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Acute Inpatient Psychiatric Nursing: Section 2 Crisis Stabilization

Instructor-led deck for Ontario AIPU practice: crisis phases, suicide risk, concurrent disorders, withdrawal/OAT safety, and trauma-informed stabilization.

Reveal.js local build Speaker notes included Ontario AIPU lens

Section 2 map

The Elevation Suite

2.1
Advanced crisis intervention and BERT/Code White thinking
2.2
Suicide risk, lethality inquiry, and safety planning
2.3
Concurrent disorders, withdrawal, harm reduction, and OAT
2.4
Trauma-informed crisis intervention and post-crisis repair

Instructor frame

Crisis stabilization is not containment alone

Immediate goal

Prevent harm, reduce physiological arousal, preserve dignity, and keep options open.

Longer goal

Leave the patient less isolated, less ashamed, and more likely to accept help next time.

2.1 Crisis phases

Caplan's crisis curve: intervene before behaviour narrows

Phase 1
Usual coping still available
Phase 2
Trial-and-error, rising anxiety
Phase 3
Panic, automatic relief behaviours
Phase 4
Disorganization and unsafe behaviour

2.1

Phase-specific nursing moves

Phases 1-2

Listen, name the problem, offer choices, reduce stimuli, use brief intervention.

Phase 3

Short phrases, fewer choices, one speaker, safety support nearby.

Phase 4

Team response, role clarity, environmental control, medication pathway if ordered, least-restrictive safety action.

2.1 Brief intervention

FRAMES keeps the nurse collaborative under pressure

Feedback Responsibility Advice Menu Empathy Self-efficacy

2.1 BERT / Code White

Activation is a clinical decision, not a failure

PMH nurse
assessment, medication pathway, continuity
Security / response team
scene safety and role discipline
Social work / peer / allied health
context, support, repair

2.1 Simulation

The chair-throwing moment

Scenario

A patient is crying, incoherent, and has thrown a chair in the common area.

Instructor task

Have learners assign roles before anyone enters the patient's space.

2.1

Environmental change is treatment

Reduce
noise, audience, bright light, demands, competing voices.
Increase
space, exit access, predictability, clear roles, simple choices.
Protect
other patients, privacy, staff safety, dignity, evidence.

2.1 Post-crisis

Debrief turns an incident into prevention

Patient debrief

"What was happening for you before we saw the escalation?"

Team debrief

"What was the earliest cue, and what would we try sooner next time?"

Debriefing should not become interrogation, blame, or forced trauma disclosure.

2.2 Suicide prevention

Direct inquiry is therapeutic

Asking clearly about suicide does not plant the idea. It names the risk, reduces isolation, and creates a pathway to safety.

Try: "When you say you do not want to wake up, are you thinking about killing yourself?"

2.2

The four pillars of lethality inquiry

Plan Method Access Intent

2.2

Janet's ambiguous cue

"Everyone would be better off if I went to sleep and did not wake up."

Less useful
"You don't really mean that, right?"
More useful
"Are you thinking about killing yourself?"

2.2 Tools

Use tools to structure judgment, not replace it

C-SSRS

Plain-language questions about ideation, behaviour, intensity, and acuity.

Clinical formulation

Dynamic risk, protective factors, environment, access to means, and current presentation.

2.2 Environment

Risk assessment must change the room

Ligature

Cords, belts, drawstrings, sheets, anchor points.

Sharps and toxins

Razors, glass, medications, cleaning products, contraband.

Observation

Visibility, bathroom risk, line of sight, handoff precision.

2.2

Collaborative safety planning beats contracts

Warning signs Internal coping People and places Support contacts Professional help Means safety

2.2 Canada resource

9-8-8 belongs in the plan, not only on a poster

9-8-8 is Canada's suicide crisis helpline. It can be included in discharge, pass planning, and collaborative safety plans when appropriate.

2.3 Concurrent disorders

No wrong door means assess both

Mental health

Mood, psychosis, trauma, suicidality, cognition, sleep, medications.

Substance use

Substance, amount, route, last use, tolerance, withdrawal history, overdose history.

2.3 Harm reduction

Harm reduction is clinical realism plus respect

Meet
the person where they are.
Reduce
overdose, infection, withdrawal, injury, shame.
Keep
the door open for treatment and recovery.

2.3 Opioid toxicity

The overdose triad is a rapid-action pattern

Pinpoint pupils Respiratory depression Decreased level of consciousness

Act on breathing and level of consciousness. Naloxone does not replace airway and monitoring.

2.3 Withdrawal tracker

Alcohol withdrawal can become a medical emergency

Timeline often rises after last drink; severe risk can emerge over days Cues tremor, sweating, anxiety, tachycardia, hypertension, agitation Tool CIWA-Ar structures monitoring where local policy uses it Safety benzodiazepine pathway, thiamine, fluids, seizure/DT vigilance

2.3

Arnell at 48 hours

Cues

Pounding headache, visible tremor, sweating, anxiety, rising vital signs.

Nursing priority

Score using local withdrawal tool, check vitals, escalate per protocol, prevent seizures and delirium tremens.

2.3 OAT safety

Methadone safety is tolerance safety

If doses have been missed, verify the OAT order, last observed dose, local protocol, and prescriber/pharmacy direction before administration.

Teaching point: missed doses can reduce tolerance and increase overdose risk.

2.3

Urine drug screening is data, not punishment

Use clinically

Inform withdrawal risk, overdose risk, medication interactions, and treatment planning.

Avoid stigma

Do not use results to shame, threaten, or invalidate the patient's account.

2.3 Secondary data

Substance use assessment includes body systems

Infection
HIV, hepatitis C, wounds, endocarditis risk.
Nutrition
Thiamine, folate, dehydration, electrolyte risk.
Pain
Tolerance, undertreatment, withdrawal, trauma, injury.

2.4 Trauma-informed crisis

Universal precaution changes the first move

Assume the person may have a trauma history. Reduce coercion, explain what happens next, ask before touch, preserve dignity, and offer choice where possible.

2.4

Six principles in a crisis moment

Safety
Trustworthiness
Peer support
Collaboration
Voice and choice
Cultural, historical, and gender humility

2.4 Elena scenario

After the loud noise

Risky response

Call loudly from the end of the hall, stand over her, ask for trauma details.

Safer response

Approach slowly, stay at an angle, lower voice, explain next steps, offer a quieter option.

2.4

Anticipatory guidance reduces threat

"Here is what will happen next: I will check your pulse and breathing, then we will decide together whether the quiet room, a walk, or medication support is the next step."

2.4 Stabilization toolkit

Three tools for the first four weeks

Brief intervention

Short, structured, motivational, respectful.

Crisis planning

Patient-owned warning signs and coping steps.

Debrief / repair

Make sense of what happened without forcing disclosure.

2.4 Caregiver safety

Vicarious trauma is a team risk

Watch
numbing, irritability, dread, cynicism, over-involvement.
Use
supervision, huddles, debriefing, peer support.
Escalate
unsafe staffing, repeated violence, moral distress, burnout signals.

Section 2 wrap

The stabilization pattern

Read acuity. Name suicide risk directly. Assess substance use and withdrawal. Protect oxygen, safety, dignity, and consent. Use the team early. Repair after crisis.

Continue to Section 3: Expert Deep Dives

Section 2 references

Ontario crisis and safety anchors

  1. RNAO. Mental Health and Addiction Initiative: Clinical Best Practice Guidelines. https://rnao.ca/bpg/initiatives/mhai/purpose
  2. RNAO. Crisis Intervention for Adults Using a Trauma-Informed Approach: Initial Four Weeks of Management, Third Edition. Linked from RNAO MHAI guidelines.
  3. RNAO. Promoting Safety: Alternative Approaches to the Use of Restraints. https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints
  4. Public Services Health & Safety Association. Workplace violence resources for Ontario health care. https://www.pshsa.ca/
  5. Ontario. Occupational Health and Safety Act, workplace violence and harassment provisions. https://www.ontario.ca/laws/statute/90o01

Section 2 references

Suicide assessment and planning

  1. Columbia Lighthouse Project. The Columbia-Suicide Severity Rating Scale. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
  2. Stanley-Brown Safety Planning Intervention. https://suicidesafetyplan.com/
  3. 9-8-8 Suicide Crisis Helpline Canada. https://988.ca/
  4. Ontario Health. Quality Standard: Major Depression. https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Major-Depression
  5. CAMH. Suicide risk resources and mental health education. https://www.camh.ca/

Section 2 references

Concurrent disorders and substance use

  1. RNAO. Engaging Clients Who Use Substances. https://rnao.ca/bpg/guidelines/engaging-clients-who-use-substances
  2. Ontario Health. Quality Standard: Opioid Use Disorder. https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Opioid-Use-Disorder
  3. Ontario Health. Quality Standard: Problematic Alcohol Use and Alcohol Use Disorder. https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Problematic-Alcohol-Use-and-Alcohol-Use-Disorder
  4. CAMH. Opioid Use Disorder clinical resources. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/opioid-use-disorder
  5. Meta:Phi. Provider tools for substance use care. https://www.metaphi.ca/provider-tools/

Section 2 references

Trauma-informed stabilization

  1. SAMHSA. Concept of Trauma and Guidance for a Trauma-Informed Approach. https://www.nctsn.org/resources/samhsas-concept-of-trauma-and-guidance-for-a-trauma-informed-approach
  2. CAMH. An introduction to trauma-informed practice. https://www.camh.ca/en/professionals/professionals--projects/immigrant-and-refugee-mental-health-project/webinars/support-and-treatment-considerations/an-introduction-to-trauma-informed-practice
  3. Mental Health Commission of Canada. Guidelines for Recovery-Oriented Practice. https://mentalhealthcommission.ca/resource/guidelines-for-recovery-oriented-practice/
  4. CNO. Professional Boundaries and Nurse-Client Relationships. https://cno.org/Assets/CNO/Documents/Standard-and-Learning/Practice-Standards/41033_therapeutic.pdf
  5. CNO. Confidentiality and Privacy: Personal Health Information. https://cno.org/Assets/CNO/Documents/Standard-and-Learning/Practice-Standards/41069_privacy.pdf