Acute Mental Health Inpatient Unit Research Articles

Preceptor's experience in supervising undergraduate nursing students in mental health: A qualitative study.

Preceptorship is considered an essential component in undergraduate nursing student's clinical placement, especially those in speciality units such as mental health. During the preceptorship relationship students are granted the opportunity to work alongside experienced nurses in the ward observing their interactions with patients and other professionals. In addition, students are able to build clinical confidence and competence. There is currently a gap in the literature around the preceptorship experience in the mental health clinical environment which warrants further exploration. The aim of this study was to explore the experiences of Registered Nurses precepting undergraduate nursing students during mental health clinical placements. A qualitative, exploratory approach was performed. A total of eight registered nurses working in an acute in-patient mental health unit in a large regional hospital, were recruited and interviewed using a semi-structured interview technique. Thematic analysis was utilised to analyse the data resulting in the development of four overarching themes; (1) Time consuming and additional workload, (2) creating a safe environment, (3) providing and receiving feedback and (4) precepting is not a choice, it is an expectation. The results highlighted that preceptoring students was considered to be an extra workload that required significant time and effort. Preceptors also expressed concerns about student safety, emphasised the importance of feedback and acknowledged preceptorship as an expectation of registered nurses working in mental health. These findings underscore the necessity for further research to delve deeper into the experience of preceptors in mental health settings.

Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit.

Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 =.81, p <.001; depressive symptoms, ηp 2 =.71, p <.001; and functional impairment, ηp 2 =.42, p =.002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.

Trauma-Informed Care on mental health wards: the impact of Power Threat Meaning Framework Team Formulation and Psychological Stabilisation on self-harm and restrictive interventions.

The aim of this evaluation was to assess the impact of introducing a model of Trauma-Informed Care (TIC), comprising weekly Power Threat Meaning Framework (PTMF) Team Formulation and weekly Psychological Stabilisation staff training, to a National Health Service (NHS) adult acute inpatient mental health unit over a four-year period. A retrospective service evaluation design was employed to assess for differences in the number of incidents of self-harm, seclusion and restraint in the four-year period following the introduction of TIC, when compared to the year prior. Significant reductions were demonstrated in the monthly number of incidents of self-harm (p < 0.01; r = 0.42), seclusion (p < 0.05; r = 0.30) and restraint (p < 0.05; d = 0.55) following the introduction of TIC. Findings suggest that PTMF Team Formulation and Psychological Stabilisation training can contribute to significant reductions in self-harm and restrictive interventions (seclusion and restraint) on adult mental health wards. Qualitative interviews with staff and service users from the unit will support a better understanding of the mechanisms of this change. Further research, employing a randomised control trial design, could increase the validity and generalisability of findings. However, the ethical implications of withholding potentially beneficial practices from a control group would need to be considered.

Future-proofing structural design of an acute mental health inpatient unit.

The design of an acute mental health inpatient facility must enable the provision of safe and effective care in an environment that is therapeutic. To be able to do that, in addition to the fittings, light and general ambience, a future design of such a facility must consider how consumers are likely to access mental healthcare in the future, what aspects of care they are likely to find value-adding and how the inpatient aspect of their care is likely to be integrated within their care continuum. The future design must anticipate how consumers are likely to access information, support, care and treatment, how workflows of staff are likely to change, how the diverse needs of mental health consumers will need to be accommodated and how the needs and expectations of staff will be met to enable them to provide support to mental health consumers. A future design of a mental health inpatient unit may have to be very different from the current thinking about the design of such facilities.

EHealth Use on Acute Inpatient Mental Health Units: Implementation Processes, Common Practices, and Barriers to Use.

Information technology to promote health (eHealth) is an important and growing area of mental healthcare, yet little is known about the use of patient-facing eHealth in psychiatric inpatient settings. This quality improvement project examined the current practices, barriers, implementation processes, and contextual factors affecting eHealth use across multiple Veteran Health Administration (VHA) acute mental health inpatient units.Staff from units serving both voluntary and involuntary patients (n = 49 from 37 unique sites) completed surveys regarding current, desired, and barriers to use of Veteran-facing eHealth technologies. Two subsets of respondents were then interviewed (high success sites in eHealth use, n = 6; low success sites, n = 4) to better understand the context of their eHealth use. Survey responses indicated that 20% or less of Veterans were using any type of eHealth technology while inpatient. Tablets and video chat were the most desired overall and most successfully used eHealth technologies. However, many sites noted difficulty implementing these technologies (e.g., limited Wi-Fi access). Qualitative analysis of interviews revealed differences in risk/benefit analysis and implementation support between high and low success eHealth sites. Despite desired use, patient-facing eHealth technology is not regularly implemented on inpatient units due to multiple barriers (e.g., limited staffing, infrastructure needs). Successful implementation of patient-facing eHealth may require an internal champion, guidance from external supports with experience in successful eHealth use, workload balance for staff, and an overall perspective shift in the benefits to eHealth technology versus the risks.

Still in the shadows: a national study of acute mental health unit location across New Zealand hospitals

BackgroundThis study aimed to explore the location of acute mental health inpatient units in general hospitals by mapping their location relative to hospital facilities and community facilities and to compare their proximity to hospital facilities with that of general medical acute units.MethodsWe obtained Google maps and hospital site maps for all New Zealand public hospitals. Geographic data were analysed and mental health units’ locations in relation to hospital facilities and public amenities were mapped. Radar plots were constructed comparing acute medical and mental health units’ locations in relation to hospital facilities.ResultsTwenty-two mental health units were identified. They were located predominantly at the periphery of hospital campuses, but also at a distance from community facilities. Compared to acute medical units, mental health units were almost universally located further from shared hospital facilities – with distances approximately three times further to reach the main hospital entrance (2.7 times distance), the nearest public café (3.4 times), the emergency department (2.4 times), and medical imaging (3.3 times).ConclusionDespite the reforms of the 20th Century, mental health units still appear to occupy a liminal space; neither fully integrated into the hospital, nor part of the community. The findings warrant further investigation to understand the impact of these structural factors on parity of health care provision between mental and physical health care and the ability of mental health care services to support recovery.

A qualitative synthesis of patients' experiences of re-traumatization in acute mental health inpatient settings.

INTRODUCTION: Rates of re-traumatization among mentally ill-health patients have risen significantly over the past decade and clinical guidelines place mental health nurses at the heart of their care. To gather, analyse, and synthesize the evidence on people's experiences on re-traumatization in acute mental health inpatient settings. A systematic search for qualitative studies (CINAHL, MEDLINE, ASSIA, PsycINFO, and EMBASE) was conducted. Two authors independently assessed eligibility and appraised methodological quality using Joanna Briggs's quality appraisal tool and extracted data. The analysis followed the principles of interpretative synthesis. Fourteen papers were included for thematic synthesis. Three themes emerged: (1) Quality of staff interaction; (2) Specific interventions, (Sub-theme nature of symptoms); and (3) Nature of the environment. Our findings demonstrate that patients are experiencing re-traumatization in acute mental health inpatient settings and that there is little being done to prevent it from occurring. This study is the first to analyse the factors that contribute to re-traumatization and make recommendations to mental healthcare professionals to reduce the harmful practices in place in inpatient settings. It is suggested that training staff in trauma-informed care and allowing patients to be experts in their own care can reduce the rates of re-traumatization.

Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units.

The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units. VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory. The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement. Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

A Comparison of Shift Length and Nursing and Quality Outcomes in Acute Inpatient Mental Health Units.

This study compared outcomes between units that used either 8-hour or 12-hour shifts in acute inpatient mental health units. Most hospitals continue to use 12-hour shifts despite research suggesting safety concerns with longer shifts. There is a gap in the literature on effects of shift lengths on nursing and patient outcomes in acute mental health units. This study is a retrospective comparative analysis of cross-sectional data between 32 inpatient mental health units that used 8-hour versus 12-hour shifts. Independent samples t test was used to examine differences on several staffing, quality, and safety measures. A moderate effect size was found between the groups in quality and safety measures involving patient disruptive behaviors, with the 8-hour group having more desirable outcomes. Nurse leaders in acute mental health units should consider the impacts of shift length on quality and safety when determining staffing patterns. More research is needed to evaluate correlations or causality.

Gender and intersecting vulnerabilities on the mental health unit: Rethinking the dilemma.

BackgroundGender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them.MethodsThis paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design.ResultsKey themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit.ConclusionsWhile findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who “understand,” and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities.

Factors affecting knowledge of recovery-oriented practice amongst mental health nursing and medical staff working on acute mental health inpatient units.

Over recent decades, the shift to recovery-oriented practice has been central to mental health policy. Despite this emphasis, mental health services can struggle to meet this expectation. This study explores the knowledge and attitudes in relation to the recovery-oriented practice of clinical staff working at an Australian acute inpatient mental health unit. The Recovery Knowledge Inventory (RKI) is a widely used self-report tool that assesses mental health professionals' knowledge and attitudes towards recovery; higher scores indicate higher levels of recovery knowledge and attitudes. Seventy-four staff members (44 nursing staff and 30 medical staff) completed the RKI via an online survey. The study has been reported according to the STROBE checklist for cross-sectional studies. The relationships between the RKI scores and a range of variables were considered using inferential statistics, including multivariate regression. Medical staff had higher mean RKI scores than nursing staff, although this did not meet the predefined threshold for a clinically significant difference. More years of mental health experience were associated with increased mean RKI scores for medical staff. This Australian inpatient staff cohort demonstrated higher mean RKI scores than have been observed in recent international studies of mental health professions. However, the recovery knowledge and attitude levels were disappointingly similar to those shown in earlier Australian research completed over a decade ago. Efforts are needed to further enhance the recovery knowledge of clinicians working in mental health inpatient units.

Service User Involvement in Recovery-Oriented Care Planning: A Realist Synthesis

AimsService user involvement (SUI) in recovery-oriented care planning (ROCP) warrants more sophisticated theorisation and explanation to support practice improvement. This study investigated which changes to practice work best, in what circumstances, and to what extent, to embed an active role for service users’ involvement in ROCP during the acute inpatient mental health care pathway.MethodsA realist synthesis, combined with qualitative methods, was conducted to theoretically explore the causal mechanisms that underlie SUI in ROCP and how contextual factors influence the link between these causal mechanisms and outcomes. The study was conducted in three stages: theory-gleaning, theory-refinement and theory-consolidation. Initial programme theories were developed in the theory-gleaning stage. Theories were refined iteratively in the theory-refinement stage, using evidence from a realist review and interview data. With stakeholder involvement, refined programme theories were finely tuned using ‘if-then’ statements in the consolidation stage.ResultsFive programme theories relating to the acute care pathway were identified following the realist synthesis: 1)‘Provider-controlled care transition’ (admission to acute inpatient mental health units), referring to limitations to service users’ active involvement. The focus of care and access to acute inpatients units should be needs-led, rather than resource-led or demand-driven;2)‘Care plan as a recovery tool?’ – addressing infrastructural and organisational limitations to active SUI in care-plan formulation. The use of multidisciplinary meetings as a forum for care-plan formulation can create a cohesive approach and facilitate shared ownership;3)‘Ward rounds as a non-inclusive arena for shared decision making’, highlighting their unfulfilled potential for shared decision making about treatment. Professionals should focus on preparing service users for the ward-round process. Opportunities and access for service users to build therapeutic relationships with treating doctors are vital components;4)‘Peer support worker intervention' as a key factor in service users’ recovery’, concerning their positive impact. Their presence in ward rounds and care-planning meetings might create a more user-friendly atmosphere for service users; and5)‘Provider-controlled care transition’ (discharge from acute inpatient mental health units), increasing focus on preparing service users for transition into the community, and constraints on resources should not dictate or anticipate decisions on discharging service users.ConclusionThe study identified practices required to embed an active role for service users to be involved in ROCP, namely multi-contextual interventions at various levels (macro, meso and micro) of the mental health system. The study uncovered barriers that restrain SUI in ROCP, impacting desirable outcomes.

Places of safety? Fear and violence in acute mental health facilities: A large qualitative study of staff and service user perspectives.

To understand violence on acute mental health units according to staff and service user perspectives and experiences. The collateral damage of violence in acute inpatient mental health settings is wide-ranging, impacting on the health and wellbeing of staff and service users, and detrimental to public perceptions of people who are mentally unwell. Despite international research on the topic, few studies have examined psychiatric unit violence from both staff and service user perspectives. We conducted in-depth interviews with 85 people (42 staff, 43 service users) in four adult acute mental health inpatient units in New Zealand. We undertook a thematic analysis of perspectives on the contributing factors and consequences of violence on the unit. Both staff and service users indicated violence was a frequent problem in acute inpatient units. Four themes regarding the causes of violence emerged: individual service user factors, the built environment, organisational factors, and the overall social milieu of the unit. Staff often highlighted complexities of the system as causal factors. These included the difficulties of managing diverse service user illnesses within an inadequate and unsafe built environment whilst having to contend with staffing issues and idiosyncrasies relating to rule enforcement. In contrast, service users talked of their needs for care and autonomy not being met in an atmosphere of paternalism, boredom due to restrictions and lack of meaningful activities, enforced medication, and physical confinement as precipitants to violence. Two broader themes also emerged, both relating to empathy. Both staff and service users exhibited 'othering' (characterised by a profound lack of empathy) in relation to acutely unwell individuals. Explanations for violent behaviour on the unit differed between groups, with service users being more likely to attribute unwanted behaviour to contextual factors and staff more likely to 'blame' mental illness. The consequences of violence included stress, physical injury, and a culture of fear and stigma. Violence in acute inpatient mental health units in New Zealand is a significant, complex, and unresolved problem negatively impacting the therapeutic mission of these settings. Further in-depth qualitative investigations are urgently required into what is experienced as violence by service users, their view of how violence occurs, the role of fear and power relations, and the contributions of the built and organisational environment to all forms of violence to all unit users. A core function of the acute mental health unit is to offer a therapeutic environment for individuals at their most vulnerable. For this to happen, the unit must be a rewarding place to work, and a safe place to be.

Implementation and staff understanding of shared decision-making in the context of recovery-oriented care across US Veterans Health Administration (VHA) inpatient mental healthcare units: a mixed-methods evaluation

ObjectivesTo examine the understanding and practice of shared decision-making (SDM) within the context of recovery-oriented care across Veterans Health Administration (VHA) inpatient mental healthcare units.DesignVHA inpatient mental health units were...

The inside-out group: A mentalisation-based choose-your-own adventure

This article describes the evaluation of a novel, single-session group intervention which was offered on an acute inpatient mental health unit. The intervention was based on the principles of Mentalisation Based Therapy. We called this intervention the inside out group.In the group, attendees used their mentalising skills to discuss and decide on the course of action taken by characters in a fictional story. Hence we referred to the group as a ‘choose-your-own adventure’.Our evaluation showed that attendees were less committed to critical, self-focused explanations for others’ actions after the intervention than they had been prior to the intervention. Our findings therefore suggest that Mentalisation Based Therapy principles can be successfully adapted to produce effective, short term talking treatments on acute inpatient mental health wards.

Mental health nurses perceptions of missed nursing care in acute inpatient units: A multi-method approach.

Nurses have key roles in caring for hospitalized patients. Missed nursing care can lead to adverse outcomes, from minor discomfort to patient death. Mental health nurses have a significant role in advancing knowledge and practice due to missed, delayed, or unfinished nursing care. They are identifying, escalating, and managing warning signs of mental and physical health deterioration where the risk to patients is high in terms of compromised care quality and neglect and the evidence is scant. This study aimed to examine mental health nurses’ perceptions of missed nursing care in acute mental health inpatient units in an Australian regional health service. A cross‐sectional survey was undertaken using a modified Kalisch Phelan MISSCARE questionnaire and a qualitative content analysis was undertaken for narrative responses. Of 70 participants, the majority were aged 30–44 years, with >5 years of experience. The results indicated that care planning, safety audits, communication, and assessment of oral intake were perceived as care most frequently missed. Factors contributing to missed care need urgent exploration to ensure timely reduction of patient risk and enhancements to safe quality care.

When Lay Knowledge is a Symptom: The Uses of Insight in Psychiatric Interventions

In psychiatry, the concept of “insight” commonly refers to a patient’s judgment that they have a mental illness and need clinical treatment. However, this concept has been criticized because it imposes psychiatric knowledge on the subjective experiences of mental illness and possible interventions. A significant body of literature is critical of mental health interventions; however, insight remains under-explored in this realm. This paper adds to critical analyses of insight by exploring how it is defined and deployed by mental health professionals in an acute inpatient mental health unit in a Canadian general hospital and what disciplinary and epistemic effects it has on patients. To this end, I draw on Foucault’s theories of psychiatric power and Fricker’s concept of epistemic injustice to analyze results from an ethnographic study conducted in an inpatient mental health unit. The results show how patients’ resistance to medical compliance is framed by staff as a lack of insight, which reinforces the psychiatric model of mental illness.

Developing Best Practice Guidance for Discharge Planning Using the RAND/UCLA Appropriateness Method.

Background: Discharge from acute mental health inpatient units is often a vulnerable period for patients. Multiple professionals and agencies are involved and processes and procedures are not standardized, often resulting in communication delays and co-ordination failures. Early and appropriate discharge planning and standardization of procedures could make inpatient care safer.Aim: To inform the development of a multi-component best practice guidance for discharge planning (including the 6 component SAFER patient flow bundle) to support safer patient transition from mental health hospitals to the community.Methods: Using the RAND/UCLA Appropriateness method, a panel of 10 professional stakeholders (psychiatrists, psychiatric nurses, clinical psychologists, pharmacists, academics, and policy makers) rated evidence-based statements. Six hundred and sixty-eight statements corresponding to 10 potential components of discharge planning best practice were rated on a 9-point integer scale for clarity, appropriateness and feasibility (median ≥ 7–9) using an online questionnaire then remote online face-to-face meetings.Results: Five of the six “SAFER” patient flow bundle components were appropriate and feasible for inpatient mental health. One component, “Early Flow,” was rated inappropriate as mental health settings require more flexibility. Overall, 285 statements were rated as appropriate and feasible. Forty-four statements were considered appropriate but not feasible to implement.Discussion: This consensus study has identified components of a best practice guidance/intervention for discharge planning for UK mental health settings. Although some components describe processes that already happen in everyday clinical interactions (i.e., review by a senior clinician), standardizing such processes could have important safety benefits alongside a tailored and timely approach to post-discharge care.

Factors associated with Health of the Nation Outcomes Scales (HoNOS) in an acute young adult psychiatric unit.

The transition from adolescence to adulthood is a highly vulnerable period for mental health concerns and is a key life-stage, fundamental to later health and quality of life. Scant research has investigated the health outcomes of young adults admitted to a specialised acute psychiatric unit for this cohort. Understanding health and functional outcomes for young adults admitted to a specialised acute mental health inpatient unit is beneficial in identifying treatment effectiveness and vulnerable groups. The study examines the relationship between demographic and clinical factors with admission, discharge and change in Health of the Nation Outcomes Scale (HoNOS) scores in patients admitted to an acute young adult psychiatric unit. The HoNOS was completed at admission and discharge for patients admitted to an acute young adult psychiatric unit in Australia. Descriptive statistics, paired t-tests, generalised estimating equations, independent samples t-tests and correlations were completed. Patients (N = 130) were aged between 18 and 25 years old (M = 21.26 years old, SD = 2.31). Patients were diagnosed with mood disorders (21.54%), substance abuse disorders (20.00%), personality disorders (19.23%), and psychotic disorders (17.69%). HoNOS scores across all subscales improved from admission to discharge, when controlling for confounding variables. Admission, discharge and change in HoNOS scores were associated with gender, country of birth, number of admissions, mental health act, diagnosis and socioeconomic status. This study is the first to explore HoNOS scores, demographic factors and clinical variables in young adults admitted to a specialised psychiatric inpatient unit for this age group. While further research is required, the findings identifies vulnerable subgroups (e.g., individuals with personality disorders, individuals with substance use, those admitted involuntarily, those readmitted) that may benefit from increased tailored support to foster more optimal health outcomes.

Inpatient Mental Healthcare before and during the COVID-19 Pandemic.

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.