Felicia Merritt

Click to Download: Reflection

I have been a nurse for nearly four years. That means that it has been nearly four years since I’ve studied, written a paper, taken an exam, and been otherwise academically engaged. Additionally, working with pediatric patients requires me to modify my vernacular and speech patterns. Over time, this can lead a person to become “rusty” academically.

One major reason why I appreciated this course was that it gave me the opportunity to refresh on numerous academic skills, such as writing, reading comprehension, and critical thinking. While my other courses, pathophysiology and pharmacology, were primarily content and memorization based, I found this foundational course to be uniquely incredibly rewarding. Thinking theoretically, and recognizing the philosophy and ethics behind my current practice, really helped me to reengage in my career and remind me why I chose to become a nurse in the first place. This course has also taught me a great deal about what it means to be an advanced-practice nurse, and has initiated the cognitive shift from my current RN role into thinking more as an APRN.

I appreciate that this course allowed me the opportunity to display my writing abilities, as I find writing to be one of my personal strengths. That being said, there is still significant improvement that I hope to make before graduation. My time management skills need to be improved, especially as I continue to work while I am in school. I would also like to improve my attention to detail, specifically when it comes to writing with APA style and format.

Click Here for Download: Professional Philosophy and Framework

The Bowen Family Systems Theory as It Applies to Holistic Nursing Care

The American Holistic Nurses Association describes holistic nursing as, “nursing practice that has healing the whole person as its goal.” I find this concept to be incredibly relevant to all aspects of nursing care, but especially to psychiatric nursing. The purpose of this paper is to describe my professional nursing philosophy as it relates to pediatric psychiatry patients and their families, and discuss the relevance of the Bowen Family Systems theory in relation to holistic nursing care in an outpatient clinical setting. In this paper, I will also provide clear examples of how this theory may be implemented in advanced nursing practice.

Professional Nursing Philosophy

I was originally drawn to psychiatric care after taking some introductory psychology courses throughout my undergraduate career. While I accepted my first job as a milieu therapist in a psychiatric hospital because it was the first job to offer full time hours with benefits, I immediately found myself enamored with the field of psychiatry and passionate about helping the pediatric psychiatry patients that I was caring for. I quickly recognized the vulnerability of the psychiatric population, especially children, as I saw how few of these patients had a safe, stable environment with someone to take care of them and ensure their wellbeing. While working as a milieu therapist, I was confident in treating patients for their psychiatric disorders using behavioral interventions. Unfortunately, I found this methodology to be limited, as it restricted me from viewing my patient as a full being with a body, mind and spirit that all needed tending to. After much research, I made the decision to transition my career into psychiatric nursing, giving me the authority to provide that holistic care that I recognized that my patients needed.

My primary nursing philosophy is that, in order to treat a patient effectively, we must do so holistically. Treating a patient for only one facet of their body or mind is inconsequential if there are other ailments that the patient is experiencing. One example relating this concept to psychiatric nursing is that a patient could exhibit hypersomnia because they are depressed, or it could be a sign of a viral illness. By ignoring all other potential nursing diagnoses in favor of the one diagnosis that is relevant to our care (i.e., depression), we are neglecting the patient’s physical body and creating potentially life-threatening circumstances.

My passion as a nurse comes from working with children and their families, with the intention of helping the patients and their parents to develop that safe, stable environment that so many patients are lacking. After I become a licensed Psychiatric Mental Health Nurse Practitioner (PMHNP), I am planning to work in an outpatient setting in which I treat pediatric patients for their mental health, while also supporting the whole family in their journey through family therapy.

I believe that this focus on the family unit, in addition to the patient’s individual needs, fully embodies the nursing theory of holistic care. While the child themselves may be working towards bettering their mental health, the improvement may be negligible if the family unit is not also being treated. Additionally, the dynamics between members of a family unit have a major impact on the patient’s health and practices. Therefore, how the family views and treats their health correlates to how your patient responds to the provided treatment as well.

The Bowen Family Systems Theory

In order to fully embrace the philosophy of holistic nursing care in my current practice, I have become familiar with the Bowen Family Systems theory. As stated by Bowen, “an adequate understanding of human behavior must rest on a foundation that went beyond the study of the individual to include the relational system” (Kerr & Bowen, 1988). The basis for the Family Systems Theory is that no individual can be understood in isolation, but rather they must be viewed with respect to their family unit (Bowen, 1978). This is because each family functions as an emotional unit, and the thoughts, emotions and actions of each member of a family impact and influence the thoughts, emotions and actions of the other members of the same family (Bowen, 1978).

Under the Bowen Family Systems theory, it is evident that the family system and dynamics must be considered when creating a plan of care for a patient, in order to holistically treat the patient. The family’s beliefs on psychiatric and medical treatments may impact the adherence of an individual patient to a treatment plan; additionally, the family function may physically impact the ability of a patient to receive their medications or to attend follow-up appointments. There are eight key concepts, described below, in the Bowen Family Systems theory shape the functionality and the dynamics of the family unit ((“Introduction to the Eight Concepts”, 2020)

1. Differentiation of self- The family unit impacts the sense of self, and the differentiation of sense of self directly correlates to the emotional stability of an individual. Poorly differentiated sense of self often leads to more emotional reactiveness and less adaptability (“Introduction to the Eight Concepts”, 2020).
2. Triangles- Two people often have a third party (“scape goat”) to stabilize their relationship (“Introduction to the Eight Concepts”, 2020).
3. Nuclear family emotional system- Each family has one of four patterns of emotional functioning in a single generation, which predicts the emotional functioning in successive generations (“Introduction to the Eight Concepts”, 2020).
4. Family projection process- Parents project their emotional problems onto the child. The child then reacts, leading the parent to treat the child as if something is wrong (“Introduction to the Eight Concepts”, 2020).
5. Emotion cut-off- An individual family member “cuts-off” from the family unit when the individual has unresolved emotional issues. This cut-off may be evident in many different forms, such as emotional or geographical (“Introduction to the Eight Concepts”, 2020).
6. Multi-generational transmission process- The emotional projection of the family spans successive generations (“Introduction to the Eight Concepts”, 2020).
7. Sibling position- The emotionality of an individual is influenced by the positioning within their siblings (“Introduction to the Eight Concepts”, 2020).
8. Societal emotion process- Poorly differentiated families have a more difficult time managing stressors placed upon the family (“Introduction to the Eight Concepts”, 2020).

According to Jakimowicz (2020), The treatment goals when applying the Bowen Family Systems theory to professional practice is to, “empower individuals, decreasing reactivity and blame.” Jakimowicz directly applies this framework to critical care nursing, encouraging nurses to understand family dynamics when they are required to make difficult decisions regarding a patient’s care in an intensive care unit. This understanding, Jakimowicz argues, guides the nurse in mediating the family dynamics that can arise when families are forced into crisis situations. The application of the Bowen Family Systems Theory also helps nurses directly by decreasing compassion fatigue when managing such emotionally taxing situations day to day (Jakimowicz, Perry and Lewis, 2020). Given that the burnout rate among psychiatric providers is between 21% and 67% (Pourzand, 2016), being able to provide the Bowen Family Systems theory to psychiatric advanced practice nursing in an effort to decrease compassion fatigue and burnout is crucial.

It is also important for PMHNPs to recognize the complexity of a family unit when treating an individual. While a traditional family may consist of parents, a child receiving treatment from the PMHNP, and the siblings of that child, other families may be much more complex. Additionally, Thompson (2019) argues that it is possible for other agencies, such as healthcare providers or government agencies, to also be considered members of a client’s family unit. Including a PMHNP, it is important that these agencies and providers utilize the Bowen Family Systems Theory to recognize the role that they play in a family unit, and to be aware of their own level of differentiation (Thompson, Wojciak, & Cooley, 2019). It is also important that providers and agencies develop the ability to manage their personal anxieties effectively, so as not to have a negative impact on the family unit to which you are providing care.

 

Evaluation of Theory

The Bowen Family Systems theory has been around for several decades, and numerous studies have been conducted to evaluate the validity of the theory as a whole. While it is a psychological theory relating interpersonal relationships of a family unit, there have been many attempts to apply the Bowen Family Systems theory to other types of relationships, such as the relationship between government agencies or healthcare providers to the family unit (Thompson, Wojciak & Cooley, 2019).

While I find the Bowen Family Systems Theory to be very versatile in application to psychiatric advanced practice nursing, I also have to wonder about components that are left out of this theory. While Bowen argues that an individual cannot be properly assessed and treated without understanding the relational factors placed up the individual by the family unit, Bowen does not address the larger relational factors affecting the family unit as a whole, such as societal pressures and financial standing.

Conclusion

One of the pinnacles of nursing care is understanding each patient as a holistic being, comprising body, mind and spirit. Each of these factors must be considered when providing care and treatment. Bowen Family Systems theory takes holistic care one step further, arguing that a patient is influenced by relational factors, and as such, the entirety of the family unit must be considered. As a future PMHNP, I am forced to recognize these views, as I will be managing the care and treatment of pediatric patients who are entirely under the influence of their families and caregivers. No matter how perfect a treatment regimen may be for a child, it is ineffective if the family is not supportive of the treatment or capable of understanding the need for the regimen. As a PMHNP, I also plan to provide psychotherapy and family therapy to patients, and having a strong understanding of the Bowen Family Systems Theory allows me to provide effective therapy to my patients and their families. Only through recognizing the relational factors, in addition to a child’s mind, body and spirit, will any treatment that I provide be most successful in helping my patients with chronic psychiatric disorders.

 

 

 

 

 

 

 

 

References

About Us. (2021). Retrieved September 29, 2021, from https://www.ahna.org/About-Us/Whatis-Holistic-Nursing

Are You Considering a Career as Psychiatric Mental Health Nurse Practitioner? (2019, December 13). Retrieved from https://www.aanp.org/news-feed/are-you-considering-a-career-as-psychiatric-mental-health-nurse-practitioner

Bowen, M. (1978). Family therapy in clinical practice. New York: Aronson. Introduction to the Eight Concepts. (2020, October). Retrieved from https://www.thebowencenter.org/introduction-eight-concepts

Jakimowicz, S., Perry, L., & Lewis, J. (2020). Bowen Family Systems Theory: Mapping a framework to support critical care nurses’ well‐being and care quality. Nursing Philosophy, 22(2). doi:10.1111/nup.12320

Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W W Norton & Co.

Pourzand, M. (2016, April). Psychiatric Mental Health Nurse Practitioner (PMHNP) Burnout: Differences Between Acute/Inpatient PMHNPs and Outpatient PMHNPs [Scholarly project]. In 2016 Nursing Education Research Conference. Retrieved October 3, 2021, from https://stti.confex.com/stti/nln16/webprogram/Paper78328.html

 

Thompson, H. M., Wojciak, A. S., & Cooley, M. E. (2019). Family-based approach to the child welfare system: An integration of Bowen family theory concepts. Journal of Family Social Work, 22(3), 231-252. doi:10.1080/10522158.2019.1584776

 

What is Bowen Theory? Who is Dr Murray Bowen? (2021). Retrieved from

https://www.thefsi.com.au/us/bowen-theory/

 

 

 

 

Click Here for Download: Cultural Competency Reflection

A nurse is assigned to specific patients at the beginning of a shift, regardless of culture or any other identifying factor. Prior to receiving cultural competency training, I would have only responded to this prompt with, “the care that I provide is not impacted by a person’s culture, color, or upbringing.” While I would like to believe that this is true, I am forced through exercises, such as this one, to evaluate the care that I am providing to patients, and I am offered an opportunity to reflect on these implicit biases that may, in fact, impact the care that I am providing.

I was raised as a white, cis-gendered, heterosexual female. While I face some adversity as a female, I recognize that my race and sexual orientation provide me with a level of privilege that is not universal. As a psychiatric provider, I am frequently working with people of different cultures and colors, as well as with people of different socioeconomic statuses. While in college, I remember reading a paper entitled, The Essence of Innocence: Dehumanizing Black Children, in which the author discusses how black children are viewed as older than their biological age. This perception leads to greater expectation and harsher punishments for children of color, due to an implicit bias that is otherwise unrecognized (Goff et al, 2014). The authors aim to argue that, even something as basic as childhood innocence is a privilege. This privilege must be upheld whenever possible, and distributed equally amongst all patients in our care. While this paper may be a bit outdated, the message has stayed with me since I have begun my career as a psychiatric provider.

I prefer to believe that I am culturally competent, and that the care that I have provided to my patients has been consistent. That being said, the assessment provided as part of this exercise has offered me opportunities to improve my cultural competency as a provider. First and foremost, as an APRN, I can attempt to make my environment comfortable for people of all races, genders, and religions by offering resources that are inclusive. While I am always quick to ask about translational resources for patients who primarily speak another language, I will ensure that these resources are available whenever I am providing care as a nurse practitioner. Additionally, I will continue to advocate for my patient and the care that they receive. I will be cognizant of their family unit and morals, and I will intervene when appropriate regarding services or providers who are not respectful of the needs of my patients.

Click Here for Download: Equine-Assisted Therapy as Treatment for Pediatric Attention-Deficit Hyperactive Disorder

A Residential Treatment Center (RTC) is a facility dedicated to providing therapeutic care to children with complex psychiatric illnesses who are sub-acute in their presentation. The children stay full time at the RTC for several weeks to several months, and receive intensive therapy and consistent monitoring, in order to ensure their safety while providing an immersive therapeutic environment for recovery (Texas Health and Human Services, 2016-2021). In a healthcare system where length of stay (LOS) is considered an important measure of the quality of care provided, RTCs face a unique challenge: to maximize the therapeutic effectiveness of treatment while minimizing the length of stay for patients, specifically in patients diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).

Unfortunately, it has been documented that children with extended psychiatric stays are at risk for re-traumatization due to the negative experiences of being in a psychiatric facility (Hirsch & Steinert, 2019). Common interventions in psychiatric facilities such as restraint and seclusion have an added risk of potentially re-traumatizing pediatric patients (Hirsch & Steinert, 2019). Therefore, the longer a patient is admitted to a psychiatric facility, the greater the risk that the practices of the facility could actually worsen symptoms of trauma, leading to the worsening of symptoms of the psychiatric condition assigned upon admission.

Additionally, the cost of healthcare spending for mental health treatment is rising. Between 2009 and 2019, there has been an estimated $108.8 billion increase of expenditures towards mental health and substance abuse treatment (Substance Abuse and Mental Health Services Administration, 2010-2020). This increase in spending creates a significant burden on not only the economy, but for individual payers as well.

Intervention

         Horses, as well as many domesticated animals, have been utilized for medical treatments dating back to the second century (White-Lewis, 2019). Animal assisted therapies have been shown to improve psychosocial, physical and emotional aspects of individuals’ lives (White-Lewis, 2019). Equine-therapy is a specific form of animal-based therapy in which patients learn to ride, train, and care for horses (Garcia-Gomez et al., 2016). Equine therapy has shown effectiveness in improving patients’ overall quality of life as well as reducing symptoms often experienced by patients with PTSD and ADHD.

Interactions with horses, especially riding and caring for horses, has been shown to be an effective therapeutic intervention for children with varying diagnoses (Garcia-Gomez et al., 2016). Equine-assisted therapy (EAT), or equine-facilitated psychotherapy (EFP), typically involves grooming, riding, and practices with the neck-rope of the horse (Shelef et. al, 2019). Therapy with horses has been shown to be effective in improving quality of life in with patients with autism, post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD) (White-Lewis, 2019). Specifically geared towards PTSD, equine-assisted therapy has been shown to increase self-efficacy and self-esteem, and to improve the ability to perform daily tasks (Shelef et. al, 2019). For pediatric patients diagnosed with ADHD, equine-assisted therapy has increased executive functioning, emotion regulation, and overall self-control (Gilboa & Helmer, 2020). In pediatric patients with psychiatric disorders, the greatest predictor for length of stay is the specific diagnosis and the severity of symptoms experienced by each individual (Chakravarthy et al., 2017). This paper aims to determine if equine-assisted therapy, compared to current therapeutic practices, decreases the severity of ADHD symptoms in pediatric patients with an ADHD diagnosis currently admitted to a residential treatment center in San Antonio, Texas over a 12-week treatment program.

As mentioned previously, the length of stay within a psychiatric facility is largely based on diagnosis and severity of symptoms (Chakravarthy et al., 2017). Therefore, evidence that shows a decrease in ADHD related symptoms may potentially decrease overall length of stay in patients suffering from ADHD.

One systematic review, consisting of eight non-controlled prospective studies and 4 randomized controlled trials concluded that equine-therapy seems to improve physiological functions of patients with ADHD including physical fitness and overall brain function (Helmer et al., 2021). One of the specific studies analyzed within this systematic review was a controlled experiment that evaluated ADHD patients’ improvements in symptoms according to the Behavior Assessment System for Children (BASC) scale and a quality-of-life questionnaire (Garcia-Gomez et al., 2016). This study showed that there was a significant difference in the quality-of-life questionnaire results between the equine-therapy group and the control group (Garcia-Gomez et al., 2016).

Furthermore, another study analyzed the executive functioning (assessed by questionnaires) of pediatric patients with ADHD by comparing patients receiving equine-based therapy to a control group which received medication treatment only (Aviv et al., 2020). This study consisted of 123 children who received either 20 weeks of equine-therapy or medication alone treatment. The equine-therapy group demonstrated a significant improvement in the executive functioning of the patients, as well as improved self-esteem as compared to the control group (Aviv et al., 2020).  Improving executive functioning and patient self-esteem are essential in patients with ADHD; therefore, this data suggests that improvement in these areas may result in a decrease in severity of ADHD symptoms and potentially decrease overall length of stay within residential treatment facilities. Being that it is not uncommon for patients to remain at a residential treatment facility for six months or more, it would be reasonable to evaluate a 12-week treatment regimen (as evaluated in many of these studies) in the pediatric patients in the residential facility in San Antonio, Texas.

Conclusion

         Due to the growing concern of polypharmacy within the psychiatric field, non-pharmacologic interventions such as equine-therapy require significant consideration and research regarding their overall effectiveness. Should more research demonstrate that equine-therapy is an effective treatment option for children with ADHD, there is potential for improving overall quality of life, and decreasing the severity of ADHD symptoms. With more manageable symptomatology, children can spend less time admitted to psychiatric facilities, which reduces the risk for re-traumatization as well as limiting the financial burden that can impact treatment. When prescribing and referring patients to specific treatment models, nurse practitioners need to be aware of the risks of treatment, such as re-traumatization, as well as potential barriers to treatment, such as financial burden. One systematic review, which included nine separate articles based in equine therapy concluded that further research with higher methodological quality needs to be considered before the effectiveness of equine-therapy can be fully understood (Perez-Gomez et al., 2021). This highlights the importance of further research to better understand the potential benefits that equine-assisted therapy may have in improving the overall quality of life of patients suffering from ADHD and potentially decrease their overall length of stay within psychiatric facilities.

 

 

References

Aviv, T.-li M., Katz, Y. J., & Berant, E. (2020). The contribution of therapeutic horseback riding to the improvement of executive functions and self-esteem among children with ADHD. Journal of Attention Disorders, 25(12), 1743–1753. https://doi.org/10.1177/1087054720925898

Chakravarthy, B., Yang, A., Ogbu, U., Kim, C., Iqbal, A., Haight, J., Anderson, C., DiMassa, G., Bruckner, T., Bhargava, R., Schreiber, M., & Lotfipour, S. (2017). Determinants of pediatric psychiatry length of stay in 2 urban emergency departments. Pediatric Emergency Care, 33(9), 613–619. https://doi.org/10.1097/pec.0000000000000509

Children’s mental health residential treatment center project. Texas Health and Human Services. (n.d.). Retrieved November 5, 2021, from https://www.hhs.texas.gov/services/mental-health-substance-use/childrens-mental-health/childrens-mental-health-residential-treatment-center-project#:~:text=The%20average%20length%20of%20time,Help%20Through%20the%20RTC%20Project%3F.

García-Gómez, A., Rodríguez-Jiménez, M., Guerrero-Barona, E., Rubio-Jiménez, J. C., García-Peña, I., & Moreno-Manso, J. M. (2016). Benefits of an experimental program of equestrian therapy for children with ADHD. Research in Developmental Disabilities, 59, 176–185. https://doi.org/10.1016/j.ridd.2016.09.003

Gilboa, Y., & Helmer, A. (2020). Self-management intervention for attention and executive functions using equine-assisted occupational therapy among children aged 6–14 diagnosed with attention deficit/hyperactivity disorder. The Journal of Alternative and Complementary Medicine, 26(3), 239–246. https://doi.org/10.1089/acm.2019.0374

Helmer, A., Wechsler, T., & Gilboa, Y. (2021). Equine-assisted services for children with attention-deficit/hyperactivity disorder: A systematic review. The Journal of Alternative and Complementary Medicine. https://doi.org/10.1089/acm.2020.0482

Hirsch, S., & Steinert, T. (2019). Measures to avoid coercion in psychiatry and their efficacy. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0336

Pérez‐Gómez, J., Amigo‐Gamero, H., Collado‐Mateo, D., Barrios‐Fernandez, S., Muñoz‐Bermejo, L., Garcia‐Gordillo, M. Á., Carlos‐Vivas, J., & Adsuar, J. C. (2021). Equine‐assisted activities and therapies in children with attention‐deficit/hyperactivity disorder: A systematic review. Journal of Psychiatric and Mental Health Nursing. https://doi.org/10.1111/jpm.12710

Shelef, A., Brafman, D., Rosing, T., Weizman, A., Stryjer, R., & Barak, Y. (2019). Equine assisted therapy for patients with post-traumatic stress disorder: A case series study. Military Medicine, 184(9-10), 394–399. https://doi.org/10.1093/milmed/usz036

White‐Lewis, S. (2019). Equine‐assisted therapies using horses as healers: A concept analysis. Nursing Open, 7(1), 58–67. https://doi.org/10.1002/nop2.377

Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

 

 

 

 

 

 

 

 

 

 

Citation Complete Scholarly Article following APA	Purpose	Design and Strength /Level of Evidence	Sample participants/ volunteers	Measurement(s) if used in the study or report If qualitative may not have instrument If reports of data collected may not have instrument.	Results/ Conclusions/ Recommendations
Aviv, T.-li M., Katz, Y. J., & Berant, E. (2020). The contribution of therapeutic horseback riding to the improvement of executive functions and self-esteem among children with ADHD. Journal of Attention Disorders, 25(12), 1743–1753. https://doi.org/10.1177/1087054720925898	The purpose of this study was to evaluate the effectiveness of equine therapy on executive functioning (EF) of children with Attention-Deficit Hyperactivity Disorder (ADHD) in Isreal.	Cross- sectional Survey; (Level II)	This study surveyed 123 Israeli children diagnosed with ADHD. All participants had no other psychiatric diagnoses, and were all receiving medication as treatment for ADHD.	This study utilized surveys regarding hyperactivity, attentiveness and oppositional behaviors, filled out by the children’s mothers	Therapeutic horseback riding improves executive functioning in children with ADH, and also increased their self-esteem
Chakravarthy, B., Yang, A., Ogbu, U., Kim, C., Iqbal, A., Haight, J., Anderson, C., DiMassa, G., Bruckner, T., Bhargava, R., Schreiber, M., & Lotfipour, S. (2017). Determinants of pediatric psychiatry length of stay in 2 urban emergency departments. Pediatric Emergency Care, 33(9), 613–619. https://doi.org/10.1097/pec.0000000000000509	The purpose of this study was to evaluate the factors that lead to longer lengths of stay in pediatric patients with psychiatric diagnoses.	Cross-sectional Study; (Level II)	This study had 939 participants between the ages of 3 years and 17 years old, presenting to one of two urban emergency departments.	A retroactive chart review was performed with the intention of determining the factors that are related to increased length of stay for pediatric patients with psychiatric diagnoses.	This study found that diagnosis was the primary determinant of length of stay. Children with psychotic disorders, suicide attempts or suicidal ideation had longer lengths of stay than children with other diagnoses.
García-Gómez, A., Rodríguez-Jiménez, M., Guerrero-Barona, E., Rubio-Jiménez, J. C., García-Peña, I., & Moreno-Manso, J. M. (2016). Benefits of an experimental program of equestrian therapy for children with ADHD. Research in Developmental Disabilities, 59, 176–185. https://doi.org/10.1016/j.ridd.2016.09.003	The purpose of this study was to empirically evaluate equine therapy as a potential therapeutic resource for children with ADHD.	Quasi-experimental	(N= 14) Fourteen total children aged 7-14 years with an ADHD diagnosis, 9 in the experimental group and 5 in the control group.	A Behavioral Assessment Survey for Children (BASC) was completed for each child, consisting of two portions: one for the teacher and one for the parents.	While this study found benefits to implementing equine therapy for children with ADHD, they found the benefit to be more closely aligned with the benefits of physical exercise than with therapy.
Gilboa, Y., & Helmer, A. (2020). Self-management intervention for attention and executive functions using equine-assisted occupational therapy among children aged 6–14 diagnosed with attention deficit/hyperactivity disorder. The Journal of Alternative and Complementary Medicine, 26(3), 239–246. https://doi.org/10.1089/acm.2019.0374	This study aimed to evaluate the effectiveness of self-management intervention for attention and executive functions via equine-assisted occupational therapy (STABLE-OT)	Cross-sectional survey; (level II)	(N=25) 25 children ages 6-14 years old with ADHD diagnoses	Using The Behavior Rating Inventory of Executive Function (BRIEF) and the Canadian Occupational Performance Measure (COPM), the researchers were measuring changes in the executive function of participants	Equine-assisted therapy provided a significant increase in executive function in children with ADHD.
Helmer, A., Wechsler, T., & Gilboa, Y. (2021). Equine-assisted services for children with attention-deficit/hyperactivity disorder: A systematic review. The Journal of Alternative and Complementary Medicine. https://doi.org/10.1089/acm.2020.0482	A systemic review was performed to evaluate the current research on Equine-assisted therapy. This review was aimed to evaluate the current evidence to determine if Equine-assisted therapy would be a valuable point of study	Systematic Review of 4 RCTs and 8 noncontrolled studies (Level I)	Twelve articles were found. Of that 12, eight studies were noncontrolled prospective studies and 4 were randomized controlled trials.	Researchers reviewed electronic databases from inception to December 2020 in order to find articles regarding EAT as treatment for pediatric ADHD	There is preliminary evidence that equine-assisted therapy can promote physiologic systems in children with ADHD; however, more evidence is needed to support that EAT can improve participation and quality of life for children with ADHD.
Hirsch, S., & Steinert, T. (2019). Measures to avoid coercion in psychiatry and their efficacy. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0336	A systematic review was performed in order to evaluate the effectiveness of coercion measures in psychiatry.	Systematic Review of 84 studies in which 16 were RCTs (6 of which were controlled RCTs). (Level I)	Eighty-four studies were reviewed, primarily those focused on reducing the use of restraint and seclusion. Sixteen studies had control groups. Of those 16 studies, 6 were randomized control studies.	Researchers reviewed articles that had been found on Medline and Cinahl databases. They also reviewed the references lists on the publications found on Medline and Cinahl.	Seven categories were identified as methods to directly reduce the rates of restraint and seclusion: staff training, organization, risk assessment, environment, debriefings, psychotherapies, and advanced directives. Utilizing this information, it is possible to develop a complex program to reduce restraint and seclusion use in psychiatry.
Pérez‐Gómez, J., Amigo‐Gamero, H., Collado‐Mateo, D., Barrios‐Fernandez, S., Muñoz‐Bermejo, L., Garcia‐Gordillo, M. Á., Carlos‐Vivas, J., & Adsuar, J. C. (2021). Equine‐assisted activities and therapies in children with attention‐deficit/hyperactivity disorder: A systematic review. Journal of Psychiatric and Mental Health Nursing. https://doi.org/10.1111/jpm.12710	The purpose of this article was to perform a systematic review of updated literature about EAAT in children with ADHD	Systematic review of 9 articles     Level I	Seven studies were found to be evidence level C, and nine articles were evidence level B.	A systematic review was performed until 28 November 2019, in four electronic databases: PubMed, Web of Science, Embase and Google Scholar. The inclusion criteria included were intervention program with pre- and post-data, based on EAAT, studying children with ADHD the articles written in English.	The researchers concluded that the data supported evidence level C, meaning that clinicians should use flexibility when making treatment decisions. There is evidence to support the effectiveness of equine-assisted therapy; however, it is not substantial enough to entirely change current practice.
Shelef, A., Brafman, D., Rosing, T., Weizman, A., Stryjer, R., & Barak, Y. (2019). Equine assisted therapy for patients with post traumatic stress disorder: A case series study. Military Medicine, 184(9-10), 394–399. https://doi.org/10.1093/milmed/usz036	The purpose of this study was to assess the effect of EAT on patients with PTSD in terms of symptoms and functioning in work, family and social interaction.	Case series study – non-controlled   (Level IV would be case-control study, unsure for this because no control)	There were 23 total participants, 10 of which withdrew before completion of the study and 13 completed the study.	This study used The Short Post Traumatic Stress Disorder Rating Interview (SPRINT) and the Sheehan Disability Scale (SDS) as measurements	This study concluded that there is evidence to support the potential effectiveness of EAT; however, more research needs to be done to fully conclude this.
White‐Lewis, S. (2019). Equine‐assisted therapies using horses as healers: A concept analysis. Nursing Open, 7(1), 58–67. https://doi.org/10.1002/nop2.377	To clarify the attributes, antecedents and meaning of equine‐assisted therapy and present an operational definition	Concept Analysis (Level VII)	No Participants or volunteers used.	No measurements used. Article utilized the Walker and Avant concept analysis method	Results indicated that the attributes of equine therapy include the following: a human participant with an equine physically present to assist the human participant, a treatment or intervention as a result of the interactions between an equine and a human participant, a purposeful and regulated interaction and a positive health outcome goal from the interaction   Antecedents included the following: a live horse with a human physically able to interact with the horse, a facilitator and accessibility to an equine‐assisted therapy (EAT) program.   Consequences include: improved balance, well‐being, quality of life, trust, spasticity, self‐efficacy, self‐esteem, nurse presence, pleasure and a sense of accomplishment