The influence of nursing staff numbers and skill mix on seclusion and restraint use in public psychiatric hospitals

Seclusion and restraint use continues in psychiatric hospitals despite known effective alternatives, and associated morbidity and mortality. Wide variation in use is reportedly influenced by hospital, not patient, characteristics. Acute care hospital outcome variation has also been associated with hospital characteristics, and empirically linked to the numbers of RNs available to "rescue" patients from adverse outcomes following complications. Qualitative studies reveal that psychiatric nurses effectively "rescue" patients from harmful behavior that could lead to seclusion and restraint by using processes analogous to those used by acute care hospital nurses. These commonalities supported "failure to rescue" as the conceptual framework for this study, hypothesizing that as the total numbers of nursing staff, and the proportion of nursing staff that were registered nurses increased, the use of seclusion and restraint would decrease.; The study used extant administrative data consisting of nursing staffing and seclusion and restraint use measures from 6 of 7 public psychiatric hospitals (n=288) in a Mid-Atlantic state. Patient and hospital characteristics were predictor variables; seclusion and restraint use were criterion variables. Correlation coefficients reported significant relationships between variables. Using multiple regression analysis, a model was tested to examine the influence of six predictor variables on nine criterion variables. Standardized estimates were used to report each predictor variable's magnitude of impact on the explained variance.; The model explained from 40-81% of the variance (p<.0001) in each of the nine criterion variables tested. The proportion of RNs within the total nursing staff demonstrated the greatest magnitude of impact on the explained variance (p<.0001 - .003). An increased proportion of RNs was associated with a decrease in 8 of 9 seclusion and restraint use measures. The total nursing staff to patient ratio had a small to moderate contribution to the explained variance (p<.0001 - .04). An increased staff to patient ratio was associated with a decrease in 7 of 9 seclusion and restraint use measures.; Concluding that as nursing staff numbers and skill mix increase, seclusion and restraint use decrease, findings from this study have implications for policy decision makers and healthcare administrators who must consider the relationship between cost and quality.