Abstract
The paper examined whether having Behavioral Emergent Response Team (BERT) in a hospital settings, compared to not having one decrease the risks of injuries to patient and or staff among the adult inpatient hospital population. The first introduced the research topic and laid out its overview and background information which conveyed an accurate and broad perspectives on the topic, and a succinct summary of the past research, current application and the importance of the research topic. Different studies analyzed in the paper provided a comprehensive overview of the relevant literature that supports how BERT reduces incidences of potential harm, risks and violence to patients and the staff in the hospital. The paper also identified the strengths and weaknesses and gaps in the body literature. The identified strengths in the literature include boosting of confidence among staff members, reduction of violence or risks in non-psychiatry units in hospitals and increased collaboration among the staff in a hospital. On the other hand, the challenges identify lack of quick response from BERT team in preventing potential harm and inconsistency among the BERT members. The topic is clinically relevant and can be applied in different units in a hospital settings such as emergency, critical, pulmonary, surgical units. Recommendations for application of using BERT in hospital settings include having proper communication channels, BERT is readily available, having qualified staff members and working round the clock.
People Also Read
Introduction
Behavioral emergencies often take place among the adult in patients when they are potentially harmful to herself/himself or others or is physically aggressive. Despite the fact that they may be very rare, Allen et al (2003) noted that behavioral emergencies are situations of high risk, and, therefore, untrained staff may feel uncomfortable when dealing with these situations or events. The adult patients with the underlying development or psychiatric disorders, those who have side effects of medication, those who have ingested substances are at the highest risk of being violent. Bogert indicated that the triggers of these events could be hospital’s physical environment, change of routine, isolation, hunger, or even pain. The early warning signs of behavioral emergency include yelling, verbal threats or even silence. Moreover, the physical signs may include throwing objects, furrowed brow, crossed arms and pacing.
In events of potential behavioral emergency, the first response is trying de-escalating the situation. The medical professional should speak in calm and quite voice, or even back off and provide personal space to the patient. Similarly, the healthcare professional should try to reduce the discomfort by using rewards or distractions (Delaney, 1994). In an event where de-escalation is unsuccessful, and the patients become violent, the first role of the provider is to be safe by trying to get help and getting away. Therefore, hospitals need to have or need to develop a response team for the violent patients, which may restrain the patient physically in case of emergencies. IHI (2004) asserted that medications can be used in treating medical issues but should not be used for chemical restraint solely.
Overview
Behavior of adult inpatient with psychiatric illness and are hospitalized on the non-behavioral health units according to Jamieson, Ferrell & Rutledge (2008) can be difficult addressing by the staff members. In a hospital set up, they may recognize that responding, assessing and implementing patients care to the individual in a non-behavioral health unit and experiences behavioral health emergency may be outside the scope of the protocol. Forming the rapid response team to de-escalate potentially violent and volatile situations proactively in non-psychiatric units in hospitals allows faster and earlier management and treatment of these behavioral issues in such patients. The hospitals may consider coming up with the Behavioral Emergency Response Team (BERT) to assist the medical staff in hospitals in de-escalating patients exhibiting potentially violent behaviors proactively. Jolley et al (2007) pointed out that BERT may comprise of the staff members such as the social workers, RNs, psychiatrists, security staff among others from the behavioral health unit. The staff members in BERT should be experienced in caring for the patients experiencing acute psychiatric disorders and assault behaviors management.
Psychiatric nurses and staff are trained professionals treating many different mental health diagnoses. It is a specialty that often requires de-escalation techniques. All staff working on inpatient psychiatric unit have all had Crisis Prevention Intervention training. They are skilled in specific techniques using little or no restraints to talk down an agitated or escalating patient. Crisis Prevention Intervention training focuses on four stages of escalation: anxiety, defensiveness, acting out and tension reduction.
Psychiatric nurses and staff are trained professionals treating many different mental health diagnoses. It is a specialty that often requires de-escalation techniques. All staff working on inpatient psychiatric unit have all had Crisis Prevention Intervention training. They are skilled in specific techniques using little or no restraints to talk down an agitated or escalating patient. Crisis Prevention Intervention training focuses on four stages of escalation: anxiety, defensiveness, acting out and tension reduction.
However, other nurses in other areas in the hospital where they may be dealing with an escalating patient do not have Crisis Prevention Intervention training and have to maintain their safety and the safety of the patient. Nurses in non-psychiatric settings are expected to provide care to patients with mental health and behavioral issues. One in four American adults suffers from a diagnosable mental disorder in a given year, with 1 in 17 suffering from serious mental illness (National Institute of Mental Health, 2010).
PICO
Among the adult inpatient hospital population, does having a Behavioral Emergent Response Team (compared to not having one) decrease the risks of injuries to patient and or staff?
Theoretical Framework
The paper used Lewin’s Change Management theory as basis for building the foundation for the project. Change is a common denominator applicable to all organizations regardless of the industry, age or size. World is rapidly changing, and therefore organizations must also quickly change. The change management concept is common in most organizations nowadays but how they manage the change varies enormously depending on the organization’s nature, people involved and the change itself. Kurt Lewin developed on of the cornerstone theories crucial in understanding organization change. This model is also known as Unfreeze-change-refreeze, which refers to a process of change in three stages (Shirey, 2013).
To easily understand Lewin’s theory, the simple example analogy is provided by a cube of ice and what is needed is a cone of ice. To get the cone of ice, the cube of ice is first melted to make it easier for change (unfreeze). The melted ice is then molded into the desired shape of the cone (change) and then solidified while in the desired shape (refreeze). By critically examining change process with stages, the organization is first prepared for what is coming and then plan is made for the transition (Shirey, 2013).
Unfreeze
This is the first stage in the process of change and involves preparation f the organization to understand that change is essential. This can be done by developing messages that are compelling that shows why the current ways of doing things should be changed. The attitudes, values, beliefs and behaviors currently defining an organization should be challenged (Shirey, 2013). For instance, the beliefs that non-psychiatric nurses cannot handle patients showing symptoms of psychiatric disorders must be challenged to incorporate them in the BERT.
Change
From the uncertainty created in the unfreeze stage, the next stage of change is where individuals will start resolving their uncertainties by looking for new and better ways of doing things. They may start believing and acting in ways supporting the new direction. For a change to occur, communication and time are keys to success. People need time to understand the changes better and also to feel being part of the organization (Shirey, 2013). In this case, health workers need to understand how BERT operates, its benefits, who are the members and how it assists in the organization.
Refreeze
After people have embraced new working ways and change has taken shape, the organization can start the refreezing process. Some of the signs of refreezing process include consisted descriptions of jobs, stable chart for the organization among others. This is also the stage where the organization needs to help the organization and the people to institutionalize and internalize the changes (Shirey, 2013). In this case, the nurses will ensure that the introduced changes of alerting BERT in cases of emergencies are used all the time and is incorporated in all units in the hospital.
Background
Nurses working in the non-psychiatric settings are expected to provide care frequently to the patients with issues of behavior management and mental health. According to the National Institute of Mental Health (2010), one in every four adults in America suffer from mental disorders yearly, with one in seventeen having serious mental illness. While reviewing the literature, Zolnierek (2009) observed that several studies suggesting people suffering from mental illness experience increased medical comorbidities that often necessitates hospitalization. Berren et al (1999) in their study indicated that people with mental illnesses tend frequently to receive care in acute/urgent care settings hat individuals without mental illness.
Several factors influence the abilities of the nurses to provide interventions to patients with issues of mental health effectively in non-psychiatric inpatient settings. Several studies have cited two factors that is presence of the negative attitude to the mental ill patients along with the perceptions of the nurses of lack of confidence and competence in identification and management of behavioral symptoms (Brinn, 2000; Ross & Goldner, 2009; Reed & Fitzgerald, 2005; Zolnierek, 2009; Sharrock & Happell, 2006). In addition to the fear of the nurses and lack of confidence, mental ill patients are often perceived as dangerous and unpredictable (Ross & Goldner, 2009).
Violence at workplace is a great matter of concern. The workplace prevention guideline for violence as outlined by Occupational Safety and Health Administration (OSHA) (2004) indicate that the healthcare workers face job-related violence risks. Guidelines of OSHA state that “lack of training of staff in managing and recognizing escalating assaultive and hostile behaviors” places the workers of healthcare at a greater risk for assaults that are related to work (OSHA, 2004p. 7). In defining workplace violence, American Psychiatric Nurses Association (APNA) (APNA, 2008) include verbal, sexual and physical threats and abuse from the peers and the consumers. APNA then recommends establishment of comprehensive programs by the health organizations for prevention and management of workplace violence.
According to APNA (2008) and Roche et al (2009), the actual statistics of the number of injuries of health care workers related to patients’ assaults is unknown. The cases of violence against the healthcare workers may be underreported because of several reasons including the perception that it is part of their job. Roche et al (2009), pointed out that beyond the immediate possible injury, the effects of workplace violence instances can spread distress among the members of staff leading to increasing turnover of nurses and deterioration of the health of staff. The Joint Commissions (2010) sentinel event alert identified the need for the healthcare centers to reduce the risks of patients’ violence to staffs since there are increasing reported violence rates including assaults by the patients.
Different suggestions and solutions have been brought forward by experts in an attempt of addressing the fears of the healthcare workers, and for improving safety of staff and outcomes of patients when caring for the patients suffering from behavioral issues in the non-psychiatric settings. Some of the recommendations include exposing the nurses to patients with issues of mental health, additional nursing education and implementation of the specialised care units or consultative liaison services (Zolnierek, 2009; Atkin, Holmes, & Martin, 2005).
Another solution to the problem is the use of a team response that is modelled in line with the rapid response teams and is adapted to behavioral and mental needs. In United States, Rapid Response Teams have been introduced as a reassure of bringing specialized expertise to the bedside of a patient for earlier intervention and prevention of psychological deterioration of a patient (Donaldson et al, 2009; Scott & Elliott, 2009; Hatler et al., 2009; Wynn, Engelke, & Swanson, 2009). In the literature, the paper found only one team model to be responding to the behavioral issues that need emergent attention just like the Rapid Response Teams, which is behavioral emergency response team (BERT).
Literature Review
There are few research studies done on whether Behavioral Emergent Response Team in hospitals when compared to not having one, could decrease the risks of injuries to the patient and or staff among the patients hospitalized in non-psychiatric units. A search of literature using the database of CINAHL to look for descriptions of BERT teams showed only the result on Lester (2000). The study described BERT as providing psychiatric services for controlling control units of stress. In searching relevant studies and reaches done on the field, the researcher started the search with the most comprehensive database that is Cumulative Index to Nursing and Allied Health (CININAH) (Kennedy, 2009). The search then continued to search engines such as British Nursing Index, MEDLINE. Moreover PubMed and NCBI were other major search engines which assisted some of the relevant articles for the capstone project. These search engines were used because they contained most of the peer review articles and books. Assessment of the search strategy used was done to ensure that some relevant studies that could be a great source of information were not left out by being too specific. In data extraction, the factors considered included the following; study design, performing year, publication years, and characteristics of the population of the study, the geographical setting, variance and risk estimates and assessment procedures. The dissertation used different sources in the search strategy which include electronic databases, conference abstracts, hand searching, and internet. Most of the literature identified were descriptive in nature with no quantitative study. Therefore, the literature review for this paper will be descriptive of the different research studies identified.
Approximately one in every four adults in United States in a year is affected by mental illness (National Institute of Mental Health, 2008).Moreover, Zolnierek (2009) indicated that the persons who are mentally ill severely suffer chronic medical illnesses at a higher rate compared to the population, in general. This makes it probably that individuals with severe mental illness will seek medical care and be hospitalized. However, when hospitalized on the non-psychiatric units, the behaviors of the individuals with dementia/delirium, bipolar disorder and schizophrenia may confound the medical nurses who are accustomed to dealing with the mental illness cases. Landers & Bonner (2007) suggests that medical or the surgical staff need resources to assist them in meeting the challenges of behavioral issues that are related to the patients’ psychiatric conditions.
In the studies done by Ross & Goldner (2009) and Zolnierek (2009), the central themes discussed are discrimination, negative attitude and stigma towards the mentally ill persons among the nurses. The health care workers tend to label the mentally ill patients as “difficult” and this is influenced by the encounters of the nurse-patient and environmental factors in the hospital (Zolnierek, 2009).
According to Mackay, Paterson, & Cassells (2005) psychiatric nurses are very familiar with the mentally ill patients’ behavioral aberrations. The nurses in the acute psychiatric units commonly observe the patients for any escalating behavior predictors, and then intervene in any negative event. Moreover, these psychiatric nurses control their units’ environments such as activity level, pace and tone in an attempt of creating a therapeutic milieu which prevents the escalation of the patients’ behaviors (Delaney, 1994). Allen et al (2003) also stated that the psychiatric nurses are very familiar with the relevant medical treatments of the behavioral emergencies, and they can correctly report signs and signs warranting interventions pharmacologically.
Behavioral emergency response team (BERT) was created on the premise that these psychiatric nurses who are trained and experienced would transfer their skills to the non-psychiatric units in the hospitals where patients with psychiatric conditions which are demonstrating scary and risky behaviors. Lester (2000) described BERT as an adaptation of the RRT of the hospital for the patients that are medically ill. BERT involves proactive strategies for de-escalating situations that are potentially volatile with the behavioral health patients hospitalized in non-psychiatric units.
Behavioral emergency response team (BERT) is a consultative resource that can be used in non-psychiatric settings when there is the presence of psychiatrist behaviours. The behaviors targeted are those that are potentially threatening or disruptive actions of persons with psychiatric history or for the other patients compromising the wellbeing and safety of staff members, visitors, other patients and selves
Several studies support that having BERT decreases the risks of injuries to staffs and the patients among the adult inpatient hospital population (Loucks et al, 2010; Pestka et al, 2012). Activation of BERT is done when an inpatient unit nurse notifies the behavioral health service unit of a problem. Depending on the nature of the scenario in the unit, one or more team members of BERT will respond, assess the patient and put action strategies depending on the situation to defuse the problem and stabilize the patient (Karshmer & Hales, 1997). Moreover, when the situation has been defused, a team member of BERT debriefs the unit staff by conducting one-on-one teaching as required in such a situation.
In a study done by Loucks et al (2010), the researchers used Iowa Model of Evidence-Based Practice proposed by Titler et al (2001) to aid in their systematic approach of BERT. The model adopted directs decision making from identification of problems, through searching for evidence and appraisal to evaluation of the intervention or practice that is evidence based. The researchers were interested in learning the unit staff nurses responses in terms of their experience and knowledge with the BERT team and their level of comfort when taking care of the psychiatric patients in their units. The research used survey method, in which on-duty nurses were surveyed from the nine units. The survey was done on either short questionnaire or phone interview. From the 39 nurses interviewed, 54%stated they understood BERT clear, 31% reported high level of comfortability in caring for the psychiatric patients, and 36% or 14 nurses had been involved in BERT call and they all believed that the needs of the patients were met (Loucks et al, 2010). From their study, Loucks et al (2010) found that BERT allowed the nurses of the non-psychiatric units’ access the behavioral health nurses that are specially trained to assist in deleterious or potentially dangerous situations. Where previously the nurses approached the care for the mentally ill patients with fear and skepticism, they can now use the gained knowledge from the BERT team members and where necessary.
Summary and Conclusions of Review of Literature
Strengths of BERT
The BERT team in hospitals according to Pestka et al (2012), offered solution to the long-standing problem of the nurses engaged in direct care of patients, and created a valuable resource for the safety of both staff and patients. Apart from enhancing safety, BERT has also contributed to the satisfaction of nurses with their work. Most studies commented on the nurses knowing that their assistance request in management of emergent behavioral situations is addressed. Moreover, the psychiatry nurses reported satisfaction from the reports of affirmation of their psychiatry skills by their peers from no psychiatry following their interventions in situations of behavioral patients
Another strength of BERT is the broader collaborative efforts it creates between psychiatry and other medical areas in all disciplines (Pestka et al, 2012).
Challenges facing BERT
The biggest challenge to BERT is how to ensure that a physician responders and psychiatric nurse are readily available when requested. The role of response demand flexibility of the team members to be able to reach the location of the behavioural emergent need quickly. Another challenge is the anxiety the BERT team members have about the situations they are likely to encounter when called upon. Moreover, other lack consistency and not confident (Pestka et al, 2012).
Clinical Relevance and Application
BERT is relevant and can be applied in hospitals to avert potential harm, violence and keep the staff and patients safe. An example of clinical application of BERT is on the medical pulmonary unit since the unit often has high incidences of comorbid issues of psychiatry (Pestka et al, 2012). To begin, staff education should be done on specific guidelines for BERT team such as methods of identifying a patient, team members, communication methods, methods of activating BERT, responsibilities of BERT staff, Floor RN responsibilities.
Other relevant medical units that BERT can be applied include critical care and women’s health, medical-surgical units, and the emergency departments.
Conclusion
In conclusion, BERT is a resource for meeting the growing behavioral emergencies management and the increasing rate of reported patients’ violence. The paper examined whether having BERT compared to not having one decreases the risks of injuries to the staff and patients among the adult inpatient hospital population. The aim of BERT is to de-escalate the potentially violent or harmful situations when called upon. BERT should be formed by security staff, psychiatry nurses and the physicians among others. With the increasing cases of patient violence in non-psychiatry medical units, BERT is needed in every hospital. Many studies document improved safety for the staff in hospitals with BERT functioning than hospitals without BERT functioning. Despite its need in hospitals, BERT also has strengths and challenges. Some of the strengths include offering the long-term solution of safety to the health workers, boosting the confidence and satisfaction of the nurses, and lastly enhancement of collaboration between different departments. On the other hand, some of the challenges include ensuring faster response of the team, and availability of the team when needed. Lack of consistency and confidence is another challenge of the initiative. BERT can applied in different clinical set-ups such as pulmonary units, critical care and women’s health, medical-surgical units, and the emergency departments.
Recommendations
In applying or actualizing BERT in a hospital setting, the following recommendations are of great importance.
The BERT team should be structured in the hierarchyand with bettercommunicationlinesclearlyoutlined. Thecommunication from themedicalunit, to the Behavioral Health serviceleader, to BERT leaderandtotheteam
The BERT team should be readilyavailablewhencalled upon in cases of behavioral emergent issues
The team members should be qualified, have the proper education and understand their roles to avoid lack of confidence among team members.
The BERT team should also have an all-around team working in shifts, both at night and daytime, to ensure their availability anytime when needed.
References
Allen, M. H., Currier, G. W., Hughes, D. H., Docherty, J. P., Carpenter, D., & Ross, R. (2003). Treatment of behavioral emergencies: A summary of the expert consensus guidelines. Journal of Psychiatric Practice, 9, 16-38.
American Nurses Association. (2001). Code of ethics. Retrieved February 24, 2009, from http://nursingworld.org/ethics/code/protected_nwcoe813.htm
American Psychiatric Nurses Association (APNA). (2008). Workplace violence position statement. Retrieved from http://www.apna.org/i4a/pages/index. cfm?pageid=3786
Atkin, K., Holmes, J., & Martin, C. (2005). Provision of care for older people with co-morbid mental illness in general hos-pitals: General nurses’ perceptions of their training needs. International Journal of Geriatric Psychiatry, 20, 1081-1083.
Berren, M., Santiago, J., Zent, C., & Carbone, C. (1999). Health care utilization by per-sons with severe and persistent mental illness. Psychiatric Services, 50(4), 559- 561.
Bogert, S., Ferrell, C., & Rutledge, D. N. (in press). Experience with family activation of rapid response teams. MEDSURG Nursing.
Brinn, F. (2000). Patients with mental illness: General nurses’ attitudes and expecta- tions. Nursing Standard, 14(27), 32-36.
Delaney, K. R. (1994). Calming an escalated psychiatric milieu. Journal of Child & Adolescent Psychiatric Nursing, 7, 5-13.
Donaldson, N., Shapiro, S., Scott, M., Foley, M., & Spetz, J. (2009). Leading success-ful rapid response teams. The Journal of Nursing Administration, 39(4), 176-181.
Hatler, C., Mast, D., Bedker, D., Johnson, R., Corderella, J., Torres, J., … Plueger, M. (2009). Implementing a rapid response team to decrease emergencies outside the ICU: One hospital’s experience. MEDSURG Nursing, 18(2), 84-90, 126.
Institute for Healthcare Improvement. (2004). Rapid response teams. Retrieved November 2, 2008, from http://www.ihi.org/IHI/topics/criticalcare/intensivecare/improvementstories/fsrapidresponseteamsreducingcodesandraisingmorale.htm
Jamieson, E., Ferrell, C., & Rutledge, D. N. (2008). Medical emergency team implementation: Experiences of a mentor hospital. MEDSURG Nursing, 17, 312-316.
Jolley, J., Bendyk, H., Holaday, B., Lombardozzi, K. A., & Harmon, C. (2007). Rapid response teams: Do they make a difference? Dimensions in Critical Care Nursing, 26, 253-260.
Karshmer, J. F., & Hales, A. (1997). Role of the psychiatric clinical nurse specialist in the emergency department. Clinical Nurse Specialist, 11, 264-268.
Kennedy, J. R. (2009). Library research guide to education: illustrated search strategy and sources. Ann Arbor, Mich, Pierian Press.
Landers, J., & Bonner, A. (2007). Evaluating and managing delirium, dementia, and depression in older adults hospitalized with otorhinolaryngic conditions. ORL Head & Neck Nursing, 25(3), 14-25.
Lester, K. S. (2000). The psychologist’s role in the Garrison mission of combat stress control units. Military Medicine, 165, 459-462.
Loucks, J., Rutledge, D.N., Hatch, B., & Morrison, V. (2010). Rapid response team for behavioral emergencies. Journal of the American Psychiatric Nurses Association, 16(2), 93-100.
Mackay, I., Paterson, B., & Cassells, C. (2005). Constant or special observations of inpatients presenting a risk of aggression or violence: Nurses’ perceptions of the rules of engagement. Journal of Psychiatric and Mental Health Nursing, 12, 464-471.
National Institute of Mental Health. (2008). Statistics. Retrieved April 1, 2009, from http://www.nimh.nih.gov/health/topics/statistics/index.shtml
National Institute of Mental Health. (2010). Statistics. Retrieved from http://www. nimh.nih.gov/health/topics/statistics/inde x.shtml
Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care & social service workers (# 3148-01R). Retrieved from http://www.osha.gov/ Publications/OSHA3148/osha3148.html
Pestka, E. L., Hatteberg, D. A., Larson, L. A., Zwygart, A. M., Cox, D. L., & Borgen, E. E. J. (January 01, 2012). Enhancing safety in behavioral emergency situations. Medsurg Nursing : Official Journal of the Academy of Medical-Surgical Nurses, 21, 6.)
Reed, F., & Fitzgerald, L. (2005). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hos-pital. International Journal of Mental Health Nursing, 14(4), 249-257.
Roche, M., Diers, D., Duffield, C., & Catling- Paull, C. (2009). Violence toward nurses: The work environment and patient out-comes. Journal of Nursing Scholarship, 42(1), 13-22.
Ross, C. A., & Goldner, E. M. (2009). Stigma, negative attitudes and discrimination towards mental illness with the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 16, 558-567.
Scott, S., & Elliott, S. (2009). Implementation of a rapid response team: A success story. Critical Care Nurse, 29(3), 66-74.
Sharrock, J., & Happell, B. (2006). Com – petence in providing mental health care: A grounded theory analysis of nurses’ experiences. Australian Journal of Advanced Nursing, 24(2), 9-15.
Shirey, M. R. (January 01, 2013). Lewin’s Theory of Planned Change as a strategic resource. The Journal of Nursing Administration, 43, 2, 69-72.
The Joint Commission. (2010). Preventing vio-lence in the health care setting. Sentinel Event Alert, Issue 45. Retrieved from http://www.jointcommission.org/sen tinel_event_alert_issue_45_prevent ing_violence_in_the_health_care_set ting_/
Titler, M., Steelman, V. J., Budreau, G., Buckwalter, K. C., & Goode, C. J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13, 497-509.
Wynn, J., Engelke, M., & Swanson, M. (2009). The front line of patient safety: Staff nurs- es and rapid response team calls. Quality Management in Health Care, 18(1), 40-47.
Zolnierek, C. D. (2009). Non-psychiatric hospitalization of people with mental illness: Systematic review. Journal of Advanced Nursing, 65, 1570-1583.
With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.
