Nurse safety is an essential factor of consideration in ensuring the delivery of safe and quality care within an acute mental health setting. According to the Work Health Safety Act (2011), employers are legally obliged to provide a safe workplace as well as comply with the responsibility of protecting workers and all healthcare staff from harm. Aggression and violence toward nurses have detrimental effects on the ability of nurses to care for consumers effectively (Kelly, Fenwick, Brekke, & Novaco, 2016). Therefore, the need to address this issue will not only benefit healthcare workers but also those who are receiving care. My quality improvement proposal is to employ a 2-nurse ratio. Therefore, instead of having a traditional 1:5 ratio, it will be a 2:10 ratio. This proposal aims to increase nurse safety and increase the standard of patient care. It will ensure that when nurses attend to patients outside of the secure nurse station, they will go in pairs. The proposal will be implemented at the acute mental health unit where I conducted placement. This essay will first critically review and appraise recent evidence surrounding the need for quality improvement. I will then hypothetically implement my change using the plan, do, study, and act cycle (PDSA). I will analyze leadership and management concepts vital for successful implementation. And lastly, critically appraise my quality improvement.
During a placement at one of Canberra’s secure acute mental health units, I saw firsthand aggression and violence aimed toward healthcare staff daily. Frequently I was asked to accompany nurses to attend patient care. There was an obvious feeling of fear for one’s personal safety when attending aggressive and agitated patients alone. Addressing violence and aggression in mental health units can be complex and multi-faceted. Improvements already employed within the unit consisted of CCTV, security, personal duress alarms, and extensive interpersonal de-escalation training.
Justification
Aggression and violence towards healthcare staff in mental health facilities have been comprehensively researched with consistent findings that 70% of mental health nurses have been physically assaulted and 88%-100% of mental health nurses have experienced verbal aggression (Kelly et al., 2016; Foster, Roche, Giandinoto & Furness, 2019). Edward et al. (2015) conducted an international systematic review that found mental health nurses were three times more likely to be physically assaulted than general hospital nurses. This statistic was much more conservative in comparison to others published. Furthermore, the review suggested this may be having detrimental effects on the recruitment and retention of mental health nurses. Foster et al. (2019) have predicted by 2030, there will be a national shortage of 18,500 mental health nurses in Australia. Local media released just last year revealed mental health nurses in the same unit where I completed a placement have given warnings that their lives are at risk from patient assaults. The assaulted nurses reported insufficient post-incident follow-up, forcing them to either physically withdraw from their work or risk their own safety by deciding to remain within the unit (Scott & Evans, 2018).
Cases of significant injuries and death are rare, although the results of aggression and verbal abuse can result in significant psychological harm to nurses, such as anxiety, fear, depression, as well as post-traumatic stress disorder (Ward, 2018; Itzhaki, 2018). According to the Australian Capital Territory (ACT) Government, between January 2017 and June 2018, there were 139 reported cases of physical assaults towards healthcare staff in Canberra mental healthcare settings (Scott & Evans, 2018). Foster et al. (2019) highlighted that in Australia, the leading cause of workplace stress reported by mental health nurses was aggression and violence from patients to nurses. Safety is vital for all healthcare workers in a mental health setting as it may allow for the development of a close therapeutic relationship which may enhance patient outcomes (Haines, Brown, McCabe, Rogerson & Whittington, 2017).
Lanctot and Guay (2011) highlighted the detrimental consequences physical and verbal aggression had on nurses’ health and well-being. They found that the severity of the aggression and violence played some part, but more importantly, it emphasized how damaging cumulative minor aggressions and violence can have on mental health nurses. A recent ACT Health strategy addressing workplace violence highlighted significant underreporting of incidences (ACT Health, 2018). Therefore, when analyzing the rates of incidences, we must take into account the minor incidences that do not get documented. Violence and aggression negatively affect the professional relationship between nurses and patients by nurses to feel isolated and less empathetic toward patients (Ward, 2018). In a context where therapeutic relationships with patients are so significant in treatment, it is vital to have an understanding of how workplace safety affects the ability of nurses to engage with consumers in their care. According to a recent ACT Health strategy, nurses exposed to violence and aggression productivity decreased by 37%, as well as an overall decrease in workplace morale, increased stress levels, and a decrease in control of emotional reactions (ACT Health, 2018). The literature is quite clear that aggression and violence detrimentally affect a nurse’s well-being and subsequent patient care.
A two-staff-nurse ratio is an ideal quality improvement proposal through which violence and aggression against nurses can be improved and nurse safety enhanced. This proposal is not new and many acute mental health facilities throughout the world have this stipulated within their guidelines (NICE, 2019). Recent research conducted in community health settings concluded nurses working alone were at an increased risk of violence or aggression from patients (Terry, Le, Nguyen & Hoang, 2015). Furthermore, the National Health Service (2015) also found that nurses working alone had a 10% higher incident rate in relation to aggression and violence from their patients. Recent laws have changed in some states of Australia now banning single nurse posts in remote areas due to the increased risk and vulnerability nurses were experiencing working alone. They have also instructed nurses going on call-outs to attend in pairs to increase personal safety (SA Health, 2019). Extensive research has categorically found nurses working alone in community settings had increased risks of aggression and violence. This evidence is out of context, although provides some insight into nurses’ vulnerability when working alone. One study found in acute mental health units the prevalence of violence increased when nurses attended to patients alone (Shu-Fenn Niu, Hsiu-Ting Tsai, Ching-Chiu Kao, Traynor & Chou, 2019). Although this study was conducted in Taiwan, it may add some additional value.
Minimal literature published has focused directly on a 2-nurse staff ratio and its implications on nurse safety within a mental health context. However, one qualitative study from Canada directly assessed the effectiveness of nurses working in pairs in pod nursing. Pizzingrilli & Christensen (2014) looked at pod nursing in an acute mental health unit. Before this implementation took effect, nurses were working alone in a traditional nursing ratio of 1:5. The quality improvement designated 2 nurses to work together, caring for one pod of 10 patients. The study indicated nurses felt safer engaging consumers in their accommodation post-implementation. Furthermore, collaboration between the nurses was enhanced when compared to pre-implementation. Post-implementation survey results found 84.6% of nurses thought patient care was enhanced, and 100% of nurses did not want to move back to the pre-implementation nursing ratios. This study did fail to compare incident rates pre and post-implementation. Also, the design of the unit differs from the facility I wish to implement the specified quality improvement. However, I believe this study has suggested that there were positive changes in perceptions of nurse safety by working in pairs.
Plan, Do, Study, Act Cycle
The objective of this quality improvement is to increase safety for nurses working in acute mental health settings. I will structure my implementation using a PDSA cycle, suggested to be an effective tool when implementing and testing quality improvements. This quality improvement will be carried out at a designated acute secure mental health unit. The change team will consist of three enrolled or registered nurses, three team leaders, CNE, CNC, and a patient advocate. The change team will be encouraged to have regular team meetings throughout implementation. Incorporating all staffing levels within the change team will allow for a better understanding of participants’ perceptions and problems during the implementation of the quality improvement.
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Management’s focus during the change process will be on the operational side of the implementation. They will also have a responsibility to collate information and data regarding quality improvement. A transformational leadership concept will be employed because of its documented benefits to changing organizational nursing culture. Utilizing a transformational leadership style, team leaders and nurses will lead by example and influence positive change throughout the nursing staff in order to change cultural norms held within the facility. Leaders will value and encourage peer engagement in the implementation and welcome any suggestions or recommendations.
The first step will be gathering data from the main stakeholders within the facility, this would be mainly the nursing staff working on the floor. Looking retrospectively at incident reports from the past 12 months will give an insight into the pre-implementation rate of incidents. All levels of nurses will be required to fill in a work safety scale survey used in similar implementations to assess perceptions of ward safety. This will give the change team a baseline to compare future results. The patient population within the facility will also be required to fill out a survey detailing their perceptions of care. This will permit the change team to monitor the implementation's effects on patients’ perceptions of quality care.
The nursing staff, team leaders, and middle management will be briefed in multiple educational meetings on the plan of implementation and why we are implementing change. Evidence supports informing stakeholders of the rationale behind the change to try and get them actively engaged with the change. There will be a focus on a clear and concise vision of the desired outcomes post-implementation with the aim to increase the urgency for change. A patient information session will be held so patients within the facility are informed of the new proposal. This will also allow an opportunity for patients to raise any queries, concerns, or suggestions. High levels of communication and transparency at all levels will be held throughout this process.
The implementation will start during night shifts for the first two weeks, this will allow time to alleviate any problems before implementation during busier shifts. Hughs (2008) has advised when implementing change to utilize a minimalist approach, thus making it easier to make changes prior to implementing the quality improvement throughout the facility. This will be followed by the implementation during the evening shift for one week and finally the morning shift. Four weeks into the implementation, all shifts will be following the new quality improvement. Throughout this process, we will be assessing the effectiveness of this implementation and encouraging feedback from staff and patients. Predicting potential hurdles will allow us to structure a plan that takes these into account, allowing the change team to easily adapt (Hughs, 2008). Research indicates that acute mental health units have had difficulty implementing quality improvements because of staff resistance to change. Laker et al. (2014) highlighted nurses working in direct care positions were more ambivalent to changes. There may also be resistance from patient advocates, as the change may exacerbate negative stigma towards patient conditions (Knaak, Mantler & Szeto, 2017). Well published is the high turnover of staff within acute mental health units, thus posing some difficulties in obtaining consistency in care and knowledge of quality improvement (Lancotot & Guay, 2014).
During implementation, team leaders will record challenges experienced by nurses and patients. Data will be collected throughout the implementation process, such as near misses, incident reports, and stakeholder feedback. After the quality improvement has been implemented for three months, a complete analysis of the collected data will be undertaken. The analysis will be compared to the expected outcomes of quality improvement. Nursing staff and patients will fill out their relevant questionnaires and incident reports will be collated. Multiple meetings will take place to attain qualitative feedback about the proposal, implementation, and general feelings about working in pairs instead of alone. The change team will engage with the patients to see how they have found the change and if it has had any negative or positive effects from their perspective. With the information collected from the trial period, the change team will tailor the quality improvement proposal to maximize its use and benefits. It will be important to be flexible and work in collaboration with stakeholders throughout this process.
Critical Appraisal
The quality improvement proposal aims to enhance nurse safety within the acute mental healthcare facility specified. Due to the complexities surrounding nurse safety, there are several limitations regarding this proposal. The main disadvantage of this proposal is the potential exacerbation of stigma towards those with mental health problems. The impact of stigma towards patients with mental health illnesses is significant and can affect a patient’s recovery and ability to regain normality. Encouraging an increased nurse ratio to increase nurse safety may reinforce negative stereotypes, for example, that mental health patients are all dangerous (Knaak et al., 2016). It may also split the population creating us and them mentality. This is something I definitely do not want to create with this proposal, however, there is a fine balance that needs to be created between nurse safety and fostering a recovery-focused environment.
Staff may be resistant to this change due to the heavy workload nurses face daily. Pairing nurses together may impede their ability to complete daily tasks effectively and increase levels of stress. Maharaj, Lees & Lai (2019) found a high prevalence of depression, anxiety, and stress among Australian nurses. A thorough thought-out plan and supportive team will mitigate the risk of causing burnout to nurses. The aspect of a cost/benefit analysis has not been considered to be of primary importance, although it is recognized that the impact of a 2:10 nursing ratio will have significant monetary consequences. The most important element in the proposal to be undertaken is the need to ensure that nurses working in a potentially aggressive and hostile environment are protected from the unwanted attention of a violent nature. As well the mental health and well-being of patients will need to be at the forefront of any planned changes in order to assuage any fears held by them.
Conclusion
All modern healthcare facilities should be fostering an environment that encourages the continued development of research, leading to the maximization of quality care within those facilities. Year after year violence-related incidents in healthcare continue to rise. There is an urgent need to address this issue so that nurses may feel safe when delivering person-centered care. This proposal has highlighted a complex problem that may be addressed by implementing a two-nurse ratio in acute mental health units. I have hypothetically planned a quality improvement and highlighted some management and leadership concepts that will help with the successful implementation. Violence against healthcare workers not only has negative impacts on the psychological and physical well-being of nurses but also on job motivation, retention of highly qualified staff, and the future recruitment of suitable persons for a sometimes difficult career. Finally, the time has arrived whereby healthcare leaders and administrators will need to take a nurse-centered management approach to address the many complex issues affecting the delivery of quality care.
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