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The view that interacting with nature enhances mental wellbeing is commonplace, despite a dearth of evidence or even agreed definitions of 'nature'. The aim of this review was to systematically appraise the evidence for associations between greenspace and mental wellbeing, stratified by the different ways in which greenspace has been conceptualised in quantitative research. We undertook a comprehensive database search and thorough screening of articles which included a measure of greenspace and validated mental wellbeing tool, to capture aspects of hedonic and/or eudaimonic wellbeing. Quality and risk of bias in research were assessed to create grades of evidence. We undertook detailed narrative synthesis of the 50 studies which met the review inclusion criteria, as methodological heterogeneity precluded meta-analysis. Results of a quality assessment and narrative synthesis suggest associations between different greenspace characteristics and mental wellbeing. We identified six ways in which greenspace was conceptualised and measured: (i) amount of local-area greenspace; (ii) greenspace type; (iii) visits to greenspace; (iv) views of greenspace; (v) greenspace accessibility; and (vi) self-reported connection to nature. There was adequate evidence for associations between the amount of local-area greenspace and life satisfaction (hedonic wellbeing), but not personal flourishing (eudaimonic wellbeing). Evidence for associations between mental wellbeing and visits to greenspace, accessibility, and types of greenspace was limited. There was inadequate evidence for associations with views of greenspace and connectedness to nature. Several studies reported variation in associations between greenspace and wellbeing by life course stage, gender, levels of physically activity or attitudes to nature. Greenspace has positive associations with mental wellbeing (particularly hedonic wellbeing), but the evidence is not currently sufficient or specific enough to guide planning decisions. Further studies are needed, based on dynamic measures of greenspace, reflecting access and uses of greenspace, and measures of both eudaimonic and hedonic mental wellbeing.

Background The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) was developed to meet demand for instruments to measure mental well-being. It comprises 14 positively phrased Likert-style items and fulfils classic criteria for scale development. We report here the internal construct validity of WEMWBS from the perspective of the Rasch measurement model. Methods The model was applied to data collected from 779 respondents in Wave 12 (Autumn 2006) of the Scottish Health Education Population Survey. Respondents were aged 16–74 (average 41.9) yrs. Results Initial fit to model expectations was poor. The items 'I've been feeling good about myself', 'I've been interested in new things' and 'I've been feeling cheerful' all showed significant misfit to model expectations, and were deleted. This led to a marginal improvement in fit to the model. After further analysis, more items were deleted and a strict unidimensional seven item scale (the Short Warwick Edinburgh Mental Well-Being Scale (SWEMWBS)) was resolved. Many items deleted because of misfit with model expectations showed considerable bias for gender. Two retained items also demonstrated bias for gender but, at the scale level, cancelled out. One further retained item 'I've been feeling optimistic about the future' showed bias for age. The correlation between the 14 item and 7 item versions was 0.954. Given fit to the Rasch model, and strict unidimensionality, SWEMWBS provides an interval scale estimate of mental well-being. Conclusion A short 7 item version of WEMWBS was found to satisfy the strict unidimensionality expectations of the Rasch model, and be largely free of bias. This scale, SWEMWBS, provides a raw score-interval scale transformation for use in parametric procedures. In terms of face validity, SWEMWBS presents a more restricted view of mental well-being than the 14 item WEMWBS, with most items representing aspects of psychological and eudemonic well-being, and few covering hedonic well-being or affect. However, robust measurement properties combined with brevity make SWEMWBS preferable to WEMWBS at present for monitoring mental well-being in populations. Where face validity is an issue there remain arguments for continuing to collect data on the full 14 item WEMWBS.

Social prescribing interventions connect mental health service users to community resources, to support physical and mental wellbeing and promote recovery. COVID-19 restrictions impacted the delivery of socially prescribed activities, preventing face to face contact for long periods. The aim of this study was to understand how Voluntary Community and Social Enterprise (VCSE) organisations working with a local NHS mental health Trust responded to the challenges of social distancing during the COVID-19 pandemic. This understanding will be used to make recommendations for future practice, post-lockdown. Using a convergent mixed methods design, we surveyed VCSE providers of socially prescribed activities intended to be accessible and appropriate for people with severe mental health needs. Follow-up interviews explored further how they adapted during the first year of the pandemic, the challenges they faced, and how they sought to overcome them. The survey and interview data were analysed separately and then compared to identify convergent and divergent findings. Twenty VCSE representatives completed the survey which provided a snapshot of changes in levels of connection and numbers reached during lockdown. Of 20 survey respondents, 11 participated in follow-up interviews. Interviews revealed that lockdown necessitated rapid change and responsive adaptation; activities were limited by resource, funding, safeguarding and government restrictions; no single format suited all group members; connection was key; and impact was difficult to gauge. VCSE organisations commissioned to deliver creative socially prescribed activities during the pandemic rapidly adapted their offer to comply with government restrictions. Responsive changes were made, and new knowledge and skills were gained. Drawing on experiences during lockdown, VCSE organisations should develop bespoke knowledge, skills and practices to engage service users in future hybrid delivery of arts, sports, cultural and creative community activities, and to ensure that digital activities offer an equivalent degree of connection to face-to-face ones. Additionally, more effective methods of gaining feedback about patient experience of hybrid delivery is needed.

Background Mental well-being now features prominently in UK and international health policy. However, progress has been hampered by lack of valid measures that are responsive to change. The objective of this study was to evaluate the responsiveness of the Warwick Edinburgh Mental Well-being Scale (WEMWBS) at both the individual and group level. Methods Secondary analysis of twelve different interventional studies undertaken in different populations using WEMWBS as an outcome measure. Standardised response mean (SRM), probability of change statistic (P̂) and standard error of measurement (SEM) were used to evaluate whether WEMWBS detected statistically important changes at the group and individual level, respectively. Results Mean change in WEMWBS score ranged from −0.6 to 10.6. SRM ranged from −0.10 (95% CI: -0.35, 0.15) to 1.35 (95% CI: 1.06, 1.64). In 9/12 studies the lower limit of the 95% CI for P̂ was greater than 0.5, denoting responsiveness. SEM ranged from 2.4 to 3.1 units, and at the threshold 2.77 SEM, WEMWBS detected important improvement in at least 12.8% to 45.7% of participants (lower limit of 95% CI>5.0%). Conclusions WEMWBS is responsive to changes occurring in a wide range of mental health interventions undertaken in different populations. It offers a secure base for research and development in this rapidly evolving field. Further research using external criteria of change is warranted.

Background With urbanisation increasing, it is important to understand how to design changing environments to promote mental wellbeing. Evidence suggests that local-area proportions of green space may be associated with happiness and life satisfaction; however, the available evidence on such associations with more broadly defined mental wellbeing in still very scarce. This study aimed to establish whether the amount of neighbourhood green space was associated with mental wellbeing. Methods Data were drawn from Understanding Society , a national survey of 30,900 individuals across 11,096 Census Lower-Layer Super Output Areas (LSOAs) in England, over the period 2009–2010. Measures included the multi-dimensional Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS) and LSOA proportion of green space, which was derived from the General Land Use Database (GLUD), and were analysed using linear regression, while controlling for individual, household and area-level factors. Results Those living in areas with greater proportions of green space had significantly higher mental wellbeing scores in unadjusted analyses (an expected increase of 0.17 points ( 95% CI 0.11, 0.23) in the SWEMWBS score for a standard deviation increase of green space). However, after adjustment for confounding by respondent sociodemographic characteristics and urban/rural location, the association was attenuated to the null (regression coefficient B  = − 0.01, 95% CI -0.08, 0.05, p  = 0.712). Conclusions While the green space in an individual’s local area has been shown through other research to be related to aspects of mental health such as happiness and life satisfaction, the association with multidimensional mental wellbeing is much less clear from our results. While we did not find a statistically significant association between the amount of green space in residents’ local areas and mental wellbeing, further research is needed to understand whether other features of green space, such as accessibility, aesthetics or use, are important for mental wellbeing.

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare. A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review. Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care. A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

The risks are clear, it’s now time to learn and respond

To examine the reduction in NHS inpatient hospital beds in England from 1960 until 2020, including five categories: Acute, Geriatric, Maternity, Mental Illness and Learning Disability beds; and to measure regional differences at the end of the study period. Retrospective observational study. NHS in England. Inpatient hospital beds. NHS inpatient bed provision per 100,000 population. Rate of reduction calculated as percentage change each year. NHS bed provision in 7 regions of England compared for the year 2019/20. NHS inpatient bed provision declined for sixty consecutive years. The overall reduction was 78.0% between 1960 and 2020. Greatest reduction was in Learning Disability beds (98.7%), followed by Mental Illness (90.6%), Geriatric (75.0%), Maternity (67.4%) and the least reduction in Acute beds (63.0%). There were two periods of accelerating rates of bed reduction, the first in the 1980s, and the second in the 2000s. At the end of the study period there was significant regional variation in bed numbers. Bed reductions were a constant feature, with important differences between bed categories and across time. This needs to be addressed when planning for future pandemics and winter bed pressures. By the end of the study the NHS was no longer providing the same level of inpatient care in different regions of England, particularly for Learning Disability.

Background In the UK, healthcare assistants (HCAs) work alongside registered nurses and other clinicians to provide frontline clinical care. HCAs provide a considerable amount of essential direct patient care which, dependent on the setting, can include monitoring of temperature, pulse, respirations and ECGs, support with daily activities, emotional support and facilitating communication with other health professionals. In 2019, the leaver rate of HCAs and support workers in the UK was 13.4%. In many Trusts this was higher than the leaving rate for nurses. The aim of this study was to explore HCAs’ experiences and their perceptions of the reasons for poor retention rates. Methods We recruited HCAs from three English mental health Trusts. Recruitment information was circulated using a variety of approaches. 31 participants took part in semi-structured interviews. We explored the factors they considered to affect HCAs’ decision to leave their role, and any differences they perceived with registered staff. Interviews were coded and analysed using the framework generated in a previous phase of the study which focused on retention of registered mental health professionals. Findings Three key factors impacted HCAs job satisfaction, wellbeing, and motivation to remain in post: (1) high workloads and unclear role boundaries creating stress and concerns for patient care; (2) good relationships with line managers and colleagues providing essential support to cope with both work and personal challenges; (3) feeling undervalued by the wider organisation, with a lack of investment including pay, facilities, and opportunities for development. These factors combined to create a situation of high stress and low job satisfaction, with many HCAs expressing an intention or desire to leave, particularly when the pay is similar to much less demanding jobs in other sectors. Conclusions HCAs are a diverse group but many reported job dissatisfaction and feeling undervalued by the organisations they work for, with some struggling to cope with the cost-of-living crisis. Improved role boundaries, career pathways, and appreciation of the role such as reward and recognition schemes, could help retain this key staff group who provide a large proportion of essential patient care.

Introduction Service user involvement is increasingly considered essential in mental health service development and delivery. However, the impact of this involvement on services is not well documented. We aimed to understand how user involvement shapes service commissioning, development and delivery, and if/how this leads to improved service‐level outcomes. Methods A systematic review of electronic databases (MEDLINE, PsycINFO, CINAHL and EMBASE databases) was undertaken in June and November 2022 for studies that incorporated patient involvement in service development, and reported service‐level outcomes. Included studies were synthesised into a logic model based on inputs (method of involvement), activities (changes to service) and outputs (indicators of improvement). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analysis) guidelines were followed when conducting this review. Results From 10,901 records identified, nine studies were included, of which six were judged to have used co‐production or co‐design approaches. Included studies described service user involvement ranging from consultation to co‐production. We identified a range of outputs associated with service user involvement in service planning and delivery, and reported these in the form of a logic model. These service‐level outputs included improved treatment accessibility, increased referrals and greater service user satisfaction. Longer‐term outcomes were rarely reported and hence it was difficult to establish whether outputs are sustained. Conclusion More extensive forms of involvement, namely, co‐design and co‐production, were associated with more positive and substantial outputs in regard to service effectiveness than more limited involvement methods. However, lived experience contributions highlighted service perception outputs may be valued more highly by service users than professionals and therefore should be considered equally important when evaluating service user involvement. Although evidence of longer term outcomes was scarce, meaningful involvement of service users in service planning and delivery appeared to improve the quality of mental health services. Patient or Public Contribution Members of a lived experience advisory panel contributed to the review findings, which were co‐authored by a peer researcher. Review findings were also presented to stakeholders including service users and mental health professionals.