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Nursing “Best Practices” for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care

Nursing “Best Practices” for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care. Catherine P. Gros, N, MSc (A )

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Nursing “Best Practices” for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care

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  1. Nursing “Best Practices” for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care Catherine P. Gros, N, MSc (A) Assistant Professor, McGill University School of Nursing Nurse Clinical Specialist, Douglas Mental Health Institute Tamsin Mulvogue, MSc(A); Sacha Jarvis, MSc(A); Johanne Renaud, MD 3rd Nursing Research & Evidence-Based Practice Symposium: The Power of TEAM Inquiry University of Vermont & FAHC November 12, 2011

  2. The Power of TEAM Inquiry: What’s wrong with this picture?

  3. The Power of TEAM Inquiry: Who Decides? • In Collaborative Nursing Practice, Patients & families are • ESSENTIAL team members • ACTIVE PARTICIPANTS in assessment, planning & evaluation of care • Patient & Family-Centered Care: • means the person & family are at the center of care! • Therefore, • Nursing “Best Practices” are ultimately determined • by patients & families… • What are the perceptions of adolescents regarding “helpful” Nursing care during suicide risk?

  4. Suicide in Context: • Suicide is a principal cause of death in the adolescent population in Québec & a significant health concern worldwide • Suicide is a complex phenomenon: • Influenced by an open system of biophysical-social-environmental interactions • Related to personal life experiences, gene expression & human bio-pscho-social development

  5. Epigenetic Research Findings: • Human studies: traumatic relational life experiences (child abuse) alters gene expression, leading to changes in the brain & increased susceptibility to anxiety, depression and suicide (McGowan et al, 2009) • Animal Studies: Rat pups experiencing caring maternal interactions showed healthy brain development & were significantly calmer than ‘high stress’ rats from low care mothers. • Conclusion: caring interactions affect gene expression & determine hypothalamic-pituitary-adrenal (HPA) functioning, affecting healthy brain development and behaviour (McGowan, et al, 2009).

  6. Helping Suicidal Patients: The Nurses’ Role Frontline nurses spend more time intervening with hospitalized patients than any other professional group; admission to discharge • During suicide risk: • Nurse-patient contact is intense Intervention is: • close” to “continuous” 24/7 • High dose nursing care = High impact on patient outcomes

  7. In the Literature: The vast majority of healthcare research related to suicide focuses on interventions delivered by professionals other than nurses

  8. Regarding Nursing Interventions & Suicide Risk… • Existing research is: • Qualitative • Rare (few in number) • Narrow in scope • Current studies focus on: • Prescribed treatments & control measures1-5 • Evaluating risks • Searching for & removing dangerous objects • Implementing close or constant “surveillance”

  9. Research on Nursing Intervention during Suicide Risk… • Target outcomes focus mainly on: • Patient safety • Physical protection • Preventing self-harm1-5 • However… • The Nurse’s attitude & interpersonal approach has a significant impact on patient health outcomes. • Existing qualitative data indicate: • Suicidal patients on “close observation” report increased or decreased feelings of hope & self esteem resulting from their interactions with nursing staff 6,7

  10. In Conclusion… • Little attention has been paid to the interventions nurses • implement in their daily interactions with suicidal in-patients • Relational nursing interventions offered throughout the • course of hospitalization are poorly described • Little is known about the impact of nursing care on patient • health outcomes • The patient’s perspective of “helpful” • Nursing interventions during • suicide risk requires further study...

  11. Research Question: What Helps? What are the perceptions of adolescents at risk for suicide regarding “helpful” nursing care during hospitalization?

  12. Study Methodology Mixed Methods: Qualitative, interpretive, descriptive study • Semi-structuredinterveiwswithteensatrisk for suicide AND Quantitativemeasure • Exploratory Survey Questionnaire on « helpful » nursing ConvenienceSample teens 14-19 years • French or English speaking • Presentingwith suicide risk (anylevel) duringcurrent or previoushospitalization

  13. ResearchSample: n=9

  14. Results: Based on Interviews with Suicidal Teens: Helpful Nursing Interventions occur across 3 Domains of Care Developing aunique & caring human relationship Working in partnership to manage illness & suicide risk Creating a health-promoting hospital environment

  15. Developing aunique & caringhumanrelationship SMILE!“Be kind & friendly”. “If someone’s smiling, you’re smiling; it can spread.” GET UP-CLOSE & PERSONAL: “Be intimate.” “[Don’t] talk in the doorway…Come in & sit downon my bed.” IDENTIFY & ACCOMMODATE INDIVIDUAL PREFERENCES: “Notice [what’s] unique to me... If there’s something special I want, like chocolate milk, make sure [it’s] there for me.” INITIATE CONVERSATION: “Talk to me.” “It really helps when someone tries to start a conversation”…“Ask about my life & take an interest in what we do. Asking everyday questions like: ‘How’s your day going?’ helps us feel safe.”

  16. Working in partnership to manage illness & suicide risk LISTEN WTHOUT IMPOSING CONSEQUENCES:“If I speak of suicidal ideas, be present & listen. Don’t panic & take away my privileges. We just need to talk when we’re feeling bad.” UNDERSTAND THE PAIN: “…probably the most important thing, [is ]actually understanding, not just on a scientific level, but on an emotional level, how deep the despair is” EARN TRUST: “[having a nurse you can trust] helps you get better, because …it’s really hard to find people you trust when you’re in that situation” [suicidal]  LEARN TO TRUST:“Believe in us. We’re the best judge. No one knows better than me if I’m going to kill myself.”

  17. Working in partnership to manage illness & suicide risk OFFER PERSPECITVE: “Give a different point of view… ’cuz when you’re in that mindset, your vision is very tunneled, so to open [the patient’s] mind really could make a difference” IDENTIFY & WORK WITH STRENGTHS: “Focus on the positive”… “like notice the parents care”… “that will help so much, cuz… if you’re going to therapy, you’re saying your problems. It’s negative, negative…” “[pointing out the things you’re good at] makes you want to live. It really does. It makes you think that you’re not completely worthless.”

  18. Creating a health-promotinghospitalenvironment BE WELCOMING TO PATIENTS & FAMILIES: “The nurses would try to build this cooperative family atmosphere. Like: ‘Oh, right this way. Come on in’.” BRIDGE HOSPITAL & HOME LIFE: “Do normal activities” “… more like you’re having like your real life” “Make us feel like we’re not so detached from our normal world” ACCOMPANY PATIENTS OUTDOORS! “Just being able to feel the sun, being outside really helped me because… you got that feeling of liberation”… “It felt like I wasn’t in prison.”

  19. Summary of Findings: • This study offers detailed examples of “helpful” nursing interventions as reported by suicidal teens. • However,ONE SIZE DOESN’T FIT ALL! • Findings indicate that there is variability • amongst what individual patients find helpful • This is consistent with Collaborative, “Situation-Responsive” Nursing(The McGill Model / The Developmental Health Model)which involves timing & tailoring interventions to achieve • “goodness of fit” (Allen, 1977; Gottlieb & Feeley, 2005 & others) • What is helpful to THIS person/family? • in THIS situation? • at THIS time?

  20. Developing a Quantitative Measure: The Helpful Nursing Care Questionnaire (HNQ) Qualitative findings suggest the need to develop a quantitative measure The HNQ is a unique instrument designed to capture patient perceptions of “helpful” nursing care during suicide risk (Gros, 2010) Purpose & Objectives: To design a practical tool individual patients can use to report what nursing interventions are helpful to them Questionnaire content builds on qualitative research data & reflects evidence-based approaches to nursing & healthcare: • Nursing “best practices” (RNAO, 2002) • Collaborative, strengths-based approaches • McGill Model of Nursing 8, 9,10 • Patient-Centred Medicine 11 • Recovery Model12 • Positive psychology13,14

  21. The Helpful Nursing Care Questionnaire (HNQ) • 43 original items describing various nurse attitudes actions & behaviours • Perceived helpfulness is rated along a 5-point Likert Scale : Strongly agree---Strongly disagree

  22. Examples of Questionnaire Results: n=4

  23. Conclusions & Implications • Nursing interventions make a significant difference to the health & recovery of hospitalized teens at risk for suicide • Relational nursing interventions are low cost & relatively easy to apply. However: • They are neither routinely nor deliberately practiced • Their therapeutic value may be underestimated • Study Findings: • Illustrate the importance of collaborative, strengths-based nursing practice with suicidal in-patients • -Call for a critical review of current policies/procedures • Provide evidence for staff education & development • -Knowledge translation requires staff coaching & • support • Future research includes: To develop, validate & test the HNQ

  24. Acknowledgements With thanks to the adolescents who participated in this study ! • Réseauquébécois de recherchesur le suicide (RQRS)/FRSQ Douglas Mental Health University Institute & DSI • Dr.GustavoTurecki, Dr. AlainLesage • Marjorie Montreuil & Nursing staff, Stearns Pavilion McGill School of Nursing • Dr. Margaret Purden

  25. Selected References 1. Fletcher, R. F. (1999). The process of constant observation: Perspectives of staff and suicidal patients. Journal of Psychiatric and Mental Health Nursing, 6, 9-14. 2. Cutcliffe, J. R., & Stevenson, C. (2008). Feeling our way in dark: The psychiatric nursing care of suicidal people – A literature review. International Journal of Nursing Studies, 45, 942-953. 3. McLaughlin, C. (1999). An exploration of psychiatric nurses and patients’ opinions regarding in-patient care for suicidal patients. Issues and innovations in nursing practice, 29(5), 1042-1051. 4. Yonge, O. (2002). Psychiatric patients’ perceptions of constant care. Journal of Psychosocial Nursing & Mental Health Services, 40(6), 22-29. 5. Stewart, D., Bilgin, H. & Bowers, L. (2010). Special observation in psychiatric hospitals: A literature review. Report from the Conflict and Containment Reduction Research Programme, London: Institute of Psychiatry at the Maudsley. November, 2010. 6. Jones, J., Ward, M., Welman, N., Hall, J., & Lowe, T. (2000). Psychiatric inpatients’ experience of nursing observation. U.K perspective. Journal of Psychosocial Nursing & Mental Health Services, 38(12), 10-20. 7. Cardell, R., & Pitula, C. R. (1999). Suicidal inpatients’ perceptions of therapeutic and nontherapeutic aspects of constant observation. Psychiatric Services, 50(8), 1066-1070 8. Gottlieb, L. N., Feeley, N., with Dalton, C. (2005). The Collaborative Partnership Approach to Care: A Delicate Balance. Toronto, ON: Elsevier-Mosby 9. Pless, I.B., Feeley, N, Gottlieb, L.N, et al. (1994). A randomized trial of a nursing intervention to promote the adjustment of children with chronic physical disorders. Pediatrics. (94) 70-75 10. Gros, C. P., & Young, L. (2007). Teaching the McGill Model of Nursing and client-centered care: Collaborative strategies for staff education and development. In L. E. Young & B. L. Patterson (Eds.), Teaching Nursing: Developing a Student Centered Learning Environment (pp. 190-221). Philadelphia: Lippincott, Wms & Wilkins 11. Stewart, M.A. (1995). Effective physician-patient communication and health outcomes: a review. Can Med Assoc Journal . 152 , 1423-33. 12. Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal, 16(4), 1-23. 13. Park, N, Peterson, C & Brunwasser, SM (2009). Positive Psychology and therapy in: N.Kazantzis, MA Reinecke, A Freeman (eds). Cognitive and behavioural theories in clinicla practice. New York: guilford. 278-306. 14. Seligman, MEP, Steen, TA, Park, N & Peterson, C (2005). Positive psychology progress:Empirical validation of interventions. American Psychologist, 60, 410-21.

  26. Questions?

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