Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users' engagement in activities

A Systematic Review and Meta-analysis of Recovery Educational Interventions for Mental Health Professionals

The history of mental health care has been marked by various struggles in maintaining the dignity of service users. Some reform movements have started to use educational strategies aimed at the beliefs and attitudes of professionals, as well as changing the way that practice is carried out. This paper intends to systematically review and synthesize studies assessing awareness and training activities for mental health professionals covering aspects related to recovery, empowerment, and in general, rights-based care to achieve full citizenship of mental health services users. We reviewed 26 articles and were able to include 14 of them in meta-analytic calculations. Our results at the qualitative level show an evolution of the literature towards better quality designs and focus on aspects related to the impact and maintenance of the effects of these training activities. Meta-analytic calculations found high heterogeneity but no risk of biases and low-to moderate effect sizes with a statistically significant impact on beliefs and attitudes but not on practices. The importance of this information in improving and advancing these educational activities is addressed.

Occupational therapy delivered by specialists versus non-specialists for people with schizophrenia

BACKGROUND

Schizophrenia is a severe mental health condition that is characterised by positive symptoms, such as hallucinations and delusions; negative symptoms, such as flattened affect, thought disorder (disrupted speech), and lack of motivation; and cognitive symptoms, such as problems with memory and attention. Schizophrenia can occur as an isolated episode, or as a recurring cycle of remission and relapse, and is associated with impairment in psychosocial and occupational functioning.Although antipsychotic drugs are the main treatment for people with schizophrenia, in most countries mental health services usually provide a range of add-on interventions, including occupational therapy. This is a complex intervention designed to support and enable continued participation in daily life through engagement in activities and occupations meaningful to the individual. Occupational therapists are professionals trained to deliver therapy where the emphasis is on improving occupational function and participation rather than treating symptoms, and uses a wide range of methods based on the needs of individuals. However, similar interventions may also be delivered by staff not trained as occupational therapists.

OBJECTIVES

To examine the effects of occupational therapy delivered by occupational therapists compared to occupational therapy delivered by any other person for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including trial registers) on 4 November 2016 and 26 July 2018.

SELECTION CRITERIA

All randomised controlled trials evaluating the functional or clinical outcomes of occupational therapy, or both, for people with schizophrenia delivered by occupational therapists compared with occupational therapy for people with schizophrenia delivered by anyone other than occupational therapists.

DATA COLLECTION AND ANALYSIS

Review authors independently inspected citations, selected studies, extracted data, and appraised study quality.

MAIN RESULTS

The search yielded 1633 records. Of these, we retrieved 17 full-text reports (14 studies) for further scrutiny, which we subsequently excluded as they did not meet our inclusion criteria.

AUTHORS' CONCLUSIONS

Currently there are no randomised controlled trials comparing delivery of occupational therapy for people diagnosed with schizophrenia by occupational therapists with delivery of similar interventions by anyone other than occupational therapists. Research studies employing methodologically robust trial designs are needed to establish whether or not there are better outcomes for people with a diagnosis of schizophrenia with occupational therapy that is delivered by trained occupational therapists.

A cluster randomised controlled trial of a staff-training intervention in residential units for people with long-term mental illness in Portugal: the PromQual trial

PURPOSE

This study aimed to assess the efficacy of a staff-training intervention to improve service users' engagement in activities and quality of care, by means of a cluster randomised controlled trial.

METHOD

All residential units with at least 12-h a day staff support (n = 23) were invited to participate. Quality of care was assessed with the Quality Indicator for Rehabilitative Care (QuIRC) filled online by the unit's manager. Half the units (n = 12) were randomly assigned to continue providing treatment as usual, and half (n = 11) received a staff-training intervention that focused on skills for engaging service users in activities, with trainers working alongside staff to embed this learning in the service. The primary outcome was service users' level of activity (measured with the Time Use Diary), reassessed at 4 and 8 months. Secondary outcomes were the quality of care provided (QuIRC), and service users' quality of life (Manchester Short Assessment of Quality of Life) reassessed at 8 months. Generalized linear mixed effect models were used to assess the difference in outcomes between units in the two trial arms. The trial was registered with Current Controlled Trials (Ref NCT02366117).

RESULTS

Knowledge acquired by the staff during the initial workshops increased significantly (p ≤ 0.01). However, the intervention and comparison units did not differ significantly in primary and secondary outcomes at either follow-up.

CONCLUSIONS

The intervention increased the level of knowledge of staff without leading to an improvement in service users' engagement in activities, quality of life, or quality of care in the units.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Background

The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap.

Methods

The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses.

Results

Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study.

Conclusions

People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery.

Main limitation

Our programme included only NHS, non-secure, inpatient mental health rehabilitation services.

Trial registration

Current Controlled Trials ISRCTN25898179.

Funding

The NIHR Programme Grants for Applied Research programme.

Rapid realist review of the evidence: achieving lasting change when mental health rehabilitation staff undertake recovery-oriented training

AIM

The aim of this study was to identify the factors contributing to lasting change in practice following a recovery-based training intervention for inpatient mental health rehabilitation staff.

BACKGROUND

Staff training may help nurses and other staff groups in inpatient mental health rehabilitative settings to increase their recovery-oriented practice. There are no published reviews on the effectiveness of such training and few long-term evaluations. This review informed a realist evaluation of a specific intervention (GetREAL).

DESIGN

Rapid realist review methodology was used to generate and prioritize programme theories.

DATA SOURCES

ASSIA, CINAHL, Cochrane Library, Medline, PsycINFO, Scopus, Web of Science and grey literature searches were performed in September 2014-March 2015 with no date restrictions. Stakeholders suggested further documents. GetREAL project documentation was consulted.

REVIEW METHODS

Programme theory development took place iteratively with literature identification. Stakeholders validated and prioritized emerging programme theories and the prioritized theories were refined using literature case studies.

RESULTS

Fifty-one relevant documents fed into 49 programme theories articulating seven mechanisms for lasting change. Prioritized mechanisms were: staff receptiveness to change; and staff feeling encouraged, motivated and supported by colleagues and management to change. Seven programme theories were prioritized and refined using data from four case studies.

CONCLUSION

Lasting change can be facilitated by collaborative action planning, regular collaborative meetings, appointing a change agent, explicit management endorsement and prioritization and modifying organizational structures. Conversely, a challenging organizational climate, or a prevalence of 'change fatigue', may block change. Pre-intervention exploration may help identify any potential barriers to embedding recovery in the organizational culture.

Strategies to successfully recruit and engage clinical nurses as participants in qualitative clinical research

BACKGROUND

Research conducted in the clinical area promotes the delivery of evidence-based patient care. Involving nurses as participants in research is considered essential to link patient care with evidence-based interventions. However recruitment is influenced by nurses' competing demands and understanding engagement strategies may assist future research.

AIM

This reflective analysis aimed to understand influencing factors and strategies that support successful recruitment nurses in clinical research.

METHOD

A reflective analysis of research notes and focus group data from research with oncology nurses was completed.

RESULTS

This research identified that gaining support from key staff, understanding work constraints and developing a rapport with nurses is important. Establishing clear relevance and benefits of the research and being flexible with research requirements enabled nurses to participate in the research.

CONCLUSION

Clear information and a willingness to accommodate the demands and dynamic nature of the environment, ensures ongoing support and engagement of nurses in the clinical setting as participants in research.

Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England

BACKGROUND

Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10-20 % of all those with psychosis, they absorb 25-50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome.

METHOD

Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care.

RESULTS

Across England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients' social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00-1.08), and patients' activity (OR 1.03, 95 % CI 1.01-1.05) and social skills (OR 1.13, 95 % CI 1.04-1.24) at recruitment.

CONCLUSION

Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients' social skills and activities may further enhance the effectiveness of these services.

In-patient rehabilitation: clinical outcomes and cost implications

Aims and method A retrospective evaluation was undertaken of the clinical and economic effectiveness of three in-patient rehabilitation units across one London National Health Service trust. Information on admission days and costs 2 years before and 2 years after the rehabilitation placement, length of rehabilitation placement and the discharge pathway was collected on 22 service users. Results There were statistically significant reductions in hospital admission days in the 2 years following rehabilitation compared with the 2 years before, further reflected in significantly lower bed costs. Longer length of rehabilitation placement was correlated with fewer admission days after the placement. A substantial proportion of the sample went into more independent living, some with no further admissions at follow-up. Clinical implications The findings suggest that in-patient rehabilitation is both clinically and cost effective: if benefits are sustained they will offset the cost of the rehabilitation placement.

The readmission rate and medical cost of patients with schizophrenia after first hospitalization - A 10-year follow-up population-based study

BACKGROUND

Hospital readmissions caused by relapse in patients with schizophrenia are associated with prognosis. Identifying individuals at high risk of readmission and providing interventions to lower the readmission rate are important.

METHODS

Patients with schizophrenia who were hospitalized for the first time were recruited from the National Health Insurance Research Database from 2001 to 2010 (n=808, mean age 28.9years) and compared with matched controls. Data on the demographics, cost, and utilization of medical resources of patients who were readmitted were compared with non-readmitted patients. The readmission time curve was analyzed by the Kaplan-Meier method.

RESULT

570 (70.5%) patients were readmitted within 10years; the median time between admissions was 1.9years, and 25% of subjects were readmitted within 4months of the first hospitalization. There were no significant differences in age, gender, or length of hospitalization between the readmission and non-readmission groups. Taking into account all psychiatric medical services, the readmission group had a significantly higher mean frequency of care and a greater medical cost than the non-readmission group and matched controls. However, there were no significant differences with regard to non-psychiatric medical services.

CONCLUSION

Schizophrenia has a high rate of readmission and high medical cost in naturalistic settings. In addition to the traditional hospital-based treatment model for patients with schizophrenia, the development of an effective intervention program is important, especially in the early years of the disease.

Quality and Reporting of Cluster Randomized Controlled Trials Evaluating Occupational Therapy Interventions: A Systematic Review

Growing use of cluster randomized control trials (RCTs) in health care research requires careful attention to study designs, with implications for the development of an evidence base for practice. The objective of this study is to investigate the characteristics, quality, and reporting of cluster RCTs evaluating occupational therapy interventions to inform future research design. An extensive search of cluster RCTs evaluating occupational therapy was conducted in several databases. Fourteen studies met our inclusion criteria; four were protocols. Eleven (79%) justified the use of a cluster RCT and accounted for clustering in the sample size and analysis. All full studies reported the number of clusters randomized, and five reported intercluster correlation coefficients (50%): Protocols had higher compliance. Risk of bias was most evident in unblinding of participants. Statistician involvement was associated with improved trial quality and reporting. Quality of cluster RCTs of occupational therapy interventions is comparable with those from other areas of health research and needs improvement.

Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial

BACKGROUND

We undertook a cluster randomised controlled trial to assess the effectiveness of a staff training intervention to improve patient engagement in activities in inpatient mental health rehabilitation units. Concurrently, we undertook a qualitative study to investigate the experiences of staff within the intervention units and the contextual issues that may have influenced the effectiveness of the intervention.

METHOD

We conducted focus groups with staff working in the inpatient units that received the intervention, sampled using a maximum variation strategy.

RESULTS

The intervention was accepted by staff. However, the skills gained, and changes to the unit's processes and structures that were agreed with the intervention team were not sustained after they left. The main reasons for this were a) external factors (economic recession, resource limitations); b) organisation level factors (lack of senior staff support; competing priorities); c) limitations of the intervention itself (length of intensive training period; reinforcement of skills).

CONCLUSION

This study illustrates some of the inter-related factors which operate at different levels within and outside of NHS organisations that may impact on the success of complex interventions. These factors need to be considered when designing interventions to ensure adequate buy-in from senior staff.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN25898179 (Registered 23 April 2010).

Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients' engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial

BACKGROUND

Mental health inpatient rehabilitation services focus on people with complex psychosis who have, for example, treatment-refractory symptoms, cognitive impairment, and severe negative symptoms, which impair functioning and require lengthy admission. Engagement in activities could lead to improvement in negative symptoms and function, but few trials have been done. We aimed to investigate the effectiveness of a staff training intervention to increase patients' engagement in activities.

METHODS

We did a single-blind, two-arm, cluster-randomised controlled trial in 40 mental health inpatient rehabilitation units across England. Units were randomly allocated to either a manual-based staff training programme delivered by a small intervention team (intervention group, n=20) or standard care (control group, n=20). The primary outcome was patients' engagement in activities 12 months after randomisation, measured with the time use diary. With this measure, both the degree of engagement in an activity and its complexity are recorded four times a day for a week, rated on a scale of 0-4 for every period (maximum score of 112). Analysis was by intention-to-treat. Random-effects models were used to compare outcomes between study groups. Cost-effectiveness was assessed by combining service costs with the primary outcome. This study is registered with Current Controlled Trials (ISRCTN25898179).

FINDINGS

Patients' engagement in activities did not differ between study groups (coefficient 1·44, 95% CI -1·35 to 4·24). An extra £101 was needed to achieve a 1% increase in patients' engagement in activities with the study intervention.

INTERPRETATION

Our training intervention did not increase patients' engagement in activities after 12 months of follow-up. This failure could be attributable to inadequate implementation of the intervention, a high turnover of patients in the intervention units, competing priorities on staff time, high levels of patients' morbidity, and ceiling effects because of the high quality of standard care delivered. Further studies are needed to identify interventions that can improve outcomes for people with severe and complex psychosis.

FUNDING

National Institute for Health Research.

The effects of a brief CBT intervention, delivered by frontline mental health staff, to promote recovery in people with psychosis and comorbid anxiety or depression (the GOALS study): study protocol for a randomized controlled trial

BACKGROUND

NICE guidance states that cognitive behavioural therapy (CBT) should be offered to all patients with psychosis. However, there is a need to improve access to therapeutic interventions. We aim to train frontline mental health staff to deliver brief, structured CBT-based therapies. We have developed and piloted a manualized intervention to support people with psychosis and anxious avoidance or depression to work towards a personal recovery goal.

METHODS/DESIGN

The 'GOALS Study' is a pilot randomized controlled trial comparing usual care plus an 8-week intervention with usual care alone. The key objective is to assess clinical feasibility (recruitment and randomization; compliance with the treatment manual; acceptability and satisfaction; progress towards goals). A secondary objective is a preliminary evaluation of efficacy. Sixty-six participants with a diagnosis of psychosis, plus symptoms of depression or anxiety will be recruited from adult mental health services. Those currently refusing medication, in receipt of CBT, or with a primary diagnosis of an organic mental health problem or substance dependency will be excluded. Following informed consent, randomization will be independent of the trial team, at a 50:50 ratio, at the level of the individual and stratified by main problem focus. Following randomization, participants allocated to the intervention group will begin the 8-week intervention with a local, trained member of staff, supervised by the study coordinator. Outcomes will be assessed blind to treatment condition at 0, 12 and 18 weeks post-randomization. The primary outcome measure for the efficacy analysis will be activity levels at 12 weeks. Secondary outcome measures include mood, psychotic symptoms, quality of life and clinical distress. A health economic analysis comparing service use in each condition will also be performed. Recruitment began in March, 2013 and is ongoing until December, 2014.

DISCUSSION

This is the first trial of the GOALS intervention. The approach is brief and staff can be readily trained in its delivery: there is therefore potential to develop a cost-effective intervention that could be widely disseminated. If the trial proves clinically feasible and demonstrates preliminary evidence of efficacy, a large multi-site trial will be warranted.

TRIAL REGISTRATION

Current Controlled Trials

ISRCTN

73188383. http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=13538.

Web-based cognitive training: patient adherence and intensity of treatment in an outpatient memory clinic

Background

Cognitive training has been playing an increasing role in the treatment of patients with cognitive deficits. This type of intervention, namely its intensity, can be optimized by incorporating information technology-based systems.

Objective

The intent of the study was to determine the treatment intensity and patient adherence to home-based cognitive training strategies (Web-based cognitive training).

Methods

A cohort of 45 patients with neurologic and psychiatric diseases attending an outpatient memory clinic (average age 50.7 years, SD 17.0; average education 7.8 years, SD 4.9) was followed over 18 months. Participants were challenged to use a Web-based cognitive training system, “COGWEB”, on a daily basis, and fulfilled at least four weeks of training supervised remotely. Additionally, 11 patients attended face-to-face sessions.

Results

The average duration of continuous cognitive training was 18.8 weeks (SD 18.9). Each patient performed on average 363.5 minutes/week (SD 136.6). At 6-month follow-up, 82.8% complied with their treatment plan. The average proportion of complete weeks was 0.75 (SD 0.22). Patients with dementia trained more intensively (444.6 minutes/week), followed by patients with static brain lesion (414.5 minutes/week; P=.01). The group that held face-to-face sessions performed more training overall (481.4 vs 366.9 minutes/week), achieving a stronger expression and statistical significance in the last week of training (652.6 versus 354.9 minutes/week, P=.027).

Conclusions

Overall, the weekly training intensity was high. Patients with dementia and static lesions performed more cognitive training. Face-to-face sessions were associated with higher intensities. The combination of classical methods with information technology systems seems to ensure greater training intensity.