Family Interventions iN Dementia Mental Health Environments

Background and rationale

Mental health wards (MHW) are a significant site of care for people living with dementia (PLWD), providing care for the most unwell, vulnerable, and high-risk individuals who are detained under the Mental Health Act (1983) for their own safety and the safety of others.

The UK has around 100 MHWs (80 NHS, 20 private) for PLWD, but there's a lack of evidence on care quality and experiences. Stays average 100 days, with most PLWD moving to institutional care rather than returning home.

Admissions often follow severe psychiatric or behavioural issues, such as self-harm or assaults. This population is at high risk to themselves and others, with high acuity and comorbidity. Admissions are complex, involving frequent unscheduled transfers to general hospitals, which are associated with high rates of falls and hospital-acquired infections.

Carer involvement can significantly improve clinical and social outcomes for people in mental health wards by reducing length of stay, promoting earlier discharge, and lowering relapse and readmission rates. Carers provide essential support that staff may not, ensuring person-centred care, advocacy, decision-making support, treatment adherence, and promoting recovery. However, carers often feel marginalized and describe MHWs as a place of 'battle,' experiencing high levels of trauma and distress with unmet emotional, social, and financial needs. Reviews and inquires highlight a culture that views carers as problematic and resource-intensive, leading to their support needs being overlooked.

There is an absence of research examining carer perspectives of MHWs and no evidence-based interventions to support carers of PLWD who are admitted within MHWs. In response, this study responds to urgent calls from the Department of Health and Social Care and NHS England, for partnership working with carers and families utilising co-production to develop effective interventions and training programmes to support carers and the guidance required by services and wards to support implementation.

Research question: How can MHWs effectively work in partnership with and support family carers of PLWD?

Aim and Objectives

This study will provide detailed understandings of carers experiences and involvement when PLWD are detained within a MHW, and staff rationales and responses to carers, throughout an admission. It will deliver new knowledge and evidence-based strategies co-designed to ensure carers are appropriately supported and involved and to improve patient outcomes.

Objectives:

• To deliver a detailed description of staffing structure, patient profiles, and current support for carers and families in MHWs for PLWD.
• Provide detailed understandings of carers' experiences, perspectives of involvement, and their support needs throughout a PLWD MHW admission, during transition, and following discharge.
• Understand ward organisational cultures and staff perspectives by examining (a) ward routines and practices that involve or exclude carers (b) staff understandings and recognition of carers needs, and (c) formal frameworks and informal rationales staff draw on to inform involvement or exclusion from decision making, care, and transition to discharge.
• Translate the findings using co-design into evidence-based strategies to support best practice in the involvement and support of carers.
• (a) Assess the feasibility of implementing these strategies in practice and (b) gather feedback from people with lived experience

Design

This mixed methods study uses a convergent parallel mixed methods design integrating a national mapping survey, interviews, ethnography and experience-based co-design and feasibility testing. This approach supports the collection of detailed data from multiple and contextualized perspectives, with the goal to improve healthcare systems.

The study uses family systems theory and the Family Adjustment and Adaptation Response Model (FARR) to understand family responses to stress, such as dementia and mental health admissions. It also incorporates anthropology and sociology theories to explore family and kinship in care contexts and how healthcare professionals and MHWs recognize and respond to families. This combined approach aims to understand carers' and families' experiences and how to best support them during MHW admissions.

Survey

Inclusion criteria

• Ward managers of mental health wards that provides care to PLWD
• Ward managers from NHS wards that provides care to PLWD
• Ward managers from private providers that provides care to PLWD
• Ward managers that work on organic or mixed wards that provides care to PLWD

Exclusion criteria

• Functional older adult mental health wards that do not provide care to PLWD
• Staff members who are not the ward manager

Longitudinal interviews with current carers

Inclusion criteria

• Family member (any relationship) or friend of a PLWD currently receiving care on a mental health ward
• Aged 18 years old or above
• Has capacity to consent to participate in an interview
• Willing to take part in 3 interviews over 12 months

Exclusion criteria

• The carer is actively involved in a safeguarding investigation.
• The carer is under 18 years old
• The carer does not have capacity to consent to participate in an interview

Interviews with discharged carers

Inclusion criteria

• Family member (any relationship) or friend of a PLWD discharged from the ward within the last 3 years
• Aged 18 years old or above
• Has capacity to consent to participate in an interview
• Willing to take part in an interview

Exclusion criteria

• The carer is actively involved in a safeguarding investigation
• The carer is under 18 years old
• The carer does not have capacity to consent to participate in an interview

Interviews with People Living With Dementia (PLWD)

Inclusion criteria

• PLWD currently under the care of the mental health ward
• PLWD discharged from the care of a dementia mental health ward within the last 3 years
• Has capacity to give informed consent to taking part in an interview
• Willing to take part in an interview alongside their carer

Exclusion criteria

• The PLWD is actively involved in a safeguarding investigation
• The PLWD does not have capacity to consent to participate in an interview
• The PLWD is not willing to take part in an interview alongside their carer
• The PLWD has been discharged from the care of a dementia mental health ward for more than 3 years

Co-design study - PLWD and carers

Inclusion criteria

• PLWD who may, or may not, have experience of dementia mental health wards
• Carers (family members or friends) of PLWD who may, or may not, have experience of dementia mental health wards
• Willing to talk about mental health and dementia
• Aged 18 years old or above
• Have capacity to give informed consent

Exclusion criteria

• Participants who do not have experience of living with, or caring for someone with, dementia
• Not willing to talk about mental health and dementia
• Aged under 18 years old
• Does not have capacity to give informed consent

Co-design study - staff

Inclusion criteria

• Members of staff working within mental health wards for PLWD
• Members of staff of any professional group in a role that involves contact with carers (e.g. health care assistants, nurses, occupational therapists, psychologists, physiotherapists, speech and language therapists, family therapists, psychiatrists etc)
• Members of staff of any pay band or grade
• Students on placement in a mental health ward
• Members of staff working on NHS or private wards

Exclusion criteria

• The staff member is actively involved in a safeguarding investigation
• Members of staff that do not work within mental health wards for PLWD

Feasibility study - PLWD and carers

Inclusion criteria

• PLWD
• Carer (family or friend; current or bereaved)
• Willing to review outputs related to mental health wards
• Aged 18 years old or above
• Capacity to consent to take part

Exclusion criteria

• The participant (PLWD or carer) is actively involved in a safeguarding investigation.
• Is not willing to review outputs related to mental health wards
• Aged under 18 years old
• Does not have capacity to consent to take part

Feasibility study - staff

Inclusion criteria

• Members of staff working within mental health wards for PLWD
• Members of staff of any professional group in a role that involves contact with carers (e.g. health care assistants, nurses, occupational therapists, psychologists, physiotherapists, speech and language therapists, family therapists, psychiatrists etc)
• Members of staff of any pay band or grade
• Students on placement in a mental health ward
• Members of staff working on NHS or private wards

Exclusion criteria

• The staff member is actively involved in a safeguarding investigation
• Members of staff that do not work within mental health wards for PLWD