The role of nursing in the administration of electroconvulsive therapy (ECT) is evolving. Historically, the nurse provided support and education to the ECT patient and his or her family, and assured that the patient's physical needs were met. The nurse also had limited involvement in assessment.13 It is becoming increasingly apparent that a multifaceted approach to the role of nursing in the ECT process is needed. This is due to the increasing psychiatric and medical complexities seen in the patients receiving ECT and to the change in nursing science and practice.
In 1982, the American Nurses Assodation, in its Standards of Psychiatric and Mental Health Nursing Practice, defined areas of nursing practice in ECT.4 These include education, emotional support, assessment prior to initiation of treatment, preparation and monitoring of the patient during ECT, and assessment of the patient's response to ECT. In 1987, the Royal College of Nursing of the United Kingdom developed guidelines that expanded the nurse's participation in the administration of ECT.5 These guidelines suggested that the nurse should have an active role in the preparation, administration, and recovery stages of ECT.
The American Psychiatric Association has adopted these general recommendations6 and, in turn, Burns and Stuart' propose that nurses become more active in the treatment, education, and assessment process. They suggest more comprehensive nursing that includes more independence and collaboration. We are finding that additional roles for nursing are developing, which support and expand upon these guidelines. ECT nursing today includes participation in the active clinical process, in the education of not only nurses but physicians in training and other professionals, in administrative duties, and in research ventures involving ECT
Prior to the decision to administer ECT, the nurse has actively participated in assessment of the patient, which began at the time of admission. The results of this ongoing assessment should be considered by the treatment team when deciding on an appropriate treatment for the patient. If the decision is made to treat the patient with ECT, the nurse is responsible for educating the patient and family. This begins with a further assessment of the patient's and family's needs, particularly questions and concerns they have about the ECT process.
Frequently, misconceptions about ECT or negative experiences from past treatments can be addressed at this time. A variety of educational techniques and materials are available; one-to-one teaching, written materials about the treatment, and videotapes describing the process may be used. Frequently, patients and families are given a tour of the treatment suite and recovery room. Visiting hours may be modified so the families may be present before and after treatment. It is important that the nurse provide emotional support and education throughout the treatment process.7
Nursing duties during the ECT process may vary. Clinical responsibilities involve prioritizing the patients being treated that day according to their psychiatric and medical acuity. The nurse provides assistance, assuring a smooth flow of patients in and out of the ECT suite and recovery room. The nurse's duties in assisting the psychiatrist and anesthesia staff include helping the patient onto the treatment cart, cleaning the patient's forehead, placing the treatment and monitoring electrodes on the patient's head, and then testing impedance between the head and electrodes to assure adequate contact. The nurse explains the process to the patient and offers reassurance. It is also the nurse's responsibility to acquaint the patient with the other treatment team members.
Once the treatment is administered, the nurse assists the other treatment team members in monitoring the patient and, when the patient is medically stable, transfers the patient to the recovery room. The nurse gives a brief verbal report to the nurse in the recovery room. This report includes the last vital signs and any complications encountered in the treatment process.
In the recovery room, the patient is equipped with a cardiac monitor and pulse oximeter. The recovery room nurse assures that the patient maintains an adequate airway and monitors the pulse and blood pressure. When any complications such as severe tachycardia, hypertension, or agitation do occur, the recovery room nurse is responsible for recognizing and reporting these complications to the psychiatrist and anesthesia staff and then participating in any ordered treatment.
As patients become more alert, the recovery room nurse reorients them to the surroundings. If patients become restless or agitated, the nurse is responsible for managing those patients and assuring their safety. This may involve placement of restraints or administration of physician-ordered medications. Reassurance and reorientation are ongoing during recovery.
When the patient is medically stable and reasonably oriented, the recovery room nurse will recommend to the psychiatrist that the patient be returned to the unit. Upon clearance from the psychiatrist, the nurse completes the necessary documentation and reports to the unit staff the current status of the patient and any complications encountered.
With increasing numbers of outpatients receiving ECT, a third nurse oversees the process of outpatients when they arrive and helps them prepare for their treatment. He or she inquires into any changes in the patient since the last treatment, whether they've maintained NPO status since midnight the night before, and if they need to void. Vital signs are taken and then recorded. Once this is completed, the outpatient nurse escorts the patient to and from the treatment and recovery area. He or she will then receive a report from the nurse in the recovery room and will monitor vital signs as needed, but no less than twice before discharge. Once cleared by the psychiatrist, this nurse arranges transportation of the outpatient by family or other designated person.
To safely complete the treatment process, we use two registered nurses and one licensed practical nurse. One RN serves as a charge nurse/coordinator while the other RN staffs the recovery room and is expected to fill the charge/ coordinator role when needed. The LPN, under the direction of the coordinator, assists in the outpatient process only.
The nurse in ECT also has various administrative duties. The nurse helps develop policies and procedures for ECT and any related disciplines. This job may involve participation in various departmental committees overseeing ECT and developing and maintaining quality assurance standards. The nurse also compiles various statistical data about aspects of the treatment process, including numbers of patients receiving ECT, the actual number of treatments provided, the types of psychiatric and medical diagnosis these patients have, and the types of psychiatric and medical complications encountered in the ECT process. The nurse is also responsible for maintaining equipment and ordering medical and pharmaceutical supplies.
The recovery room nurse is trained to assist in the treatment process and other duties, should that become necessary. That nurse is also responsible for maintaining equipment in the recovery room and making recommendations for improvements in the recovery room.
The nurse serves as a liaison between the psychiatry and anesthesia departments and the outpatient and ECT treatment team. This facilitates obtaining necessary medical evaluations or preparations prior to treatments. This may involve coordinating blood tests, EKGs, x-rays, or medical consultations.
Although the outpatient is followed closely by the treating psychiatrist, specific questions often arise about the treatments and the nurse can often provide answers to these questions or resources, should the psychiatrist be unavailable. Also, at the time of treatment, the nurse may help coordinate additional medical evaluations or changes in the ECT schedule for those patients, if needed.
There is a large amount of recordkeeping in the outpatient setting, which is the responsibility of the nurse. This involves keeping records of patients' current medications, last medical exam, responsible relative, special needs, and mode of transportation. The nurse also keeps and coordinates the outpatient schedule with the treating psychiatrist.
Educational needs of nursing staff and students are well documented by Burns and Stuart.7 Among their educational recommendations are programs that deal with both attitude and information; establishing standards of nursing care of patients receiving ECT; and standardized nursing care plans that reflect appropriate nursing diagnosis, goals, and intervention. Burns and Stuart7 also suggest that nursing schools should include teaching about ECT in their basic education and provide the opportunity for students to observe the procedure. They recommend that one member of the ECT treatment team should be identified as the resource person for additional information. Psychiatric nurses involved in ECT are encouraged to be available for inservice to nurses in other clinical settings.
We have incorporated the above recommendations and designated the nurse in ECT as the person to oversee this process. The nurse prepares updates including information on ECT procedures and recent theories about the mode of action of ECT. He or she also provides didactic and observational opportunities for nursing students. This requires the nurse to work closely with nursing staff; educators, and clinical specialists to develop, update, and present these educational programs.
The nurse educates patients' families, nursing homes, social service agencies, and other mental health professionals about ECT. This educational process is particularly challenging as the understanding of ECT may vary widely from group to group; therefore, careful assessment of each person's or group's knowledge base needs to be completed. Information provided includes the outpatient procedure, pre- and post-care of the outpatient, and any special precautions that should be taken.
The nurse in ECT is also expected to participate in education of physicians in training. This involves teaching how to prepare the patient for ECT, electrode placement, and use of equipment in ECT.
The nurse may be active in developing research protocols and coordinating research activities, implementing research projects, and supervising data collection. The nurse may also be expected to perform rating scales and interview patients pre- and post-ECT in the initial phases of data collection. It may also be appropriate for the nurse to develop specific computer databases for each of these research projects.
The role of nursing in ECT is still changing. Clinical, administrative, education, and research activities of nurses involving ECT need further definition and maturity. While nurses have always been active in patient and family education, their participation in other areas is being examined and developed further.
1. Sands D, McNary R, Bigler E, Becker H. Waller P. Understanding F]CT. J Psychosoc Nurs Ment Health Sen: 1987; 25(8):27-30.
2. Talbot K. ECT: exploring myths, examining attitudes. J Psychosoc Nurs Ment Health Sera 1986:24(31:6-11.
3. Fine M, Jenike M. Electroshock. exploding the myths. RN. September 1985:58-65.
4. American Nurses Association. Standards of Psychiatric and Mental Health Nursing Practice. Kansas City. Mo: American Nurses Association: 1982.
5. Royal College of Nursing. RCN nursing guidelines for ECT. Convulsive Therapy. 1987; 3:158-160.
6. American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recom menda I ions for Treatment. Training, and Privileging. Washington, DC: American Psychiatric Association: 1990.
7. Burns C. Stuart G. Nursing care in electroconvulsive therapy. Psychialr Clin North Am. 1991: M(4):971-934.