Understanding Outcomes in a Randomized Controlled Trial of a Ward‐based Intervention on Psychiatric Inpatient Wards: A Qualitative Analysis of Staff and Patient Experiences

Abstract

Objectives. Team formulation is advocated to improve quality of care in mental health care and evidence from a recent UK based trial supports its use in inpatient settings. This study aimed to identify the effects of formulation on practice from the perspectives of staff and patient participating in the trial, including barriers and enhancers to implementing the intervention.Method. We carried out semi-structured interviews with 57 staff and 20 patients. Data were analyzed using thematic analysis.Results. Main outcomes were: improved staff understanding of patients, better team collaboration and increased staff awareness of their own feelings. Key contextual factors were: overcoming both staff and patient anxiety, unwelcome expert versus collaborative stance, competing demands and management support. Conclusions.Team formulation should be implemented to improve quality of care in inpatient settings and larger definitive trials should be carried out to assess the impact of this intervention on patient outcomes.Key words: psychiatric inpatient; qualitative analysis; therapeutic relationships; psychosis; formulation SHORTENED TITLE: The pressing need for more compassionate and person-centered care across health care settings is well-acknowledged (Australian College of Nursing, 2014; Department of Health, 2013;Epstein & Street, 2011). The quality of psychiatric care in the UK is under particular scrutiny due to negative independent inquiries (Schizophrenia Commission, 2012; Mind, 2011) and the 'parity of esteem' agenda (Royal College of Psychiatrists, 2013). As in many other developed countries, current inpatient psychiatric care is noted as being exceptionally anti-therapeutic, with high associated costs when people are detained for long periods due to poor outcomes (Schizophrenia Commission, 2012). Improving quality of care and ultimately outcomes in psychiatric inpatient settings is therefore a priority (Schizophrenia Commission, 2012). One organizational intervention for improving inpatient care that is growing in popularity in the UK is 'team formulation'. This involves all ward staff setting aside dedicated time to work together to identify the full range of biopsychosocial factors responsible for each patients' difficulties and using this information to plan treatment (Kinderman, 2005). The practice of engaging in team formulation is consistent with the principles of person-centered care. It encourages staff to look beyond the patient's symptoms of illness and appreciate his or her unique life experiences, needs, strengths, goals and values.As a result treatments plans informed by formulations are tailored to the patient's unique needs and circumstances at that particular point in time. From a theoretical perspective, we hypothesize that team formulation enables staff to develop more helpful beliefs about patients' difficulties and thus promote more positive responses to service users' distress or problems. For example, a staff member may believe that a patient finds it hard to engage with treatm...

A feasibility study of a cross‐diagnostic, CBT‐based psychological intervention for acute mental health inpatients: Results, challenges, and methodological implications

“…Unlike other studies of inpatient psychological intervention (Berry, Haddock, Kellett, Awenat, et al, 2016;Donaghay-Spire, McGowan, Griffiths, & Barazzone, 2016), we observed that managerial staff and psychiatrists did not attend relevant psychological training. This may suggest either a lack of support for the therapeutic approaches, time and resource restrictions, poor intervention promotion, or disparity between disciplinary models of mental illness; further research is required to establish the precise reasons.…”

“…Similar barriers have been, and continue to be, reported in inpatient psychiatric services (Berry, Haddock, Kellett, Awenat, et al ., ; Berry, Haddock, Kellett, Roberts, et al ., ; Clarke & Wilson, ; McCann & Bowers, ). As key aims of nurse‐led group therapies are to increase access to psychological therapies and to improve therapeutic milieu, through increased psychological knowledge and skills within different staff groups, this has important implications for the reach of the intervention to both service users and staff.…”

A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol

“…These work streams will probe psychological mechanisms; barriers and facilitators to providing the CARMS trial intervention in the 'realworld'; implementation challenges and solutions; aspects of the therapy which were perceived as being both positive and negative; and the experiences of taking part in suicide research. It has been shown that qualitative work can often contextualise aspects of the design of trials which can remain hidden wherein aspects of interventions may, otherwise, be somewhat tacit [43,[121][122][123][124][125][126].…”

Using team formulation in mental health practice

“…Summers ( 2006) noted that staff believed formulation sessions improved relationships and care planning, although these findings were only taken from the team perspective. Berry et al (2017) interviewed clinicians and patients involved in a ward-based intervention, which included team formulation sessions. In this study, staff and patients said formulation improved staff understanding of patients, with patients noticing more encouragement and less criticism from staff, and observing that staff seemed increasingly open.…”