Adverse mental health inpatient experiences: Qualitative systematic review of international literature

Background:
Trauma has a well-established link with poor health outcomes. Adverse experiences in mental health inpatient settings contribute to such outcomes and should impact service design and delivery. However, there are often a failure to fully address these experiences.
Objective:
To describe the spectrum of negative experiences that people identify while they are inpatients in adult mental health services.
Design:
Qualitative systematic literature review of international literature.
Setting(s):
Inpatient mental health settings globally.
Participants:
Analysis includes findings from 111 studies across 25 countries.
Methods:
CINAHL, MEDLINE and PsycINFO were searched from 2000 onwards, supplemented by Google Scholar. Studies were appraised using the Critical Appraisal Skills Programme qualitative checklist. Data were synthesised using the ‘best-fit’ framework synthesis approach, enriched by patient and public involvement.
Results:
Adverse mental health inpatient experiences can be conceptualised under three headings: the ecosystem (the physical environment and the resources available, and other people within or influential to that environment); systems (processes and transitions); and the individual (encroachments on autonomy and traumatisation).
Conclusions:
This paper highlights the interplay between systemic, environmental and individual factors contributing to adverse experiences in mental health inpatient settings. By recognising and addressing these factors, we can significantly enhance patient outcomes. Application of adversity to Bronfenbrenner’s ecological systems theory provides a strategic approach to improving service design and delivery, advocating for environments that prioritise patient safety, dignity and respect. However, further research is needed to validate the framework and effectively integrate these insights into practice, ultimately transforming the inpatient care experience for all stakeholders.
Registration:
The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022323237).
What is already known
• Trauma and adverse childhood experiences (ACEs) are associated with negative mental health outcomes in adulthood, with a dose-response relationship indicating that increased frequency of ACEs leads to more harmful effects.
• Restrictive interventions in mental health inpatient settings, such as seclusion, restraint, and rapid tranquillisation, are all associated with a high incidence of PTSD, reflecting the need for careful consideration of their use.
• In addition to restrictive interventions, negative experiences in inpatient settings also include ward milieu, boredom, lack of information and coercion, thus a broad spectrum of patient experiences should be addressed to significantly improve outcomes.
What this paper adds
• This review is the first to comprehensively synthesise the wide range of negative inpatient experiences, resulting in a new conceptual model of adverse inpatient experiences in mental health settings.
• It highlights the impact of the ward ecosystem, processes and transitions on patient experiences, and the complex interplay between individual and systemic factors in shaping inpatient adversity.
• By focusing on the full spectrum of adversities, beyond restrictive interventions, wider service design and delivery improvements could greatly enhance patient care and outcomes.