Low Secure Mental Health Research Articles

Supporting staff at a low secure mental health setting during the COVID-19 pandemic

Supporting staff at a low secure mental health setting during the COVID-19 pandemic

A Qualitative Exploration of Service Users’ Experiences of Violence Risk Assessment and Management in Forensic Mental Health Settings: An Interpretative Phenomenological Analysis

ABSTRACT Violence risk assessment and management is central to the lives of forensic mental health service users. Whilst studies have explored mental health professionals’ experiences of violence risk assessment and management, research regarding service user views is largely absent from the literature. Using Interpretative Phenomenological Analysis, the current study interviewed seven forensic mental health service users in low secure mental health inpatient settings about their experiences of violence risk assessment and management. Interviews were recorded, transcribed, and analyzed. Results identified four superordinate themes; Who is this for?, Power, Misunderstood, and Moving Forward. The results are discussed in relation to existing literature. Clinical implications and future research directions are then considered.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

BackgroundViolence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.MethodsQualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.ResultsThe capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.ConclusionsInterventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Inequalities in women’s medium or low secure mental health settings: a scoping review

Purpose The more disadvantaged members of society generally experience poorer outcomes following the development of mental ill-health. The purpose of this paper is to scope the literature and synthesise findings on the inequalities and mental health within secure mental health settings. Design/methodology/approach Six electronic databases were searched to identify relevant studies. These were included if they examined the association between inequalities and mental health in women’s secure mental health settings. Findings Of the 608 studies reviewed, 14 met the inclusion criteria. In these papers, violence and/or abuse were described as the most prevalent inequalities. The second most frequent group of inequalities identified were socio-economic. Only three published studies researched the impact of ethnicities. Physical health, alcohol abuse and a dysfunctional family upbringing were only mentioned in one of the studies. Gender identity, transitioning and sexual orientation was not considered in any papers. These are areas, which require further investigation to determine their specific impact in this setting. Research limitations/implications This review highlights the dearth of high-quality research-based evidence underpinning an understanding of the impact of inequalities on women in secure mental health settings. The existing studies suggest that inequalities have a very particular impact and that intersectionality plays a key role. Further research is required to further understand how inequalities impact the lives of women in secure mental health settings. Practical implications The inequalities that women experience in relation to mental health need to be further researched in the context of intersectionality. There are also research gaps in terms of gender identity, sexual orientation and socio-economic background. Further primary research using a more complex methodological paradigm is required to explore these factors and their impact on mental health service provision. Social implications The role of inequalities should be considered as part of an overall care package, including the experiences of adverse childhood experiences and this should contribute towards the development of a trauma-based care approach. Originality/value To the best of the authors’ knowledge, this is the first study to scope literature about inequalities experienced in women’s secure psychiatric settings considering intersectionality.

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.

Reflections on being a ward-based assistant psychologist in a low-secure mental health hospital

As a team of assistant psychologists who are primarily ward-based working in a low-secure hospital, we have explored the benefits and challenges of working as a part of an integrated multidisciplinary team (MDT) within an inpatient setting.

Impact of peer-led quality improvement networks on quality of inpatient mental health care: study protocol for a cluster randomized controlled trial.

BackgroundQuality improvement networks are peer-led programmes in which members of the network assess the quality of care colleagues provide according to agreed standards of practice. These networks aim to help members identify areas of service provision that could be improved and share good practice. Despite the widespread use of peer-led quality improvement networks, there is very little information about their impact. We are conducting a cluster randomized controlled trial of a quality improvement network for low-secure mental health wards to examine the impact of membership on the process and outcomes of care over a 12 month period.MethodsStandalone low secure units in England and Wales that expressed an interest in joining the quality improvement network were recruited for the study from 2012 to 2014. Thirty-eight units were randomly allocated to either the active intervention (participation in the network n = 18) or a control arm (delayed participation in the network n = 20). Using a 5 % significance level and 90 % power, it was calculated that a sample size of 60 wards was required taking into account a 10 % drop out. A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at follow up. Researchers masked to the allocation status of the units assessed all study outcomes at baseline and follow-up 12 months later. The primary outcome is the quality of the physical environment and facilities on the wards. The secondary outcomes are: safety of the ward, patient-rated satisfaction with care and mental well-being, staff burnout, training and supervision. Relative to control wards, it is hypothesized that the quality of the physical environment and facilities will be higher on wards in the active arm of the trial 12 months after randomization.DiscussionTo our knowledge, this is the first randomized evaluation of a peer-led quality improvement network that has examined the impact of participation on both patient-level and service-level outcomes. The study has the potential to help shape future efforts to improve the quality of inpatient care.Trial registrationCurrent Controlled Trials ISRCTN79614916. Retrospectively registered 28 March 2014]

Evaluation of the Positive Behavioural Support (PBS) model with female forensic inpatients

BackgroundThe Positive Behaviour Support (PBS) is a multidimensional framework which aims to increase understanding of the function of a person’s behaviour. PBS consequently helps to develop effective support strategies (Allen et al., 2012; Carr et al., 1999). The PBS model was introduced in a low secure mental health hospital for females in order to maximise the support offered, increase feelings of safety, and reduce secondary gains from enhanced observations.MethodStaff views on the implementation and effectiveness of the PBS model were evaluated using qualitative and quantitative analysis. The evaluation was based upon responses from 20 participants, who were regular Care Assistants and Nurses working on admission wards within the aforementioned clinical setting. Semi-structured interviews and short questionnaires were completed anonymously by participants.ResultsOverall, staff reported that the PBS model had a positive impact on the day-to-day running of the wards. The PBS model was identified as an effective tool to address challenging behaviour. Staff reported that PBS is a useful approach when working with patients with learning disabilities and personality disorders.ConclusionIt has been suggested that further training and development of PBS strategies (e.g. functional analysis) would be beneficial.

Structured community activity for forensic mental health – a feasibility study

Purpose– The restrictive nature of low secure mental health settings and the issues associated with risk management and safe practice raise numerous challenges which need to be overcome for individuals to engage in community-based programmes. The paper aims to discuss these issues.Design/methodology/approach– Two community-based schemes are described. The first uses the natural environment as a medium in which to deliver opportunities to develop vocational skills. The second provides exercise-based activity to promote healthier living. This paper aims to explore the acceptability, feasibility and sustainability of the projects along with the views and achievements of participants.Findings– Both schemes were well-attended with positive views from participants and others. Planned positive risk taking enabled individuals to participate in a safe and structured way. Initial evaluation of the projects suggest that they were viewed as acceptable by the service and valued by participants. Participation led to some individuals engaging in new opportunities for vocational and leisure activities.Practical implications– Fostering access to community-based occupational opportunities for those in low secure mental health services can be achieved safely and with numerous apparent benefits. Research is now needed to determine further the nature and extent of the gains made through such activity.Originality/value– This is the first known study of its kind utilising inter-agency collaboration to address the needs of those residing in a low secure mental health facility. Within the forensic mental health population, the standards of care recommend a comprehensive, recovery-focused approach aimed at building resilience and preventing relapse, with the need for thorough intervention for physical health needs. This study supports these recommendations by providing opportunities for planned positive risk taking, opportunities for social inclusion, skills development, increased access to physical exercise to address overall wellbeing.

Group treatment in a male low secure mental health service: a treatment description and descriptive evaluation

Purpose – The purpose of this paper is to describe the development, content and structure of an intensive group-based intervention designed to address a range of needs common to individuals within low secure forensic mental health settings. Additionally, the feasibility, acceptability, resource implications and levels of participation and understanding are evaluated. Design/methodology/approach – This paper describes the development, content and structure of an intensive group-based intervention designed to address a range of needs common to individuals within low secure forensic mental health settings. Additionally, the feasibility, acceptability, resource implications and levels of participation and understanding are evaluated. Findings – Analysis showed that the intervention was well received by staff and participants and that those with low self-report knowledge at the start showed large improvements. Recorded levels of participation and understanding were lower than expected. Research limitations/implications – Group-based interventions in low secure settings can be developed from existing “what works” information. Such treatments can feasibly be delivered although participants may need support – something which is not reported in many intervention studies. Research is now needed to assess the impact of the General Treatment & Recovery Programme (GTRP) intervention on participants. Originality/value – The development of treatment programmes for offending behaviour within low secure forensic mental health settings is still in its infancy. This paper outlines and describes the development of such an intervention, namely the GTRP.

A Multidisciplinary Approach to Team Nursing Within a Low Secure Service: The Team Leader Role

This article critically examines the clinical utility of redesigning a nursing practice model within the Intensive Support and Intervention Service, a new low secure mental health facility in the United Kingdom. Specifically, the "team nursing" approach to care delivery has been adapted to consist of multidisciplinary team leaders as opposed to nursing team leaders. The authors describe the role, properties, and functions of the multidisciplinary team leader approach. The authors provide examples of the benefits and challenges posed to date and the ways in which potential barriers have been overcome. Nursing care leadership can be provided by multidisciplinary staff. An adapted model of team nursing can be implemented in a low secure setting.

The Development of a UK Low Secure Service: Philosophy, Training, Supervision and Evaluation

Within the UK, low secure mental health services provide care and treatment to individuals with a view to supporting their return to life within community settings. With the expansion of services in this area it is essential that effective models of care are articulated, delivered and evaluated. This paper describes the philosophical underpinnings of the Intensive Support and Intervention Service, a new low secure inpatient facility. The operationalization of the approach to recovery is described along with the role and impact of the initial staff training. Clinical supervision as a critical component to ongoing practice delivery and development is described. Finally, the methods being utilized to evaluate the service are outlined.

An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit

Psychosocial intervention (PSI) training results in enhanced knowledge, more positive attitudes, increased confidence and lower levels of clinical burnout for qualified mental health professionals and better outcomes for service users who they work with. This paper describes an evaluation of a PSI training course for qualified and unqualified nurses working in a low-secure unit. Forty-two staff (21 qualified) were randomly allocated to an experimental training group or a waiting list control group. Knowledge, attitudes and burnout were assessed before and after the training. In addition, a random sample of 44 care plans written by the qualified nurses were audited before and after to examine evidence of implementation of PSI in practice. Qualified and unqualified nurses in the experimental group showed significant improvements in knowledge and attitudes compared with the control group. Care plans showed a significant increase in the implementation of PSI. The only significant change in burnout was a reduction in depersonalization for qualified nurses in the experimental group. The PSI training may result in improvements in knowledge, attitude and practice in qualified and unqualified nurses working with severely mentally ill patients in low-secure settings, but in this study the training did not incur protection against burnout.

Addressing offending risk in low secure mental health services for men: a descriptive review of available evidence

The topic of offender rehabilitation has been subject to much research over the past decade. Numerous meta‐analytic reviews of offender treatment, particularly group treatment based on cognitive behavioural principles, have been reported. Together with the ‘triad of principles’ — risk, need and responsivity — they have formed the foundation upon which most offending behaviour interventions have developed. However, outcome data from existing programmes provides mixed evidence, and evidence for interventions for those in forensic mental health settings are still in their infancy. This paper critically considers the current evidence for the treatment of offending behaviour, and its application in forensic mental health settings, in order to inform development of such treatments in low secure mental health care. Most of the research focuses on non‐mental health settings, and is largely what will be considered here. The paper concludes that low secure interventions need to capitalise on the evidence of ‘what works’ while revisiting key concepts such as ‘dose’ and responsivity in order to design appropriate treatments. Individual outcome evaluation needs to form part of development in this area.

Clinical characteristics of patients with self harming behaviour in a low secure mental health unit

Aims: To describe the methods of self harm incidents in a low secure unit population and to identify and compare the clinical characteristics of patients displaying inpatient self harming behaviours with those who do not display such behaviours.Method: A retrospective case control study was conducted. Details about the inpatient self harming incidents were collected from an incident database. Clinical characteristics of those who displayed inpatient self harming incidents (cases) and those who did not display such behaviours (controls) were compared. Analysis was performed to establish statistical significance on the observed differences.Results: 80 admissions resulted from 78 patients during a 6½ year period. 21% of patients presented with inpatient self harming behaviours. 57% of the incidents were caused by 13% of patients. Clinical characteristics such as white ethnic background, histories of self harm, physical or sexual abuse, childhood conduct problems and lack of educational qualifications and having a diagnosis of schizoaffective disorder were more likely to be associated with inpatients self harming in low secure settings. Sexually inappropriate behaviours and a diagnosis of schizophrenia were less likely to be associated with this group.Conclusion: The majority of self harm incidents are caused by a minority of patients. Most of the clinical characteristics associated with the low secure inpatient self harming patients are similar to those observed in other psychiatric inpatient settings.

Aggression patterns and clinical predictors of inpatient aggression in a mental health low secure unit population

Aims : To describe the pattern of aggressive incidents, compare clinical characteristics of aggressive and non aggressive inpatients and determine predictors of inpatient aggressive behaviours in a low secure mental health unit population. Method : Clinical data were extracted from inpatient records and a critical incident database for a low secure unit population. Clinical variables between those with inpatient aggressive behaviours (inpatient aggressors) and those without inpatient aggressive behaviours (inpatient non aggressors) were compared. Statistical analysis was carried out on the differences to establish predictors of inpatient aggression. Results : 80 admissions resulted from 78 patients during a 6½ year period. 44% of patients presented with inpatient aggressive incidents. 64% of aggressive incidents resulted from 15% of patients. 54% of aggressive incidents were directed towards staff, 16% towards property and 15% towards other patients. 8% and 4% contributed to disturbed behaviour (non-directed aggression) and sexually inappropriate behaviour respectively. Most aggressive incidents are perpetrated by males and directed towards staff though a larger proportion of females (compared to males) were aggressive. On univariate analysis, clinical variables of more than one previous psychiatric admission, auditory hallucinations and delusions of control and persecution were significantly higher in patients displaying inpatient aggression. Logistic regression analysis identified the former two as predictors of inpatient aggression. Conclusion : In a low secure inpatient population, the majority of aggressive incidents are perpetrated by a minority of patients. Clinical variables such as history of more than one previous psychiatric admission and psychopathological symptoms such as presence of auditory hallucinations and delusions of control and persecution can influence inpatient aggression.

Ethnic group and other characteristics of patients referred to a low secure mental health service

This longitudinal audit aimed to determine the ethnic groups and other characteristics of patients referred to a Low Secure Unit in South East London over a period of 9 years between 1997 and 2005. The data provide a picture of the characteristics of those most likely to be referred to a Low Secure Unit, and highlights an over-representation of Black Caribbean and Black African people. Discussion is provided for this latter finding.

Outcome study of patients exhibiting challenging behaviours four years after discharge from a low secure mental health unit

Aim: To follow up a series of patients admitted to a low secure mental health unit for challenging behaviour. Method: Clinical outcome measures (Health of the Nation Outcome Scale (HoNOS), Global Assessment Scale (GAS) and Staff Observed Aggression Scale (SOAS)) and keyworker interviews were used to follow up the progress of patients at least one year after discharge. Results: 33 patients had a mean time since discharge of 43 months. The typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The observed improvement on HoNOS and GAS during admission had been maintained at follow up. There had been no re-convictions. All patients were compliant with medication. Five patients had been re-admitted to hospital during the follow up period. The current placement showed that more of the patients were in the community compared with at discharge. Conclusion: Patients admitted to a low secure unit improved during their stay and this improvement was maintained at follow up.

The National Survey of PICU and Low Secure Services: 2. Unit characteristics

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric inpatients. Little is known about the provision of such services in the UK.Aims: To perform the first UK wide survey developing a national data set for Low Secure Services.Method: A cross-sectional census day postal survey design was employed.Results: A total of 307 units were identified in the UK, this was comprised of 170 Psychiatric Intensive Care Units (PICUs) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The survey achieved a 98% response rate. PICUs on average had more qualified staff and were more medically oriented than LSUs. PICUs offer a time limited, medically oriented treatment strategy with a higher number of qualified nursing staff then LSUs. Whereas, LSUs placed more of an emphasis on long-term therapeutic treatment and rehabilitation.Conclusions: Although there were a variety of names, Low Secure Services were organised into two main categories of unit: the PICU and the LSU. These names should be adopted nation-wide as standard. There is need for a national strategy relating to the way PICUs and LSUs are developed.

The National Survey of PICU and Low Secure Services: 1. Patient characteristics

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric patients. Little is known about the characteristics of such patients in the UK.Aims: To perform the first UK wide survey developing a national data set of low secure services.Method: A cross-sectional census day postal survey design was employed.Results: A total of 307 units were identified this comprised 170 Psychiatric Intensive Care Unit (PICU) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The majority of patients in Low Secure care were male, white, single, unemployed and with a diagnosis of schizophrenia. Complex needs, violence and forensic histories were common. There was a clear overrepresentation of black ethnic patients.Conclusions: Patients in Low Secure Services shared many characteristics. However, there were important differences between PICU and LSU patients. The overrepresentation of black ethnic groups is concern that requires NHS action to ensure that the specific needs of black patients are met.