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Weighing up the risks of admitting children and young people to mental health inpatient units

This is the last in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Council’s code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trust

Introduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:

Elaine_Maxwell
Elaine Maxwell

The National Institute of Health Research (NIHR) was set up in 2006 as a health and care research system that focuses on the needs of patients and the public. It aims to produce an evidence base that is translatable into policy and practice. The NIHR Dissemination Centre disseminates the research generated in the form of Signals and Highlights, as well as themed reviews.

In 2018, one themed review brought 30 research studies on severe mental illness together in our report, Forward Thinking. We define severe mental illness as that which results in significant disability in terms of day-to-day functioning. While most of the research we included related to adults, a number of studies considered severe mental illness in children and young people.

Providing care for children and young people with severe mental health is particularly complex and admission to a residential facility is always the last resort, usually because it is thought that the child or young person is at significant risk.

One of the studies we included in our review was the RiSC study (Hannigan et al 2015), which looked at risks for young people moving into, journeying through and out of inpatient mental health care. It demonstrated that there are significant risks to admitting a child or young person to hospital however distressing the mental illness.

In this article, the lead researcher discusses how they undertook the research and how they involved children and young people in deciding what evidence to include, while a consultant nurse considers how these risks can be justified.

This is the last in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Council’s code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trust

Child
Picture: iStock

Introduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:

Elaine_Maxwell
Elaine Maxwell

The National Institute of Health Research (NIHR) was set up in 2006 as a health and care research system that focuses on the needs of patients and the public. It aims to produce an evidence base that is translatable into policy and practice. The NIHR Dissemination Centre disseminates the research generated in the form of Signals and Highlights, as well as themed reviews.

In 2018, one themed review brought 30 research studies on severe mental illness together in our report, Forward Thinking. We define severe mental illness as that which results in significant disability in terms of day-to-day functioning. While most of the research we included related to adults, a number of studies considered severe mental illness in children and young people.

Providing care for children and young people with severe mental health is particularly complex and admission to a residential facility is always the last resort, usually because it is thought that the child or young person is at significant risk.

One of the studies we included in our review was the RiSC study (Hannigan et al 2015), which looked at risks for young people moving into, journeying through and out of inpatient mental health care. It demonstrated that there are significant risks to admitting a child or young person to hospital however distressing the mental illness.

In this article, the lead researcher discusses how they undertook the research and how they involved children and young people in deciding what evidence to include, while a consultant nurse considers how these risks can be justified.


Ben Hannigan, professor of mental health nursing, Cardiff University:

Ben_Hannigan
Ben Hannigan

Few young people experiencing mental health difficulties are admitted to psychiatric hospital, with inpatient care being reserved for those requiring intensive, round-the-clock help.

For practitioners working in child and adolescent mental health services (CAMHS), risk of harm to self or others is an important consideration. There are other types of risk, however, and this evidence synthesis aimed to bring together research into, and evidence for, risk in the widest sense for young people receiving inpatient mental healthcare.

We were attracted to the two-stage evidence synthesis approach modelled by the Evidence for Policy and Practice Information and Co-ordinating Centre (2010) largely because it emphasises the involvement of stakeholders. The first stage in reviews of this type is scoping and mapping papers in the selected area; the second is a more in-depth review shaped by the reactions and opinions of stakeholders.

Phase 1: scoping review

Two electronic databases were searched for published research on the types of risks at the intersection of the four areas represented in Figure 1. We identified 124 articles that met the inclusion criteria, most of which addressed clinical risks.

Fig1
Figure 1. Scoping the literature

The themes were summarised in a series of thematic maps, one of which as a word cloud is shown in Figure 2.

Fig2
Figure 2. Phase 1 themes: the larger the word, the larger the number of papers relating to it

Young people, carers, managers and professionals helped determine the focus of the second phase of our review. We used a variety of consultation approaches to make sure all stakeholders were able to express a view. Agreed priorities were the risks of ‘dislocation’ and ‘contagion’.

‘Dislocation’ refers to the risks of stigma in being uprooted from school, family and friends and in facing challenges to identity and normal life. ‘Contagion’ refers to the risks of learning unhelpful behaviours and making unhelpful friendships.

Phase 2: in-depth review

We searched 17 electronic databases along with multiple websites. We also invited inpatient CAMHS staff to share information on their approaches to the assessment and management of the risks of dislocation and contagion.

A total of 40 research articles, and 20 relevant policy and guidance documents, were finally brought together under a series of categories and sub-categories, as the following summary illustrates.

Summary of phase 2 findings

Normal Life

  • Everyday life and interactions in hospital
  • Missing out on life outside and transition home

Identity

  • Mental health problems as identity-changing
  • Responding to threats to identity

Friends

  • Relationships with young people outside hospital
  • Relationships with young people in hospital

Stigma

  • Young people’s experiences during admission
  • Young people’s experiences after discharge

Education

  • Education provision and facilities
  • Quality of inpatient education
  • Academic progress
  • Reintegrating with school after discharge

Families

  • Impact on family relationships
  • Family involvement
  • Maintaining contact with families 

Contagion

  • Experiences of contagion
  • Evidence of contagion

 

We found evidence indicating that:

  • Young people can experience difficulties in maintaining friendships at a distance and in reconnecting with friends after hospital discharge.
  • Hospital admission poses risks to schooling, with professionals, parents and young people identifying the importance of educational provision in inpatient CAMHS.
  • A particular risk of family dislocation is reported where young people are cared for in hospitals that are far from home. For some, however, the quality of care at inpatient units is considered more important than the distance from the hospital to the family home. Some young people also appreciate being away from the home environment.

Although we found little evidence on how these risks might be mitigated, we concluded that the ‘less obvious’, non-clinical risks are important.

Practitioners and managers need to pay close attention to the identification, assessment and management of these risks, and research is needed to generate new knowledge underpinning the best approaches.


Marjorie Goold, child and adolescent mental health services nurse, Cheshire East Youth Engagement Service:

Marjorie_Goold
Marjorie Goold

The RiSC study highlights many clinical challenges and opportunities for CAMHS clinicians. These include frustrations in securing inpatient beds locally and nationally, and the unintended consequences of inpatient admission. These consequences include the risks of contagion and dislocation, which emphasise the need for intensive crisis support in the community.

From my experience, professionals and families push for admission when they think they have exhausted their capacity to manage a young person’s presenting risk outside of hospital.

Admission is seen as the sustained management of risk and serves to combat levels of anxiety in those providing care. Indeed, the research reiterates how inpatient environments may be perceived as safe by offering fewer opportunities to cause self-harm, including suicide. 

On reflection, however, tier-four providers need to educate the wider community, professionals and carers about the inherent risks of inpatient care, as well as the need to balance these with the risks of remaining in the community. However, insufficient intensive crisis support in the community may mean that inpatient care is the only available option, despite the risks described in this study.

The concept of contagion describes how the environmental setting and a specific client cohort can significantly influence, and lead to an increase in, an individual’s risk-taking behaviours. These behaviours may be more risky that those that led to the admission.

A clinician’s knowledge that contagion could be a potential outcome before admission is not necessarily sufficient to prevent it happening. This signifies to me that forthright discussions on the concepts of contagion, and candid dialogue with the young person and family about the benefits and unintended consequences of admission, provide a more robust and transparent process for gaining consent to admit.

Funding

This article presents independent research commissioned by the National Institute for Health Research (NIHR) under Health Service (HS) and Delivery Research (DR) (Grant Reference Number 11/1024/08).

The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

The sponsor of the study had no role in study design, data analysis, data interpretation or writing of the report.

The study prompted me to consider risks in terms of discharge, given that new risks may emerge and that they be greater than those leading to the initial admission.

The study also highlighted that new maladaptive behaviours learned in the inpatient setting can be accompanied by a decline in a young person’s self-responsibility, an unfortunate side effect of admission.

In hospital, safety becomes the responsibility of staff through regular checks and various degrees of observation to maintain safety. This made me reflect that there needs to be further thought on how self-responsibility is nurtured in inpatient settings to optimise a young person’s self-management capabilities on discharge.

Inpatient care has a critical role in psychiatric care, but tier-four clinicians need to consider the risk of contagion and how to mitigate it. They should also strive to improve the opportunities to prevent dislocation by integrating the community as far as possible.

Ultimately, safeguarding children and young people with severe mental illness may require the option of intensive community provision to offset the risks associated with inpatient admission.

References

  • Evidence for Policy and Practice Information and Co-ordinating Centre (2010) EPPI-Centre Methods for Conducting Systematic Reviews. Institute of Education, London.
  • Hannigan B, Edwards D, Evans N et al (2015) An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services. Health Services Delivery Research. 3, 22.

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