Managing Professional and Nurse-Patient Relationship Boundaries in Mental Health.

Caring nurse-patient relationships in mental health settings are key components in helping patients recover. These professional relationships provide a safe, trustworthy, reliable, and secure foundation for therapeutic interactions; however, nurses face challenges in setting and maintaining relationship boundaries. Although patients ask for special privileges, romantic interactions, and social media befriending, or offer expensive gifts, nurses must recognize that these boundary violations may erode trust and harm patients. These violations may also trigger discipline for nurses. Professional relationship guidelines must be applied with thoughtful consideration, and nurses must monitor their emotions and reactions in these relationships. The current article is a sharing of personal experiences about boundaries augmented by evidence in the literature, and focuses on managing potential boundary violations (i.e., social media, sexuality, over-involvement, and gift giving) in mental health settings. [Journal of Psychosocial Nursing and Mental Health Services, 55(1), 45-51.].

Trauma-informed care: keeping mental health settings safe for veterans.

Veterans, as military personnel returning from wars in Afghanistan and Iraq, are frequently coping with various mental health problems. These veterans are at high risk for posttraumatic stress disorder (PTSD) and associated behavioral consequences, including self-harm, verbal and physical aggression, and violence. In this article, we highlight the physiological, physical, and emotional consequences of trauma. We focus on the unique experiences that affect veterans' mental health and associated behaviors and advocate for veterans to receive evidenced-based treatment using trauma-informed and recovery-oriented care.

Improving professional practice through certification.

Certification helps ensure quality of practice and currency of nursing knowledge. We designed certification review courses and evaluated their impact on satisfaction, quality of care, adverse drug events (ADEs), and RN vacancies. Certification correlated with improved patient and nurse satisfaction, quality of care, and increased nurse rates of reporting ADEs, although the ADE total rates are consistent. Certification inversely correlated with nurse vacancies. Certification has helped to enhance nurses' knowledge, productivity, quality of care, and patient and nurse satisfaction, and has decreased RN vacancies.

Hypnosis for pain management.

Nurses are in a key position to learn and use hypnosis with patients to reduce pain and enhance self-esteem. However, most nurses lack knowledge about the clinical effectiveness of hypnosis and may seek continuing education to become skilled in its use. Painful procedures, treatments, or diseases remain a major nursing challenge, and nurses need complementary ways to relieve pain from surgery, tumors, injuries, and chemotherapy. This article examines the evidence base related to hypnosis for pain management, as well as how to assess and educate patients about hypnosis.

Sexual abuse of boys.

TOPIC: Sexual abuse in childhood can disable self-esteem, self-concept, relationships, and ability to trust. It can also leave psychological trauma that compromises a boy's confidence in adults. While some boys who willingly participate may adjust to sexual abuse, many others face complications, such as reduced quality of life, impaired social relationships, less than optimal daily functioning, and self-destructive behavior. These problems can respond to treatment if detected. PURPOSE: In this paper, we examine the prevalence, characteristics, psychological consequences, treatment, and coping patterns of boys who have been sexually abused and their failure to disclose abuse unless asked during a therapeutic encounter. Nurses have a responsibility to detect the clues to sexual abuse, diagnose the psychological consequences, and advocate for protection and treatment. SOURCES USED: Computerized literature search of the Medline and PsychInfo literature and books on sexual abuse of boys. CONCLUSIONS: Psychological responses to abuse such as anxiety, denial, self-hypnosis, dissociation, and self-mutilation are common. Coping strategies may include being the angry avenger, the passive victim, rescuer, daredevil, or conformist. Sexual abuse may precipitate runaway behavior, chronic use of sick days, poor school or job performance, costly medical, emergency and or mental health visits. In worst cases, the boy may decide that life is not worth living and plan suicide. The nurse has a key role to play in screening, assessing, and treating sexual abuse children.

Screening for depression and suicide: self-report instruments that work.

Self-report instruments for depression and suicide risk can help busy clinicians identify adult clients who may be at risk for depressive disorders. These instruments provide a baseline measure of clients' behavioral status, reflect response to treatment, and improve clinical decision making. Such scales can also detect symptoms of depression regardless of whether they are reported or observed. Clinicians' recognition of depression is improved when self-report screening tools are used. When it is not feasible to conduct a thorough psychiatric evaluation, screening instruments can identify at-risk clients who need further evaluation.

End-of-life challenges: honoring autonomy.

Patients' end-of-life decisions challenge nurses to improve palliative care, symptom management, and patient advocacy, and examine ethical issues. When terminally ill patients take charge of the last stages of life, they may challenge nurses to reexamine attitudes about lifesaving technology and autonomy and values about preserving life. Staff members can become benevolent and believe that they know what is best despite the patient's independent decisions. When patients unsuccessfully decline continued aggressive, life prolonging strategies, they may decide to hasten dying rather than accept a natural death. Researchers (Breitbart WS et al. JAMA. 2000;284:2907-2911) defined desire for hastened death as a unifying construct underlying requests for assisted suicide, euthanasia, and withdrawal of food and fluids. When a terminally ill patient considers a hastened death, the nurse needs to examine the patient's mental health, symptom management, advance directives, and decision making. Medical and psychological symptoms and spiritual distress often trigger thoughts of hastening death even when pain and symptoms have been treated (Breitbart WS et al. JAMA. 2000;284:2907-2911). Ethical issues and guidelines for management of patients and evaluation of rationality are presented.

Depression and HIV disease.

Depressive disorders are common among 20% to 32% of people with HIV disease but are frequently unrecognized. Major depression is a recurring and disabling illness that typically responds to medications, cognitive psychotherapy, education, and social support. A large percentage of the emotional distress and major depression associated with HIV disease results from immunosuppression, treatment, and neuropsychiatric aspects of the disease. People with a history of intravenous drug use also have increased rates of depressive disorders. Untreated depression along with other comorbid conditions may increase costly clinic visits, hospitalizations, substance abuse, and risky behaviors and may reduce adherence to treatment and quality of life. HIV clinicians need not have psychiatric expertise to play a major role in depression. Screening tools improve case finding and encourage early treatment. Effective treatments can reduce major depression in 80% to 90% of patients. Clinicians who mistake depressive signs and symptoms for those of HIV disease make a common error that increases morbidity and mortality.

Evaluating intimate partner violence.

PURPOSE: To describe the incidence, assessment, and management of intimate partner violence (IPV) from a cultural perspective emphasizing the values, strengths, and health care needs of African-American women. DATA SOURCES: Review of the published scientific literature, U.S. Bureau of Justice Statistics and the National Crime Victimization Survey (NCVS) supplemented with hypothetical cases. CONCLUSIONS: Violence is a social and public health emergency affecting over 10% of the population during their lives and 22% of women who are physically assaulted by an intimate. Roughly 3 million to 4.4 million women report being battered annually, although this is a low estimate. Neither gender nor age nor sexual orientation protects one from IPV. Violent crime causes 2.2 million known injuries with a huge cost in hospital days and other expenses. IMPLICATIONS FOR PRACTICE: Women often hesitate to report violence; health care professionals detect as few as 5% of battered women. Women suffer for months and years before accurate diagnosis. Clinicians need to be vigilant in case finding, education, prevention, and treatment. Cultural differences in values and beliefs, and behavioral norms influence evaluation, treatment, and referral.

Obsessive-compulsive disorder.

TOPIC: Identification and management of obsessive-compulsive disorder (OCD). PURPOSE: To increase advanced practice clinicians' awareness of the prevalence, screening tools, diagnostic criteria, differential diagnosis, and therapeutic management of OCD. SOURCES: Published literature. CONCLUSIONS: Nurses have a pivotal role in teaching self-management techniques to people with OCD.

Aftermath of a patient's suicide: a case study.

TOPIC: Nurse psychotherapists often feel poorly prepared to cope with a patient's death by suicide. The psychotherapist may identify with the family, feel sad at the death, and be plagued by feelings of guilt and responsibility. PURPOSE: A case study illustrates the meaning of the loss to the therapist and the influence on professional identity, self-confidence, and self-esteem. SOURCES: Case study and review of the literature from Medline, psychinfo, and CINAHL. CONCLUSIONS: Therapists experience their own grief as a lack of omnipotence over suicide, and the fear of their colleagues' responses. Understanding bereavement and factors influencing bereavement may help therapists facilitate and reduce negative consequences of their own grief.

Nurses' grief reactions to a patient's suicide.

TOPIC: A patient's suicide may threaten the nurse's health and work performance until grief and mourning are transformed. PURPOSE: To examine the literature, bereavement theories, and recommendations for supporting nurses' bereavement. SOURCES: Bereavement literature on Medline, CINAHL, and PsychInfo from 1965-2001, and clinicians' and nurses' responses to a patient's death by suicide. CONCLUSIONS: Nurses need a support system to help them cope with grief after a patient's suicide. Having knowledge of bereavement and using therapeutic support can help prevent burnout or stress and can encourage constructive coping strategies that transform grief. Grieving is facilitated when nurses recognize their own mortality and take time to process their grief.

Creative way to improve practice: the research journal club.

Research highlights interventions that improve patient care; however, this evidence does not consistently show up in practice. To decrease adverse events and increase patient and referral satisfaction, home care agencies must find ways to keep their clinical staff up to date. This article describes how one agency created a journal club that has met with success.

Comparison of suicide attempters and completers.

Nurses are challenged to estimate risk for suicide and to manage and prevent suicide. Evaluating and differentiating suicide attempters from completers is a serious clinical responsibility; miscalculation of risk and inadequate vigilance can have lethal consequences. In this retrospective study, suicide messages, risk, and symptom distress were examined among a matched cohort of suicide completers (SC) (n=25) and suicide attempters (SA) (n=25) at a Veterans Administration Medical Center. Staff members documented and reported patients' clear, and frequent messages about suicide. Themes within psychiatric patients' suicide messages and the number of documented suicide messages helped differentiate SA s from SCs. SCs were more likely to have a fear of being killed, hopelessness, and perceived symptom distress. SAs (28.6%) typically made a contract with staff not to commit suicide in the hospital while no SCs did so. Over 50% of the suicide messages were clear and directly referred to suicide. Indirect or unclear messages about suicide are more likely to be overlooked or discounted by staffmembers. All of the patients who completed suicide after hospital discharge, did so in the first 6 weeks after discharge. The paper includes a review of the relevant literature.

Postscript: follow-up after manuscript submission.

Tracking your manuscript is one way to help the review process go smoothly and it keeps you actively involved. Verifying the arrival of your manuscript and politely asking for feedback helps reduce needless frustrations. If a journal encourages you to revise and resubmit, the chances of acceptance and publication improve.

Evaluating and managing adult PTSD in primary care.

Posttraumatic stress disorder (PTSD) is an anxiety disorder with a sustained and dysfunctional emotional reaction to a traumatic event, threat of injury or death, and pain.

Oncology nurses' knowledge of suicide evaluation and prevention.

BACKGROUND: Cancer patients can present with a risk of suicide, making it important for oncology nurses to be knowledge about the high-risk factors for suicide in this population and to be competent in suicide detection and management. OBJECTIVE: The aim of this study was to describe oncology nurses' identification of risk factors, knowledge, and skill at suicide evaluation and prevention based on evaluation of a vignette and to describe nurses' assessments and interventions for suicidal patients. METHODS: As part of a larger exploratory, national study, clinical oncology nurses (n = 1200) from the Oncology Nurses Society responded to a knowledge survey; a total of 454 evaluable questionnaires (37% response rate) were returned. RESULTS: Nurses reviewed a vignette of a suicidal patient and correctly identified these risk factors: widower (69.8%), wishes he/she were dead (82.8%), and gives away prized possessions (79.6%). Few nurses knew that ethnicity (0.4%), age (13.2%), or sex (16.4%) indicated suicide risk. Nurses incorrectly believed that worrying, crying, and executive position indicated suicide risk (40.6-42%). Most nurses rated themselves as having little to some skill and knowledge of suicide evaluation. CONCLUSION: Oncology nurses were able to identify certain behavioral risk factors at acceptable rates but not demographic risk factors. IMPLICATIONS FOR PRACTICE: Oncology nurses are likely to interact with patients at suicide risk and would benefit from knowledge about behavioral and demographic risk factors that contribute to an oncology patient becoming high risk for suicide. Such knowledge could contribute to overall patient safety.