Acute Inpatient Mental Health Settings Research Articles

Recovery priorities of people with psychosis in acute mental health in-patient settings: a Q-methodology study.

Personal recovery from psychosis has been explored extensively in community samples but there has been little exploration with people currently receiving care from an acute mental health in-patient setting. The aim of this study was to explore the personal recovery priorities of people experiencing psychosis who are currently receiving care from an acute mental health in-patient ward. A Q-methodology mixed-methods approach was adopted. Thirty-eight participants were recruited from an outer London acute mental health hospital. They were required to sort 54 statements regarding personal recovery from most important to least important to reflect their recovery priorities. Thirty-six were included in the final analysis. Analysis revealed four distinct viewpoints relating to factors that promote recovery in the acute mental health in-patient setting. These were: stability, independence and 'keeping a roof over your head'; hope, optimism and enhancing well-being; personal change, self-management and social support; and symptom reduction through mental health support. Acute mental health in-patient wards need to ensure that they are considering the personal recovery needs of in-patients. Symptom reduction was valued by some, but broad psychosocial factors were also of priority.

Positive risk management: Staff perspectives in acute mental health inpatient settings.

To explore inpatient staff's understanding and implementation of positive risk management. Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice. Qualitative reflexive thematic analysis study. The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N=16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis. The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice. Understanding and implementation of positive risk management was dependant on multiple factors, including staffs' beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management. Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings.

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

Feasibility and Patient Experiences of Method of Levels Therapy in an Acute Mental Health Inpatient Setting

This study sought to investigate the feasibility and acceptability of a flexible psychotherapeutic approach – the Method of Levels (MOL) – in an acute mental health inpatient setting. A multi methods approach was used. The feasibility of implementation was investigated by examining the referral rate and the attendance patterns of participants. The acceptability of MOL was explored using a thematic analysis of participant interviews and by recording attendance patterns of participants. Inpatient staff consistently referred patients and the majority of eligible people accepted invitations for therapy. Thematic analysis of peoples’ experiences of the therapy generated themes that described participants’ experiences of MOL in contrast to routine NHS care, having spent meaningful time with the therapist, and having gained something from the session. The referral rate and uptake of MOL therapy indicates that the resource was appropriate for the setting and acceptable to most participants. Qualitative analyses indicated that participants were comfortable with the therapists’ approach, felt understood, and there was a meaningful quality to their interaction. Participants also valued the opportunity to reflect and generate new perspectives of their difficulties. Further research is required to determine the effectiveness of the approach and its translational value beyond this pilot investigation.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings.

To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer. Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting. An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward-based nurses (n=64) and nurse unit managers (n=8). This paper follows the COREQ guidelines for reporting qualitative health research. Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment). The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer. Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.

The Therapeutic Engagement Questionnaire (TEQ): a service user-focused mental health nursing outcome metric

BackgroundTherapeutic engagement (TE) has been described as the crux of mental health nursing but despite its perceived importance, to date, there is no measurement tool that captures it. As a result, there is no way of determining the contribution of mental health nursing interaction to service user recovery, in acute inpatient mental health settings or the wider care quality agenda.MethodsTo develop and validate a TE measurement tool in partnership with Service Users (SUs) and Registered Mental Health Nurses (RMHNs). The TEQ was developed in 3 stages: 1) item generation (and pre-testing), 2) item reduction using Principal Component Analysis (PCA), and 3) validation across Mental Health Trusts in England.ResultsThe final questionnaire has two versions, (SU and RMHN version), each scored within two contexts (1–1 SU-RMHN interactions and overall environment and atmosphere of the ward) and includes 20 items with two sub-scales (care interactions and care delivery). Psychometric evaluation of the TEQ shows high inter-scale correlations (0.66–0.95 SU; 0.57–0.90 RMHN), sound sub-scale internal consistency (> 0.95), concurrent validity (> 0.60) and adequate score variability for both versions of the TEQ. In summary, the TEQ behaves well as a measurement tool.ConclusionsThe TEQ can determine the collaborative and empathic nature of RMHN-SU interactions, capture if SUs are treated with dignity and respect and recognise that the principles of the recovery approach are being respected. The TEQ can also provide robust monitoring of nursing activity, offer opportunity for transparency of activity, feed into healthcare organizations’ key performance indicators and provide reassurance about the nature and quality of nurses’ work.

‘A different kind of space’: Mixed methods evaluation of facilitated reflective practice groups for nurses in an acute inpatient mental health unit

Despite recognising the value of reflective practice, there are challenges in implementation of clinical supervision for nurses. This study reports on the implementation of Reflective Practice Groups for nurses in an acute inpatient mental health setting as a means of introducing nurses to reflective practice. A mixed-methods approach explored participant and facilitator experiences through session evaluation questionnaires, facilitator field notes, and interviews with participants. Findings demonstrate challenges in implementing Reflective Practice Groups however the perceived benefits suggest promise in using Reflective Practice Groups to engage busy nurses in facilitated reflection with an aim to transition to reflective clinical supervision.

A Photovoice study of user experiences of an occupational therapy department within an acute inpatient mental health setting

IntroductionPeople admitted to acute mental health wards benefit from access to activities, but occupational therapy departments that are separate to wards have not been investigated from the user ...

Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: a cross national comparative mixed methods study

BackgroundInvolving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care.MethodsA cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users (n = 301) and staff (n = 290) and embedded case studies involving interviews with staff, service users and carers (n = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method.ResultsFor service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.ConclusionsThere is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning.This paper arises from a larger study published by National Institute for Health Research (Simpson A, et al, Health Serv Deliv Res 5(26), 2017).

Evaluating the introduction of assistant psychologists to an acute mental health inpatient setting

Evaluating the introduction of assistant psychologists to an acute mental health inpatient setting

"Coaching and Peer-Assisted Learning" (C-PAL) - The mental health nursing student experience: A qualitative evaluation.

Introduction This paper presents findings from a study that evaluated mental health nursing students' experience of a team mentoring model called Coaching and peer-assisted learning (C-PAL). At present there are no published research studies into the effectiveness of team mentorship utilized by nursing students within in-patient mental health settings. Aim The study utilized an interpretivist methodology where the focus was on individuals in their social world. Method Two focus groups were held with fifteen students who had experienced C-PAL in four in-patient wards. Findings Students' overall experience of piloting C-PAL was positive. Learning opportunities (Theme 3) appeared to be dependent on the quality of peer support (Theme 5) which in turn, enhanced the learner experience and increased the level of student confidence (Theme 6). Less positive experiences included inadequate preparation (Theme 1), poor understanding of the model and competition for learning experiences. Implications for practice We tentatively suggest that team mentorship models such as C-PAL may be suitable for acute in-patient mental health settings. The success of C-PAL depends upon the preparation of nursing staff, mentors (Theme 4), coaches and students in relation to role expectations, shift rostering (Theme 2) and the implementation of "huddling" to promote opportunistic learning.

'Hiding in plain sight': Exploring the complexity of sexual safety within an acute mental health setting.

It is increasingly being recognized that individuals who access acute mental health services are at risk of sexual assault. Assaults may be perpetrated by other patients but also by staff working in mental health environments, although this latter group remain largely under-researched. Following a reported professional sexual assault and review of an acute inpatient mental health setting in the UK, the overall aim of this study was to explore the mechanisms and structures that were put into place following the investigation and in so doing examine the wider questions of sexual safety in acute mental health settings. A qualitative approach was utilized and involved interviews with clinical staff (n=8). Thematic analysis was used to analyse the data resulting in four main themes: 'Feeling betrayed': The relational context of the ward environment'; 'Doing what we were meant to be doing': Quality of leadership'; 'Covering yourself': Safeguarding practice; 'The subtleties of abuse': Complexities of safeguarding '. The findings of the study highlight the need for clear organizational structures of support, a clearer understanding of 'sexual safety', and education and training which explicitly addresses recognition and complexity of sexual violence.

Recovery-focussed care: How it can be utilized to reduce aggression in the acute mental health setting.

Consumer aggression is common in the acute mental health inpatient setting. Mental health nurses can utilize a range of interventions to prevent aggression or reduce its impact on the person and others who have witnessed the event. Incorporating recovery-focussed care into clinical practice is one intervention, as it fosters collaborative partnerships with consumers. It promotes their engagement in decisions about their care and encourages self-management of their presenting behaviours. It also allows the consumer to engage in their personal recovery as their mental health improve. Yet there is a paucity of literature on how nurses can utilize recovery-focussed care with consumers who are hospitalized and in the acute phase of their illness. In the present study, we report the findings of a scoping review of the literature to identify how recovery-focussed care can be utilized by nurses to reduce the risk of consumer aggression. Thirty-five papers met the inclusion criteria for review. Four components were identified as central to the use of recovery-focussed care with consumers at risk of becoming aggressive: (i) seeing the person and not just their presenting behaviour; (ii) interact, don't react; (iii) coproduction to achieve identified goals; and (iv) equipping the consumer as an active manager of their recovery. The components equip nurses with strategies to decrease the risk of aggression, while encouraging consumers to self-manage their challenging behaviours and embark on their personal recovery journey. Further research is required to evaluate the translation of these components clinically in the acute care setting.

Post-fall reporting in aged acute inpatient mental health units: an 18-month observational cohort study.

Despite the high risk of falling for people with severe mental illness, there is limited falls research in mental health settings. Therefore, the objective of this observational cohort study was to conduct a focused post-fall review of fall episodes within aged acute inpatient mental health units at one of Australia's largest publicly funded mental health organizations. A post-fall reporting tool was developed to collect intrinsic and extrinsic fall risk factors among three aged acute mental health inpatient units over an 18-month period. Descriptive and inferential analyses were conducted to describe fall risk factors and predictors of fall risk. There were a total of 115 falls, of which the tool was used for 93 (80.9%) episodes. Falls occurred most often in consumer's bedroom/bathroom and were unwitnessed. Intrinsic risk factors were most often attributed to postural drop and losing balance during walking. However, that was in contrast to consumer's who self-reported feeling dizzy as the reason of the fall. Based on the cohort, future falls could be reduced by targeting those aged above 82 years, or with a diagnosis of dementia. Recurrent falls during admission could be reduced by targeting those with psychotic illness and males with a diagnosis of dementia. A clearer dialogue among consumers and clinical staff reporting about fall episodes may support future remedial interventions and inform programs to reduce fall risk and assist the challenge of describing unwitnessed falls in aged acute inpatient mental health settings.

Cross-national mixed-methods comparative case study of recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings (COCAPP-A)

BackgroundMental health service users in acute inpatient wards, whether informal or detained, should be involved in planning and reviewing their care. Care planning processes should be personalised and focused on recovery, with goals that are specific to the individual and designed to maximise their achievements and social integration.Objective(s)We aimed to ascertain the views and experiences of service users, carers and staff to enable us to identify factors that facilitated or acted as barriers to collaborative, recovery-focused care and to make suggestions for future research.DesignA cross-national comparative mixed-methods study involving 19 mental health wards in six NHS sites in England and Wales included a metanarrative synthesis of policies and literature; a survey of service users (n = 301) and staff (n = 290); embedded case studies involving interviews with staff, service users and carers (n = 76); and a review of care plans (n = 51) and meetings (n = 12).ResultsNo global differences were found across the sites in the scores of the four questionnaires completed by service users. For staff, there was significant difference between sites in mean scores on recovery-orientation and therapeutic relationships. For service users, when recovery-orientated focus was high, the quality of care was viewed highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Across all sites, staff’s scores were significantly higher than service users’ scores on the scale to assess therapeutic relationships. Staff across the sites spoke of the importance of collaborative care planning. However, the staff, service user and carer interviews revealed gaps between shared aspirations and realities. Staff accounts of routine collaboration contrasted with service user accounts and care plan reviews. Definitions and understandings of recovery varied, as did views of the role of hospital care in promoting recovery. ‘Personalisation’ was not a familiar term, although there was recognition that care was often provided in an individualised way. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.ConclusionsOur results suggest that there is positive practice taking place within acute inpatient wards, with evidence of widespread commitment to safe, respectful, compassionate care. Although ideas of recovery were evident, there was some uncertainty about and discrepancy in the relevance of recovery ideals to inpatient care and the ability of people in acute distress to engage in recovery-focused approaches. Despite the fact that staff spoke of efforts to involve them, the majority of service users and carers did not feel that they had been genuinely involved, although they were aware of efforts to keep them safe.Future workFuture research should investigate approaches that increase contact time with service users and promote personalised, recovery-focused working; introduce shared decision-making in risk assessment and management; and improve service user experiences of care planning and review and the use of recovery-focused tools during inpatient care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature.

Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person-centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.

Shared decision making PLUS \u2013 a cluster-randomized trial with inpatients suffering from schizophrenia (SDM-PLUS)

BackgroundShared decision making (SDM) is a model of how doctors and patients interact with each other. It aims at changing the traditional power asymmetry between doctors and patients by strengthening the exchange of information and the decisional position of the patient. Although SDM is generally welcomed by mental health patients as well as by mental health professionals its implementation in routine care, especially in the more acute settings, is still lacking. SDM-PLUS has been developed as an approach that addresses both patients and mental health professionals and aims at implementing SDM even for the very acutely ill patients.MethodsThe SDM-PLUS study will be performed as a matched-pair cluster-randomized trial in acute psychiatric wards. On wards allocated to the intervention group personnel will receive communication training (addressing how to implement SDM for various scenarios) and patients will receive a group intervention addressing patient skills for SDM. Wards allocated to the control condition will continue treatment as usual. A total sample size of 276 patients suffering from schizophrenia or schizoaffective disorder on 12 wards is planned.The main outcome parameter will be patients’ perceived involvement in decision making during the inpatient stay measured with the SDM-Q-9 questionnaire. Secondary objectives include the therapeutic relationship and long term outcomes such as medication adherence and rehospitalization rates. In addition, process measures and qualitative data will be obtained to allow for the analysis of potential barriers and facilitators of SDM-PLUS.The primary analysis will be a comparison of SDM-Q-9 sum scores 3 weeks after study inclusion (or discharge, if earlier) between the intervention and control groups. To assess the effect of the intervention on this continuous primary outcome, a random effects linear regression model will be fitted with ward (cluster) as a random effect term and intervention group as a fixed effect.DiscussionThis will be the first trial examining the SDM-PLUS approach for patients with schizophrenia or schizoaffective disorder in very acute mental health inpatient settings. Within the trial a complex intervention will be implemented that addresses both patients and health care staff to yield maximum effects.Trial registrationGerman Clinical Trials Register DRKS00010880. Registered 09 August 2016.

An audit of the quality of inpatient care for adults with learning disability in the UK

ObjectivesTo audit patient hospital records to evaluate the performance of acute general and mental health services in delivering inpatient care to people with learning disability and explore the influence of...

Exploring narratives of psychological input in the acute inpatient setting.

This research explored what happens when psychological input is offered in the inpatient setting and examined service users' and staff members' understanding and portrayal of these experiences. Narrative analysis, an interview design, was used to examine experiences of inpatient psychological interventions in National Health Service inpatient mental health settings. Ten participants (four service users and six staff members; five males and five females; seven White British, one White Irish, one Black African, and one Black Caribbean) were recruited via clinical psychologists from an inpatient psychology department and participated in 18- to 90-min interviews. Evidence suggested that direct, indirect, and strategic psychological interventions were used in the inpatient setting, with formulation and the therapeutic relationship conceptualized as common features. Connections between inpatient psychology and change, evidenced in the stories, suggested that interventions can help people make sense of a crisis, improve relationships, and contribute to meaningful recovery. Evidence of barriers suggests that psychological input in this setting might not always be compatible with everyone's needs. This paper explored service users' and staff members' experiences of psychological input in the inpatient setting. The analysis revealed that psychological provision in the inpatient mental health setting is varied and encompasses direct and indirect input, valued by service users and clinicians. It also identified that psychological input in the acute inpatient mental health setting is perceived as meaningful and can lead to changes at an interpersonal and intrapersonal level. There is a sense that providing psychological thinking in the inpatient setting can be challenging due to environmental constraints and individual factors. This highlights the need for further research focused on the costs and clinical effectiveness of providing psychological thinking within the acute inpatient mental health setting. Staff members and service users made connections between psychological input and change, suggesting that interventions can improve relationships, help people make sense of a crisis, and contribute to meaningful recovery. There are significant barriers to and challenges of providing psychological input in this setting: Some participants suggested that this approach might not suit everyone.

Tensions and Risks in the Blanket Use of Locked Door Policies in Acute Mental Health Inpatient Facilities: Balancing Human Rights, Clinical Utility and Public and Patient Protection

Although there has been a consistent trend away from institutionalised mental health care over the past decades, this has occurred at the same time as increased coercive care measures are employed in mental health inpatient facilities, as these facilities become weighted to more serious cases. Locked wards, which regulate the ability of both voluntary and involuntary patients to leave psychiatric units, are increasingly common in acute mental health inpatient settings. This article focuses on the controversy surrounding a recent initiative to extend locked door policies across all public acute inpatient facilities in Queensland, explores the legal, ethical and clinical issues around the implementation of locked door policies in acute mental health inpatient facilities, and examines the tensions in balancing individual rights and public and personal protections in the treatment of acute mental health disorders.