APNA Position: Staffing Inpatient Psychiatric Units

The publicly available Executive Summary is below, with the full paper published in The Journal of the American Psychiatric Nurses Association.

Introduction

Psychiatric-mental health (PMH) nurses maintain 24-hour accountability for all aspects of inpatient psychiatric care, shape the patient experience, and are key to safety (Kanerva et al., 2013). The quality and effectiveness of inpatient psychiatric treatment relies on sufficient staffing levels and teams of staff with particular expertise and capabilities. Thus, through advocating for safe and effective staffing, PMH nurses are championing quality care.

Discussion

While current research demonstrates the relationship between the practice environment and PMH nurses’ capacity to deliver quality care, it does not support a universal method to determine staffing needs (ANA, 2020). Instead, staffing decisions demand consideration of several distinct aspects which impact how care is organized: consumer needs, staff capacities/capabilities, unit culture, practice environment, and staffing evaluation model. In this way, staffing is not an external calculation, but a participatory process that requires ongoing systematic evaluation and monitoring of select patient, staff, and system outcomes (ANA, 2020). This requires that front-line staff, management, and psychiatric-mental health care consumers work together, with a shared understanding of patient needs and their complexity as well as how these needs are met by PMH nurses with specific skills and experience levels (Thériault et al., 2019; Twigg et al., 2019). Together, they must examine and evaluate the complex safety, staff, and patient experience variables at play when ensuring safe and quality care (Lawes et al., 2017). Organizational staffing models should incorporate the concept that when PMH nurse staffing is at an appropriate level, adverse events decline, and overall outcomes improve (ANA, 2020).

The following questions can guide the participatory process of staffing inpatient psychiatric units:

• Patient variable: Does the staffing level align with consumer needs?
• Staff Context: What is the mix of staff experience levels and the stability of the staff team?
• Unit Context: What is the health of the organizational culture and practice environment?

Conclusion

It is the position of the American Psychiatric Nurses Association that when PMH nurse staffing is appropriate, adverse events decline and overall outcomes improve, including cost outcomes.

APNA recommendations to guide current and future inpatient psychiatric unit staffing practices:

1. Resist endorsing or defining any single staffing model. Limited evidence supports existing methods to evaluate staffing (e.g., nursing hours per patient day, ratio models).
2. Utilize public platforms for sharing quality data. With these platforms, staffing data could be compared within both general psychiatric inpatient units and private for-profit systems, which would also facilitate consumers’ awareness of staffing levels.
3. Prioritize the development of healthy work environments. Staff and patient outcomes rely on healthy work environments and positive cultures.
4. Structure care delivery so PMH nurses work at the top of their scope of practice. PMH nurse therapeutic skills that promote engagement, safety, and an optimal patient experience should be used to their fullest extent on the inpatient psychiatric unit.
5. Develop research priorities around safety and inpatient nurse staffing. Direct research focused on patient safety, linking outcomes and critical safety indicators to staffing.
6. Develop models for capturing cost/benefit ratio of staffing. Cost modeling will demand defined outcomes and a cost capture of either improved positive or decreased adverse outcomes

The relationship between PMH nurse staffing and outcomes is mediated by consumer needs, PMH nurse experience, PMH nurse expertise, and the practice environment. Research must continue to move towards demonstrating the relationship between appropriate PMH nurse staffing and outcomes – be they positive or adverse events. In addition, further research is needed to develop staffing models that promote optimal use of PMH nurses in hospital settings. Developing an inpatient psychiatric unit PMH nursing outcome dashboard can help build a data repository of PMH nurse-sensitive outcomes that are necessary for any efforts to benchmark unit performance and staffing.

View the full APNA Staffing Inpatient Psychiatric Units Position Paper published in the Journal of the American Psychiatric Nurses Association. APNA members, to access the full article:

• Click the red Get Access button
• Click the Society option
• Log in with your APNA username and password

References

American Nurses Association (2020). Principles for nurse staffing, 3rd edition. https://cdn2.hubspot.net/hubfs/4850206/PNS3E_ePDF.pdf

Kanerva, A., Lammintakanen, J., & Kivinen, T. (2013). Patient safety in psychiatric inpatient care: a literature review. Journal of Psychiatric and Mental health nursing, 20(6), 541-548.

Lawes, A. , Marcus, E., & Piling, S. (2017) What staffing structures of mental health services are associated with improved patient outcomes? A rapid review. Report, National Collaborating Center for Mental Health. http://allcatsrgrey.org.uk/wp/download/governance/clinical_governance_2/NCCMH_Literature_Review_Mental_Health_Final_2.pdf

Thériault, M., Dubois, C. A., Borgès da Silva, R., & Prud’homme, A. (2019). Nurse staffing models in acute care: A descriptive study. Nursing Open, 6(3), 1218-1229.

Twigg, D. E., Kutzer, Y., Jacob, E., & Seaman, K. (2019). A quantitative systematic review of the association between nurse skill mix and nursing‐sensitive patient outcomes in the acute care setting. Journal of Advanced Nursing, 75, 3404-3423.

Staffing Position Task Force Members

Celeste Johnson DNP, APRN, PMH CNS – Chair
Avni Cirpili DNP, RN
Janette O’Connor MS, BS, BSN, RN, PMH-BC
Kathleen Delaney PhD, PMH-NP, RN
R. John Repique DNP, RN, NEA-BC
Suzie Marriott MS, RN, PMH-BC

Approved by the APNA Board of Directors: September 13, 2011. Updated February 2023.