TOPIC. A psychiatric intensive care unit shown to be of value to patients and staff was closed within a year, ostensibly for economic reasons
PURPOSE. To examine the usefulness of psychiatric intensive care units, and the importance of thinking through the ramifications of downsizing
SOURCE. A case study of a psychiatric ICU in Northern Ontario, Canada and a review of the literature
CONCLUSIONS. When downsizing is considered, a careful examination of values must take place, remembering patient care comes first.
Key words: Dignity, downsizing, psychiatric intensive care units
Psychiatric mental health nurses are frequently called upon to care for patients who are acutely psychotic, aggressive, highly destructive, suicidal, or at risk of elopement. Traditionally, "management strategies" of such patients have included the use of physical restraints, seclusion rooms, or constant one-to-one observation. These strategies have been critized on grounds of ethics, economics, and efficacy. In general hospitals, intensive care units have been a place to provide care for acutely physically ill patients since the 1950s (Fairman, 1992). In psychiatric settings, psychiatric intensive care units (PICUs) have evolved as an a way to care for patients with acute needs (Allen, Brown & Laury, 1988; Craig, Ray, & Hix, 1989; Moldin, 1984, Musisi, Wasylenki, & Rapp, 1989; Rachlin, 1973; Warneke, 1986).
The fundamental purpose of PICUs is to create a safe and controlled environment where intensive nursing care can be provided for psychiatric patients whose behavior warrants unusual vigilance. The underlying presupposition is that intensive nursing care will help the patient move to a more adaptive level of functioning without the loss of dignity that is inevitable with the use of chemical and mechanic restraints, seclusion or constant observation. The period of care in the PICU is short- term after which the patient is integrated into, or perhaps returned to, a general patient unit.
Studies document that PICUs are effectively fulfilling their purpose. Craig et al. (1989) found a reduction in the use of restraints when a patient unit was renovated to segregate one part as an intensive care area. Musisi et al. (1989) reported a reduction in constant observation and seclusion hours as well as a reduction in numbers of patients requiring seclusion after the opening of a PICU. Tooke and Brown (1992) found that patients in a five-bed secure area, separated from another unit by two locked doors, reported more positive feelings of safety, relief, control and satisfaction than patients in locked rooms. Norris and Kennedy (1992) conducted an exploratory and descriptive study on patients' perceptions of the seclusion process and their suggestions for its improvement. They found patients desired dignity, understanding and reassurance during seclusion, which the authors believed was more consistent with intensive care than isolation.
The positive outcomes resulting from the use of PICUs are reported not only from the patients' perspective; nurses also appreciate the opportunity to give highly skilled care in an environment conducive to doing so (Musisi et al., 1989). When patients needing intensive care are housed on a general patient unit, concerns about the safety of other patients and staff can override therapeutic considerations of the individual patient. Patients requiring extra vigilance on a general patient unit put nurses in the position of standing guard or "policing" behavior. Not only are the patients' dignities compromised by treatment they may consider punitive, but also nurses are not able to provide the kind of humane and therapeutic care of which they are capable and which they find satisfying. In a PICU, however, because nurses are relieved of the necessity of intensive one-to- one vigilance, they are free to concentrate on their specialized role. Most of all, they are able to direct their energy to engaging in the kind of therapeutic interactions that facilitates the patient's return to optimal functioning. …