Inpatient behavioral health facilities benefit greatly from accreditation from the Joint Commission (JC) and must meet several standards in order to maintain this recognition. Nurses and healthcare professionals must be able to understand and identify JC standards and their National Patient Safety Goals (NPSGs) in order to assist the administration in obtaining and maintaining accreditation (JC, 2019a). Future job growth for registered nurses is expected to be approximately 15%, which is higher than the national average for the past 10 years. According to the Bureau of Labor Statistics (2019), the need for nurses working in psychiatric units, or behavioral health settings is expected to grow even faster. According to Johnson (2017), behavioral health facilities and hospitals are having trouble attaining and maintaining adequate staffing, and many are facing financial difficulties due to issues with reimbursements for services and payments. Facilities have difficulty justifying reimbursement as mental health is misunderstood and may require increased documentation to obtain approval for services, unlike other specialties in healthcare. When working in behavioral health facilities, nurses must be flexible and able to handle high-stress situations and be creative in maintaining a safe, therapeutic environment (Johnson, 2017).
Aspects of Behavioral Health Nursing
Behavioral health nursing can be a very rewarding and in-demand occupation with a variety of opportunities. According to Wolf (2019), due to the stigma and prejudice toward people suffering from mental illness, it is often hard to find enough nurses and funding to run programs in behavioral health. As the population grows, so does the demand for behavioral health nurses. RNs and LPNs can work in a behavioral health inpatient, outpatient, community health clinic, or home health setting; there is a wealth of travel opportunities available within this specialty for nurses as well. Behavioral health nurses are needed by agencies and travel companies for short-term and long-term assignments (Wood, 2015).
Important qualities that a nurse should possess when entering this particular field include patience, sound clinical judgment, open-mindedness, and the ability to be assertive without being aggressive. Behavioral health nurses should also have good critical thinking skills, empathy, and strong communication skills (Bybel, 2019). Nurses going into this field should be aware of the stigma toward mental health conditions and understand the associated social injustices to care for these patients properly. Nurses considering this field should identify their own biases as well. Nurses must also assist patients in overcoming barriers to accessing healthcare services (Thomson, Racher, & Clements, 2019). The nurse will care for a variety of patients diagnosed with mood disorders, psychotic disorders, substance abuse disorders, anxiety or panic disorders, personality disorders, or intellectual/cognitive disabilities. Many of the patients being cared for in inpatient behavioral health facilities have multiple diagnoses, in addition to patients who suffer from multiple medical conditions in addition to their mental health conditions (Ohnishi et al., 2019).
The most common diagnoses seen are generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), bipolar disorder, depression, schizophrenia, and borderline personality disorder. There are both voluntary and involuntary admissions. An involuntary admission, or pink slip, typically involves a 72-hour hold requiring the patient to stay on the unit, as they are a safety risk to themselves or others. Voluntary admissions are usually due to acute psychosis, mental instability, extreme stress or symptoms related to their illness, inability to function normally, or daily activities that are negatively impacted by their illness. For a patient to be discharged, they must demonstrate that they are no longer suicidal and will remain free from harm due to self-injury, are no longer a threat to the safety of others, have regained control of their emotions, their symptoms have generally improved, and they are stable. A patient who requires more long-term treatment due to severe mental illness, disability, or advancement of a disease process such as dementia or Alzheimer’s may then be transferred to a more long-term facility or unit (Wolf, 2019).
Considerations for Joint Commission Survey Preparation in Behavioral Health
JC accreditation is recognized for excellence in patient safety efforts and the quality of care provided. Gaining and maintaining accreditation assists with risk reduction, management, qualification for Medicare and Medicaid, requirements for private insurances, and regulation requirements by local or state entities (Knopf, 2016). Accreditation can assist in performance improvement initiatives and help maintain and strengthen patient safety efforts (JC, 2019a). Facilities should make every effort to maintain or obtain accreditation, not solely for the benefits of being accredited, but for the improvements made towards the quality of patient care and the implementation of safety measures on the unit and throughout the facility. Healthcare providers must collaborate as a team and understand their roles when preparing for successful JC surveys (Knopf, 2016).
One of the first considerations of administrators and nursing staff is to understand who is going to be conducting the survey on the unit. The team should consist of professionals who are experienced in behavioral healthcare (Clark, 2018). Understanding who might be conducting the survey and what their educational background and experience might be may assist administrators and staff in understanding the focus of the team’s visit. Having staff utilize a checklist as a guide can help with organization and can prevent crucial areas that may need attention from being missed. The process allows the team to evaluate their environment to reduce possible safety risks and promotes a positive view regarding change within the facility. According to Caruso (2015), inpatient behavioral health units might be encouraged to include the following within their checklist:
- Ensure hallways are clear of clutter.
- Discard and replace outdated or expired supplies.
- Discard and replace expired medication.
- Clean microwaves, refrigerators, and storage areas, and ensure items are properly labeled.
- Ensure that whiteboards, room numbers, beds, and areas within the unit are properly labeled, updated, and identified. Flyers or informational sheets are properly covered in plastic or laminated, no glue or tape is used to secure to pegboards or walls.
- Keep patient information confidential and discard properly.
- Keep drinks, snacks, or food out of the nursing station or other clinical areas.
- Clean the entire unit, including the nursing station and common areas. Remove debris, clutter, dust, and organize properly.
- Ensure that care plans have complete information and nursing interventions are identified, addressed, and proper documentation is complete.
- Secure all lockers, storage rooms, group rooms, report rooms, kitchen areas, and any other doors that should not be accessible to patients.
- Inspect and maintain gas systems.
- Maintain and inspect emergency power systems.
- Properly document all advance directives.
- Properly document all orders.
- Ensure that no unacceptable abbreviations are utilized.
- Include informed consent is with all charts.
- Remove all ligature risks (towel racks, doors, shower curtains, anything that is a potential hanging risk).
- Review emergency codes/plans with staff (i.e., what to do in a code violet, red, or blue).
- Review who the safety officer is for the facility and telephone extensions to other departments such as security.
- Review how to locate the MSDS.
- Review how to locate policy and procedure manuals.
- Ensure that staff have ID badges and are in uniform.
- Review how to report injuries or adverse events (Caruso, 2015).
Checklists can assist in preparing, planning, identifying safety risks, and assisting staff in understanding how they can play an important role in becoming accredited by the JC (Clark, 2018). It can also help staff in becoming more involved in decision-making processes regarding accreditation and improving patient outcomes, patient safety initiatives, and the quality of care provided within the facility (Jansson et al., 2015). Nursing staff can take an active role in identifying areas that may need improvement and contribute to a facility being successfully accredited as essential members of the team. Utilizing checklists and guides can also assist in eliminating ligature (hanging) risks, or items that are unsafe for the inpatient behavioral health unit (Gilk, 2015).
An organization may conduct a mock survey to recognize areas of concern prior to the actual team visit. Mock surveys can greatly benefit the organization by preparing nursing staff, healthcare providers, administrators, and unlicensed personnel, and allow for necessary improvements to be made prior to the actual survey. They can assist in identifying ligature risks, improving the quality of patient care, and involving staff in decision-making processes (Pluket, 2018). This activity allows the administration and staff to identify patient safety risks and improve documentation practices properly. Additionally, educational opportunities can be delivered to the staff (Clark, 2018). Mock surveys should involve all members of the healthcare team, provide the opportunity for collaboration and teamwork, and allow staff to reflect on the rationale behind different changes and interventions. This assists with viewing the changes as positive necessities that improve patient care (Martin, 2017). Proper preparation for a survey allows for the identification of ligature and other safety risks and allows for staff to be involved in the process which can empower staff and assist staff in understanding the importance of achieving and maintaining accreditation.
National Patient Safety Goals (NPSGs)
It is imperative that nursing professionals understand the behavioral health care NPSGs:
- NPSG 1: Improve the accuracy of the identification of individuals served.
- NPSG 3: Improve the safety of medications.
- NPSG 7: Reduce the risk of healthcare-associated infections.
- NPSG 15: Reduce the risk of suicide (JC, 2019c).
Nurses have a responsibility to the public to reduce risk and adequately meet the needs of their patients. It is imperative that healthcare professionals identify ways to reduce risks to the public and identify ways to improve care for at-risk populations served (Martin, 2017).
NPSG1 encourages nurses to improve the accuracy of the identification of individuals served. The accurate identification of patients is imperative in providing safe and efficient care to the public. Nurses must be sure they are giving the correct care to the correct patient; failure to do so could result in injuries or increased comorbidities for the patient, even death, and civil and criminal legal ramifications for the staff and the facility at large(Voskanyan, Shikina, Kidalov, & Davidov, 2020; Yum, 2015).
NPSG 3, to improve the safety of medications, is primarily the responsibility of the nurse, as nurses oftentimes are the last line of defense prior to the medication being administered to the patient. Nurses must be aware of the role they play in medication administration, as many errors can be prevented by the nurse appropriately questioning incorrect medications or doses. Improving the safety of medications and medication administration includes accurate medication reconciliation, communication of accurate medication orders, coordination of care, and collaboration of healthcare professionals (Hunt & Chakraborty, 2020).
NPSG 7, to reduce the risk of healthcare-associated infections, is another aspect of the NPSGs that nurses must pay attention to, in order to promote patient outcomes and health. Reducing risks to patients is a primary responsibility of the nurse, especially when it comes to reducing the risk of healthcare-associated infections. Nurses must be able to identify health risks to patients and ways that staff can help reduce or combat those risks to promote patient health (Picton-Barnes, Pillay, & Lyall, 2020). This process of evidence-based practice to reduce hospital-acquired infections improves patient outcomes and reduces the risks to patient health (Sajjad, Ahmad, & Azam, 2020).
NPSG 15 focuses on reducing ligature risk. A ligature risk is defined as any item a patient could use to hang or strangle themselves. This is essential to both gaining and maintaining JC accreditation, and in improving the quality of care provided to patients (Martin, 2017). Anything a patient can utilize to harm themselves is considered a safety risk. The JC (2019b) states that intentional hanging is one of the most problematic areas when it comes to mental health, inpatient behavioral health units, and suicide attempts. Ligature risks could include doorways, tops of toilets, towel racks, and corners. It is imperative that healthcare organizations develop committees, teams, and checklists to work towards reducing these risks and increasing safety on inpatient units. According to Pluket (2018), a checklist could also be developed and utilized by staff and administrators to eliminate issues related to patient safety, such as:
- Check for tubing, such as oxygen tubing, IV tubing, or wires.
- Ensure that sharps and sharp containers are not accessible to patients.
- Check for unattended items such as mops, cleaners, carts, or custodial supplies.
- Lock all unused rooms (such as storage, activities rooms, kitchenettes, medication rooms, and report rooms) when not in use.
- Ensure that the unit is staffed adequately at all times.
- Anchor or secure all chairs and furniture.
- Secure and lock all closets and lockers.
- Remove all drapes or curtains, strings, cords, ropes, extra sheets or bedding, towel racks or knobs, and handrails or doorknobs.
- Install collapsible doors for bathrooms.
- Assess all rooms for any exposed plumbing, dispensers such as soap, door hinges, and anything with corners that could be used for self-harm.
- Protect all light fixtures.
- Ensure all windows are locked and unable to be forced opened or broken.
- Install solid ceilings in lieu of dropped ceilings.
- Clean and remove clutter from throughout the unit and patient rooms.
- Address all nursing diagnoses in the patient plan of care (Pluket, 2018).
Utilizing a list can empower administrators and staff to be involved in reducing safety risks to both patients and staff. Positive outcomes are best achieved by involving staff, incorporating shared decision-making processes, providing educational opportunities to fill knowledge gaps among staff, and allowing for quality improvement measures involving teamwork and collaboration (Schwartz et al., 2018). Transformational leadership is the most successful form of leadership in healthcare. By utilizing a checklist and conducting a mock survey, this allows staff to be involved, and encourages participation among the different team members within the organization. Staff must view this as an opportunity to make improvements, increase staff morale, reduce safety risks, and improve the quality of patient care to assist in meeting JC standards (Bogaert et al., 2018). Staff can assist in making necessary changes to prepare the facility for the survey and be involved with equipment changes, updating procedures or policies, and thus improve the staff response to these changes (Campione & Famolaro, 2018).
Inpatient behavioral health facilities must understand and review the JC standards that affect their practices prior to a survey and understand how to address patient safety concerns that may arise properly. Standards must be met for the main facility’s accreditation, as well as the secondary survey, which concentrates solely on behavioral health. Standards for inpatient behavioral health services target the following areas: opioid treatment programs for chemical dependency patients; restraint and seclusion use, documentation and assessment practices; pain assessment and management; safety standards; suicide prevention; and infection control. The JC will review documentation as well as nursing care plans and evaluate the facility to be sure they are upholding their standards and state regulations. Identifying current standards and expectations is imperative for the facility to be successful in maintaining or gaining accreditation by the JC (JC, 2019b, 2019c).
Considerations for Behavioral Health Nursing
Behavioral health nurses must have good communication and assessment skills maintain a calm and professional demeanor at all times, and recognize their own biases and prejudices (Baker, Dower, Winter, Rutherford, & Betts, 2019). Unfortunately, due to the stigma associated with mental illness, nurses may not realize their bias regarding mental health. It is difficult to admit to a diagnosis of anxiety, depression, PTSD, or another mental illness for many people, yet they likely would not be uncomfortable sharing if they had a disease such as diabetes or hypertension (McCleary-Gaddy & Scales, 2019). It is important to recognize this as prejudice and identify ways to change our thought process. Bias can exist within the nursing profession. A nurse suffering from behavioral health issues may be treated differently from a nurse with another illness such as epilepsy or diverticulitis (Klik, Williams, & Reynolds, 2019).
Behavioral health nurses should actively listen to their patients, understand proper communication techniques, and be able to differentiate therapeutic and non-therapeutic communication. For example, if a patient is experiencing a hallucination or delusion, it is important to avoid reinforcing or challenging the patient. The nurse should ask questions and assess the patient’s perception of the event and any precipitating factors leading to it (Fredwall & Larsen, 2019). Nurses should understand techniques to manage patients who suffer from OCD. If a patient is completing a ritual, it is important to allow the patient to complete the ritual and avoid interruption, or they may experience even more anxiety (Samantaray, Kar, & Singh, 2019). Behavioral health nurses need to apply appropriate non-pharmacological methods of care and help patients develop and apply appropriate coping mechanisms into their daily lives. The nurse’s communication and interaction can make a difference in the lives of their patients. They should strive to maintain consistency, patience, and a calm demeanor (Falk & Taylor-Schiller, 2019).
Behavioral health nurses require sound assessment skills to recognize non-verbal cues and body language and react calmly and quickly to prevent self-harm or physical injuries on the unit (Lester et al., 2018). The environment should be assessed frequently, and suicidal or homicidal patients should be closely monitored to avoid self-harm or harm to others. A calm and stable environment that is both safe and therapeutic should be maintained at all times. Behavioral health nurses monitor patient behaviors to evaluate the effectiveness of their interventions, coping mechanisms, or patient education (Nguyen, Holton, S., Tran, & Fisher, 2019). Early recognition of behavioral changes allows the nurse to implement appropriate measures to manage symptoms and reduce psychological stressors effectively (Halcomb, McInnes, Patterson, & Moxham, 2019).
Safety Considerations for Behavioral Health Nursing
Behavioral health nurses must be vigilant in maintaining a safe therapeutic environment. It is important for nurses to understand facility policies and procedures for managing combative or violent patients to keep themselves and other patients safe and free from injury (Havaei, MacPhee, & Lee, 2019). As with any nursing specialty, there is no guarantee of remaining free from injury or assault, but there are measures the nurse can take to reduce risk. Participation in continuing education activities on the management of combative patients can increase the nurse’s knowledge, reduce assault risk, and promote safety on the unit (Best Practices for Behavioral Health Safety & Security, 2017). Nurses that care for inpatient behavioral health patients should develop an exit plan and ensure that exit is available at all times (Cooke, 2017). A safe but therapeutic distance should be maintained in the event a patient becomes combative. Early recognition of non-verbal behaviors such as increased agitation allows the nurse to initiate early interventions and aid in preventing violent outbursts, or behaviors (Zicko, Schroeder, Byers, Taylor, & Spence, 2017). Nurses should learn self-defense techniques to escape injury by patients. Behavioral scales can be used to recognize potential escalation and prevent violence in the facility (Broderick, Azizian, Kornbluh, & Warburton, 2015).
Many facilities utilize codes for combative/violent patients or extreme risk to the safety of others. Codes are often color-coded (i.e., “Code Violet”) and may be initiated to alert staff that a violent or potentially violent situation is occurring, and assistance is needed on the unit (Using Code Words for Violence Prevention, 2017). These codes can assist in identifying the location where a team of professionals trained to handle potentially violent patients is needed (O’Connor, 2017). Facilities should implement methods to identify response team members, develop appropriate response protocols to codes, and properly educate staff regarding professional and appropriate handling of potentially violent situations. According to Smith, Ashbridge, Davis, and Steinmetz (2015), staff assaults, restraint use, and seclusion were dramatically reduced through well-coordinated response teams, clinical alerts, staff education, and early recognition tools.
Restraint Considerations for Behavioral Health Nurses
Restraints are a significant concern in healthcare facilities, but particularly with inpatient behavioral health units. Mishandling restraints can cause injury to the patient and create unnecessary risks to staff (Wilson, Rouse, Rae, & Kar Ray, 2017). The nurse must understand the legal responsibilities regarding the use of restraints and their facility’s protocols. If nurses do not understand legal implications of utilizing restraints, they could easily harm a patient or face legal repercussions. Violent restraints such as four-point restraints should not be utilized unless the patient is at-risk for harming others or self-harm (Crutchfield, Gibb, Redinger, Ferman, & Livingstone, 2019). A complete order by a licensed provider is needed to initiate restraints every time a restraint is utilized. A new order must be written each time a restraint is placed as well as every 24 hours for the extended use of restraints. Nursing staff must assess circulation, assist with range of motion (ROM), provide hydration, monitor for skin breakdown, and ensure hygiene and elimination for all patients in restraints. This should be done every 4 hours when in a non-violent restraint, and every 2 hours when in a violent restraint (Eskandari, Abdullah, Zainal, & Wong, 2018). When evaluating and assessing patients in restraints, the nurse must look at the patient’s emotional status, physical status, and response to the restraint or device. Proper documentation and flow sheets must be completed each time a patient is placed in restraints or seclusion. These documents have a high potential for being audited by nursing administrators and by regulatory surveyors as well (Goulet, Larue, & Lemieux, 2018). Nurses must differentiate and be familiar with the use of various restraints utilized by their facility such as safety devices, chemical restraints, violent restraints, non-violent restraints, and seclusion.
It is imperative that nursing staff make every effort to avoid the use of restraints whenever possible by instituting appropriate interventions early (Via et al., 2019). Nurses can decrease agitation and the potential for violence by reducing stimuli, re-directing the patient, utilizing coping mechanisms, or identifying the cause of the behavior and alleviating it if possible. No matter what, the nurse must also remember the significant power of simply listening to the patient (Matthews, Blackhurst, Moschella, & Lommel, 2018). The use of restraints or seclusion can be stressful and traumatic for the patient and the staff. Therefore, it is important that staff collaborates and works together to identify methods and interventions that could prevent the need for restraints or seclusion. Every effort should be made to assist the patient in identifying coping mechanisms and methods that can help reduce anxiety and anger. Staff should work to alleviate the root cause of these emotions if possible, as this could prevent both violent behaviors and the need for restraints (Leahy, Varghese, Day, & Curtin, 2018).
Inpatient behavioral health facilities must make every effort to maintain a safe and therapeutic environment, not only to obtain JC accreditation but also to maintain safety for patients and staff. Behavioral health nurses must be good communicators who are able to handle high-stress situations calmly, promptly, and professionally. Nurses must maintain a calm, therapeutic environment conducive to the patient's needs (Thomson et al., 2019). Nurses who work in this specialty should possess excellent assessment skills and a keen ability to identify non-verbal cues to provide early interventions and prevent potentially violent situations or injuries. When preparing for a JC accreditation survey, these basic principals can aid staff in their preparation by removing potentially harmful objects, identifying safety risks, and utilizing different scales to assess escalating behavior or suicide risk. This can help administrators and staff be successful during their JC survey, reduce/correct safety risks, and implement changes to improve patient care. Utilizing a checklist or mock surveys can assist staff in preparing for the official survey and assist administrators in highlighting potential safety risks to patients and staff. Checklists should include proper documentation and restraint utilization. This process can empower staff and involve them in the decision-making processes on the unit. Nurses have a legal and ethical responsibility to their patient population. Behavioral health nurses should be mindful of their own biases and find ways to promote patient health and safety (Ohnishi et al., 2019). Behavioral health nursing can be a very rewarding career with a wealth of opportunities for those seeking to work with patients suffering from mental illness; however, it is important that nurses are able to identify their own biases and understand that this can be a stressful occupation just like any other specialty in nursing.
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