Healthcare workers in the U.S. face an array of complex challenges on a daily basis, and psychiatric hospitals can be particularly high risk environments for both patients and nurses and nurse practitioners (NPs). The safety culture and risk factors involved with any given mental health unit vary on a case-by-case basis. But facilitating a safe environment and ensuring that the nursing staff providing psychiatric care are safe from harm is essential and should always be the top priority for psychiatric services and mental health facilities nationwide.
Why is safety important in psychiatric nursing?
Psychiatry is the study and treatment of mental illness, emotional disturbance, and abnormal behavior. As opposed to general nursing (which focuses on physical health), mental health nursing deals with behavioral health. Patients who suffer from mental illness can often be erratic and unpredictable. Therefore, psychiatric wards, general hospitals (with both outpatient and inpatient psychiatric units), and other mental health care units have an increased risk of workplace violence.
Moreover, psychiatric nurses and NPs work in a variety of different settings — from doctors’ offices and private clinics to assisted living facilities and long-term care centers, from rehabilitation centers and correctional facilities to schools and colleges, from military clinics to private homes, and so on. Patient safety and the safety of staff members are crucial to delivering the best care possible. Ultimately, staff safety ensures the well-being of everyone involved.
What Type of Patients and Diagnoses do Psychiatric Nurses and NPs handle?
Psychiatric nurses and NPs provide both acute care (i.e., active but short-term treatment) and primary care (day-to-day treatment given by healthcare providers). The work locations vary greatly, and since mental illness can affect people of any age, socio-economic background, etc., nurses can be faced with a number of different and often difficult issues. The psychiatric patients they care for suffer from conditions ranging from depression and anxiety to autism and dementia to more severe illnesses like schizophrenia and bipolar disorder. No two patients are the same, and neither are the care provided nor the safety issues and risk levels involved.
What kind of Safety Issues/Concerns do Psychiatric Nurses / NPs Face?
One factor that contributes to the overall safety of nurses and patients are sentinel and adverse events. The Joint Commission (a non-profit U.S.-based enterprise dedicated to “quality improvement and patient safety in health care”) defines a sentinel event as “any unanticipated event that results in death or serious physical or psychological injury to a patient;” a sentinel event is “not related to the natural course of the patient’s illness.” An adverse event, on the other hand, is an unexpected medical problem that happens during treatment with a drug or other therapy. These often have little to do with a nurse’s training or level of competency and, therefore, can be a tricky factor.
Other key factors include things like the specific health systems and physical environments, staffing (and staff training), inpatient/outpatient care, patient populations, diagnoses, medication, and so on. For example, patients arriving in the emergency department of a facility might be in greater distress than those receiving daily in-house care (and may, therefore, react violently.) Nursing homes are generally safer than psychiatric wards or prisons; patients dealing with minor disorders and/or with no history of mental illness tend to be less violent and unpredictable than more high risk patients struggling with serious ongoing mental health issues, and so on. Below are some of the more serious and common safety concerns associated with the psychiatric nursing profession:
Suicide and Constant Observations
According to the World Health Organization, in 2017, 1.4% of all deaths worldwide were from suicide. Most suicides are linked to psychiatric disease — with depression, substance abuse, and psychosis being the most relevant risk factors. With timely and proper care, however, suicide is preventable. So constant observations (COs) with the purpose of interventions and prevention are commonplace when it comes to patients who exhibit self-harm and/or suicidal tendencies or behavior, and can be life-saving. But they can also pose a real danger to the caregiver involved, which is why proper training and communication are vital.
Inpatient violence and Self Isolation
Inpatient violence is not uncommon in mental health facilities, psychiatric wards, and in both private and public health clinics in general. Sentinel and adverse events play a role here. But incidents of violence also depend on a patient’s diagnosis and background, the medication they are taking, and the emotional and physical state they are in. Depression, loss of sleep and/or appetite, inactivity, lack of social interaction, and self-isolation can at times all be signs of possible future aggression.
The COVID pandemic presented an array of new challenges for the psychiatric nursing industry as well. For example, according to sciencedaily.com (and based on a 2017 study from the California Institute of Technology), a certain neural chemical is overproduced during long-term social isolation, leading to increased aggression and fear. Psychiatric nurses and NPs are carefully trained to recognize warning signs and know how to react in a timely manner in order to prevent potential harm.
Absconding and Door Locking
Even if not exhibiting any violent behavior, erratic and/or distressed patients may often try to get away from their caretakers, suddenly and without warning. Depending on the individual facility/home and its physical settings (security levels, staff and population numbers, type of patient rooms, etc.), this can pose a real problem. It is crucial to make sure that you are familiar with and have access to all areas of a facility and are able to respond quickly (and/or contact fellow staff promptly.)
Blame and Defensive practice
Defensive practice (or defensive medicine) is commonly defined as the practice of ordering medical tests, procedures, and/or consultations in order to protect the prescribing physician from criticism, malpractice suits, or general blame. Being one of the more controversial areas in the U.S. medical industry, defensive practice is an ongoing topic of debate among medical professionals and scholars alike. But while there is no consensus on its merits, it is generally agreed that the safety and well-being of psychiatric patients depends, for the most part, on the safety and well-being of the professionals whose care they’re in.
Tips for Recognizing Patient Behavior and Knowing How to Respond
Every mental health facility and provider has their own unique safety culture. Avoiding secluded areas, having clear and easy access to exits, promptly reporting past (and potential) incidents and behaviors, and staying diligent and aware of your surroundings are common guidelines across the board. Meanwhile, here are a few more general tips on how to stay safe in psychiatric nursing:
1. Read and Understand the Standards for Worker and Patient Behavior
Maintaining eye contact, knowing the patient’s personal details (such as their preferred name), being conscious of body language, using active listening techniques (open-ended questions, for example), using courtesy, respect, and proper phone etiquette — these are just some of the essentials when dealing with psychiatric patients in any area. Make sure you complete and comply with all the necessary safety training at your place of employment.
2. Consider Wireless Panic Buttons as Personal Protective Equipment
No matter your level of training and professionalism, certain psychiatric patients can pose a danger to themselves and those around them. Being able to call for help quickly can not only help deescalate a situation but also prove to be life-saving. Wireless panic buttons can be invaluable when dealing with unpredictable situations, and this is especially true for the psychiatric medical profession.
3. De-escalation Model to Prevent Violence
Generally speaking, de-escalation is a communication strategy that uses calm, patience, empathy, and restraint to understand the patient’s concerns, manage and resolve any issues, and prevent aggression and violence. There are various de-escalation models in psychiatry today, such as the 2014 Len Bowers model, or the 2009 De-Escalating Aggressive Behavior Scale (DABS). Talk to colleagues and familiarize yourself with your employer’s particular de-escalation methods.
4. Avoid Harmful Clothing and Accessories
If a situation does escalate, you want to make sure that there is as little as possible on your person that a patient can use to harm you. Items like scarves, necklaces, earrings, as well as any sharp objects (like pens, pencils, needles, etc.) should be avoided whenever possible.
5. Educate yourself and stay informed
There are countless resources online to help you stay up to date on the latest safety measures and guidelines used in psychiatric nursing today. For example, the U.S. Department of the Interior (doi.gov) has a ton of information on safety in the medical profession, which you can access here. Talk to colleagues, do your homework, be diligent, and stay informed. Prioritizing your own well-being will help guarantee that you stay safe, can handle any situation, and, thereby, deliver the necessary and appropriate care to those in need.