Daily ward process in inpatient mental health care

This chapter describes regular daily processes within the inpatient mental health ward that form the backbone of the ward’s functioning and underpin the ability of wards to provide therapeutic and safe environments. Precisely because acute inpatient wards can be unpredictable, with changing circumstances generating unremitting challenges to patients, carers, and staff, these daily processes, such as handover, medication, and mealtimes, are crucial to help create a sense of structure as well as safe clinical care. These processes must be followed if inpatient psychiatric wards are going to be able to provide an environment that allows the development of enabling and therapeutic relationships for patients, carers, and staff themselves.

Clinical pharmacy: safe prescribing and monitoring

The roles of the clinical pharmacists and medicines management technicians within the inpatient psychiatric setting are many and varied. This chapter explores some of these roles and examines how they enhance patient care and support the aims of mental health trusts and inpatient psychiatry. This is primarily achieved through effectively and efficiently managing medicines. The aim of the clinical pharmacy team is to promote high-quality, value-for-money care which is patient-centred and based upon improving patient outcomes. The chapter also discusses how pivotal papers and reports have shaped the services that pharmacy departments deliver to psychiatric inpatients.

Electroconvulsive therapy

In an acute inpatient environment, clinicians are often faced with patients experiencing mental illness to an extent that is life-threatening, whether this is through absolute loss of the will to eat and drink, through the intense impulse towards suicide, or through the sheer exhaustion of severe mania. It is essential to have the ability to bring these symptoms under control in a way that is rapid, effective, and humane, and electroconvulsive therapy (ECT) provides this. Despite enormous advances in the safe delivery, regulation, and efficacy of ECT over the last 70 years, and its ability to bring patients from stupor to recovery over (on average) just 6–12 treatments, it remains a stigmatized and stigmatizing treatment in the public eye. This chapter outlines the history of ECT, and explains how it can be safely prescribed and monitored, and who will be most likely to benefit.

Adverse reactions to medication

Adverse reactions to medication represent a major issue in inpatient psychiatry. This chapter systematically explores the most relevant, concerning, and problematic adverse effects routinely encountered in an inpatient setting. It describes the typical presentation, pathophysiology, incidence, and practical management of these problems. Extrapyramidal side effects including acute dystonia, drug-induced parkinsonism, akathisia, and tardive dyskinesia are considered before the chapter explores the rare but potentially life-threatening condition of neuroleptic malignant syndrome. Other adverse effects common to antipsychotics that are described include hyperprolactinaemia and psychotropic-induced arrhythmias including QTc prolongation. Sexual dysfunction is an under-recognized and undertreated adverse effect common to several classes of psychotropic medication and is also considered. Focusing on antidepressants, the chapter reviews the frequently encountered issue of hyponatraemia as well as serotonin syndrome and selective serotonin reuptake inhibitor-induced bleeding risk. Finally, the chapter addresses perinatal considerations for psychotropic drugs.

Initial assessment, ward rounds, the discharge process

Hospital admission to an acute psychiatric unit can be a challenging and at times distressing experience for patients, relatives, and friends. This chapter outlines the main multidisciplinary clinical tasks that must be carried out from admission to discharge, with a view to provide care that promotes dignity, autonomy, as well as a sense of hope for patients and all those involved. Taking as context the frameworks and standards provided by a several bodies, the chapter follows a chronological order starting and ending with a close look at the community mental health teams with which inpatient units must closely work for the benefit of patients and their families and friends.

International perspectives on inpatient mental health care

Inpatient care varies enormously, both between countries and regions and within them. These variations are most stark when based on economic factors, but stigma, prevailing societal attitudes, and the role of the family also play a significant part in the amount and quality of mental health care overall. This chapter begins by outlining global economic factors and their impact on provision. It then focuses on the concept of a whole systems approach, looking briefly at the evidence base for different components of services generally seen in high-income group countries. Alternative suggestions to ‘high-income group’ models are discussed as the evidence internationally emanates almost exclusively from a small number of wealthy westernized countries. The chapter ends with a section looking at several internationally important themes in inpatient care and outlining examples of differences between countries in challenges and in solutions to what is one of the longest standing issues in mental health care: how to provide humane, effective inpatient care to those who need it (and not to those who do not).

Staff burnout and staff turnover on inpatient wards

This chapter examines a range of personal, organizational, and contextual causes of occupational stress affecting inpatient mental health nurses, and offers a range of potential interventions which may help to reduce stress and burnout, and improve staff retention. It examines the consequences of burnout, its effects on patient care, and the situational factors which contribute to stress. It goes on to explore supportive factors which reduce burnout in nurses and to outline interventions and potential organizational responses which could improve the resilience of the workforce and support retention of staff and high standards of care.

Psychological treatment on the acute ward

Psychological approaches to treatment on inpatient units have been increasingly valued both by staff and service users. Such approaches have been delivered by specialist psychologists and psychotherapists but also adopted and used by the wider multidisciplinary ward team as a framework for guiding treatment. This chapter outlines both direct interventions with service users, as well as broader, more indirect psychological working with staff, families, and other external stakeholders. It also outlines the key stages of psychological working including assessment, formulation, intervention, and evaluation, and provides an overview of the types of therapies commonly delivered. The importance of staff well-being, team working, clinical supervision, and reflective practice is discussed, as are the challenges of working psychologically within an inpatient context.

Working with relatives and friends

Working with relatives and carers on inpatient wards demands careful consideration and reflection on how best to adapt practice to meet their needs, working in partnership as stipulated by national policy and practice guidelines. Making all staff ‘carer aware’ means having a systematic approach to building on carers’ strengths and addressing their needs. The role of mental health practitioners in an acute inpatient ward requires a specific set of skills and values when working alongside carers and consideration of the impact that the caring role has had. Attention to best practice, guidance, and protocols go some way to addressing the need to be carer inclusive.

Post-incident debriefing, team formulation and staff support

Acute inpatient mental health wards are characterized by constant change. The creation and maintenance of facilitated talking spaces for teams to reflect with each other is integral for both staff and service user well-being on these wards. There is a growing evidence base that supports the client-centred philosophy and principles of trauma-informed care whereby service users’ strengths are highlighted over pathology and skills building over symptom reduction. A systemic team formulation model is proposed as a useful, trauma-informed, staff support intervention that could be used on the wards, as it offers numerous intra- and interpersonal benefits for teams that engage in the process of shared formulations. A case example illustrating the methodology of systemic team formulation is explored. In addition, post-incident debriefing is also a necessary form of staff support, as a way of mitigating the negative emotional impact of serious untoward incidents and restrictive practices on staff.