Inpatient Mental Health Rehabilitation Research Articles

Exploring women’s experiences of an inpatient mental health rehabilitation service

Exploring women’s experiences of an inpatient mental health rehabilitation service

Assessing the clinical and cost-effectiveness of inpatient mental health rehabilitation services provided by the NHS and independent sector (ACER): protocol

BackgroundMental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people’s homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness.MethodsACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners’ experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is ‘successful rehabilitation’ defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months.DiscussionThe ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services.Trial registrationISRCTN17381762 retrospectively registered.

The Experiences of Women with a Diagnosis of Borderline Personality Disorder (BPD) Using Sensory Modulation Approaches in an Inpatient Mental Health Rehabilitation Setting

Sensory approaches are being used increasingly within in-patient mental health, however, few published studies into the service user perspective exist. This interpretative phenomenological study used semi-structured interviews with four women with a diagnosis of borderline personality disorder (BPD) to provide insight into the benefits and applicability of sensory strategies in a mental health rehabilitation setting and their part in the recovery process. Four superordinate themes were identified: barriers to using sensory strategies; emotion regulation; impact of the environment; and empowerment. While preliminary in nature this study highlighted the need for an individualized approach and transferability of strategies into the community.

Evaluating the Impact of Inpatient Mental Health Rehabilitation on Quality of Life and Recovery

Previous evaluations of mental health rehabilitation services have mostly examined clinician-rated or objective outcomes. There is also a need to consider subjective, patient-rated outcomes such as quality of life and recovery. Service users in a rehabilitation unit were invited to complete quality of life and recovery measures at admission and discharge. Of 79 eligible service users, 48 (60.8%) completed measures at both admission and discharge. Significant improvements were noted in overall quality of life and recovery, as well as most individual domains of quality of life. Satisfaction with family relationships showed only modest improvement. Satisfaction with sex life showed no significant change. Users of the rehabilitation service experienced improvements in quality of life and recovery. The evaluation’s main limitations were the lack of a control group, the lack of follow-up, and the possibility of differential drop-out. Clinical and research implications are discussed.

Impact of inpatient mental health rehabilitation on psychiatric readmissions: a propensity score matched case control study

Background: Examination of readmission data is a standard method for evaluating health service outcomes. Limited work has evaluated the efficacy of mental health rehabilitation, despite the need for evidence-based approaches.Aims: To evaluate the impact of inpatient mental health rehabilitation using metrics of psychiatric readmissions routinely collected at occasions of service.Methods: Consumers (n = 252) of a nonacute inpatient mental health rehabilitation unit were case matched with normative clients from community mental health services. The impact of inpatient care was measured on: (1) the occurrence of a psychiatric readmission within 12 months of discharge; (2) the total number of psychiatric readmissions within 12 months of discharge; and (3) the number of days to a psychiatric readmission after discharge.Results: The proportion of consumers experiencing a readmission significantly decreased following inpatient care, comparable to the normative group. The number of readmissions also significantly decreased, approaching normative group levels, except in consumers with comorbid bipolar, substance use, or personality disorder. Time to a readmission significantly increased following inpatient care, approximating normative group values, and was related to the number of previous admissions.Conclusion: Routinely collected service data demonstrated nonacute inpatient mental health rehabilitation reduces re-hospitalization, which will have benefits for both consumers and health services.

Review of physical health care in patients with chronic psychiatric conditions in a rehabilitation unit

IntroductionAn important aspect to consider in chronic patients on psychotropic medication is their physical health status. Along with an aging population and the side effects of the medication it is key to identify complexities of their physical health that may be troubling the patient or can potentially effect the patient.ObjectivesUsing the standards for inpatient mental health rehabilitation services highlighted by AIMS Rehab.we will assess if the current method used to highlight any physical health concerns are being met for the new patients admitted in to the unit from January 2016 to September 2016.AimsEvaluate the quality of physical healthcare in Margaret Laurie House (Surrey and Borders NHS trust Rehabilitation unit).MethodsWe designed a spreadsheet to capture the standards as outlined in ‘physical healthcare’ section of the AIMs Rehab document.We obtained the relevant patient data using the System One electronic patient record. The system contains an embedded template where physical health parameters are entered so we were able to simply copy the data from these sections. We then translated this information into an Excel spreadsheet format.ResultsThe analysis of the data remains as work in progress at the current time. We anticipate low compliance with the 8 outlined standards (9.1.1–9.2.2). These were all considered type 1 standards; according to the AIMS rehab guidance the expectation is that the service must meet 100% of these standards. Upon re-audit we aim for 100% compliance.ConclusionWork in progress-to be updated.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

BackgroundThe REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap.MethodsThe programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses.ResultsMost NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study.ConclusionsPeople who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery.Main limitationOur programme included only NHS, non-secure, inpatient mental health rehabilitation services.Trial registrationCurrent Controlled Trials ISRCTN25898179.FundingThe NIHR Programme Grants for Applied Research programme.

Rapid realist review of the evidence: achieving lasting change when mental health rehabilitation staff undertake recovery-oriented training.

The aim of this study was to identify the factors contributing to lasting change in practice following a recovery-based training intervention for inpatient mental health rehabilitation staff. Staff training may help nurses and other staff groups in inpatient mental health rehabilitative settings to increase their recovery-oriented practice. There are no published reviews on the effectiveness of such training and few long-term evaluations. This review informed a realist evaluation of a specific intervention (GetREAL). Rapid realist review methodology was used to generate and prioritize programme theories. ASSIA, CINAHL, Cochrane Library, Medline, PsycINFO, Scopus, Web of Science and grey literature searches were performed in September 2014-March 2015 with no date restrictions. Stakeholders suggested further documents. GetREAL project documentation was consulted. Programme theory development took place iteratively with literature identification. Stakeholders validated and prioritized emerging programme theories and the prioritized theories were refined using literature case studies. Fifty-one relevant documents fed into 49 programme theories articulating seven mechanisms for lasting change. Prioritized mechanisms were: staff receptiveness to change; and staff feeling encouraged, motivated and supported by colleagues and management to change. Seven programme theories were prioritized and refined using data from four case studies. Lasting change can be facilitated by collaborative action planning, regular collaborative meetings, appointing a change agent, explicit management endorsement and prioritization and modifying organizational structures. Conversely, a challenging organizational climate, or a prevalence of 'change fatigue', may block change. Pre-intervention exploration may help identify any potential barriers to embedding recovery in the organizational culture.

Every voice should be valued.

During a second-year placement on an inpatient mental health rehabilitation unit, I observed two isolated incidents of what I felt to be poor nursing care.

Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England.

BackgroundMental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10–20 % of all those with psychosis, they absorb 25–50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome.MethodInpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care.ResultsAcross England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients’ social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00–1.08), and patients’ activity (OR 1.03, 95 % CI 1.01–1.05) and social skills (OR 1.13, 95 % CI 1.04–1.24) at recruitment.ConclusionInpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients’ social skills and activities may further enhance the effectiveness of these services.

Quality assessment of mental health rehabilitation services

ObjectivesProviding good quality mental health care is vital to achieve better outcomes but service quality is a complex, multidimensional construct that extends beyond the delivery of specific evidence based treatments and interventions. This makes it difficult to operationalize and measure, particularly at the international level where different socioeconomic and political contexts impact. Mental health rehabilitation services focus on people with severe and complex psychosis. This group are one of the most socially excluded in society and are vulnerable to exploitation and abuse. They are also, be definition, difficult to treat and, historically, have often been institutionalised in hospital or community facilities.AimsThis presentation will report on the development and application of an internationally validated quality assessment tool for longer term mental health care facilities, the Quality Indicator for Rehabilitative Care (QuIRC).MethodsThe content of the QuIRC was derived from a systematic literature review, international Delphi exercise and review of care standards in ten European countries. Its psychometric properties were assessed in over 200 longer-term mental health facilities across Europe involving validation with over 1750 service users. It has subsequently been used in a national programme of research into inpatient mental health rehabilitation services in England which will also be briefly described.ResultsThe QuIRC has excellent inter-rater reliability and validity. Specific aspects of care assessed by the QuIRC have been found to be associated with successful community discharge from inpatient mental health rehabilitation services.ConclusionsThe QuIRC is a free to use, standardised and validated on-line international quality assessment benchmarking and research tool, available in ten European languages.Disclosure of interestThe author has not supplied his declaration of competing interest.

Development of a staff training intervention for inpatient mental health rehabilitation units to increase service users’ engagement in activities

Introduction This study developed a training intervention (‘GetREAL’) to change the practice of staff working in National Health Service inpatient mental health rehabilitation units in order to increase service users’ engagement in activities. Method The intervention was developed through eight consultation events and piloting in two settings, drawing on the expertise of occupational therapists, psychiatrists, organisational change specialists and service users, together with multi-disciplinary teams. Results A manual for the intervention, a fidelity checklist, an induction programme and training materials were produced. The intervention applied a three-stage change model (predisposing, enabling and reinforcing) and was informed by theories from occupational therapy and organisational development. It was delivered by psychiatrists, occupational therapists, activity workers and service users. Staff were encouraged to change their ward structures and routines as well as their practice. Clinical supervision and reflective practice were integral to the trainers’ regime. Conclusion The intervention was theoretically coherent, allied to practice and shown to be feasible to deliver. It offered tailored work-based training to the whole multi-disciplinary team, including support staff. Making activity central to rehabilitation could improve patients’ use of time and their consequent function and wellbeing. However, questions were raised about long-term sustainability of change processes.

Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial.

BackgroundWe undertook a cluster randomised controlled trial to assess the effectiveness of a staff training intervention to improve patient engagement in activities in inpatient mental health rehabilitation units. Concurrently, we undertook a qualitative study to investigate the experiences of staff within the intervention units and the contextual issues that may have influenced the effectiveness of the intervention.MethodWe conducted focus groups with staff working in the inpatient units that received the intervention, sampled using a maximum variation strategy.ResultsThe intervention was accepted by staff. However, the skills gained, and changes to the unit’s processes and structures that were agreed with the intervention team were not sustained after they left. The main reasons for this were a) external factors (economic recession, resource limitations); b) organisation level factors (lack of senior staff support; competing priorities); c) limitations of the intervention itself (length of intensive training period; reinforcement of skills).ConclusionThis study illustrates some of the inter-related factors which operate at different levels within and outside of NHS organisations that may impact on the success of complex interventions. These factors need to be considered when designing interventions to ensure adequate buy-in from senior staff.Trial registrationCurrent Controlled Trials ISRCTN25898179 (Registered 23 April 2010)

Occupational therapists as change agents in multidisciplinary teams

IntroductionThis qualitative study explored the experiences of occupational therapists attempting to implement change within multidisciplinary teams via a 5-week training intervention. This encouraged ward staff in inpatient mental health rehabilitation units to facilitate service user engagement in activities. This study is supplementary to a randomised control trial (RCT).MethodDaily diaries and training reflections completed by two therapists (P1 and P2) during the training were subjected to Framework analysis. The indexing stage of this process was completed in collaboration with the participants.FindingsWhen implementing change, the occupational therapists encountered a number of barriers such as emotional responses and attitudes towards service users. Facilitators of change included openness, sharing knowledge and skills, and reported change. The analysis revealed a change process moving from ‘assessing the context’, to ‘building relationships’ and ‘addressing issues’ that was aided by the therapists’ high-level skills and capacity for social and self-awareness.ConclusionThe process of change aligned well with the chosen three-stage model of change as well as occupational therapy philosophy. When acting as change agents, the therapists adapted and applied their clinical skills to the organisational context in accord with their core values and capacity for social and self-awareness.

Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users’ engagement in activities

BackgroundThis study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this.Methods/designThis study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users’ engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a “hands-on”, manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care.DiscussionThe study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).

‘I know how to look after myself a lot better now’: service user perspectives on mental health in-patient rehabilitation

Aims: This research explored experiences of an in-patient mental health rehabilitation unit. This setting has a place in current services but has not been the focus for recent developments. Perspectives were sought from people who had been discharged more than a year previously. Method: A qualitative method was used. Ten service users were interviewed individually, using photographs of the unit to elicit responses. The data were subject to detailed analysis. Findings: Of the three overarching themes, the first, ‘past’, suggested that a need for the unit arose from complex and severe problems, often for people in transition. The experience of the unit, the second theme, ‘present’, considered four aspects; routine, looking after yourself, time and space, and choice, based on the staff approach. The third theme, ‘future’, identified that following time at the unit, participants had restored, reconstructed, and developed routines, identities, and roles. Conclusions: Overall, these themes suggested the diversity of experiences and indicated the importance of recovery-oriented practice. Most participants valued their time in the unit and could see the benefits for others. Staff skills in enabling individual rehabilitation and recovery are critical, to ensure individual goals are identified and remain the focus of interventions.

Nursing handover within mental health rehabilitation: An exploratory study of practice and perception

Nursing handover is an established practice that involves an interchange of information between nurses to inform of the condition of patients. It is essential to nursing practice in terms of continuity and quality of patient care. However, there is a lack of agreement about the quality, content, and process of handover and, in particular, a lack of information specific to mental health contexts. This paper reports the results of exploratory research of the practice and beliefs about verbal nursing handover within an inpatient mental health rehabilitation setting. Qualitative data were obtained from audiotaped handovers and interviews with nurses and analysed using content analysis. Handovers were found to lack structure and content, be retrospective, problem-focused and inconsistent. The findings were fairly consistent with the literature and would likely be applicable across nursing settings; however, the need to appraise nursing handover in unique contexts was also revealed. The study raised questions about how nursing handover reflects the goals and philosophies of mental health rehabilitation and whether nursing handover is an activity fully integrated with the focus of mental health rehabilitation.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders

A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.