Staff Builders provides mental health aide class

How do you take a group of certified nursing assistants who have had little formal education and train them to specialize in dealing with some of the most complex home care cases? Staff Builders of Lake Success, NY, put time, money, and personnel resources into creating a comprehensive training protocol that prepares home health aides to deliver care to mentally ill patients.

Program development took two years, including the time spent piloting the program in Staff Builders agencies, says Carolyn Scott, RN, MS, national coordinator of the behavioral health program for Staff Builders Home Health Care in Chicago. Scott developed the program along with Verna Benner Carson, PhD, RN, CSP, national director of behavioral health for Staff Builders Home Health & Hospice in Fallston, MD. Carson has co-written a psychiatric textbook for nurses, Mental Health Nursing: The Nurse-Patient Journey.1

Scott and Carson spoke about how to prepare mental health aides at the recent National Association for Home Care conference in Atlanta.

Staff Builders’ mental health aide program is divided into four segments of two hours each. Trainers are given a packet of information including handouts for participants and a post-test that must be passed with 75% accuracy. (See post-test, p. 183.) Trainers attend to these details:

• determine who will follow up on training effectiveness;

• create a form for attendance;

• develop a tracking system for training?

• invite and screen aides;

• reserve training room;

• make time for training;

• provide training materials;

• serve refreshments.

The training material includes hard copies and transparencies for each of the four sections. Aides receive the handouts, and instructors have the outlines. (See handouts, inserted in this issue.) An instructor’s outline clearly states the objectives, content, teaching strategies, and evaluation strategies, referring instructors to appropriate pages in the training packet. Here’s how one might look:

CLASS 1: What is mental illness?

TIME: Two hours

OBJECTIVES: After the class, the aides should be able to:

1. State four symptoms of schizophrenia.

2. State four symptoms of depression.

3. State four symptoms of mania.

4. State four symptoms of anxiety.

5. State four symptoms of borderline personality disorder.

6. Complete handout with 75% accuracy.

7. Complete post-test with 75% accuracy.

CONTENT: See pages (insert page numbers) for content and post-test.

TEACHING STRATEGIES:

1. Give lecture on content. Use examples through out, preferably of patients with whom the aides are familiar; this will make the material come alive.

2. Use written case scenarios for the aides to read and complete.

3. Provide handout on content.

EVALUATION STRATEGIES:

1. Participants are able to complete handout on case scenarios with 75% accuracy.

2. Post-test to evaluate knowledge (if aide does not score 75%, consider reviewing areas of deficiency and re-testing).

Scott explains that the four two-hour segments in Staff Builders’ training program for mental health aides cover the following issues:

1. What is mental illness?

There are four key points that describe mental illness, Scott says:

• affects thinking and moods;

• can be acute or chronic;

• affects everyday functioning;

• can be caused by brain diseases.

"Then the instructor talks about how patience and acceptance are essential when working with mentally ill patients, and the goal is to make the patient as independent as possible. Some times you need interventions, like limit setting, attention to boundaries, and behavioral contracts," she says.

Next, instructors discuss the major types of mental illness, which are thought disorders, anxiety disorders, borderline personality disorders, and mood disorders such as major depression and bipolar anxiety disorders. Instructors describe each mental illness type in detail:

• Schizophrenia is a thought disorder characterized by thinking problems, hallucinations, delusions, trouble functioning, relationship problems, communication problems, and strange affect.

• Major depression is a mood disorder characterized by sadness or irritability; no interest in life; changes in sleep, appetite, and weight; lack of energy; anxious pacing; feelings of worthlessness; and suicidal ideation.

• Bipolar illness includes major depression or mania. A patient may be irritable, hyperactive, fast-talking, having grandiose thoughts, going without sleep, not eating much, and disdaining treatment.

• Patients with anxiety disorders — including generalized anxiety, panic disorder, and obsessive-compulsive disorder — worry a lot and may be at risk for suicide. Medication and therapy help.

• Borderline personality disorder patients characteristically have intense unstable relationships, feelings of love/hate toward others, and fear of rejection. They need firm boundaries, consistency, and patience.

2. What is the role of the mental health aide?

"The role includes encouraging independence with personal care and being a sounding board, reinforcing the nurse’s plan, and oftentimes being a role model," Scott says. Also, the agency expects mental health aides to inform the nurses of any concerns.

Personal characteristics include empathy, a nonjudgmental attitude, responsibility, and the ability to set limits, maintain boundaries, and help patients maintain dignity and feel accepted.

"We try to educate them about the difference between a professional therapeutic relationship and a social relationship because many times aides, and even nurses, get their roles mixed up," Scott says. A social relationship, for example, is based on friendship. Both parties get their needs met; spontaneity is the rule, and there is an equal sharing of personal concerns.

"A therapeutic relationship means the focus is on the patient, and the patient is accepted without judgment," she says. "And the focus also is on the treatment goals set up in the nurse’s care plan." In addition, aides schedule time to see patients, so visits aren’t spontaneous, and promptness and reliability are very important.

Then instructors discuss personal space and how important it can be to psychiatric patients. "Particularly with schizophrenics, if you get too close to them or touch them, they have a real problem with your stepping into their space," Scott explains. "We tell aides they need to give patients 1½ to two feet of space when talking with them." Limits on touching should be set. Neither aides nor patients should engage in inappropriate touching.

Instructors cover good communication skills, such as exhibiting empathy and kindness. They teach aides how to deal with hallucinations or delusions by not challenging them but accepting them as a patient’s current reality. Aides must learn to solve problems and deal with criticism and anger. They also learn about "boundaries," which means setting limits and communicating them in a firm but respectful manner.

Finally, they outline the agency’s care plans for psychiatric patients. Care plans are divided into three sections: physical and mental status assessment, patient’s knowledge, and the patient’s skills.

The health status or physical assessment care plan includes the following:

• vital signs;

• observation;

• sleep and appetite;

• patient complaints;

• dangerous behaviors;

• direct care;

• mood behaviors;

• safety concerns.

The patient’s knowledge care plan reinforces the nurse’s teaching about medicines, illness, use of 911, and nutrition. The patient’s skills care plan covers the following:

• skin care;

• safe transfer;

• personal care;

• coping skills;

• socially appropriate behavior.

3. Overview of psychiatric medications.

Instructors give aides a simplified overview of psychiatric medication. "This is so they can be the eyes and ears of nurses if side effects should pop up," Scott says. "We give them a whole list of side effects to educate them about what may be a problem and when to call the nurse if they see these."

Instructors discuss antidepressants, major tranquilizers or neuroleptics, mood stabilizers such as Lithium, anti-anxiety drugs, and a combination or "drug cocktail" of those medications. Common side effects include constipation, blurred vision, drowsiness, restlessness, weight gain, slow movement, dry mouth, anxiety, urinary retention, drooling, photosensitivity, impotence, and blood pressure drops when standing.

There also is a handout on serious side effects that might be life-threatening. Serious side effects include vital sign changes, muscle rigidity, confusion, muscle aches, nausea, vomiting, diarrhea, tremors, signs of infection, problems with speech, strange movements, seizures, sweating, and eyes rolling back.

4. Psychiatric emergencies: Treatment plans and documentation.

Instructors tell aides what to do in cases of psychiatric emergencies so they know exactly what procedure to follow in alerting the nurse and agency, Scott says. "It might mean they have to call 911 themselves and have an ambulance or police come for the patient if it’s an imminent situation," she explains. For example, if a patient appears to be suicidal or is exhibiting self-destructive behavior, the aide should stay with the patient, take all threats seriously, and call the nurse. However, if a patient appears to be homicidal or is exhibiting aggressive behavior, the aide must get to safety and call for help.

Instructors define the term "escalating behavior," which refers to behavior that appears to be growing in intensity. This might involve angry looks, threats and other angry words, pacing, and making fists. When a patient exhibits escalating behavior, the aide should do the following:

• don’t challenge the patient;

• don’t argue;

• stay calm;

• try to keep the patient talking;

• reassure the patient;

• keep a safe distance from the patient.

"We tell aides they need to stay between the patient and the door, so the patient is never blocking them from the door," Scott says.

The final lesson also covers the treatment plan and documentation. "We tell aides to write what they observe and to not give an opinion or judgment. Stick to the facts and write down the patient’s words and about the specific care given."

Reference

1. Carson VB, Arnold EN. Mental Health Nursing: The Nurse-Patient Journey. Philadelphia: W.B. Saunders; 1996.