4011: Predicting and Intervening Safely with Violence in the Psychiatric Pod of an Emergency Department
Camille Kennedy, MSN, RN-C

PURPOSE: Multiple episodes of violence from mental health patients occurred in the psychiatric pod of our Emergency Department (ED). This led to research and collaboration to develop an alert system,violence assessment, and intervention tool to be used on all mental health patients presenting to the ED. SUMMARY OF EVIDENCE: Research of literature, discussions with area hospitals and staff interviews led to a proposed change in practice. We did not have a standardized process to predict violence and maintain a safe environment. DESCRIPTION: A multidisciplinary committee researched current trends for predicting violence. A sub-committee with nursing and security trialed various tools in our setting. The Information technology department developed an alert system for when a patient registers in the ED. We then developed a violence assessment, intervention, and plan of care tool. VALIDATION OF EVIDENCE: We created a survey monkey for key stakeholders to understand their perceptions of violence management pre-implementaiton. This presentation will discuss steps taken pre- and post-implemention of the pilot phase and plan for further roll out.  RELEVANCE/OUTCOMES: Nurses working in an ED setting should collaborate with key stakeholders to predict and respond to violence pro-actively to mitigate harm. Increasing staff confidence and decreasing injuries to safety and effectively respond to psychiatric emergencies is necessary. Staff have vocalized improved communication, collaboration, and predictability to safety intervene with patients presenting with behavioral dyscontrol. IMPLICATIONS: We need to address concerns of violence in the ED and arm nurses with the knowledge and tools necessary for early intervention, prevention of harm and the ability to maintain a safe environment.



4012: Collaborating with Patients and Families to Advance Patient Safety in Mental Health Settings
Nicole Kirwan, RN BSCN MN CPMHN(C)

PURPOSE: In mental health care, patient safety incidents that impact the lives of patients and families as well as providers and organizations can and do occur. This interactive workshop will be of interest to psychiatric mental health nurses responsible for, or involved in managing, analyzing and/or learning from patient safety incidents. SUMMARY OF EVIDENCE: In recent years, considerable focus on patient safety has been aimed at the culture of safety within health organizations, the knowledge associated with patient safety, analysis of patient safety incidents as well as sharing and communicating resulting learning and improvements with others. Greater understanding of the importance of collaborating with patients and families to conduct thorough and credible patient safety incident analyses has also surfaced. DESCRIPTION: A Mental Health Patient Safety Incident Analysis Team of interprofessional mental health clinicians, patients and families was developed to support management, analysis, learning and improvements from mental health patient safety incidents. A structured incident analysis framework is utilized by the team to understand what happened, how and why it happened and what can be done to reduce the risk of recurrence and make care safer. VALIDATION OF EVIDENCE: Meaningful participation of patients and families during all phases of the incident analysis process is actively promoted and tracked by the team using structured tools.  RELEVANCE/OUTCOMES: Real-life examples of collaborative strategies that have been successfully employed to involve diverse stakeholders in conducting concise, comprehensive and multi-incident patient safety analyses in mental health will be shared. IMPLICATIONS: Advancing patient safety in mental health requires meaningful collaboration with patients and families.



4013: Cognitive Enhancement Therapy (CET): An Innovative Evidenced Based Practice that Improves Social Cognition, Vocational Success and Physical Health
Raymond Gonzalez, ACSW,LISW-S; Charlene McAndrews, RN, MSN

PURPOSE: Despite the development of effective antipsychotic medications, many individuals with severe and persistent mental illness remain stalled in their recovery. Cognitive Enhancement Therapy (CET) is a highly effective treatment program for these individuals offering a rehabilitation component focused on improving processing speed, attention, memory, problem solving and social cognition. SUMMARY OF EVIDENCE: CET evolved at the University of Pittsburgh with a NIMH funded grant. Since 2001, CET , a now SAMHSA recognized Evidence Based Practice form of cognitive remediation, has been successfully disseminated to 32 sites in ten states, helping more than 1,550 people significantly improve in their recovery from mental illness and their ability to function in independent community and vocational settings. There are 47 CET groups now being conducted DESCRIPTION: CET is a 48 week curriculum with group interactions and mentoring that promotes interpersonal effectiveness and improves neurological functioning. CET picks up where other treatments such as CBT end helping the individual to improve their cognitive functioning and social cognition. VALIDATION OF EVIDENCE: In addition to numerous published articles on CET, we as CET coaches and trained therapists have witnessed its effectiveness in observed changes in behavior among participants. Specific outcomes have been measured using pre and posttests as well as monitoring the reduction of inpatient psychiatric admissions.  RELEVANCE/OUTCOMES: CET is a recovery oriented approach to active treatment. PMH nurses may practice as CET coaches or as part of the CET collaborative team. IMPLICATIONS: CET offers individuals the hope to move from simply maintenance management to active treatment and recovery.



4014: Nursing Student Attitudes and Readiness for Psychiatric Mental Health Clinical Practice: A Quasi-Quantitative Experimental Study
Todd Hastings, Ms, RN, PhD(c)

PROBLEM STATEMENT: Undergraduate nursing students harbor negative stereotypes and impressions prior to their psychiatric mental health (PMH) nursing class and clinical rotation.  In addition, nursing students tend to feel they have a poor sense of understanding of mental illness and feel ill prepared to work with psychiatric patients. THEORETICAL FRAMEWORK: Peplau’s Theory on Interpersonal Relations provides a foundation for examining nursing student perceptions of clinical engagement in the behavioral health environment. METHODS & DESIGN: A quasi-experimental quantitative research design using a pre- and post-test format was used to examine nursing student feelings about performing in mental health settings.  A reliable and valid Likert-type survey tool was administered to over 300 nursing students at eight professional nursing programs on the first and last day of their PMH nursing class.  RESULTS: Nursing students demonstrate less positive feelings and limited readiness to effectively work with behavioral health patients.  Classroom and clinical exposure significantly improves student impressions, knowledge, and preparation to work with the mentally ill. IMPLICATIONS FOR PRACTICE: Nurse educators need to better understand the nature of nursing student feelings and readiness relative to mental health clinical rotations.  Guided instruction in PMH nursing leads to improvement in most factors of concern characterizing student preparedness to effectively perform in PMH treatment environments. IMPLICATIONS FOR FUTURE RESEARCH: Nurse educators may further clarify the differences in perceptions of nursing students relative to age, gender, prior exposure to mental health settings, and different types of nursing programs.  Ultimately nurse educators will use information from this study to help determine which classroom techniques can improve nursing students perceptions of the PMH specialty.


4015: How a Military Treatment Facility Progressed from Setting the Initial Goal to Sustaining a Culture of Restraint-Free Patient Care: A Collaborative Effort to Educate Military Healthcare Professionals in the Restraint-Free Management of Aggressive, Agitate
Joseph Tomsic, MHPA, MN, NEA-BC, PMHNP-BC;Naomi Winterheld, MS, CMSRN, ACCNS-AG

PURPOSE: The 48th Medical Group set the goal in 2009 to provide a restraint-free patient care environment. CBT with a hands-on safe restraint application training was the education platform used 2010 to 2013. This resulted in three to six restraint episodes per year. In 2013, efforts were increased to create a culture of restraint-free patient care.. SUMMARY OF EVIDENCE: The initial restraint free patient care training was presented April 2014 to all nursing service staff and available physicians. This training resulted in 11-months of restraint-free patient care so far. Starting in 2015 ”Restraint-Free Patient Care” is a required annual training for all direct-care healthcare professionals. DESCRIPTION: Training military medical professions to use triggers, warning signs, calming mechanisms and LEAP communication when providing care for agitated patients resulted in drastic reduction of restraint incidents. VALIDATION OF EVIDENCE: The literature supports the use of triggers, warning signs and calming mechanisms when providing care for agitated patients. LEAP principles are useful to deal with agitated patients. Additionally non-restraint alternatives and increasing understanding of decision making capacity are important in managing agitated patients.  RELEVANCE/OUTCOMES: Case studies highlight the importance of restraint free patient care. PMH nurse are seen as subject matter experts. The result is restraint free patient care since July 2013. IMPLICATIONS: This training may serve as a blue print for other hospitals seeking to foster a culture of restraint free patient care. It is an example of linking critical topics such as triggers, warning signs, calming mechanisms, to LEAP communication and combining them with exercises and group discussion.


4016: Motivational Interviewing within Compliance/Adherence Therapy to Improve Outcomes of People with Severe Mental Illness: Meta-analysis
Choochart Wong-Anuchit, PhD (Candidate)

PROBLEM STATEMENT: Motivational interviewing (MI) is a popular intervention in health care research.  However, no published meta-analysis has been reported examining its effectiveness in people with severe mental illness.  The purpose of this meta-analysis was to synthesize studies that test the effects of MI interventions on three primary outcomes reflecting treatment adherence: symptoms, medication attitude, and functioning. THEORETICAL FRAMEWORK: Miller and Rollnick proposed that therapeutic behavioral change occurs by engaging individuals to argue for change. MI is a purposive counseling style to resolve ambivalence for change.  It has been widely used with compliance/adherence therapy to improve adherence in people with severe mental illness. METHODS & DESIGN: We retrieved and coded primary studies [studies (s)=16] involving adults with severe mental illness with at least five participants/group where researchers used MI within compliance/adherence therapy.  RESULTS: Using random-effects models, summary effect sizes with 95% confidence intervals (CI) were computed using Hedges’ g.  Two-tailed p-values for the Z tests were used to test the null hypotheses that the mean effects were equal to zero.  MI within compliance/adherence therapy significantly improved psychotic symptoms [g=-0.353 (CI: -0.662, -0.044; p=0.025), s=15, N=1153], and global functioning [g=0.653 (CI: -0.004, 1.310; p=0.051), s=6, N=385].  However, it did not improve attitude [g=0.175 (CI: -0.046, 0.395; p=0.120), s=14, N=1058].  All studies were significantly heterogeneous warranting follow-up moderator analyses. IMPLICATIONS FOR PRACTICE: MI within compliance/adherence therapy improved symptoms and functioning, informing psychiatric-mental health nurses about using MI in clinical practice to improve treatment adherence outcomes. IMPLICATIONS FOR FUTURE RESEARCH: Moderator analyses of participant, design, and intervention characteristics need to be examined to provide insight for future interventions.


4017: Psychiatric Polypharmacy: Questions or Concern?
Melissa Whitesell, MS, CPNP-AC, FNP-BC, PMHS-BC

PURPOSE: Antipsychotic polypharmacy compared to monotherapy is found to have an increased risk association of pre-metabolic syndrome even after adjusting for individual lifestyle characteristics. Serious concerns regarding polypharmacy are the lack of evidence based strategies to guide practice & the risk of adverse effects including mortality associated with such combinations. SUMMARY OF EVIDENCE: The term polypharmacy are that two or more psychiatric medications are being used in the same client/patient or two or more medications, of the same chemical class or pharmacological actions, are being used to treat the same condition. The National Institutes of Mental Health found those with three or more psychotropic medications including antipsychotics, increased from 3.3% in 1974-1979 to 44% in 1990-1995. Studies report that 25-50% clients are prescribed more than one antipsychotic medication concurrently. DESCRIPTION: The prevalence of add on or adjunct pharmacotherapy has been reported in about 28-75% of clients/patients. Education of clinical staff and the client/patient population need to occur simultaneously. Polypharmacy can come in multiple forms including: same class polypharmacy, multiclass polypharmacy, adjunct polypharmacy, augmentation polypharmacy, and total polypharmacy. VALIDATION OF EVIDENCE: A comprehensive literature search was conducted to locate evidence regarding assessment, diagnosis, and management of multiple psychiatric illnesses. Including mono & polypharmacy, monitoring needed, and other adjunct therapy options. Analysis was conducted on randomized control trials, evidence summaries, reports of medical treatment, comparative studies, and safety and efficacy studies conducted from 2005 to 2014.  RELEVANCE/OUTCOMES: Focuses on the response of the client/patient, environmental factors including stressors, and the use of primary, secondary, and tertiary prevention of psychiatric polypharmacy. IMPLICATIONS: Prevention/Monitoring



4021: Recovery Based Care in a Psychiatric Emergency Department Results in a Near Restraint Free Environment for Patients: It IS Possible!
Constance Noll, MA, MSN, PMHNP-BC; Zelda Falck, MS, BSN, RN-BC

PURPOSE: An urban academic medical center planned a Psychiatric Emergency Services (PES) area adjacent to the Emergency Department (ED). Community and clinical challenges were the hospital’s port city location; ranking among the top ten cities for crime and labeled the ‘heroin capital’ of the U.S. Psychiatric patient presentations in the ED environment are often involuntary, accompanied by significant agitation and/or complications of intoxication and withdrawal. SUMMARY OF EVIDENCE: With reports of physical seclusion and restraint (S&R) use ranging from 8% to 24% for ED patients, substantial risk existed for psychological/physical injuries in PES. Recovery theory/principles were adopted, informing all patient approaches and clinical care. Goals included reduction in S&R events by mindful appraisal of antecedents, triggers, and efficacy of interventions. DESCRIPTION: Using this model, multidisciplinary staff emphasizes empathy, attitudes of hope, focus on moving forward, and treatment engagement. Patient choice, respect, and de-escalation strategies are employed in assessment to disposition discussions. Forced medication is a last resort. Staff review and discuss results weekly. VALIDATION OF EVIDENCE: After 4 years, rate of S&R use has decreased over 95%. In the past eighteen months, < 1% of admitted patients experience S&R events, and patient assaults with staff injuries have decreased 50%; all without any increase in PRN medications. Patient satisfaction scores are consistently good to excellent.  RELEVANCE/OUTCOMES: Psychiatric nursing leadership was instrumental in championing performance improvement efforts and involving key stakeholders. With education, leadership support, and mentoring, a cultural shift using a recovery model became the norm. IMPLICATIONS: Follow up evaluation of patient experience/engagement outcomes in subsequent treatment environments is indicated.



4022: Intentional Hourly Rounding in an Acute Mental Health Department
Beckie Langenbach, MSN, RN-BC

PURPOSE: An introduction to the concept of Intentional Hourly Rounding in the Mental Health for the purpose of increasing patient safety, identifying risks and also building a more collaborative patient/nurse relationship. SUMMARY OF EVIDENCE: This program was created to identify concerning behaviors and escalating patients, increase the number of PRN medications used before escalation, and decrease the number of S&R events. The program was created used the acronym ASAP (A-anxiety/agitation, S-safety, A-ADLs and P-pick up) and was implemented to be used on an hourly basis with all patients. DESCRIPTION: The program has ensured a more collaborative relationship between the patient and staff along with identified safety concerns prior to escalation events in the Mental Health unit. VALIDATION OF EVIDENCE: There is limited evidence available on the use of IHR in Mental Health - evidence in Med/Surg units has shown decreases in patients safety events and increased patient satisfaction score with the use of IHR. Since implementation, effectiveness has been measured by patient satisfaction scores, and the number of S&R events.  RELEVANCE/OUTCOMES: Safety is the primary focus and IHR provides a tool that can ensure safety and identify concerning behaviors or trends early to prevent seclusion and restraint events. IMPLICATIONS: Intentional Hourly Rounding has the possibility to impact all Mental Health departments to help identify escalating patients early, intervene early, and reducing the seclusion & restraint events on inpatient units. Patients can become more involved in their care, build a strong relationship with more frequent interactions, and feel more confident in their healthcare providers while they are in the hospital.


4023: Neurofeedback: What Is It? How to Use It as an Integral Part of Psychiatric Nursing Practice
Susan Bindewald, PMHCNS-BC

PURPOSE: Consider a symphony with some instruments out of tune, others not playing at all. Think of our DSM-5 diagnoses of Autism, Major Depression, Generalized Anxiety Disorder, PTSD, and ADHD and understand that the brain’s optimal performance would ameliorate these symptoms. SUMMARY OF EVIDENCE: Psychiatric nurses are using the quantitative electroencephalogram (qEEG) or “brain map”, a sophisticated computerized analysis tool used to study the brain’s electrical activity, to determine electrical activity and patterns of brain dysfunction in order to target areas for “training” with NFB. NFB, scientifically built on operant conditioning to teach clients how to self-regulate specific areas of brain dysfunction, and neuroplasticity, the brain’s ability to change and reorganize neural pathways as a response to new learning, is the brain receiving the challenge to “fix” itself, and then doing it. DESCRIPTION: Neurofeedback (NFB) is a research-supported therapy used to directly train the brain to function better. Neurofeedback is a self-initiated, non-medication, non-invasive therapy used to correct the root problem, and not just provide symptom relief. VALIDATION OF EVIDENCE: Thomas Insel, Director of NIMH, announced that NIMH is re-orienting its research and focusing on “disorders of the human connectome” (interconnected network of neurons in the brain). Reportedly there are no known studies regarding negative outcomes involving NFB.  RELEVANCE/OUTCOMES: How can we not pursue the use of neurofeedback when people are giving up on life and feel they have no hope with the treatment modalities currently available? IMPLICATIONS: Psychiatric nurses are on the cutting edge of this important therapeutic advancement as clinicians and researchers.



4024: Breaking Down Stigma for the Next Generation of Nurses
Janet Merritt, PhD, RN, PMHCNS-BC

PURPOSE: The purpose of this presentation will be to assist Psych Mental health (PMH) nurse educators to decrease stigma towards those with mental illness. SUMMARY OF EVIDENCE: Stigma is an ongoing barrier to accessing care and a significant barrier to recovery (Parle, C. 2012). Consistent with the recommendations of Penn and Couture (2002), the recommended interventions will focus on ways to decrease stigma via “protest, education, and contact”. DESCRIPTION: The educational practice to be presented includes a series of clinical experiences, classroom presentations, simulations, use of person first language, and guided discussions that are aimed at reducing the stigma of mental illness. The interventions involve active learning strategies that engage the student in the content VALIDATION OF EVIDENCE: The method of evaluation is based on qualitative feedback from the students. For example, one student stated, “I realized that people with a mental illness shouldn't be looked down upon, be scared of, or judged for simply having a mental illness as opposed to a physical illness”. Plans are in place to more formally measure a decrease in stigmatizing attitudes of nursing students before and after their completion of PMH course work.  RELEVANCE/OUTCOMES: This content is very relevant to all of PHM nursing because we must be advocates for those with brain diseases and help decrease the stigma of mental illness to help ensure that our clients fully access all treatment options and have limited barriers to their recovery. IMPLICATIONS: This is true today and will be true in the future as health care delivery systems and public attitudes evolve.



4025: Practicing within VA/DoD Clinical Practice Guidelines for the Management of PTSD: A Case Review and Outcomes from a Civilian Provider serving Military Personnel in Europe
Catherine Stuart, APRN, CNS, FPMHNP

PURPOSE: To underscore Veterans Affairs/ Department of Defense (VA/DoD) Clinical Practice Guidelines (CPGs) for PTSD. SUMMARY OF EVIDENCE: The degree to which a provider adheres to the standards plays an important role in sucessfully treating PTSD, especially when accompanied by other disorders. Novice nurse practitioners can achieve competency and confidence when treating military sexual or combat trauma using the CPGs. DESCRIPTION: A case study demonstrates combined medication/psychotherapy approaches . The index patient has post concussive head ache, depression and substance abuse allowing for an extensive review of the Guidelines relative to each disorder when in combination with PTSD. VALIDATION OF EVIDENCE: The Behavioral Health Data Portal (real-time computer system) was used to measureimprovement of 49 patients. Raw data: 67% of patients psychiatrically managed under the CPGs had lower scores then on initial exam. A subset with PTSD, were assessed using the PCL. BHDP data for the 26 AD Service Members treated using the CPG for PTSD as an exclusive framework for treatment, showed that 81% of the patients experienced a reduction in PTSD symptom severity; 53% to a significant degree.  RELEVANCE/OUTCOMES: VA/DoD CPGs are best practice for PTSD and not only increase the probability that patients recover from PTSD, but elevates the NP to the status of expert in the provision of care for PTSD when we practice within them. IMPLICATIONS: Work remains in researching the effect of tools like the Behavioral Health Data Portal in providing practitioners a real time tool to use as a positive-feedback loop when engaging with our patients.



4026: Evaluation of Motivational Interviewing to Improve Medication Adherence in Adolescents Taking Psychotropic Medication
Vanya Hamrin, DNP, PMHNP

PROBLEM STATEMENT: Low psychotropic medication adherence rates, which commonly average 50%, lead to poorer mental health outcomes. THEORETICAL FRAMEWORK: Social Exchange Theory is used to evaluate medication adherence and motivational interviewing. METHODS & DESIGN: This quasi-experimental study is a preliminary efficacy and proof of concept evaluation of the effectiveness of motivational interviewing (MI) to improve antidepressant adherence in adolescents. The study evaluates if medication attitudes correlate with adherence and if MI changes attitudes towards medications. Forty-two adolescents (ages 12-18) receiving treatment in a university based mental health center completed the study. The Medication Electronic Monitoring System (MEMS) and the Drug Attitude Inventory (DAI) respectively measured adherence and attitudes toward medication. T-tests were used to compare pre and post adherence rates and DAI scores.  RESULTS: Adolescents significantly improved medication adherence to antidepressants and mood stabilizers as a result of MI (p< .0001). Mean adherence scores were 63.0% at baseline and 80.2% at endpoint.  At baseline only 40% of adolescents were between 80% to 100% adherent over 30 days, compared to 64% at endpoint. DAI scores were not significantly different between adherent and non-adherent participants at baseline or endpoint as a result of MI. IMPLICATIONS FOR PRACTICE: Medication adherence behavior can be changed by MI without demonstrated change in attitudes. Psychiatric nurses can incorporate motivational interviewing to improve medication adherence in adolescents.  IMPLICATIONS FOR FUTURE RESEARCH: This is the first known study to evaluate the effectiveness of motivational interviewing on psychotropic medication adherence in adolescents. Replication in longitudinal and randomized controlled trial studies is warranted.


4027: We're Not Opposing Magnets: Engaging Persons Court Ordered to Outpatient Psychiatric Treatment
Judith Gentz, MSN, PMHCNS-BC, NP

PURPOSE: Recidivism within the judiciary system of persons with mental illness and/or substance use disorders has led to the advent of mental health and sobriety courts. Psychiatric APRNs may be part of the treatment team designated to treat individuals who are mandated to outpatient treatment as a means to avoid incarceration. SUMMARY OF EVIDENCE: Developing a therapeutic relationship with a people court ordered to treatment requires a variety of treatment strategies. Several evidenced based treatment models allow the APRN flexibility in aligning with people who have been disenfranchised. Realistic goals and measureable outcomes are required by courts and are part of treatment planning. DESCRIPTION: APRNs utilize pharmacologic and psychotherapeutic interventions that support the clients' success in meeting the expectations of court. Evidenced based care reduces overall costs for the local and state governments by diverting people from either incarceration or hospitalization. VALIDATION OF EVIDENCE: Evidence suggests mental health and sobriety courts reduce recidivism of incarceration, and relapse to substance use. Many states are currently collecting data that will measure efficacy over time.  RELEVANCE/OUTCOMES: APRNs assess the bio-psycho-social and physical needs of this population, who often have neglected themselves, have been homeless, etc. Working with people court ordered to treatment requires the clinician to be flexible, utilize several therapeutic frameworks at once, and to be mindful about when to change strategies. IMPLICATIONS: The cost of incarceration significantly exceeds that of outpatient care . Outpatient care addresses the underlying cause of judicial engagement, that being behavior directly related to mental illness or addiction.



4031: Understanding Non-Pharmacological PTSD Treatments
Leah Pickett, DNP, PMHNP-BC; Leah Pickett, DNP, PMHNP-BC; Susanne Fogger, DNP, CRNP

PURPOSE: Introduce evidence-based non-pharmacological adjuvant therapies for PTSD treatments. SUMMARY OF EVIDENCE: Patients with PTSD often only have a partial response to treatment. A body of evidence is emerging revealing logotherapy, eye-movement desensitization and reprocessing (EMDR), yoga, and mindfulness-based interventions as adjuvant therapy to assist with further PTSD symptom reduction. DESCRIPTION: Incorporate evidence based non-pharmacological PTSD treatments into therapies and strategies. VALIDATION OF EVIDENCE: Logotherapy, EMDR, yoga, mindfulness based meditations; Tai Chi topics are included to increase awareness of evidence based adjuvant PTSD treatments.  RELEVANCE/OUTCOMES: Nurses should consider these non-pharmacological therapies in the treatment of PTSD and continue evaluating emerging evidence. IMPLICATIONS: Non-pharmacologic interventions provide low-stimulating, low maintenance, and cost-effective ways of managing PTSD symptoms in conjuction with traditional therapies. Participants can utilize techniques outside of the medical setting to sustain benefits gained while in treatment.


4032: Safety Monitoring - One Size Does Not Fit All
Linda Paradiso, MSN, RN, NPP, NEA-BC; Laura Shamailov, MSN, MPH, RN

PURPOSE: Safety observation monitoring in inpatient settings is not one size fits all. Best practices are trauma informed and recovery oriented. Why monitor a paranoid patient at arm's length, check someone with a sexual trauma history repeatedly in the middle of the night and count respirations more than the medical units? SUMMARY OF EVIDENCE: The prevalence of incidents occurring while patients are monitored is frequent and fraught with error. Studies have identified that careful assessment can aid in the prediction and prevention of incidents. DESCRIPTION: Data analysis identified safety risks requiring increased observation as aggression, suicide, self-harm, sexual predation, sexual victimization, elopement, disorganization and medical concerns. Nursing safety tool kits were designed for ancillary staff to employ interventions specific to the type of safety risk. For example, "community constant" observation for aggression provides a 10 foot boundary between the patient and community and "respiratory risk" determines which patient's respirations are monitored. Analysis also revealed that frequent safety observation rounds was creating "alarm fatigue" in our staff. VALIDATION OF EVIDENCE: In collaboration with physicians, risk assessments were critically analyzed and safety monitoring criteria revised. Monitoring was determined based upon the patient's trauma and point of recovery in their illness, often decreasing frequency.  RELEVANCE/OUTCOMES: After one year data was examined. No significant incidents related to increased time between observations occurred. This demonstrated accurate assessment by the teams. Other benefits identified were patient and staff improved satisfaction and fiscal savings by reduced one-to-one observations. IMPLICATIONS: Active treatment rather than passive safety monitoring was developed by our interdisciplinary team and can be replicated.



4033: Brain Stimulation – What Psychiatric Mental Health (PMH) Nurses Need to Know
Donna Ecklesdafer, MSN, BSN, RN; Mary Rosedale, PhD, PMHNP-BC, NEA-BC; Paula Bolton, MS, RN, ANP-BC

PURPOSE: In this workshop, we will present the best available evidence concerning mechanisms of action, clinical efficacy and safety, and current status of brain stimulation modalities in treatment algorithms. We will examine DBS, ECS, VNS, ECT, MST, deep TMS, superficial TMS, and tDCS We will provide information about national and international PMH Nursing contributions to the field of brain stimulation treatment in psychiatry and key future directions for PMH nurses. SUMMARY OF EVIDENCE: Research supports that brain stimulation techniques provide new promise to patients experiencing severe psychiatric disorders that have failed to respond to conventional treatments. Research has provided insights into how the brain functions in illness and in health and how brain stimulation can influence neuronal firing rates, excitability of neuronal circuits, and neuroplasticity for therapeutic effects. PMH nurses should be full partners in clinical, educational, research and health policy development concerning brain stimulation. DESCRIPTION: We will examine the critical role of PMH Nurses in brain stimulation as nurses provide and participate in clinical approaches, education, research, and shape health policy. VALIDATION OF EVIDENCE: Efficacy of brain stimulation interventions treatments are determined by valid and reliable neuropsychiatric rating scales which are conducted by trained PMH Nurses. These rating scales in conjunction with clinical assessment identifies patient outcomes, response and remission rates.  RELEVANCE/OUTCOMES: We will present patient outcomes data on each brain stimulation approach focusing on patient response and remission rates. IMPLICATIONS: Brain stimulation is a rapidly expanding field in PMH Nursing. PMH Nurses play a central role providing outstanding patient care, education research, and health advocacy including policy development.



4034: Reducing Stigma Among NP Students of Varying Disciplines with the use of Standardized Patient Simulation
Ruth Milstein, DNP, PMHNP-BC, LMHC; Clare Conner, DNP, APRN

PURPOSE: Simulation with standardized patients to reduce stigma and raise awareness of mental disorders among NP students of various specialties created a collaborative environment utilizing evidence-based interventions. Anxiety and fear were reduced by increased knowledge, exposure, and experiential simulations. SUMMARY OF EVIDENCE: Stigmatization along with myths and misconceptions surround the mentally ill and create fear and anxiety among healthcare professionals. Psychiatric simulation is not widely used currently. Clinical sites for psychiatric experiences are becoming more difficult to obtain. Most non-PMHNP's receive little exposure to this vulnerable population. Simulation has proven to be effective as a significant educational tool. Standardized patients create real life scenarios that are evidence-based effective educational tools. DESCRIPTION: Standardized patient scenarios were provided to NP students, not only PMHNP students, creating an interdisciplinary approach to care. Simulations created were based on Watson's theory of caring, Alder's unconditional positive regard and the therapeutic use of self. VALIDATION OF EVIDENCE: Pre/Post questionnaires as well as evaluations were utilized and results will be presented and published. Open discussion exposed the NP specialties (Acute Care Adult/Peds; Primary Care Adult; FNP; PMHNP) to various viewpoints.  RELEVANCE/OUTCOMES: Psychiatric simulation with standardized patients provides clinical experience in a nonthreatening, safe setting. Providing educators with alternative approaches to expose students to the psychiatric population resulted in reduction of stigma and raised awareness which optimizes care while reducing anxiety/fear in students across specialties. IMPLICATIONS: The APRN can provide care to the full extent of their education while treating those with mental disorders therefore improving outcomes while creating an environment of patient satisfaction.



4035: Barriers to Mental Health Care and Challenges to Veterans’ Transition from Military to Civilian Life
Bayani Dilag, RN;Ann Dalter, MSEd, CCM, RN

PURPOSE: In 2008, a RAND study “Invisible Wounds of War” included a survey of service members which identified barriers to mental health care. In this study, RAND divided these barriers into three, broad classes of barriers to care, namely, (1) logistical barriers, (2) institutional and cultural barriers, and (3) beliefs and preference for treatment. We posed the question in 2014-2015, do these barriers still exists or are there new barriers that emerged since the 2008 RAND study? SUMMARY OF EVIDENCE: From a collection of vignettes from about 49 Combat Casualty Assistance (CCA) Visiting Nurses from a non-profit organization, we can make a comparison of current barriers to mental health care to those listed in the 2008 RAND study. Furthermore, a compilation of challenges during transition from military to civilian life can be distinguished in addition to barriers to mental health care. DESCRIPTION: Based on these collection of qualitative data, we can identify the specific interventions in minimizing barriers to mental health care and the challenges to transition from military to civilian life. VALIDATION OF EVIDENCE: Qualitative evidence (vignettes) will show the psychosocial impact of both emotional and material support generated by a network of organizations to support the service members and veterans.  RELEVANCE/OUTCOMES: The provision of material support (financial & resources) has as much relevance in mental health recovery as emotional support. IMPLICATIONS: Mental health recovery of service members and veterans require a community of resources that need to address both the psychosocial and material needs at the key point of transition from military to civilian life.



4036: Dialectical Behavior Therapy: Its Impact on Resilience in Homeless Young Adults
Linda Grabbe, PhD, FNP-BC, PMHN-BC

PROBLEM STATEMENT: Homeless youth are vulnerable to mental health problems, substance abuse, and other  health risks.  Many have experienced traumatic childhoods, have no social support, and deal with severe emotion dysregulation.  An intervention to increase their resilience to withstand adversity may increase their chances of success in their life trajectories. THEORETICAL FRAMEWORK: Dialectical Behavior Therapy (DBT) was intentionally created for persons with emotion dysregulation and may prove effective as secondary prevention for high-risk homeless youth. Resiliency theory will be explored. METHODS & DESIGN: Multi-level mixed longitudinal modeling will be used for the analysis of repeated resilience measures over time during the DBT skills training.  RESULTS: Preliminary results show improvement in the Connor-Davidson resilience measure.  It is expected that data from over 100 participants will be presented. IMPLICATIONS FOR PRACTICE: DBT skills training is a dynamic intervention which can be applied in a variety of practice settings.  Lessons learned regarding the particular issues of research with a homeless population will be discussed.   Marsha Linehan's new edition of her Skills Training Manual provides adequate background for psychiatric nurses to provide this intervention. IMPLICATIONS FOR FUTURE RESEARCH: Longer term studies would provide rich data on the impact of a DBT intervention on high-risk youth, i.e.,attending to mental health needs and dealing with impulsive, high-risk substance use, interpersonal conflict, and sexual risk-taking.   Further research should control for underlying mental health disorders, and using interviews to clarify content of the greatest value from the repertoire of DBT skills training.


4037: Patient Satisfaction with Shared Medical Appointments for Women with Depression
Jerilyn Hagan, JD, MSN, CNS

PURPOSE: Difficulty gaining timely access to psychiatric care has become a problem of great magnitude. An efficient, readily available vehicle was necessary to address the increased demand for services. The creation of a Shared Medical Appointment (SMA) in Behavioral Health addressed this need. The purpose of this project is to assess patient satisfaction with the SMA. SUMMARY OF EVIDENCE: Shared Medical Appointments (SMAs) are an innovation in treatment, delivering efficient, quality care to a group of patients in a supportive environment. Developed by Kaiser Drs. John Scott and Edward Noffsinger, the approach is now being used across the nation. In 2003, the Center for Behavioral Health (CBH) at the Cleveland Clinic implemented an SMA for medication management. DESCRIPTION: The SMA is comprised of women above the age of 18. The participants, referred by internists, OB/GYNs or self-referred, are initially seen on an individual basis for a complete psychiatric evaluation. As part of the treatment plan, the SMA is offered for mediation management. Participation is voluntary. The group is opened to twelve (12) members with the ideal number of participants at any given time being approximately 8-10. During the group, needs of each participant are addressed. Confidentiality is stress. Questions are answered; medication adjustments are made; prescriptions are electronically generated. VALIDATION OF EVIDENCE: The satisfaction of the SMA participants was measured through the use of the Patient Satisfaction Quesionnarie-18 (PSQ-18), validated instrument (RAND, 1994).  RELEVANCE/OUTCOMES: Participant satisfaction with the SMA was high. IMPLICATIONS: SMAs can be created in other areas of Behavioral Health to improve access, quality care and efficiency.





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