By Rachel Clements

High fidelity simulation (HFS) is an educational tool that is often used in nursing education today. Simulation is used in many different professional fields, ranging from aviation to construction to molecular biology. Gaberson et al. (2015) define nursing HFS as life-like scenarios that include full-size mannequins which respond in real time to students’ actions in realistic ways. Some abilities of high-fidelity mannequins include speaking; breathing with breath sounds; heart tones; palpable pulses; monitors that display EKG, blood pressure, and pulse oximeter; and even giving birth. During HFS, students practice skills they are learning in a safe environment without posing a risk to actual patients. Mistakes in simulation can be made without causing actual harm, and errors can be corrected without consequences (Eyikara & Baykara, 2017). High Fidelity Simulation provides students with opportunities to experience caring for different types of patients they may not have the opportunity to care for during their clinical experiences. It also aids in evaluation of clinical skill performance and allows students to repeat an experience for additional practice (Cordeau, 2010).

            In addition to the benefits for students, simulation offers nursing schools greater flexibility in providing clinical experiences for students. Securing clinical sites for the increasing number of nursing schools and students presents a major hurdle in clinical nursing education. High Fidelity Simulation provides an alternative educational strategy that assists in responding to this disparity (Shearer, 2016). Hayden et al. (2014) published the results of their study investigating the appropriateness of replacing clinical hours with HFS. They reported that up to 50% of clinical hours can be suitably replaced by simulation. Effective simulation programs allow nursing schools to continue to provide students with clinical experiences when actual clinical sites are limited.

            Though HFS clearly plays an important role in nursing education, several recent studies show that HFS produces moderate to high levels of anxiety in nursing students. This anxiety poses a threat to learning, performance, and student safety (Al-Ghareeb et al., 2019; Cantrell et al., 2017; Cheung & Au, 2011; Cordeau, 2010; Nielsen & Harder, 2013). Students report feelings of anxiety in simulation stemming from a variety of sources, including not knowing what to expect in a HFS, being watched, and fear of doing something wrong (Cantrell et al., 2017). Elevated levels of anxiety have repeatedly been shown to reduce the performance of nursing students during simulations (Al-Ghareeb et al., 2019; Shearer, 2016).

Effects of Anxiety on Learning

            Anxiety is known to have both positive and negative effects on learning and performance. Low levels of anxiety in High Fidelity Simulation (HFS) can motivate higher level performance, but high levels of anxiety in HFS increase the likelihood of negative effects (Cantrell et al., 2017; Labrague et al., 2016). Cantrell et al. (2017) performed an integrative review of 17 studies from 2010 to 2015 that measured stress and anxiety levels during HFS. They identified that high levels of stress and anxiety experienced by nursing students during simulation can endanger the participant’s health causing adrenal enlargement, thymus and lymph node atrophy, gastric erosions, and depletion of emotional and physical resources. These stress levels were higher during HFS than during clinical experiences. They concluded that simulation caused an increase in stress for nursing students overall and recommended further research into methods for decreasing stress and anxiety.

            Labrague et al. (2016) state that simulation has detrimental effects on nursing students’ health and well-being when students are unable to cope with the feelings of stress and anxiety they feel during simulation. These effects include feelings of sadness, guilt, grief, lack of self-esteem, depression, and feelings of listlessness and sleeplessness. They also noted that stress during nursing education affects a student’s ability to learn, make decisions, and think critically, and may contribute to a shortage of nurses entering the profession.

Al-Ghareeb, et al. (2019) conducted a study of 33 nursing students to discover the effect of anxiety on performance during HFS. Students’ anxiety was measured through participant completion of the Stressors Appraisal Scale (SAS) before and after the simulation. The SAS is a two-part situation evaluation. In part one, participants were asked to evaluate the personal relevance, significance, and meaning of the simulation. Part two of the SAS was completed after the simulation where participants were asked to evaluate the resources they had to cope with their stress in the simulation. The researchers also measured the variability in the students’ heart rates. The results of the survey helped identify student reactions to HFS. Students participated in two HFS scenarios focused on rapid deterioration of the health status of a simulated patient. The authors concluded that while low anxiety led to higher performance, moderate to high anxiety reduced performance.

            Similar results of decreased performance in the presence of elevated levels of anxiety during simulations appeared in several other studies. Cheung and Au (2011) assigned students to watch either a calming or an anxiety provoking video clip before performing a stitch-removal procedure and discovered that anxious nursing students underperformed. Gantt (2013) measured students’ anxiety during HFS using the Spielberger State-Trait Anxiety Inventory (STAI). This inventory asks respondents to rate their anxiety on Likert scales. The STAI measures participants’ state anxiety and their trait anxiety. State anxiety refers to how the students feel in the moment, and trait anxiety refers to how anxious they feel generally (Spielberger, 1979). Gantt (2013) found that students with higher anxiety scores on the STAI had lower simulation scores.

Sources of Anxiety During Simulation

            Numerous researchers investigated the sources of anxiety for nursing students surrounding HFS. Some of the most common sources of anxiety include feeling uncomfortable being watched or videotaped (Nielsen & Harder, 2013; Teixeira et al., 2014), fear of not knowing what to expect during the simulation (Cordeau, 2010), fear or making mistakes (Yockey & Henry, 2018), and the pressure of being primary nurse (Yockey & Henry, 2018).

Yockey & Henry (2018) performed a mixed-methods study investigating the sources of simulation anxiety for nursing students at different points in their education, using nursing students in their first and final semesters. First, focus groups were held where nursing students were asked about their simulation experiences and causes of anxiety during simulation. Then, anxiety levels during a simulation were quantified using the Westside Simulation Anxiety Scale, which consists of Likert-type questions that ask about performance and cognition impairment. Students also rated 24 sources of anxiety using the Elements of Simulation Survey Tool, another five-point Likert scale which asks students to rate the degree to which each item caused them anxiety. Both levels of nursing students rated fear of making a mistake and being the primary nurse as causing extremely high levels of anxiety. A student in a focus group stated, “just being called the primary nurse makes you want to cry on the spot” (Yockey & Henry, 2018, p. 32). The authors discovered that both first and final semester nursing students had significant anxiety surrounding a fear of making mistakes, in spite of having more time in the educational process.

Cordeau (2010) described anxiety throughout the simulation experience. In her phenomenological study, 19 students responded in writing to a prompt asking them to describe their lived experience in HFS, including a description of their state of mind, mood, and emotions. She discovered that the level of anxiety students experience varies during all phases of the simulation experience, from pre-simulation preparation to reflection following the simulation. Management of the anxiety by faculty and students increased the student’s ability to focus on the skills needed for simulation rather than their anxiety, which allowed the students to better meet the outcomes of the simulation. When students perceived they had done something wrong, their in-the-moment self-evaluation negatively affected the rest of their simulation experience. Additionally, the entire experience was overshadowed by anxiety around receiving a “needs improvement” grade.

Nielsen and Harder (2013) investigated causes of anxiety during simulation. They found the most common reason for simulation anxiety was being observed or videotaped. In a study by Teixeira et al. (2014), a comparison of students’ anxiety levels was measured in simulations where the students were filmed without an evaluator in the room to students not filmed and with an evaluator present. Students from both groups identified moderate levels of anxiety using a self-assessment scale, but there was no difference between the groups who were directly observed by the evaluator and those that were filmed; both groups experienced anxiety equally.

Management Strategies for Anxiety

            There is a significant gap in the literature surrounding strategies for managing anxiety in HFS. Several researchers suggest methods for managing anxiety, though few have been empirically studied. An article by Janzen et al. (2016) describes a focus group conversation with a group of simulation facilitators who met to discuss the challenges of simulation and the potential harm simulation anxiety can cause. The focus group members had between one and eight years of experience facilitating simulations They developed a list of strategies educators should consider when facilitating student simulation experiences. Strategies include teaching and encouraging self-care after simulations, normalizing situations of stress, having a facilitator in the room, and providing resources for handling feelings of severe stress, such as counseling and health services. These strategies were the result of experience and discussion. They concluded that more research is needed to explore the effectiveness of their identified interventions.

A single study was found in the literature that sought to specifically identify the effectiveness of an intervention designed to reduce anxiety in simulation scenarios. Gantt (2013) compared two groups of nursing students to evaluate the effect of preparation for HFS on students’ anxiety levels. The experimental group was prepared for simulations with practice sessions and focused debriefings. The control group had no preparation, practice, or debriefing prior to the simulation experience. Anxiety levels from both groups were measured using the STAI (Spielberger, 1979) and then compared. No significant difference in the anxiety scores was found. Limitations of this research included a small sample group size and possible discussion between the control and experimental groups resulting in contamination of findings. Though preparation did not seem to decrease anxiety levels in this study, higher anxiety levels correlated with lower simulation scores.

Although many suggestions were found in the literature for reducing stress and anxiety surrounding the HFS experience for nursing students, no evidence was found addressing the current coping mechanisms used by students. Cantrell et al. (2017) identified that senior-level nursing students rated their mental health the poorest out of all nursing students. They concluded that this could be related to the cumulative stress of their college experience, suggesting a need for stress-reduction and coping techniques to be included in the curriculum.

Overall, the current research suggests that the high levels of anxiety observed in nursing students during HFS negatively impacts their learning (Al-Ghareeb, et al. 2019; Cheung and Au 2011; Cantrell et al., 2017; Gantt, 2013; Labrague et al., 2016). In multiple studies, nursing students identified assignment to the role of primary nurse as a significant cause of anxiety during HFS (Yockey & Henry, 2019; Zulkosky et al., 2016). There is a noted deficit in the research concerning coping methods currently used by nursing students to manage simulation-related anxiety and the effectiveness of these coping methods.

References

Al-Ghareeb, A., McKenna, L., & Cooper, S. (2019). The influence of anxiety on student nurse performance in a simulated clinical setting: A mixed methods design. International Journal of Nursing Studies, 98,57-66. htpps://doi.org/10.1016.j.ijnurstu.2019.06.006

Baddeley, A. (1992). Working memory. Science, 255, 556-559.

Cantrell, M. L., Meyer, S. L., & Mosack, V. (2017). Effects of simulation on nursing student stress: An integrative review. Journal of Nursing Education, 56(3), 139-144. https://doi.org/10.3928/01484834-20170222-04

Cheung, R. Y., & Au, T. K. (2011). Nursing students’ anxiety and clinical performance. Journal of Nursing Education, 50(5). 286-289. htpps://doi.org/10.3928/01484834-20110131-08

Cordeau, M. A. (2010). The lived experience of clinical simulation of novice nursing students. International Journal for Human Caring, 14(2), 9-15.

Coy, B., O’Brien, W., Tabaczynski, T., Northern, J., & Carels, R. (2011). Associations between evaluation anxiety, cognitive interference and performance on working memory tasks. Applied Cognitive Psychology, 25, 823-832.

Eyikara, E., & Baykara, Z. C. (2017). The importance of simulation in nursing education. World Journal on Education Technology, 9(1), 2-7. https://doi.org/ 10.18844/wjet.v9i1.543

Gaberson, K. B., Oermann, M. H., & Shellenbarger, T. (2015). Clinical teaching strategies in nursing (4th ed.). Springer Publishing Company.

Gantt, L. T. (2013). The effect of preparation on anxiety and performance in summative simulations. Clinical Simulation in Nursing, 9(1), 25-33. https://doi.org/10.1016/j.ecns.2011.07.004

Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis and generation of evidence (8^th ed.). Elsevier.

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, S. (2011). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2) (Suppl), 4-41.

Huebner, M., Vach, W., & le Cessie, S. (2016). A systematic approach to initial data analysis is good research practice. The Journal of Thoracic and Cardiovascular Surgery, 151(1), 25-27. http://dx.doi.org/10.1016/j.jtcvs.2015.09.085

Janzen, K. J., Jeske, S., MacLean, H., Harvey, G., Nickle, P., Norenna, L., Holtby, M., & McLellan, H. (2016). Handling strong emotions before, during, and after simulated clinical experiences. Clinical Simulation in Nursing, 12(2), 37-43. http://dx.doi.org/10.1016.j.ecns.2015.12.004

Kardong-Edgren, S. Handberg, A. D., Keenan, C., Ackerman, A., & Chambers, K. (2011). A discussion of high-stakes testing: An extension of a 2009 INACSL conference roundtable. Clinical Simulation in Nursing, 7(1), 19-24. https://doi.org/10.1016/j.ecns.2010.02.002

Kreuger, R. A., & Casey, M. A. (2014). Focus groups: A practical guide for applied research (5^th ed.). SAGE publications, Inc.

Labrague, L. J., McEnroe-Petitte, D. M., Gloe, D., Thomas, L., Papathanasiou, I. V., & Tsaras, K. (2017). A literature review on stress and coping strategies in nursing students. Journal of Mental Health, 26(5). 471-480. https://doi.org/10.1080/09638237.2016.1244721

Lasater, K. (2007). High-fidelity simulation and the development of clinical judgement: Students’ experiences. Journal of Nursing Education, 46(6), 269-276.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE Publications, Inc.

Linneberg, M., & Korsgaard, S. (2019). Coding qualitative data: A synthesis guiding the novice. Qualitative Research Journal. https://doi.org/10.1108/QRJ-12-2018-0012

Nielsen, B., & Harder, N. (2013). Causes of student anxiety during simulation: What the literature says. Clinical Simulation in Nursing, 9(11), 507-512. http://dx.doi.org/10.1016.j.ecns.2013.03.003

Sarason, I. G., Sarason, B. R., & Pierce, G. R. (1990). Anxiety, cognitive interference, and performance. Journal of Social Behavior and Personality, 5(2), 1-18.

Shearer, J. N. (2016). Anxiety, nursing students, and simulation: State of the science. Journal of Nursing Education, 55(10), 551-554. https://doi.org/10.3928/01484834-20160914-02

Spielberger, C. (1979). Understanding stress and anxiety. Harper & Row.

Teixeria, C. R. S., Kusumota, L., Pereira, M. C. A., Braga, F. T. M. M., Gaioso, V. P., Zamarioli, C. M., & de Carvalho, E. C. (2014). Anxiety and performance of nursing students in regard to assessment via clinical simulations in the classroom versus filmed assessments. Invest Educ Enferm, 32(2), 270-279. http:/doi.org/10.1590/S0120-53072014000200010 

Yockey, J., & Henry, M. (2019). Simulation anxiety across the curriculum. Clinical simulation in nursing, 29, 29-37. https://doi.org/10.1016/j.ecns.2018.12.004

Zulkosky, K. D., White K. A., Price A. L., & Pretz J. E. (2016). Effect of simulation role on clinical decision-making accuracy. Clinical Simulation in Nursing, 12(3), 98-106. http://dx.doi.org/ 10.1016/j.ecns.2016.01.007.

By Rachel Clements

Long-term Consequences of Pain Exposure

            The previously held belief that infants do not perceive pain is no longer held by most caregivers in the Neonatal Intensive Care Unit (NICU). Recent research shows that preterm infants have a lower threshold for pain than adults (Mehrnoush, Ashktorab, Heidarzadeh, Momenzadeh & Kahlafi, 2017a; Mehrnoush, Ashktorab, Heidarzadeh, Momenzadeh & Kahlafi 2017b), and one study stated that the threshold may even be as much as 30-50% lower than adults (Mehrnoush, Ashktorab, Heidarzadeh, Momenzadeh & Kahlafi, 2016). Premature infants are also more likely to experience long-term effects of repetitive pain (Kocek, Wilcox, Crank & Patra, 2016).  This increased sensitivity is due to the fact that infants develop nociceptive pathways as early as 23 weeks, but have not yet developed the descending neurotransmitters that are responsible for modulating pain (Aucott, Donohue, Atkins & Allen, 2002).

            The literature also shows that the pain experienced by premature infants is harmful in the long-term. Infants can experience developmental disabilities, cognitive, social and emotional problems because of pain exposure and shortening of the sensory area of the brain (Mehrnoush et al. 2016, 2017b; Zwimpfer & Elder, 2012). Aucott et al. (2002) states that in the long-term, a premature an infant’s response to pain may also be altered because of the structural reorganization that can occur in the nervous system, and they are also likely to show greater aversion to pain at ages eight to ten than their peers. At age 11, former extremely low birth weight infants who were exposed to surgical procedures display altered sensory perceptions (Marlow, 2013). It was even reported that without analgesia during surgery there was an increased morbidity (Rana et al, 2017). We can conclude from these studies that exposure to pain is harmful for premature infants and it is imperative that it is appropriately managed.

Harmful Consequences of Analgesics and Sedatives

            Sedatives and analgesics are regularly used in NICUs, especially benzodiazepines and opioids (Borenstein-Levin et al., 2016; Kocek et al., 2016; Mehrnoush et al., 2017a, 2017b, Rana et al., 2017). Opioids are depressive and can cause significant short-term effects such as increased days of mechanical ventilation, but are also suspected to cause apoptotic neurodegeneration (Kocek et al., 2016). Kocek et al. (2016) also found that infants who received higher or more frequent doses of opioids had an increased likelihood of necrotizing enterocolitis (NEC) and had more surgical procedures in addition to more days of being on mechanical ventilation. However, some studies showed use of opioids did not have an effect on the number of ventilated days (Borenstein-Levin et al., 2016).

Both benzodiazepines and opioids are related to slowing down the gut and slowing the passage of meconium, and frequent usage of these drugs increases the risk of infants needing a period of withdrawal from them (Rana et al. 2017). The study performed by Rana et al. (2017) showed that while decreasing the amount of analgesics and sedatives did not increase mortality, it did decrease the amount of days total parenteral nutrition (TPN) was required because the gut was not slowed by these medications.

            In the long term, infants who were exposed to opioids showed poorer outcomes than their peers in several areas including short-term memory, head circumference, cognitive scores, and social behaviors (Borenstein-Levin et al., 2016; Kocek et al., 2016). Kocek et al. (2016) found that for morphine equivalent drugs, an increase of 1mg/kg decreased the cognitive score by 0.238 points on the Bayley Scales of Infant and Toddler Development (BSITD-III). However, this study also showed that the behavioral difference between these children and their peers mostly resolved by age 7, though they say larger studies are needed to confirm this. Additionally, many long-term effects are still unknown (Borenstein-Levin et al., 2016).

            Long-term effects of benzodiazepines may be more serious than those of opioids, as recent studies are finding evidence of damage to the development of the hippocampus in premature infants, and animal models show neuroapoptosis and slowed neurogenesis (Borenstein-Levin et al., 2016). Interventricular hemorrhage (IVH), periventricular leukomalacia (PVL) and death are also associated with continuous infusions beginning with a loading dose of midazolam in one study (Borenstein-Levin et al., 2016). There is also some evidence of longer NICU stays with use of benzodiazepines (Rana et al., 2017).

Effectiveness of Non-pharmacological Pain Management Techniques

            Many types of non-pharmacological methods of pain relief were identified and supported as effective by the literature. Methods included swaddling, pacifier, 24% oral sucrose, massaging, presence of a parent, and skin to skin holding (also called Kangaroo Care) (Aucott et al., 2002; Fleishman, Gleason, Mayaing, Zhou & Mangione-Smith, 2013; Mahrnoush et al., 2016, 2017b,; Rana et al., 2017; Zwimpfer & Elder, 2012). When soothing is assisted by an adult caregiver, infants develop the neural pathways to learn how to do this for themselves (Zwimpfer & Elder, 2012). A method called the “Tipple T Intervention” uses touch, taste (in the form of 24% oral sucrose) and talk as a non-pharmacologic method of pain management, and studies have showed this to reduce pain on assessment (Zwimpfer & Elder, 2012).

A common thread in most of the reviewed literature was the underutilization of non-pharmacologic pain management techniques (Borenstein-Levin et al., 2016; Kocek et al., 2016; Mehrnoush et al., 2016, 2017a, 2017b). One qualitative study found that nurses were not aware of these technique’s usefulness for pain management, but nurses still reported that these techniques did make the infants calmer (Mehrnoush et al., 2017b). Another study showed that nurses believed these interventions were more effective than analgesics or sedatives (Mehrnoush et al., 2016).  

Other studies showed varying levels of education of nurses determined the type of pain management an infant received. Nurses with bachelor’s degrees were more likely to use a combination of opioids and non-pharmacological methods, and nurses with lower levels of education used topical drugs. This same study also showed nurses with more experience were more likely to use pharmacological methods (Kostak, Inal, Efe, Bal Yilmaz & Senel, 2015).

Need for NICU Nurse Education for Pain Management

The literature as stated in the previous sections shows that varying ideas exist among NICU nurses about appropriate pain management. It is recommended that nurses manage pain using a combination of both pharmacological and non-pharmacological methods (Mahrnoush et al., 2016, Rana et al., 2017). What nurses do know is that premature infants do have pain and that analgesics and sedatives do have side effects, but less than 50% believe pain is properly managed (Mehrnoush et al., 2017a). What nurses do not understand, according to the research, is that premature infants do not have as high as a threshold for pain as adults or even term infants (Mehrnoush et al., 2017b). Also, nurses are primarily concerned only about the short-term effects of sedatives and analgesics, but understood that they needed more education on the subject (Mehrnoush et al., 2017a).

It is important to educate NICU nurses about appropriate pain management because nurses are the ones who are with the infants the most (Mehrnoush et al., 2016). One study showed administration of pain management is largely influenced by nurses’ attitudes and feelings (Mehrnoush et al., 2017a). Another study showed nurses’ empathy, education, knowledge, protocols and team work were also factors that determined appropriate pain management (Aymar, Lima, Santos, Moreno & Coutinho, 2014). Fleishman et al. (2013) suggest nurses are using more narcotics “perhaps to treat ourselves as much as our patients” (p. 337).

Several studies of barriers to appropriate pain management recommended staff education as an improvement measure (Mehrnoush et al., 2016, 2017a, 2017b). Several short-term studies have been done using education interventions to decrease the administration of sedatives and analgesics in preterm infants. A study in Brazil implemented guidelines for opioid and benzodiazepine administration and saw a reduction from 62.9% of infants receiving pharmacotherapy to 32.8% while still maintaining adequate management of pain. (Aymar et al., 2014). However, long-term studies showed that over time the percentage of premature infants that received morphine had not changed (Fleishman et al., 2013).

It is clear that an educational intervention about appropriate pain management for NICU nurses is needed. A review of the literature revealed that studies relating specifically to pain management in mechanically ventilated infants are few. Mechanical ventilation is known to be painful and agitating and is even considered a form of chronic pain (Fleishman et al., 2013). Therefore, a study is needed that explores interventions to improve appropriate pain management by nurses for mechanically ventilated neonates.

References

Aucott, S., Donohue, P. K., Atkins, E., & Allen, M. C. (2002). Neurodevelopmental care in the NICU. Mental Retardation and Developmental Disabilities Research Reviews,8, 298-308. doi:10.1002/mrdd.10040

Aymar, C. L., Lima, L. S., Santos, C. M., Moreno, E. A., & Coutinho, S. B. (2014). Pain assessment and management in the NICU: Analysis of an educational intervention for health professionals. Jornal De Pediatria (Versão Em Português),90(3), 308-315. doi:10.1016/j.jpedp.2013.09.008

Borenstein-Levin, L., Synnes, A., Grunau, R. E., Miller, S. P., Yoon, E. W., & Shah, P. S. (2017). Narcotics and sedative use in preterm neonates. The Journal of Pediatrics,180, 92-98. doi:10.101.

Fleishman, R., Gleason, C. A., Myaing, M. T., Zhou, C., & Mangione-Smith, R. (2013). Evaluating patterns of morphine use in a neonatal intensive care unit after NEOPAIN. Journal of Neonatal-Parinatal Medicine,6, 333-338. doi:10.3233/NPM-1371513

6/j.jpeds.2016.08.031

Kocek, M., Wilcox, R., Crank, C., & Patra, K. (2016). Evaluation of the relationship between opioid exposure in extremely low birth weight infants in the neonatal intensive care unit and neurodevelopmental outcome at 2years. Early Human Development,92, 29-32. doi:10.1016/j.earlhumdev.2015.11.001

Kostak, M., Inal, S., Efe, E., Yilmaz, H. B., & Senel, Z. (2015). Determination of methods used by the neonatal care unit nurses for management of procedural pain in Turkey. Journal of Pakistan Medical Association,65(5). Retrieved from http://jpma.org.pk/AboutUs/php

Marlow, N. (2013). Anesthesia and long-term outcomes after neonatal intensive care. Pediatric Anesthesia,24(1), 60-67. doi:10.1111/pan.12304

Mehrnoush, N., Ashktorab, T., Heidarzadeh, M., Momenzadeh, S., & Khalafi, J. (2016). Pain management perceptions of the neonatal nurses in NICUs and neonatal units in Ardebil, Iran. Iranian Journal of Neonatology,7(4), 23-29. doi:10.22038/ijn.2016.7854

Mehrnoush, N., Ashktorab, T., Heidarzadeh, M., Momenzadeh, S., & Khalafi, J. (2017a). Factors influencing neonatal pain management from the perspectives of nurses and physicians in a neonatal intensive care unit: A qualitative study. Iranian Journal of Pediatrics,28(1). doi:10.5812/ijp.10015

Mehrnoush, N., Ashktorab, T., Heidarzadeh, M., & Momenzadeh, S. (2017b). Knowledge and Attitude of Personnel, Key Factors in Implementation of Neonatal Pain Management in NICU: A Qualitative Study. Journal Of Clinical And Diagnostic Research,11(11), 5-9. doi:10.7860/jcdr/2017/26290.10851

Rana, D., Bellflower, B., Sahni, J., Kaplan, A. J., Owens, N. T., Arrindell, E. L., . . . Dhanireddy, R. (2017). Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines. Journal of Perinatology,37(9), 1038-1042. doi:10.1038/jp.2017.88

Zwimpfer, L., & Elder, D. (2012). Talking to and being with babies: The nurse-infant relationship as a pain management tool. Neonatal, Paediatric & Child Health Nursing,15(3), 10-14. Retrieved October 2, 2018, from http://www.cambridgemedia.com.au

By Rachel Clements

Mental health is a serious issue in the United States. In 2004, one in four adults suffered from a mental health disorder and one in 17 had a serious mental illness (“Mental Health,” n.d.). Treating mental health disorders present unique challenges and there are many barriers to providing good care to those who suffer from mental health disorders. Mental health disorders are surrounded by stigmas that, in spite of improvements over the last several centuries, still prevail and make management of mental health difficult. Poor management leads to significant negative effects which not only include risk for harm to those it affects but also to their families, friends, and communities (“Mental Health,” n.d.).

Mental Health in Crisis Mode

It is clear that mental health is in crisis mode in this country. In 2016, the suicide rate was 13.5 per 100,000 people and 12.8% of teens had a major depressive episode in the preceding 12 months (“Mental Health,” n.d.). Mental health affects all groups of people, but some groups are affected more than others. The LGBTQ community, African Americans, people who are homeless, and more are at an increased risk for mental health disorders and may not have access to the resources to manage these disorders (Niles, 2018).

There are many reasons why mental health is in crisis mode, but two particular reasons include the stigmas surrounding mental health disorders that prevent sufferers from seeking help, and the poor coverage of mental health services by insurers (Niles, 2018). Patients will often avoid or delay getting help with mental health disorders for a variety of reasons, including embarrassment and fear of letting others down. This puts them at risk for escalating their disorders and contributes to the country’s mental health crisis (Haugen, McCrillis, Smid & Nidjam, 2017).

There have been efforts to improve insurance coverage of mental health services, however coverage is still poor especially when compared to traditional medical care. Many companies, especially small companies, may not offer any mental health coverage, and employees may have to pay higher copays for mental health services. If individuals with mental health disorders are not able to work, their mental health care is typically covered by Medicare and Medicaid (Niles, 2018). When it is difficult for patients and families to afford mental health services, treatment is delayed if it even happens which also contributes to our mental health crisis.

Poor Management of Mental Health in the U.S.

Mental health has come a long way since the insane asylums of the 18^th century, but the U.S. still has work to do to appropriately care for mentally ill individuals. Rather than locking them away in asylums, these days many mentally ill individuals find their way into the prison system. Not only does this not give these individuals the help they need to manage their disorders, but it increases costs to the taxpayers, creates behavioral management problems in prisons, and puts them at higher risk for suicide (“Serious mental illness (SMI) in jails and prisons,”2016). More focus should be placed on treatment rather than punishment of the mentally ill.

Decreasing Violence in the Mentally Ill

The affordability and accessibility of mental health services remains an issue for many mentally ill individuals. Tragedies occur when there is inadequate management of mental health disorders, such as the Virginia Tech Massacre in 2007. Seung Hui Cho was previously treated for severe anxiety before he killed 32 people in the massacre. In spite of previously responding well to counseling, he discontinued therapy with disastrous results (Niles, 2018). This exemplifies the dangerous impacts poor accessibility of mental health services can have.

Although efforts have been made to improve coverage of mental health services, there are still weaknesses in these laws that make it difficult to receive mental health care. For example, A 50% copayment for outpatient mental health services is required for those covered by Medicaid, rather than the usual 20% for traditional medical care. Efforts need to be made to improve these disparities (Niles, 2018).

Conclusion

Mental health disorders are increasingly common and have significant negative consequences on our society. The stigma surrounding mental health and the poor accessibility of mental health services are large contributors to the mental health crisis that the Unites States is in today. Mental health services can be difficult to afford and are often not adequately covered by insurance providers. When mentally ill individuals are not able to get the treatment they need, they are at increased risk for suicide, violence, and other negative effects. As research on treating mentally illnesses is improving, access and affordability of mental health services also needs to improve to connect the research with the crisis and improve outcomes for everyone.

References

Haugen, P. T., Mccrillis, A. M., Smid, G. E., & Nijdam, M. J. (2017). Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. Journal of Psychiatric Research,94, 218-229. doi:10.1016/j.jpsychires.2017.08.001

Mental Health. (n.d.). Retrieved March 30, 2019, from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Mental-Health

Niles, N. J. (2018). Basics of the U.S. health care system(3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Serious mental illness (SMI) in jails and prisons(Background paper). (2016, September). Retrieved March 30, 2019, from Treatment Advocacy Center website: https://www.treatmentadvocacycenter.org/evidence-and-research/learn-more-about/3695