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Integrating Recovery Into Nursing Practice
I have practiced nursing for more than 20 years—16 of which were in psychiatric nursing. I worked in a psychiatric unit within a major medical center and a state psychiatric hospital, where it was common practice to use seclusion, restraint, and other physical containment strategies to “manage” what we viewed at the time as patients’ problematic behaviors. We were using interventions we had been taught and led to believe were the right things for our patients. Deep down, I questioned the suffering these patients went through while being contained. I felt their pain, especially when witnessing grown men and women scream and cry in agony as they were carried to seclusion. The staff’s adrenaline was pumping and their perceived goal was to keep everyone safe. But something seemed wrong with this arrangement.
I told the staff that one day we would look back and question these practices, just as we now reject ice baths, straightjackets, and lobotomies. We have come a long way in our treatments and the progress is due to the recovery movement. I took the opportunity to translate recovery concepts into practice by changing our use of seclusion and restraint.
Collaborating with a peer specialist, patient advocate, and three nurses, I taught the changes in seclusion and restraint to the staff. My goal was to influence change at three levels: organizational, staff, and patient.
At the organizational level, we aimed to create an environment with no tolerance for violence. I wanted to convey the message that physically containing a patient and using seclusion or restraint are violent acts. I also wanted people to understand the use of seclusion and restraint represented treatment failure, not successful intervention.
The staff needed tools to help patients deal with crises and distress. One strategy was to assist patients in developing individual safety plans so staff could use them at times of crisis. The safety plans would help staff coach patients in using self-selected skills during stressful times. Some examples are listening to music, taking a warm bath, talking to someone, or finding a comfort room to sit in silence.
The next step was to teach the staff about trauma-informed care. They had received training on the topic, but we did something unique to bring that training to life. Elaine Alberti, a clinical nurse specialist, worked with a group of patients on a photovoice project. The patients took pictures and created a narrative interpretation of messages they wanted to convey to staff regarding trauma, recovery, and stigma. They turned their pictures and narrative into a slideshow with music. The project sent a powerful message to the staff and many heard the patients’ voices in a new and different way.
We also reinforced the use of de-escalation tools. Our goal was to prevent crises from occurring by listening to patients, helping them problem solve, and encouraging the use of skills they had been learning in therapy groups.
The last strategy was to amplify the patient’s voice by working with a peer specialist and patient advocate—both of whom had experienced containment, restraint, and seclusion. It was the first time the peer specialist and patient advocate talked openly about their experience in a public forum. They spoke with conviction and passion and their message was raw but clear: this was not a way to treat a human being. Peer specialists ended their talks by saying “I may be deranged and psychotic, but remember I am a human being and need to be treated with dignity and respect.”
Since this initiative began, we have seen incredible results. Our seclusion and restraint hours have been reduced by 90 percent. In the past, patients had commonly stayed in seclusion for weeks, especially in our forensic unit. Our current goal is to release people from seclusion within 2 hours. We are meeting this benchmark 85 to 90 percent of the time and when we don’t, it is usually because a person required seclusion for 3 or fewer hours. The days are gone when a patient would remain in seclusion for days or weeks.
On the whole, staff are also more accepting of patients’ behaviors. When a patient expresses anger, staff are more willing to process feelings together, instead of engaging in a power struggle. Once the patient is heard, he or she feels validated and knows we care, thereby lessening the tension and conflict. We try to remember that so many patients have experienced trauma, and understand their behaviors are at times only best efforts at telling us “I need help.”
The most significant accomplishment we have made thus far was proving to staff that using less seclusion and restraint is possible. As a caring profession, when we listen and focus on each patient’s needs, we can and do make a difference. My aim was to be creative and strategic, to make training as powerful as possible, and to inform and complement the necessary bureaucratic changes with the voices of our patients. Our presentation viscerally moved people. I saw staff with tears in their eyes and many said it was the best training the hospital had ever offered. I think of recovery as bringing the voices of patients to the people who provide care and treatment. Once we hear their cries, we can, will, and do make a difference.
About the Author Jeffery Ramirez, PhD, PMHNP
Dr. Ramirez is an Assistant Professor at Gonzaga University in Spokane, Washington, and a Clinical Nurse Specialist at Eastern State Hospital in Medical Lake, Washington.