Inpatient Mental Health Services Research Articles

Incidence and Determinants of Mental Health Service Use After Bariatric Surgery

Obesity is associated with an increased prevalence of psychiatric disorders. The association of bariatric surgery with mental health outcomes is poorly understood. To investigate the association of bariatric surgery with the incidence of outpatient, emergency department (ED), and inpatient mental health service use. This statewide, mirror-image, longitudinal cohort study used data from Western Australian Department of Health Data Linkage Branch records from all patients undergoing index (ie, first) bariatric surgery in Western Australia over a 10-year period (January 2007-December 2016), with mean (SD) follow-up periods of 10.2 (2.9) years before and 5.2 (2.9) years after index bariatric surgery. The data analysis was performed between November 2018 and March 2019. Index bariatric surgery. The incidence and predictors for mental health presentations, deliberate self-harm, and suicide in association with the timing of bariatric surgery. A total of 24 766 patients underwent index bariatric surgery; of these, the mean (SD) age was 42.5 (11.7) years and 19 144 (77.3%) were women. Use of at least 1 mental health service occurred in 3976 patients (16.1%), with 1401 patients (35.2%) presenting only before surgery, 1025 (25.8%) presenting before and after surgery, and 1550 patients (39.0%) presenting only after surgery. There was an increase in psychiatric illness presentations after bariatric surgery (outpatient clinic attendance: incidence rate ratio [IRR], 2.3; 95% CI, 2.3-2.4; ED attendance: IRR, 3.0; 95% CI, 2.8-3.2; psychiatric hospitalization: IRR, 3.0; 95% CI, 2.8-3.1). There was also a 5-fold increase in deliberate self-harm presentations to an ED after surgery (IRR, 4.7; 95% CI, 3.8-5.7), with 25 of 261 postoperatives deaths (9.6%) due to suicide. Complications after bariatric surgery requiring further surgical intervention and a history of mental health service provision before surgery were the most important associations with subsequent mental health presentations after surgery. Deliberate self-harm and mental and behavioral disorders due to psychoactive substance use before bariatric surgery were the main associations with subsequent deliberate self-harm or suicide after surgery. We observed an increase in mental health service presentations after bariatric surgery, particularly among those who had prior psychiatric illnesses or developed surgical complications requiring further surgery. These findings caution the hypothesis that weight reduction by bariatric surgery will improve mental health in patients with obesity.

Predicting Inpatient Aggression in Forensic Services Using Remote Monitoring Technology: Qualitative Study of Staff Perspectives.

BackgroundMonitoring risk of imminent aggression in inpatient forensic mental health services could be supported by passive remote monitoring technology, but staff attitudes toward the relevance and likelihood of engagement with this technology are unknown.ObjectiveThis study aimed to explore staff views, specifically potential benefits and implementation barriers, on using this technology for monitoring risk of inpatient aggression.MethodsWe conducted semistructured focus groups with nurses in an inpatient forensic mental health service. We used thematic analysis with two independent raters to identify themes and subthemes related to staff attitudes toward passive remote monitoring. We subsequently checked with members to ensure the validity of the themes identified by the raters.ResultsFrom January to March 2019, a total of 25 nurses took part in five focus groups. We identified five main themes, one of which concerned the potential benefits that passive remote monitoring could provide for monitoring risk of aggression. Staff suggested it could provide an early warning of impending aggression and enable support to be provided earlier. The remaining themes concerned implementation barriers, including risks to the users’ physical and mental well-being; data security concerns and potential access by third parties; the negative impact of a constant stream of real-time data on staff workload; and design characteristics and user awareness of the benefits of passive remote monitoring.ConclusionsPassive remote monitoring technology could support existing methods of monitoring inpatient aggression risk, but multiple barriers to implementation exist. Empirical research is required to investigate whether these potential benefits can be realized, and to identify ways of addressing these barriers to ensure acceptability and user engagement.

Safety attitudes, perceived organizational culture and knowledge of the physiologically deteriorating patient among mental health nurses: Cross-sectional, correlational study.

Mental health nurses have traditionally lagged in terms of physical healthcare skills and have been found to have poorer cultural safety-related attitudes relative to other nurses. Organizational culture, including safety-related culture, is associated with important aspects of care quality. The aim of the current study was to examine the relationships between safety-related attitudes, physical healthcare-related knowledge and organizational culture among mental health nurses. By doing so, the intention was to inform decisions about interventions to improve attitudes and care related to severe physiological deterioration among mental health nurses. The study design was cross-sectional and correlational. The safety-related attitudes of N=133 nurses from the inpatient mental health services of one Local Health District in New South Wales, Australia, were examined in terms of a range of potential predictor variables of safety attitudes (Safety Attitudes Questionnaire) including individual organizational-perceiver type (Organisational Climate Assessment Inventory), knowledge of emergency medical healthcare (Lambeth In situ Training Questionnaire), use and perception of medical emergency teams (purpose-designed questionnaire) and a range of demographic variables. Regression analyses revealed that those who perceived the organization to have a primarily market-oriented culture had poorer safety-related attitudes than those who perceived a more clan-type culture. Number of years qualified was negatively associated with safety attitudes. To our knowledge, this is the first study in mental health which demonstrates a link between organizational culture-perception and safety attitudes related to physical healthcare. Results suggest that, among nurses, individuals have quite different perceptions of the organizational culture. In turn, this suggests that the 'one-size fits all' approach to changing organizational culture may be inappropriate.

The relationship between workforce characteristics and perception of quality of care in mental health: A qualitative study

BackgroundMental health services worldwide are under strain from a combination of unprecedented demand, workforce reconfigurations, and government austerity measures. There has been relatively little research or policy focus on the impact of staffing and skill mix on safety and quality in mental health services leaving a considerable evidence gap. Given that workforce is the primary therapeutic intervention in secondary mental health care this constitutes a major deficit. ObjectiveThis study aimed to explore the impact of staffing and skill mix on safety and quality of care in mental health inpatient and community services. DesignExploratory, qualitative methodology; purposive sampling. SettingsInpatient and community mental health services in the United Kingdom. Participants21 staff (including nurses, occupational therapists, psychiatrists, social workers, and care co-ordinators) currently working in mental health services. MethodsWe conducted semi-structured telephone interviews with a purposive sample of staff recruited via social media. We asked participants to describe the staffing and skill mix in their service; to reflect on how staffing decisions and/or policy affected safety and patient care; and for their views of what a well-staffed ward/service would look like. We conducted thematic analysis of the interview transcripts. ResultsThe participants in this study considered safestaffing to require more than having ‘enough’ staff and offered multiple explanations of how staffing and skill mix can impact on the safety and quality of mental health care. From their accounts, we identified how the problem of ‘understaffing’ is self-perpetuating and cyclical and how its features interact and culminate in unsafe care. We conceptualised the relationship between staffing and safety as a ‘vicious cycle of unsafestaffing’ which comprised: (1) understaffing (the depletion of resources for safe care provision); (2) chronic understaffing (conditions resulting from and exacerbating understaffing); and, (3) unsafestaffing (the qualities of staffing that compromise staff capacity to provide safe care). ConclusionsContinued policy focus on safestaffing is clearly warranted, especially in mental health as staffing constitutes both the principal cost and main therapeutic driver of care. This paper provides compelling reasons to look beyond regulating staff numbers alone, and to consider staff morale, burden and the cyclical nature of attrition to ensure the delivery of high quality, safe and effective services. Future research should investigate other mechanisms via which staffing impacts on safety in mental health settings.

Costs of Mental Health Services in Czechia: Facilitating an Evidence-Based Reform of Psychiatric Care.

Information about unit costs of psychiatric care is largely unavailable in Central and Eastern Europe, which poses an obstacle to economic evaluations as well as evidence-based development of the care in the region. The objective of this study was to calculate the unit costs of inpatient and community mental health services in Czechia and to assess the current practices of data collection by mental healthcare providers. We used bottom-up microcosting to calculate unit costs from detailed longitudinal accounts and records kept by three psychiatric hospitals and three community mental health providers. An inpatient day in a psychiatric hospital costs 1504 Czech koruna (CZK; €59), out of which 75% is consumed by hotel services and the rest by medication and therapies. The costed inpatient therapies include individual therapies provided by a psychiatrist or psychologist, consultations with a social worker, group therapies, organised cultural activities and training activities. As regards the community setting, we costed daycare social facilities, case management services, sheltered housing, supported housing, crisis help, social therapeutic workshops, individual placement and support, and self-help groups. The unit costs enable assigning financial value to individual items monitored by the Czech version of the Client Service Receipt Inventory, and thus estimation of costs associated with treatment of mental health problems. The employed methodology might serve as a guideline for the providers to improve data collection and to calculate costs of services themselves, with this information likely becoming more crucial for payers in the future.

Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives.

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia.

Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9–12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers’ responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.

Exploring therapeutic engagement with individuals with a diagnosis of personality disorder in acute psychiatric inpatient settings: A nursing team perspective.

Individuals with a diagnosis of personality disorder (PD) face negative attitudes and are often deemed harder to care for than individuals with other diagnoses. To improve care and engagement with services, it is essential to understand the ways general psychiatric nursing staff approach this client group. This research aims to examine the ways inpatient psychiatric nursing staff therapeutically engage with individuals with a diagnosis of PD. Focus groups were conducted with Registered Mental Health Nurses (n=7) and Health Care Assistants (formally known as nursing assistants; n=12) who care for individuals with a diagnosis of PD in a general psychiatric inpatient setting. A thematic analysis indicated six themes: the right frame of mind, knowing the service user, knowing when to engage, service user input, a unified approach, and structured admissions. The findings highlight what non-PD specialist inpatient nursing staff do in order to engage therapeutically with this group of service users and areas that require improvement. Supporting good practice could improve staff confidence when caring for this client group, lower stigma around the diagnosis, and promote a more positive experience of care for individuals with a diagnosis of PD who are using general inpatient mental health services.

Team psychological formulation to create a shared understanding of distress: a qualitative study in an older people’s mental health inpatient setting

PurposeTeam psychological formulation is an organisational intervention aimed at developing a shared understanding of a person’s mental health difficulties. There is a lack of evidence regarding the therapeutic value of this approach for older people. The purpose of this paper is to explore how older people and their carers experience a cognitive-behavioural approach to team psychological formulation, within a mental health inpatient service in the UK.Design/methodology/approachA qualitative study using interpretative phenomenological analysis was undertaken. In total, 13 participants were interviewed: five older people/carer dyads, two lone older people and one lone carer.FindingsThree overarching themes emerged: “Emotional impact of formulation” captured the mixed emotions that the process evoked in participants. “Making sense?” reflected the therapeutic value that participants experienced and what held them back from making gains in their recovery. “Disempowered people trapped in a biomedical world” illustrated the negative aspects of ward care, which hindered recovery.Research limitations/implicationsThe findings provide insights into the therapeutic value of team psychological formulation and the difficulties in facilitating the process effectively. More consistency is required to ensure that team formulation is standardised. Further research into the outcomes of the approach for older people is recommended.Practical implicationsRecommendations are proposed for how team psychological formulation can be conducted effectively, using the mnemonic “SETUP”.Originality/valueThis study focussed on older people’s and their carers’ own perspectives regarding the team psychological formulation approach.

Suicide risk grew for Missouri kids after managed care shift

After more than 2,000 Missouri children diagnosed with mental illness were shifted from traditional Medicaid into three for‐profit managed care companies, the state's hospitals noticed an alarming trend: a doubling in the percentage who had thoughts of suicide or attempted suicide, according to a study from the Missouri Hospital Association. The Medicaid change occurred in May 2017, Kaiser Health News reported April 1. The hospital association acknowledged that factors other than the move to managed care could have played a role behind the increase, including social media, cyberbullying and lack of access to specialized mental health care. The study looked at the impact of the state's shift of 160,000 low‐income children living in 61 mostly rural counties from traditional fee‐for‐service Medicaid to managed care in 2017. That included 2,152 children ages 5 to 19 who received inpatient mental health services before and after the switch to managed care. When these children were getting coverage through traditional Medicaid, about 10 percent had suicidal thoughts or made a suicide attempt in the 90 days after being discharged from an inpatient psychiatric hospital. That figure rose to nearly 19 percent after the move to managed care. Despite finding the study “fundamentally flawed,” the Missouri Health Plan Association added that it was taking the findings “very seriously.”

A mixed-methods survey to explore views of staff and patients from mental health wards prior to introduction of a digital early warning system for physical deterioration.

WHAT IS KNOWN ON THE SUBJECT?: The potential benefits of introducing technological innovation into all types of health services are recognized internationally. There are few studies exploring the use of technology in inpatient mental health settings, or the views of staff and patients regarding such developments. "Early warning systems" are increasingly used in inpatient mental health services to detect physical deterioration in patients and prompt staff to take appropriate action. We have identified no peer-reviewed publications concerning this development. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Using a questionnaire survey, this project gathered views from staff and patients on a planned change from a paper-based "early warning system" to one using handheld electronic devices (tablets). This study adds to the existing evidence by reporting specific staff and patient concerns about a technological development in an inpatient mental health setting. Some patients were concerned about confidentiality of data entered onto tablets. Whilst were either positive or neutral in attitude to the planned change some staff raised concerns that electronic devices could be used as weapons, and also that patients or visitors might misinterpret their use. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Views of staff and patients must be considered when introducing new technology into clinical practice, in order to make the change successful and sustainable. Inadequate or unclear information about the use and purpose of electronic devices may lead to misunderstandings as to their purpose and the security of their data, particularly in mental health settings. Further exploration across a range of services and countries would be useful in determining whether attitudes towards implementing similar technological change in mental health practice are commonly shared. ABSTRACT: Introduction Technological innovation offers opportunities to improve mental health care; however, little evidence exists regarding attitudes of inpatient staff and patients to such changes. We present a survey of staff and patients prior to introduction of a digital version of the National Early Warning Score (eNEWS) system for identifying physical deterioration. Aim To collate views of staff and inpatients related to prospective use of eNEWS, to inform the plan for implementation. Method Paper questionnaires were distributed to both groups in six wards prior to eNEWS implementation. Two discussion groups were then held. Results Eighty-two staff and 26 inpatients completed questionnaires. Some inpatients expressed concerns about data confidentiality. Most staff were neutral or positive about the planned change, but raised possible safety risks and the risk of electronic recording being misinterpreted by patients. The implementation plan was modified in response to this information, principally by improving communication processes with patients. Discussion This study adds to the existing evidence by reporting specific staff and patient concerns towards a form of information technology. Further evaluations would help determine the transferability of these findings. Implications for practice Listening to patient and staff views about planned technological innovation is essential for effective implementation.

Experiences of in-patient mental health services: systematic review.

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare. A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review. Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care. A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Social support network and continuity of care: an ego-network study of psychiatric service users.

For severely mentally ill (SMI) users, continuity of care requires consistency between the supports provided by the members of their social support network. However, we know little about their network cohesion and its association with continuity of care. We set out to investigate this association and hypothesised that it would depend on the severity of the user's situation and on his/her living arrangements. We conducted face-to-face interviews with 380 SMI users recruited in outpatient and inpatient mental health services in three areas in Belgium. Data regarding users' social networks were collected using an ego-network mapping technique and analysed with social network analysis. The cohesion indicators were density (frequency of connections between network members), centralisation (having a small number of central people), and egobetweenness (the user's centrality in his/her own network). Participants' perception of continuity of care was measured by the Alberta Continuity of Services Scale. Results show that cohesion indicators were associated with continuity of care only for users with high-severity problems, regardless of their living arrangements. The numbers of network members, professionals, and services in the network were all negatively associated with continuity of care for all the users. Satisfactory continuity of care requires fewer professionals or services in a user's network and a dense network for users with the most severe problems. This implies that those providing care must not only be able to increase cohesion within a network, but also to adapt their interventions to support the transition to a different, individualised network structure when severity decreases.

Facilitators of healthy life style behaviors in persons with schizophrenia-A qualitative feasibility pilot study.

Persons with schizophrenia experience high rates of cardio metabolic disorders and have a 20-25% shorter life expectancy than the general population. Health professionals led life style modification behavior programs have shown improvements, in managing aspects of metabolic problems. This study sought to identify the life style modification by exploring (1) facilitators that help persons with schizophrenia to adopt the lifestyle modification behaviors and (2) factors that help to adhere to life style modification behaviors. A qualitative study utilizing face to face interviews was conducted for five persons (n = 5) diagnosed as schizophrenia (ICD 10) and their caregivers (n = 13) receiving inpatient mental health services in a tertiary level psychiatry centre, in South India. Qualitative data was collected, organized and analyzed with thematic analysis using ATLAS.ti software. The study results identified four major themes as facilitators. (1) Factors of increased self- confidence, and personal development. (2) The need for social support and conducive environment; (3) level of self motivation (4) encouragement from health professional and availability of health services. Participants believed that engaging with programs of physical activity, dietary modification, and illness support from family would motivate them to live more healthily. Individuals with serious mental illnesses such as schizophrenia encounter physical health related problems, facilitators of lifestyle change behavior help them to adhere to change in their routine life. Lifestyle change interventions also motivate individuals to eat healthy diet and exercise regularly to prevent premature mortality.

The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services

Background:A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health.Method:This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts.Results:Fifty-eight mental health services submitted data on 2172 episodes of acutely disturbed behaviour. A benzodiazepine alone was administered in 60% of the 1091 episodes where oral medication only was used and in 39% of the 1081 episodes where parenteral medication (rapid tranquillisation) was used. Haloperidol was combined with lorazepam in 22% of rapid tranquillisation episodes and with promethazine in 3%. Physical violence towards others was strongly associated with receiving rapid tranquillisation in men (odds ratio 1.74, 1.25–2.44; p<0.001) as was actual or attempted self-harm in women (odds ratio 1.87, 1.19–2.94; p=0.007). Where physical violence towards others was exhibited, a benzodiazepine and antipsychotic was more likely to be prescribed than a benzodiazepine alone (odds ratio 1.39, 1.00–1.92; p=0.05). The data suggested that 25% of patients were at least ‘extremely or continuously active’ in the hour after rapid tranquillisation was administered.Conclusion:The current management of acutely disturbed behaviour with parenteral medication may fail to achieve a calming effect in up to a quarter of episodes. The most common rapid tranquillisation combination used was lorazepam and haloperidol, for which the randomised controlled trial evidence is very limited. Rapid tranquillisation prescribing practice was not wholly consistent with the relevant National Institute for Health and Care Excellence guideline, which recommends intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine. Clinical factors prompting the use of rapid tranquillisation rather than oral medication may differ between the genders.

Nurses’ discourses of challenging behaviour in inpatient mental-health services

Purpose Nurses working in acute mental-health services are vulnerable to occupational stress. One stressor identified is the challenging behaviour of some service users (Jenkins and Elliott, 2004). The purpose of this paper is to discuss the discourses drawn on by nurses to understand challenging behaviour and talk about its management. Design/methodology/approach Nurses working on acute and psychiatric intensive care unit (PICU) wards were interviewed, and data were analysed using discourse analysis. Findings Biomedical and systemic discourses were found to be dominant. Alternative psychosocial and emotional discourses were drawn on by some participants but marginalised by the dominant biomedical construction of challenging behaviour. Originality/value Existing studies have not considered how discourses socially construct challenging behaviour and its management in inpatient mental-health services.

Evaluation of family caregiver satisfaction with a mental health inpatient service.

To evaluate the satisfaction of family caregivers with a mental health inpatient service in Brazil. This was a cross-sectional study with a quantitative approach. A sample of 80 caretaking family members answered the abbreviated version of the Brazilian Mental Health Services' Family Satisfaction scale (SATIS-BR) and a sociodemographic questionnaire. Categorical variables were expressed as frequencies and percentages and quantitative variables as means and standard deviations. Interactions among variables and indexes of the scale were analyzed using the Student's t test, Pearson correlation coefficient and analysis of variance. The results showed a high mean overall satisfaction score when considering the categorization of the items of the scale, with higher satisfaction indexes in the 'Treatment results' subscale and lower ones in the 'Reception and competence of staff' and 'Privacy and confidentiality' subscales. In the comparison of the samples studied, greater scores were observed in general satisfaction and in factors in the medical residency care model than in the attending psychiatrist model. There were no significant differences in terms of family member satisfaction in relation to sociodemographic variables. Family member satisfaction was high. The need for improvement in aspects related to the infrastructure of services was evident. This paper underlines the importance of continuous and regular evaluations of the services provided, focusing on the satisfaction of users and family members in order to better understand the factors that contribute towards the quality of care provided.

Impact of a peer-review network on the quality of inpatient low secure mental health services: cluster randomised control trial

BackgroundPeer-review networks aim to help services to improve the quality of care they provide, however, there is very little evidence about their impact. We conducted a cluster randomized controlled trial of a peer-review quality network for low-secure mental health services to examine the impact of network membership on the process and outcomes of care over a 12 month period.MethodsThirty-eight low secure units were randomly allocated to either the active intervention (participation in the network n = 18) or the control arm (delayed participation in the network n = 20). A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at 12 month follow up. The primary outcome measure was the quality of the physical environment and facilities of the services. The secondary outcomes included: safety of the ward, patient mental wellbeing and satisfaction with care, staff burnout, training and supervision. We hypothesised that, relative to control wards, the quality of the physical environment and facilities would be higher on wards in the active arm of the trial 12 months after randomization.ResultsThe difference in the primary outcome between the groups was not statistically significant (4.1; 95% CI [− 0.2, 8.3] p = 0.06). The median number of untoward incidents rose in control services and remained the same at the member of the network (Difference between members and non-members = 0.55; 95% IC [0.29, 1.07] p = 0.08). At follow up, a higher proportion of staff in the active arm of the trial indicated that they felt safe on the ward relative to those in the control services (p = 0.04), despite reporting more physical assaults (p = 0.04). Staff working in services in the active arm of the trial reported higher levels of burnout relative to those in the control group. No difference was seen in patient outcomes.ConclusionsWe did not find evidence that participation in a peer-review network led to marked changes in the quality of the physical environment of low secure mental health services at 12 months. Future research should explore the impact of accreditation schemes and examine longer term outcomes of participation in such networks.Trial registrationISRCTN79614916. Retrospectively registered 28 March 2014.

Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial.

Background and objectivesPeople with personality disorders are prevalent in emergency and inpatient mental health services. We examined whether implementing a stepped care model of psychological therapy reduces demand on hospital units by people with personality disorder, in a cluster randomized controlled trial.MethodA total of 642 inpatients (average age 36.8, 50.5% female) with a primary ICD-10 personality disorder were recruited during 18 months baseline, then monitored during an 18 month active trial phase. In the active trial phase two equivalent sites were randomised to either treatment as usual (TAU), or a whole of service intervention that diverted people away from hospital and into stepped care psychological therapy clinics. The study design was cost neutral, with no additional staff or resources deployed between sites. A linear mixed models analysis evaluated outcomes.ResultsAs predicted, demand on hospital services reduced significantly in the intervention compared to TAU site. The intervention site evidenced shorter bed days, from an average of 13.46 days at baseline to 4.28 days per admission, and patients were 1.3 times less likely to re-present to the emergency department compared to TAU. Direct cost savings for implementing the approach was estimated at USD$2,720 per patient per year. Limitations included not directly comparing individual symptom changes.ConclusionsUsing a whole of service stepped care model of treatment for personality disorder significantly reduced demand on hospital services.

Introducing the recovery inspiration group: promoting hope for recovery with inspirational recovery stories

PurposeThe purpose of this paper is to undertake a preliminary evaluation of a novel intervention – Recovery Inspiration Group, which uses recovery stories to promote hope and inspiration for recovery among people with complex mental health difficulties.Design/methodology/approachThe Recovery Inspiration Group was delivered to women on a specialist personality disorder inpatient unit, who were concurrently participating in a dialectical behaviour therapy (DBT) Programme. In total, 12 service users participated in the RIG and as part of the intervention, wrote down key reflections after hearing each recovery story. A thematic analysis of these reflections formed the primary basis of the evaluation. Descriptive statistics derived from a service user feedback survey (n=6) supplemented the qualitative findings.FindingsThree themes were identified in the qualitative data, suggesting that participants had engaged with recovery-oriented reflections and experiences: recovery stories as validating and inspiring; Generalisation of DBT skills; shifting perspectives of recovery: doing better rather than being better. The survey results unanimously endorsed the RIG as a worthwhile and validating experience, which participants would recommend to other service users.Practical implicationsRecovery Inspiration Group appears to be a low-cost and easily replicable intervention with the potential to promote hope and inspiration for recovery among people with complex mental health difficulties.Originality/valueRecovery Inspiration Group is a novel approach to harnessing the wisdom of people with lived experience of mental health difficulties, to foster hope among users of mental health inpatient services.