Mental Health Inpatient Wards Research Articles

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.

Implementation of Body Worn Camera: Practical and Ethical Considerations

Body-worn cameras are increasingly being used as a violence prevention tool in inpatient mental health wards. However, there remains a limited understanding of this technology from an implementation perspective, such as protocols and best practice guidance if cameras are to be used in these settings. This study explores the perspectives of patients, mental health staff, and senior management to understand the practical and ethical issues related to the implementation of body-worn cameras. Semi-structured interviews (n = 64) with 24 patients, 25 staff from acute wards, six Mental Health Nursing Directors, and 9 community-based patients were conducted. Interviews were analysed using reflexive thematic analysis. Ethical approval was granted by the Health Research Authority. Findings from this study show that the implementation of BWC in healthcare settings requires careful consideration. The perspectives of patients and staff demonstrate the complex reality of implementation alongside the consideration of practical and ethical issues around implementation that are essential to ensures that wards recognise the need to assess their capacity to use the cameras in a way that is fair and consistent for all involved. The findings further highlight wider questions around power and autonomy in mental health care.

Patient perspectives on psychological interventions provided in adult psychiatric inpatient wards: A thematic synthesis

AbstractObjectivesPsychological intervention is an important part of psychiatric inpatient treatment for people experiencing severe problems affecting their mental health. Unfortunately, many service users accessing acute inpatient services are not being offered psychological interventions. Recent research has focussed on effectiveness, facilitators and barriers to providing psychological interventions in this setting. This review aimed to provide a qualitative synthesis of service user perspectives regarding psychological interventions provided on inpatient wards, to understand what is helpful and unhelpful about current provision.MethodA systematic literature search of four databases was conducted to identify published qualitative literature regarding service user perspectives of NICE‐recommended psychological interventions provided on adult acute mental health inpatient wards. Study quality was assessed using the Critical Appraisal Skills Programme tool. Data was analysed and synthesised using thematic analysis.ResultsThe search was completed in May 2023. Seventeen studies were included in the review and encapsulated feedback from at least 192 service users. All studies were rated as high or moderate on the quality appraisal tool. Three superordinate themes were identified: ‘Connecting with Others’, ‘Psychological Processes’ and ‘Engaging with the Intervention’. Participants valued supportive relationships with peers and therapists and felt empowered to achieve change through expression, focussing on difficulties and gaining new perspectives. Participants wanted more support to maintain benefits and sometimes struggled to engage with group therapy due to difficult peer dynamics.ConclusionsThe results give a detailed synthesis of some of the important factors, from service users' perspectives, for accessing psychological interventions. Recommendations for clinical practice and future research are provided.

What should inpatient psychological therapies be for? Qualitative views of service users on outcomes.

There is limited research on what, when and how outcomes should be measured in psychological therapy trials in acute mental health inpatient wards. This study aimed to consider what outcomes service users think are important to measure. This qualitative study explored the views of 14 participants, who had an inpatient admission within the last year, on outcomes of psychological therapies using semistructured interviews. Data were analysed using thematic analysis from a critical realist perspective with both inductive and deductive coding. The 126 outcomes that were important to participants were mapped onto an established taxonomy of outcomes across different health areas and the socioecological framework to consider the wider context and help summarise the outcomes. Most of the outcomes were mapped to the intrapersonal and interpersonal level. In addition to the outcome mapping, three themes were constructed from the qualitative data: (1) I am not a problem I am a person, (2) Feeling cared for and loved, (3) What does getting better look like. Our results highlight the need for patient-reported outcomes which are cocreated with service users, disseminating research and training on preventing dehumanising experiences, enhancing psychological safety and therapeutic relationships and improving access to psychological therapy. The wider People with Personal Experience Involvement Committee at the University of Bath were consulted which included a focus group during the early planning stages. We also collaborated with a person with personal experience, at every stage of the research. This included developing our research question and aims, protocol, participant documents (e.g., information and debrief forms), advertisement and recruitment strategy, interview topic guide, the codes, the final themes and quotes and reviewing the manuscript. People with lived experience of being admitted to an acute mental health inpatient ward participated in our study.

Racialised staff–patient relationships in inpatient mental health wards: a realist secondary qualitative analysis of patient experience data

BackgroundThe current study is a secondary analysis of qualitative data collected as part of EURIPIDES, a study which assessed how patient experience data were used to improve the quality of...

'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards.

Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians. We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview. Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input. There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues. A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

Analysis of a nursing survey: Reasons for compromised quality of care in inpatient mental health wards.

Current evidence suggests understaffing is related to poor quality and missed care in a global context, but this relationship is complex. There is also a research gap for quality in mental health care in the United Kingdom that includes a wider set of patient outcomes. This paper aims to investigate RMN's perception of quality of care on their last shift, their self-reported reasons for compromised care and potential impact on patient outcomes. A mixed methods approach, we used descriptive statistics to create a framework within which to qualitatively analyse data from the 2017 Royal College of Nursing (RCN) employment survey to consider the complex relationship between understaffing and care quality. We established three themes: 'Understaffing', 'Professional Code Expectations and Moral Distress' and 'Management'. In line with the current evidence; lack of resources and understaffing were consistently present throughout. Nurses also felt pressure from the Nursing and Midwifery Council (NMC) code of conduct which in turn instilled shame and fear for their registration when they were unable to achieve the standards expected. This was further exacerbated by poor management and supervision; leading nurses to reflect on poor outcomes for patients which compromised not only legal rights but safety of patients and staff alike. We conclude that focusing on staffing numbers alone is unlikely to improve care quality.

Anxiety Communication Notes—A Tool to Facilitate Anxiety Management and Improve the Nurse–Patient Relationship in Mental Health Nursing

Mental health care tends to be dominated by a biomedical perspective at the expense of a more recovery-oriented approach. Research on nurse-led interventions intended to strengthen the patient’s ability to manage anxiety is sparse in this context. The aim of this study was to describe nurses’ experiences of the use of anxiety communication notes in nursing patients experiencing anxiety in mental health inpatient care. Data were collected by interviewing twelve nurses working in two mental health inpatient care wards in southwestern Sweden. Semi-structured interviews were conducted, and qualitative content analysis was used to analyze the data. Findings showed that the use of anxiety communication notes was perceived to provide a nursing structure to foster the development and practice of adaptive anxiety management through a visual representation for mutual understanding of the patient’s anxiety pattern. The nurses could also use the anxiety communication notes to support nurse-patient communication and facilitate increased participation and empowerment in the patients’ anxiety management.

Complexity and practice on NHS mental health in-patient dementia assessment wards

PurposeThis study aims to address this need. In the UK, people with dementia admitted to National Health Service mental health in-patient dementia assessment wards [dementia assessment wards] present as complex and experience a number of changed behaviours, such as excessive walking, agitation and aggression. The complexity of the presentation of dementia has been identified as underpinning pre-and post-admission to these care environments, but limited study has so far been conducted to explore the boundaries and meaning of complexity and its relationship to dementia assessment ward practice.Design/methodology/approachAn online electronic survey of UK-based national dementia leaders was conducted in 2018. Nineteen completed questionnaires were returned, and mental health nurses comprised the largest sub-sample. Qualitative data of the free-text responses were analysed using manifest content analysis.FindingsFour routes to admission to a dementia assessment ward were identified. Multiplicity of needs and interconnectedness were seen as important domains in uncovering the meaning of complexity. The importance of life story and formulation approaches were highlighted. Challenges uncovered included, better understanding changed behaviour and its relationship to complexity, the need for understanding the boundaries of complexity and making visible care practices on these specific wards.Originality/valueFindings can be used to produce a heightened awareness about the meaning and function of complexity in dementia assessment wards. Policymakers and researchers need to increase the emphasis on this area of mental health and dementia care. Further training for the multidisciplinary team on formulation approaches could help to improve the evidence-base for practice.

Non-contact monitoring to support care in acute inpatient mental health

Background Averting incidents of patient self-harm is an ongoing challenge in acute inpatient mental health settings. Novel technologies that do not require continuous human visual monitoring and that maintain patient privacy may support staff in managing patient safety and intervening proactively to prevent self-harm incidents. Aim To assess the effect of implementing a contact-free vision-based patient monitoring and management (VBPMM) system on the rate of bedroom self-harm incidents. Methods A mixed methods non-randomized controlled before-and-after evaluation was conducted over 24 months on one female and one male acute inpatient mental health ward with the VBPMM system. The rates of bedroom self-harm, and of bedroom ligatures specifically, before and after implementation were investigated using quantitative methods. Qualitative methods were also used to explore the perceived effectiveness of the system and its acceptability. Results A −44% relative percentage change in bedroom self-harm incidents and a −48% relative percentage change in bedroom ligatures incidents were observed in the observational wards with the VBPMM system. Staff and patient responses gave insights into system acceptability and the ways in which these reductions may have been achieved. Conclusion The results indicate that using the VBPMM system helped staff to reduce self-harm incidents, including ligatures, in bedrooms.

Preliminary evaluation of a multidisciplinary pathway for people who self-harm in acute inpatient mental health care

Background/aims Inpatient mental health settings are required to provide biopsychosocial interventions to support service users who self-harm. This is important as self-harm has been associated with increased admissions and risk of suicide. A multidisciplinary self-harm pathway was developed in an acute inpatient mental health ward for adult women to help staff support patients who self-harm. The aim of this project was to evaluate the pathway in relation to service user distress, confidence in managing mental health, therapeutic alliances with the ward team and self-harm incidents on the ward. Methods Data were collected from the record-keeping systems and from questionnaires completed before and after the pathway was introduced. Results The pathway was well received by service users and contributed to improvements in distress, confidence and to more effective management of self-harm. Conclusions The self-harm pathway was found to be a useful framework within which to structure psychosocial interventions for self-harm and least restrictive practice.

The experiences of nurses following seclusion or restraint use and immediate staff debriefing in inpatient mental health settings.

The aim of this study is to explore nurses' experiences of seclusion or restraint use and their participation in immediate staff debriefing in inpatient mental health settings. This research was conducted using a descriptive exploratory design and data were gathered through in-depth individual interviews. The experiences of nurses following seclusion or restraint use and their participation in immediate staff debriefing were explored via teleconference, using a semi-structured interview guide. Reflexive thematic analysis was used to identify prevalent themes from the data. Interviews (n=10) were conducted with nurses from inpatient mental health wards in July 2020. Five themes emerged through the data analysis: (i) ensuring personal safety; (ii) grappling between the use of least-restrictive interventions and seclusion or restraint use; (iii) navigating ethical issues and personal reactions; (iv) seeking validation from colleagues and (v) attending staff debriefing based on previous experience. The themes were also analysed using Lazarus and Folkman's Transactional Model of Stress and Coping. Staff debriefing is a vital resource for nurses to provide and/or receive emotion- and problem-focused coping strategies. Mental health institutions should strive to establish supportive working environments and develop interventions based on the unique needs of nurses and the stressors they experience following seclusion or restraint use. Nurses in both frontline and leadership roles were involved in the development and pilot test of the interview guide. The nurses who participated in the study were asked if they can be recontacted if clarification is needed during interview transcription or data analysis.

The Acceptability of a Recovery Group Intervention in Acute Inpatient Mental Health Wards.

The aim of the present study was to evaluate the feasibility and explore the service user experience of a recovery-focused group intervention delivered in acute inpatient wards in a National Health Service (NHS) Trust in England, United Kingdom. Feedback from the Recovery Group Questionnaire given to patients who had attended the Recovery Group whilst admitted to acute inpatient wards was collated and analysed. The results suggest that patients found the group useful and supportive, as well as easy to follow. Themes which emerged from the content analysis included, value, challenges, support and understanding. The feedback also showed that patients found having an Expert by Experience co-facilitating was beneficial. The Recovery Group is an acceptable and feasible group intervention for those who are admitted to acute inpatient wards. Further research examining the clinical effectiveness of the intervention may be considered, however there are some barriers to doing so given the open-access format of the group.

Exploring the use of body-worn cameras in acute mental health wards: A qualitative interview study with mental health patients and staff

BackgroundBody-worn cameras are increasingly being used as a violence prevention tool in inpatient mental health wards. However, there is a dearth of research on their use in these settings, particularly when it comes to patient perspectives. ObjectiveThis study aimed to explore the perspectives of patients, mental health staff, and senior management on body-worn cameras to identify the possible impacts of this technology in inpatient mental health settings. DesignThis was an exploratory qualitative study. SettingWe undertook interviews online and in-person on a number of acute inpatient wards across five mental health hospitals in England. Participants were recruited in-person, online via social media, and through professional networks. ParticipantsThis study recruited 24 patients from acute wards, 25 staff from acute wards, six Mental Health Nursing Directors, and nine community-based patients. MethodsSemi-structured interviews were conducted online and in-person. Interviews were analysed using reflexive thematic analysis. Ethical approval was granted by the Health Research Authority. ResultsThe subjective nature of how violence and aggression is defined shapes how staff and patients view the prospect of using body-worn cameras. Both staff and patients cited issues resulting from an underlying culture of mistrust in inpatient settings that leave staff and patients feeling unsafe. Body worn cameras may intensify power dynamics and undermine therapeutic relationships. Participants felt that engaging existing interventions and addressing systemic causes of violence and aggression should take priority over introducing body-worn cameras. ConclusionsThere is no indication that staff or patients believe body-worn cameras will deter violence and aggression on inpatient mental health wards. They may serve as a tool for safeguarding and staff training, but there are still unexplored ethical concerns about their use and a lack of evidence to support use of this technology to deter violence in NHS mental health settings. Tweetable abstractMental health patients & staff have complex perspectives on controversial body-worn camera technology @thekeiranwilson @unafoye @maddych4dwick @gbrennancafc @cityalan.

Experiences of staff and the support received following incidents of high-risk behaviours in acute mental health inpatient wards: a qualitative exploration

Background/Aims Staff working in acute mental health inpatient environments are frequently exposed to patients who display high-risk behaviours. The aim of the study was to explore the experiences of staff working with patients with high-risk behaviours in acute mental health inpatient wards, and the support that staff receive following exposure to these incidents. Methods A total of 10 participants were recruited from two acute mental health hospitals in England. Data were gathered using semi-structured interviews and analysed using inductive thematic analysis. Results Three themes were identified: the direct impact of incidents; attempts to manage the impact of incidents; and current systems for managing incidents. Conclusions Overall, staff felt that support was lacking, and there was a fear that seeking support was a sign of weakness. Clear differences in staff reactions and responses to varying high-risk behaviours were revealed. Person-centred reflective support spaces, debriefing support, and skills training for staff, especially for self-harm and suicide, are required. Staff also require emotional support and emotion management skills.

Preventing falls in older people on mental health inpatient wards: a quality improvement project.

Older people on mental health inpatient wards are at high risk of falls due to a combination of physiological, pathophysiological and pharmacological factors. Falls prevention should therefore be a priority for nursing staff caring for this patient group. This article describes a quality improvement project conducted on four older adult mental health inpatient wards in Scotland. The project aimed to reduce the number of falls, increase staff's adherence to person-centred falls prevention care planning, and ensure every fall would prompt a post-fall review. Nursing staff participated in a falls prevention training session and registered nurses received, in addition, one-to-one coaching sessions on person-centred care planning. Despite the challenges faced by mental healthcare professionals at the time of the project, staff responded positively and there was a decrease in the number of falls, including falls resulting in harm.

Economic evaluation of a vision-based patient monitoring and management system in an acute adult and an older adult mental health hospital in England

Background and aims Patients on acute adult and older adult inpatient mental health wards are at an increased risk of accidental injuries and deliberate harm to self and others. A vision-based patient monitoring and management (VBPMM) system was designed by Oxehealth Limited to support ward staff to provide better and more efficient care and to reduce incidents. The VBPMM system uses an infrared-sensitive camera, installed in a patient’s room, that works with cleared medical device software to deliver contact-free vital sign and activity insights to clinical teams. Data from two studies undertaken at an English National Health Service (NHS) mental health trust were used to inform an early economic assessment of VBPMM implementation into acute adult and older adult mental health wards. Methods A cost calculator was used to compare the introduction of the VBPMM system as an adjunct to standard care versus standard care alone. Observational data were collected at two English NHS mental health trusts. Both compared data pre- and post-VBPMM implementation using a 12-month baseline period. The model estimated cost per occupied bed day, cost per patient, annual cost per average-sized ward, and total cost to NHS mental health trusts across England. Costs were modeled from an NHS perspective over a 12-month time horizon. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs. Results and conclusions This early analysis indicated that the VBPMM system is likely to be cost saving within both settings examined, with an estimated cost saving of £272 per acute adult mental health patient and £4,591 per older adult mental health patient. This translates to £22.3 and £63.3 million, respectively, across NHS mental health trusts in England every year. VBPMM, therefore, has the potential to augment standard care, leading to positive clinical outcomes and monetary savings.

Introducing the '3Fs model of complexity' for people with dementia accessing a NHS mental health inpatient dementia assessment ward: An interpretive description study.

In the United Kingdom, the use of the terms 'complex' and 'complexity' alongside dementia is reflected in a number of policy and practice documents. However, there is a lack of evidence that explores how complexity is perceived, constructed and experienced by people with dementia, family carers and practitioners working in the NHS dementia inpatient assessment wards [dementia assessment wards]. To explore the meaning and concept of complexity in dementia from within the setting of a dementia assessment ward and develop a practice model. The study was conducted over three phases: 1) an online electronic survey of UK national dementia leaders; 2) individual interviews and a focus group with dementia practitioners in two dementia assessment wards; 3) case studies of four patients with dementia resident on a dementia assessment ward which included their identified family carer/consultee, the named clinician on the ward involved in that person's care and a care records review. The findings highlighted that complexity is constructed through a number of interconnected and interrelated domains that vary in acuity. These findings have been developed into the '3Fs Model of Complexity' and the 3'Fs' stand for Fixed, Flexible and Fluctuating. The Fixed domain consists of six components which are always present in complexity. The Flexible domain consists of 14 components and a person with dementia may experience any number of Flexible domain components at any one time. The Fluctuating domain highlights that all components have the ability to vary in their acuity. The '3Fs Model of Complexity' may facilitate a more holistic view of a person with dementia than when 'symptoms' are viewed in isolation. Going forward, and subject to further refinement and testing, the '3Fs Model of Complexity' could help guide the selection of tailored, personalised interventions for people with dementia, including formulation approaches.

Roles reversed: The patient experience for staff on a mental health ward

Reflections following an experiential study involving staff members being admitted to an inpatient mental health ward. The reflections offer the perspectives of the researchers, the participants and some of the patients on the ward.

Barriers and enablers to implementation of the therapeutic engagement questionnaire in acute mental health inpatient wards in England: A qualitative study.

A strong association exists between the quality of nurse-service user therapeutic relationship and care outcomes on acute mental health inpatient wards. Despite evidence that service users desire improved therapeutic engagement, and registered mental health nurses recognize the benefits of therapeutic relationships, such interactions remain sub-optimal. There is a dearth of evidence on factors influencing implementation of interventions to support and encourage therapeutic engagement. This study aimed to understand the barriers and enablers to implementation of the Therapeutic Engagement Questionnaire (TEQ), across fifteen acute inpatient wards in seven English mental health organizations. Qualitative methods were used in which data were collected from ethnographic field notes and documentary review, coded, and analysed using thematic analysis. Theoretical framing supported data analysis and interpretation. Reporting adheres to the Standards for Reporting Qualitative Research. The TEQ as an evidence-based intervention co-produced with service users and nurses was valued and welcomed by many nurse directors, senior clinicians, and ward managers. However, a range of practical and perceptual factors impeded implementation. Furthermore, many existing contextual challenges for intervention implementation in acute inpatient wards were magnified by the COVID-19 pandemic. Suitable facilitation to address these barriers can help support implementation of the TEQ, with some transferability to implementation of other interventions in these settings. Our study suggests several facilitation methods, brought together in a conceptual model, including encouragement of reflective, facilitative discussion meetings among stakeholders and researchers, effort put into winning nurse 'buy-in' and identifying and supporting ward-level agents of change.