N E T W O R KC r e a t i n g C o n n e c t i o n s

Volume 35 (Issue 2), 2011

ContentsCreating a Holistic Healing Environment on SB2 . . . . . . . . . . .page 1

From the Desk of Linda Flaherty . .page 2

Creative Writing at MSE:Another Tool for the Healing Journey . . .page 3

Bob Peterson, RN,Nursing Supervisor retires . . . . . .page 4

Coming Together to Improve Quality:Piloting the Staff Observed Aggression Scale . . . . . . . . . . . . . . . .page 5

Compassion Fatigue Management . . . . . . . . . . . . . . . .page 6

Recruiters Corner . . . . . . . . . . . .page 7

Night Owls . . . . . . . . . . . . . . . .page 8

Staff Highlights . . . . . . . . . . . . . . . .page 8

continued on page 2

Creating a Holistic Healing Environment on SB2

By Jill Standish RN, BSN, HNB-BC

Holistic nursing, which is aspecialty recognized by theAmerican Nursing

Association, has five core valuesdrawn from nursing philosophy andtheory, the caring process, therapeu-tic environment and communica-tion, education and research, andnursing self-care. As a team, MarisaSchuman, RN, and I provide holisticnursing care, focusing our attentionon healing the whole person (mind,body, spirit). We recently examinedthe dynamics of the SB2 unit, withthe goal of strengthening the healingenvironment for patients, one of themajor goals of holistic nursing.

A calm, secure atmosphere isparticularly important on SB2, theGeriatric unit, which cares forpatients ranging in age from late for-ties to late nineties. Our patients arein various stages of cognitive impair-ment, from mild to end stage. It isoften challenging for staff to care forpatients with such a wide range ofmemory deficits. Our unit can beover-stimulating at times. Patientsstart to wander. They frequentlybecome confused, difficult to redi-rect or console, and frightened byADL care. In a significant numberof cases, patients strike out at staffand other patients.

Staff members on the unit knowthat anxiety, aggression, and noise

levels increase at certain times of day,particularly during morning care andafter lunch, when sundowning mayoccur. Sundown syndrome usuallydevelops in late afternoon andextends into evening as the outsidelight changes. It refers to behaviorchanges that tend to escalate whenpatients sense that work is done forthe day. They may think that it istime for them to go home. Womenoften become worried about theirchildren. Not surprisingly, thesebehaviors frequently occur when theday shift is leaving for home.

We realized that the quality ofenvironment and caring is key.Florence Nightingale’s philosophy ofplacing the patient in the best envi-

Strengthening the healing environment

Nursing Network2

Iam pleased to announce that once again we will offerthe Career Development Fellowship to RegisteredNurses, licensed Social Workers, Group Therapists

(licensed as LMHC or LAD), Expressive Therapists,Activity Therapists, and licensed Occupational Therapists.

As you may remember, the fellowship provides finan-cial support for staff to work on projects that do not typi-cally fall under their existing job responsibilities. We arelooking for proposals that would enhance clinical care,improve clinical outcomes, or result in organizationalimprovement. Some examples of projects include: initiat-ing a research study, implementing a clinical quality proj-ect, or initiating a process improvement project.

Leslie Shapiro, LICSW, from the OCD Institute, andDeborah Mindnich, RN/PC, from the Clinical Evaluation

Center, were recipients of the first fellowship. Both Leslieand Deborah presented their findings at the 2011 McLeanHospital Research Day. In addition, Leslie published herresults in the Annals of Clinical Psychiatry. Her paper wastitled,“Development and Quality Assessment of a Psychoeducational Group to Address Pathological Guilt inObsessive Compulsive Disorder”.

Deborah will be presenting her study,“Suicide RiskAssessment in the Acute Setting: A Comparison of Selfand Clinician Ratings”, at the Annual American PsychiatricNursing Association Conference in October of 2011.

Should you have any questions regarding the CareerDevelopment Fellowship, please feel free to give me acall. ■

FROM THE DESK OF LINDA FLAHERTY, RN/PCSenior Vice President for Patient Care Services

Career Development Fellowship

Creating a Holistic HealingEnvironment on SB2continued from page 1

ronment for healing took on a newrelevance. We looked at Jean Watson’stheory of caring to modify ourapproach with patients. We devel-oped a plan that centers on relaxingmusic, therapeutic or caring touch,and aromatherapy to foster a caring,calm environment that helps patients,as well as families and staff, feel morerelaxed and less stressed.

To make these proposed changeseasy to understand and their imple-mentation more readily accepted, weprovided an experiential in-servicefor MHS staff to discuss ideas forhelping our patients cope with theiranxiety, and to explore ways to mini-mize sundown syndrome and after-noon aggression.

A few weeks ago, at shift change,Marisa and I set the scene by placingcomfortable chairs around the confer-

group, we ended with a ten-minuteguided imagery.

The ten participants, who feltcalmer, more relaxed, and more pres-ent after the session, were enthusiasticabout providing this type of experi-ence to their patients. We have sinceincorporated music, which is playedduring stressful times of the day, andhave had many positive commentsfrom people coming onto the unit.Caring touch is encouraged, andhand massages are currently offeredon an individual basis. We have notyet instituted a regular group. Thearomatherapy portion of our pro-gram is in process, as I continue towork on my aromatherapy certificatecourse. We plan to continue enhanc-ing the healing environment, as weexpand our knowledge and tech-niques over time.

We would love to share ourexcitement about this concept withany of you who are interested in try-ing these techniques on your unit.. ■

ence room table. We put a blanketon the back of each chair for anyonewho felt chilled by the air condition-ing. We brewed herbal tea, playedrelaxing Reiki music, and releasedthe scent of lavender into the room.After a brief introduction, Marisaspoke about the importance of caringtouch. We then asked everyone toteam up and offer his or her partnera gentle hand massage, using lotionscented with lavender. After explain-ing how this technique could be eas-ily implemented during an afternoon

Jill Standish, RN, gives Susan Chapski, MHS,a gentle hand massage

3Nursing Network

By Bella Doumbia, M.Ed

Creative Writing at MSE: Another Tool for the Healing Journey

continued on page 6

On a Wednesday afternoon atMSE, an announcementrings out over the intercom.

“Good afternoon, ladies and gentle-men. At 4:00 pm, there will be acreative writing session in the grouproom. See you there.Thank you.”Some patients are already waiting inthe room, while the staff encouragesothers to join the group. A few walkin slowly, with apparent apprehen-sion; still others peer in, waiting to becoaxed. “Writing is not for me,”some say, while others comment thatthey haven’t written since highschool. A few patients seem enthusi-astic: “Oh boy, what? Writing?”

When the group has gathered, Iintroduce myself as leader, and Idescribe the therapeutic characteris-tics of creative writing during a briefpsycho-education presentation.Mindfulness, the awareness of oneselfin the present moment, is the pri-mary use of creative writing in thetherapeutic milieu.

To begin, I coach patients tocheck in using the weather, flowers,or animals as metaphors to describehow they feel in the moment. Thishelps patients to see their thoughts ina different light. The next step is amindfulness exercise, like breathing orstretching, to help patients releasemuscular and emotional tension.Thegoal is to bring each patient’s con-

sciousness back into the present.Next, I give a writing prompt,

often using a story. Patients may ormay not find personal meaning in astory, and some may even want toengage exclusively in a dialogueabout what a particular story wasintended to mean.The therapeuticvalue, however, lies in each person’sresponse to the story. During a fif-teen-minute period, each patientwrites down thoughts and feelingsabout the prompt or anything elsethat arises from his or her innervoice.

“Where should I begin?” someask.

“Right here, right now,” I say.“In this very moment, write aboutyour experience.”

“Who would think that a simplepen lying on a table and begging tobe picked-up could be part of mymoment right here?” one patientcomments.

Today’s prompt is a story about achild’s search for treasure. She wan-

ders into nature and experienceseuphoria, serenity, and wholeness, asnature opens up its beauty to her.The patients are moved by the story.It provokes all their senses, and stirs awide range of emotions. Some writeabout feeling a connection with thechild. Two patients discover a parallelwith their own experiences. One isreminded of things she used to enjoy.Others want to detach from thestory, expressing discontentment.“How can I see beauty in the worldwhen all I see in my world is dark-ness?”

My role is to coach and guidepatients as they write what needs tobe written in their own voices: theirfeelings, thoughts, hopes, and dreamsin the moment. Natalie Goldberg, inher book Writing Down the Bones,suggests that “we do not ignore suf-fering, we acknowledge it, and writ-ing is the aim. It is an opportunityto take the emotions we felt manytimes and give them light, color anda story.” In that moment, Goldbergadds,“you can finally align how youfeel inside with the words you write,at that moment, you are free becauseyou are not fighting those thingsinside.”

Patients find writing therapeutic.“I have to remember about thethings I used to cherish while I amhere,” one patient writes. Anothercomments that “I’ve been stuck all

Bella Doumbia, M.EdMental Health Specialist

Nursing Network4

Alicia Allen, RN and Bob Peterson, RNBob receiving a gift from

Linda Flaherty, RN/PC, SVP Patient Care Services

Bob Peterson, RN, Nursing Supervisor, retires after 50 years of service to McLean Hospital.

Nurses celebrate with him and wish him well.

Congratulations Bob we will all miss you!

photos by Angson Dhlakama & Julie Fannon

Nursing Network 5

By Ivy Zang, MPH, RN

Coming Together to Improve Quality: Piloting the Staff-Observed Aggression Scale

Aggressive acts color daily lifeon inpatient psychiatric units.Name-calling, violence-

threatening, wall-punching, food-throwing, and head-banging character-ize the inpatient milieu at times.Although incidents that result inrestraint and seclusion or cause injuryare both documented in reports, whatabout all the aggressive acts that neverlead to restraint or injury? Some ofthose actions are described in varyingdetail in nursing progress notes. Often,however, they are seen as an unre-markable and expected part of themilieu that is not passed on to otherstaff members or the medical record.Is there a way to accurately measurethe level of and changes in aggressionon inpatient units, with the hope ofreducing the number and intensity ofthese events?

In June, NB2 and SB2 piloted theStaff Observed Aggression Scale-Revised (SOAS-R), with the dualgoals of measuring the frequency andseverity of all aggressive incidentsoccurring on the units, while deter-mining if the SOAS-R is the rightaggression-measuring tool to use atMcLean Hospital. Dr. Henk Nijmandeveloped the SOAS-R in theNetherlands in 1999. It has since beenvalidated in numerous countries, withmany different inpatient psychiatricpopulations. We aimed to determine ifthe SOAS-R accurately captures thedifferent kinds of aggression that occur

at McLeanHospital, and ifstaff memberscan quickly andeffectively usethe tool to doc-ument inci-dents.

The formhas five check-off columnsthat recordprovocation of aggressive incident,means, target, consequences for thevictim, and actions taken by staff tominimize the aggression. The SOAS-R also contains a visual analog scale,which staff members use to record asubjective rating of aggression severi-ty.

At the end of May, as we pre-pared to launch the pilot program, weran group and individual educationalsessions, during which nursing staffon all shifts were encouraged to fillout an SOAS-R form for a recentincident of aggression. Staff membersneeded minimal instruction to fill outthe forms, and reported that the toolappeared easy to use. However, theyvoiced dissatisfaction with the limitedoptions provided by Nijman in the“measures to stop the aggression” col-umn. We added five additional meas-ures to the tool, based on staff sugges-tions and the primary standards ofcare for patients on NB2 and SB2.

The SOAS-R pilot was launched

on NB2 and SB2 on June 1st. Weframed the project as an opportunityfor nursing staff to quantitatively showthe intensity of their workload to therest of the McLean community, and tohelp staff identify potential areas forimprovement. On both units, staffmembers were immediately responsive,and a majority filled out the formsduring the first eleven days of themonth.

At the end of August, we con-ducted a group session with NB2and SB2 staff members to discusstheir experiences with the tool.Feedback was mostly positive, andnurses on SB2 offered their reactions.Ginybel Belgira described the SOAS-R as “fine and easy to use.” AmandaCasparriello reported that the tool“only takes 30 seconds” to use. JillStandish said that the forms “made alot of us think about the day-in, day-out stuff that we take for granted.”Jill identified an unexpected benefitto the tool, noting that if we contin-ue to take aggression in the milieufor granted, we will not work tominimize it.

Despite the generally positivefeedback, NB2 and SB2 staff mem-bers discovered a number of short-comings with Nijman’s tool whenused in practice. Due to Nijman’slimited options for provocation, stafffrequently checked “other” anddescribed the provocation in adetailed narrative, thereby losing theefficiency and simplicity intended bythe tool’s designer. Staff membersidentified that Nijman’s vocabulary

Ivy Zang, MPH, RN

continued on page 6

6 Nursing Network

Creative Writing at MSE:Another Tool for the Healing Journeycontinued from page 3

morning, and it feels good to write about it.“ “Thisexercise has been a good outlet to observe my feelings,”interjected another. Patients share their writings andgive each other feedback. They find themselves laugh-ing, crying, applauding, and “ready to face the storm,” asone patient expresses it.

Creative writing encourages patients to deal withtheir own worlds and their own pain. With the coach-ing of the group leader, patients learn skills that enablethem to come to terms with their feelings and identifyhealthy coping mechanisms. The writing process givesthe patient and the group leader a common reference asthey engage in a healing journey. It inspires patients toexplore their feelings, while offering each other supportas a community with shared interests.

One of the treatment approaches at MSE is patienteducation to improve understanding of illness and tostrengthen coping skills. As an educational tool, the cre-ative writing group at MSE has provided many benefitsin multiple diagnoses centers. I love to use this tool toinitiate change from unhealthy behaviors to healthy onesin the everyday lives of patients.That is the strength ofthe creative writing group. So let’s start writing.

Acknowledgments: Joan Kovach, MS, NursingDirector at MSE, who suggested that I write this article,and Lois Choi-Kain, MD, Gunderson Residence atMclean Hospital, encouraged me to usemy passion for creative writing as a skillscoaching tool in their respectivedepartments.

Thank you!. ■

by Sandy Tocchio, RN

Compassion FatigueManagement

Fatigued.Alarm Rings.Hurry and get ready.Have to be ahead of the buses and the train.Oh no, the traffic is slow—it’s starting to rain.Have to punch a time clock, get report, give out meds.Rounds on time,Notes to write,Demands ringing in my head.Discharges lined up,Belongings returned.We sit with the patients, they talk ofWhat they learned.They tell of their racing thoughtsAnd stress and their shame.We also sit and listen but our mindsDo the same.We’re the teachers. Examples of how to live-Slow down. Deep breathe. Limit how muchYou give.Keep in touch with friends and family.Laugh often and robust.Walk, exerciseAnd music is a must.Sit in the sunlightEat healthyMeditate and be mindfulPray daily.Renewed. ■

Nursing Network 7

RECRUITER’S

CORNER

TH

E

By Michele Bartick, RN

In the past few months there hasbeen a steady flow of new hiresfor Nursing.There have also been

a multitude of applicants. Reflectingon recruiting goals, one ever-presentpriority, as we review all of the appli-cants, is to find the person whowould be the best fit for the job.The“best fit” notion seems obvious, butthere are many factors that can deter-mine what makes a good fit. It is notalways the obvious.

For the applicant seeking a posi-tion at McLean, there is much toconsider in finding the right job.Preferences in the type of unit,patient population, shift and hoursworked, are all important factors tokeep in mind. Realizing preferencescan contribute to feeling more satis-fied on the job later on. It is onething to get a job, but yet another tomake it work, find it satisfying and

Michele Bartick, nurse recruiter

keep it a good fit.In today’s busy world, it is

important for the applicant to con-sider how a particular job will inter-face with other commitments andfuture goals. Respecting that a newjob will require time for orientationand extra attention initially is essen-tial. Maintaining the focus to meetthe demands of the job is critical toretain the job.

For recruiters and hiring man-agers, the criteria for “best fit” often-times change according to the joband include many factors.Theresume provides much of the basicinformation and nothing can substi-tute for a clear, well written resume.Education, amount of experience in

Coming Together to ImproveQuality: Piloting the StaffObserved Aggression Scalecontinued from page 5

the field, other work and life experi-ences are all considered as the appli-cation is reviewed. It is the interest inthe resume that moves a manger towant to interview. It is the actualinterview process that allows themanager to determine whether thiscandidate will be the best fit.

Meeting the candidate in personin the interview allows time to assessother important factors which aremore intangible. Being on time,knowing where to meet and dressingprofessionally are interview essentials.Coming prepared with questions,showing enthusiasm in the particularpatient population, and presenting alevel of commitment to doing thework all add volumes to potentiallybecoming the new hire. Looking forsomeone who is a team player, flexi-ble, and willing to learn new skillsare additional factors to consider.

As recruiters, we strive to alwaysfind the most well suited candidatefor the job. In this economic cli-mate, there are many well qualifiedapplicants and it is oftentimes diffi-cult for managers to decide on thebest fit. All job opportunities atMclean Hospital are posted on ourwebsite. ■

and formatting made the formtedious to use. The complicatedphrasing led to a frequent misreadingof “consequences for the victim” as“consequences for the patient.” Staff

members also cited multiple aggressiveincidents that took place on units thatdid not fit into the confined spaces ofthe form.

Using data analysis and feedbackfrom the inpatient staff, we haverevised the form, which will bereleased in August. “Staff redirection”as a provocation and “non-verbalaggression” as a means have beenadded to the form, and the formatting

and vocabulary have been simplifiedfor easier use. To encourage sus-tained enthusiasm for the secondstage of the pilot, weekly updateswill be posted for unit staff.

Only with research is effectivechange possible. Thank you to allthe wonderful staff on SB2 and NB2for their enthusiasm and willingnessto try something new. ■

Nursing Network8

Senior Vice President for Patient Care ServicesLinda Flaherty, RN/PC

Managing EditorStaff DevelopmentJulie Fannon, RN/PC

Network Committee

Mclean News, contributing articles

Pat Brain, MHS, Contributing WriterSheila Evans, RN/PC, Contributing EditorMichele Bartick, RN, Contributing WriterStephanie Marshall, Editorial AssistantLinda Hewitt, Editorial ConsultantLynne Foy, Graphic Designer

Department of Nursing

McLean Hospital’s Nursing Network,is published by the Department ofNursing to focus on patient care issuesand approaches, and to showcase theaccomplishments of staff members.Comments and story suggestions arewelcomed and should be directed toNursing Network, Dept. of Nursing,Administration Building,c/o Julie Fannon, or email jfannon@partners.org.

NIGHT OWLSNight Owls features news of interest

about McLean’s Nursing night staff. Sendsubmissions to Pat Brain, MHS,AB2.

Martha Fairbrother, RN/PH1:Martha recently had the opportunityto attend a conference on Addictionsat Harvard University.

Mary Fortune-Lewis, MHS/PH2:Mary recently spent two weeks vaca-tion visiting her family in Trinidad.

Wei-Che Ko, MHS/STU:Wei-Che wishes to continue his

graduate studies, so will be leaving his40-hour position to go per diem onthe STU.

Jennifer Sood, RN/STU:Jennifer was invited to attend theNortheastern Veteran’s AdministrationNursing Alliance Seminar forBoston’s V.A. Hospital.

Sam Ogwalo, CRC/PAV:Sam will return to working on hisPhD, so will be leaving his weekendpackage position.

Joseph Kabartas, CRC/PAV:Joe retired this past July after 37 yearsat McLean. Both a dinner and abreakfast were held in his honor forstaff to say good-bye and wish himwell as he plans to now focus on hisart and his interest in politics.

Dylan Smith, CRC/PAV:Dylan has left his position in MedicalRecords and has accepted a 40-hournight position on the Pavilion. ■

Lindsay Bradshaw, RN/MSE:Lindsay has started her active militaryservice leave with the Army. After train-ing in Texas, she will be stationed at FortCarson, Colorado.

Walkerson Bastia, MHS/NB2:Staff gave a warm welcome back toWalkerson on August 2nd when hereturned from his latest military leave ofabsence. During his year-long deploy-ment, staff sent care packages to himand his unit. This was his fourthdeployment, and he is very happy to beback.

Brooke Katz, RN/SB2:This past June, Brooke received herMasters in Psychiatric Nursing fromNortheastern University.

SB2 Welcomes New Babies!Heather Bullis, RN has a new son,Theodore.Marie Engo, MHS, also has a new sonnamed David Ryan.Ruth Wagner, RN welcomed her newdaughter, Summer Louise.

David Johnson, PMHNP, BC/PH1:Recently passing his certification exam,David is now certified as a psychiatricmental health nurse practitioner, boardcertified. David started at McLean inDecember of 2003 on PH1 as a mentalhealth specialist. You’ve come a longway, David!

Sarah Gambell, MHS/PH1:Sarah recently passed her LICSW examand is now a licensed social worker inthe state of Massachusetts.

Tiffany Parcell, RN/SB1:Formerly an MHS on SB1,Tiffanypassed the nursing boards this summer,and is now an RN on SB1. ■

Staff Highlights