Results Summary

PCORI funded the Pilot Projects to explore how to conduct and use patient-centered outcomes research in ways that can better serve patients and the healthcare community. Learn more.


There is little research on how to produce the best treatment results in psychiatric hospitals. At the time of this study, there was little research about how patients feel about the care they receive in mental health units and what experiences are important to them and their recovery.

Project Purpose

The purpose of this study was to develop and test a way to measure safety and patient-centered care in mental health care. The researchers developed a measure called the Combined Assessment of Psychiatric Environments (CAPE). The CAPE consists of two surveys: one for patients and one for nurses. The researchers created two surveys because both patients and nurses need to have a positive environment to achieve good care. The researchers did several tests to make sure the patient and nurse surveys were measuring the same issues.

Research Methods

To develop the CAPE, the researchers started by looking at studies on patient and nurse experiences. They also looked at what individuals who had been hospitalized said in earlier focus groups and what nurses working in mental health units said during past individual interviews. Then the researchers made a list of important experiences patients have while getting treatment in mental health units. They asked 30 former patients and 30 nurses to rate the importance of each experience, using a four-point scale. The researchers then used the experiences that the patients and nurses had rated as most important to create the two surveys. Expert panels consisting of eight patients and eight nurses reviewed the surveys. The expert panels looked at the substance of the questions, how the questions were grouped together, and whether any important concepts were missing. The researchers used the feedback to revise the surveys. Finally, the researchers did interviews to learn whether people understood the questions in the survey the way the researchers thought they would. Ten patients and 10 nurses were asked what questions meant, why they thought questions were or were not important, and if the questions made sense together. Researchers used these answers to improve the CAPE surveys.

After creating the surveys, the researchers did a pilot test. The pilot test was a way of seeing if the surveys worked with a small group of patients and nurses before asking larger groups to use it. The research team tested the CAPE surveys with 150 patients and 113 nurses. Patients needed to be at least 21 years old and speak English. They also had to have been in the mental health unit for at least four days and planning to go home the next day. Nursing staff needed to be registered nurses or mental health counselors who worked at least half-time in a mental health unit.

The pilot test took place in six mental health units with an average of 20 beds each. These facilities included three mental health units in community hospitals, two mental health units in medical centers, and one psychiatric hospital. Patients in these mental health units were people who had a mental illness and were considered to be dangerous to themselves or others, or unable to take care of themselves.

In the pilot test, patients and nurses completed their respective versions of the CAPE survey. Patients also completed the 16-question Perceptions of Care survey, which asks about patient satisfaction. Nurses and mental health workers also completed the 31-question Practice Environment Scale of the Nursing Work Index, which asks about the nursing work environment.

The research team looked for themes in the answers to the survey questions. The team also used statistical tests to see whether people answered similar questions the same way.


Patients’ answers to the CAPE survey focused on two themes about their treatment:

  • Were staff capable?
  • Was treatment effective?

Staff answers to the CAPE survey showed five aspects of experiences on the mental health unit:

  • a sense of being effective
  • whether there were enough resources and staff
  • management involvement with care
  • how well staff worked together
  • how much independence the staff have on the unit

For the most part, patients and staff answered similar types of questions in the same ways.


There were some unexplained differences between patients’ and nurses’ answers to survey questions. Patients’ answers suggested that they believed they frequently had all of the experiences the study asked about, regardless of what mental health unit they were in. In contrast, staff answers about topics such as whether their unit was safe were different, depending on the unit in which they worked. This could be because the survey’s questions need to be worded differently or because patients are likely to answer survey questions about treatment experiences in a positive way.

Importance of Findings

The CAPE patient and staff surveys appear to work well together and to reflect what patients and staff experience. The CAPE survey questions seem to show what patients believe are important aspects of treatment. Until recently, patients treated in mental health units were not given surveys about their experiences in obtaining mental health care. The CAPE survey is a contribution to measure what matters to patients when obtaining mental health care.

Sharing the Results

The research team has published on the CAPE and has presented the study at professional meetings (see below). Other researchers have begun using the CAPE to test the relationship between quality of care and trust in the mental health system.

Future Research

The research team is creating a shorter version of the CAPE. In addition, future research will determine whether the CAPE produces different results with patients who are in restraints than with those who are not.

Project Information

Kathleen R. Delaney, PhD, PMH-NP
Mary E. Johnson, PhD, PMH-CNS
Rush University Medical Center/Rush College of Nursing
CAPE: Patient-Centered Quality Assessment of Psychiatric Inpatient Environments

Key Dates

June 2012
December 2013

Study Registration Information


Has Results
Award Type
Funding Type
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: March 4, 2022