Customer Reviews

ISBN-13:

9781936693368

Publisher: Bull Publishing Company
Publication date: 11/01/2006
Sold by: Barnes & Noble
Format: eBook
Pages: 224
File size: 942 KB

Kathleen Regan, RN, BSN, MHA, has worked in the field of psychiatric nursing for more than 25 years. In 2001 she joined Cambdridge Health Alliance as nurse manager for the Child Assessment Unit. She was instrumental in the process of steering the unit toward humane, trauma-sensitive care for the troubled children they dealt with. These efforts have been very successful and are being adapted elsewhere. She has so far consulted with programs from Texas, Oregon, Connectticut, and within Massachussets. She lives in Hingham, Massachussets.

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Opening Our Arms

Helping Trouble Kids Do Well

By Kathy Regan

Bull Publishing Company

Copyright © 2006 Bull Publishing Company
All rights reserved.
ISBN: 978-1-936693-36-8

CHAPTER 1

ANTICIPATION

• Malik •

"All meaningful and lasting change starts first in your imagination and then works its way out. Imagination is more important than knowledge."

— Albert Einstein

One of my first memories of this job, as the nurse manager of a locked child psychiatric unit, stands out vividly. I had been on the unit less than six weeks and was still learning how the unit operated. I wanted to try and understand as much as I could: the structure, the culture, the staff's perceptions, their fears, the unit practices, and the influence of the unit's past and recent history on current unit events. The staff had shared some of their concerns in my group interview with them prior to my hiring. They had let me know that they were afraid; they felt the unit was unsafe. A number of them described an alarming, fatalistic attitude. One milieu counselor poignantly described the prevailing ethos in the following way: "It's a matter of waiting for your number to be up. When I see one of my coworkers assaulted, it's not a sense of relief that it's them and not me. It's a feeling that since one more staff has been hit, it is getting closer to when my number is up — it's just a matter of time." I also had a series of interviews with administrators of the psychiatric department within the hospital, as well as with the present administrators of the unit (all of whom were leaving). Everyone had shared their various perspectives on the issues the unit faced and the role of the nurse manager who would be co-leading the unit.

I had six interviews, which involved some people more than once. The bottom line was that the chief nursing officer (CNO) and the nursing site director (NSD) wanted me to be very clear about the challenges I would face, and they wanted to feel confident that I was up to the task. They were sensitive to the staff's perception that they had been "abandoned" and felt unsupported due to all the leadership changes and the staff turn-over. I felt ready for this challenge and had taken the job with the hope of being able to do something worthwhile for children. I had ample quantities of energy and even more of passion, and I was ready for something important. I had seen firsthand in my own life that services for children were sorely lacking, and I had lots of thoughts and opinions on the way care should be provided to children and their families. I felt up to the task.

I started the job with much enthusiasm. My first task was to identify which staff members seemed to operate in a manner consistent with my values about the care of children. I also wanted to know who was competent, but more importantly, I wanted to know who was curious and wanted to learn. At the same time, I wanted to identify who would be my challenges: Who did I think would be the stumbling blocks in the months ahead?

After only six weeks on the job, I already had a tremendous appreciation for the nurses and counselors of the unit. They were caring for the children twenty-four hours a day, seven days a week. Decisions made by the clinicians were often played out on the unit; kids would receive bad news, such as hearing that they would not be going home but to a residential program, or they would have an upsetting family meeting. Some would disclose to their therapist some horrible experience that they had been through, and then they would return to the unit. The overwhelming emotions that had been stirred up would often result in emotional explosions on the unit. Frequently, the staff had no warning, no heads up, that Johnny was in for a rough time. The staff were left with the aftermath and with an expectation to keep a sense of order at all times. They had a limited set of tools with which to manage a group of kids who had been hospitalized because they were unable to control their behavior and were deemed "too dangerous" for the community at this time. At its worst, the fear of any psychiatric unit was that of several kids exploding at once and the contagion effect taking over the unit. I sensed that there was an undercurrent of everyone anticipating a worst-case scenario. It is easy to imagine that if enough close calls occurred, or if staff members were being assaulted on a regular basis, the result would be a group of people who were hyper-alert and hyper-vigilant; they were looking to stomp out any sparks of smoldering emotional distress.

It was a spring afternoon. I was in the nurses' station talking with one of the nurses, and change of shift was about to begin. Change of shift was a daily practice on hospital units, and it was a time when one shift gave a summary of the important events that had transpired on their shift (which included information on new admissions, kids who were being discharged on the evening shift, new data learned at the clinical rounds meeting held in the morning, and visits or meetings scheduled for the shift). Most importantly, it included the children's behavior and staff observations of the children for the shift. At change of shift, a lot of staff were present, because the one shift was already working as the next shift came in to hear the reports before going on the floor. When the reports were finished, the new staff came out onto the floor to replace the people who had been there. Staff members from the previous shift were getting ready to leave. Our nurses' station was a small, crowded area that had work space with computers around two walls made of glass looking out at the living room and the corridor in front of the living room. The third wall was covered with a big white board that listed the rooms, the patients' first names, and the doctor and therapist assigned to them. The fourth wall was filled with built-in cubbies that served as individual mailboxes for all the staff of the unit.

I don't know what made me turn around to face the window looking out at the living room. Maybe the conversation I was having had ended and I was getting ready to move on to another task. I was standing there watching as Malik approached the nurses' station window. He was a stocky, eight-year-old African-American boy with great big brown eyes that sometimes were clearly focused and sometimes seemed glazed and faraway. Colleen was following right behind him, and she casually asked him what he needed. Before my very eyes, Malik turned and, with full force, threw a punch, haymaker style, into Colleen's face. There was a loud crack and then blood everywhere. The next few minutes were confusing as Colleen screamed in pain. The children in the hall had witnessed this event; some were yelling at Malik and some started crying. Staff were rushing to the scene from all directions. Malik was approached, taken down on the floor, then carried to the Quiet Room. He was put on a mattress on a steel frame, and leather cuffs were wrapped around his wrists and ankles, securing him to the bed so that he could not move. (This procedure is referred to as the application or use of mechanical restraints. It is also referred to as 4-point restraints.) A staff person stayed with him, sitting in a chair outside the room about twelve inches away, and the door was kept open. Malik was initially cursing and then quieted.

In the nurses' station, various staff were attending to Colleen, and I called the emergency department (ED) to let them know that we were bringing Colleen there for medical treatment. She was crying and in a lot of pain. A staff person accompanied her off the unit to the ED. The rest of the staff met with the children in an impromptu community meeting to discuss what had happened and to try and assure them that we could keep them safe. The children were able to state that they felt angry with Malik. They were afraid of him and wanted to know why he had hurt Colleen. Truth to be told, we did not know why he had hit Colleen. It appeared to be totally unprovoked.

Events that seem totally impulsive and unpredictable lend credence to a belief that an environment is unsafe and dangerous. They can also result in a reactive stance; they contribute to a belief that you need to put more structure in place to prevent unpredictable acts. This then leads to a sense of needing more consequences. All of this is based on the assumption that if you make the punishment hard enough, it will discourage behaviors that you do not want to see.

Could we have predicted this event as a possibility? What did we know about Malik? He was considered impulsive, violent, and intermittently psychotic. He had a severe abuse history, with many placements in foster care and residential programs. He had come to us from a residential program where he was increasingly violent and was not able to return there. Our job was to try and determine why he was so violent, provide treatments that would decrease his violence, and secure another placement for him. Hopefully, we would develop an understanding of him that was greater than the reasons for his violence. A comprehensive picture needed to include not just his vulnerabilities but, even more importantly, his strengths.

Malik had been on the unit almost three months when this event occurred, and it followed a number of previous assaults on staff that were less severe in nature. We knew that he was very wary and untrusting of adults. He had developed a belief system that life was not fair, and this was certainly an accurate assessment in his case. Life had not treated him fairly at all; horrendous things had happened to him as a young child. It was hard to form a relationship with him due to his pervading sense of mistrust of adults, and there was a natural hesitation in getting too close because of his assaultiveness. Although he was only eight years of age, he was very strong and quick. Most people were to some degree afraid of his unpredictability, and this reticence affected how much we gave to him emotionally. What had happened that day that might have had a bearing on Malik's emotional state or potential for violence? The staff were not able to identify any significant events that had occurred.

Despite this crisis, the staff continued to do their jobs. They worked hard to calm the unit, restore order, reassure the other children, and occupy them with activities.

My first priority at that time was to ensure that we were giving Colleen all the support we could. Then I needed to reassure the staff that I genuinely appreciated their fears and concerns and that I would take that into consideration in my actions. Colleen was treated for a nasal fracture and was sent home on paid leave. She was encouraged to avail herself of some trauma counseling and to take as much time as she needed before returning to work.

On an administrative level, my boss, Maryanne, the nursing site director (NSD), and Corinne, the chief nursing officer (CNO) were notified, and they were highly supportive. We temporarily froze admissions (we had three vacant beds at the time). This reassured the staff that we were not at risk of receiving another child who might be out of control while we were trying to resolve this crisis. Maryanne suggested that I contact our victims of violence team located at one of our outpatient clinics, which I did. I let them know of our situation and asked for their assistance. They encouraged me to have Colleen contact them. They also suggested that we hold a special violence debriefing session on the unit for all staff and that we use this specific incident as the focus of our discussion.

All staff were encouraged to attend and were assured that they would be paid to come in if they were not scheduled to work. Colleen agreed to participate in the debriefing, and it was scheduled for two weeks in the future, giving staff enough time to make arrangements for this meeting and for Colleen to have enough time to feel comfortable with the meeting.

The debriefing session was helpful in many ways. It helped everyone deal with the latest occurrence of violence, it provided an opportunity for everyone to show their support to Colleen, and it provided a space for everyone to share their fears and anger at the current state of things.

I was struck by an outcome that really helped us with the work ahead. The perspective of looking out for oneself, which tends to grow in situations where people feel vulnerable and unprotected, was replaced by the camaraderie of being in this together and having a sense of working together to help one another as a group. This shift was not overtly expressed in words, but there was a different feeling among staff.

The staff also expressed feelings of anger and of being let down by the administration. This recent assault was interpreted as further evidence of being undervalued by their bosses, their reasoning being that they felt the incident was a reflection of employees being expected to tolerate dangerous situations. The sharing of these perceptions provided a sense of validation and it further generated expectations from the group that there should be some help from the hospital system in making the conditions better for them.

This incident was unfortunate, but it also proved to be a sentinel moment, the center around which events were about to take place. I had already assessed that the staff as a whole appeared traumatized by the episodes of violence that had occurred on the unit over the previous two to three years. In order to think about how things might change, the staff needed to be attended to first. They needed to feel supported and heard, and they needed a sense of being in control of their environment rather than feeling like prisoners in it. They had tried to gain control by increasing the structure of the unit with various rules that were established after adverse events had occurred. They had become increasingly rigid and reactive. Despite all these rules and protocols, the unit was no less dangerous; in fact, it was more dangerous. But there did not seem to be any other way to do things.

So again, what about Malik? Malik, who had a pervading sense of life's unfairness and a well-based wariness of adults as people who could not be trusted, was thrust into an environment where he was viewed as the cause of danger. The victim had become the perceived victimizer. There are lots of psychological explanations for this development. Yet, in my opinion, a psychodynamic understanding of why Malik became violent was lacking in vision. It was looking at Malik and his difficulties to explain events. It did not look beyond Malik and his aggression, even when giving it validity. For me, an important consideration was that we had not created an atmosphere where he did not have to fear others or fear his own feelings of rage.

We were not unusual — we were the norm. Most other psychiatric hospital units were doing the same things we were doing. We had all been taught that we needed to provide containment for children who were in need of this because they were lacking the inner controls themselves and thus were dependent on us to provide this for them. It was not just about us and about Malik. It was about all the Maliks out there and all the other child-treatment units and centers.

The aftermath of this crisis was positive for our unit. It mobilized us to change. It was an event upon which I capitalized. For a few weeks, our staff meetings focused on what had happened, then moved to a broader view. The staff were encouraged to talk about what they liked about the unit and what they didn't like. They were encouraged to voice what specific policies they disagreed with and the reasons for their disagreement. They were encouraged to describe the way they would like to work and the type of place the unit should be. They were encouraged to brainstorm new ideas and to question traditional practices that we had all learned. They could wonder aloud if there was another way.

(Continues...)

Excerpted from Opening Our Arms by Kathy Regan. Copyright © 2006 Bull Publishing Company. Excerpted by permission of Bull Publishing Company.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Title Page,
Copyright Page,
ACKNOWLEDGMENTS,
INTRODUCTION,
Dedication,
SECTION ONE - Beginnings,
CHAPTER 1 - ANTICIPATION,
CHAPTER 2 - MALIK IN PERSPECTIVE,
CHAPTER 3 - GETTING STARTED,
CHAPTER 4 - FIRST STEPS,
CHAPTER 5 - OPEN HOURS: Working With Parents,
CHAPTER 6 - THE END OF THE ASSAULT PROTOCOL,
SECTION TWO - Reaching a "Tipping Point",
CHAPTER 7 - THE UNIT HEATS UP : MULTIPLE MELTDOWNS,
CHAPTER 8 - OUR FIRST TEST WITH ONGOING AGGRESSION,
CHAPTER 9 - LEARNING TO DEAL WITH AGGRESSION,
CHAPTER 10 - ADAPTING OUR STRUCTURE AND FINE-TUNING OUR LENS,
CHAPTER 11 - THE GOING GETS ROUGH,
CHAPTER 12 - OUR SECOND CHALLENGE,
CHAPTER 13 - KEEPING IT SIMPLE: Replacing Unit Rules With Basic Unit Expectations,
CHAPTER 14 - THE TIPPING POINT: Staff Consensus,
CHAPTER 15 - THE END OF THE LEVEL SYSTEM,
SECTION THREE - Moving Ahead and Lessons Learned,
CHAPTER 16 - FINE-TUNING AND RECURRING THEMES,
CHAPTER 17 - SOME MORE STORIES,
CHAPTER 18 - WRAP-UP: Lessons Learned and a Plea,
SECTION FOUR - Results and Toolkit,
APPENDIX 1 - A CASE STUDY: Our Adaptive Challenge — The Big Picture and the Role of Leadership,
APPENDIX 2 - THE RESULTS SO FAR,
APPENDIX 3 - NURSING SERVICE STANDARDS OF CARE — For the Child at Risk of Aggression,
APPENDIX 4 - NURSING STANDARDS OF CARE: Child Assessment Unit Nursing Standard of Care — For Nursing Patient Education and Teaching Interventions,
APPENDIX 5 - CAU PHYSICAL HOLDS/ RESTRAINT POLICY,
APPENDIX 6 - CONVENTION ON THE RIGHTS OF THE CHILD, GENERAL ASSEMBLY RESOLUTION 22/45,
APPENDIX 7 - NEW VOCABULARY,
APPENDIX 8 - THE MILIEU AND THE MILIEU STAFF,
APPENDIX 9 - THE BEHAVIORAL PROGRAM ON THE CAU,
APPENDIX 10 - CAU PARENT ASSESSMENT SHEET,
APPENDIX 11 - CHILD'S PROTECTION PLAN,
APPENDIX 12 - KID'S HANDBOOK FOR THE CHILD ASSESSMENT UNIT,
END NOTES,
BIBLIOGRAPHY,

Opening Our Arms: Helping Troubled Kids

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Opening Our Arms

Helping Trouble Kids Do Well

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