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Table 1 Aspects of mental healthcare services that staff perceived as good practice

From: Learning from clinicians’ views of good quality practice in mental healthcare services in the context of suicide prevention: a qualitative study

ThemeDescription of theme.Exemplar clinician responses
Promote safer environmentsThis theme centred around practice on inpatient wards and safely managing leave or discharge from the wards. Examples of good practice included:
• Good quality observations conducted by trained staff.
• Assessment of risk and mental state conducted prior to leave or discharge.
• Collaboratively developing safety, crisis and contingency, and leave plans, which includes access to support from crisis and home treatment teams.
• Copies of leave plans provided to all parties involved in the patient’s care (incl. Patients and families), and include contact details for services.
• Follow up contact with patients during leave from wards.
Effectively managing access to medication was seen as playing an important role in promoting safer environments. Safer prescribing practices included reduction in the supply of medication provided to patients to reduce risk of overdose. The care team should also communicate with patients’ GPs to plan and coordinate access to medication.
Finally, ‘no blame’ open learning cultures that provide the opportunity to review practice following patient deaths by suicide were also identified as constituting good practice.
“Observation training for it to be engaging and therapeutic” (ID43)
“Risk assessment carried out for every period of leave”(ID14)
“Use of collaboratively created crisis plans to support out of hours care” (ID57)
“Printed leave care plan with details of relapse signature, ward contact details etc given to all patients and their carers who go on leave” (ID21)
“Daily telephone contact with patients who are on overnight leave” (ID61)
“Very close liaison with the GP to prevent obtaining double prescriptions” (ID59)
“We include regular ‘learning lessons’ feedback where care can be improved and where care has gone well in our clinical improvement and business meetings”(ID61)
“We have an open culture to discuss and reflect from SI [serious incident] and new events” (ID42)
Develop strong relationships with patients and family/carersDeveloping strong relationships with patients and their families and carers was seen as a vital part of delivering good quality mental healthcare services. Good practices emphasised by respondents included:
• Active involvement of patients and their partners, families and carers in both care planning and the provision of care.
• Seek to build rapport with patients and maintain regular contact, as appropriate for the patient’s current level of need.
• Provide continuity of care by establishing consistency in the healthcare team, often through the assignment of a keyworker (e.g. care-coordinator).
• Adopt a more proactive approach to engaging patients with services, particularly in the case of proactively following up patients who miss appointments.
• Dedicated outreach service focussed on providing intensive support to enhance patients’ levels of engagement with services.
• Develop strong relationships with families that include two-way communication and information sharing.
• Responsive to family members’ concerns and staff share concerns with family members when patients missed appointments, or were not complying with medication.
• Provide support to family members in relation to their own health needs, as part of a family intervention including the patient, or in the event of a patient’s death by suicide.
“Active involvement of patient’s family in discharge planning” (ID15)
“His care co-ordinator knew him very well, had regular contact, there were clear efforts to try and have frequent contact with him” (ID55)
“Same consultant for inpatient and CRHT [Crisis Resolution & Home Treatment team] maintained continuity of care and communication” (ID57)
“Assertive outreach remaining I think the gold standard for providing intensive, multi-disciplinary treatment with continuity” (ID6)”
“Although discharged from HTT [home treatment team] the team did unplanned visit when his relative reported him missing” (ID47)
“Support for the family after patient’s death” (ID55)
Provide timely access to tailored and appropriate careThis theme centred around providing timely access to tailored support and treatment including:
• Prompt access to assessments, appropriate support, and treatment.
• Tailored needs-based care with active patient involvement in developing person-centred care plans and decision making in relation to their care.
• The adoption of a holistic multi-agency approach to care that also considers the patient’s physical health and psychosocial needs.
Clinicians also championed the provision of evidence-based specialist support and treatment that are aligned with national policies and guidelines, including access to:
• Psychological services and therapies such as Acceptance and Commitment Therapy, Cognitive Behavioural Therapy, and Dialectical Behaviour Therapy;
• Specialist alcohol and substance misuse services
• 24/7 crisis resolution and home treatment teams and crisis houses.a
Detailed and routinely updated assessments were also perceived as good practice, including the assessment of safety, risk, and mental capacity.
The ability for patients to easily re-access mental healthcare services, without having to endure long referral times, was also important.
“Easy/quick access to treatment”(ID11)
“Patient’s wishes were taken into consideration” (ID60)
“Good liaison with housing department, input from employment specialist” (ID59)
“Provide a high quality, evidence-based service in line with national and local policies and guidelines” (ID60)
“Availability of psychology service in both primary and secondary care setting” (ID24)
“Crisis service is 24 h 7 days a week service, response to emergency referrals is usually within 2 h”(ID52)
“Repeated mental state examinations and risk assessments” (ID54)
“[.] discharged patients [have] rapid access back into services when they relapse; i.e. no need for GP referral triage or allocation” (ID35)
Facilitates seamless transitionsThis theme highlighted the importance of effective communication practice that facilitates seamless transitions between, and discharge from services. Practices included:
• Care planning should include and be communicated with the relevant care team and other health and social care providers, particularly the patient’s GP.
• Patient notes should be up-to-date and accessible to all staff teams involved in providing care.
• Follow up contact with patients post transition/ discharge.
• Consistency of staff across transition, e.g., staff from new service introduced prior to transition to their service.
“Discharge/transfer of care plans to be communicated with GP and the relevant services” (ID41)
“Electronic records across all treatment services in the trust which allows immediate access” (ID51)
“Clear discharge planning on leaving inpatient unit, with onward referrals and follow ups made” (ID32)
Implementation of key worker system within Crisis Teams which designates a specific worker to oversee the patient’s care and transition to ongoing service” (ID50)
Establish a sufficiently skilled, resourced and supported staff teamHaving sufficient staff with the appropriate mix of skills and expertise was perceived as an essential aspect of delivering good practice.
Respondents saw value in:
• Staff having time and capacity to build relationships and cover absence in order to meet patient needs.
• Multi-disciplinary teams within service, plus provision of input from wide range of expertise and specialist disciplines, such as psychologists, and occupational therapists.
• Regular and timely access to input from consultant psychiatrists.
• Staff expertise in assessment and formulation.
Clinicians also highlighted the importance of addressing staff needs through:
• Meeting the training, development and support needs of staff.
• Providing regular clinical supervision including observation of practice, and having the opportunity for debriefing and reflective practice.
• Offering support following a patient’s death by suicide
“Urgent cover offered when care coordinator not available to meet needs of patient” (ID13)
“Multidisciplinary team approach including psychology, recovery, wellbeing and care coordination” (ID28)
“Was seen by the consultant within hours after initial assessment” (ID29)
“Regular supervision and at agreed intervals” (ID51)
“Increased emphasis on training and education in suicide prevention” (ID25)
“Staff support following suicide” (ID46)
  1. aIn the UK, the specific set up of Crisis houses vary, but they generally provide intensive, short-term support to people during a mental health crisis. Typically, they offer support in a home-like setting and act as an alternative to psychiatric hospital care. Crisis houses are only available in some areas of the UK and may be provided either by the NHS or by an independent provider