Medical–Surgical Nurses' Perceptions of Psychiatric Patients: A Review of the Literature With Clinical and Practice Applications

    Medical-Surgical Nurses’ Perceptions of Psychiatric Patients: A Review of the Literature with Clinical and Practice Applications Vinette Alexander, Horace Ellis, Barbara Barrett PII: DOI: Reference:

S0883-9417(15)00140-5 doi: 10.1016/j.apnu.2015.06.018 YAPNU 50737

To appear in:

Archives of Psychiatric Nursing

Please cite this article as: Alexander, V., Ellis, H. & Barrett, B., Medical-Surgical Nurses’ Perceptions of Psychiatric Patients: A Review of the Literature with Clinical and Practice Applications, Archives of Psychiatric Nursing (2015), doi: 10.1016/j.apnu.2015.06.018

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ACCEPTED MANUSCRIPT Title Page Title: Medical-Surgical Nurses’ Perceptions of Psychiatric Patients: A Review of the

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Literature with Clinical and Practice Applications

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The following authors participated equally in preparing this manuscript:

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Vinette Alexander, DNP, ARNP - Corresponding author 12335 NW 51St, Coral Springs, FL 33076 Tel: 954-709-6545 Email: [email protected] Affiliation – Nova Southeastern University 3200 S. University Drive, Davie, FL 33328

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Horace Ellis, DNP, ARNP, PMHNP-BC 10246 SW 24 Court, Miramar FL 33025: Cell: 954-303-2906: Work PH: 305-355-7228: Email: [email protected] Affiliation: Jackson Medical Center 1611 NW 12 Ave, Miami, FL 33136

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Barbara Barrett, DNP, ARNP 5521 SW 160 Avenue, Southwest Ranches, FL 33331 Tel: 754-581-2064 Email: [email protected] Affiliation: Nova Southeastern University 3200 S. University Drive, Davie, FL 33328

ACCEPTED MANUSCRIPT Abstract The literature consistently shows that medical-surgical nurses frequently lack the

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knowledge, skills, and attitudes necessary to render holistic nursing care to patients

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with severe mental illness (SMI). The negative perceptions often portrayed by medical-

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surgical nurses towards SMI patients with comorbid medical-surgical disorders must be addressed in order to ameliorate treatment gaps. Current concepts, issues, and

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challenges associated with the perceptions of nurses who care for patients with (SMI) in

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medical-surgical settings can prove overwhelming to both nurses and patients, and can result in concerning practice gaps. In accordance with a contemporary model of patient-

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centered care, it is imperative that medical-surgical nurses acquire the knowledge,

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skills, and attitudes necessary to work with this high-risk population. Cultivating an environment that promotes apposite attitudes along with effective training programs

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for medical-surgical nurses, may shift negative perceptions and ultimately meet best

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practice standards and improve outcomes for patients with SMI.

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Introduction

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There is growing evidence to suggest that individuals with severe mental illness

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(SMI), such as schizophrenia and other thought disorders, bipolar-affective disorder,

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severe depression, anxiety, substance abuse, or post-traumatic stress disorder (PTSD), seem to have higher comorbid rates of cardiovascular disease, diabetes mellitus,

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respiratory disease, infectious disease, and certain types of cancer than their non-

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psychiatric counterparts (Iacovides & Siamouli, 2008; Saik et al., 2007). There is also growing evidence that nurses in the acute care medical settings may cultivate negative

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perceptions, stereotyped attitudes, and prejudices towards these patients (Arvaniti et al., 2009). Additionally, the epidemic of drug and alcohol abuse, domestic and public

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violence, and suicidal behaviors adds to the degree of negative perceptions that pose

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Aiken, 2008).

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major management problems throughout diverse clinical environments (Hanrahan &

Compared to patients without such co-morbidities, patients with comorbid psychiatric and/or substance abuse and somatic disorders are more complex to manage and associated with increased cost and poorer health outcomes (Saik et al., 2007). Many are also under-diagnosed and under-treated, or even mistreated, resulting in wide treatment gaps (Kuey, 2008). The prevalence of poorer health outcomes for this population may be attributed to pervasive stigma against the physical health problems of people with SMI, as well as the negative attitudes and perceptions of both the general public and health care workers towards people with SMI (Kuey, 2008). The impact of

ACCEPTED MANUSCRIPT negative perceptions on somatic treatments for people with comorbid psychiatric and medical disorders is now being viewed as a public-health problem (Saik et al., 2007;

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Kuey, 2008).

Aims

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This review of the literature serves to explore nurses’ perceptions toward the

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care for mentally ill patients in medical-surgical settings, and to highlight the current issues and challenges associated with such care. Additionally, this paper outlines some

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of the unique challenges that this special client population often brings to a wide variety

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of non-psychiatric clinical settings. Contemporary recommendations grounded in a transformative caring approach are presented as clinical applications.

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Two epistemological reasons served as the impetus for this review. First, it is

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important that nurses in the clinical areas become aware that perceptual stigma and labels toward medical-surgical patients with psychiatric diagnoses are pervasive, that they contribute to barriers to care, and that nurses can become change agents in addressing this enormous problem. Second, it is essential for medical-surgical nurses to cultivate positive perceptions toward patients with SMI while developing the basic knowledge, skills, and comfort-level needed to work with persons with SMI. Recent studies exploring factors affecting nurses’ perceptions of care processes of persons with SMI are limited in the United States (Zolnierek & Clingerman, 2012; Zolnierek, 2009).

ACCEPTED MANUSCRIPT This paper can be used as a tool to help correct the existing clinical gap and to add to the literature on how to affect best practice and achieve quality-care outcomes.

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Nurses are considered frontline caregivers who make important contributions to

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the quality of complex and comprehensive care of patients and their families, regardless

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of their diagnoses (Zolnierek, 2009; Zolnierek & Clingerman, 2012). However, results of most studies exploring the care experience from medical-surgical nurses’ perspectives

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to patients with psychiatric comorbidity were less than favorable; here, patients were

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often viewed as “difficult” and “problematic” (Zolnierek & Clingerman, 2012). Conversely, it is significant to note that individuals with SMI and a medical

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comorbidity also perceived their care as "difficult" and "problematic" (Meehan &

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Glover, 2007; Zolnierek & Clingerman, 2012). These phenomena support the hypothesis that the medical-surgical health outcomes of this population will be poorer than their

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non-mentally ill counterparts (Zolnierek & Clingerman, 2012).

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Prevalence of the Problem

It is estimated that 46% (141 million) of the American population will experience some form of mental illness in their lifetime, costing billions of dollars in direct and indirect health care (Galson, 2009). Iacovides & Siamouli (2008) asserts that 50% of psychiatric patients have known medical comorbidities, while 35% have undiagnosed medical conditions that may have caused or triggered their mental conditions. Data suggest that depression and anxiety seem to be related to obesity, asthma, and renal disease, while bipolar disorder has higher rates of comorbid hypertension, hyperlipidemia, type 2 diabetes, musculoskeletal problems, gastrointestinal problems,

ACCEPTED MANUSCRIPT hepatitis C, and HIV viruses (Iacovides & Siamouli, 2008). Conversely, individuals with a chronic medical condition, such as cardiovascular disease or diabetes, have a greater

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risk of developing mental disorders such as depression and anxiety (Galson, 2009).

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Definition and Concept of Perception

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Perception is defined as a person’s experience of a phenomenon and how that person takes in information related to that phenomenon (Goldstein, 2010; Harms, 2009).

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Prior beliefs and expectations might trigger inflexible assumptions making it difficult to

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formulate personal, social, and professional wisdom congruent with basic human needs (MacNeela et al., 2012). For example, claims of human rights violations by individuals

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with SMI are at times questioned by providers or institutions, as people with SMI are

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often stereotypically misperceived of having limited intellectual capacity or as being unreliable sources of information (McDonald et al., 2003), though these beliefs have not

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been supported by the literature (McDonald et al., 2003; Klin & Lemish, 2008).

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Medical-surgical nurses have the legal and ethical responsibility to rectify their perceptions and attitudes toward persons with SMI, in order to provide appropriate, non-discriminatory care as well as avoid legal violations of patients' rights. Factors Influencing Medical-Surgical Nurses’ Perceptions of Psychiatric Patients Nurses’ Perception Factors Experts in in the field of social-cognitive psychology postulate that perceptions influence and shape human attitudes, decision-making, and behaviors (Crowe, 2012). Research also suggests that a lack of knowledge of the causes, symptoms, and treatment options of mental disorders, and a lack of personal contact with persons suffering from

ACCEPTED MANUSCRIPT those disorders, can lead to misperceptions and care exclusion (Baumann, 2007). Lack of knowledge, skills, and experience in psychiatry among medical nursing staff was also

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identified as contributing to misperceptions regarding the care process of the mentally

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ill (Lethoba et al., 2006), nurses self-perceptions of their skills (Mavundla, 2000), and

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ultimately patient care (Harms, 2009). An example would be misperceiving an anxious patient as agitated, an assertive patient as angry, or psychotic behavior as violent or

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aggressive, dangerous, or threatening. Reasons for these misperceptions include

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unfamiliarity with, and lack of understanding of, psychiatric diseases and symptomatology. The consequences of misperception may include care-neglect,

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segregation or expulsion of patients, seclusion/isolation, or even the unnecessary

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physical or chemical restraint of these mentally-ill patients (Rose et al., 2007). Nurses Skill Factors

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Caring for psychiatric patients requires specialized skills and techniques grounded in the

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art of therapeutic communication, which lay the foundation for therapeutic relationships. Nurses in the medical-surgical setting frequently express anxiety about working with patients with psychiatric diagnoses or who display behaviors associated with mental health problems (Gilje et al., 2007). These uncomfortable feelings have been attributed to lack of essential communication skills, fear of being physically hurt, and negative views toward mental illness that are often perpetuated by the media and the general public (Harms, 2009; Zolnierek & Clingerman, 2012; Gilje et al., 2007). Multiple studies have noted that facilitative communication skills supports general hospital nurses in promoting clear, efficient, and appropriate conversation when caring for mentally ill patients (Chant et al., 2002; Shattell, 2004; & Lethoba et al., 2006). However,

ACCEPTED MANUSCRIPT mastering these skills can be difficult even for the experienced nurse, and can contribute to burnout or even vicarious trauma. It becomes even more challenging for those nurses who lack

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the ability to incorporate the principles of empathy, active listening, nonjudgmental attitude and

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self-awareness into the paradigm of therapeutic and professional nurse-patient relationship. Patient Factors

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The unique characteristics of psychiatric patients’

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presentations/symptomatology (i.e. disorganized thought, speech, and bizarre and inappropriate behaviors; incongruous affect and mood) can be intimidating to the

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unskilled medical-surgical nurse and thus contribute to faulty perceptions towards this

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patient population, the basis for stereotyping and labeling of mentally ill patients (Hamilton & Manias, 2006). “Difficult” is probably the most frequent label ascribed to

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psychiatric patients by medical-surgical nurses, which inevitably influences the quality

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of care provided (Zolnierek, 2009). Hamilton & Manias (2006) and Mavundla (2000) indicated that perceptive

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stereotyping often involves generalizations about character traits that usually emerge from unscientific assumptions. In fact, these assumptions are usually formed and molded based on societal or culturally ingrained narratives (Hamilton & Manias, 2006). For example, it is common for persons with SMI to be perceived as violent, manipulative, attention-seeking, inappropriate, pretending, or they “don’t look sick” or “not that sick” (Hamilton & Manias, 2006). It is also often the perception that SMI persons are in fact in control of their behaviors and, therefore, “know what they are doing”, though these perceptions have

ACCEPTED MANUSCRIPT not been empirically validated (Hamilton & Manias, 2006). There is, however, data suggesting an overpowering influence of deregulatory brain chemicals influencing the

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patient’s ability to think, feel, and relate in a rational manner (Neumann et al., 2010).

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According to work done by Johnson & Delaney (2007), the greater majorities of SMI

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patients are aware of their thoughts and behaviors but are not in control of them and, in most cases, restless, irritable or agitated behaviors are warning signals as primitively

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subjective ways of asking for help (Johnson & Delaney, 2007). Unfortunately, these

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warning signs are often missed by unskilled staff whose negative perceptions and attitudes create risky blind-spots that often result in aggressive behaviors by the patient

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Review of the Literature

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(Johnson & Delaney, 2007).

Methodology

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To add to the literature in this area, the current review aims to illustrate the

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evidence regarding clinical outcomes experienced by individuals with SMI from medical-surgical nurses. Using a literature review process outlined by Zolnierek (2009), comprehensive searches in CINAHL, MEDLINE, and PsycINFO databases were conducted using the following keywords: "medical-surgical nurse", "psychiatric patients", "mental illness", "perceptions", "attitudes", and "stigma". Two hundred and ninety-three English peer reviewed journals published between 2000-2014 were reviewed. Inclusion criteria were identified as quantitative and qualitative studies and other relevant scholarly articles within the time frame allotted; and within the context of SMI patient being cared for in non-psychiatric settings by non-psychiatric nurses.

ACCEPTED MANUSCRIPT Results of an initial search of articles published over the last seven years identified several studies that focused on attitude or stigma as separate attributes, or the

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combination of perception and attitude as a single attribute which did not meet

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inclusion criteria. Due in part to articles overlapping between search terms, the authors

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screened titles by reviewing the abstracts and eliminated those not obviously relevant to the intended goal of the topic (Zolnierek, 2009). Rarely was perception found as a single

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construct influencing care of SMI persons within the medical-surgical clinical setting.

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As a result, it was necessary to broaden the literature search time frame to thirteen years. Nine scientific studies were chosen to support the epistemological

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undertaking of this paper. These reviews were chosen based on their stated purpose,

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study design, outcomes measured and results influencing clinical relevance to the topic of interest, and the need for evidence based interventions to bridge the identified gaps

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in practice (Zolnierek, 2009).

Analysis

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Summary of Literature Review

Over a decade of empirical research and scholarly works from the United States, Great Britain, Ireland, Australia, and South Africa, and using various methodological designs, are cited in this review. Analysis of the nine studies supporting the hypothesis that proper care by medical-surgical nurses of persons with comorbid psychiatric and somatic conditions is in need of major overhaul. Although failure to report measurable outcomes was an observed limitation of some studies, all nine studies identified lack of knowledge, skills, and insufficient training as primary attenuating factors for the

ACCEPTED MANUSCRIPT practice gaps in medical-surgical nurses not being able to adequately care for psychiatric patients. These practice gaps are the primary precept for this review. There

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were also subthemes of fear, discomfort, frustration, lack of empathy, among other

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stereotypical perceptive assumptions as frequent etiological factors influencing medical-

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surgical nurses’ negative perceptions and attitudes toward persons with SMI. Details of each study included in this review are listed in Table 1.

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Inquiries by Mavundla (2000) and Lethoba et al. (2006), among others, supported

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the hypothesis that there can be meaningful benefits to medical-surgical nurses receiving proper training, and honing the necessary knowledge and skills to properly

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care for mentally-ill people in general hospital settings. The authors also concluded that

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knowledge and skills are the prerequisites to achieving confidence and competence, likely resulting in positively shifting nurses’ perceptions toward patients with SMI, an

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Goossens, 2011).

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idea found in two of the studies (Reed & Fitzgerald, 2005); and Van der Kluit &

In contrast, Lethoba et al., (2006) was the only study where nurses predominantly showed favorable perceptions toward psychiatric patients. The authors pointed to levels of education and training, number of years of practice, and experience caring for psychiatric patients guided by a framework of positive self-perception and confidence as the reasons for this result. Consistent with the need for evidence-based practice, the result of this study might serve as a guide for future research to determine if similar outcomes can be achieved.

ACCEPTED MANUSCRIPT Several other clusters of perceptual themes depicting negative constructs of caring for patients with SMI in non-psychiatric settings emerged. In studies by

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Zolnierek & Clingerman (2012), Arnold & Mitchell (2008), Reed & Fitzgerald (2005),

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Mavundla (2000), Lethoba et al., (2006) and McDonald et al., (2003), medical-surgical

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nurses judged themselves as unable to connect and establish therapeutic alliance with patients who were diagnosed with SMI, despite the patients’ behaviors. Nurses also

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attributed these deficits to poor job satisfaction and even advocated the transferring of

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psychiatric patients regardless of their medical condition. In contrast, Lethoba et al. (2006) was the only study reviewed where the results were equally divided between

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undesirable and optimistic perceptions of SMI patients.

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Additionally, there is consensus among these scholars that individuals with SMI tend to have poorer physical health status and health outcomes than persons without

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SMI (Saik, 2007; Keuy, 2008). Often, negative perceptive attitudes, stigma, and labeling

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that obstruct healthcare professionals’ ability to provide consciously-intentional holistic, patient-centered quality care contributes to this. All studies reviewed recommended some psychiatric educational interventions for medical-surgical nurses. However, none of these studies provided data on the effects of any such interventions in a comparable environment or cohorts of nurses. This inherent but necessary weakness highlights opportunities for future randomized qualitative or quantitative explorations. Although lacking randomized-control trials, the studies reviewed were consistent in that interventions are needed to bridge the treatment gap between nurses and patients with

ACCEPTED MANUSCRIPT SMI, thereby achieving uniformity in practice standards for patients regardless of diagnoses or clinical settings.

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Discussion

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Impact on mentally ill patients

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In reviewing the literature, the evidence became clear that faulty perceptions by medical-surgical nurses toward SMI patients contribute to negative stereotypes and, to

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an extent, compromises nurses' ability to respond to medical symptoms and deliver

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quality, competent, compassionate, and holistic care. Negative perceptions contributed to nurses being unable to develop therapeutic relationships or psychosocial

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engagement, having low levels of empathy, and being less supportive toward patients

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(Roos, 2005; MacNeela et al., 2012). Negative perceptions by nurses also resulted in speculations about illness and complaints, and uncertainty or failure to comprehend the

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2006).

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patients’ condition (Roos, 2005; Mavundla, 2000; MacNeela et al., 2012; Lethoba et al.,

Several studies highlighted clinical practice gaps that lead to overshadowing or misinterpretation of patients’ physical or psychological needs (MacNeela et al., 2012; Mavundla, 2000; McDonald et al., 2003; Lethoba et al., 2006; Zolnierek, & Clingerman, 2012), including estimating a lower probability that the patient is in need of urgent medical attention. Negative evaluations, resulting in failure to identify physiological health problems and delayed medical treatment, were also identified. Negative perceptions by nurses led to these nurses’ inability to assess for, respond to, and effectively manage pain or medication side effects, or to accurately read warning

ACCEPTED MANUSCRIPT signs/symptoms of potential violence; there were no differences in nursing interventions for patients scoring high on depression and anxiety scale from those

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scoring low (McDonald et al., 2003; MacNeela et al., 2012; Mavundla, 2000; Lethoba et

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al., 2006; Zolnierek, & Clingerman, 2012).

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The coexistence of medical and psychiatric disorders creates unique challenges for those in the clinical practice setting, as well as for the patients. It is not uncommon

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for persons with SMI to present as if in good physical health and frequently deny

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having any problems (Roos, 2005; Mitchell et al., 2012). Additionally, and due in part to lack of insight, persons with SMI may refuse to accept their diagnosis, often refuse

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needed treatment, minimize pain, or insist on maintaining their independence despite

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this being contrary to their health and wellbeing (Roos, 2005; Mitchell et al., 2012; Zolnierek, & Clingerman, 2012). These health constraints may contribute to nurse’s

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negative perceptions, add to treatment barriers, increase frequency of hospitalization

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and length of stay, and contribute to morbidity and even mortality results (Mitchell et al., 2012). Roos (2005) noted that nurses had a linear view of illness that is determined by the degree of physical limitation: those patients who fall outside of this physicalillness equation are at increased risk of being considered “not ill” and often labeled “difficult”, which may lead to avoidance or segregation. Relevance to Clinical Practice From their studies, several authors theorized that there is relevant information that could be incorporated into the process of developing transformative clinical teaching tools for medical-surgical nurses, revolutionizing the care for psychiatric

ACCEPTED MANUSCRIPT patients in the non-psychiatric clinical settings (Roos, 2005; Mitchell et al., 2012; Zolnierek, & Clingerman, 2012; MacNeela et al., 2012; Lethoba et al., 2006; and

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Zolnierek & Clingerman, 2012). This review identifies three primary areas needing

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further systematic attention as well as offering some practical and achievable methods

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for improving the care for SMI patients in non-psychiatric clinical settings: (1) education and training, (2) skills competency development, and (3) mentoring and supervision.

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Education and Training

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The literature affirms that professional nurses play a pivotal role in improving the care of this vulnerable population, but struggle in their attempts to do so (Reed &

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Fitzgerald, 2005; Van der Kluit & Goossens, 2011). Both Happell & Sharrock (2002) and

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Lethoba et al. (2006) assert that the implementation of training programs or mentoring is key for non-psychiatric nurses to achieve the necessary skills to care for psychiatric

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patients, as education and increased exposure to persons with mental illness can alter

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negative perceptions (Zolnierek, & Clingerman, 2012; and Sharrock & Happell, 2006). This can be accomplished through structured epistemological and pedagogical methods where mental health and interpersonal skills are acknowledged as core components of care (Zolnierek, & Clingerman , 2012; MacNeela et al., 2012; Lethoba et al., 2006; McCamant, 2006; Ancel, 2006). Achieving these skills would facilitate the ability of using oneself to build trust, impart empathy, instill hope, and provide support by showing genuine concern through active listening combined with a nonjudgmental attitude. Several authors, including Ancel (2006) and Vandemark (2006), have suggested that professional nurses

ACCEPTED MANUSCRIPT practice these principles in the hope of expanding their consciousness and gain insight into their own self-awareness, thereby becoming more prepared to appreciate human

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problems, better able to facilitate the process of the nurse-patient relationship, and

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better able to carry out the nursing functions of being caring. Midrange theory, such as

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Peplau’s interpersonal relationship framework (1997), can be used to effectively strengthen the relationship roles and responsibilities between medical-surgical nurses

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and individuals with SMI through the concepts of mindfulness, self-awareness, and

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self-reflection (Roos, 2005).

Contemporary qualitative and quantitative research is needed to determine best

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approaches to promote nurses’ knowledge, self-confidence and eventual shifting of

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perceptions toward the care of patients with psychiatric and medical comorbidities (Zolnierek, 2009). Investigation of the patient perspective and lived experiences might

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provide insight for designing practical and effective training curriculums aimed at the

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care process (Zolnierek, 2009). Skills Competency Development In light of the evidence that general nurses have difficulty in caring for patients experiencing mental health problems (Sharrock & Happell, 2006), there might be a need for nurses to acquire some basic psychiatric skill-based competency. This review identifies that a large number of psychiatric patients continue to be admitted to the medical and surgical units of general hospitals and that nurses are experiencing overwhelming stress-responses associated with caring for them. Faulty perceptions, negative attitudes, and a lack of blended knowledge and skills to effectively care for

ACCEPTED MANUSCRIPT psychiatric patients are reasons identified for the collected feelings of incompetence reiterated by non-psychiatric nurses.

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Clinical and research scholars urge that psychiatric patients on non-psychiatric

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units receive the same standard of integrated care as those in the psychiatric unit (Druss

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et al., 2001; Mitchell et al., 2012). However, the literature is lacking the systematic evidence on how non-psychiatric nurses can achieve these specialized skills

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competency. Suggestions include preceptorships, clinical rotations that integrate mental

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and physical health care within various settings (general hospital, psychiatric hospital, and ambulatory care), immersion experiences, and psychiatric internship that can be

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translated into the non-psychiatric setting, though they have not been studied

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(Zolnierek, & Clingerman, 2012).

Using the latest research in clinical and practice principles, there is an

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opportunity for nurse-driven multidisciplinary, interdisciplinary, and collaborative

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exploration aimed at bridging these gaps, thereby promoting both quality and safety in care. Based on the recommendations by researchers and scholars cited in this review, tables 2 & 3 offer some suggestions for achieving skills competency and Tables 4 & 5 offer examples of structured engagement that facilitate therapeutic communication, all of which can be used in developing in-service training or education programs. These recommendations are consistent with the eight essentials of practice outlined in the Essentials of Doctoral Education for Advanced Nursing Practice (American Association of College of Nursing, 2006), and scope and standards of practice defined in the

ACCEPTED MANUSCRIPT Psychiatric-Mental Health Nursing Scope and Standards of Practice (American Nursing Association, 2014).

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Mentoring and Supervision

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Providing medical-surgical nurses with mentoring and supervision through

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psychiatric liaison services are practical and achievable interventions that could be incorporated into broader educational initiatives (Atkin et al., 2005). The predominant

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principle of experiential learning through mentoring and supervision is guided by the

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philosophy of the mentee being able to reflect on situations, develop self-awareness, understand the uniqueness of people, and be aware of patients’ rights (Roos, 2005).

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Psychiatric-mental health nurses are in a unique position to lend their clinical expertise

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while simultaneously using the opportunity to develop interdisciplinary, collaborative and collegial relationships with their medical-surgical colleagues, and mentorship has

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been shown to be a crucial ingredient for novice nurses to become more self-reflective,

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develop positive perceptions of themselves and patients, and increase knowledge linked to improved competencies in holistic nursing practice (Ronsten et al., 2005). These concepts are supported by Benner’s conceptual model “From Novice to Expert” (2004), and can be used to guide the process of mentoring and supervision, and in transitioning to the acquisition of competency through critical thinking and experiential learning. Case Example The following case example is based on the imbedded assumptions and thematic analysis of this review. It is intended to highlight a sampling of factors influencing

ACCEPTED MANUSCRIPT medical-surgical nurses’ perceptions toward psychiatric patients. As a result, this case example attempts to demonstrate how interventions of mentoring and supervision

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relationships can help facilitate medical-surgical nurses understanding of psychiatric

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patients’ symptomatology and as results enhance their care approach.

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T.M. is a 30-year-old male admitted to the medical unit for a severe left foot cellulitis that requires potent antibiotic therapy that is expected to last 4-6 weeks. He also has a co-morbid

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diagnosis of schizophrenia that is in partial remission with medication. Shortly after being

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admitted to the floor, T.M. begins to exhibit psychiatric symptoms that the staffs were unfamiliar with, and they soon became quite uncomfortable around him.

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T.M. refuses to stay in his room as instructed. He frequently paces the hallways talking, laughing, and gesturing to him-self. He occasionally wanders into other patient’s rooms, making

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nonsensical conversations with them. He has a habit of collecting piles of linens and storing them

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in his room, and hoards various food items that usually end up spoiling. There are moments

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when T.M. engages in rapid body rocking behavior that the staff interprets as agitated behavior. The nurses view T.M.’s behavior as bizarre, anxiety- and fear-provoking, disruptive, and a distraction to the usual flow of the unit’s routine. Due to a lack of knowledge and skills on how to deal with T.M.’s unusual behavior, the staff developed a range of emotional reactions towards him. Some staff viewed him as agitated, aggressive, manipulative, uncooperative, inappropriate, not following redirections, and inappropriate for placement on that unit. Frustrated with T.M.’s behavior, the staff resorted to locking him in his room. This intervention proved ineffective and caused T.M. to become very

ACCEPTED MANUSCRIPT agitated. He began yelling, screaming and banging the walls and doors. He also pulled his intravenous lines out and refused his medication.

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Responding to what the staff viewed as a clinical challenges posed by T.M., a

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psychiatric clinical nurse specialist (CNS) consult was requested. Upon arriving to the

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unit, the medical-surgical nurses’ negative emotions were quite obvious. After interviewing the nurses, reviewing T.M.’s medical record, and conducting a face-to-face

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assessment with T.M., the CNS proceeded to assess the nurses’ knowledge and

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perceptions of schizophrenia, and their skill-level in caring for a patient with this type of co-morbid diagnosis. Based on the information obtained, a behavioral treatment plan

Providing a brief overview of schizophrenia that includes the disease process,

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

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was developed for T.M.:

symptom recognition/management and pharmacological management. Providing simple, practical and easy to use therapeutic communication

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

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skills/techniques, as well as personal safety strategies. 

Recommend a 1:1 sitter by a mental health specialist (MHS).

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Develop a modified form of recreational activity for T.M.

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Plan to meet with staff for one-hour sessions three-times weekly for two weeks to allow them to verbalize their feelings and concerns and to evaluate the progress of the intervention.

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Plan on providing more mental health and psychiatric in-services for staff. Meeting the psychosocial, emotional, and physical needs of persons with

comorbid psychiatric and medical conditions present real challenges to nurses in any

ACCEPTED MANUSCRIPT setting and, in particular, medical-surgical settings. In the preceding case example, the reactions of the nurses toward T.M.’s behavior reflect a recurring theme throughout the

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literature about general nurses perceptions of psychiatric patients. The nurses were

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unable to link T.M.’s behavior to his underlying psychiatric illness and thus skewed

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their perceptions towards him. Delany & Johnson (2006) observed that when staff members are able to attribute patients’ behaviors to their psychopathology, the

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behavior becomes more acceptable and positively influences the staff members’

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subsequent responses. At the same time, Delany & Johnson (2006) outlined how skilled nurses are able to balance the patient’s need for control of themselves and the nurses’

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need to control the situation.

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In this case example, the CNS was able to provide supportive guidance through in-service education, mentoring, and supervision. The goal is for the nurses to gain

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some level of confidence and educational competency that could translate into future

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independent clinical practice with satisfactory quality outcomes. The CNS assigned a senior, more experienced nurse to re-model the techniques for others while continuing to provide mentoring, supervision and support. This type of experimental learning was highlighted by Lethoba et al., (2006), and by Zolnierek, & Clingerman, (2012). Based on their research findings, Lethoba et al. (2006) recommended that general nursing units invest in the expertise of psychiatric staff, such as the CNS, to facilitate inservice training or mentoring for less experienced staff. In addition, mental health technicians with the training and skill-competence to effectively provide structural engagements for patients such as T.M. could be employed to decrease some of the

ACCEPTED MANUSCRIPT burden and stress experienced by the non-psychiatric nurses. This type of collaboration may offer promising new paradigms for future practice.

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Impact on Nursing

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Caring for mentally ill patients in the general medical settings can affect the

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intellectual, emotional and social nursing environment (Mavundla, 2000). The importance of the nurse-patient therapeutic relationship is central to all professional

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nursing training (Peplau, 1997), and is the single most important tool that can ensure, as

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well as measure, total quality of care (Terry, 2011). The literature also shows that significant gaps exist between the ability of medical-surgical nurses’ to acquire and

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maintain this essential attribute toward persons with SMI (Björkman, et al., 2008).

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Research has indicated that if medical-surgical nurses can develop the knowledge, skills, and techniques required to effectively relate to SMI patients, care outcomes will

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be improved (Zolnierek, & Clingerman, (2012).

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Nurses who have received training acknowledging the SMI client as a person will embody attitudes of inclusiveness, hopefulness, empowerment and illness management (Ancel, 2006). Because perception is a precursor to attitude (Goldstein, 2010; Harms, 2009), if medical surgical nurses’ perceptions of mentally ill individuals are positive, the same caring attitude will be afforded to medical-surgical patients with and without psychiatric conditions , thus achieving similar outcomes within similar time-frames for all patients. This review concludes that achieving educational competency in caring for the SMI person is a key component for medical-surgical nurses, including interpersonal

ACCEPTED MANUSCRIPT skills, assertiveness skills, and skills for dealing with psychiatric emergencies (Mavundla, 2000). Multiple studies have postulated that competency is achieved when

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the medical-surgical nurse is able to achieve and demonstrate positive self-perception,

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self-confidence, self-efficacy, communicate effectively, conduct proper assessments, and

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carry out comprehensive and impartial physical and psychological patient-centered and humanistic care (Mavundla, 2000; Zolnierek, & Clingerman, 2012; Brinn, 2000; Sharrock,

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& Happell, 2006).

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Although achieving competency through education was overwhelmingly identified as a recommendation for medical-surgical nurses to better care for psychiatric

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patient, recommendations for achieving these core standards seem more theoretical

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than pragmatic. Sharrock, & Happell, (2006) suggest that achieving competency is to move away from the notion that separates the mind from the body and approach each

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patient as an integrated being. In their study, medical-surgical nurses expressed a desire

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to achieve competence in caring for patients with mental health by being able to move from a reactive to a more calculated approach to quality patient-centered care. None of the studies reviewed here offered mental health education as a dependent variable for medical-surgical nurses’ perception of psychiatric patients. As a result of their study, Zolnierek, & Clingerman (2012) cautioned that although medical-surgical nurses perceived achieving competency in caring for the mentally ill as positive, they failed to demonstrate improvement in patient outcomes when controlling for confounders such as severity of symptoms and level of function. Brinn, (2000) acknowledged that competency cannot always be achieved and carried-

ACCEPTED MANUSCRIPT out outside of those nurses’ specialty. By virtue of the abstract view of how medicalsurgical nurses can achieve mental health competency, there is fertile ground for further

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methodological, quantitative research.

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Conclusion

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This paper is a review of the literature exploring the perceptions of nurses who care for mentally-ill patients in medical-surgical settings and the current clinic and care-

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related issues and challenges associated with those perceptions. Additionally, this

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paper highlights some of the practice challenges as outlined in the objectives that this special patient population often brings to a wide variety of non-psychiatric clinical

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settings. The conclusion drawn from this review is supported by the scholarly works

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cited – that faulty perceptions among nurses in the acute care medical setting are factual and prevailing phenomena that is in need of prompt educational attention in order to

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improve care outcomes of psychiatric patients being treated in those clinical areas.

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Further research is needed to report more measurable outcomes on the factors contributing those negative perceptions cultivated by medical-surgical nurses toward psychiatric patients.

Alongside other health and social care providers, medical-surgical nurses have an important role in caring for patients with co-existing mental- and physical-health related issues. It is therefore imperative that medical-surgical nurses obtain the skills, knowledge, and attitudes necessary to work with this patient population. One way to cultivate such an environment is through apposite and effective on-going education and training programs (Terry, 2011; Happell & Sharrock, 2002; Lethoba et al., 2006). The

ACCEPTED MANUSCRIPT evidence-based approach required for promoting development and implementation of basic mental health training programs geared toward medical-surgical nurses is under-

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developed (Sharrock, & Happell, 2006; MacNeela et al., 2012; Zolnierek, & Clingerman,

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2012; Lethoba et al., 2006), and provides fertile ground for future research. Bridging

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these gaps provide opportunities for promoting best practice initiatives through decreasing unnecessarily emotional burden on nurses and decreasing care disparities

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for patients, thereby enhancing recovery and wellness. It is the hope that this article can

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serve as a tool for medical-surgical nurses to: promote debates at levels aimed at reducing and eliminating negative perceptions toward people with mental disorders;

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outlining the nature, causes and consequences of negative perceptions of SMI patients;

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and make recommendations for education, practice, administration, and research

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intended to combat negative perceptions.

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Peplau, H. E. (1997). Peplau's theory of interpersonal relations. Nursing Science Quarterly,10 (4), 162-167. doi: 10.1177/089431849701000407 Reed, F., & Fitzgerald, L. (2005). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14(4), 249-257. doi:10.1111/j.1440-0979.2005.00389.x Roos, J. H. (2005). Nurses’ perceptions of difficult patients. Health SA Gesondheid, 10(1), 5261. doi:10.4102/hsag.v10i1.188 Rose, D., Thornicroft, G., Pinfold, V., & Kassam, A. (2007). 250 labels used to stigmatize people with mental illness. BMC Health Services Research, 7, (97), 1-7.

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Ronsten, B., Andersson, E., & Gustafsson, B. (2005). Confirming mentoring. Journal of

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medical care in the state psychiatric hospitals. North Carolina Medical Journal, 68(2), 95-98.

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theory analysis of nurses’ experiences. Australian Journal of Advanced Nursing, 24(2), 9- 15.

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Zolnierek, C. D., & Clingerman, E. M. (2012). A medical-surgical nurse’s perceptions of caring

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for a person with severe mental illness. Journal of the American Psychiatric Nurses

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Association, 18 (4), 226-235. doi:10.1177/1078390312446223

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10 nurses randomly selected from two wards in a rural hospital

Qualitative descriptive assessment of issues that impact nurses’ ability to provide care, as well as the effects of education, experience, and support

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McDonald et al. (2003), United States

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Design/Intervention

Posttest-only experimental outlined in one of three vignettes about a patient (control, antianxiety medication, antipsychotic medications) was given to examine nurses' perceptions of how a patient's potential psychiatric diagnosis

Outcomes

Nurses felt treating mentally ill patients was not their responsibility; expressed multiple negative emotions towards and perceptions of this population; and felt they should be kept in a separate environment. Small percent of the respondents felt mentally ill patients could be cared for more effectively with adequate training and support Nurses assigned the antipsychotic vignette were significantly less likely than nurses in the other two groups to identify the symptoms of myocardial infarction and provide appropriate treatment.

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Participants

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Author/year/countr y Reed & Fitzgerald (2005), Australia

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Table 1 – Summary of Studies Reviewed Recommendations Provide education to improve experiences of nurses, and foster positive perceptions and attitudes towards patients with SMI

People with psychiatric diagnoses might be especially vulnerable when they experience medical problems due to nurses' perceptions of their symptoms. Nurses are encouraged to take conscious steps in avoiding unconscious stereotyping of

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affects medical care 124 professional nurses in a general hospital

Qualitative survey measuring perceptions of ability to care for mentally ill patients, and perceptions of mentally ill patients

Arnold & Mitchell (2008), United Kingdom

14 registered staff nurses, nurse managers, charge nurses, and nurse educators at an acute-care hospital for the elderly

Focus groups in the form of our semi-structured, open-ended questionnaires to identify participants perceptions of caring for older people with mental health issues

Atkin at al. (2005), United Kingdom

19 qualified nurses

Mavundla (2000),

12 professional

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Focus groups were conducted to explore training needs perceived by general nurses to provide care for older people with comorbid psychiatric and medical conditions.

Semistructured interview

Majority had a positive self-perception of caring for the mentally-ill person in medical settings, and predominantly negative perceptions of mentally ill people Identified eight perceptions of caring for elderly people with SMI. Difficulties included workload; stigma; lack of sufficient education and training; inadequate preparation to communicate and assess mental health Patients were perceived as difficult to manage and disruptive to routines, and did not receive best quality care in general hospital setting. Participants felt unprepared to recognize and manage mental illness. Overwhelmingly

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Lethoba et al. (2006), South Africa

patients with psychiatric diagnoses Develop policies to promote the use of psychiatricallytrained nurses on medicalsurgical units

Increased inter-professional discussion of stigma and labeling relating to mental health issues. Improve patient-care collaboration across disciplines

Incorporate mental health training for nurses who frequently encounter patients with mental illness. Provide ongoing training and access to liaison support

Increase nurses’ knowledge

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Zolnierek & Clingerman (2012), United States

One baccalaureateprepared medicalsurgical nurse.

Descriptive case study to explore how psychiatric patients in a medical hospital are perceived by nurses

MacNeela et al., (2012), Ireland

Thirteen nurses working in medicalsurgical wards in two acute care hospitals.

negative perceptions of SMI patients and effect on nurses’ functioning. Respondents perceived themselves as lacking knowledge and skills to adequately care for SMI patients. Also expressed fears of mentally ill patients, and feelings of frustration and despair having to care for them Concerns for patient’s risk of self-harm and violence toward others; feelings of discomfort at dealing with complexities of psychiatric symptoms; perceived demand from patients with SMI interfering with completing patient care assignment; and lack of professional satisfaction None endorsed empathy as a quality in identifying the patient as a vulnerable individual; some took authoritative stance. Subjects felt it was difficult to form

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and observational field work to explore medicalsurgical nurses’ perceptions of nursing mentally ill patients

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and skills about working with this population. Provide emotional support in the form of counseling

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South Africa

Think-aloud/interviewbased simulated case studies that dealt with psychiatric patients who had physical health problems

Using enhanced understanding to improve practice environment and to develop new models of care approaches that would better support both nurses and patients

Improve professionals’ preparedness for psychiatric patients’ condition on medical-surgical units. The development of therapeutic communication skills is key to achieving pedagogical

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objectives

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Varied

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Van der Kluit & Goossens (2011), varied

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therapeutic alliances with this population and that they would be better on a psychiatric unit Investigative literature Found insufficient review using qualitative training and a lack of and quantitative research knowledge and skills as designs to explore different causes of negative perceptions and attitudes perceptions and attitudes of nurses toward patients with comorbid mental illness; exact correlating relationships among these variables were imprecise.

The adaptation of a holistic nursing vision that foster physical, emotional/psychological and spiritual support. A conscious effort to equalized the mixture of age, skills and workload might influence positive attitudes

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Table 2 – Training Considerations The client as a holistic system: physical, psychological, emotional, spiritual, family and community Mastering the principles of ‘Motivational Interviewing’ Manipulating the environment to maximize safety Mastering the therapeutic/professional relationship process Professional skills development that promote reality, hope, self-control and recovery Table 3 – Assessment Considerations

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Possible Causes(s) of Psychiatric Patients Behavioral Challenges on Medical-Surgical Units Psychiatric/Psychological Physical/Environmental  Psychosis/unstable  Pain, hunger, thirst, temperature, mood/depression/anxiety elimination, sleep deprived  Issues related to psychotropic medications  Underlying medical issues (sub-therapeutic levels, side effects,  Increased stimulation toxicity, other)  Communication issues  Sleep pattern disturbances  Unfamiliar  Increased stimulation environment/surroundings  Change in routine  Demands placed on client  Loneliness/boredom  Physical restrictions  The need to take action Medical Cognitive  Drug/ETOH intoxication/withdrawal  Dementia(s)/Delirium  Electrolyte imbalance  Traumatic Brain Injury  Reactions to medications  Other developmental/cognitive issues  Other specific disease states Levels of Behavioral Changes De-escalating Response  Pacing/rocking  Calm, supportive, empathetic listening and communicating  Irrational/defensive  Avoid personalizing behaviors  Repetitive questioning  Speak slowly and clearly, avoid  Refusal/venting frustration jargon  Crying/yelling/cursing  Challenging/confrontational/intimidation  Explain what is happening and answer questions  Physical acting out  Offer choices  Tension resolution  Treat individual with respect and dignity  Help with problem solving & reality orientation

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Table 5 – Communication Considerations Therapeutic Responses to Patients by Med-Surge Nurses “Yes Mr. Doe, I hear what you are saying.” “Ok Mr. Doe, I am here with you.” “Uh hum, go on . . . and then?” “You feel you are not benefiting from being here?” “You are having tremors Mr. Doe.” “It must be difficult staying in a place you hate.” “That must have been very difficult, embarrassing, frustrating, etc. for you.” “Tell me about your life no longer having a purpose Mr. Doe.” “I noticed you can’t sit still Mr. Doe. Are you feeling nervous?”

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Do Not Do This Assume that you are 100% safe. Attempt to physically control an agitated/aggressive person by yourself Invade the person’s personal space Try to make sense of the person’s deluded thought process or content. Confirm or deny any false beliefs Confront or ridicule the patient even when behavior seems disturbing or unacceptable Over-react to unusual or disturbing behaviors Respond in kind to insults, ridicules, and sarcasms

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Table 4 – Interaction Considerations Do This Aim to establish rapport and build trust Be supportive by integrating principles of active listening, therapeutic silence, empathy, and nonjudgmental Treat individual with respect and dignity Use open-ended questions to maximize the chance of obtaining pertinent information. Set limits on disturbing/unacceptable behaviors Be aware of your verbal, non-verbal, and para-verbal behaviors Maintain safe environment

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Set behavioral limits Offer medication Decrease stimulation and increase distraction Maintain safety

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Non-Therapeutic Responses to Patients by Med-Surge Nurses “Everything will be alright, don’t worry.” “Why are you upset?” or “There is no reason to be upset.” “What you should do is…” or “I think you should…” or “I agree with you.” “You are wrong about that.” “That is not true” or “You are lying.” “You should listen to your doctor.” “She is a good nurse and she wouldn’t do that.” “If he did that he is not a good nurse.”

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“Watch your mouth.” “You’re inappropriate.” “I know just how you feel.” “You are not the only patient here, please wait your turn.” “If you are dead, how come you are still breathing?” “Your mother isn’t coming; she is dead.” “Humans cannot fly”

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“I noticed you are talking and laughing but I don’t see anyone with you. Is there someone in here with you?” “I know you have something important to tell me and I want to hear it, but I can only listen if you try to speak more softly and quietly.

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