Monday September 16th 2019

Collaboration, connection key to culture of safety in mental health care

Safely and effectively addressing the needs of patients with mental health and behavioral disorders is an important part of nursing practice. RNs caring for the mentally ill can draw on a variety of effective methods and resources to promote a culture of safety in their work environment, a goal that the American Nurses Association urges for all nurses with its yearlong campaign, “Safety 360 Taking Responsibility Together.”

But establishing a culture of safety may require nurses to address assumptions about mental illness and recognize that behavioral health issues are not limited to behavioral health settings, but rather span the spectrum of health care.

“A culture of safety is extremely important for nurses in all settings,” said Diane Allen, MN, RN-BC, NEA-BC, assistant director of nursing at New Hampshire Hospital and chair of the American Psychiatric Nurses Association’s Institute for Safe Environments.

“People with mental illness sometimes behave in unexpected, unusual ways that can be very frightening for nurses,” said Allen, a New Hampshire Nurses Association member. “We have to remember that we cannot let our desire to maintain safety overpower our
fundamental duty to try and help people manage the symptoms of their illness.”

Disorders are widespread

According to the Centers for Disease Control and Prevention, at any point in time about 25 percent of the U.S. adult population has a mental health disorder, and 50 percent will develop at least one mental illness during their lifetime. Injury rates are two to six times higher among people with a mental illness than among the population at large.

Freida Outlaw

Further, people with a mental illness are more likely to abuse alcohol or drugs, posing related safety concerns to themselves or others, according to Freida Hopkins Outlaw, PhD, RN, FAAN, executive program consultant for the Substance Abuse and Mental Health Services Administration’s Minority Fellowship Program at ANA. The MFP helps ethnic minority nurses obtain advanced degrees in mental health nursing so they can reduce disparities and improve health outcomes in diverse communities. SAMHSA estimates that in 2014 just over 8 percent of the population — some 20.2 million adults — abused alcohol or drugs, and of those, 7.9 million had a co-occurring mental and substance abuse disorder.

Depression, a mental health disorder, is a common and significant health care problem, accounting for increased mortality from suicide and impaired ability to manage other health issues, according to the U.S. Preventive Services Task Force.  In January, the task force released updated guidelines recommending depression screening in primary care for adults and for adolescents aged 12-18.

“As a nurse, my perspective is that all primary care providers who care about prevention and their patients’ quality of life — including nurses, midwives, physicians and others — have an important role to play in screening for depression,” said Ann E. Kurth, PhD, MPH, RN, dean of the Yale School of Nursing and an ANA-New York member, who served on the task force.

Challenging cultural misperceptions

To help create a safer work environment, RNs must understand and sometimes challenge the cultural context in which mental health is viewed, according to Allen.

“The kind of philosophy that focuses on control, restriction and containment is not an effective means of ensuring safety,” Allen said. “And, not all [patients with mental illness] are violent. Many suffer silently.”

Similarly, Outlaw stresses the integration of physical and mental health, and cautions against viewing mental health knowledge as an umbrella that’s “over in the corner and we pull it out when we need it.”   She said the large body of information about mental illness and its treatment must be incorporated across the health care spectrum at the primary care level.

And it is at the primary care level that depression screening should be done, according to the USPSTF.

Kurth and the other task force members hope that the depression screening recommendations will help decrease the stigma surrounding depression and other mental health illnesses. They also dovetail with the nursing imperative for self-care, an essential element in a culture of safety.

“As nurses, we need to take care of our own health to provide adequate care and to support our patients through prevention and counseling to prevent illness,” she said.

Patient engagement and collaboration

Stigmas and stereotypes aside, at the heart of a culture of safety is engaging the patient and establishing a human connection.

Diane Allen

“What makes the biggest difference to people with mental health issues is nurses who are able to connect with them in their darkest hours,” Allen said. “Safety can mean that we engage with people, collaborate with them during treatment and lead them toward the path of recovery.”

Allen and her colleagues authored a white paper “Engagement as an Element of Safety,” published in 2015 by the Journal of the American Psychiatric Nurses Association. The paper outlines research that consistently points to nurse-patient engagement as an important element of safe and therapeutic nursing practice.  “Establishing trusting, respectful and collaborative relationships with people is what really keeps them safe,” Allen said.

Allen is presenting ANA’s Navigate Nursing webinar, “Practicing Prevention: Safely Engaging Patients in Mental Health Crises,” scheduled for April 20. The webinar covers factors that increase the likelihood of violence in clinical settings and the role that nurse-patient engagement plays in maintaining a safe, therapeutic environment, and offers strategies to help RNs practice safely and effectively in a crisis situation.

Nurse-patient engagement carries another benefit. “The experience of human connectedness is what nurses say makes the work most meaningful to them,” Allen said.

RNs who care for people with mental illness need a special skill set that includes a well-developed sense of self-awareness, exceptional communication abilities and the ability to tolerate unexpected, unusual and frightening behaviors, and to recognize that these behaviors may be related to symptoms of mental illness, Allen said.

“If you mirror an intent to help, remain calm in a very tense situation, and convey the message that people are safe, aren’t going to be harmed, and all are working on the same team, that works a lot better [than restriction],” she said.

Making room for emotional safety

Outlaw, a Tennessee Nurses Association member, believes a culture of safety includes what she calls emotional safety.

“I’m talking about safety as being more than protection from physical harm,” Outlaw said. Both nurses and patients must feel safe “to say and be who they are,” and that organizations sometimes create cultures where people don’t feel safe to express their ideas, whether nurse-to-nurse or nurse-to-patient.

“Safety doesn’t mean people always have to agree with you,” Outlaw said, but it does mean that there is “respect for dignity and equality of ideas.” A culture of safety also recognizes and tries to lessen a nurse’s “anticipatory fear” of danger posed by patients who in fact may be more emotionally than physically threatening, she said.

Organizational support

Allen maintains that a culture of safety must be nurtured by all involved.

“Safety needs to be a part of the culture, held by the administration, and supported by sufficient staffing, training and managerial practices,” Allen explained. And she noted that New Hampshire Hospital has had great success in moving away from a culture where being hurt is considered to be part of the job. The Staying Safe initiative encouraged staff to avoid physical interventions whenever possible and to get help and have a plan before physically intervening with anyone.  As a result, assaults to staff, staff injuries and workers’ compensation cases have decreased by over 60 percent.

Another significant component for building a culture of safety is the element of hope.

Nurses and colleagues must maintain “a hopeful environment” built around “a firmly held hope that people do recover from mental illness,” Allen said.

— Kathryn Desmond is a registered nurse and writer.


APNA Institute for Safe Environments

U.S. Preventive Services Task Force screening tools
Depression in Adults: Screening

Depression in Children and Adolescents: Screening

ePSS Electronic Preventive Services Selector

CDC Fact Sheet: Mental Illness Surveillance Among U.S. Adults

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