Improving the provision of psychological therapies in inpatient care: The DOORWAYS project

Research output: Other contribution


Objective: The Care Quality Commission reported that less than half of the 52 per cent inpatients wanting psychological therapies received any. While providing psychological therapies to inpatients is a laudable aim, it is sometimes said to be impossible, due to the lack of access to clinical psychologists, the perceived inability of nurses to implement therapies, or the acuity of patients’ symptoms. We believe that it is possible to overcome these concerns, and one of the aims of the DOORWAYS project is to ascertain this. DOORWAYS started in March 2009 we present preliminary findings. Design: The study is best described as a stepped wedge design. Every six months the eight wards taking part are randomised and two are allocated to the treatment arm, repeated until all wards receive treatment. Data collection precedes randomisation.

Method: Psychological interventions were identified, each with some evidence base in an inpatient setting. Wards then choose which of these are most appropriate for their service, along with a core required set. The intervention phase consists of training staff in the implementation of these approaches by a clinical psychologist, who initially runs the groups. Gradually the responsibility for running the groups is passed to the ward team. The psychologist continues to provide support in order to maintain continuity.

Results: In the first two wards randomised, the interventions chosen were: Problem Solving Skills, Self Esteem-Coping with Stigma, and Hearing Voices groups. The non optional treatments were: Social Cognition and Interaction Training, Cognitive Remediation Therapy, Medication Education, Communications skills for staff, and Occupational Therapy led Remotivation Process. The training and implementation was staggered. A total of 20 training sessions were run, meaning that all nursing staff were trained in at least one intervention, with many attending training in more than one. Of the interventions in which training was provided, all are now up and running in at least one of the two wards, with the average service user attendance being 6 per group.

Conclusions: The project has demonstrated that nurses are able to deliver psychological therapies, when appropriately trained and supported. The view that this would be beyond their abilities both undersells their skills, and assumes a more complex model of psychological therapy than would sensibly be recommended. The uptake by service users of the interventions also demonstrates the receptiveness of acutely unwell people to this type of intervention. The acuity itself can be addressed by elements of the therapies offered, such as relaxation, emotion regulation, and anger management. This project was made possible because it was supported by staff at every level, from the nurses running groups, to ward managers who freed the time for nurses to take part in training and running the intervention. This was in turn supported by nursing mangers and service directors who made clear that they would expect the skills learned to be implemented. Nonetheless, implementation was not without difficulty. One ward was notably more successful at taking on the interventions at the point where the clinical psychologist began to pass on the role of facilitator. The main difficulty was in ensuring that the right staff were on shift at the right time. Overcoming this obstacle is essentially a management issue, and on a ward where the management is prepared to make psychological therapy a priority, and plan rotas accordingly, it is possible to ensure the groups then take place. In conclusion, the uptake of these interventions by both staff and service users demonstrates the feasibility of psychological therapies in an acute inpatient service. We look forward to presenting further data, when it becomes available, which demonstrates if this leads to a statistically significant improvement in ward atmosphere, patient and staff satisfaction.
Original languageEnglish
Media of outputPoster
Publication statusPublished - Dec 2009


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