Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances

Healthcare Professional Perspectives on the Impact of the Physical Health Nurse Consultant

Early mortality experienced by people living with mental health issues (hereon termed consumers) is largely preventable. Healthcare professionals perceive healthcare system inadequacies such as diagnostic overshadowing, stigma and fragmentation of physical and mental healthcare services can be resolved through effective integration approaches. Service- and individual-level integration approaches involve multidisciplinary teams collaborating and coordinating care to holistically meet consumers' physical and mental health needs. Evidence suggests appropriately trained healthcare professionals can deliver effective integrated treatment without financial or organisational restructuring. Specialist nursing positions such as Physical Health Nurse Consultants can support and integrate physical and mental health care. Consumers report the Physical Health Nurse Consultant as providing dedicated, integrated, coordinated and holistic mental and physical health care. This study aimed to explore the Physical Health Nurse Consultant role from the perspectives of healthcare professionals. A qualitative exploratory study design was used. Fourteen healthcare professionals participated in individual interviews or focus groups. Interview recordings were transcribed, and thematically analysed. Three themes were identified: (i) role functions, including integration of physical and mental health care, (ii) impact on consumer physical health outcomes and (iii) impact on service delivery. Healthcare professionals perceive the Physical Health Nurse Consultant effectively integrates physical and mental health care and subsequently support the continuation and embedding of the role in routine practice. Future research is required to explore healthcare professionals' experiences and perceptions of how these roles be translated to routine clinical practice. Examining the professional development requirements, service provider constraints and economic implication to achieve these outcomes also warrants attention.

Implementing Behavioral Optimization and Outcomes Support Team in a Medical/Surgical Telemetry Unit

BACKGROUND

A community hospital reported 21 staff assaults with injuries and 242 emergency response code green (CG) calls for violent behaviors, resulting in a loss of time in the 2022 fiscal year. Evidence has shown that exposure to violent behavior can compromise effective patient care and lead to job dissatisfaction, high turnover, and higher healthcare costs.

PURPOSE

This quality improvement project aims to develop and implement behavioral optimization and outcome support team (BOOST) in a medical-surgical telemetry unit to reduce patient-to-staff assaults/injuries.

METHODS

BOOST was piloted for 15 weeks; process data included staff knowledge and satisfaction with BOOST; outcome data included the number of BOOST and CG calls and staff assaults/injuries. The team members included registered psychiatric nurses, nursing supervisors, and security officers. Data were collected and analyzed weekly using a run chart.

RESULTS

The survey data demonstrated increased staff knowledge of the behavioral response team and staff satisfaction with the BOOST implementation. No staff injuries or assaults were reported during the BOOST implementation.

CONCLUSIONS

Behavioral optimization and outcome support team was effective in de-escalating patients and the team provided support to nursing staff. BOOST utilization can effectively reduce assaults and injuries in the workplace.

Views of Mental Health Nurses on Responding to Clinical Aggression on General Wards

The overall aim of this study was to explore the views of mental health nurses (MHNs) about their experience of responding to workplace violence (WPV) and aggression (code greys and blacks) within acute general wards. WPV continues to pose a significant source of challenge within healthcare settings despite several initiatives that have been trialled over the years. It has the potential to impact patient care and overall staff health and well-being. Nurses play a significant role in the management of WPV; hence, it is important to understand how they respond to and manage incidents of WPV. The study design was an explorative descriptive qualitative design. Data were collected through semi-structured interviews involving n = 10 MHNs working within a mental health consultation liaison team that responds to incidents of violence and aggression (codes grey and black) in acute general wards. Participants were recruited using a convenient sampling method. Data were analysed using thematic analysis. The findings of this study highlighted the following themes: (1) Patient care (subthemes: patient frustration with hospital processes, lack of time and resources); (2) Staffing skills and confidence (subthemes: lack of adequate training, inability to intervene early and communication skills); (3) Understanding patient behaviours (subthemes: it's a psychiatry problem and zero tolerance approach). The management of WPV within acute hospital settings needs to be given due attention by healthcare services. Although a number of organisations are developing measures and guidelines to manage WPV, there is still a gap in the ability of general nursing staff to properly manage such incidences. Proper attention needs to be taken to the training of staff.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis

BACKGROUND

The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA.

OBJECTIVE

This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors.

DESIGN

The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019.

PARTICIPANTS

Hospitalized patients aged 18 and older.

MAIN MEASURES

Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges.

KEY RESULTS

In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race.

CONCLUSIONS

In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Stigma towards patients with mental illness: An online survey of United States nurses

People with mental illness experience significant health disparities, including morbidity and premature mortality. Evidence suggests that stigma is a contributing factor to these observed inequities. The tripartite conceptualization of stigma proposes that three problems underlie stigma: problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). There is limited prior research concerning stigma towards mental illness among nurses in the United States (US). The aims of this study were to assess stigma among US nurses towards patients with mental illness, compare the stigma expressed by nurses working in medical/surgical settings with mental health settings, and identify factors associated with stigma. Participants were recruited online from national professional nursing organizations in the US. We collected demographic data and administered measures of mental health stigma and stigma-related mental health knowledge. Mental health nurses demonstrated comparatively lower levels of stigma and higher levels of knowledge than the medical/surgical nurses. Nursing speciality and personal contact with mental illness were the most significant predictors of stigma and knowledge. Knowledge was found to partially mediate the relationship between nursing speciality and stigma. We found support for the 'contact hypothesis', that is, having a personal experience of mental illness or a friend or family member who has a mental illness is associated with lower stigma towards mental illness. These findings support the development of contact-based and educational anti-stigma interventions for nurses in order to reduce stigma towards mental illness.

The impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions: An integrative literature review

Mental Health Nurse Consultants are advanced practice mental health nurses who consult with nurses and other health professionals in a general hospital setting. The aim of this review was to analyse and synthesize the available evidence related to the impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions. The integrative literature review method was utilized as it allows for the inclusion and integration of quantitative, qualitative, and mixed methods research which produces a synthesized understanding of data to inform practice, policy, and research. The Preferred Reporting Items of Systematic Review and Meta-Analyses guided the search strategy. All published studies examining the impact of clinical consultations provided by Mental Health Nurse Consultants on the mental health care of general hospital patients were included. The 19 selected articles were from North America, Australia, the United Kingdom, and Europe. Fifteen were quantitative, three were qualitative, and one used mixed methods. The findings highlight the role is generally positively received by hospital staff. The results indicate that clinical consultations provided by Mental Health Nurse Consultants (i) may improve patient experiences of mental health conditions, (ii) influence aspects of care delivery, (iii) are valued by staff, particularly nurses, and (iv) increase staff competence and confidence in the provision of mental health care. The review highlighted significant limitations of the available evidence, the need for contemporary discussion and debate of MHNC theory and practice, and further evaluation of the role to inform future service delivery.

Mapping of Transdiagnostic Neuropsychiatric Phenotypes Across Patients in Two General Hospitals

BACKGROUND

Multidimensional transdiagnostic phenotyping systems are increasingly important to neuropsychiatric phenotyping, particularly in translational research settings. The relationship the National Institute of Mental Health's Research Domain Criteria multidimensional approach to psychopathology and nonpsychiatric diagnoses has not been studied at scale but is relevant to those caring for neuropsychiatric illness in medical and surgical settings.

METHODS

We applied the CQH Dimensional Phenotyper natural language processing tool to estimate National Institute of Mental Health's Research Domain Criteria domain-associated symptoms of individuals admitted to nonpsychiatric wards at each of 2 large academic general hospitals over an 8-year period. We compared patterns in individual domain symptom burden, as well as a new pooled unidimensional measure, by primary medical and surgical diagnosis.

RESULTS

Analysis included 227,243 patients from hospital 1 of whom 68,793 (30.3%) had a prior psychiatric history and 220,213 patients from hospital 2 of whom 50,818 (23.1%) had a prior psychiatric history. The distribution of Research Domain Criteria symptom burdens over primary diagnosis was similar across hospital sites and differed significantly across primary medical or surgical diagnosis. The effect of primary medical or surgical diagnosis was larger than that of prior psychiatric history on Research Domain Criteria symptom burden.

CONCLUSION

Research Domain Criteria-based neuropsychiatric symptom burden estimated from general hospital patients' clinical documentation is more strongly associated with the primary hospital medical or surgical diagnosis than it is with the presence of a previous psychiatric history. The bidirectional role of psychiatric and somatic illness warrants further study through the lens of transdiagnostic phenotyping.

Distribution of agitation and related symptoms among hospitalized patients using a scalable natural language processing method

BACKGROUND

Agitation is a common feature of many neuropsychiatric disorders.

OBJECTIVE

Understanding the prevalence, implications, and characteristics of agitation among hospitalized populations can facilitate more precise recognition of disability arising from neuropsychiatric diseases.

METHODS

We developed two agitation phenotypes using an expansion of expert curated term lists. These phenotypes were used to characterize five years of psychiatric admissions. The relationship of agitation symptoms and length of stay was examined.

RESULTS

Among 4548 psychiatric admissions, 1134 (24.9%) included documentation of agitation based on the primary agitation phenotype. These symptoms were greater among individuals with public insurance, and those with mania and psychosis compared to major depressive disorder. Greater symptoms were associated with longer hospital stay, with ~0.9 day increase in stay for every 10% increase in agitation phenotype.

CONCLUSION

Agitation was common at hospital admission and associated with diagnosis and longer length of stay. Characterizing agitation-related symptoms through natural language processing may provide new tools for understanding agitated behaviors and their relationship to delirium.

The Role of Institution-Based Peer Support for Health Care Workers Emotionally Affected by Workplace Violence

BACKGROUND

Academic health centers with peer support programs have identified a significant increase in requests linked to workplace violence (WPV) exposure. However, no known research has focused on supportive interventions for health care workers exposed to WPV. This study aimed to describe the expansion of two long-standing programs-University of Missouri Health Care's (MU Health Care) forYOU Team, The Johns Hopkins Hospital's (JHH) RISE (Resilence in Stressful Events) team-to WPV support, retrospectively summarize the related data, and share generalizable lessons.

METHODS

A retrospective extraction and summary of the forYOU and RISE databases and the MU Health Care and JHH databases was performed tracking hospitalwide data on WPV. Two cases describe the experience of WPV victims.

RESULTS

Between 2009 and 2019, forYOU documented 834 peer support interventions, 75 (9.0%) related to WPV (57 one-on-one encounters, 18 group support encounters). In 2018-2019 the forYOU Team experienced an increase in WPV encounters, with 43 of the team's activations (20%) related to WPV. Between 2011 and 2019, RISE recorded 367 peer support interventions, 80 (21.8%) of which were WPV-related (61 group support encounters, 19 one-on-one encounters). Forty-eight (60.0%) of these 80 encounters occurred in 2018-2019 alone, marking an increase in WPV encounters. Nurses were the most frequent callers of both programs.

CONCLUSION

This study indicates the growing need for health care workers' support in the aftermath of WPV exposure in today's health care environment. Health care institutions should take a holistic approach to WPV, including timely access to interventional peer support programs.

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction

OBJECTIVE

Psychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation-liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction.

METHODS

We implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months.

RESULTS

The provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days.

CONCLUSIONS

Team-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.