Evidence
Alert

How can acute mental health wards be improved?

Service users, carers and nurses suggested ways of improving acute mental health wards. In a new study, they came up with a list of potential improvements, including less paperwork and more staff training. Service users suggested events in which they could interact with nurses through ordinary activities such as playing music or going for a walk. Nurses suggested they sit with service users at mealtimes. There was overlap in the suggestions. For example, service users suggested a compassion champion and nurses suggested a therapeutic engagement champion. 

People undergoing a mental health crisis need urgent treatment in a safe environment. They may be admitted as inpatients on an acute ward. To develop personally and emotionally, they need to engage with mental health nurses. Some people may exhibit challenging behaviour, but nurses need to interact with them by listening, understanding, and responding to their needs. 

However, nurses’ workload and staff shortages can make it difficult to create a calm environment. Many wards rely on agency staff who do not know the service users personally. As a result, many acute wards do not meet the needs of either service users or staff. Service users can feel disregarded and dehumanised, while nurses can feel unsupported and unsafe. There is little research to show which interventions successfully promote engagement.

In this study, researchers observed nurses and service users talking to each other. They also carried out interviews. They identified emotional moments that were important to both. Themes emerged from the data such as service users feeling dismissed and nurses feeling unsafe. 

Further information on where to get urgent help for a mental health crisis is available on the NHS website.

What’s the issue?

When service users and staff on acute mental health wards interact positively with each other, both sides benefit. When staff and service users have high quality engagement, they come to trust each other, are more satisfied with the care provided, and have better wellbeing. There is also less violence and aggression on the ward.  

However, workload pressures and busy wards make it difficult for nurses to offer people individual attention in a way that feels safe. Service users may exhibit challenging behaviour. People with psychosis lose some contact with reality. Those with a personality disorder think, feel or behave differently to others.

Interventions to increase opportunities for interaction have been proposed. But to date, interactions have not tended to improve the quality of engagement. 

This research was intended to improve understanding of service users’ engagement on an acute mental health ward. It started conversations with service users and nurses about their experiences. This was a first step towards designing interventions to increase engagement. 

What’s new?

The researchers interviewed 14 service users, 8 of whom had psychotic disorders. Others had mood disorders, such as depression or personality disorders. They also interviewed 2 carers and 12 clinicians (mental health nurses, healthcare assistants and a psychological therapist). For 80 hours, a researcher observed interactions between nurses and service users, noting tone of voice, body language, patterns of behaviour and the general atmosphere on the ward.

Several themes emerged that were important to service users and carers. 

    • Do not dismiss me: Service users and carers often felt their concerns were not acknowledged. This led to anger, which was sometimes punished by withdrawal of privileges. One service user said: “There was no insight that my frustration wasn’t a symptom of my mental health, it was a symptom of what had happened to me.”
    • When you tell me something, please give a reason: Service users often did not understand the reasons for ward routines or practices, and could be angry, upset or confused.
    • Please give me some of your time: Time was in short supply. One carer said: “Listening could be the key to everything. Such an easy thing but I can tell you there is a lack of listening.” When nurses did make time to talk, this was highly valued.
    • Validate me as a person: When nurses discussed upsetting events with service users, both felt their emotions were validated. The observer said: “As the conversation progressed, the patient became visibly less tense. They both apologised and ended the interaction with a hug.” 
    • Unhelpful behaviours: These included nurses making administration a priority, or clustering around the nursing station away from service users. And care that was given automatically, without tailoring it to meet individual needs. 

Other themes were important to clinicians.

    • Improving ward culture: Nurses felt unsafe when their team was unsupportive. One nurse said: “I became very aware that when there is an incident I’m left on my own... I stopped trusting the team.”  
    • Improving interactions with service users: Medication rounds were often the only time a nurse would spend one-on-one time with service users. One nurse said: “One of the major problems on the ward is because we are a little bit distant from the patients… we need to find a bond.. create time.” 

Both groups came up with solutions. Service users prioritised solutions to improve their relationships with clinicians. Nurses prioritised ward routines and relations between clinicians. However, there was overlap in the suggestions. They included:

    • events where nurses and service users could interact through ordinary activities, such as playing music, or going for a walk off the ward 
    • streamlined working practices to reduce paperwork and free up time for interactions
    • a compassion champion was suggested by service users; a therapeutic engagement champion by staff 
    • staff training, which service users thought they should run; nurses suggested self-awareness training and confidence-boosting workshops. 

Why is this important?

Service users, carers and clinicians were all frustrated by the lack of engagement. Nurses felt dehumanised by their workloads and unappreciative management. Service users felt they were on a conveyor belt of standardised care.

Nurses need to maintain order and manage people who are acutely unwell. With reduced staff, they have to carry out administrative duties alongside one-on-one nursing care. Their overwhelming workload often means care is left undone. They may stop engaging with service users to protect themselves from feeling guilty.

This study shows that, although they are stressed, clinicians still want to engage with service users. The researchers say that adequate staffing levels are key to ensuring safe, high quality nursing care. 

The results demonstrate the importance of involving service users and those providing the services in development of new initiatives. Without gathering experience from those on the ground, there is a risk that proposed solutions will not work in practice. 

What’s next?

Since this study was completed, the researchers have held further workshops with service users and nurses to work on proposed solutions. The solutions are low-cost and do not involve sophisticated technology.  They have developed an intervention toolkit comprising:

    • a training film for nurses voiced by service users, which gives good and bad examples of engagement 
    • a smiley face/blank face sign for service users to put on the door to indicate when they want to talk 
    • reflective practice workshops with staff and service users 
    • workbooks to help nurses structure conversations
    • booklets for service users explaining ward routines and processes such as ward rounds and medication 
    • improvements to ward culture and nurse handover to better protect and support nurses.

The interventions are due to be tested in one hospital, but this was delayed by the COVID-19 pandemic. If successful, the interventions will be rolled out within the NHS trust and thereafter more widely. 

You may be interested to read

This NIHR Alert was based on: McAllister S, and others. “What matters to me”: A multi-method qualitative study exploring service users’, carers’ and clinicians’ needs and experiences of therapeutic engagement on acute mental health wards. International Journal of Mental Health Nursing 2021;30:3

A paper looking at the concept of therapeutic engagement in mental health: McAllister S, and others. Conceptualising nurse-patient therapeutic engagement on acute mental health wards: an integrative reviewInternational Journal of Nursing Studies 2019;93:106–18

A paper looking at interventions to improve engagement: McAllister S, and others. Developing a theory-informed complex intervention to improve nurse-patient therapeutic engagement employing Experience-based Co-design and the Behaviour Change Wheel: an acute mental health ward case study. BMJ Open 2021;11:e047114 

Crisis services and planning for a crisis: a guide from the charity Mind, explaining what mental health crisis services are available, how they can help and when to access them.

 

Funding: This research was funded by the HEE/NIHR ICA Programme Clinical Doctoral Research Fellowship. 

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

The research highlights how important it is to use people’s experiences, particularly service users, and that’s not really been done before. Interventions usually come from a top-down approach. That has not worked well. 

Staff on the ward are facing a lot of difficulties. Wards are chaotic. Beds are closing left, right and centre and people coming on to them are more acutely unwell. There’s a reliance on agency staff. Staff are doing the best they can in this situation. 

They want to make changes, they just need the support to take time out to do it. I was really impressed with their input, and that of service users.

Sarah McAllister, Improvement Coach, Quality Improvement Team, Central and North West London NHS Foundation Trust (CNWL) 

Mind

This research underlines what many people with mental health problems who receive inpatient care tell Mind – that receiving it in a supportive, well-staffed, therapeutic environment can make all the difference to their treatment. It is good to see simple, low-cost solutions that increase people’s dignity and choice and improve the experiences of staff and people with mental health problems on wards.

Alongside this, the Government must invest in the workforce, as this research highlights how understaffing impacts the culture on wards and outcomes for people. It is crucial that the Government commits to long term funding to boost the mental health workforce if we are to really change the experiences of those receiving care.

Alison Cobb, Specialist Policy Advisor, Mind, the mental health charity 

Mental health nurse

This interesting study suggests that a change in organisational culture is needed within Health and Social Care services. The researchers identified that putting the findings into practice will be time intensive. Staff will need support to make changes to the system. 

The research took place in one acute mental health setting, and I would have liked a more in-depth discussion of the environment, the nuances between participants and the level of experience of the staff. All could impact on how relevant the findings are in other settings. However, the insights into different viewpoints could enhance current practice and are highly applicable to other areas of mental health in-patient care. Nurses who care for adults with learning disabilities could benefit, for example. 

It would be useful to include this research in pre-registration nursing education, in support of previous research. National professional networks such as Safewards or the NHS Benchmarking Network might be useful in developing the champion roles suggested, to promote the culture change.  Given the emphasis on joint working between service user, carer and clinician, it is vital that implementation encompasses a co-production approach.

Gemma Breitschadel, Senior Lecturer in Mental Health Nursing, University of Derby