Nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings: An integrative review

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.     

The use and nursing management of benzodiazepines in acute, mental health inpatient care: a discussion

The use of medication in acute mental health is common practice however, there is a lack of research into all aspects of pharmacology within inpatient settings. This paper explores the specific use of benzodiazepines and areas of potential mismanagement. A number of priorities for investigation are raised and implications for nursing roles and responsibilities discussed.     

Stepping out of the box: broadening the dialogue around the organizational implementation of cognitive behavioural psychotherapy

The dissemination and uptake of cognitive behavioural interventions is central to the evidence-based mental health agenda in Britain. However, some policy and related literature, in and of itself social constructed, tends to display discursive naïvety in assuming a rational basis for the dissemination and organizational integration of cognitive behavioural approaches. Rational constructions fail to acknowledge that the practice settings of key stakeholders in the process are likely to be socially constructed fields of multiple meanings. Within these, the importance of evidence-based interventions may be variously contested or reworked. To illustrate this, a case example from the first author will discuss the hypothetical introduction of a cognitive behavioural group for voice hearers in a forensic mental health unit. This will highlight contradictions and local organizational problems around the effective utilization of postgraduate cognitive behavioural knowledge and skills. A synthesis of social constructionist with organizational theory will be used to make better sense of these actual and anticipated difficulties. From this basis, specific ways in which nurses and supportive stakeholders could move the implementation of cognitive behavioural psychotherapy agenda forward within a postmodern leadership context will be proposed.     

Challenging the smoking culture within a mental health service supportively

Smoking is an entrenched part of the culture of mental health care services. This paper discusses the smoking culture in mental health care settings and demonstrates a supportive model to engage staff to actively address their tobacco use and to influence a change in smoking-related workplace policy, practice, and culture. With management endorsement, two 9-week staff smoking cessation support groups were implemented and subsidized nicotine replacement therapy was provided to staff within the Alma Street Mental Health Service, Fremantle Hospital, Western Australia. Eighteen staff members from nursing, social work, administration staff, and patient care assistants participated in the group programme. At the conclusion of the programme, 61% (n = 11) of participants had quit as a result of the groups. Furthermore, a 3-month follow-up evaluation revealed that 39% (n = 7) of the group had abstained from smoking because of the programme. More importantly, the groups engaged staff to discuss workplace smoking issues and produced five recommendations to review policy and practice to further influence a change in the smoking culture of the mental health care service. The groups also provided the opportunity to develop a model of intervention to address smoking in a mental health setting and to raise the public health role of mental health nurses.     

State of mental health research in the american journal of occupational therapy, 2008-2011

In this article, I examine the state of mental health research in the American Journal of Occupational Therapy from 2008 to 2011. Although other practice areas have seen an increase in the number and rigor of intervention effectiveness studies, mental health occupational therapy research has been insufficient to support the profession's role in traditional mental health services. Strategies to enhance the profession's role in mental health practice are suggested and include using occupational therapy behavioral health management research in school-based and transition services to support occupational therapy's role in traditional mental health practice settings.     

Clinical handover in acute psychiatric and community mental health settings

This study collected an area-wide snapshot of current handover practice in psychiatric settings which included acute care units and community mental health centres. The study was conducted in two stages. Firstly, a questionnaire was sent to all clinical mental health staff within an area-wide health service regarding normal handover procedures and processes. The second part of the study used non-participant observers to evaluate actual handovers in inpatient and community settings. Of the 1125 surveys distributed in stage one, 380 (34%) were returned completed. Of the 40 handovers observed in stage two in which 637 patients were discussed, 40% included at least one consultant psychiatrist or registrar as a participant. Almost all the handovers were completed face-to-face in a specific location with a set time and duration. Eighty-six per cent of respondents reported that deteriorating patients were escalated for rapid response. The results of the survey and structured observations support the issues emerging from the literature from medical, surgical and clinical team handovers. Additionally, the issue of identifiers for deterioration of a psychiatric patient emerged as an area worthy of further investigation and incorporation into clinical handover education and training for psychiatric services.     

Mental Health and Emergency Medicine: A Research Agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.     

How reliable is the current evidence looking at the efficacy of harm reduction and motivational interviewing interventions in the treatment of patients with a dual diagnosis?

Current policy from the Department of Health advocates for an integrated approach to treating patients with a dual diagnosis. However, pragmatic and clinically effective brief interventions that can be delivered by nurses across mental health settings remain underdeveloped. Motivational interviewing has had some successful exposure in the field of dual diagnosis; however, harm reduction remains unexplored both conceptually and in terms of clinical intervention. This literature review examines the notion of harm reduction as a method of identifying and reducing the harm associated with the misuse of drugs and alcohol in relation to mental health problems. Currently there is a paucity of good quality evidence for integrated interventions in the treatment of dually diagnosed patients. Therefore, the papers are analysed in respect of their methodological quality and contribution to the evidence base to inform both future research and mental health nursing practice.     

Assessing falls risk in older adult mental health patients: A Western Australian review

Falls are a common and costly complication of hospitalization, particularly in older adult populations. This paper presents the results of a review of 139 falls at two older adult mental health services in Western Australia, Australia, over a 12‐month period. Data were collected from the hospital incident report management system and from case file reviews of patients who sustained a fall during hospitalization. The results demonstrated that the use of different risk assessment and falls management tools led to variations in practice, policies, and management strategies. The review identified mental health‐specific falls risk factors that place older people with a mental illness at risk when admitted to the acute mental health setting. With the expansion of community mental health care, many older people with a mental illness are now cared for in a variety of health‐care settings. In assessing falls risk and implementing falls‐prevention strategies, it is important for clinicians to recognize this group as an ambulant population with a fluctuating course of illness. They have related risks that require specialized falls assessment and management.     

Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

TOPIC:  The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings.
PURPOSE:  In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder.
SOURCES:  This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality.
CONCLUSIONS:  Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.     

'Let a hundred flowers blossom, let a hundred schools of thought contend': a case for therapeutic pluralism in mental health nursing

With the dominance of cognitive behavioural therapies within mental health nursing educational and practice settings, a danger exists that a narrow application of therapy interventions and micro skills will result. Given the rich and diverse variations of presenting circumstances to community mental health services, an incorporation of therapy approaches beyond the cognitive behavioural model is essential. This paper initially aims to demonstrate the core values of mental health nursing as being at least partially incongruent with those of cognitive behavioural therapies. This paper also aims to provide brief examples of the use of alternate evidential practice-based therapies more reflective of mental health nursing values across a spectrum of community mental health service where the authors are employed.     

Restraint and the question of validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.     

District nurses' involvement and attitudes to mental health problems: a three-area cross-sectional study

Aims and objectives. The main aims of this study were to obtain information on the extent of staff contact and input with mental health problems and to determine their experience, training and attitudes to such problems. Background. Historical changes and policy shifts have resulted in primary care providers playing an increasing role in the care of mental health problems. Such problems are common within community settings and a major cause of suffering and disability. District nurses in particular are likely to encounter a high level of psychological co‐morbidity in their patients. Information is lacking on their involvement, attitudes and specific training for this area of their work. Design and methods. A cross‐sectional study was conducted of the staff of district nursing services in three areas, Jersey (Channel Islands), Lewisham and Hertfordshire, using a postal questionnaire. Results. Questionnaires were sent to 331 staff; 66% responded. Community and district nurses estimated a 16% prevalence of mental health problems among their patients, most commonly dementia, depression and anxiety disorders. Staff noted participation in a wide range of psychological care activities, but identified a lack of training for this aspect of their role (three‐quarter of nurses had received no such training during the past five years). They reported a willingness to develop their understanding and skills by means of educational programmes. Attitude measures revealed generally optimistic views concerning depression treatment, a rejection of deterministic attitudes about this condition and confidence in the role of district nursing staff in managing such problems. Conclusions. The need for primary care mental health training is widely noted and based upon consistent evidence of the limited detection and treatment of these problems. This study has employed quantitative methods to clarify the extent and nature of district nursing staff involvement in this area of practice and indicates that training needs are acknowledged by community nurses from geographically distinct settings. Relevance to clinical practice. Staff are interested in developing knowledge and skills pertinent to the psychological problems of their patients and their views reveal a consensus that the most important areas for learning are recognition of mental disorders, anxiety management, crisis intervention and pharmacological treatments for depression.     

Acute mental health nurses: comprehensive practitioners or specialist therapists?

This paper examines the aids and barriers to implementing the psychosocial interventions (PSI) which trainees learned on two teaching modules. The main purpose of the modules is to teach trainees PSI to help them be more effective in their care of patients with severe mental illness. The trainees were qualified nurses working in acute mental health wards in various London hospitals. PSI has been found to be helpful for patients with psychotic symptoms in community contexts. In this study, the implementation of PSI specific to acute inpatient mental health settings is explored. This was achieved by conducting semi-structured audiotaped interviews with all 20 trainees from a single cohort. The data were analysed by categories and themes to elicit not only the problems but also helpful strategies which can be used when working with PSI in acute inpatient mental health settings. The paper concludes by offering recommendations for future good practice for this area of mental health service.     

A national survey of practice nurse involvement in mental health interventions

BACKGROUND: The move in the United Kingdom (UK) from institutional to community care has led to an inevitable increase in the involvement of practice nurses (PNs) in mental health care. Around 20 000 PNs are currently working in the United Kingdom (UK). However, the extent and nature of PN involvement in delivering mental health interventions has not been adequately explored. AIM: This study aimed to quantify practice nurses' involvement in delivering mental health interventions in primary care settings. METHOD: A questionnaire was sent to a random sample of 1500 practice nurses registered with the Practice Nurse Forum at the Royal College of Nursing. Sixty per cent of questionnaires were returned; however, once non-eligible respondents were removed an adjusted response rate of 54% was achieved. RESULTS: Practice nurses play a significant role in the assessment and treatment of mental health problems, most frequently via the administration of depot antipsychotics and the screening for depression. However, antipsychotic side-effects were infrequently monitored and PNs' understanding of treatment issues in depression is poor. These findings may be associated with the reported lack of mental health training that PNs have received. CONCLUSIONS: The findings of this study have important implications for the training of practice nurses in mental health, specifically in the areas of medication management and the detection of mental disorders.     

Mental health nurses’ attitudes towards consumer involvement in nursing handover pre and post an educational implementation

Involving mental health consumers in nursing handover is a recent introduction to practise in acute mental health units. However, implementation must recognize that mental health care is complex and the approach needs to include recovery‐focused philosophies of practice. Evidence shows that nurses and other health professionals consider poor handover practices may be the source of adverse events; however, the views of mental health nurses about involving consumers in nursing handover have not been previously reported. The aim of this study was to identify nurses’ attitudes towards consumer involvement in handover and to measure the effect of a training programme upon these attitudes. A single‐group pre‐post‐test intervention study was undertaken. The study was conducted on the adult acute mental health inpatient unit of a major metropolitan hospital in Victoria, Australia, 2016–2017. Questionnaires were developed to capture the views of the nurses about proposed changes in the afternoon nursing handover process. A questionnaire was administered before and after the training intervention, an innovative, multi‐media education handover package. We found that training had a significant influence on mental health nurses’ attitudes towards involving consumers in the handover. Therapeutic engagement improved following training and miscommunication reduced when all players are informed and have the opportunity to engage with the information. This study has demonstrated that well‐planned education can influence nurses’ attitudes about involving consumers in the nursing handover processes.     

A clinical improvement project to develop and implement a decision‐making framework for the use of seclusion

The use of seclusion within acute psychiatric settings is contentious. As evidenced by its use in practice, seclusion continues to be supported by mental health‐care professionals. However, there is a growing evidence base that indicates that it is viewed negatively by patients and causes symptoms of severe distress. In Australia and several other countries, the use of restraint and seclusion is now being questioned, and there are now policy directives to reduce or abandon these practices. Despite mental health‐care professionals' awareness of the potential detrimental effects of seclusion, the practice is strongly embedded in Australian mental health settings. This paper describes an improvement project to develop and implement a clinical decision‐making framework around the use of seclusion. The setting was an acute mental health‐care facility servicing a large health district in south east Queensland, Australia. The impetus for this project was driven by concerns expressed by consumers of the service and our own need to reduce the incidence of seclusion and the length of time of seclusion events to below 4 hours' duration. This improvement project employed practice development and action research principles to engage colleagues in the development of the framework. The project duration was 6 months, and resulted in two decision‐making frameworks around the use of seclusion: the decision to seclude and the decision to release.