The mental and behavioral health crisis in youth: Strategic solutions post COVID-19 pandemic: An American Academy of Nursing consensus paper.

The COVID-19 pandemic wrought significant negative impacts on youth well-being, particularly among Black, Hispanic, American Indian, Alaska Native, and LGBTQ+ (Lesbian, gay, bisexual, transgender, queer or questioning) youth. The pandemic disrupted connections to family, school, and community, which are essential supports for youth mental health. Lessons learned from the pandemic suggest the role of stress and windows of opportunity to build resiliency. Drawing from a policy dialog on the youth mental health crisis conducted by 4 American Academy of Nursing Expert Panels, we present approaches to the current increase in youth mental health problems. Included is emerging literature on building youth resilience, particularly via re-establishing school and community connections. The role of families, schools, and community support is emphasized, particularly by creating a healing school environment and the pivotal role of school nurses. Recommendations include increased support for families, engaging the school nurse role, and developing school-based innovative programs to build connections and youth wellness.

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.

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.

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.

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.

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.

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.

Let's Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation.

Inpatient psychiatric nurses regularly dispense pro re nata (PRN) medication to individuals during their psychiatric hospitalization. International studies indicate that 66% to 90% of patients receive PRN medications during hospitalization, a large percentage of which are benzodiazepines (BZDs). Although clear opportunities exist for nursing intervention to reduce BZD use, there is little recent U.S. literature on inpatient psychiatric nurses' proactive approach to the issue. The current article examines the factors that support BZD use during inpatient hospitalization, including nurses' attitudes around BZD use, the perceived effectiveness of the medication to address difficult situations, and the barriers to using alternative nonpharmacological methods. Suggestions are presented for how nurses might begin dialogues with patients around BZD use and alternative strategies to manage distress. It is recommended that the specialty initiate a research agenda for reducing BZD use during inpatient psychiatric treatment and champion the issue as a focus for systematic improvement efforts. [Journal of Psychosocial Nursing and Mental Health Services, 58(1), 33-38.].

Implementation of Acceptance Commitment Therapy on a Mood Disorder Unit: A Quality Improvement Project.

The current quality improvement project was conducted on an adult, short-term inpatient psychiatric unit to improve the consistency and structure of group sessions. The aim of the current project was the implementation of groups that were consistent with an acceptance and commitment therapy (ACT) framework. Following staff education and discussion, ACT focused groups were systematically introduced into patient schedules. Patient responses to groups were monitored by the Acceptance and Action Questionnaire II (AAQII) and patients' perception of the group experience. Data gathered indicated patients' positive perception of new group programming. Patients' AAQII scores showed a slight improvement, particularly psychological flexibility. Findings indicate ACT is an appropriate and useful framework for individuals hospitalized on inpatient psychiatric units. [Journal of Psychosocial Nursing and Mental Health Services, 57(11), 22-27.].

The Psychiatric Mental Health Advanced Practice Registered Nurse Workforce: Charting the Future.

AIMS: To characterize the future Psychiatric Mental Health (PMH) Advanced Practice Registered Nurse (APRN) workforce in light of the high demand for psychiatric providers in all aspects of mental health service delivery. Over the past 20 years, there has been significant growth of the PMH APRN workforce, a provider group capable of addressing mental health provider shortages. However, continued growth may be limited by anticipated retirements and traditional volume of graduations from PMH nurse practitioner (NP) programs. Optimum utilization of PMH APRNs in service delivery systems and State workforce planning may also be impeded by their frequent mischaracterized in federal reports and mental health workforce studies. METHODS: Based on a review of the literature, this discussion paper evaluates trends related to PMH NP programs and graduates, anticipated retirements of current PMH ARPNs, facilitators and barriers to increasing the PMH APRN workforce, and opportunities and threats to workforce development. RESULTS: The PMH APRN workforce faces significant challenges owing to barriers and facilitators to growth of the specialty. These factors conspire to limit the supply of PMH APRNs at a time when they are needed to compensate for declining numbers of providers in the United States, particularly practicing psychiatrists. CONCLUSION: Recommendations are forwarded as to how best shape the educational pipeline to meet the current and emerging needs of American citizens for quality mental health care.

Report on the APNA National Psychiatric Mental Health Advanced Practice Registered Nurse Survey.

BACKGROUND: Further exploration of the practice roles of psychiatric mental health (PMH) advanced practice registered nurses (APRNs) is warranted. OBJECTIVE: In March of 2016, the American Psychiatric Nurses Association (APNA) conducted a national survey to gather data on the demographics, practice roles, and activities of certified PMH APRNs. DESIGN: The e-mail survey contained 46 questions consistent with minimum data set requirements of the Forum of State Nursing Workforce Centers. RESULTS: The data indicate that PMH APRNs are a clinically active workforce; the majority deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing, and providing psychotherapy. CONCLUSION: PMH APRNs are delivering care to clients dealing with a range of serious mental illnesses across the life span in a variety of roles. It will be critical to monitor the activities and outcomes of this expanding behavioral health care workforce.

Observing the advanced disease course in mucopolysaccharidosis, type IIIA; a case series.

This follow-up study of a subgroup of the patients seen in a natural history study of mucopolysaccharidosis type IIIA (Sanfilippo syndrome type A) addressed the adaptive and medical characteristics of their advanced disease manifestations. Of the original 24 patients, specific data was collected on only 58% primarily due to difficulty in locating families and coordinating time for interviews two to four years after the original study. At the last contact with the patient, age range was 8 to 24years of age. Data were collected from telephone interviews from the Vineland Adaptive Behavior Scales II and medical and treatment history. We report the case data from rapid progressing and slow progressing patients separately. By the end of our data collection, 5 patients had died; 4 rapid progressing patients between 8 and 12years of age and 1 slow progressing patient at age 21. Two patients were in out-of-home placements in the year before they died. We found that the incidence of surgeries and epilepsy was relatively low and that behavior problems largely subsided. Adaptive levels were very low with children functioning at below a two-year age equivalent level in all adaptive functions, but motor skills were slightly more intact. Only one slow progressing patient was functioning above a three-year level. Parent burden had shifted from behavioral control to physical management. Although their quality of life was clearly negatively impacted by physical management and palliative care, parents were more able to cope and adapt to such demands than in the initial stages of the disease.

Determining the drivers of population structure in a highly urbanized landscape to inform conservation planning.

Understanding the environmental contributors to population structure is of paramount importance for conservation in urbanized environments. We used spatially explicit models to determine genetic population structure under current and future environmental conditions across a highly fragmented, human-dominated environment in Southern California to assess the effects of natural ecological variation and urbanization. We focused on 7 common species with diverse habitat requirements, home-range sizes, and dispersal abilities. We quantified the relative roles of potential barriers, including natural environmental characteristics and an anthropogenic barrier created by a major highway, in shaping genetic variation. The ability to predict genetic variation in our models differed among species: 11-81% of intraspecific genetic variation was explained by environmental variables. Although an anthropogenically induced barrier (a major highway) severely restricted gene flow and movement at broad scales for some species, genetic variation seemed to be primarily driven by natural environmental heterogeneity at a local level. Our results show how assessing environmentally associated variation for multiple species under current and future climate conditions can help identify priority regions for maximizing population persistence under environmental change in urbanized regions.

Steps to Achieve Universal Suicide Screening in Emergency Departments: A Call to Action.

American individuals attempt suicide at alarmingly high rates of approximately 1.1 million times per year. Yet the United States has failed to adopt a systematic approach to suicide prevention, particularly via universal screening. Given the increasing number of individuals with suicidal ideation presenting to emergency departments (EDs), all patients who present to the ED for treatment should be screened, as opposed to only individuals with mental health complaints. In the current article, barriers to suicide screening in the ED are discussed, as well as strategies to move ED providers toward the goal of universal screening. The current article entreats nurses to be leaders in achieving universal screening and provides practical actions to begin the process. Specific recommendations for action include improving training, increasing lethal means assessment, and achieving compliance with The Joint Commission suicide screening guidelines. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 21-26.].

Implementation of Trauma-Informed Care and Brief Solution-Focused Therapy: A Quality Improvement Project Aimed at Increasing Engagement on an Inpatient Psychiatric Unit.

Addressing tense and escalating situations with noncoercive measures is an important element of inpatient psychiatric treatment. Although restraint rates are frequently monitored, the use of pro re nata (PRN) intramuscular (IM) injections to address agitation is also an important indicator. In 2015, at the current study site, a significant increase was noted in PRN IM medication use despite unit leadership's efforts to build a culture of trauma-informed care (TIC). The purpose of the current quality improvement project was to educate staff on methods to incorporate TIC into daily practice and the use of brief solution-focused therapy techniques in escalating situations. Measurement of attitudes toward patient aggression and engagement with patients followed two waves of staff education. Upon completion of the project, a decrease in PRN IM medications, improvement in staff attitudes toward patient aggression, and improved sense of staff competency in handling tense situations were noted. [Journal of Psychosocial Nursing and Mental Health Services, 56(8), 16-22.].

Cognitive and adaptive measurement endpoints for clinical trials in mucopolysaccharidoses types I, II, and III: A review of the literature.

Sensitive, reliable measurement instruments are critical for the evaluation of disease progression and new treatments that affect the brain in the mucopolysaccharidoses (MPS). MPS I, II, and III have early onset clinical phenotypes that affect the brain during development and result in devastating cognitive decline and ultimately death without treatment. Comparisons of outcomes are hindered by diverse protocols and approaches to assessment including applicability to international trials necessary in rare diseases. We review both cognitive and adaptive measures with the goal of providing evidence to a Delphi panel to come to a consensus about recommendations for clinical trials for various age groups. The results of the consensus panel are reported in an accompanying article. The following data were gathered (from internet resources and from test manuals) for each measure and summarized in the discussion: reliability, validity, date and adequacy of normative data, applicability of the measure's metrics, cross cultural validity including translations and adaptations, feasibility in the MPS population, familiarity to sites, sensitivity to change, and interpretability. If, resulting from this consensus, standard protocols are used for both natural history and treatment studies, patients, their families, and health care providers will benefit from the ability to compare study outcomes.

Assessments of neurocognitive and behavioral function in the mucopolysaccharidoses.

The mucopolysaccharidoses (MPS) are a group of rare, inherited lysosomal storage disorders in which accumulation of glycosaminoglycans (GAGs) leads to progressive tissue and organ dysfunction. In addition to a variety of somatic signs and symptoms, patients with rapidly progressing MPS I (Hurler), II, III, and VII can present with significant neurological manifestations, including impaired cognitive abilities, difficulties in language and speech, behavioral abnormalities, sleep problems, and/or seizures. Neurological symptoms have a substantial impact on the quality of life of MPS patients and their families. Due to the progressive nature of cognitive impairment in these MPS patients, neurocognitive function is a sensitive indicator of disease progression, and a relevant outcome when testing efficacy of therapies for these disorders. In order to effectively manage and develop therapies that address neurological manifestations of MPS, it is important to use appropriate neurocognitive assessment tools that are sensitive to changes in neurocognitive function in MPS patients. This review discusses expert opinions on key issues and considerations for effective neurocognitive testing in MPS patients. In addition, it describes the neurocognitive assessment tools that have been used in clinical practice for these patients. The content of this review is based on existing literature and information from a meeting of international experts with extensive experience in managing and treating MPS disorders.

Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement.

Staff members' engagement with patients is a critical element of inpatient psychiatric care, essential to safety, the hospitalization experience and the development of a culture of care. Currently broad concerns exist around the amount of time inpatient psychiatric nurses expend in patient engagement and the quality of these interactions. In this paper we present a model of engagement that clarifies necessary skills to support the engagement process. The model is based on Peplau's theory of interpersonal relations, patients' ideas on healing elements of psychiatric hospitalization and research on inpatient therapeutic relationships. We are currently using this model for a web-based teaching/learning course to cultivate interpersonal engagement, and to explicate how through operationalizing their inpatient role, nurses support patients in the development of their mental health and well-being.

Implementation of a Health Indicator Monitoring System in an Assertive Community Treatment Team at a Community Outpatient Behavioral Health Organization.

Persons with severe mental illness have increased risk for medical co-morbidities and early mortality. The purpose of this project was to implement a health indicator monitoring system for an Assertive Community Treatment team and to utilize this system to generate referrals to appropriate medical providers. The system established utilized Substance Abuse and Mental Health Services Administration (SAMSHA) recommended health indicators and pre-post data analysis to assess the effectiveness of the initiative. Targets for health indicator collection were partially reached, with results indicating that metabolic lab monitoring at this site was insufficient. Recommendations for improving integration of medical and mental health care within the ACT setting are given.