Parity of esteem: Addressing the inequalities between mental and physical healthcare

Discourses of compassion from the margins of health care: the perspectives and experiences of people with a mental health condition

BACKGROUND

Evidence supports the positive influence of compassion on care experiences and health outcomes. However, there is limited understanding regarding how compassion is identified by people with lived experience of mental health care.

AIM

To explore the views and experiences of compassion from people who have lived experience of mental health.

METHODS

Participants with a self-reported mental health condition and lived experience of mental health (n = 10) were interviewed in a community setting. Characteristics of compassion were identified using an interpretative description approach.

RESULTS

Study participants identified compassion as comprised three key components; 'the compassionate virtues of the healthcare professional', which informs 'compassionate engagement', creating a 'compassionate relational space and the patient's felt-sense response'. When all these elements were in place, enhanced recovery and healing was felt to be possible. Without the experience of compassion, mental health could be adversely affected, exacerbating mental health conditions, and leading to detachment from engaging with health services.

CONCLUSIONS

The experience of compassion mobilises hope and promotes recovery. Health care policymakers and organisations must ensure services are structured to provide space and time for compassion to flourish. It is imperative that all staff are provided with training so that compassion can be acquired and developed.

Item development for a patient-reported measure of compassionate healthcare in action

BACKGROUND

Compassionate care is a fundamental component of healthcare today; yet, many measures of compassionate care are subjective in focus and lack clarity around what compassionate care looks like in practice. Measures mostly relate to physical healthcare settings, neglecting mental healthcare. They also lack significant involvement of people with lived experience (PLE) of healthcare delivery in their development. This study aimed to begin the process of developing a new patient-reported measure, one that captures the observable actions of compassionate care delivery or 'compassionate healthcare in action' by any healthcare professional working in any care setting. The study involves PLE of healthcare delivery, both patients and staff, throughout.

METHODS

A multistage mixed-methods scale development process was followed. First, items were derived inductively from reflexive thematic analysis of patient and clinician interviews about what compassionate care meant to them (n = 8), with additional items derived deductively from a literature review of existing measures. Next, a panel of patient, clinician and researcher experts in compassionate care was recruited (Round 1: n = 33, Round 2: n = 29), who refined these items in a two-round modified online Delphi process.

RESULTS

Consensus was reached on 21 items of compassionate care in action relating to six facets: understanding, communication, attention, action, emotional sensitivity and connection. These items will form the basis for further scale development.

CONCLUSIONS

This item development work has laid the foundation of a potential new tool to systematically measure what compassionate healthcare in action looks like to patients. Further research is underway to produce a valid and reliable version of this proposed new measure. We have outlined these initial stages in detail in the hope of encouraging greater transparency and replicability in measure development, as well as emphasising the value of involving PLE throughout the process.

PATIENT OR PUBLIC CONTRIBUTION

This study involved PLE of both physical and mental healthcare (as staff, patients and service users) throughout the development of the new measure, including initial project conceptualisation and participation in item generation and refinement stages.

Consent with complications in mind

Parity of esteem describes an aspiration to see mental health valued as much as physical. Proponents point to poorer funding of mental health services, greater stigma and poorer physical health for those with mental illness. Stubborn persistence of such disparities suggests a need to do more than stipulate ethical and legal obligations toward justice or fairness. Here, I propose that we should rely more on our legal obligations toward informed consent. The latter requires clinicians to disclose information about risks in a way that is sufficient to satisfy what a prudent patient would reasonably want to understand in their circumstances. I argue that inadequate disclosure of the mental health complications of common surgeries risks exposing the craft specialists performing them to clinical negligence claims. Patients could argue they were counselled about said risks, improperly or not at all: improperly, if advised by a craft specialist lacking sufficient expertise in mental health; not at all, if mental health complications were simply forgotten. From this, I argue that a prudent approach for craft specialists would be to support and fund 'integrative' specialists (from rehabilitation medicine, liaison psychiatry and health psychology), more often to work alongside them within a multidisciplinary team that is better placed to navigate consent (via a prehabilitation process, for example). Based on duties toward consent, the extension of this type of coworking is another way to improve the resource and understanding accorded to mental health-but by starting within the citadels of physical health.

Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity

AIM

To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness.

DESIGN & METHODS

A discursive paper, drawing on clinical experience and research of the authors and current literature.

RESULTS

Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care.

PATIENT AND PUBLIC INVOLVEMENT

This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

Challenges and opportunities for improvement when people with an intellectual disability or serious mental illness also need palliative care: A qualitative meta-ethnography

BACKGROUND

People with diagnoses of intellectual disability or serious mental illness have higher mortality rates due to physical comorbidities; better understanding is needed to guide best practice in provision of palliative care for these populations.

AIMS

To identify multivoiced perspectives, drawn from lived experience of: what works, and what does not, in palliative care for people with intellectual disability or serious mental illness; challenges in, and opportunities to improve, palliative care.

DESIGN

A systematically constructed qualitative meta-ethnography. Protocol published (PROSPERO: CRD42021236616).

DATA SOURCES

MEDLINE, PsychINFO, CINAHL PLUS and Embase used without date limitations. Papers published in English, containing qualitative data on palliative care provision for people with a diagnosis of intellectual disability or serious mental illness were included. Global five-point strength score applied for relevance/quality appraisal.

RESULTS

Familiarity (of location, people and/or things) is important for good palliative care. Assumptions and misunderstandings about the role of mental capacity assessment to appropriately involve the patient in decision-making are common. Adapting training for palliative care staff to address concerns and beliefs about mental illness is one of the methods that helps avoid diagnostic overshadowing. Proactive identification of service arrangements to meet needs of persons with personality, psychotic, delusional and bipolar affective disorders will help optimise care.

CONCLUSIONS

Evidence, including the voices of people with intellectual disability or serious mental illness is urgently needed to guide efforts to improve their access to and experience of palliative care. More evidence is especially needed to understand, develop and implement best practice for people with psychosis, bipolar affective disorder, mania and personality disorder.

No safety without emotional safety

This Personal View highlights how emotional safety is required for a person to keep themselves physically safe. We explain how trying to control behaviour to increase physical safety in the short term can carry the unintended consequence of reducing emotional safety, which might in turn result in higher levels of stress and hopelessness. We use examples from institutions with psychiatric inpatients to describe these processes. We argue that emotional and physical safety cannot be separated, and therefore that the absence of emotional safety compromises basic care either in an acute crisis or in the long term. Staff who fear being criticised, and so feel driven to take autonomy and responsibility away from patients, unwittingly undermine patients' experience of being empathically understood and supported, adding to patients' sense of emotional turmoil and lack of safety. We suggest that a change in culture and regulatory reform is required to bring psychiatric care more in line with the psychological needs of patients to achieve both physical and emotional safety.

A protocol to identify the barriers and facilitators for people with severe mental illness and/or learning disabilities for PErson Centred Cancer Screening Services (PECCS)

OBJECTIVES

To identify the barriers and facilitators that people with severe mental illness and people with learning disabilities may encounter when accessing cancer screening and make recommendations for implementing reasonable adjustments throughout cancer screening services.

METHODS AND ANALYSIS

An 18-month sequential, mixed-methods study comprising of two phases of work and underpinned by Normalisation Process Theory, recruiting from across the North-East and North Cumbria. The first phase aims to identify the barriers and facilitators for people with severe mental illness in accessing cervical, breast and colorectal cancer screening. A systematic review of eight databases (Part 1a; PROSPERO registration number: CRD42022331781) alongside semi-structured interviews of up to 36 people with severe mental illness (Part 1b) will occur. Additional characteristics indicating populations whose perspectives may not have been accounted for in the systematic review will be targeted in the interviews. Potential participants will be identified from a range of settings across the North-East and North Cumbria, including through social media and gatekeepers within National Health Service Trusts and charities. Interviews will be analysed using framework analysis, which will be in line with the Normalisation Process Theory. The second phase of the project (part 2a) involves triangulating the results of the systematic review and interviews with existing research previously completed with people with learning disabilities accessing cancer screening. This will be to identify population specific barriers and facilitators across people with learning disabilities and people with severe mental illness to access cancer screening services. Following triangulation, part 2b will include designing and planning a future study involving stakeholders in cancer screening to explore the feasibility, practicality, and priority for implementing the recommendations to improve person centred cancer screening services (PECCS).

ETHICS AND DISSEMINATION

This study has received Teesside University ethical approval, Health Research Authority approval (IRAS: 310622) and favourable opinion (REF: 22/PR/0793). Findings will be disseminated through a range of academic and non-academic modes including infographics, blog posts and academic publications.

Hodges' model: the Sustainable Development Goals and public health - universal health coverage demands a universal framework

Background to issue

Future sustainable healthcare delivery and systems need reflective practitioners and critical thinkers to engage the public to achieve health policy aims and objectives. Therefore, this descriptive review introduces a generic conceptual framework, adopting a specific theme to illustrate and demonstrate a model of care or any other context. Whatever the purpose, context or philosophical stance in healthcare and health literacy, there is no standardised generic conceptual framework to structure reflection and critical thinking. This work presents a pragmatic solution focused on the one-to-one relationship of learner-mentor, patient-clinician, public health professional-public and groups.

Methods

The method is constructivist, an educational exercise, practical and the target group can be defined/viewed as student, teacher, patient, carer or member of the public in a health promotion campaign, for example. The building blocks are health and care concepts that arise clinically in practice, or for a student writing an assignment. As will be explained, concepts (including the Sustainable Development Goals) are assigned by the subject(s)-in this instance the authors-to a domain of knowledge.

Results

As two-by-two tables, the results represent the structure of the conceptual framework, framing the content in a series of four knowledge (care) domains. The contents, ultimately the Sustainable Development Goals, may then be linked and relationships discussed. Results are produced gradually, building a cognitive or mind-map. The results, it must be stressed, are therefore qualitative.

Conclusion

Drawing on educational theory and practice, the results are explored and justified using the theme of nutrition, and the often stated desirability in education of reflective practice and critical thinking abilities. Providing a series of cross-disciplinary, the reader will gain insight into the potential of Hodges' model to facilitate integrated, person-centred and care that improves parity of esteem, supporting students and qualified personnel in their learning careers.

Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study

BACKGROUND

There is consensus that services supporting people with complex emotional needs are part of a mental health care system in which change is needed. To date, service users' views and co-production initiatives have had little impact on the development of interventions and care. This needs to change, and our paper evidences the experiences and perspectives of a diverse range of people on how community services can best address the needs of people with complex emotional needs.

METHODS

A co-produced qualitative research study. Lived experience researchers led data collection and analysis. Individual interviews were conducted with 30 people across England who had a diverse range of experiences and perspectives of using community services for complex emotional needs. Participants were asked about their experiences of using community services for their mental health, and views on how community services can best address their needs. Thematic analysis was used to analyse the data.

RESULTS

Participants reported some experiences of good practice but also of experiences of severely stigmatising interventions, a lack of effective support and service fragmentation. Relational Practice was identified as the central overarching theme and describes how community services can best support people with complex emotional needs. This approach involves care delivered in a non-stigmatising, individualised and compassionate way and care that is trauma-informed. It involves care that is planned collaboratively with service users to ensure their multiple needs are addressed in a flexible, holistic and consistent way which accounts for the long-term and fluctuating nature of their needs.

CONCLUSIONS

Relational practice approaches have potential to facilitate better community care for people with complex emotional needs. Research and service development are needed to examine how best to implement such approaches across the mental health service system. This work must be co-produced with people with relevant lived experience, their carers and the professionals who support them.

End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study)

BACKGROUND

Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all.

AIM

To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness.

DESIGN

A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches.

DATA SOURCES

Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary.

RESULTS

Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness.

CONCLUSIONS

Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.

Structured physical exercise and recovery from first episode psychosis in young adults, the FitForLife study

Optimising autonomy is increasingly important in recovery from psychosis. To date, physical exercise has shown promise in the treatment of severe, enduring mental illnesses including psychosis - when used as an adjunct treatment. To assess the association between physical exercise and autonomy in young adults, a simple pre-post experimental design was utilised. Individuals aged 18-35 years, treated at one of three specialist outpatient units for first-episode psychosis in Stockholm, Sweden were invited to participate in a 12-week programme of structured group exercise. Autonomy was measured using four questions from the Camberwell Assessment of Needs questionnaire (physical health, social and close relationship and daily tasks). Comparisons were made between: 'no attendance' and 'any attendance'. The latter group was bisected into higher and lower categories. Ninety-four participants enrolled with a post-intervention response rate of 61%. Significant reductions were seen in self-rated needs for care, though there was no significant change in total scores or evidence of a dose response association. The results suggest a plausible association between physical exercise and autonomy which may represent the recovery process following the first episode of psychosis. Further randomised control trials are needed to explore the potential causality and robustness of this change.

Parity of esteem: evaluating inequalities in older adult healthcare

Addressing inequalities between mental and physical healthcare in older adult healthcare is imperative for safe patient care. This evaluation of services at The Harbour mental health hospital, Blackpool, UK gives insight into parity of esteem and prompts investigation into the clinical decisions of doctors working in older adult mental healthcare.

DECLARATION OF INTEREST

None.