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Vogt KS, Baker J, Kendal S, Griffin BL, Mizen E, Sharp H, Johnson J. 'Safer, Not Safe': Service Users' Experiences of Psychological Safety in Inpatient Mental Health Wards in the United Kingdom. Int J Ment Health Nurs 2024. [PMID: 39030900 DOI: 10.1111/inm.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/22/2024]
Abstract
Research on patient safety in mental health settings is limited compared to physical healthcare settings. Recent qualitative studies have highlighted that patient safety is more than just physical safety but includes psychological safety. Traditionally, psychological safety has been defined as the belief that it is safe to take interpersonal risks, such as speaking up, without a fear of negative consequences. However, to date, it is not clear what constitutes psychological safety for service users of inpatient mental health settings. To understand this, we conducted 12 interviews with former inpatient mental health service users. Interviews were analysed with Reflexive Thematic Analysis, and five themes were developed. All themes had subthemes. Overall, we found that participants were more readily able to draw on situations where they felt psychologically unsafe, rather than safe. Psychological safety in service users was influenced by (1) healthcare staff attitudes and behaviours towards them, (2) their relationships with other service users, (3) whether they felt they had any control over their environment and medical decision-making regarding their care, (4) their experiences of physically safety, feeling listened to and believed and (5) access to meaningful occupation on the wards. These findings suggest that changes are needed to enhance inpatient mental health service users' general experiences of psychological safety. Further research will need to (1) further develop understanding of the concept of psychological safety for service users and (2) identify interventions, and such interventions should be co-designed with service users.
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Affiliation(s)
- Katharina Sophie Vogt
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
- School of Psychology, University of Leeds, Leeds, UK
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Sarah Kendal
- School of Healthcare, University of Leeds, Leeds, UK
| | - Bethany Leigh Griffin
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
- School of Psychology, University of Leeds, Leeds, UK
| | - Emily Mizen
- Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | - Hannah Sharp
- School of Healthcare, University of Leeds, Leeds, UK
| | - Judith Johnson
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
- School of Psychology, University of Leeds, Leeds, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Shields MC, Davis KA. Inpatient Psychiatric Care in the United States: Former Patients' Perspectives on Opportunities for Quality Improvement. J Patient Exp 2024; 11:23743735241257810. [PMID: 38827226 PMCID: PMC11141210 DOI: 10.1177/23743735241257810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Patient-centered care is a salient value expressed by stakeholders, but a commitment to implementing patient-centered care environments lags in the context of inpatient psychiatry. The current study aimed to describe patients' suggestions for improving the quality of inpatient psychiatry. We fielded a national survey online in 2021, in which we asked participants to report their recommendations for care improvement through a free-response box. We used an inductive qualitative approach to synthesize responses into themes. Most responses described negative experiences, with suggested improvements implied as the inverse or absence of the respondent's negative experience. Among 510 participants, we identified 10 themes: personalized care, empathetic connection, communication, whole health approach, humane care, physical safety, respecting patients' rights and autonomy, structural environment, equitable treatment, and continuity of care and systems. To implement the value of patient-centered care, we suggest that those in positions of power prioritize improvement initiatives around these aspects of care that patients find most in need of improvement.
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Affiliation(s)
- Morgan C. Shields
- Brown School, Washington University in St. Louis, St Louis, Missouri, USA
| | - Kelly A. Davis
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Mental Health America, Alexandria, Virginia, USA
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Xu KY, Gold JA, Szlyk HS, Rolin SA, Shields MC. Mental Illness and Violence Among People Experiencing Homelessness: An Evidence-Based Review. MISSOURI MEDICINE 2024; 121:14-20. [PMID: 38404439 PMCID: PMC10887459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Division of Addiction Science, Prevention, and Treatment, Washington University, and in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Jessica A Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Hannah S Szlyk
- Health and Behavior Research Center, Division of Addiction Science, Prevention, and Treatment, Washington University, and in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Rolin
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Ochman FJ, Shields MC. COVID-19 Mitigation Activities in Inpatient Psychiatry Were Associated With Patient-Reported Institutional Betrayal, Changes in Trust, and Fear of Getting Sick. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241237689. [PMID: 38462912 DOI: 10.1177/00469580241237689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Institutional betrayal occurs when the institutions that people depend on fail to protect them from harm, which was exemplified by a failure to manage COVID-19 risks. Inpatient psychiatry provides a rich context for which to understand the effects of institutional betrayal, and this is amplified in the context of the COVID-19 pandemic. Using a retrospective cohort design, we administered an online survey to former patients (n = 172) of inpatient psychiatry hospitalized at the height of the COVID-19 pandemic (March 2020 to February 2021) to understand the relationship between facilities' use of COVID-19 mitigation activities (ie, offering or requiring face masks, keeping patients and staff 6 feet apart, access to hand sanitizer, use of telemedicine for clinical consults, and routine cleanliness of the unit) and former patients' reports of institutional betrayal, changes in their trust in mental healthcare providers, fear of getting sick, and having contracted or witnessed someone else contract COVID-19. The quantity of COVID-19 mitigation activities was monotonically negatively associated with the probability of reporting any betrayal, the probability of reduced trust in mental healthcare providers, and the probability of being afraid of getting sick always or most of the time while hospitalized. COVID-19 mitigation activities either directly affected these psychological outcomes, or facilities that engaged in robust mitigation had greater cultures of safety and care quality. Additional qualitative work is needed to understand these mechanisms.
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Affiliation(s)
| | - Morgan C Shields
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
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Hameed S, Humayun A, Yaqoob M, Rehm MH. Patient Safety Culture: A Healthcare Provider's Prospect. Cureus 2023; 15:e49989. [PMID: 38179365 PMCID: PMC10766388 DOI: 10.7759/cureus.49989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Safe care is a challenge around the globe, especially in developing countries. In resource-limited settings achieving patient safety is an additional complexity. Patient safety is now considered a significant public health concern worldwide. Despite a vital role in delivering quality care, little attention has been given to describe healthcare professionals' perceptions of the patient safety culture in Pakistan. This study aimed to assess the patient safety culture at a tertiary care public hospital in Lahore from the perspectives of doctors and nurses. METHODS During this cross-sectional study, data were collected from 290 nurses and doctors using a validated safety assessment survey tool of the Hospital Survey of Patient Safety Culture (HSOPSC). The respondent's demographic characteristics and study variables influencing patient safety culture were presented, and a chi-square test was applied to identify the variables influencing patient safety. RESULTS A total of 114 medical doctors (39.3%) and 176 registered nurses (60.7%) participated in assessing patient safety culture (PSC) across tertiary care public healthcare centers in Lahore. The dimensions of organizational learning and continuous improvement (90.6%) and teamwork within units (86.6%) were the highest. Other dimensions include feedback and communication about the error (71.8%), teamwork across units (74.9%), management support for patient safety (67.3%), supervisor/manager expectations, and actions promoting patient safety (64.6%), communication openness (64.5%), overall perceptions of patient safety (65.3%), frequency of events reported (58.7%), and handoffs and transitions (60.9%) showed moderate status. The dimensions of staffing (35.8%) and non-punitive response to errors (39.1%) had the lowest score. CONCLUSIONS The present public hospital survey results revealed that medical staff working in a healthcare setting have a less positive perception of patient safety culture.
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Affiliation(s)
- Sajid Hameed
- Public Health, University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, Lahore, PAK
| | - Ayesha Humayun
- Public Health and Community Medicine, Shaikh Zayed Postgraduate Medical Institute, Lahore, PAK
| | - Muhammad Yaqoob
- Public Health, University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, Lahore, PAK
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Smith CM, Daley LA, Lea C, Daniel K, Tweedy DS, Thielman NM, Staplefoote-Boynton BL, Aimone E, Gagliardi JP. Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study. Psychiatr Serv 2023; 74:1063-1071. [PMID: 37042104 PMCID: PMC10732806 DOI: 10.1176/appi.ps.20220533] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
OBJECTIVE Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU). METHODS Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis. RESULTS Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received. CONCLUSIONS This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.
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Affiliation(s)
- Colin M Smith
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Lori-Ann Daley
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Chris Lea
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Keith Daniel
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Damon S Tweedy
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Nathan M Thielman
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - B Lynette Staplefoote-Boynton
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Elizabeth Aimone
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Jane P Gagliardi
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
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Shields MC, Hollander MAG, Busch AB, Kantawala Z, Rosenthal MB. Patient-centered inpatient psychiatry is associated with outcomes, ownership, and national quality measures. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad017. [PMID: 38756837 PMCID: PMC10986256 DOI: 10.1093/haschl/qxad017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 05/18/2024]
Abstract
Following discharge from inpatient psychiatry, patients experience elevated suicide risk, unplanned readmission, and lack of outpatient follow-up visits. These negative outcomes might relate to patient-centered care (PCC) experiences while hospitalized. We surveyed 739 former patients of inpatient psychiatric settings to understand the relationship between PCC and changes in patients' trust, willingness to engage in care, and self-reported 30-day follow-up visits. We also linked PCC measures to facility-level quality measures in the Inpatient Psychiatric Facility Quality Reporting program. Relative to patients discharged from facilities in the top quartile of PCC, those discharged from facilities in the bottom quartile were more likely to experience reduced trust (predicted probability [PP] = 0.77 vs 0.46; P < .001), reduced willingness to go to the hospital voluntarily (PP = 0.99 vs 0.01; P < .001), and a lower likelihood of a 30-day follow-up (PP = 0.71 vs 0.92; P < .001). PCC was lower among patients discharged from for-profits, was positively associated with facility-level quality measures of 7- and 30-day follow-up and medication continuation, and was inversely associated with restraint use. Findings underscore the need to introduce systematic measurement and improvement of PCC in this setting.
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Affiliation(s)
- Morgan C Shields
- Brown School, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Alisa B Busch
- Department of Health Care Policy, Harvard University, Harvard Medical School, Boston, MA 02115, United States
- McLean Hospital, Belmont, MA 02478, United States
| | - Zohra Kantawala
- Brown School, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard University, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
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Asikainen J, Vehviläinen-Julkunen K, Repo-Tiihonen E, Louheranta O. Patients' Perceptions of Safety and Debriefing in Forensic Mental Health Care in Finland. JOURNAL OF FORENSIC NURSING 2023; 19:187-196. [PMID: 37590941 DOI: 10.1097/jfn.0000000000000436] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
BACKGROUND Safety is of paramount importance to patients and staff in forensic mental health hospitals. Previous research has focused on organizational and nurses' perceptions of safety and violence in psychiatric wards. However, little is known about how patients view their safety. This study aimed to describe how patient debriefing can improve safety. METHODS Qualitative research using thematic analysis was used. Data were collected by semistructured interviews and debriefing forms. Inpatient interviews ( n = 45) were conducted between June and July 2018, with debriefing forms ( n = 376) collected retrospectively. RESULTS Forensic inpatient responses were divided into two main categories: psychological and physical security. Psychological safety included care culture and patient-related themes. Responses on care culture highlighted weaknesses in nurse-patient communication, whereas patient-related themes related to respondents' descriptions of the challenges posed by mental illness. Physical safety related to both the environment and patient-related themes, with various restrictions and environmental distractions seen by respondents as negatively affecting patient safety. CONCLUSIONS Patients who participated in the study felt that care culture, especially communication with nurses, most significantly impacted their safety. Forensic hospitals should consider patients' perceptions of their care while systematically gathering information through debriefing, as these practices can contribute to the development of a safer care environment. The next step will be clarifying how changes in nursing practices and the care environment can be used to prevent violence in psychiatric wards.
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Affiliation(s)
- Jaana Asikainen
- Author Affiliations: Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
| | | | - Eila Repo-Tiihonen
- Author Affiliations: Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
| | - Olavi Louheranta
- Author Affiliations: Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
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Shields MC, Hollander MA. Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018. J Patient Exp 2023; 10:23743735231179072. [PMID: 37323757 PMCID: PMC10265359 DOI: 10.1177/23743735231179072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.
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Affiliation(s)
| | - Mara A.G. Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
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Barnes T, Fontaine T, Bautista C, Lee J, Stanley R. Developing and Aligning a Safety Event Taxonomy for Inpatient Psychiatry. J Patient Saf 2022; 18:e704-e713. [PMID: 35617595 DOI: 10.1097/pts.0000000000000935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this project was to develop and align an inpatient psychiatric safety event taxonomy that would blend well-established safety events with psychiatry-specific concerns. METHODS A hybrid inductive-deductive thematic analysis was used to generate novel descriptive safety event categories for inpatient psychiatry and align these categories with an established taxonomic framework. In the inductive phase, an initial taxonomy was developed by describing the semantic subject and context of reported safety concerns. In the deductive phase, existing literature, national standards, and local content experts were used to align our taxonomy with the safety event measurement system at our institution. RESULTS A total of 2291 events were extracted and 483 were analyzed. After thorough review, the data was divided into 4 domains: (1) Provision of care, (2) patient actions, (3) environment/equipment, and (4) safety culture. Each domain reflects a mutually exclusive typology of events and provides a parsimonious view of safety concerns in inpatient psychiatry. Each domain was further divided into categories, subcategories, and subcategory details. CONCLUSIONS Safety events on inpatient psychiatric units are understudied and lack the measurement infrastructure to identify care processes that result in exposure to harm. We develop and align an inpatient psychiatric safety taxonomy based on real-world data, existing literature, and measurement standards. This taxonomy can be used by psychiatric hospitals to improve their patient safety measurement systems-and ultimately-the safety of their patients and communities.
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Affiliation(s)
- Todd Barnes
- From the Yale New Haven Psychiatric Hospital, New Haven, Connecticut
| | - Thomas Fontaine
- From the Yale New Haven Psychiatric Hospital, New Haven, Connecticut
| | | | - Jaeyeon Lee
- From the Yale New Haven Psychiatric Hospital, New Haven, Connecticut
| | - Rebecca Stanley
- From the Yale New Haven Psychiatric Hospital, New Haven, Connecticut
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Shields MC, Beaulieu ND, Lu S, Busch AB, Cutler DM, Chien AT. Increases in Inpatient Psychiatry Beds Operated by Systems, For-Profits, and Chains, 2010-2016. Psychiatr Serv 2022; 73:561-564. [PMID: 34433287 DOI: 10.1176/appi.ps.202100182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study explored trends in the quantity of inpatient psychiatry beds and in facility characteristics. METHODS Using the National Bureau of Economic Research's Health Systems and Provider Database, the authors examined changes in the number of psychiatric facilities and beds, focusing on system ownership, profit status, facility type (general acute care versus freestanding), and affiliation with psychiatric hospital chains from 2010 to 2016. RESULTS The number of psychiatric beds was relatively unchanged from 2010 (N=112,182 beds) to 2016 (N=111,184). However, the number of beds operated by systems increased by 39.8% (N=15,803); for-profits, by 56.9% (N=8,572); and chains, by 16.7% (N=6,256). Net increases in beds were primarily concentrated in for-profit freestanding psychiatric hospitals. In 2016, most for-profit beds were part of chains (70.2%) and systems (61.3%). CONCLUSIONS Inpatient psychiatry has shifted toward increased ownership by systems, for-profits, and chains. Payers and policy makers should safeguard against profiteering, and future research should investigate the implications of these trends on quality of care.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Nancy D Beaulieu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Sifan Lu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alisa B Busch
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - David M Cutler
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alyna T Chien
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
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Simpson SA, Loh R, Goans CRR, Ryall K, Middleton M, Dalton A. Reply to Letter to the Editor. J Emerg Med 2022; 62:570-571. [PMID: 35065864 DOI: 10.1016/j.jemermed.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Scott A Simpson
- Department of Behavioral Health Services, Denver Health and Hospital Authority, Denver, Colorado
| | - Ryan Loh
- Department of Behavioral Health Services, Denver Health and Hospital Authority, Denver, Colorado
| | | | | | - Molly Middleton
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Alicia Dalton
- Rocky Mountain Poison and Drug Safety, Denver, Colorado
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Varpula J, Välimäki M, Lantta T, Berg J, Soininen P, Lahti M. Safety hazards in patient seclusion events in psychiatric care: A video observation study. J Psychiatr Ment Health Nurs 2022; 29:359-373. [PMID: 34536315 DOI: 10.1111/jpm.12799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.
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Affiliation(s)
- Jaakko Varpula
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland.,Xiangya School of Nursing, Central South University, Hunan, China
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Johanna Berg
- Department of Nursing Science, University of Turku, Turku, Finland.,Turku University of Applied Sciences, Turku, Finland
| | | | - Mari Lahti
- Department of Nursing Science, University of Turku, Turku, Finland.,Turku University of Applied Sciences, Turku, Finland
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Han X, Jiang F, Shen L, Liu Y, Liu T, Liu H, Wang P, Yang Z, Tang YL, Zhu J. Workplace Violence, Workforce Stability, and Well-being in China's Psychiatric Hospitals. Am J Prev Med 2022; 62:e265-e273. [PMID: 34865934 DOI: 10.1016/j.amepre.2021.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Workplace violence against psychiatric professionals is a growing problem, yet nationally representative data in China are lacking. This study examines workplace violence against psychiatrists and psychiatric nurses in China as well as its association with workforce stability and well-being . METHODS Data came from a 2019 national survey of 14,264 participants (including 4,520 psychiatrists and 9,744 nurses) from 41 psychiatric hospitals across China. The occurrence of physical and verbal assaults among psychiatrists and psychiatric nurses was reported. Logistic regression models were constructed to examine the participants' characteristics associated with encountering workplace violence and the association of encountering violence with self-reported quality of life, health status, turnover intention, and career satisfaction. Analyses were performed during 2020. RESULTS In 2019, among 14,264 psychiatrists and psychiatric nurses in China, 81% reported encountering workplace violence during the past year. Psychiatrists were 0.68 (95% CI=0.55, 0.83) times less likely to report an encounter of violence than nurses. Male and younger nurses were 2.20 (95% CI=1.72, 2.81) and 1.21 (95% CI=1.01, 1.45) times more likely to report violence. Psychiatrists who had a higher educational degree or a higher professional rank were more vulnerable to violence. Encountering violence was significantly associated with poor quality of life, less satisfaction with health status, greater intention to leave the current job, and career dissatisfaction. CONCLUSIONS Workplace violence against psychiatrists and psychiatric nurses are common in China, indicating that China's psychiatric professionals are facing a significant threat to occupational safety. To maintain psychiatric workforce stability, actions are needed to reduce the prevalence of workplace violence at the system, institutional, and individual levels.
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Affiliation(s)
- Xinxin Han
- Vanke School of Public Health, Tsinghua University, Beijing, China; School of Medicine, Tsinghua University, Beijing, China
| | - Feng Jiang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China; Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, China
| | - Lijun Shen
- Vanke School of Public Health, Tsinghua University, Beijing, China; School of Medicine, Tsinghua University, Beijing, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingfang Liu
- Institute for Hospital Management, Tsinghua University, Beijing, China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China; Department of Psychiatry, Anhui Psychiatric Center, Anhui Medical University, Hefei, China
| | - Peicheng Wang
- School of Medicine, Tsinghua University, Beijing, China; Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Zimo Yang
- School of Medicine, Tsinghua University, Beijing, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia; Mental Health Service Line, Atlanta, Georgia
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China.
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Svensson J. Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review. J Patient Saf 2022; 18:245-252. [PMID: 34347739 PMCID: PMC9359776 DOI: 10.1097/pts.0000000000000885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm. METHOD A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy. RESULTS The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization. CONCLUSIONS The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.
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Affiliation(s)
- Jakob Svensson
- From the Division of Risk Management and Societal Safety, Lund University, Sweden
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16
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Shields MC, Trinh NHT, Borba CPC, Chen R, Reddy AK, Singer SJ. Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff. J Psychosoc Nurs Ment Health Serv 2022; 60:15-22. [PMID: 34590985 PMCID: PMC10182870 DOI: 10.3928/02793695-20210916-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 15-22.].
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Riblet NB, Gottlieb DJ, Watts BV, Levis M, Scott R, Shiner B. Is It Time for the Mental Health Field to Consider Unplanned Discharge a Key Metric of Patient Safety? J Nerv Ment Dis 2022; 210:227-230. [PMID: 35199662 PMCID: PMC8937566 DOI: 10.1097/nmd.0000000000001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Mental health lacks robust measures to assess patient safety. Unplanned discharge is common in mental health populations and associated with poor outcomes. Clarifying whether unplanned discharge varies across settings may highlight the need to develop measures to reduce harms associated with this event. Unplanned discharge rates were compared across the Department of Veterans Affairs' acute inpatient and residential mental health treatment settings from 2009 to 2019. Logistic regression was used to create facility-level, adjusted unplanned discharge rates stratified by setting. Results were described using central tendency. Among 847,661 acute inpatient discharges, the mean unplanned discharge rate was 3.3% (range, 0%-18%). Among 358,117 residential discharges, the mean unplanned discharge rate was 17.9% (range, 1%-48.3%). Unplanned discharge is a marked problem in mental health, with large variation across treatment settings. Unplanned discharge should be measured as part of patient safety efforts.
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Affiliation(s)
- Natalie B. Riblet
- Veterans Affairs Medical Center, Mental Health Service, White River Junction, Vermont
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth Institute, Hanover, New Hampshire
| | | | - Bradley V. Watts
- Veterans Affairs Medical Center, Mental Health Service, White River Junction, Vermont
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth Institute, Hanover, New Hampshire
- Department of Systems Improvement, VA Office of Systems Redesign and Improvement
| | - Maxwell Levis
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth Institute, Hanover, New Hampshire
- Research Service, Veterans Affairs Medical Center
| | - Robert Scott
- Veterans Affairs Medical Center, Mental Health Service, White River Junction, Vermont
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth Institute, Hanover, New Hampshire
| | - Brian Shiner
- Veterans Affairs Medical Center, Mental Health Service, White River Junction, Vermont
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth Institute, Hanover, New Hampshire
- National Center for PTSD, Mental Health Service, White River Junction, Vermont
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Jones N, Gius BK, Shields M, Collings S, Rosen C, Munson M. Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care. Soc Psychiatry Psychiatr Epidemiol 2021; 56:2017-2027. [PMID: 33751175 PMCID: PMC10105343 DOI: 10.1007/s00127-021-02048-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Few studies have focused on the experience of involuntary psychiatric hospitalization among youth, especially the impact of these experiences on engagement with mental health services post-discharge. In this study, we contribute to a deeper understanding of youth experiences of involuntary hospitalization (IH) and its subsequent impacts on trust, help-seeking, and engagement with clinicians. METHODS The study utilized a grounded theory approach, conducting in-depth interviews with 40 youth and young adults (ages 16-27) who had experienced at least one prior involuntary hospitalization. RESULTS Three quarters of the youth reported negative impacts of IH on trust, including unwillingness to disclose suicidal feelings or intentions. Selective non-disclosure of suicidal feelings was reported even in instances in which the participant continued to meet with providers following discharge. Factors identified as contributing to distrust included perceptions of inpatient treatment as more punitive than therapeutic, staff as more judgmental than empathetic, and hospitalization overall failing to meet therapeutic needs. Conversely, participants reporting more mixed experiences of hospitalization and simultaneously strong indirect benefits, including greater family support, diminished family judgement members and greater access to care. CONCLUSION Findings draw attention to the ways in which coercive experiences may impact youth pathways to and through care. Additional research is needed to understand the impact of these experiences across larger samples, and their influence on downstream outcomes including engagement and long-term wellbeing. Finally, these data may inform the development and testing of inpatient and post-discharge interventions designed to mitigate potential harm.
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Affiliation(s)
- Nev Jones
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 4202 East Fowler Ave, Tampa, FL, 33620, USA.
| | - Becky K Gius
- Department of Psychology, University of South Florida, Tampa, FL, USA
| | - Morgan Shields
- Department of Psychiatry, Center for Mental Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Shira Collings
- Department of Counseling, Troy University, Tampa, FL, USA
| | - Cherise Rosen
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Michelle Munson
- Silver School of Social Work, New York University, New York, NY, USA
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Shields MC. Patient Characteristics Associated With Admission to Low-Safety Inpatient Psychiatric Facilities: Evidence for Racial Inequities. Psychiatr Serv 2021; 72:1151-1159. [PMID: 33993716 DOI: 10.1176/appi.ps.202000657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities. METHODS Massachusetts all-payer 2017 discharge data (N=39,128 psychiatric patients) were linked to facility-level indicators of safety (N=38 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1,000 discharges (α=0.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately. RESULTS Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]=1.71, p<0.01; for non-Hispanic Asian, RRR=5.60, p<0.01; for non-Hispanic "other" race, RRR=2.17, p<0.01; and for Hispanic-Latinx, RRR=1.29, p<0.01) and not having private insurance (for self-pay or uninsured, RRR=2.40, p<0.01; for Medicaid, RRR=1.80, p<0.01; and for Medicare, RRR=1.31, p<0.01). CONCLUSIONS To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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20
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Stokes DC, Kishton R, McCalpin HJ, Pelullo AP, Meisel ZF, Beidas RS, Merchant RM. Online Reviews of Mental Health Treatment Facilities: Narrative Themes Associated With Positive and Negative Ratings. Psychiatr Serv 2021; 72:776-783. [PMID: 34015944 PMCID: PMC9116241 DOI: 10.1176/appi.ps.202000267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Previous studies indicate that patients' satisfaction with mental health care is correlated with both treatment outcomes and quality of life. The aims of this study were to describe online reviews of mental health treatment facilities, including key themes in review content, and to evaluate the correlation between narrative review themes, facility characteristics, and review ratings. METHODS United States National Mental Health Services Survey (N-MHSS) facilities were linked to corresponding Yelp pages, created between March 2007 and September 2019. Correlations between review ratings and both machine learning-generated latent Dirichlet allocation topics and N-MHSS-reported facility characteristics were measured by using Spearman's rank-order correlation coefficient. Significance was defined by a Bonferroni-adjusted p<0.001. RESULTS Of 10,191 unique mental health treatment facilities, 1,383 (13.6%) had relevant Yelp pages with 8,133 corresponding reviews. The number of newly reviewed facilities and the number of new reviews increased throughout the study period. Narrative topics positively correlated with review ratings included caring staff (Spearman's ρ=0.39) and nonpharmacologic treatment (ρ=0.16). Topics negatively correlated with review ratings included rude staff (ρ=-0.14) and safety and abuse (ρ=-0.14). Of 126 N-MHSS survey items, 11 were positively correlated with review rating, including "outpatient mental health facility" (ρ=0.13), and 33 were negatively correlated with review rating, including accepting Medicare (ρ=-0.21). CONCLUSIONS Narrative topics provide information beyond what is currently collected through the N-MHSS. Topics associated with positive and negative reviews, such as staff attitude toward patients, can guide improvement in patients' satisfaction and engagement with mental health care.
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Affiliation(s)
- Daniel C Stokes
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Rachel Kishton
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Haley J McCalpin
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Arthur P Pelullo
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Zachary F Meisel
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Rinad S Beidas
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
| | - Raina M Merchant
- Penn Medicine Center for Digital Health (Stokes, McCalpin, Pelullo, Merchant), Center for Emergency Care Policy and Research, Department of Emergency Medicine (Stokes, Meisel, Merchant), Department of Psychiatry (Beidas), and Penn Medical Ethics and Health Policy (Beidas), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Clinician Scholars Program (Kishton), Leonard Davis Institute of Health Economics (Meisel, Merchant), and Penn Implementation Science Center at the Leonard Davis Institute (Beidas), University of Pennsylvania, Philadelphia
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Shields MC. Effects of the CMS' Public Reporting Program for Inpatient Psychiatric Facilities on Targeted and Nontargeted Safety: Differences Between For-Profits and Nonprofits. Med Care Res Rev 2021; 79:233-243. [PMID: 33709840 DOI: 10.1177/1077558721998924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The Centers for Medicare and Medicaid Services implemented the Inpatient Psychiatric Facility Quality Reporting Program in 2012, which publicly reports facilities' performance on restraint and seclusion (R-S) measures. Using data from Massachusetts, we examined whether nonprofits and for-profits responded differently to the program on targeted indicators, and if the program had a differential spillover effect on nontargeted indicators of quality by ownership. Episodes of R-S (targeted), complaints (nontargeted), and discharges were obtained for 2008-2017 through public records requests to the Commonwealth of Massachusetts. Using difference-in-differences estimators, we found no differential changes in R-S between for-profits and nonprofits. However, for-profits had larger increases in overall complaints, safety-related complaints, abuse-related complaints, and R-S-related complaints compared with nonprofits. This is the first study to examine the effects of a national public reporting program among psychiatric facilities on nontargeted measures. Researchers and policymakers should further scrutinize intended and unintended consequences of performance-reporting programs.
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22
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Cutler NA, Sim J, Halcomb E, Moxham L, Stephens M. Nurses' influence on consumers' experience of safety in acute mental health units: A qualitative study. J Clin Nurs 2020; 29:4379-4386. [DOI: 10.1111/jocn.15480] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Natalie Ann Cutler
- School of Nursing University of Wollongong Northfields Ave Wollongong NSW 2522 Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong NSW Australia
| | - Jenny Sim
- School of Nursing University of Wollongong Northfields Ave Wollongong NSW 2522 Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong NSW Australia
| | - Elizabeth Halcomb
- School of Nursing University of Wollongong Northfields Ave Wollongong NSW 2522 Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong NSW Australia
| | - Lorna Moxham
- School of Nursing University of Wollongong Northfields Ave Wollongong NSW 2522 Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong NSW Australia
| | - Moira Stephens
- School of Nursing University of Wollongong Northfields Ave Wollongong NSW 2522 Australia
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The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion. Med Care 2020; 58:889-894. [PMID: 32925415 DOI: 10.1097/mlr.0000000000001393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients in inpatient psychiatry settings are uniquely vulnerable to harm. As sources of harm, research and policy efforts have specifically focused on minimizing and eliminating restraint and seclusion. The Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting (IPFQR) program attempts to systematically measure and reduce restraint and seclusion. We evaluated facilities' response to the IPFQR program and differences by ownership, hypothesizing that facilities reporting these measures for the first time will show a greater reduction and that ownership will moderate this effect. METHODS Using a difference-in-differences design and exploiting variation among facilities that previously reported on these measures to The Joint Commission, we examined the effect of the IPFQR public reporting program on the use and duration of restraint and seclusion from the end of 2012 through 2017. RESULTS There were a total of 9705 observations of facilities among 1841 unique facilities. Results suggest the IPFQR program reduced duration of restraint by 48.96% [95% confidence interval (95% CI), 16.69%-68.73%] and seclusion by 53.54% (95% CI, 19.71%-73.12%). There was no change in odds of zero restraint and, among for-profits only, a decrease of 36.89% (95% CI, 9.32%-56.07%) in the odds of zero seclusion. CONCLUSIONS This is the first examination of the effect of the IPFQR program on restraint and seclusion, suggesting the program was successful in reducing their use. We did not find support for ownership moderating this effect. Additional research is needed to understand mechanisms of response and the impact of the program on nontargeted aspects of quality.
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Staggs VS. Variability in Psychiatric Facility Seclusion and Restraint Rates as Reported on Hospital Compare Site. Psychiatr Serv 2020; 71:893-898. [PMID: 32487008 DOI: 10.1176/appi.ps.202000011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study examined variability among U.S. hospitals in rates of seclusion and physical restraint, including the effects of hospital type and ownership, as reported on Hospital Compare. Broader aims were to highlight the wide variability in use of these measures, the need for improved data reporting, and the data source itself, which deserves further development and more attention from regulatory agencies, researchers, and others. METHODS Facility-level data from Hospital Compare for 2013-2017 were analyzed. Rates of seclusion and restraint were computed by aggregating across study years and compared by hospital type and ownership. Rates were also examined by year. RESULTS Data cleaning revealed hundreds of errors. The final sample comprised 7,416 seclusion rates and 7,398 restraint rates from 1,642 hospitals. For both acute care and psychiatric hospitals, marked differences were noted in seclusion and restraint rates above the median, with for-profit hospitals reporting markedly lower rates compared with government and nonprofit hospitals. Rates above the median declined substantially during the study period. Although 67% of hospitals reported comparably low rates of seclusion (≤0.09 hours per 1,000 patient-hours) and restraint (≤0.15 hours per 1,000 patient-hours), 10% of hospitals reported rates at least five to 10 times higher. CONCLUSIONS Despite some progress, many hospitals continue to report very high rates of seclusion and restraint. It is unlikely that this variability can be fully accounted for by patient-level factors. Centers for Medicare and Medicaid Services data reporting should be expanded to include frequency of seclusion and restraint use and duration of episodes.
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Affiliation(s)
- Vincent S Staggs
- Division of Health Services and Outcomes Research, Biostatistics and Epidemiology Core, Children's Mercy Kansas City, and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City
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Shields MC, Ritter G, Busch AB. Electronic Health Information Exchange At Discharge From Inpatient Psychiatric Care In Acute Care Hospitals. Health Aff (Millwood) 2020; 39:958-967. [PMID: 32479237 DOI: 10.1377/hlthaff.2019.00985] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To address the complex health care needs of patients with mental illness-who commonly have co-occurring medical conditions and substance use disorders-it is critically important for providers to use electronic health records (EHRs) for health information exchange (HIE) when patients are transferred from inpatient psychiatric units in acute care hospitals. Efficient and timely HIE is necessary to ensure that patients receive adequate and informed follow-up care. This study examined the percentage of inpatient psychiatric units that reported using EHRs for HIE at transfers of care and hospital characteristics associated with that use. We linked national data from the Inpatient Psychiatric Facility Quality Reporting Program of the Centers for Medicare and Medicaid Services, the American Hospital Association Annual Survey, and state mental health privacy laws. In 2016 the use of electronic HIE upon transfer from psychiatric units lagged behind the corresponding overall use rates from acute care hospitals (56.3 percent versus 88 percent), with wide variation across states. Hospital size and accountable care organization participation were associated with electronic HIE, but a state's having mental health privacy laws more stringent than the Health Insurance Portability and Accountability Act did not. Given these results, policy efforts to incentivize the use of electronic HIE in psychiatric settings should be strengthened.
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Affiliation(s)
- Morgan C Shields
- Morgan C. Shields is a PhD candidate and NIAAA fellow at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts, and a research assistant in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Grant Ritter
- Grant Ritter is an associate research professor at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University
| | - Alisa B Busch
- Alisa B. Busch is an associate professor of psychiatry and health care policy at McLean Hospital and the Department of Health Care Policy, Harvard Medical School. She is also the chief medical information officer at McLean Hospital
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Berzins K, Baker J, Louch G, Albutt A. A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services. Health Expect 2020; 23:549-561. [PMID: 32045094 PMCID: PMC7321733 DOI: 10.1111/hex.13025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/21/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Service user and carer perspectives on safety issues in mental health services are not well known and may be important in preventing and reducing harm. The development of the Yorkshire Contributory Factors Framework-Mental Health (YCFF-MH) provides a broad structure within which to explore these perspectives. OBJECTIVE To explore what service users of mental health services and their carers consider to be safety issues. DESIGN, SETTING AND PARTICIPANTS Qualitative interviews with 13 service users and 7 carers in the UK. Participants were asked about their experiences and perceptions of safety within mental health services. Perceived safety issues were identified using framework analysis, guided by the YCFF-MH. RESULTS Service users and carers identified a broad range of safety issues. These were categorized under 'safety culture' and included psychological concepts of safety and raising concerns; 'social environment' involved threatened violence and sexual abuse; 'individual service user and staff factors' dominated by not being listened to; 'management of staff and staffing levels' resulting in poor continuity of care; and 'service process' typified by difficulty accessing services during a crisis. Several examples of 'active failures' were also described. DISCUSSION AND CONCLUSIONS Safety issues appear broader than those recorded and reported by health services and inspectorates. Many safety issues have also been identified in other care settings supporting the notion that there are overlaps between service users and carers' perspectives of safety in mental health services and those of users in other settings. Areas for further research are suggested.
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Affiliation(s)
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Gemma Louch
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford Royal Infirmary, Bradford Institute for Health Research, Bradford, UK
| | - Abigail Albutt
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford Royal Infirmary, Bradford Institute for Health Research, Bradford, UK
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Nilsson L, Borgstedt-Risberg M, Brunner C, Nyberg U, Nylén U, Ålenius C, Rutberg H. Adverse events in psychiatry: a national cohort study in Sweden with a unique psychiatric trigger tool. BMC Psychiatry 2020; 20:44. [PMID: 32019518 PMCID: PMC7001519 DOI: 10.1186/s12888-020-2447-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/21/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The vast majority of patient safety research has focused on somatic health care. Although specific adverse events (AEs) within psychiatric healthcare have been explored, the overall level and nature of AEs is sparsely investigated. METHODS Cohort study using a retrospective record review based on a two-step trigger tool methodology in the charts of randomly selected patients 18 years or older admitted to the psychiatric acute care departments in all Swedish regions from January 1 to June 30, 2017. Hospital care together with corresponding outpatient care were reviewed as a continuum, over a maximum of 3 months. The AEs were categorised according to type, severity and preventability. RESULTS In total, the medical records of 2552 patients were reviewed. Among the patients, 50.4% were women and 49.6% were men. The median (range) age was 44 (18-97) years for women and 44.5 (18-93) years for men. In 438 of the reviewed records, 720 AEs were identified, corresponding to the AEs identified in 17.2% [95% confidence interval, 15.7-18.6] of the records. The majority of AEs resulted in less or moderate harm, and 46.2% were considered preventable. Prolonged disease progression and deliberate self-harm were the most common types of AEs. AEs were significantly more common in women (21.5%) than in men (12.7%) but showed no difference between age groups. Severe or catastrophic harm was found in 2.3% of the records, and the majority affected were women (61%). Triggers pointing at deficient quality of care were found in 78% of the records, with the absence of a treatment plan being the most common. CONCLUSIONS AEs are common in psychiatric care. Aside from further patient safety work, systematic interventions are also warranted to improve the quality of psychiatric care.
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Affiliation(s)
- Lena Nilsson
- Department of Anaesthesiology and Intensive Care, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Department of Anaesthesiology and Intensive Care, University Hospital, 583 81, Linköping, Sweden.
| | - Madeleine Borgstedt-Risberg
- 0000 0001 2162 9922grid.5640.7Centre for Organisational Support and Development (CVU), Region Östergötland, Linköping University, Linköping, Sweden
| | - Charlotta Brunner
- 0000 0001 0597 1373grid.466900.dDepartment of Psychiatry, Kalmar County Council, Kalmar, Sweden
| | - Ullakarin Nyberg
- 0000 0004 1937 0626grid.4714.6Stockholm Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Urban Nylén
- 0000 0004 0511 9852grid.416537.2National Board of Health and Welfare, Stockholm, Sweden
| | - Carina Ålenius
- 0000 0001 2106 9080grid.452053.5Swedish Association of Local Authorities and Regions, Stockholm, Sweden
| | - Hans Rutberg
- 0000 0001 2106 9080grid.452053.5Swedish Association of Local Authorities and Regions, Stockholm, Sweden
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Schwappach DLB, Niederhauser A. Speaking up about patient safety in psychiatric hospitals - a cross-sectional survey study among healthcare staff. Int J Ment Health Nurs 2019; 28:1363-1373. [PMID: 31609065 PMCID: PMC6919932 DOI: 10.1111/inm.12664] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 12/02/2022]
Abstract
Speaking up is an important communication strategy to prevent patient harm. The aim of this study was to examine speak up-related behaviour and climate for the first time in psychiatric hospitals. A cross-sectional survey was conducted among healthcare workers (HCWs) in six psychiatric hospitals with nine sites in Switzerland. Measures assessed speak up-related behaviour with 11 items organized in three scales (the frequency of perceived safety concerns, the frequency of withholding voice, and the frequency of speaking up). Speak up-related climate was assessed by 11 items organized in 3 subscales (psychological safety for speaking up, encouraging environment for speaking up, and resignation). Statistical analyses included descriptive statistics, reliability, correlations and multiple regression analysis, confirmatory factor analysis, and analysis of variance for comparing mean scores between professional groups. A total of 817 questionnaires were completed (response rate: 23%). In different items, 45%-65% of HCWs reported perceived safety concerns at least once during the past four weeks. Withholding voice was reported by 13-25% of HCWs, and speaking up was reported by 53%-72% of HCWs. Systematic differences in scores were found between professional groups (nurses, doctors, psychologists) and hierarchical groups (lower vs higher status). The vignette showed that hierarchical level and perceived risk of harm for the patient were significant predictors for the self-reported likelihood to speak up. Situations triggering safety concerns occur frequently in psychiatric hospitals. Speaking up and voicing concerns should be further promoted as an important safety measure.
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Affiliation(s)
- David L B Schwappach
- Swiss Patient Safety Foundation, Zürich, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University Bern, Bern, Switzerland
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