NUR 601 Week 7 Group Assignment 1: Application to Pragmatic Adequacy

The theory that will be discussed in this paper is Crisis emergencies for individuals with severe, persistent mental illness (SPMI): A situation-specific nursing theory.  This theory was chosen because it is an important topic for nursing education.  There is a large and growing presence of clients with SPMI in crisis engaging nurses in emergency departments.  For many years access to necessary mental health resources has been an issue in this country.  It is a stigmatized and underfunded branch in healthcare.  With the decline in mental health facilities over the past decades, emergency rooms have had to bridge the gap to mental health resources for patients in crisis.  The number and proportion of mental health crisis emergency department visits have been steadily increasing in the United States in recent years. In 2014, there were more than 2.2 million emergency department visits by patients whose primary diagnosis was serious mental illness (O’Neil, 2016). For people with the most severe mental illnesses, delays in care simply because treatment is unavailable or inefficient may result in such deterioration in their condition that recovery is less achievable.

This theory presents itself as an extension of Ball’s mid-range theory for crisis. The mid-range theory for crisis was already an expansion upon crisis theory. The mid-range theory for crisis explores vulnerabilities that individuals suffering from mental illnesses have in conjunction with crises experienced whereas prior research looked primarily on how external factors influence crises. In essence, the center point of the theory presented in the article explores a situation specific application of a patient’s crisis experience. In the article by Brennaman (2021), it states, “This extension is a situation-specific theory that focuses on the specific phenomenon of ISPMI “getting help” when experiencing crisis.” They do so by focusing on situation specific factors about an individual who is experiencing a mental health crisis like looking at their community environment, their gender, their race, the local laws, and their ability to pay for aid. This situation-specific theory’s main concepts are directed towards nurses in the emergency department so that they can distinguish between a need for mental health crisis intervention and mental health emergency intervention.

Evaluation

Using the “theory to practice to theory strategy”, the author portrayed Ball’s model of crisis experience for ISPMI for use in emergency care settings such as the emergency department. The goal of this was to aid nurses and other health care providers in giving the most appropriate level of care that addresses the long and short-term needs of clients who are experiencing a mental health emergency. The purpose of the emergency departments is to maintain client safety and facilitate entry into inpatient mental health care that provides the least restrictive and most therapeutic care for the patient. Ball’s model of crisis states that when people are experiencing crisis, they may exhibit a variety of behaviors stemming from the sense of being overwhelmed and loss of control. The nurse or other health care practitioner must first determine whether the client is experiencing an emergency or crisis and implementing the appropriate intervention based on this. Then nurses and providers must be educated regarding what is best to follow suit. From there, they can decide whether physical or medicinal restraints are necessary.

Although Ball’s model describes this briefly, it does not completely describe it when it is applied to a practice context. In this theory from the article by Brennaman (2012), the author attempts to place Ball’s model for crisis experience for ISPMI in the practice setting of the hospital ED. The easiest way for this model to be applied to practice is to state these patients must get help when experiencing crisis.

There is a plethora of nursing research on situation specific theories.  The benefit of situation specific theories is that they can drill down to become more specific as an extension of a midrange theory.  Ratchneewan et. al. (2020) published a situation-specific theory titled Systemic Assessment of Depressive Symptoms Among Registered Nurses: A New Situation-Specific Theory (SAD-RN).  This study used depressive symptoms as the anchor concept and found related concepts of depressive symptoms among registered nurses to include context, stressors, protective factors, negative health outcomes, and low patient care quality.  The authors claim that SAD-RN is an evidence-based comprehensive model that offers researchers a guiding theory to be used in their future research on depressive symptoms among RNs (p. 207).

A situation specific theory presents a lower level of abstraction when compared to large theories and medium‐sized theories. In addition, the approach of nursing research and clinical practice becomes more evident with an SST (Teixeira et. al., 2021, p. 29).  Brennaman’s (2012) extension of Ball’s crisis model attempts to link the phenomena that create immediate risk of harm within the framework of crisis to provide structure to the type of interventions that are appropriate to the intensity of the situation (p. 252).  A favorable outcome that results from using this theory as a basis for nursing practice is to allow for nurses in emergency departments to distinguish between a need for mental health crisis intervention and mental health emergency intervention.  A second favorable outcome would be for SST to guide future situation specific interventions and research.

Healthy People 2020

The Office of Disease Prevention and Health Promotion (2020) “Healthy People 2020” include mental health goals for the present and future. The mental health goals’ aim is to improve mental health through preventions and ensuring access to appropriate, quality mental health services. The two areas of objectives include treatment expansion and mental health status improvement.

The treatment expansion efforts identified by healthy people 2020 include increasing the number of adults 18 or older receiving treatment for serious mental illness, major depressive disorder, and co-occurring metal illness and substance abuse. Brennaman (2012) identified that “the individuals toward whom this theory is directed lack routine access to appropriate care that could mitigate the frequency with which they must deal with crises and emergencies”. The objectives of Health People 2020 are fitting of Brennan’s theory because it identifies the gap existing in mental health care. Preventative measures increasing in the community with the intent to decrease amount of acute mental health crisis leading to emergency department visits. Chang et al. (2019) conducted a study to examine the effects of outpatient services through primary care for those struggling with substance use disorder and mental illness. The study concluded that those with outpatient services had fewer emergency department visits and less overall days spent in emergency department with these services in place as opposed to similar patients without outpatient services. This study supports the initiative of Healthy People 2020 to increase access of mental health services.

In order to achieve treatment expansion, some changes must happen, such as insurance coverage, adding more mental health treatment facilities, extensive screening for mental health issues. Health insurance coverage is such a problem for the everyone and half the time, the people that really need to be covered are not. Therefore, the eligibility requirements should be revised to cover all the patients that really need the treatment. Brennaman (2012) points out how mental patients resort to frequenting the emergency room as a result of not having resources to obtain treatment or even pay for private insurance. More facilities should screen for mental health issues, especially now where mental health is one of the biggest problems facing both the young and old, facilities should be screening for issues before they become a big problem. There are a few mental health hospitals that patients can be admitted to, but all most admissions can be avoided if the patients are evaluated sooner and treated as outpatients. Disorders like anxiety, depression, substance abuse are some of the illnesses that can be treated on an outpatient basis if they are caught before progression. Providers must fully examine their patients for mental health issues during visits. Instead of rushing through an examination, doctors and nurse practitioners should go into depth of the patients’ emotions and how they are handling different situations in their lives. Spiegler (2019) emphasizes that behavioral assessments are important for collecting information which in turn helps to diagnose mental health conditions and in turn lead to early treatment options.  Mental health patients are a vulnerable group whose needs are crucial. Therefore, designing nursing interventions for this group requires nurses to know and understand the CE-ISPMI major concepts which include underlying vulnerability, crisis, mental health emergency, crisis intervention, emergency intervention, immediate responses, and resolution (Brennaman, 2012). Therefore, it is crucial to assess and treat these disorders soon.

We must understand what risks this group faces, such as discrimination, stigma, risk of abuse (emotionally, sexually, mentally and physically), impoverishment (mha.org). These risks set this group into a category of their own. Identifying the signs and symptoms of

a patient in crisis and needing crisis or emergency intervention is another factor. Patients in crisis might exhibit aggressive behavior toward self or others, have mood swings, unable to take care of self or own family, agitation, isolation. Nurses should be able to recognize these signs and more which lead to crisis situations, because early observation leads to early intervention instead of a crisis intervention which might require providers from the emergency department or emergency intervention which involves a one to one with a provider. Additionally, knowing who their immediate response person is, in times of crisis would be something to consider. And finally, how to help the patient transition back to normalcy. These patients desire to life a like us, so we must be able to help them get to the life they had before or even better. Designing nursing interventions is a simple task but we must put into consideration which populations these interventions suitable for. Interventions must be made to fit and help mental help patients depending on their specific needs.

Summary

Overall, the differences between the care of a mental health crisis intervention and mental health emergency intervention needs to be identified. The use of Ball’s mid-range theory helps identify the bridge and applies its concepts to the emergency department. The Healthy People 2020 topic of mental health was used in this project. The topic recognized the gaps in mental health such as preventative measures and the accessibility of treatment. Mental health patients deserve an opportunity to receive the proper healthcare to prevent and treat such crises.

References

Bredow, T. S., & Peterson, S. J., (2020). Middle range theories: Application to nursing Research (5th ed.). Wolters Kluwer Lippincott, Williams & Wilkins.

Brennaman, L. (2012). Crisis emergencies for Individuals with severe, persistent mental illnesses: A Situation-specific theory. Archives of Psychiatric Nursing, 26(4), 251–260.

Chang, Y., Erwin, A., Herman, G.E., Metlay, J.P., Rigotti, N.A., & Wakeman, S.E., (2019).  Effect of integrating substance use disorder treatment into primary care on inpatient and emergency department utilization. Journal of General Internal Medicine, 34, 871–877. Doi:

Mental illness and the family: Recognizing warning signs and how to cope. (n.d.). Retrieved April 14, 2021, from

Office of Disease Prevention and Health Promotion, (2020).  Mental Health and Mental Disorders: Healthy People 2020.

O’Neil, A. (2016). The need for national data on “Boarding” psychiatric patients in emergency

departments. Psychiatric Services, 67(3), 359-360.

Spiegler, M. (2019). Behavior therapy. Salem Press Encyclopedia of Health, 5p.

Week 7 Group Assignment 1: Application to Pragmatic Adequacy