Structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia in Japan: A cross-sectional study

Schizophrenia is a disorder characterized by psychotic relapses. Globally, about 15%–30% of patients with schizophrenia discharged from inpatient psychiatric admissions are readmitted within 90 days due to exacerbation of symptoms that leads to self-harm, harm to others, or self-neglect. The purpose of this study was to investigate the structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia. A new questionnaire was developed to assess the extent to which respondents delivered in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia. This study adopted a cross-sectional research design. The survey was conducted with the new questionnaires. The participants were registered nurses working in psychiatric wards. Item analyses and exploratory factor analyses were performed using the new questionnaires to investigate the structure of in-hospital nursing care leading to reduction in early readmission. Stepwise regression analyses were conducted to examine the factors predicting in-hospital nursing care leading to reduction in early readmission. Data were collected from 724 registered nurses in Japan. In-hospital nursing care leading to reduction in early readmission was found to consist of five factors: promoting cognitive functioning and self-care, identifying reasons for readmission, establishing cooperative systems within the community, sharing goals about community life, and creating restful spaces. In-hospital nursing care leading to reduction in early readmission was predicted by the following variables: the score on the nursing excellence scale in clinical practice, the score on therapeutic hold, and the participation of community care providers in pre-discharge conferences. Japanese psychiatric nurses provide nursing care based on these five factors leading to reduction in early readmission. Such nursing care would be facilitated by not only nurses’ excellence but also nurses’ environmental factors, especially the therapeutic climate of the ward and the participation of community care providers in pre-discharge conferences.

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Ethical approval to conduct this study was granted by the ethics committee of the Graduate School of Medicine, Nagoya University, Japan (No: 17-155). The participants were informed about the aims of the study and the benefits and risks of participation through printed forms. The participants provided written informed consent. They responded to each questionnaire anonymously, enclosed the completed questionnaires in sealed envelopes, and returned them to the researchers. Hospital directors and nurse managers did not participate in the data collection process. If participants had any questions about the study, they were able to call or email the principal investigator, whose phone number and address were listed on the documents for research cooperation. Permissions to use the EssenCES-JPN and the NES were obtained from the copyright holders.  Schizophrenia is a disorder characterized by psychotic relapses. Some patients with 23 schizophrenia are re-admitted to hospitals when their condition worsens so that they cannot 24 live in communities. The purpose of this study was to investigate the structure and predictors 25 of in-hospital nursing care to prevent early readmission in patients with schizophrenia.

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A new questionnaire was developed to assess the extent to which respondents delivered 27 in-hospital nursing care to prevent early readmission in patients with schizophrenia. This study 28 adopted a cross-sectional research design. The survey was conducted with the new 29 questionnaires. The participants were registered nurses working in psychiatric wards. Item 30 analyses and exploratory factor analyses were performed using the new questionnaires to 31 investigate the structure of in-hospital nursing care to prevent early readmission in patients 32 with schizophrenia. Stepwise regression analyses were conducted to examine the factors 33 predicting in-hospital nursing care to prevent early readmission.

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Data were collected from 724 registered nurses in Japan. In-hospital nursing care to 35 prevent early readmission was found to consist of five factors: promoting cognitive functioning 36 and self-care, identifying reasons for readmission, establishing cooperative systems within the 37 community, sharing goals about community life, and creating restful spaces. In-hospital 38 nursing care to prevent early readmission was predicted by the following variables: the score 39 on the nursing excellence scale in clinical practice, the score on therapeutic hold, and the 40 participation of community care providers in pre-discharge conferences. 41 Japanese psychiatric nurses provide nursing care based on these five factors to prevent Introduction 47 Schizophrenia is a disorder characterized by psychotic relapses [1]. Many people with 48 schizophrenia suffer recurrent symptoms of psychosis (i.e., hallucinations, delusions, and 49 disorganized speech) and chronic cognitive deficits (i.e., impaired executive function, memory, 50 and speed of mental processing) [2]. Various indicators are used for relapse in schizophrenia.

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Readmission rates are widely used as an indicator for relapse among schizophrenia patients [3,  Several studies examined the factors that contribute to readmission. Schizophrenia is one 57 of the diagnoses of mental disorders associated with psychiatric readmission [7][8][9] a psychiatric ward of more than 28 days plays a protective role in preventing readmission [4].

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In particular, readmissions within 90 days of discharge are usually defined as early re-  for patients in communities are not enough to prevent early readmission in patients [4]. 87 Japanese hospital nurses need to be more proactive in providing nursing care to prevent early 88 readmission in patients, so that the patients can spend their lives more comfortably after 89 discharge. However, the predictors of in-hospital nursing care to prevent early readmissions 90 are unknown.

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In-hospital nursing care to prevent early readmission may be predicted by nurses' 92 environmental factors as well as their individual factors. The risk of early readmission could 93 be predicted by not only community follow-ups but also by length of stay in hospital [4].

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Nursing performance is influenced by nurses' environmental factors as well as personal factors 95 [29]. A positive social climate in hospitals is associated with higher patient treatment 96 motivation, treatment engagement, and patient-nurse therapeutic alliance [30]. A significant 97 relationship between social climate and staff performance and morale has been reported [31]. 98 We hypothesized that in-hospital nursing care to prevent early readmission could also be 99 predicted by the social climate in psychiatric wards as well as by nurses' individual factors.

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The purpose of this study was: (a) to investigate the structure that underlies in-hospital This study adopted a cross-sectional research design and utilized self-administered 107 questionnaires, which participants completed anonymously.  The following demographic characteristics of the participants were examined: gender, 133 years of psychiatric experience, advanced practice registered nurse (APRN) status (certified 134 nurse or certified nurse specialist), experience as a psychiatric home-visiting nurse, experience 135 in providing psychiatric outpatient care, experience in somatic care wards, and educational 136 level. Further, the following characteristics of the hospitals or wards in which they were 137 working were asked: hospital establishment, adoption of primary nursing, whether or not pre-138 discharge conferences were usually held, the participation of patients' families in the pre-139 discharge conferences, and the participation of multidisciplinary teams in the pre-discharge 140 conferences. Only participants who answered that "pre-discharge conferences were usually 141 held" responded to the question if the patients' families attended the pre-discharge conferences.

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Similarly, only participants who explained that "pre-discharge conferences were usually held" 143 responded to the question of whether the conference member consisted only of hospital staff 144 or consisted of both community and hospital staff.

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The in-hospital nursing care to prevent early readmission in patients with 146 schizophrenia scale (IPERSS) 147 A 43-item IPERSS was developed in this study. In the IPERSS, respondents were 148 required to recall a patient with schizophrenia who had previously been readmitted within 90 149 days of discharge, but who could live in a community for more than 90 days after receiving an 150 in-hospital intervention. The respondents answered to what extent they provided the nursing 151 care indicated in the questionnaire during the patient's in-hospital intervention (see S1 Figure.).  Higher scores indicated that respondents perceived the hospital ward climate as more positive.

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"Patients' cohesion and mutual support" reflected an essential quality of therapeutic 177 communities and effectively working treatment groups [35]. "Experienced safety" referred to    Table 1. cognitive functioning and self-care" and consisted of nine items. Factor 2 was labeled 267 "Identifying reasons for readmission" and consisted of eight items. Factor 3 was labeled 268 "Establishing cooperative systems within the community" and consisted of seven items.

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Factor 4 was labeled "Sharing goals about community life" and consisted of seven items.

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Factor 5 was labeled "Creating restful spaces" and consisted of five items. Their Cronbach's 271 alphas ranged from .81 to .91 (see Table 2). The mean overall score of the IPERSS was 131.92 272 (SD = 18.09). The Cronbach's alpha of the 36-item IPERSS was .96.  score on the IPERSS and the overall score on the NES was r = .59, p < .01, between the overall 284 score on the IPERSS and the score on the "Patients' cohesion and mutual support" was r = .18, 285 p < .01; between the overall score on the IPERSS and the score on the "Experienced safety" 286 was r = -.07, p = .06; and between the overall score on the IPERSS and the score on the 287 "Therapeutic hold" was r = .33, p < .01.  Table 5. The main findings of this study can be summarized as follows: the IPERSS was found The five-factor structure of the IPERSS was largely consistent with the findings of the