The Relationship Between Evidence-Based Practices and Emergency Department Managers Perceptions on Quality of Care for Self-Harm Patients ? Practicing Healthcare Professionals E

https://doi.org/10.1177/1078390319889673

Journal of the American Psychiatric Nurses Association 2020, Vol. 26(3) 288 –292 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1078390319889673 journals.sagepub.com/home/jap

Brief Report

Introduction

More than 45,000 Americans over age 10 years died by suicide in 2016, making it the 10th leading cause of death in the United States (Centers for Disease Control and Prevention, 2018). Among adults who complete suicide, in the year prior to their death, approximately 20% to 25% have an emergency department (ED) visit for delib- erate self-harm (Ahmedani et al., 2014; Ahmedani et al., 2015) and associated suicidality (hereafter referred to as DSH), which can include nonsuicidal self-injury. Because EDs are providing front-line suicide prevention services, improving the overall quality of ED mental health care for patients who present with DSH represents an opportu- nity to intervene with these high-risk patients. While pre- vious studies have attempted to determine the quality of care in EDs for DSH patients, the literature is lacking in recent, U.S.-based research.

ED nursing managers were surveyed because of their broad knowledge of typical unit policies, practices, and

staffing structure. In addition to providing management of frontline nurses, they also oversee the organizational structure of nursing treatment for DSH patients and are therefore well-positioned to shape the processes of care for these patients. Essential to improving this process is understanding the aspects of care that managers perceive as important to providing quality care, as well as the extent to which evidence-based practices (EBPs) have translated

889673 JAPXXX10.1177/1078390319889673Journal of the American Psychiatric Nurses AssociationDiana et al. research-article2019

1Amaya H. Diana, The University of Pennsylvania, Philadelphia, PA, USA 2Mark Olfson, MD, MPH, Columbia University, New York, NY, USA 3Sara Wiesel Cullen, PhD, MSW, The University of Pennsylvania, Philadelphia, PA, USA 4Steven C. Marcus, PhD, The University of Pennsylvania, Philadelphia, PA, USA

Corresponding Author: Sara Wiesel Cullen, School of Social Policy and Practice, the University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA 19104- 6243, USA. Email: [email protected]

The Relationship Between Evidence-Based Practices and Emergency Department Managers’ Perceptions on Quality of Care for Self-Harm Patients

Amaya H. Diana1, Mark Olfson2, Sara Wiesel Cullen3 , and Steven C. Marcus4

Abstract OBJECTIVE: To understand the extent to which implementation of evidence-based practices affects emergency department (ED) nurse managers’ perceptions of quality of care provided to deliberate self-harm patients. METHODS: ED nursing leadership from a nationally representative sample of 513 hospitals completed a survey on the ED management of deliberate self-harm patients, including the quality of care for deliberate self-harm patients on a 1 to 5 point Likert-type scale. Unadjusted and adjusted analyses, controlling for relevant hospital characteristics, examined associations between the provision of evidence-based practices and quality of care. RESULTS: The overall mean quality rating was 3.09. Adjusted quality ratings were higher for EDs that routinely engaged in discharge planning (β = 0.488) and safety planning (β = 0.736) processes. Ratings were also higher for hospitals with higher levels of mental health staff (β = 0.368) and for teaching hospitals (β = 0.319). CONCLUSION: Preliminary findings suggest a national institutional readiness for further implementation of evidence-based practices for deliberate self- harm patients.

Keywords emergency department, deliberate self-harm, suicide prevention, evidence-based practices, quality of care

Check for Updates

Diana et al. 289

to the ED. For instance, after a DSH event, the provision of appropriate assessment and safety planning reduces risk for repeat DSH and suicide attempts (Boudreaux et al., 2016; Stanley et al., 2018). Safety planning is a brief behavioral intervention that can be performed by nurses in the ED that involves restricting access to lethal means, teaching coping skills, identifying a social and emergency network, and building motivation for con- tinuing mental health treatment (Stanley et al., 2018). Despite the evidence supporting the efficacy of assess- ment and safety planning, it remains unknown how often these strategies are actually employed in EDs or the extent to which they improve the quality of care for DSH patients.

In order to assess the gap between research and prac- tice in this area, a national survey of over 500 ED manag- ers collected data on the extent to which EDs provide assessments, the elements of safety planning practices identified above, and mental health referrals on discharge. We then examined the extent to which implementation of these practices influenced ED nurse managers’ percep- tions of the quality of care provided to DSH patients.

Methods

Between May 2017 and January 2018, we mailed an ED management of DSH survey to a random sample of 665 ED managers at hospitals with ≥5 self-harm visits in the prior year, as identified by national Medicaid claims data (Bridge et al., 2019). Deliberate self-harm was defined as an act of nonfatal self-poisoning or self-injury with or without suicidal intent (ICD-9: E950-E959). Although the survey was typically sent to ED nursing managers or directors, in some cases it was completed and returned by other hospital staff. Respondents were offered a $100 gift card in return for answering the survey, provided their hospital policy allowed for the acceptance of gifts. The response rate was 77.1% (n = 513). Voluntary com- pletion of the survey constituted implied consent. The study was approved by the University of Pennsylvania Institutional Review Board.

The survey included components of two evidence-based interventions: The Patient Safety Screener (Boudreaux et al., 2016) and the Safety Planning Intervention, desig- nated as a best practice by the Suicide Prevention Resource Center and American Foundation for Suicide Prevention (Stanley & Brown, 2012). Ten questions were used to understand how frequently each of these EBPs was used: “Never or rarely,” “Sometimes,” “Usually but not routinely,” and “On a routine basis.” These values were assigned a numeric scale of 0 to 3, with the possibil- ity of another 0.5 added if the respondent reported use of a standardized template for the item in question (yes/no response). We created three subscales to assess the

frequency with which “assessment” (3 questions), “safety planning” (6 questions), and “discharge planning” (1 ques- tion) were routinely provided to ED DSH patients. All of the assessment and discharge planning scores were dichot- omized to represent the routine presence or absence of the practice using a cut-point of 2.5. For safety planning, scores were dichotomized using a cut-point of 2.0 since these (six) questions did not ask about the presence of a template. For all of the items, cut scores were set in order to delineate whether an ED was implementing a practice more often than not. The dependent variable of perceived quality of care was determined by a question that asked directors to “rate the overall quality of mental health care provided in your ED to DSH patients” given the options “poor,” “fair,” “good,” “very good,” and “excellent.” Perception of quality of care values were also assigned a scale of 1 to 5, with perception referring to the relatively subjective nature of the ratings.

Hospital Covariates

Given the research on perceived quality of care, mental health staffing levels were also included as a covariate (Innes, Morphet, O’Brien, & Munro, 2014). The survey asked about the availability of mental health profession- als during various times—standard business hours, after standard business hours, on weekends, or not at all. EDs were considered “highly staffed” if they had either (a) mental health staff (adolescent and adult psychiatrists, psychologists, and psychiatric nurses) during and after standard weekday hours and on weekends or (b) a social worker during and after standard weekday hours and on weekends with a mental health staff member available at any of these times. Other structural characteristics were determined by linking survey data to the AHA hos- pital dataset and included hospital teaching status, urbanity (urban or rural), and hospital volume deter- mined by dividing the survey responses to annual cen- sus into quartiles, with the mid-sized hospitals being the 25th to 75th percentiles (23,000 to 64,000; American Hospital Association, n.d.).

Analysis

A linear regression examined associations between the overall presence of the EBPs as independent variables and perceived quality of mental health care to DSH patients as the dependent variable, controlling for staffing status, hospital teaching status, size, and location. Survey weights were used to accommodate the sampling design that selected hospitals with probability proportional to their DSH patient volume and to produce representative estimates of the 2,228 EDs (weighted N) from which the random survey sample was drawn. All statistical analyses

290 Journal of the American Psychiatric Nurses Association 26(3)

were conducted using SAS 9.4 (Cary, NC). Prior to com- mencing the study, a rigorous power analysis was con- ducted revealing that with our selected sample, we have 80% power with two-tailed test (α = .05) to detect effect sizes of Cohen’s d = 0.31.

Results

Nursing leadership contributed to the majority (78.4%) of the completed surveys; 59.8% of surveys were completed by only ED nursing directors or managers (n = 285) and 21.2% of surveys were completed by more than one indi- vidual in the ED (e.g., nursing director and social worker; of these, 88 of the 96 included nursing leadership). The remaining surveys were completed by ED medical direc- tors (1.7%, n = 8); social workers (3.1%, n = 15); “oth- ers,” such as RNs or behavioral health directors (8.6%, n = 41); and 6.5% of respondents did not indicate their position (n = 31).

There was a broad distribution of characteristics of hospitals, in volume (26.5% low, 48.3% medium, and 23.5% high), urbanity (75.7% urban, 24.3% rural), teach- ing status (42.1% teaching, 57.9% nonteaching), and level of staffing (58.3% high staffed, 41.7% not high staffed). Frequency of routine provision of the examined EBPs was 69.1% for self-harm/suicide assessment, 50.1% for dis- charge planning care, and 46.0% for safety planning.

Approximately 8.5% of the ED directors rated the qual- ity of their mental health care for DSH patients as “Poor,” 26.6% as “Fair,” 22.3% as “Good,” 33.0% as “Very Good,” and 9.6% as “Excellent,” for an overall mean quality rating of 3.09 (confidence interval = 2.96, 3.21). The unadjusted quality rating differed between routine and not-routine provision of discharge planning (3.45 vs. 2.72, p < .0001), self-harm assessment (3.17 vs. 2.88, p = .0470), and safety planning (3.45 vs. 2.72, p < .0001). The rating also dif- fered between places with high and low mental health staffing levels (3.31 vs. 2.77, p < .0001) and teaching and nonteaching hospitals (3.31 vs. 2.92, p = .0025).

After controlling for hospital covariates, EDs that practiced routine discharge planning and safety planning were found to have a significantly higher quality rating (β = .488 and β = .736, respectively). High ED staffing levels and teaching status were also associated with higher quality ratings (β = .368, β = .319). In order to ensure that high mental health staffing levels were not driving the results, a sensitivity analysis was conducted. Excluding staffing levels did not change the original find- ings (Table 1).

Discussion

As compared with EDs that do not provide routine discharge planning and safety planning for DSH patients, EDs that

routinely provide these services received significantly higher quality of care ratings from ED nursing leadership. More mental health staff support was also directly related to quality of mental health care ratings. However, routine assessment of DSH patients was not related to the quality of care ratings.

Given that higher levels of ED mental health staff and routine safety practices were associated with perceived quality of care suggests that ED leadership is well posi- tioned to lead efforts to implement EBPs in the emer- gency mental health management of DSH patients. Unfortunately, many hospitals lack dedicated mental health staff in their EDs (Bridge et al., 2019) and hiring additional professionals may be cost prohibitive. Thus, future research should focus on ways to institutionalize staff training (including non–mental health staff) in safety planning and formalize linkages with outpatient services to ensure continuity of care, which together could improve the ED care for DSH patients while likely posing a lower burden on limited ED resources. In addition, drawing on techniques from implementation science

Table 1. Associations Between Selected Evidence-Based Mental Health Practices and Quality Rating by Emergency Department Directors (n = 513).

Safety practices Unadjusted

mean p value Beta

Overall 3.09 — Mental health discharge

planning <.0001

Routinely (50.1%) 3.45 +0.488* Not routinely (43.8%) 2.72 Ref Self-harm assessment .0470 Routinely (69.1%) 3.17 +0.051 Not routinely (30.3%) 2.88 Ref Safety planning practices <.0001 Routinely (46.0%) 3.62 +0.736* Not routinely (54.0%) 2.64 Ref ED mental health staffing

level <.0001

High staff 3.31 +0.368* Low staff 2.77 Ref Hospital location .8017 Rural 3.11 +0.129 Urban 3.07 Ref Hospital teaching status .0025 Teaching 3.31 +0.319* Nonteaching 2.92 Ref Hospital volume .4661 High 3.19 −0.218 Medium 3.09 −0.132 Low 2.97 Ref

Note. ED = emergency department. *Significant at .05 level. Quality was rated on a 5-point scale.

Diana et al. 291

(Williams, Glisson, Hemmelgarn, & Green, 2017) could provide an opportunity to engage leaders on incorporat- ing these EBPs into practice at all EDs, with an eye toward customizing interventions that meet the specific needs of various types of hospitals, including underre- sourced and/or rural hospitals.

The findings offer an optimistic message that ED staff may be receptive to these strategies. There is always a con- cern that there may be a disconnect between research- based recommendations and the opinions of on-the-ground staff, but the fact that ED nurse managers reported that these evidence-supported practices were linked to favor- able views of the quality of care for DSH patients is prom- ising (Betz et al., 2013). Thus, nursing leaders may be well-poised to incorporate and teach EBPs to staff nurses and other ED staff using publicly available resources on assessment and safety planning, such as the recent National Association of State Mental Health Program Directors webinar on implementing safety planning1 or the Suicide Prevention Resource Center’s Patient Safety Screener validated assessment tool.2 These types of strat- egies which are available at little to no cost could be adopted by clinical staff even at the smallest, most rural, or resource-strained hospitals.

The study is limited in that despite a fairly high response rate (77.1%), there may nevertheless be nonre- sponse bias. While it may be considered a limitation that the study relied on self-report data, along with some sub- jective questions raising the possibility of response bias, this information also helps illuminate perceptions of ED leadership on the current quality of care provided for DSH patients. We also acknowledge that these findings are measuring perceptions (self-report) of the quality of the process rather than direct patient outcomes. Next, although survey development did not include formal item reliability testing, earlier versions were pilot tested with 22 respondents to improve item clarity. Finally, while responses were predominantly from nursing leadership whose perspective may differ from frontline nurses, they were targeted due to their knowledge and management of typical unit policies and practices.

ED managers are well positioned to influence and shape the processes of care that conform to their ideals of quality. These preliminary findings are promising in that they suggest that ED leaders are aware of the need for these changes. They also suggest that there may be a national institutional readiness for further implementa- tion of EBPs for deliberate self-harm patients.

Author Roles

MO and SCM designed the study and obtained funding. AD, SWC, and SCM were responsible for acquiring data. AD per- formed the statistical design and drafted the article. All authors participated in the revision process.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of inter- est with respect to the research, authorship, and/or publication of this article: Dr. Marcus reports receipt of consulting fees from Allergan, Alkermes, Johnson & Johnson, Sage, and Sunovion. No other disclosures were reported by other authors of the article.

Funding

The author(s) disclosed receipt of the following financial sup- port for the research, authorship, and/or publication of this arti- cle: This research was supported by Grant R01-MH107452 from the National Institute of Mental Health (NIMH), National Institutes of Health (Marcus, Olfson, Multi-PIs).

ORCID iD

Sara Wiesel Cullen https://orcid.org/0000-0002-7846-5727

Notes

1. http://www.nasmhpd.org/sites/default/files/SAMHSA%20 SPI%20SMI%20PPT%20final_2.pdf

2. https://www.sprc.org/micro-learning/patientsafetyscreener

References

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American Hospital Association. (n.d.). The AHA annual survey database. Chicago, IL: Author.

Betz, M. E., Miller, M., Barber, C., Miller, I., Sullivan, A. F., Camargo, C. A, Jr., & Boudreaux, E. D. (2013). Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety, 30, 1013-1020.

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References Saunders, H., Gallagher-Ford, L., Kvist, T., & Vehvilainen-Julkunen, K. (2019). Practicing Healthcare

Professionals’ Evidence-Based Practice Competencies: An Overview of Systematic Reviews. Worldviews on Evidence-Based Nursing, 16(3), 176. https://doi.org/10.1111/wvn.12363

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Practicing Healthcare Professionals' Evidence‐Based Practice Competencies: An Overview of Systematic Reviews Background: Evidence‐based practice (EBP) competencies are essential for all practicing healthcare professionals to provide evidence‐based, quality care, and improved patient outcomes. The multistep EBP implementation process requires multifaceted competencies to successfully integrate best evidence into daily healthcare delivery. Aims: To summarize and synthesize the current research literature on practicing health professionals' EBP competencies (i.e., their knowledge, skills, attitudes, beliefs, and implementation) related to employing EBP in clinical decision‐making. Design: An overview of systematic reviews. Methods: PubMed/MEDLINE, CINAHL, Scopus, and Cochrane Library were systematically searched on practicing healthcare professionals' EBP competencies published in January 2012–July 2017. A total of 3,947 publications were retrieved, of which 11 systematic reviews were eligible for a critical appraisal of methodological quality. Three independent reviewers conducted the critical appraisal using the Rapid Critical Appraisal tools developed by the Helene Fuld National Institute for Evidence‐Based Practice in Nursing & Healthcare. Results: Practicing healthcare professionals' self‐ reported EBP knowledge, skills, attitudes, and beliefs were at a moderate to high level, but they did not translate into EBP implementation. Considerable overlap existed in the source studies across the included reviews. Few reviews reported any impact of EBP competencies on changes in care processes or patient outcomes. Most reviews were methodologically of moderate quality. Significant variation in study designs, settings, interventions, and outcome measures in the source studies precluded any comparisons of EBP competencies across healthcare disciplines. Linking Evidence to Action: As EBP is a shared competency, the development, adoption, and use of an EBP competency set for all healthcare professionals are a priority along with using actual (i.e., performance‐based), validated outcome measures. The widespread misconceptions and misunderstandings that still exist among large proportions of practicing healthcare professionals about the basic concepts of EBP should urgently be addressed to increase engagement in EBP implementation and attain improved care quality and patient outcomes.

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Keywords: evidence‐based practice; knowledge; competence; systematic review; healthcare professional

Knowledge of the principles of evidence‐based practice (EBP) and skills to perform the steps of the EBP implementation process are essential competencies for all practicing healthcare professionals (Melnyk, Gallagher‐Ford, & Fineout‐Overholt, [16]). In nursing, competence has been defined as the "ability to perform the task with desirable outcomes under the varied circumstances of the real world" (Benner, [ 3], p. 304), referring to the expected knowledge, attitudes, beliefs, skills, and abilities (i.e., competencies) for successful performance of critical work functions. In health care, "core competencies offer a common shared language for all health professions for defining what all are expected to be able to do to work optimally" (Albarqouni et al., [ 1], p. 2). However, defining core competencies in EBP (i.e., outlining the expected EBP knowledge, skills, attitudes, beliefs, and implementation, which are crucially important for improving care quality and patient outcomes because they enable healthcare professionals to make clinical decisions grounded on best available evidence and integrate the evidence into their daily practice; Melnyk et al., [18]; Wallen et al., [34]) has been a relatively recent development both in nursing (Melnyk et al., [16]; Stevens, [28]) and in health care (Albarqouni et al., [ 1]). Moreover, the uptake and use of the EBP core competencies in daily practice have been slow, which hinders healthcare organizations from delivering highest quality, evidence‐based health care via consistent, broad‐based EBP implementation. Furthermore, systematic integration of best evidence into practice is challenging due to the complexity of the EBP implementation process consisting of multiple sequential steps, the mastery of which requires multifaceted interventions, such as developing individual readiness for EBP, translating and ensuring availability of best evidence in usable forms for clinical practice, and building organizational readiness, culture, and structures supportive of EBP (Melnyk, Gallagher‐Ford, & Fineout‐Overholt, [17]; Saunders, Vehviläinen‐Julkunen, & Stevens, [25]).

Similar to the idea of EBP itself (DiCenso, Cullum, & Ciliska, [ 6]; Sackett, Rosenberg, Gray, Haynes, & Richardson, [22]), the realization about the importance for all healthcare professionals to develop a sufficient level of EBP competence is not new, as the first Sicily statement (Dawes et al., [ 5]) outlined that it is a minimum requirement for all healthcare professionals to understand and implement the principles and process of EBP. To this end, two sets of nurses' EBP competencies have been developed through separate national consensus processes in the USA to evaluate practicing nurses' abilities to employ EBP (Melnyk et al., [16]) and to guide EBP professional development and education programs in nursing (Stevens, [28]). However, the EBP competencies published thus far in nursing have been self‐reported and discipline‐specific (i.e., they have focused on measuring the perceived EBP competencies of nurses). Although there have been a few actual (i.e., performance‐based) evaluation tools developed in the last 10 years for more objective measurement of EBP competencies, they have also been discipline‐specific and undertaken primarily in the fields of medicine, occupational therapy, physical therapy, and most recently, in nursing (Halm, [ 8]; Ilic, Nordin, Glasziou, Tilson, & Villanueva, [10]; Laibhen‐Parkes, Kimble, Melnyk, Sudia, & Codone, [11]; McCluskey & Bishop, [12]; Spurlock & Wonder, [27]; Tilson, [29]). However, as EBP is a shared competency (i.e., the key principles and steps of the EBP process are universal and applicable to all healthcare disciplines), a unique opportunity exists to jointly develop interprofessional core competencies in EBP that objectively measure the actual EBP performance of all healthcare professionals.

The Current State of Practicing Healthcare Professionals' EBP Competencies

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