An examination of service user satisfaction in forensic mental health settings

High levels of service user satisfaction are viewed as a reliable indicator of a service providing good care and treatment. There has been limited research looking into levels of satisfaction in forensic mental health settings with most work focused on staff satisfaction in these settings. This study examined service users' levels of satisfaction with a forensic mental health service in the United Kingdom. The service covered two sites; one a purpose-built secure unit and the other based in an old cottage hospital. Thirty-nine in-patients completed a 60-item validated forensic satisfaction scale. The scale measured seven domains of satisfaction as well as reporting an overall satisfaction score. The results indicated the service users were reasonably satisfied with the care and treatment they received. The domains of rehabilitation, safety, staff interaction and overall care showed the highest level of satisfaction. The high rehabilitation satisfaction score demonstrated the importance of meaningful activities for users accessing forensic services and may have been influenced by the security measures on the wards. The high safety domain score indicated respondents felt safe and secure within the wards and were likely to be influenced by positive interpersonal interactions. Good staff interaction was also an important factor in helping service users feel safe on the wards. These interactions are likely to be associated with longer periods of admission in secure services allowing therapeutic relationships to develop. Financial advice/support was the one domain that recorded negative satisfaction levels. Financial literacy training may help develop money management skills.

Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings? - A systematic review of the literature

BACKGROUND

Inpatient violence is a relevant issue in forensic psychiatric settings. Relevant guidelines recommend that restrictive measures are to be used exclusively if de-escalation and other preventive strategies have failed and there is a risk of harm to patients or staff if no action is taken. However, restrictive measures are untherapeutic and can be harmful. In order to enable staff to intervene before inpatient violence or other serious incidents occur and thus to avoid restrictive measures, mental health staff training programs including de-escalation components are being adopted in general as well as forensic mental health settings. There is growing evidence for the efficacy of mental health staff training in de-escalation techniques in the field of general psychiatry. However, there are no reviews evaluating the effectiveness of these interventions in reducing violent incidents in forensic psychiatric settings. Here we present the first literature review on the effectiveness staff training in de-escalation techniques in the field of forensic psychiatry.

METHOD

We searched relevant databases for original research on the effectiveness of reducing violence in forensic psychiatric settings. Studies were included if they investigated staff training programs with de-escalation techniques in forensic mental health settings.

RESULTS

A total of 5 relevant studies were identified. None of the studies was a randomized controlled trial. Four studies were before and after comparisons without control group. A one group post-test-only design was used in one study. Methodological quality was low. The maximum sample size was 112 participants. Results indicated no relevant impact of mental health staff training in de-escalation techniques on the rate of violent incidents in forensic psychiatric wards. However, staff seemed to feel safer following the training. Results have to be interpreted cautiously due to several methodological and content-related limitations.

DISCUSSION

Evidence for the effectiveness of staff training in de-escalation techniques on reducing verbal and physical aggression in forensic settings remains very limited. The existing definitions of terms like de-escalation, de-escalation training and de-escalation techniques in the healthcare context appear rather vague. Although some positive changes are reported across a variety of outcome measures it remains unclear to what extent staff training in de-esclation techniques contributes to a reduction in aggressive incidents and restrictive measures in forensic psychiatry. The clinical implications of this review are therefore limited. Yet, an important implication for future research is that a more comprehensive approach might prove worthwhile. Conducting a further review integrating a wide range of complex interventions aimed at the reduction of inpatient violence rather than focusing on de-escalation only, might be a worthwhile approach.

Relationships between dynamic risk factors for externalising problem behaviour and group climate in adults with mild intellectual disability in forensic treatment

BACKGROUND

Relationships between dynamic risk factors for externalising problem behaviour and group climate were investigated in 151 adult in-patients with mild intellectual disability or borderline intellectual functioning in a Dutch secure residential facility.

METHOD

Regression analysis was used to predict total group climate score and Support, Growth, Repression, and Atmosphere subscales of the 'Group Climate Inventory'. Predictor variables were Coping Skills, Attitude towards current treatment, Hostility, and Criminogenic attitudes subscales of the 'Dynamic Risk Outcome Scales'.

RESULTS

Less hostility predicted a better overall group climate, better support and atmosphere, and less repression. A positive attitude towards current treatment predicted better growth.

CONCLUSION

Results indicate relationships of hostility and attitude towards current treatment with group climate. A focus on both dynamic risk factors and group climate may provide a basis for improving treatment for this target group.

Validating the Essen Climate Evaluation Schema modified for people with learning disabilities in a low-risk secure forensic setting

BACKGROUND

Research has shown that an empowering and nurturing yet challenging work climate is beneficial for people receiving clinical services as it increases patient satisfaction, motivation, engagement, therapeutic alliance and functional improvement. Therefore, for inpatients, monitoring, encouraging and understanding ward climate holds considerable potential for improving forensic mental health services. To date, the most widely employed tool for ward-climate, the Essen Climate Evaluation Schema (EssenCES), has been evidenced as useful in medium and high security hospitals, but little tested with people with learning disabilities or in low security services.

AIMS

To establish the internal consistency and factor validity of the EssenCES, modified for easier reading, in a low secure hospital unit for people with learning disabilities.

METHOD

Language in the EssenCES was simplified and picture supplements added to facilitate comprehension. Patients completed the scale as part of their clinical routine, supported by National Health Service (NHS) employed psychology assistants. The research team, entirely independent of NHS staff, extracted data from the electronic records of purposively sampled residents in a low-secure forensic hospital setting for people with learning disabilities.

FINDINGS

Two hundred and twenty-seven records (70% men) were acquired. The EssenCES was shown to have good factor validity and retained the original three factor model including the subscales: therapeutic hold, safety and cohesion. One single-item from the 'therapeutic hold' subscale was removed to improve the internal consistency (p < 0.05).

CONCLUSIONS

This study adds preliminary support for the use of the EssenCES (with removal of one item) in individuals with learning disabilities within low-risk secure forensic hospital settings.

Impact of the implementation of the safewards model on the social climate on adolescent psychiatric wards

The Safewards model was created to reduce conflict and containment in psychiatric inpatient units. The model suggests alternative methods for containment and aims to create a safer hospital experience for both patients and staff. The evaluation of this model has provided evidence that it might be implemented on adolescent psychiatric wards. This study evaluated the impact of the implementation process of the Safewards model on the social climate of adolescent psychiatric inpatient wards by using the Essen Climate Evaluation Schema questionnaire. The study was carried out on six closed wards of one Finnish hospital district. Data were collected at baseline (42 adolescent inpatients and 134 staff members) and after the implementation of the model (39 inpatients and 115 staff members). The data were analysed using the Mann-Whitney U-test. The findings of this preliminary study indicate that inpatients' experience of patient cohesion and therapeutic hold and staff members' experience of safety on adolescent psychiatric wards might be improved by the implementation of the Safewards model on adolescent psychiatric wards.

The Therapeutic Engagement Questionnaire (TEQ): a service user-focused mental health nursing outcome metric

BACKGROUND

Therapeutic engagement (TE) has been described as the crux of mental health nursing but despite its perceived importance, to date, there is no measurement tool that captures it. As a result, there is no way of determining the contribution of mental health nursing interaction to service user recovery, in acute inpatient mental health settings or the wider care quality agenda.

METHODS

To develop and validate a TE measurement tool in partnership with Service Users (SUs) and Registered Mental Health Nurses (RMHNs). The TEQ was developed in 3 stages: 1) item generation (and pre-testing), 2) item reduction using Principal Component Analysis (PCA), and 3) validation across Mental Health Trusts in England.

RESULTS

The final questionnaire has two versions, (SU and RMHN version), each scored within two contexts (1-1 SU-RMHN interactions and overall environment and atmosphere of the ward) and includes 20 items with two sub-scales (care interactions and care delivery). Psychometric evaluation of the TEQ shows high inter-scale correlations (0.66-0.95 SU; 0.57-0.90 RMHN), sound sub-scale internal consistency (> 0.95), concurrent validity (> 0.60) and adequate score variability for both versions of the TEQ. In summary, the TEQ behaves well as a measurement tool.

CONCLUSIONS

The TEQ can determine the collaborative and empathic nature of RMHN-SU interactions, capture if SUs are treated with dignity and respect and recognise that the principles of the recovery approach are being respected. The TEQ can also provide robust monitoring of nursing activity, offer opportunity for transparency of activity, feed into healthcare organizations' key performance indicators and provide reassurance about the nature and quality of nurses' work.

Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit

Despite their widespread use, typical visual observation practices are not evidence-based and adverse events - such as self-harm and absconding - still occur even under the most intense forms of observation. This study aimed to (i) develop and implement an engagement-focused systematized model of clinical risk management in an adult acute psychiatric inpatient unit; and (ii) prospectively evaluate its effect on rates of violence, self-harm, absconding, sexually inappropriate behaviour, and seclusion. A new model of engagement-focused clinical risk management was developed using a participatory action research framework and implemented in an adult acute psychiatric inpatient unit. Using a mirror-image design, rates of violence/aggression, self-harm, absconding, sexually inappropriate behaviour, and seclusion were compared before and after implementation, and staff satisfaction levels were measured. The clinical engagement-based model was introduced, and 1087 admissions before implementation (24 months) were compared with 965 admissions post-implementation (18 months). The new model was associated with significantly reduced rates of absconding (pre: 10.5/1000 occupied bed days, 95% CI [9.0, 12.1] compared with post: 6.5/1000 occupied bed days [5.2, 8.1], P < 0.001) and seclusion (pre: 43.7/1000 occupied bed days, 95% CI [40.6, 46.9] compared with post: 30.9/1000 occupied bed days [27.9, 34.1], P < 0.0001). Rates of aggression, deliberate self-harm, and sexually inappropriate behaviour were non-significantly decreased. Findings suggest that this engagement-focused model of clinical risk management in an adult psychiatric inpatient unit significantly reduced adverse patient events and was preferred by staff over current practice. Other psychiatric inpatient facilities may see a reduction in adverse events following the introduction of this well-tolerated risk management model.

The meanings of place and space in forensic psychiatric care - A qualitative study reflecting patients' point of view

The outcome of care for patients sentenced to forensic psychiatric care is of importance not only for the patient but also for society, in preventing new crimes. In recent years, a person-centered perspective is influencing the care, recognizing the design of the physical environment as a therapeutic resource. To capture the complexity of patients' experience of the physical environment, a qualitative approach is needed. The aim of this study was to investigate the meanings of the patient room as a place and space in forensic psychiatric in-patient care from the patients' perspective. An explorative qualitative design was chosen, data were collected by photovoice; a combination of photographs, taken by the patients, followed by interviews. Eleven (N = 11) patients were interviewed. The interviews were analysed by a thematic analysis method. Four themes emerged from the data revealing the meanings of the patient room as a place and space: (i) striving towards normality; (ii) being anchored and protected; (iii) being at-home and homeness; and (iv) being in communion and meaningfulness. The findings show that the physical environment has a say in patients' basic needs and a role in maintaining normality. Substandard reveals a lack of respect and dignity towards this patient group. Involving patients in the design process of new facilities can be a way to make progress.

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

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

Evaluation of the EssenCES in a neurodevelopmental inpatient service for adolescents

Ward climate is a key element within psychiatric settings, associated with positive clinical outcomes. The Essen Climate Evaluation Schema (EssenCES) is a ward climate measure, which is validated for use within UK forensic settings. It has been studied within neurodevelopmental psychiatric inpatient settings with mixed findings on its appropriateness, and there is a dearth of EssenCES research which has been conducted within an adolescent psychiatric inpatient setting. The present study piloted the EssenCES within an inpatient psychiatric neurodevelopmental setting for adolescents in the East of England, in order to explore its usefulness within this setting and to provide preliminary normative data for a child and adolescent mental health services inpatient learning disability population. Staff and service users from a locked ward ( N = 28) and low secure ward ( N = 31) participated in the pilot. Results are discussed in relation to the body of the literature on ward climate, including consideration of discrepancies in the results between wards and discrepancies between staff and service.

Service user involvement in the coproduction of a mental health nursing metric: The Therapeutic Engagement Questionnaire

Service users' involvement in mental health service research is increasingly acknowledged as important, yet, whilst involving users of mental health services as research participants is commonplace, seeking out their experience and indeed their "expertise" to facilitate the development of tools to be used within mental health services is in its infancy. This article describes the involvement and views of service users in the development of a nursing metric-the Therapeutic Engagement Questionnaire. It presents their role in the three stages of development: generation, statement reduction and authentication.

A Review of Questionnaire Measures for Assessing the Social Climate in Prisons and Forensic Psychiatric Hospitals

Significant time and resources are devoted to the monitoring of social climate in secure settings. However, if these efforts are to help (rather than hinder) attempts to improve the functioning of such units, the monitoring of social climate must be based on sound psychometric methods. The aim of this review was to determine what questionnaires exist to measure the social climate in secure settings and what evidence exists regarding their psychometric properties. Twelve questionnaire-based measures of social climate were identified. The Essen Climate Evaluation Schema has received the most consistent empirical support, but this questionnaire does not provide as much of an in-depth, detailed insight into social climate as that provided by other social climate questionnaires. Although more extensive measures of climate exist, they have not yet received sufficient validation to justify their routine use in practice. Nevertheless, there is growing evidence that some questionnaire-based measures can provide a reliable and valid assessment of the social climate in secure settings, which has important clinical and theoretical implications.

Ward Climate Within a High Secure Forensic Psychiatric Hospital: Perceptions of Patients and Nursing Staff and the Role of Patient Characteristics

Within this study the relationship between patient characteristics (age, length of stay, risk, psychopathy) and individual perceived ward climate (n=83), and differences between staff's and patient perceptions of climate (n=185) was investigated within a high secure forensic hospital. Results show that therapeutic hold was rated higher among staff compared to patients, while patients held a more favorable view on patient cohesion and experienced safety. Furthermore, patient characteristics (age, risk and psychopathy) were found to be related with individual ratings of ward climate. The findings underline the importance of assessing ward climate among both patients and staff in clinical practice.

The effect of training in mindfulness and affect consciousness on the therapeutic environment for patients with psychoses: an explorative intervention study

RATIONALE

The ward atmosphere and the relationships between patients and staff contribute to the improvement in symptoms and psychiatric patient functioning and satisfaction. The quality of the therapeutic relationship is connected to the degree of self-reflection and self-awareness by the staff.

OBJECTIVE

To examine the effect of two different training programmes for healthcare professionals on the ward atmosphere in wards for psychotic patients.

DESIGN AND METHODS

Exploratory intervention study with two eight-week interventions of mindfulness training and affect-consciousness training. The outcome was measured on mindfulness and on relevant subscales of the Ward Atmosphere Scale. Data were collected by means of questionnaires and analysed using paired samples t-tests and repeated measures anova.

RESULTS

Two groups professionals (n = 27 & n = 23) participated in the study. Improvements indicated that both interventions had a positive impact on the ward atmosphere.

STUDY LIMITATIONS

The exploratory design and the small samples size make definitive conclusions difficult. Patient assessment on the ward atmosphere scale would have strengthened the validity of the results.

CONCLUSION

The ward atmosphere in two different wards for psychotic patients improved after staff training in mindfulness or affect consciousness. There were differences in change profiles for the groups in accordance with the differences in the two interventions.

PRACTICE IMPLICATIONS

We recommend awareness on the quality of the ward atmosphere in wards for psychotic patients. Both training in mindfulness and affect consciousness can support healthcare professionals in their awareness.

Measuring the evidence: reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards

Quality nursing plays a central role in the delivery of contemporary health and social care, with a positive correlation being demonstrated between patient satisfaction and the quality of nursing care received. One way to ensure such quality is to develop metrics that measure the effectiveness of various aspects of care across a variety of settings. Effective mental health nursing is predicated on understanding the lived experiences of service users in order to provide sensitively-attuned nursing care. To achieve this, mental health nurses need to establish the all-important therapeutic relationship, showing compassion and creating a dialogue whereby service users feel comfortable to share their experiences that help contextualize their distress. Indeed, service users value positive attitudes, being listened to, and being able to trust those who provide care, while mental health nurses value their ability to relate through talking, listening, and expressing empathy. However, the literature suggests that within mental health practice, a disproportionate amount of time is taken up by other activities, with little time being spent listening and talking to service users. The present study discusses the evidence relating to the therapeutic relationship in acute mental health wards and explores why, after five decades, it is not recognized as a fundamental metric of mental health nursing.

Service attachment: the relative contributions of ward climate perceptions and attachment anxiety and avoidance in male inpatients with psychosis

BACKGROUND

It has been suggested that mental health services can help meet the attachment needs of inpatients and improve patient outcomes through the provision of a 'secure base'; however, what defines the latter is unclear. Perception of ward climate might be a useful indicator.

AIM

The aim of this study was to examine whether inpatient perceptions of the ward climate, which is partly under the control of the service, or inpatients' own personal levels of attachment anxiety and avoidance are more associated with their attachment to their service.

METHOD

Seventy-six men diagnosed with a psychotic illness, who were residents in one of four regional medium-security units in England, completed questionnaire measures of service attachment, personal attachment style and ward climate.

RESULTS

Ward climate was more strongly associated with service attachment than personal levels of attachment anxiety and avoidance. The most important aspect of ward climate for service attachment was the depth and influence of staff support for the inpatients.

CONCLUSIONS

Although patient characteristics are important influences on development of service attachment, ward climate is also important. The latter may be easily and reliably monitored with a brief questionnaire. Strategies to enhance and maintain its positive components are likely to be important for progress with forensic hospital inpatients who have a psychotic illness.

The ward atmosphere important for the psychosocial work environment of nursing staff in psychiatric in-patient care

BACKGROUND

The nursing staff working in psychiatric care have a demanding work situation, which may be reflected in how they view their psychosocial work environment and the ward atmosphere. The aims of the present study were to investigate in what way different aspects of the ward atmosphere were related to the psychosocial work environment, as perceived by nursing staff working in psychiatric in-patient care, and possible differences between nurses and nurse assistants.

METHODS

93 nursing staff working at 12 general psychiatric in-patient wards in Sweden completed two questionnaires, the Ward Atmosphere Scale and the QPSNordic 34+. Data analyses included descriptive statistics, the Mann-Whitney U-test, Spearman rank correlations and forward stepwise conditional logistic regression analyses.

RESULTS

The data revealed that there were no differences between nurses and nurse assistants concerning perceptions of the psychosocial work environment and the ward atmosphere. The ward atmosphere subscales Personal Problem Orientation and Program Clarity were associated with a psychosocial work environment characterized by Empowering Leadership. Program Clarity was related to the staff's perceived Role Clarity, and Practical Orientation and Order and Organization were positively related to staff perceptions of the Organizational Climate.

CONCLUSIONS

The results from the present study indicate that several ward atmosphere subscales were related to the nursing staff's perceptions of the psychosocial work environment in terms of Empowering Leadership, Role Clarity and Organizational Climate. Improvements in the ward atmosphere could be another way to accomplish improvements in the working conditions of the staff, and such improvements would affect nurses and nurse assistants in similar ways.