Introduction
Anoka-Metro Regional Treatment Center (AMRTC) is one of the largest mental health facilities in Minnesota. It serves individuals in the Twin Cities metropolitan area, which includes the county of Anoka, Dakota, Ramsey, Scott, Sherburne, Washington, and Carver counties (DHS, 2020). The hospital has a long history of providing service to mental health patients, but also faces a variety of challenges familiar to the US healthcare industry as a whole, such as overcrowding, understaffing, scheduling, and high personnel rotation rates, in addition to problems unique to long-term mental health services, such as patients escaping wards, patients abusing hospital personnel, or vise-versa (Keltner & Steele, 2018). The purpose of this consultation is to identify a singular pressing problem within AMRTC and come up with a coherent and evidence-based change proposal to address the issue.
The consultation process includes the collection and dissemination of information about the organization in question, its evaluation in the scope of available literature on the subject, and an analysis of potential ways to improve the situation, based on change frameworks. Data about the organization is collected from publicly-available sources, such as AMRTC site, yearly reports, and government papers. An inside perspective on how things work inside of the facility is retrieved from one of the nurses, who agreed to give an interview and a subjective viewpoint on the matter. These findings are to be compared with the available sources of peer-reviewed literature on the subject. The dissemination of information would enable pinpointing one of the key issues currently faced by AMRTC, and propose a change plan to address it. The plan of implementation will be based on Lewin’s Change model (Shirey, 2013).
Organizational Analysis
Description of the Organization
AMRTC is the largest and one of the oldest psychiatric hospitals in Minnesota. As it stands, the hospital operates 110 beds, having reduced its capacity for handling patients from its 200-bed capacity due to various financing, organizational, and worker safety issues that have been going around since 2018 (MDHS, 2020). Hospital focuses on long-term treatments to individuals civilly or criminally committed by a court as mentally-ill. Some of these patients exhibit volatile behaviors or are pending a criminal trial. AMRTC takes these patients in due to the fact that community hospitals are lacking clinical expertise, secure facility, and support staff personnel. Average duration of stay for patients usually does not exceed 100 days (DHS, 2020). During the previous year (2019), AMRTC treated and released 374 patients (DHS, 2020). The majority of the patients in the hospital tend to be male, though the hospital features separate wings and quarters for female patients as well, due to the nature of it being a secure facility. At its maximum capacity, the hospital can provide the following (MDHS, 2020):
- A 200-bed facility for patients with mental health issues;
- A 28-bed center for patients with a drug or chemical dependency;
- Two independent community facilities, each housing 16 beds;
- A space for a transitional community-based support program.
AMRTC provides numerous services to patients, associated with mental, emotional, and psychological health. These services include individual treatments, assisting in maintaining psychological stability, developing valuable skills, and succeeding in community settings (MDHS, 2020). The 200-bed facility and the two apartment-sized 16-bed facilities are used for that (MDHS, 2020). The hospital offers treatment of chemical addictions and a post-substance-abuse restoration program. This program also treats mental illnesses associated with substance abuse. A subdivision of this area includes detox services for individuals that require help getting past the withdrawal syndrome or having dangerous amounts of intoxicants removed from their system (MDHS, 2020). Finally, there are community transition services and mental health initiatives. These include multidisciplinary assistance teams to patients that have been discharged, but spent prolonged periods of time in isolation or hospitalization. Mental health initiatives, on the other hand, help reintegrate people with severe and persistent mental illnesses into the community.
Primary Needs of the Population Served by the Organization
The primary needs served by the hospital for the community include the treatment of serious and potentially dangerous patients that require a secure facility, specially-trained personnel, and access to materials and resources necessary to perform treatments. AMRTC serves the needs of individuals that suffer from long-term drug and substance abuse, criminally insane individuals, patients with violent sexual disorders, as well as people who have long-term psychological issues that community hospitals are not capable of treating (DHS, 2020). Non-dangerous mental illnesses, beginner addictions, and other similar needs of the local populations do not fall in the scope of AMRTC service. It must be noted that the hospital is a singular entity serving a variety of counties and large communities. As a result, the number of beds and provided services is usually underwhelming compared to the overall demand, which lead to some patients being relocated to other hospitals (such as St. Peter’s Hospital) in order to reduce the workload and resource drain on the organization (DHS, 2020).
Nurse Leader Interview Summary
Nurse Leader Role
The nurse interviewed in the scope of this assignment is a senior staff nurse, whose job is to perform the functions of a shift manager in the hospital. Her duties include the distribution of labor, time, and resources, training of new employees, and, occasionally, performing the functions of a line nurse, addressing the needs of patients when there is a nurse shortage. According to her, the overarching purpose of her role is to ensure maximum patient care with the limited resources available to her.
Since she acts as both the shift manager and the line nurse, she has the potential of influencing multiple domains of patient care, such as the Environment, Patient, and Nursing (AACN, 2011). A shift manager has the potential to influence the environment both directly and indirectly, either by performing the role of a nurse herself, or by assigning the appropriate number of nurses to a specific environment with the purpose of improving it. Patient-nurse relationship can also be improved directly or indirectly by the nurse practicing her leadership and influence capacity to have nurses change their way of work, or by performing the task on her own (AACN, 2011). The interviewee said that balancing all three of these aspects is difficult, as personal participation leaves less time for management, and limited resources do not allow addressing all issues at the same time, forcing her to prioritize.
Characteristics of the Organization
The nurse I interviewed provided a general characteristic for AMRTC, based on its strengths and weaknesses. According to her, the organization’s strength lies in the fact that the hospital existed for a very long time and is a one-of-a-kind facility in the surrounding area, meaning that it receives full support from the budget when it is necessary. In addition, AMRTC has a strong skeleton crew of well-trained and experienced cadres, meaning that in a prolonged event of personnel rotations, the organization will be able to function, even if in decreased capacity. AMRTCs main buildings are more secure than those of community hospitals, protecting nurses and patients from themselves and each other. Organizational weaknesses, however, as described by the nurse, are much more numerous. The primary weakness lies in the chronic lack of personnel.
Because of this issue, patients receive less care per capita than they could have received. This issue is exacerbated by the influx of patients beyond the hospital’s capacity to care for. Another issue is the quality of patients – many of them have been transferred from prisons and present a danger to nurses and themselves, which exacerbates the problem. In 2018 and 2019, hospital staff had gone on strike to improve safety measures in the hospital. Finally, the state of existing accommodations is not enough to fully guarantee the security of the premise – patients have been known to flee the hospital and hijack transports to get away. All of these factors are affecting the capacity of AMRTCs to retain their employees.
Another weakness of the established system, according to the nurse, is in the relatively low compensations for the employees. By design, working with psychologically-disturbed and potentially dangerous individuals is an exhausting, taxing, and risk-filled work. At the same time, salaries in AMRTC are not high enough to justify the amounts of risk involved for everyone. Add to that the irregular scheduling with numerous reasons to work overtime, and the problem exacerbates. The interview concluded on a sustained position that in order to change AMRTC for the better, the hospital needs to put more value in the safety, appreciation, and rewarding of their employees, in order to retain specialists.
According to the nurse, hospital practices are well-rooted in evidence-based findings, with the medicine, protocols, and manners in which nurses operate towards patients being guided by evidence and outlined in the directives and laws passed along by organizations responsible for forming up the standards of practice for the country and state. In addition, novel evidence-based practice is being used in an attempt to find better ways of de-escalating conflict situations, such as music and dance therapies in contrast to the standard physical or medicament-based restraining (Biondo, 2017). As for quality improvement projects, the protests of 2018 and 2019 had an effect, and the process of improving safety conditions has started, but has hit the wall in the recent year due to the COVID-19 crisis, which overshadowed other concerns.
Recommendations for Organizational Change
Recommendation
Based on the interview, media coverage, and evidence found in the literature, one of the critical components that explains understaffing is the lack of nurse safety when it comes to handling potentially dangerous patients. The proposed solution lies in a greater scrutiny when it comes to initial patient evaluation for the potential to cause harm, and the placement of safeguards against individuals who have the potential of doing so (Zhang et al., 2017). Step one would involve filtering out patients based on three categories, including safe (green), unlikely dangerous (orange), and potentially dangerous (red). Unlikely dangerous patients are patients that have never willingly caused harm to anyone but could do so if hit with a panic attack or a mental incident (Hester et al., 2016).
Potentially dangerous patients are those convicted or pending trial, considered criminally insane (Zhang et al., 2017). Barriers and protection methods will be placed between them and the nurses, to protect the latter from harm. Finally, new nurses will follow a progressive clearance, going from safe to unlikely dangerous, to potentially dangerous over a period of time, as they gain more experience and become familiarized with the environment (Hester et al., 2016).
Rationale
Treating mental patients is a dangerous task. It is the one thing that puts AMRTC aside from community hospitals, which face largely the same problems without exposing their nurses to harm. With everything else being equal, a prospective nurse would select a safer place of work (Niu et al., 2019). Therefore, ensuring nurse safety and reducing the number of assaults on their person, as well as the potential for physical or emotional trauma, is critical to increasing retention rates and improving the quality of care in AMRTC overall.
Such a strategy addresses understaffing, which is one of the hospital’s main organizational weaknesses, as well as the community needs. Should AMRTC increase its retention and the number of people willing to work there, vacancies would be filled, and the organization will return to operating at its maximum capacity, from 110 beds to 200, along with additional support structures. Finally, the increase in retention would also improve the quality of patient treatment, which would allow for reducing the number of days under supervision and would increase the number of patients the facilities could support. In doing so, AMRTC would help the community by addressing one of its most pressing matters, for which there are no alternative answers.
Measurement of Effectiveness
The primary metric for evaluating the success of the proposed change would be the number of violent incidents per patient per nurse (Niu et al., 2019). The expected reduction in the number of incidents will be compared to the existing metrics as well as with the state and national benchmarks available. The goal of the proposed change is to bring that number below the national and the state benchmarks, or achieve a reduction in incidents and traumas associated with patient treatment, when compared to AMRTC’s previous years. Additional metrics that could be used to evaluate the effectiveness of the intervention could include retention numbers, patient scorecards for the quality of treatment, and expenditures per vacancy (Niu et al., 2019). These numbers can, too, be compared to state and national benchmarks as well as the hospital’s results for previous years.
Conclusions
AMRTC is a large and old hospital, providing a crucial service to the Minnesota community by treating individuals with severe mental health issues and providing a secure facility, equipment, and experience that community hospitals do not have. At the same time, AMRTC is plagued by a myriad of problems revolving around nurse safety, poor retention numbers, and other HR-related issues. The proposed intervention will protect nurses, reduce the number of incidents, protect both sides from causing harm to one another, and should improve associated metrics, such as nurse retention, money spent per vacancy, patient satisfaction, and the overall quality of treatment. The proposed solutions do not require significant resources, and are in line with patient treatment guidelines. Instead of providing a reflex-based solution to violence in the form of medicaments or physical restraints, the change would match difficult patients with experienced personnel and creating barriers to discourage violent attempts.
References
American Association of Colleges of Nursing (AACN). (2011). The essentials of masters education in nursing. Web.
Biondo, J. (2017). De-escalation with dance/movement therapy: A program evaluation. American Journal of Dance Therapy, 39(2), 209-225.
Department of Human Services (DHS). (2020). Anoka-metro regional treatment center. Web.
Hester, S., Harrelson, C., & Mongo, T. (2016). Workplace violence against nurses: Making it safe to care. Creative Nursing, 22(3), 204-209.
Keltner, N. L., & Steele, D. (2018). Psychiatric Nursing-eBook. Elsevier Health Sciences.
Minnesota Department of Human Services (MDHS). (2020). Anoka-metro regional treatment center. Web.
Niu, S. F., Kuo, S. F., Tsai, H. T., Kao, C. C., Traynor, V., & Chou, K. R. (2019). Prevalence of workplace violent episodes experienced by nurses in acute psychiatric settings. PLoS One, 14(1), e0211183.
Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. JONA: The Journal of Nursing Administration, 43(2), 69-72.
Zhang, L., Wang, A., Xie, X., Zhou, Y., Li, J., Yang, L., & Zhang, J. (2017). Workplace violence against nurses: a cross-sectional study. International Journal of Nursing Studies, 72, 8-14.