ALTHOUGH THE GOAL of the national policy on deinstitutionalization was to shift mental health care services from hospitals to the community, acute inpatient hospitalization remains a reality. In fact, the critical demand for acute inpatient psychiatric services is reflected by the recent increase in inpatient admissions (The National Association of Psychiatric Health Systems, [NAPHS], 2002). The contribution of acute care in the treatment of individuals with mental illness is not known or widely researched. In fact, President Bush has identified acute care as one of the four areas of mental health services deserving future research (The President’s New Freedom Commission on Mental Health, 2003. Achieving the promise: Transforming mental health care in America , July 22). Retrieved August 13, 2003, from http://www.MentalHealthCommission.gov .New Freedom Commission on Mental Health, 2003). Moreover, as a result of the changes in the mental health delivery system, quality of care has become a major concern to stakeholders and society at large. One way quality of care delivered by acute care psychiatric facilities can be assessed is through the examination of client outcomes after inpatient treatment.

The purpose of this article is to conduct a methodological review of the literature that examines the prediction, assessment and measurement of client outcomes after treatment in acute care psychiatric facilities. The literature is analyzed critically to identify the gaps in knowledge related to outcomes as valid quality indicators and outcomes that are sensitive to nursing care. Finally, the Quality Health Outcomes model (Mitchell et al., 1998) is proposed to conceptualize outcomes of acute inpatient psychiatric treatment that are sensitive to nursing interventions and the organization of nursing care (See Fig 1).

Quality Health Outcomes Model. Reprinted with permission from Mitchell et al., 1998. © 1998 Blackwell Publishing Ltd.
Background and significance

Mental illness is the leading cause of disability in the United States and other market economies (The World Health Organization [WHO], 2001). Payments for hospital care for psychiatric and addictive disorders are on the rise for the first time in 5 years (NAPHS, 2002). Thus, mental illness inflicts a phenomenal cost to society. More importantly, the emotional, social and physical sequelae of mental illness compromise the quality of life for those afflicted.

Two quality forums, the Maryland Hospital Association Quality Indicator Project and the National Association of Psychiatric Health Systems proposed the following quality indicators for psychiatric treatment: self-injurious behaviors, unplanned departures, transfers/discharges to inpatient acute care, readmissions, restraint/seclusion use, symptom improvement, level of functioning and client satisfaction. It is not known if the literature supports the use of these quality indicators as valid measures of quality care. Identifying client outcomes related to nursing care is critical to establish empirical evidence that supports the effectiveness of psychiatric nursing.

Methodology

This state of the science follows the guidelines outlined by Ganong (1987) for conducting rigorous literature reviews in nursing.

Purpose

The purpose of this synthesis is to identify research that examines the outcomes of individuals after treatment in acute care psychiatric hospitals and psychiatric units in general hospitals. The following hypotheses were tested: Empirical evidence will not support the use of readmission rates as a valid quality indicator, but will support the use of symptom improvement, client function, self injurious behaviors and client satisfaction as valid quality indicators There is a paucity of literature related to quality indicators/outcomes for acute inpatient psychiatric treatment that are currently conceptualized as nursing sensitive.

Literature search

The databases used to conduct the literature search were: Medline, CINAHL, HealthSTAR/Ovid HealthSTAR and psycINFO. To narrow the scope of the review, 1991 was the year chosen to begin data collection. A nodal point in the transformation of the health care system, 1991 was a time when quality of care, specifically client outcomes, became a significant concern with the introduction of managed care. The following search terms and combinations were used to identify articles for review: psychiatric outcomes, treatment outcomes and psychiatric hospitals, inpatient psychiatric hospital and outcome measurements, quality and outcomes and inpatient psychiatric hospitals, outcomes and inpatient psychiatric hospitals, psychiatric facilities and outcomes, psychiatric units and client outcomes, psychiatric units and treatment outcomes, outcome assessment and acute psychiatric hospitals/psychiatry and psychiatric nurses and quality assessment. To make the search more specific, five of the quality indicators mentioned previously were combined with the key words psychiatric hospitals/hospitalization and outcomes. The decision was made not to search for two of the quality indicators: transfers/discharges to inpatient acute care and seclusion/restraint. The rationale for not searching for these quality indicators is because they are largely conceptualized as process elements of care. Finally, manual reviews of reference lists were conducted throughout the review process to discover seminal articles for inclusion. The systematic data collection process was a measure taken to avoid introducing bias into the selection of articles.

Sample

Forty-seven research studies are included in this state of the science. Studies were included if they were specific to adult psychiatric clients treated in acute care psychiatric hospitals or a psychiatric unit in a general hospital; routinely collected client outcomes obtained from administrative data; clinical outcome data specific to readmissions, symptoms, function, client satisfaction and self-injury that are collected in psychiatric treatment facilities; methods used to measure the outcomes; and/or factors that relate to predicting outcomes after acute care treatment. Studies were not included if they were specific to child and adolescent or geriatric clients treated in acute care psychiatric hospitals or general hospitals with a psychiatric unit; outcomes after care in long-term psychiatric treatment facilities; outcomes after treatment with medications; and/or outcomes after the implementation of an experimental treatment not associated with standard care.