Poor organizational climate, that is, employee perceptions of the organization’s norms, values, and assumptions,1 has been tied to worse quality and safety outcomes in health care organizations both directly2–6 and indirectly via its effects on clinician morale and well-being.7–12 Despite a growing interest in understanding the effects of organizational climate and clinician morale on patient care quality and safety, this relationship remains underexplored in the context of inpatient psychiatry.
In the last 3 decades, a major focus of efforts to improve patient care quality and safety in inpatient psychiatry has been the reduction of inappropriate use of seclusion, that is, placing the patient alone in a locked room, and physical restraints, that is, manually or mechanically restricting the patient’s freedom of movement.13–16 Seclusion and physical restraints are used to manage violent or agitated behavior and thus prevent imminent harm to self, other patients, and staff.17,18 However, both practices are sometimes used excessively or inappropriately (e.g., as a quicker solution than more time-intensive therapy or, in extreme cases, as a way to punish/coerce patients).19,20 These actions may also be experienced as physically and psychologically traumatic by patients, undermining the patient-provider relationships.21–24 In recent years, many professional societies have issued guidelines that advocate a more judicious use of seclusion and physical restraints.25–30 Generally, they advise the staff to limit the use of seclusion and physical restraints and, in situations wherein it cannot be avoided, select the least restrictive form of the intervention.
Research has identified several factors that may be associated with the use of seclusion and physical restraints in inpatient psychiatry, including staffing, training programs, mandatory review procedures, internal policies and mission statements, leadership support, patient involvement, use of prevention tools, and a therapeutic physical environment.31–34 However, studies tend to focus on the associations of seclusion and physical restraint use with specific unit characteristics, policies, and practices, whereas the role of organizational climate and clinician morale remains underexplored, with a few exceptions.35–38 And yet, as research on implementation and uptake of innovations in health care suggests, an organization’s climate has a powerful effect on its ability to implement and sustain evidence-based practices.39–42 If organizational climate plays an important role in the use of seclusion and physical restraints, interventions that do not take climate and morale into account may be less effective. If a relationship between these variables is established, health care organizations could supplement their ongoing efforts that specifically target seclusion and physical restraints with broader initiatives to improve organizational climate across the board, which may have positive effects for other indicators of patient care quality and safety, as well as for clinician morale.
The objective of our study was to examine whether organizational climate and clinician morale are associated with the use of seclusion and physical restraints in inpatient psychiatric units in a large integrated health care organization in the United States. We hypothesized that measures of poor organizational climate and high burnout are associated with higher rates of seclusion and physical restraint use.
METHODS
Design, Setting, and Participants
We conducted a retrospective database analysis. Data were obtained from employee surveys, public records, and administrative data. The study was approved by the VA Boston institutional review board.
The Veterans Health Administration is a component of the U.S. Department of Veterans Affairs (VA, the abbreviation used in the rest of this article). One of the largest integrated health care systems in the United States, VA serves more than 9 million veterans each year and comprises 1255 health care facilities, including 170 VA medical centers and 1074 outpatient clinics.43 The VA regularly measures burnout and climate through surveys of clinical and administrative service areas using the All Employee Survey (AES). The AES is administered on an annual basis to all paid employees to provide data to the organization for monitoring and planning purposes.44
We included AES responses from 2014 to 2016. The numbers of annual respondents (response rates) per year were 167,674 (56.1%) in 2014, 184,357 (59.5%) in 2015, and 183,104 (56.9%) in 2016. Specific to our study, we included respondents who regularly work directly with patients in inpatient psychiatric units and could be involved with authorizing and/or carrying out seclusion and physical restraint orders. Selected individuals included respondents who self-reported their occupation as a psychiatrist, registered nurse, or licensed practical nurse. To identify respondents working in inpatient psychiatric units, we included only the respondents who indicated that they worked in an inpatient setting and listed mental health as their primary service area. To minimize bias in reliability due to small sample sizes, we required at least 5 respondents per medical center.45
Seclusion and restraint hours data for each facility were obtained from the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site46 that contains quality and performance measures for Medicare-certified hospitals, including VA facilities. To account for contextual factors, additional measures describing the facilities were obtained from VA administrative sources.
Measures
Outcome Variables
Our primary outcome variables included the following: (1) the total average number of hours per 1000 patient hours that patients in inpatient psychiatric units for whom at least one physical restraint episode was reported during the month were maintained in physical restraints and (2) the total average number of hours per 1000 patient hours that patients in inpatient psychiatric units for whom at least one seclusion event was reported during the month were held in seclusion.47 “Physical restraints” in this data set refers to the use of physical force or mechanical devices “as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement.”48 “Seclusion” encompasses the instances of “the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving,” excluding time-out (i.e., briefly placing a patient in an unlocked room).49 Total averages were obtained for each site for the period between January 2014 and December 2016.
Predictor Variables
The primary predictor measures were obtained from the AES and included burnout, employee engagement, workgroup psychological safety, relational climate, and workload (see Table 1 for description and scales). A site-level score for each measure was computed for the selected respondents between 2014 and 2016.
TABLE 1 -
Predictor Variables From the AES
| Measure |
Question(s) |
Scale |
| Burnout |
I feel burned out from my work.
I worry that this job is hardening me emotionally. |
0 = Never
1 = A few times a year or less
2 = Once a month or less
3 = A few times a month
4 = Once a week
5 = A few times a week
6 = Every day |
| Engagement |
I feel a strong personal connection with the mission of VA.
VA cares about my general satisfaction at work.
I recommend my organization as a good place to work. |
1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree |
| Workgroup psychological safety |
Members of my workgroup are able to bring up problems and tough issues.
It is safe to take a risk in this workgroup. |
1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree |
| Relational climate |
A spirit of cooperation and teamwork exists in my work group.
Disputes or conflicts are resolved fairly in my work group.
Differences among individuals are respected and valued in my work group. |
1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree |
| Workload |
My workload is reasonable. |
1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree |
Burnout was measured based on responses to 2 items representing emotional exhaustion and depersonalization that are derived from the Maslach Burnout Inventory.50 The 2-item approach has been validated against the full 22-item Maslach Burnout Inventory.51 We computed a mean value for the single-item measures. We used previously used measures to assess workgroup psychological safety (whether employees perceive that they can bring up difficult issues and take risks)52 and relational climate (the employee perceptions of cooperation and teamwork, respect for interpersonal differences, and fair resolution of disputes in their unit).3,53,54 Although workload is not a traditional measure of climate, we included this variable to assess whether perceptions of workload contribute to seclusion and restraint use.
Covariates
Our model included contextual variables that could influence working conditions in inpatient psychiatric units. We modeled unit size based on the average daily census (the average daily number of patients on the unit), and we included average patient length of stay.55,56 Teaching hospitals were identified based on their membership in the Council of Teaching Hospitals.57 Because VA studies have found that seclusion and restraint use rates vary by geographic region,58–60 we included U.S. census region in the model. Prior reports also have indicated that centers in urban areas have greater seclusion and restraint use,58–60 and we included a measure of urban/rural hospital location. Given that there may be a decision between using either seclusion or physical restraints for a particular patient, we included the number of hours of seclusion in the physical restraint model. Likewise, we included the number of hours of physical restraints as a predictor for the seclusion model.
Statistical Analysis
We first examined statistical properties of our scales by computing Cronbach α for each year. Average annual values were 0.82 for workgroup psychological safety, 0.85 for burnout, 0.77 for employee engagement, and 0.92 for relational climate. Using a standard cutoff for reliability of 0.70, these values imply that the selected indices are internally consistent. We next examined intraclass correlations (ICC) to support aggregating individual responses to the group level.61 Average annual ICC(1) values ranged between 0.11 and 0.16, and average ICC(2) values for group mean reliability ranged between 0.76 and 0.85, which supported aggregation.
We examined the stability of seclusion and restraints over time using Spearman correlations along with examining these measures against workplace climate and clinician morale. We conducted one-way analysis of variance using occupation and predictor measures. Similarly, we examined organizational characteristics in relation to greater use of seclusion and physical restraints through similar analyses.
To model the distribution of the seclusion and restraint utilization outcomes, we applied a Poisson regression with robust SEs for repeated medical center observations. This was preferred over a zero-inflated Poisson model based on the Vuong test.62 The model accounts for nonnormal distributions with many zero values. The natural logarithm of patient hours was used as the offset. Model coefficients were converted into incidence rate ratios.
All statistical analyses were conducted in SAS software v.9.4 (SAS Institute, Cary, North Carolina).
RESULTS
After applying the criteria for a minimum number of responses per site, we identified 6646 survey responses from clinicians practicing at 111 unique sites. Workplace climate and burnout averages differed by occupation (Table 2). There were modest differences among occupations, with psychiatrists scoring higher on engagement, relational climate, and psychological safety measures, but also reporting higher burnout and higher workload.
TABLE 2 -
Descriptive Characteristics of Respondents by Occupational Group for Study Period
|
Psychiatrist
(n = 797) |
RN
(n = 4331) |
LPN
(n = 1518) |
| Burnout, mean (SD)* |
2.54 (1.75) |
2.35 (1.84) |
1.96 (1.77) |
| Engagement, mean (SD) |
3.81 (0.92) |
3.70 (0.95) |
3.68 (0.92) |
| Relational climate, mean (SD) |
4.08 (0.92) |
3.46 (1.14) |
3.30 (1.14) |
| Psychological safety, mean (SD) |
3.82 (1.07) |
3.46 (1.14) |
3.36 (1.08) |
| Workload, mean (SD)* |
3.55 (1.20) |
3.76 (1.10) |
3.88 (1.00) |
*Higher burnout score suggests a greater perceived level of burnout; higher workload score means a perception that the workload is moderate.
LPN, licensed practical nurse; RN, registered nurse.
Across sites, physical restraint hours had a total average of 0.33 hours a month (SD, 1.27; median, 0.05), and seclusion hours had a total average of 0.31 hours a month (SD, 0.84; median, 0.00). Spearman correlations comparing 2014 and 2015 utilization rates were 0.6970 for restraints and 0.843 for seclusion, and those comparing 2015 and 2016 utilization rates were 0.563 for restraints and 0.80 for seclusion. In preliminary bivariate analyses using Spearman correlations, we found significant associations between physical restraint hours and relational climate (r = −0.12) and psychological safety (r = −0.13) and between seclusion hours and burnout (r = −0.12) and workload (r = 0.13). The correlations were significant at P < 0.05.
For the physical restraint hours model, we found that sites with greater burnout had higher incidence rate ratios for use of physical restraints (1.76; 95% confidence interval [CI], 1.01–3.06), whereas sites with greater workgroup psychological safety (0.40; 95% CI, 0.20–0.78), relational climate (0.69; 95% CI, 0.49–0.98), and employee engagement (0.23; 95% CI, 0.07–0.74) rates had significantly lower incidence rate ratios (Table 3). In the seclusion hours model, sites with greater psychological safety had higher incidence rate ratios for use of seclusion (2.12; 95% CI, 1.08–4.21), as did sites with greater relational climate scores (1.68; 95% CI, 1.04–2.73). There were also nonsignificant statistical associations with sites that had trends for lower burnout and higher engagement tending to have more seclusion hours (Table 3). Of note, these results were broadly consistent with results from simple bivariate Spearman correlations.
TABLE 3 -
IRRs* From Multivariable Regression Models of Workplace Climate and Morale With Physical Restraints and Seclusion Among 111 Facilities
|
Physical Restraint |
Seclusion |
|
IRR |
95% CI |
IRR |
95% CI |
| Burnout |
−1.76†
|
−1.01 to 3.06 |
0.72 |
0.44 to 1.18 |
| Engagement |
−0.23†
|
0.07 to 0.74 |
1.84 |
0.94 to 3.60 |
| Relational climate |
0.69†
|
0.49 to 0.98 |
1.68†
|
1.04 to 2.73 |
| Psychological safety |
0.40†
|
0.20 to 0.78 |
2.12†
|
1.08 to 4.21 |
| Workload |
0.73 |
0.47 to 1.16 |
1.92 |
0.96 to 3.84 |
*Each listed IRR represents a separate multivariable model, controlled for site characteristics including region, teaching hospital status, average daily census, average length of stay, and urban versus rural status. Restraint models are controlled for average seclusion hours and seclusion models for average restraint hours.
†P < 0.05.
Among facility characteristics, average daily census was negatively related to use of seclusion hours (0.94; 95% CI, 0.90–0.98). No other facility characteristics were significant (Supplementary File, https://links.lww.com/JPS/A382).
DISCUSSION
In this large nationwide study, we found a significant association between the use of physical restraints, both measures of clinician morale (burnout and engagement), and both measures of organizational climate (psychological safety and relational climate) in inpatient psychiatric units. We also found a significant association between the use of seclusion and organizational climate, as well as a strong, yet nonsignificant, association between the use of seclusion and clinician morale. Although the absolute number of recorded hours of seclusion and restraint was small, significant relationships were observed between the variables of interest. Our study contributes to the larger body of literature that seeks to understand and reduce the use of restrictive and coercive practices in inpatient psychiatry.32,63–68
The finding that units with higher burnout, lower engagement, lower psychological safety, and lower relational climate tend to have more restraint use might be explained in a variety of ways. Burnout in mental health care professionals has been tied to less empathetic and more dehumanizing attitudes toward patients.69,70 Therefore, it is possible that clinicians with higher burnout have a lower threshold for restricting a patient’s freedom of movement in response to violent or disruptive behavior. In units where psychological safety is lacking and aggression among staff members is common, staff may also perceive patients as more aggressive and hostile.68 In contrast, clinicians with lower rates of burnout and higher rates of engagement may have more emotional capacity to seek out alternative containment and conflict resolution modalities.71
In addition, it is likely that employees are more willing to speak up about the inappropriate use of physical restraints and advocate for less restrictive modalities in a culture of strong psychological safety. Similarly, employees may be more effective as a team at de-escalating conflict in a setting of improved relational climate. Because psychological safety has been tied to an organization’s ability to learn from past mistakes,72,73 it is plausible that staff of units with greater psychological safety would be more successful in drawing generalizable lessons from past episodes of restraint use and thus better equipped to reduce the incidence of such episodes in future.74 A recent study of VA hospitals reported that a culture of safety, wherein stakeholders feel safe to voice any safety concerns, is the key prerequisite for reducing adverse events.75,76 In turn, effective working relationships have been tied to improved quality of patient care in a wide variety of clinical settings.77–79 Therefore, efforts to improve psychological safety and relational climate in inpatient psychiatric units are likely to promote changes in patient safety culture, including a reduction in the avoidable use of physical restraints.
Importantly, we found that units with higher psychological safety, higher relational climate, lower burnout, and higher engagement tended to have more seclusion use. Although only the association between seclusion use and organizational climate variables was statistically significant at P < 0.05, the consistent direction of the results across morale and climate variables suggests that these variables could contribute to seclusion use. These findings seem to contradict our initial hypotheses and previous studies on the topic. For instance, in their work on acute psychiatric wards in England, Bowers and colleagues35,36 determined that wards with lower rates of containment (restraint and seclusion) had higher measures of organizational climate (ward atmosphere, team climate, attitude toward leadership) and clinician morale (higher engagement in work, lower burnout). In addition, Yang and colleagues80 found that shifts where more nursing staff with above-average empathy rankings (i.e., higher engagement and lower burnout) were present had fewer episodes of seclusion, as well as fewer episodes of restraint, whereas Happell and Koehn38 found that nurses with lower emotional exhaustion scores (i.e., lower burnout) were significantly less likely to support the use of seclusion.
Two potential explanations can be proposed to explain our findings about seclusion. As noted previously, clinicians who have lower burnout, a greater sense of psychological safety, and a better perception of relational climate in their unit may be more likely and able to seek out and advocate for noncoercive or less coercive ways of managing violent/disruptive behavior. Research shows that, although mental health care professionals recognize the deleterious effects of seclusion,81,82 they generally believe that inpatient psychiatric wards cannot safely function without seclusion as an option82–84 and find it to be a therapeutically beneficial alternative to physical restraints.85,86 Alternatively, it is possible that, because of the lack of definitional clarity around the concept of seclusion,87 sites with ostensibly similar rates of seclusion use have different practices in place, with some using seclusion for therapeutic reasons and others relying on it for coercive and/or punitive purposes. If units with such contrasting practices were grouped together in our analysis, this would have obscured the differences between them, which could explain the nonsignificant association between morale and seclusion use in the full model.
One surprising finding is that we did not find an association between perceptions of workload and use of seclusion and physical restraints in the full model. Because inadequate support for job resources has been tied to higher burnout and lower engagement,88 it is plausible that staff of units with higher perceived workload would be less able to seek out time-intensive containment methods, such as seclusion, and more likely to resort to physical restraints. However, we did not find perceived workload to be predictive of restraint or seclusion use. We did find that sites with higher average daily census tended to have lower seclusion use, which may reflect greater workload associated with a larger patient volume, although this association may also reflect multiple organizational factors that are present at larger facilities, including differences in patient characteristics and clinical practices.
Several limitations of the study need to be acknowledged. The majority of the survey responses we analyzed came from nurses, an occupational group with unique characteristics that may not necessarily be characteristic of all inpatient psychiatry clinicians. We must also account for the possibility of confounding. It is possible that the variation in clinician morale and psychological safety and the different rates of physical restraint and seclusion use could be attributed to a third factor or a set of factors, such as organizational culture, leadership, staffing levels, and so on. Physical environment and staffing have been recognized as important factors in preventing and reducing adverse events in inpatient psychiatric units,74 but we unfortunately lacked the data in this study to assess these factors. It is also possible that the staff morale and reported psychological safety and relational climate on the units were influenced by, rather than contributed to, the rates of seclusion and physical restraint use. Because this is a cross-sectional study, we have no way of rigorously evaluating this possibility, and it is also true that our findings may represent a mix of both morale and psychological safety influencing restraint use and vice versa. Because the relationship between restraint use and clinician morale may be bidirectional, a path to sustained improvement likely includes interventions that directly target both reducing restraint use and improving clinician wellbeing. It is possible that our findings could have occurred by chance alone, although the consistency of positive associations across variables of interest strengthens our results.
The study may also be limited by insufficient information surrounding seclusion and restraint use. The CMS measures report the number of patients discharged on multiple antipsychotic medications but not the use of chemical restraints89,90 during the inpatient admission, so it is also unclear to what extent chemical restraint measures may have been used instead of, or in addition to, seclusion and physical restraints. We also did not account for any ongoing interventions to reduce seclusion and physical restraints at the sites.91,92 Although we were unaware of any such interventions implemented by medical centers at the time of the study, this would be an additional factor that might affect rates of seclusion/restraints. The quality indicator measures from CMS that we used may also not be as complete as patient-level measures. Therefore, we were unable to evaluate the unique number of patients who experienced seclusion and/or restraints or to discern the number of repeat incidents among the same patients. Furthermore, we were unable to test for factors such as patient age, mental health assessment upon intake, and treatment condition. It is also possible that the CMS data may not accurately reflect the actual prevalence of seclusion and restraint use if the inpatient psychiatric units included in our analysis did not report these incidents completely or accurately.
Our study has important implications for research and clinical practice. Most importantly, we demonstrated a meaningful relationship between organizational climate, clinician morale, and use of seclusion and restraints. Because our study showed that units with better organizational climate and clinician morale tended to have greater use of seclusion, future research might want to explore whether these factors may also underlie successful efforts to reduce or eliminate both restraint and seclusion use. Teams designing interventions to reduce the use of physical restraints may want to consider designing targeted strategies to address the barriers related to organizational climate and morale that impact the use of physical restraints as well as adverse events. Although specific interventions focused on seclusion and restraint use are important, leadership should also consider implementing broader initiatives devoted to improving organizational climate and morale. If introduced on the organizational level, such initiatives may help improve patient care quality and safety in inpatient psychiatric settings and beyond.
ACKNOWLEDGMENTS
This material is the result of work supported with resources and the use of facilities at the Boston and Bedford VA Medical Centers. We are grateful for the support of the Veterans Health Administration National Center for Organization Development for data access to the AES.
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