Understanding and improving therapeutic engagement on acute mental health wards using experience-based co-design and the behaviour change wheel

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Nurse-patient therapeutic engagement on acute mental health wards is beneficial to service users’ outcomes and nurses’ job satisfaction. However, engagement is not always fulfilled in practice and interventions to improve engagement are sparse, ineffective and not theoretically underpinned.
Overarching aim: To understand and improve nurse-patient therapeutic engagement on acute mental health wards by co-designing a complex behaviour change intervention.
Methods: The study consisted of three phases, informed by the Medical Research Council’s guidance for developing and evaluating complex interventions:
- Phase 1 included a systematic integrative review guided by the COM-B model for behaviour change and the Theoretical Domains Framework
- Phase 2a was the intervention development phase, which used a novel approach combining Experience-based Co-design (EBCD) and the Behaviour Change Wheel with service users, carers and clinicians on an acute mental health ward
- Phase 2b used the Behaviour Change Wheel including the COM-B model, Theoretical Domains Framework and Behaviour Change Technique Taxonomy v1 to code (i) the freely available Point of Care Foundation EBCD toolkit, (ii) this study’s protocol, (iii) event evaluation questionnaires and (iv) fieldnotes from participant and non-participant observations of the co-design workshops conducted in this study
- Phase 3 intended to conduct a quasi-experimental pre-post-test on a control and intervention ward using a structured observation tool and the VOICE questionnaire to evaluate the intervention’s impact on the amount and quality of nurse-patient therapeutic engagement and service users’ perceptions of inpatient care respectively. Post-testing was disrupted due to COVID-19.
- The systematic integrative review included 37 studies and identified five “Principles of Engagement” (published paper 1). These principles were considered the active phase of engagement i.e., when nurses and service users interacted therapeutically. The Principles were directly influenced by either the nurses’ or service users’ capability, opportunity and/or motivation to engage. Collaborative approaches to improving engagement were recommended due to the lack of the service user voice within the identified literature - Phase 2a consisted of an experience gathering phase (published paper 2) and a co-design phase (published paper 3). Eighty hours of non-participant observation and semi-structured interviews with 14 service users, two carers and 12 clinicians explored experiences of therapeutic engagement and empirically confirmed the “Principles of Engagement”. The service users, carers and clinicians were then brought together in a series of co-design workshops and developed the Let’s Talk complex behaviour change intervention toolkit to improve nurse-patient therapeutic engagement on acute mental health wards- Phase 2b (paper 4 – submitted) found that EBCD functioned through a complex, interrelated set of mechanisms which were reinforced through the recommended staged approach and by enabling an emotional shift within participants. The first taxonomy of 31 behaviour change techniques and 11 mechanisms of action associated with EBCD was developed- Phase 3 included results from 80-hours of pre-test observations on a control and intervention ward, which showed that nurses’ most common behaviour was clinician-clinician interaction, closely followed by solitary, task orientated behaviours. A quarter of observations were found to be in the nurse-patient interactive behaviour category. Most interactions were neutral in nature, followed by positive with few interactions being negative. Phase 3 also included results from 29 VOICE questionnaires completed by service users on the intervention ward and 31 VOICE questionnaires on the control ward. Mean VOICE scores for both wards fell within the lower half of the scale, with just one-point difference between the control and intervention ward. This may suggest that service users’ overall perceptions of inpatient care were in the positive range; however, there were a large range of responses on both wards, which indicates that some perceptions were negative, whilst others positiveConclusion: Overall this thesis makes unique and important contributions to the literature on therapeutic engagement, EBCD and the Behaviour Change Wheel approach to intervention development. It has developed a new, co-designed model of engagement that has subsequently been used in local and national policy to guide nurses’ practice. A novel approach combining co-design and behaviour change theory was used successfully to design an intervention which aimed to improve nurse-patient therapeutic engagement on acute mental health wards. The Behaviour Change Wheel provides behavioural tools to guide intervention development whilst EBCD provides a collaborative process which may potentially bring about wider changes in the culture of acute mental health wards, independent from the specific impacts of a co-designed intervention.
Date of Award1 Oct 2021
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorGlenn Robert (Supervisor), Alan Simpson (Supervisor) & Vicki Tsianakas (Supervisor)

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