Acute Inpatient Mental Health Care Research Articles

Preliminary evaluation of a multidisciplinary pathway for people who self-harm in acute inpatient mental health care

Background/aims Inpatient mental health settings are required to provide biopsychosocial interventions to support service users who self-harm. This is important as self-harm has been associated with increased admissions and risk of suicide. A multidisciplinary self-harm pathway was developed in an acute inpatient mental health ward for adult women to help staff support patients who self-harm. The aim of this project was to evaluate the pathway in relation to service user distress, confidence in managing mental health, therapeutic alliances with the ward team and self-harm incidents on the ward. Methods Data were collected from the record-keeping systems and from questionnaires completed before and after the pathway was introduced. Results The pathway was well received by service users and contributed to improvements in distress, confidence and to more effective management of self-harm. Conclusions The self-harm pathway was found to be a useful framework within which to structure psychosocial interventions for self-harm and least restrictive practice.

The Collaborative Assessment and Management of Suicidality compared to enhanced treatment as usual for inpatients who are suicidal: A randomized controlled trial.

Although use of inpatient crisis hospital intervention for suicide risk is common, the evidence for inpatient treatments that reduce suicidal thoughts and behaviors is remarkably limited. To address this need, this novel feasibility pilot randomized controlled trial compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced treatment as usual (E-TAU) within a standard acute inpatient mental health care setting. We hypothesized that CAMS would be more effective than E-TAU in reducing suicidal thoughts and behaviors. As secondary outcomes we also investigated depressive symptoms, general symptom burden, reasons for living, and quality of the therapeutic relationship. All patients were admitted due to acute suicidal thoughts or behaviors. They were randomly assigned to CAMS (n = 43) or E-TAU (n = 45) and assessed at four time points (admission, discharge, 1 month and 5 months after discharge). We used mixed-effects models, effect sizes, and reliable change analyses to compare improvements across and between treatment groups over time. Intent-to-treat analyses of 88 participants [mean age 32.1, SD = 13.5; n = 47 (53%) females] showed that both groups improved over time across all outcome measures with no significant between-group differences in terms of change in suicidal ideation, depression, reasons for living, and distress. However, CAMS showed larger effect sizes across all measures; for treatment completers CAMS patients showed significant improvement in suicidal ideation (p = 0.01) in comparison to control patients. CAMS patients rated the therapeutic relationship significantly better (p = 0.02) than E-TAU patients and were less likely to attempt suicide within 4 weeks after discharge (p = 0.05). CAMS and E-TAU were both effective in reducing suicidal thoughts and symptom distress. Within this feasibility RCT the pattern of results was generally supportive of CAMS suggesting that inpatient use of CAMS is both feasible and promising. However, our preliminary results need further replication within well-powered multi-site randomized controlled trials. DRKS-ID/ICTRP-ID: DRKS00013727. The trial was retrospectively registered in the German Clinical Trials Register, registration code/ DRKS-ID: DRKS00013727 on 12.01.2018 and also in the International Clinical Trials Registry Platform of the World Health Organization (identical registration code).

Crisis-focused Cognitive Behavioural Therapy for psychosis (CBTp) in acute mental health inpatient settings (the CRISIS study): protocol for a pilot randomised controlled trial

BackgroundCognitive Behavioural Therapy for psychosis (CBTp) has an established evidence base and is recommended by clinical guidelines to be offered during the acute phases of psychosis. However, few research studies have examined the efficacy of CBTp interventions specifically adapted for the acute mental health inpatient context with most research trials being conducted with white European community populations.AimsThe aim of this study is to conduct a pilot randomised controlled trial (RCT), which incorporates the examination of feasibility markers, of a crisis-focused CBTp intervention adapted for an ethnically diverse acute mental health inpatient population, in preparation for a large-scale randomised controlled trial. The study will examine the feasibility of undertaking the trial, the acceptability and safety of the intervention and the suitability of chosen outcome measures. This will inform the planning of a future, fully powered RCT.MethodsA single-site, parallel-group, pilot RCT will be conducted examining the intervention. Drawing on principles of coproduction, the intervention has been adapted in partnership with key stakeholders: service users with lived experience of psychosis and of inpatient care (including those from ethnic minority backgrounds), carers, multi-disciplinary inpatient clinicians and researchers. Sixty participants with experience of psychosis and in current receipt of acute mental health inpatient care will be recruited. Participants will be randomly allocated to either the crisis-focused CBTp intervention or treatment as usual (TAU).DiscussionFindings of this pilot RCT will indicate whether a larger multi-site RCT is needed to investigate the efficacy of the intervention. If the initial results demonstrate that this trial is feasible and the intervention is acceptable, it will provide evidence that a full-scale effectiveness trial may be warranted.Trial registrationThis trial has been prospectively registered on the ISRCTN registry (ISRCTN59055607) on the 18th of February 2021.

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.

Activities and technologies: developing safer acute inpatient mental health care.

Activities and technologies: developing safer acute inpatient mental health care.

Recovery-oriented acute inpatient mental health care: Operationalization and measurement.

The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Relationship between nurses' use of verbal de‐escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.

Exploring the experience of acute inpatient mental health care from the perspective of family and carers of people experiencing psychosis: A qualitative thematic analysis study conducted during the COVID‐19 pandemic

Family and carers play an important role in supporting service users who are in receipt of acute mental health inpatient care, but they can also be significantly emotionally and physically impacted. The aim of this study was to examine their needs and priorities during this time. Fourteen family and carers of inpatients experiencing psychosis completed semi‐structured interviews examining their experiences of inpatient care during the COVID‐19 pandemic. Thematic analysis was used to analyse data. Four key themes were identified: ‘A turbulent journey to hospital admission’, ‘I need information and support’, ‘Maintaining my relationship with my loved one’ and ‘Inpatient care is a mixed bag’. Each theme comprised four or five subthemes. The findings demonstrated that family and carers feel excluded from inpatient care and struggled to maintain contact with their loved ones, which was exacerbated by COVID‐19 related restrictions. Communication and being regularly informed about their loved one’s care, as well as visiting loved ones, was particularly problematic. Inpatient care needs to be more inclusive of family and carers and ensure they are kept in mind at every stage of the admission.

The subjective experience of recovery from psychosis in an acute mental health inpatient setting

ABSTRACT Background: Experiences of recovery from psychosis have been well explored but not with service users in the acute stages of psychosis. This study aimed to explore the subjective experiences of recovery from psychosis from the perspective of service users receiving acute mental health inpatient care. Methods: Ten participants undertook a semi-structured interview examining their experiences of recovery from psychosis during acute mental health inpatient care. Data were analysed using Interpretative Phenomenological Analysis (IPA). Results: Five superordinate themes emerged: “My future is just being ripped out in front of me”: Living with psychosis is a struggle; “Would you want to be in here?”: Traumatic experience of being in hospital; “I know roughly why I got ill anyway and what caused this”: A journey towards reaching an understanding; Recovery/Rehabilitation/Recuperation: A process of evolution; and “You need all the help you can get”: Facilitators of Recovery. Conclusions: This study highlighted that mental health inpatient settings are not settings where everyone can be in recovery or approaching recovery. For some participants, recovery appeared to be an empty signifier, and is a word used by services but does not necessarily correspond with their experiences of mental health inpatient settings.

Experiences of acute mental health inpatient care in the UK: from admission to readmission

ABSTRACT Background Individuals experiencing psychosis are often admitted to acute mental health wards. There is increasing pressure to reduce readmission rates, by enhancing the effectiveness of care. Methods Eight service users with experiences of psychosis were interviewed about the support provided by mental services before, during and after acute mental health inpatients admissions in the UK. Results All participants had at least one other admission to an acute mental health ward in the preceding six months. Interviews were analysed using Interpretative Phenomenological Analysis. Three themes were identified: 1) Quality of therapeutic relationships, 2) Adjusting to sudden shifts in care, 3) Struggling without the ward environment. Although participants acknowledged positive care experiences within their narratives, significant challenges were evident in the abilities of services to effectively meet service users’ needs across the care pathway. Discussion Findings highlight the importance of consistent support centred on service users’ needs at all stages of care. Service users need support to build autonomy and coping skills to sustain meaningful recovery within the community and reduce the likelihood of readmission.

Small Area Analysis of Veterans Affairs Mental Health Services Data.

To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

Supplemental Material for Recovery-Oriented Acute Inpatient Mental Health Care: Operationalization and Measurement

Supplemental Material for Recovery-Oriented Acute Inpatient Mental Health Care: Operationalization and Measurement

Self-determination theory in acute child and adolescent mental health inpatient care. A qualitative exploratory study.

There is a dearth of research to guide acute adolescent mental health inpatient care. Self-determination Theory provides evidence that meeting needs for relatedness, autonomy and competence is likely to increase wellbeing and intrinsic motivation. These needs may be able to be met in the inpatient environment. This qualitative study aimed to explore young people's experience of acute mental health inpatient care with particular attention to meeting of these three needs. Fifteen young people were interviewed. The importance of relatedness with staff, other young people and families was identified. Relatedness with staff and peers were valued parts of admission. Some young people describe enhanced relatedness with family. They described loss of autonomy as a negative experience but appreciated opportunities to be involved in choices around their care and having more freedom. Coming into hospital was associated with loss of competence but they described building competence during the admission. Engaging in activities was experienced positively and appeared to enhance meeting of all three needs. Meeting of the three needs was associated with an experience of increased safety. Engaging young people in activities with a focus on relatedness, autonomy and competence may have specific therapeutic potential. Autonomy, experience of competence and connection with staff may enhance safety more effectively than physical containment. Peer contact may have untapped therapeutic value we understand little of. This study supports the value of Self-determination Theory as a guide day to day inpatient care to meet the needs of adolescents for relatedness, autonomy and competence.

Collaborative Assessment and Management of Suicidality (CAMS) compared to enhanced treatment as usual (E-TAU) for suicidal patients in an inpatient setting: study protocol for a randomized controlled trial

BackgroundThe Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that has been shown to reduce suicidal ideation and overall symptom distress. CAMS has not been previously evaluated in a standard acute inpatient mental health care setting with only short treatment times for suicidal patients. In this randomized controlled trial (RCT) we are investigating whether CAMS is more effective than Enhanced-Treatment as Usual (E-TAU) in reducing suicidal thoughts as primary outcome variable. We are also investigating depressive symptoms, general symptom relief, and the quality of the therapeutic alliance as secondary outcomes.Methods/DesignThis RCT is designed as a single-center, two-armed, parallel group observer-blinded clinical effectiveness investigation. We are recruiting and randomizing 60 participants with different diagnoses, who are admitted as inpatients because of acute suicidal thoughts or behaviors into the Clinic for Psychiatry and Psychotherapy, Ev. Hospital Bethel in Bielefeld, Germany. The duration of treatment will vary depending on patients’ needs and clinical assessments ranging between 10 and 40 days. Patients are assessed four times, at admission, discharge, 1 month, and 5 months post-discharge. The primary outcome measure is the Beck Scale for Suicide Ideation. Other outcome measures are administered as assessment timepoints including severity of psychiatric symptoms, depression, reasons for living, and therapeutic relationship.DiscussionThis effectiveness study is being conducted on an acute ward in a psychiatric clinic where patients have multiple problems and diagnoses. Treatment is somewhat limited, and therapists have a large caseloads. The results of this study can thus be generalizable to a typical inpatient psychiatric hospital settings.Trial registrationThis clinical trial has been retrospectively registered with the German Clinical Trials Register; registration code/ DRKS-ID: DRKS00013727 (on January 12, 2018). In addition, the study was also registered with the International Clinical Trials Registry Platform of the World Health Organization (identical registration code). Registry Name: „Evaluation von CAMS versus TAU bei suizidalen Patienten – Ein stationärer RCT“.

A critical narrative analysis of shared decision-making in acute inpatient mental health care

ABSTRACTShared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients’ care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

The experiences of mental health professionals and patients in the use of pro re nata medication in acute adult mental health care settings: a systematic review protocol of qualitative evidence

A previous version of this article has been retracted. See: Morkunas B, Porritt K, Stephenson M. RETRACTED: The experiences of mental health professionals' and patients' use of pro re nata (PRN) medication in acute adult mental health care settings: a systematic review protocol of qualitative evidence. JBI Database System Rev Implement Rep 2014; 12(7):164-172. doi:10.11124/jbisrir-2014-1669 REVIEW QUESTION / OBJECTIVE The objective of this review is to synthesize the best available qualitative evidence on the experiences of mental health professionals and patients with the use of pro re nata medication in acute mental health care settings. More specifically, the review question is: what do mental health professionals experience when they administer or prescribe PRN medications and what do patients who receive these pro re nata medications experience? INCLUSION CRITERIA Types of participants This review will consider studies that include mental health professionals working in an acute adult mental health care setting who prescribe and administer pro re nata medications as well as adults admitted to an acute adult mental health care setting. Phenomena of interest This review will consider studies that investigate mental health professionals’ and patients’ experiences in the use of PRN medication. Context The context for the review is acute adult inpatient mental health care settings. These settings are usually within public health systems or private mental health settings. Types of studies This review will consider English language studies only that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

Strengthening acute inpatient mental health care for Indigenous clients

Indigenous people are over-represented in inpatient mental health care in Australia. Evidence suggests client-orientated care planning increase client engagement, reduce substance dependence and improve self-management among Indigenous people. The successful uptake and implementation of interventions, however, which promote access and cultural security in primary care practice, remains challenging. The Aboriginal and Islander Mental Health initiative introduced a multi-faceted approach to client-oriented care planning, as part of routine care to the Royal Darwin Hospital inpatient psychiatric unit, to determine whether there was change in the quality of care to Indigenous clients over time.The study used a mixed methods design. It was underpinned by an action-oriented research approach and incorporated stakeholder engagement, interactive training in strengths based recovery approach and psycho-education and a quantitative audit of inpatient files. The results suggest some improvements in quality of care for clients in the inpatient unit with increased attention to social and family history, involvement of translators, and allocation of case managers. Cross-cultural training and tools promoted change in some aspects of clinical practice. Some changes, however, were often not sustained and it did not necessarily promote engagement of AMHWs in routine care. Greater emphases on follow up training and provision of clinician feedback, in conjunction with high-level system change and commitment to introduction of culturally adapted recovery principles, is required for more sustained changes to clinician care and implementation success.

Strengthening acute inpatient mental health care for Indigenous clients

Indigenous people are over-represented in inpatient mental health care in Australia. Evidence suggests client-orientated care planning increase client engagement, reduce substance dependence and improve self-management among Indigenous people. The successful uptake and implementation of interventions, however, which promote access and cultural security in primary care practice, remains challenging. The Aboriginal and Islander Mental Health initiative introduced a multi-faceted approach to client-oriented care planning, as part of routine care to the Royal Darwin Hospital inpatient psychiatric unit, to determine whether there was change in the quality of care to Indigenous clients over time.The study used a mixed methods design. It was underpinned by an action-oriented research approach and incorporated stakeholder engagement, interactive training in strengths based recovery approach and psycho-education and a quantitative audit of inpatient files. The results suggest some improvements in quality of care for clients in the inpatient unit with increased attention to social and family history, involvement of translators, and allocation of case managers. Cross-cultural training and tools promoted change in some aspects of clinical practice. Some changes, however, were often not sustained and it did not necessarily promote engagement of AMHWs in routine care. Greater emphases on follow up training and provision of clinician feedback, in conjunction with high-level system change and commitment to introduction of culturally adapted recovery principles, is required for more sustained changes to clinician care and implementation success.

Creating and establishing a recovery-oriented clinical psychology provision across an acute care mental health pathway. Ethical obligation and clinical reality

Purpose– The purpose of this paper is to summarise the development of a recovery-oriented and socially inclusive acute care clinical psychology service in one of the NHS Trusts based in East Anglia. It demonstrates the service's compliance with relevant national policies and guidelines, and addresses some of the criticisms directed at acute mental health care in recent years. Both achievements and difficulties are reflected on.Design/methodology/approach– The paper employs an organisational development case example related to applicable clinical practice model, based on national guidelines and policies, in order to demonstrate that it is possible to develop and implement a recovery-oriented clinical psychology practice in acute inpatient mental health care. This is based on the authors, experiences as a public sector clinical psychologists specialising in complex, severe, and enduring mental health needs.Findings– Clinical psychologists may effectively contribute to the development of psychosocially informed and recovery-based multidisciplinary attitudes towards emotional difficulties of individuals admitted to psychiatric wards.Research limitations/implications– Future service development project of similar nature ought to implement standardised measures (e.g. ward atmosphere scales) to increase validity of findings.Practical implications– Despite limited, and continuously decreasing, resources in the NHS it appears possible to develop and establish a successful and objectively replicable provision of recovery-based psychological services across an entire acute care mental health pathway.Social implications– Recovery-enhancing clinical psychology interventions should not be limited to those receiving care from community-based services only. Building psychologically informed understanding of mental health needs should be employed on inpatient wards too, in order to counterbalance the dominating biomedical models of mental illness.Originality\value– Dissemination of examples of effective psychosocial practice in acute mental health settings appears largely underrepresented.

Ready, Aim Fire! Mental Health Nurses Under Siege in Acute Inpatient Facilities

It has been clearly acknowledged and well-documented that physical, emotional, and psychological violence is a central theme and an expected workplace hazard for registered nurses working in acute inpatient mental health care facilities. Limited research, however, has focused on how registered nurses have been able to cope within this environment and adequately protect themselves from harm. A critical feminist research project recently explored the lived experience of 13 Australian, female, registered nurses working in a busy metropolitan acute inpatient mental health care facility. “Fear” was exposed as the precursor to violence and aggression, both “fear as experienced by the nurse” and “fear as experienced by the patient.” The participants reported experiencing a sense of fear when they could not accurately or confidently anticipate a patient response or reaction. They identified this relationship with fear as being “part of the job” and part of the unpredictable nature of caring for people experiencing complex distortions in thinking and behavior. The participants believed, however, that additional workplace pressures complicated the therapeutic environment, resulting in a distraction from patient care and observation. This distraction could lead to nurse-patient miscommunication and the potential for violence. This article discusses a major theme to emerge from this study, “Better the devil you know!” The theme highlights how mental health nurses cope with violence and why they choose to continue working in this complex care environment.