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

"When you haven't got much of a voice": An evaluation of the quality of Independent Mental Health Advocate (IMHA) Services in England

Advocacy serves to promote the voice of service users, represent their interests and enable participation in decision-making. Given the context of increasing numbers of people detained under the Mental Health Act and heightened awareness of the potential for neglect and abuse in human services, statutory advocacy is an important safeguard supporting human rights and democratising the social relationships of care. This article reports findings from a national review of Independent Mental Health Advocate (IMHA) provision in England. A qualitative study used a two-stage design to define quality and assess the experience and impact of IMHA provision in eight study sites. A sample of 289 participants – 75 focus group participants and 214 individuals interviewed – including 90 people eligible for IMHA services, as well as advocates, a range of hospital and community-based mental health professionals, and commissioners. The research team included people with experience of compulsion. Findings indicate that the experience of compulsion can be profoundly disempowering, confirming the need for IMHA. However, access was highly variable and more problematic for people with specific needs relating to ethnicity, age and disability. Uptake of IMHA services was influenced by available resources, attitude and understanding of mental health professionals, as well as the organisation of IMHA provision. Access could be improved through a system of opt-out as opposed to opt-in. Service user satisfaction was most frequently reported in terms of positive experiences of the process of advocacy rather than tangible impacts on care and treatment under the Mental Health Act. IMHA has the potential to significantly shift the dynamic so that service users have more of a voice in their care and treatment. However, a shift is needed from a narrow conception of statutory advocacy as safeguarding rights to one emphasising self-determination and participation in decisions about care and treatment

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

Technocracy, the Market and the Governance of England's National Health Service

England's National Health Service, the fifth largest employer in the world, has become heavily influenced by expert authority and the market economy, which has had implications for accountability and the receptiveness of health decisions to stakeholder needs. One response has been the introduction of a range of regulatory provisions designed to facilitate effective governance and stakeholder engagement. These provisions are scrutinized using three conceptual devices: core accountability, social reporting and social learning. These devices have significant implications, as they enable technical experts to form closed communities, communicate among themselves mainly about economic and financial matters, and make decisions that aid the market without meaningful recourse to citizens. While technical experts are necessary to help manage complex areas, current arrangements reinforce an existing gap between economic and democratic values through hardened technocratic approaches to health care governance

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

How do women with social risk factors experience United Kingdom maternity care? A realist synthesis

Background Echoing international trends, the most recent United Kingdom reports of infant and maternal mortality found that pregnancies to women with social risk factors are over 50% more likely to end in stillbirth or neonatal death and carry an increased risk of premature birth and maternal death. The aim of this realist synthesis was to uncover the mechanisms that affect women's experiences of maternity care. Methods Using realist methodology, 22 papers exploring how women with a wide range of social risk factors experience maternity care in the United Kingdom were included. The data extraction process identified contexts (C), mechanisms (M), and outcomes (0). Results Three themes, Resources, Relationships, and Candidacy, overarched eight CMO configurations. Access to services, appropriate education, interpreters, practical support, and continuity of care were particularly relevant for women who are unfamiliar with the United Kingdom system and those living chaotic lives. For women with experience of trauma, or those who lack a sense of control, a trusting relationship with a health care professional was key to regaining trust. Many women who have social care involvement during their pregnancy perceive health care services as a system of surveillance rather than support, impacting on their engagement. This, as well as experiences of paternalistic care and discrimination, could be mitigated through the ability to develop trusting relationships. Conclusions The findings provide underlying theory and practical guidance on how to develop safe services that aim to reduce inequalities in women's experiences and birth outcomes

Plans that work: improving employment outcomes for young people with learning disabilities

This article offers a critical reflection on the function of education, health and care plans (EHCPs) in pathways to employment for disabled young people. We consider ‘the education plan’ as an artefact of special educational needs systems. We problematise the often taken‐for‐granted assumption that such plans are always and only a ‘good’ thing in the lives of disabled young people seeking pathways to employment. At the same time, we consider the rise in demand for plans that are understood by many as a crucial mechanism for achieving support. Following the recent policy reforms in England, we describe a context in which the funding of education is shrinking and in which the promise of employment for disabled young people has yet to be delivered. We conclude by proposing some changes to policy and practice to enhance employment opportunities for disabled young people

Cross-national mixed methods comparative case study of recovery-focused mental health care planning and coordination in acute inpatient mental health settings (COCAPP-A)

Background: Serious concerns have been identified in relation to care planning, patient involvement and consent to treatment in mental health wards, including for those patients detained under the Mental Health Act. Further evidence is needed to develop care planning interventions that embed dignity, recovery and participation for all people using inpatient mental health care. Design: We propose to undertake a cross-national comparative study of recovery-focused mental health care planning in inpatient settings. This two-phase exploratory mixed methods study will produce theory and empirical evidence to complement that developed in our current study of community mental health services to inform a future whole systems intervention study. The study is guided by a theoretical framework emphasising the connections between different 'levels' of organisation (macro/meso/micro). In phase 1 we study the macro-level through the comparative analysis of English and Welsh policy contexts. In phase 2 concurrent quantitative and qualitative data will be collected at 6 NHS Trust/Health Board case study sites (meso-level) and within each site, a single micro-level mental health ward will be selected to provide in-depth qualitative data related to care planning processes. Phase 1: We will extend our current meta-narrative mapping review (Wong et al 2013) of English and Welsh policies and the international literature on personalised recovery-oriented care planning and coordination in community settings to include inpatient settings. We will provide a review of evidence that is useful, rigorous and relevant for service providers and decision-makers and to inform Phase 2. Phase 2: We are employing a concurrent transformative mixed methods approach with embedded case studies (Creswell 2009: 215). We will conduct six in-depth meso-level case study investigations across contrasting NHS Trusts in England (n=4) and Local Health Boards in Wales (n=2), selected to reflect variety in geography and population and include a mix of rural, urban and inner city settings providing routine inpatient care. A large sample of service users (total n=300), inpatient staff (n=300) and informal carers (n=150) will be surveyed about perceptions of acute mental health care and care planning, recovery oriented practices, therapeutic relationships and empowerment using validated questionnaires. Documents and interviews with managers, consultant psychiatrists, ward staff and informal carers (n=60) will also be generated relating to local contexts, policies and practices. In each site we will also select a single inpatient ward and conduct a series of case studies embedded within each organisational case study, to explore care planning in detail. We will invite a sample of service users (total n=36) to participate in in-depth interviews about care planning and structured narrative reviews of their care plans; undertake a structured review of anonymised care plans for a further sample (n=60) of consecutively discharged patients; and conduct observation of care planning processes (n= 18). Framework method will be employed to integrate and compare textual and statistical summaries of qualitative and quantitative analyses within each case study site, informed by the theoretical framework focused on recovery and personalisation. Armed with our set of six within-case analyses we will then conduct a cross-case analysis to draw out key findings from across all sites