Jane Alexander

The nature and purpose of acute psychiatric wards : The tompkins acute ward study

Background: Acute inpatient care in the UK is being subjected to increasing critical scrutiny, highlighting concerns about content and quality. There is an absence of clarity and consensus on what acute inpatient care is for, adding to difficulties in developing this service sector. Aim: To define the function of acute psychiatric wards. Methods: Interviews were conducted with multidisciplinary staff (13 Ward Managers, 14 F Grade nurses, 11 Occupational Therapists and 9 Consultant Psychiatrists), on rationales for admission, their care and treatment philosophy, and the roles of different professionals. Results: Patients are admitted because they appear likely to harm themselves or others, and because they are suffering from a severe mental illness, and/or because they or their family/community require respite, and/or because they have insufficient support and supervision available to them in the community. The tasks of acute inpatient care are to keep patients safe, assess their problems, treat their mental illness, meet their basic care needs and provide physical healthcare. These tasks are completed via containment, 24-hour staff presence, treatment provision, and complex organisation and management. Conclusions: Professional education, audit, research and the structuring of services all need to be oriented towards these tasks. Declaration of interest: This study was funded by the Tompkins Foundation and the Department of Health Nursing Quality initiative.

Patient-staff conflict: results of a survey on acute psychiatric wards

Abstract.Background: Disruptive behaviours of acute psychiatric inpatients have typically been studied separately, as have the methods used to contain them. There are indications that behaviours and containment methods are systematically related. Aims: The aim of this study was to assess the frequency and relationship between the differing conflict behaviours of patients, and explore the relationship between professional containment measures and those conflict behaviours. Methods: A cross-sectional survey of conflict behaviours and containment of 238 two-week admissions to 12 acute psychiatric wards in London, UK was carried out. Results: Factor analysis revealed seven patterns of conflict behaviours, with aggression being separately associated with absconding and medication refusal. Neither substance misuse nor self-harm were associated with aggression. Aggressive behaviour attracted the widest range of containment measures, including the use of special observation. Conclusions: The conflict behaviours of patients form complex patterns, and should be studied together rather than separately.

Safewards: the empirical basis of the model and a critical appraisal

Accessible summary In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model. Abstract In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Occupational Therapy and Multidisciplinary Working on Acute Psychiatric Wards: The Tompkins Acute Ward Study:

There is limited research into occupational therapy and interprofessional working on acute psychiatric wards. This study aimed to explore relations between occupational therapists and other members of the multidisciplinary team through structured interviews with 47 staff on 14 acute psychiatric wards. The study found that occupational therapists provided assessments, group activities and individual therapeutic work, with the assessment and development of activities of daily living being central. Linking patients with community resources in preparation for discharge was also important. Severity of illness among patients and speed of discharge were barriers to effective input. Nurses and psychiatrists appreciated occupational therapy input but rarely the breadth of the role. Multidisciplinary relations were generally positive, although some ward teams were disinclined to include occupational therapists in communications and decision making. The occupational therapists appreciated their professional knowledge and opinion being respected and considered. The study concluded that occupational therapists play an important if often misunderstood role on acute psychiatric wards, but that their involvement could be significantly increased through the employment of more experienced occupational therapists and the provision of interprofessional education. Further research is required to explore the facilities, resources and support required to maximise occupational therapy input and identify areas for increased interprofessional working.

Service user involvement in mental health practitioner education in Ireland

In recent years, there is an ever increasing call to involve people who use mental health services in the development, delivery and evaluation of education programmes. Within Ireland, there is very little evidence of the degree of service user involvement in the educational preparation of mental health practitioners. This paper presents the findings on service user involvement in the education and training of professionals working in mental health services in Ireland. Findings from this study indicate that in the vast majority of courses curricula are planned and delivered without consultation or input from service users. Currently the scope of service user involvement is on teaching, with little involvement in curriculum development, student assessment and student selection. However, there is evidence that this is changing, with many respondents indicating an eagerness to move this agenda forward.

Psychiatric nurses’ views on criteria for psychiatric intensive care: acute and intensive care staff compared

AIM To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care. BACKGROUND Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU. METHOD Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis. FINDINGS There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues. CONCLUSION The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed.

A survey of pedagogical approaches and quality mechanisms used in education programs for mental health professionals

The provision of high-quality education and training that is responsive, relevant, accessible and evidence based is critical if the vision for quality mental health services presented in recent policy initiatives in Ireland is to be fulfilled. This paper reports the findings related to pedagogical approaches and quality assurance mechanisms utilized within mental health education. The study involved canvassing all Higher Education Institutions in Ireland. A total of 227 courses in 31 educational institutes were identified and 149 questionnaires were returned from 129 Course Coordinators. Various quality processes were identified in existing programs; however, formal feedback from service providers, service users and carers was seldom reported. Ongoing evaluation and quality assurance strategies are a key element of governance and there is a need to develop strategies that explore the impact of education programs on mental health education and health outcomes. Recommendations are made in terms of future interprofessional mental health education and practice.