Nurse and patient activities and interaction on psychiatric inpatients wards: A literature review

Abstract

Background

Despite major developments in community mental health services, inpatient care remains an important yet costly part of the service system and patients who are admitted frequently spend a long period of time in hospital. It is, therefore, crucial to have a good understanding of activities that take place on inpatient wards.

Objective

To review studies that have measured nursing and patient activity and interaction on psychiatric inpatient wards.

Data sources and review methods

This literature review was performed by searching electronic databases and hand-checking reference lists.

Results

The review identified 13 relevant studies. Most used observational methods and found that at best 50% of staff time is spent in contact with patients, and very little time is spent delivering therapeutic activities. Studies also showed that patients spend substantial time apart from staff or other patients.

Conclusion

On inpatient psychiatric wards, evidence over 35 years has found little patient activity or patient social engagement. The reasons for this trend and recommendations for the future are discussed.

Introduction

Research indicates that greater staff–patient interaction and greater patient activity (i.e. participation in therapeutic or social activities rather than being socially disengaged or spending time alone) in inpatient wards improves clinical outcomes for patients with mental illness (Collins et al., 1985). The changing composition of UK mental health care service provision in recent years has though put a strain on acute mental health resources which has affected how nurses interact with and treat patients. This is mirrored in most western health care systems. The greater emphasis and spending on community-based mental health care has reduced the portion of the mental health care budget allocated to inpatient psychiatric care, leading to a reduction in the number of acute care and long-stay beds (this is illustrated for the UK in Fig. 1), although the amount spent on inpatient care remains substantial.

The average daily number of available psychiatric beds in England dropped from 67,122 in 1997–1998 to 26,929 in 2007–2008 (Department of Health, 2008). Admitted patients are more likely to have psychotic disorders and in 2006/2007 the median length of stay for these patients was 42 days (Information Centre, 2008). At a cost of £268 per bed-day of acute inpatient psychiatric care (Curtis, 2008), this average length of stay would cost £11,256.

Given the reduction in acute beds, priority naturally goes to those patients who are more severely mentally ill, particularly those who have been involuntary admitted or have major social problems (Ryrie et al., 1997). Nurses report that they feel pressure to discharge patients who may not have yet fully recovered in order to free up beds (Higgins et al., 1999). Due to the severity of the patient mix, staff members find it difficult to provide interaction and therapeutic activities as much of their time is spent looking after very ill patients.

In a 2004 survey by the Sainsbury Centre for Mental Health (Garcia et al., 2005) it was found that although 64% of wards routinely offer social and leisure activities (e.g. going to the gym, bingo) and 73% practical therapeutic activities (e.g. money management, cooking skills), psychological therapies were not routinely offered on the majority of acute psychiatric wards. Art therapy was the most commonly available therapy, available in 49% of wards, compared to 35% for psychosocial interventions, and less than 20% for cognitive behavioural therapy, solution focused behavioural therapy and family therapy. Besides the difficulty of staff having the time to offer activities because they are occupied with taking care of very ill patients, the reports suggest that the lack of activities and talking therapies may be partially explained by the use of agency staff, by the culture of the psychiatric wards, and by staff shortages, especially of occupational therapists and psychologists.

Assessing both the extent of interaction between patients and staff and patients’ participation in activities may be important for both clinical and economic reasons. It is helpful, therefore, to determine the extent of this input. This might help in planning for the costs of specific units by determining the appropriate amount and grade of staff members. Nursing and other professional time comes with a cost, and whilst most studies and payment systems currently focus on the average cost of an inpatient day there are reasonable grounds for deriving per patient inpatient costs. These grounds include the requirement in economic evaluations that costs reflect the actual resources used. A further, linked, reason for using actual per patient costs is that any form of prospective payment (such as ‘Payment by Results’ in the UK) should link prices/tariffs as closely as possible to care received.

Most of the high costs of inpatient care are attributable to personnel costs. Beecham et al. (2003) reported that staff costs account for 70% of the costs of child and adolescent psychiatric inpatient units. Similarly, McKechnie et al. (1982) found that the percentage of costs attributable to staffing varied by the type of unit, but ranged from 74 to 91% of total care and treatment costs of psychiatric wards.

Collins et al. (1985) have suggested that clinical outcomes are associated with patient activity and social interaction. If this is the case, then devoting more staff time to direct (and hopefully therapeutic) patient activities and care could have a positive effect on patient care and may be cost-effective. Indeed, a study by Dodds and Bowles (2001) found that changing the allocation of nursing time from formal observation of inpatients to structured, individualised activities, which often took place on a one-to-one basis, improved patient-reported quality of care while the number of staff sicknesses and staffing costs decreased. The authors estimated that in a best case scenario, an inpatient ward could save up to £44,878 on staffing costs over a year if they adopted this change in nursing time allocation. Furthermore, research indicates that for patients, the most important aspect of quality inpatient care is that staff members take their time with and care for patients (Hansson et al., 1993). Of course it should be stressed that staff time is not synonymous with therapeutic input. Merely spending more time with patients might not improve outcomes. However, given the above findings it does seem logical to expect improvements to be linked with what staff and patients do on wards and as such recording staff and patient activities seems a reasonable exercise.

The aims of this review are to (i) identify studies that have measured nursing and patient activity and interaction on psychiatric inpatient wards, (ii) compare methodologies used in these studies and (iii) examine how much time is typically spent in staff–patient interaction. Finally, we make suggestions for future work based on the findings.