Discussion Response : Quality Indicators in Specialty Areas of Interest

Respond to the discussion below using two or more of the following approaches:

1. Ask a probing question

2. Offer and support an additional quality indicator applicable to your colleague's specialty of interest.

Expand on your colleagues' postings by providing additional insights or contrasting perspectives based on readings and evidence.

Reminders:

1. 1 page only

2. Put citations

3. At least 3 references... Articles must be 2012 to 2017.

Discussion Response :

Over the past few weeks, I have done my best to put into writing many of the experiences that my coworkers and I have been a part of the past few years that I have worked in acute mental health (AMH). The events that have occurred, both the uplifting and the harrowing, have profoundly shaped my development, not only regarding nursing in general, but as a nurse specializing in AMH, and I dare say even as a person.

Going into the field, I was aware that nurses in AMH and emergency department (ED) settings are at greater risk of patient-initiated violence, even within a profession that is already at a higher risk of violence compared to the general working population (American Association of Critical-Care Nurses, 2004; Emergency Nurses Association, 10).

One thing that can color our own perceptions of any sort of statistic (regardless of the field or the concept in question) is that we can view these topics in a myopic sort of manner. We can appreciate their ability to inform our practice, but they can seem somewhat abstract at times, when the issue being studied is far-removed from our own personal and/or professional lives. This was the case for me regarding patient assaults: I had been attacked, had responded to alarms, had seen coworkers go through it- yet the depth of understanding and appreciation for its prevalence did not fully strike me until a close coworker suffered a devastating injury from a patient assault.

This coworker was an expert in the AMH field, and just as careful as myself when it came to personal safety awareness, though he lacked the non-violent defensive training I had had prior to going into nursing (his own military unarmed combatives training could not be used, as such training is designed to inflict maximal injury/death, not neutralize an assault). His injury in October of 2014 was the final catalyst in my decision to pursue my MSN for nurse education, which I started that December.

The nursing quality indicators addressed by Montalvo (2007) have numerous aspects that greatly influence AMH nursing care. While less obvious than restraint usage and patient assaults, nursing turnover is one critical area, as nurses become much more attuned to understanding the often-subtle precursory behavior to when a patient will become, the nurse's use of de-escalation techniques becomes more effective, etc. (Goetz & Taylor-Truillo, 2012; Johnson, 2010). This ability to expertly assess a patient's well-being, and provide agitation-relieving interventions (both pharmacological and non-pharmacological) is one of the most important markers of an AMH nurse's ability to safely and effectively provide nursing care in this setting (Goetz & Taylor-Truillo, 2012; Johnson, 2010). Fallout related to patient assaults came to a head when the nurses in the Allina Health System (that my hospital is a part of) were on strike for nearly six weeks during the fall.

During this time, one of the main sticking points in the negotiations between Allina and the Minnesota Nurses Association was the issue of patient assaults against nursing staff (Jacobsen, 2016). When the strike finished and I returned to work, our nurse manager notified us that we were likely to face staffing difficulties for a while, as more than a dozen full-time nurses had left the AMH department and either went to other areas of the hospital, or other health systems. Sadly, this incredibly large loss of talented, experienced nurses from the AMH cluster has still not been filed, and those positions that have been filed have been almost exclusively filled by new graduate nurses.

While many of the new nurses who have come into our department are well-suited to work within AMH, many of these nurses admit to the same driving factor that I myself faced when I was a new RN: To get into a large hospital system, whatever it required to do so. I fell into LTC/TCU work for a couple of years following graduation, along with the lower pay, worse benefits, and lackluster job satisfaction as a result. In this regard, I understand the choice these nurses made coming into AMH, even when all that I have spoken to admit they do not intend to stay in AMH, citing the very same concerns regarding patient assaults, verbal berating, etc., that have driven many of the nurses away that they are now replacing.

The article by Anderson, Manno, O'Connor & Gallagher (2010) notes that some of the hidden costs of being caught in high nurse turnover (e.g. lower job satisfaction, lower productivity, higher rates of burnout, etc.) suffer from this turnover, leading to more of the same poor outcomes. This sort of vicious feedback loop is dangerous, as it means patients are less likely to find expert and AMH-focused nurses caring for them, and is likely a source of frustration for AMH nurse managers looking to reverse such dynamics (Johnson, 2010).

The 3P's (physical health/assessment, pathophysiology, and pharmacology) as measures of effective nursing intervention and care, cannot reasonably be expected to benefit from clinical environments that are plagued by high nursing turnover. The assertions made by Anderson et al. (2010) call for nursing leadership to cultivate and maintain a workplace where nursing expertise is valued and retained, so as to improve patient care within these settings. While my nurse manager has made an effort to verbalize this with staff in our AMH unit, many experienced staff have expressed great dismay at the fact that so many great staff were lost, especially when much of the strike related to disagreements with Allina over patient violence (Jacobsen, 2016). What we are left with is (perhaps ironically) the same outcry from staff nurses to nursing leadership that I have repeatedly noted in this course's discussions, and throughout my MSN coursework: That a great disconnect exists between management goals and staff's needs.

Being supportive as a nurse leader is more than simply ‘showing up' and saying the right things- "Staff need effective training to reduce and eliminate violence", "Patient violence against staff is a problem", etc. When staff are instead actively engaged and involved in the process (both in development AND in the troubleshooting stages of violence prevention), nursing management and organizational administration demonstrate (at least in my experience) the mostimportant component of leadership: empowerment. This concept is popular as it relates to nurses empowering their patients, as it promotes not only active collaboration between the patient and their clinicians, but also promotes a sense of ownership by the patient over their own health outcomes. Is it that difficult to believe that the same dynamic exists between AMH/ED nursing staff and organizational leadership?

When patterns/trends are recognized to be important clues to clinical problems elsewhere in nursing, how is the problem of violence in the clinical setting not viewed as such? The problem of patient violence against nursing staff is NOT going to benefit from an approach that discounts the very staff that organizations rely on to provide their patients with AMH needs with effective therapeutic nursing care. Only when nursing as a profession and our individual organizations recognize, support, and seek to retain expert AMH nursing staff can we hope to see realistic and sustainable improvements in the safety of our clinical settings.

References

American Association of Critical-Care Nurses. (2004). Workplace violence prevention. Retrieved December 19, 2016 from

http://www.aacn.org/WD/Practice/Docs/Workplace_Violence.pdf

Anderson, B. J., Manno, M., O'Connor, P., & Gallagher, E. (2010). Listening to nursing leaders: Using national database of nursing quality indicators data to study excellence in nursing leadership. Journal of Nursing Administration, 40(4), 182-187. doi: 10.1097/NNA.0b013e3181d40f65

Emergency Nurses Association. (2010). ENA Workplace Violence Toolkit. Retrieved December 19, 2016 from

https://www.ena.org/practice-research/Practice/ToolKits/ViolenceToolKit/Documents/toolkitpg9.htm