Managing Professional and Nurse-Patient Relationship Boundaries in Mental Health.

Caring nurse-patient relationships in mental health settings are key components in helping patients recover. These professional relationships provide a safe, trustworthy, reliable, and secure foundation for therapeutic interactions; however, nurses face challenges in setting and maintaining relationship boundaries. Although patients ask for special privileges, romantic interactions, and social media befriending, or offer expensive gifts, nurses must recognize that these boundary violations may erode trust and harm patients. These violations may also trigger discipline for nurses. Professional relationship guidelines must be applied with thoughtful consideration, and nurses must monitor their emotions and reactions in these relationships. The current article is a sharing of personal experiences about boundaries augmented by evidence in the literature, and focuses on managing potential boundary violations (i.e., social media, sexuality, over-involvement, and gift giving) in mental health settings. [Journal of Psychosocial Nursing and Mental Health Services, 55(1), 45-51.].

Measuring a veteran's quality of healthcare managed by a nurse practitioner in a VA facility using professional practice evaluation and core performance measures.

PURPOSE: Quality of care provided by nurse practitioners (NPs) has been measured for the last 40 years; however, no known program measuring quality of care in an NP practice on an ongoing basis was found in the published literature. The purpose of this article is to describe the implementation of an ongoing professional practice evaluation (OPPE) program at a Veterans Health Administration facility. DATA SOURCES: An evidence-based review was conducted to assess, evaluate, and report findings from outcomes research, systematic reviews, and meta-analyses, and interventions regarding standards and oversight of NP practice in the following databases: PubMed, Google®, Cumulative Index of Nursing and Allied Health, Agency for Healthcare Research and Quality, Institute of Medicine, and ".gov" websites. CONCLUSIONS: NPs have established a reputation in the delivery of efficient, accessible, effective, and high-quality care. Researchers suggest episodic measurement of care. For NPs, an OPPE program provides oversight of quality of care, surveillance, education, and feedback while evaluating and validating an NP's quality of care on an ongoing basis. IMPLICATIONS FOR PRACTICE: The OPPE program provides a prototype for measuring and improving NP practice nationally. In providing validation and transparency, it reassures administrators and the public that NP practice meets strenuous national standards.

Trauma-informed care: keeping mental health settings safe for veterans.

Veterans, as military personnel returning from wars in Afghanistan and Iraq, are frequently coping with various mental health problems. These veterans are at high risk for posttraumatic stress disorder (PTSD) and associated behavioral consequences, including self-harm, verbal and physical aggression, and violence. In this article, we highlight the physiological, physical, and emotional consequences of trauma. We focus on the unique experiences that affect veterans' mental health and associated behaviors and advocate for veterans to receive evidenced-based treatment using trauma-informed and recovery-oriented care.

Recognizing and treating Adult ADHD.

Many adults with attention deficit/hyperactivity disorder are undiagnosed. Nurse practitioners should understand the etiology, screening, assessment, diagnosis, and treatment of ADHD in adults.

Nurses' psychosocial barriers to suicide risk management.

Suicide remains a serious health care problem and a sentinel event tracked by The Joint Commission. Nurses are pivotal in evaluating risk and preventing suicide. Analysis of nurses' barriers to risk management may lead to interventions to improve management of suicidal patients. These data emerged from a random survey of 454 oncology nurses' attitudes, knowledge of suicide, and justifications for euthanasia. Instruments included a vignette of a suicidal patient and a suicide attitude questionnaire. Results. Psychological factors (emotions, unresolved grief, communication, and negative judgments about suicide) complicate the nurse's assessment and treatment of suicidal patients. Some nurses (n = 122) indicated that euthanasia was never justified and 11 were unsure of justifications and evaluated each case on its merits. Justifications for euthanasia included poor symptom control, poor quality of life, incurable illness or permanent disability, terminal illness, and terminal illness with inadequate symptom control or impending death, patient autonomy, and clinical organ death. The nurses indicated some confusion and misconceptions about definitions and examples of euthanasia, assisted suicide, and double effect. Strategies for interdisciplinary clinical intervention are suggested to identify and resolve these psychosocial barriers.

Creative strategies to improve patient safety: allergies and adverse drug reactions.

Approximately 770,000 Americans are hospitalized and suffer adverse drug events (ADEs) costing billions of dollars each year. An ADE occurs when a patient is injured by an adverse drug reaction. Improved medication administration could prevent about 2.5 million ADEs (Institute of Medicine, 2004). This project provided an education for patients and nurses and a medication fact sheet. Outcomes included updating allergy records, improving medication safety knowledge, and improving nurses' adverse drug reactions and allergy reports.

Rapid cycle change projects improve quality of care.

Transforming Care at the Bedside program was developed as a way to improve care on medical-surgical units, patients' and family members' experience of care, and teamwork among care team members and to increase satisfaction and retention of nurses. Average turnover rates for this program's RNs decreased to about 3%, a 58% reduction in rate. The time RNs spent in direct patient care increased 10% compared to the control unit, and value-added care also increased from 10% to 15% over baseline. Patient and staff satisfaction improved.

Evaluating and managing adult PTSD in primary care.

Posttraumatic stress disorder (PTSD) is an anxiety disorder with a sustained and dysfunctional emotional reaction to a traumatic event, threat of injury or death, and pain.

Improving professional practice through certification.

Certification helps ensure quality of practice and currency of nursing knowledge. We designed certification review courses and evaluated their impact on satisfaction, quality of care, adverse drug events (ADEs), and RN vacancies. Certification correlated with improved patient and nurse satisfaction, quality of care, and increased nurse rates of reporting ADEs, although the ADE total rates are consistent. Certification inversely correlated with nurse vacancies. Certification has helped to enhance nurses' knowledge, productivity, quality of care, and patient and nurse satisfaction, and has decreased RN vacancies.

Oncology nurses' knowledge of suicide evaluation and prevention.

BACKGROUND: Cancer patients can present with a risk of suicide, making it important for oncology nurses to be knowledge about the high-risk factors for suicide in this population and to be competent in suicide detection and management. OBJECTIVE: The aim of this study was to describe oncology nurses' identification of risk factors, knowledge, and skill at suicide evaluation and prevention based on evaluation of a vignette and to describe nurses' assessments and interventions for suicidal patients. METHODS: As part of a larger exploratory, national study, clinical oncology nurses (n = 1200) from the Oncology Nurses Society responded to a knowledge survey; a total of 454 evaluable questionnaires (37% response rate) were returned. RESULTS: Nurses reviewed a vignette of a suicidal patient and correctly identified these risk factors: widower (69.8%), wishes he/she were dead (82.8%), and gives away prized possessions (79.6%). Few nurses knew that ethnicity (0.4%), age (13.2%), or sex (16.4%) indicated suicide risk. Nurses incorrectly believed that worrying, crying, and executive position indicated suicide risk (40.6-42%). Most nurses rated themselves as having little to some skill and knowledge of suicide evaluation. CONCLUSION: Oncology nurses were able to identify certain behavioral risk factors at acceptable rates but not demographic risk factors. IMPLICATIONS FOR PRACTICE: Oncology nurses are likely to interact with patients at suicide risk and would benefit from knowledge about behavioral and demographic risk factors that contribute to an oncology patient becoming high risk for suicide. Such knowledge could contribute to overall patient safety.

Psychiatric nurses' expertise, interest in end-of-life care, and requests for continuing education on end of life.

BACKGROUND: The time before dying can be extremely challenging and stressful. Gaps in end-of-life care include inadequate communication, education about end-of-life options, symptom control, and management of common mental illnesses (eg, mood disorders, dementia), and death anxiety. Psychiatric nurses are in a pivotal position to help address these gaps and improve end-of-life care. Psychiatric nurses can facilitate communication about end of life, educate patients about options, and provide consultation, assessment, and management of common psychosocial needs (eg, mood disorders, grief, and loss). OBJECTIVE: This survey examined psychiatric nurses' perspectives of their skills, knowledge, expertise, continuing education needs, and recommendations for the role of the psychiatric nurse. STUDY DESIGN: Using a descriptive design, we surveyed a convenience sample of psychiatric nurses from the American Psychiatric Nurses Association. RESULTS: Psychiatric nurses reported they were skilled in discussions of difficult topics, evaluation of mental status, and assessment and management of mood disorders, grief, and suicide risk. However, nurses asked for continuing education in focusing these skills for end of life, knowing the needs of the dying patient, and differentiating depression and dementia at end of life. Requests for continuing education on end-of-life care included issues about how to apply these psychiatric skills and knowledge to the dying patient and their families. CONCLUSIONS: Psychiatric nurses have skills and knowledge to reduce the gaps in end-of-life care. Many request continuing education to assist them to expand and focus their knowledge to use their psychosocial skills and to develop a specialty area in end-of-life care.

The hoarding syndrome: screening and treatment.

Hoarding syndrome is a serious public health hazard. It may pose risk of fire, falls, infestation, and bacterial growth. Hoarding can reduce activities of daily living, adherence to treatment, and quality of life. The hoarder collects excessive quantities of poorly useable items of little value, fails to discard items, and has difficulty organizing tasks. Hoarding places the individual at risk for social, psychological, and physical outcomes, which lead to a decline in quality of life. This article examines the etiology, characteristics, signs and symptoms, evaluation, and treatment of hoarding syndrome. A case example illustrates the management of hoarding syndrome in home care.

Visual disfigurement and depression.

Approximately 10% of the population has a facial disfigurement, such as a scar, blemish, or deformity that severely affects the ability to lead a normal life, and 2 to 3% have a clearly visible blemish. They may experience depressive symptoms due to disfigurement, stressful life events, or other causes. Depression is a painful and costly disorder that is often unrecognized and untreated in specialty practices; it is linked with higher costs of care, lengths of stay, and rates of rehospitalization. Often, these individuals seek plastic surgery to repair the disfigurement, and depressive symptoms are not uncommon preoperatively, perioperatively, and postoperatively. In addition, depressive disorders exist among 20 to 32% of people with a medical disease. Major depression is a recurring and disabling illness that typically responds to treatment with psychotherapy, antidepressants, and social support. Nurses have a major role to play in screening for and detecting depression so it can be evaluated and referred for treatment. Nurses also provide education, psychosocial support, and advocacy for patients with depression. Identifying those with depressed symptoms allows the nurse to recommend treatment, offer referrals, and provide supportive interventions.

Nurses improve medication safety with medication allergy and adverse drug reports.

Medicine-related illnesses cost more than 75 billion dollars annually. Adverse drug reactions (ADRs) are the fourth to sixth leading causes of death in the United States. An educational campaign to reduce ADRs and improve documentation included (1) an allergy awareness campaign, (2) staff nurses' training on documentation of allergies/ADRs, (3) patient-oriented brochures to encourage allergy reporting and ADRs, and (4) a fact sheet about ADRs. As a result, the documentation of medication allergies and ADRs improved significantly in our organization.

Innovative strategies for nurse recruitment and retention in behavioral health.

Successfully recruiting licensed nurses to work in behavioral health is challenging. This article describes and illustrates methods one hospital successfully used to attract, orient, and mentor new graduate nurses to work in mental health. The New Horizons program included a paid internship for new graduate vocational nurses, a mental health curriculum, preceptorship, a state board review course, and a new graduate program. Since 2003, the program has recruited 37 new graduates for the unfilled licensed staff vacancies in mental health who continued their professional education and pursued degrees as registered nurses. The evaluations indicated that more than 100% of graduates rated the program as excellent as well as recommended it to their friends, and retention has been more than 90%. New Horizons graduates have received promotions; one has assumed a new role as a clinical resource nurse who teaches nursing orientation. All stakeholders including nurse management, patients, other disciplines, and coworkers have high praise for the program graduates. The program increased the cultural diversity of the mental health staff because the graduates included high percentages of African Americans, Hispanic Americans, and Asian Americans and less than 10% of White Americans. Adult learning technologies were used including teaching with films, role-playing, case studies, reflective thinking, evidence-based practice, and group performance improvement projects. Research-based fact sheets were used for the course and continued education. These 1-page fact sheets help nurses apply the evidence to improve nursing practice.