Qualitative systematic literature review: the experience of being in seclusion for adults with mental health difficulties

Purpose: To conduct a systematic search of the peer-reviewed qualitative literature investigating the lived experience of seclusion for adults with mental health difficulties, to appraise the quality of the existing literature and synthesise findings. Background: Seclusion is a controversial intervention for the short-term management of unsafe behaviours in inpatient mental health services. There has been some sporadic interest in the service-users' experiences of this. Design: Systematic literature review and meta-synthesis. Data Sources: Databases MEDLINE, EMBASE, CINAHL and PSYCHINFO were searched in July 2015. Review Methods: The JBI QARI tools for critical appraisal and data extraction were used to review papers and synthesise findings. Findings: A small number of papers was found, which were of mixed quality. Value: The existing research is limited in both quantity and quality. Although most participants from the existing research described seclusion as mostly negative with the potential for causing iatrogenic harm, some described more positive experiences, often in the context of compassionate interactions with staff. Summary Statement: Why is this research or review needed? • The use of seclusion is common within mental health services but there is an absence of evidence for the purported theoretical rationale for its use. • Studies of the experiences of individuals placed in seclusion are small in number, of mixed quality and with mixed findings. • A systematic literature review and meta-synthesis of the existing qualitative literature investigating the lived experience of seclusion for adults with mental health difficulties was conducted, to synthesize the existing evidence base and make suggestions for future developments in research and practice. What are the key findings? • The existing research is limited both in quantity and quality. • Despite the limitations of existing research, the evidence does not support the purported theoretical rationale for the therapeutic use of seclusion. This poses a significant challenge to a common practice within mental health settings. • Seclusion has the potential to cause iatrogenic harm, particularly where interactions with nursing staff are not experienced as compassionate. • The actions of nursing staff in implementing seclusion procedures may mitigate iatrogenic harm. • Individuals who have experienced seclusion have suggestions for how to improve its use. How should the findings be used to influence policy/practice/research/education? • There is clearly scope for further, high quality research into people’s experiences of seclusion, particularly within the UK. • The findings include concrete ways in which the practice of seclusion can be improved. • Action research methods may offer a useful way of implementing and evaluating changes in practice

Staff perceptions and changing role of pre-hospital profession in the UK ambulance services: an exploratory study

There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. Drawing on the evidence from an empirical study in a large NHS ambulance trust in England, this article examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety. Research findings also highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences and priorities. Evidence from this study has significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand

Engaging communities to improve mental health in African and African Caribbean groups: a qualitative study evaluating the role of community well-being champions.

Over the last decade, Britain has undergone reforms to promote engagement in local structures of governance. These reforms have encouraged the promotion of active citizenship and have been central to the government's public service modernisation agenda. This article presents the findings from a study evaluating a pilot outreach intervention which adopted a community engagement model to address the mental health needs of African and African Caribbean groups, which entailed a partnership between faith-based organisations, local public services and community organisations to co-produce the pilot project. Lay people were trained to raise awareness about mental health among these communities in South London. Between 2012 and 2013, a qualitative participatory approach was used to evaluate the pilot project, which enabled a researcher to take part in the engagement phase of the pilot project, and the project co-ordinators to be involved in the research process. Semi-structured, one-to-one interviews were carried out with 13 community and well-being champions (CWBCs) recruited from African and African Caribbean communities (seven male and six female). This study examines the impact of the relationship between the intervention and community through the participants' engagement in the pilot outreach project and the action undertaken as champions. We found that although CWBCs used circles of influence to share ideas about mental health and well-being and to encourage change, they encountered resistance on the part of the people they engaged with, which resulted from a lack of knowledge about mental health, taboos and ascribed stigma. We argue that CWBCs acted as healthy examples to communicate mental health knowledge to those approached, but that they needed to be equipped with bespoke communication skills to be able to talk about such sensitive issues as mental health

Enhancing the quality of oral nutrition support for hospitalised patients: a mixed-methods knowledge translation study. (The EQONS study)

Aim - To report a multi-faceted knowledge translation intervention to facilitate use of the Malnutrition Universal Screening Tool and innovation in nutritional care for patients at risk of malnutrition. Background - Malnutrition among hospitalised patients is a widespread problem leading to adverse health outcomes. Despite evidence of the benefits of malnutrition screening and recommendations for achieving good nutrition, shortfalls in practice continue. Design - A mixed-method integrated knowledge translation study. Methods - The knowledge translation intervention comprised nutrition champions supported by knowledge translation facilitators and an action planning process. Data collection was undertaken over 18 months between 2011-2012 in a hospital in England. Data comprised observation of mealtimes, audit of patient records, survey of nurses and semi-structured interviews with nutrition champions, knowledge translation facilitators, senior ward nurses and nurse managers. Findings - Statistically significant differences (Chi Square) were observed in self-reported confidence of nurses a) to assess patients using the Malnutrition Universal Screening Tool, b) to teach colleagues how to use the Malnutrition Universal Screening Tool and c) to ensure that patients were assessed within 24 hours of admission. Ward-based nutrition champions facilitated successful innovation in nutrition support. Contextual factors operating at micro (ward), meso (organisation) and macro (healthcare system) levels acted as barriers and enablers for change. Conclusion - Nutrition champions were successful in increasing the timely assessment of patients at risk of malnutrition and promoting innovation in nutritional care. Support from knowledge translation facilitators helped nutrition champions develop their role and work collaboratively with senior ward nurses to implement action plans for improving nutrition

Mealtime support for adults with intellectual disabilities: Understanding an everyday activity

Background: Mealtime support has a direct bearing on the diet-related health of men and women with intellectual disabilities as well as opportunities for expressing dietary preferences. Method: Semi-structured interviews with a sample of direct support staff providing mealtime support to adults with intellectual disabilities. Results: When managing tensions between a person's dietary preferences and ensuring safe and adequate nutrition and hydration, direct support staff are sensitive to a wide range of factors. These include the following: clinical advice; service users’ rights to choose; their (in)capacity to weigh up risks; how service users communicate; the constituents of a healthy diet; and a duty to protect service users' health. Conclusions: Those responsible for setting standards and regulating the care practices need to look beyond too simple ideas of choice and safety to recognize ways in which providing support at mealtimes is a complex activity with serious consequences for people's health and well-being

Self-neglect and safeguarding adult reviews: towards a model of understanding facilitators and barriers to best practice

Purpose – One purpose is to update the core dataset of self-neglect safeguarding adult reviews and accompanying thematic analysis. A second purpose is to draw together the learning available from this dataset of reviews to propose a model of good practice that can be used as the basis for subsequent safeguarding adult reviews. Design/methodology/approach – Further published reviews are added to the core dataset from the web sites of Safeguarding Adults Boards. Thematic analysis is updated using the four domains employed previously. A sufficient number of reviews have been done from which to construct an evidence-based model of good practice. A framework is presented with the proposition that this can be used as a proportional methodology for further safeguarding adult reviews where self-neglect is in focus. Findings – Familiar findings emerge from the thematic analysis. This level of analysis, constructed over time and across reviews, enables a framework to be developed that pulls together the findings into a model of good practice with individuals who self-neglect and for policies and procedures with which to support those practitioners involved in such cases. This framework can then be used as an evidence-based model with which to review new cases where safeguarding adult reviews are commissioned.   Research limitations/implications – The national database of reviews commissioned by SABs is incomplete and does not contain many of the safeguarding adult reviews reported in this evolving dataset. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. It is possible, therefore, that this dataset is also incomplete. Drawing together the findings from the reviews nonetheless enables conclusions to be proposed about the components of effective practice, and effective policy and organisational arrangements for practice. Future reviews can then explore what enables such effective to be achieved and what barriers obstruct the realisation of effective practice. Practical implications – Answering the question “why” is a significant challenge for safeguarding adult reviews. A framework is presented here, drawn from research on safeguarding adult reviews featuring self-neglect, that enables those involved in reviews to explore the enablers and barriers with respect to an evidence-based model of effective practice. The framework introduces explicitly research and review evidence into the review process. Originality/value – The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also proposes a new approach to safeguarding adult reviews by using the findings and recommendations systematically within a framework designed to answer “why” questions – what promotes and what obstructs effective practice.   Keywords: Safeguarding adult reviews, evidence, self-neglect, proportionality Paper type: Research pape

‘Somebody else’s business’: The challenge of caring for patients with mental health problems on medical and surgical wards

What is known on the subject?: People with mental health problems have higher rates of physical health concerns and hospital admissions than those without mental health problems. These patients have poorer outcomes from surgery and have worse experiences of care when admitted for medical or surgical procedures. What the paper adds to existing knowledge?: This paper looks to understand why care may be poorer for patients with mental health problems by speaking to staff providing care in these settings. We spoke to 30 general hospital staff about mental health on the wards and found that a lack of leadership and ownership for prioritising mental health led to people not seeing it as their job, and that it was somebody else's business to manage that side of care. We also found that the emotional effect of caring for people who had attempted suicide or had self-harm injuries was difficult for staff, impacting on staff well-being and leading them to distance themselves from providing care in those cases. What are the implications for practice?: There is a need for staff to be supported from the top-down, with management providing clear leadership around issues and pathways for mental health needs so they know the best way to provide care and encourage collaborative working. In addition, bottom-up support is needed to help staff personally manage their own well-being and mental health, including supervision and debriefing from mental health specialists to improve understanding from the patient’s perspective and to provide emotional support to manage difficulties. Relevance Statement:: This paper places focus on the care of patients with mental health problems in medical and surgical care settings highlighting the interplay between mental and physical health from a perspective that is less often explored. This paper provides insights into the multidisciplinary nature of nursing and the need for integrated care. This provides findings that build a picture of how mental health nursing specialism is needed beyond psychiatric wards and within medical and surgical settings. Abstract: Introduction Evidence shows that patients with mental health problems have poorer physical health outcomes, increased mortality and experience poorer care during surgery and medical admissions. Issues related to lack of training, stigmatizing attitudes, fear or hopelessness may help understand these poor outcomes. Aim To explore the experiences of staff in providing care for people with mental health problems. Method A qualitative service evaluation approach was used. Participants working in an acute care hospital in inner-city London were recruited across professions and job levels using a self-selection sampling method. A total of 30 participants took part in semi-structured interviews (n = 17) and two focus groups (n = 13), and data were thematically analysed. Relevant organizational documents and service use data were utilized to inform the evaluation. Results Key themes were organized across the macro, meso and micro levels to understand the levels of disconnection and silence around mental health in acute care. Themes include systemic factors surrounding the institutional culture, ward cultures and collaborative working, and individuals’ sense-making of mental health and personal well-being. Implications for practice These findings signpost the growing need for greater mental health nursing input on medical and surgical wards and within these teams to provide informed knowledge, support and supervision.</p

Assessments of mental capacity: upholding the rights of the vulnerable or the misleading comfort of pseudo objectivity?

Purpose The purpose of this paper is to present findings from a research project which investigated the approaches of different groups of assessors to the mental capacity assessments which are required to be conducted as part of Deprivation of Liberty Safeguards (DOLS) Design/Methodology/Approach Four case study vignettes were given to participants.Three groups involved in the DOLS assessment process were interviewed by telephone about the factors that may influence their capacity assessments. Findings Most assessors did not refer to the required two stage test of capacity or the 'causative nexus' which requires that assessors must make clear that it is the identified 'diagnostic' element which is leading to the inability to meet the 'functional' requirements of the capacity test. The normative element of capacity assessments is acknowledged by a number of assessors who suggest that judging a person's ability to 'weigh' information, in particular, is a subjective and value based exercise, which is given pseudo objectivity by the language of the MCA. A number of elements of good practice were also identified. Research limitations. In this exploratory study, participant numbers were small (n= 21), and we relied on self-report rather than actual observations of practice or audit of completed assessments Practical Implications The findings are of relevance to all of those working in health and social care who undertake assessments of mental capacity, and will be helpful to all of those tasked with designing and delivering training in relation to the Mental Capacity Act 2005 (MCA). They also have relevance to policy makers in the UK who are involved with reforms to DOLS regulations, and to those in other countries which have legislation similar to the MCA. Originality/Value Much existing literature exhorts further training around the MCA. We suggest that an equally important task is for practitioners to understand and be explicit about the normative elements of the process, and the place of ethics and values alongside the more cognitive and procedural aspects of capacity assessments

Activities on acute mental health inpatient wards: a narrative synthesis of the service users’ perspective.

What is known on the subject?: Boredom is a big issue on inpatient mental health wards that is linked to poor patient satisfaction, feelings of frustration and increased incidents of self-harm and aggression. This is even more so for people detained under the Mental Health Act. Where wards have a good range of activities, for example art, music, computer games, gardening and exercise, service users felt less bored and had improved well-being. Over many years, studies have reported a lack of activities, especially during evenings and weekends. It has also been found that little is known about what activities service users want, or how activities might be meaningful for them. What the paper adds to existing knowledge?: This review found that very few studies have asked service users about what activities would be useful and why. By seeing what makes activities desirable and accessible, we can understand how to improve the experiences of service users on wards. Overall, these data help to understand what impact activities (or lack of activities) have on service users and staff experiences on these wards. What are the implications for practice?: Through identifying the activities most appreciated and engaged with by service users and by asking service users what activities they would like available, we can inform best practice guidance for the commissioning and provision of inpatient mental health care. This will enable service provider organizations to target their effort and resources on supporting good practice and to redirect resources from less useful activities. Abstract: Background Concern about the lack of activities on mental health inpatient wards is long-standing with reports consistently finding that service users receive insufficient access to a range of activities and report high levels of boredom. There is recognition that little is known about what service users want when admitted to inpatient wards. Aim This review seeks to understand service users’ experiences and views in relation to the provision and availability of activities, and to explore the perceived benefits and barriers to service users. Methods We searched multiple databases (Scopus, MEDLINE, CINAHL, PsycINFO and Embase) for studies that evaluated activities on acute adult inpatient mental health wards. We identified 12 papers across a range of methodological designs from which the narrative synthesis has been analysed. Results Findings show that the provision of activities is unsatisfactory for many service users, which in turn is related to increased boredom that has a negative impact on service users’ well-being. We explore the benefits and barriers to engagement, providing an insight into the aspects that make an activity important. Conclusion There are few studies exploring the needs of service users regarding activity provision; therefore, there is limited knowledge about what is meaningful for individuals.</p

What a discursive understanding of interprofessional team meetings might reveal: an exploration of intellectual (learning) disability managers' performances.

Clinical and academic understandings of interprofessional working are focused mainly on individual factors such as knowledge about different professional roles, and organisational opportunities for interprofessional working (IPW). Less research has examined what happens between people at an interactional level, that is, how interprofessional working is conducted in everyday face-to-face interactions in clinical practice. The current paper proposes a discursive framework for understanding what constitutes IPW in interprofessional meetings at this interactional level. Clinical effectiveness meetings held in intellectual (learning) disability services were used as an example site for IPW. The analysis explored how agenda change points were negotiated, appropriate as agenda change points require collaboration (or agreement) between practitioners to progress to the next point The study found changes in agenda points were accomplished by practitioners conjointly through using discursive strategies including closing questions, and resources such as professional identity and laughter. The agenda provided a frame for the institutional order of the meetings, invoking a trajectory towards timely completion. However, this institutional order was at times subordinated to an 'order of concern', which seemed to enable challenges by managers to the meeting Chair and the agenda that demonstrated adherence not only to the procedural nature of the meetings, but also to the needs of service users and the services discussed. We suggest discursive strategies, resources, and both institutional orders, and order of concerns might provide a framework for developing future training and research, that is able to illuminate how IPW might be enacted in face-to-face team meetings