Bored on the ward: service user experiences of activities on acute mental health inpatient wards
QUAHRC Team Member Clair Le Boutillier reviewed Foye et al.'s 2020 paper, "Activities on acute mental health inpatient wards: A narrative synthesis of the service users’ perspective" for The Mental Elf. The team at the Mental Elf have kindly allowed us to reproduce the blog post here.
The opportunity to engage in ward-based activities benefits patient outcomes, improves the experience of care, and enhances personal recovery (Donald et al, 2015). On the other hand, a lack of access to, or engagement in these activities has been associated with high levels of boredom (Newell et al, 2011). The impact of boredom on inpatient wards is well documented, with effects such as an increase in self-harm and aggressive behaviour, and a negative impact on well-being and the effectiveness of treatment (Marshall et al, 2020).
The need to offer meaningful ward-based activities in mental health inpatient settings is outlined in NICE quality standards (NICE, 2019), and this is echoed in guidance that identifies the key characteristics of recovery-orientated practice (Le Boutillier et al, 2011).
The review offered here by Foye and colleagues (2020) is timely and allows us to learn from service user experiences. The aim of the study was to review and synthesise existing literature that explored service users’ experiences and views on the provision and availability of ward-based activities on acute adult mental health wards.
A systematic search strategy was used to identify studies that explored the experiences and views of service users in relation to adult acute mental health ward-based activities. Five databases were searched, and reference lists of included articles were reviewed to identify additional relevant studies.
Studies were excluded if they reported on psychological therapy or occupational therapy interventions. Included studies were formally quality assessed using appraisal tools and analysed using a robust thematic synthesis approach (Thomas & Harden, 2008).
The initial search strategy generated 4,748 citations, of which 90 were included in full-text screening. Based on the inclusion and exclusion criteria, a total of 12 studies were included in the synthesis. Five studies explored group-based activity and seven explored ‘everyday’ activities.
The thematic synthesis process produced two superordinate themes: 1) the lack of activities and 2) values and benefits of activities. A third theme bridges the two superordinate themes to place activities in context of the changing ward milieu: barriers to engagement with activities.
1. The lack of activities
This theme equates the lack of ward-based activities with high levels of boredom and dissatisfaction. Reasons for dissatisfaction included the impact of ward rules and restrictions on the availability (irregular and hit and miss) and type of activities on offer. Boredom was linked to an increase in aggression, self-harm and containment measures on the ward (restraint, seclusion, PRN medication and special observation). The lack of ward-based activity also left time to ruminate and foster negative thoughts and was linked to reduced levels of personal recovery.
2. Values and benefits of activities
This theme encompasses three perceived benefits for those who had experience of participating in ward-based activities:
- Improved psychological well-being: the activities provided a sense of purpose, hope and meaning.
- Social connectedness: the activities offered an opportunity to build relationships with staff and other service users, providing a sense of teamwork and collaboration and a sense of community.
- Physical health: engaging in physical activity provided benefits such as managing stress, weight control and improving overall well-being.
3. Barriers to engagement with activities
This theme outlines three factors that were found to get in the way of engaging with activities:
- Ward environment: the disruptive nature of the ward and interruptions (constant telephone calls and visitors) was acknowledged as a barrier and value was placed on a therapeutic and safe environment for engaging both service users and staff in activities.
- Restrictions: restrictions placed on service users often meant they were unable to engage with self-directed activities (such as showering, or accessing mobile phones), or were involved in choosing what activities they would like to participate in.
- Wellness: a lack of energy and/or motivation, and tiredness got in the way of being able to engage in ward-based activities.
The authors concluded:
By understanding the needs of service users on wards regarding the activities that may reduce boredom and therefore potential to reduce adverse incidence, staff will be better placed to support service users on the wards to engage in these meaningful activities.
Strengths and limitations
Despite the rigorous systematic approach to reviewing, the subjectivity in identifying relevant studies is apparent because of the complexity in defining meaningful ward-based activity. The authors acknowledge this, and state that
The definition of what is an activity is itself limiting, due to the unclear boundaries that some activities have with occupation, as often focused on by occupational therapists and psychological therapies.
They also state that there is little agreement or exploration of how activity differs from therapeutic engagement with staff. The review would therefore benefit from having a clear overarching conceptual understanding of what ‘meaningful ward-based activity’ means in/for acute adult mental health inpatient services. It would also be useful to identify if and how this understanding relates to, or is different from therapeutic engagement, and other meaningful activities (either individual or group-level) provided by (occupational therapy, psychology and/or other) staff and/or peers on the ward. Additionally, it was not possible to explore the experiences of service users from Black, Asian and minority ethnic (BAME) backgrounds because accounts of those from BAME populations were lacking in the review. The authors acknowledge that the lack of detail regarding ethnicity‘is salient when considering that BAME populations are disproportionally represented within inpatient mental health services.’ Furthermore, a lack of detail means the authors were also unable to explore experiences of those detained under mental health legislation. The authors recognise that extending the review by including grey literature such as reports from service user groups would complement the findings.
Implications for practice
This review contributes to the understanding of service user experiences on ward-based activities and highlights that meaningful activity on acute adult mental health inpatient wards remains a critical topic of study. The synthesis confirms that the current provision of ward-based activities is unsatisfactory for many service users with activities being described as ‘organised’ or staff-directed, and lacking meaning.
The review identified personal barriers (wellness) to accessing and engaging with ward-based activity and environmental influences (ward milieu) on the provision of activities and the quality of what is offered. These personal and environmental factors could be extended to explore the relationship between ward-based activities and interactions and engagement with staff.
Person-centred activity planning requires therapeutic engagement that can be integrated into existing conversations around care planning to ensure that individuals are supported to access and engage in activities that are meaningful. The therapeutic benefits of participating in ward-based activities will be improved by involving service users in supportive conversations around their needs on the ward. The authors note that co-production is emerging as a powerful model to support the active participation of service users, and that recognises that the therapeutic relationship can be used to better understand what makes activities meaningful. We can also learn from initiatives such as Star Wards, a programme that facilitates partnership working; by engaging service users in conversations about time use on the ward and by providing activities that promote service user – staff engagement and that fosters interaction as a routine part of practice (Janner & Delaney, 2012). Theories by which to explore meaningful activity can also be considered such as ‘flow’. Flow is a construct that describes optimal experiences and that occurs when totally involved in an activity. Experiences of ‘flow’ enhance happiness and counteract the effects of boredom (Csikszentmihalyi, 1990). These conversations can be seen as an extension to recovery support and person-centred care, by collaboratively involving service users in activity planning and subsequently promoting autonomy, empowerment and choice (Farnworth et al, 2004).
Statement of interests
The blog author knows and works with, or has worked with, some of the authors of the primary paper. However, she has had no involvement in the piece of research presented in the blog. The blog author is an occupational therapist and has worked on research that developed guidance for recovery-orientated practice.
Csikszentmihalyi M (1990) Flow: The Psychology of Optimal Experience. New York: Harper and Row.
Donald F, Duff C, Lee S, Kroschel J, Kulkarni J (2015) Consumer perspectives on the therapeutic value of a psychiatric environment. Journal of Mental Health 24(2): 63–67.
Farnworth L, Nikitin L, Fossey E (2004) Being in a secure forensic psychiatric unit: every day is the same, killing time or making the most of it. British Journal of Occupational Therapy 67(10): 430-438.
Janner M, Delaney KR (2012). Safety issues on British Mental Health Wards. Journal of the American Psychiatric Nurses Association 18(2):104–111.
Le Boutillier C, Leamy M, Bird VJ, Davidson L, Williams J, Slade M (2011) What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance. Psychiatric Services 62(12): 1470-6.
Marshall C, McIntosh E, Sohrabi A, Amir A (2020) Boredom in inpatient mental healthcare settings: a scoping review. British Journal of Occupational Therapy 83(1): 41–51.
Newell SE, Harries P, Ayers S (2011) Boredom proneness in a psychiatric inpatient population. International Journal of Social Psychiatry 58 (5): 488-495.
NICE (2019) Service user experience in adult mental health services. Retrieved from https://www.nice.org.uk/guidance/qs14/documents/previous-version-of-qual.... Accessed on 30/11/2020.