Doctor of Nursing Practice (DNP) Final Projects

Seclusion and restraint are restrictive interventions that continue to be used in both physical care and mental health care settings as a means of controlling dangerous behavior such as aggression. Restrictive interventions place patients and healthcare staff in hostile situations that can lead to physical, mental, and emotional injuries that can last a lifetime. Unfortunately, restrictive interventions continue to be used in many healthcare organizations around the world and the number of patient and staff injuries continue to rise. Stakeholders at a Phoenix area psychiatric inpatient hospital conducted an internal audit on the number of seclusion and restraint episodes in 2019, which revealed an increase in the number of seclusion and restraints episodes on the adolescent unit.

The result of this audit led to the project question: For nurses on an acute adolescent inpatient unit, is a seclusion and restraint education program more effective than usual
practice in changing the knowledge and attitude regarding seclusion and restraint? The purpose of this practice change project was to provide staff education that focused on trauma informed care, de-escalation techniques, and therapeutic communication to improve staff confidence to ultimately lead to the reduction of seclusion and restraint use on an adolescent inpatient unit. A
pre and posttest questionnaire designed to better understand nurse attitude and knowledge regarding restrictive interventions prior to the education session was provided. A convenience sample of nurses (N=9) participated in the project. The findings from the pre and posttest questionnaire suggest that seclusion and restraint education for nurses may improve nurse knowledge and attitude regarding the use of restrictive interventions and reduce rates of use.

The number of children taking second-generation antipsychotics (SGA) is increasing. While SGAs produce fewer neurological side effects, the metabolic side effects of SGAs increase the risk for future cardiometabolic disease. In 2011, the American Academy of Child and Adolescent Psychiatry endorsed following guidelines established in 2004 recommending that people taking SGAs receive regular metabolic screening including waist circumference measurement, fasting blood glucose, and fasting lipids. Despite recommendations, studies have shown that children do not receive routine metabolic monitoring. Provider attitudes toward following guidelines can influence the rates of monitoring.

Research suggests that monitoring rates improve after psychiatric providers receive educational programs on SGA use and recommended guidelines. In response to these findings, an evidence-based educational intervention discussing SGA use in children and recommended metabolic monitoring was proposed to increase the rates of metabolic monitoring in a community-based psychiatric practice that treats children. While no results were statistically significant, the average attitude score of providers toward following guidelines was higher post-education and the proportion of providers who ordered screening tests post-education increased. To further improve metabolic monitoring, it is recommended that interventions designed to increase the subjective norms and perceived behavioral control of providers be implemented. The main limitations of this project were the small sample size and the use of self-reports to assess provider ordering of screening tests.

Suicide has become a national concern due to the increasing rates across the country. The 2012 National Strategy for Suicide Prevention aims to improve the area of clinical prevention. Emergency departments (ED) play a key role in addressing this effort as they have multiple opportunities to connect with patients who are at risk. There exists a high-risk period of time immediately following a patient’s discharge from emergency care. To address this period of concern, a review of the literature was conducted on the effectiveness of follow-up contacts as a means to prevent suicide and suicide related attempts in this at-risk population.

Based on this review, a follow-up intervention was proposed to increase patients’ social support and knowledge on suicide prevention through a safety plan and the use of caring postcards. The aim was to evaluate the degree to which implementation of a safety plan and follow-up using postcards reduces suicide risk in the ED. ED suicide prevention practices such as safety planning and caring contacts with postcards have shown to be feasible and cost-effective methods to reduce patients’ risk of suicide as they provide education and address the high-risk period of time after discharge.

Using a quasi-experimental pre and post-test design, English speaking adults 18 years of age and older, admitted to an ED in the Phoenix Metropolitan area with suicidal ideation, were voluntarily recruited for two weeks. The self-rated Suicidal Behaviors Questionnaire-Revised (SBQ-R) was used as a baseline assessment along with the introduction of a safety plan. Participants were then followed with the receipt of postcards with caring messages over a two-week period, and a final SBQ-R. The SBQ-R has shown beneficial reliability and validity measuring suicidality in the adult population. Data from the pre-SBQ-R was analyzed using descriptive statistics as no post-SBQ-Rs were received. Outcomes for this project included a reduction in suicidal ideation and suicide risk.

This project provides insight into the implementation of a safety plan and follow-up intervention in the ED and their attempts to reduce acute suicide risk as well as highlight the value that post-ED support provides.

Keywords: suicide, prevention, safety plan, caring messages, postcards, emergency department, follow-up, contacts, brief intervention