Creating a culture, not just a space-A qualitative investigation into reflective practice groups in inpatient mental health settings from the perspectives of facilitators and attendees

BACKGROUND

Working in inpatient mental health settings is often characterised by highly emotive work and staff shortages. Despite the suggested benefits of reflective practice groups on staff well-being and clinical practice across healthcare settings, to date, there have been limited empirical studies on reflective practice groups in inpatient mental health settings, especially on group engagement and improvement.

METHODS

We interviewed fifteen participants, including both facilitators and attendees of reflective practice groups. Participants were from eight inpatient mental health wards across two National Health Service settings in the UK. We analysed interview transcripts using thematic analysis.

RESULT

We deductively organised the data into themes and subthemes under three overarching domains-"Impact", "Factors on Engagement", and "Improvement". Theme development was generated inductively from the data. For impacts, we found reflective practice groups may bolster staff reflective capacity and team cohesion. The groups may help attendees create appropriate distance from their emotions and overcome power hierarchies. We discovered that the availability of reflective practice, sense of containment in groups, and team composition may influence group facilitation and engagement. For improvements, different measures could be adopted to improve access and engagement of staff with difficulties attending. Facilitators may benefit from more support to establish a reflective culture and experiment with new ways of facilitating.

DISCUSSION

Our findings add to the growing evidence base of the potential value of reflective practice groups in inpatient settings and elaborate on novel mechanisms of their potential impact. This study highlights changeable factors for engagement, concrete recommendations for improvements, and opportunities for further research.

Psychological provision in acute inpatient settings: An evaluation of indirect input

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric hospitals have input from a range of professionals, including Clinical Psychologists. Most evidence used to guide what Clinical Psychologists do is based on their work with individuals rather than staff teams. Some evidence shows working with staff teams is important, but most of this is based on interviews rather than measuring the impact using numbers and statistics. The current study aimed to investigate the effectiveness of staff-level interventions provided by a Psychology team within a psychiatric inpatient setting. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Training sessions were effective at increasing staff levels of confidence and understanding in psychological approaches, and the perceived usefulness of the session to their practice. Case discussion sessions were effective at increasing staff levels of understanding a service user, compassion towards the service user, perceived opportunities for change with the service user, their perceived skills to work with the service user and their perception of the usefulness of the session to their practice. Reflective practice sessions were effective at providing a space for learning, sharing ideas and reflecting. Other interventions were highly valued by nursing staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Staff-level interventions are effective and valued by mental health nursing staff and should be considered in allocation of psychology resources. Interventions improved staff psychological thinking which could positively impact service user experience. There is potential for people with lived experience to participate in these interventions, which could facilitate the therapeutic relationship and reduce restrictive practices.

ABSTRACT

INTRODUCTION: The role of Psychologists in psychiatric inpatient settings is well established and involves intervention at various levels; however, quantitative exploration of the effectiveness of staff-level interventions is lacking.

AIM

The aim of the study was to examine the effectiveness of a variety of staff-level interventions provided by a Psychology team within a psychiatric inpatient setting.

METHODS

The evaluation used a mixed methods approach incorporating pre-post quantitative data and post-intervention feedback. Additional data were collected via survey.

KEY FINDINGS

Results indicated all staff-level interventions were effective in achieving their aims and were highly valued by staff. Qualitative data supported the quantitative findings and showed tentative suggestion of a change to clinical practice.

DISCUSSION

Indirect psychology provision was found to significantly impact a range of staff attitudes and was highly valued by the staff team, supporting previous qualitative findings in psychiatric inpatient settings. Further quantitative evidence of the impact of staff-level interventions should be sought.

IMPLICATIONS

Staff-level interventions are effective and valued by mental health nursing staff and should be considered in allocation of psychology resources. Furthermore, there is potential for people with lived experience to participate in these interventions, which could facilitate the therapeutic relationship and reduce restrictive practices, however this requires future research.

"You Forget to Apply It to Staff": A Compassion-Focused Group for Mental Health Inpatient Staff. An Exploration of the Barriers to Attendance

This study explored the feasibility and acceptability of an experiential compassion-focused group intervention for mental health inpatient staff. Findings demonstrated that although participants found sessions enjoyable, and reported a number of benefits, the group attrition was high. Semi-structured interviews were conducted to explore issues related to group dropout. Thematic analysis highlighted overarching systemic challenges to attendance, and five key themes emerged: The Nature of the Ward; Slowing Down Is Not Allowed; It is Not in Our Nature; Guilt & Threat; We Are Not Important. Clinical implications, limitations and practice recommendations to support group attendance are also addressed.

A scoping review protocol to map the evidence on the use of action research methodology by healthcare professionals and in healthcare team settings

Background: Action research (AR) starts with an existing practical situation with which there is a concern or potential for improvement. It seeks transformative change through the simultaneous process of doing research and undertaking actions, both of which are linked together by a critical reflective process. It simultaneously allows one to systematically investigate a given social situation while promoting democratic change and collaborative participation. AR approaches have been used for many years in business management and education. More recently, AR has become an increasingly popular method of inquiry in healthcare, particularly in nursing, to investigate professional practice while simultaneously; introducing innovations; planning and undertaking action; and evaluating new ideas. The overall goal is to augment collaboration whilst improving the patient experience and outcomes. Methods: The Arksey and O'Malley methodology framework will be used to guide this scoping review process: stage 1 will identify the research questions; the eligibility criteria and search strategy will be defined in stage 2; studies will then be selected in stage 3; data will be extracted and charted from these included studies in stage 4; stage 5 involves aggregating and summarising these results along with criteria relevant for health professionals and policy-makers. An optional consultation (stage 6) exercise may potentially be included. Conclusion: This scoping review will comprehensively map the evidence on the use of AR methodology by healthcare professionals and in healthcare team settings. It is predicted that the findings will inform researchers in carrying out future AR and highlight gaps in the literature. An article reporting the results of the completed scoping review will be submitted for publication to a scientific journal and presented at relevant national and international conferences.

'A different kind of space': Mixed methods evaluation of facilitated reflective practice groups for nurses in an acute inpatient mental health unit

Despite recognising the value of reflective practice, there are challenges in implementation of clinical supervision for nurses. This study reports on the implementation of Reflective Practice Groups for nurses in an acute inpatient mental health setting as a means of introducing nurses to reflective practice. A mixed-methods approach explored participant and facilitator experiences through session evaluation questionnaires, facilitator field notes, and interviews with participants. Findings demonstrate challenges in implementing Reflective Practice Groups however the perceived benefits suggest promise in using Reflective Practice Groups to engage busy nurses in facilitated reflection with an aim to transition to reflective clinical supervision.

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Background

Schwartz Center Rounds®(Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.

Objectives

How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.

Design

(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).

Setting

(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).

Participants

(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.

Results

(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.

Limitations

Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.

Conclusion

Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work

The adaptation of Rounds to new contexts and to increase reach needs evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review of team formulation in clinical psychology practice: Definition, implementation, and outcomes

PURPOSE

Team formulation is promoted by professional practice guidelines for clinical psychologists. However, it is unclear whether team formulation is understood/implemented in consistent ways - or whether there is outcome evidence to support the promotion of this practice. This systematic review aimed to (1) synthesize how team formulation practice is defined and implemented by practitioner psychologists and (2) analyse the range of team formulation outcomes in the peer-reviewed literature.

METHODS

Seven electronic bibliographic databases were searched in June 2016. Eleven articles met inclusion criteria and were quality assessed. Extracted data were synthesized using content analysis.

RESULTS

Descriptions of team formulation revealed three main forms of instantiation: (1) a structured, consultation approach; (2) semi-structured, reflective practice meetings; and (3) unstructured/informal sharing of ideas through routine interactions. Outcome evidence linked team formulation to a range of outcomes for staff teams and service users, including some negative outcomes. Quality appraisal identified significant issues with evaluation methods; such that, overall, outcomes were not well-supported.

CONCLUSIONS

There is weak evidence to support the claimed beneficial outcomes of team formulation in practice. There is a need for greater specification and standardization of 'team formulation' practices, to enable a clearer understanding of any relationships with outcomes and implications for best-practice implementations.

PRACTITIONER POINTS

Under the umbrella term of 'team formulation', three types of practice are reported: (1) highly structured consultation; (2) reflective practice meetings; and (3) informal sharing of ideas. Outcomes linked to team formulation, including some negative outcomes, were not well evidenced. Research using robust study designs is required to investigate the process and outcomes of team formulation practice.

Facilitating the development of higher-order thinking skills (HOTS) of novice nursing postgraduates in Africa

BACKGROUND

International research in nursing education has shown to be deficient regarding both the quality of research produced and the building of disciplinary capacity. The CHENMA (Collaboration for Higher Education of Nurses and Midwives in Africa) project aimed to strengthen nursing and midwifery expertise in Africa. Sixteen French-speaking students of the Democratic Republic of the Congo (DRC) enrolled for a master's degree in nursing midwifery at a South African university in 2008. Ten of the initial 16 students graduated with a master's degree in 2012. One student withdrew and five students completed a postgraduate diploma in midwifery.

OBJECTIVES

The objective of this paper is to explore the quality of the output of those master's degree students, namely their dissertation (with specific reference to the demonstration of HOTS).

METHODS

An exploratory, evaluative, single, descriptive case study was utilised. Realist, purposeful sampling was used. Six of the 10 completed final dissertations were evaluated as well as three reflective reports from the supervisor, translator and critical reader.

RESULTS

The findings indicated that most dissertations fell below the expected standard, with a paucity of higher-order thinking and application skills. Language, and possibly cultural dynamics, seemed to be the largest barrier to learning and communication. The dissertations lacked conceptual skills, scientific writing skills, logical order of thought and congruency. Analysis of the dissertations revealed a limited ability of novice scholars to explore the nature of information and to interpret and manipulate the data in a novel way.

Qualitative evaluation of the implementation of the Interdisciplinary Management Tool: a reflective tool to enhance interdisciplinary teamwork using Structured, Facilitated Action Research for Implementation

Reflective practice is used increasingly to enhance team functioning and service effectiveness; however, there is little evidence of its use in interdisciplinary teams. This paper presents the qualitative evaluation of the Interdisciplinary Management Tool (IMT), an evidence-based change tool designed to enhance interdisciplinary teamwork through structured team reflection. The IMT incorporates three components: an evidence-based resource guide; a reflective implementation framework based on Structured, Facilitated Action Research for Implementation methodology; and formative and summative evaluation components. The IMT was implemented with intermediate care teams supported by independent facilitators in England. Each intervention lasted 6 months and was evaluated over a 12-month period. Data sources include interviews, a focus group with facilitators, questionnaires completed by team members and documentary feedback from structured team reports. Data were analysed qualitatively using the Framework approach. The IMT was implemented with 10 teams, including 253 staff from more than 10 different disciplines. Team challenges included lack of clear vision; communication issues; limited career progression opportunities; inefficient resource use; need for role clarity and service development. The IMT successfully engaged staff in the change process, and resulted in teams developing creative strategies to address the issues identified. Participants valued dedicated time to focus on the processes of team functioning; however, some were uncomfortable with a focus on teamwork at the expense of delivering direct patient care. The IMT is a relatively low-cost, structured, reflective way to enhance team function. It empowers individuals to understand and value their own, and others' roles and responsibilities within the team; identify barriers to effective teamwork, and develop and implement appropriate solutions to these. To be successful, teams need protected time to take for reflection, and executive support to be able to broker changes that are beyond the scope of the team.