Updates to American Psychiatric Nurses Association: Seclusion and Restraint Position Statement and Standards of Practice.

OBJECTIVE: The purpose of this discussion paper is to summarize the 2022 updates to the American Psychiatric Nurses Association's (APNA) Seclusion and Restraint Position Statement and Seclusion and Restraint Standards of Practice. METHOD: Both documents were the work of the APNA 2022 Seclusion and Restraint Task Force that consisted of APNA nurses with expertise in the use of Seclusion and Restraint, who practice across a wide range of clinical settings. RESULTS: The 2022 Updates to the APNA Position Statement and Standards were guided by evidence-based information found in the review of seclusion and restraint literature and clinical expertise from the 2022 Seclusion and Restraint Task Force. CONCLUSIONS: Updates were evidence-based and in line with APNA's core values and initiatives in diversity, equity, and inclusion.

Tropical Rainforest Restoration Plantations Are Slow to Restore the Soil Biological and Organic Carbon Characteristics of Old Growth Rainforest.

Widespread and continuing losses of tropical old-growth forests imperil global biodiversity and alter global carbon (C) cycling. Soil organic carbon (SOC) typically declines with land use change from old-growth forest, but the underlying mechanisms are poorly understood. Ecological restoration plantations offer an established means of restoring aboveground biomass, structure and diversity of forests, but their capacity to recover the soil microbial community and SOC is unknown due to limited empirical data and consensus on the mechanisms of SOC formation. Here, we examine soil microbial community response and SOC in tropical rainforest restoration plantings, comparing them with the original old-growth forest and the previous land use (pasture). Two decades post-reforestation, we found a statistically significant but small increase in SOC in the fast-turnover particulate C fraction. Although the δ13C signature of the more stable humic organic C (HOC) fraction indicated a significant compositional turnover in reforested soils, from C4 pasture-derived C to C3 forest-derived C, this did not translate to HOC gains compared with the pasture baseline. Matched old-growth rainforest soils had significantly higher concentrations of HOC than pasture and reforested soils, and soil microbial enzyme efficiency and the ratio of gram-positive to gram-negative bacteria followed the same pattern. Restoration plantings had unique soil microbial composition and function, distinct from baseline pasture but not converging on target old growth rainforest within the examined timeframe. Our results suggest that tropical reforestation efforts could benefit from management interventions beyond re-establishing tree cover to realize the ambition of early recovery of soil microbial communities and stable SOC.

Decreasing Duration of Mechanical Restraint Episodes by Increasing Registered Nurse Assessment and Surveillance in an Acute Psychiatric Hospital[Formula: see text].

INTRODUCTION: The application of mechanical restraints is a high-risk emergency measure that requires psychiatric intensive care to assure patient safety and expedite release at the earliest opportunity. While current Centers for Medicare & Medicaid Services regulations require trained staff to continuously observe restrained individuals, assessment by a registered nurse is required only once an hour. The experience of an acute psychiatric hospital demonstrates that more frequent registered nurse assessments can decrease duration of mechanical restraint episodes. AIMS: The aim of this three-part quality improvement project was to decrease duration of mechanical restraint episodes by increasing the frequency of registered nurse assessment and surveillance. METHODS: First, the requirement for frequency of face-to-face registered nurse assessment during episodes of mechanical restraint was increased from once every hour to once every 30 minutes. Second, the frequency of assessment was increased on half the hospital's units, from every 30 minutes to continuous registered nurse presence during restraint. Finally, the remaining units adopted 1:1 registered nurses during restraint. Mean hours of restraint per episode were measured and compared before and after each practice change. RESULTS: Mean duration of restraint episodes decreased 23% in the first change cycle, 12% in the second, and 44% in the third. Overall, there was a statistically significant 30% decrease in mean duration of restraint episodes. CONCLUSIONS: Increased frequency of registered nurse assessment and surveillance can significantly decrease duration of mechanical restraint episodes. Nurses are encouraged to adopt mechanical restraint practice standards that provide continuous psychiatric intensive care by a registered nurse.

Decreasing Physical Restraint in Acute Inpatient Psychiatric Hospitals: A Systematic Review.

OBJECTIVE: A systematic review was conducted to identify methods used to decrease the application of physical restraints in acute inpatient psychiatric hospitals. METHOD: A literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines using key words related to physical restraint. RESULTS: Three data-based studies met eligibility criteria. CONCLUSIONS: Findings suggest that multimodal intervention strategies may reduce the number of hours of physical restraint used in inpatient psychiatric settings, but quality evidence to support specific strategies is lacking. The search highlights the need for more quality research using standardized restraint reporting measures.

APNA Member Survey Results: Role of Psychiatric Nurses in Hospital Emergency Departments.

BACKGROUND: A group of hospital emergency department nurses formed a virtual community within the American Psychiatric Nurses Association (APNA) to explore who and what skills are best suited to provide care for patients with psychiatric disorders in hospital emergency departments. OBJECTIVE: The Emergency Department Nurse work group, under the auspices of APNA's Institute for Safe Environments, developed a survey to help describe the role and function of the psychiatric nurse in hospital emergency departments and to determine needs for training and competencies. DESIGN: The 25-item survey was sent via an email link to all APNA members. RESULTS: Responses from 520 nurses show consensus for the title of "psychiatric emergency department nurse," whose primary role is to provide "crisis management." A need for education in advanced medical assessment was identified. CONCLUSION: It is critical that we provide a professional practice context to assist nurses working in emergency departments.

Engagement as an Element of Safe Inpatient Psychiatric Environments.

BACKGROUND: The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety. OBJECTIVES: To describe, using supporting literature, the role that nurse-patient engagement plays in creating safe, therapeutic environments for individuals with severe mental illness. DESIGN: (1) Define engagement and describe why it is an important element of safe treatment environments; (2) identify what helps and what hinders patients in their engagement with nurses, and nurses in their engagement with patients; (3) describe how engagement may improve unit safety; and (4) propose recommendations and set future directions for practice, research, and education. CONCLUSION: Engagement may provide the foundation for safe, therapeutic, and recovery-oriented treatment. In the future, APNA's ISE plans to build upon this foundation by developing a clinical model of nurse-patient engagement and safety by drawing together emerging research and practice models.

Nurse-police coalition: improves safety in acute psychiatric hospital.

Although police officers protect and secure the safety of citizens everywhere, nurses are the primary guardians of patient safety within the treatment milieu. At New Hampshire Hospital, both nurses and police officers share ownership of this responsibility, depending on the needs that arise specific to each profession. Psychiatric nurses take pride in their ability to de-escalate agitated and potentially aggressive patients; however, times arise when the best efforts of nurses fail, or when a situation requires intervention from police officers. Nurses and police officers at New Hampshire Hospital have worked together for many years to develop a trusting, respectful alliance. This coalition has resulted in a safe, clear, orderly process for transfer of authority from nurses to police during violent, clinically unmanageable psychiatric emergencies. Nurses and police officers work collaboratively toward the common goal of ensuring safety for patients and staff, while also acknowledging the unique strengths of each profession.

Seclusion and restraint use in children and adults: differences between age groups.

This 1-year study of seclusion and restraint in an acute inpatient psychiatric hospital revealed a marked difference in reasons and duration for adults, children, and adolescents. Children and adolescents are most often secluded and restrained in response to identifiable patterns of dangerous behavior, and episodes of seclusion and restraint involving children and adolescents are considerably shorter than episodes involving adults. This information is being used to find ways to improve the care and treatment of all patients, especially for children.

Staying safe: re-examining workplace violence in acute psychiatric settings.

An educational program for staff in an acute, involuntary inpatient setting has led to positive change by challenging the widely held belief that getting hurt is an expected part of the job in acute psychiatric care settings. The Staying Safe program encouraged staff to think differently about their roles and to explore alternative responses to patient behaviors. Cultural change takes time: Staff have requested that the program be repeated multiple times over the past 5 years, and key concepts have been incorporated into employee orientation and refresher programs. During that same time, staff have learned to call for help more often and to have a plan for such help before physically intervening with patients. The strategies described in this program have resulted in decreased number of assaults on staff, injuries from assaults, and lost work time from those injuries.

Psychiatric patients are at increased risk of falling and choking.

Acutely ill psychiatric patients experience symptoms and take medications that increase their risk of both falling and choking; however, nurses and other caregivers may not be keenly aware of these risks. This article will provide a brief review of the literature related to risk factors for falls and choking and interventions to prevent falls and choking. Increased education for nursing students and staff employed at inpatient psychiatric units has the potential to reduce both incidence and injuries related to falls and choking.

Transforming the culture of caring.

Direct care staff struggle with the decision of when to physically intervene with patients. There is a widely held belief that they are expected to place themselves in danger of harm to prevent patients from hurting themselves or others. In this acute mental health care setting, an educational program was developed, using principles of adult and transformational learning, to dispel the idea that getting hurt is part of the job. The Staying Safe program strongly discourages staff from physically intervening alone and promotes staff getting enough help and having a plan. Staff are encouraged to interact with patients in helpful ways and to respond to patient requests in ways that do not increase frustration or evoke anger. There has been a positive response to the training program, evidenced by changes in the way staff think about their jobs and a reduction in the number of assaults and injuries to staff.

A study over 33 years shows that carbon and nitrogen stocks in a subtropical soil are increasing under native vegetation in a changing climate.

Soil plays a critical role in the global carbon (C) cycle. However, climate change and associated factors, such as warming, precipitation change, elevated carbon dioxide (CO2), and atmospheric nitrogen (N) deposition, will affect soil organic carbon (SOC) stocks markedly - a decrease in SOC stocks is predicted to drive further planetary warming, although whether changes in climate and associated factors (including atmospheric N deposition) will cause a net increase in SOC or a net decrease is less certain. Using a subtropical soil, we have directly examined how changes over the last three decades are already impacting upon SOC stocks and soil total nitrogen (STN) in a Vertisol supporting native brigalow (Acacia harpophylla L.) vegetation. It was observed that SOC stocks increased under native vegetation by 5.85 Mg C ha-1 (0.177 ± 0.059 Mg C ha-1 y-1) at a depth of 0-0.3 m over 33 years. This net increase in SOC stocks was not correlated with change in precipitation, which did not change during the study period. Net SOC stocks, however, were correlated with an increasing trend in mean annual temperatures, with an average increase of 0.89 °C. This occurred despite a likely co-occurrence of increased decomposition due to higher temperatures, presumably because the increase in the SOC was largely in the stable, mineral-associated fraction. The increases in CO2 from 338 ppmv to 395 ppmv likely contributed to an increase in biomass, especially root biomass, resulting in the net increase in SOC stocks. Furthermore, STN stocks increased by 0.57 Mg N ha-1 (0.0174 ± 0.0041 Mg N ha-1 y-1) at 0-0.3 m depth, due to increased atmospheric N deposition and potential N2 fixation. Since SOC losses are often predicted in many regions due to global warming, these observations are relevant for sustainability of SOC stocks for productivity and climate models in semi-arid subtropical regions.

Atmospheric concentrations of ammonia and nitrogen dioxide at a tropical coral cay with high seabird density.

Ecosystems with high seabird densities can receive extremely high inputs of nitrogen (N) from bird guano. Seabirds deposit up to 1000 kg N ha(-1) y(-1) on Heron Island, a tropical coral cay of the Great Barrier Reef. We quantified atmospheric concentrations of ammonia (NH(3)) and nitrogen dioxide (NO(2)) with passive air samplers at beach, woodland and forest along a gradient of low, intermediate and high bird densities, respectively. NO(2) concentrations at all studied sites were generally low (average 0.2-2.3 microg NO(2) m(-3)) and similar to other ecosystems. An exception was the main traffic zone of helicopter and barge traffic which had elevated concentrations (average 6.2, maximum 25 microg NO(2) m(-3)) comparable to traffic-intense urban areas elsewhere. Increasing average NH(3) concentrations from 0.7 to 17 microg NH(3) m(-3) was associated with greater seabird nesting density. In areas of intermediate and high bird density, NH(3) concentrations were substantially higher than those typically detected in natural and agricultural systems, supporting the notion that seabird guano is a major source of NH(3). The steep decline of NH(3) concentrations in areas with low bird density indicates that trans-island transport of NH(3) is low. NH(3) may not only be re-deposited in close vicinity of the source but is also transported vertically as concentrations above the tree canopy averaged 7.5 microg NH(3) m(-3). How much guano-derived NH(3) contributes to reefal waters via the possible transfer path water --> land --> water remains to be established. We discuss atmospheric concentrations of NH(3) and NO(2) in context of N-based gaseous pollutants and effects on vegetation.

Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation.

Elimination of seclusion and restraint requires support at all levels of an organization, especially from leaders who visibly champion and communicate their vision. Nurses, physicians, educators, and administrators at New Hampshire Hospital, an acute psychiatric inpatient facility, have established a standard meeting time and place for an executive-level review of every episode of seclusion and restraint. The standing meeting demonstrates the organization's commitment to caring for both patients and staff. The daily meetings foster a spirit of interdisciplinary collaboration, where direct care staff have the opportunity to tell their stories and share their ideas and concerns in an environment that is caring, supportive, and devoid of criticism or blame. Narrative descriptions of emergency interventions, including what was learned from debriefings with patients and staff involved, provide data about factors that may contribute to the use of seclusion or restraint. This forum provides visible administrative and clinical support that promotes creative thinking, collaborative problem solving, and the exploration of new ideas recommended by those directly involved in providing patient care. It has fostered exploration and development of strategies that have minimized episodes of aggressive behavior as well as seclusion and restraint.

N2-fixing black locust intercropping improves ecosystem nutrition at the vulnerable semi-arid Loess Plateau region, China.

The Loess Plateau in northwestern China constitutes one of the most vulnerable semi-arid regions in the world due to long-term decline in forest cover, soil nutrient depletion by agricultural use, and attendant soil erosion. Here, we characterize the significance of N2-fixing Robinia pseudoacacia L. and non-N2-fixing Juglans regia L. for improving nutrient availability and water retention in soil by comparing a range of biological and physicochemical features in monoculture and mixed plantations of both species. We found that N2-fixing Robinia facilitates the nitrogen and phosphorus composition of non-N2-fixing Juglans in the mixed stand as a consequence of improved soil nutrient availability, evident as higher levels of nitrogen and labile carbon compared to mono-specific stands. This demonstrates that intercropping N2-fixing Robinia with non-N2-fixing woody plants can greatly improve soil carbon and nitrogen bioavailability as well as whole-plant nutrition and can potentially mediate water retention with additional sequestration of soil organic carbon in the range of 1 t C ha-1 year-1. Thus, intercropping N2-fixing woody species (e.g. Robinia pseudoacacia or Hippophae rhamnoides L.) with locally important non-N2-fixing tree and shrub species should be considered in afforestation strategies for landscape restoration.