Background
There is a growing impetus to increase access to psychologically-informed interventions in inpatient psychiatric settings. The Care Quality Commission [
1] revealed that half of inpatients surveyed wanted access to psychological therapy. A report by the Commission on Acute Adult Psychiatric Care stated that UK inpatients and carers desire a wider range of therapies to be made available to inpatients, including psychological therapies [
2]. The report emphasised the need for acute mental health services to “deliver a full range of evidence-based biopsychosocial and physical interventions which focus on the patient’s recovery” (p.57). Despite these recommendations, nursing staff spend a disproportionately small amount of time conducting psychological interventions than social, physical or pharmacological ones [
3]. Whilst inpatient staff teams are characterised by multidisciplinary work, nursing staff are involved in the social milieu of the ward to a different extent to other health professionals [
4], and frequently encounter inpatients’ intense distress. Although nursing staff spend an average of 50% of time in contact with inpatients, just 4–20% of this involves working therapeutically [
5].
The inpatient psychiatric ward is a particularly difficult environment in which to deliver psychological interventions. Firstly, individuals meeting the threshold for admission to inpatient care are characterised by acute mental health crises, which may manifest in extreme emotional distress, impulsive self-damaging behaviour or aggression towards others, severe psychotic symptoms, and impairments in concentration and attention [
2,
6‐
8]. These presentations may make it difficult for psychiatric inpatients to engage with traditional psychotherapy [
9]. Secondly, the length of inpatient stay in the UK is often brief. The Health and Social Care Information Centre state that the median length of stay for people discharged from inpatient mental health services in 2013–2014 was just 23 days [
10]. This limits the time available to build a therapeutic relationship, formulate an adequate understanding of the inpatient’s psychological difficulties, and conduct therapy sessions [
9,
11]. Thirdly, high levels of demand for acute services mean that staff are under pressure to release beds and tackle administrative duties whilst handling inpatient crises involving high levels of risk [
2,
12‐
14]. In the context of staff shortages [
15], this contributes to excessive emotional exhaustion and work-related ‘burnout’ [
16,
17]. Staff may often feel that they lack the time, or emotional energy, to deliver psychological interventions.
Aarons and Sawitzky [
18] propose that the uptake of evidence-based interventions in mental health settings depends on the setting’s organisational climate and culture. The factors discussed above contribute to the complex organisational structure of inpatient psychiatric hospitals. An inpatient population characterised by acute psychological distress, short and highly variable hospital stays, and pressurised services mean that these environments are dominated by risk-oriented practice. Aarons and Sawitzky [
18] describe defensive organisational cultures as those that: “encourage or implicitly require interaction with others in ways that are self-protective and will not threaten perceived personal security” (p.62). Successful risk management is vital in inpatient psychiatric care, and yet emphasis on this may pose a significant challenge to encouraging staff to implement psychological interventions [
19], by contributing to a defensive organisational culture that is “resistant to change” [
4,
20].
High levels of emotional distress, coupled with difficulties in self-regulating, are a common experience amongst psychiatric inpatients, irrespective of their clinical diagnoses [
7]. The authors therefore developed a psychosocial intervention that could empower inpatients to understand their emotional distress and to develop coping strategies. The content and modes of delivery utilised were intended to bypass the challenges discussed in implementing psychological interventions in inpatient settings. Inspired by Clarke and Wilson’s work on this topic [
9], the authors drew on ideas from Dialectical Behaviour Therapy (DBT) [
21], and Cognitive Behavioural Therapy (CBT) [
22] to inform the intervention content. DBT asserts that emotional distress is maintained by invalidation of one’s emotions by oneself and the social environment, and the lack of necessary skills to self-regulate [
23]. CBT suggests that emotional distress is maintained by cognitive distortions or ‘thinking errors’ [
22]. Previous studies have demonstrated the benefits of using both DBT and CBT in inpatient settings. However, such studies have typically involved specialist residential units, diagnosis-specific groups, intensive formats such as daily group sessions, or time periods that exceed the typically short length of stay in an acute psychiatric ward [
10,
24‐
27]. The authors wished to harness these therapeutic techniques to create a more flexible and generalisable intervention for typical inpatient care settings.
The developed intervention is a workbook that contains two sections. Part One aims to help inpatients develop a better understanding of their emotions. Firstly, inpatients are asked to focus on a recent episode of emotional distress. They are encouraged to try to use ‘emotion words’ to label their feelings, and they identify the events and thoughts that preceded an increase in emotional distress, the bodily manifestations of the emotion (e.g. sweating, heavy chest, heart racing) and any behavioural urges precipitated by the emotions. Part Two of the workbook aims to teach inpatients about coping strategies for regulating their emotions, such as challenging their thoughts and interpretations of a distressing situation or using a variety of distraction techniques.
The authors sought to develop intervention content and modes of delivery that could overcome some of the challenges to implementing psychological interventions in inpatient settings, by:
1)
Presenting information that is applicable across a wide range of clinical diagnoses. This was addressed by focusing on the trans-diagnostically relevant concept of learning to understand and cope with emotional distress.
2)
Using a workbook format that could be applied by nursing staff in their everyday interactions with inpatients, in order to create an intervention that nurses could deliver without increasing their workload. Nursing staff could use the workbook during daily scheduled one-to-one time with their allocated caseload of inpatients. The workbook was designed to be self-explanatory, requiring minimal staff training.
3)
Communicating information using simple messages illustrated with pictures, to ensure accessibility for acutely distressed inpatients with impairments in attention and memory.
4)
Facilitating inpatients to apply the information to their individual situations as often as needed and to develop a therapeutic rapport with the nurse delivering the workbook. The workbook was designed to be delivered in a one-to-one format by an inpatient’s allocated staff nurse rather than during group sessions.
5)
Teaching coping strategies that are applicable and workable in the restricted environment of an inpatient psychiatric unit.
Following preliminary development of the intervention, the authors aimed to conduct a qualitative focus group investigation of the views of nursing staff and allied mental health professionals on the potential benefits, negative effects, feasibility and barriers to using it. This is in line with Medical Research Council [
28], British Medical Journal [
29] and National Institute of Clinical Excellence [
30] guidance on the development of complex interventions, which state that early-stage development should use qualitative methodology to explore the views of workers intended to implement an intervention about its workability and barriers [
28]. By contrast, it has been argued that top-down approaches to introducing new interventions into health services that do not incorporate the views of frontline staff contribute to unsuccessful intervention implementation [
19]. It is also in line with the tenets of Normalisation Process Theory [
31] - a theory that delineates factors that promote and inhibit the routine incorporation of complex interventions into everyday practice. In evaluating whether an intervention can feasibly be incorporated into routine practice, NPT asks whether the intervention is coherent (can clinicians differentiate it from their normal clinical practice; is it believed it will be valuable; and will it fit with the values of the investigation). It also asks what cognitive participation will be like (will participants engage and commit to the intervention). Furthermore, NPT considers what the collective effect of the intervention will be (will it help or impede existing working practice; is extensive training required) [
32]. NPT emphasises the importance of considering the context of where the intervention will be deployed during the process of development, and to examine staff’s current and foreseeable concerns to assess whether the proposed intervention will fit [
32].
The present investigation aimed to assess whether, in the views of inpatient psychiatric staff, the workbook intervention could be a valid method of addressing inpatients’ emotional distress, and whether they believe its implementation to be feasible in inpatient psychiatric settings, by addressing the following research questions:
1)
What is the opinion of inpatient psychiatric staff about any potential benefits or negative consequences of using the workbook with inpatients?
2)
To what extent does the workbook fit in with already existing methods used by staff to manage inpatients’ emotions?
3)
What barriers do staff envisage in using the workbook, and in what ways could it be improved?
Discussion
Main findings
The present study aimed to explore opinions of inpatient psychiatric nursing staff regarding the validity, feasibility and acceptability of a workbook designed to help inpatients understand and cope with emotional distress. Staff felt the workbook was a valuable resource that could increase their confidence in addressing inpatients’ emotional distress and help them to structure their conversations around this topic. They suggested the validity of the workbook could be improved by ensuring it the content was relevant across all diagnostic presentations, and that this would help with implementation. They emphasised the value of creating a resource that could be flexibly used in different formats. Furthermore, they discussed the necessity of thinking carefully about the right time to introduce the workbook, depending on the individual inpatient’s hour-by-hour fluctuations in emotional distress, and what stage they are at within their overall recovery journey.
Implications for implementing psychological interventions in inpatient psychiatric settings
Staff emphasised the importance of introducing the workbook at times when inpatients were feeling calmer, rather than in moments of acute distress. Similarly, they felt that using the workbook with inpatients at an acute stage of presentation would be ineffective, as they would not be able to understand or concentrate on the material. They suggested it would be more helpful for inpatients who were further along in their journey towards recovery. This has wider implications for the timing and nature of psychological interventions on inpatient wards, suggesting that interventions are more likely to be effective and incorporated into practice when staff are able to adjust the timing of their delivery in the context of each inpatient’s fluctuations in distress and overall stage of recovery. This could be more effective for individual inpatients than, for example, a rigid schedule of weekly sessions that does not adapt to the individual inpatient’s needs. Nursing staff, who are with inpatients at all times and observe changes in their mental state on a day-to-day basis, may be best placed to implement such a flexibly timed intervention [
19].
Staff also suggested that additional work was needed to validate the workbook content to ensure it was relevant for inpatients with psychotic presentations. In particular, the sections on helping inpatients to recognise and challenge the patterns of thoughts contributing to their emotional distress could be adapted to draw on ideas from CBT for psychosis [
41]. This might help to increase the focus on validating inpatients’ feelings in response to ‘delusional’ thoughts, whilst enabling them to consider the evidence for their thoughts. The lack of emphasis on psychotic presentations in the initial version of the workbook may reflect the difficulty of attempting to create a cross-diagnostic resource whilst drawing ideas from diagnostic-specific therapeutic models such as DBT. This therapy was primarily developed for individuals who were chronically self-harming, and those meeting criteria for emotionally unstable personality difficulties [
21].
The stressful working environment of inpatient wards and the dominant emphasis on risk management and medical models of mental illness were also described as key barriers to implementing the workbook. It is well established that the inpatient psychiatric hospital is a stressful working environment [
12,
16]. As reported elsewhere, staff in the present study explained that difficulties with understaffing and an often-chaotic ward environment could limit opportunities for therapeutic work [
2,
12,
13,
19]. Participants worried that the workbook could be perceived as an extra burden amongst the large amounts of administration staff are required to complete. Applying NPT, this worry might lead to low cognitive participation with the intervention, which could result in low collective action (an unwillingness to invest time or energy in implementation) [
32]. To counter this, staff stressed that being able to break the workbook down into smaller sections could make it easier for both staff and inpatients to manage. This suggests that allowing staff to flexibly apply the parts of interventions they feel are most appropriate for each inpatient could increase the utility of those interventions. Indeed, in their analysis of staff fidelity of different behavioural interventions, McConnachie and Carr [
42] suggest that ‘user friendliness’ of treatment protocols might be critical for successful treatment implementation. Furthermore, when new psychological interventions are introduced it is vital to acknowledge the stressful working climate. The intervention should be emphasised as a tool that could help staff by making what they already do with inpatients easier [
19], such as providing additional structure to one-to-one time already spent with inpatients and generating useful information to incorporate into care plans. Participants also commented on the workbook’s potential to help them understand their inpatients and assist in developing strategies to handle and avert future crises. Focusing on the ways in which the intervention is coherent with the needs and concerns of staff might help to foster cognitive participation and collective action regarding use of the intervention [
32]. Indeed, the ‘fit’ of new interventions with the existing environment, skills, and capacity of those enforcing it has been identified as key for successful implementation [
43].
Some participants felt that the dominant emphasis on risk management and medical models of mental illness within inpatient wards, in addition to inpatients’ reluctance to directly address their emotional difficulties, could often lead to emotional issues being neglected. Linked to this, it has been argued that an emphasis on medicalisation of psychiatric diagnosis can lead to pathologising human distress without understanding its context, neglecting to address the interpersonal trauma and social disadvantages that in many cases contribute to psychological distress [
44]. Related to this culture of emotional neglect, inpatients were reported to frequently be unwilling or unable to talk about their emotions and to instead focus on resolution of their distress by practical means such as cigarettes and medication. Participants reported the central use of medical and physical management approaches by staff, adding to literature suggesting that a medical framework still dominates inpatient psychiatric practice [
9,
45] whilst psychosocial therapeutic strategies remain underused [
3,
5,
46]. Participants worried that staff might feel under-confident and inexperienced in discussing emotional issues with inpatients. This suggests that training for staff in implementing psychological interventions should emphasise the importance and relevance of psychological approaches to emotional distress, and how these approaches might benefit their work. In the context of the workbook, we would hope to reiterate the coherence of the intervention with staff’s needs. Specifically, we would aim to elucidate the ways in which therapeutic engagement with emotional distress might help to reduce incidents with inpatients resulting in crises, and over time help work towards recovery. In turn, this might help to encourage cognitive participation and collective action in staff implementing the intervention [
32]. Indeed, a recent RCT reported that staff training in evidence-based therapeutic activities significantly improved perceptions of and satisfaction with inpatient mental health care in legally detained inpatients [
47]. Highlighting the relevance of new interventions may lead to a greater perceived sense of competency in staff [
48].
Focus group participants also highlighted accessibility and visibility as key to maintaining the workbook’s use, and suggested putting copies in communal spaces, care plans, welcome packs and on notice boards. This would increase staff and inpatients’ opportunity to engage with the workbook’s content and help to embed its use in the culture of the ward. Its visibility could also act as a prompt to remind staff of the things learnt in training. This suggests that the flexibility and physical accessibility of a workbook format could be particularly helpful in enabling a psychological intervention to become routinely incorporated into the everyday practice of an inpatient ward. Adaptability of interventions has been identified as a key part of a consolidated framework for fostering implementation of health services research findings into practice [
49], whilst accessibility and visibility may mediate the link between intending to implement an intervention and actually implementing it [
50].
Strengths and limitations
A strength of the study was the sampling of nursing staff of varying levels of seniority, including unqualified nursing staff, qualified nurses and ward managers, as well as occupational therapists and clinical psychologists. This ensured that the voices of the nursing staff, who would be primarily involved in delivering such an intervention, were prioritised, whilst the multidisciplinary nature of work in inpatient psychiatric wards was acknowledged. This enabled representation of a breadth of perspectives and experiences of working on the wards. The separation of staff in more senior and less senior positions into different focus groups also helped to minimise the impact of hierarchy on the discussions. An additional strength is that much of the feedback from the present investigation might be applicable to other interventions aimed at emotion regulation. We hope that these findings are contemplated during the development of such interventions.
A limitation is that the present investigation was restricted to two NHS hospitals. The findings are not necessarily generalisable to other hospitals around or outside of the UK, which may differ in terms of service structure, access to and distribution of resources, and staff and inpatient demographics. Additionally, it is unclear whether the way staff anticipate use of the workbook on wards, as described in this investigation, will reflect the real outcome. Furthermore, this study did not include the feedback of another crucial stakeholder group, the inpatients themselves. Finally, the study authors consisted of academic and clinical psychologists not currently employed on inpatient wards – this reinforces the vital importance of consulting inpatient psychiatric staff, as we have done, and ultimately service-users, when designing such a resource.
Implications for further research
The next stage of workbook development will be to incorporate the feedback from this investigation into an updated version of the Emotional Coping Skills workbook. Following this, it will be essential to gain feedback from inpatients and use this to modify the workbook further. If this suggests that the workbook is likely to be feasible and acceptable, it would be useful to pilot it on an inpatient ward to determine whether this remains true in practice, and to generate preliminary evidence on its effectiveness.