Environmental Scan of the Inpatient Psychiatric Unit

by Brenda Marshall, EdD, MSN, RN

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    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.

    About the Lecture

    The lecture Environmental Scan of the Inpatient Psychiatric Unit by Brenda Marshall, EdD, MSN, RN is from the course Accessing Acute Psychiatric Care (Nursing).

    Included Quiz Questions

    1. Walks over to the client and states, "You look upset now. Do you need any support?"
    2. Observe the client's behavior for 30 minutes before initiating questions.
    3. Keep an eye on the client from a distance and document that the client appeared upset during the environmental scan.
    4. Calls out to the client from the other end of the hallway, stating, "Is there anything wrong?"
    1. “Thank you for your question, but I would prefer to focus on you instead.”
    2. “I know I said that you would have to leave the group if you used hurtful language again, but I’m going to give you one final chance.”
    3. “I don’t give hugs, but I will make an exception as it’s your last day here.”
    4. “Okay, I’ll tell you a little bit about myself, but then you have to promise to answer my questions in return.”
    1. Safety
    2. Medication adherence
    3. Establishing routine
    4. Infection control
    1. A visitor is giving a client a glass vase as a gift in the dining room.
    2. Seven clients standing around in one of the client’s single occupant room.
    3. An IV pole sitting outside the storage closet
    4. A chair that is bolted to the floor in the client lounge
    5. Two clients sitting at a table laughing at the magazine they are reading
    1. Milieu therapy
    2. Adlerian therapy
    3. Bibliotherapy
    4. Experiential dynamic therapy
    1. "By having a whiteboard with the date and weather, and update it daily."
    2. "Not correcting clients when they suggest it is the wrong year."
    3. "Only providing newspapers and magazines from previous years."
    4. "Encouraging clients to keep their blinds closed so they are not distracted or upset by the outside view."
    1. Educate the client about the medication's side effects and encourage engaging in healthy eating habits.
    2. Inform that gaining weight is a rare occurrence and the medication needs to be stopped immediately.
    3. Encourage the client to take half of the recommended dosage instead, to stop gaining weight.
    4. Offer to advocate on the client’s behalf to have the medication discontinued and instead try to manage the condition without the prescription.

    Author of lecture Environmental Scan of the Inpatient Psychiatric Unit

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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