LR28 / The registered nurse in an acute mental care settings

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice
Handover/ Communication and documentation
Patient safety theme the SCP/clinical risk management practice is aimed at
The CRM practice is focused on the role of the registered nurse in an acute mental health inpatient setting.
Objective of the CRM practice
This study aimed to establish perceptions that registered nurses have regarding their roles performed in current day inpatient care [p.135, 1].
Short description of the CRM practice, including any references for further information
The study was carried out in an acute care inpatient unit at a large mental health service using a qualitative descriptive exploratory approach [p.135, 1]. Related to Patient safety and risk management, the themes of ‘safety’ in the nonparticipant observations and ‘risk management’ in the focus groups were virtually interchangeable. The focus groups emphasized the defensive practice aspects of risk management. From the observations, activities related to patient safety included carrying out routine 15-min checks on all patients, searching for missing patients, carrying out constant observation on some patients, and ensuring the unit environment was secure. Maintaining unit safety was deemed fundamental to nursing practice in inpatient care. Consultation with other nurses and the multidisciplinary team was considered a vital component in maintaining safety on the unit. Protection of the nurse from possible legal consequences of their practice was a significant finding [p.136, 1].
Innovator of the SCP, country of origin
The study was carried out in New Zealand [p.134, 1].
Involved health care staff
Registered nurses [p.135, 1].
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
An acute care inpatient unit in a large mental health service [p.135, 1].
Summary of evidence for effectiveness, including references
The study is focused on the functioning of a crisis-orientated model of care, as participants described nursing care that focused on triage, assessment, stabilization, and the containment of risk, which are all common features of crisis intervention. By adopting such a model, nurses could then accept the realistic expectations of their roles in this setting and view their practice in a more positive way. In essence, it would enable nurses to acknowledge and value the roles that they are currently performing [p.140, 1]. The findings suggest that nurses believe that practice is driven more by the needs of the organization than the patient. Further research needs to explore if this is the reality in inpatient care and the effect that this has on employee–employer relationships [p.139, 1]. In order to inform practice, further research could explore what it is that enables nurses to remain patient-focused and therapeutic in such a challenging environment, what are the personal characteristics of the nurse, and where do nurses obtain their supports from that enable them to maintain their standards of practice [p.139, 1].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There are no described evidence for transferability, but this study support international studies in suggesting that high acuity and issues of safety are the main drivers of acute admissions [p.140, 1].
Summary of available information on feasibility, including references
In acute inpatient settings, mental health nurses are often the only persons around whose time for caring is long enough to develop trusting therapeutic relationships with patients. Changes in technology and management systems related to patient care occupy nurses’ time, and may result in less direct contact with patients. [p.135, 1]. Administrative activities, for which there was broad agreement between observations and perceptions, were seen as detracting from the patient contact/therapeutic role of the registered nurse. Whilst it cannot be denied that administrative activities do take nurses away from patients, the perception was that these activities are so demanding and time-consuming that little time is left for interactions with patients [p.139, 1].
Existing implementation tools, including references
Nonparticipant observation and focus group interviews. Nonparticipant observation took place first, and observers recorded the range of activities of registered nurses in the acute inpatient setting. Focus group interviews were used to establish the perception that registered nurses had regarding their roles in the acute inpatient setting. [p.135, 1].
Potential for/description of patient involvement in the CRM practice, including references
Focus group participants acknowledged that creating and sustaining a nurse–patient relationship in a busy inpatient unit was difficult to achieve but that it remained central to their daily practice. They recognized that they needed to make the most of any opportunity to engage patients and that the primary nurse allocation of patients meant that each nurse was expected to interact with their patients on any given duty in order to document patient progress. This was deemed a real challenge in a busy inpatient unit [p.136-137, 1].
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
Willem J. Fourie, Stuart McDonald, John Connor, Steve Barlett (2005), The role of the registered nurse in an acute mental health inpatient setting in New Zealand: Perceptions versus reality, International Journal of Mental Health Nursing, 14, 134-141.
To be added
National School of Public Health Management and Professional Development, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)
Participants appeared at times to struggle with the realities of inpatient practice as it conflicted with their perceived vision of mental health nursing. There is a need to establish what is fundamental to acute inpatient care practice and identify specific minimal standards relating to nursing practice in this specialty context. This may require a review of the current job description for registered nurses in order to create descriptions that more accurately reflect the roles that nurses are expected to perform [p.140, 1]