Quality of care in Swiss psychiatric hospitals considering structures, processes, and patient outcomes from nurses’ perspective

The main aim of this dissertation was to examine the quality of care at psychiatric hospitals in Switzerland on the basis of selected structure, process, and outcome dimensions and to explore the associations between the nursing work environment, nursing care left undone, nurse outcomes, and patient outcomes on the unit level as described in the protocol paper (Chapter 3).
Chapter 2 gives a detailed description of this aim, which was divided between three studies. The studies’ findings are reported in Chapters 4 to 6.
Chapter 1 provides an overview of quality of care and introduces the structure, process, and outcome framework. It also offers insights into mental health and mental disorders. The Swiss health care system and the nurses employed within it are described, with a specific focus on inpatient mental health settings.
Chapter 2 describes the aims of this dissertation.
In Chapter 3 the MatchRN Psychiatry study protocol provides a general introduction to the studies’ background, aims, design, and method, including the scales used.
Chapter 4 reports on the first of the dissertation’s studies, which describes nurses’ perceived control of their work schedules, their perceived support from their supervisors, shift changes at short notice, and overtime in a sample of 994 nurses from 114 adult inpatient units at 13 psychiatric hospitals. The perception of work-schedule control was 3.32 (SD 1.39, range 0–5); of work schedule
support from their supervisor, it 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 minutes overtime on their most recent shift. Emotional exhaustion was significantly associated with supervisor support and overtime; leaving intentions were significantly associated with perceived control, supervisor support, and overtime. 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 stability and influence over their work schedules. This could reduce early career endings and early retirement and counteract nurse shortages.
Chapter 5 describes the frequency of nursing care left undone at psychiatric hospitals and its association with nurse staffing levels. Data from 994 nurses were analyzed. 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. As in somatic-care settings, at psychiatric hospitals, “indirect” care activities were most commonly omitted.
Chapter 6 presents patients’ nonaccidental self-injuries and key features of nurses’ work environment, including staffing adequacy, leadership, the nursing foundations of quality care in units at psychiatric hospitals, and the association between units of patients’ nonaccidental self-injuries at discharge and low levels in nurses’ perception of staffing adequacy and their perception of leadership and the nursing foundations of quality care. The results show that among 16,273 patients, 2.5% displayed severe or very severe nonaccidental self-injuries at discharge. The data from 1,097 nurses revealed lower levels of staffing adequacy, leadership, and the nursing foundations of quality care on the unit level to be associated with higher rates of nonaccidental self-injuries.
Lower staffing adequacy and leadership in nurses’ work environments were linked to increased levels of nonaccidental self-injuries at discharge. Addressing these organizational factors alongside treatment can reduce the risk of nonaccidental self-injuries, improve patient outcomes, and lower readmission and suicide rates. Further research is needed for interventions to enhance the work environment and patient safety in inpatient psychiatric settings.
Finally, Chapter 7 synthesizes and discusses the major findings of all the studies in the context of the literature. The strengths and weaknesses of the studies are discussed, and implications for research, practice, and policy are presented. This dissertation contributes to the existing literature by providing evidence regarding staffing nursing care left undone and patient and nurses outcomes.