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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Royal Free and University College Medical School, London
Islington Learning Disabilities Partnership, London
Camden Learning Disabilities Service, London
Department of Mental Health Services, Royal Free and University College Medical School, 48 Riding House Street, London W1W 7EY, email: a.hassiotis{at}ucl.ac.uk
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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A study was undertaken to investigate the views of professional staff and paid and informal carers’ views of a new integrated mental health service for people with learning disabilities.
RESULTS
Twenty semi-structured interviews were conducted and transcribed. Most staff and carers were generally satisfied with the in-patient facility. However, information exchange, ward rounds and the ward environment were identified as areas requiring improvement.
CLINICAL IMPLICATIONS
Many of the participants had no previous experience of supporting a person with learning disabilities and mental health problems in an in-patient setting. However, over time they became supportive of the mental health service and provided valuable input in improving the service provision for people with learning disabilities.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In services for people with learning disabilities there has been little research on the experiences of healthcare staff and of paid and informal carers who support adults with learning disabilities and mental illness (Allen, 1999), despite these individuals’ greater reliance on social and professional networks compared with other service users. In our experience carers are often instrumental in enabling individuals to understand mental health legislation and treatment decisions. Carers also have a significant role within the psychiatric assessment process, as assessments of mental state of people with learning disabilities are often carer-led (Moss et al, 1993).
The authors have developed a new mental health service for adults with learning disabilities and mental illness (Hall et al, 2006). As part of this service we have four dedicated in-patient beds within a generic mental health service. Funding was approved at the outset for increased ward staffing levels, and learning disabilities mental health training is provided to nursing staff twice a year from within the local learning disabilities services. During the evaluation of this new service we interviewed professionals and paid and informal carers about their views.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Interview process
The questionnaire included questions about all aspects of in-patient stay,
such as reasons for admission, the ward environment, safety and security on
the ward, the range of activities available, quality of nursing care, ward
rounds, care programme approach meetings, quality of medical care and use of
medication. The interviews were audiotaped and transcribed.
Data analysis
Two of the authors (S.S. and C.P.) independently read the transcribed
interviews to identify themes before each interview was analysed using
specialist data management software (Qualrus version 1;
http://www.ideaworks.com).
Open coding was used initially to link codes to segments of the original text.
For external validity, another colleague with no other involvement in the
study read excerpts from the interviews to ensure that they corresponded with
the proposed themes.
The study received ethical approval from the local research ethics committee.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Admission process
Risk to self and others was reported as the main reason for admission in 11
patients. The process of admission was felt to be satisfactory by all but
three of the participants. Half felt that the admission had been of an
appropriate length, whereas five felt it was too long and three that it had
not been long enough. Twelve participants felt that the in-patient stay had a
positive outcome in improving the mental state of and service input to the
service user.
Ward environment
Eight carers described the ward environment in negative terms, for example,
‘stark and clinical’, ‘drab, gloomy and run-down’ and
‘depressing rather than welcoming’. Four of the participants said
that they did not feel that the ward environment was adequate to promote
mental well being, contrasting it with other residential environments for
people with learning disabilities. However, a third of participants commented
positively on the availability of single rooms and space on the ward.
All participants thought that the ward was a relatively safe environment for the service user. A few concerns related to the safety of personal possessions, as service users had reported items missing during the admission. Four participants suggested that a ‘signing book’ could improve security on the ward. Two paid carers were quite negative about the main door to the ward and the door to the female dormitory being locked:
‘I suppose being an acute psychiatric unit you can’t make it really homely because you’ve got to ensure it’s a safe environment.’
Activities and socialisation
Half of the respondents thought that there was a good range of activities
available on the ward, such as relaxation, art, crafts and music, as well as
talking to staff and friends on the ward, watching television and playing
games. Seven participants felt that additional support around daily living and
further psychological interventions should also have been offered.
Participants reported that most service users were able to make friends with
other service users who did not have learning disabilities.
Nursing and medical care
Nursing staff were described as ‘nice’, and
‘professional’, although some paid carers felt that they had not
had enough contact with the staff during the admission. No one reported
significant concerns with nursing care. The monitoring of and investigations
into patients’ health were thought to be exceptionally good by three
participants; although a similar number described this as lacking.
Communication with nursing staff and doctors and use of agency nurses were
described as creating occasional problems in caring for the service users or
as hindering adequate contribution to care plans.
Use of medication
All participants were satisfied with how decisions regarding any changes in
medication were explained and thought that the medication given was
appropriate. However, three felt that they needed more information about its
indications and side-effects.
Ward rounds
With the exception of one part-time professional, all carers and
professionals had attended at least one of the regular weekly ward rounds or a
pre-discharge care programme approach meeting. Nine participants described how
it was useful to meet regularly with ward staff and other professionals, and
felt it provided a regular opportunity to receive updates on progress and was
a useful forum for discussion:
‘I think it’s good that the patient becomes involved and is invited into that ward round and also anyone else that’s involved in the life of that person whether it be a carer, next of kin, you know, whoever.’
The majority of those interviewed were able to participate in discussions within the ward rounds; however, six were concerned about the number of people attending each time, and they and the service user had felt overwhelmed by this. Seven interviewees also felt that the ward round, which is chaired by the consultant, did not always allow for effective participation of carers and service users.
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Discussion |
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Comments about the physical environment mirror the findings of a number of studies of in-patient psychiatric care (Sainsbury Centre for Mental Health, 1998; Rose, 2001) that have found in-patient units unsatisfactory and poorly maintained. Our participants, particularly those with little experience of psychiatric in-patient care, highlighted the need for alternatives to admission for adults with learning disabilities, the importance of a clean and stimulating ward environment, the essential issue of proactive communication between the in-patient and community teams, and the facilitation of access to advocacy. One of the consequences of the extensive service networks of the adults with learning disabilities was that ward rounds sometimes became very crowded and quite intimidating for service users and carers alike.
Service culture
Great effort had been made during the service development stage to address
shortcomings of previous arrangements. There was wide consultation with local
stakeholders, ongoing training of psychiatric nursing staff to increase
awareness of issues relevant to caring for people with learning disabilities,
and continuous input by community team members to in-patients, which included
specialist sessions for psychology, speech and language therapy, occupational
therapy and community nursing, as well as support with activities.
The participants in this study were positive and encouraging about the new service but recognised that there are several areas where further progress could be made. We have tried to address the issues raised by implementing the following changes: we have been asking service users to indicate who they would like to be present when seen in the ward round and we have offered to meet with them and key staff outside the ward round. We have started to produce accessible information leaflets about the in-patient process as part of the respective service plans. We continue to provide ongoing seminars on aspects of mental health, including the care programme approach, at least annually to both service professionals and formal carers as part of the service training programmes.
We acknowledge that it is essential to work together with carers of adults with learning disabilities and mental health problems. We have made some progress in improving our current service compared with past provision. Future work should explore in depth the attitudes of different stakeholders towards mental health services for adults with learning disabilities, including nursing staff and managers of the in-patient adult mental health services. The publication of a guide for the improvement of mental health services for adults with learning disabilities, Green Light for Mental Health (Department of Health, 2004), is a significant recent development which also may help to improve local mental healthcare pathways and support to people with learning disabilities.
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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DEPARTMENT OF HEALTH (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century. TSO (The Stationery Office).
DEPARTMENT OF HEALTH (2004) Green Light for Mental Health: How Good Are Your Services for People with Learning Disabilities? A Service Improvement Toolkit. http://www.valuingpeople.gov.uk/documents/MentalHealthGLGuide.pdf.
GRALTON, E., PEARSON, S., SUTHERLAND, A., et al
(2001) The environment psychiatric patients create for
themselves. The varying perceptions of professional staff.
Psychiatric Bulletin,
25, 134
–137.
HALL, I., PARKES, C., HIGGINS, A., et al (2006) The development of a new integrated mental health service for people with learning disabilities. British Journal of Learning Disabilities, 34, 82 –87.[CrossRef]
HERVEY, N. & RAMSAY, R. (2004) Carers as partners
in care. Advances in Psychiatric Treatment,
10, 81
–84.
LACEY, Y. & THOMAS, P. (2001) A survey of
psychiatrists’ and nurses’ views of mental health advocacy.
Psychiatric Bulletin,
25, 477
–480.
MOSS, S., PATEL, P., PROSSER, H., et al
(1993) Psychiatric morbidity in older people with moderate and
severe learning disability. II. Development and reliability of the patient
interview (PAS-ADD). British Journal of Psychiatry,
163, 471
–480.
ROSE, D. (2001) Users’ Voices. The Perspectives of Mental Health Service Users on Community and Hospital Care. Sainsbury Centre for Mental Health.
SAINSBURY CENTRE FOR MENTAL HEALTH (1998) Acute Problems: A Survey fo the Quality of Care in Acute Psychiatric Wards. Sainsbury Centre for Mental Health.
This article has been cited by other articles:
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  E. Yacoub, I. Hall, and J. Bernall Secure in-patient services for people with learning disability: is the market serving the user well? Psychiatr. Bull., June 1, 2008; 32(6): 205 - 207. [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
