“Evidence-Based Practice: A Firm Foundation for Solving Clinical Problems” was the theme of McLean’s annual Nurses’ Day Conference, held on May 5, 2023.
McLean’s nurses also attended and presented at the American Psychiatric Nursing Association’s 36th annual conference, held on October 4-7, 2023, in Orlando, Florida.
At these events, staff presented on topics ranging from how to organize group programming for electroconvulsive therapy (ECT) patients and families, nursing’s role in transcranial magnetic stimulation (TMS), and the operations of McLean’s Ketamine Service to defining, framing, and applying evidence-based practice.
Below are highlights from these presentations.
How To Organize Group Programming for ECT Patients and Families Virtually and In Person: Meeting a Need for Education and Support
Presenters: Teresa Henderson, BSN, RN, and Vona Davis, PMHNP
There were several reasons McLean decided to create electroconvulsive therapy (ECT) support groups for patients and their families. Most importantly, they were started to help ECT patients, and their loved ones, deal with the stigma and isolation they often experience.
Many patients also need guidance in making treatment decisions, including when to stop or resume treatment. In addition, anxiety about side effects—memory concerns and cognitive clouding—looms large.
“The primary rationale for the development of ECT-specific support group programming is a desire to offer this opportunity for patients to come together, to discuss issues in a very safe environment, to get support, but also to think about the continuity of care, and are we meeting all of the needs for this specific patient population?” said Vona Davis, PMHNP.
The groups also enable the sharing of resources and knowledge among patients and families at all stages of treatment. At times, ECT clinical staff present on topics such as anesthesia and memory concerns. The groups also yield valuable feedback from patients that the facilitators can bring back to the ECT Service.
Now in its ninth year, the group meets once a month for an hour and is co-facilitated by two ECT nurses and a peer specialist with lived experience. The peer specialist facilitates open sharing, according to Teresa Henderson, BSN, RN.
“The presence of a peer specialist encourages other members of the group who are undergoing ECT to feel more comfortable talking about their experience when they know somebody who is a facilitator has had ECT. It brings a lot of comfort to that space,” said Henderson.
The peer specialist also provides information about resources that the nurse co-facilitators may not be familiar with.
The service offers a second group called ENCODE, which stands for enhancing cognitive domains after ECT. The group is for people who are experiencing distress about cognitive clouding and/or memory loss.
The manualized program consists of six, 75-minute sessions co-led by a peer health educator and two nurses, typically Henderson and Davis.
Participants learn skills and strategies to strengthen memory and ways to cope with memory challenges.
For example, journaling is introduced as a way to stimulate the retrieval of lost long-term memories, and role-playing teaches participants how to work through awkward social situations—like forgetting someone’s name at a party. Participants are also shown how to better commit information to memory through repetition and paraphrasing.
The support group and ENCODE became virtual during the pandemic, which has made the programming much more accessible, according to Davis. McLean’s Psychiatric Neurotherapeutics Program intends to create similar support groups for TMS and ketamine patients in the future.
Transcranial Magnetic Stimulation: Nursing’s Role in the Clinical Treatment Area
Presenters: Roan Bautista, BSN, RN-BC, and Paula Bolton, MS, CNP, ANP-BC
Transcranial magnetic stimulation (TMS) uses magnetic pulses to induce electric currents that, in turn, stimulate neurons in the brain to improve symptoms of major depression.
A treatment course typically consists of 36 daily treatments. Roan Bautista, BSN, RN-BC, gave an overview of treatment protocols, how the device functions, and the brain mechanisms that improve patients’ depressive symptoms.
Anecdotally, about 60% of McLean’s TMS patients get some type of response, and about 30% go into remission with TMS treatment. When patients relapse, they may return for a second round of treatment.
Where do nurses fit in? A charge nurse oversees the day-to-day workflow and manages the scheduling of patients, which can be challenging because of the frequency of visits—five days a week for six to seven weeks. Charge nurses also do a lot of case management.
“Remember, these are patients that have treatment-resistant depression or treatment-resistant OCD, and case management issues come up when things happen in patients’ lives that may affect their ability to get to the treatment, or we may need to have interaction with the outpatient treaters when issues or problems arise,” said Paula Bolton, MS, CNP, ANP-BC.
Although TMS is a very technical procedure, the nurses’ role is critical in “terms of managing treatments and then really working with patients and providing that patient-centered care,” said Bolton.
Nurses provide orientation sessions with patients to explain the treatment and scheduling and assess patients for any issues—medical, neurological, or ophthalmological—that could interfere with treatment. At each treatment session, nurses also review the patient’s sleep, drug use, and any medication changes that may increase the risk of a seizure during the procedure.
Nurses also perform the technical parts of the procedure, particularly for difficult-to-treat patients, and oversee the mental health specialists (MHS) who are also involved in treatment.
“Our MHS staff know that if there’s a problem during the treatment—the patient is complaining of pain, they’re seeing a lot of muscle movement, or the patient is becoming agitated, anxious, or upset during the treatment—they are to pause the treatment and get the nurse to come in and help do that evaluation,” said Bolton.
Nurses answer phone calls from patients who may have questions about things like side effects, how long remission lasts, and when it may be time to return for another round of treatment. “All of those education pieces are why it’s so important to have nurses involved in TMS,” said Bolton.
Ketamine Treatment Strategies: Five Years of Experience in a Clinical Setting
Presenters: Paula Bolton, MS, CNP, ANP-BC, and Courtney Miller, RN, ADN, BA
The Ketamine Service is McLean’s neurotherapeutic third service. Ketamine is FDA-approved as an anesthetic and has a long history of being used for anesthesia because of its safety profile. When administered in low doses, it can serve as a fast-acting antidepressant. McLean offers both IV and intranasal esketamine treatment.
“If you think about the connection in your brain like a tree with branches, ketamine makes the branches and connections grow even more,” said Bolton. “This is one of the ways that esketamine and IV ketamine may affect depression—because of these new connections and new pathways that are being developed.”
IV ketamine is used off-label for people with treatment-resistant depression, acute suicidality, and bipolar depression. Patients start treatment twice a week for four weeks and most patients will experience some benefit after 1-3 treatments. The goal of repeated treatments is to get people into remission.
Nurses play pivotal roles in the Ketamine Service. They are involved in performing pre-treatment assessments to check on things like changes to medications, health, mood, and to help identify areas of concern or the need to change the treatment plan.
The nurse is involved in medical assessments that are needed, including measuring weight and blood pressure pre-treatment, as well as monitoring vital signs and patient experience during the treatment administration.
Because ketamine infusions can bring on feelings of disassociation, the nurse provides a lot of reassurance to the patient during the treatment and may use ice packs and stress balls to help with grounding. “Sometimes having a conversation with the patient is enough to bring them back down to reality,” said Miller.
The durability of the antidepressant effects of ketamine varies significantly. In one study, the median duration of response was up to 70 days. Some subjects relapsed at 25 days, but others still noticed a response at 168 days. Ketamine has been shown to have powerful anti-suicidal ideation effects even when it has not relieved depression symptoms.
McLean uses esketamine, which is an FDA-approved medication, to treat treatment-resistant depression and acute suicidality.
The patient self-administers the medication under the supervision of a nurse or mental health specialist, and their blood pressure is monitored for 45 minutes afterward. They remain in the treatment room for an hour after the first spray of the medication and in a recovery room with other patients for the second hour.
Why would IV ketamine be chosen over esketamine or vice versa? IV ketamine has a limited course of treatment: eight sessions and perhaps a couple of taper treatments. In contrast, esketamine is a maintenance medication, requiring an initial course of eight treatments, then regular visits anywhere from every week to every month.
Because IV ketamine is not FDA-approved, it is often not covered by insurance, while more and more insurers are covering esketamine. Some patients may also opt for esketamine because of their fear of IVs.
Because IV ketamine is used off-label, treaters have “more leniency with medical considerations,” said Miller.
“There are absolute contraindications that the drug company puts forth for esketamine. We don’t have those for IV ketamine. We may require special medical clearance for some patients. For example, if a patient has a history of glaucoma that is adequately treated, and their intraocular pressure has been great for years, we might just require a clearance from their ophthalmologist.”
Transferability of Mental Health Simulation Skills to Practice: A Nursing Postgraduate Follow-Up Study
Presenter: Denise Soccio, DNP, RN
The purpose of Denise Soccio, DNP, RN’s study was to explore perceptions of postgraduate nurses regarding the transferability of student-learned mental health simulation knowledge and skills to acute care practice settings.
Eleven participants answered eight questions specific to the knowledge and skills they had learned in three mental health simulation (sim) labs. It built upon a previous study Soccio had done comparing students for whom 25% of their clinical time was replaced with simulation lab work to those who had none of their clinical time replaced.
“What my earlier study showed, similar to a large study that came out in 2013, was that there were no differences between the two groups, so they had equivalent knowledge and clinical confidence,” said Soccio.
“I used simulation with standardized patient scenarios and trained actors. The students loved having the actors. They learned a lot in the sim labs. However, they also reported that they didn’t think it should be a total replacement for actual clinical with real patients.”
In Soccio’s recent study, participants were asked about specific skills—such as whether they had done a suicide assessment, de-escalated an agitated patient, or completed a CIWA (clinical withdrawal assessment for alcohol)—and whether they remembered learning these skills in a sim lab.
“There were three main themes among the participants. They reported they learned effective de-escalation techniques, felt more prepared with psych assessments, and felt empathy for patients hearing voices,” said Soccio.
“And there were two sub-themes: nurses described being therapeutic with patients and more confident in psych emergencies.”
Study participants’ comments regarding de-escalation focused on remembering the importance of recognizing early signs of distress and how to intervene with calm, effective verbal techniques.
“Overall, the comments suggested mental health sim scenarios help postgraduate nurses feel more competent, confident, and empowered to manage conflicts and crises in the work environment.”
They felt similarly with assessments, said Soccio. “The comments reflected that they felt more comfortable and more familiar with the components of each assessment, how to ask the questions, and how to make observations that transferred to practice.”
Several study subjects commented on the value of participating in Pat Deegan’s “Hearing Distressing Voices” simulation.
According to Soccio, one participant stated: “I frequently think about the exercise we did in the lab where we had to complete a worksheet while listening to voices. This gave me a lot of empathy and I’ve recommended it to coworkers. I believe it has helped me have more patience.”
Comments related to the first sub-theme—being therapeutic with patients—included remembering to use therapeutic communication techniques such as being non-judgmental, supportive, and showing empathy for patients in crisis.
Regarding the second sub-theme—being more confident in psychiatric emergencies—Soccio reported that “the comments showed that they were more comfortable in responding to actual emergencies after being exposed to self-harm or simulated aggressive behaviors in the lab.”
Subjects also said that it was helpful to practice safety interventions because it helped build confidence and combat fears and anxieties about psychiatric emergencies.
Soccio’s study can be accessed online.
Defining, Framing, and Applying EBP
Presenter: Denise Soccio, DNP, RN
Soccio began her presentation with a definition of evidence-based practice (EBP): “the integration of best research evidence with clinical expertise, patient preferences, and local circumstances”—a definition originating with researchers Denise Polit and Cheryl Beck.
“Gone are the days where we say in nursing, ‘Well, let’s just do it that way because that’s the way it’s always been done.’ What we want to do now is look to the evidence to see: What is best practice? What can be done differently? What can be done better?” said Soccio. “The starting point is usually a clinical question.”
Soccio went on to describe several models that guide EBP practice, which differ in how they translate research findings into practice.
The Iowa model, which works well in hospital settings, begins with identifying a clinical issue or improvement opportunity, stating your question or purpose, then making sure the topic is a priority. “If not, you want to consider something that is more of a priority,” said Soccio.
Next comes forming a team to assemble, appraise, and synthesize the body of evidence. If there is not enough, you may have to conduct research. Then, you determine what outcomes you’re looking for and whether the change is appropriate for adoption and practice.
“Pilot based on the outcomes,” said Soccio. “If you have really good results, you could adopt this practice change.” Disseminating your results is also an important step.
Soccio then asked the audience to brainstorm with other conference participants about a clinical problem or issue that needs improvement and how they determined it was a priority. The problems ranged from improving fall prevention among dementia patients to better responding to self-injurious behavior with plastic utensils.
Finding evidence is easier than ever, because now McLean staff have access to an online evidence-based medicine tool offered by Lippincott.
“There are policies and procedures, and in addition, there are also educational activities with contact hours and evidence-based research that could help you determine what’s being done in other facilities for these problems,” said Soccio. McLean’s librarian, Stephanie Friree Ford, MLIS, is always willing to do literature reviews as well.
How do you judge the quality of a study? The more recent the study and the larger the sample size, the better. Keep in mind that randomized control trials are the gold standard, said Soccio. Multi-site studies are also preferable to single-site ones. “Then, of course, evaluate the scales being used to be sure they are reliable and valid.”
In the second breakout session, participants were asked to break down their clinical questions into their key concepts using an evidenced-based formula.
One good example came from participants connecting to the conference virtually from McLean SouthEast: “In the acute inpatient psychiatric setting, what is the effect of decreased cell phone usage on improving patient participation in treatment?”
Soccio urged the audience to consider doing a quality improvement project related to their identified clinical question.
“Don’t forget to use a valid, evidence-based model to guide you. Start with a small pilot project, share your findings with other units, write it up for publication, and consider submitting an abstract to the American Psychiatric Nurses Association (APNA) to present your work at the annual APNA conference. That way your good ideas can prove to be useful in other settings.”
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