CNE Activity 

CNE Activity

  • Journal of Psychosocial Nursing and Mental Health Services
  • February 2012 - Volume 50 · Issue 2: 23-42, 44-51
  • DOI: 10.3928/02793695-20120116-50

Instructions

4.0 contact hours will be awarded by Vindico Medical Education upon successful completion of the posttest and evaluation. To obtain contact hours:

  1. Read the following articles carefully, noting the tables and other illustrative materials, which are provided to enhance your knowledge and understanding of the content:

    • Implementation of Comfort Rooms to Reduce Seclusion, Restraint Use, and Acting-Out Behaviors

      Kim Sivak, RN-BC, DNP, on pages 24–34.

    • Psychiatric Nursing Emergency: A Simulated Experience of a Wrist-Cutting Suicide Attempt

      Mary L. Lilly, PhD, RN, MSN, APRN, BC; Melinda S. Hermanns, PhD, RN, BC, CNE; and Bill Crawley, RN, MS, MA, on pages 35–42.

    • Using Pedometers to Document Physical Activity in Patients with Schizophrenia Spectrum Disorders: A Feasibility Study

      Lora H. Beebe, PhD, PMHNP-BC; and Robin Faust Harris, MSN, ANP-BC, on pages 44–49.

  2. Read each question and record your answers on the CNE Registration Form on page 51.

  3. Complete all sections of the CNE Registration Form, including indicating the total time spent on the activity (reading articles and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

Contact Hours

Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commission on Accreditation, P188-6/09-12. This activity is co-provided by Vindico Medical Education and the Journal of Psychosocial Nursing.

This is a Learner-Paced Program. Answers to the posttest will be graded, and you will be advised that you have passed or failed within 60 days of receipt of your completed test. A score of 70% or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the test. A contact hour is 60 minutes of instruction. Contact hour verification can be awarded only at the completion of a program.

Activity Objectives

  1. Describe the benefits associated with the use of comfort rooms in psychiatric settings.

  2. Examine the process of implementing a psychiatric emergency nursing simulation.

  3. Discuss how pedometers can be used to determine the level of physical activity in patients with schizophrenia spectrum disorders.

Author Disclosure Statements

  • Dr. Sivak has disclosed no potential conflicts of interest, financial or otherwise.
  • Dr. Lilly, Dr. Hermanns, and Mr. Crawley have disclosed no potential conflicts of interest, financial or otherwise.
  • Dr. Beebe and Ms. Harris have disclosed no potential conflicts of interest, financial or otherwise. This project was supported by a grant from the University of Tennessee College of Nursing Center for Nursing Research.

Commercial Support Statement

All authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

Implementation of Comfort Rooms to Reduce Seclusion, Restraint Use, and Acting-Out Behaviors

According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2011), approximately 150 people die each year as a result of practices used to seclude or mechanically restrain someone with a mental illness, and myriad others are injured or traumatized. The National Association of State Mental Health Program Directors (NASMHPD) stated that there is empirical evidence showing that use of seclusion and restraint has led to psychological harm, physical injury, and even death for both the clients subjected to these events and the staff members who apply these techniques (Haimowitz, Urff, & Huckshorn, 2006). In 1998, the Hartford Courant published a series of articles entitled, “Deadly Restraint” that chronicled 142 deaths nationwide related to the procedures used in seclusion and restraint in mental health facilities from 1988 to 1998 (as cited in Haimowitz et al., 2006). This report was prompted by the death of an 11-year-old boy who died when two aides sat on his back and crushed him to death after his refusal to move to another breakfast table (NASMHPD, 2009). This article will examine the positive impact on clients and nursing staff when comfort rooms are implemented at one small, rural, tertiary mental health hospital.

Background

According to the Centers for Medicare & Medicaid Services (CMS, 2005), a restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a person to freely move his or her arms, legs, body, or head. Seclusion is the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving (CMS, 2005).

LeBel and Goldstein (2005) developed a model that determined the cost of an average duration of mechanical restraint use; when including for pre-restraint, the actual restraint episode, and post-restraint, the process cost $309.21. This figure included number of tasks involved, number of staff disciplines, and staff time in all three phases (LeBel & Goldstein, 2005). Additionally, they posited the facility’s annual inpatient service budget to be $3,998,741 and the cost evoked from annual use of restraints to be $1,446,740. Therefore, approximately 36% of the budget was consumed by the use of mechanical restraints.

Curie (2005) stated that use of seclusion and restraint and enforcing external control is keeping clients in a margin that prohibits them from learning how to manage their illnesses and lives. Through these practices, dependence and learned helplessness and hopelessness are encouraged, and clients are not seeking the necessary treatment due to the fear of losing power and control (Curie, 2005). Staff members do not look at clients as individuals but as pejorative labels. Glover (2005) asserted that many inpatient psychiatric settings focused on characteristics of clients that staff considered negative, such as substance abuse, age, race, and childhood environment, which is responsible for an atmosphere where staff members view the clients as the only cause of unit violence and aggression. By identifying clients this way, staff may expect them to live up to the self-fulfilling prophecy of negative behaviors and staff may also absolve themselves of any responsibilities for clients’ aggressive acts.

NASMHPD (2009) concluded that the “worse possible punishment” in prisons is seclusion or solitary confinement, yet in psychiatric settings clients who are presumed to have behaved inappropriately are placed in seclusion and it is termed “therapeutic.” As a cogent argument, Bloom (2002) asserted that clinicians should assume that clients in psychiatric settings, especially women, have been exposed to violence, and coercion and forceful actions could trigger previous experiences that lead to retraumatization. Placing these clients alone in a locked room or having staff forcibly hold them against their will so other staff members can apply mechanical restraints to all four extremities could cause these clients to relive past similar experiences that were done to punish or torture them.

New and Promising Directions

No evidence supports the therapeutic value of seclusion and restraint, and the current focus is moving from a medical model that defines individuals as mentally ill patients toward the recovery model aiming to define clients with mental illness. There is renewed optimism that new interventions will support those with serious mental illness and treat them as individuals with a sense of hope and personal choice (Huckshorn, 2004). The recovery model is becoming the cornerstone for the future of the treatment of people with mental illness (SAMHSA, 2010). Some of the tenets of recovery for mental health include hope, empowerment, individualized and person-centered care, peer support, and respect (SAMHSA, 2010). Although no one method is identified as the best, it appears a multifaceted approach of numerous methods all grounded in the movement toward the recovery model should be used as methods to reduce the use of seclusion and restraint.

Promising research offers numerous approaches that lead to the reduction of seclusion and restraint. SAMHSA (2010) asserted that a focus on the recovery model would include client involvement, development of partnerships between clients and staff, and data collection. Some studies concluded that the following were necessary components in the reduction of the use of seclusion and restraint (Ashcroft & Anthony, 2008; Kontio et al., 2010):

  • Strong leadership direction.
  • Specific staff training.
  • Debriefing.
  • Nursing interventions such as nurse presence with clients in conversations that provide clients a sense of safety and comfort.
  • Interprofessional agreements with nurses and physicians and the client that negotiate behaviors in a written or verbal contract.

Champagne and Stromberg (2004) voiced the need for a national initiative that would focus on the reduction of seclusion and restraint use in inpatient psychiatric facilities through the use of creative methods that include the client in the recognition of self-care and positive change. They asserted that to ensure a person-centered care environment, it is the health care worker’s responsibility to develop strategies that respond to clients’ needs and essentially to design interventions with clients’ input that show responsiveness to these daily needs. Bloom (2002) stated that for an environment to be truly safe it must be safe for clients and staff and that staff cannot create an environment that is safe without the active participation of the clients.

Use of Comfort Rooms

Champagne and Stromberg (2004) posited that all human brains seek information through the senses such as to look, listen, touch, taste, and smell. According to Bluebird Consultants (n.d.), a comfort room is a preventive tool or alternative to the use of seclusion and restraint, as it is a sanctuary and place for clients to go to experience their feelings of anger or anxiety within acceptable boundaries, a place to participate in various activities of their choice that could engage all of their senses. Bluebird (2005) also asserted that among the numerous approaches toward the reduction of seclusion and restraint, comfort rooms are one of the most popular tools cited by both staff members and clients in the psychiatric facilities. She also posited that by using these rooms the use of seclusion and restraint can lessen through stress reduction, and the rooms are cost effective and require no specialized education to use. She strongly emphasized that use of a personal safety plan increases the effectiveness of a comfort room. A safety plan is a form given to clients to complete on admission to the facility that provides them the opportunity to identify difficulties and potential triggers, as well as what helps them during times of distress (Bluebird, 2005).

As part of a pilot project, Cummings, Grandfield, and Coldwell (2010) studied the effects of a comfort room on an admission unit at one institution. The intent was to promote a therapeutic, safe, and supportive environment for clients at the facility. To decrease staff anxiety levels, it was decided to keep one existing seclusion room on the unit instead of converting that room to a comfort room so the project could move forward with equal optimism from the staff members and the clients (Cummings et al., 2010). They concluded that overall, the comfort room—a converted alcove area—was effective for the majority of clients in providing the tools for them to successfully manage distress or anxiety; however, it was not effective for the small number of select high-risk clients that use a disproportionate amount of more restrictive measures.

Comfort Room Initiative

In support of this recovery-focused initiative, an interdisciplinary team led by the author was formed to develop a comfort room on each of the female and male inpatient admission units of a small, rural, tertiary mental health hospital. The comfort room doctor of nursing practice Capstone Project was approved through the Institutional Review Board at Waynesburg University and received authority approval from the practice site. This project was developed to provide an alternative tool in the mission to cease the use of seclusion and restraint in the institutionalized mental health patient population.

Team Formation

In January 2010, a comfort room plan was presented to the executive staff members and leadership team at the mental health hospital. The comfort room committee recommended that with the institution of comfort rooms, clients could volunteer to use the rooms for up to 30 minutes when they first feel anxious or angry. Use of the comfort rooms would be effective in decreasing negative acting-out behaviors such as self-injury, assaulting other clients or staff, or any other similar behaviors that could result in the use of seclusion or restraint for clients. The goals of the project included:

  • Within 4 months of instituting the comfort rooms, there would be zero use of seclusion and restraint at the hospital.
  • Within 4 months of instituting the comfort rooms, there would be a 50% reduction in client-to-client assaults, client-to-staff assaults, and self-injurious behaviors at the hospital. (The hospital defines assault as an aggressive act involving physical contact that may or may not result in injury, while self-injurious behavior is a self-directed act that injures the client.)

The project team leader invited all hospital division leaders to present the development of comfort rooms to their subordinates and solicit volunteers. Members of the team included a financial office representative to approve the costs, a representative from the procurement office to assist with ordering the necessary items, someone from the performance improvement department to assist with data collection, a psychologist to assist with procedures and current practices in mental health, a member of the activity department to guide the committee on various tools used as comfort measures, two direct-care RNs, and two nursing supervisors. Client representation was imperative, and the first four clients who volunteered were chosen to join the team. One male and one female client attended each meeting, and the other male and female clients served as alternates. Clients who participate on committees receive minimum wage for their attendance time at the meetings.

Mission

Prior to the second and subsequent meetings, an agenda and meeting minutes from the previous meeting were sent to all committee members. By group consensus, a mission statement was developed to communicate the shared vision of the project: “The mission of the comfort room initiative is to provide clients an opportunity to practice self-management techniques in a low-stress environment.” The committee met every 2 weeks. Committee members presented this initiative to stakeholders both within and outside the hospital, in addition to including information about the comfort rooms in the employee, client, and family newsletters.

Comfort Room Development and Design

The two admission units’ direct care nursing staff and clients chose the comfort room locations on the units and began discussing these rooms with all clients at the weekly community ward meetings. These weekly meetings occur on each unit, and all clients’ attendance is requested to receive education and information about unit- and hospital-wide current concerns and initiatives. The committee’s clients also informed their peers of the committee’s progress at these meetings. All clients throughout the facility were given a survey to voluntarily complete that included a description and purpose of the initiative, items to include in the rooms such as a comfortable chair and music, and queried as to what additional items they would like to see in these rooms that would promote a relaxing and soothing environment. Although the rooms would initially only be located on two admission units, the committee decided that all clients in the building would have the same opportunity to vote on the different proposals. This led to increased client buy-in and created a sense of client pride and ownership in these rooms.

The first project proposal that sought all client participation was choosing a wall mural. One wall in each of the comfort rooms would be covered by a mural. Seven different calming murals were chosen by the comfort room committee members. A screenshot of all seven scenes was placed on a large cardboard poster. One of these posters was given to each of the five units, and at the units’ next community meetings, nursing staff asked the clients to pick their favorite mural through a show of hands. Approximately 75 male and 50 female clients were present, and the majority them voted. Both the male and female unit clients chose the scene titled “Mountain Stream.” This mural displays a small waterfall cascading through a forest of brown, green, and red hues.

The next project proposal aimed at increasing client participation was to hold a contest for each unit, allowing clients to suggest a name for each comfort room. The two winners received a $5 coupon book to the hospital’s canteen and were acknowledged publicly. The men chose the name “Tranquility,” and the women chose “Relaxation Station.” The names were placed on a plaque identifying the rooms and were unveiled in a ribbon-cutting ceremony in mid-November 2010, which signified the official commencement of the comfort rooms.

With the assistance of the clients, the committee selected the items to be placed in the comfort rooms. The walls were painted a pastel green, and one wall also had the mural on it. Another wall had an area covered with chalkboard paint near the floor so clients could sit on a mat and write on the wall if they chose to do so. Drop ceilings were installed to help decrease the noise level in the rooms. Light panels with sky scenes were used to improve the ambience and produce a feeling of being outside, as well as aid in decreasing the harsh lighting. The clients selected these last two items in the same manner they selected the wall mural, by choosing from screenshots on a large cardboard poster.

A recliner, rocking chair, foam chair, and lap desk were placed in each carpeted room, as well as a large liquid crystal display television and Blu-ray Disc player for DVDs with calming scenes. The televisions can only be used with these DVDs, as there is no cable connection. A surround-sound system is housed in the drop ceilings. Because the television and Blu-ray player needed to be housed safely in a cabinet, a carpenter was added to the committee. Additional items that are kept in a locked cabinet or closet are stress balls, writing or drawing tools and paper, mind-challenging paper games and puzzles, and pads of various types of aromatherapy scents that may be dabbed onto the skin. The cost to supply both rooms totaled $11,456.98, the three most expensive items being the drop ceilings with designer panels ($2,573), the carpets ($2,154), and the two 40-inch televisions ($1,596).

Policies, procedures, and guidelines governing the use of these rooms were developed with full involvement and agreement of the client committee members. The New York Office of Mental Health website (MacDaniel, 2009) details specific information in the development of comfort rooms—as contributed by five facilities that use them—and this was used as a template. The comfort room committee used this website when developing policies and procedures and added site-specific ideas during brainstorming sessions. A hospital-wide policy, a comfort room use login sheet, an agreement form for use of the comfort room (Figure 1), and a comfort room voluntary feedback form (Figure 2) were developed. To ensure confidentiality, the committee decided where to store each of the forms. Clients and staff were informed that use of the comfort rooms is strictly voluntary. It is an alternative prior to engaging in negative acting-out behaviors, when a client first verbalizes or demonstrates feelings of anxiety or frustration.

The client is to sign the agreement form on admission when the nursing staff describes the intent of the comfort room to the client. However, the client is expected to again read the agreement form and date and initial the back of the form each time prior to using the room. The committee members unanimously believed it is imperative that the client be reminded of the importance of keeping the comfort room in good condition for all clients to use. The objective is that the client recognizes symptoms of increased anxiety, or accepts staff members’ suggestion to voluntarily use the room prior to engaging in any behaviors that could result in negative outcomes. If the client is unable or unwilling to initial the agreement form, then the committee felt use of the comfort room was not an appropriate option at that time.

Another form kept in a binder in the nursing station is a copy of the client’s personal safety plan (Figure 3). Prior to painting or other physical changes to the rooms, photographs of each room were taken (Photo 1) to later use as a comparison to the end product (Photo 2). The infection control nurse was consulted to identify any infection control issues with the items for the rooms, and the safety manager was consulted for any fire safety concerns.

The committee decided that the identified outcome data to measure the impact of this initiative would be to compare the average rate of occurrence per 1,000 days of the client care categories of seclusion and restraint, client-to-client assaults (CTCA) and client-to-staff assaults (CTSA), and self-injurious behaviors for the 4 full months prior to the implementation of the comfort rooms to the next 4 full months after implementation. Table 1 shows data for the months of July through October 2010, and Table 2 shows data for the months of December 2010 through March 2011. November 2010 data were not used since the rooms opened mid-month. Additionally, a form was developed to monitor whether the client required an extra dosage of medication within the 30-minute time frame prior to and after using the comfort room. The purpose of this monitoring tool was to assess a possible positive relationship in decreasing agitation if extra medication were used in conjunction with the comfort room.

Findings and Results

Table 3 lists the number of clients who used the comfort rooms and the total times the rooms were used monthly. An average of 28 women and 42 men who could use the rooms were in the facility each month. Clients’ ages ranged from 18 to 79, with 36.6% of clients in the 50–59 age range. Approximately 63% of clients were at the facility less than 2 years, and 81.4% were Caucasian.

Fourteen voluntary feedback forms were completed during the 4 months. The forms asked clients to rate their level of distress before and after using the comfort room based on a Likert scale ranging from 1 (lowest level of distress) and 5 (highest level of distress); 8 clients stated the room lowered their levels of distress by at least a difference of 2. Five clients noted higher numbers post-comfort-room use, yet all 5 circled the choice that the room helped them. Those clients who circled increased levels of distress on the scale after use of the comfort room may not have understood the scale. One male client indicated that the room was not beneficial and had only identified his level of distress prior to use and did not rate his level after use. He was the only client who believed the room did not help him.

Since the initiation of the comfort rooms, there has been no use of seclusion or restraint. Previously, from October 2009 through October 2010, five occurrences of mechanical restraint use at the hospital were documented. Using LeBel and Goldstein’s (2005) model, which determined the cost of an average duration of mechanical restraint as $309.21, the hospital could have saved $1,546.05 by not using restraints over that period of time.

Although not a 50% decrease, the CTCA rate decreased from a 4-month average of 3.98 to 3.05 (–23.4%), and the CTSA rate decreased from an average of 2.31 to 1.20 (–48.1%). However, self-injurious behavior did increase from an average rate of 2.32 to 2.64 (+12.1%). Written comments by clients as reasons they believed the room was a positive experience included: “the atmosphere,” “the DVD,” “it was relaxing,” “it was calming,” “one could only focus on self,” “it was a private area,” “the nice recliner,” and “it was peaceful.” One female client wrote that the room was “just beautiful” and the only improvement would be if she could use it all the time. Written comments by clients about what they did not like included: “it was only 20 or 30 minutes,” “no cable,” and “no movies.” Clients’ comments about how the room would be more helpful and other suggestions included: “adding country music,” “adding movies,” “staying in the room all the time,” and “adding a computer and pool table.”

Discussion

Four unit RNs were queried about possible reasons they thought clients did not use the comfort rooms (Sidebar). How many times clients refused to use the comfort room when it was offered was not documented or considered as part of this project.

Changes in the rates of each event cannot be fully attributed to the comfort rooms, as numerous variables are involved, including different clients throughout this period, the fact that one client’s actions could significantly alter the outcome, and that other alternatives may also have been used that were not documented. The data collection period was limited to 4 months of data prior to and after inception of the comfort rooms. Future studies are needed to evaluate other variables that might indicate success with the comfort rooms, including analyzing clients’ underlying mental health disorders, gender, age, or change in number of extra medications used.

Although not all goals were met, positive outcomes were noted with decreased rates of CTCA and CTSA, as well as zero use of seclusion and mechanical restraints. In addition, no one used additional antianxiety or antipsychotic medications within 30 minutes before or after using the room, which could indicate that the participants used the comfort room as an alternative to asking for extra medication. Although the cost of supplies for these two rooms was close to $11,500, there are no rules about how much or how little to spend in the development of these rooms. The cost savings in staff time and staff and client injuries, as well as the negative emotional effect on both parties involved, was not measured, although measuring these outcomes could be warranted for future studies. The hospital’s leadership believed the comfort rooms proved to be a viable intervention that allowed clients to practice self-management techniques in coping with their anxiety or anger in an acceptable manner, as well as a preventive tool to the use of seclusion or restraint. The comfort room committee continues to meet quarterly to review feedback forms, to identify areas needing improvement, and to assess the outcomes data.

Due to the success of this pilot project in markedly decreasing restraint, plans are underway to create comfort rooms on the remaining units. Although adoption of this approach was not discussed at a statewide level, if this facility could save approximately $1,500 in a 13-month time frame—and the other five facilities within the state followed suit—there could be a statewide cost savings of $9,000.

Clinical Implications and Conclusion

By nurses allowing and encouraging clients in psychiatric facilities to use the comfort room as a place to privately self-manage anxiety and distress, they could effectively prevent a potential negative outcome, such as the use of seclusion or restraint or staff and client injuries. Seclusion and restraint use and events that result in injuries are disruptive and stressful to the unit milieu. These same events could create fear, anger, and distrust among both clients and staff, which creates difficulty in promoting a safe and secure unit.

The author believes that if nurses encourage the use of the comfort room when a client first feels distressed or anxious, negative outcomes could be decreased, and thus, the use of seclusion and/or restraint could be prevented. Self-management empowers clients and promotes autonomy on their road to recovery. Comfort rooms should be considered an important tool in the goal toward the reduction of seclusion and restraint use.

References

  • Ashcroft, L. & Anthony, W. (2008). Eliminating seclusion and restraint in recovery-oriented crisis services. Psychiatric Services, 59, 1198–1202. doi:10.1176/appi.ps.59.10.1198 [CrossRef]
  • Bloom, S.L. (2002). Creating sanctuary. Networks, Summer/Fall. Retrieved from the National Technical Assistance Center for State Mental Health Planning website: http://www.nasmhpd.org/general_files/publications/ntac_pubs/networks/SummerFall2002.pdf
  • Bluebird Consultants. (n.d.). Comfort rooms. Retrieved from http://www.bluebirdconsultants.com/index_files/Page1127.htm
  • Bluebird, G. (2005). Comfort rooms: Reducing the need for seclusion and restraint. Residential Group Care Quarterly, 5(4), 5–6. Retrieved from http://www.cwla.org/programs/groupcare/rgcqspring2005.pdf
  • Centers for Medicare & Medicaid Services. (2005). Regulations and guidance. In 42 CFR Ch. IV (10-1-05 edition) (pp. 484–486). Retrieved from http://edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr482.13.pdf
  • Champagne, T. & Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing and Mental Health Services, 42(9), 34–44.
  • Cummings, K.S., Grandfield, S.A. & Coldwell, C.M. (2010). Caring with comfort rooms: Reducing seclusion and restraint use in psychiatric facilities. Journal of Psychosocial Nursing and Mental Health Services, 48(6), 26–30. doi:10.3928/02793695-20100303-02 [CrossRef] doi:10.3928/02793695-20100303-02 [CrossRef]
  • Curie, C.G. (2005). SAMHSA’s commitment to eliminating the use of seclusion and restraint. Psychiatric Services, 56, 1139–1140. doi:10.1176/appi.ps.56.9.1139 [CrossRef]
  • Glover, R.W. (2005). Reducing the use of seclusion and restraint: A NASMHPD priority. Psychiatric Services, 56, 1141–1142. doi:10.1176/appi.ps.56.9.1141 [CrossRef]
  • Haimowitz, S., Urff, J. & Huckshorn, K.A. (2006, September). Restraint and seclusion—A risk management guide. Retrieved from the National Association of State Mental Health Program Directors website: http://www.nasmhpd.org/general_files/publications/ntac_pubs/R-S%20RISK%20MGMT%2010-10-06.pdf
  • Huckshorn, K.A. (2004). Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42(9), 22–33.
  • Kontio, R., Välimäki, M., Putkonen, H., Kuosmanen, L., Scott, A. & Joffe, G. (2010). Patient restrictions: Are there ethical alternatives to seclusion and restraint?Nursing Ethics, 17, 65–76. doi:10.1177/0969733009350140 [CrossRef]
  • LeBel, J. & Goldstein, R. (2005). The economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatric Services, 56, 1109–1114. doi:10.1176/appi.ps.56.9.1109 [CrossRef]
  • MacDaniel, M. (2009, February). Comfort rooms: A preventative tool used to reduce the use of restraint and seclusion in facilities that serve individuals with mental illness. Retrieved from the New York Office of Mental Health website: http://www.omh.state.ny.us/omhweb/resources/publications/comfort_room/
  • National Association of State Mental Health Program Directors. (2009, September). Module II—Assumptions presentation. Paper presented at the meeting of the National Executive Training Institute. , Alexandria, VA. .
  • Substance Abuse and Mental Health Services Administration. (2010, March). Promoting alternatives to the use of seclusion and restraint: A national strategy to prevent seclusion and restraint in behavioral health services. Retrieved from http://www.samhsa.gov/matrix2/IssueBrief1_B.pdf
  • Substance Abuse and Mental Health Services Administration. (2011). SAMHSA seclusion and restraint overview. Retrieved from http://www.samhsa.gov/matrix2/seclusion_matrix.aspx

Average Rates of Incidents Before Comfort Room Implementation

Month Seclusion Restraint Client-to-Client Assaults Client-to-Staff Assaults Self-Injurious Behaviors
July 2010 0 0.39 5.29 3.72 2.35
August 2010 0 0 3.16 3.16 3.75
September 2010 0 0 3.18 0.99 2.19
October 2010 0 0 4.27 1.36 0.97

Average Rates of Incidents after Comfort Room Implementation

Month Seclusion Restraint Client-to-Client Assaults Client-to-Staff Assaults Self-Injurious Behaviors
December 2010 0 0 2.97 3.56 2.77
January 2011 0 0 3.14 0.20 1.77
February 2011 0 0 2.58 0.64 4.29
March 2011 0 0 3.49 0.39 1.74

Summary of Comfort Room Use

Women Men
Month Number Who Used Rooma Number Eligibleb Total Times Used Number Who Used Rooma Number Eligibleb Total Times Used
December 2010 9 26 35 1 41 1
January 2011 7 29 22 3 36 5
February 2011 6 29 7 2 45 3
March 2011 2 29 4 1 44 1

Sidebar

  1. Why do you think women use the comfort room more often than men?

    • “The men have other rooms on the unit they prefer to use such as a diversion room,” which allows the men to physically exercise on a treadmill or stationary bicycle.
    • “Men seem to tend to unwind better when they can listen to loud music of their choice, which is not always what women find comforting.”
    • “The women felt special using it, as well as it separates them from their peers. Men may typically prefer to be physical than calming.”
    • “The women appear to find more elegance with the room.”

  2. Are staff members suggesting the use of the room? If not, could you ask them why they do not suggest the room? Do they have any ideas how to increase room usage?

    • “I do believe it is suggested at times, but the guys would rather go to their rooms. Men also tend to have less advanced notice before they become out of control. To increase its usage we need to be more proactive with new admissions.”
    • “Multiple times the room has been offered, however, by the point that some of them escalate, it is beyond helping per their statements. Sometimes staff are unavailable to accommodate when they [clients] feel they would like to use the room.”
    • “Staff do suggest the room but often times more than once the person has to be the one with the idea.”

RN Observations about Comfort Room Use

Sivak, K. (2012). Implementation of Comfort Rooms to Reduce Seclusion, Restraint Use, and Acting-Out Behaviors. Journal of Psychosocial Nursing and Mental Health Services, 50(2), 24–34.

  1. Among the numerous approaches toward reduction in seclusion and restraint use, comfort rooms are one of the most popular choices of both staff members and clients.

  2. It is critical to include patient representatives along with staff members in the development of comfort rooms to develop a sense of ownership.

  3. Comfort rooms are cost effective and require no specialized education to use.

  4. In this study, positive outcomes were noted with decreased rates of client-to-client and client-to-staff assaults, as well as zero use of seclusion and mechanical restraints.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

Psychiatric Nursing Emergency: A Simulated Experience of a Wrist-Cutting Suicide Attempt

Students are expected to master a number of skill sets to meet the minimum standard of professional nursing practice. These skill sets require that students attain knowledge, incorporate critical thinking as well as psychomotor skills, cultivate self-awareness, develop self-confidence in their skills, and subsequently apply their knowledge in the clinical setting. Development of appropriate skills related to a psychiatric emergency presents a challenge in the current health care environment where clinical sites are limited and clinical experience may consist of observation and brief patient contacts or one-on-one encounters (Patzel, Ellinger, & Hamera, 2007). Therefore, it is imperative to explore and develop innovative, research-based learning experiences using all possible resources.

Cognitive, behavioral, and emotional exposure to psychiatric emergency situations is essential for novice nurses as they prepare for graduation and entry into the clinical milieu (The Joint Commission, 1998, 2010; Spunt, Foster, & Adams, 2004). While this kind of situation is relatively infrequent and students may not encounter a psychiatric emergency during their clinical experiences, in the real world, emergency events have a high impact in terms of patient, staff, and organizational outcomes. Patients and staff may be severely traumatized, and organizational exposure is high in areas of community relationships, branding, legal consequences, and staff morale. One example of such exposure was highlighted in a widely distributed report of findings on allegations of mental health safety issues on an inpatient unit. The Department of Veterans Affairs Office of Inspector General (2010) reported that “Inpatients were put at risk because staff did not comply with requirements for suicide risk assessments.... Additionally, we found inadequate policies related to contraband” (p. i).

Typically, students get acquainted with concepts integral to psychiatric emergency situations by completing assigned readings, attending lectures, and reviewing handbooks provided in various clinical settings. However, many concepts may remain dry and lifeless in the absence of some kind of experiential anchor. Simulation can provide this anchor, particularly for rare, infrequent, and/or high-impact clinical events.

Patzel et al. (2007) reported online survey results on the topic of psychiatric-mental health clinical experiences from 160 faculty respondents recruited from the Education Council of the American Psychiatric Nurses Association. The authors noted that approximately 23% of faculty respondents from baccalaureate, associate, and diploma programs communicated use of simulation as a clinical activity; the percentage of total clinical time spent as simulation ranged from 1% to 8%. Qualitative comments documented the use of role-play and case study to provide simulated activities on topics such as violence, aggression, and limit setting.

Purpose

The purpose of this article is to report on the process and content of achieving the overall goal of integrating simulation into the psychiatric nursing clinical experience on a mid-sized Southern university campus. Supporting goals included (a) enacting and modeling the College of Nursing philosophy of caring through an experiential learning activity with undergraduate nursing students in a psychiatric clinical experience, and (b) partnering with a clinical expert in developing an evidence-based best practice simulation designed to convey the key concepts to novice nurses and staff in the psychiatric-mental health area. A related simulation on the concept of suicide by hanging was successfully enacted, evaluated, and reported by Hermanns, Lilly, and Crawley (2011b). The evaluation form for the current simulation report was adapted from the prior simulation activity.

Background and Significance

Research has demonstrated that certain outcomes are more readily achieved when simulation is used for student learning. For example, it has been shown that students retain knowledge learned from a simulation for a longer period of time compared with when the same skill is learned via traditional methods (Jeffries, Woolf, & Linde, 2003). Critical thinking and clinical reasoning are improved, and as a result, students experience increased self-confidence and improved problem-solving abilities (Benner, Sutphen, Leonard, & Day, 2010). In a landmark publication, Benner et al. (2010) identified important elements needed to transform the delivery of education to current and future generations of nurses. Integrating classroom didactic and clinical instruction in the service of learning how to “think like a nurse” is but one of the elements supported by Benner et al. Simulated learning scenarios and environments are important opportunities for blending of didactic and clinical instruction to approach the goals of thinking, doing, and feeling congruent with safe and effective nursing care.

Fortunately, we live in an era that affords students many settings and opportunities for practice of clinical skills, including learning resource centers, clinical skills laboratories, and actual clinical settings equipped for and amenable to simulated activities. Using these resources, students can grapple with theoretical concepts embedded in clinical scenarios and experience the “gut-level” emotional and behavioral responses they elicit, in a safe and supportive learning environment. Students can learn and practice skills and techniques prior to entering the clinical setting as a novice nurse or new employee. Safety and support are clearly important if students are to perceive, process, value, and retain clinically significant information, regardless of where the learning experience takes place.

No doubt many, if not all, faculty and clinical practice professionals can recall that first foray into a “psych unit” and particularly the intrapersonal anxiety experienced by the many unknowns in that setting. Reflecting on this internal state, and informed by Maslow’s (1998)hierarchy of needs, it is probable that in this novel situation, many of us focused on our anxieties and fears, and perhaps even on getting enough oxygen. In fact, Stuhlmiller (2005) reported on survey results from 419 undergraduate nursing students evaluating a revised mental health nursing course designed to stimulate interest in mental health nursing. Results indicated that nearly all respondents doubted their ability to manage their intrapersonal anxiety related to interacting with mental health clients.

Description of the Simulation

“Behind The Door” clinical simulation and training #2 (Hermanns, Lilly, & Crawley, 2011a) is one of a series of simulated clinical activities designed to promote the comfort and competence of baccalaureate nursing students in the psychiatric-mental health treatment setting. The following list outlines the essential components of the wrist-cutting simulation activity.

Event

You open up the door to the patient’s room and find that the patient has smuggled in a knife and slashed the right wrist. You see arterial bleeding and realize the patient could “bleed out” and die.

  • Critical action: Manage two active (i.e., radial, ulnar) arterial bleeds in a rapid manner.
  • Available material: Emergency cart.
  • Observation points: (a) elevation of extremities, (b) adequate pressure source to control bleeding, and (c) infection control and safety actions.

Wrist-Cutting Background and Significance

Wrist-cutting may be an act of self-harm rather than an intentional suicide attempt. To separate the act of self-harm from suicide attempt, it is necessary to evaluate the degree of injury and overall circumstances. Nevertheless, individuals with a suicide attempt of any kind are at greater risk of progressing to a completed suicide in subsequent years (Dewing, Mashadi, & Iwuagwu, 2010; Runeson, Tidemalm, Dahlin, Lichtenstein, & Längström, 2010; Suominen et al., 2004).

Events After the Cut

Relative to the severity and amount of bleeding, the patient can experience cardiac arrhythmias if the body is unable to compensate for the blood loss. If the exsanguination is allowed to continue, the resulting severe hypovolemia will cause shock, followed by cardiovascular collapse, cardiac arrest, and death. Related concerns after wrist-cutting include security of the treatment environment, management of other patients, and infection control.

Key Observations

Arterial bleeding is characterized by a rhythmic gush of blood (in unison with the heartbeat) that is bright red in color. Arterial bleeding from both the radial and ulnar areas suggests suicidal intent on the part of the patient, as significant self-inflicted trauma is necessary to produce such an injury. Venous bleeding, on the other hand, produces a continuous stream of blood of a darker red color. Venous bleeding typically originates from superficial cutting, and the injuries are relatively less severe.

Actions

The best first choice is application of pressure directly over the wound site to overcome the force of the heartbeats. However, if blood flow from the injury cannot be controlled after the application of direct pressure, then it may be necessary to apply indirect arterial pressure; for example, in a case of cut wrist, one might apply brachial artery pressure to reduce bleeding from the wound site (Cloonan, 2004). However, the effectiveness of this approach has been questioned (Markenson et al., 2010; Swan, Wright, Barbagiovanni, Swan, & Swan, 2009). It is important to keep in mind that pressure points should be used with caution because inadequate blood flow may cause severe damage to a limb.

In the worst case scenario, where risk of loss of life is impending, one can apply tourniquets but with extreme caution due to concerns about damage to vessels and tissue (Cloonan, 2004; Kragh et al., 2008; Markenson et al., 2010; Swan et al., 2009). For example, there is a military saying, “If you choose to use a tourniquet, be prepared to defend the loss of everything distal to the tourniquet” (B. Crawley, personal communication, April 16, 2010).

Preparation for the Simulation

Student Preparation

Didactic content covered prior to psychiatric-mental health clinical exposure includes the role of the nurse in therapeutic interactions with individuals having altered mental status, use of critical thinking in assessment and for addressing ethical dilemmas in the psychiatric setting, and safety and infection control in the psychiatric arena. The topics of therapeutic communication/use of self, self-awareness, and reflection on practice, as well as avoiding dual or social relationships, are also included in the didactic content.

Simulation-specific preparation includes informing students that Behind the Door, they will find a patient (simulation mannequin) with a right wrist laceration and displaying arterial bleeding. They are asked to respond to the patient using the knowledge and behaviors gained from previous learning experiences, including working as a team to leverage all knowledge and experience available in the group.

Students are encouraged to “think out loud” and to seek and provide assistance to peers and from faculty throughout the scenario. Students are also reassured that faculty understand their level of clinical skills and recognize that some skills may be unfamiliar; however, the underlying purpose of the activity is to challenge their thinking, promote team interaction, and practice intervening in a high-stress, high-stakes clinical episode. Students are also advised that questions will be posed by faculty to further the critical thinking process. The state of “not knowing”—by a student or by the team—is considered normal, but the expectation is set forth that participants will actively help solve the problems posed by the clinical scenario presented in the simulation.

Setting and Equipment

The simulation takes place in the clinical skills laboratory or the actual clinical setting, depending on resources available. This scenario requires the availability of a simulation mannequin with arterial blood function, moulage (i.e., mock wound), emergency cart, proxy weapon, and proxy blood.

Objectives

Desired learning outcomes include, but are not limited to, demonstrating communication and collaboration with peers and faculty, planning and implementing appropriate nursing actions using patient data and evidence-based interventions, evaluating outcomes, and revising plan and actions as needed. Participants are also expected to recognize and apply legal, ethical, and safety principles within the emergency care scenario.

Simulation Process

A pre-briefing session clarifies the major components of the simulation activity, which include situation discovery and identification, situation assessment and management, and situation monitoring with patient management and maintenance until transfer to an acute care facility. Faculty presence alternates between guidance, participation, and observation, prompting individuals and the group to comprehend and complete the essential tasks for each component.

In the identification and discovery component, Behind the Door participants find the simulation dummy with a moulage right arm injury and arterial bleed. Bright red dye is pumping from the right lower arm of the mannequin, partially covered with a gown and offering a visually stimulating array. In all cases so far, the nursing students immediately focus on the bleed, at which point the facilitator (B.C.) asks the students to “freeze” in their positions. From under the patient’s gown, and obstructed from view, the facilitator retrieves the left arm bearing a knife; participants are informed that they have sustained a stab wound.

The impact of the overall clinical scenario is then processed with questions such as:

  • What effect did the presence of active bleeding have on prioritizing the next best action?
  • Was the likely presence, but unknown location of “sharps,” an element of concern?
  • Did you have all of the knowledge you needed to prevent self-injury before you came into the room?
  • How do you explain the injury to the nurse, if all necessary knowledge for situation management were available?

Observations and comments are summarized by noting that in many nursing schools the priority focus is the medical condition. While medical stabilization is crucial, in the psychiatric setting, assessment and intervention must encompass the whole problem, if safety is to be maintained (Delaney & Johnson, 2008; McCoy & Johnson, 2011). In this particular case, assessment begins with identifying the mechanism of injury, thinking through the ongoing danger of the contraband (weapon), and considering the possibility of other-directed aggression by a patient experiencing psychosis and/or delusions even as treatment efforts are initiated.

Simulation action begins again at this point, and students learn the medical aspects of assessing and managing a persistent arterial bleed, including monitoring the patient’s response to significant blood loss. As noted in the summary above, assessment and management are linked to hemostasis and prevention of further tissue injury. The preferred method for accomplishing this goal is identified as direct pressure to overcome two physical forces: gravity and the energy of the beating heart.

Assessment and management also include safety of the affected patient’s roommate and the first responders, as noted above. These goals will be accomplished through location of the instrument of injury, determination of the patient’s willingness to accept treatment, availability of sufficient staff to ensure containment of aggression, and implementation of universal (standard) precaution considerations. After the patient is stabilized, the following questions are appropriate for participants:

  • What critical behaviors are necessary while awaiting transport to a higher level of care?
  • What level of staff is most appropriate to remain in immediate attendance of the patient?
  • What type of staff are needed to maintain safety and environmental security during the maintenance and transport period?
  • What physical assessment parameters are needed during this period?

Debriefing and Evaluation

A debriefing conference lasting approximately 20 minutes provides all participants with the opportunity to dialogue about the content and process of the simulation. In our experience, students are eager to reflect on their thoughts, feelings, and behaviors, and to examine specific elements that might help or hinder their ability to provide care for themselves and others in high-stress clinical encounters. This is also a time for faculty to communicate the importance of each action, as part of an entire sequence of actions, in addressing and resolving a clinical situation. The debriefing and evaluation period is well suited for faculty sharing of past psychiatric emergency encounters and for appropriate self-disclosure about his or her performance at an earlier period of professional development. This kind of sharing accentuates faculty commitment to convey presence, attention, interest, and knowledge with students engaged in the crisis simulation. Further, faculty storytelling may highlight the idea of a lifelong process of professional development, rather than points of completion (Higgins, 1996; Kowsowski, 1995).

We have found it is possible to nurture students while conducting a well-designed, psychiatric-mental health clinical simulation, if it is based in Watson’s (2006, 2008) principles of caring and includes the best evidence available. Student evaluations (Figure) of the content and process of the learning activity have supported this claim. Specifically, the evaluation content items targeted students’ perceptions of learning in the areas of physiological parameters, nursing role, team behaviors, and opportunity to actively engage in motor skills relevant to a psychiatric emergency. Process items targeted the students’ internal experience, such as whether they felt supported and whether appropriate faculty guidance occurred. Feedback included in the students’ evaluations has provided both validation and direction in our ongoing integration of psychiatric-mental health simulations into baccalaureate nursing students’ clinical experience.

Discussion

McGarry, Cashin, and Fowler (2011) provided an interesting review and discussion, informed by Roger’s model of diffusion of innovation, about the topic of high-fidelity human simulation in the arena of child and adolescent psychiatric-mental health nursing. While the example provided in this article does not use a high-fidelity simulator, the points made by McGarry et al. are pertinent to the purpose of this article. Specifically, they noted the promise of this teaching approach within psychiatric-mental health undergraduate education, particularly to address availability and reliability of clinical experiences. An additional positive aspect of simulation is the ability to modify and adapt the various levels of fidelity to a virtually unlimited number of scenarios, with faculty time, motivation, and training as limiting factors. However, as any faculty member understands, the time devoted to seeking, arranging, confirming, and completing psychiatric-mental health clinical experiences is also significant, and there is no guarantee as to the richness of any particular student clinical experience.

As indicated above, the student evaluations provide valuable information about learner perceptions of the content and process of the simulation activity. In our experience, students are overwhelmingly positive in their evaluations, supporting prior research by Nau, Dassen, Halfens, and Needham (2007) that nursing students desire information and practice in handling volatile patient situations. Additionally, the simulation activity incorporated suggestions from Bremner, Aduddell, Bennett, and VanGeest’s (2006), who proposed best practices for the use of human patient simulators with novice nursing students. Specifically, the simulation was planned and organized to address specific learning outcomes; course and clinical objectives were clearly linked to the activity; the faculty and clinical expert engaged in ongoing dialogue about the conduct of the simulation; the activity was evaluated and revised based on student comments; and debriefing occurred following the experience.

The Joint Commission’s (1998, 2010) Sentinel Event Alert addresses the issue of suicide, a familiar psychiatric crisis, which can occur in emergency departments, general medical hospitals, psychiatric hospitals, and residential facilities. Further, the Joint Commission’s (2011) National Patient Safety Goal 15.01.01 requires risk assessment, identification of safety needs, and care in the most appropriate setting. In the emergency department setting, Rossi, Swan, and Isaacs (2010) detailed clinical vignettes of violence and agitation involving failure to discover contraband and the consequences thereof. Similar to The Joint Commission, these clinical experts promote education in recognizing environmental and behavioral cues to an impending crisis and in responding to all elements of such a crisis. Likewise, McCoy and Johnson (2011) advised, “The primary goal in caring for a patient with a behavioral emergency is safety. Safety for the patient as well as the staff should be considered at all times” (p. 106). An important action proposed in these publications is to “Check the patient for contraband that could be used to commit suicide” (The Joint Commission, 2010, p. 3), or in the emergency setting, be aware of and develop standardized methods for detecting contraband and removing sharps from the environment.

Clinical Implications

The original simulation activity was implemented to improve code responses by nurses working in the psychiatric-mental health hospital setting. The activity was expanded to baccalaureate nursing students completing their psychiatric-mental health clinical rotation. A simulated psychiatric emergency of this type allows for exposure to situations of care that are infrequent and demanding, both cognitively and emotionally. Further, achieving this level of collaboration between a practice and university setting promotes enhanced learning opportunities for staff and students. These opportunities have real promise for yielding quality care for patients.

Summary

Even when a psychiatric emergency occurs during a clinical rotation, the nature and context of the emergency may preclude student participation in the management and resolution of the episode. A well-designed psychiatric-mental health clinical simulation, combining multiple emergency/crisis concepts, such as contraband, personal safety, and environmental assessment, is undeniably worthwhile in bridging this experiential gap for nursing students and novice nurses preparing to enter any clinical setting. While the resulting post-graduation clinical outcomes of these efforts are unknown at this time, a large body of cognitive, behavioral, and affective research suggests that students engaging in this kind of practice experience will have access to their prior learning in future clinical situations.

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Lilly, M.L., Hermanns, M.S. & Crawley, B. (2012). Psychiatric Nursing Emergency: A Simulated Experience of a Wrist-Cutting Suicide Attempt. Journal of Psychosocial Nursing and Mental Health Services, 50(2), 35–42.

  1. Nursing student access to psychiatric-mental health emergency episodes is infrequent.

  2. Caring behaviors during such episodes are demanding in terms of knowledge, skills, and self-awareness.

  3. Simulation provides a readily available context for the rehearsal of such behaviors.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

Using Pedometers to Document Physical Activity in Patients with Schizophrenia Spectrum Disorders: A Feasibility Study

Schizophrenia, schizoaffective disorder, and schizophreniform disorder comprise the schizophrenia spectrum disorders (SSDs). The similarities between the three disorders are numerous: diagnostic overlap (American Psychiatric Association [APA], 2000), symptom categories (Kopelowicz, Ventura, Liberman, & Mintz, 2008), executive functioning deficits (Premkumar et al., 2008), and difficulties with associative learning (Sacchetti, Galluzzo, Panariello, Parrinello, & Cappa, 2008). Another commonality is the greatly increased risk for adverse health outcomes (i.e., cardiovascular disease, obesity, glucose dysregulation, dyslipidemias) these diagnoses share (Brunero & Lamont, 2010; DeHert, Schreurs, Vancampfort, & Van Winkel, 2009; Mathur & Stöppler, 2010; von Hausswolff-Juhlin, Bjartveit, Lindström, & Jones, 2009).

Exercise—defined as planned, structured, repetitive body movement performed in formal programs—is clearly associated with health risk reductions through reduced body weight (Beebe et al., 2005; Centorrino et al., 2006; Chen, Chen, & Huang, 2009) and improvements in glucose regulation (Helge et al., 2010; Pérez et al., 2010; Sanz, Gautier, & Hanaire, 2010) and triglyceride levels (Kwon et al., 2006; Varady & Jones, 2005). However, exercise-related health improvements are unlikely to be sustained unless physical activity (defined as unstructured activities outside formal exercise groups) is also increased. There is thus a need to identify feasible, effective objective measures of physical activity for this group. The purpose of this pilot study was to describe the feasibility and acceptability of extended-wear pedometers to document physical activity in individuals with SSDs.

Background

Research exploring pedometer use in psychiatric clients is limited. We located one study in which investigators used pedometers to monitor daily activity in a sample of 32 female outpatients with depression. Women participating in a clinic-based group exercise program had higher pedometer step counts than those assigned to a home-based exercise program. Pedometer step counts were positively correlated with fitness level and negatively correlated with body mass index (Craft, Freund, Culpepper, & Perna, 2007). To our knowledge, ours is the first published work to describe the use of extended-wear pedometers in individuals with SSDs.

Method

Measures

We chose pedometers for physical activity assessment (steps, distance, and calories burned per day) because of research team expertise, feasibility, and cost. Our team has prior experience documenting step counts with single-use pedometers in exercise groups with SSDs (Beebe et al., 2011). Pedometers provide data on ambulatory activity, the most common activity in SSDs (Faulkner, Cohn, & Remington, 2006; Richardson et al., 2007) and are cost effective (Bassett et al., 1996; Trost, McIver, & Pate, 2005). Considering accuracy and ease of use, we selected the Omron® GoSmart pedometer (Omron Healthcare, Inc., Kyoto, Japan). This particular pedometer is easy to use and reliable. A small, pager-like device worn on the right or left waistband or pocket, it records total steps, aerobic steps (steps taken at a rate of more than 60 per minute or for at least 10 minutes continuously), distance, and calories burned for up to 7 days using dual piezoelectric sensors.

Walking trials at various speeds established validity of the Omron GoSmart, with fewer than 3 missed steps per 100 (Holbrook, Barreira, & Kang, 2009). Less than 10% of missed steps is considered an accepted pedometer criterion (Atkinson & Nevill, 1998). Holbrook et al. (2009) examined Omron GoSmart step counts in individuals completing manipulations designed to elicit error from fidgeting and vehicular travel. None of the conditions resulted in erroneous step counting, suggesting that neither akathisia nor vehicular travel will affect measures obtained with this device. The device has a clean silhouette with minimal buttons. It remains on at all times and resets automatically each night at midnight. A single button allows users to toggle between displays of daily steps, daily aerobic steps, daily distance in miles, and daily calories burned.

Setting and Sample

Twenty-four outpatients with SSDs were enrolled from individuals receiving treatment at a community mental health center (CMHC) located in the southeastern United States. The CMHC is a regional, not-for-profit integrated system providing mental health services in 20 counties. Case management, outpatient, psychosocial rehabilitation, prevention, residential treatment, and employment services are provided to more than 300 patients with SSDs.

Prior to data collection, university Institutional Review Board approval, as well as the approval of the CMHC’s research committee, was obtained. Inclusion criteria were a chart diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, or any subtype of these, according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2000); and home or cell phone access. Exclusion criteria were chart documentation of coexisting mental retardation, neurological disorder, head injury, or hearing deficit precluding telephone communication.

The CMHC’s Notice of Privacy Practices (signed by all patients) allows disclosure of protected health information for research, authorizing the initial case reviews and communications required to identify potential participants. After potential participants were identified, researchers verified inclusion criteria and then approached potential participants regarding study participation while they were at the CMHC for regularly scheduled treatment appointments. Researchers met with interested individuals in private offices at the recruitment site to explain the study and obtain written informed consent.

Procedures

After giving informed consent and basic demographic data, participants were provided with previously activated extended-wear pedometers. Researchers set the pedometer’s time display and programmed each pedometer with the individual participant’s weight and stride length according to the manufacturer’s instructions. Participants were verbally instructed on the use of the pedometer, including appropriate placement and wear. Participants were instructed to place the pedometer in the location of their choice after arising each day and remove when they retired at night, without altering their usual daily activity. All participant questions were answered, and written information on the pedometer was reviewed.

Each participant received a twice-daily reminder call from the research assistant (RA) to wear the pedometer each morning and remove it each evening. The RA queried for problems with the pedometers at each contact. After 1 week, participants were contacted by telephone to make an appointment for research staff to retrieve the pedometer. Pedometers were retrieved at the CMHC or individual homes, according to participant preference. Each participant was compensated with a $20 gift card.

Results

Sample

The 24 outpatients receiving pedometers consisted of 12 men and 12 women with a mean age of 48.7 (range = 23 to 71, SD = 12.8 years) (Table). The participants were spoken to on average 6.9 times (range = 0 to 13, SD = 4.5) during the week to receive pedometer-wear reminders and assess any problems. If unable to reach participants directly, the RA left a reminder message. Participants received an average of three reminder messages (range = 0 to 12, SD = 3.5) during the 1-week data collection period.

All participants retained their pedometers for the entire 1-week of data collection. On average, participants wore the pedometers 6 days of the week (range = 0 to 7, SD = 1.9). Two participants (both men) reported that their pedometers were misplaced for 1 to 2 days during the week, but the pedometers were found and wear resumed. One female participant reported forgetting to wear the pedometer for 1 day during her week of wear.

Very few problems with pedometer use (n = 3) were reported—all reported problems related to the pedometer’s single button being inadvertently depressed and switching the display from “steps” to “aerobic steps.” During most days, participant activity did not meet the threshold for aerobic step counting (steps taken at a rate of at least 60 per minute or for 10 minutes continuously). Thus, when switched to “aerobic steps,” the display read 0 and participants became concerned that the pedometer had malfunctioned. When this occurred, the RA explained the display and directed the participant to depress the button to return the display to “steps.”

Discussion

This pilot study provides the first published data on the use of extended-wear pedometers to monitor physical activity in individuals with SSDs. Our preliminary findings indicate that the majority of those with SSDs are willing to use pedometers and are able to do so with few problems.

This pilot investigation identified several possible barriers to the use of pedometers in this group, mostly related to cognitive or memory deficits. We noted that 2 participants misplaced their pedometers for a portion of the week of wear, and 1 participant reported forgetting to wear the pedometer. Nevertheless, all of the participants retained their pedometers for the full week, and the majority (87.5%) wore their pedometer for at least 6 of the 7 days. These results support the feasibility of activity estimates via pedometer, since 3 to 5 days of data are required to reliably estimate physical activity (Faulkner et al., 2006; Hultquist, Albright, & Thompson, 2005).

This pilot study is subject to a number of limitations. The small sample and lack of a control condition limit generalizability; thus, there is a need for further examination of extended-wear pedometers in a larger sample. However, these preliminary data have implications for researchers and clinicians considering extended-wear pedometers to monitor physical activity level in patients with SSDs and provide introductory evidence of feasibility.

Implications

These pilot data may suggest subsets of individuals who might need additional support to use such a device. Providers considering the use of extended-wear pedometers to monitor physical activity level in patients with SSDs should assess the presence of individuals who could remind the person to wear the pedometer daily. Failing this, daily reminder calls will probably be necessary for most individuals with SSDs. Those living in unsecured environments such as personal care homes or homeless shelters may benefit from suggestions on ensuring the safety of their pedometer when not in use. In addition to feasibility, future investigations should examine correlations between data obtained from extended-wear pedometers and self-reports of physical activity level.

Conclusion

These preliminary findings indicate that a majority of individuals with SSDs are willing to wear pedometers for activity monitoring and can do so with few problems. Possible barriers to the use of extended-wear pedometers in this group include cognitive and memory deficits. Future investigations should test concurrent validity by examining the correlations between pedometer data and self-reported activity level. Extended-wear pedometers are an easy-to-use, cost-effective way to document physical activity and evaluate our efforts to assist this vulnerable group in achieving activity-related health improvements.

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Characteristics of the Sample (N = 24)

Characteristic n (%)
Diagnosis
  Schizoaffective disorder 14 (58.3)
  Schizophrenia 10 (41.7)
Sex
  Women 12 (50)
  Men 12 (50)
Race
  African American 13 (54.2)
  Caucasian 11 (45.8)
Living arrangement
  Alone 13 (54.2)
  With caregiver 9 (37.5)
  With family 2 (8.3)
Prescribed medications
  Antiparkinson agents 18 (75)
  Mood-stabilizing agents 14 (58.3)
  Atypical antipsychotic agents (oral) 13 (54.2)
  Typical antipsychotic agents (injection) 12 (50)
  Hypnotic agents 11 (45.8)
  Antianxiety agents 10 (41.7)
  Antidepressant agents 5 (20.8)
  Atypical antipsychotic agents (injection) 4 (16.7)
  Typical antipsychotic agents (oral) 3 (12.5)
  Othera 16 (66.7)

Beebe, L.H. & Harris, R.F. (2012). Using Pedometers to Document Physical Activity in Patients with Schizophrenia Spectrum Disorders: A Feasibility Study. Journal of Psychosocial Nursing and Mental Health Services, 50(2), 44–49.

  1. The purpose of this pilot study was to describe the feasibility and acceptability of extended-wear pedometers to document physical activity in patients with schizophrenia spectrum disorders (SSDs).

  2. Twenty-four outpatients with SSDs wore extended-wear pedometers daily for 1 week without altering their usual activities. The majority wore their pedometer at least 6 days.

  3. Difficulties with the pedometers included difficulty reading the step display and misplacing or forgetting to wear the pedometer.

  4. These preliminary findings indicate that a majority of people with SSDs are willing to use extended-wear pedometers for activity monitoring and can do so with few problems.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

CNE Quiz

How to Obtain Contact Hours by Reading This Issue

Instructions

4.0 contact hours will be awarded by Vindico Medical Education upon successful completion of the posttest and evaluation. To obtain contact hours:

  1. Read the following articles carefully, noting the tables and other illustrative materials, which are provided to enhance your knowledge and understanding of the content:

    • Implementation of Comfort Rooms to Reduce Seclusion, Restraint Use, and Acting-Out BehaviorsKim Sivak, RN-BC, DNP, on pages 24–34.
    • Psychiatric Nursing Emergency: A Simulated Experience of a Wrist-Cutting Suicide AttemptMary L. Lilly, PhD, RN, MSN, APRN, BC; Melinda S. Hermanns, PhD, RN, BC, CNE; and Bill Crawley, RN, MS, MA, on pages 35–42.
    • Using Pedometers to Document Physical Activity in Patients with Schizophrenia Spectrum Disorders: A Feasibility StudyLora H. Beebe, PhD, PMHNP-BC; and Robin Faust Harris, MSN, ANP-BC, on pages 44–49.

  2. Read each question and record your answer on the CNE Registration Form provided.

  3. Complete all sections of the CNE Registration Form, including indicating the total time spent on the activity (reading articles and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

  4. Forward the completed form with your check or money order, drawn on a US bank, for $20 (USD) made out to JPN-CNE.

CNE Registration Forms must be received no later than February 28, 2014.

Contact Hours

Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commission on Accreditation. P188-6/09-12. This activity is co-provided by Vindico Medical Education and the Journal of Psychosocial Nursing.

This is a Learner-Paced Program. Answers to the posttest will be graded, and you will be advised that you have passed or failed within 60 days of receipt of your completed test. A score of 70% or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the test. A contact hour is 60 minutes of instruction. Contact hour verification can be awarded only at the completion of a program.

Objectives

  1. Describe the benefits associated with the use of comfort rooms in psychiatric settings.

  2. Examine the process of implementing a psychiatric emergency nursing simulation.

  3. Discuss how pedometers can be used to determine the level of physical activity in patients with schizophrenia spectrum disorders.

10.3928/02793695-20120116-50

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