Inpatient Mental Health Settings Research Articles

Ensuring that psychological interventions are delivered as intended on mental health inpatient wards.

Talk, Understand and Listen for InPatient Settings (TULIPS) was a multi-centred randomized control trial of an intervention that aimed to increase patient access to psychological therapies on acute mental health wards. This paper aims to: (i) describe a strategy for designing a psychological intervention that is implementable in inpatient mental health settings; (ii) describe methods for assessing the fidelity of interventions within these settings; (iii) report on the extent to which fidelity was achieved in the TULIPS trial. The TULIPS intervention was designed using information from a systematic review, stakeholder interviews, pilot work and a consensus workshop. We assessed fidelity to the model in terms of the delivery and dose of essential elements of the intervention, quality of intervention delivery, engagement of participants with the intervention and differentiation between the intervention and usual care. Although the TULIPS intervention targeted known barriers to the delivery of psychological interventions on mental health wards, we found issues in implementing aspects of the intervention that were dependent upon the participation of members of the multidisciplinary team. Psychologists were able to overcome barriers to delivering individual therapy to patients as this provision was not reliant on the availability of other staff. The intervention period in the study was 6 months. A greater period of time with a critical mass of psychological practitioners is needed to embed psychological interventions on inpatient wards. Our fidelity framework and assessment methods can be used by other researchers implementing and testing psychological therapies within inpatient environments.

An inpatient mental health placement for paramedic undergraduate students: a pilot study

BackgroundThe prevalence of mental and behavioural illnesses in the Australian community is increasing. Paramedics are frequently the first health responders to a mental health crisis, and their workload associated with mental health presentations is also increasing. The present study explored the experience and perspectives of undergraduate paramedic students who participated in a pilot mental health placement.MethodsA pilot workplace learning opportunity was established in which students completed a portion of their community service hours in an inpatient mental health setting at Port Macquarie Base Hospital. Eight students attended and completed the placement and were administered the Clinical Placement Evaluation Questionnaire.ResultsStudent responses to this placement experience were overwhelmingly positive. The data showed that all the students responded “Strongly Agree” or “Agree” to each of the survey items. Thematic analysis of the qualitative data yielded four central themes related to benefits, additional training and education, nursing staff, and improvements.ConclusionsThis pilot study suggests that mental health placements for paramedics have meaningful educational value and can impact student learning. Since this pilot study, mental health placements have been permanently included as part of the undergraduate curriculum in our institution.

'I Think the First Priority is Physically Safe First, Before You Can Actually Get Psychologically Safe': Staff Perspectives on Psychological Safety in Inpatient Mental Health Settings.

While the concept of psychological safety has been gaining momentum, research concerning psychological safety in inpatient mental health wards is lacking. To investigate how psychological safety is conceptualised by healthcare staff in inpatient mental health units, and what barriers and facilitators exist. Reflexive Thematic Analysis was used to analyse 12 interviews. Participants conceptualised psychological safety as feeling safe from physical harm, being able to develop meaningful relationships and feeling valued at work. Participants often did not feel physically safe at work, which led them to feel psychologically unsafe. Barriers to psychological safety were reliance on agency workers, punitive management approaches and the inherent risk in working with mental health inpatients. Facilitators included appropriate staffing ratios and skill mix, being able to form meaningful relationships and having access to support. The emphasis on the physical safety element within psychological safety means that existing definitions of psychological safety require extension for the mental healthcare context. However, large-scale research is needed to further understand experiences of psychological safety in this group. A better understanding of the dimensions of psychological safety in inpatient mental health settings could support the development of tools to investigate psychological safety interventions. Organisations could support psychological safety through regular staff supervision and improved staffing ratios and skill mix.

Delivering a Cognitive Behaviour Therapy for psychosis (CBTp) informed crisis intervention in acute mental health inpatient settings: a therapy protocol

ABSTRACT Background People experiencing psychosis in acute crisis should be offered Cognitive Behavioural Therapy for psychosis (CBTp) however there are no protocols developed to inform delivery specifically for people in acute crisis receiving inpatient mental health care. This paper narratively describes a CBTp-informed crisis-focused therapy protocol to inform the delivery of therapy in inpatient settings. Method This study draws on relevant systematic reviews, qualitative interview studies with stakeholders, Delphi studies, and coproduction to develop the protocol. It draws upon crisis theories and CBTp theories to underpin it. Results This paper outlines a modularised approach to working with people with psychosis and in crisis. It outlines the key values underpinning the protocol, and the key modules of: engagement, assessment and identifying priorities; formulation of the crisis, stabilisation, safety, and problem solving, crisis plans and crisis cards, change strategy work focusing on crisis appraisals, and discharge and relapse planning. Discussion A crisis-focused cognitive behavioural therapy protocol is presented which can be used to inform therapy for people experiencing psychosis and in crisis. More research is required to explore the efficacy of such therapies.

How can we measure psychological safety in mental healthcare staff? Developing questionnaire items using a nominal groups technique.

There have been growing concerns about the well-being of staff in inpatient mental health settings, with studies suggesting that they have higher burnout and greater work-related stress levels than staff in other healthcare sectors. When addressing staff well-being, psychological safety can be a useful concept. However, there is no measure of psychological safety that is suitable for use in inpatient mental health settings. Edmondson (1999) is the most commonly used measure of psychological safety, but it was designed for use in general physical healthcare settings. As inpatient mental health settings are unique environments, transferability of knowledge from physical to mental healthcare settings cannot be assumed. We sought to develop questionnaire items that capture psychological safety among healthcare staff working in acute inpatient mental healthcare settings. We used the nominal group technique, a consensus method involving rounds of discussion, idea generation, and item rating/ranking to identify priorities. Twenty-eight stakeholders participated, including 4 who had lived experience of mental health problems, 11 academics and 18 healthcare professionals (8 participants identified with more than 1 category). The study involved a workshop with three parts: (i) an overview of current research and limitations of the Edmondson (1999) measure as outlined above, (ii) discussion on what items should be retained from the Edmondson (1999) measure, and (iii) discussion on what items should be added to the Edmondson (1999) measure. Twenty-one items were generated and retained to capture psychological safety in inpatient mental health settings. These measure professionals' sense of being valued by their team and organization, feeling supported at work, feeling physically safe and protected from physical harm, and knowing they can raise concerns about risk and safety. This is the first study to generate questionnaire items suitable for measuring staff psychological safety in mental health settings. These have been generated via a consensus method to ensure stakeholders' views are reflected. Further research is needed to evaluate factor structure, internal reliability, and convergent validity.

Ecological virtual reality-based cognitive remediation among inpatients with schizophrenia: A pilot study

Schizophrenia presents a considerable clinical challenge due to limited progress in promoting daily-life functioning among diagnosed individuals. Although cognitive remediation (CR) has emerged as a promising approach to improving cognitive and functional outcomes in schizophrenia, its effectiveness among inpatients and within hospital environments—where opportunities to practice skills in real-world contexts are limited—remains unclear. Here, we aimed to establish the feasibility and initial efficacy of a short, ecological virtual reality-based CR training (CR-EVR) in acute mental health inpatient settings. Efficacy was assessed at four levels: training engagement, near transfer, far transfer, and ecological transfer. Twenty-three inpatients with schizophrenia (Male: 33.3 ± 8.5; 4 Female) completed 8, 20-min CR-EVR sessions, with exercises training the cognitive abilities of inhibition, planning, working memory, shifting, self-initiation, persistence, and attention. Their cognitive functioning, schizophrenia symptoms, functional capacity, and participation in occupations were evaluated pre- and post-training to address four levels of effectiveness. Of the recruited participants, 25.8 % dropped out. Inpatients who completed the full protocol reported high rates of satisfaction (1-not satisfied; 5-very satisfied)) from the intervention (Median = 4, IQR:3.5–5). Post-training, significant improvements were found in the trained cognitive components (intervention engagement: −6.58 < t/Z < 2.02, p < .05), general cognitive functioning (−2.59 < t/Z < 2.29, p < .05), functional capacity (t = −2.9, p < .05), and diversity of participation in everyday activities (t = −3.36, p < .05). This preliminary study suggests that CR-EVR may be a feasible and practical tool to enhance cognitive and ecological outcomes in short-stay acute inpatient settings. Subject to further research, such intervention may be considered an add-on to current practices that promote recovery and health among inpatient populations.

Exploring therapeutic engagement in Finnish adult acute inpatient mental health settings

Exploring therapeutic engagement in Finnish adult acute inpatient mental health settings

Damaging dichotomies and confounding contradictions in mental health inpatient nursing: lessons learned from Orwell’s 1984

PurposeThis discursive paper considers the use of restrictive practices in mental health inpatient settings and how these are often prioritised over relational approaches, especially where the diagnostic label of personality disorder intersects with risk.Design/methodology/approachKey concepts from Orwell’s 1984 are studied for their pertinence to mental health inpatient settings, supporting our argument that restrictive practices arise from dichotomous thinking and externalised fears.FindingsDrawing upon Orwellian themes of power, social control and digital surveillance from 1984, the authors highlight the role of fear in perpetuating restrictive practices under a guise of benevolent care in mental health inpatient settings, especially for those who are diagnosed with a personality disorder. A lack of preparedness to work with complexity in such environments, coupled with a deficit in self-reflexivity and critical thinking, can exacerbate challenges.Research limitations/implicationsTo transcend damaging dichotomies and reduce restrictive practices in inpatient settings, the authors make the argument for the adequate preparation and education of the mental health nurse and authentic, collaborative, user-involved care.Originality/valueThe authors use Orwell’s novel to support a critical discourse around those damaging dichotomies and inherent contradictions that contribute to restrictive practice in contemporary mental health settings and to question whose interests’ these restrictive practices serve.

De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives

BackgroundDe-escalation is often advocated to reduce harm associated with violence and use of restrictive interventions, but there is insufficient understanding of factors that influence de-escalation behaviour in practice. For the first time, using behaviour change and implementation science methodology, this paper aims to identify the drivers that will enhance de-escalation in acute inpatient and psychiatric intensive care mental health settings.MethodsSecondary analysis of 46 qualitative interviews with ward staff (n = 20) and patients (n = 26) informed by the Theoretical Domains Framework.ResultsCapabilities for de-escalation included knowledge (impact of trauma on memory and self-regulation and the aetiology and experience of voice hearing) and skills (emotional self-regulation, distress validation, reducing social distance, confirming autonomy, setting limits and problem-solving). Opportunities for de-escalation were limited by dysfunctional risk management cultures/ relationships between ward staff and clinical leadership, and a lack of patient involvement in safety maintenance. Motivation to engage in de-escalation was limited by negative emotion associated with moral formulations of patients and internal attributions for behaviour.ConclusionIn addition to training that enhances knowledge and skills, interventions to enhance de-escalation should target ward and organisational cultures, as well as making fundamental changes to the social and physical structure of inpatient mental health wards. Psychological interventions targeting negative emotion in staff are needed to increase motivation. This paper provides a new evidence-based framework of indicative changes that will enhance de-escalation in adult acute mental health inpatient and PICU settings.

'Safer, Not Safe': Service Users' Experiences of Psychological Safety in Inpatient Mental Health Wards in the United Kingdom.

Research on patient safety in mental health settings is limited compared to physical healthcare settings. Recent qualitative studies have highlighted that patient safety is more than just physical safety but includes psychological safety. Traditionally, psychological safety has been defined as the belief that it is safe to take interpersonal risks, such as speaking up, without a fear of negative consequences. However, to date, it is not clear what constitutes psychological safety for service users of inpatient mental health settings. To understand this, we conducted 12 interviews with former inpatient mental health service users. Interviews were analysed with Reflexive Thematic Analysis, and five themes were developed. All themes had subthemes. Overall, we found that participants were more readily able to draw on situations where they felt psychologically unsafe, rather than safe. Psychological safety in service users was influenced by (1) healthcare staff attitudes and behaviours towards them, (2) their relationships with other service users, (3) whether they felt they had any control over their environment and medical decision-making regarding their care, (4) their experiences of physically safety, feeling listened to and believed and (5) access to meaningful occupation on the wards. These findings suggest that changes are needed to enhance inpatient mental health service users' general experiences of psychological safety. Further research will need to (1) further develop understanding of the concept of psychological safety for service users and (2) identify interventions, and such interventions should be co-designed with service users.

Evaluation of a novel co-designed and co-delivered training package to de-escalate violence and aggression in UK acute inpatient, PICU and forensic mental health settings.

BACKGROUND: Evidence suggests a discrepancy between recommended and routine practice in de-escalation in mental health settings, suggesting a lack of impact of existing training. To investigate the acceptability and perceived impact of a co-designed/delivered training intervention on a trauma-informed approach to de-escalation on mental health wards. Trainees were invited to complete the Training Acceptability Rating Scale (TARS) post-training. Responses to the quantitative items were summarized using descriptive statistics, and open-text responses were coded using content analysis. Of 214 trainees, 211 completed the TARS. The trainees rated the training favourably (median overall TARS = 55/63), as acceptable (median 33/36) and impactful (median 23/27). There were five qualitative themes: modules of interest; multiple perspectives; modes of delivery; moulding to context; and modifying other elements. The EDITION training was found to be acceptable and impactful, with trainees particularly valuing the co-delivery model. Trainees suggested several ways in which the training could be improved, particularly around the need for further moulding of the intervention to the specific ward contexts/teams. We recommend co-designing and co-delivering staff training to mental health professionals that tackles restrictive practices. This research is relevant to lived experience practitioners who want to be involved in training mental health professionals around restrictive practices, demonstrating the value and importance of their voice. It is relevant to current providers of de-escalation training, and to staff receiving training, outlining a novel, but acceptable and impactful, form of training on a key area of mental health practice. It is relevant to anyone with an interest in reducing restrictive practice via co-delivered training.

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

A Review of the Quality of Physical Health Care Provided to Adult Patients Admitted to Mental Health Inpatient Settings Across East and Central North Wales in Line With the National Confidential Enquiry Into Patient Outcome and Death (NCEPOD) Recommendations

A Review of the Quality of Physical Health Care Provided to Adult Patients Admitted to Mental Health Inpatient Settings Across East and Central North Wales in Line With the National Confidential Enquiry Into Patient Outcome and Death (NCEPOD) Recommendations

P.116 Days at home after traumatic brain injury: moving beyond mortality to evaluate patient-centered outcomes using population health data

Background: Despite the utility of administrative health data, there remains a lack of patient-centered outcome measures to meaningfully capture morbidity after traumatic brain injury (TBI). We sought to characterize and validate days at home (DAH) as a feasible measure to assess population-level moderate to severe TBI (msTBI) outcomes and health resource utilization. Methods: We utilized linked health administrative data sources to identify adults with msTBI patients presenting to trauma centers in Ontario injured between 2009-2021. DAH at 180 days reflects the total number of days spent alive and at home excluding the days spent institutionalized in acute care, rehabilitation, inpatient mental health settings or post-acute readmissions. Construct and predictive validity were determined; we additionally estimated minimally important difference (MID) in DAH180days. Results: There were 6340 patients that met inclusion criteria. Median DAH180days were 70 days (interquartile range 0-144). Increased health resource utilization at baseline, older age, increasing cranial injury severity and major extracranial injuries were significantly associated with fewer DAH180days. DAH180days was correlated to DAH counts at 1-3 years. The average MID estimate from anchor-based and distribution-based methods was 18 days. Conclusions: We introduce DAH180days as a feasible and sufficiently responsive patient-centered outcome measure with construct, predictive and face validity in an msTBI population.

The attitudes of nurses towards seclusion: A New Zealand in-patient mental health setting.

Seclusion is a form of restraint practised in mental health services world-wide, and has been criticised as unethical and traumatising to patients. Several countries have committed to reducing or eliminating seclusion. In New Zealand, there has been a focus on reducing seclusion of the indigenous Māori population, who experience particularly high rates. Nurses typically lead decisions to place patients in seclusion and their attitudes towards seclusion likely influence this process. This study aimed to address the primary question: what are the attitudes of registered nurses towards the use of seclusion? A mixed methods pragmatic approach was used involving qualitative interviews of nurses working in a high seclusion mental health ward located in the North Island of New Zealand, and a quantitative analysis of the seclusion data from this ward. This report is adherent with COREQ and STROBE. Thirteen nurses were interviewed and four main themes were identified: seclusion is necessary; seclusion is being used unnecessarily; nurse characteristics influence the use of seclusion; nurses perceived their ward culture to be improving in the use of seclusion. However, analysis of seclusion data indicated that rates had been increasing for this ward prior to this study, and the rates for indigenous Māori patients were especially elevated. This pattern of increasing rates was congruent with the 'supportive' attitudes of nurses towards seclusion. Interestingly, during the time of this study, the seclusion rates began to decline, including for Māori patients. This decline may have been partially due to the increased awareness prompted by the study.

Envisioning a safety paradigm in inpatient mental health settings: Moving beyond zero-risk approaches

A zero-risk paradigm currently dominates the organization and delivery of mental health care within inpatient settings, giving rise to a proliferation of risk management strategies that are ineffective and produce harms. Drawing on Foucault's confinement and grounded in a comprehensive analysis of the extant literature, we identify three central processes that constitute this paradigm, including: risk is situated within the patient; eliminating risk is a foundational aim; and mental health professionals lead decision-making. Responding to the zero-risk paradigm, this paper proposes a novel safety paradigm comprised of four intersecting components, undertaken collectively by mental health professionals to guide practice: i) holding risk, ii) building capacity, iii) prioritizing relationships, and iv) re-envisioning environments. Foundationally underlying these commitments is direct action toward reducing coercive practices and structures, such as chemical and physical restraints, seclusion, and door locking. Mental health professionals are encouraged to challenge the zero-risk paradigm and its resultant risk management approaches, and embrace a safety paradigm to meaningfully re-orient care toward enhancing patients' safety and well-being during and following hospitalization.

Exploring psychiatric patient restraints: Balancing safety, ethics, and patient rights in mental healthcare

Restraint, often linked with limiting an individual's freedom of movement, has become a focal point of extensive discussion and evaluation within the realm of mental healthcare. Striking a delicate balance between ensuring individual safety and minimizing reliance on restraint methods poses a significant challenge. In mental health inpatient settings, the prevalent forms of restraint encompass physical, chemical, environmental, and psychological methods. Paradoxically, the consequences of employing restraint can be severe, ranging from injuries and cognitive decline to sedation and, in extreme cases, fatalities. This paper seeks to offer a nuanced exploration of the landscape surrounding psychiatric patient restraints, considering both global perspectives and specific insights from the Indian context. The guidelines outlined in India's Mental Healthcare Act of 2017, which governs the use of restraint on individuals suffering with mental illnesses, are also examined in detail.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial.

Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings. We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting. This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks. Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024. An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings. ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268. DERR1-10.2196/49548.

Ethical aspects of technologies of surveillance in mental health inpatient settings - Enabling or undermining the therapeutic nurse/patient relationship?

Ethical aspects of technologies of surveillance in mental health inpatient settings - Enabling or undermining the therapeutic nurse/patient relationship?

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey

Purpose To explore mental health staff’s responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings. Methods We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention. Results A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either ‘agree’ (45.2%) or ‘strongly agree’ (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as ‘building relationship’ and ‘patient-related knowledge’ claimed high scores in the staff’s rankings of the interventions’ importance concerning implementation. Conversely, interventions like ‘carers’ and ‘standardised assessments’ received low scores. Conclusions The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.