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What good acute inpatient care should look like and how to achieve this
The Sainsbury Centre Report 2006 and also the HUG reports of 2001 and 2003 offered context, background and proposals to draw from. Several aspects of good acute inpatient care are highlighted in particular, including:
a. Ward culture - A range of elements apply; in particular, what a ward "feels like" is as important as what it looks like. (Both are relevant).
The culture of a ward is set by the people who work there and the values to which they aspire. "Good ward culture" is shorthand for positive and supportive relationships between staff, service users, relatives and carers.
A clear vision shared by all of how to help service users towards recovery is essential.
Of significant importance is that service users are, and feel, valued. Service users should be encouraged to participate as fully as they can in their care and treatment. Staff and service users being treated with respect sets a positive tone of being valued.
Important aspects of ward culture will capture:
- User centred service;
- Focus on recovery;
- Focus on social inclusion;
- Equality, diversity, cultural and spiritual awareness; and
- Promotion of the principles of the Mental Health(Care and Treatment) (Scotland) Act (2003) including sections 25 and 26.
b. Physical environment - A ward should look welcoming and homely but not be a home. It should provide sanctuary and safety.
Important aspects of the physical environment will capture:
- Cleanliness and hygiene;
- A single sex environment;
- Maximum space standards with access to quiet areas;
- Healthy food and access to drinking water;
- Facilities for sleep;
- Toilet/Shower/bath room facilities;
- Access to exercise facilities (both in and outwith the hospital where feasible);
- Well maintained furnishing and décor; and
- Rooms for consultations and private meetings.
c. Activities within the ward
It is important that a range of activities are available to all patients, outwith normal working hours and at weekends. Different therapeutic activities should be considered (physical, fun, artistic and creative). To encourage participation, service users should be involved in discussions about the kind of activities they would like to see in a ward.
d. Information
Service users and carers should have access to good quality, understandable information in a number of areas including:
- Participation in the development of their care plan;
- Who their consultant is, accessibility to care plan and role of key worker;
- Their illness and treatments, medication and psychological treatments;
- The admission and discharge process including ward activities; and
- Other (non NHS) services of relevance to them e.g. advocacy, housing benefits etc.
e. Access to staff (including access to psychological therapies)
Access to staff by patients is of singular importance in any care environment and in any positive relationship between staff and patient. Patients need regular access to key workers and to know they are being listened to.
Delivering this important aspect will capture and include consideration of:
- Administrative support to relieve nursing staff of certain administration tasks. (The value of this is already proven through posts established in medical, surgical and obstetric wards);
- Use of trained volunteers to befriend patients, (this is complementary to existing staff and does not replace therapeutic contact);
- Complementary therapies;
- Access to multi-disciplinary staff including paid peer support workers; pharmacists, dieticians, voluntary sector staff, physiotherapists and psychologists (in addition to doctors and nurses); and
- Links with implementation of the Mental Health Nursing Review in relation to acute care.
Engaging more clinical psychologists and occupational therapists to work in an inpatient setting is an important consideration. However psychological therapies can be (and already are) delivered by staff other than clinical psychologists.
There are now a large number of nurses and psychiatrists who are trained in psychological interventions. Consideration should be made of how best to use this valued skilled resource to better effect, perhaps through protected time. There are links to be made to the work being taken forward by NHS Education Scotland in relation to training in talking and psychological therapies.
f. Training Issues
All staff should have access to ongoing appropriate training. Both the National Review of Mental Health Nursing in Scotland and other key documents highlight the importance of ongoing appropriate training for staff. Monitoring mechanisms for uptake should be in place.
g. Risk management and safety
Good risk assessment and risk management procedures need to be in place. A balance must be struck between the reduction of risk and the provision of a therapeutic inpatient environment, and in line with the principles of the new Mental Health Act with the least restriction being placed on service users. No ward or service can be entirely risk free and the involvement of service users and carers is essential in developing a service that strikes the right balance.
Good risk assessment practices help staff and service users alike. Individual care plans provide a basis for the appropriate management of risk.
The physical environment, operational processes and available resources of any inpatient service should be appropriate for the provision of the assessed care of individual service users, including the management of risk.
There should be a clear local understanding of the degree of risk that can be safely managed in any particular acute inpatient service. Again the link should be made to the work NHSQIS are taking forward around admission and discharge.
h. Process issues
A number of process issues are of importance in the provision of good care. These include:
- Systematic collection and analysis of clinically relevant data;
- Good, collaborative and accessible multi-disciplinary case records;
- Clear policies on referral, admission and discharge;
- Good discharge planning, commencing immediately on admission; and
- The need for protocols on how and when clinical information on service users should be shared between staff.
i. Provision of integrated services
Excellent and effective acute care is best provided within a locally integrated mental health service. Services which operate as silos can lead to the detriment of service user/carer experience and outcomes.
Solutions to the challenges faced by acute services rest in whole system approaches. This can involve significant change in the organisation of acute care including, where needed, a realignment of community services towards a common purpose, that matches services to fit people's needs ( Bowles, N, 2005).
Best practice suggests the ongoing involvement of community services on and following admission. Again there are links to be made with the NHSQIS work around standards for admission and discharge.
j. Policies on challenging issues
Care in safety is a clear objective for all. All services should have protocols under regular review which accord with the guidelines set out in NHSHDL (2002) 41 on Managing Incidental Drug Misuse and Alcohol Problems in Care Settings. Protocols should also be in place on measures to prevent sexually inappropriate behaviour, ensure respect for cultural diversity etc, as set out previously.
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