Managing Professional and Nurse-Patient Relationship Boundaries in Mental Health.

Caring nurse-patient relationships in mental health settings are key components in helping patients recover. These professional relationships provide a safe, trustworthy, reliable, and secure foundation for therapeutic interactions; however, nurses face challenges in setting and maintaining relationship boundaries. Although patients ask for special privileges, romantic interactions, and social media befriending, or offer expensive gifts, nurses must recognize that these boundary violations may erode trust and harm patients. These violations may also trigger discipline for nurses. Professional relationship guidelines must be applied with thoughtful consideration, and nurses must monitor their emotions and reactions in these relationships. The current article is a sharing of personal experiences about boundaries augmented by evidence in the literature, and focuses on managing potential boundary violations (i.e., social media, sexuality, over-involvement, and gift giving) in mental health settings. [Journal of Psychosocial Nursing and Mental Health Services, 55(1), 45-51.].

Trauma-informed care: keeping mental health settings safe for veterans.

Veterans, as military personnel returning from wars in Afghanistan and Iraq, are frequently coping with various mental health problems. These veterans are at high risk for posttraumatic stress disorder (PTSD) and associated behavioral consequences, including self-harm, verbal and physical aggression, and violence. In this article, we highlight the physiological, physical, and emotional consequences of trauma. We focus on the unique experiences that affect veterans' mental health and associated behaviors and advocate for veterans to receive evidenced-based treatment using trauma-informed and recovery-oriented care.

Evaluating and managing adult PTSD in primary care.

Posttraumatic stress disorder (PTSD) is an anxiety disorder with a sustained and dysfunctional emotional reaction to a traumatic event, threat of injury or death, and pain.

Improving professional practice through certification.

Certification helps ensure quality of practice and currency of nursing knowledge. We designed certification review courses and evaluated their impact on satisfaction, quality of care, adverse drug events (ADEs), and RN vacancies. Certification correlated with improved patient and nurse satisfaction, quality of care, and increased nurse rates of reporting ADEs, although the ADE total rates are consistent. Certification inversely correlated with nurse vacancies. Certification has helped to enhance nurses' knowledge, productivity, quality of care, and patient and nurse satisfaction, and has decreased RN vacancies.

Oncology nurses' knowledge of suicide evaluation and prevention.

BACKGROUND: Cancer patients can present with a risk of suicide, making it important for oncology nurses to be knowledge about the high-risk factors for suicide in this population and to be competent in suicide detection and management. OBJECTIVE: The aim of this study was to describe oncology nurses' identification of risk factors, knowledge, and skill at suicide evaluation and prevention based on evaluation of a vignette and to describe nurses' assessments and interventions for suicidal patients. METHODS: As part of a larger exploratory, national study, clinical oncology nurses (n = 1200) from the Oncology Nurses Society responded to a knowledge survey; a total of 454 evaluable questionnaires (37% response rate) were returned. RESULTS: Nurses reviewed a vignette of a suicidal patient and correctly identified these risk factors: widower (69.8%), wishes he/she were dead (82.8%), and gives away prized possessions (79.6%). Few nurses knew that ethnicity (0.4%), age (13.2%), or sex (16.4%) indicated suicide risk. Nurses incorrectly believed that worrying, crying, and executive position indicated suicide risk (40.6-42%). Most nurses rated themselves as having little to some skill and knowledge of suicide evaluation. CONCLUSION: Oncology nurses were able to identify certain behavioral risk factors at acceptable rates but not demographic risk factors. IMPLICATIONS FOR PRACTICE: Oncology nurses are likely to interact with patients at suicide risk and would benefit from knowledge about behavioral and demographic risk factors that contribute to an oncology patient becoming high risk for suicide. Such knowledge could contribute to overall patient safety.

The hoarding syndrome: screening and treatment.

Hoarding syndrome is a serious public health hazard. It may pose risk of fire, falls, infestation, and bacterial growth. Hoarding can reduce activities of daily living, adherence to treatment, and quality of life. The hoarder collects excessive quantities of poorly useable items of little value, fails to discard items, and has difficulty organizing tasks. Hoarding places the individual at risk for social, psychological, and physical outcomes, which lead to a decline in quality of life. This article examines the etiology, characteristics, signs and symptoms, evaluation, and treatment of hoarding syndrome. A case example illustrates the management of hoarding syndrome in home care.

Visual disfigurement and depression.

Approximately 10% of the population has a facial disfigurement, such as a scar, blemish, or deformity that severely affects the ability to lead a normal life, and 2 to 3% have a clearly visible blemish. They may experience depressive symptoms due to disfigurement, stressful life events, or other causes. Depression is a painful and costly disorder that is often unrecognized and untreated in specialty practices; it is linked with higher costs of care, lengths of stay, and rates of rehospitalization. Often, these individuals seek plastic surgery to repair the disfigurement, and depressive symptoms are not uncommon preoperatively, perioperatively, and postoperatively. In addition, depressive disorders exist among 20 to 32% of people with a medical disease. Major depression is a recurring and disabling illness that typically responds to treatment with psychotherapy, antidepressants, and social support. Nurses have a major role to play in screening for and detecting depression so it can be evaluated and referred for treatment. Nurses also provide education, psychosocial support, and advocacy for patients with depression. Identifying those with depressed symptoms allows the nurse to recommend treatment, offer referrals, and provide supportive interventions.

Innovative strategies for nurse recruitment and retention in behavioral health.

Successfully recruiting licensed nurses to work in behavioral health is challenging. This article describes and illustrates methods one hospital successfully used to attract, orient, and mentor new graduate nurses to work in mental health. The New Horizons program included a paid internship for new graduate vocational nurses, a mental health curriculum, preceptorship, a state board review course, and a new graduate program. Since 2003, the program has recruited 37 new graduates for the unfilled licensed staff vacancies in mental health who continued their professional education and pursued degrees as registered nurses. The evaluations indicated that more than 100% of graduates rated the program as excellent as well as recommended it to their friends, and retention has been more than 90%. New Horizons graduates have received promotions; one has assumed a new role as a clinical resource nurse who teaches nursing orientation. All stakeholders including nurse management, patients, other disciplines, and coworkers have high praise for the program graduates. The program increased the cultural diversity of the mental health staff because the graduates included high percentages of African Americans, Hispanic Americans, and Asian Americans and less than 10% of White Americans. Adult learning technologies were used including teaching with films, role-playing, case studies, reflective thinking, evidence-based practice, and group performance improvement projects. Research-based fact sheets were used for the course and continued education. These 1-page fact sheets help nurses apply the evidence to improve nursing practice.

Oncology nurses' teaching and support for suicidal patients.

Although the nursing literature contains many references to the nurses' teaching, support, and advocacy functions, the consumer and other health care professional literature suggests that the potential importance of nurses in these roles is not widely accepted. In a secondary analysis, we examined nurses' interventions for teaching and support in survey of a random sample of oncology nurses in a national organization. Clinical oncology nurses (n = 454) reported their attitudes to and knowledge about suicidal patients. They reported their goals, interventions, and emotional support for a suicidal patient. When nurses described their care, they rarely mentioned patient teaching, emotional support, and advocacy. A gap also existed between the recommended assessments, related goals, and interventions. The nurses' difficulties in responding therapeutically to suicidal patients also emerged from their religious/other values, uncomfortable feelings, inadequate knowledge, personal experiences, and weight of professional responsibility. A small percentage of oncology nurses with good psychiatric skills reported they had no difficulty in their caregiving role including teaching, support, and advocacy.

Hypnosis for pain management.

Nurses are in a key position to learn and use hypnosis with patients to reduce pain and enhance self-esteem. However, most nurses lack knowledge about the clinical effectiveness of hypnosis and may seek continuing education to become skilled in its use. Painful procedures, treatments, or diseases remain a major nursing challenge, and nurses need complementary ways to relieve pain from surgery, tumors, injuries, and chemotherapy. This article examines the evidence base related to hypnosis for pain management, as well as how to assess and educate patients about hypnosis.

Screening for depression and suicide: self-report instruments that work.

Self-report instruments for depression and suicide risk can help busy clinicians identify adult clients who may be at risk for depressive disorders. These instruments provide a baseline measure of clients' behavioral status, reflect response to treatment, and improve clinical decision making. Such scales can also detect symptoms of depression regardless of whether they are reported or observed. Clinicians' recognition of depression is improved when self-report screening tools are used. When it is not feasible to conduct a thorough psychiatric evaluation, screening instruments can identify at-risk clients who need further evaluation.

Evaluation of innovative research-based fact sheets.

Research-based fact sheets are simple, clear, and concise one-page reviews of a topic (e.g., culture and ethnicity, homelessness) with tips to improve culturally competent care. Using research helps nurses achieve promotion, advance careers, and enhance patient care. The background, literature, purpose, methods, and evaluation of fact sheets are reported. In a survey, 142 nurses reported that the fact sheets about general topics (end of life, depression, heart failure, smoking cessation, ethnicity, homelessness, hypertension, conflict management, medication safety, and pressure ulcers) were 99% excellent in efficiency, usefulness in practice, effectiveness, and importance in improving practice. Nurses (93.5%) said they improved the professional's knowledge. Fact sheets 8 and 9 (i.e., schizophrenia and advance directives) were rated as excellent by 88-97% of nurses. Nurses use fact sheets with an average of seven patients to improve education, assessment, intervention, and follow-up care.

Recruiting licensed staff in mental health.

This 4- to 6-month mental health internship program for new graduates vocational nurses (GVNs) involves a 4-month mental health course, a new graduate course, management of assaultive behavior course, and a 1:1 preceptorship in mental health. This successful program has recruited and trained 18 VNs to improve licensed staff/patient ratios in mental health. These new graduates are licensed at the end of 4 months and are working successfully as licensed staff on the psychiatric units. All of these licensed vocational nurses (LVNs) are now completing prerequisites or entering registered nurse (RN) programs to earn an advanced degree. They bring their medical skills, positive attitudes, and therapeutic strategies to contribute to the milieu on the nursing units. They have reduced the facility's licensed staff shortage in mental health.

Sexual abuse of boys.

TOPIC: Sexual abuse in childhood can disable self-esteem, self-concept, relationships, and ability to trust. It can also leave psychological trauma that compromises a boy's confidence in adults. While some boys who willingly participate may adjust to sexual abuse, many others face complications, such as reduced quality of life, impaired social relationships, less than optimal daily functioning, and self-destructive behavior. These problems can respond to treatment if detected. PURPOSE: In this paper, we examine the prevalence, characteristics, psychological consequences, treatment, and coping patterns of boys who have been sexually abused and their failure to disclose abuse unless asked during a therapeutic encounter. Nurses have a responsibility to detect the clues to sexual abuse, diagnose the psychological consequences, and advocate for protection and treatment. SOURCES USED: Computerized literature search of the Medline and PsychInfo literature and books on sexual abuse of boys. CONCLUSIONS: Psychological responses to abuse such as anxiety, denial, self-hypnosis, dissociation, and self-mutilation are common. Coping strategies may include being the angry avenger, the passive victim, rescuer, daredevil, or conformist. Sexual abuse may precipitate runaway behavior, chronic use of sick days, poor school or job performance, costly medical, emergency and or mental health visits. In worst cases, the boy may decide that life is not worth living and plan suicide. The nurse has a key role to play in screening, assessing, and treating sexual abuse children.