Effectively managing tense and escalating situations is an important component of inpatient psychiatric treatment (Delaney & Johnson, 2014). In the past decade, psychiatric systems have focused tremendous effort on reducing use of coercive measures (i.e., restraint and seclusion) by training staff to proactively address tense situations and de-escalate potentially aggressive interactions (Wisdom, Wenger, Robertson, Van Bramer, & Sederer, 2015). In fact, a core quality measure of inpatient psychiatric treatment is the use of restraint and seclusion—indicative of the frequency that staff use what is considered an emergency measure when the situation poses serious threat to patients and others. Restraint and seclusion is also a critical issue for psychiatric–mental health nurses (PMHNs). In 2014, in the American Psychiatric Nurses Association position statement on restraint and seclusion, the authors asserted that PMHNs play an important role in proactively maintaining the safety of the environment for patients and staff, particularly by decreasing restraint and seclusion on mental health inpatient units via effective management of potentially dangerous behaviors.
A related issue to the goal of reducing coercive interventions is the use of pro re nata (PRN) medications to address agitation, particularly if they are delivered regardless of the patient's objection (Hayes & Russ, 2016). PRN medication is commonly used to control aggression in adults in inpatient psychiatric units despite sporadic evidence supporting the effectiveness of this practice (Morkunas, Porritt, & Stephenson, 2016; Yoshida, Suzuki, Uchida, & Mimura, 2013). This practice also circumvents the patient's right to refuse medication and may be physically and emotionally traumatic for patients and staff (Hayes & Russ, 2016). Questions also surround how nurses use clinical data and their decision-making process in determining if PRN medication is needed (Baker, Lovell, & Harris, 2007). The lack of data demonstrating the effectiveness of PRN medication use along with its high potential to violate patient rights has prompted clinicians to call for discontinuing use of PRN medications for agitation on inpatient psychiatric units (Hayes & Russ, 2016).
In 2010, in an attempt to reduce the use of seclusion and restraint, the current study site adopted trauma-informed care (TIC). TIC is an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma (Muskett, 2014). One principle of TIC is that staff should be actively engaged with patients. Engagement with patients includes activities such as having purposeful, deliberate, and meaningful interaction with the sole aim of establishing a trusting and helpful relationship (Polacek et al., 2015). It is believed that this type of engagement will reduce patient agitation, which in turn should decrease overall patient violence, as well as restraint, seclusion, and involuntary emergency medication administration (Muskett, 2014). The unit began this culture change approximately 6 years ago.
Currently, leadership believes that staff practice is not in alignment with set efforts to engage clients and view the increased use of PRN intramuscular (IM) medications as indicative of this lack of engagement. According to retrospective data collected in the fourth quarter of 2013, the rate of injectable medications administered on the unit was 3.25 per week due to patient agitation. However, between July 1 and October 5, 2015, the rate of injectable medications for patient agitation increased to 11.9 per week. Thus, despite rigorous attempts at adopting TIC and encouraging engagement, which should reduce coercive interventions, the use of IM medications persisted at high levels.
The purpose of the current quality improvement project was to train new nursing staff and reinforce with seasoned staff how to incorporate TIC engagement principles in their daily practice. The initial instruction included a discussion on patient engagement and also how brief solution-focused therapy (BSFT) can be used at the point of patient escalation. The broad goal of the current project was to decrease involuntary emergency medication administration and decrease episodes of patient aggression.
Use of Intramuscular Medication in Inpatient Psychiatry
IM medications are widely used in inpatient psychiatric units and are viewed as one form of containment, often given when nonpharmacological interventions could be used. Hilton and Whiteford (2008) assert that PRN IM medications are commonly used to manage acute psychiatric symptoms and behaviors, although evidence supports that alternative nonpharmacological treatment options are as effective and associated with fewer side effects.
There is also apprehension about the clinical decisions supporting the use of PRN medications (Haw & Wolstencroft, 2014). Research demonstrates that nurses have insufficient knowledge of best practices when making decisions around IM medication use, and their decisions can be based more on clinical experience and habit than evidence-based practice (Usher, Baker, & Holmes, 2010). In a study of 522 adult inpatients recruited from 84 acute psychiatric wards in England, two thirds of patients received PRN medication during a 2-week period, but only 30% of administrations were preceded by patient aggression (Stewart, Robson, Chaplin, Quirk, & Bowers, 2012). IM injections were typically administered to prevent escalation of patient behavior and help patients sleep.
Another issue is the discrepancy between why IM medications are ordered and why they are given. Providers routinely prescribe PRN IM medication based on a patient's history, mental state, and risk assessment. Nurses, on the other hand, assert that their decision to administer IM medications is based on safety, level of patient distress, and their familiarity of the patient. Finally, there is the issue of restricting use of PRN IM medications to emergency situations or when alternative interventions to de-escalate the situation have been exhausted. In one of the only investigations on when PRN IM medications are used, most nurses identified instances when they administered IM medications as a first resort intervention when alternatives could have been used (Baker et al., 2007).
The use of PRN IM medications is complex and has been related to staff factors, unit structure, and unit atmosphere. Bowers (2014) mapped the use of conflict and containment measures (including PRN IM medications) to staff factors and found that during periods of staff turmoil, use of containment measures increased; conversely, conflict decreased during periods of staff activity with patients and engagement. Increased staff activity, such as becoming more involved in various groups, spending more time engaging patients, and using work time productively, is highly associated with decreased conflict and use of containment measures (Papadopoulos, Bowers, Quirk, & Khanom, 2012). Finally, the quality of the work environment, which is influenced by level of staff engagement, is related to the rate of aggressive incidents (Lewin et al., 2012). Thus, while evidence is emerging around the relationship of engagement and aggression/use of coercive measures, the association between these variables is often influenced by a mediating variable, such as quality of staff interactions, work environment, or unit structure.
Few articles have documented focused efforts to reduce the use of IM medications on inpatient psychiatric units. In a project on an acute psychiatric unit, Hayes and Russ (2016) studied the impact of eliminating PRN IM medications for agitation on patient and staff safety. They found that elimination of PRN medications for agitation did not have a negative impact on patient and staff safety on in-patient behavioral health units. In the Pennsylvania State Hospital system, a decision to end the custom of standing orders for PRN medication resulted in significant reductions in the use of IM medications, as well as a safer hospital system (Smith et al., 2008).
Trauma-Informed Care as an Intervention
Individuals who have experienced trauma represent a significant proportion of individuals accessing public mental health, forensic health, and drug and alcohol services. TIC has been identified as a key intervention to better meet their needs. TIC introduces best practice initiatives and assists health care professionals in gaining insight into the theories around causes of violence and aggression and understanding factors that may preempt or exacerbate violent episodes. Organizations that provide TIC services are also conscious that their services can retraumatize admitted patients with significant trauma histories through the indiscriminate application of coercive practices. TIC strategies rely on promoting least restrictive ways of managing a patient's behavior by reducing risk factors for violence and aggression (Ewington, 2016). Research has demonstrated that a unit's adoption of TIC reduced restraint and aggression via prevention and early intervention (Muskett, 2014).
Improving Staff Engagement. A particular component of TIC, and a focus of the current project, was to increase the amount and quality of staff engagement with patients. Mollon (2014) believes that patient engagement correlates with creating a safe environment on in-patient mental health units. As noted above, there is emerging research that the quality of staff interactions (i.e., engagement) is related to decreased incidents of conflict and containment. The relationship operates in several different ways. Patient engagement by staff is a core component of keeping units safe and reducing conflict, because providing timely intervention to situations likely to deteriorate into aggression depends on such engagement (Bowers et al., 2014). According to Delaney and Johnson (2014), meaningful patient engagement forges a connection that conveys a sense and appreciation of an individual's human struggle. When patients feel connected to staff, they are more likely to respond to or seek out these individuals in moments of distress, which can prevent or de-escalate a personal crisis (Delaney & Johnson, 2014). For this reason, it is important to facilitate staff interaction and connection with patients and discourage isolation, detachment, or disengagement.
Staff lack of engagement with patients on inpatient psychiatric units is a recognized problem. In their study on nurse–patient interaction, Seed, Torkelson, and Alnatour (2010) found that nurses spent only 2.18 minutes per shift teaching symptom management and approximately 2 hours on paperwork. Correlations between time spent in specific tasks and job satisfaction indicated that nurses who spent more time performing direct patient care were more satisfied. Some factors that prevent nurses from engaging patients on inpatient behavioral health units include high workloads, staff shortages, higher patient acuity, lack of supervision to support patient engagement, and inability of nurses to understand the necessity of engagement (McCrae, 2014). It has been suggested that some of the identified barriers have led to a higher dependence on pharmacological rather than interactive therapeutic intervention (McAndrew, Chambers, Nolan, Thomas, & Watts, 2014).
Interventions to Increase Engagement. Staff's level of patient engagement can be increased, as demonstrated by Oregon's Salem Hospital's inpatient behavioral unit, which shares certain characteristics with the current study site (e.g., number of beds on the unit, age groups admitted to the unit). Between 2001 and 2006, at Salem Hospital, researchers demonstrated that enhancing patient engagement on the unit decreased involuntary emergency medication by 70% and IM medication administration by 80% (Bennington-Davis & Murphy, 2006). Other efforts to increase nurses' engagement have focused on increasing their sense of presence with patients (Kostovich & Clementi, 2014), their ability to interact effectively with individuals with serious mental illness, and their capacity to understand the patient experience (Cruz, Caeiro, & Pereira, 2014).
The study site, an affiliate of a large health care system, is located in rural Illinois. The Inpatient Adult Psychiatric Unit has 25 beds and has served the community for more than 35 years. The proposed approach is in line with the site's patient care model and its efforts to implement TIC. Leadership was committed to implementing TIC principles and using the best evidence available to reduce the risk of retraumatizing patients and keep patients and staff safe. Nursing leadership contribution is critical to assuring consistency of patient engagement via their influence on educational training needs and effects on workflow and setting the organizational culture. An overview presentation on the project was made to the Chief Operating Officer and nurse manager to solidify their support.
The main project efforts were directed toward strengthening TIC, increasing patient engagement, and improving staff's skills at intervening in escalating situations. Consistent with practice on the unit, staff received education on patient engagement and new staff were educated on their role in creating and maintaining a TIC organization, building trusting relationships, and creating a safe, healing environment. The ongoing discussion of these principles with staff helped create buy-in from front-line nurses and behavioral health technicians (BHTs), which the planning team hoped would build autonomy and ownership of the project. For the next several months, at unit meetings, staff were reminded about the project.
Staff were interviewed about the project and their thoughts/reactions. They expressed concerns about TIC and engagement, particularly not having enough time to sit with the patient due to shift tasks (e.g., documentation, admission of new patients). Informally, staff conveyed other concerns, particularly being worried about their safety due to the perception that any decrease in PRN use might increase patient violence. Some BHTs stated that they were not comfortable engaging patients and lacked confidence on how to engage and the skills involved. Other interdisciplinary team members believed that patient engagement was the responsibility of nurses or therapists. For this reason, patient engagement training was extended to all staff members to enhance their comfort engaging patients and view of patient safety as a collective responsibility. Nurses and BHTs from all shifts were included in the initial training. Institutional Review Board approval was sought and obtained for the project.
Evaluation Plan and Instruments/Measures
The evaluation plan for the current project comprised process and outcome evaluations. Process evaluation involved reviewing data collected 1 month after the initial training and every 3 months thereafter, and staff attendance at each mandatory educational offering. Outcome evaluation was accomplished by assessing staff comfort of patient engagement before and after engagement training, reviewing shift documentation and nurses' notes reflecting patient engagement, and monitoring the amount of PRN IM medications administered.
To measure staff comfort when handling aggression and engaging clients during escalating behaviors, the Management of Aggression and Violence Attitude Scale (MAVAS) was used. The MAVAS is a self-reference scale of 30 items developed to assess attitudes of staff to various strategies of managing aggression in clinical practice. The items on the tool represent four themes reflecting three descriptive models of causes of aggression and specific views about the management of patient aggression. The MAVAS focuses on how staff interpret the causes and management of aggressive behavior of patients. Construct validity and reliability of the MAVAS have been established (Lepiesova & Tomagova, 2014).
To measure staff engagement, the Combined Assessment of Psychiatric Environments (CAPE)–brief version was used. The instrument was designed to assess staff engagement and patient experience of care on inpatient psychiatric units (Delaney, Johnson, & Fogg, 2015). The CAPE–staff version comprises 12 items that assess staff's perceptions of their interactions with patients and their sense of management support for their work. Face, content, and construct validity were established. Reliability for the CAPE instrument was determined to be 0.91 via test-retest reliability testing (Delaney et al., 2015).
To determine use of PRN IM medications, data were collected on the number of injectable medications dispensed by pharmacy to the unit per week for two time periods: October 20 to December 14, 2013, and July 1 to October 5, 2015. To track the IM medications dispensed, Pandora® Analytics was used, a software technology that extracts key data from medication and supply dispensing systems and converts the data to a user-friendly interactive console. Pandora reports data across any time period and provides trending capabilities. The same software was used to generate medication reports that served as the background data for the current project and collect data post engagement training to determine program effectiveness.
Chart audits were performed to determine the use of BSFT concepts. All nursing notes and BHT shift documentation within a 2-week period were reviewed. Nurses' notes following an incident of de-escalation were also reviewed. The audit involved searching for terms descriptive of BSFT, such as discussion on coping skills, patient's view of the situation, discussion with patient on what might be done presently to ease the problem, patient's goals, and documentation of possible solutions reached with patient.
Engagement Training. Patient engagement training was provided to all staff working on the adult behavioral health unit. Education included how to engage patients and enhance staff's communication and active listening skills. Part of the engagement training was devoted to training staff members on BSFT. This form of therapy involves creating conversations directed toward developing and achieving patients' visions of solutions (Hosany, Wellman, & Lowe, 2007). These concepts should be evidenced in discussion of coping skills with emphasis on clear, concise, realistic goal negotiations. Staff were also educated on finding specific time during each shift to have purposeful interaction with patients and how to document the occurrence of patient engagement in their shift nurses' note.
Training occurred in two waves. Participants in the initial training (January 2017) included 11 staff members (five nurses, six BHTs; six women, five men) currently working on the adult behavioral health unit. Average age of participants was 41.7 years (SD = 12.2 years), and the mean number of years worked in the field of psychiatry was 7.3 years (SD = 7.4 years). The majority of participants had an associate's degree (n = 7; 63.6%), and all were employed full-time (≥32 hours per week).
Another educational offering was provided in April 2017 for those who did not attend the first session. Participants in this wave included 22 staff members (21 women, 1 man). Of 22 participants, 14 were nurses and eight were BHTs. Average age of participants was 45.95 years (SD = 15.56 years), and mean number of years worked in the field of psychiatry was 8.19 years (SD = 10.96 years). Seven (31.8%) participants had a high school diploma, six (27.3%) had an associate's degree, three (13.6%) had a college diploma, five (22.7%) had a baccalaureate degree in nursing, and one (4.5%) had a master's degree in nursing. Of these participants, 17 (77.3%) were employed full-time (≥32 hours per week). All participants completed the pre-test MAVAS and CAPE questionnaires before attending 2-hour training on patient engagement. Participants also completed the same questionnaires 1 month after attending the educational offerings.
Pre-/posttest scores on the CAPE and MAVAS were examined for differences using the Wilcoxon signed rank test for paired data. In the first wave of training, the difference between mean pre- and posttest scores on the CAPE (pretest = 32.4 [SD = 5.3] vs. posttest = 33.9 [SD = 5.9]) was not statistically different (p = 0.087). The difference between mean preand posttest scores on the MAVAS (pretest = 66.5 [SD = 6.6] vs. posttest = 69.8 [SD = 5.6]) was also not statistically different (p = 0.244). However, in both cases, the posttest scores for the CAPE and MAVAS increased in the anticipated directions.
In the second wave of training, pre-/posttest scores on the CAPE and MAVAS were slightly improved. The difference between mean preand posttest scores on the CAPE (pretest = 31.6 [SD = 3.2] vs. posttest = 32.6 [SD = 4.9]) was not statistically different (p = 0.323). The difference between mean pre- and posttest scores on the MAVAS (pretest = 70.2 [SD = 11.9] vs. posttest = 69.2 [SD = 10.1]) was statistically significant (p = 0.010). In both cases, the posttest scores for the CAPE and MAVAS increased in the anticipated directions.
The percentage of PRN IM medications administered on the unit pre and post training was also obtained. The initial patient engagement classes were conducted at the end of January 2017, with first data on PRN IM medications administered on the unit scheduled for collection in April 2017. In 2015, the number of PRN IM medications administered on the unit was 11.9 per week. In March 2017, the number of PRN IM medications administered on the unit was 12.1 per week. Following the second wave of training, PRN IM medications administered per week decreased drastically; in April, the number of medications was 3.2 per week and in May, 5.4 per week.
Use of Brief Solution-Focused Therapy
A chart review was performed to determine when BSFT concepts appeared in clinical notes, such as documentation reflecting staff engagement of individual patients and the quality of such discussion as measured by the topics discussed. Examples of BSFT documentation included encouraging patients to focus on future-oriented solutions and not dwell on past problems. Documentation also reflected coping questions, such as how patients have managed to prevent their situation from getting worse. A total of 21 notes were reviewed, of which 76% contained information indicative of patient engagement.
The purpose of the current study was to train nursing staff to incorporate TIC and engagement principles into daily practice. The educational offering included a discussion on patient engagement and enhancement of therapeutic communication using BSFT. It was predicted that using engagement principles in daily practice would increase staff confidence managing tense situations, reduce patient outbursts, decrease involuntary emergency medication administration, and decrease overall patient aggression. The results of the efforts were mixed, some were in the right direction but the focal objective (i.e., reduction in the use of PRN IM medications) increased after the initial training but eventually improved after the second wave of training. There are several possible explanations for these findings.
One explanation could be related to the acuity of patients admitted to the unit. Patients come to the inpatient unit from a Crisis Stabilization Unit. During data collection, data obtained from the Crisis Stabilization Unit indicated that of the 698 clients who presented for crisis evaluation, 63.5% were reconnected back to the community after being provided with outpatient resources. Of the 36.5% of clients who were admitted to the inpatient unit, the majority were acutely psychotic. Their acute state more than likely made the use of BSFT difficult and may explain the use of PRN IM medications. In addition, as some of these patients were prone to physical aggression, the unit staff may have concentrated more on physical safety issues than engagement. It may be that the staff needed more explanation for the relationship between engagement and unit safety so that efforts at keeping the unit safe and patient engagement proceeded concurrently (Polacek et al., 2015). Usher et al. (2010) used similar interventions and also found a high incidence of PRN psychotropic medication administration and an excessive reliance on the use of this measure by staff.
The increase in the amount of medication administered after the first wave of training may have been affected by the poor attendance at the engagement training. The scores on the MAVAS and CAPE demonstrated small increases post training but were not significant because only a small number of nurses attended training. There was also a rumor circulating on the unit that the training was intended to ultimately eliminate PRN IM medications as an option, which was not true. The scores on both measures improved when more staff attended the training, which was mandatory for the second wave.
According to participants' shift documentation, there was an increase in the use of BSFT techniques. The current authors believe this occurred because participants perceived BSFT as a good communication tool that could be incorporated into their practice, especially when engaging patients. This finding is similar to results of a study by Ferraz and Wellman (2009), in which participants said that once they started experimenting with BSFT techniques after attending the training, they found the techniques to be helpful during their one-on-one sessions with patients. However, based on chart review in the current study, there is still work to be done and a need to follow through with staff to sustain the gains made.
Finally, there are many factors that influence staff members' engagement and involvement with patients that are difficult to control. Demands on staff, particularly documentation, require a great deal of time in front of the computer. As mentioned, the unit admits very ill patients whose length of stay is brief, which contributes to a persistently high unit acuity. Although management supports the idea of TIC and increased staff engagement, what may be lacking is the tangible support staff need to consistently engage patients. Staff training requires time away from patients and a financial commitment, which can also be factors in the level or reach of staff training.
One-to-one feedback with staff on the use of BSFT is planned. Aggregate data on PRN IM medication use will also be regularly presented to encourage staff to view these data in relationship to their efforts at patient engagement. Staff members who do not feel comfortable recording engagement in their shift notes will be encouraged to review the content of other staff members' shift documentation to learn how to document engagement.
There are several limitations related to the current project. The sample was small; thus, it lacked power in determining statistical significance. Few nurses attended the engagement training in the first wave when it was voluntary. Results improved in the second wave when training was mandatory. The acuity of patients admitted to the unit made evaluating shift documentation for engagement challenging, as it is difficult to engage patients with acute psychosis and the focus is on physical safety. The acuity of patients admitted to the unit also may have had an effect on the number of PRN IM medications administered in the first quarter of 2017, but this is difficult to determine without a systematic inspection of acuity over time and its relationship to PRN IM medication use.
The study site is committed to TIC and patient engagement. The effort to increase staff competency in collaborative strategies and training to improve staff's confidence in managing aggression will continue. Although there has been a great deal of conjecture by clinical researchers regarding the effectiveness of PRN IM medication use and safe methods for the management of aggression on adult behavioral health units, it is only in the past decade that there have been well-designed studies available to address this issue. Although some of the results of this initial effort are disappointing, the commitment to quality patient care persists.
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