Life in acute mental health settings: experiences and perceptions of service users and nurses

Contextual factors influencing the use of coercive measures in Portuguese mental health care

The use of coercive measures in mental health care is an important indicator of the quality of care being provided, and non-patient-related factors are increasingly recognized to contribute to their use. The study aimed to explore the perspectives of mental health care professionals who have first-hand experience with the use of coercion on the contextual factors that influence the use of coercion in the Portuguese mental health care. Five focus group discussions were conducted among 23 doctors and 17 nurses from five psychiatric departments in urban and rural regions of Portugal. Discussions were audio recorded, transcribed, and analyzed with the aid of MAXQDA. Four broad themes related to insufficient resources, staff-related factors, inefficient services, and socio-legal factors were derived. Participants highlighted how inadequate structures, staff shortages, staff attitudes, a lack of training, restrictive ward rules, an inefficient organization of services, the mental health legislation, and public attitudes contributed to the use of coercive measures. The COVID-19 pandemic complicated existing shortfalls in the system and increased the use of coercive measures. The study confirms that the use of coercive measures in mental health care is influenced by factors that are independent of patient characteristics. Addressing existing systemic problems is crucial for the successful implementation of interventions to reduce coercion in mental health care.

"My life isn't my life, it's the systems": A qualitative exploration of women's experiences of day-to-day restrictive practices as inpatients

WHAT IS KNOWN ON THE SUBJECT?: Sometimes someone needs to be in hospital because they are struggling with their mental health and need some extra support but being in hospital can also be a difficult experience. There are a lot of restrictions in place in hospital, like locked doors, rules to follow and not much choice about what happens to you. Other research has found that these restrictions can feel difficult and stressful for people and so more research is needed about this. We wanted to know what being in hospital felt like for women in particular. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We interviewed women who were in hospital because of their mental health about what it was like for them in hospital. The women told us that they felt powerless while they were in hospital. They sometimes felt like they were being punished and this could affect their mood and could lead to them hurting themselves. They also said that they were not always listened to by staff, and they found it difficult being away from their family and friends while they were in hospital. The women also told us that being in hospital could sometimes help them to feel safe. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Women should be looked after in hospital in a way that helps them to feel in control of what happens to them. They should be supported to be able to go outside the hospital on leave, to keep in touch with their family and friends, and they should be listened to by staff. A project called "safewards" has suggested some ways for helping to make hospital wards safer. They have suggested that everyone should be clear about what the rules are when they go into hospital and ways that staff could communicate more clearly with the people they are working with. Our research supports using these techniques. ABSTRACT: Introduction Inpatient care often involves restrictive interventions such as seclusion and restraint and restrictive practices that limit the person's freedom, rights and daily activities. Restrictive practice has not been the explicit focus in previous research; however, it often appears as an important theme, with participants identifying it can have a detrimental effect on their well-being. More research specifically on this topic in an inpatient setting is, therefore, needed. Women might be particularly vulnerable to adverse effects of restrictive practices compared to men as women generally occupy less powerful positions in society and more often experience abuse. Aims The study aimed to explore women's experiences of routine restrictive practices in mental health inpatient settings. Methods Twenty-two women who were currently inpatients on mental health wards were interviewed about their experiences of restrictive practices in hospital. Interviews were analysed using thematic analysis. Results An overarching theme emerged of powerlessness. Four key sub-themes were also identified: restrictions perceived as punitive, having no voice, impact of restrictions on relationships and restrictions providing safety and support. Discussion Although restrictive practices were found to provide the women with a sense of safety, they were also found to impact upon the women's well-being, leading to increases in self-harm and over-reliance on restrictions. Implications for practice This research highlights the importance of gender-informed inpatient services for women that foster independence, empowerment and allow women to have their voices heard. Safewards interventions such as clear mutual expectations and soft words could contribute to mitigating the impact of restrictive practices.

Is 'another' psychiatry possible?

In this paper, we examine a number of approaches that propose new models for psychiatric theory and practices: in the way that they incorporate 'social' dimensions, in the way they involve 'communities' in treatment, in the ways that they engage mental health service users, and in the ways that they try to shift the power relations within the psychiatric encounter. We examine the extent to which 'alternatives' - including 'Postpsychiatry', 'Open Dialogue', the 'Power, Threat and Meaning Framework' and Service User Involvement in Research - really do depart from mainstream models in terms of theory, practice and empirical research and identify some shortcomings in each. We propose an approach which seeks more firmly to ground mental distress within the lifeworld of those who experience it, with a particular focus on the biopsychosocial niches within which we make our lives, and the impact of systematic disadvantage, structural violence and other toxic exposures within the spaces and places that constitute and constrain many everyday lives. Further, we argue that a truly alternative psychiatry requires psychiatric professionals to go beyond simply listening to the voices of service users: to overcome epistemic injustice requires professionals to recognise that those who have experience of mental health services have their own expertise in accounting for their distress and in evaluating alternative forms of treatment. Finally we suggest that, if 'another psychiatry' is possible, this requires a radical reimagination of the role and responsibilities of the medically trained psychiatrist within and outside the clinical encounter.

Service User and Carer Views and Expectations of Mental Health Nurses: A Systematic Review

Service users' views and expectations of mental health nurses in a UK context were previously reviewed in 2008. The aim of this systematic review is to extend previous research by reviewing international research and work published after the original review. Five databases were searched for studies of any design, published since 2008, that addressed service user and carer views and expectations of mental health nurses. Two reviewers independently completed title and abstract, full-text screening and data extraction. A narrative synthesis was undertaken. We included 49 studies. Most included studies (n = 39, 80%) were qualitative. The importance of the therapeutic relationship and service users being supported in their personal recovery by mental health nurses were core themes identified across included studies. Service users frequently expressed concern about the quality of the therapeutic relationship and indicated that nurses lacked time to spend with them. Carers reported that their concerns were not taken seriously and were often excluded from the care of their relatives. Our critical appraisal identified important sources of bias in included studies. The findings of our review are broadly consistent with previous reviews however the importance of adopting a recovery approach has emerged as a new focus.

Virtual reality-based training for mental health staff: a novel approach to increase empathy, compassion, and subjective understanding of service user experience

Background

Mental health service users report that staff empathy is key to developing positive therapeutic relationships but promoting empathy in staff training is challenging. Staff may struggle to maintain their compassion, particularly in challenging settings, and have limited clinical confidence when treating conditions of which they lack subjective understanding. Novel interventions are required to address these needs.

Main body of the text

Virtual reality-based simulation training has been shown to be an effective training modality for healthcare professionals; it has the potential to deliver crucial empathy-building learning for frontline mental health staff due to its capacity to increase staff understanding of service users’ experiences. Virtual reality and simulation technology take interactivity and experiential learning to a level beyond which we have seen in teaching and training before. Subjective understanding is elicited because this is a technology for enhanced experiential learning, which in turn fosters greater empathy and compassion. Increased empathy in the workforce is likely to yield significant benefits for service users. Greater empathy in nursing is linked with reduced restrictive practices and reduced conflict between staff and service users. Restrictive practices, including restraint and seclusion, are widely used in mental health settings within the UK, and are an aspect of mental health nursing that is at odds with the therapeutic role of nursing. Despite these innovative developments, there are challenges ahead. Many nurses feel that complete eradication of restrictive practices is impossible and that barriers include a limitation of resources, communication, management, and lack of education. There is a need to make simulation training economically viable so that it can be upscaled and widely available. Therefore, greater investment and resources are needed to bring this innovative training to the wider workforce to support staff and to realise the benefits for service users.

Short conclusion

Virtual reality-based training has great potential for mental health staff, which could have important consequences in terms of improved staff empathy and reductions in harmful restrictive practices. Further research and funding for such training is necessary so that it can be more widely available.

The Use of 360-Degree Video in Developing Emotional Coping Skills (Reduced Anxiety and Increased Confidence) in Mental Health Nursing Students: A Protocol Paper

Higher education institutions are uniquely placed to introduce emotional coping skills to promote resilience in pre-registration nurses in order to reduce anxiety and increase confidence before they enter clinical placement for the first time. In this qualitative study, we will explore the use of a 360-degree video in developing skills for coping. The participants will be mental health nursing students. We will develop a 360-degree video in collaboration with a mental health service user. All participants will watch the video. A sub-group will receive a supportive clinical supervision discussion within a cognitive reappraisal/solution-focused/VERA framework. We will record the experiences of the participant to explore: (1) how students felt about the use of 360-degree video, as an education tool to build skills of resilience; (2) whether the students involved felt more confident and less anxious about the situation in the video as a result of participating in the cognitive reappraisal/solution-focused/VERA supervision discussion.

Staff experience of team case formulation to address challenging behaviour on acute psychiatric wards: a mixed-methods study

BACKGROUND

Team case formulation on acute psychiatric wards aims to support staff to manage significant levels of challenging behaviour. However, there is limited research on staff experience of case formulation in this setting.

AIM

This study aimed to investigate staff experience of team case formulation sessions on acute psychiatric wards and their impact on staff wellbeing.

METHODS

Eighteen multidisciplinary staff (nurses, doctors, occupational therapists, support workers, activities coordinators) from five acute wards at a South London psychiatric hospital completed a semi-structured interview and visual analogue scales on their experience of attending case formulation. Thematic analysis was employed to analyse qualitative data.

RESULTS

Participants reported that case formulation supported staff to develop a holistic understanding of service users, provided a safe space for staff to discuss the impact of challenging behaviour and improved teamwork and communication. Participants reported that these benefits increased their ability to identify and support the needs of service users and improved therapeutic relationships. Challenges with establishing continuity of care were highlighted.

CONCLUSION

Team case formulation is an important intervention to support ward staff and has significant benefits to staff wellbeing and quality of care. Greater integration with existing ward practices may benefit both staff and service users.

It's Not Just in the Walls: Patient and Staff Experiences of a New Spatial Design for Psychiatric Inpatient Care

The environment in psychiatric inpatient care is key to patient recovery and staff job satisfaction. In this qualitative study of patient and staff experiences of a new spatial design in psychiatric inpatient care, we analysed data from 11 semi-structured interviews with patients and five focus group discussions with staff using qualitative content analysis. The new design contributed to feelings of safety and recovery, but patients and staff also reported some frustration and added stress. The results lead us to conclude that while the new spatial design improves some conditions for recovery and job satisfaction, the design itself is simply not enough. Changes in care environments require that both patients and staff be informed and involved in the renovation to ensure that patients feel respected and staff feel confident in using the new environment before and during treatment and follow-ups.

Design features that reduce the use of seclusion and restraint in mental health facilities: a rapid systematic review

Increasing efforts are being made to prevent and/or eliminate the use of seclusion and restraint in mental health facilities. Recent literature recognises the importance of the physical environment in supporting better outcomes in mental health services. This rapid review scoped the existing literature studying what physical design features of mental health facilities can reduce the use of seclusion and physical restraint.

DESIGN

A rapid review of peer-reviewed literature.

METHODS

Peer-reviewed literature was searched for studies on architectural design and the use of restraint and seclusion in mental health facilities. The following academic databases were searched: Cochrane Library, Medline, PsycINFO, Scopus and Avery for English language literature published between January 2010 and August 2019. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of included studies.

RESULTS

We identified 35 peer-reviewed studies. The findings revealed several overarching themes in design efforts to reduce the use of seclusion and restraint: a beneficial physical environment (eg, access to gardens or recreational facilities); sensory or comfort rooms; and private, uncrowded and calm spaces. The critical appraisal indicated that the overall quality of studies was low, as such the findings should be interpreted with caution.

CONCLUSION

This study found preliminary evidence that the physical environment has a role in supporting the reduction in the use of seclusion and restraint. This is likely to be achieved through a multilayered approach, founded on good design features and building towards specific design features which may reduce occurrences of seclusion and restraint. Future designs should include consumers in a codesign process to maximise the potential for change and innovation that is genuinely guided by the insights of lived experience expertise.

Psychiatric inpatients' view of the therapeutic environment: A Turkish interview study

PURPOSE

The aim of the study was to determine the feelings, thoughts, and experiences of inpatients in a psychiatric clinic about the therapeutic environment of the clinic.

DESIGN AND METHODS

The data were collected in interviews using the phenomenological method and interpreted using Strauss and Corbin's approach to qualitative data analysis.

FINDINGS

As a result of the data analysis, four themes, "Activities," "Physical Environment," "Personnel," and "Rules" were determined, and each with a number of related subthemes.

PRACTICE IMPLICATIONS

The therapeutic environment is a dynamic space that can be modified according to the needs of the patients. Psychiatric nurses will benefit from responding to the feedback from patients by providing, for example, more activities or additional psychotherapeutic interventions.

"What matters to me": A multi-method qualitative study exploring service users', carers' and clinicians' needs and experiences of therapeutic engagement on acute mental health wards

Nurse-patient therapeutic engagement on acute mental health wards is beneficial to service users' outcomes and nurses' job satisfaction. However, engagement is not always fulfilled in practice and interventions to improve engagement are sparse and ineffective. We explored the experiences of service users, carers, and clinicians drawing from 80 hours of non-participant observations in an acute mental health ward and semi-structured interviews with 14 service users, two carers, and 12 clinicians. Analysis of these data resulted in 28 touchpoints (emotionally significant moments) and eight overarching themes. Service users, carers, and clinicians identified a lack of high-quality, person-centred, collaborative engagement and recognized and supported efforts to improve engagement in practice. Potential solutions to inform future intervention development were identified. Our findings align with previous research highlighting negative experiences and support the need to develop multicomponent interventions through participatory methods.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.

Chemical restraint: A qualitative synthesis review of adult service user and staff experiences in mental health settings

With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background : The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim : To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology : A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results : The analysis of the forty-six selected studies revealed four distinct themes : coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion : Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Experiences of acute care by persons with mental health problems: An integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Understanding experiences of acute care by persons with mental health problems is vital for improving these experiences through the development of different parts of the care delivery and its facilities. Literature has extensively addressed experiences of persons with mental health problems in acute care settings. Yet, there is a paucity of studies that aggregate and organize these findings in presenting development-oriented solutions for the improvements of these experiences. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Acute care can be understood through patients' experiences of structure (such as setting, staff and resources); process (such as communication and interpersonal relations); and outcome (such as satisfaction and post-discharge well-being and health) and suggests improvements in these domains. The paper illuminates that previous literature has mainly captured negative experiences of acute care by persons with mental health problems, and suggests diverting the focus to the best practices and to seek inspiration from other fields of research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Attending to the improvement and development of different parts of the acute care might be an important step in improving experiences of persons with mental health problems. For example, improving resource allocation systems and facilities, emphasizing professionalism in encounters with these patients and systematically assessing patient satisfaction during and after visits are important areas that require attention. ABSTRACT: Aim The provision of acute care to persons with mental health problems is challenging due to difficulties in encountering this group and the vulnerability of these persons. Understanding this group's experiences with acute care is thus an important endeavour. The purpose of this review was to critically and systematically identify and assess previous research on experiences of acute care by persons with mental health problems, guided by Donabedian's structure-process-outcome framework (Prospero ID: CRD42019116652). Method and results An integrative literature review was performed, resulting in the identification of 43 studies. The search was conducted using five electronic databases: Web of Science Core, PubMed, MEDLINE, CINAHL and PsycINFO. Discussion The review revealed that patients experienced structure components such as setting, staff and resources in a predominantly negative way. A predominately negative picture also emerged of the process components, where, for example, communication and interpersonal relations were represented by negative experiences, with limited positive experiences reported. The outcome components, related to patients' satisfaction and their well-being after discharge, were also predominantly experienced negatively. Implications for practice Using Donabedian's framework of structure, process and outcome allowed us to systematize the literature reviewed, to identify the research gaps and to suggest ways forward for the field's development.

Mothers' experiences of acute perinatal mental health services in England and Wales: a qualitative analysis

BACKGROUND/OBJECTIVE

Perinatal mental health services are a current NHS priority and services are being increased for women. There is limited research on mothers' perspectives of these services and most research focuses on mother and baby units (MBUs). This study explored women's views of their experiences of generic wards, MBUs and crisis resolution teams.

METHODS

A qualitative thematic analysis was conducted on written feedback on a service-user-designed questionnaire. One hundred and thirty-nine women recruited across 42 mental health trusts made comments.

RESULTS

Two key themes were identified: support networks and staff authority. Support networks included subthemes relating to families, peers and staff. The theme of staff authority incorporated subthemes about communication, confidence in staff and service-user autonomy. All themes contributed to whether mothers felt safe in these services. Mothers reported the benefits of positive, non-coercive relationships with family and staff for their recovery. The findings highlight that the challenges women face in perinatal settings reflect the literature on general psychiatric services, particularly around coercion.

CONCLUSIONS

Specific implications for mothers accessing perinatal mental health services: 1) integrated mental health care and support with babies; 2) support with separation from babies for mothers in acute wards; 3) improvement of women's relationships with social services across all services.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Feasibility and Patient Experiences of Method of Levels Therapy in an Acute Mental Health Inpatient Setting

This study sought to investigate the feasibility and acceptability of a flexible psychotherapeutic approach - the Method of Levels (MOL) - in an acute mental health inpatient setting. A multi methods approach was used. The feasibility of implementation was investigated by examining the referral rate and the attendance patterns of participants. The acceptability of MOL was explored using a thematic analysis of participant interviews and by recording attendance patterns of participants. Inpatient staff consistently referred patients and the majority of eligible people accepted invitations for therapy. Thematic analysis of peoples' experiences of the therapy generated themes that described participants' experiences of MOL in contrast to routine NHS care, having spent meaningful time with the therapist, and having gained something from the session. The referral rate and uptake of MOL therapy indicates that the resource was appropriate for the setting and acceptable to most participants. Qualitative analyses indicated that participants were comfortable with the therapists' approach, felt understood, and there was a meaningful quality to their interaction. Participants also valued the opportunity to reflect and generate new perspectives of their difficulties. Further research is required to determine the effectiveness of the approach and its translational value beyond this pilot investigation.

The impact of ward climate on staff perceptions of barriers to research-driven service changes on mental health wards: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: To date, improvements on U.K. acute mental health wards have been difficult to sustain. The barriers to change may be context dependent. Mental health wards are volatile workplaces with service user violence/aggression, frequent staff and patient changes, and ongoing service improvements. The evidence suggests that burnout affects staff perceptions of barriers to change, and ward climate affects burnout. As two potentially important, independent predictors of staff perceptions of barriers to change, the impact of ward climate and burnout on how staff regard changes should be considered. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Elements of ward climate such as high numbers of incidents and temporary staff independently worsened mental health staff perceptions of barriers to change, in addition to negative impacts from burnout and occupational status. How staff perceived ward climate was also linked their perceptions of barriers to change; however, burnout was no longer a significant consideration with these variables. Staff with low job satisfaction and high interaction anxiety also had low confidence regarding changes. Staff with low job satisfaction were also demotivated towards changes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ward climate is clearly an important factor in how nurses view organizational changes. In this study, nurses' perceptions of barriers to change were worse if they viewed ward climate negatively, or if temporary staff and incident numbers were high. Staff perceptions of ward climate and barriers to change should be assessed, ahead of service changes. Developing change strategies based on such information is likely to produce better implementation outcomes. Specifically, targeting staff confidence and motivation (which are barriers to change) may improve how staff regard their ward climate. Abstract Introduction To create successful change programmes for mental health wards, it is necessary to understand which aspects of ward climate prevent change. Question Does ward climate influence mental health nurse's perceptions of barriers to change? Method Random-effects models were used to test whether the following ward climate variables influenced the outcome measure "staff perceptions of barriers to change" (VOCALISE) and its subscales (powerlessness/confidence/demotivation): (a) Perceptions of ward climate (VOTE: subscales included work intensity/job satisfaction/interaction anxiety). (b) Ward climate indicators (incidents/detention under the Mental Health Act (2007)/staffing/bed pressure). As known predictors of VOCALISE, burnout (Maslach Burnout Inventory) and occupational status were included in the models. Results Perceptions of ward climate (VOTE), incidents, temporary staff, occupational status and burnout significantly and negatively affected perceptions of barriers to change (VOCALISE). Staff with low job satisfaction (VOTE) and high interaction anxiety (VOTE) also had low confidence (VOCALISE). Staff with low job satisfaction (VOTE) were also demotivated (VOCALISE). Discussion Ward climate is an important predictor of how staff regard service changes in mental health wards. Implications for practice Staff perceptions of ward climate and barriers to change should be assessed ahead of service changes to identify pressures that impede progress and lower morale.

An exploration of perceived coercion into psychological assessment and treatment within a low secure forensic mental health service

Psychologists working within forensic mental health (FMH) services face challenges around supporting clients' informed consent when engaging in psychological assessment and treatment. Given that there is little research in this area, this qualitative study interviewed ten forensic inpatients from a low secure FMH service, to determine the impact of any perceived coercion to engage with psychologists. Interviews were transcribed and subject to Thematic Analysis. Three over-arching themes emerged from the analysis: 'Awareness of Coercive Power', 'Experiencing and Responding to Coercion' and 'Psychological Treatment is Helpful, But…'. Participants perceived coercion to engage with psychologists. Perceived coercion led to psychological distress, wanting to resist, and superficial engagement. Despite this, therapeutic alliance was established with the psychologist but the quality of the therapeutic alliance was compromised. The findings have implications for psychologists working in FMH services. Suggestions for reducing perceived coercion and future directions for research are discussed.

Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study

Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.¹ A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the 'REsTRAIN Yourself' (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma-informed care represents a potentially alternative legitimacy.

Participatory action research to pilot a model of mental health service user involvement in an Ethiopian rural primary healthcare setting: study protocol

BACKGROUND

Involvement of service-users at all levels of the mental health system is a policy imperative in many countries internationally. However, putting policy into practice seems complex; little is known about how best to involve service users and efforts are often criticized for being tokenistic. In low-and-middle income countries, less attention has been given to the roles of service users within mental health systems. The proposed study is part of a larger project intended to develop service-user involvement in mental health system strengthening in Ethiopia. A Theory of Change (ToC) model has already been developed through a participatory approach. This study protocol aims to describe the theoretical background and methods to pilot this model using participatory action research (PAR) and explore participants' experience of involvement.

METHODS

The proposed study will apply a PAR approach situated in critical social theory and conduct a phenomenological case study to find out participants' experience of involvement. This will be conducted in three stages. The focus of Stage 1 will be to(i) establish a Research Advisory Group (RAG), and Research Participant Group (RPG) at district and primary healthcare facility levels, respectively, and (ii) identify and prioritize potential areas of concern for involvement in the domains of advocacy, service planning and development, monitoring and improving service quality. In Stage 2, we will work with the RPG to develop a plan of action for the selected area. Stage 3 will aim to assist the RPG to implement and evaluate the plan of action. Process indicators and observation will be combined with in-depth interviews with participants to elicit their experiences of involvement. Thematic content analysis will be used.

DISCUSSION

The participatory approach to mental health service user involvement in health system strengthening employed by this study will support the implementation of solutions through locally relevant and contextualized actions. Findings from this study will contribute to the body of knowledge towards understanding the complexity of implementation of service user involvement and refine the ToC model for transferability to similar settings.

Nurses’ experiences of informal coercion on adult psychiatric wards

Background:

Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy.

Aim:

To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care.

Research design:

The study has a qualitative, inductive design.

Participants and research context:

Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis.

Ethical considerations:

The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university.

Findings:

Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together.

Discussion:

Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy.

Conclusion:

If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient.

The side effects of service changes: exploring the longitudinal impact of participation in a randomised controlled trial (DOORWAYS) on staff perceptions of barriers to change

BACKGROUND

Staff and service users have expressed concerns that service improvements in British mental health wards have been slow or transient. It is possible that certain changes are positive for some (e.g. service users), but negative for others (e.g. staff), which may affect implementation success. In this study, we explore whether a programme of change to improve the therapeutic milieu on mental health wards influenced staff perceptions of barriers to change, 12 months after implementation.

METHOD

A cluster randomised controlled trial called DOORWAYS was conducted on eight British, inner-city acute mental health wards. Randomisation was achieved using a list randomly generated by a computer. A psychologist trained ward staff (mainly nurses) to deliver evidence-based groups and supported their initial implementation. The impact of these changes was measured over 12 months (when 4 wards were randomised), according to nurses' perceptions of barriers to change (VOCALISE), using unstructured multivariate linear regression models. This innovative analysis method allows maximum use of data in randomised controlled trials with reduced sample sizes due to substantial drop out rates. The contextual influences of occupational status (staff) and of workplace setting (ward) were also considered.

RESULTS

Staff who participated in the intervention had significantly worse perceptions of barriers to change at follow up. The perceptions of staff in the control group did not change over time. In both groups (N = 120), direct care staff had more negative perceptions of barriers to change, and perceptions varied according to ward. Across time, direct care staff in the intervention group became more negative than those in the control group.

CONCLUSION

Participation in this program of change, worsened staff perceptions of barriers to change. In addition, occupational status (being from the direct care group) had a negative effect on perceptions of barriers to change, an effect that continued across time and was worse in the intervention group. Those providing direct care should be offered extra support when changes are introduced and through the implementation process. More effort should be placed around reducing the perceived burden of innovation for staff in mental health wards.

TRIAL REGISTRATION

ISRCTN, ISRCTN 06545047. Registered 29/04/2010, https://www.isrctn.com/search?q=06545047.

A qualitative comparison of experiences of specialist mother and baby units versus general psychiatric wards

BACKGROUND

Mother and baby units (MBUs) are an inpatient mental health service where women experiencing acute severe postpartum psychiatric difficulties can be admitted with their babies. They are currently viewed as best practice in the UK and elsewhere. However, as service provision is fragmented, some women residing in areas without MBUs are admitted to acute general psychiatric wards without their infants. This study aimed to compare qualitatively experiences of these two service types from the perspectives of women and clinicians.

METHODS

Semi-structured interviews were conducted with fifteen women who received treatment for perinatal mental health problems on a general psychiatric ward and/or MBU in England. Two focus groups were also conducted, one with MBU staff (n = 11) and one with acute ward staff (n = 6). Data were analysed thematically.

RESULTS

Women generally preferred being co-admitted with their baby to an MBU over lone admission to a general psychiatric ward. Women and clinicians felt that MBUs provided more perinatally-focused, family-centred care, and were better-equipped to meet women's needs. General wards were reported by women and staff to lack the necessary facilities and expertise to support perinatal women adequately, while separation of mothers and babies was often experienced by women as traumatic and detrimental to recovery. However, some areas for improvement were also identified across both service types, particularly relating to difficulties transitioning home post-discharge, inadequate support for family members, staffing issues and access problems (with MBUs).

CONCLUSIONS

Findings suggest that specialist perinatal inpatient care is considered preferable to generic care in the perinatal period from both service user and staff perspectives. Increased collaboration between perinatal and non-perinatal services could help improve perinatal expertise on general psychiatric wards, while further expansion of perinatal services (e.g. to cater for women currently considered too high risk for MBUs and for those discharged from inpatient settings) could tackle other shortfalls in care.

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

BACKGROUND

Therapeutic 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.

METHODS

The 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.

RESULTS

Only 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.

CONCLUSION

These 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.

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.

Working with consumers who hear voices: The experience of early career nurses in mental health services in Australia

Mental health consumers who hear voices frequently experience distress and express a desire to discuss their voice-hearing experience. Nurses do not regularly demonstrate a willingness to engage in such discussions. With the introduction of educational strategies that develop empathy and an understanding of voice-hearing experiences, it is anticipated that early career nurses will be able to translate such understanding into their professional nursing practice. To explore early career nurses' understanding of providing care to mental health consumers who hear voices, a qualitative exploratory descriptive study was conducted in which nine early career Registered Nurses were interviewed regarding their experiences of caring for people who hear voices. Thematic analysis was employed to analyse the data and generate themes. Participants reported difficulty in developing relationships with consumers who hear voices, due to a workplace culture that was focussed on risk and lacking professional support. Nurses need specific education to develop the skills necessary to respond to consumers who hear voices and engage in dialogue that assists consumers to relate to the voices in a meaningful way. However, for this to succeed in practice, changes need to be supported by addressing the cultural barriers, such as risk-focussed environments, that prevent nurses implementing best practice.

Conceptualising nurse-patient therapeutic engagement on acute mental health wards: An integrative review

OBJECTIVES

The review aimed to 1) explore the constituents of nurse-patient therapeutic engagement on acute mental health wards; 2) map factors that influence engagement to the Theoretical Domains Framework and 3) integrate results into a conceptual model of engagement to inform the development of interventions to improve engagement.

DESIGN

A systematic integrative review using an established framework specific to the integrative review methodology.

DATA SOURCES

Database searches (CINAHL, PsycINFO, BNI and Cochrane Library) and hand searching identified 3414 articles. After screening, applying eligibility criteria, and quality appraisal, 37 articles were included: n = 27 empirical research studies, n = 10 expert opinion pieces, n = 1 case study and n = 1 theoretical report.

REVIEW METHODS

Peer-reviewed empirical studies, theoretical reports or expert opinion pieces that explored therapeutic engagement as a stated aim and were conducted in acute mental health inpatient settings from the patient or nurse perspective were included. Data were extracted from the introduction, results and discussion sections of empirical research, and the complete article of theoretical and expert opinion pieces. Data were coded then grouped into subthemes and themes. Data relating to influencing factors were further categorised according to the Theoretical Domains Framework. Results were synthesised into a conceptual model of engagement.

RESULTS

Five conceptually distinct, but closely related constructs of engagement - called the "Principles of Engagement" - emerged: 1) Understanding the person and their experiences; 2) Facilitating growth; 3) Therapeutic use of self; 4) Choosing the right approach and 5) Authoritative vs. emotional containment. Influences on engagement ranged across all 14 theoretical domains of the Theoretical Domains Framework.

CONCLUSION

A holistic understanding of the essential components of engagement may make it easier for nurses to recognise what they do, and to do it well. The model can be used to generate testable hypotheses about how and where to target behavioural change interventions. The Principles of Engagement must be reflected in the development of interventions to improve engagement.

Patient involvement in improving the evidence base on mental health inpatient care: the PERCEIVE programme

Background

Despite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programme provides a particular focus on the inclusion of the patient’s perspective in the development and evaluation of evidence.

Objectives

To understand how changes to inpatient care affect the perceptions of the ward by service users and staff by using stakeholder participatory methods.

Design

The programme consisted of four work packages (WPs). (1) Lasting Improvements for Acute Inpatient SEttings (LIAISE): using participatory methods we developed two new scales [Views On Therapeutic Environment (VOTE) for staff and Views On Inpatient CarE (VOICE) for service users]. (2) Client Services Receipt Inventory – Inpatient (CITRINE): working with nurses and service users we developed a health economic measure of the amount of contact service users have with staff. The self-report measure records interactions with staff as well as the number of therapeutic activities attended. (3) Delivering Opportunities for Recovery (DOORWAYS): a stepped-wedge randomised controlled trial to test if training ward nurses to deliver therapeutic group activities would improve the perception of the ward by service users and staff. A total of 16 wards were progressively randomised and we compared the VOICE, VOTE and CITRINE measures before and after the intervention. A total of 1108 service users and 539 staff participated in this trial. (4) Bringing Emergency TreatmenT to Early Resolution (BETTER PATHWAYS) was an observational study comparing two service systems. The first was a ‘triage’ system in which service users were admitted to the triage ward and then either transferred to their locality wards or discharged back into the community within 7 days. The second system was routine care. We collected data from 454 service users and 284 nurses on their perceptions of the wards.

Main outcome measures

The main outcomes for the DOORWAYS and BETTER project were service user and staff perceptions of the ward (VOICE and VOTE, respectively) and the health economic measure was CITRINE. All were developed in WPs 1 and 2.

Results

We developed reliable and valid measures of (1) the perceptions of inpatient care from the perspectives of service users and nurses (VOICE and VOTE) and (2) costs of interactions that were valued by service users (CITRINE). In the DOORWAYS project, after adjusting for legal status, we found weak evidence for benefit (standardised effect of –0.18, 95% CI 0.38 improvement to 0.01 deterioration;p = 0.062). There was only a significant benefit for involuntary patients following the staff training (N582, standardised effect of –0.35, 95% CI –0.57 to –0.12;p = 0.002; interactionp-value 0.006). VOTE scores did not change over time (standardised effect size of 0.04, 95% CI –0.09 to 0.18;p = 0.54). We found no evidence of an improvement in cost-effectiveness (estimated effect of £33, 95% CI –£91 to £146;p = 0.602), but resource allocation did change towards patient-perceived meaningful contacts by an average of £12 (95% CI –£76 to £98;p = 0·774). There were no significant differences between the triage and routine models of admission in terms of better perceptions by service users (estimated effect 0.77-point improvement in VOICE score on the triage ward;p = 0.68) or nurses (estimated effect of 1.68-point deterioration in VOTE on the triage ward;p = 0.38) or in terms of the cost of the length of care provided (£391 higher on triage;p = 0.77).

Strengths and limitations

We have developed measures using methods involving both service users and staff from mental health services. The measures were developed specifically for acute inpatient services and, therefore, cannot be assumed to be useful for other services. For instance, extensions of the measures are under construction for use in mother and baby units. The strength of the BETTER PATHWAYS and DOORWAYS projects is the large-scale data collection. However, we were testing specific services based in inner city areas and stretching to inner urban areas. It may be that different effects would be found in more rural communities or in different types of inpatient care.

Future work

Our database will be used to develop an understanding of the mediating and moderating factors for improving care quality.

Trial registration

Current Controlled Trials ISRCTN06545047.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 7. See the NIHR Journals Library website for further project information.

An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings

In Western society, policy and legislation seeks to minimize restrictive interventions, including physical restraint; yet research suggests the use of such practices continues to raise concerns. Whilst international agreement has sought to define physical restraint, diversity in the way in which countries use restraint remains disparate. Research to date has reported on statistics regarding restraint, how and why it is used, and staff and service user perspectives about its use. However, there is limited evidence directly exploring the physical and psychological harm restraint may cause to people being cared for within mental health inpatient settings. This study reports on an integrative review of the literature exploring available evidence regarding the physical and psychological impact of restraint. The review included both experimental and nonexperimental research papers, using Cooper's (1998) five-stage approach to synthesize the findings. Eight themes emerged: Trauma/retraumatization; Distress; Fear; Feeling ignored; Control; Power; Calm; and Dehumanizing conditions. In conclusion, whilst further research is required regarding the physical and psychological implications of physical restraint in mental health settings, mental health nurses are in a prime position to use their skills and knowledge to address the issues identified to eradicate the use of restraint and better meet the needs of those experiencing mental illness.

Psychometric properties of the Patient Dignity Inventory in an acute psychiatric ward: an extension study of the preliminary validation

BACKGROUND

During the last decades, dignity has been an emerging issue in mental health since its ethical and therapeutic implications became known. This study is an extension of the preliminary validation of the Patient Dignity Inventory (PDI) in a psychiatric setting, originally designed for assessing perceived dignity in terminal cancer patients.

METHODS

From October 21, 2015 to December 31, 2016, we administered the Italian PDI to all patients hospitalized in an acute psychiatric ward, who provided their consent and completed it at discharge (n=165). We performed Cronbach's alpha coefficient and principal factor analysis. We administered other scales concomitantly to analyze the concurrent validity of PDI. We applied stepwise multiple linear regression to identify the patients' demographic and clinical variables related to the PDI score.

RESULTS

Our response rate was 93%, with excellent internal consistency (Cronbach's alpha coefficient=0.94). The factorial analysis showed three factors with eigenvalue >1, which explained >80% of total variance: 1) "loss of self-identity and anxiety for the future", 2) "concerns for social dignity and spiritual life", and 3) "loss of personal autonomy". The PDI and the three factor scores were positively and significantly correlated with the Hamilton Scales for Depression and Anxiety but not with other scale scores. Among patients' variables, "suicide risk" and "insufficient social and economic condition" were positively and significantly correlated with the PDI total score.

CONCLUSION

The PDI can be a reliable tool to assess patients' dignity perception in a psychiatric setting, which suggests that both social and clinical severe conditions are closely related to dignity loss.

Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement

Staff members' engagement with patients is a critical element of inpatient psychiatric care, essential to safety, the hospitalization experience and the development of a culture of care. Currently broad concerns exist around the amount of time inpatient psychiatric nurses expend in patient engagement and the quality of these interactions. In this paper we present a model of engagement that clarifies necessary skills to support the engagement process. The model is based on Peplau's theory of interpersonal relations, patients' ideas on healing elements of psychiatric hospitalization and research on inpatient therapeutic relationships. We are currently using this model for a web-based teaching/learning course to cultivate interpersonal engagement, and to explicate how through operationalizing their inpatient role, nurses support patients in the development of their mental health and well-being.

"Treat me with respect". A systematic review and thematic analysis of psychiatric patients' reported perceptions of the situations associated with the process of coercion

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric patients have generally negative experiences of being exposed to coercive measures. Existing research has generally not investigated coercion as a process; that is, it does not address issues that arise before, during and after exposure to coercion. A part of existing research within the area does not clarify and define the type of coercive measure(s) investigated. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients place great significance on the link between the positive and negative perceived impact of a coercive situation and the professionals' ability and willingness to interact and communicate respectfully. Psychiatric patients associate the use of seclusion, physical restraint/holding, mechanical restraint and forced medication with strong negative perceptions and wish to be treated with respect by professionals, rather than being subjected to the professionals' control. What patients perceive as moderating factors in regard to the use of coercive measures is currently under-researched. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Increased sensitivity to the patient's views of the situation at each point in the coercive process would help professionals to respond to the patients' individual needs. Professionals need to articulate concern and empathy towards patients and to improve communication skills before, during and after a coercive incident. Greater emphasis should be placed on de-escalation and the use of non-coercive strategies or coping skills before the initiation of coercive measures.

ABSTRACT

Introduction There is a lack of research into psychiatric patients' perceptions of coercion that discriminates between different types of coercive measures, while also investigating patients' perceptions of undergoing coercion as a process. This knowledge is required to improve our understanding and provide a foundation for improving clinical practice. Aims To review existing research literature in order to investigate adult psychiatric patients' reported perceptions of situations before, during and after specific and defined types of coercive measures, and to investigate what patients perceive as moderating factors, in regard to the use of these coercive measures. Method A systematic review and thematic analysis of 26 peer-reviewed studies was undertaken. Results The analysis identified six themes and additional subthemes, where "interactions with professionals" and "communication" were predominant themes across the timeline of coercion. Altogether, themes were associated with either "positive or negative patient-perceived impact." Implications for practice Increased sensitivity to patients' views of the situation at each point in the process is desirable in order to respond to the patients' individual needs. Professionals also need to articulate concern and empathy towards the patient and to improve communication skills before, during and after a coercive incident. Use of de-escalation and noncoercive strategies is required. Relevance statement Coercion within psychiatric/mental health care remains controversial, and repeated international calls have recommended a reduction of their use. This review indicates that greater attention to how patients perceive the use of coercive measures (before, during, and after incidents) needs to be considered in order to improve the evidence-based and clinical practice.

A systematic review of factors associated with service user satisfaction with psychiatric inpatient services

BACKGROUND

Satisfaction is seen as an indicator of the quality of mental health services and has been related to outcomes and compliance with treatment. The current review seeks to examine the factors relating to satisfaction with inpatient services.

METHOD

A search was conducted of PsycInfo, Web of Science, Cinahl, Embase and Medline databases. Screening resulted in 32 papers being included in the review. Papers were subject to quality assessment using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Review of the included papers suggested factors relating to satisfaction could be broadly classified as either service user or service/ward related. Service user related factors included findings that satisfaction was higher when service users were admitted voluntarily. Service related factors included findings that satisfaction was negatively associated with experiences of coercion and positively associated with being on an open ward.

CONCLUSION

It appears that coercion has a key role in ratings of satisfaction. Additionally, service users reported an impact of staff relationships, and the ward environment. Satisfaction is associated with a range of factors, an awareness of which will allow for the development of quality services that meet the needs of service users.

The therapeutic role of mental health nurses in psychiatric intensive care: A mixed-methods investigation in an inner-city mental health service

WHAT IS KNOWN ON THE SUBJECT?: Mental health services have been radically transformed since the 1990s, with an emphasis on care in the community. However, acute psychiatric wards remain an important component of service provision. Research shows that patients receive limited therapeutic interaction with nurses in such settings. A recent review showed that just 4%-12% of nurses' time was spent on activities that could be considered therapeutic. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: Whereas nurses wanted more time for individual therapeutic activity, patients were content with brief interactions. However, such contact was not always available, partly due to workload pressures. Both nurses and patients believed that a collaborative approach, involving the whole multidisciplinary team, was key to the success of therapeutic engagement. The meaning of therapeutic engagement remains nebulous. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse education, ward management and clinical supervision should have greater emphasis on therapeutic engagement. Further research is needed to develop therapeutic engagement in acute psychiatric settings; such work should involve patients as active and equal partners.

ABSTRACT

Introduction Despite indications that therapeutic interaction is beneficial for patients and for nurses' job satisfaction in acute psychiatric care, research shows a small amount of nurses' time is spent on such activity. Aims This study investigated the actual and potential therapeutic role of the mental health nurse in psychiatric intensive care, where admission is due to violence or aggression. Methods In a mixed-methods concurrent triangulation design, clinician and patient activity was observed using a structured measurement tool, and qualitative interviews were conducted with four practitioners and six patients. Findings were generated using thematic analysis and descriptive statistics. Results Of the directly observed 234 clinician and 309 patient activities, 20.9% and 15.9%, respectively, were classified as therapeutic engagement. Interviews revealed that both clinicians and patients wanted more therapeutic contact, but whereas nurses wanted longer time to spend in individual sessions, patients preferred brief but more frequent interaction with nurses. Discussion This study shows disparity between actual and desirable levels of therapeutic interaction. Apart from organizational constraints, a fundamental problem is the lack of definition or established practices of therapeutic engagement. Implications for Practice There should be more emphasis on therapeutic engagement in nurse education, ward management and clinical supervision.

Service user perspectives on coercion and restraint in mental health

Coercion remains a central aspect of many people's mental healthcare. It can include the use of legislation to restrict freedoms, the use of physical restraint, the restriction of freedom of movement and/or association, and the forced or covert administration of medication. There is good evidence that the use of such measures can traumatise service users. This article reports the findings of a survey of service users regarding their experiences of coercion and restraint and embeds this in the wider international and institutional environment.

The Use of the Addiction Severity Index Psychiatric Composite Scores to Predict Psychiatric Inpatient Admissions

The high prevalence of co-occurring mental health and substance use disorders indicates a need for integrated behavioral health treatment that addresses both types of disorder simultaneously. One component of this integrated treatment is the use of an assessment process that can concurrently identify the presence of each class of disorder. The Addiction Severity Index (ASI) has been extensively used and researched in the field of substance use disorders for over 30 years. The ASI has seven sections, including a section on substance use disorders and a section on psychiatric symptoms, making it a potential candidate for a co-occurring screen during intake. The following study utilized a receiver operating characteristic curve analysis to determine an optimal cutoff score on the ASI psychiatric composite score to identify which individuals seeking substance use disorder treatment were admitted to the Milwaukee County Behavioral Health Division's psychiatric hospital in the year subsequent to their ASI administration. Of the 19,320 individuals who completed an initial ASI in our system, 343 had an inpatient admission. The receiver operating characteristic curve was statistically significant, with an area under the curve of 0.75. A cutoff of 0.27 had a sensitivity of 0.77 and a specificity of 0.61, such that over 60% (11,963/19,320) of the sample was excluded. These results suggest that the ASI psychiatric composite score may be a useful initial screen to identify those with potential mental health problems/needs in a behavioral health system attempting to integrate addiction and mental health services.

The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: a cross-sectional study

Background

Poor service user experiences are often reported on mental health inpatient wards. Crisis houses are an alternative, but evidence is limited. This paper investigates therapeutic alliances in acute wards and crisis houses, exploring how far stronger therapeutic alliance may underlie greater client satisfaction in crisis houses.

Methods and Findings

Mixed methods were used. In the quantitative component, 108 crisis house and 247 acute ward service users responded to measures of satisfaction, therapeutic relationships, informal peer support, recovery and negative events experienced during the admission. Linear regressions were conducted to estimate the association between service setting and measures, and to model the factors associated with satisfaction. Qualitative interviews exploring therapeutic alliances were conducted with service users and staff in each setting and analysed thematically.

Results

We found that therapeutic alliances, service user satisfaction and informal peer support were greater in crisis houses than on acute wards, whilst self-rated recovery and numbers of negative events were lower. Adjusted multivariable analyses suggest that therapeutic relationships, informal peer support and negative experiences related to staff may be important factors in accounting for greater satisfaction in crisis houses. Qualitative results suggest factors that influence therapeutic alliances include service user perceptions of basic human qualities such as kindness and empathy in staff and, at service level, the extent of loss of liberty and autonomy.

Conclusions and Implications

We found that service users experience better therapeutic relationships and higher satisfaction in crisis houses compared to acute wards, although we cannot exclude the possibility that differences in service user characteristics contribute to this. This finding provides some support for the expansion of crisis house provision. Further research is needed to investigate why acute ward service users experience a lack of compassion and humanity from ward staff and how this could be changed.