'What good looks like' in inpatient and specialist care from a user perspective

“Where staff had prioritised making sure new admissions to the ward had received a care plan, diagnosis, and medication, for example, service users all prioritised communication with staff as the most important first intervention. Some staff admitted the constant demands made on them through the repetitive processes involved in acute wards had obscured their value as people, to patients”[1]

Key points

Literature about user experience and perception findings about inpatient care included the importance and value of:

  • communication in high-quality therapeutic relationships, primarily between trusted staff and service users
  • feeling safe and enabled in a positive environment and the appropriate management of risk and consistency in regulation
  • avoiding negative experiences of coercion and associated communication
  • increasing service user and carer/family information provision and involvement in holistic care planning, and decision making, particularly at points of transition including admission and discharge
  • having a shared understanding of approach to recovery and supporting staff to meet identified needs

Reviews of service user experiences

A 2020 meta-review of systematic reviews[2] examined factors influencing inpatients perception of psychiatric hospitals. They identified these factors as relationships on the ward, the ward environment, coercive measures, legal status, autonomy, feeling deserving of care, and expectations of care at admission and discharge. The authors noted that these factors appear interlinked, so that ‘striving for excellence’ in one domain could have a positive effect on other domains, particularly in relation to developing good quality relationships between inpatients and staff, the most consistent factor reported. It was noted that if there are acute safety concerns or complex care needs, inpatient admission can be a necessary aspect of mental health care and so the need for inpatient wards to be therapeutic is essential. The authors suggest that services may already be aware and striving to improve but for those settings that are ‘struggling to create a safe and therapeutic environment’ they should start to intervene where appropriate, for example: conducting staff training about communication, making changes to the physical environment, increasing therapeutic activity on the ward to minimise boredom, community teams collaboratively deciding on achievable goals for treatment prior to admission, and providing inpatients with information and choice throughout their admission regardless of legal status.  Studies reported that the opportunity to make small decisions such as choice of meals, snacks, or activities was comforting.

A 2019 systematic review[3] of qualitative research on experiences of in-patient mental health services examined 72 studies from 16 countries and identified four themes that were consistently related to significantly influencing in-patients’ experiences of crisis and recovery-focused care. These were: the importance of high-quality relationships, averting negative experiences of coercion, a healthy, safe and enabling physical and social environment, and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care. The authors suggested that these themes can be used to design and deliver high-quality services. A consistent thread across all four themes was the key role of staff in facilitating a high-quality patient experience, but the authors noted that staff operate within the context of a wider system that needs to support the delivery of care. Good staff and patient relationships facilitated the care pathway and reduced coercive measures. Ward rounds were an important setting for staff/patient interaction. The importance of dignity in communication was raised around coercion, medication and seclusion. Patients wanted the reasons for measures to be communicated and to be addressed professionally. Talking with staff following restraint or being allowed to examine records of the event was considered helpful.  Patients valued persuasion over threats of force and coercion. It was reported good communication could support patients’ trust of staff and feeling safe.

A 2019 Meta-synthesis[4] of the experiences of people with borderline personality disorder admitted to acute psychiatric inpatient wards identified four explanatory themes: contact with staff and fellow inpatients, staff attitudes and knowledge, admission as a refuge; and the admission and discharge journey. Opportunities to be listened to and to talk to staff and fellow inpatients, time-out from daily life and feelings of safety and control were positively perceived elements of inpatient care. Negative experiences were ascribed to: a lack of contact with staff, negative staff attitudes, lack of staff knowledge about BPD, coercive involuntary admission and poor discharge planning.

A 2020 narrative synthesis[5] examined 12 studies from 7 countries and reported that boredom on inpatient mental health wards is linked to poor patient satisfaction, feelings of frustration and increased incidents of self-harm and aggression, particularly for people detained under the Mental Health Act. A good range of activities such as art, music, computer games, gardening and exercise, was linked with improved well-being.

Experience based co-design

As part of a UK research study[6] exploring the experience of hospitalisation from three perspectives (early intervention in Psychosis service users, their families, and inpatient nursing staff connected with seven inpatient units at two hospitals in the Midlands) an experienced based co-design event involving 50 service users, family members, inpatient and community mental health staff, and managers developed the following action plans:

Identified area for redesign

1. Pathways in and out a. Develop a “patient journey” flowchart.
2. Providing staff with a rewarding and well-supported role

a. Establish protected time on wards, for staff– patient contact.

b. Demonstrate that supervision is embedded within the organization to increase a supportive culture for staff.
3. Communicating with families and service-users

a. Develop effective ways of sharing information with service-users and families (about what is happening with regard to admission, care, intervention, support, and discharge).

b. Develop effective ways of involving service users and families in decision making (about what will happen with regard to admission, care, intervention, support, and discharge).
4. Recovery-focused practice a. Establish a working group to identify a model of recovery that is transferable across services.
5. Creating a positive environment for everyone in it

a. Consistent recreational and activity program.

b. Consistent welcome and information for patients and family members.

c. Improve signage, colour, and access to designated spaces (e.g., quiet space) in the ward environment.
6. Recognising and sharing good practice across professions and services a. Create a regular early intervention slot in an existing inpatient meeting and vice versa.

Review of nurses’ experiences 

A 2017 narrative synthesis[7] of nurses’ experiences of delivering care in acute inpatient mental health settings identified three overarching themes, which either facilitated or hindered provision of recovery-focused care:  1) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); 2) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); 3) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). The authors suggest that a compassionate system of support is needed to enable person-centred practice and that it is critical to have a work environment is supportive of autonomy, ensures workload balance, and is safe, and which fosters hope and optimism.

Staff experience in transformational planning

In 2016 the Royal College of Nursing Scotland carried out one-to-one interviews with nurses and other partner professionals, and reviewed literature on the reform of Scotland’s mental health system and identified some key enablers of transformational change for those planning and leading integrated services, learning from the experience of mental health nursing[8]. They identified key enablers as (reproduced here verbatim):

  • Change is well led, managed and funded.
  • Health and wellbeing are defined by the individual
  • People using services are involved both in decision making about their care and at a strategic level
  • Real relationships are developed as the foundation of effective teamwork
  • An environment is created which enables people to take risks proactively
  • Services have the right staff with the right support and training to meet identified needs
  • Integrated care pathways enable people to access the level of support they require
  • There are services available for people needing care in the community in times of crisis.

The mental health crisis care concordat is a national agreement between services and agencies involved in the care and support of people in crisis in England, which sets out how organisations will better work together to make sure that people get the help they need when they are having a mental health crisis.

The concordat suggests effective commissioning ensures that the support and services reflect[9]:

  • The needs of people of all ages and all ethnic backgrounds, reflecting the diversity of local communities
  • An equal relationship between physical and mental health
  • The contribution of primary, community and hospital care, as well as other partners
  • The inclusion of seldom-heard groups, or those that need improved early intervention and prevention.

It is suggested that this can be achieved through service user and carer involvement in all elements of the commissioning cycle, strategic direction, and monitoring of crisis care standards, and that partnership working is best supported by services working within meaningful catchment areas for example within the same area covered by local Emergency Departments and ambulance services[9].

Examples could include:

  • “effective care pathways from police custody suites and courts for individuals with co-existing mental health and substance use issues.
  • resources to support a crisis care pathway which ensures patient safety and choice to make sure individuals can be treated as close to home wherever possible. This may also include working with housing organisations, people experiencing homelessness or vulnerable people who are noticed on the rail transport network.
  • needs of children and young people with mental health conditions, such as self-harm, suicidality, disturbed behaviour, depression or acute psychoses.
  • a focus on recovery which is demonstrated by measuring outcomes and clearly shown in service specifications, including patient and carer experience and satisfaction data.
  • effective local safeguarding arrangements in place to prevent or reduce the risk of significant harm to people whose circumstances make them vulnerable.”[9]

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