Respect for all patients
The topic of caring for individuals with comorbid mental health and substance use (MH/SU) issues in a medical-surgical setting is an important and timely issue, and I was pleased to see this topic included in Nursing Management. Yet, as I read the article "Behavioral Challenges: A Novel Approach to Mental Health Workers in Medical Nursing" by Nadine Rosenthal, DNP, RN, CCRN, NEA-BC; Asmin Brown, DNP, RN, NEA-BC; Natalie Mohammed, MA, RN, NEA-BC; Lorelle Wuerz, PhD, RN, NEA-BC, VA-BC; Kristen Magnuski, MSN, RN-BC; and Erich Goodman, MPA, RN-BC (December 2018), I was concerned that it seemed to label "behavioral health patients" as separate from other patients, thus stigmatizing people with MH/SU comorbidities and attributing violence to them.
Up to 70% of patients in such settings have MH/SU comorbidities and such patients tend to have poorer outcomes and greater costs of care when hospitalized in medical-surgical settings. Nurses describe their caring experience of patients with MH/SU issues as "difficult," yet research suggests that the difficulty lies not with the patient but rather with the nurse-patient relationship and the care environment. The authors missed this broader context in their consideration of behavioral challenges.
The authors also suggest that reports of increased MH/SU comorbidities in medical-surgical patients and increased violence aren't only correlated, but that a cause-effect relationship exists. However, many patients who become violent don't have MH/SU disorders and instead are experiencing situational distress and anxiety, perhaps due to a previous trauma. Likewise, many patients with MH/SU disorders aren't violent. Labeling individuals with MH/SU disorders as violent is stigmatizing and does them a disservice.
I applaud the authors' approach to educating care team members on MH/SU conditions and crisis prevention and intervention. Together with the addition of a mental health worker to the team, these interventions can improve the care experience for all patients, not just "behavioral health patients," as well as staff. I wonder if a more comprehensive conceptualization of the behavioral challenges experienced would enable even greater improvements in the care experience.
-Cindy Zolnierek, PhD, RN
Thank you for your thoughtful review. The authors appreciate the opportunity to further clarify the difference between behavioral health (mental health comorbidities) and patients who have behaviors that are challenging. Our intention wasn't to stigmatize the mental health patient population. Our lived experience includes those with psychiatric comorbidities and those without. We were innovatively and meaningfully addressing a real issue seen on the units that was resulting in harm/violence to the nurses and staff. Previously, these staff members hadn't experienced or received education or support to address these types of interactions on a medical unit. The infusion of mental health workers was pivotal in building an interdisciplinary team that has been able to meet the unique needs of our patients, further educate and support our nursing staff, and foster optimal patient relationships. Our program continues to evolve and develop, and we look forward to sharing with you and others our future experiences and successes in addressing workplace violence to nurses and supporting zero employee harm.
-Nadine Rosenthal, DNP, RN, CCRN, NEA-BC; Asmin Brown, DNP, RN, NEA-BC; Natalie Mohammed, MA, RN, NEA-BC; Lorelle Wuerz, PhD, RN, NEA-BC, VA-BC; Kristen Magnuski, MSN, RN-BC; and Erich Goodman, MPA, RN-BC
Too soon for genetics/genomics competencies
This letter is in response to "Are Genetics/Genomics Competencies Essential for all Clinical Nurses?" by Patricia Newcomb, PhD, RN, CPNP; Deborah Behan, PhD, RN-BC; Martha Sleutel, PhD, RN, CNS; Judith Walsh, PhD, RN; Kathleen Baldwin, PhD, RN, ACNS-BC, AGPCNP-BC, FAAN; and Suzy Lockwood, PhD, RN, OCN, FAAN (January 2019). I've been in a clinical nurse educator role for almost 2 years and my facility is currently reevaluating our competency assessment. After all my research, this is a topic I've become passionate about.
It's without question that diseases and patient conditions have a genetics/genomics (G/G) component and that patient care will have increasingly more G/G involvement. However, the implementation of G/G competencies for all RNs regardless of practice setting or specialty goes against Donna Wright's Competency Assessment Model, which is based on the foundation that nursing competencies should mean something to nurses and have a positive effect on patient care. This model assists with and ensures that the identification, selection, validation, and evaluation of competencies are consistent and individualized to meet the needs of specialized units. Mandating that nurses complete a standardized competency list without thinking about the relevance and value to the specialized unit is neither effective nor productive.
Competencies should be revised yearly to reflect the ever-changing nursing environment. Who's to say that G/G competencies won't be needed in the future? But I have concerns over the attempt to mandate competencies that won't be used in practice by most nurses at this time. More research and evidence-based practice are needed before we push mandated G/G competencies for all clinical nurses.
-Lynsay Malone, BSN, RN, CCRN
Organizational accountability for workplace incivility
This letter is in response to the article "Workplace Incivility: Nurse Leaders as Change Agents" by Cheryl Ann Green, DNP, PhD, RN, LCSW, CNE, CNL, MAC, FAPA (January 2019). The author remarks on nurse leaders recognizing incivility, feeling empowered to stop it, and making changes to prevent it.
Having been an RN for 19 years, I've witnessed bullying and incivility in the workplace for most of that time in one form or another. Although the ideas mentioned by Green are valuable, what I find to be missing is organizational accountability. The Joint Commission references the National Academy of Medicine's (formerly the Institute of Medicine) 2004 report "Keeping Patients Safe: Transforming the Work Environment of Nurses" and expresses that workplace bullying and incivility are at record numbers. However, currently only eight states require mandatory workplace violence programs and, shockingly, just one state requires incident reporting.
In 2015, the American Nurses Association (ANA) set forth a zero-tolerance policy stating, "The nursing profession will no longer tolerate violence of any kind from any source." The ANA statement encourages reporting and shares strategies for preventing and dealing with bullying but, again, no mandates for reporting or holding organizations accountable are mentioned. The Joint Commission Standard LD.03.01.01 states that leaders create and maintain a culture of safety and quality throughout the organization. Again, the reporting component is missing.
In all my research and years of experience, I've seen that nurses can stand up for themselves, feel empowered, and report incidents, but this is all for naught if the offender isn't held accountable by an organization that feels responsible for resolving and reporting incidents. Personally, I've seen no notable improvement in workplace incivility, and I feel that a lack of reporting responsibility is the main reason.
-Christina Chambers Miller, BSN, RN, CNOR