Mental Health Inpatient Wards Research Articles

Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis

BackgroundThe transition from acute mental health inpatient to community care is often a vulnerable period in the pathway, where people can experience additional risks and anxiety. Researchers globally have developed and tested a number of interventions that aim to improve continuity of care and safety in these transitions. However, there has been little attempt to compare and contrast the interventions and specify the variety of safety threats they attempt to resolve.MethodsThe study aimed to identify the evidence base for interventions to support continuity of care and safety in the transition from acute mental health inpatient to community services at the point of discharge. Electronic Databases including PsycINFO, MEDLINE, Embase, HMIC, CINAHL, IBSS, Cochrane Library Trials, ASSIA, Web of Science and Scopus, were searched between 2000 and May 2018. Peer reviewed papers were eligible for inclusion if they addressed adults admitted to an acute inpatient mental health ward and reported on health interventions relating to discharge from the acute ward to the community. The results were analysed using a narrative synthesis technique.ResultsThe total number of papers from which data were extracted was 45. The review found various interventions implemented across continents, addressing problems related to different aspects of discharge. Some interventions followed a distinct named approach (i.e. Critical Time Intervention, Transitional Discharge Model), others were grouped based on key components (i.e. peer support, pharmacist involvement). The primary problems interventions looked to address were reducing readmission, improving wellbeing, reducing homelessness, improving treatment adherence, accelerating discharge, reducing suicide. The 69 outcomes reported across studies were heterogeneous, meaning it was difficult to conduct comparative quantitative meta-analysis or synthesis.ConclusionsThe interventions reviewed are spread across a spectrum ranging from addressing a single problem within a single agency with a single solution, to multiple solutions addressing multi-agency problems. We recommend that future research attempts to improve homogeneity in outcome reporting.

The quality and quantity of staff-patient interactions as recorded by staff. A registry study of nursing documentation in two inpatient mental health wards

BackgroundTherapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation.MethodsThe study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward.ResultsOnly 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models.ConclusionThese findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts.

Factors related to hospital utilisation for people living with schizophrenia: Examining Allen's Cognitive Level Scores, recommended supports and routinely collected variables.

Australian occupational therapists working on mental health inpatient wards are often requested to assess a person's function and, based on that assessment, recommend the best support environments for that person post-discharge. The Allen Cognitive Level Screen (ACLS) is a tool used by some therapists to screen cognitive functioning as a basis with which to make support recommendations. There is limited examination of the outcomes for people post-discharge if the ACLS score-based support recommendations are followed. A retrospective cohort design involved quantitative analysis of archival data for 150 adult (18-65years old) consumers with a primary diagnosis of schizophrenia and an ACLS completed pre-discharge. Data up to 12months post-discharge from hospital were studied. Outcomes examined included re-presentations or readmission to hospital, length of time in community prior to re-presentation and length of stay in hospital if readmitted. Being younger, male, receiving formal supports, having a drug and alcohol disorder comorbidity, living in public housing and having a lower cognitive level as measured by the ACLS were significant univariate factors associated with higher hospital utilisation for one or more of the outcome variables. Multivariate analyses revealed fewer significant relationships, with being younger and receiving formal supports significantly associated with greater likelihood of return to hospital. This research contributes to evidence of the complexity of living with schizophrenia in the community and supporting people to stay out of hospital. More research regarding how the ACLS score-aligned support recommendations are carried out and the impact on hospital utilisation is needed in order to enhance occupational therapists confidence in their use and prescription.

Stakeholders views of medicines administration by pharmacy technicians on mental health inpatient wards

Background The involvement of pharmacy technicians in medicines administration has been highlighted as an opportunity to enhance medicines management support for nurses and service users. Currently, there is no published evidence around this development within psychiatry. Objective To explore the perceptions of key stakeholders toward the feasibility and acceptability of pharmacy technician-led medicines administration within a mental health inpatient setting. Setting Ten acute adult and older-adult wards across five inpatient units within one UK mental health provider. Method Stratified purposeful sampling was used to recruit participants from primary (pharmacy technician, nurse and service user) and secondary (pharmacist, doctor and senior manager) stakeholder groups. One-to-one, semi-structured interviews were audio recorded, transcribed and analysed thematically using Framework analysis. Main Outcome Measure Themes arising from perspectives of stakeholders concerning the feasibility and acceptability of pharmacy technician-led medicines administration. Results Twenty participants were recruited, including twelve primary stakeholders. Attitudes towards implementation were favourable overall. Anticipated risks included de-skilling of nurses around medicines and a potentially detrimental impact on the nurse-patient therapeutic relationship; these were contrasted by potential benefits including the release of nurse time and medicines education opportunities with staff and service users. Conclusion Technician-led medicines administration was perceived as a feasible service, potentially bringing opportunities for medicines optimisation and released nursing time to care. These findings may be a source of guidance for policymakers and researchers who wish to explore the development of such services. Further exploration of safety and effectiveness is required, particularly within mental health settings.

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

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

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

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

Staff experiences and understandings of the REsTRAIN Yourself initiative to minimize the use of physical restraint on mental health wards

International efforts to minimize coercive practices include the US Six Core Strategies© (6CS). This innovative approach has limited evidence of its effectiveness, with few robustly designed studies, and has not been formally implemented or evaluated in the UK. An adapted version of the 6CS, which we called 'REsTRAIN Yourself' (RY), was devised to suit the UK context and evaluated using mixed methods. RY aimed to reduce the use of physical restraint in mental health inpatient ward settings through training and practice development with whole teams, directly in the ward settings where change was to be implemented and barriers to change overcome. In this paper, we present qualitative findings that report on staff perspectives of the impact and value of RY following its implementation. Thirty-six staff participated in semi-structured interviews with data subject to thematic analysis. Eight themes are reported that highlight perceived improvements in every domain of the 6CS after RY had been introduced. Staff reported more positively on their relationships with service users and felt their attitudes towards the use of coercive practices such as restraint were changed; the service as a whole shifted in terms of restraint awareness and reduction; and new policies, procedures, and language were introduced despite certain barriers. These findings need to be appreciated in a context wherein substantial reductions in the use of physical restraint were proven possible, largely due to building upon empathic and relational alternatives. However, yet more could be achieved with greater resourcing of inpatient care.

Tools for measuring nursing workload in mental health inpatient wards

Tools for measuring nursing workload in mental health inpatient wards

Brief narrative group work on acute inpatient mental health wards

This article describes the development of three single-session narrative therapy groups on acute mental health wards. The article describes the general theoretical underpinnings of the group, before going on to describe the format of each group session. A brief illustrative case study is provided alongside each group session description.

Recovery-oriented practice: Participant observations of the interactions between patients and health professionals in mental health inpatient settings.

Despite an increasing attention towards recovery orientation in the mental health services, the provision of recovery-oriented practice is challenged in the inpatient wards. Moreover, the existing research within this area is modest and we currently have limited knowledge of how recovery-oriented practice is integrated into inpatient settings. A cornerstone of recovery-oriented practice is the collaboration, patient involvement, and choices, particularly when deciding and planning treatment options. Thus, this ethnographic study aimed to explore how recovery-oriented practice is reflected in the interactions between patients and health professionals around treatment in two mental health inpatient wards in Denmark. Participant observations were conducted in two mental health inpatient wards from November 2014 to January 2015. The Recovery Self-Assessment scale inspired the observation guide and the initial data analysis. Field notes were analysed deductively and inductively using qualitative content analysis. One theme with four subthemes emerged showing that interactions were characterized by an 'as-if collaboration' where 'negotiating on limited grounds' was an important feature of interactions, in which health professionals seemed to have superiority, acting on behalf of 'competing demands'. Patients had to navigate in a field of 'inconsistent guidance and postponed decisions' and faced tendencies of 'control and condescending communication'. The results suggest that recovery oriented values such as equal collaboration, choice and patients' personal preferences are reflected rhetorically in the interactions between patients and health professionals. However, they are negotiated within organizational logics and often overruled by competing demands.

Electronic recording of vital signs for mental health inpatients

The use of electronic monitoring of vital signs is becoming increasingly widespread in general hospital settings in the National Health Service (NHS) in the United Kingdom, and numerous advantages when compared to using paper charts have been shown. However, electronic systems are not yet widely used within mental health inpatient care. We present a pilot implementation of a novel system of electronic vital signs monitoring introduced in two adult mental health inpatient wards, designed to assess feasibility and acceptability to staff and patients. Development and implementation of the new system, adapted from a system designed for use in acute medical nursing, has presented challenges. However, over the course of the 10-month period presented here, nursing compliance, measured by percentage of observations recorded on time, improved by 72.7%. Service users and clinical staff both reported positively to the new system. Efforts to improve monitoring psychiatirc inpatients’ physical health are of increasing importance. Implementing electronic recording of observations is practical, affordable and feasible within the mental health inpatient setting, and offers many potential advantages over the use of paper charts.

Nursing staff-led behavioural group intervention in psychiatric in-patient care: Patient and staff experiences.

A promising intervention in mental health in-patient care is behavioural activation (BA). Interventions based on BA can be used by mental health nurses and other staff members. The aim of this study was to evaluate patients' and staff members' experiences of a nursing staff-led behavioural group intervention in mental health in-patient care. The intervention was implemented at three adult acute general mental health in-patient wards in a public hospital setting in Sweden. A self-administrated questionnaire, completed by 84 patients and 34 nurses and nurse assistants, was administered, and nonparametric data analysed using descriptive statistics. Our findings revealed that both patients and nursing staff ranked nursing care and care environment as important aspects in the recovery process. Patients and staff members reported overall positive experiences of the group sessions. Patients with higher frequencies of attendance and patients satisfied with overall care had a more positive attitude towards the intervention. A more positive experience of being a group leader was reported by staff members who had been leading groups more than ten times. The most common impeding factor during implementation, reported by staff members, was a negative attitude to change. Conducive factors were having support from a psychologist and the perception that patients were showing interest. These positive experiences reported by patients and nursing staff, combined with previous research in this field, are taking us one step further in evaluating group sessions based on BA as a meaningful nursing intervention in mental health in-patient care.

Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study.

Introduction Physical restraint has negative consequences for all involved, and international calls for its reduction have emerged. Some restraint reduction interventions have been developed, but limited qualitative research explores suggestions on how to reduce physical restraint (and feasibility issues with implementation) from those directly involved. Aims To explore mental health patients' and staff members' suggestions for reducing physical restraint. Methods Interviews were conducted with 13 inpatients and 22 staff members with experience of restraint on adult mental health inpatient wards in one UK National Health Service Trust. Results Findings centred on four overarching themes: improving communication and relationships between staff/patients; making staff-related changes; improving ward environments/spaces; and having more activities. However, concerns were raised around practicalities/feasibility of their implementation. Discussion Continued research is needed into best ways to reduce physical restraint, with an emphasis on feasibility/practicality and how to make time in busy ward environments. Implications for Practice Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. However, fundamental issues related to understaffing, high staff turnover and lack of time/resources need addressing in order for these suggestions to be successfully implemented.

Recovery orientation in mental health inpatient settings: Inpatient experiences?

Offering mental health treatment in line with a recovery-oriented practice has become an objective in the mental health services in many countries. However, applying recovery-oriented practice in inpatient settings seems challenged by unclear and diverging definitions of the concept in and the organization of these settings. In Denmark, educational and organizational efforts have been made to organize inpatient services with a recovery-oriented approach. Hence, we aimed to explore whether and how these efforts are reflected in the inpatients' experiences of their care and treatment. Semi-structured interviews were conducted with 14 inpatients from two mental health inpatient wards using an interview guide based on factors from the Recovery Self-Assessment. Qualitative content analysis was applied in the analysis. Six themes covering the participants' experiences were identified. The participants felt accepted and protected in the ward and found comfort in being around other people but missed talking and engaging with health professionals. They described limited choice and influence on the course of their treatment, and low information levels regarding their treatment, which they considered to consist predominantly of medication. Furthermore, they described feeling continuously observed and assessed from a distance by health professionals. Like the sparse previous research among inpatients, the results highlight ambivalent experiences of health professionals' support and ward structure as well as the medical treatment hegemony. As such, the educational and organizational efforts of introducing recovery-oriented practices in the wards seemed not very well reflected in the participants' experiences of their stay.

Higher participation in physical activity is associated with less use of inpatient mental health services: A cross-sectional study

There is a stark disparity in the physical health of people with mental illness compared to those without mental illness, resulting in shorter life expectancy and increased rates of preventable deaths. Physical activity has previously been shown to have a positive impact on various markers of mental health and has been linked with a reduction in hospital admissions for those with chronic physical illness. The purpose of this study was to investigate whether there is a relationship between physical activity and the number of days spent admitted to acute inpatient mental health wards in people with enduring mental illness. Eighty participants from four acute mental health wards in Oxfordshire, UK were included. Subjective and objective measurements of physical activity levels were collected alongside the amount of days spent admitted on acute mental health wards over the year previous. Participants who recorded higher levels of physical activity, both subjectively and objectively, were found to have spent less time admitted to acute mental health services. With a significant negative correlation found, future research should aim to investigate any causative link between physical activity and mental health admission.

Trauma-Informed Care and Practice: Practice Improvement Strategies in an Inpatient Mental Health Ward.

A growing body of evidence highlights that trauma is the single most significant predictor that an individual will need support from mental health services. Yet despite this association, mental health services have been slow to provide approaches to care and treatment that deal directly with trauma. Embedding the principles of trauma-informed care and practice (TICP) in acute inpatient ward practice can lead to practice improvement and cultural change over a number of areas. The current service evaluation highlights how these principles can inform practice and the positive affect this has on areas such as seclusion and restraint, therapeutic engagement, and ward routines. TICP complements recovery-focused models of care and promotes collaborative and empowering relationships in the inpatient setting. Embedding this approach in inpatient mental health units can lead to changes in professional practice and service provision that benefit service users. [Journal of Psychosocial Nursing and Mental Health Services, 55(10), 34-38.].

Traversing the Services: A Constructivist Grounded Theory of Admission in Two Adult Acute Mental Health Inpatient Wards

It is increasingly acknowledged that service-user satisfaction and experience are fundamental to the achievement of high quality care delivery worldwide. Research in this area identifies a need to capture the experience of care providers, to expand methodological approaches beyond the survey instrument and to develop patient-centred approaches that include effective partnerships between professionals, patients and their carers or family members. Evidence highlights the coercive potential of admission in adult acute mental health, and the increased complexity associated with enhancing patient satisfaction and experience in these environments. This study aimed to explore the experiences of staff, service-users, and carers with admission in two adult acute inpatient mental health wards. A grounded theory (GT) approach was adopted such that theory was developed inductively through data collection and analysis. A total of twenty-two participants were interviewed, this included: 9 (40%) service-users, 10 (46%) members of staff and 3 (14%) carers. The substantive theory of admission produced was organised across three major categories, namely: a person-centred beginning; building relationships along the way and barriers to the service received. These interrelated factors determine the meaningfulness of the admission and have the power to hinder or facilitate improvement to a service-user’s wellbeing and their evaluation of being admitted to an inpatient mental health ward. The process of admission in an acute inpatient mental health environment can pre-determine satisfaction and experience with services. It is essential that person-centred ideals are maintained from the outset in order to maximise the quality of care received. This includes the implementation of strategies that facilitate involvement approaches and nurturing positive relationships to improve communication, concordance, shared decision-making and participation with care delivery.

Feasibility of training nurses in motivational interviewing to improve patient experience in mental health inpatient rehabilitation: a pilot study.

Introduction There is limited research addressing the experiences of patients in inpatient rehabilitation (rehabilitation), who often spend long periods in hospital, and the nursing approaches utilized. Aim Based on evidence that motivational interviewing (MI) may improve nursing practice, this was a pilot study evaluating the feasibility of training rehabilitation nurses in MI and measuring patient experience. Method Nurses underwent training and supervision focusing on MI spirit. Quantitative and qualitative measures were taken pretraining, 2months post-training and 8months post-training. Expert-by-experience research assistants facilitated patients' participation in the study. Results This study showed that training rehabilitation nurses in MI was feasible and relevant to their work. Patients participated in interviews and focus groups with support and potential improvements that require further empirical investigation in patient experience were found following the MI training. Discussion This pilot study establishes the feasibility of a larger study addressing efficacy. Tentative qualitative findings question whether interactions between nurses and patients are valued in rehabilitation and support MI as a promising skill set for rehabilitation nurses. Implications for practice Bringing MI into inpatient rehabilitation provoked reflection on nursing practice. Dilemmas for nurses about balancing safety with promoting autonomy and communicating constructively with patients emerged as important.

A work-based learning approach for clinical support workers on mental health inpatient wards.

Background With a rise in the number of unqualified staff providing health and social care, and reports raising concerns about the quality of care provided, there is a need to address the learning needs of clinical support workers. This article describes a qualitative evaluation of a service improvement project that involved a work-based learning approach for clinical support workers on mental health inpatient wards. Aim To investigate and identify insights in relation to the content and process of learning using a work-based learning approach for clinical support workers. Method This was a qualitative evaluation of a service improvement project involving 25 clinical support workers at the seven mental health inpatient units in South London and Maudsley NHS Foundation Trust. Three clinical skills tutors were appointed to develop, implement and evaluate the work-based learning approach. Four sources of data were used to evaluate this approach, including reflective journals, qualitative responses to questionnaires, three focus groups involving the clinical support workers and a group interview involving the clinical skills tutors. Data were analysed using thematic analysis. Findings The work-based learning approach was highly valued by the clinical support workers and enhanced learning in practice. Face-to-face learning in practice helped the clinical support workers to develop practice skills and reflective learning skills. Insights relating to the role of clinical support workers were also identified, including the benefits of face-to-face supervision in practice, particularly in relation to the interpersonal aspects of care. Conclusion A work-based learning approach has the potential to enhance care delivery by meeting the learning needs of clinical support workers and enabling them to apply learning to practice. Care providers should consider how the work-based learning approach can be used on a systematic, organisation-wide basis in the context of budgetary restrictions.

Improving multidisciplinary clinical discussion on an inpatient mental health ward

Purpose– Multidisciplinary team (MDT) clinical supervision is being used in many mental health services but at present has not received adequate attention by researchers in order to generate evidence-based approaches. The purpose of this paper is to explore the utility and staff perspectives of an MDT model of clinical supervision in the form of a “Clinical Discussion Group” (CDG) on an acute inpatient mental health ward within the context of the current literature on the components of effective supervision in order to make recommendations for practice.Design/methodology/approach– In total, 12 members of staff working on the ward were interviewed to gather their perspective on attendance, helpful aspects, outcomes, unhelpful aspects, and changes. Interview transcripts were analysed using thematic analysis.Findings– In total, 11 themes were identified, three within “The Group and how it operates” (attendance, discussion topics and facilitation), five within “Impact and Usefulness” (valued by staff, understanding a case, emotional benefit, learning and working together as a team) and three within “Changes to the Group” (organisation, discussion topic and group outcomes).Originality/value– This paper explores the benefits and challenges of a CDG from the perspective of the staff who attend. It presents some recommendations for good practice which should be of use to managers and supervisors who wish to use team supervision to improve patient outcomes and also makes suggestions for future research in this field.