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APNA ConferenceOctober 14, 2010Louisville, KY

Peer Support in Acute Care Settings

by Gayle Bluebird, RNPeer

Networking Consultant, Delaware

Roles for Peer Specialists

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Increasingly common in acute care settingsPlaying vital roles in helping to transform hospitals to more recovery –oriented environments

Rationales for Peer Involvement in

Acute Care Settings:Peers can serve as role models, communicators, mediators, advocates, teachers and legal protectors

Peers provide support from a perspective of experiential rather than professional authority

(Borkman, 1975)

First hand experiences provide unique insights and interpretations of situations

Typical Peer Specialist Duties and Responsibilities in Acute Care Settings

Participate in treatment team meetings Facilitate peer support groupsProvide individual peer supportWork with people at risk for crisesAddress minor complaints Help develop hospital policies

Other Common Responsibilities:

• Helping people advocate for themselves• Administering consumer satisfaction surveys• Assisting in orientation and training of new

employees• De-briefing following crises• Personal Safety plans

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Example of Peer Roles in Support and Recovery

One core function of many Peer Specialists is facilitating Wellness Recovery Action Planning (WRAP), a ‘personal monitoring system in which an individual documents techniques and strategies for reducing symptoms, as well as for ongoing managementand prevention of symptoms

(www.mentalhealth recovery.com/vtrecovery.html)

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Peer Roles in Acute Care Settings

Benefits to Clients

• Acceptance/Empathy/Compassion• Sharing what works/Strategies for Recovery• Empowerment• Use of Holistic approaches• Earlier Discharge with Social Support

(Campbell and Leaver, 2003; Clay, 2005)

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Peer Roles in Acute Care SettingsStaff Benefits

Potential to be a force for positive changeEducate mental health professionals about Recovery from a mental illnessIncrease client choice within the existing mental health systemWork as an equal team member with staffReduce staff workload

(Campbell and Leaver, 2003; Clay, 2005)

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Ingredients for Success:

Preparation of all staff-- Train, Train, Train!Flexible Job DescriptionA good interview process thought outPlacing role at appropriate level of supervisionHiring more than one personAssigning to one unit at firstNeed for advisory and support group

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Challenges to Success:

Staff not trained adequately; not knowing what a peer specialist should do;Staff not familiar with recovery principlesDistrust of peer potential –using them as token Peer employee filling traditional role—not recovery roleStaff afraid that peer will become illPeer worker overworks and is too ambitiousPeer not far enough along in recovery

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Examples of Specific Roles: Client Liaison/“De-Briefer”

Position created in Massachusetts, now in several MA state hospitals

Conducts individual interviews following seclusion and restraint episodes

Serves as a full member of the clinical team

Works preventively with patients at risk for crises

Works with patients proactively on their treatment plans(Worcester State Hospital, MA, in Bluebird, 2008)

Peer Roles in Inpatient Settings:Peer Bridger

Provides support to individuals in institutions 3-5 months prior to discharge and 6-months to a year afterward in person’s home

(Bluebird, 2008)

Provides intensive support through a balance of social, recreational, and skills teaching

Establishes linkages to community-based services and natural supports

(Mead & MacNeil, 2003)

Other New Roles

Emergency RoomsCrisis AlternativesOlder Adult Peer SpecialistsForensic FacilitiesWellness Centers/Arts

Contact Information:

Gayle Bluebird, RNPeer Networking Coordinator, gaylebluebird@aol.comwww.bluebirdconsultants.com

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Resources to Consider

American Psychiatric Nurses Association:American Psychiatric Nurses Association:Competency Based Training for Conducting Competency Based Training for Conducting the One Hour Facethe One Hour Face--toto--Face Assessment for Face Assessment for

Patients in RestraintsPatients in Restraintsor Seclusionor Seclusion

Institute for Safe EnvironmentsInstitute for Safe EnvironmentsSubSub--CommitteeCommittee

Marlene NadlerMarlene Nadler--Moodie, David Sharp: CoMoodie, David Sharp: Co--ChairsChairsJan Adams, Maria Fisk, Karen Taylor, Janet Jan Adams, Maria Fisk, Karen Taylor, Janet ThelanThelan, ,

Karen Karen VerganoVergano

ObjectivesObjectives

List the key components included in the List the key components included in the one hour faceone hour face--toto--face assessment of a face assessment of a patient in restraints or seclusion.patient in restraints or seclusion.Describe the potential dangers associated Describe the potential dangers associated with the use of restraints or seclusion. with the use of restraints or seclusion. Perform a one hour facePerform a one hour face--toto--face face assessment of a patient in a restraint or assessment of a patient in a restraint or seclusion. seclusion.

Conflict of Interest DisclosureConflict of Interest Disclosure

The ISE Faculty has no commercial The ISE Faculty has no commercial support to disclose for this activity. support to disclose for this activity.

Introductory commentsIntroductory comments

Future goal is a restraintFuture goal is a restraint--free environmentfree environment

What the Competency Based Training is What the Competency Based Training is and is not…and is not…

Note additional facility specific optionsNote additional facility specific options

Evaluation Includes (CMS rule)Evaluation Includes (CMS rule)

The patient’s immediate situation;The patient’s immediate situation;The patient’s reaction to the restraint The patient’s reaction to the restraint intervention;intervention;The patient’s medical and behavioral The patient’s medical and behavioral condition; andcondition; andThe need to continue or terminate the The need to continue or terminate the restraint or seclusion.restraint or seclusion.

Four Key Elements of Four Key Elements of EvaluationEvaluation

1) Physical risks of loss of life.1) Physical risks of loss of life.

2) Physical dangers and discomforts.2) Physical dangers and discomforts.

3) Psychological State & Mental Status.3) Psychological State & Mental Status.

4) Legal and Ethical Considerations. 4) Legal and Ethical Considerations.

1) Physical Risks of Loss of Life1) Physical Risks of Loss of Life

Restraint AsphyxiaRestraint Asphyxia–– Compromised respirations cause hypoxiaCompromised respirations cause hypoxia–– Choking from positional airway compromiseChoking from positional airway compromise–– Aspiration potential from positioning, excess Aspiration potential from positioning, excess

salivationsalivation–– Airway and chest obstruction due to Airway and chest obstruction due to

positioning, pressurepositioning, pressure–– Obstruction of mouth and noseObstruction of mouth and nose

AsphyxiationAsphyxiation

Mechanical device strangulatesMechanical device strangulates

Mechanical device causes thoracic and Mechanical device causes thoracic and abdominal compressionabdominal compression

Compression of thorax and or abdomen Compression of thorax and or abdomen caused by positioning.caused by positioning.

Physical Risks of Loss of LifePhysical Risks of Loss of Life--22

Agitated Delirium/Acute Excited StateAgitated Delirium/Acute Excited State–– Combination of agitation, aggression and Combination of agitation, aggression and

hyperpyrexiahyperpyrexia–– Cocaine intoxicationCocaine intoxication–– Adrenal catecholamine rushAdrenal catecholamine rush–– Metabolic Acidosis Metabolic Acidosis

Physical Risks of Loss of LifePhysical Risks of Loss of Life--33

Cardiac ComplicationsCardiac Complications–– ArrhythmiasArrhythmias

Catecholamine release is followed by epinephrine Catecholamine release is followed by epinephrine and and norepinephrinenorepinephrine outputoutputStress and exertionStress and exertionPsychopharmacologicalPsychopharmacological-- QQ--T ProlongationT Prolongation

–– Cardiac collapseCardiac collapsePhysical traumaPhysical trauma

Warning of Cardiopulmonary Warning of Cardiopulmonary ArrestArrest

Cessation of the struggle against the Cessation of the struggle against the restraints and restraints and

Respiratory distress evidenced byRespiratory distress evidenced byshallow or labored breathing…shallow or labored breathing…

Comparative Risks Comparative Risks r/tr/tPositioningPositioning

ProneProne SupineSupine SeatedSeated StandingStandingAspirationAspiration XX XX LessLess LessLessAirway Airway CompromiseCompromise XX LessLess XX XXArrhythmiaArrhythmia XX XX XX XXChest Chest CompressionCompression XX LessLess XX XXPsychopharmPsychopharm XX XX XX XX

ObesityObesity XX XX XX XXBased on Table Based on Table By By TieshaTiesha

JohnsonJohnsonWith permissionWith permission

2) Physical Dangers & 2) Physical Dangers & DiscomfortsDiscomforts

Observe total physical positioning and Observe total physical positioning and conditioncondition–– Mechanical restraint checksMechanical restraint checks

Potential for laceration, bruisingPotential for laceration, bruising

–– Body positionBody positionPotential for strangulationPotential for strangulation

–– Clothing and bedclothesClothing and bedclothesas aboveas above

Physical Dangers & DiscomfortPhysical Dangers & Discomfort--22

ObesityObesity–– Multiple “cases” identified Multiple “cases” identified ––high riskhigh riskNerve DamageNerve Damage–– PositioningPositioning--body/restraint applicationsbody/restraint applicationsHead TraumaHead Trauma–– Self Induced/Other InducedSelf Induced/Other InducedPressure UlcersPressure Ulcers

SeclusionSeclusion

Evaluation of the environmentEvaluation of the environment

Safety hazardsSafety hazards

Patient’s medical conditionPatient’s medical condition

Review of record and labsReview of record and labs

General Medical ConditionGeneral Medical Condition

Specific to this patientSpecific to this patient–– Consider ANY and ALL medical problems in Consider ANY and ALL medical problems in

the context of the restraintsthe context of the restraints–– Vital Signs Vital Signs ASAPASAP–– Review History and PhysicalReview History and Physical–– Current laboratory valuesCurrent laboratory values

PrePre--Existing Conditions of ConcernExisting Conditions of Concern

CardiovascularCardiovascular

NeurologicalNeurological

RespiratoryRespiratory

MetabolicMetabolic

Developmental DelayDevelopmental Delay

Special Notice to:Special Notice to:FeverFever

Abnormal blood pressureAbnormal blood pressure

Abnormal pulse and respirationsAbnormal pulse and respirations

Altered skin colorAltered skin color

Breath odorBreath odor

Conduct a Review of SystemsConduct a Review of Systems

General State of General State of HealthHealthSkinSkinEyes/Ears/Nose/ Eyes/Ears/Nose/ Mouth/ThroatMouth/ThroatCardiovascularCardiovascularRespiratoryRespiratory

GastrointestinalGastrointestinalGenitourinaryGenitourinaryMusculoskeletalMusculoskeletalNeurologicalNeurologicalEndocrineEndocrineAllergic/ Allergic/ ImmunologicImmunologic

EnvironmentalEnvironmental

Room TemperatureRoom TemperatureSafety Hazards Safety Hazards Seclusion:Seclusion:–– Room ReadinessRoom ReadinessRoom must be always ready for an Room must be always ready for an

emergency!emergency!

3) Psychological State3) Psychological State& Mental Status& Mental Status

Observation and AssessmentObservation and Assessment–– Condition prohibiting interviewCondition prohibiting interview--observation is observation is

usedusedPossible “formal mental status” via Possible “formal mental status” via interview?interview?–– Based on patient’s conditionBased on patient’s condition–– Return at a later timeReturn at a later time–– Comparative to previous and futureComparative to previous and future

Psychological StatusPsychological Status

AnxietyAnxietyFearFearAngerAngerDepressionDepressionHallucinations or delusionsHallucinations or delusionsDisorientationDisorientationConfusionConfusionStuporStupor

Mental Status ExaminationMental Status Examination

The mental status exam in The mental status exam in psychiatric nursing offers a psychiatric nursing offers a comprehensive examination of a comprehensive examination of a person’s emotional state and person’s emotional state and thinking processes at a given thinking processes at a given point in time. point in time. NadlerNadler--Moodie, “Psychiatric Principles and Applications for General Moodie, “Psychiatric Principles and Applications for General Patient Care”, Western Schools, 2004Patient Care”, Western Schools, 2004

Mental Status ExamsMental Status Exams

Different FormatsDifferent Formats

Complete and “Mini”Complete and “Mini”

Specifically earmarkedSpecifically earmarked

Facility specificFacility specific

Components of the MSEComponents of the MSE

General AppearanceGeneral Appearance–– Physical characteristicsPhysical characteristics

Apparent ageApparent ageGrooming, hygiene, dressGrooming, hygiene, dressPosturePosture

Behavior and Psychomotor StatusBehavior and Psychomotor Status–– Body language, movements and facial Body language, movements and facial

expressionexpression–– Gestures, mannerisms, movements, gaitGestures, mannerisms, movements, gait

MSE Components, continued MSE Components, continued (2)(2)

Attitude Attitude –– Examples: angry, dramatic, cooperative, Examples: angry, dramatic, cooperative,

passivepassiveAffect and MoodAffect and Mood–– Affect is the Affect is the expressionexpression of emotional state of emotional state

(usually facial expression)(usually facial expression)–– Mood is a Mood is a descriptiondescription of the emotion in of the emotion in

words such as flat, constricted, or widewords such as flat, constricted, or wide

MSE Components, continued MSE Components, continued (3)(3)

SpeechSpeech–– Characteristics of how the person speaks such as: Characteristics of how the person speaks such as:

the quantity of words, how fast or slow, quality the quantity of words, how fast or slow, quality

Thought ProcessesThought Processes–– Form such as flight of ideas, loose associations, Form such as flight of ideas, loose associations,

circumstantialitycircumstantiality, concrete, concrete–– Content evidenced by delusions, suicidal ideas, Content evidenced by delusions, suicidal ideas,

paranoiaparanoiaPerceptual DisturbancesPerceptual Disturbances–– Hallucinations, illusions, depersonalizationHallucinations, illusions, depersonalization

MSE Components, continued MSE Components, continued (4) (4)

SensoriumSensorium and Cognitionand Cognition–– Orientation x 3Orientation x 3–– Alertness, level of consciousnessAlertness, level of consciousness–– MemoryMemory

ImmediateImmediate–– Tested with 3 objects recallTested with 3 objects recall

RecentRecentRemoteRemote

MSE Components, continued MSE Components, continued (5)(5)

General Fund of KnowledgeGeneral Fund of Knowledge–– Questions: who is PresidentQuestions: who is President–– Simple mathematical calculationsSimple mathematical calculations

Serial 7’s: 100, 93, 86, 79 etc.Serial 7’s: 100, 93, 86, 79 etc.

Insight and JudgmentInsight and Judgment–– Description of person’s thinking about current Description of person’s thinking about current

situation and decisionsituation and decision--making thoughtsmaking thoughts

Process of examinationProcess of examination

Patient’s ability, cooperationPatient’s ability, cooperation

CircumstancesCircumstances

Abbreviating the examAbbreviating the exam

Specific components of an examSpecific components of an exam–– Dementia: ability to learn, naming and word findingDementia: ability to learn, naming and word finding

Consider DiscontinuationConsider Discontinuation

Stability of patientStability of patient–– Meets criteria for releaseMeets criteria for release–– Debrief potentialDebrief potential

Communicate with the TeamCommunicate with the Team

4) Legal and Ethical 4) Legal and Ethical ConsiderationsConsiderations

Current laws, regulatory, facility policyCurrent laws, regulatory, facility policy–– CMS, Department of Health RegulationsCMS, Department of Health Regulations–– The Joint CommissionThe Joint Commission–– Policies and ProceduresPolicies and Procedures–– Best PracticesBest Practices

Competency Demonstration for 1 Competency Demonstration for 1 Hour Face to Face AssessmentHour Face to Face Assessment

Competency StatementCompetency Statement Verification MethodsVerification MethodsSuccessfully Successfully demonstrates ability demonstrates ability to assess for the need to assess for the need for basic life support for basic life support (BLS)(BLS)Successfully Successfully demonstrates ability demonstrates ability to perform cardioto perform cardio--pulmonary pulmonary resusitationresusitation (CPR)(CPR)

Current BLS (or Current BLS (or higher) Certificationhigher) Certification–– __________________Expiration DateExpiration Date

Competency StatementCompetency Statement Verification MethodsVerification Methods

Demonstrates ability Demonstrates ability to assess a variety of to assess a variety of potential physical potential physical problems related to problems related to patients in restraints. patients in restraints.

Demonstrates correct Demonstrates correct principles related to principles related to the safe application of the safe application of restraints restraints

Passes QuizPasses Quiz

Completion of 8 or 16 Completion of 8 or 16 hour course: Prohour course: Pro--ACT, ACT, CPI, “inCPI, “in--house” or other. house” or other. ____________________

Completion Date Completion Date

Competency StatementCompetency Statement Verification MethodsVerification Methods

Applies critical Applies critical thinking skills to thinking skills to assessing mental assessing mental status and the status and the psychological state of psychological state of a patient in restraints a patient in restraints

ExemplarExemplar

Case ReviewCase Review

Competency StatementCompetency Statement Verification MethodsVerification Methods

Role models Role models leadership skills leadership skills working with and/or working with and/or leading the team leading the team when the use of when the use of restraints is restraints is necessary.necessary.Identifies the earliest Identifies the earliest opportunity for opportunity for discontinuation.discontinuation.

Successful demonstration Successful demonstration of skill, observed by of skill, observed by supervisor.supervisor.

Successful demonstration Successful demonstration of skill, observed by of skill, observed by supervisor. supervisor.

Competency StatementCompetency Statement Verification MethodsVerification Methods

Evidence of Evidence of knowledge regarding knowledge regarding regulations by outside regulations by outside agencies and facility agencies and facility policy and procedure.policy and procedure.

Passes Quiz Passes Quiz

Attests to reviewAttests to review

References (2010) References (2010)

See Study GuideSee Study Guide

Q & AQ & A

Good Luck with your restraint Good Luck with your restraint reduction efforts!reduction efforts!

APNA ConferenceLouisville, KY

October 13, 2010

Amistad Peer Support ProgramHolly Dixon, LCSW

Peer Services DirectorRiverview Psychiatric Center

Augusta, Maine

Peer Services Provided at RiverviewRecovery training

Recovery groups with a focus on wellness toolsPeer bridger

3-6 month post-discharge supportTransportation

For transition purposesInpatient peer support

Support on inpatient unitsPeer support on ACT team

Support to forensic and outpatient commitment populationsCrisis intervention

Responding to psychiatric crisesAssisting in preventing seclusion and restraint incidents

What makes our program unique?We are involved in all aspects of care for people served at the facilityWe are involved at all levels of operation in hospitalWe are not hospital employeesWe are equal members of the treatment teamsPeer Support is its own departmentWe have 12 staff that serve 126 people

9 peers for 92 people inpatient1 for 34 people outpatient (ACT)2 Recovery Trainers

Role of Peer SpecialistsProvide peer support to people during hospitalizationProvide recovery and wellness tools to people being servedProvide consumer perspective on treatment teamsAssist in transition from hospital to communityProvide low-level advocacy to ensure:

peoples’ voices are being heard they are being treated with dignity and respectthat care being provided is person-centered and recovery focused

Peer Support InvolvementAdmissions Service Integration meetingsTreatment team meetingsMorning and community meetingsClient forumsDischarge planning meetingsSignificant event reviewsPrivilege level meetingsStaff development and training Client Satisfaction surveysPost-discharge surveysOne-on-one support

Morning roundsExecutive leadershipClinical CouncilAdvisory boardHuman rights committeeEthics committeeRecovery groupsProcessing grievances/ complaintsProcess improvement teamsPersonal safety plansDebriefingPeer bridgingCommunity support (ACT services)

Initial Reactions by Some Hospital StaffHere to tell staff how to do their job“Mental patients” with keysBoundaries are poorStaff did not want consumer working in the hospitalAccess to information and areas of the hospital were restrictedOverpaidRumors and negative comments left on the doorFear of letting clients out of the building

Impact of Peer Support on ClientHigher level of trustEmpowermentKnow their rightsTheir voice is heard and they are taken more seriouslyFeel more comfortable in voicing their needs and wantsEasier to relate to someone who “has been there”A safe place to share, learn, and practice new coping skills and strategies

Impact of Peer Support on Peer Specialists

Better understanding of mental illnessHigher awareness of issues people faceLearned to speak up for themselvesMore confidence in speaking to medical professionalsChanged perception of some client populationsLearned new ways to manage their own illnessesBetter understanding of clinical decisions

Impact on HospitalStaff attitudes toward clients is more positiveMore respect for consumer viewpointsProcedures and policies are adhered to more closelyPeer Specialists are a vital and valued role on the treatment teamStaff are more open about sharing their own personal recovery storiesIncreased individualized treatment to accommodate a range of recovery goalsLarger emphasis on alternatives and holistic practices

Then and Now5 years ago

Peers hung out on the units talking with people and did not interact with hospital staffPeers were seen as just another patient to care for and a liabilityStaff worried about peers getting hurt in crisis situations and frequently asked them to leave the areaStaff hostile toward peers due to fear of job lossDid not have a “voice” Access to records, meetings, and some areas of the hospital were restricted

NowPeers are involved in all aspects of care and work side-by-side with staff as an equalPeers are seen as professionals who are experts in their field and are invited to support people and provide feedback to staffPeers are actively sought out to provide support to people who are experiencing crisis to provide supportPeers are sought for their inputPeers have unrestricted access to everything

Initiatives to Reduce Coercive PracticesPsych stat callsDebriefingPersonal Safety PlansSensory roomsComfort and wellness toolsCoping skill developmentReduction of seclusion and restraint

Peer support involvementStaff philosophyAdministrative involvementAdjustment in assessment timelines

Client advocatesComprehensive grievance/complaint process

Barriers/ChallengesStaff felt we were here to tell them how to do their jobDifference in boundaries and confidentialityAccess to information and areas of the hospital were restricted—limited our ability to support peopleStaff felt we were overpaid for the work we didNegative attitude of staff toward peersStaff feared we would let people out of the buildingDocumentation and reporting requirementsSupervisionMedical model of treatmentStigma, countertransference, and dual rolesPolicies that didn’t support a recovery focusTokenism

Ingredients for SuccessEducate staff about the principles of recovery and some fundamentals about what is needed to implement themPeer Specialists should have regularly scheduled meetings with their supervisor with caution that they are not therapy sessionsOrientation and training are critical in preparing peers for their work and the environment they will be working in Peers should be supported to go to conferences that provide additional training and information, as well as staying connected to the larger consumer movementAdministrative “buy-in” and support for peer support role

PitfallsPeers who are not prepared to work as part of a team or in the environment they are hired to work inPeers promoting their own personal agendasHolding peers to a different performance standard

Contact InfoHolly Dixon, LCSWPeer Services DirectorAmistad, Inc.SHS #11250 Arsenal St.Augusta, ME 04333(207) 624-4610

holly.dixon@maine.gov

www.maine.gov/dhhs/riverview

Amistad Inc.P.O. Box 99266 State St.Portland, ME 04104(207) 773-1956

amistad1@maine.rr.com

www.amistadinc.org