What is The Purpose of Community Meeting in an Inpatients Psychiatric Unit?

(	Ala`a Alnasser Correspondence: Ala`a Alnasser Email: to_alaa84@yahoo.com

Introduction Recent attention has been developed for the provision of inpatients mental health care (Harms, Benson, 2003). Large group meetings of patients and health team widespread in the majority of Mental hospitals, which often called "community are meetings" ( Lipgar, 1999). The community meeting occurs in inpatients setting as a part of the therapeutic action delivered to clients (Harms, Benson, 2003). Community meeting is a part of milieu program (Kisch, Kroll, Gross; & Carey, 1981); it is a regular meeting in an inpatient unit for all staff and patients on the unit. The duration ranges from 45 to 60 minutes, and it can be held once daily to once weekly (Novakovic, Francis, Clark, & Caring, 2010). The members of the meeting includes nurses, social workers, occupational therapists and psychiatrists (Fiddler et al, 2010). The meeting is derived from work done in England during World War II by Maxwell Jones (1965), Wilifred Bion (1959), and S.H. Foulkes (1990). At that time, a large number of patients needed care for the treatment of mental illnesses. The treatmenst are primarily guided by psychoanalytic theory and clinical experience. The use of commua nity meeting is classified as " milieu therapy" ( Lipgar, 1999).

Clinical Question
Lipgar (1999) points out that although there is a long history of use of community meetings as an essential part of the united treatment programme, their purpose and methods are rarely defined and staff are seldom trained in how to contribute to these meetings. The purpose of the psychiatric inpatient unit community meeting is often unclear to the staff and patients (Kisch, Kroll, Gross; & Carey, 1981). The frequent complaint from clients is that the community meetings are useless (Novakovic, Francis, Clark, & Caring, 2010).

The aim of this paper is to address the question - what is the purpose of the community meeting in an inpatients psychiatric inpatients unit and to search the literature for evidence to answer this question.

Searching strategies
An electronic search of databases was conducted through academic search engines: EBSCO, CINAHL, MEDLINE. The reference lists of included studies and reviews were searched for additional studies.

Two search sets were used, one related to community meeting and used the terms "inpatients community meeting" or "large group meeting" or "Ward meeting" or "patients-staff community meeting" . The second search set related to conditions and used the terms " psychiatric unit" or "mentally ill " The two search sets were linked with the instruction 'AND'. A wildcard asterisk was applied to search for related terms. A number of limiters were used such as English language, content type (journal), no specific dates were chosen.

This search yielded 155 references, of which 85 were in the English language and had abstracts. Most of the studies are excluded for not being free access or as not being related to the topic.

Literature review
After an extensive search about the purpose of psychiatric inpatients community meetings most of the studies found were qualitative studies that highlight the living experience of a community meeting, so outdated papers which considered the original and classical papers where the authors addressed the purposes of community meeting in an inpatients psychiatric unit, were used so as to present a models to conduct these meetings.

Winer, Klamen (1997) presented a large group interpretive model for the community meeting in psychiatric inpatients setting which focuses on studying the relationship between the staff and clients, and to focus on the maladaptive ways that the clients interpret the staff behaviors. The authors state that the purpose of the community meetings is to reveal the attitudes that clients have towards the staff and what is the meaning of these attitudes. It present a form of quality control for staff and the clients to discuss hidden subjects from both staff and clients perspectives, and another purpose to address in the model is to take feedback from the clients about staff behaviors; so as to give psychodynamic understanding to the clients about pharmacological intervention to increase clients compliance to medication. Finally community meetings can decrease the tension on psychiatric units as the authors stated.

Another interesting paper done in 2010 by Novakovic, Francis, Clark, & Caring discuss the issue of whether the community meeting is a therapeutic intervention or a meaningless exercise? This paper presented the findings of group discussion from the point of view from the patients and the staff as a literature search. The results explain many dimensions of the benefits of community meetings. Firstly, it benefits patients by 1) a space and time to address and solve problems, 2) a safe space to be seen and heard by peers, 3) a space to address issues about relationships between staff and patients, 4) provide connection and intimacy as a group. Secondly, development of the therapeutic relationship between patients and staff. Thirdly, improvement of the milieu therapy and finally increases the relationships with colleagues and other professionals.

A qualitative study highlights the experience of once a week traditional ward round and the experience of daily inpatients meeting. The authors used interview technique to collect data from 21 purposive samples for a 4 week period, and the sample consists of seven nurses, one social worker, two occupational therapists, three psychiatrists and eight managers. This study reveals the following according to community meeting and its aim to 1) provide short, efficient timetabled sessions, 2) better access to multidisciplinary team to discuss the patient decisions. In comparison to weekly ward rounds it results in an increased contribution of patients in the services which can improve the patient's satisfaction (Fiddler et al, 2010).

Another qualitative research article was done by Benson, Harms (2003). This study builds up an understanding of the client's experience according to daily community meetings.
Semi-structured interviews were conducted with a sample of four patients for three to six weeks. Data were collected by tape recording, and transcribed. Most of the staff were mental health nurses. The study reveals three themes: Whose Responsibility? Me vs. Them, What Works? In the concern of the aim of community meeting the authors stated that it was developed to examine the relationship between the clients and others so as to discover new ways of adjusting stressors and promoting self esteem.

One of the purposes of the community meeting is to reduce violence against nurses (Lanza, Rierdan, Forester, Zeiss, 2009). An experimental study was conducted by applying Violence Prevention Community Meeting (VPCM) to two groups of inpatients with psychiatric disease, twice weekly for thirty minutes. he focus of the meeting was on violence prevention and empathic listening so the patients and staff can work together.

Discussion
To make useful community meetings and to enhance participation from the staff and the patients, the distinctive purposes of the meeting must be discussed and approved by evidence, to address the appropriate way to administer this meeting (Lipgar, 1999).

Searching the literature for evidence of the community meeting purposes as discussed in the literature review section, reveals that all the studies and papers agreed that community meetings will be of benefit to the patients as wel as the staff (Winer, Klamen, 1997; Novakovic, Francis, Clark, & Caring, 2010; Fiddler et al, 2010; Benson, Harms, 2003; Lanza, Rierdan, Forester, Zeiss, 2009).

Benefits to the clients
According to the psychiatric inpatients units, the community meeting appears to give psychodynamic understanding to the clients about pharmacologic intervention to increase clients compliance to medication (Winer, Klamen, 1997). Novakovic, Francis, Clark, & Caring (2010) stated that community meeting can benefit patients by 1) a space and time to address and solve problems, 2) a safe space to be seen and heard by peers, 3) a space to address issues about relationships between staff and patients, 4) provide connection and intimacy as a group. Community meeting can improve the patient's satisfaction (Fiddler et al, 2010), by discovering new ways of adjusting stressors and promoting self esteem (Benson, Harms, 2003).

Benefits to the staff
Lanza, Rierdan, Forester, Zeiss (2009) believed that community meetings can reduce violence towards nursing staff. It reveals the attitudes that clients have towards the staff and what is the meaning of these attitudes. It takes feedback from the clients about staff behaviors (Novakovic, Francis, Clark, & Caring, 2010). It also increases the relationships with colleagues and other professionals and provides better access for multidisciplinary team to discuss the patient decisions. (Novakovic, Francis, Clark, & Caring, 2010; Fiddler et al, 2010).

Recommendation
Evidence from the articles suggests that community meetings are as useful to the patients as the staff as apart of the treatment programme in an inpatients psychiatric unit. So we recommend applying community meeting with inpatients in psychiatric units.

In conclusion, this recommendation was based on a process that begins with asking a clinical question "what is the purpose of conducting a community meeting in an inpatients psychiatric unit?", then collecting the most relevant and best evidence from literature we used data bases CINAHL, Science Direct, and Medline, and five relevant studies which consisted of two papers (Winer, Klamen., 1997; Novakovic, Francis, Clark, & Caring., 2010), and two qualitative studies ((Fiddler et al., 2010; Benson, Harms., 2003) and one quantitative study (Lanza, Rierdan, Forester, Zeiss, 2009) were selected then we critically appraised the evidence and integrated the articles to formulate new evidence.

This is level B evidence as it is consistent and highly recommended evidence but it is not based on strong design studies, so further randomized controlled trials are needed to support this evidence.

Maybe these studies are not adequate to apply this intervention in the Jordanian inpatients in psychiatric unit but this give us a pathway to work on and a new research question to study. Although the studies are not strong in design they clearly reveal the living experience of community meetings from patient and staff points of view.

Community meeting is a simple and highly effective intervention that can be done by nurses, however to have adequate knowledge some training session may be neededas they must take into consideration the multidisciplinary team working in the community meeting in the psychiatric inpatients unit. However special consideration must be taken into account when applying community meetings to manage the focus of the education and make a policy to apply this intervention.

Special Consideration
To achieve the goals of the community meeting there are some recommendations for the implications for community meetings; these recommendations are according to Novakovic, Francis, Clark, & Caring (2010) include the following:

- The room chosen for the meeting should provide a safe space and the seating
preparations should be made to include all participants.
- All staff and clients on the ward should be empowered to be present at and participate where possible.
- Community meetings should be conducted at a regular time. The duration of the meeting should be specified.
- Community meetings should be facilitated by at least two identified staff from the
multidisciplinary team in order to provide stability.
- The rules and aim should briefly be presented at the start of each meeting. The
role of the staff and the clients should be defined at the beginning of the meeting and an agenda could be written on a board for all to see.
- Community meetings should provide an opportunity for the clients to think about
subjects connected to the experience of living on the unit, issues around discharge, and
practical issues such as hygiene, sleep regime, smoking regulations.
- Management should consider the reorganisation of ward activities in order to
enable improved capacity for multidisciplinary working and for all professionals to take
part in these meetings, as well as any other designated group work or activities provision.
- Ongoing development and training for staff is to be encouraged, if clinical practice and
understanding is to be improved.
- All attending the community meeting should have an opportunity to engage in the group
discussion. The staff's role is to help all to express their views by encouraging and
inviting them into the subject discussed.
- Organisational support is needed for provision of a work discussion
group for leader and the ward staff team.

References
Fiddler M., Borglin G., Galloway A., Jackson C., McGowan L., & Lovell, K. (2010).
Once a week psychiatric ward or daily in patients team meeting? A multidisciplinary mental health team's experience of new ways of working. International Journal of Mental Health Nursing.19, 119-127.
Harms S., & Benson A. (2003). The clients experience of the community group: implication for nurse facilitators. Journal of Psychiatric and mental health Nursing, 10, 49-56.
Kisch J. Kroll J. Gross R., & Carey K. (1981) In-patient community meetings: problems and purposes. British Journal of Medical Psychology, 54, 35-40.
Lanza M. L., Rierdan J., Forester L., Zeiess R. A. (2009). Reducing violence against nurses: the violence prevention community meeting. Issues in Mental Health Nursing. 30, 745-750.
Lipgar, R. M. (1999) Guide to patient-staff large group meetings: a sociotherapeutic approach. Group Dynamics 3(1) 51-60.
Novakovic A., Francis K., Clark J., & Caring L. (2010). Community meeting on acute psychiatric wards: a therapeutic intervention or a meaningless exercise? Mental Health Review Journal. 15(3), 45-53.
Winer, J. A., Klamen, D. L. (1997). Interpretive psychotherapy in the inpatient community meeting on a short term unit. Psychiatric services. 48, 91-92.