Inpatient psychiatric units are intended to provide a safe, structured, and supportive environment for acutely ill patients that facilitates stabilization of their illness (Gwinner & Ward, 2013). Fundamental to a unit's structure are groups and activities scheduled throughout the day that help organize the patient's day and provide socialization and creative and educational experiences (Janner & Delaney, 2012; Steele, Henderson, Lennon, & Swinden, 2013).
On a short-term psychiatric inpatient unit located within a large Mid-western medical center, the interdisciplinary leadership team (unit director [UD], assistant UD, and medical director) had concerns about the focus of groups currently available for patients. The unit admits adult patients in need of acute hospitalization for stabilization and evaluation. Units are staffed by nurses, mental health counselors, and occupational therapists. The unit's current group structure was largely based on cognitive-behavioral therapy (CBT) principles. This was the guiding framework since the unit began approximately 20 years ago. However, after examining the unit group's content and structure, the interdisciplinary leadership team agreed that groups would appeal to a greater breadth of patients if they were based on a model not exclusively operating from a cognitive approach.
The current quality improvement project was developed. The goal was to implement evidence-based group programming aimed at enhancing coping skills of patients hospitalized on the unit and creating a group environment of positivity. After discussion, the interdisciplinary leadership team decided to implement groups that were in line with acceptance and commitment therapy (ACT).
Acceptance and commitment therapy views an individual's psychological difficulties as problems of psychological inflexibility, a rigid response to unfolding reality, marked by a difficulty with being fully present in the current situation and adopting behaviors to fit with the present context and one's values. An ACT approach encourages individuals to practice psychological flexibility, connecting with the present moment, calling to mind long-term values, and then making a conscious choice to change or persist in behavior (Kashdan & Rottenberg, 2010). The approach encourages compassionate self-acceptance for uncontrollable conditions while taking committed actions toward creating the kind of life most patients desire.
Interventions are designed to help individuals increase their awareness of environmental demands, personal values, and coexist with challenging thoughts and feelings while taking actions in the service of achieving necessary and desired life goals (Twohig, Woidneck, & Crosby, 2013). In the context of a therapeutic relationship, an ACT approach aims at establishing greater psychological flexibility through acceptance, a transcendent sense of self, contact with the present moment, values clarification, and building a larger pattern of committed action linked to those values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The ACT approach also involves a process called defusion, which is standing outside of thoughts and changing the way one interacts with them; seeing oneself as a third party to the thought and not embracing or dwelling on its content. For example, when a self-defeating thought enters one's mind, ACT principles would instruct one to not embrace the idea “I am no good” but rather realize “I am having a thought that I am not worthwhile.” Such interventions are designed to help individuals increase their awareness of situations and coexist with challenging thoughts and feelings while taking actions in service of achieving necessary and desired life goals.
A planning group for the current quality project was formed, comprising the UD, assistant UD, milieu coordinator, and one of the unit's occupational therapists (C.M., J.F.H., C.F., C.P.). This planning group also examined the ACT approach and saw its potential to help patients ease distress and see options for addressing their issues. The group also recognized an opportunity to improve consistency and structure of group sessions with an emphasis of a single approach. Occupational therapy staff had recently developed groups that integrated ACT concepts, and feedback collected from patients indicated ACT concepts were effective and applicable to their issues. The planning group also believed groups would be more effective and appeal to more patients on the unit if based on a model that contained cognitive and emotion-focused approaches, an approach consistent with ACT.
An ACT approach has been used in therapies with a variety of individuals with mental health issues. Empirical and clinical research supports ACT as effective and appropriate for individuals with a variety of anxiety disorders (Arch et al., 2012), depression (A-Tjak et al., 2015), and substance use disorder (Lee, An, Levin, & Twohig, 2015). The ACT approach has proven effective on inpatient psychiatric units for individuals with eating disorders (Juarascio et al., 2013), conversion disorders (Baslet & Hill, 2011), and psychotic symptoms (Gaudiano, 2012).
The work of Gaudiano et al. (2017) is particularly relevant to inpatient treatment of individuals with serious mental illness (SMI). The team plans to adapt ACT for individuals with psychosis and determine its effectiveness in routine care in inpatient settings. They note that preliminary trials have demonstrated promising results with this population particularly in areas of changes in believability of psychotic symptoms. Their work will move the field in adapting this approach with a wider range of patients who are hospitalized for a brief period.
The ACT approach is also effective across lifespans. A pilot trial of ACT was conducted with older adults in long-term care facilities with symptoms of depression and anxiety (Davison, Eppingstall, Runci, & O'Connor, 2017). Researchers demonstrated that depression scores were significantly lower for intervention groups who received ACT compared with the wait-list control. These outcomes were maintained at 3-month follow up. Treatment satisfaction was rated highly by residents and care staff. Therefore, ACT shows significant promise not only in outpatient settings, but with individuals during inpatient and residential care.
The current project was designed as a quality improvement study and the process was consistent with the Plan, Do, Check, Act (PDCA) cycle (Johnson, 2002). Once the initial problems were identified and strategies were devised to address issues (plan), an evidence-based set of interventions was implemented (do), results were monitored (check), and adjustments were planned based on data (act). In line with the PDCA approach, issues with groups and their content or staff's consistency in using guidelines were also addressed. The current project was reviewed and approved by the site's Institutional Review Board.
Once the interdisciplinary leadership team determined the focus of the project, a planning group was formed (UD, assistant UD, milieu coordinator, and occupational therapist). The planning group then involved a larger cohort, including nursing staff, occupational therapists, and Rush College of Nursing faculty and students. These meetings aimed to ensure a clear understanding of ACT and set the expectation of staff involvement in the groups. The team realized staff education was critical as they would be conducting groups. To begin, several staff members attended outside workshops to gain a better understanding of ACT and how to implement this therapy on an inpatient unit. The materials from these workshops were incorporated into the on-unit in-service training.
The planning group conducted educational sessions with all nurses and mental health counselors employed on the unit. This 1-hour session detailed all six ACT principles and how they could be applied to inpatient groups. At the time the current project was initiated, students from the Rush University College of Nursing were on the unit completing their psychiatric practicum. They initiated a project aimed at helping staff understand ACT language by placing a poster with ACT language and definitions about the unit. Although not a part of formal training, their efforts added to the effort to help staff incorporate ACT language into everyday practice.
After initial staff education, the planning group received feedback from staff stating that they were still uncomfortable with performing in ACT-based groups. Staff were reeducated using additional tools and specific examples. Thorough definitions of the six components of ACT were provided. Video examples of therapists using ACT within patient interactions were shown on the unit. The team also provided scripting of ACT–consistent verbiage and how to use this in day-to-day interactions. Members of the planning group consistently queried staff on how they perceived the groups and how they problem solved any emerging issues/questions.
Data were collected on the impact of ACT programming based on two instruments. Patients' responses to groups were monitored by the Acceptance and Action Questionnaire II (AAQII) and the Evaluation of Group Experience. The AAQII is a seven-item measure specifically designed to gauge an individual's tendency toward experiential avoidance and psychological flexibility (Bond et al., 2011). The assessment of these psychological constructs falls in line with goals of ACT therapy, which are to decrease avoidance and increase flexibility in approaching difficult situations. The instrument has demonstrated good psychometric properties, the mean alpha coefficient is 0.84 (0.78 to 0.88), and the 3- and 12-month test–retest reliability is 0.81 and 0.79, respectively. The AAQII also demonstrates appropriate discriminant validity. It is predictive of a range of functional and mental health outcomes that are consistent with ACT (Bond et al., 2011).
The Evaluation of Group Experience is an investigator-designed measure that asked patients to rate a group along five dimensions on a 5-point scale (1 = not true to 5 = very true). The tool's dimensions focus on the group leader's manner as well as relevance of the material. The five items asked were: Did the therapist seem present, attentive, and non-judgmental? The next questions dealt with the patient's reactions to the group: “I felt understood and accepted.” Finally, the patient was queried on how well the group content met his/her needs (three questions): The group focused on stuff I cared about; The group focused on stuff that could be helpful; The group seems to fit and work well for me.
Ratings of the group experience were collected after each group. All forms were administered by staff. In the current project, the AAQII was administered at admission and discharge. The form contained minimal patient data—name and age. The group feedback form asked the patient's name and identified staff who conducted the group. Data were analyzed in aggregate for overall satisfaction with the ACT groups and changes in the AAQII.
ACT–focused groups were systematically introduced into patient schedules, one to two per day. The initial groups were flexible. Staff members were asked to introduce and use ACT principles in groups. For example, staff members who ran a music group began to ask participants what their reactions to a piece of music were “in the present moment.” Staff members who were comfortable with ACT organized groups in line with one ACT idea, such as exploring the notion of committed actions. Binders were available with ideas for how to organize groups and suggested activities. During the first month, ACT groups occurred at least once per day.
Evaluation of the current project focused on patient perceptions of groups and their responses on the AAQII. AAQII scores post-implementation demonstrated a 1-point average improvement but did not reach significance (t = 0.559). However, post-intervention variance increased significantly, demonstrating that some patients had significant improvement. In 2016 before unit groups began, the occupational therapist was conducting ACT groups and distributing the AAQII. A total of 35 pre/post scores were collected pre-implementation of unit-based groups, and a total of 34 pre/post scores were collected following implementation of unit-based groups. The data show an increase in the number of patients who experienced an improvement in AAQII scores, which indicates improvement in psychological flexibility (Figure 1). The graphs indicate the AAQII data collected on patients in 2016 and then again in 2017 following the implementation of unit-based ACT groups. The authors saw a 12% increase in patients who experienced improved scores, an 11% decrease in patients with a decline in AAQII scores, and a 4% decrease in patients who experienced no change in scores after staff education was implemented and groups were run on a regular basis (Figure 2 and Figure 3). No other changes were implemented on the unit during this time.
Variance of Acceptance and Action Questionnaire data for the years prior to (2016) and after (2017) initiating groups.
Patients' responses collected at the beginning of hospitalization and discharge, 2016.
Note. AAQ = Acceptance and Action Questionnaire.
Patients' responses collected at the beginning of hospitalization and discharge, 2017.
Note. AAQ = Acceptance and Action Questionnaire.
All patients rated group dimensions as true or very true with scores on each question each month averaging ≥4 (Figure 4). In June/July, scores decreased, but the number of patients on the unit was smaller in these months. Therefore, any negative rating had a bigger impact.
Average patient response, 3 months in time, across five questions.
Scores indicate that patients believed the therapist seemed present, attentive, and non-judgmental (Question 1) and that they felt understood and accepted (Question 2). Interestingly, there was a small decrease in agreement on Question 3, the group focused on “stuff I cared about,” and Question 4, the group focused on “stuff that could be helpful.” There was also less agreement on Question 5, “the group seems to fit and work well for me.”
Based on the first trial, unit leadership intends to retain ACT orientation to treatment. The plan is for units to continue ACT groups. The program planning group found that ACT was a good fit within the unit's population because it provided another avenue for managing distressing thoughts. The approach also addressed patients' issues while providing optimism. ACT helped patients see problems in a new light, such as a person can still move forward while experiencing distressing thoughts. Group leaders also sensed that patients were engaged in the groups, even individuals who did not participate. Groups also added a sense of variety to schedules and a sense that the group would not be a mundane repeat of yesterday's agenda. In the next cycle, training materials will be evaluated for relevance to staff. Additional training sessions will be added. In the next iteration, the planning group will aim at groups being conducted with greater consistency and try to bring more staff into the training process and engagement with the current project. Patient attendance at ACT groups will be collected so that the relative “dose” of ACT groups can be calculated.
Through the systematic implementation of ACT–based group sessions, the planning team achieved the goal of improving consistency and structure of group sessions on the inpatient unit. Evidence of the achievement was measured by patients' positive perceptions of the new group programming and AAQII scores, which showed an increase in psychological flexibility in most participants.
An ACT approach was a good fit with individuals hospitalized on the unit because it shifted the culture in a positive direction with a focus on promoting growth and change. Findings were confirmed from patient feedback through Press Ganey® surveys distributed on the unit. In the survey feedback prior to the change to ACT, patients indicated the previous CBT model was confusing. It is possible that because of the nature of inpatient hospitalization, admission on Tuesday could mean that the patient missed an explanation of CBT that occurred on Monday. Following the change to ACT, patients expressed thorough understanding of ACT, that it was an enjoyable therapy to be involved with, and they believed they would be able to use this information independently outside of the hospital setting.
As indicated in the literature, ACT can be implemented on short-term psychiatric units and is beneficial to patients (Gaudiano et al., 2017). Yet for this to happen, especially if staff members are designated to run groups, staff members must be engaged with ACT philosophy. As described, all staff were involved in the roll out of groups and additional education was provided to staff members who did not feel comfortable conducting groups. Even staff members who were on board with the groups often found it difficult to conduct groups due to the hectic nature of units; a barrier reported in the literature by inpatient nurses who are charged with running groups (Wykes et al., 2018). Other staff members did not feel comfortable running groups and did not see it as a component of their position.
However, select staff members were highly motivated to run groups. As groups took place, staff members saw changes in patient behaviors and the joy shown in patients who wanted to attend groups. Family members began to see changes, which prompted them to attend groups as well. Family sessions were offered once per week where an explanation of ACT was reviewed. The sessions seemed to help families cope and understand not only their loved one, but also how to apply the teachings to their daily lives. Therefore, one stimulus for staff members to become involved in conducting groups can be the positive feedback from patients and families, which even when not systematically collected, can motivate staff members to continue with the groups.
As a single-site quality improvement study, findings cannot be generalized to a larger audience. Although the authors hoped to have a larger number of patients complete the AAQII, it was difficult to capture every patient at discharge. Sometimes discharges happened suddenly and forms were not distributed. There were no available data on the effectiveness of CBT–style groups that had been conducted on the unit. Therefore, it is difficult to draw any comparisons around the outcomes of ACT groups compared to a CBT framework. Staff training occurred via various platforms (e.g., workshops, on-unit in-services, videos). Although all staff members attended the in-services, the authors did not track their hours of training and cannot assess if training influenced their willingness to conduct ACT groups.
Using a quality improvement framework, a group programming based on ACT principles was instituted on a short-term inpatient unit. Data collected from patients indicated that they enjoyed the groups and demonstrated slight improvement in psychological flexibility. Although some staff members were reluctant to conduct groups, the authors were able to maintain a schedule of at least five ACT groups per week. The current project demonstrates that it is possible to implement an evidence-based intervention and create a positive impact during brief in-patient treatment. The plan is to continue ACT groups and encourage increasing staff participation in the effort.
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