45th Biennial Convention (16-20 November 2019)

Regulations and the Psychiatric Technician Workforce: A Policy Catalyst to Ensure Safe, Competent Care

Teresa D. Serratt, PhD, RN School of Nursing, Boise State University, Montgomery, TX, USA

Introduction: The World Health Organization (WHO) estimates 76%-85% of people with mental disorders in low-income countries and 35%-50% in high-income countries receive no treatment. For those fortunate enough to receive care, the quality of care is often poor (WHO, 2018). In the U.S., six percent of the population has a serious mental illness (National Institute of Mental Health, 2015). Mental illness affects people across the lifespan and hospitalizations for mental illness have increased, with the largest increase seen in children 5-12 years of age (Blader, 2011, Bardach, et al., 2014). There are an estimated 1.4 million hospitalizations for mental illness annually (Saba, Levit & Elixhauser, 2008). A significant amount of care and interaction during a patient’s stay in acute psychiatric facilities is provided by psychiatric technicians/aides and supervised by registered nurses. Ensuring that these care providers have the necessary knowledge and skills has implications for the quality and safety of care that is provided in acute inpatient psychiatric facilities in the U.S. as well as throughout the world. Background & Significance: According to the Bureau of Labor Statistics (BLS, 2016) there are 139,700 psychiatric technicians/aides in the United States with a projected increase of approximately 6% over the next 10 years. While job descriptions and position titles vary by type of care facility and state, the BLS (2017) describes common job duties as providing therapeutic care, monitoring patients’ conditions, assisting patients in their daily activities and ensuring a safe, clean environment. While federal regulations are in place to ensure education and training standards for aides working in home health and long term care, psychiatric technicians/aides’ regulations are left to each state. Purpose: The purpose of this study was to identify and describe state regulation requirements for psychiatric technicians/aides in the United States as a first step in examining staffing in acute psychiatric hospitals. The analysis of current regulatory requirements helps to identify if requirements in licensure, certification, registry and standards for training and competency evaluation are in place that ensure that safe, high quality care is being provided to a vulnerable population. Methods: Guided by the Centers for Disease Control and Prevention’s Policy Process Framework (2012), this study focused on the problem identification step of the process. Utilizing search text, an internet bot initiated the search for relevant state regulations using search terms such as psychiatric technician/aide/mental health technician/behavioral health technician, regulation, health code, health statute in August 2018. A confirmatory search was conducted in September 2018 to validate the internet bot findings and ensure that no state regulatory requirements had been missed or misinterpreted. Results: Few states have regulatory requirements for licensure, certification, registry, or standards for training and competency evaluation for psychiatric technicians/aides. Only four states (AR, CA, CO and KS) have regulations requiring licensure for psychiatric technicians/aides. Arkansas uses the title of licensed psychiatric technician nurse while California uses licensed psychiatric technician but define their scopes of practice similar to that of a licensed practical nurse rather than an aide/technician. Educational preparation requirements vary but California defines specific theoretical and clinical content and hour expectations in their regulations. Only California and Kansas require continuing education. In all other states, standards are set at the individual employer level. An additional finding of this study was the vast differences in titles and role definitions within and across states. Implications: While regulatory measures have been implemented for other similar workforce categories working with vulnerable populations; such as nursing home residents and nursing aides, acutely mentally ill patients in 46 out of 50 states have not been subject to this protective measure. Further exploration of this problem, beyond the U.S., including potential policy solutions that ensure safe, high quality care is being provided to acute psychiatric patients is indicated. Registered nurses, as direct supervisors of this segment of the workforce, must be patient advocates by being engaged in the next steps of the policy process that include policy analysis, strategy and policy development, policy enactment, and policy implementation. Conclusion: Mental illness is being called the pandemic of the 21st century (Lake & Turner, 2017) and accounts for nearly 1/3 of adult disability (Anderson, Jane-Llopis and Hosman, 2011). It affects all ages and occurs in all countries and is the largest cause of preventable deaths in adolescents and young adults (WHO, 2018). Quality of care must be a priority for this vulnerable population. Nurse leaders must address workforce issues as part of a comprehensive strategy to improve care quality by utilizing data and evidence to support efforts at the organization level and to inform regulatory efforts at the state/regional, national and international levels. They need to provide leadership through engagement in the policy process and commit to ongoing collaboration with colleagues and stakeholders to disseminate best practices and lesson’s learned’ as they work to address this issue.

Title: Regulations and the Psychiatric Technician Workforce: A Policy Catalyst to Ensure Safe, Competent Care

Keywords: Mental Health, Policy and Workforce

References: Anderson, P., Jane-Llopis, E. and Hosman, C. (2011). Reducing the silent burden of impaired mental health. Health Promotion International, 26(l). pp.14-19. Bardach, N.S., Coker, T. R., Zima, B. T., Murphy, J. M., Knapp, P., Richardson, L. P., Edwall, G., Mangione-Smith, R. (2014). Common and costly hospitalizations for pediatric mental health disorders. Pediatrics, 133(4), pp. 602-609. Blader, J.C. (2011). Acute inpatient care for psychiatric disorders in the United States, 1996 through 2007. Archives of General Psychiatry, 68(12), pp. 1276-1283. Lake, J. & Turner, M. (2017). Urgent need for improved mental health care and more collaborative model of care. Permanente Journal, 21(4), pp. 44-51. Saba, D. K., Levit, K. R., & Elixhauser, A. (2008). Hospital stays related to mental health, 2006: Statistical brief #62. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK54564/ US Department of Health and Human Services, The Centers for Disease Control and Prevention (2012). Overview of CDC’s Policy Process. Retrieved from https://www.cdc.gov/policy/analysis/process/docs/cdcpolicyprocess.pdf U.S. Department of Health and Human Services, National Institute of Mental Health (2015). Serious mental illness (SMI) among U.S. adults. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among- us-adults.shtml U.S. Department of Labor, Bureau of Labor Statistics, (2018). Occupational Outlook Handbook, Psychiatric Technicians and Aides. Retrieved from https://www.bls.gov/ooh/healthcare/psychiatric-technicians-and-aides.htm World Health Organization. (2018). Mental health: strengthening our response [Mental Health Fact Sheet]. Retrieved from https://www.who.int/en/news-room/fact- sheets/detail/mental-health-strengthening-our-response

Abstract Summary: A study was conducted to identify and describe state regulation requirements for psychiatric technicians/aides in the United States as a first step in examining staffing in acute psychiatric hospitals. A discussion of these findings and their implications for nurse leaders and policymakers in the U.S. and globally will be presented.

Content Outline: 1. Introduction 1. Background & Significance 1. The WHO estimates 76%-85% of people with mental disorders in low-income countries and 35%-50% in high-income countries receive no treatment. For those fortunate enough to receive care, the quality of care is often poor (WHO, 2018). 2. There are an estimated 1.4 million hospitalizations for mental illness in the U.S. annually (Saba, Levit & Elixhauser, 2008). 3. A significant amount of care and interaction during a patient’s stay in acute psychiatric facilities is provided by psychiatric technicians/aides and supervised by registered nurses yet little is known of their initial or continued preparation to work with mentally ill patients. 2. Study Aim: An analysis of current regulatory requirements for psychiatric technicians/aides across the U.S. was conducted to identify if requirements in registry, certification and standards for training and competency evaluation are in place that ensure that the care being provided to a vulnerable population is safe and of high quality. 3. Methodology 1. The Centers for Disease Control and Prevention (CDC, 2012) Policy Process Framework was utilized to guide this study. 2. Letter of Determination was obtained prior to initiating the study as the study didn’t met the criteria for Human Subjects Research. 3. In August 2018, an internet bot was utilized to initiate a systematic review of existing state regulations for psychiatric technicians/aides across the U.S. A confirmatory search was conducted in September 2018 to validate the internet bot findings and ensure that no state regulatory requirements had been missed or misinterpreted. 2. Key Findings & Implications 1. Key Findings 1. There are vast differences in titles and role definitions within and across states. 1. Common titles: psychiatric technician/aide/mental health technician/behavioral health technician 2. Arkansas uses the title of licensed psychiatric technician nurse while California uses licensed psychiatric technician but define their scopes of practice similar to that of a licensed practical nurse rather than an aide/technician. 3. Role and scope of practice is defined by the organization 2. Few states have regulatory requirements for licensure, certification, registry, or standards for training and competency evaluation for psychiatric technicians/aides. 1. Only four states (AR, CA, CO and KS) have regulations requiring licensure for psychiatric technicians/aides. 3. Educational preparation requirements vary but California defines specific theoretical and clinical content and hour expectations in their regulations. 4. Only California and Kansas require continuing education. 5. In all other states, standards are set at the individual employer level. 2. Implications 1. While regulatory measures have been implemented for other similar workforce categories working with vulnerable populations; such as nursing home residents and nursing aides, acutely mentally ill patients in 46 out of 50 states have not been subject to this protective measure. 2. Further exploration of this problem, beyond the U.S., and including potential policy solutions that ensure safe, high quality care is being provided to acute psychiatric patients is indicated. 3. Registered nurses, as direct supervisors of this segment of the workforce, must be patient advocates by being engaged in the next steps of the policy process that include policy analysis, strategy and policy development, policy enactment, and policy implementation. 3. Conclusion 1. Mental illness is being called the pandemic of the 21st century (Lake & Turner, 2017). 1. Accounts for nearly 1/3 of adult disability (Anderson, Jane-Llopis and Hosman, 2011). 2. Affects all ages and occurs in all countries (WHO, 2018). 3. Largest cause of preventable deaths in adolescents and young adults (WHO, 2018). 2. Quality of care must be a priority for this vulnerable population. 3. Nurse leaders must address workforce issues as part of a comprehensive strategy to improve care quality: 1. Utilize data and evidence to support efforts at the organization level and to inform regulatory efforts at the state/regional, national and international levels. 2. Provide leadership through engagement in the policy process. 3. Collaborate with colleagues and stakeholders to disseminate best practices and lesson’s learned’.

First Primary Presenting Author Primary Presenting Author Teresa D. Serratt, PhD, RN Boise State University School of Nursing Associate Professor Montgomery TX USA

Author Summary: Dr. Teresa Serratt is an associate professor in the School of Nursing at Boise State University. She earned her doctorate in nursing from the University of California, San Francisco, with a specialty in health policy. She currently teaches courses in healthcare project management, leadership, economics, and evidence-based practice. As a health services researcher, her primary research focus is health policy, healthcare workforce, and organizational analysis of economic and quality issues in acute care facilities.