Staff developed a range of community-based activities for psychiatric inpatients to promote social inclusion and integration into the community
Catriona Hutcheson, BSc, is occupational therapist; Hazel Ferguson, HNC Occupational Therapy Support, is activity coordinator; Paula Hendren is nursing assistant; George Nish, RMN, is charge nurse; all at Ailsa Hospital, Ayr.
Hutcheson, C. et al (2009) Developing community-based activities for inpatients in a mental health hospital. Nursing Times; 105: 19, early online publication.
A regional mental health hospital with a successful hospital-based activity programme created an activity coordinator role. The aim was to promote social inclusion by encouraging patients to take part in activities in mainstream settings.
This article outlines the process of developing the activity programme. Patients’ feedback was extremely positive.
Keywords: Mental health, Community-based activities, Social inclusion
- This article has been double-blind peer-reviewed
- Patients choose to participate in the hospital and community-based group sessions, which indicates they enjoy and benefit from them.
- A patient-led steering group successfully established a supported art group in the local college. There should be more opportunities for patients to be involved in service provision.
- Community and inpatient staff teams should provide easily accessible groups for patients in mainstream settings.
- Social inclusion should be a priority. All staff should include patients’ work aspirations and leisure opportunities in their care plans and actively support them to pursue these.
- One in four British people will experience a diagnosed mental health problem in one year (MentalHealth Foundation, 2009).
- The Star Wards (2006) guidelines highlighted the importance of hospital-based activity. This also raised awareness of the importance of sustainable activity after discharge.
- Grove (1999) found that 90% of mental health service users wanted to gain or return to work.
- Sayce and Measey (1999) argued the government has not placed any explicit priority on reducing social exclusion on mental health grounds.
Ailsa Hospital comprises three adult acute wards, two adult rehabilitation wards and four adult continuing care wards, as well as six elderly wards.
The activity team based at the hospital offered a wide-ranging programme of activities. The programme was popular and well attended, but an increasing number of patients identified difficulties with continued participation in activities in mainstream settings.
Our team adopted a focus on social inclusion, and developed links with external providers, including mainstream ones. We supported and developed a programme of activities in community settings for inpatients.
Social exclusion and inclusion
Sayce (2001) argued that people with significant mental illness are among the most excluded in society. She said social exclusion can be conceptualised in relation to mental health service users as ‘the interlocking and mutually compounding problems of impairment, discrimination, diminished social role, lack of economic and social participation and disability’ (Sayce, 2001).
She explained that lack of status, joblessness, lack of opportunities to establish a family and small or non-existent social networks cause social exclusion and the restriction of hope and expectation.
Beck et al (1997) defined social inclusion as ‘the extent to which citizens are able to participate in the social and economic life of their communities under conditions which enhance their well-being and individual potential’.
Huxley and Thornicroft (2003) argued that this could be achieved by enabling people to develop or rejoin their leisure, friendship and work communities.
Sayce (2001) said research with service users had identified their desire for social inclusion. She said they wanted more friends and relationships, less rejection by neighbours, employers and family, and more opportunity to be part of mainstream groups and communities.
Mental health professionals can help by including service users’ aspirations for work, education, relationships and other chosen journeys of recovery in care plans (Sayce, 2001).
This team comprises a charge nurse, occupational therapist, activity coordinator, occupational therapy assistant, staff nurse and two nursing assistants. The team is an unofficial one, and no additional resources are available in the hospital to address activity provision.
Team staff have individual caseloads, and are motivated and dedicated to provide therapeutic activities for patients.
The activity team carries out a questionnaire on interests with every inpatient before they start the hospital-based activity programme. This means we are able to encourage them to take part in activities of interest.
The team works with group nurses in the adult acute wards who provide educational groups, such as anxiety management. This is beneficial as the team can support patients to use these skills in a practical setting in groups.
However, group participants who wanted to do activities post discharge but lacked confidence to attend mainstream groups often highlighted the lack of community-based group sessions for inpatients.
Under a four-month pilot programme, the activity coordinator role has been recently created to coordinate activity provision in mainstream settings for inpatients. The aim is to enable service users to continue this after discharge to promote social inclusion.
As patients’ confidence and self-esteem grew and they became more motivated to pursue activities, the team encouraged them to identify mainstream opportunities. To raise awareness of community resources and to reduce anxiety, our team developed close links with community providers.
On occasions it is enough to provide patients with information about the variety of opportunities available, including college courses, paid and voluntary work, leisure and sports pursuits. However, the majority prefer to do activities in a supported setting before starting mainstream activities.
We developed strong links with the local college and tutors visit the hospital weekly to offer dance, drama, music, digital photography, art and crafts.
The dance and drama groups offer light exercise and encourage communication skills and self-expression. They have also helped patients to develop confidence and self-esteem.
The art tutor offers a range of activities including clay, pastels, painting and screen printing. We also held art exhibitions which gave service users the satisfaction of knowing their artwork was good enough to sell. At patients’ request, we organised an art exhibition in the local town centre for June this year, in the centre of the shopping mall.
The music group offers patients the opportunity to learn how to write music, and to play guitar, drums, keyboard and instruments from around the world. The local college recently offered them the opportunity to record their own music in the studio and cut their own CD. They are now aspiring to form a band.
A patient-led steering group successfully developed an art group in the local college for artists with mental health problems who wanted to be in a mainstream location, but in a supported environment.
Every month, a representative from the volunteer centre visits the hospital and holds an information session. Patients are advised about the variety of voluntary jobs available and how to pursue voluntary placements. Other vocational providers are also piloting information sessions in the hospital.
Sports interests are also encouraged, and mainstream centres offer badminton, tennis, yoga, walking, bowling and golf groups for inpatients.
Over a sample two-week period, six sport-based groups, five vocational groups and three leisure groups were offered to inpatients in community-based settings.
The sports groups included racket sports, golf, walking and yoga.
Several providers of supported employment and volunteer centres offered information sessions in the hospital and provided advice for patients wanting to pursue paid or voluntary work.
The leisure groups took place in community settings, where patients took part in mainstream groups, including digital photography, arts and crafts and music.
The vast majority of participants felt they benefited from the links with external providers and from tutors holding group sessions in the hospital.
Participants were also asked to rate their experience of the group, and virtually all gave positive feedback. They were asked if they would continue to take part in the activity after discharge and most replied they would.
Patient comments reflected the programme’s impact. One said the groups ‘helped me to use my imagination and put my skills to the test and now I use my talent to distract myself from the fast pace of life and have some tranquil time for myself’.
Another said: ‘If it wasn’t for them, I don’t think I would be here at times. The activity team are the people that put you on the road to recovery.’
In addition to our regular activity programme, we were offered two days of complementary therapy taster sessions for inpatients, provided by specialist trained therapists.
They offered hand reflexology, Reiki, Bowen technique, foot reflexology and acupressure. Over two days they offered 72 25-minute sessions, of which 67 were for patients and four for staff (one patient did not attend). Patient feedback was extremely positive.
Some 88% said they enjoyed the session a lot, while the remaining 12% enjoyed it a little. No one said they did not enjoy the sessions. When asked if they would continue to access complementary therapies after discharge, 97% said they would.
Patients reported a range of benefits from the session: 44 felt reduced anxiety; 44 felt more relaxed; 14 felt more optimistic; 10 had increased energy; and 16 experienced reduced pain.
Following his treatment, one patient remarked: ‘It has cured my anxiety. I didn’t remember I could feel like this.’
Financial constraints are so often a source of difficulty in the NHS. We have been incredibly fortunate that local activity providers, the NHS Lottery in Ayrshire and Arran and the health promotion department have been of great help.
However, the issue of ongoing funding will continue to threaten the project’s success.
Patient engagement is often difficult in mental health hospitals. We found that initially engaging patients needed time and enthusiasm from staff but, after patients started to attend groups, their motivation increased significantly.
Social exclusion is a long-standing problem for people with mental illness. The desire to develop and maintain roles, status, jobs, friends, interests and social networks is often met with stigma and rejection. Therefore, clients lose daily structure in their lives.
The opportunity to participate in educational and activity-based groups in the hospital setting is the first step towards social inclusion. This is an essential step which can help to rebuild self-esteem and confidence.
The next step is the ability to access mainstream resources. Our project aims to encourage and help patients to access mainstream activities of interest while in a supportive environment. Patients are then encouraged to continue to take part in activities in mainstream settings.
Integration in the community could contribute to reduced hospital admissions and improved quality of life for patients.
We would like to thank Greg Murdoch from our clinical effectiveness department, for his support in the project
Beck, W. et al (1997) The Social Quality of Europe. The Hague: Kluwer Law International.
Grove, B. (1999) Mental health and employment. Shaping a new agenda. Journal of Mental Health; 8: 131–140.
Huxley, P., Thornicroft, G. (2003) Social inclusion, social quality and mental illness. The British Journal ofPsychiatry; 182: 289–290.
Mental Health Foundation (2009) Statistics on Mental Health. London: MHF.
Sayce, L. (2001) Social inclusion and mental health. Psychiatric Bulletin; 25: 121–123.
Sayce, L., Measey, L. (1999) Strategies to reduce social exclusion for people with mental health problems. Psychiatric Bulletin; 23: 65–67.