Staff experience of team case formulation to address challenging behaviour on acute psychiatric wards: a mixed-methods study

Figures & data

Table 1. Demographic characteristics staff participants from acute psychiatric wards (N = 18).

Demographic	Frequency
	N (%)
Age (years)
18–25	3 (17)
26–35	10 (55)
36–45	2 (11)
46–55	3 (17)
Gender
Male	5 (28)
Female	13 (72)
Ethnicity
Asian/Asian British	1 (6)
Black/Black British	4 (22)
White British	7 (39)
White other	3 (17)
Mixed/multiple ethnic groups	2 (11)
Other	1 (6)
Length of work on acute wards
<1 year	5 (28)
1–5 years	9 (50)
6–10 years	3 (17)
>10 years	1 (6)
Ward
Female acute ward 1	5 (28)
Female acute ward 2	2 (11)
Male acute ward 1	4 (22)
Male acute ward 2	4 (22)
Male Psychiatric Intensive Care Unit	3 (28)

Table 2. Thematic analysis of staff experience of team case formulation of service users with challenging behaviour (N = 18).

Theme	N (%)	Explanation	Illustrative quotes
Wish for improved continuity of care	17 (94)	Participants reported that they would like to improve consistency with which care strategies are implemented by the team through integrating it into existing practices such as handover and allocating tasks to groups of individuals. They reported that they would like to have an ongoing discussion about which care strategies have been implemented and how effective they have been.	“Maybe it could be something in handover that could be said…just to say, ‘this is what’s happened during the group and this is what we are going to do now’, I think that could be useful, because sometimes, when it’s just a couple of people saying to other people, it…gets lost…from shift to shift.” (#17) “We could be more particular, about who is responsible for certain things being achieved…even if it’s just generally like doctors to do this, nurses to do this.” (#7) “The only suggestion I would see is if…at the next meeting, have an update…speak about the last person.” (#1)
Safe supportive space	15 (83)	Participants reported that they appreciated having a confidential space to acknowledge that they may be feeling stressed and where they are able to support each other.	“It does allow you…an opportunity to just say ‘this person stresses me out’… showing vulnerability is rarely something you’re capable of doing…so to have the opportunity to do that in a way that is just socially sanctioned can be helpful, because otherwise you have to just uphold a very professional demeanour and that can be quite exhausting.” (#7) “There is actually only certain kinds of safe environments, like when we do the case-based discussion, where it’s purely MDT, it’s…your choice to go…and I think people enjoy that sort of safe hour, you know it’s uninterrupted, and it’s a good time for me to realise that someone else was really stressed by that.” (#6) “It does have a lot of impact on staff, whether it’s physical, emotional, and being stressed…it’s like it gives permission to be thinking about and acknowledging that it is really hard on you and if you’ve been…getting someone shouting at you or saying things that are unkind to you, that it’s quite normal to be feeling that way. (#10) “You find that you’re not alone, because everyone is going through the same thing. And that’s why it’s good that it’s done as a group.” (#1) “The ward is so fast-paced and a highly intensive environment, sometimes you just need that space to just, let yourself be heard, because it can be frustrating.” (#17) “I think we should maybe encourage people to talk a little more on that point, because it would be nice for staff to really have a good think about, talking out loud about how actually it makes them feel and not feel…embarrassed to say ‘oh I felt really upset about that.’” (#6)
Holistic understanding	14 (78)	Participants reported that they valued developing a broad understanding of service users, which was difficult to do outside of case formulation due to the busy working environment of the ward. They reported that this helped them to understand the contextual factors that have contributed to the service user’s current presentation, rather than looking at their behaviour in isolation.	“A lot of the time these guys on the ward will have a lot of, a lot to tell you about their life…and I think that probably does play a big part… into why they are here now, so it’s definitely a good idea to look back at that and obviously, it…helps to get…a broad understanding of the person…like their background and who they are.” (#3) It gives you time to sit down and really get…that in-depth background in the patient that you might not have time to do when on the ward, you’re quite busy, so you’ll get a snapshot, so you might not be able to delve into [medical records].” (#17) “Sometimes, if we are not careful, we will end up using one aspect, which is mental health, to decide on what sort of care plan we’re going to create for the patient, whereas if we sit down to do case formulation we put everything else into context, we consider all the factors that concerns the patient and then we use that to create a care plan, which at the end of the day, looks at the holistic person…that is why case formulation is different and beneficial.” (#12) “Because everyone’s got different experiences and different sort of professions that they’ve come from, everyone’s got different contributions to make to that discussion, so it does feel like we have a good picture of the person afterwards.” (#10) “It’s nice that there is space for the [psychology] interventions or recommendations but also…nursing interventions or OT interventions are also included in that, it’s…more…well-rounded, which is really nice for us to think in that way.” (#5) “On this template, you have everything, all on one page and it’s good to just see it all in one go and put it all together and that’s quite hard to do by myself and it’s good to have that in that sense, so we can all sort of feed into it and build a big picture rather than a small one.” (#14)
Shared understanding of behavioural patterns	13 (72)	Participants reported that formulating as a team helped to develop a shared understanding of service users’ behaviour. They reported that this was useful for bringing information together from different professionals, who may have different relationships with service users and may notice different aspects of behaviour on their shifts.	“I think it’s quite good to identify the behaviour in the first instance and highlight what’s happening because it helps you think ‘is there a pattern to it?’…having a think about what happened before, is there anything that caused it.” (#14) “If you see a pattern, you can almost predict if some behaviour is going to come up, so you can look at ways of managing it.” (#4) “The good thing is, because different staff work around with the patients, everybody may have experienced different aspects of their behaviour, so when we come together as a team, it helps for different people to share their experience around the patients’ behaviour…so that we can have a collective view about what actually is happening with these patients.” (#12) “I think everyone sees a different part of it depending on what you observe on the ward, so it’s really good to sort of bring that together in a group discussion.” (#6)
Improved clinical confidence	12 (67)	Participants reported that generating an informed care plan which addressed patient needs allowed them to feel more in control and confident to assist with their care.	“It helps because you come in and it works, it makes you happy, that means that you’re working along with patient’s needs and that’s it, that solves the problem…so…coming up with that, it does help…it gives a better understanding to manage the patient on the ward.” (#9) “Before I was a bit lost, working out how to deal with this person, or I found them a bit dangerous, or a bit intimidating…I felt more confident afterwards to be able to interact with that patient and more confident in how I can assist with their care.” (#8) “When you come out with the recommendations, you kind of know more how you should try and respond to them, maybe you should try and engage them with activities or get them to go to groups and things like that so I think it definitely does impact how you engage with them.” (#3) “You…come at a time when we have really difficult patients to manage, where we’re probably thinking ‘I don’t know what else we can do to manage them,’…We were able to use some of the strategies that we identified which we wouldn’t have thought of…on our own…so it’s a good standing board.”(#17)
Improved team relationships and communication	11 (61)	Participants reported that listening to their colleagues’ perspectives has brought them closer together, made them feel less alone and more like part of a team. Participants reported that agreeing upon a single care plan has improved consistency of care delivery.	“Because of this stress you rarely get to see the sensitivity of others…because the only time you are really interacting [is] when it’s…a crisis…so to have a moment where people show this side of themselves…it can really make you feel very close to them, you think ‘oh no you do, you really care about this person’…it gives you…a lot of faith in your colleagues.” (#7) “We are all in this together and let’s see, let’s try to understand all together what’s going on and how we can help each other in this.” (#15) “It gave people structure that they could follow and I think it…unified the staff approach to caring for the patient.” (#18)“It just…makes everyone…on the same page and…we understand the client more and understand our own roles… our own recommendations as well.” (#5) “I think it improves the communication because we are all sharing and it doesn’t really matter what your role is, everyone has an opportunity to give their perspective and their views so I think it brings us closer together.” (#10)
Improved therapeutic alliance	11 (61)	Participants reported that case formulation improved their ability to connect with service users, through gaining a better understanding of how to engage with them and support them. They reported that case discussion increased their motivation to approach service users and take extra steps to help them.	“I think from the patient’s perspective…we can be more caring about them and we show interest about their situation, I think that they feel more listened to and that we are here to help as well.” (#2) “After you do a case formulation you find that you speak to that person a lot more because you want to find out what’s going on in their heads…So it’s definitely important, because something switches in your brain and you think, maybe I should try a bit more with that particular patient right now because they are actually being really challenging and see if you can possibly help them overcome that.” (#1) “I had no idea that [this is] something that they are really interested in and…it gives me something I can then try and introduce to them or you know, have a further discussion about.” (#10) “I think it just helps us understand in what way to approach them and how to help them manage their needs and…get them to achieve their needs…because some of their behaviours might be because we’re not understanding what they’ve been through and that could result in a negative or challenging behaviour but then if we just sort of change the way we approach them and how we deal with things with them [this] could lead to more positive behaviour.” (#14) “It does help us to connect better with the patient because the person feels well supported and this is one of the bases… when the patient recognises that they feel well supported by the team, why would they want to be aggressive.” (#12)
Increased job satisfaction	10 (56)	Participants reported that they felt more valued as a result of case formulation. They reported feeling heard and able to make important contributions to the discussion, regardless of seniority. Participants also reported finding more meaning in their work, due to gaining a broader understanding of service users.	“I feel like everyone is heard in that…group, it’s really nice…some people think that because they are like a level 3 compared to a really high up level…that there is some sort of hierarchy, but …everybody…contributes evenly to it, which is really nice.” (#5) “Especially when you’ve got something to contribute to the discussion and it could be new information that you realise other people didn’t know, it makes you feel a bit more valued…like you are actually making a really important contribution.” (#10) “It gives more meaning to my job because obviously you’ve got this new information that helps you to see the person…behind the illness.” (#15) “It motivates you to go that extra step, to try a bit more, so it drives you and motivates you.” (#17) “She’s doing really well, and you know, through activities, engaging her, it’s made me think ‘oh we’re getting somewhere’. It makes you even more interested because it makes you try to find out more and sort of like keep chipping away at the wall.” (#1)
Reflective practice	9 (50)	Participants reported that they appreciated a space to slow down and think about service users in more depth, which can be difficult in a fast-paced environment of the ward. They reported that discussing service users with the MDT encouraged them to reflect on their practice and consider different points of views.	“When…you’ve got a patient who maybe is displaying some challenging behaviour, it’s easy to become frustrated and to…really struggle to think about…what are they trying to tell me… So it’s easy to get lost in that, but…in those sessions you just…get to sit down and just get to think and I really appreciate that.” (#3) “It just gives you a bit of a nice, sort of protected space to actually think about the patient in a non-rushed, sort of, I often might see patients on call and you’re really rushed and you’re stressed and you don’t get the time to sort of stop and think about it in detail.” (#6)“Developing an approach that we can all agree with…that is appropriate for this patient, and is empathetic and…curious and I think…that is rarely achieved in a very fast-paced environment.” (#7) “It gives us a link with the psychology team and it makes us think a little bit deeper about our patients and not just kind of in, out, in treat, out.” (#6) “I think that’s the beauty of having so many people in there and I think sometimes, especially when you’ve got a…quite an unwell patient and it can be quite draining on you sometimes, and then to look at it from another point of view and you think ‘oh actually, I do feel quite bad for them, or I might change that’ so it’s a really good way to reflect on your own practice.” (#4)

Table 3. Thematic analysis of staff views on important factors to discuss in team case formulation for service users with challenging behaviour (N = 18).

Theme	N (%)	Explanation	Illustrative quotes
Life Story	18 (100)	Participants reported that learning about service users’ life stories was one of the most interesting parts of case formulation, as it increased their understanding of service users’ behaviours through discussing significant life events, triggers and patterns of behaviours. Participants reported that learning about service users’ life stories often made them aware of the traumatic events that service users have experienced, which made them more compassionate and understanding of their behaviour and increased their ability to provide trauma-informed care.	“If I were to highlight one particular box in which I think actually this is an area that I see as…really…pushing how we might have otherwise thought about this patient…it might be that element. This person does this, because of this element in their background…this experience, what are ways in which we can try and…positively, encourage other behaviours through understanding that pattern.” (#7) “I think when you understand someone’s life story and why they are here and what’s got them to this point, it just makes you a little bit more understanding of this behaviour or any negative behaviour and then you think ‘okay, maybe they just need an extra bit of time today’.” (#14) “[Working in an acute unit] you can sometimes forget about…where a person comes from. In Australia we talk a lot about…trauma-informed care… this reminds me of this, because it’s all about…understanding the person and where they come from and what sort of things they’ve been through in their life that might impact their behaviours now and I always find after it that, there is… way more understanding and…compassion and…willingness to…work with this person who has these challenging behaviours.” (#5) “When we’ve got more of a background, we can be more innovative about how we discuss, how we do the care planning, so if it’s somebody…with post-traumatic stress disorder, and triggers with noises and all those…things that we may not have picked up on before.” (#13) “You know when I hear the life story, I feel like I am more compassionate towards him, because when the person grew up with no family support, no friends, I can completely understand why that person ended up having such a difficult time and definitely affected their mental state.” (#2)
Service users’ needs and perspectives	16 (89)	Participants reported that it was very important to be reminded to consider how service users may be feeling and what needs they may be trying to communicate through their behaviour. Participants reported that thinking about this as a team and hearing different perspectives has shifted their perspective and allowed them to see that service users’ behaviour may not be deliberate. They reported that it was difficult to think in this way outside of case formulation, due to work demands and staff burnout.	“I think a lot of the time, although people might not want to admit it, we are selfish, so their behaviour can affect us and that’s what we think about…But you forget actually someone might be kicking off because they are really upset, they are feeling lonely. If you sit down and have a chat to them you find out more often than not, that is the reason they are getting annoyed. So I think that is really important, so we know how they are feeling, we think about it in more depth.” (#1) “I think, we have to understand it from their perspective, it’s their recovery and it’s their journey and we’re here to help them, I think if we’re not thinking about what they’re thinking, then we’re not doing it right, but it can be hard.” (#14) “Staff can be burned out…it’s hard and you…get into…the routine of the ward, but it’s nice to put yourself in someone else’s shoes.” (#5) “Through the case formulation, what comes out, is another aspect behind the behaviour that is not immediately obvious.” (#15) “It’s…making us think, at the end of the day, what are they trying to communicate…If they are being aggressive towards staff and patients, is there something else?” (#8) “I think this is the hardest one. Out of all of them, because it’s just so…subjective isn’t it. Because it’s not just observations.” (#4) “Quite often, we’re thinking about the behaviour and how it’s presenting us with a challenge and that gets us to stop and think, why is this person doing this and are they trying to tell us that they are frustrated, are they just really unwell… I think it gets us to stop and put ourselves into their perspective for a minute and think about…how this must feel just as bad for them as it might be feeling for us.” (#10) “I think sometimes you can get a little bit presumptuous, but it’s good to, because sometimes we’ll say completely different things and that’s quite interesting, sometimes things you just never even thought that they might be thinking or feeling.” (#6)
Awareness of cognitive and functional abilities	13 (72)	Participants reported that the discussion made the whole team more aware of possible cognitive or functional dysfunctions and reduced blame-based thinking through realising that service users’ behaviour is often unintentional. Participants reported that it was useful to identify alternative approaches to engage and communicate with service users who have additional needs.	“It can be quite hard to recognise cognitive dysfunction… [it is] easy to assume it with lots of our patients, that they are just doing things deliberately, and I think it could be important to try and take people away from that blame-based thinking.” (#7) “I think it gives people that reminder…or…a better understanding of why someone might be acting a certain way. And quite often it’s easy to just think ‘oh someone is being aggressive’ and we might not have thought about that they maybe, this is their way of communicating or they haven’t understood a situation… I might know something from an assessment that somebody has autism or a learning disability or maybe has issues reading and writing, and…the nurses may not have known that, and it might help to piece pieces together if they realised, oh if I’m giving him something written, he’s not understanding it and I need to make sure I’ve done it a different way.” (#10) “I think if we establish what are the cognitive abilities we might use alternative approaches with the patient to facilitate the communication and for the patient to be more engaged with us.” (#2)
Impact on others	11 (61)	Participants reported that it was useful to consider the impact of challenging behaviour on staff members, service users’ families and other service users on the ward.	“It gets us to think about consequences we haven’t thought about…the impact that it has on the staff member…or what it has for the relationships they have got with their family or the other patients who have observed it…and being asked that question gets us to think a bit wider about what is the real issue with this behaviour and who else is it possibly affecting.” (#10)
Physical health	11 (61)	Participants reported that physical health is often overlooked on psychiatric wards and it can provide an important link to behaviour. Participants reported that it was useful to consider medication side-effects, noncompliance and how it may affect service users’ daily routines.	“I think it’s good that we’re focusing on that as well because a lot of the time, because we’re working in mental health, physical health can sort of be put to one side, but it’s also as important…to see how that can influence their behaviour.” (#8) “They might be over-sedated…some medications…can actually cause [a] patient to go a little bit high or manic, sometimes we give patients medications that they have tolerance of or even have dependence on and so their behaviour can be a way of trying to get those medications.” (#11)
Social relationships	10 (56)	Participants reported that it was helpful to reflect on service users’ social networks inside and outside the hospital, which may positively or negatively impact their mental state.	“A lot of them discuss a lot of things…which is nice and it benefits them a lot…at other times, it can be really detrimental and [there are] interactions between 17 different patients, so you have, quite a complex network of things going on.” (#6) “The ward is like a small society, so…the way patient behaves, we can definitely reflect how it’s going to be on the outside world and how they will behave with their families, with their friends, in the community.” (#2)
Maintenance factors	8 (44)	Participants reported that it was helpful to reflect on factors, including staff behaviour, which could be inadvertently reinforcing challenging behaviour.	“They’ve learnt different ways of…getting their needs met, and it depends on the consequences that they get and so they learn either to, it perpetuates the behaviour or to refrain from it completely…So in our discussions we explore all these areas as to whether we are reinforcing the behaviour.” (#12) “It is quite helpful when you’re thinking about the behavioural conditioning with the consequences for the patient, they do this…and then we tell them to go outside and that’s what they really like and so essentially we are reinforcing it. ” (#11)
Distressing ward environment	8 (44)	Participants reported that it was helpful to consider how the environment of the ward may be contributing to challenging behaviour. They reported that loss of power and freedom and the behaviour of other acutely unwell service users are contributing factors. Participants reported that the discussion encouraged them to think about possible adaptations to improve service users’ wellbeing on the ward.	“Environment plays a crucial part in patients’ treatment on the ward…there’s only so many areas they can access at the time, this is not a normal, homely environment, so it’s very difficult to get everything you need at all times…your bedrooms, staff members need to open the door before you can access it, because nobody is allowed a key on the ward, so you’ve got so many…compromises…your privacy.” (#12) “We have other patients who are very unwell and…people who are not able to sleep and they are constantly distressed, pressing the alarms, constantly a lot of commotion on the ward, and it will have definite impact on people’s behaviour and this we try to also identify.” (#12) “There are some solutions that we can look at and it could be whether it’s moving someone’s room, or…thinking about the level of activities that they are engaging in, or if there’s certain people, they get on better with others and maybe we need to involve their family a bit more.” (#10)

Table 4. Mean scores of staff experience of team case formulation for service users with challenging behaviour (N = 18).

Visual analogue scale (0-10) (Please mark on the line…)	Mean (SD)
…How helpful you found case formulation in understanding patients’ challenging behaviour	8.67 (1.18)
…How supportive you found case formulation for your emotional wellbeing	8.44 (1.21)
…To what extent case formulation has helped you to feel more engaged with your work	8.31 (1.30)
…To what extent case formulation has helped you to tolerate the pressure of your work	7.17 (1.59)
…To what extent case formulation has helped you to feel more energised at work	7.58 (1.86)
…To what extent case formulation has helped you to manage the amount of work you do	5.33 (2.18)
…To what extent case formulation has improved communication between you and your colleagues	7.97 (1.52)
…To what extent you felt your voice was heard during case formulation	9.17 (0.77)
…How helpful it was to identify psychology care plan strategies based on case formulation	8.47 (1.01)
…To what extent the psychology care plan strategies identified during case formulation felt achievable	7.72 (1.50)