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In this article we discuss the necessity of fully informing patients and their families of what constitutes physical interventions and their attendant risks under the established principles and obligations of informed consent. After a brief review of the elements of informed consent and the nature of the duty to advise patients and their families of treatment risks, we argue that physical interventions are an unvalidated treatment for aggressive and violent behavior and should be used only as a safety intervention. We focus our discussion on the informed consent issues for school aged children, adolescents, and emancipated minors and contend that if restraints are used they must pose less risk than the behavior they are trying to alleviate. We also opine that if restraints are misused by mental health or child welfare treatment settings, then their misuse may be considered a subject of a patient maltreatment, abuse, criminal or civil action. A central thesis of the article is that informed consent must be seen as an integral and dynamic process of treatment. We recommend strategies that gain parental permission and child assent, that view informed consent as a dynamic and individualized process that aids and supports the therapeutic relationship, and that stress the importance of simplicity and clarity.

This commentary was prompted by Dr. Sandra Thomas's (2008) editorial on wilderness programs that was published in Issues in Mental Health Nursing. It is laudable that Dr. Thomas has brought this to...

This article differentiates between the concepts of spirituality and religion and analyzes the strengths and weaknesses of the research findings related to spirituality, religion, and mental health. To discuss the importance of clarifying values and becoming self-aware in relation to implementing spiritual and religious interventions. The components of spiritual assessment are presented as well as spiritual coping practices and interventions the nurse might use when working with clients. Review of literature from MEDLINE, CINAHL, and current texts. Spirituality and religion are too often neglected foci of psychiatric mental health assessment and intervention. In order to maximize therapeutic effectiveness, nurses should be aware that for many patients spirituality is a critical life factor. Accordingly, they should screen patients and strive to meet patient needs for spiritual expression, while recognizing that there are important boundary and ethical issues in psychiatric mental health settings.

This ethnographic research constitutes a study of the culture of a family-run advocacy organization for families of children and youth with mental health needs. Data collection includes 703 pages of interview transcripts, observations, field notes, and archival material collected by the principle investigator during 2.5 years of participant observation with this support group. This article provides the context for the study and describes the support group's cultural ideologies and cultural forms that are a concrete expression of those ideologies. There are four major categories of cultural forms as follows: symbols, language, narratives or stories, and practices. Manifestations of each form are discussed and described. The proliferation of support and advocacy groups in the mental health arena promises a rich source of understanding of the needs of families in distress as well as inspiration for new and practical interventions.

One area in which children’s rights are rarely considered in the USA is that of autonomy over their bodies. This right is routinely ignored in the arena of health care decision making. Children are routinely excluded from expressing their opinions involving medical decisions that affect them. This article discusses the complex reasons why children’s voices are typically not heard in the USA, the consequences of their disempowerment, and the ethical obligations of health care providers to advocate for the rights of children, even in the absence of a legal mandate to do so.

This article discusses some of the most recent developments in US mental health services that follow on the heels of the for-profit hospital scandal that was brought to public attention less than a decade ago. As individuals and as a profession, nurses have a responsibility to uncover, openly discuss and condemn malfeasance when it occurs, yet there has been a collective silence about these developments. The authors explore the reasons for this and make recommendations for regaining nursing’s moral voice and integrity.

We discuss how organizations, as cultures, react to times of turbulence, stress, and the importance of their foundational values during those times. By adapting the framework pioneered by the organizational analyst Manfred Kets de Vries, we use psychodynamic concepts to discuss a descriptive typology of behavior in which persons and organizations engage under stress. We also discuss the hazards inherent in losing sight of common core values, the dangers in the disconnects between stated values and behaviors, and how those disconnects can be destructive to organizations and to persons. We conclude with a plan that involves achieving insight, trust, and open communication on which members of organizations can base discussion and find common ground in articulating common core values. Throughout the article, we make applications to nursing organizations to focus attention on the currency of this topic for the profession.

The belief that poor parenting and dysfunctional families give rise to mental illness has been perpetuated by psychodynamic and family systems theories that lack supporting scientific evidence, and interventions based on these theories have failed to produce clinical improvements. Nevertheless the National Alliance for the Mentally III (NAMI) found that many clinical training programs continue to teach these outdated theories and interventions and that the mental health system is often destructive to family systems. This article describes a new 10-week program that is designed to educate service providers that will include families in the care of their chronically ill loved one. The program is based on a competence and adaptation rather than a pathology foundation and it shifts the discourse from causes to effects of illness.

In September 1997, the NationalAlliance for the Mentally Ill issued a national report card asserting that managed care companies are falling short of their promise to deliver high-quality care to people with mental illnesses. This article traces how mental health care has evolvedfrom the overbuilding of psychiatric facilities in the mid and late 1980s to a situation in which millions of mentally ill Americans cannot receive adequate care. It traces events that led to the unprecedented boom in psychiatric care through the 1980s to the place where health care reform has evolved. The disparity between insur ance coverage of mental health care services and general medical care services is dis cussed, and the legislative outcome of recent mental health reform is described. Finally, implications for nursing and recommendations for action are considered. (J Am Psychiatr Nurses Assoc [1998]. 4, 153-161)

Children with behavior problems are put in units with milieu therapy for the support and guidance of a specialized health care team, supposedly experts in the care of children with these unique and urgent needs. The reality of such units, however, is that those with the most contact with the children are often inadequately prepared, both in terms of knowledge and skills, to manage disruptive behaviors. As a result, the milieu that is supposed to provide support and structure can actually exacerbate the trauma for the vulnerable child. Preliminary data are presented from an ongoing study that is investigating the experiences and memories of formerly hospitalized children. Three types of traumatic experiences are described: vicarious trauma, alienation from staff, and direct trauma. Many of the traumatic events endured by child patients are the result of an inappropriate use by staff of power and force. There was a marked lack of understanding by the children of why given interventions were used. Although coercive interventions are sometimes necessary, ethical, legal, and other professional considerations make it clear that more work is needed. Research to identify the patterns of lack of knowledge and skills, as well as to develop appropriate interventions are recommended.

During 1985–1991 state, federal and media investigations uncovered widespread fraud, patient abuse, and unethical conduct in investor-owned psychiatric hospitals. The purpose of this research study was to determine how nurses who were employed in these settings during this time experienced their work situations. Inquiry centered on ethical misgivings, sense-making, and patient advocacy. The experiences discussed in this article are the results of interviews with a theoretical sample of 30 Texas nurses. Their experiences have research, policy, education, and practice implications in that health care settings are becoming increasingly corporatized and are under great pressures to maximize profits to increase returns on investors' equity.

Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.

TOPIC. Structuring of inpatient behavioral programming in child-adolescent psychiatric, residential treatment, and juvenile justice settings. PURPOSE. To review the underlying theory underpinning current practices and recommend remedies to the uncovered problems. SOURCES. A review of the literature from 1965 to 2001 from selected nursing and medical psychiatric and mental health publications. CONCLUSIONS. Intensive professional and staff education and greater precision in communication about patients' behaviors are needed in many settings. There is also a need to move away from generic treatment approaches and return to individual treatment planning based on individual assessments and the unique needs of an increasingly volatile and complex in-patient population.

Problem Little of clinical relevance has been derived from research studies conducted on seclusion and restraint. Most studies elicit staff, as opposed to patient, views of the restraint event. Methods Content analysis, descriptive statistics of debriefing incidents (N = 81) following the initiation of seclusion and restraint from both patient and staff perspectives. Findings Patients and staff had varied views of the restraint incidents, but overall they were closer in their perceptions of precipitants and what could have been done to prevent the incident. Conclusions Debriefing incidents can be used as learning tools for staff and patients, to track staff and patient progress, and as a way to change the culture of psychiatric settings.

Based on recent BSN student clinical observations and evaluations from inpatient hospital units to which they were assigned, we were concerned about the absence of nursing leadership in these settings and the impact this absence has on our profession. In this opinion article, we explore how nursing leadership is being influenced by the structure of health care institutions and by an anti-intellectual stance among members of the profession. We discuss how these factors are influencing the current state of our profession and recommend a course of action to ensure the professional presence of nursing in the future. We also encourage readers to think about what they can do to prevent the fading of nursing leadership.

The curriculum that was described in this article reflects our school's broad and bold definition of what constitutes knowledge in nursing. It also represents the faculty's dedication to a creative approach to education and practice, as well as a commitment to change in an age of change. It portrays a desire to design education that would develop the full range of human potential, the full potential of the university, and incorporate the full range of approaches to human problems. Our current changing practice environment underscores the challenges and complexities facing faculties and student nurses in pursuit of relevant and useful theoretic and clinical content. In addition, those of us who have practiced in the psychiatric field know that the care of clients with psychiatric problems requires heterogeneous approaches to treatment that vary with respect to type, frequency, severity, and chronicity of their conditions. We know that the impact of certain conditions is linked to age and developmental status, and we know that the effects of deviations from health are mediated by numerous features of ecology, including poverty, job and family instability, parental stress, social isolation, and community violence. As a result, nursing interventions and their outcomes no longer can be viewed in terms of simple cause and effect relationships; nor can they be thought of as occurring in the familiar settings of hospitals or institutions. For better or worse, those facilities have closed. This reality and the enormous complexities of human science speak to the multidimensional factors involved in the construction of new and different models of teaching and learning within a comprehensive conceptual framework to guide both learning and practice.

Objective: This study is the context portion of a larger study that described the experience of 30 nurses in Texas, USA who worked in for-profit psychiatric hospitals during a documented period of corporate deviance. The objective of the contextual portion was to describe the major findings in 1997-1992 of investigating agencies that probed the scandal. Design: Exploratory descriptive. Sample: Over 1,240 pages and 40 hours of corporate records obtained under subpoena, and written and oral testimony before the USA House Select Committee on Children, Youth, and Families. Methods: Content analysis, triangulating sources, and comparing as well as cross-checking themes. Findings: Four themes: insurance games, dumping patients, patient abuse, and playing with language. Conclusions: Organizational deviance may become more widespread in profit -driven systems of care. Lobbying for whistleblower protection, collective advocacy, and creative educational reforms are used.

The ethos of the corporation and the urgency for profit maximization place pressures on health care corporations to act in a way that may be incompatible with ethical practice. Profit-driven incentives often result in corporate deviance and criminal behavior. Nurses may be pressured to go along with schemes that may be unethical or illegal and because of shaky job markets may be unable to adhere to professional ethical guidelines. Recent events in health care are drawn on to argue that ethical theory and research must begin to consider the issue of moral compromise of professionals as a result of deviant organizational environments.

The deviant outcomes of the private psychiatric hospital system were a logical, if extreme, extension of the events that transpired and the ideologies that shaped the greater culture. Can good nursing and the corporation coexist?

1. Developments in many «for-profit» psychiatric hospitals over the past decade raise concerns about the nature of values in proprietary health care. These developments raise questions of whether nursing values and ideologies can coexist with those of the current health care environment. 2. There are two influences that are important in considering the issue of nursing within the for-profit context: the commercial motivation of the present health care system and the possible subordination of nursing values to the objectives of lay (business) persons. 3. It is imperative to initiate dialogues of the problematic ideological and ethical dilemmas confronting nurses in the work setting

The recent events that transpired in the for-profit psychiatric hospital industry in which hospitals were alleged to engage in practices which ranged from unethical to illegal underscore the importance of examining the contexts of nursing practice. A wide range of environmental factors and unchallenged assumptions may influence the care of clients and may become obstacles to effective and ethical nursing practice. Critical social theory offers nursing a potentially valuable tool from which to illuminate and examine otherwise unexamined aspects of the environment.

B eing published rather extensively, I am accustomed to reviewers' comments, their conflicting suggestions, and other idiosyncrasies. For the most part, like other scholars, I pick my battles and issues with care, being ever cognizant that taking oneself too seriously is a most unattractive attribute. However, recently I have been criticized by several reviewers for using first person pronouns in several research and expository papers. This puzzles me, particularly when I consider the two decades or more of literature written by several feminist, naturalistic, and postmodern scholars urging the social science community to find its voice.l-3 These scholars argue that scientific writers should abandon their fruitless search for "objectivity" and expose the limitations of the I/eye of the author, by writing in the first person and describing the interaction between what is being observed and who is doing the observing. Amid the widely recognized failure of the social sciences to ground themselves in methods and theoretical commitments that can share the scientificity of the natural sciences, many of our reviewers persist in promoting a traditional social science writing style. This traditional social science writing enhances the authority of the author by making the author disappear, leaving only the impersonal voice of "truth" speaking--usually in the passive voice. In nursing, as in the other social sciences, scholars have raised this form of