Staff-Designed Culture Transforms Delivery of Behavioral Health Care

Added on Dec 5, 2019

snipe-overview-exploreHCA Virginia’s Retreat Doctors’ Hospital: Staff-Designed Culture Transforms Delivery of Behavioral Health Care
By Audrey Doyle

In May 2017, as construction crews were putting the finishing touches on the new behavioral health unit at HCA Virginia’s Retreat Doctors’ Hospital, the unit’s newly hired staff were putting the finishing touches on a transformational culture they helped design to support patients on their journey to emotional recovery.

“Having our staff play such an important role in developing the culture was monumental for us. Not only did it generate immediate buy-in for how the unit would be run, it has also helped keep the staff engaged in their work,” said Burgin Collis, RN, the unit’s nurse manager.

Additionally, every staff member had worked in behavioral health at a facility either within or outside of the HCA system, and many of them were familiar with patient experience measurement, so they were able to give valuable insights on how best to run the new unit from a provider and patient perspective.

This, combined with the high level of workforce engagement, has positively influenced patients’ perceptions of their care experience, according to Collis, who co-delivered a session on this topic at the 2019 Press Ganey National Client Conference in Orlando, Florida, last month. Since receiving its first round of patient experience survey results in Q4 2017, Collis said, the unit has remained in the top 10% of all HCA inpatient psychiatric facilities for questions regarding patients’ overall impression of their hospital stay and their likelihood to recommend the hospital to others. Also, the unit has consistently ranked above the 80th percentile for “Overall Rating.” This performance aligns with recent Press Ganey research on engagement patterns and trends that correlate high workforce engagement and sustained or improved patient experience scores.

The Role of Trauma in Behavioral Health Disorders

Located in Richmond, Virginia, Retreat Doctors’ Hospital is a 226-bed acute care facility that is part of the Capital Division of HCA Healthcare, a large health system comprising 185 hospitals and approximately 1,800 sites of care in 21 states and the United Kingdom. Retreat Doctors’ 20-bed behavioral health unit, also known as the Retreat Center for Emotional Growth, opened in June 2017. Its staff of psychiatrists, registered nurses, nutritionists, case managers, activities therapists, and mental health technicians provide care to voluntary and involuntary adult patients who are in crisis and need short-term, intensive treatment for mood disorders such as depression, anxiety, and post-traumatic stress disorder; thought disorders such as schizophrenia and psychosis; and substance use and abuse disorders.

While the unit was still in the planning stages, leadership determined that its treatment objectives and strategies would focus heavily on trauma-informed care. Trauma is defined as a person’s psychological or emotional response to a deeply distressing experience such as abuse, violence, neglect, family dysfunction, poverty, the sudden or violent death of a loved one, an accident or natural disaster, discrimination, or racism. Although most often occurring in childhood, trauma can strike at any time in a person’s life and significantly increases their risk for developing mood and substance use/abuse disorders as well as chronic medical conditions such as obesity, heart disease, high blood pressure, and lung cancer.

In trauma-informed care, clinicians are trained to recognize symptoms of trauma in patients, and instead of trying to stop their problematic behavior or disorder, they try to identify what caused their trauma, acknowledge how it has affected their lives, and help them heal while taking steps to avoid re-traumatizing them.

“Essentially, trauma-informed care is about changing the fundamental question from ‘What’s wrong with the patient?’ to ‘What happened to the patient?’” Collis said. The goal, she added, is to help patients recover in an empowering manner in an environment that’s free of cultural and historical stereotypes and biases and where they feel physically and emotionally safe, understand what’s happening and likely will happen to them during treatment, and can actively participate in decision-making and goal setting.

Thanks to increasing awareness of the role trauma plays in a person’s mental, behavioral, and physical health, most behavioral health systems incorporate principles of trauma-informed care into their treatment philosophies. Nevertheless, according to Collis, it can still be challenging for staff to adopt a trauma-informed mindset. Many can find it difficult to deviate from the strict rules and regimented schedules typically employed in behavioral health settings, she said, or they find it frustrating not to have a one-size-fits-all rule for patients.

Recruiting the Staff for Cultural Fit

As staff input would be key in developing a unit culture that would provide an optimal trauma-informed care experience for patients, it was important for leadership to ensure that every person who would be working on the unit either already had a trauma-informed mindset or possessed traits that are well-suited to this approach.

Therefore, as part of the interview process, leadership conducted behavioral interviews to assess prospective employees’ future actions based on their past behavior. This helped them gauge the interviewees’ ability to, for instance, recognize and acknowledge trauma, empathize with patients, de-escalate agitated patients in a nonjudgmental way, and foster growth and positivity. In addition, it helped them gauge their willingness to implement trauma-informed methods, such as always asking permission instead of assuming patients will discuss or do anything that’s asked of them, and reducing the use of restraints and seclusion.

The interview process also gave leadership an opportunity to assess how well prospective staff would assimilate to the way the unit was laid out. As Collis explained, leadership had determined that patient privacy would be a key factor in the unit’s design. As such, instead of having semi-private rooms, which is typically the case at psychiatric facilities, the unit has only private rooms, each with a private bathroom. Not only does this allow patients to have some time alone when they feel they need it, but it’s also beneficial for the unit’s fairly high number of patients who identify as transgender, as this eliminates the need to secure blocked rooms for these patients, which can create or exacerbate stigmas around their identity, noted Collis. In addition to private rooms, the unit also has private consulting rooms for conducting patient admission and discharge, and it has multiple individual spaces for patient de-escalation and family meetings.

“Giving patients some privacy is an important element of trauma-informed care because it helps build a sense of control and empowerment. But lots of facilities don’t have single rooms or offer lots of options for patient privacy, so we made sure everyone we hired would feel comfortable working in a facility that has this type of setting,” said Collis.

Determining the Unit Guidelines

Once the staff were hired, Collis and the leadership team held a weeklong orientation that included a staff summit. During this daylong meeting, the staff discussed what had and hadn’t worked well at the facilities they were with previously. Additionally, as most of those facilities utilize the patient experience survey, they also discussed what patients reported had contributed to a positive experience for them and what had been lacking. “We took all of this information from the staff and, together with them, developed the guidelines for running the unit,” Collis said.

According to Collis, behavioral health units tend to be highly regimented, which means most aspects of a patient’s stay are tightly controlled. The staff wanted to give a small amount of that control to patients, as they felt this would go a long way toward providing optimal healing and outcomes. Therefore, many of the guidelines they developed are atypical for a behavioral health setting.

For example, on psychiatric units, patients’ cell phones usually remain locked up until discharge. Here, patients’ cell phones remain on the unit. This allows patients to, with staff assistance, find an alcohol or narcotics support group near their home that they can attend when they’re discharged, download a free meditation app to help them with anxiety both during and after their hospital stay, or draft an email to a professor or a boss to explain their absence from school or work, for instance.

Similarly, on psychiatric units, meals and snacks are typically offered at only certain times of the day. But a common side effect of psychiatric medication is increased appetite, and in the staff’s experience, this one-size-fits-all approach to meals and snacks didn’t work for all patients. So, instead of enforcing a set snack time, the unit provides patients with healthy snacks throughout the day. In addition, the medication nurse has hard candies handy for patients experiencing dry mouth, another common side effect of psychiatric medication.

“These may sound like small things, but they make a huge difference in a patient’s comfort,” said Collis. “In a medical unit, if a patient is hungry or thirsty, all they have to do is ask and, barring any food restrictions, they can have something to eat or drink whenever they want. Our staff felt that it shouldn’t be any different on this unit.”

Also, at most facilities, behavioral health patients can have visitors only once a day. But staff felt this was too restrictive as it didn’t accommodate family members and friends who work during the day. So at Retreat Doctors’, behavioral health patients can have visitors twice a day, from 2 to 3 p.m. and from 8 to 9 p.m.

Keeping the Positive Momentum Going

As noted, hiring for fit and involving staff in culture development have been key factors in the unit’s high workforce engagement and sustained patient experience scores. According to Collis, she and her team are taking some important steps to keep that momentum going.

For instance, they’re providing ongoing workforce development and staff training to ensure that the trauma-informed mindset remains at the center of care. In addition, nurse leaders round on all staff members every quarter to address any emotional stress that may have arisen as a result of working with patients who have experienced trauma.

Staff rounds also give leaders an opportunity to continue to solicit input on how well things are going on the unit and whether any guideline changes need to be made. As an example, one recent change that was made based on staff feedback concerns nighttime noise. Every 15 minutes, staff are required to conduct a safety check on patients, but for some patients, the sound of their door opening and closing was disturbing their sleep. At the suggestion of the staff, the unit now has battery-operated ambient noise machines available for patients who want one in their room.

Nurse leaders also round daily on all patients, and when they receive a compliment about a staff member from a patient, they make sure they recognize the staff member for their work through a handwritten thank-you note or a congratulatory message on the staff bulletin board. As a final step, the leadership team continues to review patient experience survey scores and comments each quarter, and Collis shares the feedback with the team at their monthly staff meeting.

According to Collis, these actions contribute to a positive patient experience because they help prevent staff burnout and turnover and keep staff engaged. “Working in behavioral health presents significant challenges, and it would be easier to just throw up our hands and do things the way they’ve always been done,” Collis said.

“Involving staff from the outset, and keeping them involved, has allowed them to craft their own experience,” she concluded. “And when they can see that what they’re doing is helping their patients heal, it motivates them to continue this work.”