Inclusion of Psychiatric-Mental Health Advanced Practice Nurses in Federal Behavioral Workforce Planning.

Psychiatric-mental health (PMH) advanced practice nurses have the education, certification, and licensure to address the need for providers who can deliver the full scope of mental health services and thereby increase access to mental health care. Although the PMH nurse practitioner (PMHNP) segment of this workforce is rapidly growing, it has scant visibility in workforce planning and the evolving national behavioral health workforce database. An understanding of PMHNP characteristics and practice roles seems to be lacking. Addressing this limitation demands clear messaging around this workforce's scope of practice and data indicating how PMHNP capabilities meet mental health treatment needs.

The Future of the Psychiatric Mental Health Nursing Workforce: Using Our Skill Set to Address Incongruities in Mental Health Care Delivery.

The USA is dealing with well-documented issues around mental health and its treatment. The Psychiatric Mental Health (PMH) workforce is growing and practicing in a variety of roles within the mental health system. How will PMH nurses address instances when the structure of services does not meet the mental health needs of the population? In this piece, I argue that to some degree the future of the PMH workforce will be determined by how well we use our capacity and capabilities to address incongruities in service structure and population needs. Five areas of concern with mental health services are outlined; they all involve factors that can be addressed with innovative approaches and optimum utilization of the PMH workforce. Included are suggestions on how PMH nurses might direct efforts toward these service issues, particularly by using their skill set and presence in the mental health system. Strategies include forging a tighter connection between the work of advanced practice and registered nurses in delivering care. Broadly, these efforts should be directed at building models of patient-centered care that address the needs of populations, reducing disparities, and demonstrating how engagement is a critical lever of effective inpatient and community-based care.

American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units.

OBJECTIVE: An American Psychiatric Nurses Association (APNA) task force reviewed current staffing research to revise and update the 2011 APNA "Staffing inpatient psychiatric units" position paper and provide recommendations to the APNA Board of Directors on how psychiatric mental health (PMH) nurses might champion the staffing needs of inpatient psychiatric units. METHODS: Current research on staffing and nursing practice in inpatient psychiatric units was reviewed as well as variables believed to influence staffing and nursing practice, such as consumer needs and workplace culture. Since current nurse staffing principles emphasize nursing value and how that value is connected to outcomes, the literature search included a focus on staffing and related patient outcomes. RESULTS: PMH nurses are critical to the safety and quality of care in inpatient psychiatric units. However, there are little existing data on the relationship between staffing levels and even common adverse events such as staff injury and restraint of patients. Furthermore, there is scant research conducted on inpatient psychiatric units that informs optimal staffing models or establishes links between staffing and patient outcomes. CONCLUSIONS: Consistent with current evidence, the universal use of a single method or model of determining staffing needs (e.g., nursing hours per, case mix index, or mandatory ratios) is not recommended. PMH nurses should champion systematic evaluation of staffing on their inpatient units against select patient, nurse, and system outcomes. A data repository of PMH nurse-sensitive outcomes is necessary to benchmark unit performance and staffing.

Presentation of Depressive Symptoms in Autism Spectrum Disorders.

BACKGROUND: Depressive disorders are frequently mis- and underdiagnosed in individuals with autism spectrum disorders (ASD). OBJECTIVE: Our objective was to identify and synthesize current knowledge regarding (1) the presentation of depressive symptoms and (2) the use of self-reports in assessing depressive symptoms in individuals with ASD and comparisons between self-reported and observer-reported symptoms. A scoping review was conducted to capture the full range of literature on the topic and to identify research gaps. METHODS: Articles were identified through a search of academic literature and screened for relevance to the aims of the review. RESULTS: In addition to typical depression symptoms, individuals with ASD may demonstrate atypical symptoms such as changes in autistic symptoms, self-injurious behavior, and psychomotor changes. Moreover, the review revealed a bias toward observer-reports of symptoms. Self-reports frequently were not included or were ascribed less weight than observer-reports. Self-reports typically differed from reports given by parents or other caregivers, but a consistent pattern in these differences has not been established. CONCLUSIONS: Further research on the use of self-reports in assessing depressive symptoms in individuals with ASD is needed. Self-reports may provide information not obtainable through observer-reports, and integrating both self- and observer-reports in psychiatric evaluations may produce more comprehensive and accurate assessments.

Development and Validation of an Operational Model for Nursing Academic-Practice Partnerships.

BACKGROUND: Several definitions and guiding principles for nursing academic-practice partnerships exist. PROBLEM: There remains a gap between academic-practice partnership definitions and practical operational models, thereby limiting schools of nursing ability to engage in productive partnerships. This article describes the development and validation of a novel Operational Model for Nursing Academic-Practice Partnerships. APPROACH: An email survey of all nursing faculty (n = 228) identified quantity and types of faculty-led academic-practice partnerships. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed via thematic analysis conducted by 2 members of the project team and validated by the full project team. OUTCOMES: The Operational Model for Academic-Practice Partnerships was created and is comprised of 8 partnership strategies: innovation, embedded faculty, joint appointment, consultant, independent practice, volunteer, scholarship, and clinical site development. CONCLUSION: We offer this model as a framework to structure the development, implementation, and evaluation of academic-practice partnerships at nursing schools.

Psychiatric Nursing Workforce Survey: Results and Implications.

OBJECTIVE: The last national survey of psychiatric-mental health (PMH) nurses was conducted in 2016 and was limited to advanced practice registered nurses (APRNs). Data on the demographic and employment characteristics of the PMH workforce could inform how to optimize the PMH nursing workforce to address increasing demands for mental health services. The objective was to conduct a national survey of PMH registered nurses (RNs) and PMH-APRNs to gather data on their demographic, educational, and practice characteristics. METHODS: An email survey was administered between October 2020 and February 2021 to all members of the American Psychiatric Nurses Association and to all PMH-APRNs certified by the American Nurses Credentialing Center. Separate surveys included 51 questions (RN) and 52 questions (APRN). Survey questions were informed by several sources including the Minimum Data Set for the Behavioral Health Workforce. RESULTS: Surveys were completed by 4,088 PMH-RNs and 5,158 PMH-APRNs, with a combined response rate of 12.1%. Findings suggest that the workforce is aging but has increased slightly in diversity. In all, 62.4% of RNs reported a hospital as their primary employment setting, while the majority of APRNs (70.4%) practice in outpatient settings. Forty-four percent of the PMH-APRN respondents indicated that most of their patients receive federal insurance. CONCLUSIONS: Nursing must plan for significant retirements in the PMH workforce in next 5 years. Hospital-based practice continues to dominate PMH-RN roles but might be expanded to community-based settings teaming with PMH-APRNs in outpatient sites. Increasing the diversity of the workforce should be prioritized.

Evaluation of Psychiatric Rehospitalization of Individuals Treated at a Federally Qualified Health Center.

At a federally qualified health center which often receives discharge referrals from the local hospital, rehospitalization rates and reasons were unknown yet pertinent information for assuring timely follow-up appointments. This study examined psychiatric discharge and rehospitalization between August 2020 and January 2021. Between August and October 2020, all adult patients of the FQHC were investigated who presented to or were discharged from the hospital. Those who received a primary psychiatric diagnosis were then examined retrospectively (between November 2020 and January 2021) to determine readmission status. During the study period, 36 patients were hospitalized with primary psychiatric diagnoses, 81% of whom did not establish behavioral health care subsequent to their initial hospitalization. The overall 90-day readmission rate of the sample was 41.7% with 80% of these individuals returning within 30 days.

Natural and anthropogenic landscape factors shape functional connectivity of an ecological specialist in urban Southern California.

Identifying how natural (i.e., unaltered by human activity) and anthropogenic landscape variables influence contemporary functional connectivity in terrestrial organisms can elucidate the genetic consequences of environmental change. We examine population genetic structure and functional connectivity among populations of a declining species, the Blainville's horned lizard (Phrynosoma blainvillii), in the urbanized landscape of the Greater Los Angeles Area in Southern California, USA. Using single nucleotide polymorphism data, we assessed genetic structure among populations occurring at the interface of two abutting evolutionary lineages, and at a fine scale among habitat fragments within the heavily urbanized area. Based on the ecology of P. blainvillii, we predicted which environmental variables influence population structure and gene flow and used gravity models to distinguish among hypotheses to best explain population connectivity. Our results show evidence of admixture between two evolutionary lineages and strong population genetic structure across small habitat fragments. We also show that topography, microclimate, and soil and vegetation types are important predictors of functional connectivity, and that anthropogenic disturbance, including recent fire history and urban development, are key factors impacting contemporary population dynamics. Examining how natural and anthropogenic sources of landscape variation affect contemporary population genetics is critical to understanding how to best manage sensitive species in a rapidly changing landscape.

Psychometric Validation of the Haemo-QOL-A in Participants with Hemophilia A Treated with Gene Therapy.

Purpose: The hemophilia-specific health-related quality of life (HRQOL) questionnaire (Haemo-QOL-A) is validated for detecting QOL changes following standard therapy for hemophilia A, but has not been rigorously evaluated after gene therapy. This post hoc analysis evaluated the psychometric properties of Haemo-QOL-A in adult people with severe hemophilia A (PWSHA) receiving valoctocogene roxaparvovec (AAV5-hFVIII-SQ) in 2 clinical trials (phase 1/2, NCT02576795; phase 3, NCT03370913). Patients and Methods: Adult PWSHA (factor VIII levels ≤1 IU/dL) received 1 AAV5-hFVIII-SQ infusion (6×1013 vg/kg). Participants were assessed using the Haemo-QOL-A and the EuroQOL (EQ)-5D-5L and visual analog scale (VAS) questionnaires pre- and post-infusion. Psychometric analyses included convergent and discriminant validity, internal consistency, and reliability. Clinically important difference (CID) was estimated using 3-point change in EQ-5D-5L VAS as anchor. Results: Haemo-QOL-A data were analyzed from 7 (phase 1/2, 3-year follow-up) and 16 participants (phase 3, 26-week analysis). Change in Haemo-QOL-A Total Scores correlated with EQ-5D-5L VAS score change at 26 weeks (Pearson's correlation 0.77). At 26 weeks, increased Haemo-QOL-A Physical Functioning was associated with decreased EQ-5D-5L Pain and Discomfort and decreased Anxiety and Depression (Spearman's Rank correlations -0.73 and -0.62, respectively, P <0.01). Internal consistency analysis showed good reliability for all domains (Cronbach's alpha >0.7) except Treatment Concern (Cronbach's alpha = 0.31). Anchor-based CID estimates were met for Haemo-QOL-A Total Score (≥5.5) and domain scores (≥6) for Consequences of Bleeding, Physical Functioning, Role Functioning, and Worry. Conclusion: Our preliminary results suggest that the Haemo-QOL-A is a valid, reliable instrument for HRQOL assessment in PWSHA undergoing gene therapy. Future research should be undertaken to confirm these findings in a larger number of participants.

Caregivers' assessment of meaningful and relevant clinical outcome assessments for Sanfilippo syndrome.

OBJECTIVES: Sanfilippo syndrome is a rare multisystem disease with no approved treatments. This study explores caregiver perspectives on the most impactful symptoms and patient-relevant clinical outcomes assessments. The pediatric onset and progressive neurodegenerative nature of Sanfilippo limits use of self-report in clinical research. This study obtains Sanfilippo caregiver data to support the selection of fit-for-purpose and patient-relevant clinical outcome assessments (COAs). METHODS: We conducted an asynchronous online focus group (n = 11) followed by individual interviews with caregivers (n = 19) of children with Sanfilippo syndrome. All participants reported on the impact of disease symptoms and level of unmet treatment need across Sanfilippo symptom domains. Focus group participants reviewed existing assessments relating to 8 symptom domains (15 total assessments) and provided feedback on meaningfulness and relevance. Focus group data were used to reduce the number of assessments included in subsequent interviews to 8 COAs across 7 symptom domains: communication, eating, sleep, mobility, pain, behavior and adapting. Interview respondents provided data on meaningfulness and relevance of assessments. Data were coded using an item-tracking matrix. Data summaries were analyzed by caregivers' responses regarding meaningfulness; relevance to Sanfilippo syndrome; and based on caregiver indication of missing or problematic subdomains and items. RESULTS: Participants' children were 2-24 years in age and varied in disease progression. Caregivers reported communication and mobility as highly impactful domains with unmet treatment needs, followed closely by pain and sleep. Domains such as eating, adaptive skills, and behaviors were identified as impactful but with relatively less priority, by comparison. Participants endorsed the relevance of clinical outcome assessments associated with communication, eating, sleep, and pain, and identified them as highly favorable for use in a clinical trial. Participants specified some refinements in existing assessments to best reflect Sanfilippo symptoms and disease course. DISCUSSION: The identification of impactful symptoms to treat and relevant and meaningful clinical outcome assessments supports patient-focused drug development. Our results inform targets for drug development and the selection of primary and secondary outcome assessments with high meaningfulness and face validity to Sanfilippo syndrome caregivers. Assessments identified as less optimal might be refined, replaced, or remain if the clinical trial necessitates.

Quantitative brain MRI morphology in severe and attenuated forms of mucopolysaccharidosis type I.

OBJECTIVE: To assess our hypothesis that brain macrostructure is different in individuals with mucopolysaccharidosis type I (MPS I) and healthy controls (HC), we conducted a comprehensive multicenter study using a uniform quantitative magnetic resonance imaging (qMRI) protocol, with analyses that account for the effects of disease phenotype, age, and cognition. METHODS: Brain MRIs in 23 individuals with attenuated (MPS IA) and 38 with severe MPS I (MPS IH), aged 4-25 years, enrolled under the study protocol NCT01870375, were compared to 98 healthy controls. RESULTS: Cortical and subcortical gray matter, white matter, corpus callosum, ventricular and choroid plexus volumes in MPS I significantly differed from HC. Thicker cortex, lower white matter and corpus callosum volumes were already present at the youngest MPS I participants aged 4-5 years. Age-related differences were observed in both MPS I groups, but most markedly in MPS IH, particularly in cortical gray matter metrics. IQ scores were inversely associated with ventricular volume in both MPS I groups and were positively associated with cortical thickness only in MPS IA. CONCLUSIONS: Quantitatively-derived MRI measures distinguished MPS I participants from HC as well as severe from attenuated forms. Age-related neurodevelopmental trajectories in both MPS I forms differed from HC. The extent to which brain structure is altered by disease, potentially spared by treatment, and how it relates to neurocognitive dysfunction needs further exploration.

Youth suicide risk screening in an outpatient child abuse clinic.

PROBLEM: Child abuse is an important independent risk factor for suicide. The purpose of the project was to evaluate the implementation of a universal suicide risk screening and assessment tool in an outpatient child abuse evaluation clinic. METHODS: Participants consisted of all patients between the ages of 10 and 18 years who received services at the study site within a 3-month period (n = 162). The study site implemented a tool created for the sole purpose of detecting suicide risk, the Ask Suicide-Screening Questions (ASQ) tool. Data was retrospectively collected using electronic health records; rates of compliance with screening and screen positive rates were calculated. FINDINGS: Suicide risk screening with the ASQ was conducted on 90.7% (147) of the patients. Forty-three (29.2%) patients screened positive for suicide risk. This is a significant increase in detection rates compared to baseline preimplementation data. Of the 67 preteens, 10-12 years of age, that were screened, 14.9% (10/67) screened positive for suicide risk, making up 23% of the positive screens. CONCLUSIONS: Implementing a universal suicide risk screening tool was a successful strategy for detecting suicide risk. A quarter of the youth who screened positive on the ASQ were preteens, highlighting the importance of screening the 10- to 12-year olds for suicide risk.

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.