Psychiatric Nursing Consultation in a University Medical Center KATHLEEN M. PRZEPIORKA, Clinical Nursing Specialist Psychiatric Aftercare Program University of Michigan Medical Ann Arbor, Michigan
LAURIE
S. BENDER,
R.N.,
R.N.,
M.S.
Center
M.S.
Clinical Nursing Specialist Virginia Centerfor Children Richmond, Virginia A program of psychiatric nursing consultation was established at a large university medical center in response to requests from nonpsychiatrlc nurses; they generally felt that patient evaluations provided by the psychiatry liaison service did not have specific application to nursing care. The program is operated by two part-time coordinators who train and supervise the nurse-consultants through monthly group sessions and individual supervision. One aim is to set up ongoing consultative meetings with nursing staffs who request help rather than providing only one-time or crisis consultation. During the program’sfirst year, 146 consultations were given, and an average of 9.5 nursing units received consultation services each month. ‘The impetus for a psychiatric nursing consultation program at the University of Michigan Medical Center came from nurses in the medical-surgical, pediatric, and obstetrical areas of the center. The only psychiatric resource available to them was consultation from psychiatric residents assigned to the department of psychiatry’s liaison service, which was also staffed by senior staff psychiatrists and a psychiatric social worker. Usually a resident evaluated the patient about whom consultation was requested and then prepared a formal consultation summary. It was often written in psychiatric terminology, and most nurses had difficulty making use of it in developing a nursing care plan. Ms. Przepiorka also is assistant professor of nursing at the University of Michigan School of Nursing. Her address at the medical center is Riverview Building, 900 Wall Street, Ann Arbor, Michigan 48105. Ms. Bender formerly was a clinical nursing specialist in the department of psychiatry at the University of Michigan Medical Center and assistant coordinator of the psychiatric nursing consultation program.
Although many liaison service residents tried to provide guidelines for incorporating the results of the evaluation into patient care, they had limited knowledge of the responsibilities of a nurse on a particular unit and of the nursing staff in general. The nurses felt that other nurses would be more aware of their needs and could help them develop usable nursing care plans, and they asked that psychiatric nurses consult with them about patients with known psychiatric problems or with problem behaviors. A proposal for the consultation service was developed by the senior author and submitted to nursing administrators throughout the medical center. It was approved
by
the
administrative
staff
group,
and
the
program
began operation in March 1974, with the senior author as coordinator. In July an assistant coordinator for pediatrics (the second author) was appointed. Both coordinators have a master of science degree in psychiatric nursing and were clinical nursing specialists in the department of psychiatry. Forty per cent of the coordinator’s time and 30 per cent of the assistant coordinator’s time was released for the consultation program. The program was designed to provide consultation by psychiatric nurses to the staffs of several of the nonpsychiatric facilities within the medical center, specifically the 596-bed adult general hospital, the 286-bed children’s hospital, and the 97-bed women’s hospital. (The service was later extended to the outpatient department, which sees about 1200 patients a day. ) All requests for nursing consultation are assessed by the coordinators of the nursing consultation program and the psychiatry liaison service to determine whether a nurse, a psychiatrist, or a nurse-psychiatrist team will answer the request. That decision is based on the problem presented and on the interests of the consultants available. The consultants are registered nurses who are interested in developing consultation skills and in applying their clinical knowledge in another nursing setting. They include clinical nursing specialists, faculty memhers, head nurses, and staff nurses. Before potential consultants are assigned to the service, the coordinators assess their current psychiatric knowledge and their group skills. It is understood that a consultant’s primary responsibility is her work assignment in the department
VOLUME
28
NUMBER
10 OCTOBER
1977
755
The frequency and type of consultation depend on the preference of the consultant and the consultees. However, calling on the consultant only for crisis intervention is discouraged. of psychiatry. If a nurse assigned to provide consultation to a particular unit cannot respond to a crisis call, she contacts the consultation program coordinator to see if arrangements for another consultant can be made. The coordinators also provide orientation and teaching in basic consultation theory and methodology for all nursing consultants. They provide ongoing supervision through monthly peer-group sessions in which consultants report on their progress and raise problems that the group attempts to solve. The coordinators also provide individual supervision as needed.
THE
METHOD
OF
CONSULTATION
When the program began, information about its availability was widely disseminated to such groups as nursing administrative staff, head nurses, and clinical specialists. Currently a consultant relays information about the service at each orientation seminar for new nurses. Nurses are made aware that consultation is provided only on request, and that ideally a request for a consultant should be based on a decision by the majority of the nursing staff of a unit. When a unit wants nursing consultation, the head nurse contacts the coordinator of the program; if the coordinators of the nursing program and the psychiatry liaison service decide that the consultant should be a nurse, the nursing coordinator matches the skills of available consultants to the needs of the unit. The consultant is assigned to the unit for whatever continuing service is desired rather than to answer just the single consultation request. The purpose is to enable the consultant to develop a trusting, working relationship with the unit’s staff. (Consultation may be provided if only one nurse requests it, but it would be on a one-time basis, about a specific patient, rather than an ongoing arrangement.) At this point the consultant negotiates a contract for subsequent sessions with the unit staff; it includes an agreement about the goals of the sessions, the means of accomplishing them, and the expected outcomes. The consultant also makes the group aware of her limitations as well as of the assistance she can offer. The frequency and type of consultation is determined by the preference of the consultant and the
756
HOSPITAL
&
COMMUNITY
PSYCHIATRY
consultees. The consultant may hold regularly scheduled problem-solving conferences with the staff, in a mental health education model, or she may respond only to specific problems, in a crisis intervention model. Usually a combination of approaches is used. Exclusive use of the crisis model is discouraged. It is hoped that through regular meetings with a consultant, the nursing staff will build their psychosocial skills, will be better able to handle crises when they arise, and will develop a more preventive orientation. Ideally, if those processes continue, the consultant would work herself out of a job. But in reality the nurses’ schedules and the high rate of turnover make it difficult to establish enough consistency in group membership that a consultant would no longer be needed. In almost all instances, the consultants work with staff rather than seeing patients. Staff often ask that a consultant assess a patient directly, but usually such requests are denied. The coordinators believe that the consultants should work with the staffs perception of the patient; the consultant does not care for the patient eight hours a day and does not have the same information, feelings, and biases as the nurses who do. The goal of consultation is not to provide an expert assessment’ of the situation but to work on nursing care problems from the nurses’ own frame of reference. The consultant may offer suggestions, but the final decision on patient care lies with the staff responsible for that care. The consultant functions primarily as a facilitator in the problem-solving process. ‘ ‘
‘
THE
PROGRAM’S
OBJECTIVES
The consultant’s role as a facilitator is recognized in the objectives of the nursing consultation program. Three of the objectives relate to the different kinds of prevention. . To facilitate the process by which nursing staff meet the emotional needs of patients who experience stress due to hospitalization (primary prevention). A consultant working in this area is dealing with program development for a particular unit or group, such as a diabetes group. The consultant helps the group identify the target, method, and goal of the intervention. To do that, she must have a working knowledge of the larger system within which her consultee group operates and of the impact of each new program on the total system. Although she need not be an expert about the kind of program being developed, she helps the nurses identify and use appropriate resources. She also helps the group find a means of evaluating the new program. . To facilitate the process by which nursing staff increase their ability to recognize early, and intervene in, problems that might lead to prolonged hospitalization or psychiatric hospitalization (secondary prevention). The consultant working in this area is dealing with problems related to the stress of hospitalization or illness. She recognizes that hospitalization is often a difficult time for both patients and families. She helps the nursing staff to assess behavior that might result
.
from this stressful situation and to plan interventions that will alleviate stress and let the patient function at the highest possible level. She also helps the staff identify other support systems for patient and family. Finally, she assists the staff in evaluating the effectiveness of their interventions. . To facilitate the process by which nursing staff plan and evaluate the nursing care of patients with identifled psychiatric problems (tertiary prevention). Here the consultant is dealing with identified psychiatric problems, and she must have demonstrated ability in working with psychiatric patients. She helps the nursing staff plan behavioral interventions that are appropriate to their unit. She also assesses whether a psychiatric evaluation is indicated; if it is, she instructs the nursing staff in how to obtain one. One of her primary responsibilities is to alleviate the fears and dispel the myths held by nurses not accustomed to caring for psychiatric patients. . To facilitate the process by which nursing staff increase their skill in meeting patients’ emotional needs. The concern here is primarily with staff education. The consultant assumes that most nurses come to their work setting with some basic preparation for meeting the emotional needs of patients; it is her responsibility to assess the nurses’ level of functioning in that area and to build on existing skills. Her goal is to help nurses transfer new skills and knowledge from one situation to another. Eventually they will be able to independently intervene in situations in which they previously would have needed help. I To facilitate the process by which nursing staff identify obstacles and barriers to meeting the emotional needs ofpatients. In this area the consultant is dealing with interpersonal processes, group dynamics, and systems issues. She works to increase the staffs awareness of the effects these elements have on the delivery of nursing care. She also helps staff examine what options they have for either reducing or working around barriers to meeting patients’ needs.
A CONSULTATION
SESSION
Some of the objectives of the program as well as the actual workings of a consultation session can be illustrated by the case of a three-year-old boy hospitalized on a pediatric rehabilitation unit. Roy had ingested lye at the age of 18 months, which resulted in extensive injuries to his upper gastrointestinal tract. Except for a total of seven days at home, he had been hospitalized ever since. Thus, in addition to the difficulties of normal growth and development, there were a number of problems resulting from the stresses of illness, hospitalization, and maternal separation. One objective of the consultation about Roy was secondary prevention, prevention of a psychological disorder. Another objective, as Roy was demonstrating repeated attention-seeking negative behaviors, was to define those behaviors so the nursing staff could recognize them and make consistent interventions.
Consultants almost always work with the staff rather than assessing patients directly because the coordinators believe the consultants should work with the staff’s perception of the patient. The consultation was one of the regularly scheduled sessions held with the unit’s nurses and social worker. The purpose of the meetings, which had been established before the first session, was to discuss any nursing problems the staff were having and arrive at a group solution to them. The staff described Roy as an extremely active, curious three-year-old who seemed to get into everything. He required a great deal of staffs attention and energy. They did not want to limit his normal growth and development by severely restricting his activity, but his behavior endangered himself, other patients, and the staff. For instance, he had poured cleaning powder all over a floor; had dashed into areas dangerous for him, such as a treatment room; did not adhere to his very limited diet but grabbed food from other children’s trays; had played with the buttons on a patient’s respirator; and had pulled tubes attached to a patient’s tracheostomy. The nurses and consultant attempted to identify which behaviors were most frequent, which were occasional, and which occurred just once. They found that most unacceptable behaviors were demonstrated only once. However, the nurses noted that the total number of the behaviors made management of Roy quite difficult. Thus the group decided to examine the management of a behavior that was not recurrent-pouring cleanser on the floor-and a behavior that was, grabbing and eating forbidden foods. The nurse who caught Roy in the act of pouring the cleanser had taken it from him; scolded him, telling him he was a bad boy; and sat him on his bed. She told a colleague who was passing by the room what had happened. Soon there were many people in Roy’s room, hearing about his adventure. Many of them thought it was kind of funny” or cute.” The staff recognized that much of the potency of the scolding had been lost by the amount of attention and laughter Roy received immediately afterward. Re-examining the incident, the staff agreed the cleanser should never have been left where a toddler might get hold of it. They also agreed it was appropriate to demonstrate disapproval of a potentially dangerous behavior, but they must be careful not to reject the patient himself. Roy had several drainage fistulas on his neck that “
“
VOLUME
28
NUMBER
10
OCTOBER
1977
757
Among all the units, common subjects of requests for consultation included moral and ethical issues, death and the nurses’ reaction to ‘it, the nurses’ reaction to patients’ behaviors, and interstaff difficulties.
nursing staff reported that Roy’s behavior was no longer a major nursing problem. The consultant had thus laid the groundwork for an emotionally healthier patient and a less frustrated, more knowledgeable staff. THE
prevented him from drinking fluids and eating most foods. His diet consisted of intravenous fluids and peanut butter on toast, which he was given on request; he also received lemon mouth swabs. He would become excited at mealtime, running from bed to bed trying to get food from other patients’ trays. The nurses tried to provide him with an activity for that hour, but he ignored it and continued grabbing. The group talked about why Roy might need to continue that behavior and about how difficult mealtime must be to an orally deprived little boy. The nurses decided to give Roy a meal tray with peanut butter toast and a lemon swab. Thus he would experience a more normal meal regime and have a meal at a time when the ward was filled with the smells, sounds, and sights of food. Staff also believed it would be helpful to determine as a group what other of Roy’s behaviors were unacceptable, naughty, or dangerous, and they decided on a consistent approach to dealing with them. A primary nurse was to be assigned to Roy. She would formulate a nursing care plan and have the main responsibility for his care. At this point the consultant asked the staff what happened when Roy was a good boy. They admitted they were kept so busy with his negative behaviors that they tended to overlook or ignore his positive behaviors. They decided that more attention needed to be paid to the acceptable behaviors. The role of the consultant during this meeting was mainly that of a sounding board. She reflected on what the nurses said, asked general questions about areas she felt were overlooked, and redirected the nurses’ questions to the group. The staff were then able to solve the problems and to formulate a plan of action based on Roy’s special needs. Occasionally the consultant also served as a role model. She described similar incidents in which she had been involved, and the alternative courses of action she had identified. These accounts gave staff some distance from the current problem. During the next session the nursing staff briefly discussed Roy in order to review some of the outcomes. Roy had been assigned a primary nurse, and she was able to apply solutions worked out in the group to several of his problem behaviors. In later sessions the
758
HOSPITAL
& COMMUNITY
PSYCHIATRY
FIRST
12
MONTHS
In reviewing the first year of the consultation program, the coordinators were unable to identify many patterns or trends in the type of problems presented for consultation. Each nursing staff presented different problems at different points in the consultation process. However, some general topics were common among the units: they included moral and ethical issues within nursing, death and the nurses’ reaction to it, nurses’ reaction to patients’ behaviors, family issues, and interstaff difficulties. The coordinators hypothesized that the lack of further consistency among the units could be accounted for by variables within the program and the system. For instance, the units that request consultation are administratively and functionally different from one another, the consultants have different levels of consultation skill, and the consultants use different consultation frameworks. A total of 146 consultations were provided during the first year. As Table 1 shows, the number of units receiving consultation increased from seven when the program began to 1 1 a year later, with some fluctuations month by month. The number of units receiving consultation each month averaged 9.5. During the year the number of consultations per month increased from 14 to 17; the average was slightly more than 12 consultations per month. The number of consultants remained fairly steady, between six and eight. The coordinators realize that research is needed in order to demonstrate the effectiveness of the program, and the collection of baseline and other data has begun. At this point the evidence of the effectiveness of the program is based on the increase in requests for consultation over the first year and the tremendous enthusiasm that both the consultants and the consultees have for the program. I 1 ing the first
Status
TABLE
12
consultation
program
of units
N
Month
of the nursing
months
receiving
N of con-
consultation
sultants
N of consultations
March1974 April
7
7
14
4
6
10
May
5
6
11
June
5
6
6
July
5
6
9
August
12
6
11
September
12
7
17
October
13
8
16
November
15
7
16
December January 1975 February
15 10
7 8
7 12
11
8
17
dur-
LAURIE
S. BENDER,
R.N.,
R.N.,
M.S.
Center
M.S.
Clinical Nursing Specialist Virginia Centerfor Children Richmond, Virginia A program of psychiatric nursing consultation was established at a large university medical center in response to requests from nonpsychiatrlc nurses; they generally felt that patient evaluations provided by the psychiatry liaison service did not have specific application to nursing care. The program is operated by two part-time coordinators who train and supervise the nurse-consultants through monthly group sessions and individual supervision. One aim is to set up ongoing consultative meetings with nursing staffs who request help rather than providing only one-time or crisis consultation. During the program’sfirst year, 146 consultations were given, and an average of 9.5 nursing units received consultation services each month. ‘The impetus for a psychiatric nursing consultation program at the University of Michigan Medical Center came from nurses in the medical-surgical, pediatric, and obstetrical areas of the center. The only psychiatric resource available to them was consultation from psychiatric residents assigned to the department of psychiatry’s liaison service, which was also staffed by senior staff psychiatrists and a psychiatric social worker. Usually a resident evaluated the patient about whom consultation was requested and then prepared a formal consultation summary. It was often written in psychiatric terminology, and most nurses had difficulty making use of it in developing a nursing care plan. Ms. Przepiorka also is assistant professor of nursing at the University of Michigan School of Nursing. Her address at the medical center is Riverview Building, 900 Wall Street, Ann Arbor, Michigan 48105. Ms. Bender formerly was a clinical nursing specialist in the department of psychiatry at the University of Michigan Medical Center and assistant coordinator of the psychiatric nursing consultation program.
Although many liaison service residents tried to provide guidelines for incorporating the results of the evaluation into patient care, they had limited knowledge of the responsibilities of a nurse on a particular unit and of the nursing staff in general. The nurses felt that other nurses would be more aware of their needs and could help them develop usable nursing care plans, and they asked that psychiatric nurses consult with them about patients with known psychiatric problems or with problem behaviors. A proposal for the consultation service was developed by the senior author and submitted to nursing administrators throughout the medical center. It was approved
by
the
administrative
staff
group,
and
the
program
began operation in March 1974, with the senior author as coordinator. In July an assistant coordinator for pediatrics (the second author) was appointed. Both coordinators have a master of science degree in psychiatric nursing and were clinical nursing specialists in the department of psychiatry. Forty per cent of the coordinator’s time and 30 per cent of the assistant coordinator’s time was released for the consultation program. The program was designed to provide consultation by psychiatric nurses to the staffs of several of the nonpsychiatric facilities within the medical center, specifically the 596-bed adult general hospital, the 286-bed children’s hospital, and the 97-bed women’s hospital. (The service was later extended to the outpatient department, which sees about 1200 patients a day. ) All requests for nursing consultation are assessed by the coordinators of the nursing consultation program and the psychiatry liaison service to determine whether a nurse, a psychiatrist, or a nurse-psychiatrist team will answer the request. That decision is based on the problem presented and on the interests of the consultants available. The consultants are registered nurses who are interested in developing consultation skills and in applying their clinical knowledge in another nursing setting. They include clinical nursing specialists, faculty memhers, head nurses, and staff nurses. Before potential consultants are assigned to the service, the coordinators assess their current psychiatric knowledge and their group skills. It is understood that a consultant’s primary responsibility is her work assignment in the department
VOLUME
28
NUMBER
10 OCTOBER
1977
755
The frequency and type of consultation depend on the preference of the consultant and the consultees. However, calling on the consultant only for crisis intervention is discouraged. of psychiatry. If a nurse assigned to provide consultation to a particular unit cannot respond to a crisis call, she contacts the consultation program coordinator to see if arrangements for another consultant can be made. The coordinators also provide orientation and teaching in basic consultation theory and methodology for all nursing consultants. They provide ongoing supervision through monthly peer-group sessions in which consultants report on their progress and raise problems that the group attempts to solve. The coordinators also provide individual supervision as needed.
THE
METHOD
OF
CONSULTATION
When the program began, information about its availability was widely disseminated to such groups as nursing administrative staff, head nurses, and clinical specialists. Currently a consultant relays information about the service at each orientation seminar for new nurses. Nurses are made aware that consultation is provided only on request, and that ideally a request for a consultant should be based on a decision by the majority of the nursing staff of a unit. When a unit wants nursing consultation, the head nurse contacts the coordinator of the program; if the coordinators of the nursing program and the psychiatry liaison service decide that the consultant should be a nurse, the nursing coordinator matches the skills of available consultants to the needs of the unit. The consultant is assigned to the unit for whatever continuing service is desired rather than to answer just the single consultation request. The purpose is to enable the consultant to develop a trusting, working relationship with the unit’s staff. (Consultation may be provided if only one nurse requests it, but it would be on a one-time basis, about a specific patient, rather than an ongoing arrangement.) At this point the consultant negotiates a contract for subsequent sessions with the unit staff; it includes an agreement about the goals of the sessions, the means of accomplishing them, and the expected outcomes. The consultant also makes the group aware of her limitations as well as of the assistance she can offer. The frequency and type of consultation is determined by the preference of the consultant and the
756
HOSPITAL
&
COMMUNITY
PSYCHIATRY
consultees. The consultant may hold regularly scheduled problem-solving conferences with the staff, in a mental health education model, or she may respond only to specific problems, in a crisis intervention model. Usually a combination of approaches is used. Exclusive use of the crisis model is discouraged. It is hoped that through regular meetings with a consultant, the nursing staff will build their psychosocial skills, will be better able to handle crises when they arise, and will develop a more preventive orientation. Ideally, if those processes continue, the consultant would work herself out of a job. But in reality the nurses’ schedules and the high rate of turnover make it difficult to establish enough consistency in group membership that a consultant would no longer be needed. In almost all instances, the consultants work with staff rather than seeing patients. Staff often ask that a consultant assess a patient directly, but usually such requests are denied. The coordinators believe that the consultants should work with the staffs perception of the patient; the consultant does not care for the patient eight hours a day and does not have the same information, feelings, and biases as the nurses who do. The goal of consultation is not to provide an expert assessment’ of the situation but to work on nursing care problems from the nurses’ own frame of reference. The consultant may offer suggestions, but the final decision on patient care lies with the staff responsible for that care. The consultant functions primarily as a facilitator in the problem-solving process. ‘ ‘
‘
THE
PROGRAM’S
OBJECTIVES
The consultant’s role as a facilitator is recognized in the objectives of the nursing consultation program. Three of the objectives relate to the different kinds of prevention. . To facilitate the process by which nursing staff meet the emotional needs of patients who experience stress due to hospitalization (primary prevention). A consultant working in this area is dealing with program development for a particular unit or group, such as a diabetes group. The consultant helps the group identify the target, method, and goal of the intervention. To do that, she must have a working knowledge of the larger system within which her consultee group operates and of the impact of each new program on the total system. Although she need not be an expert about the kind of program being developed, she helps the nurses identify and use appropriate resources. She also helps the group find a means of evaluating the new program. . To facilitate the process by which nursing staff increase their ability to recognize early, and intervene in, problems that might lead to prolonged hospitalization or psychiatric hospitalization (secondary prevention). The consultant working in this area is dealing with problems related to the stress of hospitalization or illness. She recognizes that hospitalization is often a difficult time for both patients and families. She helps the nursing staff to assess behavior that might result
.
from this stressful situation and to plan interventions that will alleviate stress and let the patient function at the highest possible level. She also helps the staff identify other support systems for patient and family. Finally, she assists the staff in evaluating the effectiveness of their interventions. . To facilitate the process by which nursing staff plan and evaluate the nursing care of patients with identifled psychiatric problems (tertiary prevention). Here the consultant is dealing with identified psychiatric problems, and she must have demonstrated ability in working with psychiatric patients. She helps the nursing staff plan behavioral interventions that are appropriate to their unit. She also assesses whether a psychiatric evaluation is indicated; if it is, she instructs the nursing staff in how to obtain one. One of her primary responsibilities is to alleviate the fears and dispel the myths held by nurses not accustomed to caring for psychiatric patients. . To facilitate the process by which nursing staff increase their skill in meeting patients’ emotional needs. The concern here is primarily with staff education. The consultant assumes that most nurses come to their work setting with some basic preparation for meeting the emotional needs of patients; it is her responsibility to assess the nurses’ level of functioning in that area and to build on existing skills. Her goal is to help nurses transfer new skills and knowledge from one situation to another. Eventually they will be able to independently intervene in situations in which they previously would have needed help. I To facilitate the process by which nursing staff identify obstacles and barriers to meeting the emotional needs ofpatients. In this area the consultant is dealing with interpersonal processes, group dynamics, and systems issues. She works to increase the staffs awareness of the effects these elements have on the delivery of nursing care. She also helps staff examine what options they have for either reducing or working around barriers to meeting patients’ needs.
A CONSULTATION
SESSION
Some of the objectives of the program as well as the actual workings of a consultation session can be illustrated by the case of a three-year-old boy hospitalized on a pediatric rehabilitation unit. Roy had ingested lye at the age of 18 months, which resulted in extensive injuries to his upper gastrointestinal tract. Except for a total of seven days at home, he had been hospitalized ever since. Thus, in addition to the difficulties of normal growth and development, there were a number of problems resulting from the stresses of illness, hospitalization, and maternal separation. One objective of the consultation about Roy was secondary prevention, prevention of a psychological disorder. Another objective, as Roy was demonstrating repeated attention-seeking negative behaviors, was to define those behaviors so the nursing staff could recognize them and make consistent interventions.
Consultants almost always work with the staff rather than assessing patients directly because the coordinators believe the consultants should work with the staff’s perception of the patient. The consultation was one of the regularly scheduled sessions held with the unit’s nurses and social worker. The purpose of the meetings, which had been established before the first session, was to discuss any nursing problems the staff were having and arrive at a group solution to them. The staff described Roy as an extremely active, curious three-year-old who seemed to get into everything. He required a great deal of staffs attention and energy. They did not want to limit his normal growth and development by severely restricting his activity, but his behavior endangered himself, other patients, and the staff. For instance, he had poured cleaning powder all over a floor; had dashed into areas dangerous for him, such as a treatment room; did not adhere to his very limited diet but grabbed food from other children’s trays; had played with the buttons on a patient’s respirator; and had pulled tubes attached to a patient’s tracheostomy. The nurses and consultant attempted to identify which behaviors were most frequent, which were occasional, and which occurred just once. They found that most unacceptable behaviors were demonstrated only once. However, the nurses noted that the total number of the behaviors made management of Roy quite difficult. Thus the group decided to examine the management of a behavior that was not recurrent-pouring cleanser on the floor-and a behavior that was, grabbing and eating forbidden foods. The nurse who caught Roy in the act of pouring the cleanser had taken it from him; scolded him, telling him he was a bad boy; and sat him on his bed. She told a colleague who was passing by the room what had happened. Soon there were many people in Roy’s room, hearing about his adventure. Many of them thought it was kind of funny” or cute.” The staff recognized that much of the potency of the scolding had been lost by the amount of attention and laughter Roy received immediately afterward. Re-examining the incident, the staff agreed the cleanser should never have been left where a toddler might get hold of it. They also agreed it was appropriate to demonstrate disapproval of a potentially dangerous behavior, but they must be careful not to reject the patient himself. Roy had several drainage fistulas on his neck that “
“
VOLUME
28
NUMBER
10
OCTOBER
1977
757
Among all the units, common subjects of requests for consultation included moral and ethical issues, death and the nurses’ reaction to ‘it, the nurses’ reaction to patients’ behaviors, and interstaff difficulties.
nursing staff reported that Roy’s behavior was no longer a major nursing problem. The consultant had thus laid the groundwork for an emotionally healthier patient and a less frustrated, more knowledgeable staff. THE
prevented him from drinking fluids and eating most foods. His diet consisted of intravenous fluids and peanut butter on toast, which he was given on request; he also received lemon mouth swabs. He would become excited at mealtime, running from bed to bed trying to get food from other patients’ trays. The nurses tried to provide him with an activity for that hour, but he ignored it and continued grabbing. The group talked about why Roy might need to continue that behavior and about how difficult mealtime must be to an orally deprived little boy. The nurses decided to give Roy a meal tray with peanut butter toast and a lemon swab. Thus he would experience a more normal meal regime and have a meal at a time when the ward was filled with the smells, sounds, and sights of food. Staff also believed it would be helpful to determine as a group what other of Roy’s behaviors were unacceptable, naughty, or dangerous, and they decided on a consistent approach to dealing with them. A primary nurse was to be assigned to Roy. She would formulate a nursing care plan and have the main responsibility for his care. At this point the consultant asked the staff what happened when Roy was a good boy. They admitted they were kept so busy with his negative behaviors that they tended to overlook or ignore his positive behaviors. They decided that more attention needed to be paid to the acceptable behaviors. The role of the consultant during this meeting was mainly that of a sounding board. She reflected on what the nurses said, asked general questions about areas she felt were overlooked, and redirected the nurses’ questions to the group. The staff were then able to solve the problems and to formulate a plan of action based on Roy’s special needs. Occasionally the consultant also served as a role model. She described similar incidents in which she had been involved, and the alternative courses of action she had identified. These accounts gave staff some distance from the current problem. During the next session the nursing staff briefly discussed Roy in order to review some of the outcomes. Roy had been assigned a primary nurse, and she was able to apply solutions worked out in the group to several of his problem behaviors. In later sessions the
758
HOSPITAL
& COMMUNITY
PSYCHIATRY
FIRST
12
MONTHS
In reviewing the first year of the consultation program, the coordinators were unable to identify many patterns or trends in the type of problems presented for consultation. Each nursing staff presented different problems at different points in the consultation process. However, some general topics were common among the units: they included moral and ethical issues within nursing, death and the nurses’ reaction to it, nurses’ reaction to patients’ behaviors, family issues, and interstaff difficulties. The coordinators hypothesized that the lack of further consistency among the units could be accounted for by variables within the program and the system. For instance, the units that request consultation are administratively and functionally different from one another, the consultants have different levels of consultation skill, and the consultants use different consultation frameworks. A total of 146 consultations were provided during the first year. As Table 1 shows, the number of units receiving consultation increased from seven when the program began to 1 1 a year later, with some fluctuations month by month. The number of units receiving consultation each month averaged 9.5. During the year the number of consultations per month increased from 14 to 17; the average was slightly more than 12 consultations per month. The number of consultants remained fairly steady, between six and eight. The coordinators realize that research is needed in order to demonstrate the effectiveness of the program, and the collection of baseline and other data has begun. At this point the evidence of the effectiveness of the program is based on the increase in requests for consultation over the first year and the tremendous enthusiasm that both the consultants and the consultees have for the program. I 1 ing the first
Status
TABLE
12
consultation
program
of units
N
Month
of the nursing
months
receiving
N of con-
consultation
sultants
N of consultations
March1974 April
7
7
14
4
6
10
May
5
6
11
June
5
6
6
July
5
6
9
August
12
6
11
September
12
7
17
October
13
8
16
November
15
7
16
December January 1975 February
15 10
7 8
7 12
11
8
17
dur-
