Behavioral Health Nursing CE Course

improved, and they are medically and psychologically stable. Voluntary admissions usually occur 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; National Alliance on Mental Illness, 2020).

Considerations for The Joint Commission Survey Preparation in Behavioral Health

TJC accreditation signifies that a health care facility has been recognized for its excellence in patient safety efforts and the quality of care it provides. Obtaining and maintaining accreditation helps health care organizations reduce risk, manage their operations effectively, qualify for Medicare and Medicaid reimbursement, meet the requirements of private insurance companies, and comply with regulations from local or state entities. Additionally, accreditation can support performance improvement initiatives, strengthen patient safety efforts, and enhance nurse recruitment and retention efforts. Facilities should make every effort to obtain and maintain accreditation, not solely for the benefits of being accredited, but for the improvements made toward the quality of patient care and the implementation of safety measures on the unit and throughout the health care facility. HCPs must collaborate and understand their roles when preparing for a successful survey by TJC (TJC, n.d.-e, n.d.-h; Wadhwa & Boehning, 2023).

One of the first considerations in preparing for accreditation is for health care administrators and nursing staff to understand who will conduct the unit survey. TJC surveyors are trained professionals experienced in behavioral healthcare who understand the day-to-day issues that health care organizations and providers experience. Understanding who will be conducting the survey, their educational background, and their experience can help administrators and staff better understand the focus of the team’s visit. Having staff utilize a checklist as a guide can help with organization and prevent areas crucially in need of attention from being missed. The process enables the team to assess their environment, identify potential safety risks, and promote positive changes within the facility (TJC, n.d.-b, n.d.-c, n.d.-e, 2025b; Wadhwa & Boehning, 2023). Inpatient behavioral health units and health care facilities should implement the following steps to success outlined by TJC in their survey activity guide:

• 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 that 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—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.-b, n.d.-c, n.d.-e, 2025b; Wadhwa & Boehning, 2023)

Health care organizations can create checklists to assist in preparing, planning, identifying safety risks, and helping staff understand their essential role in achieving accreditation from 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 play an active role in identifying areas needing improvement and contributing to successful accreditation as essential team members. Utilizing checklists and preparatory guides can also help identify and eliminate ligature (hanging) risks or hazardous items, specifically within the inpatient behavioral health unit (TJC, n.d.-b, n.d.-c, n.d.-e, 2025b; Wadhwa & Boehning, 2023).

Many organizations conduct a mock survey to recognize areas of concern before the actual survey. Mock surveys can prepare HCPs, administrators, and unlicensed personnel, allowing for necessary improvements before the actual survey. They can assist in identifying hazardous risks, improving the quality of patient care, and involving staff in decision-making processes (Plunkett, 2018). This activity enables health care administrators and staff to identify and address patient safety risks and enhance documentation practices. Additionally, educational opportunities can be delivered to the staff. Mock surveys should involve all health care team members provide the opportunity for collaboration and teamwork and also 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.-b, n.d.-c, n.d.-d, 2025b; Wadhwa & Boehning, 2023).

National Patient Safety Goals

Nurses have a responsibility to the public to reduce risk and adequately meet the needs of their patients. Therefore, PMHNs must identify ways to fulfill this responsibility when caring for the at-risk population they serve. To provide safe, high-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 (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 2025 NPSGs for behavioral healthcare and human services are (TJC, n.d.-a, 2025a):

• NPSG 1: Improve the accuracy of the identification of individuals served
• NPSG 3: Improve the safety of medications
• NPSG 7: Reduce the risk of health care–associated infections
• NPSG 15: Reduce the risk of suicide
• NPSG 16: Improve health care equity

NPSG 1 encourages nurses to enhance the accuracy of identifying 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, 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, 2025a; Tariq et al., 2024; 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 involves accurate medication reconciliation, clear 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 prescribed. Medication reconciliation can be challenging with behavioral health patients due to a lack of recall and willingness to share information. TJC acknowledges a good-faith effort to collect this information (TJC, n.d.-a, 2025a; Tariq et al., 2024). Please refer to the Medical Errors Nursing CE Course for more information on preventing medical errors.

NPSG 7 focuses on reducing the risk of health care–associated infections (HAIs) to promote patient outcomes and health. Reducing risks to patients is a primary responsibility of nurses, particularly in preventing HAIs. Millions of individuals acquire an infection each year while receiving care, treatment, or other services in health care organizations. 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, thereby reducing HAIs, improving patient outcomes, and decreasing risks to patient health (Monegro et al., 2023; TJC, n.d.-a, 2025a). For more information on preventing HAIs, please refer to the Hospital Acquired Infections Nursing CE Course.

NPSG 15 focuses on reducing the risks inherent in the population of individuals it serves, specifically the risk of self-harm. The risk of suicide is elevated in patients who have behavioral and mental health diagnoses. 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 crucial for gaining and maintaining accreditation, as well as for enhancing 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. Health care organizations must develop committees, teams, and checklists to reduce these risks and increase inpatient unit safety (TJC, n.d.-a, 2025a). TJC provides resources for suicide prevention, including the US Department of Veterans Affairs (VA) Mental Health Environment of Care Checklist (MHEOCC), which helps 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 open 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 (TJC, n.d.-f; US Department of Veterans Affairs, n.d.)

NPSG 16 focuses on improving health care equity. According to TJC, health care disparities must be addressed in the same manner as health care organizations address other high-risk situations such as elopement, medication errors, and the use of restraints and seclusion. Health care organizations must investigate the root causes of health care disparities and implement targeted interventions to address these issues. Health-related social needs are often identified as the root cause of disparities in health outcomes. Health care organizations need to develop effective leadership and structured processes to identify and address health care disparities (TJC, 2025a).

Positive outcomes are best achieved by involving staff, incorporating shared decision-making, providing educational opportunities to address knowledge gaps among staff, and supporting quality improvement measures that involve teamwork and collaboration. Transformational leadership is the most successful form of leadership in healthcare. The use of checklists and mock surveys enables staff to be involved and encourages participation among team members within the organization. Staff must view this as an opportunity to make improvements, reduce safety risks, and enhance the quality of patient care, thereby increasing staff morale and meeting 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 (Bashir et al., 2024; Campione & Famolaro, 2018; Greene et al., 2025; TJC, 2017).

              Inpatient behavioral health care facilities must understand and review TJC standards that affect their practices before a survey and know how to properly address patient safety concerns that may arise. 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 it upholds its 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, 2025b).

Considerations for Behavioral Health Nursing

Behavioral health nurses must possess strong communication and assessment skills, maintain a calm and professional demeanor, and acknowledge their own 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 would likely not be uncomfortable sharing if they had a disease such as diabetes or hypertension. It is essential to acknowledge this as a barrier to effective diagnosis and treatment, and nurses must identify effective strategies to recognize and address personal biases. Bias can also exist within the nursing profession. For example, coworkers or supervisors may treat a nurse experiencing behavioral health issues differently than a nurse with another illness, such as epilepsy or diverticulitis. Mental Health First Aid (MHFA) is a program designed to train HCPs to recognize mental health disorders and provide support to those experiencing problems related to their mental health diagnosis. MHFA has been applied in 25 countries and has been effective in improving mental health literacy among participants, giving them confidence in identifying and providing support to someone experiencing a mental health problem (Ahad et al., 2023; Klik et al., 2019; Li et al., 2025).

Behavioral health nurses should actively listen to their patients, understand proper communication techniques, and differentiate between therapeutic and nontherapeutic 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. Nurses should understand techniques to manage patients who experience 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 must employ appropriate nonpharmacological methods of care and assist patients in developing and applying effective 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 nonverbal cues and body language and react calmly and quickly to prevent self-harm or physical injuries on the unit. 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 (CALM America, n.d.; 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; however, nurses can take certain measures to reduce this risk. Participation in continuing education activities on managing combative patients can enhance the nurse’s knowledge, reduce the risk of assault, and promote safety on the unit. A safe but therapeutic distance should be maintained if a patient becomes combative. Early recognition of nonverbal behaviors, such as increased agitation, enables the nurse to initiate early interventions and prevent violent outbursts or other aggressive behaviors. Behavioral scales can be used to recognize potential escalation and prevent violence. Nurses should learn self-defense techniques to protect themselves from potential patient aggression. Nurses caring for inpatient behavioral health patients should develop an exit plan, ensuring an exit is always available (Havaei et al., 2019; Menendez et al., 2024; Rajwani et al., 2023).

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 that 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). Research has shown that 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.; Rajwani et al., 2023).

Restraint Considerations for Behavioral Health Nurses

Restraints are a significant concern in health care 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 associated with using restraints, their health care facility’s protocols, and relevant 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. Nursing staff should strive to avoid the use of restraints whenever possible by implementing appropriate interventions promptly. Nurses can decrease agitation and the potential for violence by reducing stimuli, redirecting the patient, utilizing coping mechanisms, or identifying the cause of the behavior and alleviating it if possible. Regardless, 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 (Craven et al., 2020; Crutchfield et al., 2019; TJC, 2024; Parkes & Tadi, 2022).

An order from a licensed provider is required to initiate restraints every time they are used. A new order must be written each time a 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 (Craven et al., 2020; Crutchfield et al., 2019; TJC, 2024; Parkes & Tadi, 2022).

Conclusion

Inpatient behavioral health facilities must make every effort to maintain a safe and therapeutic environment to achieve TJC accreditation and ensure the safety of 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 and therapeutic environment that is conducive to the patient’s needs. Nurses in this specialty should possess excellent assessment skills and a keen ability to identify nonverbal cues, which can 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 achieve success during their TJC survey, mitigate safety risks, and enhance patient care. Utilizing a checklist or mock surveys can help staff prepare for the official survey and assist administrators in identifying potential safety risks to patients and staff. Checklists should include proper documentation and the utilization of restraints. 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; TJC, 2025b; Thomson et al., 2019).

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