Closing o fa Psychiatric Intensive Care Unit: A Manifestation of Lost Values

Phyllis Montgomery, MScN, RN, and Barbara Johnson, MScN, RN

TOPIC.A psychiatric intensive care unit shown to be

of value to patients and staf was closed within a

year, ostensibly for economic reasons

PURPOSE. To examine the usefulness of psychiatric

intensive care units, and the importance of thinking

through the ramifications of downsizing

SOURCE. A case study ofa psychiatric ICU in

Northern Ontario, Canada and a review of the

literature

CONCLUSIONS. when downsizing is considered, a

carqfzl examination of values must take place,

remembering patient care comes first.

Key words: Dignity, downsizing, psychiatric

intensive care units

Phyllis Montgomery, MScN, RN, is Assistant Professor, School of Nursing, Laurentian University, Sudbury, Ontario, Canada. Barbara Johnson, MScN, RN, is Associate Professor, Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Psychiatric mental health nurses are frequently called upon to care for patients who are acutely psychotic, aggressive, highly destructive, suicidal, or at risk of elopement. Traditionally, ”management strategies” of such patients have included the use of physical restraints, seclusion rooms, or constant one-to-one obser- vation. These strategies have been critized on grounds of ethics, economics, and efficacy. In general hospitals, intensive care units have been a place to provide care for acutely physically ill patients since the 1950s (Fairman, 1992). In psychiatric settings, psychiatric intensive care units (PICUs) have evolved as an a way to care for patients with acute needs (Allen, Brown & Laury, 1988; Craig, Ray, & Hix, 1989; Moldin, 1984, Musisi, Wasylenki, & Rapp, 1989; R a c k , 1973; Wameke, 1986).

The fundamental purpose of PICUs is to create a safe and controlled environment where intensive nursing care can be provided for psychiatric patients whose behavior warrants unusual vigilance. The underlying presupposition is that intensive nursing care will help the patient move to a more adaptive level of functioning without the loss of dignity that is inevitable with the use of chemical and mechanic restraints, seclusion or con- stant observation. The period of care in the PICU is short- term after which the patient is integrated into, or perhaps returned to, a general patient unit.

Studies document that PICUs are effectively fulfilling their purpose. Craig et al. (1989) found a reduction in the use of restraints when a patient unit was renovated to segregate one part as an intensive care area. Musisi et al. (1989) reported a reduction in constant observation and seclusion hours as well as a reduction in numbers of patients requiring seclusion after the opening of a PICU. Tooke and Brown (1992) found that patients in a five- bed secure area, separated from another unit by two

Perspectives in Psychiatric Care Vol. 32, No. 3, July-September, 1996 33

Closing of a Psychiatric Intensive Care Unit: A Manifestation of Lost Values

locked doors, reported more positive feelings of safety, relief, control and satisfaction than patients in locked rooms. Norris and Kennedy (1992) conducted an exploratory and descriptive study on patients’ percep- tions of the seclusion process and their suggestions for its improvement. They found patients desired dignity, understanding and reassurance during seclusion, which the authors believed was more consistent with intensive care than isolation.

The positive outcomes resulting from the use of PICUs are reported not only from the patients’ perspec- tive; nurses also appreciate the opportunity to give highly skilled care in an environment conducive to doing so (Musisi et al., 1989). When patients needing intensive care are housed on a general patient unit, con- cerns about the safety of other patients and staff can override therapeutic considerations of the individual patient. Patients requiring extra vigilance on a general patient unit put nurses in the position of standing guard or ”policing” behavior. Not only are the patients’ digni- ties compromised by treatment they may consider puni- tive, but also nurses are not able to provide the kind of humane and therapeutic care of which they are capable and which they find satisfying. In a PICU, however, because nurses are relieved of the necessity of intensive one-to- one vigilance, they are free to concentrate on their specialized role. Most of all, they are able to direct their energy to engaging in the kind of therapeutic inter- actions that facilitates the patient’s return to optimal functioning.

Case Example

The staff of a community psychiatric hospital in northern Ontario, Canada, when confronted with esca- lating staff-patient incidents, was forced to recognize the limitations of caring for an increasingly complex patient population in a general ward milieu. Because an alterna- tive approach to care was needed for the acutely ill patients, a specialized care unit was opened in a more secure, separate area. This unit, referred to as the Northern Psychiatric Intensive Care Unit (NPICU)

included five patient rooms, a dayroom, and a seclusion room-all in view of the nursing desk. The smaller, highly secure area was intended to maximize safety while supporting independence, self-control and dignity of the patients. Although the unit included a seclusion room, it was used only in rare emergencies. Access into the unit could be gained only by permission from the intensive care nurses via intercom or telephone. Thus, the nurses controlled and reduced external stimuli, which in turn promoted patient safety.

Data about the patients admitted to the NPICU dur- ing its first seven months of operation revealed that, prior to admission to the unit, 67% of the patients mani- fested destructive behaviors such as aggression, violence, and suicide attempts (Montgomery & Santi, 1991). Similar precipitating PICU admission behaviors have been found in other studies (Allen et al., 1988; Musisi et al., 1989, Warneke, 1986). Within a short time after admission to NPICU (mean = 5 days), data revealed that patients were less destructive, less agitated and angry, less cognitively and perceptually distorted, and better- rested. All of the full-time NPICU nurses, who had pre- vious experience in caring for the acutely ill psychiatric patient on a general unit, believed that both the environ- ment of NPICU and the therapeutic relationships that developed in this unit facditated the patients’ ability to achieve self-control.

Closing the Unit

Nevertheless, the NPICU was closed within 11 months of its operation even though the unit seemed to hold so much promise for the care of all the psychiatric patients in this hospital. Why? The discussion that follows is not meant to attach blame, but rather to examine issues so that other staff members in psychiatric settings contem- plating the development of a psychiatric intensive care unit may profit from what was learned in this situation.

Reasons of economy. The opening and closing of the NPICU occurred in 1985, a time of severe economic restraint. The reason given for the closure was lack of financial resources. However, it is important that cost be

34 Perspectives in Psychiatric Care Vol. 32, No. 3, July-September, 1996

considered from both a long-term and a short-term per- spective. In addition, the PICU must be seen not as an isolated service, but rather as a setting for treatment dur- ing one phase of the illness. Society has a responsibility to mentally ill people in all phases of their illness to carefully allocate available resources (Armstrong, Simpson, Nield, Lentz, & Mitchell, 1991; Ministry of Health, 1993). A scrupulous examination of policies related to resource allocation may lead to the consideration of cost-saving strategies less drastic than closing the unit. Such strategies might include stricter criteria for the use of intensive care, the development of precise unit policies, the provision of educational and support services for staff, the involve- ment of nurses in patient consultations, and the regular re-evaluation of the unit's procedures and functioning (Chassin, 1982; Marcus, 1987). Such measures promote a stable, cohesive, experienced, and supportive bond among staff members that, in turn, will reduce staff stress, staff turnover, and the resulting need for continual staff orientation (Marcus).

The NPICU was not in operation long enough for an assessment of long-term costs. It is possible, and even probable, that intensive nursing care during an acute phase of illness may shorten the total treatment program and expedite the patient's return to the community, thus saving money. Marcus (1987) believes that early inten- sive treatment of people who are acutely mentally ill, although costly in the short run, may save money in the long run.

Whatever the arguments about short-term and long- term costs, it is especially important during times of eco- nomic restraint that the community at large address issues of fundamental values. It has been said that soci- ety is judged by how it treats its most vulnerable mem- bers (Blackstone, 1970). The closure of the NPICU removed a facility intended to provide optimal thera- peutic care for acutely mentally ill people who are cer- tainty among society's most vulnerable members. Even, and maybe especially, during economic hard times, deci- sions directing the allocation of resources should be guided by moral and therapeutic principles, not primar- ily monetary ones.

Lack of authority. Nurses in the NPICU did not per- ceive their practice to be highly valued by the adminis- tration of the hospital (Montgomery, 1993). From the time of the opening of the NPICU, nurses sought input into decisions concerning the functions of the unit and, more importantly, patient care. Over time, the nurses believed their suggestions for patient care and for policy reform, such as revised methods of documentation, were not considered seriously. Similarly, their requests for in- service education and greater involvement in patient consultations were not granted by management. Eventually, several of the intensive care nurses came to regard themselves as insigruficant in the NPICU milieu. Some nurses saw themselves as "glorified baby sitters," and believed management viewed them in the same way (Montgomery). Kavanagh (1988), in her qualitative study of the stresses, rewards, and coping mechanisms of nurses in psychiatric intensive care units, reported the nurses believed neither their patients nor their nursing skills were valued by the community outside the hospi- tal. Furthermore, many believed their lack of authority and involvement in decision-making led to underutiliza- tion of their skills and abilities. This, in turn, fostered role confusion and a lack of self-respect (Kavanagh).

We do not know why the NPICU nurses believed they lacked the necessary authority to implement poli- cies and decisions about individual care based on their knowledge and skill. Perhaps the situation in the NPICU is simply another manifestation of a general situation in nursing today. On the other hand, perhaps there were some particular policies, written or unwritten, in the NPICU that might have had a bearing on the amount of authority these nurses had to implement care decisions.

Lack of understanding. The NPICU nurses also believed that a change occurred in their relationships with the general unit nurses, who did not seem to appre- ciate the purpose of the intensive care unit, nor the skills of the nurses working there. For example, the general unit nurses tended to refer patients to the NPICU for any behavioral or management problems despite established admission criteria. Kavanagh (1988) found that PICU nurses in her study believed improvement in critically ill

Perspectives in Psychiatric Care Vol. 32, No. 3, July-September, 1996 35

Closing of a Psychiatric Intensive Care Unit: A Manifestation of Lost Values

patients’ conditions was more likely to be attributed to medication than to intensive nursing care.

The social distancing between general unit nurses and NPICU nurses may have been compounded further by feelings of isolation of several NPICU nurses. These nurses noted that such feelings were partially the result of the architecturally separate area and of limited social and professional interactions with staff who worked out- side of the unit (Montgomery, 1993). Furthermore, Kavanagh (1988) found that the highly emotionally charged atmosphere of PICU decreased the nurses’ opportunities and motivations for relationships with other nurses. These variables may have contributed to the lack of peer respect and valuing NPICU nurses per- ceived (Montgomery).

In the studies cited, information was gathered only from the PICU nurses. No study was made of what the general unit nurses actually thought about the PICU. Both points of view must be validated by each group before attempts can be made to overcome the problems hindering open communication and understanding.

Conclusion

Hospital administrators controlling the purse strings must be guided in their allocation of financial resources by more than short-term monetary considerations. Hard economic times are not the times to abandon humane and therapeutic principles of patient care. Psychiatric intensive care units represent an efficient way to provide intensive nursing care for patients in one phase of their illness. To eliminate this setting makes no more eco- nomic sense than to eliminate intensive care units for physically ill patients in times of economic constraint.

It is also important to reaffirm the need for hospital administrators to rethink policies that, on the one hand, require highly skilled nurses to give expert care to acutely ill patients, and on the other hand, limit the authority they need to carry out that care. An open dis- cussion of these policies by the nurses and the adminis- trators in an atmosphere of mutual respect ensures that the welfare of the patients remains predominant.

Finally, it is important for nurses to understand the total program of care their patients receive and to under- stand the role nurses play in various phases of that care. Effectiveness of a total program of care depends on open communication and mutual respect among the nurses involved at various stages.

References

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Blackstone, W. (1970). Human rights and human dignity. In R. Gotesky & E. Laszlo (Eds.), Human dignity: This century and the next (pp. 3-37). New York Gordon and Breach.

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36 Persuectives in Psvchiatric Care Vol. 32. No. 3. Tulv-Seotember. 1996