Effect of a psychiatric diagnosis on nursing care for nonpsychiatric problems

The Role of Bias in Clinical Decision-Making of People with Serious Mental Illness and Medical Co-morbidities: a Scoping Review

The aim of this review was to examine the evidence for the impact of explicit and implicit biases against mental illness on the clinical decision-making of primary care physicians, medical students, and nurses when they are providing care to individuals with serious mental illness for cardiovascular disease, diabetes, and cancer. Studies were identified by searching MEDLINE, EBSCO host, and PsychINFO. A total of 18 studies published between 1996 and 2020 were reviewed and summarized. The studies were divided into two groups-studies that used a simulation or vignette methodology and those with a qualitative approach (interviews and focus groups). Of the simulation/vignette studies that allowed participants to report what they would have done in various clinical scenarios, there were roughly equal numbers of neutral or negative clinical decisions that represented 80% of the relevant behavioral results. Only 21% of the findings demonstrated a clinical decision that was favorable towards people with mental illness. Of the qualitative studies, all of the studies reported behaviors (either self-reported or observed) that were likely to be biased against people with mental illness, while 3 of the studies reported mixed results. Healthcare provider bias against individuals with mental illness does exist and impacts clinical decisions negatively. Much more empirical work needs to be done to determine the full extent and impact of the problem, including how these decisions affect the lives of individuals with mental illness.

Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Nurses' and Mental Health Technicians' Attitudes and Social Acceptance of People with Mental Illness

Over 43 million Americans are diagnosed with a mental illness. Various factors, including health professionals' attitudes, prevent patients from seeking care. Previous evidence fails to identify nursing staff attitudes toward patients with mental illness. This cross-sectional study investigated attitudes toward mental illness of 146 registered nurses and mental health technicians in a psychiatric hospital. The study was guided by the Modified Labeling Theory. Respondents expressed stereotyping beliefs that people with mental illness would be devaluated and discriminated, and endorsed stigmatizing attitudes expressing stronger desire for social distance from a person with schizophrenia than depression or diabetes. Implications for future research, nursing education and practice are discussed.

Effectiveness of direct contact intervention with people with mental illness to reduce stigma in nursing students

People with mental illnesses are at a higher risk than the general population of suffering from somatic diseases. However, they receive less attention from healthcare services. Some studies have indicated that this situation can be partially explained by the stigmatizing attitudes of health professionals, including nurses. With the objective to improve future nursing professionals' attitudes towards people with mental illnesses, an intervention involving direct contact with people who had lived experience with mental illnesses was designed and its effectiveness was measured. It consisted of a single 90-min session involving a mental health professional, a person with a mental illness, and a family member of someone with a mental illness. The intervention was based on a structured script where they described their experiences with the illness and their history of recovery, and then, they had a discussion with the attendees. The effectiveness of this approach was measured through a quasi-experimental study with a pretest-post-test design. The differences in the scores obtained in the AQ-27-E questionnaire before and after the intervention indicated that there was a decrease in fear, feelings of danger, avoidance, segregation, and coercive attitudes, while positive feelings increased, including a tendency to help and compassion. These results are important for clinical practice because this intervention could improve the quality of care provided to people with mental illnesses.

Let's get physical: improving the medical care of people with severe mental illness

There is clear evidence of increased medical comorbidity and related mortality in people with severe mental illness, despite numerous guidelines for managing medical conditions in this population. This article assesses inequalities in medical treatment and preventive healthcare received by psychiatric patients compared with the general population. It considers whether the medical care provided is adequate and whether published guidelines improve it. Mental health specialists, general practitioners and hospital specialists appear to deliver poorer than average medical care for this vulnerable population. Implementation of physical healthcare guidelines is incomplete and the guidelines must be matched with resources to address this deficit.

The Variability of Nursing Attitudes Toward Mental Illness: An Integrative Review

Mental illnesses are common worldwide, and nurses' attitudes toward mental illness have an impact on the care they deliver. This integrative literature review focused on nurses' attitudes toward mental illness. Four databases were searched between January 1, 1995 to October 31, 2015 selecting studies, which met the following inclusion criteria: 1) English language; and 2) Research in which the measured outcome was nurses' attitudes toward mental illness. Fourteen studies conducted across 20 countries that 4282 participants met the inclusion criteria. No study was conducted in the United States (U.S.). Studies reported that nurses had mixed attitudes toward mental illness, which were comparable to those of the general public. More negative attitudes were directed toward persons with schizophrenia. Results indicate the need for further research to determine whether attitudes among nurses in the U.S. differ from those reported from other countries and to examine potential gaps in nursing curriculum regarding mental illness.

Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

OBJECTIVE

This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events.

METHODS

Medical record review was conducted for medical-surgical hospitalizations occurring during 1994-2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization.

RESULTS

A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3-1.7) and procedure-related events (OR=1.6, CI=1.2-2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4-10.3).

CONCLUSIONS

Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness.

Medical-Surgical Nurses' Perceptions of Psychiatric Patients: A Review of the Literature With Clinical and Practice Applications

The literature consistently shows that medical-surgical nurses frequently lack the knowledge, skills, and attitudes necessary to render holistic nursing care to patients with severe mental illness (SMI). The negative perceptions often portrayed by medical-surgical nurses towards SMI patients with comorbid medical-surgical disorders must be addressed in order to ameliorate treatment gaps. Current concepts, issues, and challenges associated with the perceptions of nurses who care for patients with (SMI) in medical-surgical settings can prove overwhelming to both nurses and patients, and can result in concerning practice gaps. In accordance with a contemporary model of patient-centered care, it is imperative that medical-surgical nurses acquire the knowledge, skills, and attitudes necessary to work with this high-risk population. Cultivating an environment that promotes apposite attitudes along with effective training programs for medical-surgical nurses, may shift negative perceptions and ultimately meet best practice standards and improve outcomes for patients with SMI.

A medical-surgical nurse's perceptions of caring for a person with severe mental illness

BACKGROUND

When hospitalized for medical conditions, many people with severe mental illness (SMI) have poor outcomes, yet little is known about contributing factors. Studies exploring the care experience from nurses' perspectives described care processes as "difficult." None of these studies were conducted in the United States, and sociocultural contexts significantly affect perceptions of SMI.

OBJECTIVE

The purpose of this inquiry was to explore a medical-surgical nurse's perceptions of caring for a hospitalized person with SMI in the United States.

DESIGN

A qualitative, descriptive case study was used.

RESULTS

The nurse's experience was characterized by categories of tension, discomfort, lack of professional satisfaction, and difficult.

CONCLUSIONS

This case study revealed a negative care experience, similar to conclusions of investigations conducted in other countries. Understanding of nurses' care experiences can inform efforts to improve practice environments, provide resources, or develop models of care that support nurses who care for patients with SMI and improve health outcomes for people with SMI.

Survey of general practitioners' attitudes to prescribing statins in different patient groups: a web-based survey

Low rates of statin prescribing have been noted in several major studies of patients with schizophrenia and the aim of this study was to investigate clinicians' attitudes to prescribing statins to different patient groups. The general practitioners (GPs) in Dumfries and Galloway were randomized into two groups. They received an email invitation to a web-based survey. The survey asked for treatment recommendation for three patient vignettes, each with a 10-year cardiovascular risk of 20%. In one group descriptions of the patient included type 1 diabetes, epilepsy and unemployed and in the other group these were replaced by type 2 diabetes, schizophrenia and retired. The questionnaires had no other differences. After three email invites, 53 questionnaires were completed (40% of a potential 133 participants). Statin therapy was recommended by 88% and 85% of respondents for patients with type 1 and type 2 diabetes, respectively; by 37% of respondents for patients with schizophrenia and 31% for patients with epilepsy; by 33% of respondents for retired patients and 23% of respondents for patients who are unemployed. This study demonstrates under-prescribing of statins. This was not worse for patients with schizophrenia as compared with patients with epilepsy. This suggests that the low rates of treatment of metabolic risk factors in patients with schizophrenia are not the result of clinician bias when compared with patients with epilepsy. Clinician bias, however, may reduce the chances of an unemployed patient receiving statin treatment.

A risk to himself: attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical-surgical units

Psychiatric patients are liable to stereotyping by healthcare providers. We explored attitudes toward caring for psychiatric patients among 13 nurses working in general hospitals in Ireland. Participants thought aloud in response to a simulated patient case and described a critical incident of a patient for whom they had cared. Two attitudinal orientations were identified that correspond to stereotypical depictions of risk and vulnerability. The nurses described psychosocial care strategies that were pragmatic rather than authentically person-centered, with particular associations between risk-oriented attitudes and directive nursing care. Nurses had expectations likely to impede relationship building and collaborative care. Implications arising include the need for improved knowledge about psychiatric conditions and for access to professional development in targeted therapeutic communication skills.

Poor clinical outcomes among pneumonia patients with schizophrenia

Despite the recent attention to patient safety and quality of care, no prior studies have addressed outcomes of hospitalization for pneumonia among patients with schizophrenia. This study investigated the extent to which clinical outcomes of pneumonia were different among patients with schizophrenia. This study used data from the Taiwan National Health Insurance Research Database. Of the total of 81,599 patients admitted with a principal diagnosis of pneumonia from 2002 to 2004, 949 had previously been admitted with a principal or secondary diagnosis of schizophrenia within the 2 years of their index pneumonia admission. We randomly selected 2847 pneumonia patients matched with the study group in terms of gender, age, year of admission, length of stay, and Charlson Comorbidity Index score as the comparison cohort. Conditional logistic regression models were used for analysis. Findings indicated a higher prevalence of adverse outcomes among patients with schizophrenia. Patients with schizophrenia were independently associated with a 1.81 times greater risk of intensive care unit admission (95% confidence interval [CI] = 1.37-2.40), a 1.37 times greater risk of acute respiratory failure (95% CI = 1.08-1.88), and a 1.34-fold greater risk of mechanical ventilation (95% CI = 1.04-1.92) after adjusting for characteristics of patients, physicians, hospitals, and potential clustering effects. Adjusted odds ratios were further evident among those treated in private hospitals and in regional/district hospitals. Significant barriers to prompt and appropriate medical care for pneumonia persist for patients with schizophrenia. Careful monitoring of physical health and proper integration between psychiatrists and physicians should be stressed to reduce poor clinical outcomes in this vulnerable population.

Non-psychiatric hospitalization of people with mental illness: systematic review

AIM

This paper is a report of a literature review of the evidence regarding outcomes experienced by severely mentally ill individuals hospitalized in general medical-surgical settings for non-psychiatric conditions.

BACKGROUND

Severely mentally ill individuals experience chronic medical illnesses at a rate greater than the general population. When hospitalized in non-psychiatric settings, they tend to be experienced as 'difficult' by nurses and to have longer lengths of stay.

DATA SOURCES

The CINAHL and PUBMED databases were searched from 1 to 9 March 2008 to identify studies published between 1998 and 2008 investigating outcomes among people with mental illness hospitalized for non-psychiatric illness in general hospitals.

METHODS

Included studies were those published in English in peer reviewed journals and investigating patient outcomes. The studies were reviewed for relevance and inclusion criteria; the methodological quality of studies was not evaluated.

RESULTS

Twelve studies met inclusion criteria. All studies examining length of stay, costs of care or resource utilization showed increased measures for patients with psychiatric comorbidity. Interventions described included psychiatric liaison psychiatry and nursing, which failed to demonstrate improvement in outcomes.

CONCLUSION

Nurses play a pivotal role in improving the inpatient care of this vulnerable population, but they struggle in their attempts to do so. Research to determine the best approaches to promote nurses' knowledge, positive attitudes and self-confidence in caring for patients with psychiatric comorbidity is needed. Investigation of the patient perspective on the inpatient experience might also provide insight for designing effective care processes.

Thinking like a nurse: a research-based model of clinical judgment in nursing

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.