Delineating Quality Indicators of Inpatient Psychiatric Hospitalization.

BACKGROUND: Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist. AIMS: To isolate and describe quality elements of inpatient psychiatric treatment. METHODS: A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units. RESULTS: Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience. CONCLUSIONS: The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

Use of a Standardized Procedure to Improve Behavioral Health Patients' Care: A Quality Improvement Initiative.

PROBLEM: Meeting the complex needs of behavioral health (BH) patients in the emergency department is an ongoing challenge. Delays in care can have adverse consequences for patient and staff safety and delay transfer to specialized care. METHODS: A quality improvement, nurse-driven initiative using a standardized procedure (STP) was developed and implemented in our busy Southern California Emergency Department, which focused on improving time to first medication and reduction of restraints. The project used a multidisciplinary team to develop the STP scoring tool and corresponding medications. Improvement was seen in all quality metrics. Time to first medication decreased from 43 minutes to less than 5 minutes. Adopting the STP resulted in a 50% decrease in use of restraints and time in restraints. Staff injuries remained low, with less than 3.6% of staff sustaining physical injuries. DISCUSSION: The STP is an effective method to initiate immediate treatment of patients with signs of anxiety and aggression and thus reduce risk of violence. Additional benefits are reduced time to disposition and earlier initiation of specialized BH care. This process can be replicated in other emergency departments with similar clinical environments through the use of STPs or protocols based on state regulations. Contribution to Emergency Nursing Practice.

Effect of Concentrated Psychiatric Education on Perceived Competence to Care for Behavioral Health Patients.

CONTRIBUTION TO EMERGENCY NURSING PRACTICE: ABSTRACT INTRODUCTION: Increasing numbers of behavioral patients are presenting to emergency departments, where competency of staff to care for this group is unknown. METHODS: This pre-post study measured the effects of a 7-hour conference on perceived competency of nurses and allied health professionals to care for behavioral health (BH) patients, as measured by the 23-item Behavioral Health Care Competency (BHCC) survey. RESULTS: Of 102 participants, most were emergency nurses (72%), acute care nurses and case managers (20%), and allied health personnel (trauma technicians and paramedics) (8%). Before the conference, participants had moderate average perceived competency in caring for BH patients. BHCC scores differed significantly by job category, with emergency nurses scoring higher than did nonemergency nurses and allied health personnel. Overall competence of participants increased significantly after the conference. The effect size, as reflected by partial eta squared, was 0.265. Significant increases in scores from before to after the conference occurred for the total BHCC and 2 competencies: practice/intervention and resource adequacy. DISCUSSION: This study provides needed research demonstrating improved perceived competency of nurses and allied health professionals to care for BH patients in emergency departments after brief concentrated education. Improvements occurred despite the fact that participants had initial baseline competencies that were higher than those of general hospital nurses from a historical sample.

Educating law enforcement officers about mental illness: nurses as teachers.

With the advent of new psychotherapeutic agents, many individuals with mental illness are living successfully in communities. However, they may become involved in situations with law enforcement officers, which may lead to potentially negative experiences. During police academy training, new officers may receive training focused on optimizing interactions with people with physical/mental disabilities; however, this may be inadequate to enable effective communication between officers and individuals with mental illness. Given the growing prevalence of mental illness, it is increasingly likely that officers will encounter such individuals. An exemplar educational program geared to staff police officers in the city of Orange, California is described. This program provides law enforcement officers with training about psychiatric disorders and affected individuals, effective communication skills, and interventions that may assist in management of field contacts with individuals with mental illness.

Instrument validation: hospital nurse perceptions of their Behavioral Health Care Competency.

AIM: To report the development and psychometric testing of the Behavioral Health Care Competency survey, designed to measure hospital nurse perceptions of behavioral healthcare competency. BACKGROUND: Hospital nurses working in general or other non-psychiatric units may lack behavioral healthcare competency to manage disruptive behaviours associated with mental illnesses. DESIGN: Instrument development. METHOD: A nurse study team including clinical experts and nurse researchers from three community hospitals in southern California (USA) reviewed content validity of each item and the 31-item instrument and created a behavioral health care competency conceptual model based on the nursing process. Separate institutional review board permissions were obtained from each hospital. The study team collaborated in the timing of survey administration (November 2010), analysis of the results and survey validation. RESULTS: A total of 844 nurses completed the survey, representing approximately 23-41% of eligible nurses from each hospital. Using principal component analysis with varimax rotation, 23 items led to a factor structure with four components. Four subscales with adequate alpha coefficients were formed: Resource Adequacy, Patient Assessment, Practice/Intervention Competency, and Psychotropic Recommendation. CONCLUSION: The 23-item hospital nurse Behavioral Health Care Competency survey is an adequate and valid newly developed instrument. Further testing with diverse samples is needed to strengthen generalizability and address unique and specialized nursing care needs.

Hospital Nurse Competency to Care for Patients With Behavioral Health Concerns: A Follow-Up Study.

Nonpsychiatric nurses care for hospital patients with behavioral health (BH) conditions. This study found BH care competencies of hospital nurses slightly changed from those 9 years earlier. On average, nurses reported moderate to strong perceived competence about assessing/intervening and accessing resources to care for BH patients. They perceived less competence in recommending psychotropic drugs for patients who may need them. Staff development programs that aim to enhance nurse BH care competencies are needed.

The implementation of a new-graduate nurse residency training program directly into psychiatric-mental health nursing.

The specialty of psychiatric mental health nursing, as with all of nursing, has reached a critical shortage, which is posing a crisis in health care. Historically, the practice in schools of nursing has been to strongly encourage graduates to experience medical-surgical nursing during their first year of employment while discouraging those new graduates who may be interested in going directly into a specialty from doing so. New-graduate nurse residency training programs have focused on the general nursing areas such as critical care, emergency nursing, and medical-surgical nursing, leaving the specialty area of psychiatric mental health with less of a cadre to draw from, as attraction to these training programs is great among new-graduate nurses. The focus of this article is the description of a creative and successful new-graduate residency training program directly into psychiatric mental health nursing. The components of this program are easily replicable to other facilities and nursing specialties.

Rapid response team for behavioral emergencies.

Behaviors of patients with psychiatric illness who are hospitalized on nonbehavioral health units can be difficult to address by staff members. Instituting a rapid response team to proactively de-escalate potential volatile situations on nonpsychiatric units in a hospital allows earlier treatment of behavioral issues with these patients. The behavioral emergency response team (BERT) consists of staff members (registered nurses, social workers) from behavioral health services who have experience in caring for patients with acute psychiatric disorders as well as competence in management of assaultive behavior. BERT services were trialed on a medical pulmonary unit; gradual housewide implementation occurred over 2 years. Tools developed for BERT include an activation algorithm, educational cue cards for staff, and a staff survey. Results of a performance improvement survey reveal that staff nurses have had positive experiences with BERT but that many nurses are still not comfortable caring for psychiatric patients on their units.

Hospital staff nurse perceptions of competency to care for patients with psychiatric or behavioral health concerns.

Disruptive behaviors are common among hospitalized patients with psychiatric and substance abuse behaviors. Nurses working on nonpsychiatric units, however, may lack competencies to care for patients with such behaviors. A survey was developed and administered to 844 nurses across three hospital settings that revealed a lack of nurse confidence to intervene in situations that require de-escalation techniques and crisis communication. This study provides direction for further research and interventions in hospital settings with similar professional development needs.