Acute Inpatient Wards Research Articles

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).

A feasibility study of a cross-diagnostic, CBT-based psychological intervention for acute mental health inpatients: Results, challenges, and methodological implications.

Acute psychiatric inpatient wards are characterized by minimal provision of therapeutic activities and high readmission rates. Implementation of a comprehensive inpatient psychological intervention service has been recommended to overcome these problems; however, whether this is feasible or effective remains unclear. This non-randomized parallel cluster feasibility trial examined the feasibility of delivering and evaluating cross-diagnostic psychologically informed acute psychiatric care the Edinburgh-Acute Psychological Inpatient Therapy Service (EDAPTS) and gathered preliminary clinical outcome data. Patients able to consent and complete questionnaires were recruited from two adult acute wards (i.e., clusters) and received either EDAPTS plus TAU or TAU. Between October 2015 and October 2016, 96 inpatients were recruited. Findings suggested that there were good data completion rates for several clinical outcomes, that several EDAPTS components were successfully delivered, and that some initial effects appeared to favour the intervention, depending on outcome. However, difficulties relating to the recruitment process were also identified, as well as problems relating to adequate delivery of group therapies, participant engagement in some intervention components, and data completion at follow-up. These issues, and the feasibility of randomization and rater-blinding, have important implications for the design of future trials. Overall, this study provides an important insight into the challenges and complexities of developing and evaluating a comprehensive psychological intervention service in an acute psychiatric setting. Individual therapy sessions can be delivered in the acute environment. The EDAPTS intervention showed some promise on outcomes of distress and self-efficacy. Delivery of nurse-led groups was challenging and may need to be embedded into routine clinical practice to increase intervention and outcome reach. More parameters, for example, randomization at cluster level, should be tested before progressing to an adequately powered, single-blind, definitive cluster RCT.

Humanising the inpatient experience through service user-led Tree of Life workshops

The article summarises our work using Tree of Life workshops across 17 adult acute inpatient wards in South London and Maudsley NHS Trust. The workshops were all service user co-led and the team won a national award for ‘promoting equality and diversity in service delivery’. We also featured on BBC4’s ‘All in the Mind’.

Brief narrative group work on acute inpatient mental health wards

This article describes the development of three single-session narrative therapy groups on acute mental health wards. The article describes the general theoretical underpinnings of the group, before going on to describe the format of each group session. A brief illustrative case study is provided alongside each group session description.

Implementation of the Safewards model in public mental health facilities: A qualitative evaluation of staff perceptions

BackgroundThe Safewards model is gaining increasing acceptance in the mental health field in Australia and overseas. One of the most important goals of inpatient psychiatric services is to provide a safe and therapeutic environment for both patients and staff. However, this goal can be difficult to achieve if staff-patient interaction is not conducive to preventing violence and aggression. ObjectiveThe purpose of this study was to explore nursing staff perceptions of the factors impacting on their capacity to establish Safewards in acute adult inpatient wards. DesignThis study was guided by a phenomenological approach to develop a rich understanding of staff perceptions using semi-structured interviews. Setting and sampleThe setting was three acute mental health wards attached to general hospitals; one in a large provincial hospital and two in metropolitan hospitals in south-east Queensland. Interview participants were a purposive sample of fifteen registered nurses across each of the three wards. MethodSemi-structured interviews were conducted at 12 months post-implementation of Safewards. The study was underpinned by Michie’s integrative framework of behaviour change that helped identify target areas in order to enhance successful implementation of this model. ResultsContent analysis of interview transcripts highlighted a range of factors including failure to address the difficulties encountered by some staff in engaging with Safewards interventions, lack of support from management, poor use of nurse educator time, the ‘language’ of Safewards, high acuity on the study wards, and staff and patient turnover. ConclusionThis study highlights some difficulties with implementing Safewards and maintaining fidelity of the Safewards interventions in busy acute inpatient wards. Although these findings are from a qualitative study consisting of only 15 staff, our results indicate that efforts to implement Safewards need to address challenges faced by staff in engaging with the interventions, ensure buy-in from management, ensure adequate training and support during implementation and review training materials to ensure they fit with the local (i.e. Australian) context. Safewards provides an opportunity for a change in attitudes and development of a more therapeutic ward environment.

Reolication study: Exploring the efficacy of relaxation groups for older adults on an acute inpatient psychiatric ward

This is a replication study of a previous service evaluation of a relaxation group, conducted on an acute inpatient ward for older people experiencing a range of mental health difficulties. Attendees rated levels of relaxation before and after each relaxation group session usinga10-pointLikert scale. Analysis ofdata collected over a period ofa year found a small but significant positive effect for those who attended the relaxation group, supporting the findings of the original service evaluation. These findings provide evidence for the effectiveness of such groups and may offer a cost and time effective method for reducing anxiety on inpatient wards.

The association between nurse staffing and omissions in nursing care: A systematic review.

AimsTo identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.BackgroundResearch has established associations between nurse staffing levels and adverse patient outcomes including in‐hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.DesignSystematic review.Data SourcesWe searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.Review MethodsTwo reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.ResultsEighteen studies gave subjective reports of missed care. Seventy‐five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.ConclusionsLow Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

Patient participation in inpatient ward rounds on acute inpatient medical wards: a descriptive study.

BackgroundMeaningful partnering with patients is advocated to enhance care delivery. Little is known about how this is operationalised at the point of care during hospital ward rounds, where decision-making concerning patient care frequently occurs.ObjectiveDescribe participation of patients, with differing preferences for participation, during ward rounds in acute medical inpatient services.MethodsNaturalistic, multimethod design. Data were collected using surveys and observations of ward rounds at two hospitals in Melbourne, Australia. Using convenience sampling, a stratified sample of acute general medical patients were recruited. Prior to observation and interview, patient responses to the Control Preference Scale were used to stratify them into three groups representing diverse participation preferences: active control where the patient makes decisions; shared control where the patient prefers to make decisions jointly with clinicians; and passive control where the patient prefers clinicians make decisions.ResultsOf the 52 patients observed over 133 ward rounds, 30.8% (n=16) reported an active control preference for participation in decision-making during ward rounds, 25% (n=13) expressed shared control preference and 44.2% (n=23) expressed low control preference. Patients’ participation was observed in 75% (n=85) of ward rounds, but few rounds (18%, n=20) involved patient contribution to decisions about their care. Clinicians prompted patient participation in 54% of rounds; and in 15% patients initiated their own participation. Thematic analysis of qualitative observation and patient interview data revealed two themes, supporting patient capability and clinician-led opportunity, that contributed to patient participation or non-participation in ward rounds.ConclusionsParticipation in ward rounds was similar for patients irrespective of control preference. This study demonstrates the need to better understand clinician roles in supporting strategies that promote patient participation in day-to-day hospital care.

Nursing staff-led behavioural group intervention in psychiatric in-patient care: Patient and staff experiences.

A promising intervention in mental health in-patient care is behavioural activation (BA). Interventions based on BA can be used by mental health nurses and other staff members. The aim of this study was to evaluate patients' and staff members' experiences of a nursing staff-led behavioural group intervention in mental health in-patient care. The intervention was implemented at three adult acute general mental health in-patient wards in a public hospital setting in Sweden. A self-administrated questionnaire, completed by 84 patients and 34 nurses and nurse assistants, was administered, and nonparametric data analysed using descriptive statistics. Our findings revealed that both patients and nursing staff ranked nursing care and care environment as important aspects in the recovery process. Patients and staff members reported overall positive experiences of the group sessions. Patients with higher frequencies of attendance and patients satisfied with overall care had a more positive attitude towards the intervention. A more positive experience of being a group leader was reported by staff members who had been leading groups more than ten times. The most common impeding factor during implementation, reported by staff members, was a negative attitude to change. Conducive factors were having support from a psychologist and the perception that patients were showing interest. These positive experiences reported by patients and nursing staff, combined with previous research in this field, are taking us one step further in evaluating group sessions based on BA as a meaningful nursing intervention in mental health in-patient care.

Individual psychological therapy in an acute inpatient setting: Service user and psychologist perspectives.

The acute inpatient setting poses potential challenges to delivering one-to-one psychological therapy; however, there is little research on the experiences of both receiving and delivering therapies in this environment. This qualitative study aimed to explore service users' and psychologists' experiences of undertaking individual therapy in acute inpatient units. It focused on the relationship between service users and psychologists, what service users found helpful or unhelpful, and how psychologists attempted to overcome any challenges in delivering therapy. The study used a qualitative, interview-based design. Eight service users and the six psychologists they worked with were recruited from four acute inpatient wards. They participated in individual semi-structured interviews eliciting their perspectives on the therapy. Service users' and psychologists' transcripts were analysed together using Braun and Clarke's (2006, Qualitative Research in Psychology, 3, 77) method of thematic analysis. The accounts highlighted the importance of forming a 'human' relationship - particularly within the context of the inpatient environment - as a basis for therapeutic work. Psychological therapy provided valued opportunities for meaning-making. To overcome the challenges of acute mental health crisis and environmental constraints, psychologists needed to work flexibly and creatively; the therapeutic work also extended to the wider context of the inpatient unit, in efforts to promote a shared understanding of service users' difficulties. Therapeutic relationships between service users and clinicians need to be promoted more broadly within acute inpatient care. Psychological formulation can help both service users and ward staff in understanding crisis and working collaboratively. Practice-based evidence is needed to demonstrate the effectiveness of adapted psychological therapy models. Developing 'human' relationships at all levels of acute inpatient care continues to be an important challenge for clinical practice. Due to the distress of individuals and the constraints of the acute inpatient environment, psychologists need to be flexible and adaptable in delivering individual therapy. Making meaning and psychological formulation can give service users a sense of hope and empowerment, and can contribute to a shared understanding within the ward team of service users' difficulties.

The Utility of the Frailty Index in Clinical Decision Making.

Using clinical vignettes, this study aimed to determine if a measure of patient frailty would impact management decisions made by geriatricians regarding commonly encountered clinical situations. Electronic surveys consisting of three vignettes derived from cases commonly seen in an acute inpatient ward were distributed to geriatricians. Vignettes included patients being considered for intensive care treatment, rehabilitation, or coronary artery bypass surgery. A frailty index was generated through Comprehensive electronic Geriatric Assessment. For each vignette, respondents were asked to make a recommendation for management, based on either a brief or detailed amount of clinical information and to reconsider their decision after the addition of the frailty index. The study suggests that quantification of frailty might aid the clinical judgment now employed daily to proceed with usual care, or to modify it based on the vulnerability of the person to whom it is aimed.

Cross Sectional Study on Characteristics of Bipolar Disorder Association with Alcohol Dependence in a Tertiary Care Center in South India

Bipolar disorders are commonly associated with other psychiatric disorders, which influence the course, severity and outcome of the disorder Aim: to study the association of alcohol dependence on bipolar disorder and to compare bipolar patients without alcohol dependence in tertiary care center in south India Methods: A total of 83 patients with age of 18-65 years who were admitted in the acute in-patient ward of the Institute of mental Health were administered M.I.N.I PLUS neuropsychiatric interview module and the patients who fulfil the diagnostic criteria for BPAD after ruling out the secondary causes of mood disorder were included in the study. The scales utilized to study the alcohol dependence association with bipolar disorder are in the form of illness variables and symptoms severity. Results: Group-A (n=42) patients with bipolar disorder and co-morbid alcohol dependence and group-B (n=41) patients with bipolar disorder without alcohol dependence (Group-B) was noted in our study. Strong positive correlation between severity of alcohol dependence score and YMRS score, functioning score, positive scale of PANSS and aggression scores noted and Only treatment adherence, family H/o BPD and family H/o alcohol dependence show significance in the present study. Conclusion: Increase in severity of alcohol dependence is associated with severity of Bipolar disorder.

Higher participation in physical activity is associated with less use of inpatient mental health services: A cross-sectional study

There is a stark disparity in the physical health of people with mental illness compared to those without mental illness, resulting in shorter life expectancy and increased rates of preventable deaths. Physical activity has previously been shown to have a positive impact on various markers of mental health and has been linked with a reduction in hospital admissions for those with chronic physical illness. The purpose of this study was to investigate whether there is a relationship between physical activity and the number of days spent admitted to acute inpatient mental health wards in people with enduring mental illness. Eighty participants from four acute mental health wards in Oxfordshire, UK were included. Subjective and objective measurements of physical activity levels were collected alongside the amount of days spent admitted on acute mental health wards over the year previous. Participants who recorded higher levels of physical activity, both subjectively and objectively, were found to have spent less time admitted to acute mental health services. With a significant negative correlation found, future research should aim to investigate any causative link between physical activity and mental health admission.

Validity of routine clinical diagnoses in acute psychiatric inpatients

AimTo examine the validity of diagnoses obtained by clinicians during routine clinical examination on acute psychiatric inpatient wards. MethodsN=100 inpatients with a broad spectrum of major mental disorders were randomly selected in a mental hospital's department of general psychiatry. Patients were diagnosed by independent assessors within Md = 5 (Range: 1–18) days of admission using the SCID I in order to examine the validity of the diagnoses given by the clinical staff based on routine assessments. ResultsThe commonly used clinical examination technique had good overall agreement with the SCID I assessments regarding primary diagnoses at the level of ICD-10 main categories (F2, F30-31, F32-F33, F4; κ = 0.65). However, agreement between routine clinical diagnoses and the SCID I diagnoses tended to be low for some specific mental disorders (e.g., depressive disorders) and for secondary diagnoses. ConclusionsThe validity of routine clinical diagnoses established in acute inpatient settings is limited and should be improved.

The development, validation, and feasibility of the Experienced Coercion Scale.

Existing scales for experienced coercion have limitations. We developed and validated a short self-report form for experienced coercion for use across care settings, care phases, and care measures. In Stage 1, we developed an item pool, based on the literature, patient accounts, interviews, and expert feedback. Stages 2 and 3 consisted of 2 cross-sectional studies, with patients from acute and nonacute inpatient wards, outpatient care, and supported housing. In Stage 2, patients (N = 212) responded to the Coercion Ladder and the experienced coercion items from Stage 1. We selected 20 items for Stage 3 based on item performance in typically coercive versus voluntary care settings, each items' relation to the Coercion Ladder score, and with regard to the component structure from principal component analysis (PCA). In Stage 3, we collected and examined item responses and clinical and coercion data from a new sample of patients (N = 219). We selected 15 items based on factor loadings to form part of the final Experienced Coercion Scale (ECS). The internal consistency was high and score distribution approached the normal curve. ECS sum scores correlated strongly with scores on the Coercion Ladder. In a regression analysis, demographic variables, diagnosis, duration of treatment, and care setting did not predict ECS scores, while legal status and continuing involuntary medication significantly predicted scores. In this initial study, the ECS scores showed promising psychometric properties, suggesting it can be used across care settings and is suitable for research and service evaluation. (PsycINFO Database Record

Enhancing the therapeutic interaction skills of staff working in acute adult inpatient psychiatric wards: Outcomes of a brief intervention education programme

Background and objective: Clinical practice in acute inpatient environments is complex and demanding for clinical staff. To facilitate service user recovery, it is essential that personnel working in these environments are competent and confident in a range of therapeutic interaction skills, which can have impact in a brief period. This paper describes an exploratory study which determined the outcomes of a brief therapeutic engagement education and training short course for staff working in adult inpatient acute wards. As far as we know this was the first time, based on evidence from earlier research involving service users that Heron’s Six Category Intervention Analysis and solution focused brief therapy (SFBT) have been combined in an education and training short course that was coproduced and delivered in partnership with service users for staff working in acute environments.Methods: The short course explored the myriad applications of the six categories of intervention initially proposed by Heron and the widespread applicability of SFBT. The programme evaluation adopted focus group methodology and examined: (1) how useful the training content was to daily practice and how relevant the skills learn were to interactions with service user residing on the ward; (2) the factors than helped enable the transference of the learning to the ward environment as well as any barriers; (3) personal learning; and (4) strengths of the learning experience and suggestions for improvement to the training and learning experience.Results: Feedback from participants reflected a high degree of skill and knowledge acquisition and enhancement. Staff found the content of the training useful and helpful to their daily practice as it aided in increasing confidence, therapeutic interventions and care-planning. Skills learnt by the trainees were considered relevant to interactions with service users residing on the ward. Factors that helped to enable encounters with service users, as well as the barriers, when transferring the learning to the ward environment were discussed and included managerial support, demand for beds, time, opportunity and staffing shortages. Regarding personal learning, staff reported feeling more able to connect with service users when employing SFBT techniques and Heron’s intervention approaches and felt that the training validated their current working practice.Conclusions: The SFBT training appears to have provided an interactional communication toolkit for healthcare professionals and could be further embraced given the right circumstances e.g. managerial support and attitude change of nursing staff in general. Further research is needed to gain an understanding of the effect of short and concentrated education and training programmes aimed at staff members working within adult acute inpatient mental healthcare settings, as well as measuring whether the activity, i.e. healthcare professional–service user interactions, is meaningful to service user outcomes.

Should I stay or should I go? How healthcare professionals close encounters with people with dementia in the acute hospital setting

Around a quarter of hospital beds in the UK are occupied by patients living with dementia (PWD), and communication impairments are common across all types of dementia, often exacerbated by the hospital environment. Unsurprisingly, healthcare professionals (HCPs) report particular challenges in caring for this patient group, whilst trying to recognise and value their personhood as per the underpinning ethos of person-centred care. However, whilst there is a growing body of research that underlines the importance of communication in dementia care, there is far less that actually examines this communication in real time interaction. Suggestions and pointers for good communication do exist, but these do not tend to be empirically derived, and sometimes conflict with empirical findings. This paper focuses on a specific area of interaction which has previously received very little attention: the way in which healthcare encounters are ended or closed. There is potentially a conflict between a pressure to manage a patient as efficiently as possible, and endeavouring to ensure person-centred care and deal with communication difficulties arising from dementia. Using conversation analysis, we examined forty-one video recordings of HCP/PWD interactions collected from an acute inpatient ward. We identify three phenomena around which there were recurring troubles in our dataset: ‘open-ended pre-closings’, ‘mixed messages’ and ‘non specifics and indeterminate terms’. We conclude that moves towards closing an encounter that appear intuitive to HCPs as competent interactants, and that may represent best practice in other healthcare settings, may in fact serve to confuse a PWD and create difficulties with closings. Our findings underline the importance of examining best practice guidance as it is actually talked into being, using approaches which can unpack the interactional detail involved. They also emphasise the importance of context in the analysis of healthcare delivery, to avoid a ‘one size fits all’ approach.

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.

Spice boys: an exploratory study around novel psychoactive substance use on a male acute ward

PurposeNovel psychoactive substances (NPS) – often known as “legal highs” – are a varied group of substances that are causing concern due to their possible effects on mental health. Particular concerns have been raised about synthetic cannabinoid receptor agonists often known as “Spice”. The purpose of this paper is to identify the prevalence of NPS use and explore any association with acute psychological disturbance.Design/methodology/approachThe authors reviewed the case notes for 153 admissions to a male acute inpatient ward. Prevalence of reported NPS use and admissions to psychiatric intensive care unit (PICU) were recorded.FindingsIn total, 18.9 per cent of individuals admitted to acute inpatient care were reported to have used NPS. NPS users were almost ten times as likely as their non-NPS using peers to require care in PICU. This result was statistically significant (Fisher exact test: p<0.001). Although caution is required given the limitations of this study, the data and clinical experience suggest that synthetic cannabinoids may be the specific type of NPS that is being used by this group.Practical implicationsMental health professionals can expect to care for people using NPS in acute inpatient environments, and so they need to understand the nature and effects of these substances. It is possible that NPS use may be associated with sustained acute psychological disturbance.Originality/valueThere have been few studies on the prevalence of NPS use in inpatient environments and none of them have published that explore the association with PICU admission. Despite the limitations of this study, it has significant value by identifying an urgent need for comprehensive research in this area.

The Big D(eal): professional identity through discursive constructions of 'patient'.

Professional identity formation has become a key focus for medical education. Who one becomes as a physician is contingent upon learning to conceptualise who the other is as a patient, yet, at a time when influential ideologies such as patient-centred care have become espoused values, there has been little empirical investigation into assumptions of 'patient' that trainees take up as they progress through their training. Our team employed a critical discourse analysis approach to transcripts originally produced from a micro-ethnography of medical student learning on an acute care in-patient paediatric ward. The dataset included 20 case presentations and 14 sign-over rounds taken from a 3-week observation period. We paid specific attention to how trainees used language to talk about, refer to and categorise patients. Identified discourses included patient-as-disease-category, patient-as-educational-commodity and patient-as-marginalised-actor. These discourses conceptualise 'patient' as an entity thatis principally biomedical, useful for clinical learning and spoken for and about. Medical student participation in these discourses contributes to an identity that allows them to move further into the professional medical world they are joining. We contend that as learners participate in these discourses, they are also performatively produced by them. By making these discourses visible, we can consider how to minimise unintended effects such discourses may cause. Our findings, although limited, offer a glimpse of the effects that those assumptions may have as we look to align better the formation of professional medical identity with the ideals of patient-centred care and socially responsible health care systems.