Effect of Psychiatric Liaison Nurse Specialist Consultation on the Care of Medical-SurgicalPatients WithSitters Sandra Talley, Dianne S. Davis, Nora Goicoechea, and Linda L. Barber
Linda Brown,
One hundred seven patients in an acute care setting who had lay sitters to provide the constant observation judged necessary to meet their safety needs were studied to determine the effect of psychiatric liaison nurse specialist (PLNS) consultation on nursing care and the use of sitters. After placement in either a suicidal or nonsuicidal group, subjects were randomiy assigned to recieve consultation or not. Outcome variables of number of sitter shifts, number of nursing note observations, number of patient and sitter incidents and length of hospital stay were considered. Multiple analysis of variance indicated no significant differences among the groups for number of sitter shifts or number of nursing note observations. A significant main effect for group on length of hospital stay was found with suicidal patients having a significantly shelter hospital stay. Number of patients and sitter incidents were too small for analysis.
0 1990 by W.B. Saunders Company.
G
ENERAL hospitals face greater acuity and complexity of patient care problems. Of particular concern are the burdens of caring for patients who are confused, may be harmful to themselves or others, and whose behavior is unpredictable or difficult to manage. As a supplement to nursing care, many departments of nursing have hired lay sitters to monitor and protect these high-risk patients. These sitters are not expected to provide nursing care, but rather, to provide constant observation and meet the immediate safety needs of these patients. While many of the problems underlying these behaviors are considered psychiatric in nature, the patients assigned sitters are rarely referred for psychiatric liaison nursing consultation. This study was designed to examine the effect of psychiatric liaison nurse specialist From the School of Nursing, Yale University, and the Yale-New Haven Hospital, New Haven, Connecticut. Supported in part by funding from Sigma Theta Tay Delta Mu Chapter. Address reprint requests to Sandra Talley, R.N., C.S., M.N., 850 16th Ave., Salt Lake City, UT84103. 0 1990 by W.B. Saunders Company. 08a3-9471/90/0402-cOO7$3.00/0
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(PLNS) consultation on the care of patients assigned sitters. LITERATURE REVIEW AND BACKGROUND OF THE STUDY
The need for constant observation of confused, suicidal, or unpredictable patients is well known to clinicians, but less frequently reported in the literature. Goldberg (1987) surveyed New England general hospitals for policies and practices of constant observation with suicidal patients. He found 92% of the 73 hospitals reported the use of constant observation with suicidal patients. From the hospitals reporting statistical data, from one to 480 patients were seen per year, with an average of 5.5 shifts provided. The use of sitters for constant observation of suicidal patients must be part of a systematic approach to the care of the suicidal patient in the general hospital setting. A suicidal precautions policy designed by Hogarty and Rodaitis (1987) addressed the need for a thorough evaluation, determination of appropriate degree of observation (minimal to high), interdisciplinary review of the need for observation, and a time-limited order for observation that was reviewed every 48
Archives of Psychiatric Nursing, Vol. IV, No. 2 (April), 1990: pp. 114-123
PLNS CONSULTATION
hours. Most importantly, their policy assigned responsibility for the sitter, and ultimately the patient, to the registered nurse or primary nurse caring for the patient under suicide precautions. Another group of patients necessitating increased observation and interventions to prevent harm are those who become confused and/or those who may fall (Williams, Campbell, Raynor, Musholt, Mlynarczyk, & Crane, 1985; Janken, Reynolds, & Swiech, 1986). For this group, their unpredictable behavior and inability to comply with physical restrictions places them at great risk. In the absence of staff for one-to-one contact, the use of physical restraint has been identified as a common, albeit controversial, intervention for patients with a potential for harm to self or others (Silver, 1987; Strumph & Evans, 1988). Model policies have been put forth for the use of restraint in order to ensure that patients receive ongoing assessment and appropriate nursing care (Morrison, Crinklaw-Wiancko, King, Thibeault, & Wells, 1987). Though Williams, Campbell, Raynor, Mlynarczyk, and Ward ( 1985) have noted “increased nursing surveillance always is indicated when persons are confused, at times to the point of constant attendance” (p. 329), few others mention constant observation as an alternative to ensure patient safety. The provision of safety should not. however, compromise opportunities for nursing interventions that would result in less restrictive forms of treatment. In their study of elderly patients with hip fractures, Williams and her colleagues (1985), using interventions carried out by the nursing staff, were able to reduce the severity and duration of confusion from 51.5% to 43.9%. The most effective interventions were orientation, clarification, continuity of care, and reduction of sensory deficits. The addition of a psychiatric clinical nurse specialist intervention with the subjects did not result in greater patient improvement. These findings may indicate that both comprehensiveness of interventions and involvement of the primary nurse are critical to successful patient outcomes. The consistent application of selected interventions known to reverse or stabilize mental, emotional, or behavioral problems is the major consultation technique for advanced nursing practice. Psychiatric liaison nursing has traditionally focused on the care of difficult patients in the general hospital setting (Nelson & Schilke, 1976; Davis &
Nelson, 1978; Lewis & Levy, 1982; Robinson, 1982). Studies of nursing attitudes toward caring for suicidal and other psychiatric patients in the general hospital setting indicate that these patients are often viewed negatively and staff derive little satisfaction for their care (Holland & Plumb, 1973; Patel, 1975; Marsh, 1986). Robinson (1987) stated that patients with behavioral management problems often make nurses angry. While psychiatric consultations usually focus on differential diagnosis, Robinson (1987) suggested that psychiatric liaison nursing consultations are more likely to address issues related to behavioral symptoms that are problematic to nursing care. Davis and Nelson (1980) found that sustained psychiatric liaison nurse consultation with nursing staff increased the sophistication of the consultation request, which became more focused on the needs and problems of the patient. In addition, consultation requests generally became more comprehensive. Unfortunately, there are no studies in the literature documenting the effectiveness of psychiatric liaison nursing consultations. The current study was conducted at a large, Northeastern, urban university hospital where psychiatric liaison nursing had been established for over 14 years. At the time of the study a pool of sitters was used by the Department of Nursing for shift work with patients for whom a sitter was ordered. This order was generated by nursing for nonsuicidal patients and by medicine for suicidal patients. These were the two groups of patients for whom sitters were provided. A policy required psychiatric consultation for evaluation of all suicidal patients to determine the need for constant observation. High risk, nonsuicidal patients were provided sitters to protect them from harming themselves and others. Typical problems of this group included falls, elopement, or pulling out tubes or intravenous lines (IVs), as well as unpredictable, abusive, or threatening behavior. This study was designed to examine the effects of PLNS consultation on the care of patients with sitters. HYPOTHESES
The following five hypotheses were tested. Patients with sitters who received PLNS consultation compared with those who do not will: (1) require fewer sitter shifts, (2) have more charted nursing observations of mood, behavior, and mental sta-
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TALLEY ET AL.
tus, (3) have fewer patient incident reports during the time with sitters, (4) have fewer incidents of sitter refusal or walkoffs, (5) have fewer days of hospitalization.
sitter during the study period (January 4, 1988 to March 3 1, 1988) were included in the study if they met the following criteria: (1) assignment of a sitter for at least one shift on 2 consecutive days, and (2) admission to an adult medical, surgical, obstetrical, or gynecological unit. Subjects assigned to the experimental group were seen by the PLNS for the duration of the sitter order. Subjects assigned to the control group received no intervention. If PLNS consultation was ordered for a control subject, she or he was dropped from the study in order to receive consultation. Four suicidal and 17 nonsuicidal subjects initially assigned to experimental groups were dropped from the study because sitters had been discontinued before intervention. A total of 107 patients with sitters were included in the study. The suicidal group had 22 subjects, 11 experimental and 11 control; the nonsuicidal group had 85 subjects, 36 experimental and 49 control. As noted in Table 1, males comprised 60% of the total sample, although females were more represented in the suicidal group. Seventy-seven per-
METHOD Design
A randomized experimental design was used in which all patients with sitters who met study criteria were assigned to a suicidal or nonsuicidal group. Patients in each group were then randomly assigned to either the treatment or control group. Multivariate Analysis of Variance (MANOVA) was used to test for the effects of PLNS consultation on the outcome variables of sitter shifts, number of charted observations, number of sitter and patient incidents, and length of hospital stay. Subjects
Approval for the study was obtained from the Human Subjects Review Committee of the university School of Nursing and the Nursing Research Committee of the hospital. All patients assigned a Table 1. Demographic Suicidal (Exp = 11)
Gender Male Female
on
Characteristics
of Sample
IN = 221 = 111
Nonsuicidal
(N = 85)
Whole
Group
%
(Exp = 36)
(Con = 49)
%
N = 107
6
4
45%
22
32
64%
60%
5
7
55%
14
17
36%
40%
20%
Age 20-39
6
4
45%
5
6
13%
40-59
3
3
27%
6
9
18%
19%
60-79
2
3
23%
19
15
40%
36%
80-90 +
0
1
5%
6
19
29%
25%
Race White
9
9
82%
30
34
75%
77%
Black
1
0
4%
3
12
18%
15%
Hispanic
1
2
14%
3
3
7%
Marital status Single
8%
5
4
41%
5
10
18%
22%
Married
0
3
14%
15
19
40%
35%
Widowed
4
2
27%
9
15
28%
20%
Divorced/separated
2
2
18%
7
5
14%
15%
Living situation Alone
0
1
5%
7
13
24%
20%
Family/friends
a
8
72%
24
29
62%
64%
Nursing home
1
1
9%
2
4
6%
7%
Other hospital
0
1
5%
2
2
5%
6%
Other
2
0
9%
1
2
3%
3%
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PLNS CONSULTATION
cent of the subjects were white. Sixty-one percent of the subjects were over the age of 60, with 25% of the subjects 80 years of age or older. While only 35% of the sample were married, 64% were living with family or friends at the time of admission to the hospital. Seven percent were admitted from nursing homes. As noted in Table 2, the most frequently noted medical diagnoses were cardiovascular and respiratory conditions (28%), followed by equal numbers (15%) of subjects with cancer or central nervous system (CNS) disorders. In addition to their admitting diagnosis, 64% of the subjects had other medical problems that were active, but unrelated to the admitting condition. Forty-four subjects (4 1%) had no prior psychiatric history recorded, while the remaining 63 subjects had 74 psychiatric diagnoses among them. The most common psychiatric condition was substance abuse (42%), followed by affective disorders (3 1%). The majority of subjects (61%) were admitted to the hospital secondary to an acute medical or surgical problem (Table 3). Of note, only 16 of the 22 suicidal-group subjects were admitted following a suicide attempt. Fifty-nine percent of all subjects were discharged home; only 9% were transferred to a nursing home. Twelve subjects (11%) died, all in the nonsuicidal group.
Data on reason for sitters and their discontinuation were collected from nursing and medical notes in the patients’ charts. “Harm to self” (34%) was the most common reason for a sitter, followed by “generally unpredictable” behavior (26%). Nineteen of the twenty-two suicidal subjects had sitters ordered per the suicidal precaution policy. Eight nonsuicidal patients represented a threat to others necessitating sitters. Forty percent of the subjects recovered sufficiently to have sitters discontinued during their hospital stay. A slightly larger number (46%) were provided a sitter until the time of discharge from the hospital. Another 14% had sitters discontinued because of transfer to the intensive care unit (ICLJ), death, or unclear reasons in the chart. Fifty-nine percent of all subjects were discharged directly home, including some of the patients still receiving sitters. A comparison of the suicidal subjects and the nonsuicidal subjects showed many differences. A major unexpected difference was the number of subjects between groups. The study design anticipated equal numbers of subjects in each group, although this was never approached during the 3month data collection period. There was a reversal of figures for age and gender. Forty-five percent of the suicidal group were in the 20-to-39-year-old age category and over half were females. The non-
Table 2. Medical Characteristics
of the Sample
Suicidal IN = 221 (Exp = 111
Ken
= 17)
Nonsuicidal(N = 85) %
Whole Group
(Exp = 36)
(Con = 49)
%
N = 107
Primary medical diagnosis Cardiovascular/respiratory
0
2
9%
16
12
33%
28%
Cancer
0
0
-
9
7
19%
15%
AIDS
1
0
5%
1
1
3%
3%
CNS disorder
1
3
18%
5
7
14%
15%
Other trauma
3
1
18%
GI
0
0
Other
0
0
Overdose/self-poisoning
6
5
Yes
5
No
6
1
2
1
5
7%
9%
-
2
11
15%
12%
-
2
6
9%
50%
0
0
-
8%
6
50%
23
34
67%
64%
5
50%
13
15
33%
36%
19
22
10%
Multiple unrelated active diagnoses
Psychiatric diagnoses None
-
-
Yes
41%
no
39%
Affective disorder
7
7
58%
4
5
18%
31%
Substance abuse
6
1
29%
8
16
48%
42%
Organic mental disorder
2
1
13%
6
9
30%
24%
Psychosis
0
0
1
1
4%
3%
-
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TALLEY ET AL.
Table 3. Factors Related to Assignment Suicidal
of Sitter
(N = 22)
(Exp = 11)
Nonsuicidal
(Con = 11)
(Exp = 36)
(N = 85) icon
Whole = 49)
Group
N = 107
Reason for admission Suicide attempt
9
7
0
0
Nonsuicide trauma
0
0
5
4
8%
Work-up/elective
0
1
7
9
16%
2
3
24
36
61%
surgery
Acute medical/surgical
15%
Reason for sitter General
unpredictability
Harm to self Harm to others and self/others Suicide precaution
-
Chart unclear, other
-
1
0
13
14
26%
1
1
15
19
34%
10
5
11 -
14%
9
3
5
8%
-
-
18%
Reason for sitter’s discontinuation No longer needed
3
3
16
21
40%
Patient discharged or transferred Patient transferred, ICU
8
8
13
20
46%
-
-
2
2
4%
Patient died
-
-
5
3
7%
Chart unclear
-
-
3
3%
59%
-
Discharge Home
4
6
23
30
Nursing home
1
0
2
7
9%
Other hospital
5
4
1
4
13%
Death
0
0
6
6
11%
Other
1
1
4
2
8%
Psychiatric
10
11
7
4
30%
Social work
9
6
19
33
63%
Consultations
suicidal group had 64% males and was a much older population. A large percentage of subjects in the suicidal group were single with a primary psychiatric diagnosis of affective disorder. Almost half of the nonsuicidal subjects had no psychiatric diagnosis. For those nonsuicidal subjects with a psychiatric diagnosis, organic brain syndrome and substance abuse problems were most common. Overdose (10%) was the most common suicide attempt, with trauma next. As noted in “reason for admission”, the remaining six (27%) subjects in the suicidal group developed suicidal ideation while hospitalized for medical or surgical conditions or trauma. Interestingly, nine suicidal subjects were discharged to other treatment settings, and 10 were returned to the community. Six suicidal subjects had their sitters discontinued before discharge, while 16 had sitters until discharge or transfer to another facility. Thus, since only nine subjects transferred to other treatment settings, the need for further treatment was not a consistently applied criteria for continuance of sitters in the
hospital. The nonsuicidal group was more likely to discontinue sitters secondary to patient improvement (N = 37, 43%), although 33 (39%) retained sitters until discharge or transfer to another facility. Death was a reason for sitter discontinuation in eight nonsuicidal patients and worsening physical condition with transfer to the ICU for an additional four patients. Behavioral problems in the suicidal group were virtually nonexistent or superseded by the suicide precaution policy as the reason for sitters. Conversely, the nonsuicidal group had well-documented descriptions of patients’ behavioral problems, indicating various types of actual or potential harm to self or others. instrument An instrument designed by the researchers was used to collect data on patient demographics, medical and psychiatric conditions, hospital stay, and nursing observations from the patient record. Hospital incident reports and sitter service records in
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PLNS CONSULTATION
tus, provided reassurance through the use of touch and a calm approach, and suggested behavioral interventions such as reorientation, symptom management, and the use of physical restraint. With patients who were only episodically confused, the PLNS was able to provide information and clarification, which facilitated the patient’s understanding of his or her situation and cooperation with the treatment plan. With cognitively intact patients on suicide precautions, the PLNS was able to do crisis intervention and facilitate the patient’s goal setting and cooperation with the disposition plan. A subgroup of patients who were frequently substance abusers and acted out toward staff required limitsetting as well as symptom management. When family members were available, the PLNS saw them for collaborating history, to address their concerns, and to include them in disposition planning. If coordination with other professionals was indicated, they were contacted by the PLNS. These professionals included consulting psychiatrists, social workers, and discharge planning nurses. All patient records were reviewed following discharge to complete data collection. Sitter service records were examined daily for sitter use and sitter incident data. Patient incident reports involving study subjects were reviewed through the Nursing Quality Assurance Program. Data collection was done by members of the research group.
the Department of Nursing were used for the data on use of sitters, and patient and sitter incidents. A second instrument was designed to categorize and describe PLNS interventions. The descriptive data on the intervention process will be reported in a subsequent article. Procedure
PLNS consultation was initiated with experimental group subjects as soon as possible after the second sitter day by one of the hospital’s two PLNS (D. S .D., L.L.B.). The standard PLNS consultation (Lewis & Levy, 1982) was modified to accommodate the special problems of patients requiring sitters. The consultation was individualized to the particular patient situation, and typically began with the reason for sitter request, a review of the chart, and exploration of the staff nurse’s view of the patient problem. The patient was then seen for an assessment of: mental status; suicidality; behavior that harmed others, self, or was generally unpredictable; psychosocial history; and behavioral and management issues. Interventions were based on the identified problems with approaches targeted to nursing staff, patients, and sitters. Interventions for nursing staff included clarification of problem behaviors, based on assessment and formulation of the etiology and trajectory of the behavior. Staff were assisted with patient management via specific patient care management recommendations, care planning conferences and disposition planning. When necessary, staff were taught intervention techniques. The PLNS provided support and guidance for staff as they continued to work with these difficult patients. Patients received ongoing, direct PLNS interventions based on their potential for cooperation and the nature of the problem necessitating sitters. With patients who were so confused that they were unable to be engaged in a therapeutic relationship, the PLNS did repeated assessments of mental sta-
RESULTS
Presented in Table 4 is a summary of the means on the variables of number of sitter shifts, charted observations per sitter day, and length of hospital stay. A log transformation was done with each variable to create a more normal distribution. Hypothesis I: Number of Sitter Shifts
The mean number of sitter shifts for the entire sample was 18.23 shifts (SD, 17) with a range of two to 97 shifts. Group means are presented in
Table 4. Summary of Findings: Group Means Nonsuicidal lExp = 38)
Sitter shifts Observations Stay
20.19 shifts per sitter day
1.72 observations 21.44 days
IN = 85) ICon = 491
16.78 shifts 1.75 observations 25.33 days
Suicidal (Erp
= 11)
27.9 shifts 1.4 observations 16.0 days
(N = 22) (Con = 11)
16.2 shifts 1.6 observations 9.7 days
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Table 4. Although the group means ranged from 16.78 shifts for patients in the nonsuicidal, nontreatment group to 27.9 shifts for those in the suicidal, treatment group no significant overall group, treatment or interactional effects were found on number of sitter shifts. Thus, hypothesis 1 was rejected. Hypothesis 2: Number of Charted Nursing Observations
It was hypothesized that sitter patients with PLNS consultation would have more nursing note observations of mood, behavior, and mental status per sitter day than those without consultation. A maximum of 12 observations per 24 hours was possible. The mean number of observations for the total sample was 1.7 (SD, .88) per 24 hours with a range of 0 to 7. Group means are presented in Table 4. No significant overall group, treatment, or interactional effects were found. Thus hypothesis 2 was rejected. Hypotheses 3 and 4: Number of Sitter and Patient incidents
A shared view among nursing staff members that an unexpected and disturbing number of incidents such as falls and IV removals occurred in spite of the presence of sitters led to the hypothesis that patients with sitters who receive PLNS consultation will have fewer reported incidents than those who do not receive consultation. When written incident reports were examined, no substantiation of staff perceptions of incidents was found. Only three patient incident reports for the entire sample were received by the Nursing Quality Assurance Office. These included incidents of IV removal and medication errors. All occurred in the nonsuicidal group. Given the small number of incidents, no further analysis was done. As with patient incidents, there was shared staff perception of a number of sitters walking off assignments or refusing to sit with certain patients. Documentation of these incidents was done by the Department of Nursing staff responsible for sitter assignment. The four documented sitter incidents did not support staff perception of sitter behavior. All incidents involved sitter walkoffs with one incident in the suicidal group and the others in the nonsuicidal group. Given the small number of incidents, no further analysis was done.
TALLEY ET AL.
Hypothesis 5: Length of Hospital Stay
Length of stay for the total sample ranged from 2 to 175 days with a mean stay of 21.6 days. Group means are shown in Table 4. A significant overall group effect on length of hospital stay was found (Wilks A = .90. f = .Ol). Patients in the suicidal group had a significantly shorter length of stay independent of PLNS consultation. No significant treatment or interactional effects were found, leading to rejection of the hypothesis that patients receiving PLNS consultation would have shorter lengths of stay. DISCUSSION
While the use of sitters with patients in the general hospital is common, little is found in the literature about the characteristics of this group of patients. The findings of this study help define this population. Unpredictable behavior with the potential of harm to self or others was the most common patient characteristic in the decision to use lay sitters. With the exception of patients who had sitters secondary to a preadmission suicide attempt, patients with sitters were older with multiple medical problems. These patients were particularly susceptible to confusion due to illness, hospitalization and/or surgery. Unpredictable and volatile behavior with a history of substance abuse was characteristic of the smaller number of younger patients who required sitters. The decision to discontinue sitters for suicidal subjects was largely at the discretion of the psychiatrist who had the authority and responsibility for deciding when to discontinue suicide precautions. Sixteen of the 22 suicidal patients had sitters until discharge, regardless of disposition. This was seen as a fundamentally conservative decisionmaking style aimed at ensuring patient safety for the duration of the hospital stay. This may, in part, be based on concern for the liability of the hospital in these cases or a reticence to change the suicide policy to include assessment of suicidal ideation and intent by nonpsychiatric personnel. The lack of nursing note observations on suicidal evaluation further weakens the case for using sitters on an as-needed versus continuous basis. Decision making regarding the initiation and discontinuation of sitters for nonsuicidal subjects was entirely a nursing decision, and theoretically, more susceptible to influence by the PLNS. The
121
PLNS CONSULTATION
behaviors that necessitated a sitter order were generally quite specific; the criteria used to discontinue the sitter seemed more diffuse. For example, patients who had harmed themselves through falling or discontinuing IVs or equipment, or had harmed staff, had a sitter ordered. Once this safety measure or intervention was in place, discontinuation only occurred if the patient’s mental status clearly improved or their physical status improved enough for them to be free of IVs and equipment. The sitter was an extremely powerful intervention, as evidenced by staff refusing PLNS recommendations for discontinuation, and prestudy practice of infrequent use of the PLNS for consultation with these patients. The sitter resource was available without financial constraints or accountability and documentation to justify further use. Under nursing shortages, these very difficult patients had someone with them, and the scope of safety provided probably outweighed the enormous and consistent effort needed to bring about behavioral improvements . For other patients, behavioral change was either unlikely (e.g., advanced dementia) or dependent on the tincture of time, (e.g., neurological injuries). The futility of expecting behavioral improvement gave way to provision of safety alone for this group. For patients receiving sitters only on off-shifts, there was no access to nursing staff that might have allowed for increased use of other interventions beside the sitter. The overall lack of documentation of mood, behavior, and mental status by nursing staff was disappointing. The required dociimentation in the hospital was that nurses chart once in 24 hours unless there was a change in the patient’s condition and, in spite of the condition of the patients with sitters, this level of charting was the norm. Charting related to the psychosocial and behavioral aspects of patient care was clearly not a priority and the intervention of a PLNS consultation did not change this aspect of patient care. A frequent PLNS recommendation was that the nurse continue to assess, intervene, and document the patient’s behavior, mood and mental status, particularly as these related to the ongoing need for constant observation. This probably created a double-bind for nursing staff. If their interventions brought about some patient improvement, the sitter could be discontinued. This would require staff to trust the
permanency of the patient’s improvement or become diligent in continuing interventions to prevent relapse. By contrast, the current situation allowed for the sitter to be the only intervention with unconditional availability as determined by nursing staff. We noted a great deal of relevant patient data recorded in places other than the chart, such as the kardex and various flow sheets used for informal communication. This information did not become a part of the formal patient record and so was lost to analysis. This is another finding of the study that has strong practice implications. The potential for affecting length of stay for experimental subjects was based on the premise that their behavioral problems may have extended hospital stay and interventions could result in improvement and earlier discharge. A number of factors mitigated against this outcome, such as the heterogeniety of subjects within groups, the fact that discharge was dependent on availability of a nursing home bed or psychiatric treatment facility bed regardless of behavioral improvement, and the high acuity of subjects admitted to the hospital. The finding that PLNS consultation had no significant effect on any of the outcome variables was disappointing but not surprising. One explanation, in addition to those already mentioned, is that the subjects varied so widely on the outcome measures that group differences were obscured. Length of stay ranged from 2 to 175 days, while number of sitter shifts ranged from two to 97 shifts. A more carefully selected subset of patients with sitters may benefit from PLNS consultation. It is also possible that the outcome variables used in the study were not those most sensitive to the effects of the intervention by the PLNS. IMPLICATIONS The findings reinforced many of the concerns that generated interest in the use of lay sitters for safety and behavioral management of selected general hospital patients. The “sitter as primary intervention” was a powerful resource, providing little incentive for nursing staff to replace this continuously available resource with their own nursing staff and specific interventions. The inability of the PLNS to alter sitter usage was undoubtedly due to the heterogeneity of the group, number of different nursing units requiring consultation, and limited time available to teach nursing staff assessment
122
and intervention skills necessary to promote patient improvement. On a more positive note, there was general agreement and documentation of the resource and need for sitters. Obviously, nursing staff have less difficulty determining when to increase safety measures than they have with other interventions (besides a sitter) that could improve patient behavior. The characteristics of subjects in the study provide baseline information on high risk general hospital patients who required interventions to promote their own or others’ safety. Both ends of the continuum were found with very short and lengthy hospital stays. Confusion in the elderly was expected as well as behavioral management problems in substance-abusing patients. This complexity of behavioral problems in this mixed group of patients required a range of resources necessary to bring about improvement. Interventions beyond the PLNS included medications, restraints, sitters, and consultations by psychiatrists and/or social workers. To better understand how the PLNS influences the use of sitters, a smaller unit of intervention and analysis is probably required. A homogeneous group of subjects with similar behavioral problems would allow nursing staff to learn interventions for those subjects’ problems. For example, a single nursing unit with a smaller range of patient problems might benefit from substantial and focused in-service education programs. The variables of sitter shifts, length of stay, and nursing observations could provide an evaluation of PLNS interventions with this smaller, more homogeneous population of subjects who shared a narrower range of behavioral problems. Many units had already adopted some interventions for behavioral problems that they commonly dealt with, but for unfamiliar behaviors used the sitter resource. The prestudy practice of sitter use without PLNS consultation continued in the poststudy phase. Again, this may have represented the power of an unconditionally available resource that required almost no nursing care oversight versus primary nursing responsibility for decreasing these problems with multiple interventions that might reduce the total availability of the sitter. The model proposed by Hogarty and Rodaitis (1987) could be used as an adjunctive intervention for patients with
TALLEY ET AL.
sitters. Their care plan included need for evaiuation, degree of observation, interdisciplinary team review of case, time-limited order reviewed every 48 hours, and assignment of the sitter to the R.N. With this level of completeness and specific attention to problematic behavior, one could expect a range of interventions and highly sophisticated nursing care of difficult patients. The availability of sitters would not be the target intervention to be reduced, merely reevaluated. Research procedures like those of Hogarty and Rodaitis (1987) produces other somatic, physical, and environmental interventions useful with these patients, or a comprehensive policy aimed at improving the care of very difficult, often unpredictable patients. SUMMARY The findings of this study contribute to the identification and description of patients for whom lay sitters are used to ensure patient and staff safety. Nurses seem to agree on the indication for the initial use of sitters, but lack criteria for discontinuing use, which may result in the unnecessary use of sitters. Psychiatric liaison nurse specialist consultation does not appear to significantly affect the number of sitter shifts, the number of charted nursing observations, or the length of patients stay in a large heterogeneous group of patients. REFERENCES Davis, D., & Nelson, J. (1978). Psychiatric liaison nursing at Yale-New Haven Hospital. Connecricuf Medicine, 42, 721-723. Davis, D., & Nelson, J. (1980). Referrals to psychiatric liaison nurses: Changes in characteristics over a limited time period. General Hospital Psychiatry, 2, 41-45. Goldberg, R. (1987). Use of constant observation with potentially suicidal patients in general hospitals. Hospital and Community Psychiatry, 38(3), 303-305.
Hogarty, S., & Rodaitis, C. (1987). A suicide precautions policy for the general hospital. Journal of Nursing Administration, 17( lo), 36-42. Holland, J., & Plumb, M. (1973). Management of the serious suicide attempt: A special ICU nursing problem. Heart and Lung, 2(3), 376-38 1.
Janken, J., Reynolds, B., & Swiech, K. (1986). Patient falls in the acute care setting: Identifying risk factors. Nursing Research, 3X4), 215-219.
Lewis, A., & levy, J. (1982). Psychiatric liaison nursing: The theory and clinical practice. Reston, VA: Reston Publishing. Marsh, N. (1986). Nurse’s at&&s toward caring for the sui-
PLNS CONSULTATION
cialal patient in the general hospital setting. Unpublished master’s thesis, Yale University, New Haven, CT. Morrison, J., Crinklaw-Wiancko, D., King, D., Thibeault, S., & Wells, D. (1987). Formulating a restraint use policy. JOWM~ of Nursing Administration, Z7(3), 39-42. Nelson, J.. & Schilke, D. (1976). The evolution of psychiatric liarson nursing. Perspectives in Psychiatric Care, 14(2), 61-65. Patel, A. (1975). Attitudes toward self-poisoning. British Medical Journal, 2, 426-430. Robinson, L. (1982). Psychiatric liaison nursing 1962-1982: A review and update of the literature. General Hospital Psychiatry, 4, 139-145. Robinson, L. (1987). Psychiatric consultation liaison nursing and psychiatric consultation liaison doctoring: Similar-
123
ities and differences. Archives of Psychiatric Nursing, 1, 73-80. Silver, M. (1987). Using restraints. American Journal of Nursing, 87(l), 1414-1415. Strumpf, N., & Evans, L. (1988). Physical restraints of the hospital elderly: Perceptions of patients and nurses. Nursing Research, 37(3), 132-137. Williams, M., Campbell, E., Raynor, W., Musholt, M., Mlynarczyk, S., & Crane, L. (1985). Predictors of acute confusional states in elderly patients. Research in Nursing and Health, 8, 3140. Williams, M., Campbell, E., Raynor, W., Mlynarczyk, S., & Ward, S. (1985). Reducing acute confusional states in elderly patients with hip fractures. Research in Nursing and Health, 8, 329-337.
Linda Brown,
One hundred seven patients in an acute care setting who had lay sitters to provide the constant observation judged necessary to meet their safety needs were studied to determine the effect of psychiatric liaison nurse specialist (PLNS) consultation on nursing care and the use of sitters. After placement in either a suicidal or nonsuicidal group, subjects were randomiy assigned to recieve consultation or not. Outcome variables of number of sitter shifts, number of nursing note observations, number of patient and sitter incidents and length of hospital stay were considered. Multiple analysis of variance indicated no significant differences among the groups for number of sitter shifts or number of nursing note observations. A significant main effect for group on length of hospital stay was found with suicidal patients having a significantly shelter hospital stay. Number of patients and sitter incidents were too small for analysis.
0 1990 by W.B. Saunders Company.
G
ENERAL hospitals face greater acuity and complexity of patient care problems. Of particular concern are the burdens of caring for patients who are confused, may be harmful to themselves or others, and whose behavior is unpredictable or difficult to manage. As a supplement to nursing care, many departments of nursing have hired lay sitters to monitor and protect these high-risk patients. These sitters are not expected to provide nursing care, but rather, to provide constant observation and meet the immediate safety needs of these patients. While many of the problems underlying these behaviors are considered psychiatric in nature, the patients assigned sitters are rarely referred for psychiatric liaison nursing consultation. This study was designed to examine the effect of psychiatric liaison nurse specialist From the School of Nursing, Yale University, and the Yale-New Haven Hospital, New Haven, Connecticut. Supported in part by funding from Sigma Theta Tay Delta Mu Chapter. Address reprint requests to Sandra Talley, R.N., C.S., M.N., 850 16th Ave., Salt Lake City, UT84103. 0 1990 by W.B. Saunders Company. 08a3-9471/90/0402-cOO7$3.00/0
114
(PLNS) consultation on the care of patients assigned sitters. LITERATURE REVIEW AND BACKGROUND OF THE STUDY
The need for constant observation of confused, suicidal, or unpredictable patients is well known to clinicians, but less frequently reported in the literature. Goldberg (1987) surveyed New England general hospitals for policies and practices of constant observation with suicidal patients. He found 92% of the 73 hospitals reported the use of constant observation with suicidal patients. From the hospitals reporting statistical data, from one to 480 patients were seen per year, with an average of 5.5 shifts provided. The use of sitters for constant observation of suicidal patients must be part of a systematic approach to the care of the suicidal patient in the general hospital setting. A suicidal precautions policy designed by Hogarty and Rodaitis (1987) addressed the need for a thorough evaluation, determination of appropriate degree of observation (minimal to high), interdisciplinary review of the need for observation, and a time-limited order for observation that was reviewed every 48
Archives of Psychiatric Nursing, Vol. IV, No. 2 (April), 1990: pp. 114-123
PLNS CONSULTATION
hours. Most importantly, their policy assigned responsibility for the sitter, and ultimately the patient, to the registered nurse or primary nurse caring for the patient under suicide precautions. Another group of patients necessitating increased observation and interventions to prevent harm are those who become confused and/or those who may fall (Williams, Campbell, Raynor, Musholt, Mlynarczyk, & Crane, 1985; Janken, Reynolds, & Swiech, 1986). For this group, their unpredictable behavior and inability to comply with physical restrictions places them at great risk. In the absence of staff for one-to-one contact, the use of physical restraint has been identified as a common, albeit controversial, intervention for patients with a potential for harm to self or others (Silver, 1987; Strumph & Evans, 1988). Model policies have been put forth for the use of restraint in order to ensure that patients receive ongoing assessment and appropriate nursing care (Morrison, Crinklaw-Wiancko, King, Thibeault, & Wells, 1987). Though Williams, Campbell, Raynor, Mlynarczyk, and Ward ( 1985) have noted “increased nursing surveillance always is indicated when persons are confused, at times to the point of constant attendance” (p. 329), few others mention constant observation as an alternative to ensure patient safety. The provision of safety should not. however, compromise opportunities for nursing interventions that would result in less restrictive forms of treatment. In their study of elderly patients with hip fractures, Williams and her colleagues (1985), using interventions carried out by the nursing staff, were able to reduce the severity and duration of confusion from 51.5% to 43.9%. The most effective interventions were orientation, clarification, continuity of care, and reduction of sensory deficits. The addition of a psychiatric clinical nurse specialist intervention with the subjects did not result in greater patient improvement. These findings may indicate that both comprehensiveness of interventions and involvement of the primary nurse are critical to successful patient outcomes. The consistent application of selected interventions known to reverse or stabilize mental, emotional, or behavioral problems is the major consultation technique for advanced nursing practice. Psychiatric liaison nursing has traditionally focused on the care of difficult patients in the general hospital setting (Nelson & Schilke, 1976; Davis &
Nelson, 1978; Lewis & Levy, 1982; Robinson, 1982). Studies of nursing attitudes toward caring for suicidal and other psychiatric patients in the general hospital setting indicate that these patients are often viewed negatively and staff derive little satisfaction for their care (Holland & Plumb, 1973; Patel, 1975; Marsh, 1986). Robinson (1987) stated that patients with behavioral management problems often make nurses angry. While psychiatric consultations usually focus on differential diagnosis, Robinson (1987) suggested that psychiatric liaison nursing consultations are more likely to address issues related to behavioral symptoms that are problematic to nursing care. Davis and Nelson (1980) found that sustained psychiatric liaison nurse consultation with nursing staff increased the sophistication of the consultation request, which became more focused on the needs and problems of the patient. In addition, consultation requests generally became more comprehensive. Unfortunately, there are no studies in the literature documenting the effectiveness of psychiatric liaison nursing consultations. The current study was conducted at a large, Northeastern, urban university hospital where psychiatric liaison nursing had been established for over 14 years. At the time of the study a pool of sitters was used by the Department of Nursing for shift work with patients for whom a sitter was ordered. This order was generated by nursing for nonsuicidal patients and by medicine for suicidal patients. These were the two groups of patients for whom sitters were provided. A policy required psychiatric consultation for evaluation of all suicidal patients to determine the need for constant observation. High risk, nonsuicidal patients were provided sitters to protect them from harming themselves and others. Typical problems of this group included falls, elopement, or pulling out tubes or intravenous lines (IVs), as well as unpredictable, abusive, or threatening behavior. This study was designed to examine the effects of PLNS consultation on the care of patients with sitters. HYPOTHESES
The following five hypotheses were tested. Patients with sitters who received PLNS consultation compared with those who do not will: (1) require fewer sitter shifts, (2) have more charted nursing observations of mood, behavior, and mental sta-
116
TALLEY ET AL.
tus, (3) have fewer patient incident reports during the time with sitters, (4) have fewer incidents of sitter refusal or walkoffs, (5) have fewer days of hospitalization.
sitter during the study period (January 4, 1988 to March 3 1, 1988) were included in the study if they met the following criteria: (1) assignment of a sitter for at least one shift on 2 consecutive days, and (2) admission to an adult medical, surgical, obstetrical, or gynecological unit. Subjects assigned to the experimental group were seen by the PLNS for the duration of the sitter order. Subjects assigned to the control group received no intervention. If PLNS consultation was ordered for a control subject, she or he was dropped from the study in order to receive consultation. Four suicidal and 17 nonsuicidal subjects initially assigned to experimental groups were dropped from the study because sitters had been discontinued before intervention. A total of 107 patients with sitters were included in the study. The suicidal group had 22 subjects, 11 experimental and 11 control; the nonsuicidal group had 85 subjects, 36 experimental and 49 control. As noted in Table 1, males comprised 60% of the total sample, although females were more represented in the suicidal group. Seventy-seven per-
METHOD Design
A randomized experimental design was used in which all patients with sitters who met study criteria were assigned to a suicidal or nonsuicidal group. Patients in each group were then randomly assigned to either the treatment or control group. Multivariate Analysis of Variance (MANOVA) was used to test for the effects of PLNS consultation on the outcome variables of sitter shifts, number of charted observations, number of sitter and patient incidents, and length of hospital stay. Subjects
Approval for the study was obtained from the Human Subjects Review Committee of the university School of Nursing and the Nursing Research Committee of the hospital. All patients assigned a Table 1. Demographic Suicidal (Exp = 11)
Gender Male Female
on
Characteristics
of Sample
IN = 221 = 111
Nonsuicidal
(N = 85)
Whole
Group
%
(Exp = 36)
(Con = 49)
%
N = 107
6
4
45%
22
32
64%
60%
5
7
55%
14
17
36%
40%
20%
Age 20-39
6
4
45%
5
6
13%
40-59
3
3
27%
6
9
18%
19%
60-79
2
3
23%
19
15
40%
36%
80-90 +
0
1
5%
6
19
29%
25%
Race White
9
9
82%
30
34
75%
77%
Black
1
0
4%
3
12
18%
15%
Hispanic
1
2
14%
3
3
7%
Marital status Single
8%
5
4
41%
5
10
18%
22%
Married
0
3
14%
15
19
40%
35%
Widowed
4
2
27%
9
15
28%
20%
Divorced/separated
2
2
18%
7
5
14%
15%
Living situation Alone
0
1
5%
7
13
24%
20%
Family/friends
a
8
72%
24
29
62%
64%
Nursing home
1
1
9%
2
4
6%
7%
Other hospital
0
1
5%
2
2
5%
6%
Other
2
0
9%
1
2
3%
3%
117
PLNS CONSULTATION
cent of the subjects were white. Sixty-one percent of the subjects were over the age of 60, with 25% of the subjects 80 years of age or older. While only 35% of the sample were married, 64% were living with family or friends at the time of admission to the hospital. Seven percent were admitted from nursing homes. As noted in Table 2, the most frequently noted medical diagnoses were cardiovascular and respiratory conditions (28%), followed by equal numbers (15%) of subjects with cancer or central nervous system (CNS) disorders. In addition to their admitting diagnosis, 64% of the subjects had other medical problems that were active, but unrelated to the admitting condition. Forty-four subjects (4 1%) had no prior psychiatric history recorded, while the remaining 63 subjects had 74 psychiatric diagnoses among them. The most common psychiatric condition was substance abuse (42%), followed by affective disorders (3 1%). The majority of subjects (61%) were admitted to the hospital secondary to an acute medical or surgical problem (Table 3). Of note, only 16 of the 22 suicidal-group subjects were admitted following a suicide attempt. Fifty-nine percent of all subjects were discharged home; only 9% were transferred to a nursing home. Twelve subjects (11%) died, all in the nonsuicidal group.
Data on reason for sitters and their discontinuation were collected from nursing and medical notes in the patients’ charts. “Harm to self” (34%) was the most common reason for a sitter, followed by “generally unpredictable” behavior (26%). Nineteen of the twenty-two suicidal subjects had sitters ordered per the suicidal precaution policy. Eight nonsuicidal patients represented a threat to others necessitating sitters. Forty percent of the subjects recovered sufficiently to have sitters discontinued during their hospital stay. A slightly larger number (46%) were provided a sitter until the time of discharge from the hospital. Another 14% had sitters discontinued because of transfer to the intensive care unit (ICLJ), death, or unclear reasons in the chart. Fifty-nine percent of all subjects were discharged directly home, including some of the patients still receiving sitters. A comparison of the suicidal subjects and the nonsuicidal subjects showed many differences. A major unexpected difference was the number of subjects between groups. The study design anticipated equal numbers of subjects in each group, although this was never approached during the 3month data collection period. There was a reversal of figures for age and gender. Forty-five percent of the suicidal group were in the 20-to-39-year-old age category and over half were females. The non-
Table 2. Medical Characteristics
of the Sample
Suicidal IN = 221 (Exp = 111
Ken
= 17)
Nonsuicidal(N = 85) %
Whole Group
(Exp = 36)
(Con = 49)
%
N = 107
Primary medical diagnosis Cardiovascular/respiratory
0
2
9%
16
12
33%
28%
Cancer
0
0
-
9
7
19%
15%
AIDS
1
0
5%
1
1
3%
3%
CNS disorder
1
3
18%
5
7
14%
15%
Other trauma
3
1
18%
GI
0
0
Other
0
0
Overdose/self-poisoning
6
5
Yes
5
No
6
1
2
1
5
7%
9%
-
2
11
15%
12%
-
2
6
9%
50%
0
0
-
8%
6
50%
23
34
67%
64%
5
50%
13
15
33%
36%
19
22
10%
Multiple unrelated active diagnoses
Psychiatric diagnoses None
-
-
Yes
41%
no
39%
Affective disorder
7
7
58%
4
5
18%
31%
Substance abuse
6
1
29%
8
16
48%
42%
Organic mental disorder
2
1
13%
6
9
30%
24%
Psychosis
0
0
1
1
4%
3%
-
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TALLEY ET AL.
Table 3. Factors Related to Assignment Suicidal
of Sitter
(N = 22)
(Exp = 11)
Nonsuicidal
(Con = 11)
(Exp = 36)
(N = 85) icon
Whole = 49)
Group
N = 107
Reason for admission Suicide attempt
9
7
0
0
Nonsuicide trauma
0
0
5
4
8%
Work-up/elective
0
1
7
9
16%
2
3
24
36
61%
surgery
Acute medical/surgical
15%
Reason for sitter General
unpredictability
Harm to self Harm to others and self/others Suicide precaution
-
Chart unclear, other
-
1
0
13
14
26%
1
1
15
19
34%
10
5
11 -
14%
9
3
5
8%
-
-
18%
Reason for sitter’s discontinuation No longer needed
3
3
16
21
40%
Patient discharged or transferred Patient transferred, ICU
8
8
13
20
46%
-
-
2
2
4%
Patient died
-
-
5
3
7%
Chart unclear
-
-
3
3%
59%
-
Discharge Home
4
6
23
30
Nursing home
1
0
2
7
9%
Other hospital
5
4
1
4
13%
Death
0
0
6
6
11%
Other
1
1
4
2
8%
Psychiatric
10
11
7
4
30%
Social work
9
6
19
33
63%
Consultations
suicidal group had 64% males and was a much older population. A large percentage of subjects in the suicidal group were single with a primary psychiatric diagnosis of affective disorder. Almost half of the nonsuicidal subjects had no psychiatric diagnosis. For those nonsuicidal subjects with a psychiatric diagnosis, organic brain syndrome and substance abuse problems were most common. Overdose (10%) was the most common suicide attempt, with trauma next. As noted in “reason for admission”, the remaining six (27%) subjects in the suicidal group developed suicidal ideation while hospitalized for medical or surgical conditions or trauma. Interestingly, nine suicidal subjects were discharged to other treatment settings, and 10 were returned to the community. Six suicidal subjects had their sitters discontinued before discharge, while 16 had sitters until discharge or transfer to another facility. Thus, since only nine subjects transferred to other treatment settings, the need for further treatment was not a consistently applied criteria for continuance of sitters in the
hospital. The nonsuicidal group was more likely to discontinue sitters secondary to patient improvement (N = 37, 43%), although 33 (39%) retained sitters until discharge or transfer to another facility. Death was a reason for sitter discontinuation in eight nonsuicidal patients and worsening physical condition with transfer to the ICU for an additional four patients. Behavioral problems in the suicidal group were virtually nonexistent or superseded by the suicide precaution policy as the reason for sitters. Conversely, the nonsuicidal group had well-documented descriptions of patients’ behavioral problems, indicating various types of actual or potential harm to self or others. instrument An instrument designed by the researchers was used to collect data on patient demographics, medical and psychiatric conditions, hospital stay, and nursing observations from the patient record. Hospital incident reports and sitter service records in
119
PLNS CONSULTATION
tus, provided reassurance through the use of touch and a calm approach, and suggested behavioral interventions such as reorientation, symptom management, and the use of physical restraint. With patients who were only episodically confused, the PLNS was able to provide information and clarification, which facilitated the patient’s understanding of his or her situation and cooperation with the treatment plan. With cognitively intact patients on suicide precautions, the PLNS was able to do crisis intervention and facilitate the patient’s goal setting and cooperation with the disposition plan. A subgroup of patients who were frequently substance abusers and acted out toward staff required limitsetting as well as symptom management. When family members were available, the PLNS saw them for collaborating history, to address their concerns, and to include them in disposition planning. If coordination with other professionals was indicated, they were contacted by the PLNS. These professionals included consulting psychiatrists, social workers, and discharge planning nurses. All patient records were reviewed following discharge to complete data collection. Sitter service records were examined daily for sitter use and sitter incident data. Patient incident reports involving study subjects were reviewed through the Nursing Quality Assurance Program. Data collection was done by members of the research group.
the Department of Nursing were used for the data on use of sitters, and patient and sitter incidents. A second instrument was designed to categorize and describe PLNS interventions. The descriptive data on the intervention process will be reported in a subsequent article. Procedure
PLNS consultation was initiated with experimental group subjects as soon as possible after the second sitter day by one of the hospital’s two PLNS (D. S .D., L.L.B.). The standard PLNS consultation (Lewis & Levy, 1982) was modified to accommodate the special problems of patients requiring sitters. The consultation was individualized to the particular patient situation, and typically began with the reason for sitter request, a review of the chart, and exploration of the staff nurse’s view of the patient problem. The patient was then seen for an assessment of: mental status; suicidality; behavior that harmed others, self, or was generally unpredictable; psychosocial history; and behavioral and management issues. Interventions were based on the identified problems with approaches targeted to nursing staff, patients, and sitters. Interventions for nursing staff included clarification of problem behaviors, based on assessment and formulation of the etiology and trajectory of the behavior. Staff were assisted with patient management via specific patient care management recommendations, care planning conferences and disposition planning. When necessary, staff were taught intervention techniques. The PLNS provided support and guidance for staff as they continued to work with these difficult patients. Patients received ongoing, direct PLNS interventions based on their potential for cooperation and the nature of the problem necessitating sitters. With patients who were so confused that they were unable to be engaged in a therapeutic relationship, the PLNS did repeated assessments of mental sta-
RESULTS
Presented in Table 4 is a summary of the means on the variables of number of sitter shifts, charted observations per sitter day, and length of hospital stay. A log transformation was done with each variable to create a more normal distribution. Hypothesis I: Number of Sitter Shifts
The mean number of sitter shifts for the entire sample was 18.23 shifts (SD, 17) with a range of two to 97 shifts. Group means are presented in
Table 4. Summary of Findings: Group Means Nonsuicidal lExp = 38)
Sitter shifts Observations Stay
20.19 shifts per sitter day
1.72 observations 21.44 days
IN = 85) ICon = 491
16.78 shifts 1.75 observations 25.33 days
Suicidal (Erp
= 11)
27.9 shifts 1.4 observations 16.0 days
(N = 22) (Con = 11)
16.2 shifts 1.6 observations 9.7 days
120
Table 4. Although the group means ranged from 16.78 shifts for patients in the nonsuicidal, nontreatment group to 27.9 shifts for those in the suicidal, treatment group no significant overall group, treatment or interactional effects were found on number of sitter shifts. Thus, hypothesis 1 was rejected. Hypothesis 2: Number of Charted Nursing Observations
It was hypothesized that sitter patients with PLNS consultation would have more nursing note observations of mood, behavior, and mental status per sitter day than those without consultation. A maximum of 12 observations per 24 hours was possible. The mean number of observations for the total sample was 1.7 (SD, .88) per 24 hours with a range of 0 to 7. Group means are presented in Table 4. No significant overall group, treatment, or interactional effects were found. Thus hypothesis 2 was rejected. Hypotheses 3 and 4: Number of Sitter and Patient incidents
A shared view among nursing staff members that an unexpected and disturbing number of incidents such as falls and IV removals occurred in spite of the presence of sitters led to the hypothesis that patients with sitters who receive PLNS consultation will have fewer reported incidents than those who do not receive consultation. When written incident reports were examined, no substantiation of staff perceptions of incidents was found. Only three patient incident reports for the entire sample were received by the Nursing Quality Assurance Office. These included incidents of IV removal and medication errors. All occurred in the nonsuicidal group. Given the small number of incidents, no further analysis was done. As with patient incidents, there was shared staff perception of a number of sitters walking off assignments or refusing to sit with certain patients. Documentation of these incidents was done by the Department of Nursing staff responsible for sitter assignment. The four documented sitter incidents did not support staff perception of sitter behavior. All incidents involved sitter walkoffs with one incident in the suicidal group and the others in the nonsuicidal group. Given the small number of incidents, no further analysis was done.
TALLEY ET AL.
Hypothesis 5: Length of Hospital Stay
Length of stay for the total sample ranged from 2 to 175 days with a mean stay of 21.6 days. Group means are shown in Table 4. A significant overall group effect on length of hospital stay was found (Wilks A = .90. f = .Ol). Patients in the suicidal group had a significantly shorter length of stay independent of PLNS consultation. No significant treatment or interactional effects were found, leading to rejection of the hypothesis that patients receiving PLNS consultation would have shorter lengths of stay. DISCUSSION
While the use of sitters with patients in the general hospital is common, little is found in the literature about the characteristics of this group of patients. The findings of this study help define this population. Unpredictable behavior with the potential of harm to self or others was the most common patient characteristic in the decision to use lay sitters. With the exception of patients who had sitters secondary to a preadmission suicide attempt, patients with sitters were older with multiple medical problems. These patients were particularly susceptible to confusion due to illness, hospitalization and/or surgery. Unpredictable and volatile behavior with a history of substance abuse was characteristic of the smaller number of younger patients who required sitters. The decision to discontinue sitters for suicidal subjects was largely at the discretion of the psychiatrist who had the authority and responsibility for deciding when to discontinue suicide precautions. Sixteen of the 22 suicidal patients had sitters until discharge, regardless of disposition. This was seen as a fundamentally conservative decisionmaking style aimed at ensuring patient safety for the duration of the hospital stay. This may, in part, be based on concern for the liability of the hospital in these cases or a reticence to change the suicide policy to include assessment of suicidal ideation and intent by nonpsychiatric personnel. The lack of nursing note observations on suicidal evaluation further weakens the case for using sitters on an as-needed versus continuous basis. Decision making regarding the initiation and discontinuation of sitters for nonsuicidal subjects was entirely a nursing decision, and theoretically, more susceptible to influence by the PLNS. The
121
PLNS CONSULTATION
behaviors that necessitated a sitter order were generally quite specific; the criteria used to discontinue the sitter seemed more diffuse. For example, patients who had harmed themselves through falling or discontinuing IVs or equipment, or had harmed staff, had a sitter ordered. Once this safety measure or intervention was in place, discontinuation only occurred if the patient’s mental status clearly improved or their physical status improved enough for them to be free of IVs and equipment. The sitter was an extremely powerful intervention, as evidenced by staff refusing PLNS recommendations for discontinuation, and prestudy practice of infrequent use of the PLNS for consultation with these patients. The sitter resource was available without financial constraints or accountability and documentation to justify further use. Under nursing shortages, these very difficult patients had someone with them, and the scope of safety provided probably outweighed the enormous and consistent effort needed to bring about behavioral improvements . For other patients, behavioral change was either unlikely (e.g., advanced dementia) or dependent on the tincture of time, (e.g., neurological injuries). The futility of expecting behavioral improvement gave way to provision of safety alone for this group. For patients receiving sitters only on off-shifts, there was no access to nursing staff that might have allowed for increased use of other interventions beside the sitter. The overall lack of documentation of mood, behavior, and mental status by nursing staff was disappointing. The required dociimentation in the hospital was that nurses chart once in 24 hours unless there was a change in the patient’s condition and, in spite of the condition of the patients with sitters, this level of charting was the norm. Charting related to the psychosocial and behavioral aspects of patient care was clearly not a priority and the intervention of a PLNS consultation did not change this aspect of patient care. A frequent PLNS recommendation was that the nurse continue to assess, intervene, and document the patient’s behavior, mood and mental status, particularly as these related to the ongoing need for constant observation. This probably created a double-bind for nursing staff. If their interventions brought about some patient improvement, the sitter could be discontinued. This would require staff to trust the
permanency of the patient’s improvement or become diligent in continuing interventions to prevent relapse. By contrast, the current situation allowed for the sitter to be the only intervention with unconditional availability as determined by nursing staff. We noted a great deal of relevant patient data recorded in places other than the chart, such as the kardex and various flow sheets used for informal communication. This information did not become a part of the formal patient record and so was lost to analysis. This is another finding of the study that has strong practice implications. The potential for affecting length of stay for experimental subjects was based on the premise that their behavioral problems may have extended hospital stay and interventions could result in improvement and earlier discharge. A number of factors mitigated against this outcome, such as the heterogeniety of subjects within groups, the fact that discharge was dependent on availability of a nursing home bed or psychiatric treatment facility bed regardless of behavioral improvement, and the high acuity of subjects admitted to the hospital. The finding that PLNS consultation had no significant effect on any of the outcome variables was disappointing but not surprising. One explanation, in addition to those already mentioned, is that the subjects varied so widely on the outcome measures that group differences were obscured. Length of stay ranged from 2 to 175 days, while number of sitter shifts ranged from two to 97 shifts. A more carefully selected subset of patients with sitters may benefit from PLNS consultation. It is also possible that the outcome variables used in the study were not those most sensitive to the effects of the intervention by the PLNS. IMPLICATIONS The findings reinforced many of the concerns that generated interest in the use of lay sitters for safety and behavioral management of selected general hospital patients. The “sitter as primary intervention” was a powerful resource, providing little incentive for nursing staff to replace this continuously available resource with their own nursing staff and specific interventions. The inability of the PLNS to alter sitter usage was undoubtedly due to the heterogeneity of the group, number of different nursing units requiring consultation, and limited time available to teach nursing staff assessment
122
and intervention skills necessary to promote patient improvement. On a more positive note, there was general agreement and documentation of the resource and need for sitters. Obviously, nursing staff have less difficulty determining when to increase safety measures than they have with other interventions (besides a sitter) that could improve patient behavior. The characteristics of subjects in the study provide baseline information on high risk general hospital patients who required interventions to promote their own or others’ safety. Both ends of the continuum were found with very short and lengthy hospital stays. Confusion in the elderly was expected as well as behavioral management problems in substance-abusing patients. This complexity of behavioral problems in this mixed group of patients required a range of resources necessary to bring about improvement. Interventions beyond the PLNS included medications, restraints, sitters, and consultations by psychiatrists and/or social workers. To better understand how the PLNS influences the use of sitters, a smaller unit of intervention and analysis is probably required. A homogeneous group of subjects with similar behavioral problems would allow nursing staff to learn interventions for those subjects’ problems. For example, a single nursing unit with a smaller range of patient problems might benefit from substantial and focused in-service education programs. The variables of sitter shifts, length of stay, and nursing observations could provide an evaluation of PLNS interventions with this smaller, more homogeneous population of subjects who shared a narrower range of behavioral problems. Many units had already adopted some interventions for behavioral problems that they commonly dealt with, but for unfamiliar behaviors used the sitter resource. The prestudy practice of sitter use without PLNS consultation continued in the poststudy phase. Again, this may have represented the power of an unconditionally available resource that required almost no nursing care oversight versus primary nursing responsibility for decreasing these problems with multiple interventions that might reduce the total availability of the sitter. The model proposed by Hogarty and Rodaitis (1987) could be used as an adjunctive intervention for patients with
TALLEY ET AL.
sitters. Their care plan included need for evaiuation, degree of observation, interdisciplinary team review of case, time-limited order reviewed every 48 hours, and assignment of the sitter to the R.N. With this level of completeness and specific attention to problematic behavior, one could expect a range of interventions and highly sophisticated nursing care of difficult patients. The availability of sitters would not be the target intervention to be reduced, merely reevaluated. Research procedures like those of Hogarty and Rodaitis (1987) produces other somatic, physical, and environmental interventions useful with these patients, or a comprehensive policy aimed at improving the care of very difficult, often unpredictable patients. SUMMARY The findings of this study contribute to the identification and description of patients for whom lay sitters are used to ensure patient and staff safety. Nurses seem to agree on the indication for the initial use of sitters, but lack criteria for discontinuing use, which may result in the unnecessary use of sitters. Psychiatric liaison nurse specialist consultation does not appear to significantly affect the number of sitter shifts, the number of charted nursing observations, or the length of patients stay in a large heterogeneous group of patients. REFERENCES Davis, D., & Nelson, J. (1978). Psychiatric liaison nursing at Yale-New Haven Hospital. Connecricuf Medicine, 42, 721-723. Davis, D., & Nelson, J. (1980). Referrals to psychiatric liaison nurses: Changes in characteristics over a limited time period. General Hospital Psychiatry, 2, 41-45. Goldberg, R. (1987). Use of constant observation with potentially suicidal patients in general hospitals. Hospital and Community Psychiatry, 38(3), 303-305.
Hogarty, S., & Rodaitis, C. (1987). A suicide precautions policy for the general hospital. Journal of Nursing Administration, 17( lo), 36-42. Holland, J., & Plumb, M. (1973). Management of the serious suicide attempt: A special ICU nursing problem. Heart and Lung, 2(3), 376-38 1.
Janken, J., Reynolds, B., & Swiech, K. (1986). Patient falls in the acute care setting: Identifying risk factors. Nursing Research, 3X4), 215-219.
Lewis, A., & levy, J. (1982). Psychiatric liaison nursing: The theory and clinical practice. Reston, VA: Reston Publishing. Marsh, N. (1986). Nurse’s at&&s toward caring for the sui-
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cialal patient in the general hospital setting. Unpublished master’s thesis, Yale University, New Haven, CT. Morrison, J., Crinklaw-Wiancko, D., King, D., Thibeault, S., & Wells, D. (1987). Formulating a restraint use policy. JOWM~ of Nursing Administration, Z7(3), 39-42. Nelson, J.. & Schilke, D. (1976). The evolution of psychiatric liarson nursing. Perspectives in Psychiatric Care, 14(2), 61-65. Patel, A. (1975). Attitudes toward self-poisoning. British Medical Journal, 2, 426-430. Robinson, L. (1982). Psychiatric liaison nursing 1962-1982: A review and update of the literature. General Hospital Psychiatry, 4, 139-145. Robinson, L. (1987). Psychiatric consultation liaison nursing and psychiatric consultation liaison doctoring: Similar-
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ities and differences. Archives of Psychiatric Nursing, 1, 73-80. Silver, M. (1987). Using restraints. American Journal of Nursing, 87(l), 1414-1415. Strumpf, N., & Evans, L. (1988). Physical restraints of the hospital elderly: Perceptions of patients and nurses. Nursing Research, 37(3), 132-137. Williams, M., Campbell, E., Raynor, W., Musholt, M., Mlynarczyk, S., & Crane, L. (1985). Predictors of acute confusional states in elderly patients. Research in Nursing and Health, 8, 3140. Williams, M., Campbell, E., Raynor, W., Mlynarczyk, S., & Ward, S. (1985). Reducing acute confusional states in elderly patients with hip fractures. Research in Nursing and Health, 8, 329-337.
