A Hero's Journey: Supporting children throughout inpatient psychiatric hospitalization using a therapeutic comic book.

PROBLEM: Art- and narrative-based interventions are an integral component of pediatric inpatient psychiatric care. We describe a novel therapeutic comic book we developed for hospitalized children and young adolescents. METHODS: A Hero's Journey is a 38-page zine that can be freely downloaded and photocopied for distribution. The short booklet is intended to demystify and offer guidance throughout the experience of hospitalization, promote interaction and socialization, provide scaffolding for skill-building, and prepare patients for moving forward after discharge. FINDINGS: The underlying foundations of the booklet include: 1) Theoretical sources (Joseph Campbell's hero's journey; Donald Schön's reflective practice; and the principles of narrative medicine); and 2) Clinical sources (collaborative problem solving; cognitive-behavioral therapy, and trauma-informed care). We articulate how each page relates to the different components, and how individual pages can be used as worksheets for practice of specific skills. We next provide suggestions on how best to use the booklet: from arrival at the emergency room, through inpatient hospitalization, and toward discharge. We also propose ways for staff, caregivers, and any child-facing adult to make use of this clinical resource in support of a patient's recovery and reintegration into their community. CONCLUSIONS: Even though not yet empirically tested, this therapeutic comic book is available for dissemination free of cost. We encourage leaders in nursing and therapeutic recreation to try using this resource in their emergency room and milieu settings.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors.

WHAT IS KNOWN ON THE SUBJECT?: The impacts of racism on health are well documented and are greater for mental than for general health. Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings. AIM/QUESTION: We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff. METHODS: We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework. RESULTS: We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants. IMPLICATIONS FOR PRACTICE: Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

Cognitive-behavioral therapy training for multidisciplinary inpatient psychiatric teams: A novel curriculum using animated simulations.

PROBLEM: Nurses assume primary responsibility teaching children self-management skills, yet few of them have formal training in evidence-based treatments such as cognitive-behavioral therapy (CBT). METHODS: We developed a novel CBT training curriculum specifically tailored for nurses and other child psychiatric inpatient team members. The curriculum was anchored in three components: (1) a structured manual; (2) instructional videos of common clinical scenarios using animated simulations; and (3) interactive role-play exercises. The CBT curriculum was implemented through small group training sessions. We then conducted focus group sessions with the 20 participants to assess change in self-reported knowledge of, and utilization of CBT skills in clinical practice. FINDINGS: The curriculum was well received by staff members, who found its content relevant and applicable to their daily inpatient work. Staff reported four main themes: (1) routine clinical care (feelings, challenges, and approaches); (2) CBT utility in practice; (3) CBT training components that facilitated learning of the discrete skills; and (4) professional development needs. CONCLUSIONS: We were able to implement the curriculum within the time and staffing constraints of a clinically active inpatient setting. Future refinements of the model will include videotaped interactions between expert clinicians and simulated patients in high acuity situations.

Disclosure of caregiver-fabricated illness to a child: A team-based approach to communicating with pediatric patients.

Clinical practice guidelines for informing children they have been subjected to caregiver-fabricated illness are highly limited in the current literature. This article addresses this issue by offering an ethically informed, psychological approach to the disclosure of this form of abuse to school-aged children and adolescents who have been significantly harmed. A multidisciplinary, staged model of communication which illustrates that truthful communication with children and their families is a necessary component of the recovery process is proposed.

Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study.

OBJECTIVE: This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. METHODS: The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. RESULTS: There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41+/-8 to 18+/-20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16+/-10 to .3+/-.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27+/-5 to 21+/-5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15+/-6 to 7+/-6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CONCLUSIONS: CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.

Characterizing aggressive and noncompliant behaviors in a children's psychiatric inpatient setting.

This study was conducted to evaluate aggression and noncompliance among child psychiatric inpatients in relation to demographic, clinical, and hospitalization characteristics, including the use of restraints and seclusion. Eighty six children (10.8+/-2.4 years old, 67% male) consecutively admitted to an inpatient psychiatric unit were rated weekly using the Modified Overt Aggression Scale (MOAS) and the Disruptive Behavior Rating Scale (DBRS) between November 1, 2002 and June 30, 2003. Moderate to high correlations were observed between the four types of aggression (verbal, and physical against self, others, or objects) and noncompliant behavior. In hierarchical regression analyses, only mental retardation emerged as a significant predictor of aggression and noncompliance. Aggression and noncompliance were associated with different characteristics of inpatient treatment. Aggressive behavior was significantly associated with the use of restraints and seclusion, and noncompliant behavior with length of hospitalization and number of psychiatric medications at time of discharge. Modifying milieu interventions for youths with mental retardation, and adapting behavioral interventions empirically proven to target noncompliance may be effective loci for reducing aggression in child psychiatric inpatient units.