Enhancing Therapeutic Environment in Acute Mental Health Wards - Literature review Example

Enhancing therapeutic environment in acute mental health wards Recently more emphasis has been placed on improvement of inpatient therapeutic experience on mental health wards. Research shows that service users often report that there is not enough therapeutic interventions in these settings focussing on their recovery (Department of Health, 2002; MIND 2004). Availability of therapeutic interventions has been strongly associated with reduction of boredom, frustration, self harm and violence as well as improved recovery and treatment outcomes (Baker, 2013). Government programmes such as releasing time to care and improving inpatient experience have both been instigated to raise the importance of enhancing therapeutic environment in mental health as a means of improving service users’ therapeutic experience. This importance cannot be over emphasized that in acute mental health wards where there are many obstacles to facilitate regular and ongoing nursing therapeutic interventions and where there is a need to have proactive and structured engagement with service users (Mullen, 2009). This report will discuss how therapeutic environment on acute mental health wards can be enhanced by the change agent applying Lewins theory of change as well as certain leadership qualities to improve service users’ experience and implement change. The importance of having therapeutic interventions in inpatients mental health settings as means of enhancing therapeutic environment According to NHS Confederation report (2010) gaining understanding of how service users experience their care and making necessary improvements would ensure delivery of high-quality services that are based on individual needs. This report stated that the government is working towards improving service user experience and putting them at the heart of everything the NHS does. Baker, Sanderson, Challen and Price (2013) argues that in the last 15 years a number of government initiatives have been instigated in order to improve the quality of care in mental health acute settings. Programmes such as productive ward releasing time to care (NICE, 2007) ,that helps staff increase the time they spend directly with service users by making changes in their working environment and improving the inpatient therapeutic experience (NICE, 2011) have both emphasized requirement for protected engagement time with service users to improve their inpatient experience. Recently “No Health Without Mental Health” policy (Department of Health, 2011) stated that services in mental health should be designed on principle of humanity, dignity and respect, in regards to organisation that are fostering these principles. In addition, the policy stated that the wards need to operate in such way that they will make service users safe and therapeutic (Department of Health Estates and Care Services Improvement programme, 2008). However, Centre for Mental Health (2012) stated that that although there are some very good inpatient mental health services, there is evidence from service users’ feedback which suggests that some acute inpatients care is not experienced as safe or therapeutic. This is in line with (NICE, 2011) guideline report on service user experience in adult mental health is that they generally find that there is not enough therapeutic activities and occupations available to service users when being treated on an inpatient mental health ward. However, their survey could not specify what activities and occupations service users want or how improvements could be made to improve their experience. Department of Health (2002) argues that therapeutic activities should be provided on the basis of the service user assessment of needs. MIND (2004) report stated that “Meaningful activity should be determined within an individual care plan negotiated with the service user... the creation and maintenance of a therapeutic activity milieu needs to include evening and weekend activities and opportunities both on and off the ward. This may include educational, social, artistic, recreational and leisure activities...There is currently an imbalance of emphasis and deployment of staff skills in organisation of inpatient wards... (MIND, 2004, p13). Royal College for Psychiatrist (2011) argues that not having enough therapeutic activities in acute inpatient settings are often associated with boredom and frustration that can affect service user recovery and lead to challenging behaviours. One of the early studies that examined how the atmosphere on the ward can affect service user outcome was by Wing and Brown (1970) who found out that not engaging in activities was associated with decline in service user mental health functioning whereas more stimulating social environment improved their mental state. A more recent study by Hansen and Slevin (1996) found out that the introduction of group therapy and planning as well as community meetings on acute wards increased service user participation as well as improved relationship between staff and service users. Apart from improving clinical outcome and relationship between staff and service users, the availability of therapeutic groups in inpatient settings decreases violence and aggression as well as boredom and frustration that can create risk (Department of Health, 2002). Similarly, Dodds and Bowles (2001) argue that regular facilitation of therapeutic activities reduces incidents of self harm, violence, absconding and the requirement for containment strategies. Collins, Elsworth and Casey (1985) argue that inpatients wards that are more socially engaging are more likely to achieve better treatment outcomes. The availability of therapeutic activities and group programmes with acute inpatient setting are more likely to reduce service user stress as well as social isolation and provide opportunity for learning new skills (Yalom, 1983). Centre for Mental Health (2012) introduced implementation framework as a means of improving mental health services and one of their focus area in relation to inpatient service was the service users’ engagements in particular to ensuring that there are meaningful therapeutic activities available to them. Similarly, Royal College of Psychiatrist (2011) report argues the need of wards being a therapeutic space that can help service user and empower them to be in control of their recovery of mental illness. They further stated that the ward needs to ensure that a range of therapeutic activities are available to service users on weekday and weekends that are culturally appropriate and available to all service users. According to this report the worth of therapeutic activities being available to service users cannot be overestimated. However, research suggests that in inpatient settings at any time during the day service users are socially disengaged and inactive (Radcliffe and Smith, 2007). Although this decline in social activities can be attributed to the lack of occupational therapy staff, CQC (2010) argues that all staff working on inpatient wards should share this responsibility. Radcliffe et. al. (2007) states that provision of therapeutic activities should be a priority in mental acute mental health wards and that more decisive approach should be made by staff to engage service users in therapeutic group activities. Department of Health (2006) strongly argued for recovery approach to inform mental health nursing practice that should value social inclusion. According to this report a good way to promote social inclusion is to look beyond individual illness and symptoms and by mental health nurses helping access to relevant housing, employment, education and leisure activities to service users. Shepherd, Boardman and Slade (2008) argue that recovery ideas are very much supported by government and applied in many mental health services throughout England. Shepherd et. al. (2008) argues that recovery interventions in mental health would involve nurses to work in collaboration with service users towards social inclusion through participation in meaningful activities. According to this report the role of nurses would be to provide service users with the resources such as information, skills and support recovery and help service users to achieve personally meaningful outcome. s.Enhancing therapeutic environment in acute mental health ward by applying Lewins theory of change and leadership skills to improve service user experience Baguley, Alexander, Middleton and Hope (2007) acute care is very important for service users with mental health problems. It is equally important to keep pace with service development to ensure that essential therapy is provided in inpatient settings (Royal College for Psychiatrist, 2011). According to this report promoting therapeutic activities that are aiming to improve service users’ recovery and clinical outcome as well as reducing their risk should be a priority in inpatient settings. Walsh and Boyle (2009) states that service users that are receiving inpatients services are in general expecting improvements in care and treatment that is currently being provided to them. The Nursing and Midwifery Council (NMC) (2008) argue strongly that nurses should deliver care to service users based on best practice, in practice this can only be achieved through continuous update and change to practice. However, implementing change can prove to be more challenging than perceived (Mitchell, 2013). Managing change can prove to be difficult in acute settings due to busy and chaotic nature of the ward (Mullen, 2009). However, Mistral, Hall and McKee (2002) argue that despite this, improvements can be made to the service provision that is focussing on promotion of therapeutic environment to service users. This would require commitment from staff, service users and the organisation as a whole. In addition, Garcia, Kennett, Quraishi and Durcan (2005) argue that inpatient settings that provide structure and engagement as part of providing individualised care and treatment to service users demonstrate a more therapeutic and safe environment. According to Mithell (2013) when implementing change in healthcare settings one commonly used theory of change is Kurt Lewins (1951), often called a force field model of change that includes three stages: unfreezing stage, moving stage and freezing stage In this report, the author is going to apply Lewins theory of change to enhance therapeutic environment in acute mental health setting. The change agent is going to explain how this theory can be used to ensure meaningful and therapeutic activities are available to service users that will improve service user experience, promote recovery from mental health illness, reduce boredom, frustration and treatment outcome. The first step in implementing change would be to identify the change focus, which in this case would be enhancement of therapeutic environment in acute mental health ward. This would involve communicating with all staff working in this setting and service users in order to motivate them and to build trust and respect (Glenn, 2010). According to Burnes (2000), this is very important as the change agent would need to ensure that all those affected believe that this change is necessary. The role of the change agent is to talk openly about the consequences of not having enough meaningful activities in the ward and about the benefits of enhanced therapeutic environment. Department of Health (2011), states that there should be regular meetings with service users and staff to discuss how the ward is run and to provide a forum for service user involvement in identifying what activities are available on the ward that they are finding therapeutic and engaging. In addition, it would be beneficial if therapeutic activities could be determined in individual service user care plan, taking into consideration their admission circumstances and duration of stay on the ward. One of the key factors staff would need to consider is how make these activities available and consistent throughout the week (Department of Health, 2011). Walsh et.al (2009) suggested it is highly recommended for the service users to be involved in reviewing their care on acute mental health ward as a means of empowering them in decision making. Therefore regular community and treatment planning meeting should be facilitated on the ward to obtain service user and staff perspective of needs (Hansel and Slevin, 1996). According to Walsh et.al (2009) senior management would also be responsible to ensure this happens, therefore support from management is very important at this stage. During this stage there should be open discussion about any barriers (restraining force) to enhancing therapeutic environment on acute ward and how they could be addressed as well as any factors that would help to drive this project (Mitchell, 2013). Taking into consideration that acute mental health wards are often characterised as busy and unpredictable settings, common barriers are often described as lack of time for staff to engage with service users, lack of confidence of staff to facilitate therapeutic activities, service user poor mental state and reluctance to engage in therapeutic activities and the high use of agency and bank staff that are not necessarily familiar with the service users needs or the wards environment (Sainsbury Centre for Mental Health, 1998; Baker et.al, 2013; Department of Health, 2011). To overcome the barrier of lack of time to engage with service user, the change agent should discuss how protected therapeutic and engagement time (PTET) should be implemented on the ward. Butler (2006), argues that implementation of protected therapeutic and engagement time on acute time would ensure that staff clinical time is reorganised in such a way that would ensure that the time spent with service user is meaningful and is actively engaging them in therapeutic activities. Similarly, Kent (2005), argues that during protected time all other activities should stop for a set period during the day. This would enable staff to facilitate therapeutic interventions with service users. Butler (2006) adds that to maximise the benefit and use of protected time discussions should take place with other teams and agencies to be aware of agreed protected time so that they are not interrupted by them as well as involving service users in choosing what they would prefer to use these sessions for. When planning session with service users, the change agent should emphasize how important it is to work as a team, encourage and support each other as lack of motivation from staff can be noticed by service users and resemble on their participation (Butler, 2005). Adequate supervision from management with staff facilitating therapeutic intervention would prove beneficial at this stage as nurses often lack training and confidence to facilitate therapeutic intervention (Mullen, 2009). Considering the fact that nurses are often tied up with administrative duties and paperwork and that there are shortages of occupational therapist and psychologist on acute mental health wards, the change agent should explore whether it would be useful if therapeutic activities are led by unqualified staff that are trained and equipped with the right skills and knowledge to facilitate groups as well the possibility to recruit volunteers on the ward (Sharac, McCrone, Saben-Figuera, Csipke, Wood and Wykes, 2010). Working in this way would free qualified staff as well as make maximum use of staff on duty. It is also important to emphasize that when facilitating therapeutic groups on the ward service users needs, their current mental state as well as their level of functioning should be acknowledged by staff. Research shows that often nurses find it difficult to persuade service users to attend activities because they are in most of cases quite withdrawn and resentful about being in hospital (Radcliffe and Smith, 2007). According to Radcliffe et.al. (2007) although nurses cannot insist for service users to attend against their will, they should emphasize that attendance in therapeutic activities is important for their treatment and would improve their recovery. To maximise the impact of bank staff on acute wards Janner (2012), suggested they should be recruited with creative and group skills. This would ensure that they can support the ward staff in facilitating therapeutic activities and engaging with service users in a meaningful and therapeutic way. Janner (2014) , also argues that it would be beneficial if former service users could be involved in facilitating activities as they could bring additional insight and empathy having been through the same experience as current service users. Having identified the barriers to implement change and how they could be addressed to enhance therapeutic environment on acute mental health ward, the moving stage would represent the actual change (Mitchell, 2012). The enhancement of therapeutic environment the ward through ensuring that regular therapeutic activities are available to service users will involve cooperation and effort from all those affected such as the staff, management and service users as they would be affected by this change (Department of Health, 2011). Department of Health (2011), states that in adult acute inpatient care provision there must be absolute commitment to service user and staff collaboration in providing care and treatment on inpatient ward. This would involve encouraging service users to give feedback and suggest improvement to the organisation on the ward and for staff to make necessary changes based on their feedback. Mullen (2009) suggests that responsibility of ensuring meaningful activities are available to service users lies with the staff and employers. After gathering all the feedback from staff and service users, the change agent should be able to determine what activities should be available on daily basis to service users as well especially when protected therapeutic and engagement time should be applied on the ward and ensure this is consistent and ongoing. Another area to consider would be availability and training needs of staff (Mullen, 2009). Research shows that in order to ensure activities are available to service users would require staffs that are well trained, skilled and motivated for this change to be implemented (Mullen, 2009). It would also be beneficial if there is a staff member who had been delegated to oversee this implementation and how protected time is used on the ward (Butler, 2006). This could be the role of the change agent. To help staff feel more confident in facilitating therapeutic interventions, regular meetings should be held to discuss how the project is progressing in addition to planning future interventions (Butler, 2006). Support from the team is important at this stage to ensure that the ward is accommodating activities on regular basis. McGann and Bowers (2005) argue that it would also be useful if training programme could be provided to nurses as a group to prepare themselves for therapeutic interventions as this would require nurses to have relevant skills and knowledge. The emphasis should be put on ensuring that therapeutic activities become part of work culture that would meet everyone’s needs and should not be perceived as something that is temporary with limited life span (Mullen, 2009). The refreezing stage is the third stage of Lewins theory which in this case occurs when the therapeutic activities become part of ward’s daily routine. The aim is to ensure this change continues and is long term (Finkelma, 2006). Continued support should be provided to all those involved in this project until staff, nursing managers and service users feel satisfied with therapeutic programme on the ward. Bowers (2011) suggests that in this final stage all stakeholders are feeling empowered to embrace this change and ensure it is embedded in their practice. This report outlines the importance of enhancing therapeutic environment in acute mental health wards. Successful implementation of regular and ongoing therapeutic interventions on the ward would decrease frustration and boredom as well as improve service user recovery from mental illnesses (Royal College of Psychiatrist, 2011). In addition to these benefits, it is important to emphasize that staff and organisation as a whole would benefit from this implementation as this would reduce service user recovery time, increase levels of pleasure and satisfaction and improve their experience of being treated on inpatient wards (Mullen, 2009). Applying Lewins theory of change to enhancement of therapeutic environment would help the change agent to plan and implement regular therapeutic interventions on acute mental health ward. This can be achieved by having open discussions with all those affected about what are the restraining and driving forces that would need to be addressed to ensure successful implementation of this change. Involving staff and service users and inviting them to give feedback and be involved in decision making would help to develop trust, increase their motivation and reduce resistance to change. Furthermore, having regular meetings to discuss how protected therapeutic and engagement time is being used on the ward would help to keep staff and service users updated and raise the importance of therapeutic interventions on the ward. Implementation of this change would require the change agent to have leadership skills of team building, role modelling and good communication skills to promote and guide the team through the course of change (Andrews, 1993). Conclusion The requirements for acute wards have increasingly become multifaceted in the last on decade and the anticipations of main stakeholders have risen with time. Typically there is the anticipation that recently qualified nurses should; manage the most distressed patients safely, provide talking treatment ,be knowledgeable about evidence-based interventions in addition to promoting service user as well as carer involvement, management of complex systems as well as being responsible for promotion of a conducive learning atmosphere. It may be logical claim that such anticipations are unreasonable given the training, grade and experience of ward nurses(Evans, 2003). Consequently, a polemical recommendation would be inverting of the present career pathway. Thus, the recently qualified nurse may at the beginning be placed for instance in a community mental crisis resolution team/health team (CRT/CMHT) at grade D/E, facilitating a consolidation as well as grounding of his/her skills and knowledge. Afterwards the nurse would then gradually progress via the grading structure of the clinic, with the aim of becoming an F or G-grade nurse in the clinical speciality of acute inpatient mental health (Evans, 2003). Acute wards typically have several positive therapeutic features. If any enhancements are to be implemented, they must be built upon such aspects. Practical improvements within the short term towards practice should be made such as introducing family interventions whereby other family members are inclusive of the general treatment programme. Nevertheless, changes should ,in the long term be essential and tackle the goals, purpose, structure as well as the intended patient group in the acute wards. Finally, the above recommendations surrounding career pathways would assist wards to be increasingly more nurturing atmosphere not only patients but also staff (Evans, 2003). List of references Evans, R.2003 "Presenting the Case for Acute Mental Health Wards." Clinical: pg 1-2. 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