Patient-reported outcomes of psychiatric and/or mental health nursing in hospitals: a systematic review protocol

Introduction

The use of validated and reliable scales for outcome measurement is globally recognised as essential in psychotherapeutic research and in improving mental health services.1–6 However, there is a consensus in the nursing literature that psychiatric and/or mental health nursing falls short in describing the benefits of their work through outcome measures despite the vast amount of their outcomes in qualitative research.7–9 Developing valid and reliable scales to measure outcomes of nurse-sensitive care, particularly in the interprofessional context of mental healthcare in hospitals, is a complex challenge.10–13 Having valid and reliable scales to measure outcomes of psychiatric and/or mental health nursing is important for various reasons. It guides clinical practice and nursing education, facilitates the assessment of nursing quality through monitoring and benchmarking, enables the development of research-based nurse-delivered care and interventions and enhances public accountability of the nursing profession.7 9 14 15 The lack of plausible outcome measures for nurse-delivered care and interventions has a negative impact on demonstrating the quality of current and future nursing practice, as well as on the skills and role development of psychiatric and/or mental health nurses within the workforce.16–20 Moreover, the absence of distinct measured outcomes poses a risk to the erosion of the specialisation of psychiatric and/or mental health nursing and hampers their involvement in reforming guidelines and policies for improving outcome-based mental healthcare services.8 21–25

There is a substantial body of literature emphasising the importance of patient-centred outcomes research to better understand, address and improve what matters to patients, thereby improving care.17 26 Patient-centred measurement includes tools for capturing patient voices regarding outcomes and experiences.27 28 Patient-reported outcomes, patient-reported data by means of measurable outcomes, play a key role in enhancing healthcare value and resource allocation by providing opportunities for the design, delivery and quality assessment of services.29–31 Recognising the inter-relatedness but fundamental distinction between patient-reported outcomes and patient outcomes is important.32 Patient-reported outcomes encompass any aspect of a patient’s health status or condition directly reported by the patient, without interpretation by anyone else.33–35 Patient outcomes by means of clinician-rated or family-rated outcomes measures are not self-defined by the patient.36 On the other hand, patient-reported experiences capture patients’ unique perspectives on their mental health services or condition, focusing on the impact of the care process and their illness experience rather than the outcome.34 37

Understanding the factors that influence patient-reported outcomes in psychiatric and/or mental health nursing is crucial for providing tailored care that aligns with the evolving needs and expectations of individuals with mental health problems, both in clinical practice and research.9 12 38–44 Patient-reported outcomes, along with their associated factors, have the potential to systematically capture information regarding a broader conceptualisation of health improvement from the patient’s perspective, thus assessing the effectiveness of nursing care and interventions.15 29 45

A preliminary search across relevant databases did not identify any existing or ongoing systematic reviews or scoping reviews on patient-reported outcomes of psychiatric and/or mental health nursing in hospital settings. Conducting a systematic review is considered the most valid approach to assess the effectiveness of a specific treatment or practice.46 A robust and structured process is essential to ensure reliable and meaningful findings. While not all components of the PICO (population, intervention, control and outcomes) framework are necessary to define the review question in detail, precision in treatment formulation is crucial.33 47

A systematic review that identifies, appraises and synthesises research in the field of patient-reported outcomes, associated factors, measured nursing care and interventions, and measurement scales in psychiatric and/or mental health nursing holds the potential to offer valuable insights into the effects of psychiatric and/or mental health nursing across clinical, educational and managerial practice. Furthermore, this review can pinpoint gaps in current research, guiding future nursing/psychotherapeutic research. The insights derived from this review pose a potential to inform the future directions of nurses and patients in clinical practice within hospitals, advance the education of psychiatric and/or mental health nursing as a specialised field, assess current and future nursing care and interventions, influence participation in healthcare reform policy and enhance nursing outcome research in the rapidly changing field of mental healthcare.

As such, our objective of this systematic review will be to identify, appraise and synthesise available evidence on patient-reported outcomes, associated factors, measured nursing care/interventions and used measurement scales of psychiatric and/or mental health nursing care/intervention(s) in hospitals.

Review questions

Primary review question

What has been identified as patient-reported outcomes of psychiatric and/or mental health nursing in hospitals?

Secondary review questions:

  • What factors have been identified to influence patient-reported outcomes of psychiatric and/or mental health nursing?

  • What nursing care and nursing interventions have been measured?

  • What scales are used to measure patient-reported outcomes of psychiatric and/or mental health nursing?

Methods and analysis

Design

This article outlines the protocol for a systematic review that will be conducted according to the guidelines in the Cochrane Handbook33 to ensure rigour and facilitate replicability of the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol Checklist (PRISMA-P) will be used to report.48 The review protocol has also been registered in PROSPERO (CRD4203363806). The review is scheduled to be conducted between May 2023 and June 2024.

Patient and public involvement

An expert by experience will be consulted as one of the experts to define the definitive search, including all identified keywords and index terms for each included database.

Eligibility criteria

We will consider original, peer-reviewed studies in English as eligible. Conference abstracts, opinion papers, white papers, studies in progress and book chapter are excluded. There is no limit to publication date of peer-reviewed studies to reduce risk of publication bias. Studies will be screened and selected based on a PICO format as follows:

P (population)

The population of interest will be any group of individuals aged 18 years or older admitted to hospitals including acute, intensive and forensic psychiatric wards. Studies involving individuals with psychiatric and/or mental health problems in non-psychiatric wards will be excluded (eg, psychiatric liaison nurses providing nurse-led care in geriatric wards or emergency departments). For purposes of this review, when a study may have included individuals <18 years, the study will be included if the average age is 18 years or older. For the scope of this, review hospitals are defined as facilities providing continuous inpatient treatment, operating 24/7, for individuals with psychiatric and/or mental health problems.

I (Intervention)

For inclusion, studies must measure outcome(s) of psychiatric and/or mental health nursing. We have defined psychiatric and/or mental health nursing as nursing on acute, intensive and forensic wards providing any technical interventions, biomedical support, relationship-based care, (psycho)therapeutic interventions or interaction, holistic supportive and person-centred care, and providing assistance to persons with mental health problems. Studies measuring outcomes of other nurse-led liaison service in acute, intensive and forensic wards will be excluded (eg, diabetes liaison nurses providing nurse-led care in psychiatric wards). When a study includes interprofessional team interventions, the study will be included if the results of the distinct nursing care/intervention are reported separately.

C (Control)

Any or none.

O (Outcome)

This review will include studies reporting patient-reported outcomes. We define a patient-reported outcome as any aspect of a patient’s health status or condition that is directly collected from the patient without the interpretation of the patient’s response by anyone else. When a study may have included patients and other perspectives (eg, professionals, families, nursing students), the study will be included if the results of patients are reported separately. Patient outcomes reported by other perspective than the patient will be excluded. Cost-effectiveness or economic outcomes and patient-reported experiences, focusing on the impact of healthcare processes and the illness experience rather than the outcome, will also be excluded from this review.

Search strategy and data sources

Formative work: development of the search strategy

An initial limited search of Ovid MEDLINE was undertaken to identify articles on the topic. The review question guided the development of the search strategy for the three main study concepts: (1) patient-reported outcomes, (2) psychiatric and/or mental health nursing and (3) hospitals. Our starting point was to identify synonyms and related terms by Medical Subject Headings, text words, contained in the titles and abstracts of relevant articles and the index terms, used to describe the articles, to develop a full strategy for Ovid MEDLINE. We searched Ovid MEDLINE for each of the main study concepts to determine whether they were Medical Subject Headings (MeSH). Text mining, subject trees and Boolean operators were used as appropriate. The draft search strategy for Ovid MEDLINE is displayed in box 1. The pilot search resulted in 4803 articles.

Box 1

Draft search strategy Ovid MEDLINE

Patient-reported outcomes

exp Patient Reported Outcome Measures/ or Patient Outcome Assessment/ or (PRO or PROM or PROMS or ‘individual outcome*’ or ((patient or client or self) adj4 (report or reported or reporting or rated or rating or ratings or based or assessed or assessment or assessments)) or ((disabilit* or function or functional or functions or utility or utilities or ‘health profile*’ or ‘health status’ or ‘health condition*’) adj5 (outcome or outcomes or index or indices or instrument or instruments or status or measure or measures or questionnaire or questionnaires or profile or profiles or scale or scales or score or scores or status or checklist or tool or tools or evaluation or evaluations or survey or surveys or effect or effects))).ti,ab,kf.

Psychiatric and/or mental health nursing

exp Psychiatric Nursing/ or (‘mental health nurs*’ or ‘psychiatric nurs*’ or RMN or ‘mental nurs*’ or ‘psychiatric mental health Advanced Practice Nurs*’ or ‘psychiatric clinical nurse specialist*’ or ‘mental health clinical nurse specialist*’ or ‘mental health registered nurs*’ or ‘psychiatric registered nurs* ‘ or ‘psychosocial nurs*’).ti,ab,kf.

Hospitals

(((psychiatric OR ‘mental health*’ OR mental) ADJ5 (hospital* OR setting* OR institution* OR ward* OR unit* OR ‘inpatient care’ OR service* OR care OR inpatient* OR in-patient* OR patient*)) OR ((‘mentally ill’) ADJ3 (patient* OR inpatient* OR ‘ in-patient*’)) OR ‘psychiatric emergency service*’ OR ((HIC OR ‘High and intensive care’ OR ‘High Intensive care’ OR ’emergency service’) AND (psychiatry OR ‘mental health’ OR mental))).ti,ab,kf.

Data sources

The initially developed search strategy for Ovid MEDLINE will be adapted for the other databases. The final search, including all identified keywords and index terms for each included database, will be identified by consultation with clinical and methodological experts (psychiatric/mental health advanced practice nurse, expert by experience, university librarian, psychiatrists, nursing and sociology academics) and by exploring the literature. The following electronic databases will be consulted December 2023 and updated in the first week of April 2024: Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Experta Medica Databases (EMBASE), APA PsycINFO, Web of Science and Scopus.

Screening procedures of eligible studies

A pilot search of the collaborative review process by two researchers (KD and BV) on Ovid MEDLINE will be performed using five randomly selected studies. This pilot training aims to train the two researchers and to test both the ratio of recall and precision ratios for retrieval. The final eligibility criteria will be developed, in consultation with the experts. Each database will be searched individually, and all results will be exported to EndNote V.21 (Clarivate Analysis (USA)). Citations will be exported from EndNote V.21 into Rayyan, an AI-assisted collaboration tool for managing systematic reviews. Identical references will be identified and removed using Rayyan’s duplicate detection feature. Subsequently, the researchers (KD and BV) will contact the first author when multiple papers are identified reporting the same single data set. Required data will be extracted and checked for consistency between manuscripts. Two researchers (KD and BV) will apply eligibility criteria separately and independently to review citations for inclusion in the review. The screening will be undertaken in two stages using Rayyan software. Stage 1: title and abstract screening against the review inclusion/exclusion criteria. Stage 2: full-text screening, following the same process. If the two researchers are unable to decide about the inclusion of a study because further information is required, the study will be categorised as awaiting assessment until additional information is obtained. Any conflicts will be resolved by a third independent researcher. The results of the search and the study inclusion process, including the reason for excluded reports with full text, will be reported in full in the final systematic review and presented in a PRISMA flow diagram.

Assessment of risk of bias

The quality of randomised trials will be assessed by using the Johanna Briggs Institute (JBI) Critical Appraisal Checklist for Randomised Controlled trials. Study quality of observational studies will be assessed using the JBI Critical Appraisal Checklist for Cross-Sectional Studies. The methodological quality assessment of future included studies will be conducted separately and independently by two independent researchers (KD and BV). Authors of papers will be contacted to request missing or additional data for clarification when required. Disagreements will be discussed in consultation with an independent researcher. The results of the quality assessments will be reported in a table with an accompanying narrative. The aim of this review is to assess the evidence of studies on patient-reported outcomes, associated factors, measured nursing care/interventions and used measurement scales of psychiatric and/or mental health nursing care/intervention(s) in hospitals. Consequently, all studies, regardless of the results or methodological quality, will undergo data extraction and synthesis (where possible).

Data extraction

The data extraction from each included study will be performed separately and independently by two researchers (KD and BV). The final data extraction will be performed by consensus based on the individual data extraction worksheets (table 1). Disagreements will be discussed in consultation with an independent researcher.

Table 1

Data extraction worksheet

Prior to full implementation, the data extraction worksheet will be pilot tested by the two researchers (KD and BV) on five randomly selected studies. Their feedback will be integrated to further refine the worksheet.

Data synthesis and analysis

A narrative synthesis will be provided to describe how the results relate to the review objectives and questions. Summaries of included studies will be presented in a tailored table format that will consist of the first author, country and year; study design and study setting; study population; measured nursing care/intervention(s); patient-reported outcome, associated factors and used measurement scales. If possible and appropriate, the included studies will be organised into clusters. Approaches to present the results may be further refined during the review process and explained in the resulting review.

Validity and reliability

For the design and reporting of this systematic review, we will strictly follow the recommendations of the Cochrane Handbook33 and PRISMA-P.48

Ethics and dissemination

This study does not involve participants nor unpublished secondary data. Therefore, approval from a research ethics committee is not required. Following the completion of the systematic review, findings will be presented to academic audiences at international conferences. The results will also be published in a peer-reviewed academic journal to reach clinical and academic experts interested in the topic. Plain language summaries and presentations to hospitals and other relevant clinical programmes will also be developed.

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