Acute Mental Health Wards Research Articles

Improving multidisciplinary clinical discussion on an inpatient mental health ward

Purpose– Multidisciplinary team (MDT) clinical supervision is being used in many mental health services but at present has not received adequate attention by researchers in order to generate evidence-based approaches. The purpose of this paper is to explore the utility and staff perspectives of an MDT model of clinical supervision in the form of a “Clinical Discussion Group” (CDG) on an acute inpatient mental health ward within the context of the current literature on the components of effective supervision in order to make recommendations for practice.Design/methodology/approach– In total, 12 members of staff working on the ward were interviewed to gather their perspective on attendance, helpful aspects, outcomes, unhelpful aspects, and changes. Interview transcripts were analysed using thematic analysis.Findings– In total, 11 themes were identified, three within “The Group and how it operates” (attendance, discussion topics and facilitation), five within “Impact and Usefulness” (valued by staff, understanding a case, emotional benefit, learning and working together as a team) and three within “Changes to the Group” (organisation, discussion topic and group outcomes).Originality/value– This paper explores the benefits and challenges of a CDG from the perspective of the staff who attend. It presents some recommendations for good practice which should be of use to managers and supervisors who wish to use team supervision to improve patient outcomes and also makes suggestions for future research in this field.

Preparing for Completely Smoke-Free Mental Health Settings: Findings on Patient Smoking, Resources Spent Facilitating Smoking Breaks, and the Role of Smoking in Reported Incidents from a Large Mental Health Trust in England.

Introduction: Despite high smoking prevalence and excessive smoking-related morbidity and mortality among people with mental disorder compared to the general population, smoking treatment is often neglected in mental health settings. The UK National Institute of Health and Clinical Excellence (NICE) recently issued public health guidance stipulating completely smoke-free mental health settings. This project evaluated existing smoking-related practices in preparation for guidance implementation. The objectives were to: audit the recording of smoking-related information and treatment provision; explore current arrangements relating to the facilitation of patient smoking; measure staff time spent and identify costs of facilitating smoking; and explore the role of smoking in smoking-related incidents. Methods: A mixed-methods study was conducted across four acute adult mental health wards, accommodating 16 patients each, over six months. It included a case-note audit, on-site observations, and a qualitative content analysis of incident reports. Results: Smoking status was recorded for less than half of the 290 patients admitted (138, 48%). Of those, 98 (71%) were recorded as current smokers, of whom 72 (74%) had received brief smoking cessation advice. Staff spent 6028 h facilitating smoking, representing an annual cost of £131,040 across four wards. Incident reports demonstrated that smoking facilitation was often central to the cause of incidences, triggered frustration in patients, and strained staff resources. Conclusion: The findings highlight the importance and potential of implementing completely smoke-free policies using comprehensive pathways.

A feasibility study comparing UK older adult mental health inpatient wards which use protected engagement time with other wards which do not: study protocol.

BackgroundProtected engagement time (PET) is a concept of managing staff time on mental health inpatient wards with the aim of increasing staff and patient interaction. Despite apparent widespread use of PET, there remains a dearth of evidence as to how it is implemented and whether it carries benefits for staff or patients. This protocol describes a study which is being carried out on mental health wards caring for older adults (aged over 65) in England. The study shares a large proportion of the procedures, measures and study team membership of a recently completed investigation of the impact of PET in adult acute mental health wards. The study aims to identify prevalence and components of PET to construct a model for the intervention, in addition to testing the feasibility of the measures and procedures in preparation for a randomised trial.Methods/designThe study comprises four modules and uses a mixed methods approach. Module 1 involves mapping all inpatient wards in England which provide care for older adults, including those with dementia, ascertaining how many of these provide PET and in what way. Module 2 uses a prospective cohort method to compare five older adult mental health wards that use PET with five that do not across three National Health Service (NHS) Foundation Trust sites. The comparison comprises questionnaires, observation tools and routinely collected clinical service data and combines validated measures with questions developed specifically for the study. Module 3 entails an in-depth case study evaluation of three of the participating PET wards (one from each NHS Trust site) using semi-structured interviews with patients, carers and staff. Module 4 describes the development of a model and fidelity scale for PET using the information derived from the other modules with a working group of patients, carers and staff.DiscussionThis is a feasibility study to test the application of the measures and methods in inpatient wards for older adults and develop a draft model for the intervention. The next stage will prospectively involve testing of the model and fidelity scale in randomised conditions to provide evidence for the effectiveness of PET as an intervention.Trial registration ISRCTN31919196

Experiences of ward rounds among in-patients on an acute mental health ward: a qualitative exploration.

Aims and method To address the gap in qualitative research examining patients' experiences of ward rounds. In-depth interviews were conducted with five in-patients on an acute mental health ward. Data were analysed using thematic analysis.Results Data were organised into three first-order themes, positioned within an overarching theme relating to patients' perceptions of the use of power and control within ward rounds.Clinical implications Systemic factors may make it difficult to facilitate ward rounds in a manner which leaves patients feeling fully empowered or in control, but there are practical measures to address these issues, drawn from participants' accounts.

Staff nurse perceptions of the impact of mentalization-based therapy skills training when working with borderline personality disorder in acute mental health: a qualitative study.

People diagnosed with borderline personality disorder (BPD) are highly prevalent in acute mental health wards, with staff nurses identifying a challenge in working with people who can be significantly distressed. This has contributed to a negative stereotype verging on stigmatization. Mentalization-based therapy (MBT) is a psychological therapy which has been shown to be of benefit to people with a diagnosis of BPD, yet it has been utilized and evaluated only in partial hospitalization and outpatient settings. Despite this, most people diagnosed with BPD will continue to be treated in generic inpatient settings such as acute mental health. Mentalization-based therapy skills training (MBT-S) is a new and cost-effective 2-day workshop aiming to provide generalist practitioners with MBT skills for use in generic settings. This study aimed to capture staff perceptions of the impact of MBT-S on their practice when working with people with a diagnosis of BPD in acute mental health. Through two focus groups, this study assessed the perceptions of nine staff nurses. An interpretive phenomenological approach was utilized in data analysis. Participants found the approach easy to grasp, improving of consistency between staff and flexible in its use in planned or 'off the cuff' discussions. MBT-S promoted empathy and humane responses to self-harm, impacted on participants ability to tolerate risk and went some way to turning the negative perception of BPD through changing the notion of patients as 'deliberately difficult'. Staff felt empowered and more confident in working with people with a diagnosis of BPD. The positive implication for practice was the ease in which the approach was adopted and participants perception of MBT-S as an empowering skill set which also contributed to attitudinal change. In acute mental health environments, which may not have the resources to provide long-term structured treatments to patients, MBT-S could be viewed as ideal as participants applauded its flexibility. The promotion of empathy also sees a move away from iatrogenic damage caused by unhelpful responses to self-harm. In the context of wider research, this study shows that staff nurses find the MBT-S skill set valuable in the generic inpatient setting of acute mental health.

The Experiences of Lesbian and Gay Adults on Acute Mental Health Wards: Intimate Relationship Needs and Recovery

This study explores the psychiatric inpatient experiences of lesbian and gay service users in relation to their intimate relationship needs and how these experiences affected their mental health recovery. Semi-structured interviews were conducted with three gay men and three lesbians who had been resident on public sector psychiatric wards in the United Kingdom. The data were analyzed using Interpretative Phenomenological Analysis (IPA). Five master themes emerged: the conceptualization of intimacy, the relationship between intimate relationships and recovery, experiences of the ward, experiences of prejudice and discrimination in services, and a loss of power and personal identity as a service user.

A day in the life of a peer support worker: the ward reviews

Purpose – The purpose of this paper is to share the experiences and reflections of a Peer Support Worker over the course of a day working within mental health services. Design/methodology/approach – A narrative approach has been taken to structure reflections based on the experience of attending a series of reviews on an acute mental health ward. Findings – The experience of attending ward reviews creates reflections based on how this system affects and challenges both those who are served by it and those work within it. Originality/value – This paper adds to the small number of accounts of the experiences of Peer Support Working in mental health services and as such is highly original.

Reflective practice on inpatient mental health wards (2/2): evaluation of CBT-integrated reflective learning process

This second article—of two—further discusses the important role of reflective learning in the modern practice of mental health practitioners. It outlines the benefits that regular and structured reflection on clinical experiences might have for the professional development of nurses and healthcare assistants working in inpatient mental health settings.It argues for an incorporation of cognitive-behavioural therapy (CBT) principles into the reflective learning process, and demonstrates the effectiveness of CBT-based reflective practice groups facilitated by a clinical psychologist on acute mental health wards.Finally, it illustrates the outcomes of a reflective practice group (RPG) service evaluation project.

Helping those in crisis

As clinical team leader on an acute inpatient mental health ward at Cygnet Health Care's Kewstoke Hospital, my role is to supervise and support my team and to work with the ward's 15 patients.

Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards

Quality nursing plays a central role in the delivery of contemporary health and social care, with a positive correlation being demonstrated between patient satisfaction and the quality of nursing care received. One way to ensure such quality is to develop metrics that measure the effectiveness of various aspects of care across a variety of settings. Effective mental health nursing is predicated on understanding the lived experiences of service users in order to provide sensitively-attuned nursing care. To achieve this, mental health nurses need to establish the all-important therapeutic relationship, showing compassion and creating a dialogue whereby service users feel comfortable to share their experiences that help contextualize their distress. Indeed, service users value positive attitudes, being listened to, and being able to trust those who provide care, while mental health nurses value their ability to relate through talking, listening, and expressing empathy. However, the literature suggests that within mental health practice, a disproportionate amount of time is taken up by other activities, with little time being spent listening and talking to service users. The present study discusses the evidence relating to the therapeutic relationship in acute mental health wards and explores why, after five decades, it is not recognized as a fundamental metric of mental health nursing.

Starting out - I aim to teach mental health patients about the dangers of illicit drugs

While on placement on an acute admissions mental health ward, a male patient, who I will call Mr Smith, returned after weekend leave.

Is there a crisis in inpatient mental health care?

The standards of care in the NHS are the subject of debate. Frequently, members of the public have complained about poor staff attitudes towards patients and visitors alike and this has generated discussion as to the best way forward for the nursing profession. In mental health, poor standards have been reported on numerous occasions and the first author had firsthand experience of casual nursing attitudes when she visited a friend in an acute inpatient mental health ward. This article uses her anecdotal account to highlight poor standards in mental health. The paper then examines possible antecedents to this vexed issue before suggesting a way forward.

Views of the Therapeutic Environment (VOTE): Stakeholder involvement in measuring staff perceptions of acute in-patient care

BackgroundThe impact of staff perceptions of daily work pressures on burnout requires further exploration because both issues may be adversely affecting the quality of staff interactions with service users. ObjectivesTo use a model of ‘stakeholder involvement’ to develop and test a self-report instrument capturing nursing staff perceptions of the daily pressures of working in acute in-patient mental health wards. DesignMeasure development followed a participatory methodology, followed by psychometric testing of the new measure of the daily pressures of working on an acute ward (VOTE). SettingsAcute in-patient wards in an inner London mental health trust. ParticipantsAll nursing staff from acute in-patient settings are eligible for this study. In total 376 staff (qualified nurses and healthcare assistants) were involved at the various stages of measure development and testing. MethodsFocus groups of nursing staff met to discuss their perceptions of acute wards. A twenty item measure was generated through thematic analysis of these data and staff feedback. Reliability and validity were tested and the effects of demographic characteristics on VOTE, and VOTE on burnout were examined. ResultsStaff found VOTE easy to understand and complete. Test–retest reliability and the internal consistency of the measure and subscales were good. A test of criterion validity showed that staff with negative perceptions of the daily pressures of the working on an acute ward also had negative perceptions of job satisfaction and high levels of burnout. Regression modelling showed that VOTE had a significant effect on burnout. ConclusionsVOTE is a concise measure which combines aspects of care provision as well as the organisational and professional stressors of acute ward working. VOTE can be used to further explore how staff perceptions of the daily pressures of acute ward working affect the quality of care delivered.

The Reality of Teamwork in an Acute Mental Health Ward

The study aims to explore the activities of mental health nurses in an acute inpatient ward. Teamwork emerged as one of several important matters for analysis. Ethnography and data collection took place through participant observation. This included recording of naturally occurring talk. Three themes emerged: nurses' continuing attention to teamwork, the handover, and the team meeting. The vast potential of information to be communicated across the nursing team was observed to result in the use of summarizing practices. These appeared to mitigate nurses' ability to give sophisticated accounts of their evident expertise in multidisciplinary meetings. Nurses should be challenged to articulate their interventions and display their work within the acute mental health setting.

Delphi research: issues raised by a pilot study.

This paper will explore the issues raised by the pilot stage of a three-round Delphi study. The Delphi method involves a range of complex activity for the expert panellists and the researcher and yet there is a lack of debate in the academic literature about how Delphi research should be piloted. A Delphi study aimed at establishing areas of agreement between service users and registered nurses about therapeutic nursing on acute mental health wards. A pilot Delphi study tested the first-round questions, the use of two measurement approaches and the process of analysis and administration across three rounds. A brief review of published Delphi pilot studies in health care between 2001 and 2011; ten of 25 relevant papers are included here. Approaches to pilot tests for the Delphi method are discussed. Delphi researchers should publish greater detail about their approach to pilot studies. Pilot Delphi studies can support the development of first round questions but also offer a means to test measurement methods and define consensus in subsequent rounds. Pilot studies in Delphi research provide useful guidance about first-round questions as well as measurement methods, consensus thresholds and controlled feedback in subsequent rounds. They support the involvement of professionals and service users and they need to trial the recruitment strategy to avoid between-round delays. Delphi researchers should publish details of their approach to pilot studies.

Acute mental health nurses: comprehensive practitioners or specialist therapists?

This paper examines the aids and barriers to implementing the psychosocial interventions (PSI) which trainees learned on two teaching modules. The main purpose of the modules is to teach trainees PSI to help them be more effective in their care of patients with severe mental illness. The trainees were qualified nurses working in acute mental health wards in various London hospitals. PSI has been found to be helpful for patients with psychotic symptoms in community contexts. In this study, the implementation of PSI specific to acute inpatient mental health settings is explored. This was achieved by conducting semi-structured audiotaped interviews with all 20 trainees from a single cohort. The data were analysed by categories and themes to elicit not only the problems but also helpful strategies which can be used when working with PSI in acute inpatient mental health settings. The paper concludes by offering recommendations for future good practice for this area of mental health service.

Under the Gaze of Staff: Special Observation as Surveillance

This study explores the relationship of special observation (SO) to a range of patient, staff, and ward variables. End-of-shift reports were completed by nurses on 136 acute mental health wards in England during 2004 and 2005. Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach). Significant relationships were found between SO and measures of ward surveillance, door locking, and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of staff without a nursing qualification were on duty. Improved ward design, less reliance on unqualified staff, and greater use of surveillance measures may reduce the need for SO.

Security rules and banned items in psychiatric acute admission wards in Athens, Greece

Mental health nurses play a key role in maintaining the safety of patients, themselves, and others during hospitalization. The aim of the research was to evaluate the safety measures that are taken by mental health nurses to identify the security policies that exist in acute mental health wards. The Ward Safety and Security Rules Survey was used as a method of data collection. Descriptive analysis and content analysis were carried out in order to identify nurses' practices. The total sample consisted of 172 mental health nurses and nurses' assistants who worked in 14 acute inpatient psychiatric wards in three psychiatric hospitals in the greater area of Athens, Greece. The results show a minimum number of security features existing in the wards. Only one of the 14 wards had an intercom system. In only nine wards, there was a panic alarm in the office, and in eight, an emergency response telephone extension. A wide range of practices were noted concerning banned items and patient searches upon admission and return from leave. The results indicate the significant lack of protocols and specific safety rules to guide nurses' actions across psychiatric acute admission wards in Athens.

How does an accreditation programme drive improvement on acute inpatient mental health wards? An exploration of members' views

Background: Concerns have been raised about inpatient mental health care. An accreditation model can improve compliance with standards associated with improved quality of health care.Aims: To explore the effects of a standards-based, peer review, accreditation model on standards of care in acute inpatient wards and explore how staff achieved change.Method: Quality of care was assessed by independent peer review against evidence-based standards in an accreditation process. Staff from the 11 wards receiving subsequent accreditation were interviewed to find out what processes had enabled accreditation.Results: Sixteen wards enrolled: four achieved immediate and 11 subsequent accreditation. The most common reasons for initial failure of accreditation were lack of psychological therapies or 1:1 time for patients, and presence of ligature points. Ward staff perceived the accreditation process improved communication, gave power to negotiate for resources, clear guidance how to practice, rewarded good practice and led to additional unrelated improvements in care.Conclusions: Acute wards need to attend to basic safety and provide talking treatments (both formal psychotherapy and basic time spent with patients). An accreditation, peer-reviewed, standards-based process can enable staff to feel confident about improvements in the quality of care.

Alternatives to standard acute in-patient care in England: differences in content of care and staff–patient contact

Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched. To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction. Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored. No significant difference was found in intensity of staff-patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives. Similarities in care may be more marked than differences at alternative and standard services. Staff-patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.