Title: Understanding and improving therapeutic engagement between nurses and patients on acute mental health inpatient wards: a feasibility and evaluation study of Experience-Based Co-Design
Funder: Health Education England

Abstract: Background Therapeutic engagement has long been regarded as the essence of mental health nursing1. Its benefits are well documented: inpatients who are socially engaged adjust better to community life15, have greater symptom improvements during treatment14 and exhibit fewer violent and aggressive behaviours11. Nurses who spend more therapeutic time with patients have greater job satisfaction and take fewer sick days5, which may reduce the costly use of unfamiliar agency nurses. Despite this, research spanning 35 years shows that just 4-12% of nurses' time was spent on therapeutic activities9.Past attempts to improve therapeutic engagement, e.g. Protected Engagement Time (PET), where nurses devote an hour each day for nurse-patient sessions20, does not appear to have the desired effect7. This may be because patients suggest they prefer shorter, more readily available therapeutic interactions6 however PET emerged from ward practice rather than evidence-based collaboration with service-users21. While there is consensus that therapeutic engagement should be prioritised, a practical solution is yet to be found. A promising new approach to this is Experience-Based Co-Design (EBCD)26. EBCD has been previously used in a mental health service redesign which reduced the number of formal complaints29. The EBCD process, outlined in the King's Fund EBCD Toolkit27, brings patients and staff together in partnership to co-produce an intervention to improve therapeutic engagement within an acute inpatient mental health ward. Aims This study aims to explore the feasibility of using an EBCD approach to co-produce an intervention to improve therapeutic engagement within an acute inpatient mental health ward, then evaluate whether that intervention is effective in improving the type and amount of therapeutic engagement when implemented into the ward. The results of this study will inform a postdoctoral multi-centre feasibility trial that evaluates whether the co-produced intervention can be successfully implemented in further mental health wards. This will then inform a stepped wedge cluster randomised control trial.Methods Phase 1: months 1-9 Conduct integrative review of nurse-patient therapeutic engagement literature.Phase 2: months 6-36 Phase 2 consists of two components conducted simultaneously. Component 1: EBCD Using an adapted form of EBCD observations and focus groups will gather patient and staff experiences of therapeutic engagement. Then a series of co-design events led by staff and patient facilitators will draw from the experience data and bring patients and staff together to co-design and implement an intervention to improve therapeutic engagement within an inpatient ward. Component 2: EvaluationA mixed-methods evaluation that 1) examines whether patients and staff can co-design and implement an intervention to improve therapeutic engagement within an inpatient ward; 2) employing a causal modelling approach44, identify ways in which EBCD and the resulting intervention may improve therapeutic engagement and create an intervention implementation model to guide implementation. Phase 3: months 24-36 Develop a behavioural mapping tool to evaluate the impact of using the co-produced intervention to improve therapeutic engagement within an inpatient ward. Observations on one intervention and one control ward pre and post-intervention implementation will use the tool to measure and compare type and amount of therapeutic engagement.Dissemination Publish results in academic journals and present at national/international conferences. Due to the project's very collaborative nature, we intend to co-write and co-present some results with service-users. Benefits of the research Intervention co-designed by patients that receive it and staff that deliver it will be immediately implemented to improve therapeutic engagement Increased amounts of nurse-patient engagement Improved patient and staff experience and satisfaction Strengthening of service-user/service-provider relationships Foster a culture of collaborative working between staff, patients and the NHS Trust Generation of new knowledge e.g. increase evidence about whether patients and staff can co-design interventions to improve therapeutic engagement

Lay abstract: We have known for a long time that patients in an acute inpatient mental health setting appreciate spending time with their nurses and like to feel listened to and understood by clinicians. Such therapeutic interaction is beneficial for inpatients' outcomes and for nurses' job satisfaction. In spite of knowing this, research consistently shows us that as little as 4-12% of nurses' time is spent on activities that can be considered therapeutic. With this in mind, it is imperative that we find ways of improving the amount of time that patients spend with their nurses. Patients have told us that they experience inpatient wards as un-therapeutic and frightening; all at a time when there is an escalating demand for inpatient services. Improving patient experience is a priority for mental health services, and the NHS as a whole. To do this we need both a better understanding of what it is like to be a patient and also to give patients the opportunity to directly influence and design services in ways that are sensitive to their needs.Experience-based co-design (EBCD) is an approach that brings local patients and staff together, in a series of sperate and joint events, to co-design and improve services in partnership with each other. It has been successfully used to redesign an inpatient mental health service and reduce the number of formal complaints, and in a chemotherapy outpatient setting to develop an intervention to help carers who are looking after their loved ones at home. However it has never been used to co-design an intervention to improve the amount of therapeutic time that mental health nurses spend with their patients.Therefore we aim to test whether patients and staff can come together to co-design and implement an intervention to improve therapeutic engagement within an inpatient mental health ward. We are also interested in examining what makes EBCD work, and the processes through which EBCD and the resulting intervention might improve therapeutic engagement. Below is a brief guide of the study's design and structure to show how we intend to meet the above aims:Stage 1 (months 1-9) A literature review that combines the findings of previous research on nurse-patient therapeutic engagement.Stage 2 (months 6-36) Stage two has two parts that will be conducted simultaneously.Part 1 EBCD: This will follow the steps of EBCD and involve us carrying out observations of ward practice, using the data identified in stage one; focus groups with staff and patients to discuss their current experiences of therapeutic engagement and their main priorities for improving therapeutic engagement; then a series of events that will bring patients and staff together to work as equal and active partners in co-designing and implementing an intervention to improve therapeutic engagement. Part 2 Evaluation: Part two will evaluate both the EBCD process conducted in part one and the resulting co-designed intervention. This will involve us observing the events that bring patients and staff together to work as equal and active partners in co-designing the intervention; semi-structured interviews with patients and staff to discuss their personal views and experiences of the co-design process and the resulting intervention; questionnaires that will examine behavior change throughout the process and examination of the co-designed intervention to decide on the best way to implement it into the ward.Stage 3 (months 24-36) We will make a research tool that can be used to map nurse and patient activity. We will then use the tool to look at nurse-patient activity before and after the EBCD process. We will compare any similarities and differences to see if the intervention has improved or changed the amount and type of therapeutic engagement between nurses and patients. This will be done on the ward that is involved with the EBCD process and one ward that is not.We intend to use the results of this research to develop a future feasibility study that will examine whether an intervention to improve therapeutic engagement co-designed on one ward can be successfully implemented and improve therapeutic engagement in further mental health wards. This feasibility study will then inform a larger randomised control trial of the intervention. Equal and active patient involvement is at the forefront of our research and this includes when we make our results available to the public. We intend to publish our results in academic journals and co-write papers with patients who are involved in the study. We also intend to co-present results alongside patients at conferences.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH