00:01
So let's think about when we are
doing this environmental scan
when you walk onto a unit.
00:14
This scan is taking into consideration
everything that's going around you
and just see that full
environment is also checking,
checking the people
that are walking around.
00:32
Noticing if there are
any external signs
that they have
personal distress.
00:40
So what does that look like?
It might be a person pacing.
00:44
It might be a person rocking.
00:47
It might be somebody who's
looking at you with wide eyes.
00:52
You want to make sure
that you are checking,
you are scanning the
environment and you're checking.
01:00
And then if you notice
that there's someone there,
and that person looks as though
they are somewhat distressed,
you want to connect with them.
01:11
You want to be able to
approach, keep a good distance,
whatever you're comfortable
with, I usually say arm's length.
01:20
I'm going to keep
myself an arm's length.
01:22
This way, if somebody swings at
me, I can step back.
01:28
I then will connect with them.
01:30
I will say, "I notice, I'm curious
about, it seems, what I see is."
And then as I am
talking to that person,
I am also thinking about,
what should I do next?
Do I need someone else to
help me with this situation,
I want to make sure that I am secure
and that the environment is secure.
01:59
And that my patient is...
02:02
You guessed it.
02:04
Safe.
02:05
This is all about safety.
02:12
Now let's think about
our own behaviors.
02:14
Let's think about the attitudes
we walk on to that unit with.
02:22
I say when I think about that
spectrum of mental health,
I say that we are all
somewhere on that spectrum.
02:33
Some of us are happier, some of us are
sad or some of us are less stressed,
some of us are more stressed.
02:43
And whatever my patient is
experiencing deserves my respect.
02:49
Because their struggle is real.
02:52
And their struggle is to move on
that spectrum towards recovery.
02:57
My respect is going to help
them find their own respect.
03:01
So are first and cardinal idea about
our own attitudes in psychiatric nursing
is to be respectful.
03:13
It's okay to have boundaries,
not only physical boundaries,
like I just said, I usually stay for
about a good arm's length from anybody.
03:23
Now, after dealing with COVID,
it's even maybe a little bit further
that you want to give
yourself as a boundary.
03:32
But there are also other kinds of
boundaries in the care delivery area,
the boundaries of people asking you
personal questions about yourself,
and being able to say, "You know what,
I would much rather us focus on you."
Remember that flashlight is
therapeutically always on the patient.
03:54
Your boundaries about how close you
allow someone to get in to your life.
04:00
These are professional
boundaries.
04:04
Boundaries about what the
patient is allowed to do
within the rules
and regulations.
04:10
We want to respect those
boundaries as well.
04:15
That brings us to the policies that
the hospital and your unit have.
04:20
And not only your
hospital and the unit,
but we have to follow
laws and regulations.
04:26
Our patients are
protected by law.
04:30
And so we want to make sure
that when we are doing that
first introduction to our
environment and every day thereafter,
that we are able to
explain what our policy is,
and then enforce our policy.
04:46
And that means that we have
to know what our policy is.
04:51
And it's really important when you
are working on a psychiatric floor
to know your policies,
to know what your restraint policy is,
to know what your
isolation policy is,
to know about the refusal
for medication policy,
to know about the use
of telephone policy,
and then to have to enforce it,
to have to be able to have that boundary
and understand I am not
this person's friend.
05:20
I'm here to keep them.
05:22
There's that word again, safe.
05:25
Safety has to be your priority.
05:28
And remember the safety
is safety for the patient,
safety for the staff,
safety for you,
safety for other patients,
safety for visitors.
05:40
This is our priority.
05:42
Once an environment becomes
unsafe, we cannot deliver care.
05:47
One of the things that I
would like you to keep in mind
is that on a psychiatric floor,
anything can become a projectile.
05:56
And so when we do our environmental
scans, we are looking.
06:00
We're looking for things
that should not be there
that perhaps have
been left by someone,
even a pen or a pencil, depending on the
level of unit that you are working on.
06:14
And I have worked on units
that are double locked units
where pens and
pencils are counted.
06:20
I've also worked on units
where people are allowed to go
into refrigerator and get food.
06:27
Your unit is going to
have their policies.
06:32
And their policies are going to be
specific for your patient population,
and to keep you and
the patients safe.
06:45
We also need to be looking
at the environment.
06:48
Because the environment
is going to be affecting
the way our patients feel
and the way they behave.
06:55
Is the environment too crowded?
Are you looking in the day room
and you're seeing there's not
a single chair that's left
and people are now
starting to mill around.
07:06
Is it overcrowded?
What I had mentioned before
the idea of projectiles,
are there loose objects that
people have left around?
Is there a telephone that is
sitting up on the nurse's desk?
Or is there a pen,
something that can become a projectile?
Are there tissue boxes
being left around?
Has someone gone and interviewed
someone and it was very sad.
07:37
And so they grabbed a box of
tissues, they came down,
they did their interview,
they were tears.
07:44
And then when they left
they forgot the tissue box,
they didn't bring it back
to the nurse's station.
07:50
In most of the units
that I have worked in,
the chairs in the unit
are extremely heavy,
which doesn't mean that
they can't be picked up.
08:01
But they're less likely to be.
08:04
But there are some areas
where chairs are not so heavy,
maybe in day programs.
08:11
You want to make sure are those
chairs in the right places
are there people in that
room where that chair
might become something
that becomes a weapon.
08:23
Most likely, if you are working inside of a
unit that is an inpatient psychiatric unit,
beds do not move,
there is just a one mattress
and just the sheets
for that mattress.
08:41
So you most likely will
not be having dressers.
08:45
But think about other things in the
environment that might become projectiles
and assess whether or not you
are in a near crisis situation.
08:57
You want to move people
away from that area.
09:00
Some of the things now we're
going to be thinking about
is going to be how the environment
itself can be therapeutic.
09:10
And what is the nurses role
in a therapeutic environment.
09:16
So this is called
Milieu therapy.
09:20
Milieu therapy just means the
environment is a therapeutic one.
09:25
And when we are behaving and
acting as nurses in a milieu
that is specific for the
recovery of an individual.
09:37
Then we are part of that milieu,
we are part of that therapy.
09:43
And our primary role there,
of course, always safety.
09:49
But in doing so, we want to
establish that trusting relationship.
09:54
How do you establish a
trusting relationship?
Well think back to
those five things,
autonomy, veracity,
beneficence, nonmaleficence.
10:05
We want to make sure that we are there
for the person and we are authentic.
10:11
We want to make sure that
we are there for support,
that we can validate when
they are making progress,
that we can reflect to them
what they are telling us.
10:26
We are giving them a voice.
10:28
We're allowing them to be heard,
we're allowing them
to have some mass.
10:35
They are not invisible beings,
they are being helped,
and they are being heard.
10:42
We also want to make sure that we meet
all of those custodial responsibilities
that we have by meeting
their physiological needs.
10:52
And for those who are
having a difficult time,
staying in our reality, we want to
engage them in reality orientation.
11:02
We want to reorient
them to where they are,
who they are, who we are.
11:09
These are really
important things.
11:11
Many of the units will have a
board right by the nurse's station
that will say today is
such and such a day.
11:20
The weather is sunny,
it is the season of spring.
11:26
And each day they
will change the board
and help to orient the
person to where they are,
why they're there and how they
are moving towards recovery.
11:42
Part of Milieu therapy
also and quite frequently,
the reason why a person has been brought
into a psychiatric inpatient unit
is because they have had
non-adherence to their medication.
11:58
And so a very important part of
the nurses role is med management.
12:03
Medication management looks at
what the patient's diagnosis is.
12:09
What the medications are?
And through that therapeutic
engagement that we have,
were able to find out what is the
resistance that the patient is having
to taking the medication,
and trying to see if there's some
way that we can help the patient.
12:27
It may be better if this patient has taken
medication that makes them very drowsy.
12:32
Let's find out if we can
give it in the evening,
which helps them have a good night's sleep
rather than taking it in the morning.
12:40
If it is, because it's
making them gain weight,
many of our psychiatric meds have
as a secondary effect, weight gain.
12:49
Why don't we see if we can't help them
to learn a different method of eating
so that at least we will be
counteracting that weight gain.
13:00
Another piece that we can play in that role
as part of the Milieu that's therapeutic
is helping them to set limits.
13:11
Letting them know that there is
a dinner time and after dinner,
there's no more food,
that perhaps limit the time
that they watch television,
just helping them figure
out how to become someone
who can set their own limits.
13:31
Our role as educator is
enormously important,
not only educator
for our patients,
but also educators
for their families.
13:42
And so when we think
about their medication,
we can teach them
about the medication.
13:48
We can teach them about the side
effects and what they can expect.
13:52
We can teach them about how
by taking their
medications as instructed.
14:00
Some of the other negative things
in their life might fall away.
14:06
And by bringing them and
their family together,
and educating the family
to the patient's diagnosis.
14:13
We also might reduce
some of their stress
for when they are in
recovery and home.