Improving patient experiences of mental health inpatient care : a randomised controlled trial

Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients’ views of ward care.Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect −0·35, 95% CI −0·57 to −0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, −0.01, 95% CI −0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect −0.18 s.d., 95% CI −0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI −£76 to £98, p = 0.774).Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions

Mental simulation and experiences determinants of performance expectancies in people with schizophrenia spectrum disorder

People with schizophrenia demonstrate both impairment in mental time travel and reduced expectancies of performance on future tasks. We aimed to reconcile these findings within the Kahneman and Tversky (1982) simulation heuristic framework by testing a key prediction that impaired future simulation would be associated with reduced performance expectancies in people with schizophrenia spectrum disorder (SZSPEC). A total of 54 individuals (30 people with SZSPEC and 24 healthy controls) generated mental simulations of everyday scenarios; after each response they rated performance expectations, distress and the similarity of the scenario to experience. Independent raters coded the coherence of responses. We found that people with SZSPEC had, compared to healthy controls, lower performance expectations and greater anticipated distress when imaging everyday scenarios. Lower performance expectancies were associated with lower experience of similar scenarios, greater negative symptoms and social withdrawal in the SZSPEC group. The current study confirmed previous findings of both impaired mental simulation and abnormal performance expectations in people with SZSPEC, together with the association of the latter with negative symptoms. Experience with social or occupational activities plays a more important role in determining performance expectancies in people with SS than the ability to mentally simulate scenarios

Lessons learnt? The importance of metacognition and its implications for Cognitive Remediation in schizophrenia

The cognitive problems experienced by people with schizophrenia not only impede recovery but also interfere with treatments designed to improve overall functioning. Hence there has been a proliferation of new therapies to treat cognitive problems with the hope that improvements will benefit future intervention and recovery outcomes. Cognitive remediation therapy (CR) that relies on intensive task practice can support basic cognitive functioning but there is little evidence on how these therapies lead to transfer to real life skills. However, there is increasing evidence that CR including elements of transfer training (e.g. strategy use and problem solving schemas) produce higher functional outcomes. It is hypothesised that these therapies achieve higher transfer by improving metacognition. People with schizophrenia have metacognitive problems; these include poor self-awareness and difficulties in planning for complex tasks. This paper reviews this evidence as well as research on why metacognition needs to be explicitly taught as part of cognitive treatments. The evidence is based on research on learning spanning neuroscience to the field of education. Learning programmes, and CRT, may be able to achieve better outcomes if they explicitly teach metacognition including metacognitive knowledge (i.e. awareness of the cognitive requirements and approaches to tasks) and metacognitive regulation (i.e. cognitive control over the different task relevant cognitive requirements). These types of metacognition are essential for successful task performance, in particular, for controlling effort, accuracy and efficient strategy use. We consider metacognition vital for the transfer of therapeutic gains to everyday life tasks making it a therapy target that may yield greater gains compared to cognition alone for recovery interventions

Design in mind: eliciting service user and frontline staff perspectives on psychiatric ward design through participatory methods

Background: Psychiatric ward design may make an important contribution to patient outcomes and well-being. However, research is hampered by an inability to assess its effects robustly. This paper reports on a study which deployed innovative methods to capture service user and staff perceptions of ward design. Method: User generated measures of the impact of ward design were developed and tested on four acute adult wards using participatory methodology. Additionally, inpatients took photographs to illustrate their experience of the space in two wards. Data were compared across wards. Results: Satisfactory reliability indices emerged based on both service user and staff responses. Black and minority ethnic (BME) service users and those with a psychosis spectrum diagnosis have more positive views of the ward layout and fixtures. Staff members have more positive views than service users, while priorities of staff and service users differ. Inpatient photographs prioritise hygiene, privacy and control and address symbolic aspects of the ward environment. Conclusions: Participatory and visual methodologies can provide robust tools for an evaluation of the impact of psychiatric ward design on users