Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland

INTRODUCTION

Nursing care left undone occurs when nurses omit activities because of resource shortfalls. Higher levels of nursing care left undone are associated with worse nurse staffing and organizational factors. Plentiful evidence from acute, long-term and community care supports such associations; however, mental healthcare settings are under-studied.

AIM

The aim of the study was to describe nursing care left undone's frequency in mental health inpatient settings and explore its association with nurse staffing levels.

METHOD

As part of the multi-centre cross-sectional MatchRN Psychiatry study, data were collected by questionnaire from 114 units in 13 Swiss psychiatric hospitals. Nursing care left undone was analysed describing frequencies descriptively and used linear mixed models to assess its association with staffing.

RESULTS

Data from 994 nurses were analysed. The most commonly omitted activities were evaluating nursing processes (30.5%), formulating nursing diagnoses (27.4%) and defining care objectives (22.7%). Nursing care left undone was higher in units with low staffing levels.

DISCUSSION

As in somatic care settings, in psychiatric hospitals, 'indirect' care activities are most commonly omitted.

IMPLICATIONS FOR PRACTICE

This study highlights factors affecting the frequency of nursing care left undone, including staffing levels and perceived leadership. The findings emphasize the importance of nurse managers taking action to improve work environment factors.

Work-schedule management in psychiatric hospitals and its associations with nurses' emotional exhaustion and intention to leave: A cross-sectional multicenter study

BACKGROUND

Managing nurses' work schedules in hospitals is challenging because employer needs, like shift changes at short notice and overtime, may conflict with nurses' desires for a predictable and stable schedule. Nurses should have a certain degree of control over their work schedules, and their supervisors should support their needs in scheduling. How perceived control over work schedules, perceived support from supervisors in scheduling, shift changes at short notice, and overtime affect nurses' emotional exhaustion and intentions to leave has not been studied.

OBJECTIVES

The aims are (1) to describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses in psychiatric hospitals; (2) to assess the variation of these four factors between units at psychiatric hospitals; and (3) to investigate the association between these factors with nurses' emotional exhaustion and intentions to leave.

DESIGN

Cross-sectional survey study.

SETTING(S)

Swiss psychiatric hospitals with 24-hour services.

PARTICIPANTS

Registered nurses (N = 994) from 114 adult-inpatient units.

METHODS

To describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses, we calculated frequencies, percentages, means, and standard deviations of their responses to the survey. To assess the variation between units, we computed intraclass correlations for the four factors. We constructed random-effects models accounting for the clustering of nurses in units for emotional exhaustion and intentions to leave separately.

RESULTS

Perception of work-schedule control was 3.32 (SD 1.39, range 0-5); perception of supervisor work-schedule support was 3.28 (SD 1.14, range 0-4). On average, 9 % of the nurses had to take over a shift at short notice at least three times per month, and 40 % worked at least 15 minute overtime on their most recent shift. Intraclass correlation for all four factors was higher than 0.05. Emotional exhaustion was significantly associated with supervisor support and overtime, and leaving intentions were significantly associated with perceived control, supervisor support and overtime.

CONCLUSION

Perceived control, perceived supervisor support, shift changes at short notice, and overtime are promising factors for interventions to prevent nurses' emotional exhaustion and allay their intentions to leave. Unit managers should provide nurses with increased predictability and influence on their work schedules. This could reduce early career endings and early retirement and counteract nurse shortages.

The Interaction Between Leadership, the Patient-to-Nurse Ratio and Nurses' Work-Life Balance in the Psychiatric Inpatient Setting in Switzerland: A Secondary Data Analysis of Cross-Sectional Data

Psychiatric nurses' work environment factors, including long hours, heavy workloads and leadership issues, can serve as barriers to achieving a healthy work-life balance. However, for both individuals and organizations, that balance is crucial as it is a key determinant of job satisfaction and leaving intentions. To address the limiting evidence to that topic, this study had two objectives: (1) to describe the work-life balance of nurses working in psychiatric inpatient settings; and (2) to examine those nurses' work-life balance and its associations with individual (i.e., age, gender), psychosocial (i.e., leadership) and structural factors (i.e., employment percentage). To analyze these factors and their impacts, we conducted a cross-sectional study in a sample of 1209 nurses from 116 units in 13 psychiatric hospitals of the German-speaking part of Switzerland and analyzed the resulting data via multilevel analysis. This led to three main results. First, nurses reported a high mean value regarding their work-life balance. Second, multivariable regression results indicated that their work-life balance ratings correlated directly with certain psychosocial work environment factors (leadership and support of nurses, perceived staffing resources) and inversely with structural factors (employment percentage, overtime). And third, we found an interaction between leadership and support of nurses and the patient-to-nurse ratio: the lower the leadership level, the stronger the inverse association between patient load and work-life balance. No individual factors were significantly associated with work-life balance. Overall, though, we found that organizational factors are vital to nurses' work-life balance. Therefore, interventions to improve nurses' work-life balance should be institution-level, and should focus on improving either leadership or structural factors, e.g., employment percentage, overtime, and patient-to-nurse ratios.

The deployment of temporary nurses and its association with permanently-employed nurses' outcomes in psychiatric hospitals: a secondary analysis

Aims

This study's objective was to investigate possible associations between the frequency of temporary nurse deployments and permanently-employed nurses' outcomes including staffing levels in Swiss psychiatric hospitals.

Background

Faced with widespread nursing shortages, some nursing managers frequently deploy temporary nurses to meet their staffing needs. While various studies have investigated the relationships between temporary nurses' deployment and permanently-employed nurse outcomes, few anywhere, and none in Switzerland, have explored such deployments' relationships with permanently-employed nurses' job satisfaction, burnout, or intent to leave their organization or profession. Furthermore, especially in psychiatric hospitals, research on temporary nurse deployments and their association with permanently-employed nurses' outcomes remains scarce.

Methods

This secondary analysis is based on the Match^RN Psychiatry study, which included 79 psychiatric units and 651 nurses. Using descriptive analyses and linear mixed modeling, we assessed the frequency of temporary nurses' deployment and its association with four permanently-employed nurse outcomes: staffing levels, job satisfaction, burnout, and intention to leave their organization or profession.

Results

Roughly one-quarter of the studied units reported frequently deploying temporary nurses. Nonetheless, no differences in nurse staffing levels were found. Regarding permanently-employed nurses' outcomes, we identified slightly higher levels of intention to leave the profession (beta = 0.18; 95% CI [0.03-0.33]) and burnout (beta = 0.19; 95% CI [0.4-0.33]) on units where temporary nurses were frequently deployed.

Conclusion

Deploying temporary nurses appears to help units maintain adequate staffing levels. However, additional research will be necessary to better understand whether working conditions are the common cause of temporary nurses' deployment and permanently-employed nurse outcomes. Until more information is available, unit managers should consider alternatives to deploying temporary nurses.

Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study

Aim

The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard.

Findings

This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%.

Message

The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents.

Purpose

Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard.

Methods

This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult.

Results

85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer.

Conclusion

The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.

Prevalence and severity of verbal, physical, and sexual inpatient violence against nurses in Swiss psychiatric hospitals and associated nurse-related characteristics: Cross-sectional multicentre study

This analysis (1) describes the prevalence and severity of psychiatric inpatient violence against nurses in Switzerland's German-speaking region and (2) investigates the associations between nurse-related characteristics (socio-demographics; previous exposure to severe forms of psychiatric inpatient violence; attitude towards psychiatric inpatient violence) and nurses' exposure to various types of psychiatric inpatient violence. We used cross-sectional survey data from the Match^RN Psychiatry study sample of 1128 nurses working on 115 units across 13 psychiatric hospitals. In addition to lifetime severe assaults, nurses' exposure to violence against property, verbal violence, verbal sexual violence, physical violence, and physical sexual violence was assessed for the 30 days prior to the survey. Descriptive statistics (frequency and percentage) were calculated for each class of violence as also for items under study. With generalized linear mixed models, odds ratios and 95% confidence intervals were calculated. Of nurse respondents, 73% reported facing verbal violence, 63% violence against property, 40% verbal sexual violence, 28% physical violence, and 14% physical sexual violence. Almost 30% had been subjected to a serious assault in their professional lifetimes. All nurse characteristics were associated with psychiatric inpatient violence against nurses, especially a history of sexual assault (OR 4.53, 95%-CI 2.19-9.34; P = 0.00) and ≤3 years' professional experience (OR 3.70, 95%-CI 1.95-7.02; P = 0.00). Prevalence data suggest that widely used strategies such as aggression management courses or alarm devices cannot fully reduce patient violence against nurses in psychiatry. This situation demands proactive strategies in safety and violence prevention.

Matching Registered Nurse Services With Changing Care Demands in Psychiatric Hospitals: Protocol for a Multicenter Observational Study (MatchRN Psychiatry Study)

BACKGROUND

The quality of care is often poorly assessed in mental health settings, and accurate evaluation requires the monitoring and comparison of not only the outcomes but also the structures and processes. The resulting data allow hospital administrators to compare their patient outcome data against those reported nationally. As Swiss psychiatric hospitals are planned and coordinated at the cantonal level, they vary considerably. In addition, nursing care structures and processes, such as nurse staffing, are only reported and aggregated at the national level, whereas nurse outcomes, such as job satisfaction or intention to leave, have yet to be assessed in Swiss psychiatric hospitals. Because they lack these key figures, psychiatric hospitals' quality of care cannot be reasonably described.

OBJECTIVE

This study's purpose is to describe health care quality by exploring hospital structures such as nurse staffing and the work environment; processes such as the rationing of care; nurse outcomes, including job satisfaction and work-life balance; and patients' symptom burden.

METHODS

MatchRN Psychiatry is a multicenter observational study of Swiss psychiatric hospitals. The sample for this study included approximately 1300 nurses from 113 units of 13 psychiatric hospitals in Switzerland's German-speaking region. In addition, routine patient assessment data from each participating hospital were included. The nurse survey consisted of 164 items covering three dimensions-work environment, patient safety climate, and the rationing of care. The unit-level questionnaire included 57 items, including the number of beds, number of nurses, and nurses' education levels. Routine patient data included items such as main diagnosis, the number and duration of freedom-restrictive measures, and symptom burden at admission and discharge. Data were collected between September 2019 and June 2021. The data will be analyzed descriptively by using multilevel regression linear mixed models and generalized linear mixed models to explore associations between variables of interest.

RESULTS

The response rate from the nurse survey was 71.49% (1209/1691). All data are currently being checked for consistency and plausibility. The MatchRN Psychiatry study is funded by the participating psychiatric hospitals and the Swiss Psychiatric Nursing Leaders Association (Vereinigung Pflegekader Psychiatrie Schweiz).

CONCLUSIONS

For the first time, the MatchRN Psychiatry study will systematically evaluate the quality of care in psychiatric hospitals in Switzerland in terms of organizational structures, processes, and patient and nurse outcomes. The participating psychiatric hospitals will benefit from findings that are relevant to the future planning of nurse staffing. The findings of this study will contribute to improvement strategies for nurses' work environments and patient experiences in Swiss psychiatric hospitals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26700.

Exploring omissions in nursing care using retrospective chart review: An observational study

BACKGROUND

Omissions in nursing care can compromise patient safety. To date, this phenomenon has been investigated almost exclusively via nurse surveys. However, such surveys restrict the range of activities which can be assessed for omissions, and patient level analysis. As an alternative, retrospective chart review methodology has been used successfully in other research fields, but not yet for omitted nursing care.

OBJECTIVES

To describe characteristics and frequency of omitted nursing care using a retrospective chart review methodology.

DESIGN, SETTING AND PARTICIPANTS

Observational single center study in two German neurological inpatient units. A random sample of 100 patient admissions was used.

METHODS

A structured chart review protocol to detect nursing omissions was developed and applied. The full range of expected nursing care activities were assessed regarding the importance of documenting them and whether they had been fully or partially omitted. Vital sign measurements were assessed regarding both the measurement target number and the number of measurements recorded.

RESULTS

In total, 1885 activities-a mean of 19 per patient-were identified. Of the reviewed activities, 52% (n = 971) were fully or partially omitted. Patients experienced between one and 22 omitted nursing care activities during their hospital stay (8-84% of expected care activities). Ranging from 6% to 100% some activities were more commonly omitted than others during admission. The most frequently omitted nursing activity was giving emotional care (88%, n = 66); the least frequently omitted was teaching (10%, n = 29). Vital signs were recorded only 50% (n = 141) of the targeted number of times.

CONCLUSIONS

Using a retrospective chart review protocol to identify omissions in nursing care allows the assessment of a broad range of nursing activities. Additionally, this is the first-time patient-level data on a broad range of activities have been analyzed. The newly developed chart review methodology can complement established survey methods and provide a new perspective on the phenomenon of omitted nursing care.

[Quality and general practice development in Swiss acute hospitals as a result of study results - a follow-up survey of nursing directors of RN4CAST hospitals]

In the RN4CAST (Nurse forecasting in Europe) study all 35 participating Swiss hospitals received a study report, which allowed them to anonymously compare findings in relation to structure, process and outcome variables. Thus, this benchmarking allowed the hospitals to identify potentials for improvement and to plan counter measures for developing the quality of their practice environment. We surveyed the RN4CAST hospitals 18 months after submitting the study report and asked chief nursing officers if the results of the RN4CAST study report had been discussed and analysed within their hospitals and if the results had led to any quality improvement or practice development projects. Out of 35 questionnaires 30 were returned (response rate = 85 %). The study report was discussed and analysed in 27 hospitals (90 %), whereby the quality (n = 27) and the usefulness (n = 22) were rated as good or very good. Less then half of the hospitals (41 %) discussed the results with the hospital units. The study report stimulated practice development and quality improvement efforts in view of the nurses' work environment (n = 20) and safety culture/climate (n = 16). Replicating the RN4CAST study in the participating hospital would allow evaluating changes on the measured variables, e. g., due to this quality improvement and practice development projects.

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