Reprints of this article are available from UMI Article Clearinghouse: 800/521-0600. From Alaska & Michigan: call collect 313/761-4700. From Canada: 800/343-5299.
Erikson, E. (1963).Childhood and society.New York Norton. Fox, K. (1980). Adolescent ambivalence: A therapeutic issue. ]ournul of Psychiatric Nursing and Mental Health S m i e s , 18(9),29-33. Hubley, J. (Producer), & Hubley, F. (Director).(1976). Everybody rides the carousel,Part I1 [Film].Santa Monica, CA: Pyramid Films.
Advocates for Child Psychiatric Nursing, Inc.
Lidz, T. (1968).The person. New York Basic Books Long, K. (1985).Pitfalls to avoid and positive approaches in the nurseadolescent relationship.Perspectives in Psychiatric Care, 23(1), 22-26. Loomis, M. (1970). Nursing management of acting-out behaviors. Perspectives in Psychiatric Care, 8(4), 168-173. McBride, A. (1988).Coming of age: Child psychiatric nursing. Archives in Psychiatric Nursing, 2(4), 5 7 4 . Montgomery, C. (1987). How to set limits when a patient demands too much. Amm'can ]ournu/ of Nursing, 87,365-366. National Institute of Mental Health. (1986).A n update on child and adolescent psychiatric hospitalization (unpublished survey). Rockville, MD: Author. Opie, N. (1988).Improving nursing care senices for children and ad* lescents with severe emotional disorders. Iournal of Child and Adolescent Psychiatric and Mental Health Nursing, 2(1), 14-19. Pother, P. (1988). Child mental health problems and policy.Archizvs of Psychiatric Nursing, 2,185169. JCPNVol. 5, No. 3, July-September,1992
What organization sets the standards for child and adolescent psychiatric and mental health nursing? ACPN Join other nurses in your clinical specialty for networking, information exchange, and professional growth in ACPN. Join ACPN and receive JCPN as a membership benefit. For more information, call 800/352-2441 or 904/474-9231. Or write to: ACPN National Office, 437 Twin Bay Drive, Pensacola FL 32534
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