Acute Psychiatric Inpatient Wards Research Articles

Exploring the relationship between activities and emotional experience using a diary in a mental health inpatient setting.

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n=102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11hours assessed (34%) were spent doing nothing, only 0.88hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

Group-based rehabilitative interventions in the Department of Mental Health of Viterbo, Italy

This paper aims at examining the effectiveness of four group-based rehabilitative interventions carried out in the Acute Psychiatric Inpatient Ward and in the Department of Mental Health of Viterbo, Italy. The effectiveness of the four group-based interventions on patients and their relatives was evaluated in both inpatient and outpatient settings in terms of clinical efficacy, disease awareness, quality of life, and ability to cope with stress. A set of specific assessment tools was used for the purpose. Group-based interventions showed high level of effectiveness in improving patients' insight, clinical stability, quality of life and satisfaction in using the services, and in enhancing family members' ability to manage stress. Group-based rehabilitative interventions enable mental health services to provide users with additional treatment options complementary to drug therapy, improving the quality of life of patients and their families in a recovery-oriented perspective.

An in-depth observational study of an acute psychiatric ward: combining the psychodynamic observational method with thematic analysis to develop understanding of ward culture

The question of how to create benign organisational cultures in health care is a topic of particular concern in the UK at the present time. The current study aimed to further understanding of complex health care cultures in the National Health Service (NHS), with a focus on an acute adult in-patient psychiatric ward. The psychoanalytic observational method was used for this purpose. The first author conducted six-hour long observation sessions on the ward at weekly intervals, writing detailed process recordings after each observation to take to a supervision group for discussion. The six presentations of observational material and the responses of the supervision group were audiotaped and transcribed. These data were then analysed thematically. The picture that emerged was of a fragile ward environment in which staff appeared fearful of engagement with patients, there was a sense of confusion regarding roles and decision-making processes, and the nursing team felt burdened by responsibility, isolated and anxious about criticism from outside. Contemporary developments within the social defence paradigm are applied to these findings in the context of the intense pressures currently facing staff in the NHS.

Continuous quality improvement in a Maltese hospital using logical framework analysis

Purpose The purpose of this paper is to present the application of logical framework analysis (LFA) for implementing continuous quality improvement (CQI) across multiple settings in a tertiary care hospital. Design/methodology/approach This study adopts a multiple case study approach. LFA is implemented within three diverse settings, namely, intensive care unit, surgical ward, and acute in-patient psychiatric ward. First, problem trees are developed in order to determine the root causes of quality issues, specific to the three settings. Second, objective trees are formed suggesting solutions to the quality issues. Third, project plan template using logical framework (LOGFRAME) is created for each setting. Findings This study shows substantial improvement in quality across the three settings. LFA proved to be effective to analyse quality issues and suggest improvement measures objectively. Research limitations/implications This paper applies LFA in specific, albeit, diverse settings in one hospital. For validation purposes, it would be ideal to analyse in other settings within the same hospital, as well as in several hospitals. It also adopts a bottom-up approach when this can be triangulated with other sources of data. Practical implications LFA enables top management to obtain an integrated view of performance. It also provides a basis for further quantitative research on quality management through the identification of key performance indicators and facilitates the development of a business case for improvement. Originality/value LFA is a novel approach for the implementation of CQI programs. Although LFA has been used extensively for project development to source funds from development banks, its application in quality improvement within healthcare projects is scant.

Internalized Stigma and Perceived Family Support in Acute Psychiatric In-Patient Units

AimThis descriptive study aims to identify the relationship between internalized stigma and perceived family support in patients hospitalized in an acute psychiatric unit. MethodThe sample is composed of 224 patients treated in an acute inpatient psychiatric ward in İstanbul, Turkey. The data were collected using information obtained from the Internalized Stigma of Mental Illness Scale and Social Support from Family Scale. ResultsThe mean age of the patients was 37±11.56years, and the mean duration of treatment was 6.27±5.81years. Most patients had been hospitalized three or more times. Of the total number of patients, 66.1% had been taken to the hospital by family members. We noted a statistically significant negative correlation between the total scores obtained from the perceived Social Support from Family Scale and the Internalized Stigma of Mental Illness Scale. ConclusionThe patients were observed to stigmatize themselves more when the perceived social support from their family had decreased.

Clinical Handover: Quality Assessment of the Multidisciplinary Handover Process On an Acute Psychiatric Mixed Gender General Adult Inpatient Ward

Handover allows the transfer of responsibility for patient care between healthcare professionals. In 2011, The Royal College of Physicians (RCOP) outlined a set of standards for a ‘good handover’. Poor quality handover leads to error and is a preventable cause of patient harm. The aim of this audit was to analyse the handover process on a 26-bedded general adult inpatient ward, and make recommendations from the findings to improve patient-safety based upon these standards. During 14 handovers, quantitative information was collected on duration, attendees and content of information, graded against the RCOPs standards. In 100% of handovers, 1 nurse and 2 doctors were present. Members from other professional bodies attended less often (14-79%). Information duplicated on consecutive days ranged between 27% and 42%. The handover process met 50% of the RCOP’s standards. Handover process is embedded in the hospital culture and is recognised as a multidisciplinary activity. However, inconsistent attendance did not provide equal opportunity for the transfer of information or result in clear arrangements for ongoing care, which was felt to be a risk to patient safety. A system of fluid and transferable data on documentation should be in place. It was agreed that a computerised handover-sheet available to all professionals to review and access during the course of the day would be in place. A suitable time to maximise attendance was agreed. Re-audit following these recommendations would form a robust framework to implement these changes across the Unit.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia.

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

Reproductive health in women with serious mental illnesses

To determine what problems female psychiatric patients have in terms of reproductive health. The reproductive health problems faced by female psychiatric patients are matters that have been neglected in the areas of both psychiatry and women's health. This study aims to make a contribution from Turkey to the literature in this neglected field. The study is descriptive and was conducted with 292 female patients treated in an acute inpatient psychiatric ward. Data were collected through face-to-face interviews and a questionnaire based on the literature and prepared by the researchers which was designed to determine the kinds of reproductive health issues the patients were experiencing. It was found that compared with healthy women, the distinctive features of the participants in terms of sexuality were more negative; in particular, patients diagnosed with bipolar disorder were more likely to have been forced by their partners to have sex, they had suffered from rape or sexually transmitted diseases, the majority of those who had previous sexual experience had tried to use contraceptives but had been unable to continue using them, they were most likely to choose the method of withdrawal for contraception, their rates of pregnancy and abortion were high, they received less antenatal care, and they were more likely to have smoked during pregnancy. It was found that female patients with psychiatric disorders had more negative attributes with regard to marriage, sexuality, family planning, maternal characteristics and pregnancy, compared with a corresponding healthy population. The results of this study may be useful for nurses in the clinical field for calling an attention and raising an awareness of the reproductive health problems of women with psychiatric disorders, taking the necessary preventive measures, and developing damage-reducing strategies.

Staff happiness and work satisfaction in a tertiary psychiatric centre

Mental health professionals are at a high risk of burnout. Positive psychology outcomes of staff in acute in-patient psychiatric wards are poorly researched and unclear. To quantify the satisfaction with life and work-life satisfaction of mental health staff at a large university-affiliated tertiary psychiatric centre. We utilized the Satisfaction with Life Scale (SWLS) and the Work-Life Satisfaction Questionnaire (WLSQ). Two hundred and nine out of 450 staff members (46%) participated; mean age 48.2 + 9.9 years; 63% were male. On average the participants had been practising their speciality for 21.1 + 9.8 years (range: 2-48). The mean total SWLS scores differed significantly between professions (P < 0.05). The highest levels of happiness were reported by psychologists and social workers, followed by the administrative staff, the psychiatrists and finally the nursing staff. Staff scored the highest for work as a 'calling' followed by work as a 'career' and the lowest rating for work as a 'job'. The mean total WLSQ score differed between professions, (P < 0.01). The highest levels of work as a calling were reported by psychiatrists (mean 2.87 of possible 5.0), followed by psychologists and social workers, nursing staff and finally administrative staff. Satisfaction with life and work orientation do not correlate among mental health professionals. Although highly motivated and perceiving psychiatry as a 'calling' psychiatrists score low on levels of satisfaction with life. Improving staff happiness may contribute to increase in moral and counter burnout.

‘Safe enough in here?’: patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward

To understand the experience of being a patient on an acute psychiatric inpatient ward. Acute psychiatric inpatient care is an integral part of the mental health system. A key driver for admission to acute wards is risk. Previous research indicates that people do not always feel safe when in an acute ward. Understanding the patient experience of safety can influence nursing practice, as well as policy and service development. A qualitative approach was used. Patient experience was conceptualised as represented through narrative as data. Sociolinguistic theories linking narrative structure with meaning informed the development of the analytic framework. Thirteen patients with a variety of diagnoses were recruited from an acute ward. Unstructured interviews were carried out in participants' homes two and six weeks postdischarge. Holistic analysis of each individual's data set was undertaken. Themes running across these holistic analyses were then identified and developed. Participant narratives were focused around themes of help, safety and power. This study presents findings relating to the experience of safety. Participants expected to be safe from themselves and from others. Initially, they experienced a sense of safety from the outside world. Lack of knowledge of their fellow patients made them feel vulnerable. Participants expected the nurses to keep them safe, and felt safer when there were male nurses present. Participants talk about safety in terms of psychological and physical safety. A key issue was the perception of threat from other patients, highlighting the need to consider patient safety as more than physical safety. Nurses need to be sensitive to the possibility that patients feel unsafe in the absence of obvious threat. Institutional structures that challenge patients' sense of safety must be examined.

Hearing voices: re/presenting the findings of narrative research into patient experience as poems

The study aimed to understand the experience of being a patient on an acute psychiatric inpatient ward. A further aim was to open up spaces for the voices of participants to be heard. Contemporary government policy places patient experience at the centre of healthcare policy and service development. Despite this, those who occupy marginalized discourses struggle to be heard within the dominant discourse of health care. A qualitative approach was used, and narrative was conceptualized as representing experience. Sociolinguistic theories informed the development of the analytic framework treating meaning as contextual and arising from both content and structure of narratives. Concepts of representation, voice and authorship were problematized. Thirteen people who had been inpatients on an acute psychiatric inpatient ward participated. Narrative data were gathered using unstructured interviews. The data were analysed holistically using a method that attended to both the structure and content of the narrative. The product of these holistic narratives was the development of a poem representing each participant's experience. This paper focuses on the development of these poems as a method of decentring the authorial voice and opening up spaces for the voices of the participants to be heard.

Valproate in acute mania: is our practice evidence based?

This audit was conducted on acute psychiatric in-patient wards with the aim of establishing if valproate prescribing in acute mania followed evidence-based guidelines with particular emphasis on formulations used and whether accelerated valproate dosing was employed. Case notes from 43 (42 percent male) patients admitted with mania and subsequently discharged on valproate were reviewed. Valproate formulation, weight measurement (necessary for dose-calculation in accelerated dosing), initial valproate dose and increments, serum valproate monitoring and other prescribed psychotropic agents were noted. Most (95 percent) patients received sodium valproate (epilim chrono/generic), the remaining received valproate semi-sodium (depakote). All but one patient received antipsychotic medication in combination. Weight was recorded in only four (9 percent) patients. The mean valproate daily dose after the first week was 1,027mg (sd = 408). It took 29 (sd = 42) days to reach the maximum daily dose (1,426 mg sd = 467) from valproate initiation. Serum levels were monitored in 34 (79 percent) cases, but the mean period between valproate initiation to the first serum level test was 38 (sd = 47) days. A significant positive correlation was found between days taken to reach maximum dose and hospital stay (Spearman's rho = 0.41, n = 43, p = 0.006, two-tailed). Accelerated valproate dosing was not common practice, which may have resulted in suboptimal efficacy, probably leading to combination treatment. This study highlights the need for adequate initial dosing and dose increments when treating manic patients and suggests current practice is not evidence-based. Local prescribing policy and national guidelines' influence on practice are discussed.

Events Preceding Changes in Conflict and Containment Rates on Acute Psychiatric Wards

The main objective of this study was to learn more about what increases or decreases the likelihood of patient conflict (such as verbal abuse, violence, and rule breaking) and containment (such as seclusion, manual restraint, and enforced medication) events in acute inpatient psychiatric wards. Line graphs that mapped the total conflict and containment scores over two years on 16 acute inpatient psychiatric wards in the United Kingdom (London) were matched with chronological events that were documented in 120 qualitative semistructured interviews with ward managers and consultant psychiatrists during the same two-year period. Conflict and containment scores were derived from the validated Patient-Staff Conflict Checklist-Shift Report, which was completed by nurses at the end of each shift to log the frequency of conflict behaviors of patients and the staff containment measures. A total of 463 score transitions (upturns and downturns) were identified in the graphs. A total of 323 events were matched to these transitions. A thematic analysis of these events produced 40 themes, which were organized into four categories: patient centered, staff centered, practice or ward centered, or other themes. Thirteen themes were significantly associated with conflict and containment score transitions, 11 of which were staff centered. For example, negative staff morale and staffing change resulting in a negative impact significantly increased the likelihood that conflict and containment would occur, whereas report of positive staff practice significantly decreased the likelihood of such events occurring. The results support the theory that ward staff play a crucial role in influencing the likelihood that conflict or containment events will occur in inpatient psychiatric settings.

„Alle sagen, du kannst kommen und mit uns sprechen“: Patientenerwartungen und -erfahrungen hinsichtlich der Betreuung auf einer psychiatrischen Aufnahmestation

Zusammenfassung der Studie: Stenhouse, R. C. (2011). ‚They all said you could come and speak to us: patients‘ expectations and experiences of help on an acute psychiatric inpatient ward. Journal of Psychiatric and Mental Health Nursing, 18, 74-80.

Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.

Adoption of an Internet‐based patient education programme in psychiatric hospitals

Internet-based patient support systems are widely assumed to predict a future trend in patient education. Coherent information is still lacking on how patient education is adopted in psychiatric hospitals and how information technology is used in it. Our aim was to describe nurses' adoption of an Internet-based patient education programme and the variables explaining it. The study was based on Rogers' model of the diffusion of innovation. The Internet-based patient education sessions were carried out by nurses on nine acute psychiatric inpatient wards in two Finnish hospitals. They were evaluated with reports and analysed statistically. Out of 100 nurses, 83 adopted the programme during the study period. The nurses fell into Rogers' groups, late majority (72%), laggards (17%), early majority (7%), early adopters (3%) and innovators (1%). Three groups were formed according to their activity: laggards, late majority, adopters (including early majority, early adopters, innovators). There was a statistical difference between the nurses' programme adoption between the two hospitals (P= 0.045): more laggards (65% vs. 35%) and adopters (73% vs. 27%) in the same hospital. The findings help to provide insight into the contexts and settings when adopting information technology programmes in the area of mental health care.

‘They all said you could come and speak to us’: patients' expectations and experiences of help on an acute psychiatric inpatient ward

Acute psychiatric inpatient care forms an integral part of mental health services. Few studies have focussed on the patient experience of acute care. Research into patient experience is increasingly important to policy and service development processes. Knowledge of patient experiences facilitates the development of nursing practice. The aim of the study was to gain insight into the experience of being a patient on an acute inpatient psychiatric ward. Thirteen participants were recruited from the acute ward. Unstructured interviews were used to gather narrative data of their experiences. Holistic analysis of the narratives was informed by Gee's socio-linguistic theories that meaning is linked to narrative structure. Reading of the holistic analyses yielded themes of help, safety and power running across the participants' experiences. The patient experience was characterized by dissonance between expectation and experience, the search for a nurse-patient relationship and the development of strategies to cope with being on the acute ward. This paper focuses on the theme of 'Help' where participants describe their expectation that they will receive help through the development of relationships with the nurses, and their experience of the barriers to this. In response, participants developed strategies to support each other.

Ethnic variations in pathways to acute care and compulsory detention for women experiencing a mental health crisis.

Background: Much recent debate on excess rates of compulsory detention and coercive routes to care has focused on young black men; evidence is less clear regarding ethnic variations among women and factors that may mediate these.Aim: To explore ethnic variations in compulsory detentions of women, and to explore the potential role of immediate pathways to admission and clinician-rated reasons for admission as mediators of these differences.Method: All women admitted to an acute psychiatric inpatient ward or a women’s crisis house in four London boroughs during a 12-week period were included. Data were collected regarding their pathways to care, clinician-rated reasons for admission, hospital stays, and social and clinical characteristics.Results: Two hundred and eighty seven (287) women from white British, white other, black Caribbean, black African and black other groups were included. Adjusting for social and clinical characteristics, all groups of black patients and white other patients were significantly more likely to have been compulsorily admitted than white British patients; white British patients were more likely than other groups to be admitted to a crisis house and more likely than all the black groups to be admitted because of perceived suicide risk. Immediate pathways to care differed: white other, black African and black other groups were less likely to have referred themselves in a crisis and more likely to have been in contact with the police. When adjustment was made for differences in pathways to care, the ethnic differences in compulsory admission were considerably reduced.Discussion: There are marked ethnic inequities not only between white British and black women, but also between white British and white other women in experiences of acute admission. Differences between groups in help-seeking behaviours in a crisis may contribute to explaining differences in rates of compulsory admission.

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.

Evaluation of the effect of a structured intervention for the management of behavioural disturbance on the level of seclusion in an acute psychiatric inpatient ward

Background: Seclusion in psychiatric inpatient settings is contentious, and services attempt to minimize its use. Many studies compare seclusion rates before and after the introduction of an intervention, but few control for the effect of external factors such as legislative constraints and patient characteristics.Aims: To evaluate the effect of a programme designed to manage acute arousal.Method: Seclusion rates in a six-month period incorporating a programme to manage acute arousal were compared with the previous six months. The intervention focused on formal assessment of arousal levels and an escalating set of actions by nursing staff.Results: Seclusion rates in the two periods were comparable, both before and after controlling for patient characteristics. Duration of seclusion events appeared to be heavily influenced by local legislative constraints.Conclusions: A programme designed to reduce seclusion showed no difference from baseline after taking various factors into account. This may have been at least partly because most seclusion events occurred early in an admission. Many patients arrive on the unit already requiring seclusion, and any impact of a ward programme on them is limited. Since seclusion is a comparatively uncommon event, and attributable to a minority of patients, appropriate analytic methods are required.