The major psychiatric diagnoses of patients discharged from short-stay hospitals are listed in Table 33-1. In previous years most patients with maladaptive coping responses entered the psychiatric hospital in the acute treatment stage and were able to stay in the hospital until the goal of symptom remission was attained. Currently, most patients are admitted to hospitals in the crisis stage, with the treatment goal of stabilization rather than symptom remission.

TABLE 33-1

FIRST-LISTED DIAGNOSIS FOR PATIENTS DISCHARGED FROM SHORT-STAY HOSPITALS

DIAGNOSIS	PERCENTAGE
Mood disorders	44
Substance use disorders	24
Schizophrenic disorders	14
Anxiety disorders	4
Nonorganic psychosis	4
Organic mental disorders	3
Adjustment reactions	2
Other	5

From Hall MJ et al: National hospital discharge survey: 2007 summary. Advance data from vital health and statistics, No 29, Hyattsville, Md, 2010, National Center for Health and Statistics.

Critical Reasoning

Does your community have any crisis beds? If so, how often are they used and by what type of patient?

State Hospitals

Changes in hospital-based psychiatric care are most evident in the changes that have taken place in state mental hospitals across the United States. The number of state hospital beds has declined by 90% over the past 50 years while the number of people with mental illness has increased (National Association of Psychiatric Health Systems, 2011).

The first data collected on state hospitals from 1831 reported 150 patients in four state hospitals. The number steadily rose until 1955, when it peaked at 559,000 patients in 352 state hospitals (Manderscheid et al, 2009). These institutions provided custodial care to patients believed to be unable to safely function in the community or those thought to be a threat to society.

The 1950s brought new trends in treatment, including psychotropic medication and changing philosophies regarding the best location of treatment for persons with severe mental illness. A shift occurred in favor of community-based services. One driving force for this change was concern about institutionalism, or the tendency of long-term hospital patients to demonstrate passive dependent behavior and become resistant to discharge. Advocates for the mentally ill expressed a strong belief that community-based treatment models integrating family and social living were better than institutionalization.

Deinstitutionalization moved patients out of state hospitals into community-based treatment facilities. Hospital funding was reallocated to advancing treatment, especially psychopharmacological and outpatient services. The period from 1955 to 2003 produced a steady decline in the numbers and size of state hospitals, with a peak of closures in the 1990s. In 2004 there were 57,302 state and county psychiatric hospital beds, which is about 10% of the beds that existed in 1955. As a result of this drastic reduction in beds, there are major concerns about the outcomes of deinstitutionalization and the lack of adequate community resources.

Because there are so few beds available, individuals with severe psychiatric disorders who need to be hospitalized are often unable to get admitted. Those who are admitted are often discharged prematurely and without a treatment plan. The consequences of this reduction in psychiatric hospital beds include the following (Treatment Advocacy Center, 2011):

• Homelessness: A 2005 federal survey estimated that approximately 500,000 single men and women are homeless in the United States at any given time, and multiple studies have reported that one third have a serious mental illness.

• Jails and prisons as psychiatric hospitals: Since the reduction in public psychiatric hospital beds occurred, there has been a significant increase in severely mentally persons in jails and prisons. Estimates have placed the number at 7% to 10% of all inmates, but some studies have put the figure at 20% or higher.

• Hospital emergency room overflow: Emergency rooms are often used as waiting rooms for people in need of a psychiatric bed. This backs up the entire hospital system and compromises other medical care.

• Violent crime: Studies have shown that between 5% and 10% of seriously mentally ill persons who are not receiving treatment will commit a violent act each year, accounting for 5% of all homicides.

The state hospital of the twenty-first century must focus on the needs and characteristics of the specific patient populations it serves, including patients with criminal justice histories, forensic patients, sexually dangerous persons, and the difficult-to-discharge patient with complex ongoing care needs. Research is needed to address the unique treatment and rehabilitative challenges for these populations and to inform future policy decisions (Fisher et al, 2009).

Despite advancements, some patients continue to require long-term, highly structured care on a 24-hour basis. Safety of the patient and society, inconsistent availability of appropriate services in the community, and preventing the mentally ill from becoming homeless or incarcerated are a few of the challenges that must be faced to meet the needs of the most severely mentally ill.

Critical Reasoning

Some say that state psychiatric hospitals have created a two-tiered (insured and indigent) system of mental health care that does not exist in general health care settings. How do you respond to this?

Partial Hospitalization Programs

Partial hospitalization programs (PHP) are an important part of the continuum of care for mental health and chemical dependency treatment. A PHP is designed to prevent relapse and avoid hospital admission or to provide active treatment for serious mental disorders with reasonable expectation of improvement. PHPs use crisis stabilization and recovery-oriented approaches (Khawaja and Westermeyer, 2010).

• Crisis stabilization approaches assist patients to identify personal and environmental triggers, understand the crisis, and develop healthy patterns of problem solving and coping.

• Recovery-oriented approaches focus on patient improvements through engagement in their treatment plan, choosing options, and establishing realistic goals in a respectful environment that emphasizes hope and quality of life.

PHP patients usually receive 4 to 6 hours of services per day for 4 to 5 days per week (National Association of Psychiatric Health Systems, 2011). Typically, the patient receives the maximum service for the first 1 to 2 weeks after discharge from an inpatient unit. As the crisis stabilizes and the patient’s level of functioning improves, participation in the program is reduced, allowing for transition back to home, work, or school.

The PHP team is multidisciplinary and usually includes a psychiatrist, psychiatric nurse, social worker, and activity therapist. Some programs also include occupational therapists and vocational counselors. PHP patients typically are seen by the psychiatrist weekly, and the psychiatric nurse assumes the primary responsibility for assessing and identifying biological issues that may be contributing to the patient’s psychiatric condition. Studies of PHPs have raised questions about their clinical effectiveness and whether they promote the recovery model of psychiatric care (Yanos et al, 2009; Lariviere et al, 2010).

Critical Reasoning

How do you think the changes in hospital-based psychiatric care affect the families and support systems of the mentally ill? How can nurses help them with the problems they face?

The Role of the Nurse

Most psychiatric nurses work in inpatient and PHP psychiatric settings. Psychiatric nurses are the only group of mental health professionals who are responsible for meeting the needs of inpatients 24 hours per day, 365 days per year. To deliver cost-effective, high-quality inpatient or PHP care, psychiatric nurses must manage the nurse-patient relationship within a complex social and organizational environment. The scope of contemporary hospital-based psychiatric nursing practice requires knowledge and expertise in three broad areas:

• Managing the therapeutic milieu

• Implementing caregiving activities

• Integrating and coordinating care delivery

This chapter is organized around these areas because they represent the structure and the process of hospital-based psychiatric nursing care.

Managing the Milieu

A basic difference among care settings is the structured environment, or milieu, in which treatment occurs. Hospital-based treatment provides physical and emotional shelter. It gives patients an opportunity to stabilize while being protected from factors that can interfere with treatment. PHP treatment provides structure and intensive support on a more limited basis while promoting development of a more home-like environment that supports the patient’s progress. The goal of managing the milieu is to provide patients with a safe, stable, and consistent social environment that facilitates the development and implementation of an individualized treatment plan.

The Therapeutic Community

In the 1950s, Maxwell Jones described the inpatient environment as a therapeutic community with cultural norms for behaviors, values, and activity (Jones, 1953). He viewed patients’ social interactions with peers and health care workers as treatment opportunities and proposed that clinical staff share community governance with the patient group on an equal basis. He emphasized the benefit of patient’s participation in each other’s treatment, predominantly through sharing information and giving feedback in group settings.

The concept of the inpatient therapeutic community is less relevant to today’s inpatient environment. It was developed when patients spent months or years in the hospital, which is very different from the current short-term stays. Democracy and equality among patients and clinical staff is not compatible with the medical model of current inpatient settings.

Critical Reasoning

The therapeutic community is an example of the social model of psychiatric care. Discuss how it differs from the medical model in the roles of patient and clinician and the therapeutic process.

The Therapeutic Milieu

In the late 1960s, the idea of the therapeutic milieu emerged (Abroms, 1969). It had two main purposes:

• To set limits on disturbing and maladaptive behavior

• To teach psychosocial skills

Five categories of disturbing behaviors and interventions that can help patients keep maladaptive behaviors under control and allow treatment to progress are listed in Table 33-2. After maladaptive behaviors are limited, the therapeutic milieu can be used to develop the following four important psychosocial skills in mentally ill patients:

TABLE 33-2

MANAGING DISTURBING BEHAVIORS IN THE MILIEU

DISTURBING BEHAVIOR	DEFINITION	INTERVENTIONS
Destructiveness	Physically destructive behavior that is a response to a variety of feelings, such as fear or anger	In working with destructive behavior, the goal is to control or set limits on the maladaptive response but support the feeling underlying the behavior. Validation is essential to help the patient recognize the feeling and ultimately regain control of maladaptive behavior.
Disorganization	Distorted or unusual behavior a psychotic patient may exhibit as symptomatic of the illness may be triggered by elevated anxiety, profound depression, or organic dysfunctions.	Reassure and help the patient while reducing the degree to which these behaviors inhibit therapeutic processes.
Deviancy	Behaviors often described as acting out are the result of the patient expressing conflicts overtly in the environment. It is often difficult to determine precisely what acting-out behavior is or what is justifiable or even tolerable, because much of it may be influenced by sociocultural factors.	The therapeutic goal in working with deviancy is to analyze how the behavior affects the milieu and how it inhibits the patient’s progress. Examining the behavior with the patient and identifying consequences and alternatives are useful approaches.
Dysphoria	Patients with mood alterations may be dysphoric, which is evident in maladaptive responses, such as withdrawal from the environment, obsessional behaviors, intrusiveness, or hyperreligiosity.	Establishing a therapeutic alliance is the first task. From there, the nurse and patient can explore feelings and dysfunctional thoughts and begin to modify behavioral responses.
Dependence	Behavior is evidenced by patients who do not identify and meet their own needs despite being able to do so; the avoidant nature of dependency interferes with therapeutic progress.	The initial therapeutic goal is to work with the patient to draw on any remaining areas of independence and strength. Then situations can be identified in which the patient can apply these independent behaviors successfully.