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This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.

Over the past decade in the United States, the number of private residential facilities for youth has grown exponentially, and many are neither licensed as mental health programs by states, nor accredited by respected national accrediting organizations. The Alliance for the Safe, Therapeutic and Appropriate use of Residential Treatment (A START) is a multi-disciplinary group of mental health professionals and advocates that formed in response to rising concerns about reports from youth, families and journalists describing mistreatment in a number of the unregulated programs. This article summarizes the information gathered by A START regarding unregulated facilities. It provides an overview of common program features, marketing strategies and transportation options. It describes the range of mistreatment and abuse experienced by youth and families, including harsh discipline, inappropriate seclusion and restraint, substandard psychotherapeutic interventions, medical and nutritional neglect, rights violations and death. It reviews the licensing, regulatory and accrediting mechanisms associated with the protection of youth in residential programs, or the lack thereof. Finally, it outlines policy implications and provides recommendations for the protection of youth and families who pursue residential treatment.

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.

Support groups have increased rapidly in number and become a viable alternative to formal treatment in the United States. However, little is known regarding how mental health advocacy or support groups start and develop, or about challenges that can threaten their survival. In this 21/2-year ethnography, the author studied the culture of a developing family support program associated with a system of care. Several phases emerged, reflecting an organizational dynamic. The group dynamics and response to challenges have implications for organizers and parent organizations about the need for technical assistance necessary for survival of the group. Participant observation and immersion in the culture of such groups can provide a deeper understanding of the ideologies and values around which they organize and the kinds of tensions that members can experience during the group’s cycle.

Systems of care represent a fundamental departure from traditional service provision by espousing genuine family-centered, culturally competent philosophies and blending the funding streams of multiple payers (e.g., education, mental health, child welfare). In Marion County, Indiana, local leaders created a system of care based on these principles called the Dawn Project. Currently, a comprehensive, multidisciplinary evaluation is being implemented to evaluate the program. Preliminary findings from initial evaluation efforts suggest that for youth in the project, there is significant clinical improvement during the first year of receiving services, a reduction in the use of more restrictive settings, and a decrease in recidivism among those who successfully complete the program.

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.

Parental loss of a child to mental illness and the resulting grief is a relatively unacknowledged phenomenon. This study aimed to capture the process through which parents journey in the face of their child's mental illness. Conducting a series of focus groups, the authors sought to further the understanding and the needs of these families. They identify seven themes from initial awareness to the formation of a new stability. Identification of this grief process is an important step that can heighten practitioners' awareness so that future interventions and support systems can be developed to help these families deal with their pain and burden.

The purpose of this study was to deconstruct the language of psychiatric nurses' documentation and charting. Employing concepts developed by post-modern theorists, everyday professional activities can be examined in unique ways that uncover how they conceal or skew rather than reveal and illumine patient conditions. The study design and sample was exploratory; content analysis with first and second level analyses. Nine major categories of charting entry were found. Deconstruction of the language and discourse of nursing through a Foucaultian lens goes beyond what is manifest to what is not said. Professional assumptions about patients and the social construction of patients and patient problems are exposed.

TOPIC. The impact of psychiatric hospitalization on children and adolescents hospitalized during the Texas mental health scandal. METHODS. Content analysis of archival data and in-depth interviews. FINDINGS. subjects (N = 19) voiced complaints about the stigma resulting from the hospitalization as well as lack of individual care, violations of personal boundaries, ineffectual outcomes, permanent disruption to family relations, separation from family, trauma of seeing others restrained, and being restrained themselves. CONCLUSIONS. Unnecessary psychiatric hospitalization has long-term ramifications for children and adolescents in terms of self-view, family, and social relationships. Key words: Child psychiatry, mental health, psychiatric hospitalization, qualitative studies Little comprehensive or systematic research has been conducted on the experiences of the psychiatric hospitalization of young people (Schwartz, 1989) or the long-term memories and sequelae associated with such hospitalizations under the best of circumstances (Crespi & Ivey, 1987). Specifically, there has been no attempt to address the experiences of youngsters and families affected by the scandal involving widespread hospitalizations of patients during the mid-1980s and early 1990s at a time when the psychiatric hospital industry ran amuck and afoul of the law. This study was conducted to examine the experiences of these former patients as they look back on their hospitalizations during this time. This article (1) discusses the sociopolitical context of the scandal, (2) presents the major complaints by former patients and their families, and (3) reports the outcomes of in-depth interviews conducted with patients and families. Background No study results can be understood without an awareness of the greater context and some of the history within which the events under study are embedded. The events surrounding the for-profit psychiatric hospital scandal occurred during a time described by Phillips (1990) as "a glorification of capitalism, free markets, and finance" (p. xvii). Wall Street firms expanded in a newly deregulated environment, and the focus of collective corporate management narrowed to an intense profit orientation. Company and executive incentives and bonuses were based on the profit margins they generated, and the frenetic pace of financial activity was reflected in the short-term perspective adopted by top executive offices. Quarterly earnings replaced long-term strategic planning as a focus of scrutiny. Together with a nonstop pressure to produce, "too often ... little attention [was paid] to methods employed" (Johnson, 1992, p. 237). As mass media sources reported insider trading and other scandals, Wall Street executives denied that financial markets were infected with serious and fundamental ethical problems, attributing each emerging scandal to "just a few greedy kids" (Bruck, 1988). America's spiritual leadership became tarnished by corruption as well, justifying a "Gospel of Prosperity" with Biblical justification for their enterprises (Reichley, 1985). Television evangelists founded vast empires and lived in luxury, flexing their political clout and influence with the Republican administration. By the end of the 1980s, however, many of them began to self-destruct amid scandalous and sensational allegations of sexual indiscretions, hush money, and misuse of church funds (Hadden & Shupe, 1988). Corruption and abuse of office characterized President Ronald Reagan's administration as scandals emerged at the Postal Service, Environmental Protection Agency, Federal Aviation Administration, Agriculture Department, Health and Human Services Department, Pentagon, and at least 13 other federal agencies (Johnson, 1992). In addition, ethical misconduct tainted the president's most valued associates at the highest levels of government (Johnson). Against this background, American medicine underwent a transformation. …

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.

This article describes an aspect of a larger study of the experiences, outcomes, and consequences of hospitalization during the years that constitute the "for-profit psychiatric hospital scandal" in Texas. Specifically, this article is concerned with patients who were children during 1985-1991. The author presents a case study of one such patient, followed by discussion of perceived outcomes as well as the long-term professional, economic, and policy sequelae of questionable psychiatric hospitalization. Questions are also raised as to the implications of applying a purely marketplace orientation to the care of society's most vulnerable individuals.

This article is an affirmative rejoinder to a recent editorial calling for revitalizing psychiatric research and education. It reviews the shortcomings of our present knowledge- and research-base using the state of child psychiatry as an exemplar. It concludes that we, as a specialty, must be cautious in setting a course for a research agenda in the new millenium and posits that the most informative research and intervention will occur by using multiple measures and sources of information. As understanding of patients and their problems in development and in context grows, intervention research that will be useful, timely, and cost-effective must include cross-discipline teams of researchers and practitioners who will speak to these complexities.

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.

In this article the author argues for the importance of reintegrating the neglected pattern of esthetics into the teaching and practice of nursing. Approaching art as both a means and end, the essay illustrates, how art can inform the specialty. By exposure to selected literary works, nurses can vicariously achieve understanding of human conditions that they could not otherwise experience. Through the art act, nurses can examine the depths of their interventions, identify them, and creatively center themselves. Integrating esthetics into nursing education and collaborating with colleagues in the field of humanities can invigorate a discipline in search of identity and justification during a time of professional turbulence.

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.

1. Psychoeducation provides patients with the tools necessary for social reintegration through education; the practice of skills has the potential to empower mentally ill clients. 2. Psychoeducation programs should include a needs assessment and input from the staff and patients as well as consulting literature. Staff involvement elicits creative ideas and can help implement and maintain a good program. 3. Psychoeducation programs can provide opportunities for education, appropriate role modeling of skills, and ongoing assessment of client's progress, as well as generate questions for research regarding the efficacy of different modalities. 4. Psychoeducation classes should consider time factors, client mix, and should have an evaluative component. They should also build on knowledge from each preceding class and be interesting, relevant, and fun.

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

In recent years, researchers have focused attention on children who are exposed to domestic violence. Although presently there are no scientifically credible estimates of the national prevalence of children exposed to domestic violence, existing data suggest that large numbers of American children are affected. This article discusses the limitations of current databases and describes a promising model for the collection of reliable and valid prevalence data, the Spousal Assault Replication Program, which uses data collected through collaboration between police and university researchers. Research examining the effects of childhood exposure to domestic violence is also limited by a range of methodological problems. Despite this, however, sufficient evidence from the body of studies exists to conclude that such exposure has adverse effects. The specific effects may differ depending on a host of variables, such as the children's ages, the nature and severity of the violence, the existence of other risk factors in the children's lives (for example, poverty, parental substance abuse), and whether the children are also directly physically abused. In general, childhood exposure to domestic violence can be associated with increased display of aggressive behavior, increased emotional problems such as depression and/or anxiety, lower levels of social competence, and poorer academic functioning. A scientifically credible body of research on the prevalence and effects of childhood exposure to domestic violence is necessary to promote the development of effective interventions and to permit the proper channeling of public and private funds. This article identifies some of the steps that can be taken to build the research capacity necessary to obtain the needed data.