Calming the milieu: Reducing Stress via Creativity and Connection

1. Calming the milieu: Reducing Stress via Creativity and Connection Kathleen R. Delaney, PhD, PMH-NP Professor Rush College of Nursing

4. Well Known Factors Hectic Competing demands on nursing staff Paper work Pressures Internal Pressures Administrative- Keep beds full State/local- Find a bed for any client. Short LOS Discharges and admissions Fluctuating acuity Inflexible staffing

5. Particular focus will be Inpatient Child and Adolescent Units : These children add additional dimensions Inpatient units are populated by children with regulation issues Disruptive Behavior Disorders Anxiety Post-Traumatic Stress Bi-Polar Disorder Autistic Spectrum

6. Self-regulation theory is a key platform for this approach Self-regulation is concerned with how one brain system governs the reaction of another. Particular building blocks of self-regulation: attention control, inhibitory control, emotional suppression and response flexibility

8. Keeping the noise and pace of a milieu at an acceptable range: Level of skill development Keeping outward calm Using space to create sense of calm, splitting group, positioning children in the group. Using all available resources (staff: talent and numbers). These techniques are in : Delaney, K. R. (1994). Calming an escalated inpatient milieu. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 7(3), 5-13. Skills: Top down Techniques

9. Today is about the bottom-up strategies for building Safe milieus

11. Basic Premise: Achieve a safe milieu via Connection with clients

12. Three Conditions/Platforms For Safety via Connection

13. Three Platforms are Drawn from Len Bower�s Inpatient Model

14. Tools for Developing Positive Appreciation of Clients Develop a Philosophy of the Unit: How patients should be treated Weave in a sense of how you expect patients to heal/regain a sense of control/ while in the hospital Children � afford them a sense of mastery and self-efficacy, a sense of their evolving narrative and self

15. Four Kellogg� All behavior has meaning. To therapeutically intervene with a child, staff they must first understand the meaning of a particular behavior. �� Relationships matter. Learning and growth occur in the context of a relationship. �� Children ask only for as much as they need. Staff works with the child to achieve an understanding of any limitations of what the adult world can provide. � Children vary in their ability to process information, sort stimuli, and manage their emotions. By experiencing the child�s ability to meet milieu expectations staff determine the amount of structure and clarity the child needs to function Competence matters. Staff structure educational and social experiences so the child�s sense of competence � The goal of all interventions is to help the child achieve self-regulation. Rules and norms need to be flexible enough to service the needs of the child. � Children should experience joy in their lives. The environment is structured to enhance the child�s experience of joy and pleasure with themselves, peers and adults. � Empathic resonance with a child�s self state enables staff to intervene and bolster the child�s faltering functions (the ability to deal with demands, frustrations and powerful affects). Through this repeated, reliable and consistent attunement, the child gradually takes on staff�s organizing, affirming and soothing functions.

17. Second Foundation for Connection

18. Needs-based involvement requires staff have a sense of purpose and control of practice Support Democratization Empowerment

19. Vehicles for Creating Staff Decisional Control-Democratization Regular meetings where issues are aired, staff has a voice in reaching solutions Front �line managers that understand the purpose of staff�s work and advocate for space, time and staffing to accomplish it Building a philosophy that includes patients� and staff�s voice in decision Develop the first component of this platform- STAFF SENSE OF PURPOSE

22. Why controlling one�s own emotional response is crucial: Mindful Behavior Being mindful means having intention in your actions. You purposively choose your behavior with the idea of your patient�s well being. Only then can we begin to not only grasp patient�s narrative of illness but feel our way into the patient�s felt experience

23.  The ability to forge an experiential-connect is a talent that nurses cultivate Responding to patients� Expectations, worries, hopes

24. For Children: Why space between action and response is critical. Key elements of Connection Empathic attunement with affects Maintaining a positive tone to interactions Monitor for threatening tone

25. The final platform deals with how a staff uses space, constructs interactions & structure of day

28. Children/Adolescents may have difficulties with meeting milieu expectations Increased Threat Perception Response Flexibility Processing expectations Keep expectations in line with a child�s ability to process expectations Patterning a child�s reaction to the un-expected and complex social situations Structure mixed with tolerance: Rules can be bent for a good enough reason