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Table of Contents
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 35-40

Quality assurance in psychiatric nursing

Faculty, AIIMS College Nursing, New Delhi, India

Date of Web Publication17-Jun-2019

Correspondence Address:
Sandhya Gupta
Faculty, AIIMS College Nursing, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-1505.260547

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How to cite this article:
Gupta S. Quality assurance in psychiatric nursing. Indian J Psy Nsg 2016;12:35-40

How to cite this URL:
Gupta S. Quality assurance in psychiatric nursing. Indian J Psy Nsg [serial online] 2016 [cited 2023 May 28];12:35-40. Available from: https://www.ijpn.in/text.asp?2016/12/1/35/260547

  Introduction Top

Morbidity on account of mental illness is set to overtake cardiovascular diseases as the single largest risk in India. There are over two crore persons in our country who are in need of treatment for serious mental disorder and about five crore people who are affected by common mental disorder[1].

Quality Assurance system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems

Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war[2].

Quality refers to excellence of a product or a service, including its attractiveness, lack of defects, reliability, and long-term durability.

Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources.

Quality assurance is generally and defined as the process where the performance of a system or service is assessed and evaluated to ensure that a high quality, safe service is offered and delivered to those using it, and that it complies with agreed standards, accreditation and any relevant legislation and safety requirements. Quality assurance generally takes the form of a range of activities, from the identification and monitoring of appropriate standards (international, national, regional and local) including clinical safety and clinical standards, to the formal and Informal monitoring and inspection of services, to the lodging of, investigation into and reporting of complaints and serious incidents to advocacy for those using the service. The main objective of these activities is to ensure a good quality and safe Service system for those using them, their families and carers and a level of assurance for all the communities[3].

Meaning of Improved quality in mental health care

  • Preserve the dignity of people with mental disorders
  • Provide accepted and relevant clinical and non-clinical care aimed at reducing the impact of the disorder and improving the quality of life of people with mental disorders.
  • Use interventions which help people with mental disorders to cope by themselves with their mental health disabilities.
  • Make more efficient and effective use of scarce mental health resources.
  • Ensure that quality of care is improved in all areas, including mental health promotion, prevention, treatment and rehabilitation in primary health care, outpatient, inpatient and community residential facilities.

Quality comprises of

  • – Acceptability
  • – Affordability
  • – Effectiveness
  • – Comprehensiveness

Assurance refers to the process that includes[4]

  • – the identification of values and standards
  • – Specification of criteria
  • – Measurement of observable aspect of care

Aim of QA in psychiatric Nursing

QA is an important aspect of psychiatric nursing

  • – Funds are available only after evidence is provided that predetermined standards of care have been met.
  • – QA helps nurse monitor their own practices in a systematic way.
  • – QA ensures the public confidence in health care professionals
  • – QA is one way in which professional nurses regulate their profession in order to maintain high level of nursing practice and at the same time retain the confidence of the public.

How To Improve Quality Of Mental Health Care

The steps in improving quality are cyclical.

Step 1. Align policy for quality improvement

Policy-makers have a key role in the quest for quality. They are in a position to establish the broad parameters of quality through consultation, Partnerships, legislation, funding and planning.

Consultation (Functions):Obtaining input from various stakeholders, sharing information across stakeholder groups and building a common understanding. The development of such an understanding is an essential task of policy-makers.

Partnerships (Functions):Partnerships with professional groups, academic institutions, advocacy groups, Other health and social service sectors.

These partnerships form the backbone of the quality improvement process and enable long-term sustainability.They build consensus and consistency in messages related to the need for quality and can also serve to mobilize resources and other necessary supports. Legislation: Policy-makers should promote legislation that reflects concern for and emphasis on quality.

Funding: Financial systems for mental health care should be aligned so that they maximize quality and do not become an obstacle to quality improvement.Improved efficiency is an essential goal in relation to both quality improvement and cost containment.

Planning : Quality processes can inform planning by providing a knowledge base for evidence-based practice. In the course of planning, several issues pertaining to resource allocation and priority-setting have a bearing on quality.

Step 2. Design standards

Once policies have been aligned for quality the next essential step is to develop a set of standards against which services can be measured. Planners and managers should establish a working group Consult with relevant stakeholders and draft a standards document.

The standards document should cover all aspects of a mental health service.

  • Criteria for each standard should be specified.
  • These criteria should provide a means for rating existing services.
  • The rating of services should be supplemented by observations on the quality of all aspects of mental health care.

Step 3. Establish accreditation procedures[5]

  • Accreditation provides the opportunity to assess the quality of care delivered by a mental health service and to provide the service with the appropriate legal recognition.
  • Accreditation is essential because it makes quality a cornerstone of the official licensing of mental health services or facilities.
  • Service planners should ascertain whether any accreditation procedures already exist which can be used to assess current services.
  • Outdated procedures should be reformed in keeping with the evidence for the most clinically effective and humane forms of mental health care.
  • Accreditation procedures should be developed if there are none.
  • The standards document developed in step 2 can be used as a structure to provide criteria and a rating system for assessing services and conferring the appropriate legal status.

Step 4. Monitor the mental health service by using the quality mechanisms

  • Use standards to assess the service annually.
  • Use of accreditation procedures to assess and accredit new service developments and to review the ongoing functioning of services.
  • Routine information-gathering through existing information systems, particularly by means of performance and outcome indicators.
  • Consultation with independent organizations for to assess people with mental disorders and advocacy groups.

Step 5. Integrate quality improvement into the ongoing management and delivery of services

  • Managing annual service quality reviews; including quality checks in service planning targets;
  • Building quality improvement into clinical practice through evidence-based practice, clinical practice guidelines, teamwork and continuing professional development;audit.

Step 6. Consider systematic reform for the improvement of services

  • An assessment of the quality of a mental health service may indicate a need for systematic reform or improvement.
  • This step may require concrete planning and coordination by various sectors.

Step 7. Review the quality mechanisms

A review of quality mechanisms is necessary in order update them in accordance with evidence on the mosteffective methods of quality improvement.

Key components in quality assurance includes[6]

  • – Standards of care
  • – Criteria specific to practice
  • – Protocols for nursing intervention
  • – Audits or review of care procedure
  • – Peer review
  • – Level of practice
  • – Professional development activities
  • – Credentials
  • – Licensure
  • – Certification

Standards of care

Standards of care is drawn from available knowledge about human being, the norms of group who care for patients and values of nurses.

  E.g Rights of client

  • – to safeguard
  • – To experience a sense of personal acceptance

Formation of Standards of care[7]

Involves a task forces or other committees and presentation of preliminary statements of standard to the members of organization for criticism and revision.Nurses who are most influential in development of standards are those

  • – who have achieved a significant level of experience in a particular functional area
  • – Higher education
  • – Recognized by the peers as being outstanding.


Criteria are specific, predetermined rules or principles developed by health care practices for a given setting and against which the health care practices implemented in that setting are compared.Three types of criteria are generally used:Structure criteria, Process criteria and Outcome criteria.

Structure criteria

It indicates the aim and purposes of institution or agency or program and can be designed for the institution, or agency, the client or the nurse.Statement may be made about the philosophy and objectives of the institution, the facilities, administrative organization, regulations ,standards and procedures. E.g of structure criteria are

  • – The expectation that staff nurses have completed a course in group therapy
  • – The requirement that each client in each unit has an attendant to provide care.

Process Criteria

Process criteria are used in the evaluation of actions and the sequence of behavior and events during the provision of client care.E.g documentation of the therapeutic one to one relationship and progress notes

– Data to indicate whether or not the nursing care plan was developed


To identify problems that occur while caring for clients and to take immediate measures that can change or improve the final outcome of care.Enables the nursing dept. to evaluate the extent to which care is completed.The implementation of policy and procedures and the activities.

Outcome criteria

– Developed to evaluate the end result of the care and services provided to the client E.g client orientation about time, place, person and his responsibility for activities of daily living when discharged from hospital.

Limitation of outcome criteria

When the outcome or effect of intervention are reviewed and it is found that it is not reaching the standards or predetermined criteria then It is difficult to determine whether

  • – it is due to faulty nursing process or
  • – due to uncooperative patient


A protocol is an instrument that guides a practitioner in the collection of data and recommends specific action based on that data.

  • – Written statement of specific interventions for certain signs and symptoms
  • – Guidelines to be used in chronic illness.

In hospital quality assurance programs protocols may be defined as statement of behaviors identified as discrete steps used by nurses in the attainment of long and short-term goals


  • To become more aware of the procedure.
  • To identify specific stages in client care that have been accomplished well or poorly.
  • To direct nursing intervention.
  • To intervene in client care when physicians are not available.
  • To serve as specific statements of nursing behavior that can be incorporated into quality assurance activities.

Development of protocol [8]

Developed by multidisciplinary committee composed of professional health providers who function within that setting.Members are physician often because they are recognized as health team leader and have the right to prescribe medication.Such committee also develop protocol after a review of literature.

Audits : Auditing is the verification that the nursing care given to client is appropriate and in accordance with the predetermined standards of nursing care in a particular area.It is a mechanism used to asses and verifies the quality of client care.

Methods of nursing audit are the Concurrent view and the Retrospective view

Concurrent audit: It is a method of evaluating ongoing activities, assessment at the time of review of one particular aspect of care.E.g whether side rails are up on the beds of confused elderly client.Benefits are:-

  • Allows corrective actions to be taken immediately.
  • Quickly improves the quality of care.
  • Immediate feedback.
  • Opportunity to develop greater capabilities in clinical role.

Retrospective audit : It was applied after services have been rendered. Data one can get from records or interview

Peer review : It is the process by which the quality of nursing care rendered by a nurse is evaluated by other psychiatric nurses actively involved in clinical nursing practice.


  • To improve overall client care.
  • Allows the contribution of individual nurses to be appraised.
  • Promote individual accountability and are often the primary way of recognizing clinical expertise. It allows degree of consistency between practice and predetermined standards.

Levels of practice

Ranking or a degree of performance supported by a particular knowledge base and development of required skill.The inclusion of the levels of practice concept in a quality assurance provides a more precise description of the unit being evaluated and the level of care being rendered.Eg: Psychiatric Registered Nurses, Psychiatric Nurse Practitioners, psychiatric nurse managers

Professional development : The term professionalism implies[9]

  • – certain levels of competence in nursing practice and
  • – educational accomplishments
  • – that reflect breadth of knowledge, skill, and personal maturity.

Continuing education program: Includes short term planned programs of courses under the direct direction of staff educators or academicians. Learning experience are designed to enhance previously acquired knowledge and skill. Post Basic and Post-graduate education: Includes program of study under the direction of professional educators in college or university. Function: To prepare nurse specialist with the additional knowledge and skill necessary to exercise independent judgment.

Diploma in Psychiatric Nursing (DPN):Is apost basic mental health psychiatric nursing programs, emphasis is usually placed on

  • – Assessment
  • – Awareness of the most frequently encountered emotional problems and pathological conditions,
  • – Appropriate nursing intervention
  • – Modes of evaluation

Post graduate in Psychiatric Nursing(MSc-Psychiatric Nursing.) : Is a post graduate mental health psychiatric nursing programs, emphasis is usually placed on

  • – Clinical competences in assessment,psycho-pathology of various conditions, diagnostic criteria, appropriate treatments, nursing interventions and rehabilitation.
  • – Modes of promotion of mental health and prevention of mental disorders.
  • – Teaching of mental health nursing.
  • – Research in the areas of Mental health. Credentials

A credentials attests the institution or a person to function in a function in a particular area of expertise.

To acquire a credential, an institution or individual is identified by a recognized authority as credentials are inherent in any quality assurance program and the possession of appropriate credentials constitutes a part of the audit process[10].

Four fundamental features are quality, identity, protection and control.

Nursing credentials includeLicensure, certification and Accreditation

Licensure : They suggest that institutional licensure will costs and promote efficiency by:

  • – Providing opportunity for evaluation of individual on site performance
  • – Allowing for innovative continuing education programme in hospitals
  • – facilitating career mobility

Certification : It is the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes.

Practice models : Practice models may be defined as various pattern in delivery of nursing services by which health care is made available to diverse groups of people in different settings.

Frame work for Quality Assurance

One suggested framework for quality assurance consists of two key’pillars’, each with a core set of interrelated functions:

1. Rights and protections

  • Protecting the rights of involuntary users of services
  • Protecting the rights voluntary users of services and their carers /supporters
  • Independent advocacy for users of services and their carers/supporters
  • A complaints procedure for users of services and their carers/supporters

2. Quality management

  • Setting standards and outcomes
  • Independentinspection,monitoringandevaluation
  • Pre qualification and licensing ofproviders
  • Reportingandmonitoringofsentinel events

Professional Performance Standards

As the field of nursing grows and changes in defining the role of a nurse, the central theme will always be that of caring. It can be said that, all other duties and responsibilities of nurses have centered around, “caring”. With the emergence of the, “caring”, theorists also came the emergence of “Standards of Profession Performance”.

The American Nursing Association set forth the following requisites for standards of professional performance[11].

Standard I : Quality of care

Psychiatric mental health nurse systematically evaluates :

  • – Quality of care
  • – Effectiveness of mental health nursing practice.

Standard II: Performance appraisal

Mental health nurse evaluates

  • – One’s own mental health nursing practice standards
  • – In relation to national and state statutes and regulations.

Two ways of performance appraisals

Administrative performance appraisal: Involves review, management, regulation of competent psychiatric nursing practice.Involves supervisory relationship in which a nurse’s work performance is compared with the role expectations.Helps in identify the competency area and areas of improvement.

Clinical performance appraisal:Guidance provided through a mentoring relationship and clinical supervision with a more experienced, skilled and educated nurse.

Standard III: Education

Psychiatric nurse acquires and maintains current knowledge in nursing practice.

Standards IV : Ethics

The psychiatric nurse’s assessments, actions & recommendation on behalf of the patient are determined and implemented ethically.

Standard V : Research

The psychiatric nurse contributes to nursing & mental health through the use of research methods and findings.

Role of psychiatric nurse in QA [12]

Acute(Emergency ward)

Shorten duration of hospital stays

Prevention of re-hospitalization

Consideration of human rights

Family support

Careful nursing

Sub-acute(General ward)

Enhancement of intensive rehabilitation

Improvement of patient’s QOL

Enhancement of patient and family psycho-education

Improvement of adherence

Recuperation(Convalescent ward)

Enhancement of rehabilitation by interdisciplinary team

•The roles of nursing administrators and managers in improving psychiatric care services

Improvement of patient’s daily life skills and abilities Enhancement of patient mental education Improvement of adherence and self-care


QA is the process by which the maintenance of excellence in the provision of health care is ensured. Everyone in need should have access to basic mental health care, the key principles are that care should be equitable and accessible.

To improve the quality of psychiatric services, the following matters require attention :

Clarifications of psychiatric service goalsprecise measurement of effects, shortened hospitalizations. Implementation of patient-centered care includes establishment of trust relationships with patients based on open communicationand effective interdisciplinary teamwork.In addition, nursing administrators and managers must judge the clinical competency of nurses and assign them appropriately.

  References Top

Quality improvement for mental health :Mental Health Policy and Service Guidance Package, WHO.2003. http://www.who.int/mental_health/resources/en/Quality.pdf. 24-Aug-2016.  Back to cited text no. 1
World Health Organization. (2001b) Atlas: mental health resources in the world. Geneva: World Health Organization.  Back to cited text no. 4
World Health Organization. (2001a) World Health Report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization.  Back to cited text no. 6
Koch M.W And Fairly T.M. Integrated Quality Management: The Key To Improving Nursing Care Quality. 1st Edition.St.Louis,Missouri:MosbyPublications;2009.  Back to cited text no. 7
Yeaman C, et al. (2000) Performance improvement teams for better psychiatric rehabilitation. Administration and Policy in Mental Health 27:113-2  Back to cited text no. 8
World Health Organization, 2003. Quality improvement for mental health: Mental health policy and service guidance package. Url: http://www.who.int/mental_health/resources/en/Quality.pdf  Back to cited text no. 9
Gaebel a, et al. Guidance on quality assurance in mental healthcare. European Psychiatry. 30 (2015). Pp. 360-387  Back to cited text no. 10
Developing a Quality Assurance Framework for Mental Health in Western Australia.http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs/WA_QA_  Back to cited text no. 12


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