Favourable Hospital Environment

Attention to the hospital environment can make the period of hospitalization a more positive experience for patients. For example, flexible visiting times will encourage continued contact between the patient, family and friends. Personal comfort and respect for individual privacy should be encouraged, with an emphasis on small but important details such as diet, access to and safety of personal possessions, access to phones, and provision of accurate information about the expected length of stay. Staff can help to demystify and humanize the experience of hospitalization, rather than the opposite.

A specific unit for young patients with psychosis is ideal, but not always achievable. Exposure to older patients with chronic mental illness can be a distressing and demoralizing experience. Staff can become desensitized to the typical environment of an acute psychiatric unit, but should not underestimate how frightening and distressing it can be for young people and their families.

Calm but sociable wards facilitate recovery, and distraught but disorganized patients benefit from a ward environment that reduces environmental chaos [66]. In the absence of a specialized early psychosis unit, in addition to the demarcation of specific early psychosis beds, it may be possible to provide a meaningful activity programme in as relaxed an atmosphere as possible for inpatients away from the ward, aimed at reducing negative symptoms, encouraging the development of social skills and improving self-esteem. This can begin the process of patients gradually developing more insight, acquiring coping strategies and resuming responsibility before being discharged.

Staff in an early psychosis inpatient unit must strive to allow flexibility in their management of patients, with considerable tolerance of ''normal'' adolescent behaviour and an effort to accept frustration, anger and other emotions as normal reactions to illness. Such flexibility must be balanced by the need to maintain safety. It often necessitates a compromise in the desire of staff to ''control'' all aspects of patients' behaviour and to ''win'' each potential confrontation. This approach is more dependent on the culture of the unit than on a high level of resources.

The ward, which should be of modest size (12-16 beds maximum), should not be locked, but a small lockable intensive care area should be available for aggressive patients and for those who are at high risk of absconding when safety is an issue. At least one nurse should be on duty for each four patients. With patients at high risk of self-harm, one-to-one nursing is preferable to placing the patient in a locked area with agitated or aggressive patients. A policy of low-dose antipsychotic therapy and avoidance of excessive sedation is adopted in order to enhance the outcomes for patients, but it adds to the demands on nursing staff. However, night-time sedation with benzodiazepines should be freely available.

Ward routines should be less rigid than in other units. For example, there should be flexibility as to when patients get out of bed each day, when they eat, and when they have visitors. Family members or friends should be able to stay overnight on the ward if this assists in reducing anxiety and distress. This is the mirror-image of the home-based care model.

Whenever possible, treatment, including medication, should be negotiated with patients rather than imposed without discussion. For example, patients are allowed some time and actively assisted to gain control over their behaviour wherever possible, before involuntary use of medication. Openness to negotiation increases the prospects for engagement with staff and for long-term compliance.

On their first admission, patients should be given a tour of the unit with a clear statement about the rules of the ward, including respect for others. Specific fears can be addressed with information, explanation and reassurance. Staff can clarify the reason for admission, the likely course and duration of treatment, and the plans for discharge.

Anxiety and Depression 101

Anxiety and Depression 101

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