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Critical Issues and Factors
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Critical Issues and Factors

That Affect Implementation of the Therapeutic Community

And

Potential Solutions to Maintain the Therapeutic Community

 

This paper is not for copy, in whole or in part, or for distribution without my express permission. Where permission has been given, please ensure that reference citations to selected passages are given proper recognition.

 

Healthcare in its continuing evolution has brought about changes to the therapeutic environment in which clients and professional psychiatric nurses interact, operate and function. These changes have been brought about by external and internal influences placed upon the healthcare system.

This paper discusses critical issues and factors that threaten the implementation of principles commonly associated with a therapeutic community. Exploration of solutions to these issues, which can be provided by the professional psychiatric nurse, will be presented.

THERAPEUTIC COMMUNITY

To discuss critical issues and factors that threaten the implementation of the principles associated with a therapeutic community, an understanding of what constitutes a therapeutic community is necessary.

Descriptions of the therapeutic community using a variety of terms interchangeably have created a blurring of the term. These similar, yet unalike terms offer different connotations when used in varying contexts. In exploring principles commonly associated with a therapeutic community, clarification of the terms becomes evident.

An example of the blurring of terms is illustrated by Jones when indicating that "the idea of a therapeutic environment (and sometimes referred to as therapeutic community, therapeutic milieu or milieu therapy) arose from reactions to the dehumanizing conditions in mental institutions and motivated the move to improve hospitals and to treat clients as distinct individuals with dignity and rights" (1998, p. 3-1). These terms therapeutic community, therapeutic milieu and milieu therapy are interchangeably used to describe a set of conditions present in treatment settings for mental health clients. A more concise definition of a therapeutic community is that of Shives (cited in Jones, 1998) who refers to a therapeutic community as "a special type of milieu or environmental therapy using social and interpersonal interactions in the hospital as therapeutic tools to bring about change in the client by encouraging active participation in treatment". Within this definition, the concept of the client being an active participant in their treatment plan is introduced. This environment as described by Shives (cited in Jones, 1998) is inclusive of a variety of settings such as "the hospital, community, home or a private office of a therapist". Jones notes that "this definition emphasizes that the therapeutic community is: aimed at the restoration of social functioning or, in other words, rehabilitation rather than treatment or containment of the mental disorder, a community of staff and clients, a setting where clients are expected to actively participate in their own treatment and carried out in various settings"(1998, p.3-6).

In order for the existence of such an environment, and for clarification, four principles are noted as being indicative of a therapeutic community. These principles as put forward by Wilmar (cited in Jones, 1998) are:

  1. "The therapeutic community is a democratic social organization. Every decision in the group should involve every other member of the group. Staff and patients have equal say in the community.
  2. Staff in a therapeutic community should be intimately aware of the roles of the other team members so that fullest use is made of all members in furthering the therapeutic goals.
  3. A clear concept of different staff roles should be developed to allow for personal differences.
  4. Individual roles grow with the growth of the group experience and insight. Roles are not to be imposed from outside the group".

These four principles are enhanced by three commonly descriptive components. Jones describes these components as "distribution of responsibility and decision making, clarity of the role of members and the leadership of the program and high levels of interaction between staff and clients" (1998, p.3-7).

Having clarified the meaning and principles of a therapeutic community, the next section examines critical issues, which can affect implementation of the therapeutic community.

CRITICAL ISSUES

This section examines critical issues affecting the implementation of the therapeutic community. Jones (1998) noted that eight critical factors could affect the therapeutic community. These factors are financial, deinstitutionalization, treatment, the unit team, staff morale, therapeutic community factors and treatment models. Each issue will be explored separately.

Financial

The last several years has seen dramatic change in the structure of the healthcare system in British Columbia. This structural change, known as New Directions in Healthcare has regionalized healthcare services. Regionalization of health services attempts to provide geographically drawn communities with health services that meet the needs of the community. The provincial government in the form of block funding provides funding for these services. An appointed Regional Health Board (RHB) oversees the provision of those services. The RHB determines the financial allocation of resources to meet health needs of the community. Through public consultation with the community, the RHB makes determinations of the kinds of health services needed and desired by the health region.

Providing services based on geographically drawn boundaries has had profound impact on delivery of mental health services. Different health regions have varying pre-existing infrastructures. In my experience, this has led to the restriction of movement of mental health clients and has created an environment of territoriality in the provision of service by healthcare providers. This has led to increased pressure on existing regional services, especially emergency mental health services. In my own work setting, an emergency short stay treatment facility, we have seen an increase in the acuity of clients and our client lengths of stay. The average length of stay in 1997 was six days (PCLA Admission Records, 1997). So far this year, the length of stay has increased to nine days (PCLA Admission Records, 1998). This increase in the length of stay illustrates the increased pressure on existing emergency care facilities within the community.

Another example of the effect of financial constraints placed upon the delivery of mental health services has been the policy of special authority for payment of new psychotropic agents. The newer antipsychotics and antidepressant medications are being limited in their distribution to those that have the financial resources to pay for them and those that meet stringent criteria for being declared "treatment resistive". This illustrates the interrelationship amongst the critical issues that affect the therapeutic environment.

One of the more serious financial constraints is the financial resource of mental health clients and the cost of living. Using the area of New Westminster as the example, a single person, deemed unemployable is eligible for what is called a handicapped pension provided through the Ministry of Social Services and Housing. The current rate for this pension is $771.00 monthly. This rate is inclusive of shelter, food, clothing, transportation and any other comforts required by the recipient. According to the Housing Registry in New Westminster (personal communication March 12, 1998), the cost of a bachelor apartment ranges between $450.00 - $550.00 monthly. These were average numbers for the city of New Westminster. Considering that the handicapped pension is all-inclusive, after paying for shelter, little money is left for the purchase of food, clothing, transportation and other items. This has contributed to the burden being placed on already stretched emergency services. The impact of limited financial resources of mental health clients can be best summarized by a comment attributed to a mental health client in the 1998 Mental Health Plan. He stated that "I managed to get a van (to live in). The police checked me out one day…and said, "Find a place when you can". It's been four years now" (1998, p. 12).

Deinstitutionalization

Deinstitutionalization from its inception decades ago has encountered obstacles every step of the way. As Barofsky and Budson note "were deinstitutionalization merely concerned with the exchange of settings for patient care, many of the problems known to exist would not have arisen" (1983, p. 16). They continue by stating "the community would simply have replaced the hospital as the locus of care, and resultant problems would have been of a logistical nature, easily negotiated and resolved" (1983, p. 16).

The process of deinstitutionalization has in many ways failed to meet the needs of the most seriously mentally ill. Barofsky and Budson ascribe this failure to "the requirements of the most seriously ill have been subordinated to those of patients who are essentially healthy but unhappy" (1983, p. 21-22). They note that this can be attributed to "those seriously impaired patients with their peculiar combination of service requirements, chronicity and impotence, have had to compete for scarce resources with others who are less seriously impaired and more socially acceptable" (1983, p. 22). Although these views are dated, they are still relevant when looking at the current state of deinstitutionalization. The 1998 Mental Health Plan notes that "patients transferring from Riverview Hospital to the community need essentially the same range of services as was available to them at the hospital" (1998, p.8). At the local level, an example of the seriously mentally ill not having ready access to necessary services was described in an interview with Dr. C. Kogan (personal communication, March 13, 1997). He reported that the day program at Royal Columbian Hospital was no longer serving its original intended purpose. He reported that the program was established as a means of providing ongoing monitoring of first break Schizophrenics. He reported that at present the day program is clogged with clients having a personality disorder.

Pharmacological Breakthroughs

From the late 1980's to present, advances have been made in pharmacotherapy resulting in the discharge of chronic patients to the community. These advances have produced new atypical antipsychotics and classes of antidepressants that have fewer side effects combined with desirable effects on such things as the negative symptoms of schizophrenia.

Littrell, Peabody and Littrell, in their study of Olanzepine as a new atypical antipsychotic (cited in The Journal of Psychosocial Nursing, 1996 pp. 41-46) attributes the improvements in pharmacotherapy as being "a major force in creating the paradigm shift in the treatment of schizophrenia in which expectations are now focused on improvement rather than stabilization". As earlier noted, these medications are not presently available to everyone due to pharmacare restrictions for payment of the medication. Therefore, while advances are being made in pharmacology, only those with sufficient financial resources or those meeting the criteria of treatment resistive as defined by the pharmacare plan are eligible to receive these medications.

Treatment

Treatment failures can result for a number of reasons. Jones notes that treatment failures includes "those clients characterized by uncertain diagnosis, clients with a tendency to acting out and clients with intense separation reactions" (1998, p. 3-19). Barofsky and Budson describe these failures as "patients who appear not to fit into the system despite persistent efforts to engage in an ongoing treatment process, keep returning to the emergency ward where they constitute a familiar revolving-door population" (1983, p. 22). Although not eloquently stated, Lamb (cited in Barofsky and Budson, 1983 p.22) refers to those emergency ward regulars as "psychiatric hoboes". This revolving door is evident in my workplace. For the year ending 1997 60% of admissions to my facility had a previous admission within the prior calendar year (PCLA Admission Records, 1997). Despite these observations, the "revolving door syndrome" may in fact not truly represent a treatment failure. Kramer and Rubinson (cited in Barofsky and Budson, 1983 p. 22) write "visits by former patients frequently reflect either "meaningful relationships with staff members and other patients" or "continuing treatment needs of various kinds". Support on this point is provided by Gruber, Brown and Mazarol (cited in Barofsky and Budson, 1983 pp. 22-23) who note that "visits by these patients represent a response to real but unarticulated needs that are not being met by the mental health system and that while hospital readmission is commonly thought to indicate failure, it may be better to look on the brief hospital admission as an episode of temporarily increased dependency in the course of a long-continuing disability".

The Unit Team

With deinstitutionalization came the transfer of care from the hospital to community care teams. This transfer from hospital to the community led to the development of an array of support services. The creation of these services increased the number of unit teams that would now be providing service to the client. The proliferation of these unit teams or treatment teams brought new professional and non-professional staff with a multitude of different backgrounds, education, experience, values and attitudes together with the common goal of serving the needs of the client.

The approach of setting up these separate inpatient and outpatient treatment teams makes provision of service fragmented for the client. Barofsky and Budson believe that "chronic patients suffer most from our tendency to keep inpatient and outpatient staffs separate, and to move the patient from one clinical team to another when the locus of treatment needs to be changed" (1983, p. 40). Panzetta (cited in Barofsky and Budson) concurs with this assessment of separating the treatment teams. He notes that "outpatient staff tended to see the patient as having been rushed out of the hospital without adequate treatment or preparation. The inpatient staff tended to see the outpatient staff as disorganized and unwilling to follow up on patient needs"(1983, p. 40). This highlights the differences between inpatient and outpatient services and is consistent with what I find occurring in my own practice. Working in an emergency short stay facility puts me between the mental health centres (outpatient treatment) and the hospital (inpatient treatment). It is common to hear that the mental health centre believes the hospital has failed to keep the patient long enough and to provide adequate treatment. Conversely, I often hear the hospital complaining that if the mental health centre was more organized and coordinated in its provision of service that the client would not be in the hospital in the first place. These conflicts may in part be related to what Bell and Ryan (cited in Jones, 1998 p. 3-19) see as being staff values that may conflict with the concept of the therapeutic community. Those values identified are "treatment precepts (involving contradictory therapeutic precepts), leadership (being involved in other demanding pursuits at the same time), power relations (different ideals held by professionals and non-professionals) and attitudes towards clients (containment of and controlling client behaviours)".

Staff Morale

The demands placed on the professional psychiatric nurse are many. As members of multidisciplinary teams consisting of a mix of other professionals and non-professional staff, we function in a variety of different roles. We act as team leaders, case managers, providers of direct care, client advocates and health educators. These roles are being fulfilled in a period of uncertainty within our present healthcare system.

In examining staff morale, an understanding of the interrelationship of the other critical issues is necessary. Shrinking healthcare budgets mean we work harder with less. Changes in the delivery of healthcare require creative adaptability. Advances in pharmacotherapy necessitates creativity in delivering components of care not related to pharmacology, which has brought about briefer periods of hospitalization for the seriously ill.

Another aspect of professional relationships that could affect the therapeutic environment is the history of psychiatric nursing in context of the health care system and the ongoing division between Registered Nurses and Registered Psychiatric Nurses. As Duncan notes "Given the history of the health care system and psychiatric nursing there has been a constant struggle to be a colleague with other professionals and not just the person who carries out the doctors orders" (1997, p. 5-10). Duncan further notes "add to that reality the even more painful reality of the division within the profession of nursing itself. There exists the Registered Psychiatric Nurses Association of British Columbia and the Registered Nurses Association of British Columbia with members practicing psychiatric nursing in competition with each other for employment and status" (1997, p. 5-10). In considering how this might impact on the therapeutic community, Duncan states "individually you may work on a team with effective team relationships. The fact remains that there is not a cooperative effort being generated between the two professional associations to professionally heal the damage that continues to effect nurses and ultimately the standard of care to clients and communities" (1997, p. 5-10).

Therapeutic Community Factors

In today's delivery of mental health care, especially facility care, clients of differing pathologies and degrees of severity are cared for on the same unit. When considering therapeutic community factors, Jones notes that "the therapeutic community can fall victim to the clients' psychopathology" (1998, p.3-18). This means that under certain circumstances and conditions, the clients illness may interfere with the principles of a democratic setting. In considering examples of such situations, Jones notes "when manic and borderline personality disorder clients are in a group surrounded with a stimulating atmosphere they may become more difficult then they would normally be" (1998, p.3-18-3-19). Jones also notes that "the therapeutic community can exert a harmful and regressive effect on the client with character disorders because of their specific rehabilitation needs. That is, for example, it may allow more opportunity for manipulation of clients and staff" (1998, p. 3-19).

The examples of Jones provides for an illustration of the difficulties that can be encountered when trying to implement the general principles of a therapeutic community with such a diverse patient population in a single treatment setting.

Treatment Models

One goal of the therapeutic community is democracy. This goes to the belief that clients are active participants in their own treatment. Jones notes that "the emphasis on democratization may compromise the essential goal of individualized therapy" (1998, p. 3-18). Also noted by Jones is that "attention has therefore to be paid to the composition of groups" (1998, p. 3-18). In today's health care system, little attention is paid to the composition of groups in a care setting. With the restriction of health care monies, clients are placed in the first available bed. Ward settings and indeed community settings provide care to a diverse patient population with varying illnesses and varying degrees of severity. The acute client is mixed with the chronic client and the symptomatic client is placed with the asymptomatic client. This indeed has been my experience in my own facility. The composition of clients is dictated by the one in and one out method of service delivery.

SOLUTIONS TO THREATS TO THE THERAPEUTIC COMMUNITY

This section explores potential solutions to threats posed to the therapeutic community. The solutions explored relate to accountability, leadership, client advocacy and acting as a change agent. Each solution is presented separately.

Accountability

Leddy and Pepper indicate that to be accountable "a profession must know what it is accountable for. It does this by establishing professional standards and attempting to enforce them" (1993, p. 273). This accountability, as described by Leddy and Pepper is to "the client and public, the profession, to self and the employing agency" (1993, p. 274-279).

In looking at nursing responsibility to the client and public, Leddy and Pepper believe that "the consumer has the right to receive the best possible quality of care, care grounded in a firm knowledge base and performed by those who can make use of that knowledge base by applying sound judgement and a clear and appropriate value system" (1993, p. 274). In expanding this view beyond individual clients, Leddy and Pepper state "as a knowledgeable professional, the nurse should be ultimately accountable for health care delivery nationally. When she seeks to blame others (such as physicians, administrators or politicians) for the state of the health care delivery system, she weakens her position and her power base" (1993, p. 275). In accepting an appropriate degree of responsibility for the current situation and actively pursuing methods of improving it, Leddy and Pepper state "the nurse acts on a more professional level and stakes her claim to a piece of the health care pie" (1993, p. 275). Psychiatric nurses possess the knowledge base to provide the best quality care possible for the clients that we serve. This knowledge and expertise translates in a power base. It is the responsibility of every psychiatric nurse to use this knowledge and expertise to influence national and local health care issues related to mental health. A means of achieving a place on the national and local stage is through advanced levels of educational preparation and research. Advanced education and continuing research in psychiatric nursing would place psychiatric nurses in the forefront of decision making related to mental health policy. When policies are implemented that are contrary to the therapeutic environment, psychiatric nurses must ensure that they are part of the decision making process. Whether the issue is regionalization of health services or continued deinstitutionalization, psychiatric nurses need to accept responsibility for their practice and must ensure that the needs of the client are clearly articulated to those in decision making circles. When policies are presented that are detrimental to the well being of the client, we must use our knowledge and expertise to assist in reformulating policies so that the needs of the client are met. This means providing the best possible quality care that is currently available.

In the nurses accountability to the profession, Leddy and Pepper report that "the nursing profession in exercising its accountability toward itself in the performance of its duty to formulate its own policy and control its activities" (1993, p. 275). A nurses accountability to the profession according to Leddy and Pepper includes "the need to be aware of and accountable not only for her own actions but also for those of her colleagues" (1993, p. 276). In discussing the nurses accountability to the profession, the education of its members is also important. Leddy and Pepper note "the nurse is also accountable to the profession when she considers the issue of which educational system will prepare its members most satisfactorily for practice. It is not enough to let nursing be buffeted by external winds of change or by individuals and forces outside its perimeter" (1993, p. 276). In British Columbia, the Registered Psychiatric Nurses' Association of British Columbia (RPNABC) regulates the practice of Registered Psychiatric Nurses. The RPNABC (1995, pp. 13-35) sets competencies expected of the beginning practitioner of psychiatric nursing, outlines the minimum standards of practice required of all practicing psychiatric nurses and provides a code of ethics to ensure the moral and ethical practice standards of psychiatric nursing are maintained. Each nurse has a moral, ethical and legal obligation to ensure that the standards of practice are not only met but also constantly challenged and exceeded. The status quo is not the goal of nursing. The forward movement of health attainment and betterment for all is the goal of nursing. Standards of practice and competencies need continual review and revision to ensure they reflect current standards of care and practice.

When examining the nurses accountability to self, Leddy and pepper believe the nurse "must be the one responsible for maintaining her own mental and physical health and for keeping all aspects of her life in a balanced perspective" (1993, p. 277). Accountability to self involves the nurse being self-aware. Leddy and pepper note this includes "refusing to work in situations that she considers unsafe, either because of her own lack of knowledge or experience in an area or because of insufficient staffing or some other problem inherent in the situation itself" (1993, p. 277). Leddy and Pepper continue by noting the nurse must "acknowledge personal limitations and recognizing the need for further education to be more fully and safely perform the nursing role" (1993, p. 277). There are factors outside nursing which influence the nurses accountability to self. As Leddy and Pepper note "government can aid or hinder the nurses ability to do her best through legislation, funding of education and research and health care priorities. The nurse must consider political activism, a means to ensure accountability to self, as a method of bringing public policy and the most expert care into congruence" (1993, p. 277). Political activism includes lobbying efforts at both the individual and association level. Although the association has the protection of the public as its main mandate, it must also assume lobbying efforts on behalf of the profession to advance the expertise and knowledge of the psychiatric nurse in looking at the complex issues related to mental health care delivery. When a nurse recognizes limitations in their knowledge, skills and abilities, it is incumbent on every nurse to further increase their knowledge, be it through education, research or sharing of knowledge related to advanced practice.

Leadership

In describing leadership, Bennis and Nanus (cited in Leddy and Pepper, 1993 p. 397) state "leadership is what gives nursing its vision and its abilities to transform clients' health". They further note that "this transformation occurs through the leader's translation of vision into reality with clients" (cited in Leddy and Pepper, 1993 p. 397). Within this transformational relationship, Leddy and Pepper note it is "characterized by the sharing of power rather than the wielding of power by the nurse" (1993, p. 398). This leadership based on the sharing of power can have powerful impact on health policy decisions related to the delivery of health care. In describing how nurses can best use their leadership and power base, Leddy and Pepper state "nurses potentiate their power more when they unite using the power of numbers and associative power with the consumer to generate support for desired policies" (1993, p. 406). Leddy and Pepper further note that "the collective power of nurses exercising expert power with clients and interpersonal power with unified purposes could be a major force toward reshaping the health care delivery system" (1993, p. 406). When issues of importance are identified by our clients, psychiatric nurses have an obligation to work with clients to effect necessary change. If clients of mental health and psychiatric nurses' join together on health related issues, the numbers would be overwhelming. Strength comes in numbers in that the profile of issues are elevated in the public domain and decision and policy makers are then forced to not only look at the issue but to seek input from stakeholders as to how issues can best be dealt with.

Client Advocate

The nurse as a client advocate has positive implications for the client, the delivery of health care and the image of the profession in the eyes of the public.

Newman (cited in Leddy and Pepper, 1993 p.438) indicates that when the nurse acts as an advocate for the client "the professional enters into a partnership with the client with the mutual goal of participating in an authentic relationship, trusting that the process of its evolving, both will grow and become healthier. Our goal is not to change the client; rather, it is to be with the client as he identifies his concerns and the actions he wants to pursue". In this context, Leddy and Pepper note "power is shared and neither the nurse nor the client is placed in a dependent relationship" (1993, p. 438).

For the client, Leddy and Pepper indicate that "whenever the client perceives that the nurse not only has truly acted on his behalf to ensure adequate health care but also has respected his ability to assume responsibility for his own health and make his own decision, he grows in feelings of personal worth and competence, and the nurse gains respect and appreciation for professional services" (1993, p. 449). From this respect and appreciation for professional services, the morale of the professional psychiatric nurse could certainly be enhanced through increased satisfaction in knowing that the client has been empowered to help themselves.

In increasing respectability with the public, in acting as advocates, Leddy and Pepper state "the fulfillment of the advocacy role with clients, therefore, gives nurses excellent opportunities to influence society's image of nursing. It offers the opportunity to portray an image of a professional person who brings about a good result . . . and as giving selfless attention to a client's affairs" (1993, p. 449).

In examining how the nurse as a client advocate can change the delivery of health care, the perception of the public is important. Leddy and Pepper indicate that "public support cannot be underestimated. Both a public image of the nurse as competent and an appreciation of the nurse's advocacy efforts with build public support" (1993, p. 448). The importance of this public support is noted by Leddy and Pepper as being "one of the most powerful forces for change in society" (1993, p. 448). Having this support, Leddy and Pepper note "nursing can use the public's help to restructure the health care delivery system" (1993, p. 448). This support of the public has other benefits to nursing as Leddy and Pepper indicate that "as nurses gain the respect of the public they serve, the more likely they are to gain the respect of interdisciplinary peers" (1993, p. 448).

Change Agent

The role of change agent requires accountability, leadership and client advocacy on the part of the professional nurse. To act as a change agent, according to Leddy and Pepper, the nurse must as a first step "is to identify dissatisfaction with the current state" (1993, p. 418). When individuals are satisfied with the way things are, there can be little motivation to change. This can be viewed as resistance to change. In identifying this potential resistance, Leddy and Pepper note "the agent may need to unfreeze the organization by making persons receptive to change" (1993, p. 418). Strategies for making organizations receptive to change as described by Leddy and Pepper include "creation of dissatisfaction with the status quo, building in participation in the change, giving participants the time and the opportunity to disengage from the present state, and building in rewards for the desired behavior" (1993, p. 418).

Wooten and White (cited in Leddy and Pepper, 1993 pp. 426-427) have identified five basic change agent roles. These roles are educator/trainer, model, researcher/theoretician, technical expert and resource linker. These roles are filled by psychiatric nurses at every level of practice making the psychiatric nurse the ideal change agent. As an educator/trainer, the psychiatric nurse may be engaged in the formal education of other nurses or providing health teaching and education to clients and the communities that we serve. Psychiatric nurses through their practice act as models not only for other nurses but other professional and non-professional staff that we interact with every day. Our specialized knowledge, skills, experiences and abilities makes us the "technical" experts in the field of psychiatric mental health nursing. As nurses, particularly those in community, a large portion of our work is resource linking on behalf of the client and the agency.

When psychiatric nurses identify themselves as change agents, recognize the change agent roles we assume and combine that with accountability, leadership and advocacy on behalf of our clients, the therapeutic community can be maintained while expanding the role and scope of psychiatric nursing practice.

CONCLUSION

As discussed, many factors can threaten the establishment and continuance of the therapeutic community. These factors are interdependent on one another, as no one factor is solely responsible for potential disruption to the therapeutic community.

The professional psychiatric nurse is in a unique position to ensure the development and continuance of a therapeutic community be it at the unit level or the larger health care delivery system. Through demonstration of professional behaviours which include professional accountability, leadership, client advocacy and by acting as a change agent, the professional psychiatric nurse can ensure that the therapeutic community is maintained and thrives in the face of uncertainty in the ever changing and evolving health care system.

 

 

 

REFERENCE

Barofsky, I., Budson, R. (1983). The chronic psychiatric patient in the community: principles of treatment. Jamaica, New York: Spectrum

Duncan, K. (1997). Professional psychiatric nursing concepts (3rd ed.). New Westminster, British Columbia: Douglas College

Jones, D. (1998). Adjunctive therapies: issues and interventions in psychiatric nursing practice (4th ed.). New Westminster, British Columbia: Douglas College

Leddy, S., and Pepper, J.M. (1993). Conceptual bases of professional nursing (3rd ed.). Philadelphia, Pennsylvania: J. B. Lippincott

Littrell, K., Peabody, C.D. & Littrell, S.H. (1996). Olanzepine: A New Atypical Antipsychotic. Journal of Psychosocial Nursing, 34 (8), 41-46.

Ministry of Health Responsible for Seniors (1998). The 1998 mental health plan: revitalizing and rebalancing british columbia's mental health system. Victoria, British Columbia: Government of British Columbia

Pioneer Community Living Association (1997). Admission records and statistics. New Westminster, British Columbia: Pioneer Community Living Association

Pioneer Community Living Association (1998). Admission records and statistics. New Westminster, British Columbia: Pioneer Community Living Association

Registered Psychiatric Nurses Association of British Columbia (1995). Competencies expected of the beginning practitioner of psychiatric nursing standards of psychiatric nurses in british columbia code of ethics Coquitlam, British Columbia: Registered Psychiatric Nurses Association of British Columbia

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