MH-CREST: How do community crisis care services work, who do they work for, and in what circumstances?

I am excited to announce the start of MH-CREST following an intense year of development. The MH-CREST research team is a partnership between The School of Healthcare at the University of Leeds, the University of Sheffield and our sponsor Sheffield Health and Social Care NHS Foundation Trust. Together, the MH-CREST team hold expertise in mental health nursing, lived experience, social and psychological sciences, psychiatry, information science, evidence synthesis, and realist methodology. As a new NIHR Principal Investigator, I have been on the steepest learning curve but so far have survived with the support of my colleagues!

Nicola has been on a steep learning curve

We held our first research team meeting in September and started to tackle some important but tricky questions:

What is a mental health crisis?

Mental health crises can be defined in different ways, but after much discussion, the MH-CREST team decided we would define crisis as:

1. A relapse in a psychiatric condition, characterised by increased symptom severity (such as voice hearing, suicidal thoughts, and other behaviours that could cause harm) and decreases in social functioning (including reduced self-care) (Crompton & Daniel, 2006)

2. A reaction to adverse life events that disrupts the lives of the person and their family because their usual ways of coping have not worked (Tobitt & Kamboj, 2011)

3. An opportunity for change that may enable people to develop new ways of coping (Caplan, 1989)

These definitions have helped us to decide what types of evidence we will include in our project and which stakeholders we should speak to.

map of crisis services developed with stakeholders

What evidence will be included in MH-CREST?

Most UK mental health crisis care is in community settings because hospital care is hard to access, unpopular, and costly for the NHS. There is some evidence that community crisis services in the UK provide value for money and are effective for many people, others report not being able to access services and their needs not being met (Mind, 2011, 2012; CQC, 2015). Before the project started, we consulted people who have accessed mental health crisis services and these sessions suggested that crisis services resemble a tangled web of overlapping services with complex referral routes and blurred functions.

a tangled web of overlapping services with complex referral routes and blurred functions

UK crisis services are diverse, vary in different parts of the country and have many different names. They are provided by the voluntary sector, NHS, local authority or social enterprise (a type of business that uses profits to improve people’s lives) and are increasingly delivered as a collaboration between providers.

some of the different names for crisis services in the UK

Following discussion, the MH-CREST research team agreed to focus on crisis care for people who are in a community setting. The people we consulted before the project started also thought that the focus should be on crisis services for people in community settings rather than hospital because community services are generally preferred, provide the respite, information and support that people ask for, and avoid the need to be away from home and family. Crisis care is complex so we will revisit and refine our definitions as the project progresses.

How do crisis care services work, who do they work for, and in what circumstances?

We will review previous research and speak to stakeholders to understand how crisis care services work, for whom and in what circumstances – this type of literature review is called ‘a realist evidence synthesis’ (Pawson et al., 2005). We will start by developing informed hunches (‘programme theories’) about how crisis services are supposed to work by reading journals, books, policy documents and talking to stakeholders with expertise as health professionals, service users, family members, commissioners, policy makers and academics.

Once we have identified programme theories about how crisis services are supposed to work, we will test them by re-examining previous research and consulting stakeholders. We may also be able to link what we find to broader (middle range) theories that help us to explain how crisis services work (or don’t work). In a final step, we will work in partnership with the stakeholders to write ‘pen portrait’ examples that connect our theories to peoples’ lived experiences.

Why is the project important and what will it do?

UK mental health crisis services have had investment for some time and important research has been published, but there are still gaps in our understanding. We already know from research findings and from listening to the experiences of people using services, that crisis care outcomes vary in different contexts and people find it hard to access the right help when they need it. For example:

  • in some parts of the UK, crisis services are not available 24 hours
  • people who are black or belong to a minority ethnic group (BAME) find it hard to access crisis care that meets their needs

This project will explain why outcomes vary across different services designs and providers and identify what is needed to simplify the pathways through crisis care, improve access and reduce variability. Using this information, health services commissioners will be able to design crisis care based on what leads to the best outcomes for people experiencing a mental health crisis wherever they live enabling them to access the right crisis care at the right time.

Nicola Clibbens is a Lecturer in Mental Health at the University of Leeds. To find out more about the MH-CREST project click here and here or contact Nicola. Follow Nicola and the MH-CREST project on Twitter @UniLeedsMH using the hashtag #MHCrest.

This study is funded by the National Institute for Health Research (NIHR) HS&DR programme (NIHR127709). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

References

Caplan, G. (1989) Recent developments in crisis interventions and the promotion of support services, Journal of Primary Prevention, 10, 1, 3-25.

Crompton, N., & Daniel, D. (2006) Guidance statement on fidelity and best practice for crisis services. London, Department of Health, NHS National Institute for Mental Health in England, Care Services Improvement Partnership, London.

Mind (2011) Listening to experience: An independent inquiry into acute and crisis care, Mind, London.

Mind (2012) Mental Health Crisis Care: A briefing for clinical commissioning groups, Mind, London.

Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2005) Realist review: a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy, 10, 21-34.

The Care Quality Commission (2015) Right here, right now: People’s experiences of help, care and support during a mental health crisis, CQC, London.

Tobitt, S. & Kamboj, S. (2011) Crisis resolution/home treatment team workers’ understanding of the concept of crisis, Social Psychiatry and Psychiatric Epidemiology, 46, 671-683.

#ICUrestraint study: using audio-visual vignettes

Using audio-visual vignettes to explore how nurses make the decision to restraint delirious patients on the critical care unit

How do nurses make the decision to restrain a delirious patient? What influences their decision? Do they follow protocols or base their decision on an individual assessment of the patient? If they assess the patient, what impacts on this process: the nurse’s experience, the acuity of the unit, or perhaps just how they felt that day? These are some of the questions I am seeking to answer through my PhD research.

My background research showed that nurses were the main decision makers when managing patient agitation and lacked support from medical colleagues. The literature suggests that nurses found caring for agitated and delirious patients physically and emotionally challenging. Nurses used negative subjective terms such as ‘mad’ and ‘poorly behaved’ to describe patient behaviours associated with hyperactive delirium despite the existence of objective, validated tools such as RASS and CAM-ICU. This can lead to the sharing of judgements of dysfunctional or deviant patient behaviour (Carveth, 1995). Wide variations in restraint use appear to be influenced by previous adverse clinical experiences and unit custom rather than evidence based practice.

What is delirium? Delirium is a rapid onset, reversible, fluctuating condition characterised by inattention, changes in cognition, disordered sleep-wake cycle and increased or decreased psychomotor activity (American Psychiatric Association, 2013). It affects approximately 20-50% of mechanically ventilated patients in critical care (Krewulak et al., 2018).  Hyperactive delirium presents as psychomotor agitation, which is often cited as a rationale for initiating chemical and physical restraint in critical care despite a poor evidence base (Ai et al., 2018).

Think aloud

To answer these questions, I wanted to develop a data collection method which would help me to understand how nurses make the decision to restrain a patient, and identify potential modifiable factors. I rejected direct observation because it risked disrupting clinical care and I decided against written scenarios as i doubted these could convey the clinical urgency of caring for an agitated patient. Together with my supervisors, I chose audio-visual vignettes, or short films with ‘Think Aloud’ as the data collection method. ‘Think Aloud’ aims to reveal the thought processes involved in making decisions by encouraging participants to vocalise their thoughts.

Developing the method

I began by writing scenarios based on my reflections on practice and cues identified from my background research. I asked a clinical expert (an Advanced Critical Care Practitioner) to check the scenarios before I developed illustrated storyboards that detailed the patient behaviours I wanted to ask participants about. An enthusiastic group of colleagues agreed to simulate these patient behaviours, and I filmed and edited the audio-visual vignettes early this year. The vignettes depict a range of delirious critical care patients with varying levels of potential risk inference, such as agitated or combative behaviour or the presence of medical devices. Each film is preceded by a verbal handover, which provides an opportunity to explore whether subjective descriptors influence how the participants perceived the patient and if this affected their decision-making.

I piloted the vignettes with three participants. The method works well and simulates decision-making under time-pressure in the critical care environment. Early data suggests variations in practice, and a focus on short-term management over a consideration of the long-term impact of restraint use.

For more information about my PhD research please visit my study page. Data collection is ongoing and the study is actively recruiting new participants.

Would you like to take part?

please see the Participant Information Sheet

Your can contact me at a.m.teece@leeds.ac.uk. You can also follow me on Twitter @AngelaTeece

References

AI, Z.-P., GAO, X.-L. & ZHAO, X.-L. 2018. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive & Critical Care Nursing, 47, 62-68.

AMERICAN PSYCHIATRIC ASSOCIATION, D. S. M. T. F. 2013. Diagnostic and statistical manual of mental disorders: DSM-5, Arlington, Va;London;, American Psychiatric Association.

CARVETH, J. A. 1995. Perceived Patient Deviance And Avoidance by Nurses. Nursing Research, 44, 173-178.

KREWULAK, K. D., STELFOX, H. T., LEIGH, J. P., ELY, E. W. & FIEST, K. M. 2018. Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine, 46, 2029-2035. 3

CArDiNAL: A New Clinical Academic Research Fellowship

The beginning…

I am delighted to be starting my PhD journey with the University of Leeds in tandem with Leeds and York Partnership Foundation Trust. The new CArDiNAL (ClinicAl Doctoral Nurses and ALlied Health Professionals) Clinical Academic Research Fellowship embeds and promotes my research role within my clinical (Speech and Language Therapist) Specialist post. A strength of this new post is the support of a cohort of clinical academic fellows – including different Allied Health Professionals and Nursing Specialists – together, we form a community of research active clinicians across the Yorkshire and Humber footprint.

“The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic.”

Without this important initiative by Yorkshire and Humber NIHR CLAHRC I would not have been able to embark on this research journey whilst continuing to practice as a Speech and Language Therapist. As well as adding to the wider evidence-base for dysphagia in mental health, my research and ongoing clinical practice will inform each other. The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic and I will use my specialist skills to support involvement from other service users with communication difficulties in co-production.

“How can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems?”

My PhD research will consider everyday quality of life around mealtimes and I will continue to identify and unpack good practice. My pilot work progressed from an initial case study (highlighting the different perspectives of an inpatient and members of his staff team; see Guthrie et al. 2012) to projects considering the risks associated with swallowing difficulties, communication and choking incidents in adults with mental health conditions (Guthrie and Stansfield 2017; Guthrie and Roddam 2011), leading me to ask: how can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems? I developed a free booklet to support service user, carer and staff discussions about mealtimes (Guthrie 2013). The pictures, text and checklist suggest conversation topics, including aspects of swallowing difficulty that may have gone unrecognised or been overlooked. Any concerns about swallowing should always be referred to Speech and Language Therapy for assessment and advice.

I am keen to hear any patient or caregiver “stories” of the experience of living with mental health conditions and dysphagia.

Susan Guthrie is a Highly Specialist Speech and Language Therapist and CArDINAL Clinical Academic Research Fellow. For more information about her PhD research you can contact her here or directly via hcsg@leeds.ac.uk. You can also follow Susan on Twitter @SusanGuthrieSLT and on Researchgate.

References

Guthrie, S. and Roddam, H. (2011) Reporting and learning from choking incidents in adults with learning disabilities. Speech and Language Therapy in Practice.

Guthrie, S., Roddam, H., Panna, S. and Fairburn, G. (2012) Capacity to choose and refuse? A case study. Advances in Mental Health and Intellectual Disabilities, 6(6), pp.293-300.

Guthrie, S. (2013) Me at Mealtimes [Free online booklet]

Guthrie, S. and Stansfield, J. (2017) Teatime Threats. Choking Incidents at the Evening Meal. Journal of Applied Research in Intellectual Disabilities, 30(1), pp.47-60.

Tickets Available – Reducing Restrictive Practices: Understanding Key Intervention Components

As we move into the final stages of COMPARE: Establishing components of programmes to reduce restrictive practices: an evidence synthesis, we are pleased to announce that we will share our findings at a dedicated event:

Reducing Restrictive Practices: Understanding Key Intervention Components

12.30-15.30 5 June 2019
Horizon Conference Centre, Leeds

We have identified and mapped over 100 interventions that have been implemented in various adult mental health settings across the world. A free, interactive directory will be made available following this event. Using a specially designed taxonomy, we were able to discern between the active components of a substantial proportion of these interventions. Consequently, for the first time, we will be able to indicate which intervention components have the most (or least) potential to reduce restrictive practices.

We will also introduce a new study that builds on and extends this work: CONTRAST: Establishing components of interventions to reduce restrictive practices with children and young people: an evidence synthesis. Here, we will seek to identify interventions to reduce restrictive practices with children in a range of residential settings.

“We particularly encourage service users and carers to come along and join in the discussion.”

A draft programme for the event can be found below. Please join us for a complimentary lunch from 12.30 onwards. We hope that we will be joined by a wide range of stakeholders with an interest in the reduction of restrictive practices for plenty of networking and discussion. We particularly encourage service users and carers to come along and join in the discussion and we can cover travel expenses for those who wish to do so. Please contact us to make arrangements.

If you have any questions about the event, please do not hesitate to contact us. For travel and parking information visit Horizon, Leeds

Tickets are available via Eventbrite.