In a study led by Morgan Shields, assistant professor at the Brown School, psychiatric patients who reported better patient-care experiences while hospitalized were more likely to report increases in trust in mental healthcare providers and willingness to voluntarily go to the hospital when in emotional or psychological distress. They were also more likely to report having a follow-up visit within 30-days of discharge.
Shields says the study, the first of its kind, suggests improvements to patient-centered care (PCC) during inpatient psychiatric treatment can reduce negative outcomes such as suicide, unplanned readmission, and missed follow-up appointments.
“Patient experience should be the central aspect of care and a measure that payers and regulators pay attention to,” she said. But research is lacking on the quality of inpatient psychiatric care and the frequency of unsafe settings that result in inappropriate use of medication, dehumanization of patients, the use of restraints and seclusion, as well as inattention to patients’ needs and preferences.
“There is a large body of evidence demonstrating that principles of patient-centered care – which are similar to those of trauma-informed care – reduce violence and the use of restraint and seclusion, which keeps both staff and patients safer,” she said. “The study’s findings held true for both patients hospitalized on a voluntary and involuntarily basis, suggesting that concerns over the validity of patient experience reports from those involuntarily hospitalized are not backed by evidence.
The research team conducted quantitative surveys of more than 700 psychiatric patients who had been hospitalized. The study was part of larger research that included asking patients about their experience and suggestions for improvement. Their most common complaint was generally related to disrespectful treatment. A few examples:
- “It was horrible and made me feel less than human. I will never ask for help in that way again, even at the very depths of desperation.”
- “What made me feel even more unsafe, though, was that there was one specific doctor who threatened to sedate anyone who even raised their voice at him. People were being sedated left and right, even at times that I felt were inappropriate.”
- “I needed personalized and individual help, and I didn’t receive that. I left feeling not helped at all. I was literally dropped off and forgotten”
Shields’s study, published in Health Affairs Scholar, also found that patient-centered care was higher among patients at nonprofit hospitals than at for-profit facilities, which is important to consider given the rise in for-profit ownership of psychiatric facilities; PCC was also associated with many facility-level quality measures, suggesting that patient-reports of their care may be valid signals of the overall quality of care in a hospital.
Shields offers a small but telling example of the potential impact:
“A patient is used to going to the refrigerator for apple juice at 11 p.m. when at home in the community, but while in the hospital, the staff tell the patient that there is a hard policy against drinking anything but water after 11 p.m. This policy is unnecessary and has no therapeutic value. In fact, it can agitate the patient, cause staff to raise their voice and escalate the situation, and could result in restraint and consequences like physical harm or trauma. Doctors should be speaking with patients about past treatments, their desires, and preferences, and create a treatment plan in cooperation with a patient.”
The study notes that while humane treatment of patients produces better outcomes, it is also an end in itself. Findings suggest that the systematic collection of data at a national level will enable rigorous research and accountability and can help identify strategies to improve quality of care in psychiatric treatment both in and out of hospitals.
That collection of data is on the way. It was required by Congress, which passed legislation in 2022. The new law says the Centers for Medicare & Medicaid Services (CMS) must start collecting patient-experience information from inpatient psychiatric facilities in hospitals, who had been the only facilities excluded from such requirements. CMS, part of the U.S. Department of Health and Human Services, will publish a final rule in October to give hospitals time to prepare.
“This is a big deal,” said Shields, whose work has focused on policy changes like the Congressional action, that she outlined recently in a column published in The Milbank Quarterly.
Shields said she has been motivated to conduct this research given her own experiences of abusive treatment inside of institutional settings when she was young, by the experiences of family members, and by the many people who have shared their experiences with her. “These places can be a source of trauma, rather than healing, as it was for me,” she said, adding that she was inspired by an undergraduate mentor who told her: “If you can convince people they should listen to patients of inpatient psychiatry, you will have had a successful career.”