critical thinking psych nursing

Critical Thinking in Nursing

• First Online: 02 January 2023

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• Şefika Dilek Güven 3  

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

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Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

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Critical Thinking and Reflection for Mental Health Nursing Students

• Marc Roberts
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The ability to reflect critically is a vital nursing skill. It will help your students to make better decisions, avoid errors, identify good and bad forms of practice and become better at learning from their experiences. The challenges they will face as a mental health nurse are complex so this book breaks things down to the foundations helping them to build critical thinking and reflection skills from the ground up.

Key features:

· Covers the theory and principles behind critical thinking and reflection

· Explores the specific mental health context and unique challenges students are likely to face as a mental health nurse

· Applies critical thinking to practice but also to academic study, showing how to demonstrate these skills in assignments

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

The set of books is an excellent resource for students. The series is small, easily portable and valuable. I use the whole set on a regular basis. 

I will be referring to this book (ch4) for my values-based practice class. I think the students will appreciate the way this book is written, using the NMC standards as a guide for this learning and making it real with the use of case studies.

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The nursing process and standards of care for psychiatric mental health nursing

CHAPTER 7 The nursing process and standards of care for psychiatric mental health nursing Elizabeth M. Varcarolis Objectives 1.  Compare the different approaches you would consider when performing an assessment with a child, an adolescent, and an older adult. 2.  Differentiate between the use of an interpreter and a translator when performing an assessment with a non–English speaking patient. 3.  Conduct a mental status examination (MSE). 4.  Perform a psychosocial assessment, including brief cultural and spiritual components. 5.  Explain three principles a nurse follows in planning actions to reach agreed-upon outcome criteria. 6.  Construct a plan of care for a patient with a mental or emotional health problem. 7.  Identify three advanced practice psychiatric mental health nursing interventions. 8.  Demonstrate basic nursing interventions and evaluation of care following the ANA’s Standards of Practice. 9.  Compare and contrast Nursing Interventions Classification (NIC) , Nursing Outcomes Classification (NOC) , and evidence-based practice (EBP). Key terms and concepts evidence-based practice (EBP) health teaching mental status examination (MSE) milieu therapy Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) outcome criteria psychosocial assessment self-care activities Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis http://coursewareobjects.elsevier.com/objects/ST/halter7epre/index.html?location=halter/three/seven The nursing process is a six-step problem-solving approach intended to facilitate and identify appropriate, safe, culturally competent, developmentally relevant, and quality care for individuals, families, groups, or communities. Psychiatric mental health nursing practice bases nursing judgments and behaviors on this accepted theoretical framework ( Figure 7-1 ). Theoretical paradigms such as developmental theory, psychodynamic theory, systems theory, holistic theory, cognitive theory, and biological theory are some examples. Whenever possible, interventions are also supported by scientific theories when we apply evidence-based research to our nursing plans and actions of care (refer to Chapter 1 ). FIG 7-1  The nursing process in psychiatric mental health nursing. The nursing process is also the foundation of the Standards of Practice as presented in Psychiatric-Mental Health Nursing: Scope and Standards of Practice ( ANA et al., 2007), which in turn provide the basis for the: •  Criteria for certification •  Legal definition of nursing, as reflected in many states’ nurse practice acts •  National Council of State Boards of Nursing Licensure Examination (NCLEX-RN ® ) Safety and quality care for patients has become the new standard for nursing education. As of the late 1990s, the Institute of Medicine (IOM; based on their Quality Chasm reports) and other organizations found a need to improve the quality and safety outcomes of health care delivery. As nursing practice focused more on quality and safety issues, it became evident that graduating nursing students were missing critical competencies for safety and quality of care. The context and approach of nursing education is changing, and new models of education are needed (Valiga & Champagne, 2011). The competencies mandated by the IOM require changes throughout health professionals’ education to better prepare students with the responsibilities and realities in the health care setting. There is now a strong national focus on improving patient safety and quality that is known as Quality and Safety Education in Nursing (QSEN) (Sullivan, 2010). The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes (KSAs) required to enhance quality, care, and safety in the health care settings in which they are employed ( Cronenwett et al., 2007). QSEN bases their work on six competencies ( Box 7-1 ). These competencies are integrated into this chapter and throughout the textbook. BOX 7-1    QUALITY AND SAFETY EDUCATION FOR NURSES (QSEN) COMPETENCIES Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Safety: Minimize risk of harm to patients and provide optimal health care through both system effectiveness and individual performance. Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Teamwork and collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. Evidence-based practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Cronenwett, L. , Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131. QSEN has underscored the need to increase knowledge about patient safety practices and the value of redesigning student learning experiences to improve the integration of this content (Sherwood & Hicks, 2011). Clinical simulations using sophisticated mannequins, combined with instructors who can provide realistic case scenarios and provide debriefing through videotaped patient care sessions are useful in safely identifying and reinforcing quality care concepts. Self-directed computer-based simulation programs are also popular and effective. These programs portray virtual clinical settings and may use avatars to offer students a chance to implement their knowledge, skills, and attitudes without the potential for patient harm ( Durham & Sherwood, 2008). Suggestions for the use of QSEN competencies in the discussion of Standards of Practice can be found in “Competency Knowledge, Skills, Attitudes (KSAs) (Pre-Licensure)” at the website www.qsen.org/competencies/pre-licensure-ksas/ . The following sections describe the Standards of Practice, which “describe a competent level of psychiatric-mental health nursing care as demonstrated by the critical thinking model known as the nursing process ( ANA et al., 2007).” The Standards of Practice and Professional Performance are listed on the inside back cover of this book. Standard 1: Assessment A view of the individual as a complex blend of many parts is consistent with nurses’ holistic approach to care. Nurses who care for people with physical illnesses ideally maintain a holistic view that involves an awareness of psychological, social, cultural, and spiritual issues. Likewise, nurses who work in the psychiatric mental health field need to assess or have access to past and present medical history, a recent physical examination, and any physical complaints, as well as document any observable physical conditions or behaviors (e.g., unsteady gait, abnormal breathing patterns, wincing as if in pain, doubling over to relieve discomfort). The assessment process begins with the initial patient encounter and continues throughout the care of the patient. To develop a basis for the plan of care and in preparation for discharge, every patient should have a thorough, formal nursing assessment on entering treatment. Subsequent to the formal assessment, data is collected continually and systematically as the patient’s condition changes and—hopefully—improves. Perhaps the patient came into treatment actively suicidal, and the initial focus of care was on protection from injury; through regular assessment, it may be determined that although suicidal ideation has diminished, negative self-evaluation is still certainly a problem. Assessments are conducted by a variety of professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Virtually all facilities have standardized nursing assessment forms to aid in organization and consistency among reviewers. These forms may be paper or electronic versions, according to the resources and preferences of the institution. The time required for the nursing interview—a standard aspect of the formal nursing assessment—varies, depending on the assessment form and the patient’s response pattern (e.g., a patient who is lengthy or rambling, is prone to tangential thought, has memory disturbances, or gives markedly slowed responses). Refer to Chapter 9 for sound guidelines for setting up and conducting a clinical interview. In emergency situations, immediate intervention is often based on a minimal amount of data. In all situations, however, the patient, who must also receive a copy of the Health Insurance Portability and Accountability Act (HIPAA) guidelines, gives legal consent. Essentially, the purpose of the HIPAA privacy rule is to ensure that an individual’s health information is properly protected, while at the same time allowing health care providers to obtain personal health information for the purpose of providing and promoting high-quality health care ( USDHHS , 2003). HIPAA was first enacted in 1996, but compliance was not mandated until April 14, 2003. Chapter 7 has a more detailed discussion of HIPAA. Visit www.hhs.gov/ocr/privacy/hipaa/understanding/index.html for a full overview. In patient-centered care, the nurse’s primary source for data collection is the patient; however, there may be times when it is necessary to supplement or rely completely on another for the assessment information. These secondary sources can be invaluable when caring for a patient experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbors, police, health care workers, and medical records. The best atmosphere in which to conduct an assessment is one of minimal anxiety; therefore, if an individual becomes upset, defensive, or embarrassed regarding any topic, the topic should be abandoned. The nurse can acknowledge that the subject makes the patient uncomfortable and suggest within the medical record that the topic be discussed when the patient feels more comfortable. It is important that nurses not probe, pry, or push for information that is difficult for the patient to discuss; however, it should be recognized that increased anxiety about any subject is data in itself. The nurse can note this in the assessment without obtaining any further information. Age considerations Assessment of children An effective interviewer working with children should have familiarity with basic cognitive and social/emotional developmental theory and have some exposure to applied child development ( Sommers-Flanagan & Sommers-Flanagan, 2009). The role of the caretaker is central in the interview; however, when assessing children, it is important to gather data from a variety of sources. Although the child is the best source in determining inner feelings and emotions, the caregivers (parents or guardians) often can best describe the behavior, performance, and conduct of the child. Caregivers also are helpful in interpreting the child’s words and responses, but a separate interview is advisable when an older child is reluctant to share information, especially in cases of suspected abuse ( Arnold & Boggs, 2011). Developmental levels should be considered in the evaluation of children. One of the hallmarks of psychiatric disorders in children is the tendency to regress (i.e., return to a previous level of development). Although it is developmentally appropriate for toddlers to suck their thumbs, such a gesture is unusual in an older child. One study found that children felt more comfortable if their health care provider was the same gender ( Bernzweig et al., 1997). Another study indicated that although 60% of parents preferred that a man care for their children, 79% of the children, regardless of gender, requested that a female physician care for them ( Waseem & Ryan, 2005). Age-appropriate communication strategies are perhaps the most important factor in establishing successful communication ( Arnold & Boggs, 2011). Assessment of children should be accomplished by a combination of interview and observation. Watching children at play provides important clues to their functioning. From a psychodynamic view, play is a safe area for the child to act out thoughts and emotions and can serve as a safe way in which children can release pent-up emotions—for example, having a child act out their story with the use of anatomically correct dolls or tell a story of their family using a family of dolls. Asking the child to tell a story, draw a picture, or engage in specific therapeutic games can be a useful assessment tool when determining critical concerns and painful issues a child may have difficulty expressing. Usually, a clinician with special training in child and adolescent psychiatry works with young children. Assessment of adolescents Adolescents are especially concerned with confidentiality and may fear that anything they say to the nurse will be repeated to their parents. Lack of confidentiality can become a barrier of care with this population. Adolescents need to know that their records are private; they should receive an explanation as to how information will be shared among the treatment team. Questions related to such topics as substance abuse and sexual abuse demand confidentiality ( Arnold & Boggs, 2011); however, threats of suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm must be shared with other professionals, as well as with the parents. Because identifying risk factors is one of the key objectives when assessing adolescents, it is helpful to use a brief, structured interview technique such as the HEADSSS interview ( Box 7-2 ). BOX 7-2       THE HEADSSS PSYCHOSOCIAL INTERVIEW TECHNIQUE H Home environment (e.g., relations with parents and siblings) E Education and employment (e.g., school performance) A Activities (e.g., sports participation, after-school activities, peer relations) D Drug, alcohol, or tobacco use S Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses contraception) S Suicide risk or symptoms of depression or other mental disorder S “Savagery” (e.g., violence or abuse in home environment or in neighborhood) Assessment of older adults As we get older, our five senses (taste, touch, sight, hearing, and smell) and brain function begin to diminish, but the extent to which this affects each person varies. Your patient may be a spry and alert 80-year-old or a frail and confused 60-year-old; therefore, it is important not to stereotype older adults and expect them to be physically and/or mentally deficient. For example, the tendency may be to jump to the conclusion that someone who is hard of hearing is cognitively impaired. By the same token, many older adults often need special attention. The nurse needs to be aware of any physical limitations—any sensory condition (difficulty seeing or hearing), motor condition (difficulty walking or maintaining balance), or medical condition (back pain, cardiac or pulmonary deficits)—that could cause increased anxiety, stress, or physical discomfort for the patient during assessment of mental and emotional needs. It is wise to identify any physical deficits at the onset of the assessment and make accommodations for them. If the patient is hard of hearing, speak a little more slowly in clear, louder tones (but not too loud), and seat the patient close to you without invading his or her personal space. Often, a voice that is lower in pitch is easier for older adults to hear, although a higher-pitched voice may convey anxiety to some. Refer to Chapter 30 for more on assessing and communicating with the older adult. Language barriers It is becoming more and more apparent that psychiatric mental health nurses can best serve their patients if they have a thorough understanding of the complex cultural and social factors that influence health and illness. Awareness of individual cultural beliefs and health care practices can help nurses minimize stereotyped assumptions that can lead to ineffective care and interfere with the ability to evaluate care. There are many opportunities for misunderstandings when assessing a patient from a different cultural or social background from your own, particularly if the interview is conducted in English and the patient speaks a different language or a different form of English ( Fontes , 2008). Often health care professionals require a translator to understand the patient’s history and health care needs. There is a difference between an interpreter and a translator . An interpreter is more likely to unconsciously try to make sense of (interpret) what the patient is saying and therefore inserts his or her own understanding of the situation into the database. A professional translator, on the other hand, tries to avoid interpreting. DeAngelis (2010) strongly advises against the use of untrained interpreters such as family members, friends, and neighbors. These individuals might censor or omit certain content (e.g. profanity, psychotic thoughts, and sexual topics) due to fear or a desire to protect the patient. They can also make subjective interpretations based on their own feelings, share confidential details with outsiders, or leave out traumatic topics because they hit too close to home for them. For patients who do not speak English or have language difficulties, federal law mandates the use of a trained translator ( Arnold & Boggs, 2011). In fact, Poole and Higgo state that the “use of a trained translator is essential wherever the patient’s first language is not spoken English (even where the person has some English)” (2006, p. 135). A professionally trained translator is proficient in both English and the patient’s spoken language, maintains confidentiality, and follows specific guidelines. Unfortunately, professional translators are not always readily available in many health care facilities. Psychiatric mental health nursing assessment The purpose of the psychiatric mental health nursing assessment is to: •  Establish rapport •  Obtain an understanding of the current problem or chief complaint •  Review physical status and obtain baseline vital signs •  Assess for risk factors affecting the safety of the patient or others •  Perform a mental status examination •  Assess psychosocial status •  Identify mutual goals for treatment •  Formulate a plan of care Gathering data Review of systems. The mind-body connection is significant in the understanding and treatment of psychiatric disorders. A primary care provider also gives many patients who are admitted for treatment of psychiatric conditions a thorough physical examination. Likewise, most nursing assessments include a baseline set of vital statistics, a historical and current review of body systems, and a documentation of allergic responses. Poole and Higgo (2006) point out that several medical conditions and physical illnesses may mimic psychiatric illnesses ( Box 7-3 ); therefore, physical causes of symptoms must be ruled out. Conversely, psychiatric disorders can result in physical or somatic symptoms such as stomachaches, headaches, lethargy, insomnia, intense fatigue, and even pain. When depression is secondary to a known medical condition, it often goes unrecognized and thus untreated. All patients who come into the health care system need to have both a medical and mental health evaluation to ensure a correct diagnosis and appropriate care. BOX 7-3       SOME MEDICAL CONDITIONS THAT MAY MIMIC PSYCHIATRIC ILLNESS Depression Neurological disorders: •  Cerebrovascular accident (stroke) •  Alzheimer’s disease •  Brain tumor •  Huntington’s disease •  Epilepsy (seizure disorder) •  Multiple sclerosis •  Parkinson’s disease Infections: •  Mononucleosis •  Encephalitis •  Hepatitis •  Tertiary syphilis •  Human immunodeficiency virus (HIV) infection Endocrine disorders: •  Hypothyroidism and hyperthyroidism •  Cushing’s syndrome •  Addison’s disease •  Parathyroid disease Gastrointestinal disorders: •  Liver cirrhosis •  Pancreatitis Cardiovascular disorders: •  Hypoxia •  Congestive heart failure Respiratory disorders: •  Sleep apnea Nutritional disorders: •  Thiamine deficiency •  Protein deficiency •  B 12 deficiency •  B 6 deficiency •  Folate deficiency Collagen vascular diseases: •  Lupus erythematosus •  Rheumatoid arthritis Cancer Anxiety Neurological disorders: •  Alzheimer’s disease •  Brain tumor •  Stroke •  Huntington’s disease Infections: •  Encephalitis •  Meningitis •  Neurosyphilis •  Septicemia Endocrine disorders: •  Hypothyroidism and hyperthyroidism •  Hypoparathyroidism •  Hypoglycemia •  Pheochromocytoma •  Carcinoid Metabolic disorders: •  Low calcium •  Low potassium •  Acute intermittent porphyria •  Liver failure Cardiovascular disorders: •  Angina •  Congestive heart failure •  Pulmonary embolus Respiratory disorders: •  Pneumothorax •  Acute asthma •  Emphysema Drug effects: •  Stimulants •  Sedatives (withdrawal) Lead, mercury poisoning Psychosis Medical conditions: •  Temporal lobe epilepsy •  Migraine headaches •  Temporal arteritis •  Occipital tumors •  Narcolepsy •  Encephalitis •  Hypothyroidism •  Addison’s disease •  HIV infection Drug effects: •  Hallucinogens (e.g., LSD) •  Phencyclidine •  Alcohol withdrawal •  Stimulants •  Cocaine •  Corticosteroids Some people with certain physical conditions may be more prone to psychiatric disorders such as depression. It is believed, for example, that the disease process of multiple sclerosis or other autoimmune diseases may actually bring about depression. Other medical diseases typically associated with depression are coronary artery disease, diabetes, and stroke. A recent study demonstrated that women with both depression and diabetes have a significantly higher risk for mortality and cardiovascular disease than do women with either depression or diabetes alone ( Brauser & Barclay, 2011). Individuals need to be evaluated for any medical origins of their depression or anxiety. When evidence suggests the presence of mental confusion or organic mental disease, a mental status examination should be performed. Laboratory data. Hypothyroidism may have the clinical appearance of depression, and hyperthyroidism may appear to be a manic phase of bipolar disorder; a simple blood test can usually differentiate between depression and thyroid problems. Abnormal liver enzyme levels can explain irritability, depression, and lethargy. People who have chronic renal disease often suffer from the same symptoms when their blood urea nitrogen and electrolyte levels are abnormal. Results of a toxicology screen for the presence of either prescription or illegal drugs also may provide useful information. Mental status examination. Fundamental to the psychiatric mental health nursing assessment is a mental status examination (MSE) . In fact, an MSE is part of the assessment in all areas of medicine. The MSE in psychiatry is analogous to the physical examination in general medicine, and the purpose is to evaluate an individual’s current cognitive processes. For acutely disturbed patients, it is not unusual for the mental health clinician to administer MSEs every day. Sommers-Flanagan and Sommers-Flanagan (2009) advise anyone seeking employment in the medical–mental health field to be competent in communicating with other professionals via MSE reports. Box 7-4 is an example of a basic MSE. BOX 7-4       MENTAL STATUS EXAMINATION Appearance •  Grooming and dress •  Level of hygiene •  Pupil dilation or constriction •  Facial expression •  Height, weight, nutritional status •  Presence of body piercing or tattoos, scars, etc. •  Relationship between appearance and age Behavior •  Excessive or reduced body movements •  Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance, and gait) •  Abnormal movements (e.g., tardive dyskinesia, tremors) •  Level of eye contact (keep cultural differences in mind) Speech •  Rate: slow, rapid, normal •  Volume: loud, soft, normal •  Disturbances (e.g., articulation problems, slurring, stuttering, mumbling) •  Cluttering (e.g., rapid, disorganized, tongue-tied speech) Mood •  Affect: flat, bland, animated, angry, withdrawn, appropriate to context •  Mood: sad, labile, euphoric Disorders of the form of thought •  Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality) •  Thought content (e.g., delusions, obsessions) Perceptual disturbances •  Hallucinations (e.g., auditory, visual) •  Illusions

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Critical thinking as a new RN

Nurses General Nursing

Published Saturday

I recently started a job working in a hospital (will be off orientation in two shifts). And I feel like I'm lacking on critical thinking/judgement skills.

Back story: As a LPN, I worked for a little over a year on the same unit I am now. But 3 years ago, I left the hospital for school nursing. As a LPN in the hospital, my critical thinking/judgement skills were sharp (I had previously been in a RN program) and I frequently had staff request for me to stay on the unit rather then float and then them get a less experienced RN float/travel nurse. 

But when I left for school nursing, I didn't need those skills as much. Don't get me wrong, we do use critical thinking skills in school nursing but just not in the same way.

During my RN schooling (this time around), I voiced concern to my instructors about not being able to get my brain back into critical thinking. They all told me "don't worry, it will click.” 

Now I know I'm still on orientation but I feel like I should be further in the critical thinking/judgement skills than I am.  Suggestions? 

Thinking about mental health

Asu experts discuss stigmas, solutions for mental health awareness month.

Photo courtesy iStock/Getty Images

At its most basic level, mental health is related to how we think and feel. 

It is the intensity or disproportionate reaction of those thoughts and feelings that can determine our level of mental health. 

According to the Centers for Disease Control and Prevention, mental health includes our emotional, psychological and social well-being, and affects how we think, feel and act. It also helps determine how we handle stress, relate to others and make healthy choices.

“Our mental health becomes the filter through which we experience the world,” said Aaron Krasnow , associate vice president of health, counseling and wellness at Arizona State University. “It’s the filter for our relationships with others and determines our views of ourselves.”

Mental health resources at ASU

•  ASU Health Services

•  ASU Wellness

•  ASU Center for Mindfulness

•  ASU Employee Assistance Program

This May is Mental Health Awareness Month, which was established in 1949. The mission of the month is to increase awareness of the importance of mental health and wellness in our lives, and to educate the public about the reality of living with a mental health condition. 

According to the World Health Organization, mental health conditions involve significant disturbances in thinking, emotional regulation or behavior. The most common conditions in the U.S. are anxiety and depression, which make up nearly 30% of all mental illness diagnoses. 

Mental health diagnosis can also include illnesses such as bipolar disorder, post-traumatic stress disorder, eating disorders, disruptive behavior, dissocial and neurodevelopmental disorders. 

According to the Centers for Disease Control and Prevention, factors that can contribute to mental illness include adverse childhood experiences — such as trauma or a history of abuse — ongoing (chronic) medical conditions — such as a traumatic brain injury — biological factors or chemical imbalances in the brain.

Stigmas and misconceptions

But throughout history, mental illnesses has often been misunderstood. 

According to the National Alliance on Mental Illness, the pervasive stigma lies in the misconception that mental health conditions are a personal and moral failing — rather than illnesses requiring treatment, like any other health issue. 

Stigmas can be evident in the language often associated with mental illness: crazy, psycho, loony bin.

These attitudes can compound a person’s suffering and inner struggles, leading to shame and isolation. 

“Those who live with and treat mental illness know that stigma is a major contributing factor,” said Alexandra Brewis , a Regents and President's Professor in the  School of Human Evolution and Social Change . “The threat or experiences of being judged means people may be less willing to seek help and are more likely to discontinue treatment.

"The discriminations triggered by stigmas also make life more difficult in many other arenas, like being denied employment or safe and affordable housing. These then feed back into worse mental health. Without stigma, mental health is much easier to achieve and sustain.”

Stigma sticks like super glue. Once it is attached to a disease, it is incredibly difficult to remove because it requires substantial cultural changes. Alexandra Brewis Regents and President's Professor

A global issue

Nearly 58 million adults in the U.S. experienced a mental illness in 2021. According to the National Institute of Mental Health, that represents 1 in 5 adults. 

And COVID-19 only exacerbated the problem. 

The World Health Organization reported that the COVID-19 pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide. Megan Jehn says the pandemic was particularly hard on children.

“Epidemiologic data suggests that mental health issues are rising among kids, most likely being the result of a perfect storm of increasing challenges before COVID-19 struck and living through a highly disruptive pandemic,” said Jehn, an epidemiologist and professor of global health in the School of Human Evolution and Social Change.

A landmark study published during the pandemic found that 25.2% of youth experienced depression and 20.5% experienced anxiety during the pandemic worldwide, which is double that of pre-pandemic estimates, Jehn said.

The American Psychological Association described the pandemic as a "collective trauma" in their study “ Stress in America 2023: A Nation Recovering from Collective Trauma.”

The trauma was connected to the death of more than 1 million Americans and the cultural changes the pandemic ushered in. 

“It is actually a group-level vulnerability that may have exacerbated the day-to-day stressors,” said Leah Doane , a professor in ASU’s Department of Psychology.

Stopping the stigma

Despite this, stigmas may remain because society tends to separate themselves from people with mental health issues — which compounds the loneliness for those affected. 

“Part of the problem in our culture is we live in an extremely trauma- and grief-avoidance world…,” said Joanne Cacciatore , a professor at ASU’s School of Social Work whose research focuses on traumatic grief. 

Cacciatore explains that people have survived many individual and collective traumas throughout history, including the Holocaust. 

“They survived, but social support was essential. If we don’t have that, then suffering is even more debilitating. Loneliness and isolation are added to the traumatic grief experience,” said Cacciatore, who believes that the material covered in ASU’s  trauma and bereavement graduate certificate  is indispensable for mental health professionals. 

Last year, the U.S. Surgeon General Vivek Murthy put out a call to action over public health crisis of loneliness, isolation and lack of connection in our country. Even before the COVID-19 pandemic, nearly half of U.S. adults reported experiencing living with a significant level of loneliness.

“We need to remember that we all belong to one another,” said Nika Gueci , executive director of  ASU’s Center for Mindfulness, Compassion and Resilience . “We need to remember that we cannot live without one another right? So when we see someone in distress, then it’s really up to us to help.”

Gueci is working with the Arizona Department of Health Services on a statewide strategy to reduce loneliness and social isolation.

“It doesn’t always have to be up to them to pull themselves up. It's up to us to be there for them so that they can better be able to pull themselves up.”

The hope behind Mental Health Awareness Month is to uncover the stigmas and understand the struggles associated with those affected. And perhaps then, communities can become a source of comfort and healing for people.

Krasnow believes that as a society, the stigma around mental health seems to be subsiding — especially in younger generations. 

“They are more likely to share their mental health journey and more likely to be accepting of each other,” he said. “And there is evidence of that.”

But society has a long way to go before stereotypes can be completely set aside.

“Stigma sticks like super glue,” Brewis said. “Once it is attached to a disease, it is incredibly difficult to remove because it requires substantial cultural changes.”

Brewis is focused on finding solutions to complex global health challenges. Her current work is based on field research around several matters, including stigma. 

“Developing empathy is key,” Brewis said. “But that is a hard thing to teach and nurture. Interestingly, celebrities sharing their mental health struggles can move the needle and has proven to be one mechanism that can change public opinion. …

"When we start to connect a condition to someone we admire and look up to, it can foster empathy.”

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The Outcome-Present State Test Model of Clinical Reasoning to Promote Critical Thinking in Psychiatric Nursing Practice among Nursing Students: A Mixed Research Study

Affiliation.

• 1 Department of Nursing, Tzu Chi University, 701 Zhongyang Road, Section 3, Hualien 97004, Taiwan.
• PMID: 36833080
• PMCID: PMC9957117
• DOI: 10.3390/healthcare11040545

This study determined whether teaching intervention using the outcome-present state test (OPT) clinical reasoning model can effectively improve critical thinking in nursing students during a psychiatry internship. In addition, it evaluates the experiences of the students using this model in clinical practice.

Methods: In this interventional study, 19 students were taught critical thinking skills using the OPT clinical reasoning model during a psychiatry clinical practice. Work-learning forms were used in daily 1 h individual and group discussions with students. The critical thinking disposition scale was completed by every student before and after the intervention. Moreover, the students were asked to the complete reflection experience forms.

Results: The average critical thinking disposition pre-intervention score was 95.21, whereas the average post-intervention score was 97.05, indicating an increase of 1.84. There was a significant increase in the fourth dimension of open-mindedness (z = -2.80, p < 0.01). The learning experience has been likened to a process of clearing the fog, and it involves the use of limited known conditions, thinking outside the box, and adaptation to complex care issues.

Conclusion: Using the OPT clinical reasoning model as a teaching strategy during a psychiatric nursing internship significantly improved the open-mindedness dimension among the students. The student reflective experience of talking to teachers as peers helped students identify clues and reframe problems related to clinical care. Additionally, the students reported that this led to more harmonious interactions with their teachers.

Keywords: critical thinking; mixed study; outcome-present state test model.

Grants and funding

• PMN1100565/Taiwan Ministry of Education

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Teaching Strategies in Psychiatric Nursing Based on Bloom’s Taxonomy of Educational Objectives

1 Educational Management, Angeles University Foundation, Angeles, PHL

Jesse M Balinas

Bloom’s Taxonomy of Educational Objective (BTEO), as a classic method for categorizing educational objectives, provides a clear and specific framework for formulating teaching goals in the global education field. Psychiatric nursing, as a highly specialized discipline, demands high requirements for students in both theoretical knowledge and practical skills. However, traditional teaching methods often focus excessively on knowledge impartation, neglecting the cultivation of students’ practical abilities and emotional attitudes. Therefore, the purpose of this study was to Improve the existing psychiatric nursing curriculum by combining Bloom's educational goals theory, which emphasizes the comprehensive development of cognitive, affective, and psychomotor skills, providing new perspectives and methods for psychiatric nursing education. By applying BTEO, specific teaching goals at different levels can be defined more clearly, and corresponding teaching strategies and methods can be employed to achieve these goals. Furthermore, the application of BTEO requires effective interaction between teachers and students. Teachers need to monitor students’ learning progress, adjust teaching strategies promptly, and ensure that students comprehensively grasp knowledge and skills. Thus, the application of this teaching strategy contributes to improving the quality of psychiatric nursing education and cultivating outstanding psychiatric nursing professionals. We hope to cultivate students' theoretical knowledge and practical skills in mental care by helping them develop their overall skills.

Introduction

The origin of Bloom’s Taxonomy of Educational Objectives (BTEO) can be traced back to the 1950s during the educational reform movement in the United States. At that time, dissatisfaction with traditional teaching methods arose in the United States education sector, with a belief that these methods overly emphasized memorization and standardized testing, neglecting the cultivation of students’ thinking and innovation abilities [ 1 , 2 ]. Concurrently, societal expectations for education were continuously rising, aiming for education to better meet the individual and societal developmental needs of students.

In this context, Benjamin Bloom and his colleagues dedicated themselves to developing a new set of educational objectives and a classification method. They argued that to enhance students’ thinking abilities, it was crucial to clearly define educational goals and categorize them. Therefore, based on the study and understanding of human cognitive processes, they proposed an educational objective classification method that encompassed cognitive, affective, and psychomotor domains. The cognitive domain’s hierarchical levels range from lower to higher, including knowledge, comprehension, application, analysis, synthesis, and evaluation[ 1 ]. These levels focus on students’ varying levels of understanding and application of knowledge, progressing from recalling facts to making value judgments and evaluations at the highest level. The affective domain’s levels focus on students’ emotional experiences and the formation of values, starting from acceptance and gradually developing into personalized levels within a value system [ 3 ].

The goals of the psychomotor domain are to help students master necessary skills and actions, enabling them to apply them proficiently in practical situations. This classification method gained widespread promotion and application in the United States, exerting a profound global impact not only on education but also on other fields such as psychology, training, and human resources development [ 4 , 5 ]. The purpose of this study was to integrate Bloom's educational goal theory into psychiatric nursing education and explore how to cultivate nursing students into psychiatric nurses who meet clinical needs in the areas of knowledge, emotion, and motor skills.

Technical report

The classification of educational objectives covering cognitive, emotional, and psychomotor fields is shown in Table ​ Table1 1 .

Application strategies of BTEO in psychiatric nursing teaching

In psychiatric nursing, developing practical operational abilities is crucial for effectively managing patient care. By categorizing these abilities according to BTEO, we can ensure a comprehensive and structured approach to learning and skill development.

Categorization of Abilities

These abilities are categorized accordingly as follows.

Remembering: This includes recalling the signs and symptoms of common psychiatric disorders and memorizing the basic principles of patient confidentiality and privacy

Understanding: This includes explaining the therapeutic effects and potential side effects of commonly used psychiatric medications and interpreting patients' verbal and non-verbal communication cues

Applying: This includes applying de-escalation techniques to manage patients exhibiting aggressive behavior and utilizing therapeutic communication skills in patient interactions

Analyzing: This includes analyzing case studies to identify the underlying psychiatric conditions and differentiating between symptoms of various psychiatric disorders

Evaluating: This includes assessing the effectiveness of nursing interventions in improving patient outcomes and evaluating the appropriateness of care plans based on patient progress

Creating: This includes developing individualized care plans tailored to meet the unique needs of psychiatric patients and innovating new strategies for engaging patients in therapeutic activities [ 6 ].

By targeting these specific operational abilities within the framework of BTEO, psychiatric nursing education can equip nurses with the necessary skills to provide high-quality, patient-centered care in a mental health setting. This structured approach not only enhances learning but also ensures that nurses are prepared to address the complex needs of psychiatric patients effectively.

Clarifying Educational Goals

In psychiatric nursing education, the formulation of educational goals is a crucial step [ 7 ]. Following BTEO, teachers need to establish clear educational goals based on students’ actual situations and subject requirements, assisting students in mastering the necessary knowledge and skills [ 8 - 10 ]. Firstly, in the cognitive domain, educational goals aim to cultivate students’ thinking abilities and problem-solving skills [ 11 ]. In psychiatric nursing, students need to grasp basic concepts, theories, and methods, understanding and applying relevant knowledge. Teachers can use methods such as lectures, case analyses, and group discussions to help students gain an in-depth understanding of the psychiatric nursing knowledge system, fostering critical thinking and problem-solving skills. Secondly, in the affective domain, educational goals aim to cultivate students’ emotional attitudes and values [ 12 ]. In psychiatric nursing, students need to possess attitudes of empathy, care, and respect, understanding and empathizing with patients’ needs and feelings. Teachers can employ methods like role-playing [ 13 ], simulation training [ 14 ], and practical operations to allow students to experience patients’ emotions and needs firsthand [ 15 ], developing their emotional attitudes and values. Thirdly, in the psychomotor domain, educational goals aim to develop students’ practical operational abilities and technical proficiency. In psychiatric nursing, students need to master various nursing skills and methods, applying them proficiently in practical situations. Teachers can use methods such as practical operations, simulation training, and clinical internships to help students practice and master various nursing skills and methods, enhancing their technical proficiency and practical operational abilities. By clarifying educational goals, teachers can better guide students’ learning and development, cultivating psychiatric nursing professionals with good comprehensive qualities and practical abilities.

Enhancing Teaching Methods

The learning of theoretical knowledge is the first and most important stage of all achievable learning. It is crucial to help students establish learning habits and learn the ability to think independently. Therefore, we should use case discussion methods to increase students' interest in learning and independent thinking ability, group discussion methods to stimulate students' interest in learning, and role-playing methods to help students achieve empathy with patients

In psychiatric nursing education, the improvement of teaching methods is indispensable. BTEO emphasizes students’ active learning, advocating the use of various effective teaching methods, and providing teachers with new insights and directions [ 1 ]. To assist students in reaching higher cognitive levels, teachers need to continuously explore and innovate teaching methods, as illustrated in Table ​ Table2. 2 . Firstly, case analysis is an exceptionally effective teaching method. By introducing authentic patient cases, teachers can guide students in analyzing the characteristics and issues within the cases, encouraging them to think and solve problems in specific contexts. This not only helps students better understand theoretical knowledge but also cultivates their clinical thinking and problem-solving abilities. Secondly, group discussions are also a method worth promoting. By grouping students for discussions, teachers can stimulate their interest and initiative in learning, promoting communication and cooperation. In group discussions, students can freely express their opinions, share experiences, and think about problems from different perspectives, thus fostering critical thinking and a spirit of cooperation[ 11 ]. Thirdly, role-playing is a vivid teaching method. By having students simulate different roles, teachers can allow them to experience the emotions and needs of patients firsthand, cultivating empathy and a caring attitude. Additionally, role-playing helps students better understand professional roles and responsibilities, enhancing their professional qualities and practical abilities. Beyond the mentioned teaching methods, teachers can explore more effective methods based on the actual situation. For example, teachers can utilize information technology for online teaching, multimedia teaching, etc., providing students with a more diverse range of learning resources and means, enhancing their learning effectiveness and comprehensive qualities.

Assessing Learning Outcomes

Assessing learning outcomes is an important aspect of the teaching process. It is helpful to understand students' learning situation, find out the problems in teaching, and provide a basis for improving teaching methods and adjusting teaching objectives. Using BTEO can help teachers evaluate students' learning outcomes comprehensively and objectively. On the one hand, teachers need to observe students' performance in teaching activities and pay attention to students' participation and contribution in group discussions, role-playing, case studies, practical exercises, and other activities. By observing students' interactions, discussions, and thought processes, teachers grasp students' ability to understand and apply psychiatric nursing. For example, the assessment of whether students actively participate in discussions, elaborate views, analyze cases, propose reasonable nursing plans, skilled use of nursing technology, and operational skills. These observations help teachers determine whether students are meeting expected learning goals. On the other hand, teachers can test students' mastery of knowledge, skills, and abilities through tests and assessments. Tests may include written tests, practical assessments, and other forms to see how well students remember and understand theoretical knowledge and how proficient they are in applying their skills in practical exercises. Evaluation can adopt self-evaluation, mutual evaluation, teacher evaluation, and other ways to encourage students to participate in the evaluation process, so as to enhance students' self-reflection and critical thinking ability. At the same time, the evaluation results can be used as the basis for improving teaching methods and adjusting teaching objectives, and help teachers to strengthen teaching activities and improve teaching effects.

This article integrates BTEO into the teaching of psychiatric nursing, aiming to cultivate clinical nurses with high-quality nursing skills suitable for modern clinical needs by enhancing students' cognition, learning interests, and motor skills. This teaching reform is still in its early stages in China. If successfully implemented, we plan to apply Bloom's theory to more nursing higher education courses.

Based on BTEO, we help students learn and master important knowledge and skills progressively according to the difficulty of the knowledge points, thereby deepening their understanding. Moreover, continuous feedback and adjustment play a crucial role in enhancing teaching effectiveness. By assessing students' learning outcomes, teachers can gather valuable feedback to guide students more effectively and adjust teaching methods and strategies accordingly[ 16 - 18 ]. To achieve this, teachers need to provide specific feedback based on assessment results. For students who have met the expected objectives, teachers should offer affirmation and encouragement to stimulate their motivation to learn. Conversely, for those who haven't met the expected objectives, teachers need to identify areas for improvement and provide constructive suggestions. Simultaneously, teachers can guide students in self-reflection, helping them identify their challenges and find methods for improvement. Additionally, teachers must promptly adjust teaching methods and strategies based on students' feedback and performance. If certain aspects of student learning outcomes are below expectations, teachers should conduct a thorough analysis of the reasons and modify teaching strategies accordingly. For instance, if students exhibit insufficient mastery of theoretical knowledge, teachers can enhance theoretical instruction by increasing classroom explanations and post-class reviews. If students' practical skills are lacking, teachers can increase the focus on practical training.

Conclusions

In the teaching of psychiatric nursing, BTEO provides a valuable opportunity for instructors to better design courses and teaching methods, aiming to comprehensively cultivate students. In the cognitive domain, teachers can employ methods such as case analysis and group discussions to help students deepen their understanding of theoretical knowledge in psychiatric nursing. This fosters critical thinking and problem-solving skills. In the affective domain, teachers can guide students through reflection and discussions to cultivate the correct emotional attitudes and values, better preparing them for the demands of psychiatric nursing work. In the psychomotor domain, teachers can use practical exercises and simulation training to develop students’ practical skills and their ability to handle emergency situations.

Therefore, the instructional strategy in psychiatric nursing education based on BTEO is a comprehensive and systematic teaching approach. Through a holistic development of cognitive, affective, and psychomotor skills, it aids students in mastering both the theoretical knowledge and practical skills of psychiatric nursing. Simultaneously, it cultivates the right emotional attitudes and values. Over time, this approach contributes to the continuous improvement of the quality of psychiatric nursing education, nurturing a diverse pool of talents for societal development.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Zheng Jia, Jesse M. Balinas

Acquisition, analysis, or interpretation of data:   Zheng Jia

Drafting of the manuscript:   Zheng Jia

Critical review of the manuscript for important intellectual content:   Zheng Jia, Jesse M. Balinas

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Is rapidly expanding psych hospital chain a 'disaster waiting to happen?'

Tracy Valdez frantically called NeuroPsychiatric Hospital of Indianapolis for four days to find out if her adult son, who is deaf and suffers from bipolar disorder and schizophrenia, had been admitted. He was transferred to the hospital more than 250 miles from their Lansing, Michigan, home despite her objections.

"I was heartbroken. I was crying every day, every night, thinking: What is my son going through?" she said.

One week later, Valdez found out he had been prescribed medication even though he couldn't understand what was going on without a sign language interpreter. Valdez says her son's seven-day stay at the northwest Indianapolis hospital traumatized him so much he's been refusing to get much-needed care, in fear of being transferred again.

NeuroPsychiatric Hospital of Indianapolis has been the target of complaints from families and workers in recent years as the company expands its footprint in Indiana and other states. The privately owned hospital chain, which has seven sites and another under construction, has been financed by a private equity firm since 2020. Its expansion, some fear, has come at the expense of both employees and patients.

Psychiatric facilities like NeuroPsychiatric Hospital of Indianapolis take some of the region's most vulnerable patients — patients who often must travel some distance because inpatient psychiatric beds in their areas are not available. Some may be in mental crisis, some may become violent and some may need specialized one-on-one attention.

Prompt communication with family and sufficient trained staff to de-escalate conflict should be the standard, said Don Parker, the president of the National Association of Behavioral Healthcare.

And if these best practices are not followed, patients and their families can be at risk.

JoAnne Glick, an Elkhart resident, said she also struggled to get information about her husband when he was admitted because he was a danger to himself. After two weeks, she went to pick him up, expecting a discharge discussion about how to take care of him. That never happened, she said.

He's been to another hospital in Elkhart since leaving the Indianapolis facility, she said. And the contrast was stark.

"I can talk to the nurses. I can call up there. He can call me. I talked to his psychiatrist several times," she said.

Patient attacked staff

Patients and their families aren't the only ones concerned about practices at NeuroPsychiatric Hospital. Staff members say low staff-to-patient ratios can frequently lead to problems. "We are grossly understaffed," said Peter Moore, a registered nurse. "It really is a disaster waiting to happen in a lot of ways."

He said he's witnessed one nurse tasked with caring for 20 patients. Moore said the challenge increases when patients require one-on-one attention, thinning out the staff further.

On March 8 police and other emergency responders were called to the NeuroPsychiatric Hospital because a patient assaulted several health workers. Multiple employees and the patient required medical attention, according to a 911 call recording. That month police were called to the hospital 10 times and fire and EMS were called another 10 times, according to Metropolitan Emergency Services Agency. In April, police were called to the facility once and fire and EMS were called 22 times. EMS are typically called for medical issues while police are called to assist with disturbances, altercations or suspected crime.

Moore and another employee told the IndyStar they have not seen security guards at the hospital over the last year, further putting employees at risk.

The second employee, who did not share her name for fear of retaliation from the company, said she would like to see the hospital stop taking high-needs and violent patients if it doesn't have sufficient resources to care for them.

"The problem is just the severity of the patients that they are getting. If you don't have the support or the staff for those types of violent patients, don't take them," she said.

The hospital chain declined to comment for this story.

Violent outbursts

The March 8 incident was not the first time police responded to calls from the 50-bed hospital. Police were called to the location 10 times in March to investigate crimes, disturbances or to assist EMS, according to the Marion County Metropolitan Emergency Services Agency.

Parker, who ran a psychiatric hospital in New Jersey before taking on an advocacy role early this year, declined to comment about specifics at NeuroPsychiatric Hospital. However, he said his facility rarely resorted to calling police. That facility's staffing, which is reviewed by New Jersey officials, required a ratio of one employee to two to three patients.

"We just don't call on the police to handle those things," Parker said. "We know how to manage them and manage them effectively."

Private equity concerns

While providing quality mental health care has long posed a challenge, a new actor in the industry may be putting additional pressure on facilities like the NeuroPsychiatric Hospital.Across the country, patient advocates have raised alarms about the growing influence of private equity in health care because the aggressive profit-seeking business model can result in poor quality of care and cost cutting. About 8% of all private hospitals, including the NeuroPsychiatric Hospital chain, are owned by private equity and nearly a quarter of private-equity hospitals are psychiatric hospitals, according to the Private Equity Stakeholder Project, a nonprofit that tracks private equity investment in health care.

Morgan Shields, a researcher at Washington University in St. Louis, found that private equity-owned and backed hospitals were associated with lower staffing.

Since the private equity firm Enhanced Healthcare Partners invested in the NeuroPsychiatric Hospital in 2020, the chain has grown from four locations in Indiana to a total of seven hospitals, including sites in Texas and Arizona. The chain plans to open another site in Michigan soon, according to its website.

In 2021, NeuroPsychiatric Hospital and Enhanced Healthcare Partners took a loan of $15 million from another investment company, Capital Southwest Corp.

Enhanced Healthcare Partners didn't respond to a request for comment.

Indiana legislators are also concerned about the rise of private equity in health care. In March, lawmakers passed a law that required health care organizations and private equity firms to report mergers and deals such as the one between Enhanced Healthcare and NeuroPsychiatric Hospital to the Indiana Attorney General's Office.

While the outcomes of private equity investments in health care may differ depending on the company, the typical trajectory is that the investment companies increase cash flow through taking loans, cutting staff or hiring at lower pay, said Eileen O'Grady, a research and campaign director for the Private Equity Stakeholder Project.

Parker, a spokesperson for the industry, isn't worried. It's not about the nonprofit, for-profit or private equity ownership, he said, but rather the oversight and regulations that hold psychiatric care to quality and safety standards.

Past issues

Indiana's oversight of the hospital, through its inspections, has yielded more red flags.

The state has investigated eight complaints regarding the Indianapolis hospital in the last five years. Failures to follow health care law and maintain records are problems that plague the psychiatric health care industry as a whole. And complaints to regulatory bodies about health care facilities, especially psychiatric hospitals, are common.

The facility has had no complaints in the past year. But a complaint-related inspection in March 8, 2023, revealed problems. The hospital didn't ensure nurses provided wound care, including dressing changes, for a patient on four occasions, according to a review of records. The inspector also found staff didn't keep records of lab work in patient files.

In 2020 an inspector found that management did not tell staff which patients were at risk of assaulting others, didn't prevent abuse of patients in one unit and failed to show that one-on-one care was provided for a patient that needed it. The inspection took place about two months before the private equity investment was announced and as the company expanded into Arizona.

Employees look for higher staffing standards

Nurses and behavioral health workers launched a union drive earlier this year, a move that Moore hoped would fix some of the problems. They were unsuccessful during the mid-April election but Moore said they are challenging the results.

Leslie Moore, who's married to Peter Moore, left the hospital after three months because her role as a behavioral health aide at the psychiatric hospital became so overwhelming.

"Sometimes you don't have the appropriate backup when you need it the most," she said.

Peter Moore said many staff members, including middle management, are doing their best with limited resources.

"The director of nursing who supervises us is a wonderful person," he said. "She's just constrained by a system that dooms us to failure."

Binghui Huang can be reached at 317-385-1595 or [email protected] .