Impact on staff attitudes of brief personality disorder training for acute psychiatric wards

Purpose Negative attitudes towards “personality disorder” are common among mental health professionals. This study aims to design a psychoeducational training targeting attitudes to “personality disorder” for staff working in a London psychiatric hospital. Its impact on staff attitudes was evaluated. Design/methodology/approach Mental health clinicians were recruited from five acute psychiatric wards. Feasibility of implementing the training was measured. A free-association exercise explored baseline attitudes to “personality disorder” and visual analogue scales assessed staff attitudes pre- and post-training. Content analysis of staff feedback was carried out. Findings Psychoeducational training was found to be feasible, well-attended and highly valued by ward staff (N = 47). Baseline results revealed negative perceptions of “personality disorder”. Post-training, significant improvements in understanding, levels of compassion and attitudes to working with service users with a diagnosis of a “personality disorder” were observed. Staff feedback highlighted desire for further training and support. Research limitations/implications The sample size was relatively small and there was no control group, so findings should be interpreted with caution. Practical implications The findings highlight the need for support for staff working with service users with diagnoses of “personality disorder” on acute psychiatric wards. Providing regular training with interactive components may promote training as a resource for staff well-being. Planning to ensure service users’ and carers’ views are incorporated into the design of future training will be important. Originality/value This study is innovative in that it investigates the impact of a brief psychoeducational training on “personality disorder” designed for mental health staff on acute psychiatric wards.

Effects of Recovery-Orientation on the Use of Forced Medication and Maximum Daily Drug Dose: The “Weddinger Modell”

Objective: The aim of the present study was to analyze the effects of the implementation of the Recovery-orientated psychiatric care concept “Weddinger Modell” on the incidence of forced medication, the total number of forced medication incidents per affected case, the maximum dose of a singular forced medication and the maximum voluntary daily drug dose of different psychotropic drugs administered during an inpatient stay.Methods: This retrospective case-control study included 234 patients. A pre/post-comparison of patients on two acute psychiatric wards before (control group, n = 112) and after (intervention group, n = 122) the implementation of the Weddinger Modell in 2010 was performed. Patient data was selected at two reporting periods before and at two reporting periods after 2010.Results: No significant differences were found in the incidence of forced medication and the total number of forced medications. A significant reduction of the maximum forced medication dose of haloperidol in the intervention group was seen. Furthermore, the analysis of the intervention group showed a significant reduction of the maximum voluntary daily drug doses of clozapine, haloperidol and risperidone.Discussion: The results indicate that the implementation of the Weddinger Modell had no effect on the incidence of forced medication, but it can help to improve the approach to psychotropic drugs. Despite the reduction of mechanical coercive measures by the model, as shown in a previous study, there is no increase in forced medications or administered drug doses. Focus on Recovery helps in reducing coercion in acute psychiatric care.

Coping with moral distress on acute psychiatric wards: A qualitative study

Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience.

The use of benzodiazepines and Z-drugs in the Acute Psychiatric Unit at Cavan General Hospital

AimsBenzodiazepines and Z-drugs are used frequently in acute psychiatric wards, however long-term administration can result in undesirable consequences. Guidelines recommend prescription of the lowest effective dose for the shortest period and if possible to prescribe “as required” rather than regularly. The 25-beded inpatient unit at Cavan General Hospital admits adult patients requiring acute care from the counties of Cavan and Monaghan. Admissions are accepted from four community mental health teams, two psychiatry of old age teams and the rehabilitation and mental health of intellectual disability teams. In order to evaluate the potential to improve our practice of prescribing benzodiazepine and Z-drugs, it was decided to evaluate current use.MethodThe NICE guidelines were consulted, and we retrospectively reviewed the use of these agents from mid-January to the end of May 2020. Demographic variables included age, gender, and county. Patients were stratified into three groups, the benzodiazepine group, the Z-drugs group, and the combined benzodiazepine and Z-drugs group. In each group therapeutic variables were recorded including the medication type, dose, frequency, prescriber, and duration of treatment. Other variables included psychiatric diagnoses, length of inpatient admission, status on admission, and recommendations on dischargeResultThere were 101admissions during that period, and 74 of them were prescribed these agents (n = 74; 73.3%). Fifty one (n = 51; 68.9%) received benzodiazepines only, twenty-three (n = 23; 31.1%) were prescribed Z-drugs, and twelve (n = 12; 16.2%) received both benzodiazepines and Z-drugs. Forty two patients (n = 42; 56.8%) were commenced on hypnotics in the APU, 23 patients (n = 23; 31.1%) already received hypnotics from the CMHTs, and the rest were prescribed by both. Thirty two patients (n = 32; 43.2%) were discharged on hypnotics. Patients admitted involuntarily and female patients had longer admissions (mean of 16.62 ± 3.26 days and 16.16 ± 2.89 days respectively). Schizophrenia and BPAD were the commonest diagnoses.ConclusionIt appears that large amounts of these agents are used in the Acute Hospital Setting which is not overly surprising given the severity of illness and clinical indications however improved awareness could still lead to more appropriate and hopefully reduced use. We therefore recommend:A formal audit including appropriate interventions i.e., educate staff and patients, highlight guidelines, and review subsequent practice.Train staff in safer prescribing practices including prn rather than regular use if appropriate.Regularly review discharge prescriptions indicating recommended duration of use.

Assessing the quality of risk assessment conducted for new psychiatry inpatients

AimsAn audit was conducted to assess if thorough risk assessments had been documented in electronic clinical record notes (ECR) clerking for new patients in two acute mental health wards. Risk assessment is a vital part of admission clerking and when done well it can prevent early incidents and aid the ward nursing team greatly. During induction, junior doctors are advised to document assessed risks when clerking a new patient. A screening of the risks on admission could help determine the levels of observations required to minimise the identified risks whilst the patient awaits their first ward review.MethodThe NHS numbers for the 30 current inpatients across male and female acute psychiatric wards were gathered at the time of the audit (February – March 2020). Admission clerking was analysed for a clear statement of patient risk to self, others or property. Within these categories quantitative results were obtained on how often the risk of self-harm, self-neglect, absconding, vulnerability or aggression was documented. The term ‘risk’ was used for each patient on their ECR notes to search for risk assessments in all entries other than admission clerking.Result12 out of the 30 patients had a junior doctor risk assessment documented in their clerking (40%). 14 patients had no mention of risk assessment on admission (47%) and their first formal risk assessment was documented only in their senior ward review. Of the 12 assessments completed in clerking; all assessed self harm/suicide risk and violent risk to others, 1 mentioned risk of absconding, 8 mentioned risk of illicit substance use and 8 mentioned vulnerability. It was unclear if the risks documented were based on current or historic presentation. Junior doctors were anonymously surveyed following this audit and reported they did not feel confident in how to document a risk assessment or whether to document negative findings.ConclusionClear documentation of risk assessment being performed was lacking in over half of junior doctor admission clerkings. When risks were assessed it was mainly violence/self harm risk documented not vulnerability and physical health risks. Based on these findings we have designed more comprehensive teaching on risk assessments and a template for how to complete a risk assessment. We feel the use of a template will ensure all elements of risk are clearly considered even if they are not present currently. This is being reaudited to assess if the changes have impacted the quality of risk assessment conducted.

Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients

Objective. To evaluate effectiveness of Milieu Therapy in reduction of conflict and containment rates among schizophrenia patients.Methods. This study utilized quasi experimental non-equivalent control group pre-post design. One hundred schizophrenia patients admitted in acute psychiatric wards were non-randomly assigned to either of the experimental (n=50) or control group (n=50). The experimental group received both milieu therapy and routine hospital treatment. The Milieu Therapy intervention Included environmental modification and structuring ward activities, establishing effective interaction with patient, and teaching caregivers on managing conflict behavior of patient. The control group received only routine treatment in the hospital. Outcome measures on conflict and containment rates were evaluated for both the groups at baseline and at 2nd, 3rd and 15th day. The Patient–Staff Conflict Checklist Shift Report (PCC-SR) was used to collect information about rates of conflict and containment.Results. Compared with control group, the experimental group participants showed decrease in aggressive behavior, self-harm behavior and general rule breaking behavior at baseline and 2nd, 3rd and 15th day (F=4.61, p<0.004, η2=0.04; F=11.92, p<0.001, η2=0.11; F=6.94, p<0.001, η2=0.06) over seven days interval.Conclusion. The present study findings provided evidence for the effectiveness of integrating Milieu Therapy in psychiatric acute wards in reducing conflict behaviors among schizophrenia patients. Milieu therapy should be considered as an integral part of psychiatric care settings in these patients. How to cite this article: Bhat S, Rentala S, BN Raveesh, Chellappan XB. Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients. Invest. Educ. Enferm. 2020; 38(1):e06.