Care that can only be provided in hospital from a user perspective

"Conceptualising [interventions to improve discharge from acute adult mental health inpatient care to the community] from a patient safety, systems-thinking perspective and with an explicit theory of change may make it easier to: 1) describe the specific problem the interventions aim to address; 2) understand the elements of an intervention that are effective to produce the desired intermediate or long term outcomes and 3) understand what long term outcomes would indicate an effective intervention." [10]

Key points

Literature about user perception of the function of care provided in hospital included the importance and value of:

• Users were asked about the purpose of a psychiatric hospital in a Scottish context by the Mental Welfare Commission for Scotland. Themes are described below and many echo the qualitative literature from question 1 and include the importance of a focus on recovery.
• A multi-organisational study in NHS England and NHS Wales found high ratings for quality of care and therapeutic relationships when recovery-focused care was high.
• A systematic review reported that implementation of recovery-orientated practice in inpatient settings is possible, though challenging. Ongoing organisational support for the approach is beneficial.

Views on the purpose of hospital

A 2019 summary report[11] by the Mental Welfare Commission for Scotland of the views of people with lived experience on the purpose of a psychiatric hospital included 205 people via 16 focus groups in Scotland (service user and carer views and a small number of staff).

They identified:

• “When people are ill and need a hospital admission they want a safe place to go to and be looked after. Sometimes they want treatment and medication and sometimes they want a chance to find peace, to be cared for and looked after: to get a break from the responsibilities of coping in the ‘real world.’ A chance to just ‘stop’.
• They want to be around loving compassionate people who will listen to them, and help them talk about the things they want to talk about without judging them.
• On a practical level, people want a pleasant environment, good food, and adequate facilities and support for visitors and families. They want things to do and places to go outside of the hospital, especially the natural world.
• They want support from their peers, but also from staff.
• Many people prize the sense of community and belonging that existed in some hospitals some time ago.
• They don’t want to feel frightened, or to feel too controlled, but equally some people do not want so much freedom that they can take rash decisions about their safety. They don’t want to face meaningless rules; instead rules should fit their needs. They want to be sure that they have their rights and needs protected.
• Some people would like to be separated from people with addiction issues, and not to have to worry about being exposed to illegal drugs or alcohol on the ward.
• They want to feel that they will get better, and benefit from the stay, and do not want to be bored.
• They want admissions that last as long as they feel they need them.
• They want to be able to participate, and to have a sense that they might heal and recover.
• They don’t want to be moved constantly and want to be sure that there is continuity and consistency in their care.
• They don’t want the weekends to be too empty, and don’t want to be scared of the thought of admission, or ignorant of what might happen to them during their hospital stay.
• Some people would like to see alternatives to hospitals: therapeutic spaces for people in crisis and people who need to retreat from the world.
• A small number of people worry that a concentration on hospital care can detract from the non-institutional care that they might prefer.
• The reality is that some people’s experience does not fit these desires, but some other people have said that care and hospital treatment has improved over the years and that generally they get the treatment and respect they want.”[11]

Implementation of recovery-orientated care in an inpatient setting

A 2020 systematic review[12] indicated that whilst challenging, it is feasible to implement recovery-oriented practice in hospital based mental health services. More successful approaches are multimodal, applied over several years and have organisational support. Resistance to change from the embedded, biomedical model, staff attitudes towards recovery, and no service-user involvement in the implementation of recovery-oriented practice were the main barriers to implementation.

A 2019 cross national comparative mixed methods study[13] of recovery-focused mental health care planning and co-ordination in 19 acute inpatient mental health sites in England and Wales examined the views of service users, carers and staff in acute inpatient wards on facilitators and barriers to collaborative, recovery-focused care.

“For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff”.

A 2016 literature review[14] examined the extent to which a recovery-oriented approach is an integrated part of mental health inpatient settings, asthe idea of recovery-oriented practice has led to changes to elements of wider mental health care and organisational developments.Overall, the review found that:

• staff in inpatient settings had a positive attitude toward the values and principles of recovery-oriented practice, but there were different understandings of ‘recovery’: many staff tended to view recovery in the context of a traditional medical approach centred on medical stabilisation and symptom relief.
• there were difficulties applying recovery-orientated practice as low capacity led to competing demands for staff, which tended to take precedence over the individual needs of patients. High bed occupancy, high acuity levels and quick turnover of patients emphasised a crisis-driven approach which was mostly aimed at medical stabilisation.
• poor levels of engagement, communication, and collaboration between patients and staff appeared commonplace in inpatient settings. This appeared to be reinforced by physical designs and contradictory structures in organisational standards and procedures.

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