Psychiatric Inpatient Wards Research Articles

The management of substance misuse on psychiatric inpatient wards — a policy to promote effective good practice

As the use of drugs and alcohol by clients accessing mental health services becomes increasingly common, members of staff working within psychiatric inpatient areas often encounter drug and alcohol misuse among their client group. The safe and effective management of this issue has become a priority for many inpatient services. This paper outlines a policy for the management of substance misuse on psychiatric inpatient wards developed by Manchester Mental Health and Social Care Trust. The fundamental principles underpinning the policy are highlighted, and the key sections of the policy are described. There is a detailed description of how the policy has been applied in practice by members of staff working on inpatient wards, with clinical examples being presented.

Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey

BackgroundSuicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received.MethodsWe carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death.ResultsThere were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward.ConclusionMeasures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.

Medical Clearance of the Psychiatric Patient in the Emergency Department

Background: As part of the emergency department (ED) evaluation of patients with psychiatric complaints, emergency physicians are often asked to perform screening laboratory tests prior to admitting psychiatric patients, the value of which is questionable. Study Objective: To determine if routine screening laboratory studies performed in the ED on patients with a psychiatric chief complaint would alter ED medical clearance (evaluation, management or disposition) of such patients. Methods: In this retrospective chart review, the patient charts were reviewed for triage notes, history and physical examination, laboratory study results, and patient disposition. The study investigators subjectively determined if any of the laboratory abnormalities identified after admission would have changed ED management or disposition of the patient had they been identified in the ED. Results: Subjects were 519 consecutive adult patients (18 years of age and older) admitted to the Medical College of Georgia's inpatient psychiatric ward through the ED. There were 502 patients who met inclusion criteria, and 50 of them had completely normal laboratory studies. Laboratory studies were performed in the ED for 148 patients. The most common abnormalities identified were positive urine drug screen (n = 221), anemia (n = 136), and hyperglycemia (n = 139). There was one case (0.19%) identified in which an abnormal laboratory value would have changed ED management or disposition of the patient had it been found during the patient's ED visit. Conclusions: Patients presenting to the ED with a psychiatric chief complaint can be medically cleared for admission to a psychiatric facility by qualified emergency physicians using an appropriate history and physical examination. There is no need for routine medical screening laboratory tests.

Patients' perceptions of patient education on psychiatric inpatient wards: a qualitative study

This study describes patients' perceptions of different types of patient education interventions and areas where patient education should be improved on psychiatric wards. Thematic interviews were conducted with 16 patients who had completed the information technology (IT)-based patient education, conventional patient education with leaflets or patient education according to ward standards during their hospital stay. Data were analysed using inductive content analysis. Patients' perceptions of patient education varied depending on which patient education group they had participated in. Patients participating in IT-based or conventional patient education perceived education as a systematic and planned process. However, especially patients in the patient education group applying ward standard education perceived patient education as occasional information dissemination situations. To improve patient education, patients suggested that it should be based on their individual needs and offered with different methods systematically to all patients. The results indicate that patients find structured and systematic patient education programmes useful. Different educational methods should be used, not forgetting interaction between patient and nurse, which was reportedly as an essential element of patient education.

P03-372 - Evolution of patients who underwent electroconvulsive therapy (ECT) in a brazilian general hospital from 1993 to 2007

ObjectivesTo determine the outcome of patients who underwent ECT in a Brazilian General Hospital between 1993 and 2007.MethodsTelephone contact with all patients (or their relatives) who were submitted to ECT during psychiatric hospitalization in HC-Unicamp-Brazil. Data were compiled for statistical analysis at SPSS.ResultsThere were 53 successful telephone contacts (33.9% of 153 patients who underwent ECT). Losses were due to changes of telephones/addresses. No refuses occurred. The mean time between the procedure and the contact was 55.4 months (3-170). Twenty patients (37.3%) and 37 relatives (69.8%) were interviewed. Most were women (60.4% n=32), 4 were inpatients by the occasion of the call and 4 died. The mean age was 42.9±19.4. The assessments of current mental state by patients were: excellent in 5-9.4% cases, good in 12-22.6%, poor in 2-3.8%. The evaluation by family members was: excellent in 11-20.8% cases, good in 11-20.8%, poor in 7-13.2% and very poor in 5-9.4%. In 42 cases (79.2%) the patient was still under psychiatric treatment (taking psychotropic medication in 39-73.6%). In 28 cases (54%) there was need for new admission in a psychiatric inpatient ward. In 38 cases (74%) the patient reported knowing that he/she had undergone ECT, and only in 5 cases (9.4%) there was a lasting side effect of treatment reported, which was change in memory.ConclusionsData of the evolution of patients corroborate the importance of treatment with ECT for severe mental disorders, and also shows the low rate of long-term complications related to the procedure.

P03-14 - A quasi-experimental controlled intervention to reduce violence on an acute psychiatric ward

IntroductionViolence and aggression are a major concern in acute inpatient psychiatric wards. Hard outcome data on the impact of service change are scarce. This poster presents the outcomes of service changes designed to improve the acute ward environment and patient experience.Aims and objectivesTo implement changes to the delivery of acute inpatient psychiatric services and to measure the outcome of these changes in objective verifiable form.MethodSignificant changes were introduced to an acute psychiatric inpatient service. These included introducing a dedicated inpatient psychiatrist “hospitalist”, replacing weekly ward rounds with daily multidisciplinary care and discharge planning meetings and promoting increased roles for nursing staff in decision-making and patient contact. Outcomes measured included routinely recorded incidents of violence with and without injury, use of restraint for medication and use of constant nursing observation. The control group was a similar service in the same hospital subject to the same general policies and admitting patients demographically comparable, but that did not at the time undergo the interventions implemented in the trial service. All data was recorded by staff who were unaware of this study or even that any analysis of the data would occur.Results and conclusionsViolent incidents in the intervention ward dropped by 34% per patient (p=< 0.02) whilst increasing by 3% in the control ward; restraints decreased by 28% (p=ns) whilst increasing by 12% in the control ward; with an overall reduction in constant observation. The intervention was highly effective in reducing violent incidents.

Psychiatric wards: places of safety?

In recent years, the purpose and quality of provision delivered in acute inpatient psychiatric settings have been increasingly questioned. Studies from a service user perspective have reported that while some psychiatric inpatients feel safe and cared for, others feel their time in hospital is neither safe nor therapeutic. This paper explores the experiences of service users on acute inpatient psychiatric wards in England, with a particular focus on their feelings of safety and security. Interviews were conducted with 60 psychiatric inpatients in England. The majority of service users felt safe in hospital and felt supported by staff and other service users. However, anything that threatened their sense of security such as aggression, bullying, theft, racism and the use of alcohol and drugs on the ward, made some respondents feel insecure and unsafe. Psychiatric wards are still perceived by many as volatile environments, where service users feel forced to devise personal security strategies in order to protect themselves and their property. It would appear that there remains much to do before research findings and policies are implemented in ways that facilitate all service users to derive the maximum benefit from their inpatient experience.

A policy to deal with sexual assault on psychiatric in-patient wards

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Factors Related to Admission of Psychiatric Patients to Medical Wards from the General Hospital Emergency Department: A 3-Year Study of Urgent Psychiatric Consultations

Emergency Rooms (ER) of Emergency Departments (ED) in General Hospitals (GH) have a role in providing for psychiatric evaluation. The aims of the present study were to examine the decision-making process of consultation psychiatry at the GH-ER and to analyze the differences between psychiatric patients admitted to a medical ward with those admitted to the psychiatry unit and those who are discharged from the ER. Over a period of 3 years, psychiatric consultations requested by ER of ED physicians to the GH Psychiatric service were recorded by using a form to describe epidemiological and clinical data on the consultation process. Of 1,962 psychiatric consultations, most regarded subjects who had had previous psychiatric contacts (76.2%) and at least one psychiatric admission (53.6%), and were currently cared for by the Mental Health Services (51.1%). Neurotic/stress-related syndromes (27.98%), schizophrenia (27.67%), and personality disorders (21.81%) were the most frequent ICD-10 diagnoses. The psychiatrist's disposal was to discharge the patient in 49.9% cases, to admit him/her to medical wards of the GH (MGH; 26.9%) or to the acute inpatient psychiatric ward (AIP; 23.1%). MGH group statistically differed from AIP group for being female (p < 0.01), older (p < 0.01), more likely having an ICD-10 diagnosis of neurosis/stress-related syndromes (p < 0.01) or organic mental disorder (p < 0.01), and less likely having a diagnosis of schizophrenia (p < 0.01), being in charge of the Mental Health Services (p < 0.01), and having had previous psychiatric admissions (p < 0.01). These results were confirmed by logistic regression analysis. The study shows that the medical wards of the General Hospital are a significant entry-point for providing psychiatric care of patients with ICD-10 neurotic and stress-related syndromes, even if without specific medical problems.

Locked doors in acute inpatient psychiatry: a literature review

Many acute inpatient psychiatric wards in the UK are permanently locked, although this is contrary to the current Mental Health Act Code of Practice. To conduct a literature review of empirical articles concerning locked doors in acute psychiatric inpatient wards, an extensive literature search was performed in SAGE Journals Online, EBM Reviews, British Nursing Index, CINAHL, EMBASE Psychiatry, International Bibliography of the Social Sciences, Ovid MEDLINE, PsycINFO and Google, using the search terms 'open$', 'close$', '$lock$', 'door', 'ward', 'hospital', 'psychiatr', 'mental health', 'inpatient' and 'asylum'. A total of 11 empirical papers were included in the review. Both staff and patients reported advantages (e.g. preventing illegal substances from entering the ward and preventing patients from absconding and harming themselves or others) and disadvantages (e.g. making patients feel depressed, confined and creating extra work for staff) regarding locked doors. Locked wards were associated with increased patient aggression, poorer satisfaction with treatment and more severe symptoms. The limited literature available showed the urgent need for research to determine the real effects of locked doors in inpatient psychiatry.

Developing a policy to deal with sexual assault on psychiatric in-patient wards

Sexual harassment and assault on psychiatric wards is an ongoing concern. A number of incidents have been reported in the media. This paper focuses on a policy drafted to deal with allegations of sexual assault or rape on an in-patient psychiatric ward. We aimed to produce a practical, easy-to-follow guide for junior doctors and ward staff who may face complex and possibly contentious issues surrounding consent, capacity to consent and police involvement.

“On The Spot” Interventions by Mental Health Nurses in Inpatient Psychiatric Wards in Greece

The objective of this research was to explore the “on-the spot” clinical interventions mental health nurses make in critical incidents on inpatient psychiatric wards. Mental health nurses play a key role in the management of psychiatric critical incidents. Nurses' autonomy, decision-making, and training in clinical interventions are important issues in psychiatric nursing practice. A descriptive study was conducted among mental health nurses working on inpatient wards of three major psychiatric hospitals in the greater Athens area, using semi-structured interviews. Nurses' personal views also were documented. Semi-structured interviews were conducted with 103 mental health nurses, who were encouraged to make personal remarks. The results of this study show that in the majority of critical incidents, the nurses were found to be in contact with the psychiatrist on call; physical restraints were used frequently in violent episodes; reassurance and support were common interventions; the majority of nurses would have preferred not to intervene with critical incidents; and nurses expressed a need for skills training and higher autonomy. The nurses implemented a specific number of interventions in confronting the various types of crises. The need for specialized training was noticed and problems like accountability, autonomy, and medication administration, were considered crucial by the mental heath nurses.

P02-261 A national evaluation of mental health inpatient staff morale in England

Introduction:Improving the quality of care on psychiatric inpatient wards has been a major focus in recent mental health policy, a recurrent criticism being that contact between staff and patients is limited in time and therapeutic value. Change is unlikely to be achieved without recruitment and retention of a high quality and well-motivated work force.Aim:The NHS commissioned national inpatient mental health staff morale study is intended to inform service planning and policy by delivering evidence on the morale of the inpatient mental health workforce and the clinical, organisational, architectural and human resources factors that influence it.Methods:100 wards in 17 area ‘Trusts’ are participating in the study, in addition to 40 community teams. The study will take place over two years, and has 6 modules:1.A quantitative questionnaire for all staff in participating wards and2.A comparison group in 20 community mental health teams and 20 crisis teams.3.Case studies of 10 wards scoring in the top and bottom quartile for indicators of morale.4.Repeated questionnaires for 20 wards in the second year to investigate how morale changes over time.5.Staff who leave the wards in the course of the first year will be asked their reasons for leaving.6.Links between rates of staff sickness and morale will be investigated.Results:Questionnaires have been distributed to 3,500 staff with a response rate of 65%, results from which will be presented in 2009.

Identifying Key Factors Associated with Aggression on Acute Inpatient Psychiatric Wards

Aggressive behaviour is a critical issue for modern acute psychiatric services, not just because of the adverse impact it has on patients and staff, but also because it puts a financial strain on service providers. The aim of this study was to assess the relationship of patient violence to other variables: patient characteristics, features of the service and physical environment, patient routines, staff factors, the use of containment methods, and other patient behaviours. A multivariate cross sectional design was utilised. Data were collected for a six month period on 136 acute psychiatric wards in 26 NHS Trusts in England. Multilevel modelling was conducted to ascertain those factors most strongly associated with verbal aggression, aggression toward objects, and physical aggression against others. High levels of aggression were associated with a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Insufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.

Severe depression and relationships: the effect of mental illness on sexuality

This paper sought to investigate how the sexuality of patients and their partners is affected by mental illness and their experience of needing support from psychiatric services. Qualitative, designed in-depth interviews of ten patients admitted to a psychiatric in-patient ward specialising in affective disorders and their partners was carried out and the data analysed by thematic analysis. The following domains emerged: aspects related to the patient him/herself; aspects in relation to medical care; aspects related to the partner him/herself; aspects in relationship to the partner; and aspects in relation to the psychiatric services. Both patients and partners described a feeling of abandonment in the absence of any support or treatment initiative from psychiatric services. They also expressed dissatisfaction with the patient therapist treatment method being focused on one to one therapy leaving their partners feeling excluded and overlooking the partners in having a more interactive role in the treatment process. Our findings highlight the complex nature of dysfunctional sexuality, involving not only the patients who suffer from severe mental illness but their partners as well. Psychiatric services appear to lack methods of support relating to sexuality and long-term relationships.

A replication study of the City nurse intervention: reducing conflict and containment on three acute psychiatric wards

Conflict and containment on acute inpatient psychiatric wards pose a threat to patient and staff safety, and it is desirable to minimize the frequency of these events. Research has indicated that certain staff attitudes and behaviours might serve to accomplish this, namely, positive appreciation, emotional regulation and effective structure. A previous test of an intervention based on these principles, on two wards, showed a good outcome. In this study, we tested the same intervention on three further wards. Two 'City nurses' were employed to work with three acute wards, assisting with the implementation of changes according to the working model of conflict and containment generation. Evaluation was via before-and-after measures, with parallel data collected from five control wards. While simple before-and-after analysis of the two experimental wards showed significant reductions in conflict and containment, when a comparison with controls was conducted, with control for patient occupancy and clustering of results by ward, no effect of the intervention was found. The results were therefore ambiguous, and neither confirm nor contradict the efficacy of the intervention. A further intervention study may need to be conducted with a larger sample size to achieve adequate statistical power.

Predictors of psychiatric readmissions to the psychiatric unit of a tertiary health facility in a Nigerian city - a 5-year study

Little is known about predictors of readmission of psychiatric patients in the study environment. Knowledge of this, we believe could aid effective management of psychiatric patients, as well as judicious and equitable utilization of the limited mental health facilities in the North-central zone. The aim was to identify factors that may be predictive of readmissions to an in-patient psychiatric facility of a Nigerian University Teaching Hospital. A retrospective record review of all admissions and discharges to/from the psychiatric inpatient ward of University of Ilorin Teaching Hospital, (UITH) between May 2000 and April 2005. Patients and clinical characteristics were recorded and all the data were characterized according to age, gender, marital status, occupational status, length of stay on admission, number of admissions, and medication compliance. Data were analyzed with SPSS version 11 to derive the chi square figures, Pearson's correlation, and logistic regression. The level of statistical significance was set at 5%. Within the study period, 41.4% of cases were readmissions. Young age, longer length of stay, multiple admissions and the diagnosis of schizophrenia were predictive of readmission while medication non-compliance was not predictive. Provision of psycho-education to both the patients and their families, identification of early symptoms of relapse, application of immediate and appropriate measures, and adequate record-keeping by health institutions are advocated.

Effectiveness and Efficiency of Cognitive-Behavioral Group Therapy for Inpatients: 4-Year Follow-up Study

The goals of this study were to evaluate the effectiveness of manualized cognitive-behavioral group therapy (CBGT) integrated into routine care on a psychiatric inpatient unit and to compare the impact of the intervention on patients with the following diagnoses: schizophrenia, major depression, bipolar disorder, or personality disorders. The results presented here expand on those presented in a previous publication by including 2 more years of data and additional analyses concerning diagnosis and economic outcomes. A pre-post design was used to measure voluntary and compulsory readmissions, ward atmosphere, patient satisfaction, mean length of stay, and cost-income in the year before CBGT was introduced (2001) compared with the next 4 years. In the years 2001-2005, percentage of total readmissions declined from 38% to 24% (p < 0.02); of those readmissions, 17% were compulsory in 2001 compared with 0 in 2005 (p < 0.02). A progressive improvement in ward atmosphere was observed from baseline to the following 4 years (p < 0.001). There was also statistically significant improvement in patient satisfaction compared with baseline, mainly observed during the first 2 years of the intervention (p < 0.001). The reduction in readmissions was statistically significant only for patients with schizophrenia (p < 0.001) and bipolar disorder (p < 0.04). These results are promising and indicate that CBGT may contribute added benefit to treatment on an inpatient psychiatric ward.

Dual diagnosis in Manchester, UK: practitioners' estimates of prevalence rates in mental health and substance misuse services

Background: Dual diagnosis (the combination of mental health and drug/alcohol problems) has been recognized as a major health concern. Most studies in this field stem from the US and information about dual diagnosis prevalence is limited in the UK. Aims: To obtain estimates of dual diagnosis prevalence rates across mental health and substance misuse services in Manchester. Methods: Telephone interviews were carried out with team managers of mental health (n = 24) and substance misuse services (n = 9). Results: The mean percentage of dual diagnosis clients throughout services was 46%. The highest proportions were identified in the assertive outreach team (71%), followed by substance use services (59%), and psychiatric inpatient wards (56%). The acute home treatment team (12%) reported the lowest estimate of clients with dual diagnosis problems. Conclusions: Service providers perceived dual diagnosis to be of major concern across mental health and substance misuse services in Manchester. The estimates were ...

Delegation of medication administration: an exploratory study

To examine the delegation of medication administration, including the frequency of delegation, whether delegation was to a care worker or a registered nurse (RN) and whether care workers were directly supervised when administering medication. Administration of 1313 medication doses was observed on two inpatient psychiatric wards for older people. Administration was delegated by the nurse preparing the medication for four out of every five doses, usually to another registered nurse (78% of delegated doses), but also to care workers (22%). Care workers were more likely to administer medications to confused and aggressive patients than were registered nurses. Care workers who undertake delegated medication administration should receive regular training to ensure safety. Nurses remain accountable for delegated medication administration.