Problem Description: Overcrowding in Psychiatric Units
The gradual appreciation of mental health as a core component of human functioning is perhaps one of the demonstrable advancements of modern healthcare. Mental health conditions constitute a spectrum of disorders whose manifestations are protean and management is diverse (Salvador-Carulla, 2020).
Management of these conditions incorporates medical aspects and psychological techniques and may occasionally necessitate admission. The latter is true for agitated and psychotic patients who are often managed in psychiatric units. The article thus focuses on psychiatric patients and explores the aetiology and impact of overcrowding in mental health facilities. It also offers practical solutions.
Problem Statement
Description and Impact
Psychiatric units contribute immensely to the management of psychiatric patients. Despite the strides made in mental healthcare, they remain limited in number and resources, leading to overcrowding of patients admitted. In 2019, psychiatric hospitals in Virginia were fully occupied (O’Connor, 2019).
That was occasioned by the heightened admissions due to the growing burden of mental disorders, as well as difficulty in discharging some patients owing to extenuating circumstances (O’Connor, 2019). Overcrowding in these facilities remains a problem arising from multiple loopholes of healthcare both at institutional, state and national level.
Ultimately, overcrowding then tends to impact the patients negatively in many ways. First, the close monitoring of patient progress, adherence to therapy and abnormal behaviour become difficult for the staff since their number is limited while that of patients keeps rising (Chow & Priebe, 2013).
Also, Teitelbaum et al. (2016) describe that it is associated with an increased rate of adverse incidents such as violence and aggressive behaviour among patients. It is also noteworthy that cramping up patients can worsen some psychiatric conditions such as depression and schizophrenia hence prolonging their hospital stay (Teitelbaum et al., 2016). Medically, the risk of outbreaks of communicable illnesses in the facilities is rife.
Policy Origins
The problem with overcrowding in mental health facilities also lends itself to the tinkering of policies related to mental health issues over the years, hence a leadership and policy issue. By 2010, the National Institute of Mental Health provided that 6.3% of Americans suffered severe mental illness and thus needed admission into facilities to meet their short and long-term care needs (Chow & Priebe, 2013).
At the time, however, states only provided 5beds/100000 people instead of the recommended 50beds/100000 people, hence leading to lack of space and crowding. Importantly, most states have not invested in sufficient community mental health services to manage the patients at that level and prevent their transitioning to higher, already overwhelmed centres (O’Connor, 2019). Both of the scenarios are postulated to arise from the alterations in funding patterns for these facilities in the period.
The intersection between mental health and the law is also contributory. Initially, community-based mental hospitals were funded by the states, but following the introduction of Medicaid, that was done away with in favour of facilities catered for by the insurance scheme (Yohanna, 2013).
Subsequently, mental patients not enrolled with the scheme were left to crowd in the remaining underfunded facilities (O’Connor, 2019). Further, many psychiatric patients who fail in seeking admissions to the limited facilities and yet have severe mental illness end up in prison, following their committing of specific misdemeanours that ride them to the corridors of criminal justice.
These include drug offenders, homicidal people and violent personalities (Wilson, 2019). According to Wilson (2019), up to 16% of the prisoners in the USA had severe mental illness before their incarceration. Outcomes for these patients is worse in that setting.
Institutional Shortfalls
The management of psychiatric institutions and patient admissions has also undergone an evolution, and also appears to have an impact on the current conundrum. Initially, the process employed the ‘total institution’ of those with severe mental illness in psychiatric facilities (Chow & Priebe, 2013). That implied psychiatric patients were constantly confined and adhered to particular routines in those facilities.
However, Goffman advocated for the deinstitutionalization of psychiatric patients, which led to the discharge of several patients to community-based units, and subsequent systematic downsizing of large psychiatric hospitals (Chow & Priebe, 2013; Yohanna, 2013).
The decreased capacities have now bit back in lieu of the increasing caseload of mental health conditions requiring admissions and specialist care, hence occasioning overcrowding. As alluded to above, accompanying the closures was also the reduced funding which further contrived to render the facilities short on staff and requisite resources.
Relevance to BSc. Nurse Practitioners
The importance of psychiatry in nursing and vice versa straddles various care delivery spheres. At the basic level, nurse practitioners provide the first contact with psychiatric patients in primary healthcare. Therefore, their role in the initial assessment, impression and appropriate channelling of the patients is vital (Salvador-Carulla., 2020).
The nurses are responsible for consulting with general practitioners at that level to ensure the patient receives quality and affordable mental health care. Importantly, careful and needful referrals also aid in controlling the congestion at the larger psychiatric hospitals (Yohanna, 2013). Through training, the NPs provide alterative views meant to augment the existing good practices and weed out the bad ones in the management of mental health cases.
Additionally, the nurse practitioners also provide a constant pool of training speciality nurses, in this case, the psychiatric nurses. The role of the psychiatric nurse is more expanded and tuned to mirror the needs of the mental health disorders they subserve (Cusack et al., 2017).
The psychiatric nurse is an advanced nurse practitioner, who when deployed at the community level aid in comprehensive patient management at that level whilst collaborating with psychiatrists and psychologists. That reduces the overall mental case burden and hence crowding, on the larger hospitals. At the mental health facility level, they monitor the patients, administer treatment and even process discharges in collaboration with relevant caregivers, hence they ensure constant patient turnover.
When understaffed, patients may be poorly managed hence leading to extended hospital stays and soaring costs, both of which contribute to overcrowding since patients cannot be discharged (Chow & Priebe, 2013). Psychiatric nurses can also opt to indulge advocacy and policy participation aimed at streamlining the management of mental health facilities.
Patient Overcrowding and Nursing Actions
Nursing Interventions and Standards
As a follow-up to the initial information, psychiatric nurses are particularly better placed appropriately to holistically manage these patients (Cusack et al., 2017). That is true even though the role of nurse practitioners in the initial recognition at the primary care level cannot be overstated.
Psychiatric diagnoses can be challenging to make, and even trickier to manage, hence all patients referred upstream from primary care facilities with such diagnoses are initiated on prompt reevaluation to assess for their mental illness and the possibility of inpatient care (Cusack et al., 2017).
Often, the first contact at that level is the psychiatric nurse who takes the history, orders requisite tests and initiates management. Only complicated cases can be referred to the consultant psychiatrist, but usually, patient care is concerted and coordinated (Cusack et al., 2017). This phase is very crucial as it helps weed out cases that require admission from those simply managed on an outpatient basis, hence controlling patient numbers in the psychiatric units.
Part of the aetiology of the overcrowding problem, as alluded, emanated from incongruent policy formulation and application. The policy is informed by research and therefore, psychiatric nurses are advanced nurse practitioners who can opt to indulge in research ventures to solve the existing healthcare issue (Hajizadeh et al., 2020).
In this regard, research already points to the adverse effects of overcrowding patients, especially psychiatric ones. Further research can be sought to assess modalities of providing affordable care to mental health patients at the community level as well as efforts at seeking stronger ways to educate the public about ways to preserve mental health (Salvador-Carulla, 2020). Psychiatric nurses are at the centre of collaborative efforts to ensure mental health campaigns are a sustained reality, for prevention is the best route health-wise on the individual and financially on the state.
Additionally, the place of nursing advocacy is important. Advocacy has emerged as crucial in pushing through healthcare agenda as important as research has been in generating them. Indeed, on the mental health front, the increasing body of knowledge generated through research has got to be implemented, eventually, for change to be realized (Cusack et al., 2017).
Nurse advocates can seek the review of laws on controversial issues such as suicide, which sees most people land in jail whilst most agree that it is a mental condition. Advocacy is also essential in making legislators and other stakeholders see the need of improving the numbers and capacity of psychiatric units in the country to cater for the increased demand (Turale & Kunaviktikul, 2019). Healthcare costs can be prohibitive and engaging insurance providers remains important in advancing the cause.
Barriers to Implementation
The existing barriers to implementing policies to avert the problem include disordered funding of community mental health units. The onset of shared funding between the federal government and state occasioned the shift towards Medicaid accredited facilities hence the pattern of crowding (Yohanna, 2013).
Also, despite insurance cover, healthcare costs in the USA remain high and massively privatized hence the intense difficulty in increasing its affordability. Psychiatric nurses are also still few hence most facilities lack the expertise needed (Yohanna, 2013).
Finally, the attitude and poor work ethics of some staff also contribute to ignoring implementation guidelines or even openly sabotaging them, hence the importance of ensuring everyone is on board through professional education.
State Board Nursing Standards and Effect on Psychiatric Units
Impact Analysis
First, legislation by state actors actively affects the running of the units. States pass laws regarding the number of psychiatric facilities they can have, based on the existing and projected mental disease burden (Chow & Priebe, 2013).
The facilities are then distributed accordingly from primary to tertiary care, with the accompanying resources, especially human resource. However, the actualization of the process needs the setting up of infrastructure as well as employment and training for prospective service providers (Turale & Kunaviktikul, 2019).
Often, that is underperformed by the state, leading to understaffing and fewer amenities which worsen the described problem. Additionally, policy rules relating to admission and discharge characteristics have been problematic over the years and also contribute to the problem.
Funding is a central cog in the running of these psychiatric units. It is the shifted funding mechanisms that are postulated to have played a role in the downsizing of the bed capacities of psychiatric units of specific states (Yohanna, 2013).
That was on the backdrop of funding being plucked from the exclusivity of state actors to include a shared responsibility with the national government, under the auspices of the Medicaid program. Funding affects resource provision hence states should craft new strategies on enhancing their finance pool to translate it into rejuvenated care provision for mental health patient from the primary care level. That translates to better patient outcomes.
The regulatory environment for the provision of mental healthcare to patients has several stumbling blocks. First is the varied state practices regarding inpatient admission procedures and discharge parameters, which negates the benefits of uniform beneficial practice for these patients (Phoenix & Chapman, 2020).
Also, states dictate the qualifications for nurses who are employed by the facilities, some of whose requirements present unique difficulties in achieving hence leading to understaffing and subsequently poor patient care (Phoenix & Chapman, 2020). Ultimately, the state is also the employer for primary care providers hence their important role of providing the expertise to nick the cases at the community level and institute early recovery.
Nurses and Policy-Making
The evolution of healthcare has afforded nurses, rightly so, a seat at the decision-making table. Nurses now contribute to policy formulation and not just application. To that end, nurse leaders play a central role in advancing ethics, advocacy and nurses’ perspective towards each of the presented healthcare issues (Hajizadeh et al., 2020).
They communicate and prosecute points fairly as well as seek important collaborations that enhance the role of nurses in the workplace, and eventually, patient outcomes. Central to the policy-making process is usually the patient safety and quality of care, hence the crucial case of nurses being involved in the process.
Importantly, nurses are researchers, especially advanced practice nurses. They participate in research ventures aimed at knowledge generation and practice assessments, hence the improving place of EBP and hence patient outcomes (Hajizadeh et al., 2020).
Further, research informs policy and thus nurses directly contribute positively to changes in the healthcare landscape, which in this case, would be to improve care organization in psychiatric units. Also, through professional and patient advocacy, nurses continually seek to improve service provision, create awareness of mental health challenges and trigger stakeholder into instituting positive changes in the sector (Turale & Kunaviktikul, 2019). The goal is to improve care access and outcomes.
Leadership Strategies to Solve the Problem
In this context, the nurses must adopt various characteristics to tackle the resource, organizational and arching political barriers towards the betterment of mental healthcare. Leadership strategies involved would be that of effective communication and collaboration, especially for nurse advocates to the stakeholders to help win passage of appropriate policies and funding (Al-Dossary, 2017).
Also, psychiatric nurse leaders will have to contribute to a shared vision of the future of the speciality, which will inform the strategies to be employed to get there. That should be achieved through critical thinking and decision-making. Nurse leaders will also encourage continuous information sharing through CMEs and also encourage research ventures to inform EBP and nursing policies (Hajizadeh et al., 2020). Funding is a particular sticking point and can be addressed through intense advocacy, lobbying and policy monitoring.
References
Al-Dossary, R. N. (2017). Leadership in nursing. Contemporary Leadership Challenges, 251. DOI: 10.5772/65308
Chow, W. S., & Priebe, S. (2013). Understanding psychiatric institutionalization: a conceptual review. BMC psychiatry, 13(1), 1-14. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-13-169?utm_source=Yahoo&utm_medium=Beauty&utm_campaign=mental-illness-mental-patient-halloween-costume-ideas
Cusack, E., Killoury, F., & Nugent, L. E. (2017). The professional psychiatric/mental health nurse: skills, competencies and supports required to adopt a recovery‐orientated policy in practice. Journal of psychiatric and mental health nursing, 24(2-3), 93-104. https://doi.org/10.1111/jpm.12347
Hajizadeh, A., Zamanzadeh, V., Kakemam, E., & Bahreini, R. (2020). A framework for nursing participation in health policymaking: a systematic review. https://doi.org/10.21203/rs.3.rs-18185/v1
O’Connor, K. (2019). Cleared to leave Virginia’s overcrowded mental hospitals, many patients have nowhere to go. Retrieved 5 June 2021, from https://www.virginiamercury.com/2019/08/11/many-patients-have-been-clearred-to-leave-virginias-overcrowded-mental-hospitals-but-they-have-nowhere-to-go/
Phoenix, B. J., & Chapman, S. A. (2020). Effect of state regulatory environments on advanced psychiatric nursing practice. Archives of psychiatric nursing, 34(5), 370-376. https://dx.doi.org/10.1016%2Fj.apnu.2020.07.001
Salvador-Carulla, L. (2020). Mental healthcare reforms and evaluation in Continental Europe. https://rsph.anu.edu.au/files/20210304%20Mental%20health%20care%20reforms%20and%20evaluation%20in%20Continental%20Europe%20Oct%202020.pdf
Teitelbaum, A., Lahad, A., Calfon, N., Gun-Usishkin, M., Lubin, G., & Tsur, A. (2016). Overcrowding in psychiatric wards is associated with an increased risk of adverse incidents. Medical care, 54(3), 296-302. https://doi.org/10.1097/MLR.0000000000000501
Turale, S., & Kunaviktikul, W. (2019). The contribution of nurses to health policy and advocacy requires leaders to provide training and mentorship. International nursing review, 66(3), 302-304. https://doi.org/10.1111/inr.12550
Wilson, C. (2019). Incarcerating the insane: debating responsibility for criminal lunatics between prisons, hospitals, and families in British mandate Palestine. The contemporary Levant, 4(1), 39-51. https://doi.org/10.1080/20581831.2019.1594615
Yohanna, D. (2013). Deinstitutionalization of people with mental illness: causes and consequences. AMA Journal of Ethics, 15(10), 886-891. https://journalofethics.ama-assn.org/article/deinstitutionalization-people-mental-illness-causes-and-consequences/2013-10?utm_source=twitter&utm_medium=social&utm_term=3653041417&utm_campaign=ethics&Effort+Code=FBB007