Genuine ignorance, defined by John Dewey as curiosity and openmindedness in opposition to repetition of catch phrases and familiar propositions, is nurtured in graduate nursing curricula in which the educational process is congruent with course content. Preparation for advanced practice in the mental health environment of the foreseeable future required abandonment of the familiar medical model in favor of conceptual models consistent with current thinking in psychiatric nursing and exposure to current problems (homelessness, family violence, AIDS) and current problem solving strategies (brief treatment, family preservation). Involvement in practice-based research and operationalizing new perspectives on familiar clinical problems, are suggested as strategies for developing the advanced practitioner. Two of the authors, former graduate students, describe the impact of changed perspectives and research activity on their own practice.

Curriculum↗

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Reducing violence in a child psychiatric hospital through planned organizational change.

TOPIC: A successful attempt to reduce aggressive behaviors and counter aggressive staff interventions, including seclusion and restraint, in a child psychiatric hospital. PURPOSE: To offer a model for reducing violence within child psychiatric facilities. SOURCES: The agency in which this project was carried out was a 50-place public child psychiatric hospital affiliated with an urban university. Discussion includes the strategies utilized including utilization of practice-based research, assessment of the level of aggression within the agency, change in staff perception about the use of coercive interventions to manage behavior, revision of the behavior management program and of policies relating to crisis events, and increased involvement of families. CONCLUSIONS: This experience in reducing aggression within the hospital validates theory that suggests that violence within institutions is context-based, involving patients, staff, and the institutional climate. The authors believe that the outcomes support the proposition that the use of coercion is determined more by traditions of practice and the mindset of the staff than by clinical necessity, and that its use can be significantly reduced by organization interventions.

Adolescent↗

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The legacy of Parham vs. J. R.

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Adolescent↗

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Staff members' beliefs about seclusion and restraint in child psychiatric hospitals.

BACKGROUND: Staff members beliefs about seclusion and restraint are influential in determining how and when these interventions are employed. Yet there are few studies of staff beliefs in individual hospitals and no comparative studies across hospitals. OBJECTIVE: To measure staff members' beliefs about the rationale for and efficacy of the use of seclusion and restraint with children and adolescents. METHODS: A survey of staff members (N = 320) from 13 public and private child psychiatric hospitals. RESULTS: Results indicate a low to moderate level of confidence among all staff groups regarding the efficacy of seclusion and restraint. Staff members from private hospitals were significantly more positive in their assessment of these interventions than were staff members from the public sector. CONCLUSION: We hypothesize that the persistent use of coercive interventions in which staff have a low level of confidence reflect both the influence of tradition in the management of aggressive behavior and unacknowledged avoidant/coercive staff responses to patents labeled as deviant. Differences between the public and private sectors and between hospitals within each sector imply that the practice of seclusion and restraint may be idiosyncratic to each institution, and suggest the need for a generally accepted standard for their use.

Adolescent↗

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Practicing in partnership with families in the inpatient setting.

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Child↗

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Why health-care teams don't change: chronicity and collusion.

Organizational chronicity exists in many health-care settings. This syndrome organizes the agency's approach to problems, dampens enthusiasm about the possibility of change, and fosters a climate in which change behaviors are undermined and sabotaged. The authors identify collusion, characteristics of the health-care team, errors of the internal training staff, and consultant errors as four significant contributors to organizational chronicity, and offer strategies for changing settings in which chronicity is the norm.

Consultants↗