Contradictory experiences of safety and shame in inpatient mental health practice – a qualitative study

Building and sustaining therapeutic relationships across treatment settings: a qualitative study of how patients navigate the group dynamics of mental healthcare

BACKGROUND

Therapeutic relationships are vital for patients with complex and long-term psychosocial needs, yet such patients often face fragmented and unstable relationships within mental healthcare. These patients are more often than others moved between treatment settings and caregiving teams. Statutory obligations strain the relationships with frequent hospitalizations adding to the burden This study explores how these patients perceive and navigate therapeutic relationships, highlighting both positive and negative experiences across various treatment settings.

METHODS

This is a qualitative study with a narrative approach utilizing in-depth interviews focusing on participants personal experiences and perceptions. We utilized purposive sampling to recruit patients with extensive hospitalization experience, operationalized as more than four admissions within one year or more than four successive weeks of hospitalization. Our sample consisted of 16 participants, twelve women and four men. The interviews were analyzed using a holistic-content approach.

RESULTS

We found that therapeutic relationships were built on healthcare professionals recognizing and addressing patients' needs and advocating for their interests within the service system. Participants described therapeutic relationships as sources of collaboration, stability, and support but found them challenging to sustain due to fear of rejection and institutional barriers. Successful relationships worked as a vital buffer, offering protection against malpractices and depersonalized care.

CONCLUSION

Therapeutic relationships play a crucial role in supporting patients with complex needs, but relational dilemmas and malignant group dynamics often impede their development. Mental healthcare services have an ethical responsibility to foster and maintain therapeutic environments and professional cultures that enable personalized care, while maintaining boundaries through reflective practices.

Issues Related to Patient Participation in Psychiatric Hospital Care-An Integrative Literature Review of Patient Safety Research

AIM

Explore how previous patient safety research has described issues related to patient participation in psychiatric hospital care.

DESIGN

Integrated literature review.

METHODS

The literature review was conducted according to Cooper's framework with the following five-step protocol: problem identification, a literature search, data evaluation, data analysis, and the presentation of results.

DATA SOURCES

CINAHL, PubMed, PsycINFO, Scopus databases, years 2005-2023. After quality appraisal, a total of 62 articles were reviewed.

RESULTS

Three main categories related to patient participation in psychiatric hospital care were identified: communication (having information, being heard, therapeutic relationships and interaction quality), decision-making (treatment planning, treatment decisions, activities and working on behalf of patients) and restrictive measures (setting limits, exercising power, balancing patient autonomy and safety).

CONCLUSION

Psychiatric hospital care nursing staff continuously balance patients' autonomy, self-determination, and safety, taking into account their well-being and issues of responsibility. Wider use of positive risk-taking is needed to increase patient participation and safety in psychiatric hospital care.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Nursing staff should create favourable facilities for patient participation, foster an atmosphere of trust, respect, and encouragement, provide patients individual time to improve patient safety and recognise that they can exert power over patients due to constantly balancing patient autonomy and safety.

REPORTING METHOD

PRISMA guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

'It Gives Me Safety to Be Here': Patients' Perspectives About Safety on Psychiatric Wards

Providing safe care within psychiatric wards is essential to promote the well-being and recovery of patients on the wards. This can however be complicated because patients' behaviours can present risks to themselves and others. Understanding what patients think about safety on psychiatric wards holds crucial insight about addressing and managing safety issues on the wards. The aim of this study is to understand safety on psychiatric wards from the perspective of the patients. The study is a systematic review that follows PRISMA guidance and registered with PROSPERO. A comprehensive search of five electronic databases was completed. Searches were limited to peer-reviewed academic journal articles published in English language from 2014 which examine safety on psychiatric settings from the patients' perspective. An initial result of 28 567 studies was filtered to six studies that met all the eligibility criteria. Quality assessment was completed using Critical Appraisal Skills Programme whereas data synthesis was conducted using thematic analysis. Four major themes that describe safety on psychiatric wards emerged: perception of safety; prevalence of lack of safety: perpetuating lack of safety; and promoting safety. Safety on psychiatric wards is like two sides of a coin: what promotes safety can also perpetuate lack of safety. The place (hospital), people (staff) and practice can both promote safety and perpetuate lack of safety. Finding and maintaining the right balance is crucial for achieving safety on psychiatric wards. These findings have implications for the effective management of safety issues on psychiatric wards.

Estimating the link between service-user patient safety perceptions, incidents and subsequent contagion in acute mental health wards

BACKGROUND

Safety incidents are common in adult acute inpatient mental health services, and detrimental to all. Incidents spread via social contagion within the ward, but social contagion is difficult to quantify. Better measures of social contagion could support a milieu in which safety incidents are less likely to be prolonged, spread, or repeated, with widespread benefits. The WardSonar project, based in the United Kingdom (UK), developed and evaluated a prototype digital safety monitoring tool to collect real-time information from patients on acute adult mental health wards, about their perceptions of ward safety. A prototype Wardsonar tool was developed from a collaborative, co-design approach, and implemented in real-world hospital settings. The current study aimed to understand whether the tool can help to predict incidents, by examining (i) the feasibility of capturing real-time feedback from patients about safety and (ii) how the resulting data related to quality and safety metrics. This study was registered as ISRCTN14470430 on 10/January/2022.

METHOD

Patients can record real-time perceptions of ward safety using the tool, and staff can access these as anonymous, aggregated data. The tool was implemented in the UK in six National Health Service adult acute mental health wards. A novel approach to analysis involved construction of an hour-by-hour dataset over each ward. This revealed relationships between quantity and content of patient reports, staffing, time of day, and ward incidents, per ward.

RESULTS

There is strong evidence that an incident leads to increased probability of further incidents within the next four hours. This supports the idea of social/behavioural contagion and puts a measure on the extent to which the contagion persists. COVID-19 impacted the research processes.

CONCLUSIONS

There is potential to use the WardSonar digital tool for proactive real-time safety monitoring, to identify developing incidents and help staff to facilitate timely preventative or de-escalating interventions. Further refinement and testing in a post COVID-19 context are needed.

TRIAL REGISTRATION

ISRCTN14470430 https://doi.org/10.1186/ISRCTN14470430 . Registered 10/January/2022.

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services

In Australia, acute inpatient units within public mental health services have become the last resort for mental health care. This research explored barriers and facilitators to safe, person-centred, recovery-oriented mental health care in these settings. It utilised participant observations conducted by mental health nurses in acute inpatient units. These units were located in three distinct facilities, each serving different areas: a large metropolitan suburban area in a State capital, a mid-sized regional city, and a small city with a large rural catchment area. Our findings highlighted that, in the three inpatient settings, nurses tended to avoid common areas they shared with consumers, except for brief, task-related visits. The prioritisation of administrative tasks seemed to arise in a situation where nurses lacked awareness of alternative practices and activities. Consumers spent prolonged periods of the day sitting in communal areas, where the main distraction was watching television. Boredom was a common issue across these environments. The nursing team structure in the inpatient units provided a mechanism for promoting a sense of psychological safety for staff and were a key element in how safety culture was sustained.

A service-user digital intervention to collect real-time safety information on acute, adult mental health wards: the WardSonar mixed-methods study

Background

Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives.

Objective(s)

Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety.

Design

Theory-informed mixed-methods study. A prototype digital monitoring tool was developed from a co-design approach, implemented in hospital settings, and subjected to qualitative and quantitative evaluation.

Setting and methods

Phase 1: scoping review of the literature on patient involvement in safety interventions in acute mental health care; evidence scan of digital technology in mental health contexts; qualitative interviews with mental health patients and staff about perspectives on ward safety. This, alongside stakeholder engagement with advisory groups, service users and health professionals, informed the development processes. Most data collection was virtual. Phase 1 resulted in the technical development of a theoretically based digital monitoring tool that collected patient feedback for proactive safety monitoring. Phase 2: implementation of the tool in six adult acute mental health wards across two UK NHS trusts; evaluation via focused ethnography and qualitative interviews. Statistical analysis of WardSonar data and routine ward data involving construction of an hour-by-hour data set per ward, permitting detailed analysis of the use of the WardSonar tool.

Participants

A total of 8 patients and 13 mental health professionals participated in Phase 1 interviews; 33 staff and 34 patients participated in Phase 2 interviews.

Interventions

Patients could use a web application (the WardSonar tool) to record real-time perceptions of ward safety. Staff could access aggregated, anonymous data to inform timely interventions.

Results

Coronavirus disease 2019 restrictions greatly impacted the study. Stakeholder engagement permeated the project. Phase 1 delivered a theory-based, collaboratively designed digital tool for proactive patient safety monitoring. Phase 2 showed that the tool was user friendly and broadly acceptable to patients and staff. The aggregated safety data were infrequently used by staff. Feasibility depended on engaged staff and embedding use of the tool in ward routines. There is strong evidence that an incident leads to increased probability of further incidents within the next 4 hours. This puts a measure on the extent to which social/behavioural contagion persists. There is weak evidence to suggest that an incident leads to a greater use of the WardSonar tool in the following hour, but none to suggest that ward atmosphere predicts future incidents. Therefore, how often patients use the tool seems to send a stronger signal about potential incidents than patients' real-time reports about ward atmosphere.

Limitations

Implementation was limited to two NHS trusts. Coronavirus disease 2019 impacted design processes including stakeholder engagement; implementation; and evaluation of the monitoring tool in routine clinical practice. Higher uptake could enhance validity of the results.

Conclusions

WardSonar has the potential to provide a valuable route for patients to communicate safety concerns. The WardSonar monitoring tool has a strong patient perspective and uses proactive real-time safety monitoring rather than traditional retrospective data review.

Future work

The WardSonar tool can be refined and tested further in a post Coronavirus disease 2019 context.

Study registration

This study is registered as ISRCTN14470430.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128070) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

The Future of the Psychiatric Mental Health Nursing Workforce: Using Our Skill Set to Address Incongruities in Mental Health Care Delivery

The USA is dealing with well-documented issues around mental health and its treatment. The Psychiatric Mental Health (PMH) workforce is growing and practicing in a variety of roles within the mental health system. How will PMH nurses address instances when the structure of services does not meet the mental health needs of the population? In this piece, I argue that to some degree the future of the PMH workforce will be determined by how well we use our capacity and capabilities to address incongruities in service structure and population needs. Five areas of concern with mental health services are outlined; they all involve factors that can be addressed with innovative approaches and optimum utilization of the PMH workforce. Included are suggestions on how PMH nurses might direct efforts toward these service issues, particularly by using their skill set and presence in the mental health system. Strategies include forging a tighter connection between the work of advanced practice and registered nurses in delivering care. Broadly, these efforts should be directed at building models of patient-centered care that address the needs of populations, reducing disparities, and demonstrating how engagement is a critical lever of effective inpatient and community-based care.

Epistemic citizenship under structural siege: a meta-analysis drawing on 544 voices of service user experiences in Nordic mental health services

This paper presents a meta-analysis, drawing exclusively on qualitative research (n = 38), which contributes to findings on mental health service user experiences of received provisions and/or encounters in contemporary social and mental health services in the Nordic countries. The main objective is to identify facilitators of, and barriers to, various notions of service user involvement. Our findings provide empirical evidence regarding service users' experiences of participation in their encounters with mental health services. We identified two overarching themes, professional relations and the regulative framework and current rule and norm system, in the reviewed literature concerning facilitators and hindrances of user involvement in mental health services. By including the interrelated policy concept of 'active citizenship' and theoretical concept of 'epistemic (in)justice' in the analyses, the results provide foundations for broader exploration and problematization of the policy ideals of what we call 'epistemic citizenship' and contemporary practices in Nordic mental health organizations. Our conclusions include suggestions that linking micro-level experiences to organizational macro-level circumstances opens up avenues for further research on service user involvement.

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

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

Understanding how personhood impacts consumers' feelings of safety in acute mental health units: a qualitative study

Being admitted to an acute mental health unit can lead to feelings of shame, and loss of personhood for some consumers. Promoting safety for consumers is a function of acute mental health units. This paper explores how consumers' personhood influences their perception and experience of safety in acute mental health units. Semi-structured interviews were conducted with 15 participants who had previously been admitted to an acute mental health unit. Thematic analysis was used to analyse the data. Participants perceived safety as being intrinsically linked to their personhood. When participants' innate worth was affirmed in their interactions with staff, participants felt safe. Three subthemes were identified: 'Seen as an equal', 'Being respected', and 'Able to make choices'. These findings can be used to inform nursing practices that enhance consumers' sense of personhood and, in so doing, promote consumers' safety and recovery in acute mental health units.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

Sobrecarga em trabalhadores de saúde de um complexo hospitalar psiquiátrico no Nordeste brasileiro

Resumo Objetivo este artigo visa identificar os aspectos que causam a sobrecarga laboral em um complexo psiquiátrico e verificar estratégias de minimização desta sobrecarga. Método os dados foram coletados com trabalhadores de um complexo hospitalar psiquiátrico na cidade de João Pessoa, Paraíba, Brasil. Aplicou-se a Escala de Avaliação do Impacto do Trabalho em Serviços de Saúde Mental (IMPACTO-BR) na coleta de dados, os quais foram processados no software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) e submetidos à análise de conteúdo. Resultados os resultados foram sistematizados em duas categorias temáticas: Aspectos de sobrecarga laboral e Estratégias para amenizar a sobrecarga. Foi relevado que as maiores causas de sobrecarga são do contexto organizacional, enquanto que o menor impacto advém do paciente. Conclusão e implicações para a prática as estratégias sugeridas discorreram desde a aquisição de um trabalho digno, com direitos trabalhista, até as ações voltadas para um melhor atendimento para o paciente. Sugere-se que sejam implementadas ações políticas e institucionais de incentivo à integração da equipe, valorização do trabalho e cuidado da saúde física e mental do trabalhador.