Research and organizational issues for the implementation of family work in community psychiatric services

BACKGROUND: The need for evidence-based practice (EBP) to guide and develop mental health services remains fundamental for modern services. Aim. To discuss issues that impact upon implementation of EBP and practice development using family work (FW) as an example. METHODS: A selection of the FW literature was reviewed drawing on sources including the Cochrane Library, Cinahl and Medline. Keywords used were FW, community mental health team and research design. FINDINGS: Centralized policy initiatives and guidelines that are themselves guided by evidence of randomized controlled trials predominantly risk alienating practitioners and clients/carers. Family work has some demonstrable clinical benefits although models differ and the active therapeutic agent remains unclear. Its adoption into routine care is also hindered by a productivity management outlook that seeks to maximize stretched resources and whose values are likely to be internalized by practitioners. The dichotomous position of previous research and practice development make implementation of EBP difficult and highlights the need for strategic planning that embraces both factors. CONCLUSION: The current drive to increase EBP requires a bi-directional process of influence that allows individual practitioners and clients/carers to become producers of evidence and not simply recipients. The authors support wider adoption of case study research designs to reflect the unpredictable nature of mental health care. Adoption of assertive community treatment models within community services is most likely to promote the excellence management model and accommodate EBP such as FW.     

Reflecting together: developing a new strategy for continuous user involvement in mental health nurse education

This paper explores the first issues encountered when establishing a method of service user involvement in the preparation of a cohort of mental health nursing students during their branch programme. The method involved the creation of a group of service users and students whose purpose was to jointly reflect upon mental health issues. To do this students are expected to use their experience from practice placements and the service users to use their experiences as recipients of mental health services. This approach is being investigated through research utilizing an evaluative case study with features of action research incorporated into the design. The findings to date, which concern the process of negotiation, pre-study attitudinal survey and the first group process, will be presented. This will offer mental health professionals the opportunity to gain insight into one approach of actively involving service users in programmes of higher education over a sustained period of time. Reflection on practice themes will include: collaborative strategy, evaluative case study, education, mental health nursing, reflection on practice, and service-user involvement.     

Redressing the balance in mental health nursing education: Arguments for a values‐based approach

ABSTRACT: Evidence‐based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self‐examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.     

Implications of evidence‐based practice for mental health nursing

The introduction of evidence‐based practice (EBP) and the hierarchical approach to evidence it engenders within research and evaluation has aroused controversy in the mental health professions. The aim of this paper is to present a critique of EBP with a specific relationship to mental health nursing. It will be argued that in its current form, EBP presents a potential impediment to the facilitation of consumer participation in mental health services and to the recovery model. The need for the consumer voice and the importance of the lived experience of mental illness are not readily reconciled with a strong scientific paradigm that promotes detachment and objectivity. The importance of evidence in contemporary mental health care will also be acknowledged and discussed in light of the current climate of increased consumer knowledge, fiscal constraint, and extensive social criticism of mental health‐care services. The current approach to EBP requires reconstruction to support the consumer‐focused nature of mental health nursing, and to facilitate the implementation of a recovery model for mental health care.     

Nursing based evidence: moving beyond evidence-based practice in mental health nursing

Various authors suggest mental health nursing is dominated by knowledge borrowed from psychiatry, pharmacology and the behavioural sciences. These disciplines favour knowledge developed using quantitative methodologies so they and evidence-based practice (EBP) and evidence-based nursing (EBN), increasingly called for in mental health nursing, fit seamlessly together. Nevertheless, as these movements dismiss qualitative approaches to knowledge (evidence) development, I argue against the move toward EBP/EBN in mental health nursing. This is because the specialty's primary interests - human experiences of illness/health care and human relationships, often do not lend themselves to being quantitatively researched. Using nursing examples, I demonstrate how qualitative research, wholly unacceptable in relation to EBP/EBN quality of evidence scales, is indispensable to mental health nursing. The need for evidence arising from qualitative research in no way precludes the need for quantitatively derived evidence. Indeed, the specialty's twofold interest - the work of nurses with clients and the explication of phenomena which inform practice, require diverse knowledge and thus, diverse research approaches. This twofold interest defines the area of mental health nursing practice, and knowledge informing it is referred to as nursing based evidence (NBE). Because it values multiple approaches to knowledge development, NBE provides a way to articulate the specialty's distinct contribution to the health care of people experiencing mental illness and advances mental health nursing.     

Do physiotherapists' attitudes towards evidence-based practice change as a result of an evidence-based educational programme?

RATIONALE: The concept of evidence-based practice (EBP) encourages health care professionals to provide the most effective health care, and to be accountable for the interventions they provide. Little work has been undertaken to examine how practically allied health professionals' encompass EBP and how they perceptive and understand the concept of EBP. The use of opinion leaders to disseminate new evidence into practice, and thereby encourage the behaviour of health care professionals has been proposed. AIMS: The aims of this study were to investigate physiotherapists' attitudes towards EBP and to examine change in their attitudes following an education package, which utilized local opinion leaders. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work to two groups. The intervention group received an evidence-based programme on aspects of EBP including literature searching and critical appraisal. The attention control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' attitudes towards EBP were measured at baseline (before randomization) and at 3 and 6 months follow-up. RESULTS: Physiotherapists reported that they primarily relied on 'courses' and 'in-service training' for informing their clinical practice. Most agreed that clinical practice should be based on the best available evidence and that they would change their clinical practice if evidence suggested they should do so. However, many of the physiotherapists reported difficulty in reading journals and could not identify opinion leaders in key areas. In terms of clinical practice, literature, journals and research were ascribed low priority throughout. Differences in attitudes between the intervention and control groups were observed in relation to management support for EBP at 3 and 6 months follow-up. CONCLUSIONS: In this study, physiotherapists appeared to be in favour of the idea of EBP, yet they remained reluctant to change their practice. Opinion leaders were not easily identifiable by physiotherapists, suggesting that this method alone may not be an effective method of changing attitudes in clinical practice. The process of changing attitudes in the clinical environment is a complex issue worthy of further research.     

Learning,changing and managing in mental health

This paper draws on research which considers the implications for practitioners and managers of implementing new ideas for practice gained from learning and education in mental health in the UK. Using a questionnaire survey followed by eight semi-structured interviews, the research set out to identify the issues facing workers trying to implement change in the workplace as a result of new learning gained from study of an Open University mental health course. The paper argues that much management literature on change within organisations is problematic in this specific context. This is largely because it takes insufficient account of the complexities surrounding work within social care (particularly mental health). Findings show that workers who have undertaken learning in mental health often feel disempowered and isolated when attempting to introduce new ideas for practice into the workplace. The first line manager operates at the intersection of practice and learning and has a key role in enabling and supporting staff through practice as well as service change and professional development. This paper locates the distance learning experience within a wider framework of student/practitioner support, and explores the role of the first line manager in supporting and enabling staff.     

Evidence-based practice: implications and concerns

Aims The aim of this paper was to undertake a brief critical appraisal of evidence‐based practice (EBP) as it is currently perceived in health care settings. Background The past two decades have seen EBP become increasingly important in health care planning, clinical thinking, and choice of treatments. It is based on scientific rationalism and adherents claim that decisions based on EBP are superior to those based on other approaches to care. Concerns are now being expressed that positivistic approaches to health care fail to take into account people’s preferences, their internal resources and their personal understandings of health and wellbeing. It has been argued that there may be multiple types of evidence, all of which have a part to play in the formulation and execution of health care. Methods After a literature search, this paper argues that whereas EBP may be useful in treating conditions that have a biological cause, it may be less helpful in understanding and treating conditions that have their origins in the social, psychological or spiritual domains. Results The nature, strengths and limitations of evidence‐based practice is discussed in this paper. Nurses are encouraged to develop the critical skills of evaluating EBP in the lives and experiences of the people they care for. Conclusions Evidence‐based practice has a part to play in improving the treatment provided for patients. Nonetheless, nurses should be aware of other kinds of evidence, and appreciate that any single approach to determining care, no matter how popular, is likely to lead to a service that does not truly meet the complex individual needs of patients. Implications for nursing management In order for evidence‐based practice to be safe, the nursing workforce must be able to evaluate the strength and relevance of research findings, and be able to understand that there are different kinds of evidence which should be called upon in order to respond sensitively and appropriately to the preferences of patients. A responsive workforce embraces multiple ways of thinking, respects different paradigms of care, and is able to respond to and respect the forms of care people value and seek.     

Best practice management strategies for mental health nurses during the clinical application of civil commitment: an overview

AIM: The aim of this article is to outline best practice management strategies for nurses during the clinical application of civil commitment of mentally ill persons. METHOD: A thorough literature search on 'coercion' and 'civil commitment' was undertaken using MEDLINE, CINAHL and PSYCHINFO. Published and unpublished research undertaken by the authors in New Zealand on this topic was drawn upon. This research considered the use of civil commitment during admission to acute mental health services, acute forensic mental health services and community mental health services. RESULTS: The experience of coercion by service users coincides with the degree of restriction associated with the service they are involved in. Socio-demographic factors, clinical factors and the experience of coercive events have little bearing on the amount of coercion experienced. Rather it is the pattern of communication and the use of 'procedural justice' that has the potential to ameliorate the amount of perceived coercion. CONCLUSIONS: 'Procedural justice' aligns with the emphasis placed on the therapeutic relationship in mental health nursing and is an important consideration for nurses during the clinical application of civil commitment.     

Transforming Health Care from the Inside Out: Advancing Evidence-Based Practice in the 21st Century

Health care is in need of change. Major professional and health care organizations as well as federal agencies and policy-making bodies are emphasizing the importance of evidence-based practice (EBP). Using this problem solving approach to clinical care that incorporates the conscientious use of current best evidence from well designed studies, a clinician's expertise, and patient values and preferences, nurses and other health care providers can provide care that goes beyond the status quo. Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care. Key elements of a best practice culture are EBP mentors, partnerships between academic and clinical settings, EBP champions, clearly written research, time and resources, and administrative support. This article provides an overview of EBP and offers recommendations for accelerating the adoption of EBP as a culture in education, practice and research.     

Talking with the experts: evaluation of an online discussion forum involving mental health service users in the education of mental health nursing students

The Chief Nursing Officer's recent review of mental health nursing called for the widespread involvement of mental health service users in the education of mental health nurses. This paper describes an innovative project that involved mental health service users in the education of pre-registration mental health nursing students through an online discussion forum that blended e-learning with enquiry-based learning (EBL). The findings of an evaluation are presented, drawing on quantitative and qualitative methods. Overall, the project was a success with students and service users engaging in online discussions on a range of issues. EBL presentations demonstrated understanding of the service user experience and students reflected on implications for clinical practice. All participants would take part again and recommend the online forum to others. Analysis of activity data revealed different levels and styles of student involvement. Limitations in communication skills appeared to limit student participation, alongside logistical difficulties, whereas the service users eagerly utilised the forum. Potential implications for healthcare education are discussed and recommendations made for developments in user-led e-learning and further research.     

Becoming a Psychiatric/Mental Health Nurse in the UK: A Qualitative Study Exploring Processes of Identity Formation

Identity studies are well established across the social science literature with mental health nursing beginning to offer evidenced insights into what may, or may not, constitute key identity performances. For mental health nursing these performances remain contested, both from within the profession and from international contexts that favour generic constructions of mental health. This paper offers findings from a qualitative study that focused upon the process of how mental health nursing identity development is influenced, rather than what that identity may or may not be. These findings highlight that mental health nurses (MHNs) not only form their identity around service user centred education and training, but that many also use the education as a means to leave the profession. Through highlighting the impact of informal education (i.e., through work), formal education, and training upon the formation of mental health nursing identity, nurses are potentially alerted to the importance of clinically focussed mental health being prominent within curricula, rewarding mental health nursing skills specialisation, and the importance of the role of the service user in mental health nurse education and, hence, identity formation.     

Becoming a psychiatric/mental health nurse in the UK: a qualitative study exploring processes of identity formation

Identity studies are well established across the social science literature with mental health nursing beginning to offer evidenced insights into what may, or may not, constitute key identity performances. For mental health nursing these performances remain contested, both from within the profession and from international contexts that favour generic constructions of mental health. This paper offers findings from a qualitative study that focused upon the process of how mental health nursing identity development is influenced, rather than what that identity may or may not be. These findings highlight that mental health nurses (MHNs) not only form their identity around service user centred education and training, but that many also use the education as a means to leave the profession. Through highlighting the impact of informal education (i.e., through work), formal education, and training upon the formation of mental health nursing identity, nurses are potentially alerted to the importance of clinically focussed mental health being prominent within curricula, rewarding mental health nursing skills specialisation, and the importance of the role of the service user in mental health nurse education and, hence, identity formation.     

Recovery of evidence‐based practice

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence‐based practice (EBP) is judged. From a consumer‐recovery perspective, this paper re‐examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery‐focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.     

‘Meet Me Where I Am’: Mental health service users’ perspectives on the desirable qualities of a mental health nurse

Nurses play a central role in the delivery of quality mental health services. Desired qualities of a mental health nurse, in particular therapeutic relationships, have been described in the literature, primarily reflecting the nursing paradigm. Service users’ perspectives must be more fully understood to reflect contemporary mental health policy and to recognize their position at the centre of mental health service delivery and to directly influence and contribute their perspectives and experiences to mental health nursing education. A qualitative exploratory research project was undertaken to inform and enhance understanding of what service users see as the desired qualities of a mental health nurse. The project was co‐produced by service users as experts by experience, and mental health nurse academics to ensure the service user perspective was privileged. This international project conducted in Europe and Australia included a series of focus groups with service users (n = 50). Data were analysed thematically. Being with me was a major theme identified and reflected the sub‐themes: respect towards service users as persons; empathy, compassion and effective communication; understanding service users; knowledge of services; and fostering hope and believing that recovery is possible. These qualities specifically reflecting the service user perspective must be central to mental health nursing curricula to facilitate the development of holistic care and recovery‐oriented practice. These findings were utilized to directly inform development of a co‐produced mental health nursing learning module, to maximize genuine service user involvement, and to fully realize the benefits of service user led education for undergraduate nursing students.     

Clinical application of perioperative evidence-based practice

Practitioners today are seeing changes in our health care system, economic pressures related to decreased reimbursement, and the growth of managed care that are producing major adjustments in health professions' education, patient care, and research. Evidence-based practice (EBP) is considered by many to be the way of the future. This article describes factors affecting implementation of EBP in the clinical arena. It also gives some practical applications found when implementing EBP at one hospital.     

Service user involvement in undergraduate mental health nursing in New Zealand

This paper describes a service user role in the mental health component of an undergraduate nursing programme in New Zealand. The paper provides a background to mental health nursing education in New Zealand and discusses the implications of recent reforms in the mental health sector. The undergraduate nursing programme at the University of Auckland has a strong commitment to service user involvement. The programme aims to educate nurses to be responsive and skilful in meeting the mental health needs of service users in all areas of the health sector and to present mental health nursing as an attractive option for nurses upon graduation. We outline the mental health component of the programme, with an emphasis on the development of the service user role. In the second half of the paper, we present a summary of responses to a student satisfaction questionnaire. The responses indicate that the service user role is an important element of the programme and is well received by a substantial proportion of students. We consider the implications for nursing education and for recruitment into mental health nursing. Finally, we discuss some issues related to service user involvement in the development of new models of mental health service delivery.     

Learning from practice? Mental health nurses' perceptions and experiences of clinical supervision

In recent years nursing as a whole has moved from a position of apparently little manifest concern in the issue of 'clinical supervision' to a veritable explosion of interest which is beginning to find expression in the literature. Beginning with a discussion of clinical supervision from within a psychodynamically informed interpersonal nursing framework this paper reports on a small scale qualitative inquiry which aimed to explore mental health nurses' perceptions and experiences of clinical supervision. Analysis of data derived from a series of semi-structured interviews provides very encouraging early indications that mental health nurses are becoming better able to reflect upon the nature of their own formative learning needs and so to take seriously their need for professional support as they strive towards a more therapeutic relationship with their patients. However, whilst all of the participants in the study had a positive perception of the potential value of clinical supervision, there is clear evidence to suggest that their actual experience was that 'good enough supervision' was more the exception than the rule. The participants' perceptions and experiences are described and the implications for research, practice, education and the management of service delivery systems are outlined.     

The untapped potential of behaviour analysis and interprofessional care

ABSTRACT

Interprofessional collaboration has become a sought-after component of quality mental health care. Higher education institutions and mental health organizations seek to equip clinicians with the ability to provide cohesive clinical services while working collaboratively with a diverse group of professionals. Although research suggests that there may be benefits of interprofessional collaboration in mental health settings, collaborative practice initiatives have struggled with conceptual and methodological limitations. A behaviour analytic contribution to interprofessional care provides a philosophical position with an analytical goal distinguished by the prediction and influence of events, theoretical clarity, and methodological rigour that are needed within interprofessional research and practice. At the philosophical level, the extension of functional contextualism to interprofessional care research may provide a framework to achieve the valued ends of improving interprofessional collaboration and ultimately improving health-related outcomes for service users. Interprofessional collaboration can be conceptualized as metacontingency, a behaviour analytic concept that allows for a group level analysis of contributing social components. This paper uses the example of mental health care to guide a conceptual analysis of the potential application of behaviour analytic methodology within interprofessional practice, research, and education.