Quality of Inpatient Psychiatric Care in General Hospitals: An Expert Interview With Nancy P. Hanrahan, PhD, RN

Elizabeth McGann, DNSc, RN

October 22, 2010

October 22, 2010 — Editor's note: Changes in the delivery of inpatient psychiatric care were implemented as managed care took hold of behavioral healthcare in the early 1990s. Little has been known about the impact of these changes on inpatient environments in general hospitals, and on patients and nurses. Anecdotal reports of staff injuries and unsafe inpatient psychiatric environments have been noted, but policy makers need empirical evidence before they can improve the quality of care in these environments and the safety of nurses and patients. A discussion of a new study that provides such evidence was featured at the American Psychiatric Nurses Association 24th Annual Conference, held in Louisville, Kentucky, October 13 to 16.

To find out more about the safety and quality of inpatient psychiatric care in general hospitals, Medscape Medical News interviewed Nancy P. Hanrahan, PhD, RN, who is an assistant professor of psychiatric-mental health nursing at the University of Pennsylvania School of Nursing in Philadelphia.

Dr. Hanrahan's research focuses on mental health systems and policy, with the goal of improving healthcare outcomes for people with mental illnesses, particularly those with serious mental illnesses. Dr. Hanrahan is a senior fellow at the Leonard Davis Institute of Economics and a Robert Wood Johnson nurse faculty scholar.

Medscape: How many people are admitted to inpatient psychiatric units in general hospitals each year in the United States, and how many nurses care for these patients?

Dr. Hanrahan: Each year, 7.6 million individuals are hospitalized in inpatient psychiatric units in general hospitals. Two thirds of all psychiatric nurses (approximately 70,000 to 80,000) work in hospitals.

Medscape: What are some of the common reasons for admission?

Dr. Hanrahan: Admissions are due to acute psychiatric conditions, which include schizophrenia, bipolar illness, or major depression.

Medscape: Can you explain what you mean by optimal healing environments?

Dr. Hanrahan: Optimal healing environments in hospitals are places that provide safe, quality patient care where people can [recover] from their illness. Optimal healing environments also support the practice of psychiatric nurses and other staff. Some factors associated with better work environments for nurses include adequate staffing, skilled managers, a nursing model of care, formal quality improvement programs, and good relationships between nurses and physicians.

Medscape: Can you briefly describe the purpose, design, and conduct of your study?

Dr. Hanrahan: The study was a retrospective, cross-sectional study using a 2006 nurse survey of 1306 psychiatric nurses working in 325 general hospitals in 4 states: Pennsylvania, New Jersey, Florida, and California. The psychiatric nurses reported on the quality of their work environment and the presence of adverse events, such as wrong medication and physical and chemical restraint use.

Medscape: What were the findings relative to adverse events, quality, and safety issues in inpatient psychiatric environments?

Dr. Hanrahan: The findings showed that hospitals with better organizational quality had fewer adverse events — less use of physical or chemical restraints, fewer staff injuries, and higher family and patient satisfaction. Higher-quality environments in hospitals were also places where nurses reported less emotional exhaustion and higher job satisfaction, compared with hospitals with poor organizational quality. Psychiatric nurses in better hospitals also reported safer environments.

Medscape: What conclusions can be drawn?

Dr. Hanrahan: Despite immense attention to quality of care and safety over the past decade, surprisingly little is known about the quality and safety of inpatient psychiatric care in general hospitals. Care delivery in this setting, which has grown at such a rapid rate, coincided with substantial declines in length of hospital stays. We investigated the frequency of adverse events, safety, and quality assessments reported by psychiatric nurses providing direct care to patients. In conclusion, we found that only about a third of hospitals were reported by these nurses to be top-quality environments in which to work and treat patients.

Medscape: What recommendations can you make?

Dr. Hanrahan: Inpatient psychiatric care is necessary if a mental illness becomes acute where the individuals are unsafe. Little was known about the internal mechanisms of psychiatric hospital units until this study, in which psychiatric nurses reflected on adverse events, quality, and safety. The findings from this study suggest that hospital care for acute psychiatric conditions vary and need further study to build quality indicators and best-practice standards. This study is one of the first to identify adverse events and to provide evidence of quality and safety issues. The exemplar hospitals and psychiatric nurses need to be involved in setting quality of care and safety standards.

Dr. Hanrahan has disclosed no relevant financial relationships.

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