24. Recovering Adult Acute Psychiatric Inpatient Wards: Creating Recovery-Focused, Trauma-Informed and Neuro-Inclusive Culture, Relationships and Practice
Rachel Perkins, Sharon Gibbard, Yasmin Blackwood, Simon Barnitt, Lowri Smith, Anna Cheetham, Poppy Repper, Anne Rackham, Ben Dorey, Jo Luck, Julie RepperThis briefing paper has been co-produced by people who have experience of admission to acute inpatient wards (including people diagnosed with mental health challenges, complex trauma issues and neurodivergent/autistic people), family members and mental health practitioners from a variety of professional backgrounds (including nursing, psychiatry, psychology and occupational therapy).
Foreword
In recent years, much attention has been paid to the development of alternatives to hospitalisation for people in acute mental health crisis, for example crisis houses, crisis cafes, and home treatment teams. However, such developments have shown that acute inpatient wards continue to play a major role in the treatment and support of those who are the most distressed by mental health challenges and the accompanying trauma, personal, and social difficulties.
Such wards, and those who work within them, are confronting the daily challenges associated with increased demand and staff shortages. There are many dedicated and creative professionals who work in adult acute inpatient wards, but they too often feel helpless and demoralised in the context of the very real challenges they are facing.
There have been numerous academic papers, reports, and media exposés highlighting the shortcomings in treatment and support (sometimes outright abuse) that people admitted to acute inpatient wards have experienced. These reports also demonstrate how being on an acute psychiatric ward can be a traumatic experience and re-traumatising.
While such papers highlight the need for more resources and organisational changes to remedy this situation, they also identify problems with the relationships, culture, and practice on wards. In the words of Jay Watts (2022), “England’s mental health care lacks money. Yes – but it also lacks compassion.”
For the first time, NHS England (2023) has published guidance “to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible.” The guidance is designed to assist the realisation of the ambitions for acute mental health treatment and support outlined in the NHS Long Term Plan and the NHS Mental Health Implementation Plan (NHS England 2019, 2019a).
This guidance primarily focuses on resource, organisational, and process issues: eliminating inappropriate use of ‘out of area placement’; reducing avoidable long lengths of stay; improving the therapeutic offer on wards; increasing the level and skill mix of staff; and reducing the number of people with learning disabilities and autistic/neurodivergent people inappropriately admitted. These issues are important, and the guidance offers a framework for commissioners and senior managers for benchmarking and quality improvement purposes.
However, it can be argued that the relationships, culture, and practice on acute inpatient wards are of equal importance.
This briefing paper was co-produced by a diverse group of people, including those who have experienced admission to adult acute inpatient wards, family members of admitted individuals, and practitioners from various backgrounds such as nursing, psychiatry, psychology, occupational therapy, and peer support. Over six months, we came together to share our personal and professional experiences, explore relevant literature, and address the different facets of acute inpatient support and treatment.
In the process, we identified the need for and co-produced two further supporting documents:
Thinking about Recovery Together (ImROC 2023): A conversational tool for staff and people using the ward to think together about progressing recovery while in the ward, including plans for moving on and continuing recovery after leaving the ward.
A Team Recovery Implementation Plan for Acute Inpatient Wards (ImROC 2023a): A framework to foster co-production and empower teams to maximize the use of the insights, talents, and ingenuity of staff, people who have used the ward, and those close to them to develop more recovery-focused, trauma-informed support.
Front line staff cannot resolve all the difficulties that acute inpatient wards face alone, but they are not powerless. Everyone working on a ward can, and does, have an enormous impact on the experience of people using the ward and their relatives and friends. Often, it is the little things that make a big difference: a kind and encouraging word, a listening ear, the feeling that someone understands you and is there for you in your distress, and the sense that someone believes in you when you find it hard to believe in yourself.
Staff may not be able to spend as much time with people as they would like, but the quality of what happens in that time is powerful and can make an enormous difference. It is vital that we move beyond a preoccupation with bed occupancy, bed numbers, and length of stay to focus on what really matters to the people who use the ward and those who are close to them.
We need to create and enhance an inpatient ward culture based on values such as compassion, kindness, empathy, respect, humanity, and understanding. Recovery-focused, trauma-informed practice should foster hope and help people address the trauma they have experienced. A culture and practice that enables people to take control over the challenges they are facing, discover their possibilities, and move on to recover or discover a life that they value. Perhaps this is also the best way to decrease the duration of admission and the likelihood of readmission.