Investigation of the Consumer Perspective on Leisure in Mental Health Inpatient Units.

This study aimed to explore the barriers to engagement in activity and consumer satisfaction in inpatient settings. Participants were current inpatient consumers and completed an online anonymous survey. This included the Mental Health Satisfaction Improvement Program (MHSIP), Leisure Boredom Scale (LBS), and the Checklist of Leisure Interests and Participation (CLIP). A total of 57 participants partially completed the survey with 41 completed responses. Participants reported several barriers to engagement, including lack of staff, limited social engagement, limited range of activity, and a lack of resources. Most participants reported to be either "very satisfied" (24.24%) or "somewhat satisfied" (36.36%) with the level of activity offered. Participants reported to be bored due to a limited occupational range offered in the mental health inpatient unit. Participants identified the need for assistance in the facilitation of activity.

'Virtually daily grief'-understanding distress in health practitioners involved in a regulatory complaints process: a qualitative study in Australia.

Protection of the public is the paramount aim for health practitioner regulation, yet there has been growing concern globally on the association between regulatory complaints processes and practitioner mental health and wellbeing. The objective was to understand the experience, particularly distress, of health practitioners involved in a regulatory complaints process to identify potential strategies to minimise future risk of distress. Semi-structured qualitative interviews were conducted with health practitioners in Australia who had recently been through a regulatory complaints process, together with a retrospective analysis of documentation relating to all identified cases of self-harm or suicide of health practitioners who were involved in such a process over 4 years. Data from interviews and the serious incident analysis found there were elements of the regulatory complaints process contributing to practitioner distress. These included poor communication, extended time to close the investigation, and the management of health-related concerns. The study found external personal circumstances and pre-existing conditions could put the practitioner at greater risk of distress. There were found to be key moments in the process-triggers-where the practitioner was at particular risk of severe distress. Strong support networks, both personal and professional, were found to be protective against distress. Through process improvements and, where appropriate, additional support for practitioners, we hope to further minimise the risk of practitioner distress and harm when involved in a regulatory complaints process. The findings also point to the need for improved partnerships between regulators and key stakeholders, such as legal defence organisations, indemnity providers, employers, and those with lived experience of complaints processes. Together they can improve the support for practitioners facing a complaint and address the stigma, shame, and fear associated with regulatory complaints processes. This project provides further evidence that a more compassionate approach to regulation has the potential to be better for all parties and, ultimately, the wider healthcare system.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients.

OBJECTIVE: A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention. METHODS: A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact. RESULTS: ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention. CONCLUSIONS: Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

Outcomes of a co-located approach for metabolic health care for people with schizophrenia.

OBJECTIVE: Metabolic syndrome is highly prevalent among people with schizophrenia. This study aims to assess the impact on metabolic and attendance outcomes of a co-located, dedicated, endocrinologist-led metabolic clinic in a stand-alone public community mental health service. METHODS: Demographic and metabolic data on the first 48 consecutive referrals over a 12-month period were retrospectively collected and analysed. Attendance rates at the co-located clinic were compared to the general hospital obesity and diabetes clinics. RESULTS: Clinic attendees had significant reductions in triglycerides and total cholesterol, but not mean weight, BMI, waist circumference, blood pressure or HbA1c. Attendance rates were significantly higher in the co-located clinic compared to the general hospital obesity and diabetes clinics for both initial consult (80.0% vs 51.2%, p < 0.001) and review appointment (64.3% vs 47.6%, p < 0.001). CONCLUSION: The co-location of a specialist metabolic clinic within a mental health service resulted in enhanced engagement and improvement of metabolic health in people with schizophrenia.

LOVE in the time of Covid-19: a brief mental health intervention to overcome loneliness.

OBJECTIVE: The coronavirus disease 2019 outbreak and its containment through public health strategies has resulted in a parallel pandemic of psychological distress. Increased loneliness and social isolation are associated with adverse health outcomes, yet there is a gap in brief interventions that specifically target loneliness. This article introduces a brief intervention to strengthen connectedness, LOVE. In a systematic way, this solution-focused approach encourages openness and sharing of current struggles with the existing circle of support. There are four steps in LOVE: List people in one's life, Organise them on the helpfulness-availability matrix, Verify what they know to map them onto circles of trust and Engage them through self-disclosure. CONCLUSION: The article details each concept, its importance, the pragmatics involved and top tips to guide practice. The memorable acronym provides logical sequence and structure. It is time efficient in training and delivery, with no former mental health knowledge required so there is potential for wide application. It facilitates collaboration between health professionals and people in distress and promotes empowerment and self-resilience. Adapted from the safety planning component of PROTECT, a pre-existing suicide prevention framework, LOVE has to be fine-tuned as a brief intervention in the wider context of the pandemic.

Placing rehabilitation at the core of assertive community treatment.

OBJECTIVES: Assertive community treatment (ACT) teams are increasingly being adapted to suit the needs of consumers who have never experienced long-term institutional care yet struggle to retain community tenure and quality of life due to residual functional disabilities associated with severe mental illness. Support needs can be provided by the growing disability support sector but recovery-orientated rehabilitation services delivered by specialist rehabilitation clinicians are also required. The Mobile Intensive Rehabilitation Team (MIRT) within the Metro South Addiction and Mental Health Service has adapted the ACT model to deliver assertive outreach that aims to work collaboratively with the person and their chosen supports to improve their function and their sense of self-efficacy in illness self-management. We described the characteristics of the consumers referred to MIRT over a 20-month time period, and reported on on their discharge location. CONCLUSION: After two years with MIRT, half the participants were discharged out of case-management. Being on clozapine was a barrier to discharge from case-management despite functional improvement. Psychiatric hospitalisations predicted longer duration working with MIRT.

Life in 90 words: opportunities for person-centred care amidst COVID-19.

OBJECTIVE: Coronavirus disease 2019 and the consequent public health and social distancing measures significantly impacted on service continuity for mental health patients. This article reports on contingency planning initiative in the Australian public sector. METHODS: Ninety-word care synopses were developed for each patient. These formed the basis for guided conversations between case managers and consultant psychiatrists to ensure safe service provision and retain a person-centred focus amidst the threat of major staffing shortfalls. RESULTS: This process identified vulnerable patient groups with specific communication needs and those most at risk through service contraction. The challenges and opportunities for promoting safety and self-management through proactive telehealth came up repeatedly. The guided conversations also raised awareness of the shared experience between patients and professionals of coronavirus disease 2019. CONCLUSION: There is a parallel pandemic of anxiety which creates a unique opportunity to connect at a human level.

PROTECT: Relational safety based suicide prevention training frameworks.

Preventing suicide is a global priority, and staff training is a core prevention strategy. However, frontline pressures make translating training into better care and better outcomes difficult. The aim of the paper was to highlight challenges in suicide risk assessment and management and introduce training frameworks to assist with mindful practice so professionals can strike a balance between risk and recovery. We combined the scientific literature with contemporary practice from two successful initiatives from Cambridgeshire, UK: 333 - a recovery-oriented model of inpatient/community crisis care and PROMISE - a programme to reduce coercion in care by enhancing patient experience. The resulting PROTECT (PROactive deTECTion) frameworks operationalize ongoing practice of relational safety in these programmes. PROTECT is a combination of novel concepts and adaptations of well-established therapeutic approaches. It has four training frameworks: AWARE for reflection on clinical decisions; DESPAIR for assessment; ASPIRE for management; and NOTES for documentation. PROTECT aims to improve self-awareness of mental shortcuts and risk-taking thresholds and increase rigour through time-efficient cross-checks. The training frameworks should support a relational approach to self-harm/suicide risk detection, mitigation, and documentation, making care safer and person-centred. The goal is to enthuse practitioners with recovery-oriented practice that draws on the strengths of the person in distress and their natural circle of support. It will provide the confidence to engage in participatory approaches to seek out unique individualized solutions to the overwhelming psychological pain of suicidal distress. Future collaborative research with people with lived and carer experience is needed for fine-tuning.

Embedding Recovery to Transform Inpatient Mental Health Care: The 333 Model.

OBJECTIVE: The 333 model is a radical redesign of acute mental health care. Time-limited inpatient pathways for assessment (≤3 days), treatment (≤3 weeks), and recovery (≤3 months) replaced traditional geographical-sector wards. By making beds available, 333 aspired to improve access, deliver early treatment, and shorten hospital stays-generating savings through reductions in beds and out-of-area placements (OAPs). This article compares the model's performance against national benchmarking and internal targets. METHODS: The complement of general adult beds (2011-2016) was mapped out. Patient flow data (April 2015-March 2017) were extracted from the National Health Service data warehouse and compared with 2016 NHS benchmarking and 333 targets. RESULTS: Between 2012 and 2016, beds were reduced by 44% compared with 17% nationally. OAPs due to bed unavailability became extremely rare. More than 74% (N=2,679) of patients who were admitted to the assessment unit between 2015 and 2017 were discharged back to the community, minimizing fragmentation of care. Median length of stay was one-sixth as long as the national rate, but readmission rates were higher than the national mean because of the model's innovative approach to managing treatment of patients with personality disorders. Bed occupancy was below the national average, with beds available every night for 2 years. CONCLUSIONS: With its recovery-focused approach, 333 has reduced length of stay and ensured that a stay on any ward is meaningful and adds value. The article demonstrates that bed and OAP reduction and the delivery of safe care can be achieved simultaneously.

Decision-making in crisis resolution and home treatment teams: The AWARE framework.

Aims and methodThe aim of the study is to improve patient safety by identifying factors influencing gatekeeping decisions by crisis resolution and home treatment teams. A theoretical sampling method was used to recruit clinicians. Semi-structured interviews to elicit various aspects of clinical decision-making were carried out. The transcripts were thematically analysed using a grounded theory approach. RESULTS: Patient needs (safety and treatment) was the primary driver behind decisions. The research also revealed that information gathered was processed using heuristics. We identified five key themes (anxiety, weighting, agenda, resource and experience), which were constructed into an acronym 'AWARE'.Clinical implicationsAWARE provides a framework to make explicit drivers for decision-making that are often implicit. Incorporating these drivers into reflective practice will help staff be more mindful of undue influences and result in improved clinical decisions.Declaration of interestNone.

PROGRESS: the PROMISE governance framework to decrease coercion in mental healthcare.

Reducing physical intervention in mental health inpatient care is a global priority. It is extremely distressing both to patients and staff. PROactive Management of Integrated Services and Environments (PROMISE) was developed within Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) to bring about culture change to decrease coercion in care. This study evaluates the changes in physical intervention numbers and patient experience metrics and proposes an easy-to-adopt and adapt governance framework for complex interventions. PROMISE was based on three core values of: providing a caring response to all distress; courage to challenge the status quo; and coproduction of novel solutions. It sought to transform daily front-line interactions related to risk-based restrictive practice that often leads to physical interventions. PROactive Governance of Recovery Settings and Services, a five-step governance framework (Report, Reflect, Review, Rethink and Refresh), was developed in an iterative and organic fashion to oversee the improvement journey and effectively translate information into knowledge, learning and actions. Overall physical interventions reduced from 328 to 241and210 across consecutive years (2014, 2015-2016 and 2016-2017, respectively). Indeed, the 2016-2017 total would have been further reduced to 126 were it not for the perceived substantial care needs of one patient. Prone restraints reduced from 82 to 32 (2015-2016 and 2016-2017, respectively). During 2016-2017, each ward had a continuous 3-month period of no restraints and 4 months without prone restrains. Patient experience surveys (n=4591) for 2014-2017 rated overall satisfaction with care at 87%. CPFT reported fewer physical interventions and maintained high patient experience scores when using a five-pronged governance approach. It has a summative function to define where a team or an organisation is relative to goals and is formative in setting up the next steps relating to action, learning and future planning.

Is restraint a 'necessary evil' in mental health care? Mental health inpatients' and staff members' experience of physical restraint.

Restraint in mental health care has negative consequences, and guidelines/policies calling for its reduction have emerged internationally. However, there is tension between reducing restraint and maintaining safety. In order to reduce restraint, it is important to gain an understanding of the experience for all involved. The aim of the present study was to improve understanding of the experience of restraint for patients and staff with direct experience and witnesses. Interviews were conducted with 13 patients and 22 staff members from one UK National Health Service trust. The overarching theme, 'is restraint a necessary evil?', contained subthemes fitting into two ideas represented in the quote: 'it never is very nice but…it's a necessary evil'. It 'never is very nice' was demonstrated by the predominantly negative emotional and relational outcomes reported (distress, fear, dehumanizing, negative impact on staff/patient relationships, decreased job satisfaction). However, a common theme from both staff and patients was that, while restraint is 'never very nice', it is a 'necessary evil' when used as a last resort due to safety concerns. Mental health-care providers are under political pressure from national governments to reduce restraint, which is important in terms of reducing its negative outcomes for patients and staff; however, more research is needed into alternatives to restraint, while addressing the safety concerns of all parties. We need to ensure that by reducing or eliminating restraint, mental health wards neither become, nor feel, unsafe to patients or staff.