Safety issues on British mental health wards

Laboratory method to induce state boredom increases impulsive choice in people who use cocaine and controls

Background: Impulsive choice is associated with both cocaine use and relapse. Little is known about the influence of transient states on impulsive choice in people who use cocaine (PWUC).Objective: This study investigated the direct effects of induced boredom on impulsive choice (i.e., temporal discounting) in PWUC relative to well-matched community controls.Methods: Forty-one PWUC (≥1× cocaine use in past 3 months; 7 females) and 38 demographically matched controls (5 females) underwent two experimental conditions in counterbalanced order. Temporal discounting was assessed immediately after a standardized boredom induction task (peg-turning) and a self-selected video watched for the same duration (non-boredom). Subjective mood state and perceived task characteristics were assessed at baseline, during experimental manipulations, and after the choice task.Results: PWUC and controls were well matched on sex, age, and socioeconomic status. Groups were also similar in reported use of drugs other than cocaine, except for recent cigarette and alcohol use (PWUC > controls). As expected, peg-turning increased boredom in the sample overall, with higher boredom reported during peg-turning than the video (p < .001, η2p = .20). Participants overall exhibited greater impulsive choice after boredom than non-boredom (p = .028, η2p = .07), with no preferential effects in PWUC (p > .05, BF01 = 2.9).Conclusion: Experimentally induced boredom increased state impulsivity irrespective of cocaine use status - in PWUC and carefully matched controls - suggesting a broad link between boredom and impulsive choice. This is the first study to show that transient boredom directly increases impulsive choice. Data support a viable laboratory method to further parse the effects of boredom on impulsive choice.

High state boredom vastly affects psychiatric inpatients and predicts their treatment duration

Boredom is a ubiquitous, aversive human experience typically elicited by low information and monotony. Boredom can occur either as a transient mental state that prompts individuals to adapt their behavior to avoid monotony or as a temporally stable trait, describing a chronic susceptibility to feeling bored. Increased trait boredom was found to correlate with various psychopathologies and indicators of mental burden. However, the role of state boredom in psychopathological conditions and its implications for psychiatric treatment remain elusive. Here, we address this issue by investigating state boredom and trait boredom in a cohort of psychiatric inpatients and a healthy control cohort. We find that in both groups, state boredom, even more than trait boredom, shows remarkable associations with psychopathology. In the inpatient group, state boredom is implicated broadly in multiple mental disorders and shows an association with treatment in closed psychiatric wards. Furthermore, through statistical modeling, we find that high-state boredom during inpatient therapy is predictive of a longer therapy duration. Thus, we show that state boredom constitutes an indicator of mild and severe psychopathology in different mental disorders, affecting the outcome of psychiatric patients. Potential therapeutic interventions are discussed, aiming to enhance information flow in the brain in order to alleviate boredom in clinical settings.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AIM

The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression).

BACKGROUND

Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions.

METHODS

Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted.

RESULTS

Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice.

CONCLUSIONS

EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review

OBJECTIVES

The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.

METHOD

A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.

RESULTS

The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.

CONCLUSIONS

The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

Social inclusion and violence prevention in psychiatric inpatient care. A qualitative interview study with service users, staff members and ward managers

Background

Many psychiatric services include social inclusion as a policy with the aim to offer users the opportunity to participate in care and to form reciprocal relationships. The aim of this study was to explore opportunities and problems with regard to participation, reciprocity and social justice that different stakeholders experience when it comes to social inclusion for service users and minimizing violence in psychiatric inpatient care.

Methods

Qualitative interviews were performed with 12 service users, 15 staff members, and six ward managers in three different kinds of psychiatric wards in Sweden. The data were analyzed using the framework method and qualitative content analysis, which was based on the three following social inclusion values: participation, reciprocity, and social justice.

Results

Themes and subthemes were inductively constructed within the three social inclusion values. For participation, staff and ward managers reported difficulties in involving service users in their care, while service users did not feel that they participated and worried about what would happen after discharge. Staff gave more positive descriptions of their relationships with service users and the possibility for reciprocity. Service users described a lack of social justice, such as disruptive care, a lack of support from services, not having access to care, or negative experiences of coercive measures. Despite this, service users often saw the ward as being safer than outside the hospital. Staff and managers reported worries about staffing, staff competence, minimizing coercion and violence, and a lack of support from the management.

Conclusions

By applying the tentative model on empirical data we identified factors that can support or disrupt the process to create a safe ward where service users can feel socially included. Our results indicate that that staff and service users may have different views on the reciprocity of their relationships, and that users may experience a lack of social justice. The users may, due to harsh living conditions, be more concerned about the risk of violence in the community than as inpatients. Staff and ward managers need support from the management to foster a sense of community in the ward and to implement evidence-based prevention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07178-6.

Activities on acute mental health inpatient wards: A narrative synthesis of the service users' perspective

WHAT IS KNOWN ON THE SUBJECT?: Boredom is a big issue on inpatient mental health wards that is linked to poor patient satisfaction, feelings of frustration and increased incidents of self-harm and aggression. This is even more so for people detained under the Mental Health Act. Where wards have a good range of activities, for example art, music, computer games, gardening and exercise, service users felt less bored and had improved well-being. Over many years, studies have reported a lack of activities, especially during evenings and weekends. It has also been found that little is known about what activities service users want, or how activities might be meaningful for them. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This review found that very few studies have asked service users about what activities would be useful and why. By seeing what makes activities desirable and accessible, we can understand how to improve the experiences of service users on wards. Overall, these data help to understand what impact activities (or lack of activities) have on service users and staff experiences on these wards. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Through identifying the activities most appreciated and engaged with by service users and by asking service users what activities they would like available, we can inform best practice guidance for the commissioning and provision of inpatient mental health care. This will enable service provider organizations to target their effort and resources on supporting good practice and to redirect resources from less useful activities. ABSTRACT: Background Concern about the lack of activities on mental health inpatient wards is long-standing with reports consistently finding that service users receive insufficient access to a range of activities and report high levels of boredom. There is recognition that little is known about what service users want when admitted to inpatient wards. Aim This review seeks to understand service users' experiences and views in relation to the provision and availability of activities, and to explore the perceived benefits and barriers to service users. Methods We searched multiple databases (Scopus, MEDLINE, CINAHL, PsycINFO and Embase) for studies that evaluated activities on acute adult inpatient mental health wards. We identified 12 papers across a range of methodological designs from which the narrative synthesis has been analysed. Results Findings show that the provision of activities is unsatisfactory for many service users, which in turn is related to increased boredom that has a negative impact on service users' well-being. We explore the benefits and barriers to engagement, providing an insight into the aspects that make an activity important. Conclusion There are few studies exploring the needs of service users regarding activity provision; therefore, there is limited knowledge about what is meaningful for individuals.

Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

BACKGROUND

Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?

METHODS

We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.

RESULTS

Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.

CONCLUSIONS

As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Feeling safe or unsafe in psychiatric inpatient care, a hospital-based qualitative interview study with inpatients in Sweden

Background

A major challenge in psychiatric inpatient care is to create an environment that promotes patient recovery, patient safety and good working environment for staff. Since guidelines and programs addressing this issue stress the importance of primary prevention in creating safe environments, more insight is needed regarding patient perceptions of feeling safe. The aim of this study is to enhance our understanding of feelings of being safe or unsafe in psychiatric inpatient care.

Methods

In this qualitative study, interviews with open-ended questions were conducted with 17 adult patients, five women and 12 men, from four settings: one general psychiatric, one psychiatric addiction and two forensic psychiatric clinics. The main question in the interview guide concerned patients' feelings of being safe or unsafe. Thematic content analysis with an inductive approach was used to generate codes and, thereafter, themes and subthemes.

Results

The main results can be summarized in three themes: (1) Predictable and supportive services are necessary for feeling safe. This concerns the ability of psychiatric and social services to meet the needs of patients. Descriptions of delayed care and unpredictable processes were common. The structured environment was mostly perceived as positive. (2) Communication and taking responsibility enhance safety. This is about daily life in the ward, which was often perceived as being socially poor and boring with non-communicative staff. Participants emphasized that patients have to take responsibility for their actions and for co-patients. (3) Powerlessness and unpleasant encounters undermine safety. This addresses the participants' way of doing risk analyses and handling unpleasant or aggressive patients or staff members. The usual way to act in risk situations was to keep away.

Conclusions

Our results indicate that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication could enhance patient perceptions of feeling safe. It seems to be important that staff provide patients with general information about the safety situation at the ward, without violating individual patients right to confidentiality, and to have an ongoing process that aims to create organizational values promoting safe environments for patients and staff.

Providing Good Care in the Shadow of Violence - An Interview Study with Nursing Staff and Ward Managers in Psychiatric Inpatient Care in Sweden

The aim was to describe the nursing staff and ward managers' experiences of safety and violence in everyday meetings with the patients. The qualitative content analyses resulted in four themes: the relationship with the patient is the basis of care; the organizational culture affects the care given; knowledge and competence are important for safe care; and the importance of balancing influence and coercion in care. The staff had a varied ability to meet patients in a respectful way. One way of creating a common approach could be to discuss and reflect upon different options in the meeting with the patient.

Staff perspectives: What is the function of adult mental health day hospital programs?

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric day hospital (DH) treatment has been offered since the 1930s and is appropriate for individuals experiencing intense psychiatric symptoms without requiring 24-hour inpatient care. No empirical research has examined the specific purpose of DH treatment from the perspectives of healthcare providers within these programs. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study was the first to address the question of the purpose and function of DH treatment from the outlook of frontline workers within this setting, and confirmed anecdotal observations that DH treatment provides an alternative to intensive psychiatric care, and also operates as "bridge" between these intensive services and purely outpatient treatment. Additional information emerged, such as the importance of the name of DH programs avoiding connotations of illness, the benefits and skills that draw patients to these programs, and challenges that staff and patients experience within DH programs (e.g. short length of treatment, barriers to treatment access). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This information can enhance curriculum development within these settings. For example, given the importance of skill building, it is essential to integrate the provision of skill building and coping strategies within these settings. In addition, given that the name of the setting can impact staff (and perhaps service users as well), ensuring that the name of such program highlight wellness and recovery may enable a different type of therapeutic community to develop within these settings.

ABSTRACT

Introduction Despite the benefits of psychiatric day hospitals (DH), research has not addressed staff perspectives of these programs' effectiveness and barriers. Aim To elucidate staff perceptions of Adult Mental Health DH programs at two hospitals in Canada, allowing for improved programming, enhanced structure and increased understanding of DH settings within the continuum of care. Method Twenty-five DH staff members completed semi-structured qualitative interviews. Two independent coders applied content analysis to achieve data saturation. Results Four major themes emerged: (1) program purpose and function, (2) what is in a name, (3) perceived patient motivation, and (4) room for improvement. Discussion Findings highlighted the importance of a multidisciplinary team delivering education and skill-focused interventions. Services were cited as "bridging" different mental health settings. Challenges included barriers to treatment access and inadequate length of treatment. Implications for Practice Understanding the function and purpose of this treatment service may enhance service delivery by enabling programs to integrate identified key ingredients. Providers can also note treatment duration and consider how to best use that time. Finally, language used within a DH setting appears to impact staff delivering services, and may also alter patients' understanding of the services they will receive and purpose of the program.

Group engagement in persons with dementia: The concept and its measurement

Although a few papers documented benefits of group therapeutic activities for individuals with dementia, there is a dearth of studies that have investigated the effects of group activities on persons with dementia. This paper introduces a theoretical framework of studying group therapeutic recreational activity, the Comprehensive Process Model of Group Engagement, and an assessment tool, the Group Observational Measurement of Engagement (GOME). We also report the psychometric properties of this assessment. One hundred and four persons with dementia took part in ten different group activities, with each activity conducted twice at random order so that 20 activities were observed for each group of participants. Following each group activity, research and therapeutic recreation staff members used the GOME assessment to independently rate participants on individual-level measures of attendance duration and engagement, and group level measures (e.g., positive and negative interactions among group members). Reliability and validity analyses comparing observer ratings for each group activity on the individual-level measures of attendance and engagement showed good psychometric properties. Different measures collected on a group level differed with respect to their psychometric quality. We present a theoretical framework to understand group engagement and present measures that could be used in future research and practice.

Reduction of Seclusion and Restraint in an Inpatient Psychiatric Setting: A Pilot Study

The authors describe a quality and safety initiative designed to decrease seclusion/restraint (S/R) and present the results of a pilot study that evaluated the effectiveness of this program. The study sample consisted of consecutive admissions to a 120-bed psychiatric service after the intervention was implemented (October 2010-September 2012, n = 8029). Analyses compared S/R incidence and duration in the study sample to baseline (consecutive admissions during the year prior to introduction of the intervention, October 2008-September 2009, n = 3884). The study intervention, which used evidence-based therapeutic practices for reducing violence/aggression, included routine use of the Brøset Violence Checklist, mandated staff education in crisis intervention and trauma informed care, increased frequency of physician reassessment of need for S/R, formal administrative review of S/R events and environmental enhancements (e.g., comfort rooms to support sensory modulation). Statistically significant associations were found between the intervention and a decrease in both the number of seclusions (p < 0.01) and the duration of seclusion per admission (p < 0.001). These preliminary results support the conclusion that this intervention was effective in reducing use of seclusion. Further study is needed to determine if these prevention strategies are generalizable, the degree to which each component of the intervention contributes to improve outcome, and if continuation of the intervention will further reduce restraint use.

Milieu improvement in psychiatry using evidence-based practices: the long and winding road of culture change

BACKGROUND

Shorter inpatient stays have resulted in greater patient acuity, making it difficult for patients to heal and challenging for staff to manage.

OBJECTIVE

To improve the milieu for psychiatric inpatients using evidence-based practices.

DESIGN

A thorough literature review suggested 18 basic principles to improve patient outcomes while reducing violence, seclusion, restraint, and 1:1 observation. Interventions were multiple, including intensive multi-modal staff education based on the literature review and starting in orientation, introduction of comfort rooms, changes in debriefing practices, careful review of all seclusion and restraint episodes, introduction of integrative modalities, and careful review of all 1:1 observation and review of unit structure.

RESULTS

Multiple interventions resulted in favorable outcomes in the following: rates of seclusion and restraints; time devoted to 1:1 observation, patient and staff satisfaction; violent incidents; and staff and patient injury.

CONCLUSIONS

Long-term culture change toward a more therapeutic milieu can occur as a result implementing evidence-based practices.

'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward

AIMS AND OBJECTIVES

To understand the experience of being a patient on an acute psychiatric inpatient ward.

BACKGROUND

Acute psychiatric inpatient care is an integral part of the mental health system. A key driver for admission to acute wards is risk. Previous research indicates that people do not always feel safe when in an acute ward. Understanding the patient experience of safety can influence nursing practice, as well as policy and service development.

DESIGN

A qualitative approach was used. Patient experience was conceptualised as represented through narrative as data. Sociolinguistic theories linking narrative structure with meaning informed the development of the analytic framework.

METHODS

Thirteen patients with a variety of diagnoses were recruited from an acute ward. Unstructured interviews were carried out in participants' homes two and six weeks postdischarge. Holistic analysis of each individual's data set was undertaken. Themes running across these holistic analyses were then identified and developed.

RESULTS

Participant narratives were focused around themes of help, safety and power. This study presents findings relating to the experience of safety. Participants expected to be safe from themselves and from others. Initially, they experienced a sense of safety from the outside world. Lack of knowledge of their fellow patients made them feel vulnerable. Participants expected the nurses to keep them safe, and felt safer when there were male nurses present.

CONCLUSIONS

Participants talk about safety in terms of psychological and physical safety. A key issue was the perception of threat from other patients, highlighting the need to consider patient safety as more than physical safety.

RELEVANCE TO PRACTICE

Nurses need to be sensitive to the possibility that patients feel unsafe in the absence of obvious threat. Institutional structures that challenge patients' sense of safety must be examined.