Using Findings From the Human Rights Authority Reports to Inform Psychiatric Nursing Practice

Method

Results

Of the completed reports, 35.7% were related to female clients, 56.6% were related to male clients, and for the remaining cases sex was unspecified. More than one third (35.7%) came from the North Suburban Chicago area, and a similar percentage (37.2%) were from state-operated facilities. The observed diagnosis type categories were mood disorder (42.0%), schizophrenia or related (30.0%), and dual diagnosis (28.0%). The mean number of allegations per case was M = 1.92 (SD = 1.27). Table 1 shows the number and percentage of allegations in each category and the overall rate of substantiation.

OPEN IN VIEWER

Table 1.

Distribution of Allegation Type and Substantiation.

Allegation type	Frequency	%
Inadequate treatment/program	100	40.6
Restriction/notification of rights	73	29.7
Other	73	29.7
Total	246	100.0
Substantiation
Yes	74	29.8
No	174	70.2
Total	248	100.0

Allegation Type and Substantiation

Results from a chi-square analysis employing the modified Rao–Scott correction showed that allegations of restriction/notification of rights were significantly more likely to be substantiated than allegations of inadequate treatment, χ RS 2 ( 2 , N = 238 ) = 13 . 74 , p = . 001 , with a small to moderate effect size (Cramér’s V = .24). Figure 1 illustrates this relationship.

OPEN IN VIEWER

Figure 1.

Frequency distribution of allegations by type of rights issue and substantiation.

Examples of inadequate treatment allegations included failure to include patient’s guardian in treatment planning; failure to been seen by a physician in a timely manner after admission for a medical issue; services not provided in the least restrictive environment; inadequate clothing; intrusiveness by staff; unsafe environment; taunting or rudeness, threatening, or disrespectful staff behavior; failure to address patient’s needs; an unsanitary environment; and excessively restrictive rules.

Substantiation of Allegations, Provider Characteristics, and Patient Characteristics

Results showed a statistically significant, χ RS 2 ( 3 , N = 248 ) = 8 . 43 , p = . 046 , and small to moderate (Cramér’s V = .21) relationship between the type of service provider and substantiation of the allegation. Specifically, state hospitals were less likely to have allegations against them substantiated than medical hospitals. The Rao–Scott chi-square test also showed that the region in which the allegation was made was significantly related to its substantiation, χ RS 2 ( 2 , N = 248 ) = 6 . 33 , p = . 042 , with allegations from the Chicago geographical area more likely to be substantiated than allegations from the Suburban Chicago or Central/South Illinois geographical areas (see Figure 2). This effect was small to moderate in size (V = .20). No significant relationship was evident between substantiation of the allegation and (a) the gender of the client or (b) the diagnosis type

OPEN IN VIEWER

Figure 2.

Frequency distribution of allegations by geographical area and substantiation.

Allegation Type, Provider Characteristic, and Patient Characteristics

Chi-square analyses employing the Rao–Scottcorrection showed a statistically significant, χ RS 2 ( 6 , N = 240 ) = 12 . 83 , p = . 046 , and moderate (Cramér’s V = .28) relationship between allegation type and type of service provider (see Figure 3), with medical hospitals significantly less likely than state-operated hospitals, private medical hospitals, or “other” providers to have inadequate treatment allegations and significantly more likely to have restriction/notification of rights allegations. Additionally, state-operated providers were significantly less likely than all other types of service providers to have “other” allegations, whereas “other” providers were significantly less likely than state, private, or medical facilities to have restriction/notification of rights allegations. The relationship between allegation type and diagnosis type (see Figure 4) was not statistically significant, although it approached significance, χ RS 2 ( 4 , N = 83 ) = 9 . 35 , p = . 055 , with a moderate effect size (Cramér’s V = .24). Here, persons with substance disorder (including dual diagnosis) were more likely to allege restriction/notification of rights and less likely to allege inadequate treatment, whereas persons with mood disorder were more likely to allege inadequate treatment and less likely to allege restriction/notification of rights. No statistically significant relationships were observed between allegation type and geographical area or gender.

OPEN IN VIEWER

Figure 3.

Frequency distribution of allegations by type of service provider and type of rights issue.

OPEN IN VIEWER

Figure 4.

Frequency distribution of allegations by diagnosis type and type of rights issue.

Discussion

This study described the types of allegations pertaining to rights violations of PWMI who received care in Illinois in 2008 and the outcomes of the investigations into these allegations completed the Guardianship & Advocacy Commission. Results showed that rights violations most likely to be substantiated were related to restriction/notification of rights. State hospitals were found to be less likely than medical hospitals to have allegations made against them. Medical hospitals were less likely to have inadequate treatment allegations made than state hospitals, although they were more likely to have restrictions/notification of rights allegations made against them. These findings have implications for nurses as caregivers of PWMI. They highlight the importance of nurses knowing areas of risk for violations of the rights of PWMI related to nursing practice.

The results of the present study indicated that restriction of rights allegations were significantly more likely to be substantiated than inadequate treatment allegations. It is important to note that patient rights fall into clearly identified categories as defined by a state’s mental health code and that nurses follow specific hospital policies and procedures related to the documentation of patient rights. Therefore, this may explain the significantly higher likelihood of substantiation for rights/notification allegations. That is, because of the clarity of definition and documentation regarding patient’s rights, investigators are perhaps better able to identify evidence that supports the substantiation of allegation.

The lower likelihood for substantiation of inadequate treatment allegations by patients could be related to a lack of clarity, and at times, confusion, regarding what exactly constitutes adequate treatment—as well as the difficulty in investigating this allegation. Some of these allegations were substantiated, but not all. Although some examples of inadequate treatment may appear to be quite clear, there is often discord in understanding between the patient and/or staff member. For example, decisions concerning the amount of time needed to see a physician for a medical issue are often left up to clinical judgment.

Often, nurses make subjective evaluations regarding a patient’s condition, competency for self-care, and needs (Lutzen, 1998). This type of “contextual reasoning” is different from the rule-based reasoning that may be involved in other types of rights issues. Therefore, providing “adequate care/treatment” and proving “inadequate care/treatment” may be difficult. It may be that these issues fall under ethical principles rather than clear legal guidelines. For example, in a study of subtle coercion by nurses, Lutzen (1998) found that a nurse’s judgment might override a patient’s known preferences in ways that were not always in the interest of the patient but were justified by the nurse as helping, persuading, or encouraging the patient. These actions might fall under the category of inadequate treatment, as a patient who is aware that his or her preferences are being ignored could perceive a violation of this right. Yet identifying such a situation and proving the nurse or facility in error would be difficult and probably dependent on eyewitness reports rather than on clear documentation of a violation of rights. There are fewer objective measures of “adequate” treatment due to the need to use subjective evaluation in the process of nursing care. Persuading or encouraging might not be viewed by a nurse as a form of coercion needing documented justification. This use of covert coercion stands in contrast to the use of overt coercion, which a nurse might employ in clear cases of danger of harm, and which would require justification in documentation.

A significant and moderate relationship was observed between the type of service provider and substantiation of the allegation. Specifically, state hospitals were less likely than medical hospitals to have allegations against them substantiated. Possible rationales for this finding are that state hospitals provide specialized psychiatric services that include specialty units and tend to have nursing staff with more years of service and expertise than medical hospitals. In addition, state hospitals may provide more extensive continuing education to maintain and update staff’s skill and knowledge base than medical hospitals. Furthermore, in a medical facility, patients with psychiatric illness are found in the emergency room, on medical units, and on psychiatric units. In medical facilities, it is imperative to have adequate staff training with regard to caring for PWMI. This includes properly defined policies, procedures, and treatment strategies, so patients can receive suitable psychiatric care (Agency for Healthcare Research and Quality, 2011).

Findings from this study also suggested that allegations from the Chicago area were more likely to be substantiated than allegations from Suburban Chicago or Central/South Illinois areas. Chicago is a large urban area with a diverse population and a plethora of medical facilities. This is congruent with the researchers’ previous finding that allegations were more likely to be substantiated in medical facilities than in state psychiatric facilities. It was interesting to note that the relationship between gender and substantiation of the allegation, although not statistically significant, approached significance, with allegations by females more likely to be substantiated than allegations by males. Perhaps this observation might be informed by Wolfe and Powell’s (2006) study exploring the stereotype that women complain more than men. No evidence to support this stereotype was found—that is, women and men complained in equal amounts. However, the reasons for complaining differed by gender. Men were found to excuse their behavior by making complaints or as a way to appear superior. Women were found to make complaints as an indirect request for action. If this gender distinction occurred in the present population, with women with mental health problems complaining to seek action, their allegations may be more specific about actions that violated their rights than those of men, and thus more likely to be substantiated.

Medical hospitals were significantly less likely than state-operated hospitals, private medical hospitals, or “other” providers to have inadequate treatment allegations. Although the reasons for this are not entirely clear, we speculate that it may be related to the previous observation concerning the expertise and ongoing training of state facility staff, whereby state hospital patients may be more aware of their rights to make the allegation in the first place, as well as the in-place systems for documentation in state facilities that provide increased clarity of evidence in investigations. The relationship between allegation type and diagnosis type was not statistically significant, although it approached significance and the effect size was moderate. Here, at the sample level, persons with substance disorder (including dual diagnosis) were more likely to allege restriction/notification of rights and less likely to allege inadequate treatment, whereas persons with mood disorder were more likely to allege inadequate treatment and less likely to allege restriction/notification of rights. The researchers found no rationale for these findings in the literature; however, there are potential implications for nursing regarding these findings.

Limitations and Recommendations for Future Study

The findings of this report should be interpreted in the context of its limitations. The relatively small sample size, which was limited to a specific geographic area (state of Illinois), limits generalization of these findings. Another limitation was the lack of consistency/standardization of regional investigatory reporting. For example, few reports included age of the person making the allegation and not all included diagnoses. Also, the specific types of health care providers involved in the alleged violation of rights were not always indicated.

Future research could include a replication of this study with a larger sample size inclusive of a broader geographic region. Further studies might also employ qualitative methods to explore and illuminate the findings of this study. Currently, a qualitative study is being conducted to follow up on and explore the recommendations and suggestions of the HRA reports. Additional studies may provide needed evidence regarding adequate treatment from both nurses’ and patients’ perspectives. This in turn will provide a basis for facilitating a truly respectful nursing practice and improved patient recovery.

Clinical Implications and Conclusion

The results of this research study inform psychiatric nurses of the findings of the reports by the HRA and expand nursing knowledge regarding the types of patients’ rights violations reported at the state level and the outcomes of investigations into the allegations. Findings from the current study underscore the importance of educating nurses regarding the mental health code, patient rights, patient advocacy and the importance of thorough and accurate documentation. This is important not only for nurses specializing in mental health but also for nurses in other health care areas who may be caring for patients with mental health issues, such as emergency department nurses who often care for PWMI in crisis.

It is also important for nurses to have training regarding what constitutes adequate treatment, the importance of documentation (since this was noted to have a lack of clarity and at times confusion during the investigation), and areas of greatest risk for violation of patients’ rights in psychiatric nursing practice in inpatient settings. In addition, ensuring that patients are aware of their rights and that they can make allegations if they feel their rights have been violated is an important consideration for nursing staff.

In conclusion, it is a nurse’s role to promote recovery of persons with a mental health problem while protecting their rights. Rights of patients undergoing psychiatric care are sometimes challenging to navigate, and understanding areas for risk of violations of rights is important in nursing care for PWMI. This knowledge, in addition to national and professional guidelines for respecting patients and their rights, can provide a framework for psychiatric nursing practice in inpatient psychiatric settings, in which the risk for violating patients’ rights is diminished and possibly eliminated.