Introduction
Low secure units form part of a comprehensive mental health service. The reduction in the overall bed numbers and higher thresholds for admission have resulted in a larger proportion of people with high morbidity levels, complex problems and challenging behaviour compulsorily detained on mental health wards (Lelliott & Wing Reference Lelliott and Quirk1994).
The issue of life on psychiatric wards has been has been described by authors over the years from the 1960s (Goffman, Reference Goffman1961; Rosenhan, Reference Rosenhan1973) and more recently by Lelliott and Quirk (Reference Lelliott and Quirk2004). Therapeutic activity on mental health wards involves medication, weekly ward rounds, individual sessions with junior doctors, nurses and psychologists, occupational therapy sessions and weekly or daily ward meetings attended by staff and patients. The ward, or so-called, ‘community’ meetings provide a platform for interaction between staff and patients in a fairly informal, semi-structured atmosphere. The term ‘community meeting’ is used because the ethos is loosely based on the Therapeutic Community meeting model. In this model, the users plan and organise the meetings (De Leon, Reference De Leon2000). A number of user satisfaction questionnaires have been developed. MacInnes and Beer (in press) designed one specifically for users in forensic and secure settings which addresses all areas of care in a systematic fashion. The current study looks particularly at one aspect of ward life.
BACKGROUND
The ward in question is a low secure challenging behaviour unit for ten men and five women who exhibit severe challenging behaviour in the context of mental illness of longer than six months duration, which is not easily treatable and cannot be managed on an open ward. The mean HoNOS (Health of the Nation Outcome Scores) scores of 86 patients presented in an article reporting on outcomes in the same unit was 15.38 (Beer et al., Reference Beer, Tighe, Ratnajothy and Masterson2007); this illustrates the high morbidity on the unit. The mean duration of stay of patients on the unit was 399 days, with a majority of patients admitted to the unit under section 3 of the Mental Health Act (1983) because of aggression. Given the high levels of morbidity and relatively long durations spent on the ward, we asked users about ways of improving their involvement with affairs on the unit. One area where there was active participation was the twice-weekly community meeting, where one user always chairs the meeting and another takes minutes.
METHOD
LS and SD asked users for their opinions of ward life at the twice weekly ward community meetings, as we believed that this was a forum where they could express their concerns, as well as put forward their ideas and requests to the staff and get problems and issues resolved. We asked for volunteers to help with the survey as we hoped that by getting users to conduct the interviews, more candid responses would be obtained. LS and SD thus designed a semi-structured questionnaire that was administered by SD to all users on the unit over a four-week period. LS and SD then reviewed the minutes of 14 ward meetings held over three months on the unit to identify issues raised and check to see what proportion of the issues were successfully dealt with.
It was not considered necessary to submit the study to the Local Research Ethics Committee because it was seen as part of ongoing anonymised service evaluation and it had been approved by the local governance committee.
Users were asked to complete a questionnaire, which had a mixture of closed and open questions in order to maximise participation:
User questionnaire:
Do you think the issues you bring up are dealt with quickly?
Do you think the meetings are organised properly?
Do you take the community meetings seriously?
Would you like to see the ward manager present?
Do you think you should have a particular choice on who should chair the meetings? (e.g. a ward vote?)
Do you think the community meetings need changes?
When residents or staff bring up issues at a community meeting do you ever hear of the outcome?
Do you feel safe speaking up at meetings?
Do you attend the meetings regularly?
Do you get what you want out of the community meetings? (Please add any comments)
What do you get out of the meetings?
What do you want out of the community meetings?
What changes would you like to make to the meeting?
If you had to make a comment about the meetings what would it be?
How do you see the way things are dealt with in 6 months time?
Do you want issues dealt with on the same day?
If at some of the meetings issues aren't clarified that day, are you unsure that the issue will be dealt with at all?•If Yes, why?
How involved do you get with the issues you bring up?
Does it make you happy when issues are dealt with in a reasonable amount of time?
Some issues don't involve buying items for the ward. If an issue concerns you other than this, do you speak up?•If yes, do you think it is addressed to suit you?
If you could make sure issues at the meetings are dealt with in a reasonable amount of time, how would you pursue it?
RESULTS
60% of residents agreed to participate in the survey, and all the respondents completed the survey.
Almost all respondents attended the meeting regularly; they thought changes were needed to improve the meeting and wanted the ward manager to be present at the meetings. They were unanimous in wanting the issues they raised to be dealt with on the same day.
Two thirds of our respondents took the meeting seriously. Only half the respondents felt safe to speak out at the meetings and thought they were properly organised.
Further, only one fifth felt issues they brought up were dealt with quickly and they got what they wanted out of the meetings.
Review of the ward meeting minutes
The review revealed that 27 separate issues were raised over 14 meetings, ranging from lights not working, to payment for ward based chores, and would the consultant be able to attend the next meeting. 21 of these issues were dealt with over a time span of 0 to 72 days. Thus 78% of issues had been resolved overall.
These are a selection of comments which reflect issues of concern to the users, and in some cases, their mental state.
Q2. Do you think the meetings are organised properly?
“People are always late especially the doctors!!”
“Everyone (is) given a chance to speak. Patient takes minutes. The Consultant usually attends.”
“Not many people attend.”
Q10. Do you get what you want out of the community meetings?
“When I brought up how I was mistreated at (another hospital), as usual I was told I was paranoid.”
“I would like access to the computer room – this was arranged.”
Q12. What do you want out of the community meetings?
“Freedom”
“Requests to be dealt with.”
“A chance to speak up.”
Q13. What changes would you like to make to the meeting?
“To see the Consultant more”
“Chair person stand up.”
Q14. If you had to make a comment about the meetings what would it be?
“Take time and listen.”
“People don't take it seriously enough.”
“The idea is good.”
Q21. If you could make sure issues at the meetings are dealt with in a reasonable amount of time, how would you pursue it?
“Make sure ward manager keeps weekly data.”
“Through the mental health act commission and writing to MPs, advocacy, solicitors.”
“By speaking to the doctors one by one.”
DISCUSSION
The 1980s and 1990s have seen increasing user involvement in service provision and decision making (Campbell, Reference Campbell2005). There is increasing user lead research, as evidenced by the Service User Research England (SURE) at the Institute of Psychiatry.
We attempted to let a user led survey become a means of increasing users’ involvement in their care, especially in a group with high morbidity and a perceived sense of helplessness. All our respondents used the forum to raise issues and concerns about their welfare and comfort on the unit and wanted senior members of the treating team present, so issues could be dealt with quickly. They used the forum to find out about a variety of factors affecting them: jobs on the unit, Occupational Therapy schedules for the week ahead, inter-unit sports events and to report problems like plumbing faults, kitchen timings, etc. The meeting served as an important part of community life on the unit and was seen by some as a favourable, ‘safe’ time for interaction with staff, as compared to other interactions like ward rounds, where contentious issues like medication and leave were discussed. Having a user as the chairperson and another to take minutes ensured that users identified the process as belonging to them. However, only half the respondents reported feeling confident and secure enough to bring up issues at the meeting – a possible reflection of users viewing life on wards being both boring and unsafe as reported by Quirk and Lelliott (Reference Quirk and Lelliott2001).
The results of the survey were fed back to the residents at the community meeting where they were received with some surprise and general agreement. They were also presented at the Trust Clinical Audit meeting, where the findings were well received.
SD found the experience invaluable, and was planning to put it on his CV to help him find a job on discharge from the unit. He agreed to co-present the findings at the Trust Clinical Audit meeting, but found it too anxiety provoking and said he would prefer not to take part at the last minute.
CONCLUSION
Similar evaluative studies should be attempted on other units including acute short stay wards as a means of improving service user experience on the ward and empowering users. Quirk and Lelliott (2004) described numerous ethical and practical problems with participant observer studies conducted on inpatients and Bryant et al. (2001) recommend service user engagement to make meaningful changes to service provision. We suggest that involving users to map their own experiences serves as a way forward to improve the quality of care on psychiatric wards.
DECLARATION OF INTEREST
MDB is a consultant on the Challenging Behaviour Unit in the study. LS was a clinician and SD an inpatient service user on the same unit.
