Nurse-directed care model in a psychiatric hospital: a model for clinical accountability.

PURPOSE: The focus on recovery for persons with severe and persistent mental illness is leading state psychiatric hospitals to transform their method of care delivery. This article describes a quality improvement project involving a hospital's administration and multidisciplinary state-university affiliation that collaborated in the development and implementation of a nursing care delivery model in a state psychiatric hospital. DESCRIPTION OF THE PROJECT: The quality improvement project team instituted a new model to promote the hospital's vision of wellness and recovery through utilization of the therapeutic relationship and greater clinical accountability. Implementation of the model was accomplished in 2 phases: first, the establishment of a structure to lay the groundwork for accountability and, second, the development of a mechanism to provide a clinical supervision process for staff in their work with clients. Effectiveness of the model was assessed by surveys conducted at baseline and after implementation. OUTCOME: Results indicated improvement in clinical practices and client living environment. As a secondary outcome, these improvements appeared to be associated with increased safety on the units evidenced by reduction in incidents of seclusion and restraint. CONCLUSIONS: Restructuring of the service delivery system of care so that clients are the center of clinical focus improves safety and can enhance the staff's attention to work with clients on their recovery. IMPLICATIONS: The role of the advanced practice nurse can influence the recovery of clients in state psychiatric hospitals. Future research should consider the impact on clients and their perceptions of the new service models.

The Four S Model in action for de-escalation. An innovative state hospital-university collaborative endeavor.

In this article, the Four S Model is presented as a working clinical framework for generating structured nursing interventions and treatment plans. The de-escalation process, formalized by the De-escalation/Alternative to Restraint Flowsheet, is one way in which the model is being operationalized to reduce seclusion and restraints. As shown by the flowsheet, the model allows for integration of mental health and mental illness. It spans the scope of nursing practice at all levels, from para-professional to advanced practice nurse, by integrating the mental health concepts of communication, leadership, clinical judgement, critical thinking, and caring within its framework. Most important, the flexibility to individualize treatment that is built into the model allows for generalization to all psychiatric presentations.