About this course:
This module aims to review the characteristics of a successful behavioral health nurse, understand components of The Joint Commission (TJC) standards for behavioral health accreditation, and briefly review the National Patient Safety Goals (NPSGs) applicable to a behavioral health nurse.
This module aims to review the characteristics of a successful behavioral health nurse, understand components of The Joint Commission (TJC) standards for behavioral health accreditation, and briefly review the National Patient Safety Goals (NPSGs) applicable to a behavioral health nurse.
Upon completion of this module, the learner should be able to:
- review TJC NPSGs and standards for behavioral healthcare
- discuss ways a healthcare facility can prepare for a survey by TJC
- explore the care shortage and demand for nurses within the behavioral health setting
- identify common diagnoses seen within the behavioral health setting
- discuss strategies and interventions the nurse can take to maintain a safe environment
- describe indications for admission to or discharge from an inpatient behavioral health facility
Inpatient behavioral health facilities benefit from accreditation from The Joint Commission (TJC) and must meet several standards to maintain this recognition. TJC, founded in 1951, is the nation's oldest and largest accrediting body in healthcare. TJC is a not-for-profit organization that seeks to improve healthcare by evaluating the quality and safety of care services provided by healthcare organizations. Nurses and other healthcare professionals (HCPs) must be able to identify and understand TJC standards and National Patient Safety Goals (NPSGs) to assist healthcare administration in obtaining and maintaining accreditation. Future job growth for nurses is expected to increase by approximately 9% from 2020 to 2030. According to the Bureau of Labor Statistics (2022), the need for nurses working in psychiatric units or behavioral health settings is expected to grow even faster. According to the Health Resources & Services Administration (HRSA), behavioral health facilities and hospitals are having trouble attaining and maintaining adequate staffing. It is estimated that by 2030, there will be an increase in the demand for behavioral health workers: 15% for nurse practitioners, 15% for addiction counselors, 13% for mental health counselors, and 12% for social workers. In addition, many healthcare organizations face financial difficulties due to reimbursement for services and payments. Facilities have difficulty justifying reimbursement as mental health is misunderstood and may require more thorough documentation to obtain approval for services, unlike other specialties in healthcare. When working in behavioral health facilities, nurses must be flexible, able to handle high-stress situations, and vigilant in maintaining a safe, therapeutic environment (HRSA, 2020; TJC, n.d.-f).
Aspects of Behavioral Health Nursing
Behavioral health nursing can be a gratifying and in-demand specialty with various practice opportunities. Due to the stigma and prejudice toward people with mental illness, it is often hard to find enough nurses and funding to run programs in behavioral health. As this population grows, so does the demand for behavioral health nurses. According to HRSA, there are 117 million individuals residing in areas that have a mental health provider shortage. Psychiatric mental health nurses (PMHNs) have a specialized skillset and knowledge essential to providing person-centered care to individuals with mental health and substance use disorders (SUDs). However, attempts to characterize the PMHN workforce can be challenging due to diverse definitions and incomplete or inaccurate data. Registered nurses (RNs) and licensed practical nurses (LPNs) can work in behavioral health inpatient, outpatient, community health clinics, or home health settings; there is also a wealth of travel opportunities available within this specialty for nurses. Agencies and travel companies need behavioral health nurses for short-term and long-term assignments. About two-thirds of PMHNs work in the hospital setting (e.g., psychiatric inpatient or emergency departments), and about 8% work in community settings (e.g., public health organizations, home health, office settings, and hospice). Behavioral health nurses can coordinate lines of communication and services to provide appropriate, quality care to individuals with mental health concerns (Gabrielsson et al., 2020; HRSA, 2020; Merwin, 2020; Phoenix, 2019).
When entering the behavioral health field, a nurse should possess the patience, sound clinical judgment, open-mindedness, and the ability to be assertive without being aggressive. PMHNs should also have good critical thinking skills, empathy, and strong communication skills. To care for these patients appropriately, nurses in this field should be aware of the stigma toward mental health conditions and understand the associated social injustices. Nurses considering this field should first identify their own biases. By understanding their own biases, PMHNs can better assist patients in overcoming barriers to accessing healthcare services. The PMHN will care for patients diagnosed with mood disorders, psychotic disorders, SUDs, anxiety or panic disorders, personality disorders, or intellectual/cognitive disabilities. Many patients admitted to inpatient behavioral health facilities have multiple diagnoses, including various medical and mental health conditions (Bybel, 2019; Ohnishi et al., 2019; Thomas et al., 2019).
The most common diagnoses seen in behavioral health settings are generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), bipolar disorder (Type 1 and Type 2), depression, schizophrenia, and borderline personality disorder. There are both voluntary and involuntary admissions to inpatient behavior health units. 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. HCPs should consult their state and facility policies to determine who can authorize an involuntary psychiatric admission. 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, and their symptoms have generally improved, and they are medically and psychologically stable. Voluntary admissions are usually due to acute psychosis, mental instability, extreme stress, or symptoms related to their illness, causing an inability to function or perform daily activities. 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 be discharged to a long-term facility or specialty locked unit (Boyd, 2020).
Considerations for The Joint Commission Survey Preparation in Behavioral Health
TJC accreditation indicates that a healthcare facility has been recognized for excellence in patient safety efforts and the quality of care provided. Obtaining and maintaining accreditation assists healthcare organizations with risk reduction, management, qualification for Medicare and Medicaid reimbursement, meeting requirements for private insurance companies, and regulation requirements from local or state entities. In addition, accreditation can assist in performance improvement initiatives, strengthen patient safety efforts, and enhances nurse recruitment and retention. Facilities should make every effort to obtain and maintain 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 healthcare facility. HCPs must collaborate and understand their roles when preparing for a successful survey by TJC (TJC, n.d.-e, n.d.-f).
One of the first considerations in preparing for accreditation is for healt
...purchase below to continue the course
- 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 correctly labeled
- ensure that whiteboards, room numbers, beds, and areas within the unit are correctly updated and labeled
- ensure that flyers or informational sheets are correctly covered in plastic or laminated and that no glue or tape is used to secure them to bulletin boards or walls
- keep patient information confidential and discard it following appropriate procedures
- keep drinks and food out of the nursing station or other clinical areas
- clean and organize the entire unit, including the nurse's station and common areas, removing debris, clutter, and dust,
- ensure that care plans have complete information and nursing interventions are identified, addressed, and properly documented
- secure all lockers, storage rooms, group rooms, report rooms, kitchen areas, and other doors that patients should not access
- 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
- ensure informed consent is present when appropriate
- remove all ligature risks (hanging risks, e.g., towel racks, doors, shower curtains, etc.)
- review emergency codes and plans with staff (i.e., what to do in a cardiac arrest, medical emergency, or with a violent patient)
- review who the safety officer is for the facility and ensure that telephone extensions to other departments such as security are available
- review how to locate the material safety data sheets (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 (TJC, n.d.-c, 2022)
Healthcare organizations can create checklists that assist in preparing, planning, identifying safety risks, and assisting staff in understanding how they can play an essential role in becoming accredited by TJC. These resources can also help staff become more involved in decision-making processes regarding accreditation, patient outcomes, patient safety initiatives, and the quality of care provided within the facility. Nursing staff can take an active role in identifying areas needing improvement and contributing to successful accreditation as essential team members. Utilizing checklists and preparatory guides can also assist in identifying and eliminating ligature (hanging) risks or hazardous items, specifically within the inpatient behavioral health unit (TJC, n.d.-c, 2022).
Many organizations conduct a mock survey to recognize areas of concern before the actual survey. Mock surveys can prepare HCPs, administrators, and unlicensed personnel and allow for necessary improvements before the survey. They can assist in identifying hazardous risks, improving the quality of patient care, and involving staff in decision-making processes (Pluket, 2018). This activity allows the healthcare administration and staff to address patient safety risks and improve documentation practices. Additionally, educational opportunities can be delivered to the staff. Mock surveys should involve all healthcare team members, 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. Proper preparation for a survey can empower staff and provide understanding regarding the importance of achieving and maintaining accreditation (TJC, n.d.-c, n.d.-d, 2022).
National Patient Safety Goals (NPSGs)
Nurses have a responsibility to the public to reduce risk and adequately meet the needs of their patients. Therefore, PMHNs must identify ways to meet this responsibility when caring for the at-risk population served. To provide safe, quality care in the behavioral health setting, PMHNs must understand the behavioral health care NPSGs. TJC establishes these goals annually for each specific program accreditation type (e.g., behavioral health, ambulatory health, hospital, assisted living, etc.). The NPSGs are based on the prior year's data regarding patient safety concerns. The NPSGs are then used to establish the TJC's sentinel event alerts, standards, survey processes, performance measures, and educational materials. The 2022 NPSGs for behavioral health care and human services are (TJC, n.d.-a, 2021):
- 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.
NPSG 1 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. HCPs must be sure they are giving the correct care to the right patient; failure to do so could result in injuries or increased comorbidities for the patient, including death, and civil and criminal legal ramifications for the staff and the facility at large. HCPs should use at least two patient identifiers when providing care, services, or administering treatments. Treatments include high-risk interventions, specimen collection, and medication administration (i.e., methadone [Dolophine]). The TJC considers the patient's name, an assigned identification number, telephone number, or other person-specific identifiers as acceptable options for this. In certain long-term or low-volume settings with stable staffing (e.g., therapy, group homes), a patient's appearance may serve as one of the identifiers (TJC, n.d.-a, 2021; Voskanyan et al., 2020).
NPSG 3, to improve the safety of medications, is primarily the nurse's responsibility, as nurses are often the last line of defense before the medication is administered to the patient. Nurses must be aware of their role in medication administration, as many errors can be prevented by the nurse appropriately questioning incorrect medication orders. Improving the safety of medications and medication administration includes accurate medication reconciliation, communication of accurate medication orders, coordination of care, and collaboration among HCPs. Medication reconciliation occurs when the HCP compares the medications being administered with the individual's medication orders and any new medications ordered to resolve discrepancies and ensure that the patient receives what was appropriately ordered. Medication reconciliation can be challenging with behavioral health patients due to a lack of recall and willingness to share information. TJC recognizes a good faith effort to collect this information (Hunt & Chakraborty, 2020; TJC, n.d.-a, 2021). Please see the Medical Errors Nursing CE Course for more information on preventing medical errors.
NPSG 7 focuses on reducing the risk of healthcare-associated infections (HAIs) 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 HAIs. Millions of individuals annually acquire an infection while receiving care, treatment, or services in a healthcare organization. Therefore, nurses must identify patient health risks and ways that staff can help reduce or combat those risks to promote patient health. Implementing strategies such as hand hygiene can reduce the transmission of infectious agents and thereby reduce HAIs, improve patient outcomes, and reduce the risks to patient health (Picton-Barnes et al., 2020; TJC, n.d.-a, 2021). For more information on preventing HAIs, please see the Hospital Acquired Infections Nursing CE Course.
NPSG 15 focuses on reducing ligature risk. A ligature risk is any item a patient could use to hang or strangle themselves. Ligature risks can include doorways, tops of toilets, towel racks, and corners. Reducing ligature risk is essential to gaining and maintaining accreditation and improving patient care quality. Anything a patient can utilize to harm themselves is considered a safety risk. TJC states that intentional hanging is one of the most problematic areas regarding mental health, inpatient behavioral health units, and suicide attempts. Healthcare organizations must develop committees, teams, and checklists to reduce these risks and increase inpatient unit safety (TJC, n.d.-a, 2021). According to Pluket (2018), a checklist could identify issues related to patient safety, such as:
- check for tubings, 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 always staffed adequately
- 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 instead of dropped ceilings
- clean and remove clutter throughout the unit and patient rooms
- address all nursing diagnoses in the patient plan of care (Pluket, 2018)
Positive outcomes are best achieved by involving staff, incorporating shared decision-making, providing educational opportunities to fill knowledge gaps among staff, and supporting quality improvement measures involving teamwork and collaboration. Transformational leadership is the most successful form of leadership in healthcare. Utilizing checklists and conducting mock surveys 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, reduce safety risks, and improve the quality of patient care to increase staff morale and meet TJC standards. If staff can assist in making necessary changes to prepare the facility for the survey, be involved with equipment changes, and update procedures or policies, this improves the staff response to these changes (Bogaert et al., 2018; Campione & Famolaro, 2018; Schwartz et al., 2018).
Inpatient behavioral healthcare facilities must understand and review TJC standards that affect their practices before a survey and understand how to address patient safety concerns that may arise properly. Standards must be met for the main facility's accreditation and 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. TJC will review documentation, including nursing care plans, and evaluate the facility to ensure they uphold their standards and state regulations. Identifying current standards and expectations is imperative for the facility to successfully obtain and maintain accreditation by TJC (TJC, n.d.-a, 2021).
Considerations for Behavioral Health Nursing
Behavioral health nurses must have good communication and assessment skills, maintain a calm and professional demeanor, and recognize their biases and prejudices. Unfortunately, due to the stigma associated with mental illness, nurses may not realize their bias regarding mental health. For example, many people find it difficult to admit to a diagnosis of anxiety, depression, PTSD, or another mental illness. However, they likely would not be uncomfortable sharing if they had a disease such as diabetes or hypertension. It is important to recognize this as a barrier to effective diagnosis and treatment, and nurses must identify effective ways to recognize and change personal biases. Bias can also exist within the nursing profession. For example, coworkers or supervisors may treat a nurse suffering from behavioral health issues differently than a nurse with another illness, such as epilepsy or diverticulitis (Baker et al., 2019; Klik et al., 2019; McCleary-Gaddy & Scales, 2019).
Behavioral health nurses should actively listen to their patients, understand proper communication techniques, and differentiate between 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. Instead, the nurse should ask questions and assess the patient's perception of the event and any precipitating factors (Fredwall & Larsen, 2019). Nurses should understand techniques to manage patients who suffer from chronic mental health conditions. For example, if a patient with OCD is completing a ritual, it is important to allow them to complete the ritual and avoid interruption, or they may experience increased anxiety. Behavioral health nurses need to apply appropriate non-pharmacological methods of care and help patients develop and apply appropriate coping mechanisms in 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; Fredwall & Larsen, 2019; Samantaray et al., 2019).
Behavioral health nurses need keen 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 always be maintained. Early recognition of behavioral changes allows the nurse to effectively implement appropriate measures to manage symptoms and reduce psychological stressors. Finally, behavioral health nurses monitor patient behaviors to evaluate the effectiveness of their interventions, coping mechanisms, or patient education (Halcomb et al., 2019; Lester et al., 2018; Nguyen et al., 2019).
Safety Considerations for Behavioral Health Nursing
Behavioral health nurses must be vigilant in maintaining a safe therapeutic environment. Nurses must understand facility policies and procedures for managing combative or violent patients to keep themselves and other patients safe and free from injury. 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 this risk. Participation in continuing education activities on managing combative patients can increase the nurse's knowledge, reduce assault risk, and promote safety on the unit. A safe but therapeutic distance should be maintained if a patient becomes combative. Early recognition of non-verbal behaviors, such as increased agitation, allows the nurse to initiate early interventions and prevent violent outbursts or behaviors. Behavioral scales can be used to recognize potential escalation and prevent violence. Nurses should learn self-defense techniques to protect themselves from patients. Nurses caring for inpatient behavioral health patients should develop an exit plan, ensuring an exit is always available (Havaei et al., 2019; Zicko et al., 2017).
Many facilities utilize codes for combative/violent patients or extreme risk to the safety of others. Codes are often color-coded (i.e., "Code Grey") and may be initiated to alert staff that a violent or potentially violent situation is occurring and assistance is needed on the unit. These codes identify where a professional team trained to handle potentially violent patients is required. Facilities should implement methods to identify response team members, develop appropriate response protocols to these codes, and properly educate staff regarding handling potentially violent situations (Kurien & Choudhary, 2019). According to Smith and colleagues (2015), staff assaults, restraint use, and seclusion were dramatically reduced through well-coordinated response teams, clinical alerts, staff education, and early recognition tools. Similarly, Coney Island Hospital developed an early intervention and crisis prevention response team to calm agitated patients in hospital settings. Known as "Code Grey," this initiative includes an activation system, standardized communication, conflict resolution, and debriefing to ensure patient and staff safety (American Hospital Association, n.d.).
Restraint Considerations for Behavioral Health Nurses
Restraints are a significant concern in healthcare facilities, particularly inpatient behavioral health units. Mishandling restraints can cause injury to the patient and create unnecessary risks to staff. The nurse must understand the legal responsibilities of using restraints, their healthcare facility's protocols, and state laws. If nurses do not understand the legal implications of utilizing restraints, they could easily harm a patient or face legal repercussions. Physical restraints should not be utilized unless the patient is at risk of harming others or themselves, and less-restrictive methods to calm the patient have been tried and failed (Crutchfield et al., 2019; Eskandari et al., 2018; Goulet et al., 2018). Nursing staff must try to avoid restraints whenever possible by instituting appropriate interventions early. 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 remember the power of simply listening to the patient. Using restraints or seclusion can be stressful and traumatic for the patient and the staff. Therefore, staff must collaborate 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 agitation. If possible, staff should work to alleviate the root cause of these emotions, as this could prevent both violent behaviors and the need for restraints (Leahy et al., 2018; Matthews et al., 2018; Via et al., 2019).
An order by a licensed provider is needed to initiate restraints every time they are utilized. A new order must be written each time restraint is placed and every 24 hours for the extended use of restraints. The provider writing the order must assess the patient within 1 hour of ordering the restraint. Nursing staff must assess circulation, motion, and sensation (CMS) every 30 minutes while the patient is in restraints. The nurse must also assist with range of motion (ROM), provide hydration, monitor skin breakdown, and ensure hygiene and elimination for all patients in restraints. This should be done during a restraint release every 2 hours when using physical restraints. 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 regulatory surveyors. Nurses must differentiate and be familiar with various restraints utilized by their facilities, such as safety devices (e.g., mitts, bed alarms), chemical restraints (e.g., sedatives), physical restraints (e.g., wrist, chest, or leg restraints), and seclusion (Crutchfield et al., 2019; Eskandari et al., 2018; Goulet et al., 2018).
Inpatient behavioral health facilities must make every effort to maintain a safe and therapeutic environment to obtain TJC accreditation and maintain safety for patients and staff. Behavioral health nurses must be good communicators who can handle high-stress situations calmly, promptly, and professionally. Nurses must maintain a tranquil, therapeutic environment conducive to the patient's needs. Nurses in this specialty should possess excellent assessment skills and a keen ability to identify non-verbal cues to prompt early interventions and prevent potentially violent situations or injuries. When preparing for a TJC accreditation survey, facilities can prepare by removing potentially harmful objects, identifying safety risks, and utilizing different scales to assess escalating behavior or suicide risk. These strategies can help administrators and staff be successful during their TJC survey, reduce/correct safety risks, and 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 biases and find ways to promote patient health and safety for all. Behavioral health nursing can be a gratifying career with a wealth of opportunities for those seeking to work with patients who have mental illnesses; however, behavioral health nurses must be able to identify their own biases and understand that this can be a stressful occupation, just like any other specialty in nursing (Ohnishi et al., 2019; Thomson et al., 2019).
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