Читать книгу Mind-Body Medicine in Inpatient Psychiatry - David Låg Tomasi - Страница 53

In this group, patients are encouraged to socialize in a dedicated open air garden area at the hospital. This group is offered twice a day, at 1300 and 1800, and requires a special protocol to guarantee everybody’s safety and enjoyment of all the activities thereby presented, including gentle exercise, games, and mild physical activity. The protocol is discussed below:

Garden group protocol:

1 The Inpatient psychiatry group therapist (GT) needs to call security ahead of time to schedule the transport to the garden. One officer is needed unless there is a patient that will be using a wheelchair, in which case there will be a need for 2 officers.

2 The GT needs to call facilities ahead of time to ask them to turn off the fans on levels 2 and 3 of the garden.

3 The GT needs to check to see which patients are eligible to go to the group. To be eligible, the patient must have a locus of harm of level 3 or below, and he/she must be on routine observation status. Exceptions can be made for patients with a level 4 or 5 locus of harm and/or a frequent/constant observation status with written permission from the attending physician or resident physician on the day of the group.

4 The GT needs to check with patients to see if they need shoes and/or a jacket that needs to be retrieved from their pink bins or the soiled work room.

5 The GT needs to obtain frequent sheets for all patients that will be going to the garden.

6 The GT needs to write the patient names on the white board so that staff knows who is in the garden.

7 The GT needs to prepare a list of the patients that will be joining the group and also a list of what each patient is wearing. You will keep with you the list of what patients are wearing in case of elopement. The list of patient names will be given to the security officer.

8 The staff person on Shepardson 6 (generally a mental health technician, unit secretary, LPN, or LNA) will meet security outside of the team station, near the sally port. All patients that plan to go to the group should be convened in this area by the time security arrives.

9 The GT needs to take patients into sally port with security officer, allow security officer to exit first to block the stairwell, and take patients onto elevator with the officer.

10 Once reaching Shepardson 3, the GT needs again to allow officer to exit the elevator first, and allow patients to exit before the GT. The GT needs to take patients into Shepardson 3 and join staff and patients from Shepardson 3. Staff and patients from Shepardson 3should be prepared (having fulfilled steps 3–7) and convened in the main hallway (anywhere between main entrance and rear exit stairwell) when the Shepardson 6 group arrives.

11 If there is a wheel chair, one staff person (again a mental health technician, unit secretary, LPN, or LNA) will accompany the person in the wheel chair along with one security officer through an alternate route. The other staff person will accompany the walking patients and the other security officer through the rear stairwell of Shepardson 3.

12 Security officer will walk through the door to the rear stairwell first, and one staff person must take the rear of the group.

13 Once in the garden, the GT needs to give the security officer the list of patient names and arrange with the officer when to come back to transport the groups back to the units.

14 The GT needs ark frequent sheets as necessary while in the garden.

15 If a patient wants to leave the group early, security can be called from the garden phone to arrange for an officer to transport the patient. It must also be arranged for a staff person to come from the unit to accompany the patient and the security officer. Two staff must remain in the garden at all times (even if there is only one patient), so there must be arrangements for a third staff member to help with the early transport.

16 When the group ends, the GT needs to take patients up stairwell while security blocks the door on the ground floor. There must be a staff person at the front and the back of the group.

17 The Shepardson 3 staff person will put away patient items once arriving on the unit, such as shoes and jackets (this is vital, as patients can cause harm to themselves with laces or cords) to their appropriate places, return frequent sheets, and erase patient names from the board.

18 The security officer will continue on to Shep 6 with the other staff person and patients. Just as before, security officer will be the first person exiting the unit and the elevator in order to block paths of escape. Staff must not exit elevator ahead of patients.

19 Shep 6 staff will put away patient items (this is vital, as patients can cause harm to themselves with laces or cords), such as shoes and jackets, return frequent sheets, and erase patient names from the board.

We have included a very detailed description of this protocol to provide an example of the complexity of the work of therapists in an inpatient psychiatry unit. While we will discuss these aspects more thoroughly in chapter 2, we want to provide a very good flowchart of the clinical meetings/assessments with individual patients, divided by discipline. A very important element in the clinical work of the multidisciplinary treatment team in an inpatient psychiatry unit is the open, supportive and area-focused communication between team members. In other words, each discipline (psychiatry, psychotherapy, social work, and nursing) uses a very specific set of skills to relate to patient by providing expertise in one specific area. However, given the interconnected nature of a multidisciplinary treatment team, mind-body perspectives are always at the center of every therapeutic strategy, to work on the nature-nurture spectrum with the best tools for the diagnostic elements discussed during morning rounds and throughout patient admissions.

As we can immediately notice, the sequence of required steps of the inpatient psychiatry group therapist/activity therapist far exceeds any other discipline:

Stage

Patient

Psychotherapist

Psychiatrist

Resident

Nurse

Social Worker

MHT / LPN

1	Enter Inpatient Psychiatry Department	Orientation	Orientation	Orientation	Orientation	Orientation	Orientation
2		Schedule Coordination
3		Look who is working for the week
4		Decide which groups will be held for the week
5		Make Group Schedule
6	Begin Treatment	Begin Treatment	Begin Treatment	Begin Treatment	Begin Treatment	Begin Treatment	Begin Treatment
7		Distribute Group Schedule
8		Prepare Group Therapy Room
9		Meets with the Patient	Meets with the Patient	Meets with the Patient	Meets with the Patient	Meets with the Patient	Meets with the Patient

Figure 2. A complete diagram of the 2014 Inpatient Psychiatry Flowchart according to the model by Bancroft, Donaway, Freiberger, and Lyons. Of note, in this figure, the professional figure of Inpatient Psychiatry Group Therapist/Psychotherapist is still listed as Activity Therapist.

1 Direct Description available at: https://medcenterblog.uvmhealth.org/innovat ions/fletcher-allen-named-best-regional-hospital-4th-year-means-quality-patien t-care/

2 Direct Description available at: https://medcenterblog.uvmhealth.org/innovati ons/fletcher-allen-named-best-regional-hospital-4th-year-means-quality-patien t-care/ and https://www.uvmhealth.org/medcenter/news/Fletcher-Allen-Ran ks-in-Top-Ten-Among-Leading-University-Hospitals

3 The psychotherapist is directly responsible for supervising psychiatrists, social workers, and nurses during the completion of morning clinical rounds-related tasks, such as completing assessments/evaluations, updating the multidisciplinary treatment team notes and signatures, and spending a pre-determined average time-per-patient vs. new-admit description times during rounds. Furthermore, Master or Doctoral level psychotherapists also supervise students from the University of Vermont Department of Rehabilitation and Movement Science, UVM College of Nursing and Health Science, UVM Larner College of Medicine, UVM Healthcare Programs/Continuing and Distance Education, UVM Human Development and Family Studies Program/Department of Leadership & Developmental Sciences, and related programs. In some cases, psychotherapists also supervise students from other universities/departments (for instance the Albany College of Pharmacy and Health Sciences), who work or are completing their clinical rotations/internships/practicums in Inpatient psychiatry as MHTs/LNAs/USs etc. and meet with psychotherapists upon request (usually from Nursing Management or Nursing Education, as part of their training).

4 According to the International/Bologna process descriptors for Higher Education degrees (Framework for Qualifications of the European Higher Education Area and ECTS—European Credit Transfer and Accumulation System): First cycle (level): 180–240 ECTS credits (a minimum of 60 credits per academic year), usually awarding a bachelor’s degree. Second cycle (level): 90–120 ECTS credits (a minimum of 60 ECTS per academic year), usually awarding a master’s degree. Third cycle (doctoral degree): at least 180 ECTS after the completion of a master’s degree.

5 In this context, as defined by the highest academic degree and level achieved. Working on the Inpatient psychiatry unit there are also physicians, psychotherapists, etc. with a doctoral degree, thus both (in the aforementioned example) “Doctors-physicians” (PhD + MD/MBBS), “Doctors-psychotherapists” (PhD + MA/MS), etc. For the purpose of this description we omitted higher qualifications or doctorates such as Доктор наук, Habilitation, HDR, Abilitazione scientifica nazionale, Priv.-Doz., and similar.

6 There are four professional figures within the Multidisciplinary Treatment Team: physicians/psychiatrists, psychotherapists/psychologists, registered nurses, and social workers. The pharmacist is the newest addendum to the team and works interdisciplinarily, at the interface between psychiatry and psychotherapy, often with the support of pharmacy students from the Albany College of Pharmacy and Health Sciences.

7 Third Cycle Degree (Doctorate-level clinicians), i.e. PhD-MA, PhD-MD, PhD-MS, etc.

8 Second Cycle Degree, i.e. MA, MD, MEd, MS, MSW, etc. (in some cases, depending on the laws of each country/state awarding the degree, certain professional figures in this category can access the profession for licensing purposes, also with a Bachelor’s level degree, as in MBBS)

9 These are listed as example-degrees. Clinicians with a Level 2-degree might also have first-level professional degrees such as PharmD and similar. For professional (clinical) psychology, the State of Vermont recognizes two levels (Doctoral and Master’s) of degrees, although a doctorate-level licensed psychologist is not required to have a PhD, as a Psy.D. (a “Doctor of Psychology”, as opposed to the Level 3-degree “Doctor of Philosophy in Psychology”) is also recognized to sit for a doctorate-level EPPP examination for licensure.

10 First Cycle Degree, i.e. BA, BS, BSN, BSW, etc. Of note, although the professional medical degree awarded in countries following the UK/Commonwealth academic tradition is a bachelor’s level degree (MBBS—Bachelor of Medicine, Bachelor of Surgery) for the purpose of identifying professions in a clinical sense, we have included this degree in the Second Cycle. Of note, in the aforementioned countries, the MD is only awarded after the degree required to practice medicine. Therefore, this type of MD (often called MD Sci, Dr.Med.Sci., D.Sc.Med., etc.) is a real doctorate, contrary to the U.S.-awarded, second-level (not requiring a previously completed master’s level degree), MD.

11 These staff members are usually Mental Health Technicians (MHTs), Licensed Nurse Assistants (LNAs), Licensed Practical Nurse (LPNs), or Unit Secretaries (UTs). Their level of education varies (High School diploma/GED, Associate’s degree). Of note, while many RNs on the Unit do hold bachelor’s degrees (not necessarily in nursing), this is not a requirement in the State of Vermont.

12 As in the previous description, even in this case the level of education varies from High School diploma/GED, to Associate’s or Bachelor’s degrees.

13 Although management is not technically part of the Multidisciplinary Treatment Team, often a member of administrative staff (with an appropriate degree and/or licensure) can substitute a regular staff member, for instance during morning clinical rounds or other patient-related tasks.

14 No Associate’s degree required.

15 Particularly in the sense of EBM, i.e. given the amount of published peer-reviewed meta-analysis or single studies in the field. Please see the Bibliography at the end of the volume for more detailed reports.