Psychiatric Nurse Reports on the Quality of Psychiatric Care in General Hospitals

Abstract

Although acute inpatient psychiatric care has changed dramatically over the past 2 decades, little is known about how these changes have affected the quality of care, psychiatric nurse staffing, or patient outcomes. The purpose of this report is to explore the quality of care, quality of the practice environment, and adverse events as assessed by psychiatric nurses in the general hospital setting. The study sample consisted of 456 registered nurses permanently assigned to psychiatric units, compared with a larger sample of 11 071 registered nurses who work permanently on medical, surgical, or medical-surgical units. Compared with nonpsychiatric nurses, psychiatric nurse characteristics reveal an older, more experienced workforce, with a higher proportion of male nurses. Nurses rated quality of patient care lower in the psychiatric specialty than in the medical-surgical specialty. Furthermore, psychiatric nurses reported significant concern about the readiness of patients for discharge and higher incidence of adverse events. They also experienced more verbal abuse, physical injuries, and complaints from patients and families. Collectively, the results from this study underscore the organizational problems and quality-of-care issues that cause psychiatric nurses in general hospital settings to evaluate their work environments negatively.

The magnitude of change in the locus of inpatient psychiatric care is considerable. From 1990 to 2001, length of stay in the hospital decreased by 40%, psychiatric hospital facilities decreased by 32%, and psychiatric beds per capita decreased by 27%.¹ In 2001, 61% of all inpatient psychiatric spending went to general hospitals.¹ What is more, within these general hospitals 51% of the spending took place in specialty units, and the remaining 49% was paid for beds scattered on other types of medical care units,¹ Most experts would view these as positive changes, given the long history of quality-of-care problems and human rights violations in public psychiatric hospitals. Yet the epidemics of drug abuse, alcohol use, domestic and public violence, and suicide attempts² pose major management problems for general acute hospitals in a context of constrained resources, more complex overall case mix, and safety and quality challenges.

Consequences of the enormity of these changes are yet to be fully analyzed. Even so, numerous studies document poor quality of care across the spectrum of mental health and substance use conditions.³ For example, the use of seclusion and restraints is estimated to cause 150 deaths each year in the United States.⁴ Researchers reviewed charts of 31 randomly selected patients in a state psychiatric hospital and detected 2194 medication errors during the patients' collective 1448 inpatient days. Of the errors, 58% were judged to have the potential to cause severe harm.⁵

In recent years, developing quality indicators for mental health care has become a federal priority. As health care spending increases, efforts to bring down costs and increase quality of care have increased, yet development of psychiatric inpatient quality measurement continues to lag behind other types of health care services.

This article provides one of the first appraisals of how acute care general hospitals are coping with the influx of psychiatric patients, and outcomes related to psychiatric patients and psychiatric nurses. Surveys of nurses practicing in acute general hospitals were employed to gain a perspective on the safety and quality of psychiatric care. These results extend previous findings about the quality of care and safety of general surgical patients.^6,7 These earlier studies documented that mortality for surgical patients was lower in hospitals with better nurse staffing, a more educated nurse workforce, and a work environment more conducive to good nursing care. This study examines the extent to which psychiatric patients and nurses experience positive and negative outcomes as compared to those in general medical-surgical specialties. The findings have implications for improving the safety and quality of care for psychiatric patients in general acute hospitals.

BACKGROUND

Indications for psychiatric admissions have changed drastically over recent decades. Inpatient units serve as environments for addressing crises that cannot be handled in community settings, such as posing a danger to oneself or others. Consequently, present-day psychiatric inpatients are often suicidal, homicidal, or unresponsive to other treatment modalities.⁸ Moreover, the effectiveness of acute care for patients with mental illnesses is far more difficult to establish than for medical-surgical inpatients. These complex factors make it particularly important to document how psychiatric nurses view their jobs and their work environments.

Job satisfaction, quality patient care, and administrative support have been shown to be highly valued by hospital nurses. A number of studies have reported that the organization of nurse practice environments is associated with better nurse and patient outcomes and a higher rate of retention of nurses.⁹ Job satisfaction predicts nurse turnover,^10,11 job stress and burnout,^12,13 and, perhaps most importantly, quality of care and the prevalence of adverse patient outcomes.^10,14,15

What is unclear is whether these findings are applicable to nurses working in inpatient psychiatric settings. Data regarding job satisfaction for inpatient psychiatric nurses in the United States are scarce. However, data from other countries indicate that psychiatric nurses' sources of job satisfaction and dissatisfaction are highly related to organizational features.¹⁶ Studies of hospital-based psychiatric nurses from various countries have found that excessive administrative duties and poor nursing management were sources of work dissatisfaction.^17-19

METHODS

This was a cross-sectional, descriptive, and comparative study using data from a 1999 nurse survey. The survey, administered by Aiken and colleagues, drew a 50% random sample of 80 500 registered nurses (RNs) in the state of Pennsylvania.⁷ More than 43 000 RNs responded, yielding a 52% response rate. Of these nurses, 11 527 identified themselves as a staff nurses working permanently on medical units, surgical units, combined medical/surgical units, or psychiatric units in general hospitals. Two samples were identified for comparison that are as follows: 11 071 nonpsychiatric nurses and 456 psychiatric nurses.

The survey consisted of a variety of questions regarding nurse reports of their work environment, job satisfaction, burnout, intent to leave, patient-to-nurse staffing ratios, quality of care, and adverse events.²⁰ The survey embedded 2 well-known valid and reliable instruments that are as follows: The Practice Environment Scale of the Nursing Work Index Revised (PES-NWI) and the Maslach Burnout Inventory (MBI).

The PES-NWI is a 51-item 4-point Likert scale (1 = strongly agree, 2 = somewhat agree, 3 = somewhat disagree, and 4 = strongly disagree), constructed to assess nurses' perception of the presence of organizational characteristics in their hospitals associated with nursing care delivery,^20,21 The Cronbach α has been published for the subscales of the PES-NWI ranging from .71 to .84.²¹ The PES-NWI was factor analyzed for psychiatric nurses with the similar Cronbach α scores ranging from .83 to .90.²²

Measurement of the hospital work environment consisted of questions from the PES-NWI about competence of coworkers and working relations and staffing adequacy and workforce management. Nurse staffing was measured by asking each respondent staff nurse how many patients she or he cared for on the last shift. These figures were aggregated across nurses in the same hospital creating specialty unit staffing and overall hospital-level staffing policies. A question about the hiring of unlicensed assistive personnel was included to examine the difference in this practice among psychiatric hospital unit versus nonpsychiatric hospital units. Quality of care and adverse events were measured by asking nurses to provide their ratings of the overall quality of care provided on their units and the frequency of the occurrence of poor quality-of-care indicators such as medication errors, client falls with injury, complaints from clients or families, work-related injuries, and verbal abuse of nurses.

The MBI was used to measure the level of emotional exhaustion among staff nurses.²³ The MBI has well-established psychometric properties and has been used in various health care disciplines. In this study the MBI was used to measure nurses' emotional exhaustion and the results were compared to norms for health care professionals. Emotional exhaustion was computed to measure the degree to which the nurses reported experiencing emotional burden as a result of their work. The emotional exhaustion subscale is composed of 9 items from the MBI.²⁴

Analysis was primarily descriptive comparing psychiatric nurses with nonpsychiatric nurses. Demographic data were collected for descriptive and comparative purposes and were reported as means, standard deviations, and percentages. The P-value was set at .05 as the level of statistical significance. Pearson X² test was used for nominal variables and the Mann-Whitney U test for ordinal variables. The t test was used to test for statistically significant differences between the means of the 2 nurse groups for interval-level data. The F test was used to test for equal variances between the 2 groups. Stata was used to analyze the data.²⁵

FINDINGS

Nurse characteristics

Psychiatric nurses were significantly older than nonpsychiatric nurses—mean age 45 years versus 40 years (Table 1). Significantly far fewer psychiatric nurses aged 30 years or younger. A slightly higher percentage of psychiatric nurses were male (9% versus 6%). Both groups had at least 14 years of experience as an RN and an average of 10 years at their current hospital. Although more nonpsychiatric RNs held a baccalaureate degree (33% vs 28%), significantly more psychiatric RNs held a master's degree (15% vs 8%).

Table 1.

NURSE CHARACTERISTICS

	Psychiatric RNs (n = 456)	Nonpsychiatric RNs (n = 11071)	Pa
Age, mean (SD), y	45 (10.3)	40 (9.6)	.000
younger than 30 y, %	11.4	19.0	.000
Male, %	8.4	5.9	.026
Years as an RN, mean (SD)	16.4 (9.9)	14.1 (9.8)	.000
Years at hospital, mean (SD)	10.1 (8.7)	10.5 (8.2)	.305
Highest degree, %
Diploma	32.9	34.8	.395
Associate	25.4	24.2	.530
Baccalaureate	28.1	33.1	.026
Master and higher	15.0	8.0	.000

^aStatistical significance is measured from P < .05.

WORK ENVIRONMENT

For most work environment attributes, both psychiatric and nonpsychiatric RNs have similar perceptions of strengths and weaknesses. Table 2 summarizes differences in the 2 RN groups with regard to their perceptions of work relationships, staffing patterns, and management of nurse practice environments. A large percentage of both groups viewed their working relationships as positive. Psychiatric RNs and nonpsychiatric RNs reported nurse colleagues as competent (82% and 86%, respectively) with the nonpsychiatric RNs reporting more favorably on this measure. This perception is echoed in the finding that both medical-surgical and psychiatric RNs reported that physicians and nurses have good working relationships (83% for both). However, more than a quarter of psychiatric RNs conveyed that the quality of physicians care was fair to poor.

Table 2.

NURSE REPORTS OF WORKING RELATIONSHIPS, STAFFING, AND PRACTICE ENVIRONMENT MANAGEMENT

Percent agreeing with statement	Psychiatric RNs (n = 444), %	Nonpsychiatric RNs (n = 10843),%	Pa
Working relationships
Physicians give high quality care	73.2	81.7	.000
Nurses are clinically competent	81.7	86.2	.008
Physicians and nurses have good working relationships	83.0	83.3	.831
Staffing
There was an increase in the number of patients assigned to a nurse over the past year	84.2	83.2	.605
There are enough RNs to provide high quality care	40.7	34.2	.005
There is enough staff to get the work done	37.6	33.6	.079
There are adequate support services	49.1	43.0	.009
There was an increase in the hiring of unlicensed personnel in the past year to provide direct patient care previously provided hy RNs	41.0	35.0	.006
The quality of hospital care has deteriorated because of hiring of unlicensed personnel	68.1	62.0	.063
Practice management
The administration listens and responds to RNs' concerns	32.1	29.1	.105
RNs have the opportunity to participate in policy decisions	40.3	40.4	.944
RNs' contributions to patient care are publicly acknowledged	42.1	39.3	.228
RNs have opportunities for advancement	28.3	32.0	.104
Salaries are adequate	68.4	56.0	.000

^aStatistical significance is measured from P < .05.

The nurse groups reported some similarities and significant differences in their perception of staffing. The majority of nurses in both groups agreed that there was an increase in the number of patients assigned to a nurse (84% and 83%, respectively). Both groups expressed concern that there were not enough RNs to provide high-quality care, but nonpsychiatric nurses felt more strongly about this issue (P = .005). Only a third of both groups perceived that there was enough of other staff to get the work done, and more than half of both groups of nurses perceived insufficient support staff; nonpsychiatric nurses more so than psychiatric nurses P = .009).

A common cost-containment strategy is to hire unlicensed personnel to staff inpatient units. More than a third of both groups reported an increase in the hiring of unlicensed personnel to provide direct patient care previously provided by RNs, psychiatric nurses more so than the other nurses (P = .006). More than two thirds of both psychiatric (68%) and nonpsychiatric nurses (62%) agreed that the quality of hospital care had deteriorated since the hiring of unlicensed personnel.

Perceptions of the practice management showed strong agreement between both the groups. A third of both groups of nurses perceived a lack of support from management, reporting that managers in their hospitals did not listen or respond to their concerns. The nurses also perceived a lack of opportunity to participate in policy decisions, and they perceived that they were not publicly acknowledged for their work. Less than a third in either group reported opportunities for advancement. Of note, psychiatric nurses (68%) were significantly more likely to be satisfied with their salaries than nonpsychiatric nurses (56%).

NURSE-ASSESSED QUALITY OF CARE AND ADVERSE EVENTS

Although most nurses in both groups reported that their unit had excellent quality of care, almost half of both groups of nurses reported that the quality of care in their hospital had deteriorated in the past year (Table 3). The most significant contrast in these 2 groups of nurses involved their response to the question, “How confident are you that the patients you care for are able to manage their care when discharged from hospital?” Nurses could respond from very confident to not at all confident. Nearly twice as many psychiatric nurses reported that their patients were not ready for discharge (34%) than nonpsychiatric nurses (19%).

Table 3.

NURSE-ASSESSED QUALITY OF CARE AND ADVERSE EVENTS

	Psychiatric RNs (n = 447)	Nonpsychiatric RNs (n = 10 813)	Pa
Quality of care
Parcentage describing the quality of care on their unit as excellent	79.0	87.4	.000
Percentage who say the quality of care in their hospital has deteriorated in the past year	47.4	45.0	.294
Percentage “not at all confident” that their patients are able to manage their own care when discharged	34.3	18.8	.000
Percentage who would not recommend a family member to receive care in their hospital	34.1	21.1	.000
Adverse events
Percentage of nurses reporting occasional/frequent wrong medication	21.1	15.0	.000
Percentage of nurses reporting occasional/frequent nosocomial infections	20.5	34.4	.000
Percentage of nurses reporting occasional/frequent patient falls with injuries	44.0	19.1	.000
Percentage of nurses reporting occasional/frequent complaints from patients or families	63.0	49.0	.000
Percentage of nurses reporting occasional/frequent work-related injuries to employees	42.0	33.1	.000
Percentage of nurses reporting occasional/frequent verbal abuse against nurses	80.4	51.3	.000

^aStatistical significance is measured from P < .05.

A similar lack of confidence in their hospital's quality of care was reflected in the nurses' response to the question: “If a member of your family needed health care, would you recommend that it be provided in your hospital?” More than a third of psychiatric nurses (34.1%) said that they would not recommend a family member to receive care in their hospital, which was significantly higher than that of nonpsychiatric nurses (21%).

The greatest differences between the 2 groups of nurses were showed in the perception of adverse events. Nurses were asked, “Over the past year, how often would you say each of the following incidents has occurred involving you or your patients?” They could choose never, rarely, occasionally, or frequently. Both psychiatric nurses and nonpsychiatric nurses reported sizable rates of occasional or frequent adverse events occurring on their units. However, the reporting of medication errors, injuries related to falls, work-related injuries, verbal abuse directed toward nurses, and complaints from clients or their families were substantially higher for psychiatric nurses.

JOB SATISFACTION, BURNOUT, AND INTENTION TO LEAVE NURSING

Forty to 41% of both groups of nurses expressed overall dissatisfaction with their jobs (Table 4). A third or more of both nurse groups scored in the high range of the emotional exhaustion subscale of the MBI. Relative to a normative sample of other healthcare professions including medical workers, mental health workers, and social workers, both nurse groups scored high burnout levels.^23,24 Even so, psychiatric nurses reported significantly lower burnout scores than nonpsychiatric nurses (34% and 44%, respectively). However, nearly a quarter of both groups voiced their intent to leave their present jobs within the next year.

Table 4.

BURNOUT, JOB SATISFACTION, AND INTENTIONS TO LEAVE PRESENT JOB

	Psychiatric RNs (n = 450)	Nonpsychiatric RNs (n = 10 862)	Pa
Percentage dissatisfied with present job	40.0	41.3	.557
Percentage with scores in high burnout range according to norms	34.0	44.1	.000
Percentage planning to leave present job in the next year	23.1	23.1	.953

^aStatistical significance is measured from P < .05.

DISCUSSION

The results of this study provide the first report of quality concerns with inpatient psychiatric environments in general acute care hospitals. Over the past decade, the Institute of Medicine framed an active research agenda centering on improved quality of care, patient safety, and a decrease in the incidence of adverse events.²⁶ However, not until 2003 did a similar initiative come from the federal government reporting on the quality of mental health care.³ Other than noting that there was a dearth of research about the effectiveness of acute care, little was said about the importance of organizational features, adverse events, or safe staffing in psychiatric hospitals. Furthermore, despite a need to examine occurrences of adverse events such as medication errors, falls, patient complaints, etc, until recently, there was little in the literature evaluating the quality of acute inpatient psychiatric care, the importance of nurse staffing, adverse events, or job satisfaction and retention of psychiatric nurses.^5,27

An assessment of the quality of mental health and substance use care appeared from the Institute of Medicine in 2006 in Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series.²⁸ This report calls for substantive changes in the delivery of mental health and substance abuse services in the United States. Yet the focus on quality and safety issues of both patients and staff in inpatient psychiatric settings is minimal in this report.

Contrary to popular opinion that psychiatric patients may be less ill than other patients, they experience the same kinds of adverse patient outcomes that have been a source of great concern in medical-surgical patients. Although no causal links can be made, the significantly large amount of verbal abuse, physical injuries, and complaints from patients and families suggest uneven quality of care provided in these psychiatric units. Collectively, the results from this study underscore the organizational problems and quality-of-care issues that cause psychiatric nurses to evaluate their work environments negatively.

Although psychiatric nurses reported comparable levels of dissatisfaction with their job and unfavorable organizational changes, suggesting a serious lack of management support, only a quarter of them reported that management in their hospitals was responsive to their concerns. Another interesting finding is that more psychiatric nurses report dissatisfaction with their present jobs, but more nonpsychiatric nurses are more burned out. A possible explanation is that the nature of the work of psychiatric nurses demands a higher level of resilience and expertise in assessing and managing human behavior.

The trend to replace RNs with less educated and inexperienced unlicensed personnel needs careful consideration, given reports by psychiatric nurses that this trend has brought about deterioration in the quality of care. Inpatient psychiatric care is human resource intensive and, therefore, expensive. Results from this study suggest that administrators must carefully consider the best staff mix of professional and support staff to care for acutely ill persons admitted to inpatient units. This issue merits additional study.

Nearly a quarter of psychiatric nurses surveyed intended to leave their jobs. A large percentage of these nurses blame workforce management strategies that leave them feeling unheard, left out of decision making, and lacking needed support and acknowledgment from administrators. Strategies for improving work environments to ensure better quality of patient care will go a long way to retaining the expertise of psychiatric nurses.

CONCLUSIONS

Establishing a link between how nursing care is organized and delivered within inpatient psychiatric units and resulting patient outcomes is largely uncharted territory. Despite its limitations, this is the first study in the United States to describe the work environment of inpatient psychiatric nurses in general hospitals and the quality of patient care. Although relationships among coworkers are good, psychiatric nurses perceive their work environment and managers as unsupportive, with insufficient staff to get the work done. If issues related to job dissatisfaction and burnout are not addressed, the current problems with retention are likely to continue and perhaps escalate.

Over the past 40 years, the locus of acute psychiatric care has shifted from state hospitals and custodial care to general hospitals and swift stabilization of acute psychiatric conditions. Evidence suggests that general hospitals could significantly improve psychiatric care for their patients and manage the psychiatric nurse workforce more effectively.