Acute in-patient psychiatry: service improvement the time is now {

Psychiatric in-patient care is perhaps the component of mental health services that service users are most critical about. This, coupled with a growing awareness of the close association between quality and safety in this setting, has led to a recent flurry of national initiatives. These can be


Problems for acute mental health in-patient units and their causes
Three recent reports have contributed considerably to our understanding of the difficulties faced by staff and patients. In September 2004, Mind published its Ward Watch report that described the experiences of 335 people, who were current or recent users of in-patient mental health services, in relation to the environment, safety and the provision of activities (Mind, 2004). In May 2005, the Healthcare Commission released the National Audit of Violence which it had commissioned the Royal College of Psychiatrists' Research and Training Unit to undertake (Healthcare Commission, 2005). There were 265 English and Welsh mental health and learning disability wards that took part in this programme of work, representing about half of the eligible trusts. The programme was designed to gather information in a systematic way about the extent to which wards adhered to best practice in maximising safety and minimising risk to prevent and manage violence. Data were gathered from the whole constituency (i.e. staff, service users and visitors). The information collected included more than 6500 anonymous questionnaire returns, with over 20 000 lines of free-text comments. In the same week, the findings from the National Survey of Adult Psychiatric Wards by the National Institute for Mental Health in England (NIMHE) were released. The survey gathered data from 303 wards (a response rate of over 60%) relating to various detailed aspects of staffing, environment and local policy and practice (Garcia et al, 2005). The issues that were highlighted by these reports are summarised below; most were identified by more than one report.

Unsafe environments
The Healthcare Commission's National Audit of Violence reported that the design of many wards failed to meet basic safety standards (Healthcare Commission, 2005). There were particular problems with poor visibility associated with obstructed sight-lines. Many wards also had inadequate alarm systems. This finding was consistent with NIMHE's survey where over one-third of ward managers described significant reported, but unresolved, environmental risks. In relation to the impact of environmental risk: in the Healthcare Commission's audit, 36% of service users and 78% of nursing staff said that they had experienced violence on the ward that was being studied; Mind's study (Mind, 2004) reported that 27% of respondents rarely felt safe while in hospital, and over 50% had experienced verbal and physical threat during their stay.

Inadequate staffing
The NIMHE survey found that in England 13% of posts for qualified staff were unfilled (in London this figure was 22%). In addition, a national sickness figure of 6.8% was reported. Many participants of the national audit stated that there was an ongoing drain of experienced staff into higher paid, and often more highly regarded, posts in community services. The NIMHE survey confirmed this, revealing that 26% of participating wards had lost staff to community teams in the previous year. The national audit highlighted two particular adverse consequences of the loss of staff. First, that many in-patient services were left reliant upon inexperienced leaders: this was confirmed by NIMHE's survey, which showed that 13% of acute wards lacked a manager or nurse above an F grade at the time of the survey. Second, wards were overreliant on the expensive and less-than-ideal option of using bank and agency staff: at the time of NIMHE's survey, the national average usage of bank and agency staff was 152 h per week (equivalent to 4 whole-time staff on each ward).

Client mix and overcrowding
The national audit reported that many acute mental health services were 'fire-fighting' as they struggled to work with an increasingly unwell population; there was also evidence of inappropriate use of beds. The NIMHE survey found that 4.2% of acute beds were being used solely for the purposes of detoxification. Respondents in the Healthcare Commission's audit made an explicit link between the high prevalence of substance misuse among in-patients and violence; 74% of nurses from acute wards thought that alcohol caused trouble on the ward, and 81% thought that this was true for illegal drugs.

High levels of boredom
The national audit revealed that many wards were unable to offer service users a structured and therapeutic regimen of care: 35% of service users reported dissatisfaction with the choice of activities available during the day; this figure increased to 48% during the evening and 52% at weekends. The NIMHE survey found that little more than one-third of wards were able to offer psychosocial interventions, despite the evidence base to support their use; cognitive-behavioural therapy was available on fewer than 20% of wards. As well as the obvious link between 'boredom' and 'violence', this was seen to have an impact on recovery rates for service users. More than 50% of respondents in Mind's study thought that their hospital surroundings had not helped their recovery; 31% stated that it had made their health worse.

Staff training in the prevention and management of violence
The Healthcare Commission's audit revealed that significant numbers of staff were dissatisfied with the timing, content, or quality of the training they received: 39% of nurses reported not having received relevant training before working on the ward, and about 25% stated that the training that they had received at any time did not equip them to either prevent or manage a violent incident effectively.

National and local responses to the problems for acute wards
The accumulating body of evidence about the challenges facing acute wards has triggered an unprecedented level of activity to support and accelerate improvement. In Scotland, the Mental Health Director has asked the Scottish Division of the Royal College of Psychiatrists to convene a group to make recommendations about the way forward for acute in-patient services. In 2003, the All Wales Senior Nurse Group made representations about its concerns about psychiatric wards to the Welsh Assembly, via the Chief Nursing Officer.
In England, Anna Walker, Chief Executive of the Healthcare Commission, responded to the report of the audit by saying: 'This audit gives us hard evidence on an area of growing concern. It suggests that while community services have been really important, more attention must be given to in-patients. Nobody must take their eye off this ball . . .We will build on the findings of this report by refining the way we assess the performance of mental health units.There is plenty of good work going on.We've got to ensure best practice becomes standard practice.' The Healthcare Commission has since articulated this commitment in two ways: first, the 2006/2007 improvement review for mental health is focusing on acute services with an emphasis on the ward; second, a further phase of the National Audit of Violence has been funded for 2006/2007. The Healthcare Commission anticipates that the audit will involve all English and Welsh providers of mental health in-patient services, both in the National Health Service (NHS) and independent sector. The audit will include admission wards for older people, as well as acute wards for adults of working age.
The NIMHE has been leading a broad range of national, regional and locally targeted interventions. At a national level, a cross-government management of violence project was set up to take forward specific targeted pieces of work, including the establishment of a system for accrediting and regulating training in the prevention and management of violence, and the revision of the Department of Health estates guidance relating to ward design; a project board and subgroups were established to take forward various strands of work, including the development of a handbook of standards to support the Healthcare Commission's forthcoming round of acute services improvement reviews. Regionally, practice development networks and/or collaboratives were set up for acute and psychiatric intensive care units. Locally, every provider trust was asked to establish an 'acute care forum' with guidance and direction coming from a lead at the NIMHE Regional Development Centre.
The Chief Nursing Officer's Review of Mental Health Nursing was published in April 2006. Its recommendations aim to improve care and treatment in acute settings through innovations such as increasing the amount of time nurses spend in direct care contact, through schemes such as protected time initiatives, reviewing career pathways for in-patient staff and developing the leadership skills of ward managers. Linked to this, NIMHE will be leading on two initiatives: issuing guidance on the management of substance misuse on in-patient wards; and developing guidance on different approaches and innovative practice for skill mix and staffing levels in acute care which take account of new roles and ways of working.
The NHS Counter Fraud and Security Management Service is taking forward a number of initiatives aimed at tackling violence towards staff: a national physical assault reporting system; conflict resolution training for all frontline staff; a legal protection unit offering advice and support in respect of taking action against those who assault staff; and the requirement for each health body to nominate an executive director at board level charged with taking responsibility for security management, and a local security management specialist to undertake work at a local level.
The National Patient Safety Agency (NPSA) is leading a project to improve the safety of mental health service users by creating a safer environment on acute psychiatric wards (Marshall et al, 2004). The issue was identified as a priority for action when a breakdown of data from the pilot phase of the NPSA's national reporting and learning system showed a high number of mental health patient safety incidents related to in-patient wards.
The professional bodies have also been active in this area. In particular, the Royal College of Psychiatrists, in partnership with the British Psychological Society, the College of Occupational Therapists and the Royal College of Nursing have established an accreditation system for acute psychiatric wards (Lelliott et al, 2006).
All of these initiatives, however, will only be successful if trusts are able to embrace them at ward level. A recent follow-up study by the Healthcare Commission of the wards that completed the audit of violence offers considerable hope that this will happen (Healthcare Commission, 2006). Between September and December 2005, action plans and progress reports were called for from all the trusts that took part in the audit. A sample of 14 trusts were then visited or spoken to about the improvements that they had been able to bring about following on from the audit and its findings. The study indicated that the audit was perceived to be a success by staff working on the participating wards, in clinical leadership roles, and in clinical governance departments. For some, their successes were relatively simple, for example, moving public telephones to more private areas, the introduction of routine incident debriefing, and increasing service user involvement in ward decisionmaking. Others had engaged in complex, time-consuming and sometimes costly ventures such as relocating smoking facilities, installing electronically controlled blinds to assist temperature control, working with local police to minimise substance misuse or purchasing new alarm systems. Based upon a large number of interviews with staff of all grades and professional background and services users, the follow-up survey concluded that in all situations where the therapeutic environment was improved, levels of aggression had diminished. A number of key factors were highlighted: 'Staff were seen to grow in confidence within their interactions with patients and were willing to try new approaches if backed up by evidence. Junior staff particularly felt senior management and the boards were willing to listen . . . Patients felt their opinions counted especially when their views were used in planning activities and in debriefing sessions . . . Some [patients] now felt that staff dealt with issues in a more caring, confident and containing manner.' (Healthcare Commission, 2006)

Discussion
In conclusion, in-patient services are poised to make substantial improvements. The level of 'top-down' and 'bottom-up' support is unparalleled. Much is known about the factors that cause violence and potential solutions, and, although the combination of factors operating within any one service setting are highly individualised, the audit will offer participating units an insight into particular factors that are either increasing the likelihood that violence will happen, or mean that it will not be managed effectively if it does. Anecdotal information gathered through the audit suggests that psychiatrists in in-patient services have a central role to play in driving forward service improvements.